Every finding on record at Creekside Center for Rehabilitation and Nursing

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure kitchen staff used hair nets during food preparation and failed to ensure potentially hazardous food items were cooled according to acceptable standards. These findings have the potential to affect all residents of the facility. The findings include:During the initial tour of the kitchen on 2/1/26 at 7:59 AM, 3 kitchen staff were observed preparing breakfast trays. 1 of the 3 staff, the cook (Staff #15), was observed behind the counter putting cooked food items on plates as the other 2 staff called out what was on the meal tickets. Staff #15 did not appear to be wearing a hair net and was confirmed when asked by the surveyor if she was wearing one, she stated, No I'm not. On 2/1/26 at 8:06 AM. The Dietary Manager (Staff #2) arrived in the kitchen and accompanied the surveyor with the tour of the kitchen. On 2/1/26 at 8:22 AM, the walk-in refrigerator was inspected with Staff #2. The following cooked food items were observed:- Mechanical Beef dated 1/20/26- Bacon dated 1/30/26- [NAME] beans dated 1/29/26- Mechanical Turkey 1/29/26- 2 pans of roast beef dated 1/20/26- Pureed beef dated 1/30/26- Turkey dated 1/30/26- Pureed chicken dated 1/31/26- Mechanical chicken dated 1/31/26- Sausage patties dated 1/31/26- Beef mac dated 1/31/26- 2 pans of turkey dated 1/29/26On 2/1/26 at 8:31 AM, Staff #2 was interviewed regarding the cool down process for potentially hazardous food items. Staff #2 reported that the facility adheres to the requirement and documentation is kept in a binder. She then provided the binder to the surveyor for review. However, the latest entries for the cooling log were in September of 2025. Staff #2 stated, looks like we don't have one and indicated that it was the facility cook's responsibility to document the cool down process.In a subsequent interview with Staff #2 on 2/1/26 at 8:44 AM, the concerns were discussed that Staff #15 was observed processing breakfast trays without a hair net and failed to document the cool down process for potentially hazardous food items. Staff #2 stated, I have to talk to my staff to keep up with that and indicated that the identified food items in the refrigerator will be discarded. Staff #2 acknowledged the concern.

Based on record reviews and interviews, it was determined that the facility failed to provide residents with information to formulate an advanced directive. This was evident for 4 (Resident #53, #52, #22, and #2) of 4 residents reviewed for advanced directives. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. 1) Resident #53 was admitted into the facility in late 2025. The resident's medical record indicated an intact cognitive ability. A review of Resident #53's medical record was conducted on 2/2/26 at 12:20 PM. The review revealed that the resident was certified as capable of understanding and making medical decisions for self that was signed and dated by the facility's medical provider on 11/12/25. However, there was no Documentation to indicate that an advanced directive was discussed/offered to the resident. The Social Services Director (Staff #8) was interviewed on 2/3/26 at 1:24 PM. During the interview, Staff #8 explained that she discusses advanced directives to newly admitted residents of the facility and provided support in filling out the necessary forms, after determining that the resident is capable. Staff #8 reported that she documents all these activities in the resident's progress notes. A review of Resident #53's progress notes was conducted on 2/2/26 at 2:19 PM. The review revealed no documentation under the social services department. In a subsequent interview with Staff #8 on 2/5/26 at 10:37 AM, she confirmed that Resident #53 was capable of making his/her own medical decision and did not have an advanced directive in place. She reported a meeting with the resident yesterday to discuss plan for possible discharge to an assisted living but was not able to offer or discuss advanced directives. The concern was discussed with Staff #8 that the facility failed to provide Resident #53 with information to formulate an advanced directive. Staff #8 verbalized understanding and acknowledged the concern. 2) Resident #52 was admitted into the facility in mid-2025. On 2/2/26 at 11:06 AM, a review of Resident #52's medical record was conducted and revealed that the resident was certified as capable of understanding and making medical decisions for self that was signed and dated by the facility's medical provider on 7/15/25. There was no indication that the resident had an advanced directive in place. A social services assessment dated [DATE] had a section (Section B) for Advanced Care Planning had questions to indicated if 1) the resident made his/her own decision, 2a) the resident/responsible party report that advanced care planning had been completed, and 2b) what had been completed? (for example, health care power of attorney or living will). This section was unanswered. The Social Services Director (Staff #8) was interviewed on 2/5/26 at 10:27 AM. During the interview, Staff #8 reported her process with advanced directives for new admissions. Noting that Staff #8 started with the facility less than 6 months ago, she reported that about 2 months ago, she conducted an audit of the residents who were admitted prior to her hire for advanced directives. Staff #8 also reported that the social services assessment for Resident #52, documented on 7/21/25, was conducted by her predecessor and her audit revealed that the resident was capable of decision making and had no advanced directive in place. However, her audit was still in progress and had only completed 2 of the 3 units of the facility. Staff #8 also reported that she had not provided the necessary information to formulate advanced directives for capable residents identified in her audit. She indicated being overwhelmed and needing support to complete the different tasks assigned to her in the facility. 3) On 02/02/2026 at 10:51 AM, a review of R#22's hard chart revealed no evidence of a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form or an advance directive. On 02/03/2026 at 10:33 AM, a review of the electronic medical record (PCC) revealed the presence of a MOLST form; however, there was no evidence of an advance directive for R#22. On 02/03/2026 at 1:20 PM, the surveyor requested an interview with the Social Services Director (Staff #8). On 02/03/2026 at 1:23 PM, an interview was conducted with Staff #8, identified as the facility's licensed social worker and grievance officer. Staff #8 stated they are responsible for discharge planning, coordinating care plan meetings, grievances, and resident concerns. On 02/03/2026 at 1:26 PM, Staff #8 stated that upon admission, residents are provided information on how to establish an advance directive and that residents may either agree or decline. Staff #8 stated, It's documented within the progress notes under social services. Staff #8 further stated that the Social Services assessment within PCC is used for new admissions, BIMS assessments, social services assessments, discharge planning review, and social determinants of health. Staff #8 stated that they complete quarterly readmission and discharge BIMS assessments and that, at times, the Minimum Data Set (MDS) Coordinator may complete the BIMS. On 02/05/2026 at 8:48 AM, a comprehensive review of R#22's medical record, including all progress notes and assessments, was conducted. The miscellaneous tab contained the resident's MOLST form. There was no evidence of an advance directive. The assessments tab contained no documentation indicating whether R#22 had been assessed for an advance directive or that the resident declined to establish one. On 02/05/2026 at 12:30 PM, during a follow-up interview, Staff #8 stated that they did not receive clear training on how to complete an advance directive with residents or how to appropriately screen residents for advance directives. Staff #8 stated that since starting at the facility in November 2025, they have begun incorporating advance directive review into social services assessments. On 02/05/2026 at 1:15 PM, these findings were reviewed with the Nursing Home Administrator. On 02/06/2026 at 2:30 PM, no additional evidence was provided to the surveyor prior to the conclusion of the survey. 4)On 2/02/26 at 10:39 AM a review of Resident #2's paper chart was conducted. No advance directives documents were found in the chart. A Maryland Order for Life Sustaining Treatment (MOLST) document was in the record. It was dated 10/02/24 and indicated that the resident was the decision maker. On 2/03/26 at 10:36 AM a review of Resident #2's electronic medical record was conducted. There were no advanced directives or power of attorney documents found in the electronic medical record. On 02/05/26 at 12:19 PM interview was conducted with the facility social worker (Staff #8), and she was asked if she was familiar with Resident #2, and Staff #8 said she has not met with the resident yet. When asked about the process for offering residents advance directive information, Staff #8 indicated that the information would be offered at the time of admission and at each care plan meeting, but there was no evidence that this was done for this resident. Staff #8 acknowledged the deficiency. On 2/06/26 at 2:00 PM an interview was conducted with the Nursing Home Administrator to review deficient findings from this survey and offer an opportunity to provide any additional evidence. No further evidence was provided by the end of the survey.

Based on record review and interview, it was determined that the facility failed to perform required resident assessments. This was evident for 1 (Resident #2) of 6 residents reviewed for unnecessary medications. The findings include:The Resident Assessment Instrument (RAI) identifies the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The RAI process is the basis for the accurate assessment of each resident. The Minimum Data Set (MDS) assessments are an integral part of the RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic non-comprehensive MDS assessments which facilities conduct to maintain an accurate understanding of each resident's most current needs and strengths, and to ensure care planning remains current and effective. An Assessment Reference Date (ARD) is the date that shows the end of the look back (observation) period. This date is used to base responses to all MDS coding items during the MDS assessment. The Brief Interview for Mental Status (BIMS) score is a 0-15 point assessment tool used in long-term care to measure cognitive function, focusing on memory, orientation, and recall. Scores indicate cognitive levels: 13-15 (intact), 8-12 (moderate impairment), and 0-7 (severe impairment).On 2/03/26 at 3:43 PM a review of Resident #2's medical record revealed that the resident was admitted in February 2024, and had diagnoses that included, but was not limited to, Parkinson's disease and unspecified dementia. Further review revealed that the resident had a quarterly MDS assessment on 12/11/25. A review of the MDS Section C revealed that no cognitive assessment was done. The space to indicate the resident's score had a dash in it, and the questions were answered with the words not assessed.On 2/05/26 at 12:45 PM in an interview with the MDS nurse (Staff #9), she was asked about the entry in Section C of Resident #2's December MDS. She reviewed the form and said that Section C was dashed for the 12/11/25 MDS assessment. When questioned further she confirmed that a cognitive assessment was required for a quarterly MDS and should have been done but that this was a question for the facility's social worker. When asked what steps were taken when a section was incomplete, she said she sent an email to any staff who had incomplete entries and if there was no response she would send a follow up email to the Nursing Home Administrator (NHA) and the Regional MDS nurses. Further review of the resident's MDS entries revealed that Section C was also dashed for the resident's September 2025 assessment, and that the resident's last BIMS assessment was done in June 2025.On 2/06/26 at 1:16 PM in an interview with the NHA, she said that she was unaware that some MDS sections were incomplete, but she acknowledged the deficiency.

Based on record reviews and interviews, it was determined that the facility failed to conduct care plan meetings after the completion of the comprehensive and quarterly assessments. This was evident for 1 (Resident #1) of 3 residents reviewed for care planning and 1 (Resident #2) of 6 residents reviewed for unnecessary medications and 1 (Resident #47) of 1 residents reviewed for activities. The findings include: 1.) Resident #1 had been a resident of the facility since 2023. The resident was admitted with multiple health concerns including stroke and dementia. An interview with Resident #1's responsible party on 2/3/26 at 11:09 AM indicated concerns with care plan meetings being missed or rescheduled. On 2/3/25 at 1:24 PM, the Social Services Director (Staff #8) was interviewed regarding care plan meetings. Staff #8 explained that care plan meetings are scheduled quarterly in conjunction with quarterly and comprehensive assessments and documentation can be found in the residents' progress notes. A review of Resident #1's medical record was conducted on 2/3/26 at 1:38 PM. The review revealed a comprehensive assessment was completed with an assessment reference date (ARD) of 8/10/25, then followed by a quarterly assessment with an ARD of 11/10/25. Progress notes under Care Plan Note for Resident #1 with an effective date of 8/6/25 at 1:51 PM indicated that a care plan meeting was scheduled, however the resident's family member did not answer the phone call. The facility staff documented a plan that read, attempt will be made to f/u with another call to reschedule Care Conference meeting by telephone or in person. A follow-up progress notes with an effective date of 8/6/25 at 2:50 PM indicated that the facility staff was unable to reach the family member and that a voice message was left. The following note for care plan meetings had an effective date of 11/5/25 at 10:44 AM. No other note was found to indicate that a care plan meeting was held after the 8/10/25 comprehensive assessment was completed. A subsequent interview with Staff #8 was conducted on 2/5/26 at 10:50 AM. During the interview, the findings were discussed with Staff #8 and she indicated that the care plan meeting and ARD of the comprehensive assessment was prior to her hire date. She reported that during that time, the care plan meetings were conducted and scheduled by the nursing staff. They (nursing staff) also used a binder to document the schedule of the care plan meetings and indicated that further documentation may be found there. On 2/5/26 at 11:02 AM, Staff #8 reviewed the binder for care plan meetings. The review revealed that a care plan meeting was scheduled for 8/6/25 at 1:20 PM with Resident #1's RP's phone number written beside it. Staff #8 No other documentation was found to indicate that a care plan meeting was held for the resident after the comprehensive assessment was completed. Staff #8 acknowledged the concern. 2.) The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The RAI process is the basis for the accurate assessment of each resident. The Minimum Data Set (MDS) assessments are an integral part of the RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic non-comprehensive MDS assessments which facilities conduct to maintain an accurate understanding of each resident's most current needs and strengths, and to ensure care planning remains current and effective. An Assessment Reference Date (ARD) is the date that shows the end of the look back (observation) period. This date is used to base responses to all MDS coding items during the MDS assessment. Resident #2 was admitted to the facility in February 2024 with diagnoses that included, but were not limited to, Parkinson's disease and unspecified dementia. A review of Resident #2's medical record revealed that their 2025 MDS assessment dates were 1/23/25 (quarterly), 4/25/25 (quarterly), 6/10/25 (quarterly), 9/10/25 (annual), and 12/11/25 (quarterly). Further review failed to reveal evidence of any care plan meeting held in September or December. On 2/05/26 at 12:19 PM an interview was conducted with the social worker (Staff #8), who said she had worked at the facility for three months. When asked about her process for scheduling care plan meetings, she explained that she determined the need for a care plan meeting by the MDS ARD dates and that she had reports of those dates for all residents. When she was asked when Resident #2's last care plan meeting was, she said that she had not yet met with the resident and had not had a care plan meeting with Resident #2. Staff #8 said she thought that the resident's last care plan meeting was held in May. Staff #8 retrieved a binder of documents and then confirmed that the resident's last care plan meeting was on 5/07/25 and that since then, the facility failed to have 2 care plan meetings for the resident. She said she was unable to explain the reason for the missed care plan meeting in September 2025 since she did not work at the facility at that time, and she explained that she was unable to schedule the December 2025 care plan meeting. On 2/05/26 at 2:29 PM an interview was conducted with the Director of Nursing (DON) to review the deficient practice that Resident #2 did not have a care plan meeting in September 2025 or December 2025 when they were due. The DON acknowledged the deficiency. 3.) On 02/02/2026 at 10:18 AM, during an interview, R#47 stated that they did not participate in a care plan meeting. A record review completed on 02/02/2026 at 10:42 AM revealed that revisions to R#47's care plan focus areas and goals were documented with a revision date of 11/07/2025. There was no evidence of documentation in the resident's record indicating that R#47 or the resident's representative participated in or were notified of a care plan meeting on that date. On 02/03/2026 at 1:26 PM, an interview was conducted with Staff #8, the staff member responsible for coordinating care plan meetings, who has been in the role since November 2025. Staff #8 stated that care plan meetings are conducted quarterly. Staff #8 stated, Being fairly new, I picked up where they left off. We meet on Wednesday and Thursday. One day is for short-term residents and one day is for long-term residents. Sometimes, we will combine. Staff #8 stated that they coordinate care plan meetings with residents and/or family members and that scheduling is typically based on the next planned Assessment Reference Date (ARD). Staff #8 further stated that documentation regarding care plan meetings may be entered into the electronic record under a Social Services progress note, that dates are communicated to staff via email, and that a care plan schedule is maintained in a binder in the Social Services office. Staff #8 stated that they are responsible for updating resident care plans. On 02/03/2026 at 1:33 PM, the surveyor asked where documents related to R#47 could be found. Staff #8 stated, It would be in a Social Services Progress Note. On 02/03/2026 at 3:20 PM, a review of R#47's record revealed no evidence that Staff #8 documented coordination of, notification of, or participation in a care plan meeting for R#47 since 09/03/2025. There was no documentation indicating accommodations made to ensure resident or representative participation, nor any evidence that a care plan meeting occurred after that date. The most recent documented care plan meeting for R#47 occurred on 09/03/2025, as reflected in a Social Services Care Plan Progress Note authored by the previous social worker. No subsequent care plan meeting documentation was identified in the resident's record. On 02/05/2026 at 1:15 PM, these findings were reviewed with the Nursing Home Administrator. On 02/06/2026 at 2:30 PM, no additional evidence was provided to the surveyor prior to the conclusion of the survey.

Based on record reviews and interviews, it was determined that the facility failed to notify the resident's physician of a significant change in condition and a decision to transfer the resident from the facility. This was evident for 1 (Resident #83) of 2 residents reviewed for neglect. The findings include:Resident #83 passed away in late 2025. On [DATE] at 7:39 AM, the details of complaint2729325 for Resident #83 were reviewed and revealed concerns with coordination and notifying the physician to send the resident out during a change in condition.A review of Resident #83's medical records was conducted on [DATE] at 2:26 PM. The review revealed progress notes dated [DATE] that indicated the resident's code status was updated from full code to Do not resuscitate and [DATE] that indicated emergency medical services (EMS) arrived in the facility to pronounce that the resident had passed away.A Full Code means a patient wants all possible life-saving measures, including cardiopulmonary resuscitation (CPR), chest compressions, defibrillation, and intubation, if their heart stops or they stop breathingA Do Not Resuscitate (DNR) order is a legally binding medical directive instructing healthcare providers not to perform CPR if a patient's heart stops or they stop breathing. It is a proactive decision, often in conjunction with terminal illness or advanced age, designed to allow natural death, sometimes referred to as no code or Allow Natural Death. The Director of Nursing (DON) was interviewed on [DATE] at 11:33 AM. During the interview, she reported her expectations from nursing staff when a resident is experiencing a change or decline in health status. After resident assessment, the physician should be notified immediately to determine the next steps and coordinate if EMS should be called. If the physician decides to send the resident to the hospital, an order is placed in the resident's medical order to reflect that decision. The DON further explained that all actions taken by the nurse in such events are expected to be documented in the resident's medical record as a progress note and/or change in condition evaluation.Also, during the interview, Resident #83's medical record was reviewed with the DON. The DON confirmed that EMS was called into the facility on [DATE]. However, she could not tell who or which staff called the EMS and stated, the nurse should have documented that. I would expect a change in condition (to show what the nurse did and that the physician was notified), but there is none in there. The DON also reported that there was no medical order to send the resident out to the hospital on [DATE] and explained that the nurse should have done a late entry (for progress notes and medical orders) if s/he was in a chaotic situation.The concern was discussed with the DON that there was no documentation to indicate that the nursing staff had notified Resident #83's physician of his/her change in condition or decision to transfer to the hospital. The DON verbalized understanding and acknowledged the concern.

Based on record review and interview it was determined that the facility failed to ensure admission Minimum Data Set assessments were completed timely. This was evident for 1 (Resident #32) of 1 resident reviewed for respiratory care. The findings include:The Resident Assessment Instrument (RAI) identifies the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The RAI process is the basis for the accurate assessment of each resident. The Minimum Data Set (MDS) assessments are an integral part of the RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic non-comprehensive MDS assessments which facilities conduct to maintain an accurate understanding of each resident's most current needs and strengths, and to ensure care planning remains current and effective. An Assessment Reference Date (ARD) is the date that shows the end of the look back (observation) period. This date is used to base responses to all MDS coding items during the MDS assessment. On 02/03/26 at 12:52 PM a review of Resident #32's medical record revealed that the resident was admitted to the facility on [DATE] after a hospitalization for a respiratory infection. A review of the resident's MDS document indicated an entry date of 1/20/26, and an MDS Admission/Medicare - 5 day MDS with an ARD of 1/24/26 was listed as In Progress. Only Section F and Section K were completed. Multiple other sections of the MDS were incomplete. On 2/05/26 at 12:45 PM an interview was conducted with the MDS nurse (Staff #9). She was asked about her process for new admissions and explained that she received notification from the admissions office about new admissions, and that she had access to hospital medical records to obtain information even before the resident was admitted . She further explained that if the MDS timeliness was urgent, she would email all parties to let them know what needed to be completed. Staff #9 was asked to review Resident #32's admission MDS documentation. She confirmed that the resident was admitted to the facility on [DATE], and that the MDS set date was 1/24/26. The MDS was completed/signed/accepted on 2/03/26. When asked if the admission MDS was timely, she did a calculation, then looked up the information, and replied that it was not completed timely. It should have been completed on 2/02/26. She confirmed the deficiency that the MDS was late. On 2/06/26 at 1:16 PM an interview was conducted with the Nursing Home Administrator to review survey findings. She acknowledged the late admission MDS for Resident #32. No further evidence was provided by the end of the survey.

Based on observation and interview, it was determined that the facility failed to treat residents with dignity. This was evident for 2 (Resident #48, #22 ) of 24 residents screened during the initial pool portion of the recertification survey. The findings include:1) The Brief Interview for Mental Status (BIMS) score is a 0–15 point assessment tool used in long-term care to measure cognitive function, focusing on memory, orientation, and recall. Scores indicate cognitive levels: 13–15 (intact), 8–12 (moderate impairment), and 0–7 (severe impairment). Resident #48 was admitted to the facility for rehabilitation after an acute hospitalization for sepsis. The resident was [AGE] years old, and cognitively intact as evidenced by a BIMS score of 15. On 2/02/26 at 11:23 AM during the surveyor's initial interview with Resident #48, a Registered Nurse (RN), Staff #6, knocked on the resident's door, said he had to check the resident's blood sugar, and entered the room without obtaining permission. Staff #6 proceeded to put on gloves, picked up the resident's hand, and performed the fingerstick blood test without asking the resident for permission. After Staff #6 left the resident's room, Resident #48 described another experience when they were provided with personal care without regard to their privacy. S/he stated the door to the room was open and the privacy curtain was not pulled around the bed while their body was exposed. The resident described that s/he felt very embarrassed during that experience. Resident #48 then described a care plan meeting with staff, which included the Assistant Director of Nursing and the social worker, that turned into a shouting match. The resident indicated that staff would not listen to either them or their family member when they discussed their specific care concerns about facility staff. On 2/04/26 at 3:00 PM an interview was conducted with the Nursing Home Administrator. She acknowledged the finding that Staff #6 entered Resident #48's room without permission. She said that staff training will be done. 2) On 02/01/2026 at 8:17 AM, during an interview with R#22 in room [ROOM NUMBER], the breakfast tray distribution on the 400 hall was underway, the surveyor observed Staff #5, a Geriatric Nursing Assistant and Staff #7, a Licensed Practical Nurse, enter resident rooms 406, 409, 410, 411, 412, 414, 415, and 416 without knocking prior to entry. This occurred in 8 of 8 resident rooms observed during the breakfast meal tray pass. The surveyor did not observe either staff member pause, announce themselves, or request permission prior to entering resident rooms. Review of the facility policy titled Resident Rights and Dignity, revised 2025, indicated that staff are expected to knock and announce themselves prior to entering resident rooms. During an interview on 02/02/2026 at 10:12 AM, Staff #5 stated, We usually just go in during meal pass because we're trying to get trays out quickly. On 02/03/2026 at 1:15 PM, the findings were reviewed with the Nursing Home Administrator and Director of Nursing (DON). The DON confirmed that staff are expected to knock prior to entering resident rooms.

Based on record reviews and interviews, it was determined that the facility failed to ensure showers were provided/offered as scheduled to dependent residents. This was evident for 1 (Resident #89) of 2 residents reviewed for neglect. The findings include:Resident #83 was admitted into the facility in mid-2025 with diagnoses that include muscle weakness, morbid obesity, chronic pain, and abnormalities of gait and mobility. On 2/5/26 at 7:39 AM, an allegation related to complaint2729325, that showers were not being provided to the resident as scheduled was reviewed.During an interview with the complainant on 2/5/26 at 1:33 PM, s/he reported that Resident #83 would go 11 days with staff not providing showers.A review of Resident #83's medical record was conducted on 2/5/26 at 1:40 PM. The review revealed a medical order for showers scheduled on day shift every Monday and Thursday. However, this order was discontinued on 9/2/25. No other order was found for showers and there was no documentation in the resident's administration record to indicate showers were being provided.On 2/6/26 at 8:40 AM, further review of Resident #83's medical record revealed a quarterly assessment was conducted with an assessment reference date of 9/18/25, where section GG indicated the resident needed substantial/maximal assistance (helper does MORE THAN HALH the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) to safely complete shower activity.Facility staff had reported that shower/skin sheets are filled out whenever a shower is provided for a resident. A review of the shower/skin sheets for September 2025 was conducted on 2/6/26 at 9:05 AM. The review revealed Resident #83 had 1 documented shower provided on 9/11/25 (Thursday) for evening shift. The Director of Nursing (DON) was interviewed on 2/6/26 at 10:02 AM. During the interview, the DON reported that residents do not need orders for showers. All residents are scheduled for showers 2x a week and the schedule is dictated by the resident's room number and bed. (According to Resident #83's information, showers would have been scheduled on day shift every Wednesday and Saturday.) She also reported that aside from the shower/skin sheets, nursing aides document showers/baths under their task documentation.The DON was asked to print a copy of the nursing aides task documentation in September 2025 for Resident #83. A review of the documentation was conducted on 2/6/26 at 10:30 AM. The review revealed shower was provided on 9/13/25 (Saturday) for day shift.In a subsequent interview with the DON on 2/6/26 at 11:08 AM, the findings were discussed that in September of 2025, Resident #83 received 1 scheduled shower and 1 unscheduled shower. No other documentation was found to indicate showers were provided or refused on the other days the resident was scheduled to receive them. The DON confirmed the finding and acknowledged the concern.

Based on record review and interview it was determined that the facility failed to obtain a physician's order for oxygen and failed to perform a follow up assessment after a resident was treated for shortness of breath. These failures were evident for 1 (Resident #83) of 3 residents whose closed records were reviewed during the recertification survey. The findings include:Medical Orders for Life-Sustaining Treatment (MOLST), is a document that translates a patient's preferences for end-of-life care into specific, actionable medical orders signed by a healthcare professional. Unlike general advance directives, MOLST forms are portable medical orders that tell emergency responders and other providers exactly what treatments (like CPR, intubation, feeding tubes) to provide or withhold, ensuring patient wishes for serious illnesses are honored across different care settings.On [DATE] at 4:11 PM a review was conducted of Resident #83's medical records. Resident #83 was admitted to the facility in 2022 and was [AGE] years old when they expired at the facility in [DATE]. Their diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen.A care plan note in Resident #83's medical record dated [DATE] indicated that the resident did not show potential for discharge due to COPD and lack of support system. Resident unable to care for [themselves]. It also indicated that the resident required oxygen continuously at 2 liters/minute via a nasal cannula.A review of Resident #83's MOLST document revealed instructions to not attempt cardiopulmonary resuscitation for the resident.Further record review revealed a progress note dated [DATE] at 1:20 AM that indicated the resident had shortness of breath and was assessed to have a low oxygen saturation level of 90%. The record indicated that the resident received 3 interventions: 1) they were medicated with an as needed dose of an inhaler, 2) the head of the bed was elevated, and 3) their oxygen dose was increased to 3 liters/minute. There were no subsequent progress notes that described how these interventions affected the resident, and no physician's order for the increase in oxygen. The next progress note in the record was written on [DATE] at 7:43 AM and stated - expired - observed at 7:43 w/o [without] resp/pulse [respirations/pulse], M notified, family and funeral home notified.On [DATE] at 10:03 AM an interview was conducted with the Director of Nursing (DON) and when asked she said she remembered Resident #83 and knew that the resident had died at the facility. When asked about her recollection of the resident's care plan regarding end-of-life choices, the DON explained that although there had been discussion about hospice and palliative care for this resident, no decision had yet been made, and there were no physician orders for a hospice consult prior to the resident's death. When asked where the evidence was regarding those discussions, she said she had emails but that there was nothing documented in the resident's medical record. The DON was asked to review the progress notes regarding the resident's shortness of breath and the DON she said that she saw that interventions were provided to the resident, which included an increase of the resident's oxygen dose to 3 liters/minute. She was asked where the order was for the increase in oxygen, or if there was an order to titrate oxygen, but she confirmed that there were no such orders. She also confirmed that there was no evidence of any staff follow up to check how the resident responded to the interventions that were provided. She further confirmed that the progress note hours later showed that when staff went back into the resident's room, the resident was found without pulse or respiration.The DON confirmed the above deficient practices and provided no further evidence by the end of the survey.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure residents at risk for developing pressure injuries receive appropriate services for treatment and prevention. This was evident for 1 (Resident #3) of 2 residents reviewed for pressure injuries. The findings include:Resident #3 had been residing in the facility since early 2024. On 2/2/26 at 1:42 PM, during a family interview, the resident's responsible party indicated that the resident had a wound. It was also observed at this time that the resident's bed was equipped with an air mattress with the control box located at the foot of the bed. The control had a dial to set the firmness based on weight. The setting was dialed up to max weight of over 350 lbs. A review of Resident #3's medical records was conducted previously on 2/2/26 at 10:46 AM. The review revealed the resident's most recent weight was taken on 1/27/26, and was documented as 160.2 lbs.On 2/3/26 at 8:27 AM, Resident #3 was observed in bed. The weight setting for the air mattress was still set to max.The Assistant Director of Nursing who happened to be the facility's wound nurse (Staff #1) was asked to accompany the surveyor in Resident #3's room on 2/3/26 at 8:33 AM. Staff #1 confirmed that the resident's air mattress setting was turned up to max firm/weight and stated, it should be set between 150 and 180 lbs. We had a town hall meeting a couple of months ago and we went over the settings of the low air loss mattress. Our staff should be familiar with that. Then proceeded to turn the dial down to an area between the 150 and 180 markers. Staff #1 reported that nurses sign off an order to indicate that these settings are checked and appropriate.The interview with Staff #1 was continued in her office on 2/3/26 at 8:39 AM. During the interview, Resident #3's medical orders was reviewed, and Staff #1 showed the surveyor the order that read, Ensure low air loss mattress is on and in adequate working order. This order had a start date of 1/27/26 and was marked as done for all shifts on 2/1/26 and 2/2/26. Staff #1 explained that in adequate working order includes making sure the weight setting of the air mattress was appropriate. Staff #1 stated, sounds like we need to reeducate. Continue ongoing education with staff on low-loss air mattress. Thank you for letting me know.The Braden Scale is a widely used healthcare tool to assess a patient's risk of developing pressure injuries/ulcers (bedsores) by evaluating six key factors: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear. Scores range from 6 (severe risk) to 23 (no risk), with lower scores indicating higher risk (e.g., 18 or less suggests at-risk status), guiding interventions for prevention. On 2/3/26 at 12:48 PM, a review of Resident #3's medical record revealed the most recent BRADEN scale dated 5/2/25 that indicated the resident to be very high risk. The resident also had orders for weekly skin check scheduled on day shift every Thursday with a start date on 12/19/24. The administration record showed that the nurses are signing that the skin checks were done as scheduled on 1/1/26, 1/8/26, 1/15/26, 1/22/26, and 1/29/26. However, review of the assessment documentation titled weekly skin assessment was only documented on 1/15/26 and 1/22/26. No other weekly skin assessment was documented for the month of January 2026.A subsequent interview was conducted with Staff #1 on 2/5/26 at 9:12 AM. During the interview, Staff #1 explained that nurses document in the electronic treatment administration record (eTAR) that weekly skin assessment are done, then documentation of the actual assessments are found under the assessments tab in the electronic health record The finding that nurses had documented in Resident #3's eTAR that skin assessments were completed 5x in January, however only 2 of the 5 assessments were documented under the assessments tab, was discussed with Staff #1. She confirmed the finding and reported that nurses potentially could have done a progress note or documented on the skin sheet (paper document used for shower days).The binder containing the skin sheet was in the Director of Nursing's (DON) office. On 2/5/26 at 9:34 AM, after reviewing the skin sheet binder and Resident #3's medical record, Staff #1 confirmed that there was no documentation to indicate that skin assessments were completed in 3 of the 5 scheduled days in January 2026.On 2/5/26 at 9:39 AM, the concern was discussed with the DON and Staff #1 that the nursing staff failed to ensure Resident #3, who had a very high risk, receive appropriate care for prevention of pressure ulcer/injury, as evidenced by an over inflated air mattress and absence of skin assessments. Both staff verbalized understanding and acknowledged the concern.

Based on observation, record review, and interview, it was determined that the facility failed to monitor a resident's safety device. This was evident for 1 (Resident #51) of 1 resident reviewed for wandering/elopement. The findings include:A wanderguard is a wearable, electronic security device -typically a bracelet or tag-designed for senior living and healthcare facilities to monitor residents at risk of elopement. It uses radio frequency or Bluetooth technology to trigger alarms or lock doors when a patient nears unauthorized exits.Resident #51 was admitted to the facility in September 2025 with diagnoses that included, but was not limited to, Alzheimer's disease. On 10/08/25 an elopement assessment indicated that they were at high risk for elopement. On 11/13/25 the resident's cognition was assessed as severely impaired. A review of their Minimum Data Set (MDS) assessment dated [DATE] indicated a significant change in their condition related to a new onset of wandering behavior, and that a wanderguard device was placed on the resident to monitor them for safety.On 2/03/26 at 8:44 AM Resident #51 was observed as they propelled themselves in a wheelchair down the hallway of the 500 unit. The resident was neatly dressed in street clothes, easily engaged in small talk, but was oriented only to themselves - they were not aware that they were in a nursing facility, or to whom they were speaking. A wanderguard device was observed around their right ankle.On 2/03/26 at approximately 9:00 AM Resident #51 was observed as they self-propelled in the unit 200 hallway towards the dining hall near the lobby.On 2/03/26 at 12:02 PM a review of Resident #51's medical record failed to reveal documented evidence that the wanderguard device was regularly monitored for placement and functionality. On 2/03/26 at 2:31 PM an interview was conducted with agency nurse (Staff #10). She explained the process for how she checked Resident #51's wanderguard device. During the interview Resident #51, who was present in the hallway, self-propelled up to the nurse and the nurse showed the surveyor that the device had a flashing green light which indicated that the battery was sufficient. Staff #10 further explained that there were replacement devices on the unit if a check revealed that a device was not functional. When asked where she documented that she had checked the wanderguard device, Staff #10 said she documented on the Treatment Administration Record (TAR) in the resident's chart, but also added that this was her first day to work at the facility.On 2/03/26 at 2:45 PM an interview was conducted with the Director of Nursing (DON) to review Resident #51's care needs and the DON said that she was aware the resident had a wanderguard device. When asked where staff documented that they checked the wanderguard for placement and function, the DON said it should be documented on the TAR. She reviewed the resident's record and found that there was no documentation that the wanderguard device was monitored. She confirmed that there was no evidence that the resident's wanderguard was monitored. On 2/06/26 at 2:00 PM a review was conducted of the facility's policy for elopement. The policy stated, in part: If interventions include a wander guard/secure band, a physician order needs to be in place. 1.) Check location and placement of wander guard every shift (please include expiration date and identify the location). 2.) Check function of wander guard transmitter daily. 3). Check skin integrity at wander guard location every shift. All orders should be placed on the TAR and signed off by nursing.On 2/04/26 at 3:00 PM an interview was conducted with the Nursing Home Administrator. She acknowledged the deficiency that Resident #51's wanderguard was not monitored. No further evidence was provided by the end of the survey.

Based on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to residents according to professional standards of practice. This was evident for 2 (Resident #52, #19) of 2 residents reviewed for pain management. The findings include: 1) Resident #52 was admitted into the facility in mid-2025. During an interview with the resident on 2/2/26 at 9:18 AM, s/he indicated that pain medications don't always help and non-pharmacological interventions (NPI) are not provided or attempted for pain management. A review of Resident #52's medical orders was conducted on 2/0/26 at 9:26 AM. The review revealed an as needed (PRN) pain medication with a start date of 7/14/25. A pain assessment order also had a start date of 7/14/25, included NPI's with instructions that read, Do you have pain? If Denies - Stop here. If Yes - Indicate Pain score 0-10, Offer a nonpharmacological intervention: 1. Repositioning/Turning, 2. Distraction, 3. Massage, 4. Hot/Cold Compress, 5. Emotional Support, 6. Quiet Environment, 7. Other, 8. Not Applicable. every shift for Pain Monitoring Pain assessment every shift, Document Non-pharmacological interventions attempted prior to PRN medications. 1. Repositioning/Turning, 2. Distraction, 3. Massage, 4. Hot/Cold Compress, 5. Emotional Support, 6. Quiet Environment, 7. Other, 8. N/A. The electronic medication administration record (eMAR) of Resident #52 for January 2026 was reviewed on 2/4/26 at 9:40 AM. The review revealed that the PRN pain medication was administered on 1/12/26 at 10:58 PM, for an initial pain score of 0/10. The progress note corresponding to the medication administration failed to indicate location of the pain. Furthermore, there was no documentation to indicate that NPI's were provided/attempted prior to the administration of the medication. The Director of Nursing (DON) was interviewed on 2/4/26 at 10:34 AM. During the interview, the DON explained her expectations from the nursing staff when a resident complaint of pain. Proper assessment of the pain characteristics (pain score, location, intensity, etc.) must be documented and NPI's offered/attempted prior to administering PRN pain medications. She also indicated that all interventions should be reflected in the resident's administration record, where some would prompt the nurse to write a progress note to complete the documentation. The DON gave the example, when a PRN pain medication is administered, the nurse must go back to reassess the resident and document efficacy, to complete the documentation of the medication administration. All of which is reflected in the resident's progress notes where the DON indicated the pain characteristics can be found as well. Resident #52's medical record was reviewed with the DON on 2/4/26 at 10:43 AM. The DON confirmed that the PRN pain medication was administered on 1/12/26 for a 0/10 pain, no documentation of pain characteristics, and no evidence that NPI's were attempted/provided prior to the medication administration. The concern was discussed with the DON that the nursing staff failed to provide pain management to Resident #52 according to professional standards of practice. The DON verbalized understanding and acknowledged the concern. 2) Resident #19 was admitted to the facility in November of 2024, with diagnoses that included but was not limited to, chronic respiratory failure and right sided weakness from a stroke. On 2/03/26 at 8:45 AM an observation and interview was conducted with the resident in their room as part of the initial screening process of the recertification survey. The resident was awake, alert, and oriented and denied any discomfort at that time. On 2/05/26 at 3:05 PM a review of the resident's medication records revealed an entry for the administration of an as needed (PRN) dose of narcotic pain medication (oxycodone) on 2/05/26 at 8:49 AM, which had a corresponding pain level documented as NA, that was administered by Certified Medicine Aide (Staff #14). Further review revealed additional entries for PRN oxycodone doses documented as given on 2/02/26 at 8:49 AM, on 2/03/26 at 8:57 AM, and on 2/04/26 at 8:50 AM by Staff #14, and each of those corresponding pain scores was documented as NA. On 2/06/26 at 10:17 AM an interview was conducted with Staff #14, and Licensed Practical Nurse (Staff #13) to review the facility's process for resident pain assessments and administration of PRN pain medications. Staff #13 explained that a nurse would assess the resident, attempt to provide non-pharmacological interventions (NPI), and then if still needed, would administer the ordered pain medication and document the resident's location and level of pain, and then follow up to document whether the medication was effective or not. He further explained that this was accomplished through documentation in the electronic medication administration record (eMAR) portion of the facility's electronic medical record, that an entry on the eMAR automatically created a progress note of the entry. Staff #14 added that because she was not a nurse, she was not able to assess resident's pain, but she was able to administer PRN pain medications once the nurse had assessed the resident's need. She explained that as a Certified Medicine Aide (CMA) she had to enter NA as the pain score on the eMAR, but that the nurse was then required to enter the resident's pain score in the same screen. Staff #13 added that the software required the nurse to enter the information before any additional medication administrations were able to be documented for that resident. On 2/06/26 at 10:30 AM an interview with the Director of Nursing (DON) was conducted. Resident #19's eMAR was reviewed and the DON said that there was no evidence that the nurse who worked on 2/05/26, Staff #4, assessed the resident for pain, or attempted NPI prior to medication administration. The DON reviewed the eMAR entries for 2/02/26, 2/03/26, and 2/04/26 and confirmed the deficiency that there was no evidence that the resident's pain was assessed prior to the PRN administration of oxycodone on those days. No additional evidence was provided by the end of the survey.

Based on record reviews and interviews, it was determined that the facility failed to ensure the provider had a response and rationale to a medication regimen review recommendation and/or identified irregularity and that the response was documented in the resident's permanent medical record. This was evident for 2 (Resident #48, #3) of 6 residents reviewed for unnecessary medications. The findings include:1) Resident #48 was admitted to the facility in November 2025 after a hospitalization which included treatment in intensive care. The resident's diagnoses included but were not limited to, type 2 diabetes, heart failure, and malignant neuroendocrine tumors. On 2/02/26 at 12:13 PM an interview with Resident #48 was conducted in the resident's room. The resident was alert and oriented and described in detail their complicated medical history and recent treatment at a tertiary hospital where they were so sick they needed a ventilator. They also detailed their medication orders which they described as a complicated regimen with doses of insulin that were unusual. The resident stated that when they were admitted to the facility, they were concerned that their hospital discharge medication orders were altered by the facility provider because they were so unusual. A review of Resident #48's medical record on 2/04/26 revealed a progress that the pharmacist had reviewed the resident's medication regimen and made recommendations, but it indicated to see the report which was not found in the resident's record. On 2/04/26 at 1:10 PM an interview was conducted with the Director of Nursing (DON) who provided copies of pharmacy recommendations for Resident #48. The pharmacy report dated 11/30/26 described the pharmacist's review of insulin and fingerstick glucose testing orders and suggested the provider assess the need for adjustments and consider an endocrine consult. At the bottom of the form was a handwritten notation that said No response required. The notation was unsigned and undated. The DON confirmed that this notation was not evidence of a physician review, response, or rationale of the pharmacy recommendation. On 2/06/26 at 1:52 PM an interview was conducted with the Nursing Home Administrator (NHA) to review that the physician response to Resident #48's pharmacy recommendation was non-compliant. She acknowledged that the facility was cited previously for this same deficiency. The NHA said that the former DON did audits after the last recertification survey, but she acknowledged the current deficient practice found on this survey. 2) Resident #3 had been residing in the facility since early 2024. A review of the resident's medical records on 2/4/26 at 8:56 AM, revealed progress notes from the consultant pharmacist that indicated medication regimen reviews (MRR) were conducted for the past 6 months in 2025 (December to June in descending order). All notes indicated that the review was done with no irregularities identified. However, no other documentation was found to indicate an MRR was conducted in the other months of 2025 or January 2026. The Director of Nursing (DON) was interviewed on 2/4/26 at 10:24 AM. During the interview, the DON explained the process for MRR and reported that the consultant pharmacist sends her, Regional Director, Nursing Home Administrator (NHA), and the [NAME] President of Nursing, the monthly reports of identified irregularities and/or recommendations with MRR. Then she prints it out for the provider to write their response on the report. Once completed by the provider and orders are implemented, she makes a copy of the report. One copy is provided to medical records for them to scan and uploaded to the resident's chart, then the other is faxed back to the pharmacist (so they know it was addressed) and kept in a binder with the DON. The finding was discussed with the DON on 2/4/26 at 10:33 AM. The DON reported that the consultant pharmacist usually does the MRR towards the end of each month and the reports are usually sent about a week after, indicating that she had not received MRR's for January 2026 yet. She also reported that she would review Resident #3's medical records and her binder to see MRR notes or reports from January 2025 to May 2025 and report back to the surveyor. On 2/4/25 at 1:07 PM, the DON provided printed copies of the progress notes by the consultant pharmacist from January 2025 through May 2025. The 2/23/25 MRR text read, See report for comment. The DON was asked to provide a copy of the report. On 2/4/26 at 1:23 PM, further review of Resident #3's medical record failed to show provider response to the identified irregularity and/or recommendation from the 2/23/25 MRR. On 2/4/26 at 1:50 PM, the NHA provided the surveyor with a copy of the MRR report for 2/23/25. The report had a provider signature, however there was no date to indicate when it was signed. Furthermore, the top part of the document indicated that it was faxed to the facility, dated 2/4/26 at 1:32 PM. The NHA reported that the report was signed on 3/6/25 when the provider came to the facility to see Resident #3. In a subsequent interview with the DON on 2/4/26 at 2:42 PM, she confirmed that she was responsible for ensuring MRR reports are provided to the providers for their response. The DON was also asked if she could verify that the 2/23/25 MRR report was signed by the provider on 3/6/25. She answered, No. The DON showed the surveyor the email dated 2/25/25, that she received from the consultant pharmacist containing the report. However, there was no credible evidence to show when the provider responded to the report and the DON confirmed that the report was faxed to the facility as indicated on the date on the top part of the document. The concern was discussed with the DON that provider response to MRR's need to be part of the resident's medical record. The DON acknowledged the concern. Further review of Resident #3's medical record on 2/4/26 at 3:02 PM, revealed a progress note by a medical provider (different from the medical provider named in the 2/23/25 MRR report) that indicated the resident was seen in the facility with no mention of addressing the MRR recommendation. A review of the facility's policy for MRR was conducted on 2/4/26 at 3:04 PM. the review revealed item #10 that read, Copies of drug/medication regimen review reports, including physician response, will be maintained as part of the permanent medical record.

Based on interview and record review it was determined that the facility failed to administer medications timely. This was evident for 1 (Resident #48) of 1 resident reviewed for insulin. The findings include:Resident #48 was admitted to the facility in November 2025 following an acute hospitalization that included care in an intensive care unit. Their diagnoses included, but were not limited to, type 2 Diabetes Mellitus, heart failure, and malignant neuroendocrine tumors. A review of their medical record revealed that they required multiple medications, which included significant doses of insulin before meals, and as needed at bedtime.On 2/02/26 at 11:23 AM an interview was conducted with Resident #48 in their room. The resident was alert, oriented, and able to describe their medical needs, including their medication regimen, in detail. On 2/04/26 at 11:42 AM an observation and interview were conducted with Resident #48 in their room. The resident stated that they had just received all of their morning medications together, which included insulin but was supposed to have been administered before breakfast. When asked if the resident had eaten breakfast yet, they replied no, and said their habit was to sleep until around 11:00 AM but that they still usually received their morning medications, including insulin, at around 8:00 AM, as long as their blood glucose level was not too low.On 2/04/26 at 12:22 PM a review of Resident #48's medical record revealed that the morning medications were signed as given on the electronic Medication Administration Record (eMAR) by Registered Nurse (Staff #6). The actual administration times were not listed on the eMAR.On 2/04/26 at 1:10 PM an interview was conducted with the Director of Nursing (DON) regarding the resident's statement that their morning medications and fingerstick glucose check were given and done at approximately 11:30 AM today even though some of the medications were scheduled to be given as early as 7:30 AM. She was asked to provide a medication audit record to show the actual time of administration for the resident's morning medications. When asked if she was familiar with this resident's particular habits, the DON said sometimes the resident awakened briefly, agreed to have their fingerstick glucose test done and take their medications and then fell back to sleep and would not remember it. On 2/04/26 at 2:42 PM a review of the medication audit for Resident #48's medications administered that morning was conducted with the DON. The report indicated that there were medications scheduled for 7:30 AM, 8:00 AM, and 9:00 AM, but they were signed as given at 11:37 AM by Staff #6. The DON was asked what was considered a timely medication administration and she said within one hour before or one hour after the medication was scheduled. The DON confirmed that the medications were given late and that this was a deficiency. She offered no explanation.

Based on observation and staff interviews, the facility failed to ensure that 1) staff performed hand hygiene during 8 of 8 breakfast observations and 2) failed to perform hand hygiene during 2 (R#37 and R#55) of 3 medication administration observations, and 3) failed to maintain a sanitary medication storage environment in 1 of 2 medication storage rooms observed.The findings include:1) On 02/01/2026 at 8:17 AM, the surveyor observed Staff #5, a Geriatric Nursing Assistant, and Staff #7, a Licensed Practical Nurse, delivered meal trays to resident rooms 406, 409, 410, 411, 412, 414, 415, and 416 on the 400 hall. Staff #5 and Staff #7 exited 8 of 8 resident rooms without performing hand hygiene before entry or after exit.No alcohol-based hand sanitizer was observed on the meal cart. The surveyor observed three wall-mounted hand hygiene dispensers in the 400 hallway and one dispenser inside each resident room.2) On 02/04/2026 at 8:35 AM, during medication administration observation on the 500 hall, the surveyor observed Staff #6, a Registered Nurse, fail to perform hand hygiene before and after administering medications to R#37. Staff #6 also failed to perform hand hygiene prior to administering medications to R#55.3) On 02/04/2026 at 10:45 AM, Staff #4, a Registered Nurse, provided the surveyor access to two medication storage areas located behind the nursing station. Upon entering the medication storage area containing the Omni-Cell for resident medication storage, the surveyor observed disposable gloves, paper towels, sugar packets, and flip-top medication caps littered on the floor. The floor was visibly soiled.The handwashing sink basin in the medication storage area was filled with packaging and wrapping debris and was not accessible for use.Staff #4 notified Staff #9, the Assistant Director of Nursing and facility Infection Preventionist. Staff #9 arrived and conducted a dual observation with the surveyor and Staff #4, validating the surveyor's concerns regarding the conditions of the medication storage area.On 02/04/2026 at 12:10 PM, Staff #9 stated that hand hygiene audits are conducted. However, Staff #9 was unable to provide documentation of completed hand hygiene audits, the audit frequency, or evidence of staff education or reinforcement related to hand hygiene practices. On 02/04/2026 at 1:15 PM, these findings were reviewed with the Nursing Home Administrator and Director of Nursing.On 02/06/2026 at 2:30 PM, no additional evidence was provided to the surveyor prior to the conclusion of the survey.

Based on interview and record review it was determined that the facility failed to offer COVID-19 vaccinations to staff and residents and failed to educate staff and residents regarding the COVID-19 vaccination. This was evident for 7 (Staff #6, #11, #12, #16, #17, #18, #19) of 7 staff members, and 4 (Resident #2, #8, #48, and #51) of 5 residents, reviewed for vaccinations during the infection control task during the recertification survey. The findings include:On 2/05/26 at 8:31 AM an interview was conducted with a Registered Nurse (RN) who was the facility's infection preventionist (Staff #1). She was asked about the facility's process for offering information regarding COVID-19 vaccinations to staff and residents. She explained that the new admission packet for residents included education sheets for COVID-19 vaccinations and that the education sheet had a place to indicate consent for the vaccine. She further explained that each year the facility's pharmacy let her know what vaccines were available and then she ordered what was needed and offered and gave vaccines to current residents who consented.She went on to explain that although the facility held a flu clinic each year for staff, they did not do this for the COVID-19 vaccine even though the vaccine was available. She said she did not currently have any evidence that staff had been educated about or had been offered the COVID-19 vaccine.On 2/05/26 a review of immunization records for Resident #2, #8, #48, and #51 failed to reveal any documented evidence that they had been educated about the COVID-19 vaccine or been offered the COVID-19 vaccine.On 2/06/26 at 11:17 AM a review of immunizations records was conducted for Staff ##6, #11, #12, #16, #17, #18, and #19, and there was no evidence that they had been educated about or offered the COVID-19 vaccine.On 2/05/26 at 11:11 AM in an interview with the Nursing Home Administrator, she acknowledged that there was no evidence that the COVID-19 vaccine was offered to staff or residents. No further evidence was provided by the end of the survey.

Based on observation and resident interview, the facility failed to ensure the call bell system was accessible. This was evident for 1 (Resident #45) of 1 residents reviewed during the annual recertification survey. The findings include: 02/01/2026 at 8:05 AM, the surveyor observed R#45 in room [ROOM NUMBER] with the call bell cord partially disconnected from the wall outlet and out of reach while R#45 was positioned near the edge of the bed, asking for assistance.R#45 stated to the surveyor that delayed staff response to call light activation was not unusual and reported waiting up to one hour for staff to respond.The surveyor reconnected the call bell and instructed R#45 to activate the adaptive pendant-shaped call button. The call signal was activated; however, after approximately eight (8) minutes, no staff responded.The surveyor assisted R#45 back into bed and ensured the call bell was placed within reach.On 02/03/2026 at 1:15 PM, these findings were reviewed with the Nursing Home Administrator and Director of Nursing.

Based on record review and interview it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNA) received required training. This was evident for 2 (Staff #11, #12) of 2 agency GNAs reviewed for training requirements during the recertification survey. The findings include:On 2/01/26 at 8:25 AM an interview was conducted with the Nursing Home Administrator (NHA) as part of the entrance conference for the annual survey. When asked about the percentage of agency staff the facility used, she said approximately 80%.On 2/03/26 at 5:31 PM an interview was conducted with the facility's staffing scheduler, (Staff #20). When asked what percentage of scheduled GNAs were from an agency, she replied about 80%.On 2/04/26 at 9:30 AM an interview was conducted with the facility's Human Resources Director, Staff #21 to ask about staff training. She said she was responsible for staff training but only for facility hired staff, and she explained the process for orientation and monthly training. When asked specifically about agency staff training, Staff #21 explained that she did not do anything for any agency staff - not even monthly training and added that she was not involved in any way with agency staff.On 2/04/26 the NHA was asked about agency staff training records and she said that she had access to the agency's portal where the license and training information was located. She was asked to provide evidence of training for Staff #11 and Staff #12, and she said she would print out what she could from the portal.On 2/06/26 at 11:17 AM the NHA provided information for Staff #11 and Staff #12. A review of the documents failed to reveal any evidence of training for Staff #12, and Staff #11 had a packet of training information, but it did not specify who the instructor was, the length of time for the training, or whether Staff #11 passed any test or was graded on the content. The NHA was asked if she could provide any additional information and she said she would call the agency representative to see if they could give any further information. No additional evidence was provided by the end of the survey.

Based on record review and staff interview, it was determined that the facility failed to report an alleged violation involving abuse. This was evident for 1 (R#88) of 1 residents reviewed during the annual recertification survey. The findings include: On 02/03/2026 at 9:22 AM, Intake #2697168 dated 12/19/2025 was reviewed for R#88. The intake was a complaint filed with OHCQ by Adult Protective Services on behalf of the resident's family. It was determined that R#88 was no longer at the facility and had discharged on 01/09/2026. On 02/03/2026 at 9:35 AM, the summary included with intake described R#88's family reporting visiting R#88 at the facility to often find him in a saturated and wet brief or soiled.On 02/03/2026 at 10:10 AM, the facility's grievance logs were reviewed for the previous 12 months, and it was revealed that on 12/08/2025, Staff #8 documented R#88's family reported the resident was left sitting in a very wet brief. The documentation indicated staff delayed care due to the residents' agitation. The record showed internal review and referral to psychiatric services. There was no evidence that this allegation of neglect was reported to OHCQ.Further review of grievance documentation revealed a grievance dated 09/31/2025 in which a facility GNA was reported to have raised a fist toward a resident and stated, Don't tell me what to do. I know how to do my job. There was no evidence this allegation of staff mistreatment was reported to OHCQ.On 02/04/2026 at 3:09 PM, the Nursing Home Administrator stated that allegations of abuse and neglect are reportable. When asked why the above grievances were not reported as Facility Reported Incidents, the NHA was unable to provide a rationale and confirmed to the surveyor that the policy that was provided is the facility's use of a templated policy that is not facility-specific.On 02/06/2026 at 2:30 PM, no additional evidence was provided to the surveyor prior to the conclusion of the survey.

Based on record review and interviews with the resident and staff it was determined the facility staff failed to ensure the doors to the facility laundry room and the mechanical/boiler room were locked when unattended by staff, to prevent unauthorized access by residents and others. This was evident for 1 (Resident #1) of 1 resident reviewed for accident hazards during the complaint survey. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this complaint survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of [DATE].The findings include:The facility's investigation of Facility Reported Incident #2678525 was reviewed on [DATE] at 9:35 AM. The report revealed that on [DATE] at approximately 9:00 PM, Staff #1 a GNA (Geriatric Nursing Assistant) was unable to locate Resident #1 while preparing to assist him/her with evening care. After a preliminary attempt to locate the resident failed, the nursing supervisor was notified, and staff began a search of the facility. A written statement from Staff #2 a GNA, revealed that during the search at approximately 9:30 PM, She looked in the laundry room while calling out for the resident. She heard the resident respond from the mechanical/boiler room located behind the laundry room. Staff #2 opened the boiler room door and found Resident #1 sitting on the floor approximately 2 feet away from his/her wheelchair. Resident #1 was assessed by the nurse and found to have a skin tear/laceration on the left shin and a bruise on the left forearm and right elbow; s/he was otherwise unharmed. The resident could not recall how s/he got into the mechanical room and indicated that s/he was looking for his/her (deceased ) spouse.Resident #1's medical record was reviewed on [DATE] at 9:45 AM. The record revealed that Resident #1 was [AGE] years old with diagnoses which included but were not limited to Adjustment Disorder with mixed anxiety and depressed mood, Cognitive Communication Deficit, Delusional Disorders and Alzheimer's Disease with late onset.Resident #1 utilized a wheelchair for mobility and used his/her legs to propel him/herself around the unit.Resident #1 had a Plan of Care developed on [DATE] for elopement risk/wandering/related to disorientation to place, history of attempts to leave the facility unattended and impaired safety.An elopement assessment completed on [DATE] revealed Resident #1's score was 12 indicating s/he was high risk for elopement. A BIMS (Brief Interview for Mental Status) is used to assess cognitive function. A score of 0-7 = severely impaired, 8-12 = moderately impaired and 13-15 = intact. The record revealed Resident #1's BIMS score on [DATE] was 4/15 = severely impaired. An interview was conducted with Resident #1 on [DATE] at 3:25 PM. The resident was pleasant, friendly and sociable. However, s/he could not recall the incident on [DATE] and indicated that his/her memory was not very good. When asked why s/he had a bandage on his/her left lower leg Resident #1 stated, I got a really bad scratch one day about a month ago when I was riding my motorcycle. The surveyor conducted an interview and observed the laundry and mechanical rooms with Staff #3, the Maintenance Director on [DATE] 9:32 AM. The two hallway doors to the laundry room (clean side and dirty side) automatically locked when shut and required a keypad code to unlock.A door to the mechanical/boiler room was located on the back wall inside the clean area of the laundry room. This door had a locking lever type handle. The door required a key to open it from the laundry room side. A push and turn button mechanism was located on the handle on the boiler room side of the door. The door was found to be locked during the observation. Staff #3 confirmed that the door did not automatically lock. Within the mechanical/boiler room was an outside exit door. This door could be exited without a key by pushing on the crash bar and required a key to enter the boiler room from outside. Staff #3 indicated that he was contacted on the evening of [DATE] and immediately came to the facility when notified of the above incident. He inspected the laundry room door locks at that time and found them to be in good working order, and the mechanical room was locked. He indicated that due to lack of evidence of a mechanical malfunction he concluded that staff must have propped the doors open. He indicated that he immediately provided on the spot verbal education to all staff working on the evening of [DATE], on not propping any doors open due to risk of residents wandering into unauthorized potentially dangerous areas.Staff #3 explained to the surveyor that the laundry room doors are weighted and will close if they are not held open. The locks engage automatically when the door closes. This was verified by the surveyor during the observation.Staff #3 added that after this incident he inspected the doors, the locks and hinges and could not find any malfunction but, as an additional precaution, new keypad locks were purchased and installed on the laundry room hallway doors. Additional staff education was completed on [DATE].The maintenance department conducted audits of the mag lock doors, including the laundry room doors, weekly on [DATE], [DATE], and [DATE]. The incident was referred to the Quality Assurance Performance Improvement Committee for further review.The laundry room doors were observed by the surveyor closed and securely locked on [DATE] at 9:00 AM, 11:25 AM, 1:52 PM, 2:30 PM, on [DATE] at 8:30 AM 9:35 AM, and on [DATE] at 8:00 AM and 9:37 AM. During an interview on [DATE] at 10:25 AM Staff #1 confirmed she was the GNA caring for Resident #1 on the evening of [DATE]. She indicated that another GNA, #2 found Resident #1 in the boiler room during the facility search. When asked if either of the laundry room doors were ajar or propped open that evening, she stated No, the laundry room is always locked. When asked if she ever found the doors propped or unlocked she stated No, we always keep it locked. The facility corrected the deficient practice by [DATE] prior to the start of the complaint survey. F 689 cited as past non-compliant S/S: J.

Based on interviews and record review it was determined that the facility failed to 1.) provide sufficient supervision, prevent an avoidable accident, follow appropriate safety procedures and to utilize the use of two staff persons and 2) provide an appropriate mattress and bed to prevent a fall. This was evident for 2 residents (R10 and R23) of 4 residents reviewed who required a bariatric bed and mattress. The deficient practice resulted in harm to both R10 and R23. The facility implemented effective and thorough corrective measures following the incidents and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance. Findings Include: Record review of the facility undated policy titled Safe lifting and movement of Residents documented, the Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding safe lifting and moving of Residents. Safe lifting and movement of Residents is part of an overall facility health and safety program, which involves employees identifying problem areas and implementing workplace safety and injury prevention strategies. 1. Record review of R10's face sheet (a document containing Resident information and data) revealed R10's showed his/her original admission date was 05/28/2022. His/Her diagnoses included Cerebral Infarction, Chronic Systolic Congestive Heart failure with shortness of breath and presence of Heart Valve Replacement Cardiomegaly. Record review of R10's physician order, which was dated 4/7/2024, documented R10 required a bariatric pressure reducing mattress. Record review of R10's quarterly, Minimum Data Set assessment (MDS) dated [DATE], documented in section GG of the MDS that R10 was impaired on both sides of the upper extremities. R10 required maximum assistance with personal hygiene. Record review of R10's discharge/return anticipated, Minimum Data Set assessment (MDS) dated [DATE], documented in section GG of the MDS, R10 was dependent on staff with personal hygiene and required substantial maximum assistance from lying to sitting on the side of the bed. Record review of R10's significant change Minimum Data Set assessment (MDS) dated [DATE], revealed R10 had a BIMS score of 14, indicating R10 was cognitively intact. Record review of R10's progress Notes dated 08/19/2024 at 07:59 AM, revealed Registered Nurse (RN) 4 documented R10 had a witnessed fall in which they rolled out of bed during incontinent care. R10 slid and landed on his/her knees. R10 reported difficulty moving his/her lower extremities due to a pain level of 10 out of 10. R10's physician was made aware. The Physician gave orders to transfer R10 to the emergency department for evaluation and treatment. R10's Resident Representative was made aware of the incident and the hospital transfer. Record review of R10's hospital Discharge summary dated [DATE] revealed that R10 was admitted on [DATE] and was discharged on 8/26/2024. The discharge summary documented R10 sustained closed fractures of both femurs and fractured his/her tibia and fibula on his/her left leg. Record review of R10's care plan, last revised on 9/20/2024, documented R10 was bed bound due to fractures to legs, and the care plan directed staff to provide in room activity. The care plan further documented R10 had a communication problem due to a hearing deficit on the left ear which was worse than the right ear and instructed staff to allow adequate time to respond, to repeat as necessary, not to rush R10, and to request clarification from R10 to ensure understanding. The care plan directed staff to face R10 when speaking and to make eye contact. Record review of the facility bed audit dated 9/20/2024 revealed the Central Supply Director (CSD), CSD 5, documented her audit results and wrote that R10's bariatric mattress was too big for the frame. CSD 5 further documented that R10 had a new bariatric bed in the past with the correct frame and correct bariatric mattress. CSD 5 further documented that at some point the bed stopped working and staff switched to a smaller bed frame. CSD 5 concluded she was not aware when the last bed audit took place. During an interview on 10/16/2025 at 10:39 AM, the Assistant Director of Nursing (ADON), ADON 2, revealed R10 had a fall while an aide was providing incontinent care. R10 rolled out of his/her bed. ADON 2 stated she did not complete an incident report and concluded she should have completed an incident report. During an interview on 10/16/2025 at 11:42 AM, the Admissions Director (AD), AD 6, revealed the facility had Residents who required bariatric beds. AD 6 explained that part of her job duties included visiting Residents at the hospital prior to admission to determine if the Resident would require a bariatric mattress and submit the Resident information to the admission team to prepare for the Residents arrival. During an interview on 10/16/2025 at 11:58 AM, CSD 5 stated she oversaw the Medical Records and Central Supply departments. She stated R10 fell out of bed, fractured his/her legs, and was sent to the hospital. Facility staff asked the Resident to roll over during care and R10 landed on the floor. CSD 5 stated it was not the R10's fault. CSD 5 further explained facility staff did not adjust R10's bed frame to fit the size of the bariatric mattress and concluded the mattress was too big for the frame. During an interview on 10/17/2025 at 8:41 AM, the Director of Nursing (DON), DON 1 stated R10 was a maximum assist which meant at least two staff should have been present while staff provided care and concluded it was the responsibility for all staff to make sure R10's mattress fit the bed frame correctly. DON 1 stated that the accident was avoidable. During an interview with the Nursing Home Administrator (NHA), NHA 3, on 10/17/2025 at 8:50 AM, NHA 3 revealed staff should have avoided the accident. She stated that the Medical Records department did service staff after the accident. During an interview on 10/17/2025 at 9:45 AM, the former DON, RN 8, revealed a GNA from a temporal agency instructed R10 to roll over during care. R10 landed on the floor and sustained multiple fractures. The DON explained, R10's bedframe was too small for the size of the mattress. She stated R10 was a two person assist with transfers and explained for bed mobility one person was sufficient. RN 8 further explained the accident was avoidable and added that staff did not place the correct bed frame in place which caused R10 to roll over the unguarded mattress. RN 8 further explained that part of the challenges the facility faced at the time of her employment was low staffing levels. She concluded the facility was allowed to use a few agency staff, and the facility did not accommodate her staffing requests. 2. Record review of R23's face sheet showed his/her original admission was dated 09/16/2024 with diagnoses that included chronic respiratory failure with hypoxia, hyperlipidemia, morbid obesity, and muscle weakness. R23's admission Minimum Data Set (MDS) dated [DATE] indicated R23's Brief Interview for Mental Status (BIMS) score was 15/15 which indicates the residents' cognition was intact. R23's functional limitation in range of motion had no impairment on the upper extremity and impairment on one side of the lower extremity. MDS revealed the residents required substantial/maximal assistance with toileting and personal hygiene, required substantial/maximal assistance with roll left and right, needed partial/moderate assistance with sit to lying, partial/moderate assistance with lying to sitting, partial/moderate assistance with sit to stand, substantial/maximal assistance with chair/bed to chair transfer. The care plan initiated 10/31/2024 documented the resident was at high risk for falls due to history of falls, activity intolerance, Shortness of Breath (SOB) with exertion and glaucoma. The care plan directed the staff to anticipate and meet the residents' needs and to be sure the residents' call light is within reach. Review of the Admit Notice dated 09/16/2024 revealed the residents' mattress requirements as requiring the bed extended and a slightly larger mattress. It documented that R23 was tall (6'0) and his/her weight was 290pounds(lbs.). Review of R23's weight revealed the following weights. 09/16/2024-295lbs 09/25/2024-298lbs 10/07/2024-320lbs Record review of R23 nurse's note dated 01/04/2025 revealed that Licensed Practical Nurse (LPN)6 documented R23 was observed lying on the floor beside the bed on his/her back with both legs extended and bed mattress over him/her. Oxygen (O2) on at 2Litres(L)/Min. R23 complained of back pain. It documented LPN#6 was unable to move R23 from the floor. LPN#6 Called 911 to help get the resident off the floor. The resident was sent to the emergency room (ER) for further evaluation. Review of the facility report dated 01/04/2025 revealed that R23 reported that s/he turned over (in bed) and landed on the floor and his/her back hurts. LPN#6, the nurse overseeing resident care on 1/3/2025-1/4/2025 at 11pm-7am shift, reported that R23 was lying on the floor beside his/her bed on his/her back with both legs extended and his/her mattress over him/her. The resident was experiencing back pain. The report further documented R23 was not moved from his/her position. The vitals were taken, and neuro checks were performed. Medical Doctor (MD)10 was notified and gave orders to send R23 to the Emergency Department (ED) for evaluation and treatment. A call was placed to 911 and R23 was sent to the hospital's ED for evaluation and treatment. The report revealed that R23 had an X-ray performed at the hospital which showed acute mildly displaced fractures of the right transverse processes at L1, L2 and L3 vertebrae. The report further revealed at the hospital R23 was on a pain management regiment, had neurosurgery consult with no intervention from their end, the resident worked with Physical Therapist (PT)/Occupational Therapist (OT) who recommended skilled nursing facility placement, the pain was improved with time, and R23 was deemed stable for discharge from the hospital. The corrective action taken by the facility was that R23 was previously on a standard mattress with no previous falls from bed. The intervention added after the fall R23 was placed on a bariatric mattress upon return from hospital. Record review of the hospital Computed Tomography (CT) scan dated 01/04/2025 documented R23 had acute mildly displaced fractures of the right transverse processes at Ll, L2 and L3 vertebrae. The vertebral body height is maintained. There is a chronic fracture of the left transverse process of L2. There is vacuum disc phenomenon with prominent anterior marginal osteophytes at multiple levels in the lumbar spine. Record review of the Hospital Discharge summary dated [DATE] revealed discharge diagnoses as follows: Acute chronic back pain secondary to Acute mildly displaced fractures right transverse processes L1, L2, and L3 due to fall During an Interview on 10/16/2025 at 11:06 AM, the admission Director (AD6) stated that during R23's admission in September 2024, she sent an email to CSD 5 and the Housekeeping Manager (HM38) indicating the type of mattress that was appropriate for R23. AD#6 reported that she recommended R23 to have a bariatric mattress because of the resident's weight and height which was about 290lbs. During an interview on 10/16/2025 at 11:14 AM, CSD5 stated that before a resident is admitted to the facility, she receives recommendations from AD6 for the type of bed and mattress that a resident requires. CSD5 added that she usually checks the supply room to confirm that the mattress and bed recommended was available. She reported that she did not recall if she was working on the day R23 was admitted to the facility in September 2024. CSD5 stated that the housekeeping department was responsible for setting up the bed and the mattress in the residents' rooms before they were admitted to the facility. She reported that before R23 was admitted to the facility in September 2024, AD6 emailed her and the Housekeeping Manager that the required mattress was a bariatric mattress. CSD5 stated she could not explain the reason the resident was using a regular mattress and bed when s/he fell on [DATE]. She added that the resident should have been on a bariatric mattress and bed because of his/her weight and height. During an interview on 10/16/2025 at 11:21AM, the Housekeeping Manager stated that before R23's admission to the facility in September 2024, she received an email from AD6 that indicated R23 required a bariatric mattress. The Housekeeping Manager stated the resident should have been using a bariatric mattress and bed but not a regular mattress when s/he fell from bed to the floor in January 2025. During an interview on 10/17/2025 at 9:30 AM, LPN #7 stated she did not recall the fall incident because it happened in January 2025, but she recalled that the resident was wide and tall. During an interview on 10/17/2025 at 11:02 AM, the Director of Nursing (DON) stated that before a resident was admitted to the facility, the housekeeping department and central supply department were responsible for making sure they set up an appropriate mattress based on a resident's weight and height. The DON stated that at the time of Resident #23's fall in January of 2025, the resident was using a regular mattress instead of a bariatric mattress. She stated that to prevent a resident from falling off the bed again, AD6 will email the height and weight of a resident to CSD5 and HM38 so they can have a bariatric mattress and bed available upon admission. She further stated the supply department would keep a spreadsheet on what residents are on bariatric mattresses and beds upon admission. During an interview on 10/17/2024 at 11:30 AM, the Administrator stated R23 should have been using a bariatric mattress and bariatric bed to prevent a fall from happening in January 2025. She added that the facility had implemented a plan of action which included AD6 sending an email to CSD5 and HM38 so bariatric beds will be available upon admission of residents to the facility. The Administrator added that the supply department would keep a spreadsheet on what residents are on bariatric beds and they will keep a spreadsheet with admission and discharges.

Based on medical record review and interview with facility staff, it was determined that the facility failed to protect residents after substantiating that GNA staff that restrained a resident (#926) continued to have access to other vulnerable residents. This was evident during the review of 1of 13 incidents involving abuse. The findings include: On July 31, 2024 At 5:10 PM, an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to remove from duty the GNA staff who restrained a resident and continued to have access to other vulnerable residents. A plan to remove the immediacy was accepted on July 31, 2024 at 6:32 PM and abated the following day at 9:30 AM. After the removal of the immediacy, the deficient practice remained at a potential for more than minimal harm with a scope/severity of D for the remaining residents. Review on 7/30/24 at 2:30 PM of the facility reported incident related to a resident being 'secured against the wall ' revealed that per facility investigation and direct observations from other facility staff, Resident #926 was secured against the wall in his/her wheelchair against a table in the sunshine room by facility staff. This resident was unable to independently move him/herself out from the area due to the table being pushed against him/her although s/he normally would be able to move about independently, and at times would use a rolling walker to mobilize around the facility. Resident #926 did have diagnoses including muscle weakness, abnormalities of gait, anxiety disorder and dementia without behavioral disturbances according to the resident's face sheet. Resident #926 was assessed on 3/9/24 to have a brief interview of mental status (BIMS) of 4 meaning that s/he was severely cognitively impaired. Nursing progress notes prior to the incident noted on 3/20/23 that resident is pleasantly confused with various attempts to exit [his/her] wheelchair and walk around. Had to be redirected multiple times .will continue to monitor. Progress notes also stated that s/he was unable to walk 150 feet due to medical condition and safety concerns. However, Resident #926 was actively participating in physical therapy and was documented at a care plan meeting, held a week prior on 3/15/23, as able to walk with supervision 150 feet with a rolling walker for balance support, with the plan for discharge to an assisted living facility. According to a progress note at 12:38 PM on 3/26/23, Resident #926 was noted to be ' non-compliant with his/her walker/wheelchair. S/he was documented as not having a steady gait and shuffles when s/he walks. Staff will assist him/her back to their wheelchair for safety and s/he was also documented as not easily redirected. ' The facility reported incident was documented as occurring around 2PM on 3/26/23. This report noted that facility staff found Resident #926 restrained against the wall with a table pushed up against the resident in their wheelchair. On 3/26/23, a ' mood/behavior ' progress note was completed. The resident was documented as walking around hallways and stated to the nurse s/he felt nervous was documented as visibly shaking, and fast paced breathing. This note was written 2 hours after the documented restraint report. The facility nurse practitioner ordered a one-time dose of Buspar, an anxiolytic, as no other interventions such as redirection were working for the noted anxious behavior and anxiety. Prior to this documented incident, Resident #926 had no documented ' mood/behavior ' incidents and did not require any as needed anxiolytics. Interview with staff #8 on 7/30/24 at 2:30 PM, revealed that she observed the incident and immediately notified her supervisor. This supervisor, staff #9, was then interviewed on 7/30/24 at 2:45 PM and confirmed that she too saw the incident and reported it to either the DON or the Administrator, she could not recall who specifically at the time of the interview. She stated that she knows she reported it immediately to nursing as she was not in the nursing department to intervene, but knew it was a concern. Interview with the facility ADON on 7/31/24 at 2:14 PM regarding a substantiated incident of restraining a resident would make the employee a ' DNR ' (do not return). According to the facility reported incident, they noted that 2 staff members had secured the resident in a way that s/he could not move, the resident did not have enough room between the their wheelchair the table and the wall to be able to push the wheelchair back to stand up or propel his/her wheelchair away from the table. Interview with the facility human resources director (HRD) on 7/31/24 at 2:20 PM regarding GNA staff #14 revealed that, for this employee, she was rehired in December of 2023. The HRD had asked the Administrator if there were any concerns as she was not here during staff #14's previous employment. The HRD reported to this surveyor that there were no reported concerns, and if there were, the employee would not have been rehired. The facility reported incident from 3/26/23 was reviewed. The HRD reported that the GNA staff #14 should have been an immediate DNR. During an interview with the Administrator on 7/31/24 at 2:35 PM regarding the incident, it was revealed that staff #14 was rehired. She stated that she didn't know her history and that the previous DON was the one that would have handled any disciplinary action and if it was not in the employee's file, they would not have known about it. The Administrator was notified at this time that there was nothing in the employees file and that she herself was here at the time of the incident and approved for the employee to be rehired in December. Review of the assignment sheets and schedules for the February-July 2024 time frame revealed that employee #14 is continuing to work the 7-3 shift. It was also noted on the assignment sheets that she is responsible for showers. This was also noted that those responsible for showers are responsible for dining in the 'sunshine room' and she worked as recently as the day prior on 7/30/24. The incident that occurred on 3/26/23 was in the sunshine room when Resident #926 was found secured against the wall. Surveyor interviewed the DON, NHA and RDCO on 7/31/24 at 5:10 PM regarding the second employee involved as they could not locate an employee file with any information in it relevant to this incident. The DON stated that she contacted payroll and was able to locate the agency that was used. The DON then reported that, sometime after this incident GNA staff #15 was made a ' DNR. ' GNA #15's punch card was reviewed at this time showing that she worked until at least 4/6/23, a week after the restraint incident with Resident #926. The concern was raised that this incident did not cause a DNR, however, there was another incident soon after the initial incident that caused the DNR and nothing was documented in the employee file. The DON and NHA were asked if they knew what caused the second DNR situation and the DON stated you have to ask the NHA, as she was not the DON at the time. The NHA was asked, and she did not know. The HRD was asked on 8/1/24 if they had the documentation as to why GNA #14 initially left the facility in 2023, as per the review completed on 7/31/24 there was no documentation. She stated that she had to contact the corporate office for that information. A secure email was received later on 8/1/24 regarding the requested information for GNA staff #14. The paperwork showed that she was terminated on 6/27/2023, that she quit without notice and then was able to return to the facility 6 months later with a pay raise. A plan to remove the immediacy was provided to the survey team on 8/10/24 at 6:09 PM and 6:12 PM and finally a removal plan was accepted at 6:32 PM. This plan included an audit of all current residents to ensure that they were not inappropriately restrained, education to the facility Executive Director and Director of Nursing on ensuring that any employee identified as a perpetrator in any alleged abuse report was immediately suspended pending investigation, which would then be documented in their employee file and the Quality Assurance and Performance Improvement (QAPI) committee would continue to meet to identify root causes of restraint of residents and why employee files were not updated with disciplinary actions.

Based on observation, record review, and interview, it was determined that the facility failed to recognize and address changes in the condition of residents. This was evident for 2 of 14 residents reviewed for hospitalization s and quality of care. (#127 and #921) This failure resulted in an immediate jeopardy. The findings include: 1.On 7/23/24, upon entry to the facility, Resident #127 was observed sitting in a wheelchair in a common area near the nurses' station. A medical record review on 7/25/24 at 9:08 AM revealed that the resident had returned from the hospital 7/19/2024. Review of the orders revealed that, on 7/19/24, the resident was ordered a Hospice evaluation (end-of-life care) and Morphine 0.25 mg by mouth every 3 hours for pain. Review of the progress notes revealed that, on 7/19/24 at 5:13 PM, a pharmacy alert was sent stating, This order is outside of the recommended dose or frequency. Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) *Controlled Drug* Give 0.25 MG/5 ML by mouth every 3 hours for Pain. However, there was no documentation that staff called the physician to review this alert and clarify the order. Review of the medication administration record for July 2024 revealed the following order: Morphine Sulfate Oral Solution 20MG/5ML Give 0.25ml by mouth every 3 hours for Pain. The morphine was administered to Resident #127 on the following dates and times: 7/21/24- 12am, 6am, 9am, 12pm, 3pm 7/22/24- 9am, 12pm, 3pm, 7/23/24- 12am, 3am, 6am, 12pm, 3pm, 6pm, 9pm 7/24/24- 12am, 3am, 6am, 9am, 12pm, 3pm, 6pm 7/25/24- 12am, 3am, 6am, 9am Further review revealed that Licensed Practical Nurse (LPN) #2 wrote on 7/25/24, that the resident had been started on intravenous fluids (IV), that the patient was nonverbal but responded to touch. There was no other documentation about the resident's decline. There was no documentation that the doctor, family, or Hospice Care was notified of the change. Review of assessments revealed that no change in condition had been documented. Review of meal percentages for intake revealed that the resident had been eating 76% - 100% between 7/19/24 - 7/22/24 to eating 0% - 50% on 7/23/24. Then on 7/24/24 and 7/25/24, the resident was eating 0% - 25%. However, staff failed to notify hospice or the physician about this change and or investigate a possible cause of the change. An interview with LPN #2 revealed the resident was bed bound, and not eating and drinking. For this reason, she had called the resident's family who requested IV fluids, so she called the attending physician to get the order. An interview with the DON on 7/25/24 revealed that she was not aware that the resident was on morphine routinely. The DON was asked where the resident care policies and procedures were located, she reported that she does not have access to the resident care policies and procedures. She stated she knew they were electronic, but had to ask the Administrator to print them for her. An interview with the Administrator and [NAME] President of Clinical Operations (VPCO) on 7/25/24 revealed that staff had an icon on their computer desktop to access the resident care policies and procedures. The VPCO stated she was going to check to make sure they had the icon and provide education. The DON reported that when the employee's desktops were reviewed for the resident care policy icon, it was not present. A follow-up interview with the DON on 7/26/24 revealed that she had reviewed the resident's discharge summary and found that the attending physician [who was the physician who cared for the resident in the hospital] had ordered the morphine as it was entered in the orders. She reported that those orders were verified with the attending physician on the day of admission by the admitting nurse. She stated that, with these findings, she talked to the attending physician, and he stated that the morphine order was supposed to be as needed and not routinely. The DON reported that the morphine order had been changed to as needed versus routinely. An interview with the attending physician on 7/29/24 at 9:54 AM revealed that he had mistakenly put in the Morphine as a routine medication versus as needed. Furthermore, when the admitting nurse confirmed the orders with him, he failed to catch the error. He stated that the pharmacist and nurses should review the orders to check for errors. He reported that an RN or unit manager was supposed to review all new admissions to check orders and clarify them if there was a concern. When informed that a pharmacy alert had been in the progress notes, he stated nursing had not notified him regarding the alert. He stated that when Resident #127 was admitted to the facility, he observed the resident in the dining room with family eating a meal. When staff notified him that the resident was not eating and drinking and the family requested IV fluids, he stated he thought about the resident's medications, but was unsure of the cause of drowsiness. However, he did not further look into this concern, He reported that, if he had been aware of the error in the Morphine order, he would have realized that was causing the resident's drowsiness. When asked how the resident was doing now that the medication was corrected, he stated the resident was sitting up and visiting with family. After surveyor intervention, a subsequent observation on 7/29/24 at 11:35 AM revealed the resident was in a wheelchair, self-propelling in the hallway. The resident was observed interacting with staff. A medical record review revealed on 7/29/24 the morphine order was changed to as needed. On 7/26/24 the resident intake was back to the normal of 76% - 100%. A review of the medical record on 8/1/24 at 11:30 AM revealed a progress note written on 7/31/24 at 3:51 PM that read the resident was being discharged to assisted living. 30428 2. Record review on 7/23/24 at 12:25 PM for Resident #921 revealed that, around 12/8/2022, Resident #921 began complaining of abdominal concerns. Mylanta was ordered at that time. Further review revealed around 1/7/2023 that Resident #921, according to the progress notes, presented as tearful and had complaints of pain in their right lower abdomen. There was noted dimpling and with some hardened areas with pain that had been going on for approximately 2 weeks duration. S/he was also having some loose stools and was given loperamide. On 3/3/23, Resident #921 was having more nausea, vomiting and dizziness and was refusing meals for over 3 days. S/he was noted as pale with cool skin. S/he was ordered Reglan and omeprazole for the nausea and vomiting but unable to always take medications. There was an order at that time to send him/her to the emergency room for evaluation. The resident went and returned that day. Resident #921 was seen on 3/4/22 by the attending for follow up to the hospitalization and nausea and vomiting. There were no new interventions or plans for the resident according to the attending physician's note. He noted that s/he may need a gastrointestinal evaluation if not improved and if symptoms worsened. He was asked on 7/29/24 about the following up of consultations and he acknowledged that this was not completed. On 3/9/23, Resident #921 was seen by the nurse practitioner (NP). Staff were reporting s/he was refusing meals, had weight loss (approximately 30 lbs. at this point over the past few months) was on Reglan, but still had nausea and vomiting and was refusing medications. The intervention order was for a GI consult, however, that was not put into the resident's order set until 3/22/23. Interview with the DON on 7/25/24 at 2:08 PM revealed that the consult was never completed. According to a change in condition completed on 3/21/23, the nurse documented that she reported to the NP that Resident #921 was still complaining over the past few weeks regarding nausea, vomiting, abdominal pain, heartburn, sleeping more often, not wanting to get OOB, refusing medications and refusing meals. The NP ordered a nutritional consult. This was completed on 3/31/23, however, the dietitian still noted that s/he continued with weight loss and more nausea and vomiting. On 4/2/23, Resident #921 was sent to the emergency room for a change in mental status. S/he was placed on a non-rebreather. Within 2 hours of the emergency room admission, the hospitalist notified the family that they needed to admit him/her to hospice as there was nothing further that could be done. The general diagnosis was sepsis, shock and circulatory failure. The resident passed away within 48 hours. The facility medical director was interviewed on 7/29/24 at 10:42 AM regarding this resident. He stated that this was an unfortunate incident. He further stated that if there is an ongoing medical issue he does follow up with the ordered consults. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 7/29/24 at 2:07 PM and an IJ summary tool was provided to the facility at that time. The facility submitted a plan to remove the immediacy on 7/29/24 at 6:57 PM and the facility's written plan to remove the immediacy was accepted on 7/29/24 at 7:10 PM with an alleged date of compliance of 7/30/24. The immediate jeopardy was abated the following day on July 30, 2024 at 9:30 AM. The provisions of the plan to remove the immediacy included the following: Resident #921 no longer resided in the facility. Resident #127 was assessed on 7/29/24 for any changes in condition with updates to the physician if indicated, a medication review was completed and any discrepancies identified were corrected immediately. Current facility residents were assessed starting on 7/29/24 and will be completed on 7/30/24 to identify if there has been a change in condition and that the physician has been notified in a timely manner with appropriate interventions initiated if indicated and that documentation of the change in condition is present in the medical record. Current facility residents with new onset of complaints of pain or injuries of unknown source over the last 30 days were reviewed on 7/29/24 to ensure that results were reviewed timely by the physician and that if indicated, an investigation was started if the facility could not identify the source of the injury present. Current facility residents' medication orders were reviewed with the pharmacy consultant and attending physician to ensure that orders were correct and appropriate for the resident and that any pharmacy alerts had been addressed. Current facility residents' orders for consults over the past 30 days were reviewed to ensure they have been carried out or scheduled as ordered. Facility licensed nurses received education starting on 7/29/24 ( to be completed by 7/30/24) from the Director of Nursing on ensuring that residents are promptly assessed for any change in condition and ensuring that the physician was notified with documentation in the medical record along with implementing interventions in a timely manner, ensuring that physician orders with pharmacy alerts were addressed and the physician notified for changes to orders, if applicable. Staff members who did not receive the required education by 7/30/24 were to be educated prior to beginning their next shift. The facility Medical Director was re-educated on 7/29/24 by the Corporate Medical Director on the roles and responsibility of ensuring that residents are appropriately assessed for a change in condition with appropriate interventions and received follow up as indicated if the condition persists or worsens, that diagnostic tests are reviewed in a timely manner, that residents receive medication reviews according to physician and pharmacy standards and that ordered medications are reviewed with changes made if indicated by the pharmacy. The QAPI committee will continue to meet to identify the root causes, and to initiate improvements to the facility's processes and procedures ensuring that all residents are promptly assess for any changes in condition and ensuring that the physician is notified with appropriate documentation in the medical record along with implementing interventions in a timely manner, ensuring physician orders (especially related to narcotic orders) with pharmacy are addressed and physician notified for changes to the orders if applicable. Ensuring that diagnostic tests are completed and reviewed in a timely manner by the physician. If the diagnostic test reveals an injury of unknown origin the facility must investigate per regulation. Audits will occur weekly x [times] 4 weeks, biweekly x2 months, then monthly x2 months to ensure the facility remains in compliance. On 7/31/24 at 8:00 AM, after validation of the implementation of the facility's plan of removal, which included staff interviews, record reviews and direct observation, it was determined the facility met the minimum standards of compliance to remove the findings of an Immediate Jeopardy on 7/31/24 at 9:30 AM.

Based on record review and interview with facility staff, it was determined that the facility failed to have a process in place to ensure that staff 1.provided care in a manner to ensure residents were not injured. 2. provide safe equipment for residents and 3. provide care in a safe and professional manner. This was evident during the review of 1 (Resident #928) of 5 falls with injury. This deficient practice resulted in harm to resident #9 and resident #928. This was evident for 1 (#9) of 10 residents reviewed for accidents/hazards. The findings include: On 7/23/24 at 9:13 AM, a review of complaint #MD00206718 revealed that Resident #9 had been brought to the Emergency Department (ED) for treatment of a 15-centimeter (cm) leg laceration on the lower right leg. The complainant reported that the facility was unable to tell them what happened to cause the injury. The complainant reported that the resident stated that staff were transferring him/her from their wheelchair to the bed and something caught his/her leg, cutting it open. A review of the facility ' s investigation report, on 7/23/24 at 3:15 PM, revealed that, on 6/14/24 around 11:00 PM, 2 agency geriatric nursing assistants (GNA) #22 and #23 transferred Resident #9 from the wheelchair to the bed. The resident stated his/her leg hurt. When the GNAs took off the resident ' s pants, they found a large laceration that was gaping open with adipose tissue exposed. However, they were unable to say how the laceration occurred. A review of Resident #9 ' s hard chart, on 7/23/24 at 9:47 AM, revealed a history and physical dated 4/21/22, and documented by the attending physician, that stated the resident had come to the facility for rehabilitation after a hospitalization due to a fall. A medical record review, on 7/23/24 at 10:31 AM, revealed that the last attending physician ' s note was dated 6/17/22. On 7/25/24 at 1:41 PM, review of physical therapy notes for the treatment dates of 3/30/24 - 4/26/24 revealed the resident was non-ambulatory and required a mechanical lift for transfers. Further review of the medical record revealed a change in condition documented by LPN #2, for Resident #9, dated 6/14/24, that noted the resident had a deep skin tear. A review of the requested hospital ED visit notes for 6/14/24 on 8/1/24 at 8:35 AM revealed that the resident reported to the ED staff that, during a transfer from his/her wheelchair to the bed, s/he fell and cut his/her leg on the bed. The resident had a 15 cm laceration on the right calf that required 4 internal stitches and 30 external stitches to repair it. Surveyor attempted to interview Resident #9 on 7/23/24 at 9:27 AM, but the resident was unable to recall how s/he injured their leg. An interview on 7/23/24 at 1:00 PM with the Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO) was conducted. The DON reported that after investigating the incident, she thought the resident had caught his/her leg on the two metal pieces that stabilize the footrest on the wheelchair. The DON brought the wheelchair to the interview room for inspection. The top metal piece had a rough area, but the wound was vertical and in a C shape and the metal piece ran horizontally. The DON failed to recognize this as an injury of unknown origin. On 7/23/24 at 2:14 PM, an interview with GNA #22 via a phone call, revealed that she was not assigned to Resident #9 that day. GNA #22 reported she was asked by GNA #23 to assist her with transferring the resident from the chair to the bed. She stated that both of them transferred the resident by standing on each side of the resident and pivoting the resident into the bed. GNA #22 reported that the transfer was fine but then the resident stated his/her leg hurt and when they looked, they found the laceration. The surveyor attempted to interview GNA #23 by phone on 7/23/24 at 2:55 PM and 7/25/24 at 11:48 AM and left a message, but the GNA did not call back. An interview with Licensed Practical Nurse (LPN) #2 on 7/25/24 at 9:25 AM revealed that, on 6/14/24, she had responded to GNA #22 and #23 yelling for assistance. She reported that when she went into the room the resident had a large laceration on his/her right leg that was fileted open. She stated neither of the GNAs were able to tell her what happened, nor was the resident. She stated that there was some blood on the floor but was unable to find any on the chair or the bed. LPN #2 showed the surveyor a picture of the laceration that was taken on a staff cell phone to send to the DON. Observation of the picture showed a large laceration that the skin was laid back and subcutaneous tissue (layer of tissue below the layers of skin) was exposed. LPN #24 was interviewed on 7/25/24 at 9:41 AM. She reported that she was assigned to Resident #9 that evening shift. She reported that she responded to the GNAs yelling for help around 11:00 PM. When she entered the room, she saw the gaping laceration on the resident ' s leg and the GNAs were unable to say how it happened. She reported she looked on the floor, bed, and the wheelchair looking for blood and was not able to find any. A subsequent interview with the DON on 7/25/24 at 9:54 AM revealed that the facility utilized agency staff frequently. However, there was no formal orientation given to the agency staff prior to their first shift. The DON reported that the expectation was for the agency staff to sign on to the computer and access the Kardex to determine the care needs of their residents prior to starting their care and receive a report from the off-going GNA while walking from room to room. The DON was uncertain how the new agency staff would know these expectations. When concerns had been identified, the agency staff on duty have been educated, but there was no process to ensure that all agency staff were aware of the expectations to ensure resident ' s needs were provided in a safe manner. The DON reported that, when she was made aware of the incident with Resident #9 on 6/14/24, she went into the resident ' s Kardex and found that the information on how to transfer the resident had been removed due to a computer programming glitch. If GNA #22 had known to check the Kardex to see how to transfer the resident, the information would not have been available. The DON failed to interview the GNA #22 to determine the reason she had transferred the resident in the manner that she had. An interview with the attending physician (who is the Medical Director) on 7/29/24 at 9:54 AM revealed he was aware that Resident #9 had sustained a laceration during a transfer. When shown the photograph of the laceration, he reported that this type of injury would not occur during a routine transfer from a wheelchair to a bed. He stated it was likely the resident ' s leg was caught on something and pulled. 2) A facility reported incident regarding a resident (#928) falling out of bed on 3/3/23 during activities of daily living (ADL) care and sustaining a hematoma was received and reviewed on 7/30/24. Resident #928 had an admission diagnosis including morbid obesity, fluid overload, muscle weakness, and cellulitis of the bilateral lower legs. According to Resident #928 ' s medical record, s/he was assessed on 3/2/23 functionally as needing extensive assistance requiring 2-person for bed mobility which includes how the resident moves from a lying position and turns side to side, and total dependence of one person for bathing which excludes washing hair and back. According to the facility report while GNA staff #12 was bathing Resident #928, she asked the resident to roll over. The resident was rolled over away from the GNA. As Resident #928 grabbed the mattress to hold on, s/he rolled off the bed onto the floor. Staff were immediately notified and acquired a hoyer to assist Resident #928 back into bed. S/he was assessed by the nurse on duty and documented as having a hematoma on his/her forehead, since s/he was on a blood thinner, an order was made to send the resident to the emergency room for evaluation. On the facility report, the results of the investigation noted that the NHA and previous DON immediately had inspected the bed and noted that the mattress was larger than the bed frame, in addition the GNA had inappropriately rolled Resident #928 away from herself not safely towards her. On 7/24/24 at 7:17 AM the current DON had followed up with the survey teams and reported that there were multiple facility reported incidents that their team was unable to locate from 2022 and 2023, that included this one. The only investigative information related to this incident was what was available in the initial and the 5-day investigation reported to the State.

Based on review of facility investigation documentation and medical records; observations and interviews, it was determined that the facility failed to 1. provide adequate supervision to prevent vulnerable residents from exiting the facility unsupervised and 2. have a system in place to ensure that those residents not identified as at risk for elopement are leaving the facility only through the main exit. This was found to be evident for two out of eight residents (Resident #10 and #181) reviewed for accidents during the survey. On 7/19/19 at 9:44 AM, a determination of immediate jeopardy was made in regard to risk for elopement. On 7/19/19 at 4:25 PM, the facility provided an abatement plan which was accepted by the Office of Health Care Quality. On 7/25/19 at approximately 12 noon, an updated version of the abatement plan was provided with a more descriptive plan for the continued monitoring of the interventions. On 7/25/19 at 1:33 PM, after validation of the acceptable plan, the immediate jeopardy was lifted. The Administrator and DON were informed that the immediate jeopardy was lifted as of 1:33 PM at time of exit from the survey. After removal of the immediacy, the deficient practice remained with the potential for more than minimal harm for all remaining residents at a scope and severity of D. The findings include: 1) Review of the medical record revealed that Resident #10 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 10/25/18 elopement risk assessment revealed an elopement risk of 0. Review of the Wandering/Elopement Risk Assessment form revealed the total elopement risk score could be from 0-9 and the instructions stated: If assessment indicates YES to any question, consider initiating a care plan or service plan for elopement risk. Review of the Wandering and Elopement Guide used by the facility for training revealed that a score of 1 or higher is considered at risk. On 11/19/18, Resident #10's elopement risk evaluation risk score was 3; interventions of an elopement deterrent device (wanderguard) and elopement prevention care plan were initiated. Further review of Resident #10's medical record revealed a 1/19/19 nursing note which revealed that the resident had been found on the floor in the lobby. Review of the Incident Report revealed that the resident, and the resident's wheelchair, had been found in the lobby on 1/18/19 at 8:45 PM. No documentation was found in either the incident report or the nursing note regarding the fact that the resident was in the main lobby of the facility at 8:45 PM. Review of facility self- report MD 510 revealed that Resident #10 exited the facility by way of the exit door at the end of the 500 unit on the morning of 2/1/19. On 7/16/19, observation of the outside area where the resident was found revealed it offered unrestricted access to the entrance road, about a 30 foot walk on sidewalk. Approximately 20 feet from the area where the resident was found, is a drainage ditch that was approximately 10 feet deep. Per Accuweather.com the high temperature on 2/1/19 was 19 degrees. Review of the facility report investigation statements revealed that, on the morning of 2/1/19 at approximately 6:40 AM, geriatric nursing assistant ( GNA) #1 came out of room [ROOM NUMBER] and noticed an empty wheelchair by the exit door facing that door. The GNA looked in the sunroom and didn't see anyone there, then looked out the exit door window and saw some movement so she went outside. Resident #10 was noted on the concrete platform leaning on the building and waving arm. GNA #1 assisted the resident back into the building and notified the RN #2. On 7/16/19 at 12:50 PM during an interview and tour of the facility with the Director of Nursing, (DON) several exit doors were opened and the alarm sounded at the nursing unit. Alarms did not sound at the doors themselves. The alarm was audible in rooms even with the door closed, but was not as loud. It was observed that the alarms were turned off from the nursing unit. Once the exit door shuts, re-entry from the outside is not possible unless the door is opened from the inside. According to the DON, only the front door and the exit door located near the storage room were linked to the wanderguard system. Based on observation and review of facility floor plan, it was determined that there were 7 additional exits that were accessible to residents that were not linked to the wanderguard system. These exits are located as follows: 2 in the dining room, one in the sunshine room, one at the end of the 400 unit, one at the end of the 500 unit, one in the recreation room and one on the 200 unit near the therapy department. On 7/16/19 at 1:00 PM, the DON confirmed that staff can enter the facility thru the door on the 200 unit in the morning and that an alarm sounds each time the door is opened. At 2:55 PM on 7/16/19, interview with GNA #27 revealed that staff had to use the 200 unit door a few months ago when the facility was having work done on the front entrance and confirmed that an alarm would sound when this door was accessed. At 3:00 PM, the Administrator confirmed that the facility had some work done on the front door earlier in the year. On 7/17/19 at 7:04 AM, the unit nurse manager #4 reported that the exit alarm panel does state which door is open and that staff are to visualize the exit to ensure why the alarm is sounding prior to turning off the alarm. On 7/17/19, surveyor observed that the exits at the end of the 400 unit, 500 unit, storage room exit and the sunshine room exit could be visualized from nursing unit. The 200 unit exit and the exits from the dining room and recreation room were not able to be visualized from the nursing unit. On 7/17/19 at 8:48 AM, interview with Registered NurseN (RN) # 2 revealed that, during shift change, the door alarm sounds a lot due to maintenance going in and out the storage room exit. She also reported that the alarm was sounding more frequently on the morning of 2/1/19 due to staff using the therapy (200 unit) door because the main entrance door was broken. RN #2 confirmed that she had turned the alarm off prior to visualizing the area of the 500 unit door and stated, - should of turned it off after check, I know now. Review of staffing sheets and time card documentation revealed that, at the time of Resident #10's elopement, all six of the day shift GNAs and three day shift nurses had already started work. The GNAs all punched in between 5:56 AM and 6:07 AM. The two night shift nurses were also still working at the time of the elopement. Interview with GNA #1 on 7/23/19 confirmed that she found the resident outside on that (MONTH) morning. When asked if she recalled hearing an alarm, the GNA reported she could not recall if she heard an alarm or not, but stated that the wheelchair was what caught her attention. 1b) Further review of the Incident Report for the 2/1/19 elopement and the witness statements revealed that, upon assessment, after being brought back into the facility, it was noted that Resident #10 did not have on the wanderguard bracelet. This was confirmed by RN #2 during the 7/17/19 interview who stated that a new bracelet was placed on the resident. On 7/17/19 at 10:00 AM, the DON reported that the bracelet had been found and that the Assistant DON (no longer employed at facility) had mentioned the bracelet looked stretched out. On 7/18/19, the DON reported that the wanderguard bracelet had been found in the resident's room. On 7/17/19 at 7:00 AM, the surveyor entered the facility thru the main entrance. The automatic doors opened as the surveyor approached the door from outside. No staff were present in the lobby or at the reception desk at this time. Approximately 15 residents were observed in the dining room, which was visible from the main lobby. The automatic doors opened as surveyor approached from the lobby to allow access to the front of the facility. Observation of the area outside of the main exit revealed that the sidewalk started to decline (allowing wheelchair/c access to the driveway/parking lot) approximately 15 feet from the exit. An interview, on 7/17/19 at 5:18 PM, with the corporate executive director revealed that, when the electronic eye is turned off, the front door will not automatically open and that anyone leaving would have to pull the door open. Staff, visitors and residents without a wanderguard are able to exit through the front door between 8:00 PM and 6:00 AM by manually opening the sliding door without any alert or alarm to the nursing station. On 7/18/19 at 4:17 PM, interview with unit manager #4 confirmed that, at 8:00 PM, the front door is locked to prevent access from the outside. The electronic eye, which enables automatic opening from the inside, is turned off when the front door is locked. On 7/19/19 at 12:44 PM, the corporate executive director reported that she had just tested the wanderguard at the front door and that it caused the electric eye to turn off so the door would not open automatically, but the door can be opened by pulling the sliding door open. On 7/18/19, the surveyor requested credible evidence that the front door was secured in the evening from the Administrator. A sheet titled Night Shift Daily Duties which included the following statement Nursing Supervisor or Unit Manager is responsible for ensuring all doors are secure and an Orientation Guide for Supervisor/Unit Manager/RN/LPN which included a statement of Verification of secured doors was the only documentation provided. No documentation was provided to indicate the evening supervisor is to lock the front door at a specific time. On 7/19/19 at 11:32 AM, interview with the front desk receptionist (Staff #28) revealed someone was at the front desk until 7:30 in the evening. Staff #28 cstated that she starts at 11:00 AM, but was not sure what time the morning receptionist comes in, but thought it was between 7:30 AM - 8:00 AM. 2) Review of Resident #181's medical record revealed the resident was admitted to the facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. The resident's admission assessment revealed a Brief Interview for Mental Status of 15 out of 15 and the resident's initial elopement assessment, completed on 6/27/19, revealed an elopement risk score of 0. Review of the Wandering/Elopement Risk Assessment form revealed the total elopement risk score could be from 0-9 and the instructions stated: If assessment indicates YES to any question, consider initiating a care plan or service plan for elopement risk. Review of the Wandering and Elopement Guide used by the facility for training revealed that a score of 1 or higher is considered at risk. Review of a facility reported incident revealed that, on 6/30/19, Resident #181 exited the facility thru the exit door on the 200 unit hallway. The alarm sounded and nurse #29 responded, finding the resident approximately 10-15 feet past the threshold. Further review of the medical record revealed a primary care physician note, dated 7/7/19, which included a [DIAGNOSES REDACTED]. On 7/17/19 at 3:48 PM, the surveyor reviewed with the Administrator that there had been two elopements with residents who did not physically have a wanderguard on at the time of the elopement, one esident had an order but the wanderguard was not on at the time, the other had not yet been identified as an elopement risk. The concern was reviewed that there would not be any mechanism to have prevented or alerted staff to either of these elopements, if the residents had gone out the front door. In response to this concern, the corporate executive director reported that they use their assessment tools to mitigate risk and that they were looking to get a quote for a new door system. An elopement assessment completed on 6/30/19 for Resident #181 revealed an elopement risk of 4 and new interventions included elopement deterrent device and elopement prevention care plan initiated. On 7/18/19 at 2:50 PM, surveyor and Nurse # 29 observed the area where Resident #181 had been found on 6/30/19. It was confirmed that it was approximately 15 feet from the exit. Nurse #29 reported that the resident was moving in the wheelchair with his/her feet and said that s/he was heading to the front patio. Observation of the area outside the 200 exit on 7/16/19 revealed a patio and a walk-way down to the main entrance driveway. At approximately 40 feet from the exit, there was a noted decline of the walk way which lead directly onto the driveway/parking lot of the facility. Review of the facility's assessment, dated 7/8/19, revealed under Maintenance that the Door Alarms were not sufficient and that they were acquiring quotes for enhancement. The facility did provide evidence of a quote for a new wander management system, dated 1/21/19, but no documentation was provided that a new system had been approved, or was being implemented. On 7/16/19, observation of the area outside of the 400 unit door revealed a wooded area. This area was not visible from the front of the building. Review of facility reported incidents for (YEAR) revealed that, on at least two occassions in (YEAR), a resident was able to exit the facility unsupervised. Review of MD 097 revealed that, on 2/16/18 at 1:50 PM, Resident #187 exited via the sunshine room exit. Resident #187 had a [DIAGNOSES REDACTED]. Review of MD 694 revealed that on 6/12/18 at 5:20 PM a visitor reported observing Resident #40 in the parking lot beside a car. Resident #40 had a [DIAGNOSES REDACTED]. On 7/19/19 at 9:44 AM, a determination of immediate jeopardy was made in regard to risk for elopement. This determination was made based on the following: -At least 7 doors to the outside are in areas accessible to residents: 2 in the dining room; one in the sunshine room, one in the recreation room, one at the end of the 400 unit; one at the end of the 500 unit and one on the 200 unit near the therapy department. All of these doors are able to be opened from the inside. At the time to the survey, there was there is no mechanism for these doors to lock by the wanderguard system. -All of the facility exits accessible to residents lead to open areas in which a resident could proceed to wander into a dangerous area, ie: parking lot; drainage ditch; woods. -The facility has a system of alarms that alert staff if the exit doors are opened. This system can be turned off from the nursing unit prior to assessing that all residents are accounted for or the cause of the alarm has been identified. On at least two occasions in 2019, and two occasions in (YEAR) residents were able to exit the facility unsupervised. -A resident without a wanderguard is able to exit by way of the front door. The doors are set to open automatically upon approach during the day. At nigh,t the electronic eye, which enables automatic opening from the inside, is turned off when the front door is locked. Staff, visitors and residents without a wanderguard are able to exit through the front door when the electronic eye is turned off by manually opening the sliding door without any alert or alarm to the nursing station. -The potential for harm includes risks of weather related hazards as well as access to parking lots; woods and a drainage ditch. On 7/19/19 at 4:25 PM, the facility provided an abatement plan which was accepted by the Office of Health Care Quality. This plan included the following: - Doors are monitored by direct vision of staff until security cameras are in place. -Security cameras mounted at the interior identified accessible exit doors: 1. Dining room left door 2. Dining room right door 3. Sunshine room 4. End of 400 hall 5. End of 500 hall 6. Therapy (200 unit) entrance 7. Resident lounge (recreation room) 8. Front entrance -Video monitoring 24 hours a day until a permanent system is approved and installed/functioning. -A staff member will be identified for the purpose of solely monitoring the security cameras until approved system installed and functioning. -Education of staff to ensure providing continual monitoring of the identified doors that are accessible to the outside by the residents. On 7/25/19 at 8:24 AM, surveyor interviewed the Administrator and the corporate executive director regarding the monitoring of the interventions. The Administrator reported there would be regular auditing for at least 2-3 weeks covering different shifts and that the DON and the Administrator would be responsible for these audits. Surveyor requested to review the auditing tool that would be utilized. On 7/25/19 at approximately 12 noon, an amended version of the abatement plan was provided with a more descriptive plan for the continued monitoring of the interventions. A template for the auditing tool was also provided for review. The amended plan included: NHA(nursing home administrator)/Designee would conduct audits every day on every shift for 2 weeks to verify that the P[NAME] (plan of correction) was ongoing and effective. Then NHA/designee will conduct audits once daily at random times until door locking mechanism is installed/approved and operational. The Director of Maintenace/Designee will complete daily audits to ensure that the security camera system was operational until the door locking mechanism is installed/approved and operational. On 7/25/19 at 1:33 PM, after validation of the acceptable plan, the immediate jeopardy was lifted. The Administrator and DON were informed that the immediate jeopardy was lifted as of 1:33 PM at time of exit from the survey.

Based on resident and staff interviews, and review of medical record and other documentation, it was determined that in 1 of 35 residents reviewed during survey (Resident #22), the resident suffered harm when staff attempted to transfer the resident unsecured in broken lift equipment resulting in a fall with major injury (a broken bone). The findings include: Review of care planning documentation revealed that Resident #22 was a vulnerable adult who relied on staff for assistance with activities of daily living including assistance from one staff during toileting and dressing. Care planning documentation regarding fall risk included instructions that staff utilize sit to stand lift as indicated . During an interview on 10/25/2016 at 11:46 AM, Resident #22 stated that he/she recently fell from a stand-up lift (stand-up lifts, also known as stand assist lifts are used to stand an individual up from an already sitting position with use of a secured sling). The resident stated that a nursing assistant was getting him/her off the toilet when he/she fell from the lift onto the floor and broke a rib. Resident #22, who reported this concern, had been assessed by facility staff as alert, oriented and cognitively intact during a comprehensive Minimum Data Set assessment (reference date 8/16/16). Review of the medical record, on 10/28/16 at 11:00 AM, revealed a 10/4/16 note corroborating that Resident #22 had a witnessed fall on 10/4/16, reported right side pain, the physician was notified, and an order was given to obtain x-rays. Resident #22's 10/4/16 radiology report documented a probable 9th rib fracture. Additional facility documentation revealed that, on 10/4/16 at 7:30 AM, Resident #22 was being transferred off the toilet by Geriatric Nursing Assistant (GNA) #1 via a stand-up lift. The GNA put Resident #22 on the stand up lift, put the sling under him/her arms and attached the sling to the lift, and then reported to facility nursing staff that the sling was missing a buckle and therefore the resident was not safely buckled into the sling, and also that the resident's feet were not strapped to the stand-up lift leg pad. During the failed transfer and contrary to the care plan instructions, the GNA instructed resident #22 to hold on to the handles as he/she was raised off the toilet in the unsecured lift. On 10/28/16 at 12:00 PM, during an interview, RN #1 stated that he/she removed the broken sling which was given to the Director of Nurses (DON) and GNA #1 received one on one education. When asked if he/she assessed the stand-up lift used at the time of Resident #22's fall, RN #1 stated that he/she and GNA #1 assessed the stand-up lift after Resident #22 fell and the sling belt was missing one of the buckle ends used to secure the abdomen area. RN #1 stated that the sling goes under the arms and around the abdomen to help keep the resident secure and the sling should not have been used without the abdominal buckle. On 10/28/16 at 12:14 PM during an interview with the Surveyor, GNA #1 contradicted his/her earlier reports regarding circumstances of the fall. In this interview, GNA #1 stated that when he/she was getting Resident #22 off the toilet with the standing lift, the resident moved his/her right arm out of the sling, fell out of the sling to the floor and hit his/her right side. When asked what caused Resident #22 to fall, GNA #1 stated that the resident took his/her hand out of the sling and was not standing up really good. The GNA stated that the lift was in proper working condition. When asked what do you do to secure the lift, GNA # 1 stated that, with the resident in the sitting position, open legs and attach the sling behind the resident, then belt around the waist, then hook the sling on the machine then put the feet inside machine and strap the legs with Velcro. He/she stated that procedure was followed and he/she did not know why the resident fell . GNA #1 stated that he/she looked at the equipment after the resident fell , and there were no broken parts, the equipment was just old, and he/she was guessing the resident's bad movement that caused the resident to fall. When asked what was found when he/she looked at the equipment with RN #1, GNA #1 stated that it was okay. When asked if Resident #22 had taken his/ her hands out of the sling before, GNA #1 stated no, just that day and he/she didn't know why the resident was doing what he/she did. On 10/28/16 at 12:40 PM, Director of Nursing (DON) stated that a maintenance log request for the stand-up lift equipment failure resulting in Resident #22's fall was not done because when a sling is broken, the facility gets rid of it and orders new ones. Although staff were aware that sometimes slings need replacement, no systems were in place for maintenance staff to check the slings. On 10/28/16 at 2:18 PM, during an interview, the interim maintenance person stated that the maintenance department goes over the beams, the bolts, the mast and the batteries for functioning, but does not assess the slings. Facility policy #HS 007.13 in place and last updated during February 2016, stated in Section III. G that equipment will be maintained in a safe operable condition and in subsection (3) indicated that employees applying slings will examine slings for deterioration prior to use. On 10/28/16 at 1:29 PM, during an interview, the DON stated that GNAs are trained on mechanical lifts when they are hired. When asked if employees were educated on mechanical lifts following Resident #22's fall, the DON stated that the facility did small huddles. When asked if there were sign in sheets, the DON stated no. On 10/28/16, a review of Resident #22's MDS there was no indication that a Significant Change Assessment had been completed. On 10/28/16 at 12:45 PM, during an interview, MDS Coordinator #1 confirmed that a MDS significant change was not done following Resident #22's 10/4/16 fall that resulted in a broken rib.