Every finding on record at Cumberland Healthcare Center

Based on record review and interview, it was determined that the facility failed to implement an effective discharge planning process. This was evident for 4 (#4, #8, #9, and #10) of 5 residents reviewed for discharges. On 5/21/26 at 2:05 PM, an immediate jeopardy (IJ) was declared for the facility's failure to ensure that post-discharge services were set up for Resident #4 prior to their discharge date . An IJ summary tool was provided to the facility. The facility submitted a plan for removal at 2:10 pm that was not accepted, the second draft submitted at 3:09 pm, the third submitted at 4:05 pm and fourth submitted at 4:44 pm were not accepted. On 5/21/26 at 5:55 PM, the facility staff submitted an IJ removal plan to the Office of Health Care Quality (OHCQ) which was accepted, The IJ was removed on 5/22/26 at 3:30 PM after confirmation that the accepted plan had been fully executed. After removal of the immediacy, the deficient practice remained at a scope and severity of E. The findings include: The discharge care plan is part of the comprehensive care plan and must:Be developed by the interdisciplinary team and involve direct communication with the resident and if applicable, the resident representative;Address the resident's goals for care and treatment preferences;Identify needs that must be addressed before the resident can be discharged , such as resident education, rehabilitation, and caregiver support and education;Be re-evaluated regularly and updated when the resident's needs or goals change;Document the resident's interest in, and any referrals made to the local contact agency; and Identify post-discharge needs such as nursing and therapy services, medical equipment or modifications to the home, or ADL assistance. 1. A medical record review for Resident #4 on 5/19/26 at 12:20 PM for Resident #4 revealed an admission MDS (minimum data set) with the assessment reference date of 3/10/26 that documented the resident had moderately impaired cognition. On 3/13/26 a discharge care plan was initiated for the resident's decision to return to the community. The goal was the resident would understand and verbalize the discharge plan. There was no evidence that the discharge care plan was developed by the Interdisciplinary team. The resident's goals for care and treatment preferences were not included. The interventions failed to include resident-specific interventions. The resident care plan failed to identify the discharge location or post-discharge care needs: such as medical equipment or home health services. In addition, there was no evidence that the team re-evaluated the care plan regularly and updated with resident's care needs and goals. On 3/26/26 the Social Worker (SW) #5 documented that the resident had decided to appeal the insurance's decision to end coverage. On 3/31/26 Nurse Practitioner (NP) #6 completed the home health certification and certification statement that documented the resident needed the following post discharge services: skilled nursing wound management, physical therapy, occupational therapy, and a home health aide. SW #5 wrote on 4/3/26 that the resident had lost her appeal to the insurance company and wanted to move forward with the second appeal and she wanted to learn more about LTC (long term care) medicaid. On 4/16/26, 3 days after the resident discharged , SW #5 wrote a note that was a late entry for 4/9/26 that stated the resident decided not to appeal the second time and that SW #5 asked the resident if s/he wanted to be discharged home since s/he was not appealing. She noted the resident had not taken care of his/her wounds in the past and agreed to discharge home with home health services. On 4/16/26 SW #5 wrote a second note as a late entry for 4/13/26 that stated the resident was discharged home and she was sending a referral for home health services. However, this information had not been added to the discharge care plan. Facility staff failed to develop and implement a post discharge care plan with the resident and their representatives input. There was no documentation of the resident's interest in community resources instead it was noted that community resource phone numbers were provided. Furthermore, on 4/13/26 the resident was discharged home without skilled nursing wound management, physical therapy, occupational therapy, and home health aide services in place that the NP documented the resident needed post discharge. On 5/19/26 at 11:45 AM a review of complaint 3010520 revealed the complainant reported Resident #4 was unsafely discharged home. They reported the resident was unable to safely stand, ambulate, and attend to their ADLs (activities of daily living such as bathing, preparing and eating food, toileting, etc.) at the time of discharge. Reportedly the resident fell on the day s/he returned home and was not found for 3 days. A review of the emergency department (ED) and hospital course medical records on 6/11/26 at 8:00 AM, for Resident #4, revealed s/he was brought to the ED on 4/16/26 by EMS (emergency medical services) staff and they reported the resident was found on the floor of his/her apartment with large amounts of vomit and urine. They documented the family member who found the resident on 4/16/26 reported to them that no one had heard from or seen the resident since they were discharged from the facility and that the resident was wearing the same clothing that s/he was wearing on 4/13/26 when s/he was discharged from the facility. The resident was found to be hypotensive (low blood pressure), hypothermic (low body temperature), and was diagnosed with traumatic rhabdomyolysis, acute kidney injury, and cellulitis in both lower legs. Rhabdomyolysis is a condition in which muscle tissue starts to break down and can be caused by injury, prolonged immobilization, and extreme exercise with no breaks. The condition can be fatal when not treated. Per ED report the resident stated that s/he was to have wound care for his/her lower legs, but had not had that done since discharge from the facility. A review of the hospital course records revealed the resident was admitted to the intensive care unit and then transferred to a regular floor and the resident spent a total of 15 days in the hospital before being transferred to another skilled nursing facility for rehabilitation. The complainant was interviewed on 5/19/26 at 11:56 AM. During the interview, the complainant reported that the home health agency tried to call Resident #4 on 4/15/26 to set up a visit but was unsuccessful. On 4/16/26 they tried to call again and with no response they decided to try to visit the resident at home. The home health nurse reportedly went to the resident's home address and was unable to gain access to the building to knock on the resident's door. The complainant said that the home health agency called her and she called someone to conduct a welfare check on the resident. At which time the resident was found lying on the floor inside the door of the apartment. The resident was transported to the hospital via 911. An interview with SW #5 on 5/19/26 at 3:20 PM revealed that the process for discharging a resident home and in need of durable medical equipment and/or home health services was to send the referrals the day of or day after discharge. SW #5 reported that the home health agency that they used told her not to send the information before that time. When asked how the facility ensures that the resident has the needs and services post-discharge she stated that she sent the referral and after that it was up to the home health agency. When asked about Resident #4 she reported that she sent the referral on 4/13/26, however she had no evidence that she sent it on that day. On 5/19/26 at 4:02 PM the clinical manager of the local home health agency was interviewed via a phone call. She explained that a resident needed an established primary care provider (PCP) in the community who had seen them recently to obtain an order for home health services. She explained it was acceptable to send referrals prior to the discharge date and they were placed in a pending file. She further explained that although they were in the pending file the home health agency staff worked on those referrals to ensure that when the discharge occurred they were ready to start the services. She stated that as long as the resident had a PCP, they needed 48 hours to confirm services would start at the time of discharge. When asked about Resident #4, she reported that they received the referral on 4/14/26. She stated that while it was not their normal process, they attempted to call this resident on 4/15/26 because they were familiar with the resident and knew they had trouble taking care of themselves at home. They were unable to reach the resident on 4/15/26 and 4/16/26 by phone, so they attempted a home visit and it was unsuccessful. Prior to leaving the residence they called the emergency number listed for the resident and made them aware. The emergency contact told the home health nurse that they had not spoken to the resident since 4/13/26 and was going to call someone to do a welfare check. The home health nurse left the residence; however, they were informed later that the resident was found lying on the floor inside the residence during the welfare check. During an interview with the Rehab Director, who was an Occupational Therapist (OT), on 5/20/26 at 3:49 PM it was revealed that they had not made a home visit to Resident #4's home to ensure the resident could safely transition home. She stated that they provide rehab services that assist residents to meet their goals to become more independent while in the facility. They rely on the resident and/or resident families report of the home environment to work on some goals for discharge; however, a community rehab team needed to evaluate them in the home to ensure a safe discharge. The Nursing Home Administrator (NHA) was made aware of the concerns on 5/19/26 at 4:47 PM. She reported that she was unaware that home health and therapy services could be set up prior to discharge. She stated that it had taken weeks for some of their residents to be seen after discharge by home health. The facility's provisions of the plan to remove the immediacy included the following: The residents identified during the survey (Resident #4, #8, #9) no longer reside at the facility. Identified one resident who wished to sign out against medical advice (AMA). The resident was educated regarding the risks, benefits, and potential negative outcomes associated with leaving AMA including a possible decline in their medical condition and interruption of treatment. Resident/Resident Representative verbalized understanding of the information/education provided and elected to proceed with signing out AMA. Community referrals were sent today, 5/21/26, by the Nursing Home Administrator for any upcoming resident discharges, as well as discharges in the past 30 days to ensure all community referrals are in place prior to discharge. All discharges will be reviewed upon admission and weekly with updates documented on the plan of care by the interdisciplinary team to identify required post-discharge services to include: home health, durable medical equipment, outpatient therapy, dialysis, physician follow-up appointments, community resources, medication management and support, and hospice or palliative services, when applicable. The NHA will confirm that the discharge audit tool is completed at least 24 hours prior to discharge to ensure the services are in place prior to discharge. If the resident refuses to stay until the recommended services are put in place and despite identified risks, the resident/resident representative will sign out AMA on appropriate form with the required documentation. Social Services staff and interdisciplinary team received immediate reeducation by the NHA regarding the transfer and discharge regulations. The NHA will conduct an immediate audit of all current pending transfers/discharges to ensure compliance with safe discharge planning and ensure appropriate documentation is in place weekly times 4 weeks and then monthly for 3 months or until substantial compliance is met with results reported to Quality Assurance and Performance Improvement (QAPI). Compliance date of 5/21/26. On 5/22/26 at 9:15 AM, an onsite visit was conducted. After validation of the implementation of the facility's plan of removal, which included staff interviews and record reviews, it was determined the facility met the minimum standards of compliance to remove the findings of an Immediate Jeopardy on 5/22/26 at 3:30 PM. 2. On 5/20/26 at 12:18 PM a medical record review for Resident #8 revealed a progress note that the resident was admitted to the facility for management of chronic medical conditions and wound management and the resident had left side hemiparesis following a previous stroke. On 2/17/26 a discharge care plan was initiated for the resident's decision to return to the community/other location. The goal was the resident would be discharged to an appropriate location for physical and cognitive status. An intervention was entered on 2/17/26 that facility staff will determine the equipment needed and facilitate obtaining the equipment. This was not resident specific and was not updated with what the resident actually needed post-discharge. On 3/4/26 a care planning meeting note entered by SW #5 revealed the resident's wishes were to go home, however, the interdisciplinary team failed to update the care plan to reflect this and formulate a care plan to help the resident achieve this goal if possible. There were no other discharge planning progress notes entered until 4/9/26 when SW #5 wrote that she asked the resident about their discharge plans when the resident's skilled nursing coverage ends. On 3/31/26 NP #6 completed a home health certification and certification statement that documented the resident needed the following services post-discharge: skilled nursing for medication teaching, physical, speech, and occupational therapy, and a home health aide to provide personal care. Sw #5 wrote a note on 4/13/26 that documented it was the resident who requested a high back wheelchair, mechanical lift, and a hospital bed. There was no evidence that the IDT determined the post discharge equipment that the resident needed. On 4/15/26 SW #5 documented that the resident wanted to discharge home when appropriate and when s/he [the resident] had a community care plan in place. In this note the SW noted that the resident and family member were concerned that the family member had health issues of their own and may not be able to provide care for the resident even with a second family member willing to help out. However, there was no evidence this concern was addressed in the discharge care planning. The SW provided a copy of the Notice of Noncoverage issued to the resident that stated the last day of coverage was 4/17/26, however the signature page was not included and it was unclear which date it was issued. There were no progress notes written as to when the notice was given and that the appeal process was discussed with the resident. Per SW #5's progress notes the resident was back and forth about hospice at home and long-term care options. On 4/23/26 an intervention was added to discharge the resident home on 4/24/26, but there was no evidence that a post discharge care plan was developed and implemented before the resident was discharged home. A review of the resident's referral packet on 05/20/2026 2:51 PM revealed a fax cover sheet that had no date on it. There was a fax transmittal sheet that indicated the fax was sent on 4/24/26 the day the resident discharged home. A telephone interview on 5/22/26 at 2:51 PM with the home health clinical manager revealed they had not received the referral prior to 4/24/26 because the resident was not in their pending list and that services were ready to start as of 4/27/26, 3 days after the resident was discharged . On 5/20/26 at 3:49 PM an interview with the Rehab Director revealed that during the Utilization Review meeting they discussed the resident and his/her needs prior to discharge. She reported that the resident had a family member who was actively involved with the resident's care and training was provided for him during therapy. The resident used a slide board for transfers. However, this resident needed home health services, including therapy, and best practice was to have this available upon discharge. She reported a delay of 3 days may have caused the resident to decline functionally. An interview on 5/21/26 at 10:03 AM with the Nursing Home Administrator (NHA), SW #5, and the Director of Nursing was conducted. The NHA stated that she had been reading the [previous discharge regulations] and could not find the information presented by the surveyor as discharge requirements. She was unaware of the current Federal Regulations for appropriate discharge planning. SW #5 confirmed she sent the home health referral on 4/24/26 and reported that she was not sure how she was supposed to secure the post-discharge needs for their residents prior to discharge. The DON reported that the resident's family member was quite involved with the resident's care, often providing care while the resident was at the facility and was able to provide the care at home. However, this was contrary to the information provided by therapy staff who had been involved with training the family member. 3. On 5/20/26 at 11:10 AM a medical record review for Resident #9 revealed that on 3/19/26 a care plan was initiated that the resident wished to return home when safe and appropriate. The goal was that the resident would be discharged to the appropriate location based on physical and cognitive status which was not a resident centered goal. The interventions were not resident specific and generalized. On 4/16/26 SW #5 wrote a note effective for 4/6/26 which documented the resident lost an appeal regarding insurance noncoverage and was going to talk to the business office to apply for Medicaid to stay long term. However, she failed to document when the Notice of Noncoverage had been given to the resident or if the resident chose to file the second appeal. On 5/4/26 the resident's attending physician completed a home health certification and certification statement that documented the resident needed skilled nursing for medication teaching and wound management, in addition s/he needed physical and occupational therapy services and a home health aid for personal care needs. There was no evidence that staff developed and implemented a post discharge care plan for the resident. There was no evidence that the resident's interest in community resources was identified and contact information provided. On 5/4/26 an intervention was added to the care plan to discharge the resident home on 5/7/26. A progress note written by the Director of Nursing (DON) on 5/4/26 revealed the IDT reviewed Resident #9 during a meeting. The resident was transferring from one surface to another using a slide board with staff present. The resident had to be lowered to the floor by staff. Staff failed to add interventions to the discharge care plan regarding this concern. Further review of the progress notes revealed that between 4/20/26 and 5/6/26 there were no discharge planning notes written. Furthermore, there was no evidence that the IDT was reviewing the resident for discharge and ensuring that the resident was able to reach their goal to discharge home and prevent readmission if possible. On 5/7/26 the nurse documented the resident was discharged home. On the same day, 5/7/26, SW #5 wrote a progress note that she reached out to the company regarding the resident's medical equipment and that they would contact the resident regarding delivery. She also noted that she sent the home health referral to the local agency and was told they did not work with the resident's primary care physician, so she sent a referral to another home health agency and noted they did not provide the services the resident needed. The resident was discharged with instructions to contact his/her PCP to set up services s/he needed at home. A discharge visit was conducted by NP #6 that noted she was aware that the resident was discharging home and needed to follow up with their Primary Care Physician. However, she made no notes regarding the medical equipment or services that were needed post discharge. In addition, there was no indication that the attending physician was notified that the resident had been discharged without the needed resources in place. There was no evidence that the SW attempted to obtain the medical equipment that was needed or the home health services prior to the date of discharge. An interview with the Rehab Director on 5/20/26 at 3:49 PM revealed they did not conduct a home visit to ensure the resident was able to discharge home. She stated that they ask residents and resident's families about the home and anything they will need to work on for discharge, however they do not conduct a home visit to evaluate the environment themselves. She stated that the community rehab services conducted the home visit and base the therapy sessions on the needs identified. An interview on 5/21/26 at 10:03 AM with the Nursing Home Administrator (NHA), SW #5, and the Director of Nursing was conducted. SW #5 confirmed she had not attempted to set up services for Resident #9 prior to the date of discharge, reiterating that she was not sure how she was supposed to ensure that services were in place prior to the discharge date . During an interview with the home health clinical manager on 5/22/26 at 2:51 PM it was confirmed that the facility failed to attempt to set up home health services for Resident #9 before 5/7/26. She reported that the facility was notified on 5/7/26 that they did not work with the resident's PCP in the community. 4. During the survey, complaint 3022739 dated 5/26/26 was received. On 5/28/26 at 9:45 AM a review of the complaint revealed the complainant reported that Resident #10 was discharged home without the proper equipment and services needed. An attempt was made to interview the complainant on 5/28/26 at 10:04 AM and was unsuccessful. A medical record review for Resident #10 on 5/28/2026 at 10:05 AM revealed a discharge summary from the hospital dated 3/12/26. Per this document the resident had a below the knee (BKA) of the left leg during a prior admission to the hospital and during this hospital stay s/he had an above the knee amputation (AKA) of the right leg. A review of the resident's discharge care plan initiated on 3/13/26 revealed the resident wished to be discharged home/other facility. The goal was the resident would verbalize and communicate the discharge plan. The two interventions initiated were to talk to the resident about their feelings about discharge and to notify the doctor of discharge plans. Neither intervention was resident specific to address the resident's needs to reach their goal to discharge. A review of the Social Services notes revealed on 4/9/26 the resident had made it known to the facility that s/he wanted to discharge home, however the discharge care plan was not updated with this information. Also, in the note it was documented the resident was requesting an electric wheelchair, hospital bed, and a mechanical lift. There was no evidence that the IDT had reviewed the resident's discharge needs. Then on 5/4/26 the physician wrote an order for the supply company indicating the resident needed a mechanical lift and a hospital bed. However, there was no evidence that facility staff attempted to order these items until 5/6/26. On 5/4/26 a new intervention was added to the care plan that the resident was to discharge home on 5/7/26 with current medications. The plan failed to address any hospital equipment and post discharge services that were needed. A review of the discharge summary written by Nurse Practitioner (NP) #4 revealed the resident was discharged on 5/8/26. However, summary failed to include the hospital equipment that the attending indicated that the resident needed or any post-discharge services that were needed. After surveyor intervention, she made an addendum to the discharge summary on 5/14/26 that noted the resident required a hospital bed to assist with turning and repositioning in bed. There was no mention of the mechanical lift order by the attending or that this was considered or not needed. There was a note written by the Director of Nursing (DON) on 5/14/26, that documented she called the resident to check on them and see if they needed anything. She reported that she was told that the resident did not have a hospital bed yet (6 days after discharge). According to the complaint on 5/26/26 the complainant reported they had no hospital bed yet. An interview with SW #5 on 5/28/26 at 11:44 AM revealed she called the insurance company and they denied giving the resident an electric wheelchair, however there was no documentation of this in the medical record. Although there was an order from the attending physician on 5/4/26 for a mechanical lift, she reported she did not attempt to get a mechanical lift for the resident because the resident was efficient with the slide board so there was no need for a mechanical lift. There was no documentation in the medical record that this was discussed with the attending physician or the IDT. She reported that the resident was approved for the hospital bed, and this information was sent to the medical supply vendor. She remembered an Adult Protective Services employee called post discharge regarding this resident, and they were referred to the primary care physician to get home health services. She failed to document this interaction in the medical record. On 5/28/26 at 12:49 PM an interview with the DON revealed the resident had been admitted to the facility in November of 2025 after his/her left leg was amputated and then was discharged home. She reported that because the resident had been home and had no issues it was questionable whether the resident needed the hospital bed. Although it was written in the discharge summary by NP #4 that the resident needed a bed. The DON stated that the resident had a functional bed at home the first time s/he was discharged home and she was not sure what would have changed. It was further determined that the resident had one amputation the first time they went home and then had a double amputation when discharged the second time. She agreed that this would change the resident's level of function in the home, however confirmed that facility staff failed to conduct a home visit to ensure the resident had all the necessary adaptations in place. The concerns were reviewed with the Nursing Home Administrator and the DON.

Based on record review and interview, it was determined that facility staff failed to ensure that their resident's were treated with dignity and respect. This was evident for 1 (#2) of 4 residents reviewed for abuse. The findings include: A medical record review for Resident #2 on 5/26/26 at 1:54 PM revealed a discharge summary from the hospital dated 1/7/26 that documented the resident had a debridement of a right heel wound. The resident was ordered Percocet 5-325 mg noted the resident was ordered to take 1 tablet of oxycodone and Tylenol combination drug commonly referred to as Percocet 5-325 mg (5 mg of oxycodone and 325 mg of Tylenol) every 4 hours for pain as needed. A progress note dated 1/7/26 at 8:37 PM documented the resident had been readmitted to the facility. On 1/8/26 at 1:11 AM Licensed Practical Nurse (LPN) #11 wrote that the resident was upset because s/he had asked earlier for pain medication and was offered Tylenol for pain while awaiting the pharmacy to drop off Percocet. She further noted that when she took the Percocet to the resident, they became upset again because they thought it should be 2 tablets instead of 1. She wrote she attempted to explain it to the resident. On 5/26/26 at 1:35 PM a review of the facility's investigation file for facility reported incident 2711325 was conducted. A review of the final report revealed the resident accused Registered Nurse (RN) #8 of slamming discharge paperwork onto his/her chest. A review of RN #8's statement revealed that she wrote that when the resident accused her of abuse, I left the room, yelled down the hallway that resident stated I hit him and the police needed called. Review of Certified Nursing Assistant II (CNA II) #10's statement revealed she wrote that at 3:15 AM, I heard yelling. It was [RN #8] coming out of room [resident's room number] yelling call 911 [Resident #2] said I hit him. LPN #11 wrote in her statement that, I heard [RN #8] coming out of the resident's room yelling in the hall that the residents stating that she hit [him/her] & to call the cops. An interview with Resident #2 on 5/27/26 at 9:46 AM revealed that in response to a question as to whether staff treated him/her with dignity and respect, they stated that the night they were re-admitted staff had not. The resident reported that they felt RN #8 became very angry with him/her because the resident was trying to tell facility staff that the hospital was giving him/her 2 tablets of Percocet. The resident stated that all s/he wanted was to get the correct amount of pain medication because they were in a great deal of pain. The resident confirmed that RN #8 went out of the room yelling down the hallway, so staff and other residents could hear that s/he accused her [RN #8] of abuse and to call the police. During an interview with LPN #11 on 5/26/26 at 4:25 PM, via telephone, she confirmed that RN #8 came out of the room and was yelling down the hallway to the nurses' station what the resident said and that they needed to call the cops. She stated when RN #8 arrived at the nurses' station and started to call the cops, she stopped her and reminded her to call the DON first. An interview with RN #8 on 5/26/26 at 4:03 PM, via telephone, revealed she was not sure if she yelled down the hallway and what she said. Once her statement was read to her, she stated that the statement was true. On 5/27/26 at 11:49 AM the investigation was reviewed with the DON. She reported she did not think that RN #8 yelled down the hallway to intimidate the resident but that she takes abuse allegations seriously. She agreed that it was not appropriate for staff to yell what the resident said in the hallway so others could hear what was going on.

Based on observation, record review and interview, it was determined that staff failed to provide nursing services for residents that met the standards of professional practice. This was evident during 1 random observation of nursing unit 1. The findings include: 1) On 05/19/26 at 11:04 AM Certified Nursing Assistant (Aid) #9 was observed asking Resident #14 if the resident had brought back his/her medication yet. The resident responded no and Aid #2 reassured the resident that the nurse was aware and would be back shortly. The resident was observed to be sitting up in bed, pursed lip breathing with use of accessory muscles and appeared restless. The resident was asked what s/he needed and s/he reported s/he had requested his/her inhaler because s/he was having trouble breathing. The resident reported they were unsure of the time it was requested. An interview with Aid #9 at 11:11 AM revealed about 5 minutes ago she had reported to Certified Medicine Aid #13 that the resident was asking for their inhaler because they were having trouble breathing. On 5/19/26 at 11:16 AM the surveyor stopped by and asked Resident #14 if the nurse had come in yet and the resident reported no. CMA #13 was observed in the hallway stocking the medication cart. On 5/19/26 at 11:17 AM during an interview with CMA #13 she reported that when a resident requested a PRN (as needed medication) she was able to administer some without the nurse assessing the resident first. She stated that this was the case with a rescue inhaler. When asked if she was aware that Resident #14 had requested their rescue inhaler, she stated she was aware and had not been back to check the resident. She stated she was stocking her medication cart while waiting for the time the resident's inhaler was due because it had not been quite 3 hours. She stated Resident #14 would become anxious when it was close to the time for the inhaler and start asking for it early. When asked if she had reported this to the nurse she stated she had not. A medical record review for Resident #14 on 5/19/26 at 11:44 AM revealed the resident medication administration report. The documentation revealed the resident was ordered a rescue inhaler to be given every 3 hours for shortness of breath and wheezing and the last time the resident was given the inhaler was at 6:38 AM approximately 4 hours and 20 minutes prior to asking for the medication around 11:00 AM (the exact time was unknown). At 11:22 AM CMA #13 had documented a late entry administration of the rescue inhaler for 11:05 AM, which was not accurate as this was when the observation was made and before the interview with the CMA in which she reported she had not administered the medication. Further review of the progress notes revealed that a nurse had not assessed the resident prior to administering the medication. An interview with the Director of Nursing (DON) on 5/19/26 at 1:26 PM revealed that PRN medication were allowed to be administered by the CMA after a nurse assessed the resident and gave their approval. She was made aware that this had not been done for Resident #14 and made aware of the delay in treatment. She reported that it was not acceptable practice because the nurse should have assessed the resident's lung sounds prior to the administration. When asked if the facility had a standard of professional practice manual that staff could refer to she reported they had not established one. She was made aware of the late entry administration by CMA #13 indicating that she gave the resident the medication earlier than she had. The DON responded that she would find out what happened and report back to the surveyor. The DON reported back on 5/20/26 at 2:44 PM that CMA #13 had opened the PRN order when the aid told her that Resident #14 was requesting the medication. Then when she signed it off it came back as a late entry for 11:05 AM when she had initially opened the order. The DON reported that she educated the CMA that orders were not to be opened until she was ready to administer the medication to avoid this from reoccurring.

Based on record review and interview, it was determined that facility staff failed to provide appropriate pain management for their residents. This was evident for 1 (#2) of 1 resident reviewed for pain management. The finding include: A medical record review on 5/26/26 at 1:54 PM for Resident #2 revealed a Discharge summary dated [DATE], from the hospital, that documented the resident was taking Percocet 5-325 mg 1 tab every 4 hours as needed after a heel wound debridement procedure. According to a progress note written on 1/7/26 at 8:37 PM the resident was re-admitted to the facility. On 1/8/26 at 2:00 AM Licensed Practical Nurse (LPN) #11 wrote a progress note that documented Resident #2 was upset and mad at the nurse because she had offered him/her Tylenol while waiting for the physician to sign off the order for Percocet. She documented that the resident refused all pain medications offered. She wrote the resident asked again for the Percocet at 1:00 AM and at this time it was signed off, and she was able to give it to the resident. When she took in 1 tablet the resident became further upset and told her that they were receiving 2 tablets in the hospital. She failed to document when the resident first asked for the pain medication, an assessment of the pain, and what nonpharmacological interventions were offered. She failed to document that the resident informed her that s/he was told to avoid taking additional Tylenol while on Percocet (because it has Tylenol in it) and that she educated him/her. The telehealth provider documented a visit on 1/8/26 (she failed to include the time of the visit) that the resident was reporting a pain level of 10/10. The telehealth provider documented the resident appeared to be lethargic and she did not want to increase his/her dose of Percocet at this time, but that it should be considered due to uncontrolled pain. A review of the physician's orders revealed the resident was ordered Percocet 5-325 mg 1 tablet for pain 6-10. The Tylenol order stated it was to be given for a fever and for a pain level of 1-5. On 1/8/26 at 4:3 AM Physician #12 wrote a note that the resident was admitted and having pain since admission. She reported that the resident was on Percocet 5/325 mg 2 tablets every 4 hours as needed. but it was discontinued at the time of discharge, and a new order was written for continuing the Percocet 5/325 but 1 tablet every 4 hours as needed. Physician #12 gave an order for a one-time dose of Percocet 5/325 mg, 2 tablets for pain management now. LPN #11 documented on 1/8/26 at 6:20 AM that the resident had been given the 2 tablets of Percocet for a pain level of 9/10 and had no further complaints of pain. On 5/27/26 at 9:46 AM Resident #2 was interviewed and it was determined the resident was alert and oriented to person, place, and time and was able to answer questions appropriately. The resident reported, when s/he was re-admitted to the hospital following the procedure on his/her heel s/he awoke and was in a great deal of pain. The resident reported that staff were only offering Tylenol for the pain, and s/he had been told by the doctor at the hospital to avoid taking Tylenol while on Percocet. When asked if s/he told the nurse this was the reason for refusing the Tylenol, the resident report s/he had told the nurse. The resident reported that when they finally gave him/her the Percocet it was 1 tablet instead of the 2 that s/he received while in the hospital. The resident reported s/he told the nurse and the supervisor, however, all they seemed to want to do was argue with him/her. The resident stated s/he did not understand this because s/he was in a lot of pain and just wanted to be medicated to relieve the pain. During an interview with LPN #11 on 5/26/26 at 4:25 PM the timeline of when the resident started asking for the pain medication and when it had been administered was established. She reported the resident was re-admitted from the hospital 1/7/26 at 8:30 PM. The resident started complaining about pain at 10:00 PM. That was when the LPN realized the resident's admission orders had not been signed off by the physician. She sent a message to the facility providers through a system called eMedicall, however she was unsure of the time she sent the message. She reported the resident was complaining of a pain level of 10 out of 10 on the pain scale, so she took 2 Tylenol back to the resident. She stated that the resident became upset and refused the Tylenol. When asked if she had offered the resident any nonpharmacological pain management, she stated that they [the facility] doesn't offer ice and heat for pain management. She reported that when she had not heard back from their providers, she called telehealth. She stated the first provider to call back they were unable to sign off on a narcotic in Maryland. She stated she had to call telehealth again and this time she was able to get the orders signed off. She was unable to recall the timing of these events and failed to document them in the resident's medical record. She stated that when she took the Percocet back to the resident, around 1:00 AM, the resident was upset that it was only 1 tablet and not 2 tablets. She reported she attempted to explain this to the resident but then the resident stated s/he was going to file a grievance against her so she called her supervisor. She reported the supervisor took the discharge paperwork back to the resident to show the resident what had been ordered. She reported she had not called the hospital to confirm that the resident should get 1 or 2 tablets. An interview with the supervisor, Registered Nurse (RN) #8 on 5/26/26 at 4:03 PM revealed she went to the resident to listen to their concerns and then attempted to show the resident the orders on the discharge instructions. She reported she had not called the hospital to confirm the orders, offer any nonpharmacological interventions, or educate the resident that it was ok to take the Tylenol until the Percocet was signed off and available to give them. The concerns were reviewed with the Director of Nursing (DON) on 5/27/26 at 11:49 AM. She reported that if the resident was admitted at 8:30 PM then the assigned nurse was probably passing medications to their assigned residents at that time, and this would cause a delay with admission orders. She agreed that the nurses should have clarified the Percocet order for the resident versus trying to convince the resident what the discharge orders were. She stated that they should have offered the nonpharmacological interventions even though she felt that the resident would not have accepted them. The DON reported they had not addressed the concerns with the orders not being signed off by the physician at the time of admission and 1 1/2 hours later the nurse was unable to administer the medications as ordered although she reported it was a known issue with their providers failing to respond to the messages timely. The concerns were reviewed with the Nursing Home Administrator on 5/28/26 at 8:47 AM.

Based on observation and interview, it was determined that facility staff failed to implement an effective infection control policy and procedures. This was evident during 1 of 1 random observation during the complaint survey. The findings include: A treatment cart is a cart that has supplies to provide treatments for resident and will have resident specific medicated treatments. The standard of nursing practice is to use this cart in the hallway to assemble treatment supplies for a resident, but does not go into the resident rooms for infection control purposes, just as medication carts and linen carts. On 5/19/26 at 9:59 AM a resident fell in their room on the second-floor nursing unit. In response Licensed Practical Nurse (LPN) #14 took the treatment cart with supplies laying on the top, into the resident's room between the bed and the wall and shut the door. When the nurse returned to the nurses' station on 5/19/26 at 10:07 AM, with the treatment cart she was interviewed. She reported that they do not normally take a treatment cart into the resident's rooms for infection control reasons. She stated she took the cart in because she was concerned about the resident's blood sugar because the resident was diaphoretic when she was found on the floor. She stated that because of this, she [the nurse] became anxious and inadvertently taken the cart in the room. An interview with the Infection Preventionist on 5/27/26 at 11:15 AM revealed it was not the practice of the facility to take treatment carts into the residents' rooms. She stated that this was unacceptable and the nurse was educated after surveyor intervention.

Based on observation and interviews it was determined that the facility failed to ensure a sanitary and homelike environment. This was found to be evident on two out of two nursing units in the facility.The findings include: 1) On 10/1/25 at 12:58 PM surveyor observed the sink in the bathroom shared between rooms [ROOM NUMBERS]. Multiple cracks were observed around the drain and in the basin of the sink. On 10/09/25 at 10:53 AM surveyor and the Director of Nursing observed the cracks in the bathroom sink located between rooms [ROOM NUMBERS]. On 10/09/25 at 12:33 PM during an interview, the Maintenance Supervisor (Staff #14) reported that he was aware that some of the sinks were in rough shape and that they had replaced some of them. He also reported that he has submitted reports to Quality Assurance for rooms that need updating. On 10/9/25 at 12:45 PM surveyor and the Maintenance Supervisor observed sinks in two randomly selected rooms on the 200 unit, with concerns identified in one out of these two rooms. The sink shared between room [ROOM NUMBER]-206 revealed more than 30 small cracks around the drain. Additionally, multiple cracks of varying length were noted in the basin of the sink. The Maintenance Supervisor confirmed the presence of the cracks. The surveyor informed the Maintenance Supervisor of the previous observation of the sink shared by rooms 203-204. Maintenance Supervisor reported if money had been approved for renovation for these rooms it would of already had been completed. On 10/09/25 at 1:00 PM the surveyor reviewed the concern regarding the cracked sinks with the Nursing Home Administrator. 2) On 9/30/2025 at approximately 9:30 AM, Resident #114 complained their bathroom smelled of urine—surveyor observation on 09/30/2025 at 9:58 revealed a strong odor of urine in Resident #114's bathroom. Review of complaint #317846 referenced a complaint of strong odor in the facility. On 10/09/2025 at 1:33 PM, an environmental observation and walk-through was conducted with the facility Maintenance Supervisor. The Maintenance Supervisor confirmed that the facility regularly assesses the airflow and ventilation, and the facility's general ventilation was observed and questioned. This was initiated in room [ROOM NUMBER] on the first floor, followed by rooms [ROOM NUMBERS] on the same floor. Each resident bathroom was observed and tissue tested for air ventilation, in which the surveyor uses a single sheet of one-ply tissue paper against an air intake register. Two of the three resident bathroom areas observed were not able to pull up and hold a single sheet of one-ply toilet tissue against the air intake register. On 10/09/2025 at 1:47 PM, the resident room observed on the second floor, room [ROOM NUMBER], had a ceiling height of more than 10ft and was not assessed. The Maintenance Supervisor provided a record from January 2025 to September 2025 of maintenance for the second-floor exhaust fans, indicating whether they were working or not working and stating they are accessed from the outside. Provided a description that the exhaust fans in the resident rooms on the second floor engage when the light switch is turned on, and operate at a lower intake airflow horsepower, and do not provide continuous air intake. No evidence was provided that air movement is adequate for comfort or odor control, and the Maintenance Supervisor confirmed this. On the second floor, the Maintenance Supervisor was present for the observation of the air intake in the hallway outside resident room [ROOM NUMBER] and explained that air is only drawn in when the air conditioning is enabled and the facility is cooling to the set ambient temperature. Otherwise, there is no continuous air movement or air cycling. On 10/9/2025 at 2:45 PM, the findings and deficiency was reviewed with the Nursing Home Administrator and Director of Nursing.

Based on interview and pertinent document review it was determined that the facility failed to have a process in place to ensure that residents received the items listed on the meal ticket or specific items that were requested by the residents. This was found to be evident for 2 residents (Resident #70 and #15) during random dining observations and one (Resident #2) during an interview with the resident council.The findings include:1.On 10/02/2025 at 1:09 PM Resident # 70, a long-term resident of the facility and without cognitive decline was interviewed. Resident #70 reported that a week before s/he was not served a BBQ sandwich that was on the facility menu and her/his meal ticket. Resident #70 reported that s/he was looking forward to the BBQ sandwich all day. S/he reported that the facility staff told her/him that they ran out of the BBQ sandwiches. On 10/6/2025 at 3:15 PM the facility Certified Dietary Manager (Staff #23) provided the meal ticket for the resident's dinner for 9/25/25. Review of the meal ticket for Resident # 70 revealed that a BBQ sandwich was listed as the primary meal. 2.On 10/02/2025 at 8:22 AM Resident #15 was observed sitting up in bed with her/his breakfast tray on the bedside table. Further observation revealed that Resident had not eaten her/his eggs. On 10/2/2025 at 8:23 AM during a brief interview with Resident #15 s/he reported s/he did not like her/his breakfast. S/he stated s/he would request oatmeal for breakfast instead. On 10/2/25 at 8:23 AM Resident #15 was observed calling the kitchen and requested oatmeal for breakfast. In addition, the surveyor heard Resident #15 request an alternative lunch items from the always available menu. The items were a grilled cheese sandwich and tomato soup. On 10/2/25 at 12:29 PM an observation was made of Resident #15's lunch. The observation revealed a grilled cheese sandwich and chicken soup. Resident #15 reported that s/he was told that they were out of tomato soup. On 10/2/25 at 12:30 PM the surveyor observed, on the wall near the second-floor dining area, the Always available items from the kitchen, which included tomato soup. On 10/7/25 at 12:40 PM during an interview with the Certified Dietary Manager (Staff # 23), confirmed that the tomato soup is on the always available menu and comes in cans. He confirmed that the tomato soup was not available for Resident #15 on 10/2/25. 3. On 10/3/25 at 1:47 PM during a small Resident council meeting, Resident #2 reported that s/he was supposed to receive a breaded chicken sandwich for lunch on 10/3/25 but just received a plain piece of chicken. S/he reported s/he was allergic to fish and was supposed to receive the breaded chicken as her meal. On 10/3/25 at 1:52 PM the Regional Certified Dietary Manger (Staff #25) reported to the resident council meeting that there was an error in the kitchen and that regular chicken was served in place of the breaded chicken. On 10/7/25 at 12:40 PM the Certified Dietary Manager (Staff #23) reported that the facility ran out of breaded chicken because there was an unusually high request for the breaded chicken that was listed as the alternative meal. On 10/7/25 the Certified Dietary Manger (Staff #23) provided Resident #2's meal ticket for lunch on 10/3/25. Review of Resident #2's meal ticket listed that Resident #2 was allergic to fish, and that Breaded Chicken was listed as her/his primary meal and not as an alternative meal item. On 10/7/25 at 11:40 AM the above concerns were discussed with the Director of Nursing and the Administrator. They reported that they would work with the kitchen management to address the issue. No further information was provided prior to the end of the survey.

Based on observation and interview, it was determined that the facility failed to ensure proper hand hygiene; and maintain a sanitary environment in a manner that minimizes the potential development and transmission of communicable diseases and infections. This was found to be evident for three (Resident # 2, #17 and #115) out of 53 residents reviewed; and two of three medication storage rooms observed during the survey. The findings include: 1.On 9/30/25 at 10:44 AM, Resident #115, admitted to the facility for rehabilitation, reported poor hygiene practices by staff. The resident stated that staff emptied a urine bottle in the bathroom but did not rinse or wipe it before placing it back on the bedside table. On 10/2/25 at 1:12 PM, an observation was made in Resident #17's room. Resident #17 was admitted to the facility for rehabilitation and antibiotic therapy due to an infection. On 10/2/25 at 1:16 PM, continued observation revealed a plastic urinal on the resident's bedside table. The urinal fell off the table onto the floor. The Human Resource Director (Staff #24), retrieved gloves, picked up the urinal, and placed it on the resident's dresser. Further observation revealed that Nurse #15 was next to Resident #17 and providing care to Resident #17. Continued observation revealed Staff #24 placed Resident #17's lunch tray on the bedside table. Observation did not reveal that the bedside table was sanitized after the urinal was removed and before the lunch tray was placed. On 10/2/25 at 1:20 PM, during a brief interview, Nurse #15 (who is the Infection Preventionist nurse), confirmed that the bedside table was not sanitized after removing the urinal and before placing the lunch tray. Nurse #15 stated it was the facility's expectation that the table be sanitized after urinal removal and before food service. 2.On 10/6/25 at 6:00 AM, an observation was made of wound care provided to Resident #2 by Nurse #2. On 10/6/25 at 6:10 AM, Nurse #2 was observed cleaning a dirty wound, removing dirty gloves, and putting on clean gloves without sanitizing hands between tasks. On 10/6/25 at 6:20 AM, Nurse #2 confirmed during an interview that hand hygiene was not performed between removing dirty gloves and applying clean ones. On 10/6/25 at 12:07 PM, Infection Preventionist Nurse (Nurse #15) reported that it was the expectation that all nurses sanitize hands after removing dirty gloves and before putting on clean gloves. The Infection Preventionist (Nurse #15) stated that re-education of the nursing staff had begun. On 10/15/25 at 11:40 AM, these concerns were discussed with the Director of Nursing (DON) and the Administrator. The DON reported being aware of the issues and confirmed that the Infection Preventionist had initiated staff re-education to correct the deficient practices. 3. On 10/3/2025 at 8:40 AM, Nurse #3 provided a review of the medication storage room on the second floor that is at the front of the unit. The sink in the storage room had a dark, green-to-black substance around the drain, and a tabletop dehumidifying device was draining. There was an expired full canister of Sani-Cloth wipes, are designed to disinfect and kill a wide range of microorganisms, including bacteria, viruses, and bloodborne pathogens, from 09/2023. On 10/3/2025 at 8:40 AM, Nurse #3 unlocked the refrigerator in the medication storage room, and it was revealed that resident specimens were also stored in the resident medication refrigerator. This was evident from clear sleeves containing what appeared to be red, body-fluid-like samples. Nurse #3 confirmed that resident specimens are kept in the resident medication refrigerator and stated they have observed stored specimens in other resident medication storage room refrigerators. On 10/3/2025 at 9:10 AM, the first-floor resident medication storage room was observed with Nurse #5. The sink in the resident medication storage room had a dark, green-to-black substance around the drain, and a tabletop dehumidifying device was draining. Nurse #5 unlocked the refrigerator in the resident medication storage room, and it was revealed that resident specimens were stored there. This was evident from clear sleeves containing what appeared to be red, body-fluid-like samples. Nurse #5 confirmed, all resident specimens are kept in the medication refrigerator as a standard practice. On 10/09/2025 at 2:45 PM, the Nursing Home Administrator and Director of Nursing were made aware of and acknowledged the deficiency. Refer also to F 761

During observation and interview, it was determined that the facility failed to ensure that each resident had the right to a dignified existence and communication. This was found to be evident during one (Resident #7) out of two investigations regarding resident dignity conducted during the survey.The findings include: On 9/30/2025 at 9:40 AM, during the initial tour of the facility, Resident #75 shared with the surveyor concerns about interactions with a GNA on the first floor who works on the unit during the day. On 10/01/2025 at 10:35 AM, during an interview with Resident #7, the surveyor asked whether there were concerns regarding dignity, respect, staff rapport, etc. Resident #7 and their family member, who was present during the interview, referred to a GNA during the surveyor's interview. Concerns raised by both Resident #7 and #75 pertained to the GNA's approach, tone, and demeanor toward the residents. Resident #7 stated, She is rude with residents and appears aggravated with the job. Resident #75 and #7 had both described the GNA's demeanor as mean to the surveyor. On 10/1/2025 at 12:05 PM, the surveyor began observing a GNA moving throughout the unit with a meal tray cart and observing the GNA's interactions. The GNA responded to two resident call lights in rooms [ROOM NUMBERS]. Upon entry, the response to the residents was: What do you want? (in a sharp, gruff tone) and What do you need now? The staff member was identified as GNA #35, the person referenced in resident and family interviews earlier that day on 10/1/2025. On 10/01/2025 at 12:40 PM, GNA #7 was assigned to the first floor and was interviewed. The GNA was asked about general resident care, staffing, and task delegation. During the interview, GNA #7 was asked whether they had any concerns about staff interactions with residents. GNA #7 confirmed with the surveyor that she has concerns with GNA #35's interactions with residents. She states that she has not witnessed abuse; however, she stated she has observed GNA #35 speak to residents in a disrespectful tone and manner consistently. On 10/02/2025 at 1:49 PM, an observation on the first-floor nursing unit was made by the surveyor. Nurse #6 was one of the nurses on the unit for the afternoon. On 10/02/2025 at 1:59 PM, during an interview with Nurse #6, who is from the first floor. Nurse #6 denied any concerns related to abuse. When asked whether they have concerns about the dignity of residents on the unit and interactions between staff and residents, Nurse #6 stated that they have observed GNA interactions with residents on the unit that they believe 'could be handled better'. When asked if there are specific staff member(s) they have observed where staff-to-resident interactions are not dignified, Nurse #6 identified GNA #35. On 10/2/2025 at 2:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed. The DON was asked, What is your expectation when staff respond to a call light -- what kind of communication would you expect to see and hear? The DON stated, I would expect staff to be decent and respectable in approach when addressing the resident and identifying their needs. The DON was asked how staff are trained and monitored on resident rights, resident dignity, and respectful communication. The DON stated that staff are provided with computer-based training modules on topics such as abuse, neglect, and cognitive decline. Computer-based learning modules are provided to staff upon hire, annually, and as needed. The NHA confirmed that this is the in-service delivery model used for staff at the facility across multiple topics. The NHA and DON stated they were unaware of any complaints regarding GNA interactions with residents. During the interview, the surveyor shared observations of GNA #35's interactions when responding to resident call lights, along with staff interviews regarding these observations. On 10/2/2025 at 2:40 PM, the DON and NHA stated they had not been aware of this concern and confirmed the concern regarding resident dignity.

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents' personal possessions were treated with respect and safeguarded from interference by other residents. This was evident for one (Resident #37) of two residents reviewed for wandering behavior during the annual recertification survey.The findings include: On 9/30/2025 at 11:22 AM, during the initial facility tour and interview with Residents #62 and #72 on the first floor, they voiced concerns over Resident #37 coming in/out of rooms and taking personal belongings. Residents #62 and #72 stated that Resident #37 has entered their rooms at different times, most often overnight, and has taken items. On 10/1/2025 at 10:10 AM, during observation of the resident on the unit, it was observed that Resident #37 was wandering in the doorway of other resident rooms (rooms [ROOM NUMBERS]) and was redirected by irritated residents twice within ten minutes. Three other staff were present during the surveyor's observation without intervening or redirecting. On 10/06/2025 at 1:29 PM, a review of Resident #37's care plan initiated 09/20/2025 identified wandering behavior and potential for elopement, with interventions to assess for hunger, toileting, and to provide supervision and redirection when entering others' rooms. However, there was no documentation demonstrating that these interventions were consistently implemented. On 10/02/2025 at 2:25 PM, an interview was conducted with Nurse #5 regarding the resident's wandering and their reported stealing of items. Nurse #5 stated, Oh, that's just Resident #37, they are well known to wander and steal, but most often items are food-related, and it's not a big deal. Nurse #5 stated the resident is easily redirectable and is not observed to be aggressive with staff or other residents when exhibiting wandering behavior. Nurse #5 further stated that the resident does not exhibit signs of eloping during wandering and is safe on the unit, most often roaming for a snack. Nurse #5 stated that there have been no permanently missing items involving this resident that could not be recovered. Nurse #5 stated that if items go missing and cannot be found by staff, they would be reported to the Nursing Home Administrator (NHA) and the Director of Nursing (DON). On 10/9/2025 at 2:45 PM, the findings were reviewed with the DON and NHA, and the deficiency was confirmed.

Based on resident and staff interviews, observation and record review, it was determined that the facility failed to make grievance information and the process of how to file a grievance readily available to staff and residents. This was evident for 1 (Resident #77) out of 1 resident reviewed for personal property during the survey. The findings include: On 10/2/25 at 1:49 PM Resident #77 reported to surveyor that 6 underpants were missing and stated, I've told everyone who comes in here. On 10/2/25 at 1:57 PM Social Service Assistant (Staff #10) provided the requested Grievance Policy. It stated the Grievance Official defaults to the Director of Social Services. And, in part, the facility will prominently post and make information available to all residents and others involved in resident care. And, in part, the location of grievance forms.will be posted near or on the grievance box. On 10/2/25 at 2:00 PM a record review of the 2025 Grievance Log lacked documentation that a grievance was filed on behalf of Resident #77 related to missing underpants. On 10/3/25 at 7:43 AM Surveyor observed that both Nursing Stations and units, level 1 and level 2 lacked grievance forms. A broken and unsecured Grievance Box was observed near the level 2 elevator. On 10/3/25 at 9:20 AM in an interview, Resident #77 and Geriatric Nurse Assistant (GNA #9), denied knowing how to file a grievance. GNA #9 stated, I don't know how it [the grievance process] goes and honestly a lot of people don't know how. Resident #77 stated, I go directly to [NAME], (referring to the Nursing Home Administrator (NHA)). On 10/7/25 at 8:13 AM in an interview, Registered Nurse (RN #11) on level 2, reported, If there's a complaint, I would go to the Unit Manager on that floor. RN #11 could not locate nor produce a grievance form per surveyor request. On 10/7/25 at 8:45 AM in an interview, Licensed Practical Nurse (LPN #12), reported, If there's a complaint, I would go to Christa (referring to the Director of Nursing (DON)). On 10/7/25 at 1:59 PM in an interview, the NHA reported that nurses can get a grievance form at the nursing station or from the computer, however, they are not openly available. On 10/7/25 at 2:17 PM in an interview, the Director of Social Service (Staff #13), identified as the facility Grievance Officer, reported that staff, residents, or family can file a grievance either in writing or verbally. She stated, grievance forms are readily available at the nursing station. On 10/9/25 at 1:30 PM the NHA and DON were made aware of the concern.

Based on medical record review and interviews, it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was evident for one (Resident #22) of two residents reviewed for positioning and mobility during the survey.The findings include: On 10/2/25 at 10:28 AM, Resident #22, a long-term resident of the facility, was observed lying in bed and reported doing well. On 10/2/25 at 1:53 PM, a review of occupational therapy notes provided by the Director of Therapy (Staff #19), for the certification period 7/9/24–8/7/24, did not indicate that Resident #22 had an upper extremity contracture. On 10/2/25 at 1:54 PM, a brief interview with the Director of Therapy (Staff #19), confirmed that Resident #22 did not have an upper extremity contracture. On 10/2/25 at 2:10 PM, a review of the annual MDS Section GG assessment, with a reference date of 8/15/25, revealed that the resident was coded as having a functional limitation in one upper extremity. The MDS is part of the Resident Assessment Instrument, federally mandated by legislation passed in 1986. It is a standardized, comprehensive assessment process used to identify each resident's individual needs, develop a care plan based on those needs, and ensure the care provided meets those needs. On 10/2/25 at 3:06 PM, the Director of Nursing (DON) reported that the Director of MDS had made an error on the MDS and that Resident #22 did not have range-of-motion issues in either upper extremity. On 10/6/25 at 8:23 AM, a review of the MDS revealed that a correction had been made. A modification dated Thu [DATE], at 03:26:25 PM, indicated that Resident #22 did not have impairments in the upper extremities. On 10/6/25 at 8:34 AM, during an interview, the MDS Coordinator Nurse (Staff #18), reported that documenting a impairment to the upper extremity for Resident #22 was an error and that a correction was completed following surveyor intervention.

Based on record review and interview, it was determined that the facility failed to provide quality of care for their residents. This was evident for one (Resident #125) of three residents reviewed for nutrition and one (Resident #3) out of five residents reviewed for unnecessary medication.The findings include: 1.A complaint was received by the State Agency (SA) on 8/25/25, alleging the facility was not allowing Resident #125 to have water by mouth. The complainant explained that due to the extensive facial surgery (due to a diagnosis of buccal cavity (mouth) cancer) the resident had, s/he often experienced dry mouth and had been drinking water in the hospital. The complainant reported that the facility was giving the resident 1 can (237 milliliters mL) of Glucerna when s/he had been getting 2 cans (480 mL) in the hospital. The complainant reported this was due to the extra calories and protein needed to allow the resident to heal. Furthermore, the complainant reported that family had attempted to explain this to the facility on multiple occasions, but nothing was changed. On 10/8/25 at 1:33 PM a medical record for Resident #125 revealed 2 documents from the acute care hospital that was uploaded in the miscellaneous section of the electronic medical record. A Discharge summary dated [DATE], that revealed the resident had been living at home and came to the hospital for treatment of a urinary tract infection that was causing weakness and to resume the at home diet. A History and Physical from the acute care hospital dated 8/3/25 revealed in the Assessment/Plan section that the resident had buccal cavity cancer with surgical intervention, the resident tolerated oral fluids but had aspiration precautions. Furthermore, it read to continue the tube feedings via a gastric tube (g-tube is a tube that is directly inserted into the stomach) of 480 mL of Glucerna 1.5 at 9 am, 2 pm, and 7 pm. (Each can of Glucerna is 237 mL, so the resident was getting 2 cans). A review of the resident's orders revealed the resident was ordered on 8/7/25 not to have anything by mouth (NPO) except for swabs dipped in water. The tube feeding order for 8/7/25 read to give Glucerna 1.5 give 1 can (237 mL) three times a day entered by Licensed Practical Nurse (LPN) #12. There were no orders for flushing the gastric tube (g-tube) or giving the resident hydration via the gastric tube. These orders were signed off by Nurse Practitioner (NP) #33 as approved. According to nutritional facts on a can of Glucerna 1.5, one can of Glucerna 1.5 has 356 calories thus 3 cans total 1068 calories daily. According to the National Institute of Health adults should receive between 1600 – 2400 calories daily. A review of the NP #33 visit notes for 8/8/25 revealed the resident had been at the hospital for treatment of a urinary tract infection and was admitted to the facility for short term rehabilitation so s/he could return home. There was no mention of the resident's diet orders or lack of hydration fluids via g-tube. NP #33 visited the resident on 8/11/25 and noted she spoke to the resident's family member who had a concern with the amount of tube feeding the resident was receiving and scheduled the resident to see their oncologist on 8/12/25. She also noted that the resident was requesting to have water to drink because of dry mouth, but because of the receiving orders (orders from the hospital) indicated the resident was to remain NPO. However, the orders received from the hospital noted the resident was tolerating fluids orally. The NP noted that she had consulted the dietitian. The orders for 1 can of Glucerna 3 times a day remained the same. No orders were added for hydration through the G-tube and the resident remained nothing by mouth. A review of Registered Dietitian (RD) #34's nutritional assessment dated [DATE] at 1:21 PM, revealed in F. Comparative Standards, Estimated Energy, Protein, Fluid needs: the resident needed to have between 1680 – 1960 calories a day. The resident needed 1600 mL of fluids each day. The dietitian noted that with the resident's current tube feeding orders s/he was getting 33% of his/her daily fluid needs. The dietitian recommended that the resident receive Glucerna 1.5, 1 can 5 times a day with 30 mLs of water before and after each tube feeding and 120 mL of water 6 times a day to meet the resident nutritional needs. This recommendation was 1 can less than the oncologist had recommended daily. However, even though the resident as getting 712 less calories and 67 % less water than these recommendations, the dietitian failed to enter the new orders until the following day on 8/12/25, allowing the resident to go 5 days without proper nutrition and hydration. On 10/8/25 at 2:53 PM an interview with LPN #12 revealed she used the discharge summary and other information from the hospital to enter orders for new admissions. She stated that she probably got the tube feeding orders from the History and Physical dated 8/3/25. However, when shown that the order was 480 mL of Glucerna 1.5 3 times a day and she had entered 237 mL Glucerna 3 times a day, she stated that she must have gotten that order from report from the nurse at the hospital or other paperwork. Reviewed the progress note that indicated another nurse had taken report from the hospital for the resident. Requested that she review the record and bring the documentation she used to get that order. A subsequent interview with LPN #12 on 10/8/25 at 3:51 PM revealed she was unable to find any documentation to support the order she entered for the tube feedings. On 10/8/25 at 5:19 PM the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of the concerns. The DON was asked if she expected her staff to realize that 1 can of Glucerna 3 times a day did not equal the minimum number of calories a person needs each day, she stated she would not expect them to know this information and clarify the order. An interview with the Medical Director on 10/14/25 at 5:10 PM revealed that it was expected that the Nurse Practitioner reviews the resident's hospital records and follows the recommended diet orders. He stated that it was concerning that NP #33 failed to ensure that the resident had the correct diet orders and that hydration fluids were included for the resident. Cross Reference F711 2.Review of Resident #3's medical record revealed the resident had an order for Rivaroxaban 20 mg tablet every morning for the prevention of deep vein thrombosis (blood clot) in place from 8/13/25 to 9/28/25. Rivaroxaban is the generic name for Xarelto, an anticoagulant (blood thinning) medication. Deep vein thrombosis can lead to a pulmonary embolism (blood clot in the lung) and death. On 10/6/25 review of the Medication Administration Record (MAR) revealed documentation that the resident did not receive the Rivaroxaban on September 14, 15, 16, 19 or 20, 2025. Nursing staff documented a 9 on the MAR which indicated the medication was not administered and to see nursing notes for the reason why it was not administered. Review of the corresponding nursing notes revealed that on 9/14/25 the medication was not given due to Waiting for pharmacy to deliver. On 9/15/25 the nurse documented on order from pharmacy. Med unavailable at this time. On 9/16/25 the nurse documented: on order. Review of the corresponding nursing notes for 9/19/25 and 9/20/25 failed to include documentation by the nurse to indicate why the medication was not administered on those two dates. Review of a pharmacy delivery manifests revealed 14 tablets of Xarelto 20 mg were delivered on 9/9/25. This manifest was signed by Nurse #4 on 9/9/25 at 8:04 AM. On 10/07/25 at 10:40 AM the Director of Nursing (DON) reported that sometimes the manifest is wrong. On 10/07/25 at 5:14 PM surveyor reviewed with the DON the concern that for some of the 9s that were documented on the MAR for the rivaroxaban, the nurses failed to document why it was not given. On 10/09/25 at 4:19 PM surveyor reviewed the concern with the DON that, based on review of the pharmacy manifest reports, there was an adequate supply of the rivaroxaban on the dates when nursing staff had documented that it was not available due to waiting on delivery from pharmacy. DON acknowledged the concern. As of time of survey exit on 10/9/25 at 5:00 PM no additional documentation was provided regarding this concern.

Based on medical record review, observation and interview it was determined that the facility failed to ensure that prior to installation of bed rails appropriate alternatives were attempted, that residents were assessed for the risk of entrapment, and that informed consent was obtained, and failed to ensure re-evaluation for the continued use of the bed rails. This was found to be evident for two (Resident #41 and #88) out of two residents reviewed for bed rail usage. The findings include:1) Resident #41 has resided at the facility for more than a year and has a diagnosis of dementia. On 10/01/25 at 12:46 PM resident was observed in bed asleep with quarter bed rails in the up position.On 10/07/25 at approximately 11:00 AM resident was observed in bed asleep with quarter bed rails in the up position.On 10/7/25 at approximately 12 noon review of the medical record revealed the resident was dependent on staff for bed mobility. Review of the current care plan addressing activities of daily living, revealed an intervention of Bilateral bedrails to promote independence and assist with turning and repositioning. This intervention was initiated 4/12/25. Review of the physician orders revealed an 8/28/25 order to: Maintain bilateral bedrails to promote independence with turning and repositioning.Further review of the medical record failed to reveal documentation to indicate alternatives to bed rails were attempted or that a risk of entrapment was completed prior to the addition of bed rails in April 2025.Review of the facility's Safe Use of Bed Rails policy, that was provided for review during the survey, revealed in the Procedure section: 1.Assessment of residents with bed rails include: a. Level of independence with bed mobility; b. Review of prior interventions and outcomes prior to the initiation of bed rails; c. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms should be evaluated prior to initiation.On 10/07/25 at 12:38 PM the Therapy Director (Staff #19) was interviewed in regard to the use of bed rails. The Therapy Director reported that nursing does research first to see if there is anything else they can initiate prior to bed rails, and then nursing would refer to therapy for a screening. The director confirmed there is a paper that they utilize if they recommend bed rails and that they provide that document to nursing. When asked if that document goes into the medical record the director referred the surveyor to the Director of Nursing. In regard to Resident #41, the Therapy Director reported that the resident has been dependent for everything for some time and that she would have to re-evaluate the resident to see if bed rails were currently appropriate.On 10/7/25 the Therapy Director provided the discharge summary for the resident's most recent treatment by physical therapy. Review of this document revealed that the resident received services from 4/8/25 - 4/18/25. Although the skilled interventions included therapeutic activities for bed mobility training the pt demonstrating poor carryover secondary to impaired cognition with limited new learning capacity. No mention of the use of bed rails was found in this discharge summary.On 10/07/25 at 5:22 PM the Assistant Director of Nursing (ADON Staff #17) was interviewed in regard to the bed rail process. The ADON reported that the nurses are required to complete a bed evaluation and repeat this evaluation quarterly. If bed rails are required then therapy is involved. In regard to Resident #41, the ADON reported she had completed rounds with the therapy director today, the resident was unable to follow commands and that the bed rails had just been removed within the past hour. She also reported the order has been discontinued and bed rails have been removed from the care plan. Surveyor reviewed the concern that no documentation was found to indicate an initial evaluation was completed prior to the initiation of the bed rails.Further review of the Safe Use of Bed Rails policy revealed in the Procedure section: 3. Monitoring: a. Bed Safety Evaluation is completed upon admission, quarterly, and as needed such as a significant change in condition.Review of the Bed Safety Evaluation assessment form revealed it includes, but is not limited to, information about the resident's ability to make decisions, use a call light, mobility, and medications that would require increased safety precautions.On 10/8/25 further review of the medical record failed to reveal documentation to indicate a Bed Safety Evaluation was completed in 2024 or 2025. An evaluation was found for 2023, but it indicated the resident did not have bed rails at that time.On 10/08/25 at 4:40 PM surveyor reviewed the concern with Nursing Home Administrator (NHA) and the Director of Nursing (DON) that no documentation was found to indicate there was an evaluation prior to the initiation of the Bedrails. The most recent evaluation found in the electronic health record was for 2023 and indicated the resident did not have rails. Surveyor also reviewed that the bed rails were added to the care plan in April 2025, but no order was found until August 2025. As of time of survey exit on 10/9/25 at 5:00 PM no documentation was provided to indicate an evaluation was completed prior to the initiation of the bed rails in April or that a Bed Safety Evaluation was completed by the nurses since 2023.2. On 10/09/25 at 9:20 AM Resident #88 was observed in bed with bed rails in the up position. Review of the medical record revealed a current order to Maintain bilateral bedrails to promote independence with turning and repositioning. Further review of the medical record revealed a Care Plan Note, dated 5/19/25 related to the resident's care plan for falls. This note included the following: Recommendation of IDT [interdisciplinary team] was to apply perimeter mattress to make [Resident #41] more aware of mattress edges; however, [Resident] does not wish to have the perimeter overlay applied. [S/he] requested to have bilateral bedrails applied in order to promote independence with turning and repositioning. No documentation was found in the medical record to indicate therapy completed an evaluation prior to the initiation of the bed rails; and no documentation was found to indicate the resident was educated on the risks of side rails.During an interview on 10/9/25 at 9:45 AM the Director of Nursing (DON) was asked how bed rails get on a resident's bed. The DON reported we generally take a request for side rails to the clinical meeting, discuss with the team then therapy usually does an evaluation, if resident is capable and no risk factors then sometimes nursing will contact the doctor to get the order and obtain the consent and then maintenance is notified.On 10/9/25 at 10:07 AM surveyor, DON and Medical Records (Staff #26) reviewed the resident's thinned record but were unable to identify documentation to indicate an evaluation was completed or an informed consent was obtained prior to the initiation of the bedrails. The DON reported that the document that therapy uses to evaluate is an internal work document that they would share in a meeting and stated: I would throw them away. Further review of the Safe Use of Bed Rails policy revealed in the Procedure section: 2. Consent: a. Disclosure of the needs, risks and benefits of use; b. Education provided to the resident or resident representative; c. Signed by the resident or, if applicable, the resident representative.; and 6. Documentation: a. Physician order is required; b. Completion of Bed Safety Evaluation; c. Consent obtained for bed rail use; and d. Education provided to the resident or, if applicable, resident representative.On 10/9/25 at approximately 4:45 PM surveyor reviewed with the DON and the NHA the concern regarding the failure to assess and failure to obtain consent for the use of bed rails.

Based on record review and interview it was determined that the physician failed to review the hospital records for a resident who was newly admitted to the facility to ensure continuity of care. This was evident for 1 (Resident #125) of 3 residents reviewed for nutrition. The findings include:On 10/8/25 at 1:33 PM a medical record for Resident #125 revealed a History and Physical dated 8/3/25 from the acute care hospital that was uploaded in the miscellaneous section of the electronic medical record. A review of the History and Physical (H&P) revealed in the Assessment/Plan section under the treatment for buccal cavity (mouth) cancer it was documented the resident had surgical intervention, the resident tolerated oral fluids but had aspiration precautions. Furthermore, it read to continue the tube feedings and medications via a gastric tube (g-tube is a tube that is directly inserted into the stomach). The resident was ordered 480 milliliters (mL) of Glucerna 1.5 at 9 am, 2 pm, and 7 pm. A review of the resident's orders revealed an order dated 8/7/25 that the resident was to be NPO (nothing by mouth) except for swabs dipped in water. The tube feeding order dated 8/7/25 read to give Glucerna 1.5 give 1 can (237 mL) three times a day. These orders were entered by Licensed Practical Nurse (LPN) #12 and approved by Nurse Practitioner (NP) #33 on 8/8/25. According to nutritional facts listed on a can of Glucerna 1.5, there are 356 calories per can, thus 3 cans would total 1068 calories daily, which was less than the National Institute of Health recommendation that adults should receive between 1600 – 2400 calories daily. NP #33 failed to review the order for accuracy prior to signing as approved. In addition, she failed to review the orders to realize the resident had not been ordered water via the g-tube for hydrational needs. A review of the NP #33 visit notes for 8/8/25 revealed there was no mention of the resident's diet orders or lack of hydration fluids via g-tube. NP #33 visited the resident on 8/11/25 and noted she spoke to the resident's family member who had a concern with the amount of tube feeding the resident was receiving and scheduled the resident to see their oncologist on 8/12/25 because of this concern. She also noted that the resident was requesting to have water to drink because of dry mouth, but because of the receiving orders (orders from the hospital) indicated the resident was to remain NPO. This was inaccurate as the H&P from the hospital dated 8/3/25 noted the resident was tolerating fluids orally. The NP noted that she had consulted the dietitian. The NP failed to review the hospital records and current plan of care after the concerns were brought to her attention by the resident and family members. NP #33 failed to catch that the resident had no orders for hydration through the g-tube after these two visits. The NP was not working at the facility at the time of the survey. A review of Registered Dietitian (RD) #34's nutritional assessment dated [DATE] at 1:21 PM, confirmed that the resident should have received between 1680 – 1960 calories daily and 1600 mL of fluids each day for hydration. An interview with the Medical Director on 10/14/25 at 5:10 PM revealed that it was expected that the Nurse Practitioner reviews the resident's hospital records and follows the recommended diet orders. He stated that it was concerning that NP #33 failed to ensure that the resident had the correct diet orders and that hydration fluids were included for the resident. On 10/8/25 at 5:19 PM the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of the concerns. Cross Reference F684

Based on medical record review and interview it was determined that the facility failed to ensure regularly scheduled medication was re-ordered and delivered in a timely manner; and failed to ensure staff accessed interim supply of medication when needed. This was found to be evident for one (Resident #3) out of five residents reviewed for unnecessary medications.The findings include: On 10/6/25 review of Resident #3's medical record revealed the resident had an order for Atorvastatin 20 mg at bedtime for hyperlipidemia (high cholesterol). This order had been in place since 8/12/25. Review of a pharmacy delivery manifest, signed by nurse #16, revealed 30 tablets of Atorvastatin 20 mg were delivered to the facility for Resident #3 on 8/12/25. On 10/6/25 review of the Medication Administration Record (MAR) revealed documentation that the resident received the Atorvastatin when due 8/12 through 9/15/25. This is 35 dosses that were documented by staff.On 10/6/25 review of the Medication Administration Record (MAR) and the progress notes revealed the Atorvastatin was not administered on 9/16/25 because the medication was on order. The medication was documented administered as ordered for the next 12 days on 9/17 - 9/28/25. On 9/29 staff documented that the Atorvastatin was not administered due to Waiting for pharmacy to deliver. The medication was documented administered as ordered for the next 5 days on 9/30 - 10/4/25. On 10/5/25 staff documented that the Atorvastatin was not administered due to Awaiting delivery from pharmacy.During the medication storage review, on 10/3/25, surveyor observed that the facility has an Omnicell pharmacy device. The Omnicell is a device used for medication storage that staff can access as needed if a medication is required prior to delivery from the pharmacy. This supply is sometimes referred to as an interim supply. On 10/6/25 at 3:36 PM review of the Omnicell inventory sheet (which was Current as of 1/15/25) revealed Atorvastatin 10 mg tablets are kept available at the facility. On 10/06/25 at 3:41 PM Nurse #8, who was assigned to care for Resident #3, was unable to find Atorvastatin in the medication cart, either in the main supply area or in the overflow. Nurse #8 confirmed she did not see the medication in the cart. Nurse #8 then checked the computer stating, I can see if it's been re-ordered. After checking the computer, Nurse #8 reported it did not look like the medication had been re-ordered. Nurse #8 stated they usually send a 30-day supply. When asked what she would do if the medication was not available when due, Nurse #8 reported she would check the list of interim meds and could call the pharmacy. On 10/6/25 at 3:45 PM Surveyor reviewed the concern with the Director of Nursing (DON) that according to the medical record the Atorvastatin was not administered on 9/29 or 10/5 due to not being available; and there is no current supply and the nurse on the unit indicated it had not been re-ordered. The DON reported they can pull the medication from the Omnicell if available. During the 10/6/25 interview the DON went on to report a new process with the pharmacy if the resident is Long Term Care. They can sign them up to sustain refills, and if enrolled then the regularly scheduled medication auto refills and should not need to be re-ordered. Review of the computer screen with the DON revealed the resident was opted in to Sustain refill on 10/3/25. The surveyor then requested the current list of Omnicell meds; if any Atorvastatin was recently pulled from Omnicell supply; and documentation regarding the delivery of Atorvastatin from the pharmacy. On 10/07/25 at 8:45 AM the DON provided the manifest from the pharmacy for a delivery on 8/12/25 that included 30 tablets of Atorvastatin 20 mg. The only report from Omnicell provided was for a different resident and a different medication. The surveyor then reviewed the concern that staff documented on 9/29/25 that they were waiting for the medication from pharmacy; the facility is not able to provide documentation that it was delivered or that it was removed from the interim supply, but staff documented the administration of the medication for several days after 9/29/25. DON states: I can't speak to that.On 10/7/25 at 10:40 AM the DON reported that sometimes the pharmacy manifest is wrong.Further review of the medical record on 10/7/25 revealed that the Atorvastatin was not given when due on 10/6/25 due to Waiting for pharmacy to deliver. No documentation was found to indicate staff attempted to access the interim supply from the Omnicell on 10/6/25.On 10/07/25 at 11:00 AM surveyor observed resident's current supply of medication with nurse #4. The current supply included 30 tablets of Atorvastatin 20 mg. Nurse #4 reported this supply just came in that day.On 10/07/25 at 5:14 PM surveyor reviewed with Nursing Home Administrator and DON that the Atorvastatin was not given again last night. The Assistant DON, who was also present, confirmed the 10 mg is in the Omnicell. The DON reported she has started education, and indicated the nurses are going to start getting the meds out of the Omnicell.As of time of survey exit on 10/9/25 at 5:00 PM no documentation was provided to indicate a refill of the Atorvastatin was delivered after the initial delivery of 30 tablets on 8/12/25 and prior to 10/7/25.

Based on observation and interview, it was determined that the facility failed to ensure resident treatment carts were locked when unattended; ensure insulin pens were dated upon opening and discarded according to manufacturer guidelines; and ensure that insulin pens were stored in a manner that prevented potential cross-contamination. This was evident during two random observation of treatment carts; 1 of 3 medication carts and 2 out of 3 medication storage rooms observed during the annual recertification survey. The findings include: 1.On [DATE] at 6:20 AM, an observation was made on the first floor. A treatment cart was noted near the nursing station but not within direct view of staff. The cart was unlocked, and the surveyor was able to open one drawer without staff noticing. The surveyor alerted Nurse (Staff #20) to the unlocked cart. Nurse (Staff #20) stated the cart should have been locked. On [DATE] at 6:21 AM, a review of the cart contents with Nurse (Staff #20) revealed, but was not limited to, the following medications: prescription medications Nystatin Powder and Tazarotene 1% Cream. In addition, a bottle of Hydrogen Peroxide 3% Solution. On [DATE] at 6:24 AM, Nurse (Staff #20) was observed locking the treatment cart. On [DATE] at 6:32 AM, a second observation was made on the second floor near, but not in direct view of, the nursing station. The surveyor was again able to open a treatment cart drawer without staff noticing. The surveyor alerted Nurse (Staff #21) to the unlocked cart. A review of the cart contents with Nurse (Staff #21) revealed, but was not limited to, Mupirocin (prescription topical antibiotic) and Hydrogen Peroxide 3% Solution. On [DATE] at 6:35 AM, Nurse (Staff #21) locked the treatment cart. On [DATE] at 6:45 AM, the Administrator was notified of the unlocked treatment carts. On [DATE] at 4:38 PM, the Administrator provided a facility policy titled Storage of Medications, effective 9/2018. On [DATE] at 4:39 PM, review of this policy revealed that only licensed nurses, pharmacy personnel, and other individuals lawfully authorized to administer medications (such as medication aides) may access medications. The policy further states that medication rooms, carts, and supplies must be locked when not attended by authorized personnel. On [DATE] at 11:38 AM, the above concerns were discussed with the Director of Nursing (DON) and the Administrator. The DON reported that re-education of nursing staff on ensuring treatment carts remain locked had already begun. 2) On [DATE] at 8:40 AM, Nurse #3 provided a review of the medication storage room on the second floor that is at the front of the unit. Stored in the front medication storage room cabinets on the second floor were expired [NAME]-brand electrode packages from 04/2025 for what appeared to be an adult-size Automatic External Defibrillator, though Nurse #3 cannot verify that. On [DATE] at 8:40 AM, Nurse #3 unlocked the refrigerator in the medication storage room, and it was revealed that resident specimens were also stored in the resident medication refrigerator. This was evident from clear sleeves containing what appeared to be red, body-fluid-like samples. Nurse #3 confirmed that resident specimens are kept in the resident medication refrigerator and stated they have observed stored specimens in other resident medication storage room refrigerators. On [DATE] at 9:10 AM, the first-floor resident medication storage room was observed with Nurse #5. The sink in the resident medication storage room had a dark, green-to-black substance around the drain, and a tabletop dehumidifying device was draining. Nurse #5 unlocked the refrigerator in the resident medication storage room, and it was revealed that resident specimens were stored there. This was evident from clear sleeves containing what appeared to be red, body-fluid-like samples. Nurse #5 confirmed, all resident specimens are kept in the medication refrigerator as a standard practice. On [DATE] at 09:50 AM, Nurse # 4 provided access to the resident medication storage room at the rear of the second-floor nursing unit. During the observation of the resident medication cart at the rear nursing station, it was revealed that the top drawer contained loose, unlabeled insulin pens: Resident #70: had three open insulin pens in one resident-specific zip sleeve. There is no date indicating when they were first initiated for use. Resident #126: No resident-specific label, in a clear zip sleeve with a Sharpie-marked last name on the insulin pen. No open date. Resident #117: No resident-specific label, in a clear zip sleeve with a Sharpie-marked last name on the zip sleeve. No open date. On [DATE] at 10:02 AM, Nurse #4 was present during the observation of the resident's medication cart. During the observation, Nurse #4 approached the cart where the surveyor was documenting and declaring the findings. Nurse #4 implemented corrective action during the observation and began to remove all of the unlabeled insulin pens, returned to the resident medication storage room, and obtained all new insulin pens with resident-specific labels to return to the cart. Nurse #4 acknowledged this was usual storage practice, The pharmacy has us store it like this. On [DATE] at 10:37 AM, during a review of the facility's policies on the topics below, it was found that the facility does not follow its policies for medication labeling and storage. Storage of Medications (effective 09/2018, revised 08/2024): procedure 1. The provider pharmacy dispenses medication in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medication to the original container. , 3. All medications dispensed by the pharmacy are stored separately from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye medications are stored separately per facility policy. and 9. Medication storage areas are kept clean, well-lit, and free of clutter, extreme temperatures, and humidity. Medication Labels (effective 09/2018, revised 08/2020): procedures1. Labels are permanently affixed to the outside of the prescription container. No medication is accepted with the label inserted into a vial. If a label does not fit directly onto the product, the label may be affixed to an outside container or carton, but the resident's name must be maintained directly on the actual product container 2. Each prescription label includes:a. Resident's name b. When required by state regulations, specific directions for use, including route of administrationc. Medication name. Non-innovator multiple-source (generic) drug products dispensed in place of innovator brand (brand name) products are labeled with the generic name and the manufacturer's name or an acceptable abbreviationd. Strength of medication. Injectables and liquids are labeled with the strength per mL (milliliter) and the amount to be given in mL equivalents on the label. (Example: When furosemide 40mg injectable is ordered ad the pharmacy supplies it in a vial containing 40mg/mL, the directions read Inject 1mL (40 mg) e. Prescriber's namef. Date dispensed g. Quantity of medication h. beyond use or expiration date of medication i. Name, address, telephone number of the dispensing pharmacyj. DEA number of the dispensing pharmacy, if requiredk. Prescription numberl Auxiliary labels indicate storage requirements and special procedures, such as shake well, or refrigeratem. Container number and total of containers (i.e., 1 of 3, 2 of 3, 3 of 3) when multiple containers are dispensed for one prescription/order n. Initials of the dispensing pharmacist o. Lot number of the medication dispensed4. Improperly or inaccurately labeled medications should be rejected and returned to the dispensing pharmacy, and 6. Medication labels are not altered, modified, or marked in any way by nursing personnel. Contents are not transferred from one container to another. Under no circumstances are unattached labels requested from or accepted from the pharmacy. Only the pharmacy/registered pharmacist may place a label on the medication container On [DATE] at 2:45 PM, the Nursing Home Administrator and Director of Nursing were made aware of and acknowledged the deficiency. Refer also to F 880.

Based on medical record review and interview it was determined that the facility failed to have a system in place to ensure only one active version of a resident's orders for life-sustaining treatment was located in the medical record. This was found to be evident for one (Resident #3) out of four residents reviewed for advance directives.The findings include: Review of Resident #3's electronic medical record revealed, in the miscellaneous section, an upload of a current Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form that included orders to Attempt CPR. This order, also known as a full code, means if cardiac and/or pulmonary arrest occurs, attempt cardiopulmonary resuscitation (CPR); this includes any and all medical efforts that are indicated during arrest, including artificial ventilation and efforts to restore and/or stabilize cardiopulmonary function. This MOLST was dated [DATE].MOLST forms include orders for Emergency Medical Services (EMS) and other medical personnel regarding CPR. It is valid in all health care facilities and programs throughout the state. If a resident is transferred out of the facility it is expected that a copy of the MOLST will be sent with the resident. A MOLST that has not been voided (by having a line drawn across it and the word VOID) is considered to be a current active order.Further review of the electronic medical record's miscellaneous section revealed an upload titled VOID MOLST, however when surveyor opened this document an unvoided MOLST was found. Review of this MOLST, dated [DATE], revealed orders for No CPR. This order, also known as a Do Not Resuscitate (DNR) means if cardiac and or pulmonary arrest occurs, do not attempt resuscitation, allow death to occur naturally.On [DATE] at 11:57 AM interview with the Director of Clinical Operations (Staff #27) revealed that when a new MOLST is established the old MOLST is Voided and given to the social worker. The surveyor reviewed the concern that the old MOLST was not voided and that staff could have access to two different MOLST with conflicting orders.On [DATE] at 12:20 PM the Nursing Home Administrator (NHA) reported that the old MOLST was voided and showed surveyor that a voided version of the [DATE] MOLST was included with the [DATE] MOLST upload. The surveyor reviewed the concern with the NHA that staff could still access the old unvoided MOLST that had conflicting orders. The NHA reported: we train them to go with the most recent.

Based on record review and resident and staff interview, it was determined that the facility failed to document that the resident either received the pneumococcal and influenza vaccine(s) or did not receive the vaccine(s) due to medical contraindications, previous vaccination, or refusal. This was evident for 1 (Resident #117) out 5 residents reviewed for immunizations during the survey.The findings include: On 10/6/25 at 12:20 PM a record review in the electronic health record (EHR) regarding Resident #117 vaccination records revealed that the resident was admitted on [DATE]. It lacked documentation of immunization of whether the resident did or did not receive the vaccines, contraindications, vaccine history or refusal. On 10/6/25 at 12:45 PM in an interview with the Nursing Home Administrator (NHA) and the Infection Preventionist (Nurse #15), indicated that the process for immunizing or verifying a new resident's vaccine status was usually done in 5 days. They were unable to produce documentation that Resident #117's vaccine status had been assessed, whether a vaccine was offered or refused. Nurse #15 stated, s/he must have slipped through the cracks. I'll follow up today. On 10/6/25 at 1:00 PM in an interview Resident #117 indicated that s/he did not think they [the facility] even offered it. On 10/9/25 the NHA, Infection Preventionist (Nurse #15) and DON were made aware of the concern.

Based on record review and resident and staff interview, it was determined that the facility failed to document that the resident either received the Covid vaccine or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal. This was evident for 1 (Resident #117) out 5 residents reviewed for immunizations during the recertification survey.The findings include:On 10/6/25 at 12:20 PM a record review in the electronic health record (EHR) regarding Resident #117 vaccination records revealed that the resident was admitted on [DATE]. It lacked documentation of Covid immunization, of whether the resident did or did not receive the vaccine, contraindications, vaccine history or refusal. On 10/6/25 at 12:45 PM in an interview, the Nursing Home Administrator (NHA) and the Infection Preventionist (Nurse #15), indicated that the process for immunizing or verifying a new resident's vaccine status was usually done in 5 days. They were unable to produce documentation that Resident #117's vaccine status had been assessed, whether the Covid vaccine was offered or refused. Nurse #15 stated, s/he must have slipped through the cracks. I'll follow up today. On 10/6/25 at 1:00 PM in an interview Resident #117 indicated that s/he did not think they [the facility] even offered it. On 10/9/25 the NHA, Infection Preventionist (Nurse #15) and DON were made aware of the concern.

Based on record review and interview, it was determined that facility staff failed to provide an environment for residents which was free from abuse. The deficient practice resulted in a harm for Resident #74, #256, and #34. This was evident for 4 (Resident #74, #256, #7, and #34) of 16 residents investigated for abuse. The findings include: Dementia is not a specific disease, but is instead a general term for the impaired ability to remember, think, or make decisions that interfere with everyday activities. A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. 1) On 9/7/23 at 9:13 AM, a medical record review for Resident # 74 was conducted. The review revealed that a preadmission intake or referral form was completed on 4/26/22 by Resident #74's previous residence which indicated that the reason for referral was because Resident #74 had a decline in cognitive function and required increased nursing care. The referral form also stated that Resident# 74 had struck a peer due to not allowing them to enter a room. A continued review of Resident #74's medical record failed to reveal a care plan that addressed the potential to strike other residents. In addition, there was a care plan, initiated on 6/12/22, for the resident's mood problems which were listed as Altered Sleep Patterns, Disease process, Family Dynamics, Nursing Home Admission, Psychosocial issues, history of delusions (Delusion is a false belief that indicates an abnormality in the affected person's content of thought), and hallucinations (the sensory perceptions of hearing noises without an external stimulus). The goal was that the resident would not experience increased signs and symptoms of mood disturbance. The interventions were not resident-specific with ways to alert staff when the resident ' s mood was changing, having delusions and/or hallucinations, and what safety measures should be implemented. Further review revealed a care plan for wandering behaviors, but failed to include that the resident wandered into other resident ' s rooms uninvited and had a history of aggressive behavior toward others, which was documented in the preadmission intake form, dated 4/26/22. A medical record review on 9/13/23 at 10:00 AM, showed a psychiatrist's note dated 6/26/22. The note documented that Resident # 74 received treatment since 2020 for psychiatric problems characterized by worsening Dementia associated with psychotic symptoms like auditory hallucinations, agitations (a feeling of irritability or severe restlessness), and self-neglect. A review of a facility-reported incident investigation file on 9/13/23 at 10:15 AM revealed that, on 8/11/22, Resident #47 was propelling themself in the hallway, and Resident # 74 grabbed Resident # 47 ' s wrist. A continued review of Resident #74's medical record on 9/13/23 at 10:00 AM, revealed an attending provider's note, dated 8/11/2022, for a visit conducted after the incident. The note recorded that Resident # 74 was having behavioral outbursts, threatening staff, and other residents. It also stated that Resident # 74 had grabbed hold of another resident. Resident # 74 was transferred to the hospital for further evaluation and management of their aggressive and violent behaviors. However, Resident #74 ' s care plan was not updated to reflect the resident to resident altercation or include interventions to prevent further incidents. A continued medical record review revealed a nurse's note, documented on 8/17/2022, that Resident #74 continued to walk into other residents' rooms and was unable to be redirected. The behavior care plan was revised again on 8/18/22 with new interventions to speak to Resident #74 in a calm, quiet tone of voice. If Resident # 74 appeared agitated, follow-up with the nurse or attending physician. However, the resident ' s behavior of wandering into other resident ' s rooms was not addressed nor were interventions included to prevent further incidents. On 9/13/23 at 11:00 AM, a continued record review revealed a nurse's note written by staff # 9, Licensed Practical Nurse (LPN), on 11/2/2022. The note indicated that Resident #74 was observed to be entering room [ROOM NUMBER]. Staff # 9 attempted to redirect Resident # 74, who started cursing staff and then walked away from room [ROOM NUMBER] after several attempts to redirect. However, Resident # 74 ' s care plan was not updated to address the resident ' s continuing behavior of wandering into other resident ' s rooms nor did it include interventions to mitigate the wandering behavior. Further record review revealed that a psychiatrist saw Resident #74 for increasingly reckless and aggressive behaviors on 12/1/22, and the plan was to give antipsychotic medication in liquid form for better absorption and continue the antidepressant at night. Even though Resident # 74 ' s increasingly aggressive behaviors were reported to the psychiatrist by the facility, coupled with the resident wandering into another resident ' s room, they failed to implement an increased level of supervision to prevent resident-to-resident abuse. Subsequent record review revealed a progress note, dated 1/4/2023, which documented that Resident #74 was found in another resident's room by facility staff, and an attempt to redirect was met with resistance. After several attempts to redirect them out of the other resident ' s room, Resident #74 did allow staff to take them back to their room. However, the facility staff failed to update the behavior care plan to increase the level of supervision to prevent further incidents of Resident # 74 wandering into other resident ' s rooms and becoming aggressive with other residents. On 9/13/23 at 11:15 AM, a review of the facility investigation file revealed that an incident of resident-to-resident abuse occurred on 1/13/23, involving Resident #74 and Resident #256. The witness statement read that Resident #256 was blocking the doorway to his/her room from Resident #74 who also resided in the room. When Resident #74 attempted to go into the room s/he and Resident #256 started hitting each other. This altercation resulted in redness to Resident #256 ' s cheek, and Resident #74 had a red, swollen right hand. Resident #74 ' s medical record was reviewed on 9/14/23 at 9:59 AM, and revealed the resident was seen by a psychiatrist on 1/17/23 due to the physical altercation with Resident #256, however, no changes were made to their plan of care. An interview with the Director of Nursing (DON) on 9/19/23 at 8:35 AM, confirmed that she was aware that Resident #74 had a long-standing psychiatric history. She reported that, after the incident on 1/13/23, both residents had been sent to the acute care hospital for evaluation. Upon return to the facility, Residents #256 was moved to a different room on a separate unit and Resident #74 remained in the same room. When asked what interventions were implemented to prevent Resident #74 from abusing other residents residing on the same unit, she reported that she relied on psychiatric services to recommend an increased level of supervision and in this case they had not made that recommendation. On 9/22/23 at 11:00 AM, the facility ' s investigation file was reviewed for the self-reported incident involving Resident # 74 and Resident #7, dated 3/1/23. The report revealed documentation that, on 2/28/23, Resident # 74 entered Resident #7's room uninvited. Resident #7 yelled at Resident #74 to leave their room. Then, Resident #74 made a threatening gesture of raising his/her right fist at Resident #7 before leaving the room. A medical record review for Resident #7 on 9/22/23 at 11:04 AM revealed an MDS assessment dated [DATE], which reported that the resident had no behavioral challenges, no impairment with their cognition, and required help from staff with their care needs. On 9/7/23 at 9:13 AM, a review of Resident # 74 ' s medical record revealed a note written by a psychiatrist that documented that Resident #74 was evaluated on 3/2/23 after the altercation with Resident # 7 for aggressive behavior. It was noted in the Psychiatrist's notes that per staff, Resident # 74 posed a danger to staff and residents. The Psychiatrist increased Resident #74's antipsychotic medication and decreased their antidepressant medication. The psychiatrist ' s note failed to indicate the level of supervision that was needed to prevent other residents from further abuse. A review of Resident #74's physician's orders revealed an order, dated 03/02/2023, for one-on-one supervision ( defined as one staff member physically present with a resident) for behavior monitoring every shift. On 3/9/23, a new order was entered for the one-on-one supervision to be decreased to day and evening shifts only. This order was discontinued on 3/13/23, and a new order was entered for the one-on-one supervision to be provided for day shift only. This order was discontinued on 3/20/23. However, the facility staff failed to include in Resident #74 ' s plan of care the ongoing level of supervision needed to protect other residents from further abuse. During an interview with the DON on 9/19/23 at 8:45 AM, she was asked what measures had been put into place after the incident on 1/13/23 to prevent further incidents of abuse by Resident # 74. The DON reported that she relied on changes to the resident ' s psychotropic medications and had not considered increased supervision unless the attending provider or psychiatrist made that recommendation. During a medical record review on 9/14/23 at 9:59 AM, additional progress notes were found indicating that Resident #74 continued to wander in and out of other resident ' s rooms. On 5/24/2023, it was documented in a nurse ' s note that Resident # 74 was cursing at staff and other residents. Resident # 74 appeared more agitated when asked not to go into other rooms or touch other residents' belongings. On 6/4/2023, it was documented in a nurse ' s note that Resident #74 continued wandering in and out of other residents' rooms. Then, on 6/8/23, a nurse's note indicated that Resident # 74 had been up most of the night, wandering in the hallway and occasionally going into other residents' rooms. However, further review revealed that no changes in the level of supervision for Resident #74 were implemented to protect other residents from further abuse. On 9/14/23 at 9:59 AM, a review of an investigation for a facility-reported incident, dated 6/18/23, recorded a resident to resident abuse incident. The report indicated that Resident # 74 wandered into Resident #34's room and attempted to remove food from Resident #34's tray . When Resident # 34 attempted to prevent Resident # 74 from taking the food, Resident #74 hit Resident # 34 on the left hand, resulting in a skin tear to Resident #34's hand. A medical record review was done for Resident #34 on 9/21/23 at 8:59 AM. The review revealed an MDS assessment, dated 5/10/23, which recorded that Resident #34 had severe cognitive impairment, no behavioral issues, was dependent on staff with their self-care needs, and would need help getting out of bed. On 9/15/23 at 9:32 AM, an interview was conducted with the attending provider, who is the facility's Medical Director. The interview revealed that he had been unaware of Resident # 74 ' s behaviors before their admission to the facility. However, Resident #74 ' s behavior had been noted in the preadmission screening form completed on 4/26/22. He reported that the facility was aware that Resident #74 would go into other residents ' rooms, however, failed to anticipate that this behavior and the history of aggressive behaviors could lead to resident-to-resident abuse. He reported that the facility had attempted to use tape on the floor and a physical barrier with stop signs to stop Resident #74. When asked what interventions had been put into place after each abuse incident on 1/13/23, 2/28/23, and 6/18/23, he reported that a psychiatrist was seeing Resident #74 frequently. On 9/19/23 at 8:45 AM, an interview was conducted with the DON. She was asked what the facility did after the incident involving Residents # 74 and #7. She stated that they ordered one- to-one supervision for Resident # 74. However, they tapered the one - to - one supervision down by shift and then it was discontinued on 3/20/23. She reported that they had not included a level of supervision in the care plan interventions because she relied on psychiatric services to recommend this intervention. Per the DON the resident had been wandering without supervision until the next incident occurred on 6/18/23. An interview was conducted with staff # 20, a Psychiatric Nurse Practitioner, on 9/20/23 at 10:16 AM. During the interview, she stated that the facility staff should have anticipated aggressive behaviors for Resident #74 due to their diagnoses. She stated that a care plan should have been initiated with appropriate interventions to mitigate the behaviors.

Based on record review and interview, it was determined that facility staff failed to provide the supervision needed to prevent resident to resident altercations which resulted in harm. This was evident for 1(#74) of 7 residents reviewed for accidents. The findings include: Dementia is not a specific disease, but is instead a general term for the impaired ability to remember, think, or make decisions that interfere with everyday activities. A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. A medical record review for Resident # 74 on 9/7/23 at 9:13 AM revealed a preadmission intake or referral form completed on 4/26/22 by Resident #74's previous residence that indicated that the reason for referral was because Resident #74 had a decline in cognitive function and required increased nursing care. The referral form also stated that Resident# 74 had struck a peer due to not allowing them to enter a room. A continued review of Resident #74's medical record revealed that a care plan was initiated on 6/14/22 for Resident #74's behavior to wander aimlessly from place to place. The goal of the care plan was that Resident # 74 would wander without injury. However, the care plan failed to address that Resident # 74 wandered to other residents' personal space and what appropriate interventions staff could utilize to redirect Resident # 74. Further review of Resident #74's medical record revealed a care plan, initiated on 6/12/22, for the resident's mood problems listed as Altered Sleep Patterns, Disease process, Family Dynamics, Nursing Home Admission, Psychosocial issues, history of delusions, and hallucinations. The goal was that the resident would not experience increased signs and symptoms of mood disturbance. The interventions were not resident-specific to alert staff when the resident ' s mood was changing, having delusions and/or hallucinations, and what safety measures should be implemented. Furthermore, the care plan failed to include a history of aggressive behavior toward others, which was documented in the preadmission intake form dated 4/26/22. On 9/13/23 at 10:00 AM, a medical record review revealed a psychiatrist's note, dated 6/26/22, which documented that Resident # 74 received treatment since 2020 for psychiatric problems characterized by worsening Dementia associated with psychotic symptoms like auditory hallucinations ( the sensory perceptions of hearing noises without an external stimulus), agitations (a feeling of irritability or severe restlessness), and self-neglect. A continued review of Resident #74's medical record revealed an attending provider's note dated 8/11/2022 that recorded Resident # 74 was having behavioral outbursts, threatening staff, and other residents. The note stated that Resident # 74 had grabbed hold of another resident. Resident # 74 was transferred to the hospital for further evaluation and management of their aggressive and violent behaviors. A review of a facility-reported incident investigation file on 9/13/23 at 10:15 AM revealed that, on 8/11/22, Resident #47 was propelling themself in the hallway, and Resident # 74 grabbed Resident # 47 ' s wrist. However, Resident #74 ' s care plan was not updated to reflect the resident to resident altercation and include interventions to prevent further incidents. A continued medical record review revealed a nurse's note documented on 8/17/2022 that Resident #74 continued to walk into other residents' rooms and was unable to be redirected. The behavior care plan was revised again on 8/18/22 with new interventions to speak to Resident #74 in a calm, quiet tone of voice. If Resident # 74 appears agitated, follow up with the nurse or attending physician. However, Resident # 74 ' s behavior was not addressed. On 9/13/23 at 11:00 AM, a continued record review revealed a nurse's note written by staff # 9, Licensed Practical Nurse (LPN), on 11/2/2022. The note indicated that Resident #74 was noted to be entering room [ROOM NUMBER]. Staff # 9 attempted to redirect Resident # 74, who started cursing staff and then walked away from room [ROOM NUMBER] after several attempts to redirect. However, Resident # 74 ' s care plan was not updated with their continuing specific wandering behavior and interventions to mitigate it. Further record review revealed that a psychiatrist saw Resident #74 for increasingly reckless and aggressive behaviors on 12/1/22, and the plan was to give antipsychotic medication in liquid form for better absorption and continue the antidepressant at night. Even though Resident # 74 ' s increasingly aggressive behaviors were reported to the psychiatrist by the facility, they failed to implement an increased level of supervision for Resident # 74 ' s and other residents ' safety. Subsequent record review revealed a progress note, dated 1/4/2023, which documented that Resident #74 was found in another resident's room by facility staff, and an attempt to redirect was met with resistance. After several other attempts, Resident #74 did allow staff to take them back to their room. However, the facility staff failed to update the care plan to address Resident # 74 ' s continuing wandering behavior. On 9/13/23 at 11:15 AM, a review of the facility investigation file revealed that, on 1/13/2023, Resident #74 had a physical altercation with Resident # 256. The witness statement indicated that Resident #256 had been standing in the doorway of their room and was heard saying it was their room. Then, Resident #256 and Resident #74 started hitting each other. This altercation resulted in redness to Resident #256 ' s cheek, and Resident #74 had a red, swollen right hand. Further medical record review, on 9/14/23 at 9:59 AM, revealed that Resident #74 was seen by a psychiatrist on 1/17/23 due to the physical altercation with Resident #256, and no changes were made to their plan of care. An interview was conducted with the Director of Nursing (DON) on 9/19/23 at 8:35 AM. When she was questioned about what the facility knew about Resident #74 before their admission, she responded that they knew Resident # 74 had a long-standing Psychiatric history before admission to the facility. A continued interview with the DON revealed that the facility sent Residents #256 and 74 to the emergency room for evaluation after the altercation on 1/13/23. Then, they moved Resident #256 to a different unit, and Resident # 74 remained in the same room upon return from the emergency room . The interview, however, failed to reveal that any new intervention was put into place for Resident # 74 after this altercation. On 9/22/23 at 11:00 AM, the facility ' s investigation file was reviewed for the self-reported incident involving Resident # 74 and Resident #7, dated 3/1/23. The report recorded that on 2/28/23, Resident # 74 entered Resident #7's room uninvited. Resident #7 yelled at Resident #74 to leave their room. Resident #74 raised their right hand and made a fist but then left the room. A medical record review for Resident #7 on 9/22/23 at 11:04 AM revealed an MDS assessment dated [DATE], which reported that the resident had no behaviors, no impairment with their cognition, and required help from staff with their care needs. On 9/7/23 at 9:13 AM, a review of Resident # 74 medical record revealed a note written by a psychiatrist that documented that Resident #74 was evaluated on 3/2/23 after the altercation with Resident # 7 for aggressive behavior. It was noted in the Psychiatrist's notes that per staff, Resident # 74 posed a danger to staff and residents. The Psychiatrist increased Resident #74's antipsychotic medication and decreased their antidepressant medication. A review of Resident #74's physician's orders revealed an order dated 03/02/2023 for one-on-one supervision (one one-on-one is when one staff member is physically present with a resident) for behavior monitoring every shift. On 3/9/23, there was a new order for one-on-one supervision for behavior monitoring for days and evening shifts only, which was discontinued on 3/13/23, and a new order was put in place for one-on-one supervision for behavior monitoring on day shifts only, which was discontinued on 3/20/23. However, the facility staff failed to include in Resident #74 ' s plan of care the ongoing level of supervision needed to protect Resident #74 and other residents. During an interview with the DON on 9/19/23 at 8:45 AM, she was asked what measures had been put into place after the incident on 1/13/23 to prevent this incident when Resident # 74 entered Resident #7's room uninvited. The DON reported that she relied on medication changes and had not considered increased supervision unless the attending provider or psychiatrist made that recommendation. A medical record review revealed that Resident #74 had continued to wander into other residents ' rooms. On 5/24/2023, it was documented in a nurse ' s note that Resident # 74 was cursing at staff and other residents. Resident # 74 appeared more agitated when asked not to go into other rooms or touch other residents' belongings. On 6/4/2023, it was documented in a nurse ' s note that Resident #74 continued wandering in and out of other residents' rooms. Then, on 6/8/23, a nurse's note indicated that Resident # 74 had been up most of the night, wandering in the hallway and occasionally to other residents' rooms. On 9/14/23 at 9:59 AM, a review of an investigation for a facility-reported incident dated 6/18/23 recorded that Resident # 74 went into Resident #34's room uninvited to get Resident #34's muffin. Resident # 34 attempted to prevent Resident # 74 from taking the muffin. Resident #74 hit Resident # 34 on the left hand, resulting in a skin tear to Resident #34's hand. On 9/21/23 at 8:59 AM, a medical record review was done for Resident #34. The review revealed an MDS assessment dated [DATE], which recorded that Resident #34 had severe cognitive impairment, no behaviors, was dependent on staff with their self-care needs, and would need help getting out of bed. On 9/15/23 at 9:32 AM, an interview was conducted with the attending provider, who is the facility's Medical Director. The interview revealed that he had been unaware of Resident # 74 ' s behaviors before their admission to the facility. However, Resident #74 ' s behavior had been noted in the preadmission screening form completed on 4/26/22. He reported that the facility was aware that Resident #74 would go into other residents ' rooms and that the facility had attempted to use tape on the floor and a physical barrier with stop signs to stop Resident #74. When asked what interventions had been put into place once they were made aware that Resident #74 had a physical altercation with Resident #256 on 1/13/23. He reported that a psychiatrist was seeing Resident #74 frequently. When asked if he was aware of Resident #74 ' s incidents in March and June, he stated that they had discussed it in a meeting and decided that one-on-one supervision was the best option for now. On 9/19/23 at 8:45 AM, an interview was conducted with the DON. She was asked what the facility did after the incident involving Residents # 74 and #7. She stated that they immediately increased Resident # 74 ' s supervision. She was also asked what the facility did to prevent the occurrence. She indicated the Psychiatrist did make changes to Resident #74's medications and did not recommend one-on-one staff supervision. The facility relied on the Psychiatrist to make the decision for increased supervision of Resident # 74. An interview was conducted with staff # 20, a Psychiatric Nurse Practitioner, on 9/20/23 at 10:16 AM. During the interview, she stated that the facility staff should have anticipated aggressive behaviors for Resident #74 due to their diagnoses. She stated that a care plan should have been initiated with appropriate interventions to mitigate the behaviors.

Based on record review and staff interview, it was determined that the facility staff failed to provide personal care in a safe manner for a resident which resulted in a fall and the resident was hospitalized due to the injuries. This was evident with 1 (#1) of 3 residents reviewed for falls and resulted in actual harm to Resident #1. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A medical record review for Resident #1 on 11/12/20 at 12:31 PM, revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/20, which documented in section G, that Resident #1 was an extensive 2 person assist during bed mobility and toileting in bed. (Extensive is defined in the MDS worksheet as the resident is involved in the activity, but staff provide weight - bearing support). In section A of the MDS with the ARD of 8/25/20, it was documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15. According to the MDS Manual 3.0 dated 10/2019, a BIMS score in the range of 8-12 means a resident has moderate cognitive impairment. Review of the [DIAGNOSES REDACTED].#1 had been diagnosed with [REDACTED]. Further review of the medical record revealed Fall Risk Observation Tool assessments that had been completed by the nurses on 9/16/20, 9/30/20, and 10/9/20, that had indicated that Resident #1 was a fall risk. Furthermore, Resident #1 had the following care plan initiated on 8/8/19 and revised on 6/16/20: (Resident #1) is at risk for falls r/t (related to) deconditioning, gait/balance problems, right [MEDICAL CONDITION] repair, muscle weakness, difficulty walking, and obesity. The goal stated that Resident #1 would not sustain serious injury through the next review date on 1/7/21. The interventions before the fall on 10/20/20, included resident education to call for assistance, resident to inform staff immediately if a fall would occur while outside of the facility, remind the resident to use their brakes on the wheelchair before transferring, ensure call light close by, and provide a safe environment. A physical therapy evaluation note, dated 10/12/20, revealed that Resident #1 had been referred to physical therapy on 10/12/20, due to an exacerbation (an increase in a health issue) of decreased strength, decreased functional mobility, a decreased ability to transfer and reduced balance indicating the need for physical therapy. However, the care plan was not updated to reflect Resident #1 ' s change in condition and need for physical therapy. A review of complaint #MD 479 revealed that Resident #1 was receiving care from a staff member and fell out of bed while the bed was in a high position. Resident #1's hit their face on the oxygen concentrator on the way down and sustained injuries to the nose and eye. According to the complainant, Resident #1 was sent to the Intensive Care Unit for a lacerated liver that was bleeding into their abdomen and required blood replacement as a result of the fall. A review of the facility's investigation report of Resident #1's fall on 11/12/20 at 1:00 PM, revealed a written statement from Geriatric Nursing Assistant (GNA) #4 that documented GNA #4 was providing personal care for Resident #1, when she rolled Resident #1 onto their side, and then GNA#4 realized she needed some bed linens. According to GNA #4's statement, she left the room for linens, and when she came back in the room, Resident #1 was rolling out of the bed to the floor. Statements were also obtained from ADON and Resident #1. Review of a resident care sheet for the facility's residents on the 1st floor on 11/16/20 at 11:30 AM, indicated that Resident #1 was a 1-2 person assist for care and was a fall risk. Review of GNA #4's employee record on 11/16/20 at 11:30 AM, revealed an Employee Corrective Action Form that stated the subject of discipline was safety/carelessness and noted left resident unattended in high bed resulting in fall. It was also noted that GNA #4 was, educated on not leaving residents unattended when leaving room to retrieve items. Also, on following care sheet in regard to assistance status. This last statement regarding education provided was previously clarified by the Director of Nursing (DON) in an interview conducted on 11/16/20 at 10:30 AM, that GNA #4 was educated to follow the care plan in regards to how many staff should be assisting with care. An interview with the complainant on 11/13/20 at 9:23 AM, revealed that Resident #1 voiced concerns about whether they would survive the fall. According to the complainant, Resident #1 reported that the staff raised their bed to provide care then left them unattended and that was when the fall occurred. This information was the reason that the complainant filed the report with the State Agency. An interview with the ADON on 11/13/20 at 10:19 AM, revealed that she gave a statement during the investigation of Resident #1's fall because she had responded to Resident #1's call for help. She stated that, when she arrived to the room, Resident #1 was lying on the floor beside their bed. She reported that the bed was at waist level because GNA #4 had been providing care. She reported that she remembered Resident #1 had bleeding from the nose, an abrasion on the cheek, and a large hematoma on her left leg. She reported that she felt leaving a resident unattended on their side was concerning and that GNA #4 could have rolled the resident back before leaving the room and the bed should have been lowered. An interview with GNA #4 on 11/13/20 at 10:39 AM, revealed that she had not been assigned to Resident #1 that day. She reported that she had answered Resident #1's call light. Resident #1 reported she had to be changed. GNA #4 reported that when she rolled Resident #1 on their side she found that Resident #1 had soiled on the sheets. She stated she asked Resident #1 if she would be ok lying on their side until she got the linens off the cart right outside Resident #1's door. She reported that Resident #1 stated she would be ok. GNA #4 stated that while she was unzipping the plastic that was over the resident's door she saw Resident #1 roll out of bed. GNA #4 reported that Resident #1 rolled out of bed to the floor and Resident #1's face hit the oxygen concentrator on the way down. She reported the bed was at waist level. She stated she asked the resident if she was ok and because Resident #1 was bleeding she hollered for someone to help her. She reported the ambulance arrived about 10 - 15 minutes later. When asked if she had been aware Resident #1 had been a fall risk, she stated she was not aware because the resident was not on her assignment that day. On 11/13/20 at 11:18 AM, an interview with the Assistant Director of Nursing (ADON) and DON revealed that staff have a care sheet that indicated the resident's fall risk and how many staff were required to provide care. The care sheet was for the entire floor, regardless of which resident assignment the staff had on any given day. During an interview with Licensed Practical Nurse (LPN) # 5 on 11/13/20 at 11:25 AM, it was revealed that the information about the resident being a fall risk was on the care sheet. The care sheet contained all the residents on the entire floor regardless of staff assignments, so if you had been working an assignment on floor 1, then you would have had a list of all residents on that floor. On 11/13/20 at 11:28 AM, an interview with GNA #6 revealed that he used the care sheet to determine if a resident was a fall risk. He stated that, at times, this information may be given by the nurses during verbal reports especially if there had been a change. On 11/16/20 at 10:30 AM, the surveyor discussed concerns with the DON. She reported that, on the care plan and on the care sheet, this resident was considered a 1-2 person assist with care. When asked how staff were expected to determine when to have 1 or 2 staff with care, especially GNAs, she stated that the nurses determine the level of assistance and provided that information during a verbal report given to the GNA prior to the start of shift. She stated that Resident #1 had good days and bad days, so depending on what was going on, Resident #1 determined whether she had needed 1 or 2 people. However, according to staff interviews, the GNAs were independently making the decision to use 1 or 2 staff, unless there had been a change in status then the nurse would report that to them. An interview with GNA #7 on 11/16/20 at 12:02, revealed that, while they had received changes in the resident status that may affect how many staff was needed for care during a verbal report from the nurses, most days the GNAs had been making the determination. GNA #7 reported that, if the care sheets had indicated 1-2 staff for assistance with care, GNA #7 would have 2 staff for safety reasons. A subsequent interview with GNA #4 on 11/16/20 at 12:05 PM, revealed that, in the past, nurses had given verbal report when a resident was having a bad day and needed 2 staff for assistance. GNA #4 reported that when the care sheet indicated 1-2 staff for assistance with care, GNA #4 would have had 2 staff for safety reasons. GNA #4 was asked what had been different on the day that Resident #1 fell . GNA #4 reported that Resident #1 was talking normally to her and seemed to be in their right mind that day, so she had not felt she needed a second staff member. GNA stated that when Resident #1 stated that they were fine lying on their side while she went to get the linens, GNA #4 thought that Resident #1 would have been ok. During an interview with LPN #2 on 11/17/20 at 2:19 PM, a charge nurse on the unit that Resident #1 resided, she reported that she responded to GNA #4's alert that Resident #1 had fallen. LPN #2 reported that, when she arrived to Resident #1's room, the bed had been at a working level. She reported that she had assessed Resident #1 and that Resident #1 had not wanted them to move their left leg because it hurt. LPN #2 reported that they had thought Resident #2 had broken their leg. When asked whether Resident #1 required 1 or 2 staff assistance with care on that day, LPN #2 stated that she had not reported any concerns with Resident #1 that day to the GNAs. She stated that according to GNA #4, Resident #1 was alert and oriented that day and told GNA #4 he/she would be ok. When asked if GNAs should have made that type of decision regarding care, she reported they shouldn't. However, when asked if she (LPN#2) would have left Resident #1, lying on their side with the bed raised unattended, she stated she would have put the bed in a low position before leaving the resident unattended. The DON was made aware of the findings at the time of exit on 11/18/20 at 9:48 AM. Cross Reference F656

Based on complaint, reviews of a closed medical record and staff interview, it was determined the facility staff failed to provide a resident with a safe environment and enough supervision, during care, to prevent the resident from rolling off the bed onto the floor and receiving a fractured hip. This occurred for 1 of 7 (Resident #6) residents reviewed during a complaint survey. The findings include: Review of complaint MD 952 on 02/21/2017 revealed an allegation Resident #6 fell out of bed during care and suffered a fractured hip. Review of Resident #6's closed medical record on 02/21/2017 revealed nursing documentation, dated 08/07/2016 at 7:21 AM, that indicated Resident #6 was observed on the floor, was noted with right leg pain, and the right leg was observed to be externally rotated. Further review revealed nursing documentation, dated 08/07/2016 at 7:43 AM that indicated Resident #6 fell to the floor while a staff member was cleaning and changing Resident #6's sheets. The 08/07/2016 7:43 AM nursing note also indicated Resident #6 rolled out of bed between the staff member and the bed onto the floor. In an interview with GNA #2 on 02/21/2017 at 3:30 PM, GNA #2 stated he/she was rendering morning care to Resident 6# the morning of 08/07/2016. GNA #2 stated he/she had rolled Resident #6 onto his/her side towards GNA #2 without assistance. GNA #2 stated the bed moved and this is when Resident #6 rolled out of bed onto the floor. GNA #2 stated he/she notified the charge nurse immediately of the fall. Resident #6 was sent to the emergency room to be evaluated and was subsequently diagnosed with [REDACTED]. In conclusion, GNA #2 failed to provide a safe environment for Resident #6 while providing care on the morning of 08/07/2016 at 7:15 AM. This allowed Resident #6 to roll out of bed onto the floor and received a fractured right femur which required a trip to the emergency room and subsequent surgery.