Every finding on record at Deer's Head Center

Based on medical record review and interview it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives. This was found to be evident for 3 (Resident #5, #8 and #7) out of 6 residents reviewed for advance directives during the annual survey.The findings include: 1. An advance directive is a legal document that specifies a person's wishes for end-of-life healthcare. It also specifies who should make healthcare decisions on your behalf if you are unable to do so yourself. During a review of medical records for Resident #5 on [DATE] at 4:05 PM it was revealed that there was no advance directive in the medical records for Resident #5. There was also no documentation of an attempt to obtain any previously created advance directives or that education was provided to the resident or resident's representative about forming advance directives. During a review of medical records for Resident #8 on [DATE] at 4:10 PM it was discovered that there was no advance directive in the medical records for Resident #8. There was also no documentation of an attempt to obtain any previously created advance directives or that education was provided to the resident or resident's representative about forming advance directives. During an interview with the Nursing Home Administrator (NHA) on [DATE] at 9:38 AM she reported that it was standard for the advanced directive information to be included in the admission packet but confirmed there was no documentation of the advanced directives being provided and no documentation of an attempt to obtain any previously created advance directive for Resident #5 or Resident #8. 2. On [DATE] at 7:15 AM, a review of the clinical record for Resident #7 revealed a Maryland Medical Order for Life Sustaining Treatment (MOLST) form, dated [DATE] which indicated the resident was a Full Code per discussion with the resident. The MOLST form is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life sustaining treatments. Further review revealed that no Advance Directive (AD) nor documentation of a discussion on AD was on Resident# 7's clinical record. In an interview on [DATE] at 7:42 AM the Unit Manager Staff #4 stated that the Social Worker was responsible for AD and that the Social Worker had since resigned. The Unit manager advised the surveyor to speak with the Administrator who is also a Licensed Social Worker and is covering that position temporarily. On [DATE] at 8:10 AM the surveyor interviewed the Administrator who confirmed that she was covering for the Social Worker. The Administrator stated that ADs are discussed upon admission and residents/residents' representatives are given paperwork on ADs for completion. The administrator stated that she would review the clinical record of Resident #7 and get back to the surveyor. On [DATE] at 12:17 PM the Administrator in an interview confirmed that there was no AD nor documentation of a discussion on AD on Resident #7's clinical record.

Based on facility investigation, medical record review and interviews, it was determined that the facility failed to prevent an incident of resident-to-resident sexual abuse. This was evident for 1 (Resident #20) of 1 resident reviewed for abuse.The findings Include:Brief Interview for Mental Status (BIMS) is a quick, standardized screening tool used primarily in healthcare, especially long-term care facilities, to assess cognitive function. Scores range from 0-15, with higher scores (13-15) indicating intact cognition, while lower scores suggest moderate (8-12) or severe (0-7) impairment.The facility's investigation related to Facility Reported Incident # 340863 was reviewed by the surveyor on 12/09/25 at 6:45 PM. In the investigation, the facility substantiated through a witness, Staff RN # 11, that on 02/21/25 Resident #16 engaged in oral sexual interactions with Resident # 20 who was severely mentally impaired and incapable of giving consent.On 12/09/25 at 7:00 PM a review of the clinical records of Resident #16 and Resident #20 revealed as follows:Resident #16 was admitted to the Dementia Unit in December 2024 with diagnoses including Dementia and a BIMS score of 4 based on the admission MDS with Assessment Reference Date of 12/11/24. By the end of January 2025, the resident had demonstrated numerous inappropriate sexual advances and comments towards staff and other residents.Resident #20 was admitted to the Dementia Unit in November 2021 with diagnoses including Alzheimer's Disease and had a BIMS score of 1 based on an annual MDS with Assessment Reference Date of 02/3/25.On 12/15/2025 at 10:11 AM the surveyor conducted a telephone interview with RN Staff #11 who witnessed the sexual interaction. RN Staff #11stated that on 02/21/25 at around 3:40 PM while making rounds, she observed Resident #16 engaging in oral sexual interactions with Resident #20 on the Sun Porch. RN Staff #11 stated that she immediately separated the residents and called for help. The incident was reported to her supervisor. Both residents were assessed and there were no injuries. Resident #16 was transferred to the ER for evaluation and upon return was moved to a different unit in a private room and placed on 1:1 monitoring after the incident from 2/21/25 to 5/2/25. After the 1:1 observation ended the resident was on 15 minute checks. On 12/10/2025 at 10:08 AM in an interview the Director of Nursing stated that the facility investigated the incident and that the incident was substantiated since there was a witness who observed the interaction.

Based on medical record review and interviews, it was determined that the facility failed to provide adequate side effects monitoring for residents on psychotropic medications. This was evident for 2 (Resident #7 and #20) of 5 residents reviewed for unnecessary medications.The findings include:Psychotropic medications are drugs that affect the brain and central nervous system, altering mood, thoughts, perceptions, and behaviors. They are primarily used to treat mental health conditions, such as anxiety, depression, schizophrenia, and bipolar disorder.1) On 12/09/2025 at 6:00 PM a review of Resident #7's medical record revealed that he/she was admitted to the facility in March 2021 with diagnoses which included Major Depressive Disorder, Anxiety Disorder, Borderline Personality Disorder and End Stage Renal Disease.A review of Resident #7's active physician orders for psychotropic medications revealed the following:Abilify 5 mg 1 tablet by mouth every Day Start Date: 01/17/23Hydroxyzine HCL 25 mg I tablet by mouth on Tuesday, Thursday and Saturday at 6:00 AM Start Date:12/12/24Sertraline HCL 100mg I tablet by mouth every Day at 12:00 PM Start Date: 07/23/25Sertraline HCL 50 mg 1 tablet by mouth every day at 12:00 PM Start Date: 04/22/252) On 12/10/25 at 9:42 AM a review of Resident #20's medical record revealed that he/she was admitted to the facility in November 2021 with diagnoses which included Alzheimer's Disease, Epilepsy and Anxiety DisorderA review of Resident #20's active physician orders for psychotropic medications revealed the following:Divalproex Sodium 125 mg Capsule Delayed Release Sprinkle - 2 capsules by mouth two times a day at 6:00 AM and 10:00 PM Start Date: 11/7/24Divalproex Sodium 125 mg Capsule Delayed Release Sprinkle - 3 capsules by mouth one time a day at 2:00 PM Start Date: 11/7/24Risperidone 0.5 mg I tablet by mouth at Bedtime at 9:00 PM Start Date: 05/01/25Risperidone 0.5 mg I tablet by mouth every Day at 8:00 AM Start Date: 05/03/22Further review of Resident #7's and Resident #20's clinical records failed to reveal a process for monitoring side effects of psychotropic drugs, as well as the frequency of and tools used for monitoring.The facility's policy on Psychotropic Medication Management dated 04/2018, last revised 09/2025, Page 3, #12 stated Nursing staff shall monitor for and report side effects and adverse consequences of antipsychotic medications to the LP (Licensed Provider). The policy revealed that drugs in the following categories were considered psychological medications:(i) Antipsychotics,(ii) Antidepressants(iii) Antianxiety(iv) Anticonvulsant(v) Antihistamines(v) HypnoticOn 12/10/2025 at 10:08 AM the surveyor asked the Director of Nursing (DON) whether side effects for psychotropic medications were monitored and what was the process for monitoring. The DON stated that side effects were monitored but not documented daily. Documentation was done by exception when an event occurred, and one would have to look through the nurses' notes to ascertain whether any side effects occurred. The surveyor asked how the nurses knew what side effects they needed to observe. The DON responded that the nurses were familiar with the medications and their side effects and every morning they huddle to discuss the residents. The surveyor requested a copy of the records to verify that side effects were monitored for Resident #7 and Resident #20.On 12/11/2025 at 8:10 AM the DON informed the surveyor that she could not find any documentation on the monitoring of side effects for Resident #7 and Resident #20. She further stated that after the surveyor's intervention, she implemented a system to monitor side effects for all residents on psychotropic drugs, and the nurses were educated on the process. The DON provided the surveyor with documentation to verify that Resident #7 was being monitored for side effects effective 12/10/25 and Resident #20's monitoring started on 12/11/25.

Based on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility's kitchen. The findings include:During the initial tour of the Kitchen with the Dietary Manager on 12/08/25 at 9:11 AM there were foods found opened, unlabeled and foods kept past the best by dates. The following foods were identified: In the Walk-in Freezer the following items were found: 1. A clear bag of burger patties that had been opened and removed from the box was undated and unlabeled.2. A box of Oatmeal Raisin Frozen Cookie Dough had been opened with the bag left open to air and was not resealed. The cookie dough was also undated and unlabeled after opening.During an interview with the Dietary Director on 12/08/25 at 9:27 AM she reported items that have been opened should have been covered and labeled with an expiration date. She agreed that the burger patties and cookie dough should have been dated after they were opening. She also reported that the cookie dough should have been resealed after opening.During an observation of the Walk-in Refrigerator on 12/08/25 at 9:31 AM the following items were found past the best buy date:1. Three packages of English Muffins with a Best if used by date of October 16.2. A package of English Muffins with a Best if used by date of November 15.3. Three packages of English Muffins with a Best if used by date of of November 16.4. Four packages of English Muffins with a Best if used by date of November 23.5. Two loaves of Texas Toast Bread with a Best if used by date of November 03.6. Four loaves of Whole Wheat Bread with a Best if used by date of December 03.7. Nine loaves of Enriched [NAME] with a Best if used by date of December 03.8. A Bag of 12 Individual Hamburger rolls with a Best if used by date of October 30.9. Three Bags of 12 Individual Hamburger rolls with a Best if used by date of November 28.10. Three loaves of Whole Wheat Bread labeled with a Best if used by date of November 26.11. Nine loaves of Enriched [NAME] with a Best if used by date of December 03.12. Four loaves of Classic [NAME] Bread with a Best if used by date of November 24.13. Three bags of Deli Split top rolls with a Best if used by date of December 5.14. Two loaves of Rye bread with a Best if used by date of November 07.15. A bag of Italian Hoagie Rolls with a Best if used by date of November 02.16. A bag of Italian Hoagie Rolls with a Best if used by date of November 27.17. A loaf of Cinnamon Swirl Bread with Raisins with a Best if used by date of November 22. During an observation of the Kitchen's Toasting Station on 12/08/25 at 9:33 AM it was discovered to have the following items past the Best if used by date:1. A package of English Muffins with a Best if used by date of October 16.2. An opened loaf of Cinnamon Swirl Bread with a Best if used by date of October 27.3. An opened loaf of Cinnamon Swirl Bread with a Best if used by date of November 15.4. An opened loaf of Whole Rye Bread with a Best if used by date of November 075. An opened loaf of Whole Wheat Bread with a Best if used by date of November 26.During an interview with the Dietary Director on 12/08/25 at 9:52 AM she reported the bread at the toaster station should been thrown away and that staff should have checked the dates before using the loaves of bread. She reported the outdated bread in the refrigerator should not be in there and advised she doesn't know why there is so much outdated bread. During a review of the facility's Dietary-Sanitation: Dating Potentially Hazardous Food policy on 12/11/25 at 12: 21 PM it was discovered all potentially hazardous, ready to eat food will be labeled and dated to ensure appropriate rotation of food and to prevent or reduce food borne illness. It also sated, All perishable products are covered or closed in refrigeration, frozen and dry storage areas.During a review of the facility's Food Storage Chart for Retaining Food Quality on 12/11/25 at 12:26 PM it was revealed that bread expiration is the Best by, Sell by date.

Based on observations and staff interviews, it was determined that the facility failed to 1) maintain appropriate infection control practices for a resident with an indwelling urinary catheter and 2) store clean laundry in a manner that minimized the potential for the spread of infection. This was evident for 1 (Resident #6) out of 1 resident reviewed for urinary catheters and 1 random observation of the laundry room during the annual survey.The findings include:1. An indwelling urinary catheter is a tube that remains in the bladder to drain urine into a collection bag. On 12/08/25 at 12:37 PM, the surveyor observed Resident #6 lying in bed with his/her urinary drainage bag hanging from the side of the bed and touching the floor. On 12/08/25 at 12:40 PM, an interview with Charge Registered Nurse (RN) #1 confirmed that she was the assigned nurse for Resident #6 and that the urinary drainage bag was touching the floor. Charge RN #1 stated that she had just lowered Resident #6's bed and acknowledged that the urinary drainage bag should not be touching the floor. On 12/09/25 at 9:42 AM, an interview with the Director of Nursing (DON) confirmed that the expectation is for urinary drainage bags to remain off the floor. At the time of the exit conference, the findings were reviewed with the Director of Nursing (DON) and the Nursing Home Administrator, who acknowledged the deficiency. 2. On 12/09/25 at 11:00 AM the surveyor did a walkthrough of the laundry room with Laundry Aide #6. The surveyor observed a large blue bin in the clean area of the laundry room with its contents overflowing and exposed. Inside the bin were folded green hospital gowns, heel protectors and pillows. None of the items were covered. Laundry Aide #6 who accompanied the surveyor stated that the contents of the bin were clean and acknowledged that they should have protective coverings as an infection control measure. On 12/09/25 at 11:18 AM in an interview, the concerns regarding the laundry room were brought to the attention of Environmental Services Supervisor Staff #10 who stated that he would address the issue. On 12/09/25 at 12:17 PM the Administrator was made aware of the observations.

Based on observations and interviews, it was determined that the facility failed to keep a sanitary environment in the laundry. This was evident during 1 random observation of the laundry room during the annual survey.The findings include:On 12/09/25 at 11:00 AM the surveyor did a walkthrough of the laundry room with Laundry Aide #6. The surveyor observed a large amount of white lint heaped on the floor next to a white dryer. A broom was resting on top of the lint heap. Laundry Aide #6 stated that he had cleaned the dryer at 7:00 AM and left the lint on the floor I should have put it in the trash, but I did not.Further observation of the laundry room revealed three small washing machines with spillage of a blue substance on their covers. Inside two of the washing machines were visibly dirty bleach dispensers. Thick blackened material was observed around the edges of the bleach dispensers.On 12/09/25 at 11:18 AM in an interview, the concerns regarding the laundry room were brought to the attention of Environmental Services Supervisor Staff #10 who stated that he would address the issues.On 12/09/25 at 12:17 PM the Administrator was made aware of the observations.

Based on observation and interview, it was determined that the facility failed to post all required staffing information on a daily basis. This was evident in 2 of 2 units observed during the recertification survey.The findings include: On 12/10/25 at 11:52 AM, during an observation in the Magnolia Manor (MM) unit, the whiteboard that contained the staffing schedule did not indicate the facility name or the resident census.On 12/11/25 at 12:40 PM, another observation was conducted in the Whispering [NAME] (WW) unit, the whiteboard also did not indicate the facility name or the resident census.On 12/15/25 at 1:07PM, during the observation conducted in the MM unit, the posted nurse staffing information only included the date, shift, and the staffing schedule with the ratio. In an interview with Registered Nurse (RN #3), he/she confirmed completing the board at the beginning of the shift, however, failed to indicate the name of the facility and specify the resident census. At 1:12 PM, in an observation in WW unit, the posted nurse staffing schedule had a similar concern. RN #1 confirmed the resident census was not specified and stated that the total number of residents was usually written beside their names. RN #1 posted census 14, MLOA-2 ( medical leave) after surveyor intervention.On 12/15/2025 at 2:20 PM, in an interview with the Director of Nursing (DON), she stated that she expected to see the date, the assignment and the staff-to-patient ratio written on the board. She was notified of this concern and acknowledged the finding.

Based on review of records, observation, and interview, it was determined that the facility failed to keep residents safe from physical and verbal abuse. This was evident for 4 (Residents #27, #2, #11, and #28) of 10 residents reviewed for abuse, one of which was determined to have sustained actual harm (Resident #27). The Findings include: 1) On 7/10/24 at 10:14 AM, the surveyor reviewed the facility's investigation of an incident that took place between Geriatric Nursing Assistant (GNA) #36 and Resident #27. The review revealed that, on 5/30/23 at about 10:00 AM, GNA #36 was working with Resident #27 and was transporting him/her to the shower. During transport, the resident defecated onto the floor. The GNA responded by yelling at the resident, grabbing the resident's face and turning his/her head to the floor, saying 'Look at what you did, why would you do this?' This was witnessed by GNA #37, registered nurse (RN) #8, RN #38, and Assistant Director of Nursing (ADON) #4, although not all of them witnessed the GNA yelling directly at the resident or grabbing his/her face. The investigation substantiated verbal and physical abuse by GNA #36 of Resident #27 and provided evidence that GNA #36 was terminated from employment and reported to the Maryland Board of Nursing. Resident #27's medical record was reviewed on 7/10/24 at 10:30 AM. The review revealed that Resident #27 had the diagnosis of vascular dementia. Resident #27's most recent quarterly minimum data set (MDS) assessment prior to the incident on 5/30/23 had an assessment reference date (ARD) of 5/11/23. The quarterly assessment coded that Resident #27 had a brief interview of mental status (BIMS) score of 3/15 (indicating severe cognitive impairment); was totally dependent on staff for bed mobility, transfer, locomotion on and off the unit, eating, toilet use, and personal hygiene; and was always incontinent of bowel and bladder. Ongoing review of Resident #27's record failed to reveal any resident assessment or incident documentation following the incident on 5/30/23. The first note found after 5/30/23 was dated 6/3/23 at 7:35 PM and stated that there were no issues noted with Resident #27. Review of behavior documentation did not show any behaviors after the incident. Observation of the resident on 7/9/24 at 1:00 PM and throughout the survey showed that the resident was comfortable, pleasant, and showed no signs of fear. The resident was unable to communicate meaningfully with the surveyors and appeared confused. On 7/10/24 at 3:00 PM, the surveyors were provided with timekeeping documentation for GNA #36. The documentation showed that GNA #36 worked a full day on 5/30/23 (8 hours), called out sick on 5/31/23, and then was placed on administrative leave until her eventual termination on 6/28/23. An interview with GNA #37 on 7/10/24 at 2:16 PM confirmed that she witnessed GNA #36 yelling in Resident #27's ear, saying, why did you shit on the floor, and swearing at the resident. When asked if she felt that GNA #36's actions were verbal abuse, she said yes. An interview with the Staff Development Director was conducted on 7/10/24 at 3:15 PM. During the interview, the Director stated that he did not provide any additional abuse training to staff after the incident on 5/30 involving Resident #27 and GNA #36. The Director did recall performing a review of staff training on abuse, but wasn't able to confirm that it was an audit of all employee records. He stated there was no documentation of the review. On 7/11/24 at 9:00 AM, review of GNA task documentation revealed that GNA #36 documented % eaten for Resident #27's lunch on 5/30/23. A phone interview was conducted with RN #8 on 7/11/24 at 9:14 AM. During the interview, the RN stated that she was on the unit on 5/30/23 at the time of the incident involving Resident #27 and GNA #36. RN #8 stated that she witnessed GNA #36 yelling at Resident #27. RN #8 considered the yelling to be abusive and humiliating to the patient. She said that the patient was known to be incontinent and to lack the ability to respond appropriately or to show emotion. He couldn't help [defecating onto the floor], and GNA #36's actions were not right. RN #8 recalled telling RN #38 (not available for interview) to get the unit manager and report what happened as potential abuse. An interview was conducted with ADON (then-Unit Manager) #4 on 7/11/24 at 9:28 AM. The ADON remembered being called by the administrator to go investigate a commotion on the Whispering [NAME] unit. The ADON did not hear shouting herself. She arrived to find GNA #37 cleaning feces off the floor. GNA #37 said to her that Resident #27 defecated on the floor while being transported to the shower room. GNA #37 said that GNA #36 was working with the resident when the resident defecated and began shouting at the resident. The ADON instructed GNA #36 not to work with Resident #27 for the rest of the day but did not stop GNA #36 from working on the unit. The ADON requested statements from GNA #36 and #37 which were supplied to her in a short time. The ADON stated that GNA #37's statement only mentioned that GNA #36 had been yelling. Continuing the interview, the ADON stated that she was approached by the Administrator later on the same day, around 2:30 PM. The Administrator informed her that GNA #37 had reported additional details about the incident that morning. GNA #37 had claimed that, in additional to yelling at the resident, GNA #36 had also pulled on Resident #27's lip, forcing him/her to face the pile of feces on the floor. The ADON stated that she then asked GNA #37 to confirm these details and amend her statement. The ADON said that these additional details elevated the occurrence from only verbal abuse to being verbal and physical abuse. On 7/11/24 at 9:58 AM, the surveyor interviewed the Administrator. During the interview, the Administrator confirmed overhearing a commotion on the Whispering [NAME] unit outside of her office on the morning of 5/30/23. She recalled asking ADON #4 to investigate the situation but stated that she didn't witness any of the incident herself. She also confirmed that GNA #37 came to her office later in the day on 5/30/23 to provide the additional details about seeing GNA #36 pulling on Resident #27's lip and showing him/her the pile of feces. Ongoing review of the facility's investigation file revealed GNA #37's witness statement. The statement had an initial text that was signed and dated 5/30/23. An addendum could be seen below the signature in the same handwriting. The initial text stated that GNA #36 was very upset about Resident #27 defecating on the floor and that GNA #36 was pretty loud in the hallway. The initial text did not mention that GNA #36 touched the resident. However, the addendum did, stating that GNA 36 held [Resident #27's] face and showed him/her what he/she had done on the floor but it wasn't with any force or harm. Review of the facility's abuse policy on 7/11/23 revealed that the following definition was categorized as verbal abuse: Derogations - A patient shall not be spoken to in a threatening manner or by threatening words which cause the patient to have a non-therapeutic feeling of having been ridiculed, scorned or teased, or in general spoken to with rude or harsh words. Although Resident #27 did not have any documented emotional distress, behaviors, or other negative outcomes from the incident on 5/30/23, the resident was known to be unable to respond normally to situations, to communicate effectively with staff, or to express their feelings clearly. In situations where a resident is unable to express their feelings such as this, the Reasonable Person Concept can be used to approximate how a reasonable person in the resident's situation would have reacted for the purpose of determining the outcome of a deficient practice. Using this concept, it was determined that a reasonable person would have experienced humiliation, anger, shame, and intimidation in response to the actions of GNA #36. Therefore, it was determined that psychosocial harm occurred to Resident #27. 42863 2) The surveyor reviewed the facility reported incident (FRI) MD00160152 packet 07.10.24 at 2:15 PM. On 04.24.20, as staff #1 was coming up the back staircase from dialysis reportedly yelling was heard by the staff and once the door was opened, observed Resident #2 and staff # 51 screaming at each other. Staff # 51 was observed turning off the call light for room [ROOM NUMBER]A, resident #2's room, while leaving the room staff #51 yelled to hell with you to resident # 2. Staff #51 was placed on administrative leave on 4.24.20 and a facility investigation was started. On 07/09/24 09:20 AM Resident # 2 denied any current examples of abuse in recent months. Both verbal altercations involved male GNA s. The first verbal altercation that occurred was on 04.24.2020 with staff # 51 and the resident does not recall the specifics. The second incident (verbal altercations with GNA #59) the resident recalled occurred on 11.02.2020, and Resident #2 remembers the incident. Resident #2 stated that he/she was able to speak his/her mind and he/she was satisfied with the results of the investigation that the administrative team shared with him/her. On 07.10.2024 at 11:12AM Resident #2 stated that staff currently treat him with respect and that he/she enjoys being the President of the Resident Council. The Resident was out of bed in a motorized wheelchair in the hallway in front of the nurses' station On 07.12.24 at 10:30 AM the surveyor requested that the HR file for staff #51, the alleged perpetrator. At 1:16 PM on 07.12.2024 the surveyor reviewed the hard copies of staff #51's human resource (HR) record. Staff #51 had a hire date of 09.14.2013 and resigned on 05.04.2020. The packet of staff #51's HR included a copy of the employee's 12.23.19 performance evaluation. This employee was reported to the Maryland Board of Nursing (MBON) on 04.24.2020 by the facility administrator. The resident #2 wrote a statement/grievance regarding the incident on 04.24.20 and stated that he/she started ringing the call bell at 2:25 PM x's 3 requesting to be assisted with changing his diaper. Staff #51 responded at 2:40 PM and 2:55 PM and proceeded to argue and curse at the resident without providing the requested assistance with ADL's. On 07.12.24 at 1:54 PM the surveyor spoke with the nursing home administrator (NHA) who was one the witnesses for the incident related to Resident #2. She stated that she did not remember if the employee was sent home immediately. The NHA stated that the time of the incident was close to the change of shift on 04.24.2020. Also, the NHA stated that she would check with the HR director to verify the date and time staff #51 was placed on administrative leave and left the workplace. On 07.12.24 at 2:00 PM the surveyor spoke with another witness, staff # 58 who stated that she/he was not aware of when the perpetrator, staff # 51 left the unit on 04.24.20 and that she/he was in another resident's room at the time of the incident. 3) On 07.10.24 at 1:20 PM the surveyor reviewed the OHCQ intake related to Resident # 2. Per the facility related incident report (FRI) MD00160152 on 11.02.2020 at 09:00 AM, a facility employee, GNA #59 verbally abused resident #2 on the Whispering [NAME] clinical unit. The verbal abuse was substantiated by the facility in its final report dated 11.09.2020. Enclosed within the FRI was a complaint form and a handwritten statement that was completed by LPN #69 and dated 11.02.2020 in which the employee stated that resident #2 stated to her that GNA # 59 told him/her to shut the f .up. Also, enclosed within the FRI packet was a memorandum written by staff #70, dated 11.10.2020 counseling staff # 69 for not assisting and intervening not immediately responding to LPN #69 request for assistance to deescalate the verbal interactions between staff #59 and resident #2. Additionally, a statement written by GNA# 59 admitting that he /she loudly whispered shut the F .up to resident #2 was enclosed in the FRI provided to the surveyor by the administrator. The surveyor interviewed the DON and the Corporate Operations Officer (COO) on 07.11.24 at 1240 PM and reviewed the contents of resident #2's 11.02.2020 packet related to MD#00160152. On 07.12.24 at 1:20 PM the surveyor requested the administrator to provide written documentation that GNA #59 was immediately removed from the clinical setting after the incident. Documentation provided by the administrator showed that GNA #59 was placed on administrative leave around 10:00 AM after being interviewed by the unit manager, staff # 56 and remained on administrative leave for four days. On 07.12.24 at approximately 1:30 PM the surveyor reviewed the human resources records of GNA #59 who was no longer employed by the facility. 4) On 07.10.24 at 9:40 AM the surveyor reviewed the intake, MD00204619 related to resident #11. The facility reported the resident was verbally abused by a volunteer, staff # 63 on 04.10.24 at 12:15 PM. Surveyor reviewed the facility reported incident (FRI) packet which documented that Resident #11 went to the facility canteen and started yelling obscenities when it was time to pay for his food. The resident was upset that he/she was charged tax. Per the facility documentation the resident was also upset that he /she did not get a free soda. According to the facility report, staff # 64 overheard resident # 11 yelling and cursing. Also, staff # 64 observed staff #63 walk from the canteen to the hallway and ask for security. Staff # 64 also reported that resident #11 stated: You got security? and staff #63 responded, He will put you in handcuffs. Security Guard Staff #65 reported that staff #63 was agitated when he/she arrived and overheard him/her say, I hope he gets arrested and handcuffed. Staff # 65 entered the canteen and removed resident #11 and returned the resident via wheelchair to his/her room. Resident #11 requested the administrator file a complaint on his behalf shortly after the incident described above. The volunteer was suspended administratively for four days while the investigation was completed. The staff #63 was verbally counseled by his/her supervisor and received Relias training related to abuse, resident rights, customer service, and de-escalation techniques upon return from administrative leave. Staff #63, the volunteer completed the required training based on the documentation within the FRI packet. On 07.10.24 at 12:16 PM the surveyor observed resident #11 in his wheelchair in his room looking at his lunch tray. The surveyor asked the resident whether he/she remembered the incident that occurred in April 2024 in the canteen. Resident #11 stated that he/she did recall being angry with the volunteer. The resident stated that he planned to go to the canteen today to purchase food because he/she was not satisfied with the lunch that was delivered to his room. Resident # 11 denied experiencing any other verbal abuse from facility staff. On 07.10.24 at 12:20 PM the surveyor spoke with the RN passing medications in front of resident #11's room. RN #68 stated that the resident has a history of being short tempered, yelling, and being verbally abusive but when allowed to cool down will respond positively to verbal interactions displayed by staff. On 07.11.24 at 12:45 PM the surveyor interviewed the DON and CNO regarding the contents of the facility incident report related to resident # 11 and reviewed the contents of the facility incident report and the events documented. The potential citation was discussed with the administrative team on 07.12.24 prior and during the exit conference. 5) The surveyor reviewed the hard copy documents of the facility incident report (FRI) MD00193399 provided by the administrative team on 07.10. 24 at 1:00 PM. The facility report described an unusual occurrence related to an incident of resident-to-resident physical abuse. The perpetrator, resident # 38 with a history of dementia walked into resident #28's room on 06.06.23 around 07:30 PM. Resident #28 called for help and the facility staff came to the resident's room. The facility documented that resident #28 reported that resident # 38 hit resident #28's left hand and left side of his'/her face with the call bell cord which resulted in a minor injury. The surveyor found no documentation that any staff members had observed the physical abuse based on the documentation in the initial self -report. The only reported witness was resident #28, the victim per the facility documentation provided to the surveyor. Review of the resident # 38's electronic medical record showed one documented episode of physical aggression towards staff members but none towards any residents during the previous three months. The FRI packet provided by the facility administrative team, included a copy of the initial report submitted to OHCQ dated and timed: 06.07.23, at 11:00 AM. Per the initial report the incident of physical abuse perpetrated by Resident # 38 occurred on 06.06.2023 at 7:30 PM. Resident # 38 was placed on every 15 minute check, a psychiatric consult was ordered, and a medication review for his/her dementia diagnosis was recommended per the facility report completed on 06.13.23. The resident had a dementia and aggressive behavior care plan. Additionally, the facility failed to include any progressive notes or change of condition documentation related to minor injuries sustained by Resident #28 in the facility report- incident packet. The facility did not include any statements from the staff working the evening shift on 06.06.23 or any statements from other residents who were located on the same unit on 06.06.23 within the initial or the final facility report to OHCQ. During an on 07.10.24 12:06 PM resident #28 stated that he/she remembers the incident, but no serious injury occurred on 06.06.23 when he/she was struck by resident #38. Currently the resident # 28 denies any type of verbal or physical abuse occurring during the past year and does feel safe in the clinical unit. On 07.11.24 at 12:40 PM the surveyor interviewed the DON and CNO regarding the contents of the facility incident report related to resident # 28. The surveyor expressed concern regarding the lack of documentation related to the incident within its final report to OHCQ dated for 06.13.23 at 3 PM. The DON and CNO stated that they would attempt to find additional information related to the 06.06.23 FRI. The surveyor discussed the lack of documentation within the facility report regarding the perpetrator with dementia and the facility efforts to prevent the resident-to-resident physical abuse incident. As of 5:30 PM on 07.12.24 during the exit conference the facility failed to provide any additional documentation related to substantiated physical abuse towards resident #28 by resident # 38. The deficient practice to prevent a resident-resident physical abuse incident was discussed during the exit conference on 07.12.24 with facility administrative staff.

Based on review of records and interview with facility staff, it was determined that the facility failed to report instances of abuse to the state agency (SA) within 2 hours of it being identified or reported and the final report within 5 working days. This was evident for 3 of 11 facility reported incidents reviewed during the survey. The Findings include: 1) On 7/10/24 at 10:14 AM, the surveyor reviewed the facility's investigation of an incident that took place between Geriatric Nursing Assistant (GNA) #36 and Resident #27. The investigation determined that, on 5/30/23 at about 10:00 AM, GNA #36 verbally and physically abused Resident #27 after the resident defecated on the floor during transport. This was witnessed by GNA #37, registered nurse (RN) #8, and RN #38. The investigation provided evidence that GNA #36 was terminated from employment and reported to the board of nursing. Further review of the investigation file revealed an initial facility self-report form dated 5/31/23 at 7:00 AM, 21 hours after the incident occurred and was witnessed by multiple staff. Additionally, an email was found that was written by the Chief Nursing Officer (CNO, Staff #29) dated 5/31/23 at 6:51 AM that stated, I will be filing a self-report of this incident. An interview with GNA #37 on 7/10/24 at 2:16 PM confirmed that she witnessed GNA #36 yelling in Resident #27's ear, saying, why did you shit on the floor, and swearing at the resident. She confirmed that she considered what she witnessed to be abuse and that ADON #4, her unit manager at the time of the incident, had been informed of the incident only minutes after the incident occurred. A phone interview was conducted with RN #8 on 7/11/24 at 9:14 AM. During the interview, the RN confirmed that she witnessed GNA #36 yelling at Resident #27 on 5/30/23, considered it abuse, and told RN #38 (not available for interview) to get the unit manager and report what happened. An interview was conducted with ADON #4 on 7/11/24 at 9:28 AM. The ADON confirmed that she arrived to the scene of the incident around 10:15 AM on 5/30/23 and quickly determined that verbal abuse had possibly occurred. The ADON indicated that she did not complete a self-report to the state agency about the incident, saying that the CNO is usually responsible for that. No evidence could be found that the CNO had been notified of the incident prior to the morning of 5/31/23. Review of the facility's Abuse Prevention policy on 7/11/24 revealed the statement, If unable to [immediately] rule out without a doubt that alleged abuse is unsubstantiated, a self-report will be sent to the OHCQ within 24 hours of discovery. No part of the policy required staff to file a self report within 2 hours in instances of abuse or serious injury. Cross Reference F 600 49304 2) On 7/9/24 at 10:32 AM, the administrative team provided the survey team with a copy of the facility reported incident that occurred on July 17, 2020. Review of the documentation of the incident reported by the facility, it stated that, On July 17 [2020] at 11:41, Resident #37 reported to Nursing Home Administrator (NHA) #1, that on July 15th, in the evening, staff came to provide care and he/she was treated like 'a sack of potatoes'. In addition, it stated, Resident #37 further stated he/she felt this incident was 'assault and battery' though he/she declined to have law enforcement notified. The Self- Report Form completed by the facility stated the Type of Report was Abuse (as denoted by an X in the Abuse type). Furthermore, the Self- Report Form completed by the facility stated the incident was initially reported to OHCQ on 7/17/2020 at 1528 (3:28 PM). On 7/12/24 at 9:11 AM in an interview with NHA #1, when asked about the day of the incident with Resident #37 in July 2020, she stated she remembered Resident #37 and that he/she was here for quite some time. During the interview, she stated he/she was alert and oriented. Furthermore, the NHA #1 stated that the process for investigating abuse allegations is an alleged incident is reported within 2 hours if there is an allegation of abuse. She also stated that abuse was any verbal, physical, sexual, mental abuse, neglect, or misappropriation of funds. The surveyor showed NHA #1 the Self- Report Form that stated she was the staff member notified of the allegation by Resident #37 on 7/17/2020 at 11:41 AM and that the Self- Report Form documented OHCQ was notified 7/17/2020 at 3:28PM who confirmed it was outside of the 2 hour window. On 7/10/24 at 1:23 PM, review of the facility's policy, Abuse Prevention General Policy section revealed, The Administrator and Director of Nursing will send a self-report to the OHCQ within 2 hours of discovery of neglect or abuse. Furthermore, the Definitions section revealed, An Allegation is a spoken or written statement, offered without proof that an event occurred. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish (42 CFR 488.301). This also includes the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that the instances of abuse of all residents, even those in a coma, cause physical harm or pain or mental anguish. 42863 3) The surveyor reviewed the intake MD00193399 related to Resident #28 on 07.09.2024 at 11:40 AM. The facility had reported that on 06.06.23 at approximately 7:30 PM, Resident #28 called staff for help from his room, while sitting on his/her bed. The nurse found the perpetrator Resident # 38 standing in front of Resident #28. The surveyor reviewed the hard copy documents of the facility incident report (FRI) provided by the administrative team on 07.10. 24 at 1:00 PM. Within the report related to resident-to-resident physical abuse: the perpetrator, Resident # 38 with a history of dementia walked into Resident #28's room. The facility documented that Resident #28 reported that Resident # 38 hit resident #28's left hand and left side of his/her face with the call bell cord which resulted in a minor injury. The surveyor found no documentation that the any staff members observed the physical abuse based on the documentation in the initial self-report and the only witness was Resident #28, the victim. The FRI packet provided by the facility administrative team, included a copy of the initial report submitted to OHCQ dated and timed: 06.07.23, at 11:00 AM. Per the initial report the incident of physical abuse perpetrated by Resident # 38 occurred on 06.06.2023 at 7:30 PM. Additionally, the facility failed to include any progressive notes or change of condition documentation related to minor injuries sustained by Resident #28. The facility did not include any statements from the staff working the evening shift on 06.06.23 or any statements from other residents who were located on the same unit on 06.06.23. On 07.11.24 at 12:40 PM the surveyor interviewed the DON and CNO regarding the contents of the facility incident report related to resident # 28. The surveyor expressed concern regarding the lack of documentation related to incident that was substantiated by the facility within its final report to OHCQ on 06.13.23 at 3 PM which exceeded the 5-day final submission timeframe. The DON and Chief Nursing Officer (CNO) stated that they would attempt to find additional information related to the 06.06.23 FRI. As of 5:30 PM on 07.12.24 during the exit conference the facility failed to provide any additional documentation related to substantiated physical abuse towards resident #28 by resident # 38.

Based on review of resident records and interview with facility staff, it was determined that the facility failed to keep residents protected from an alleged perpetrator during an abuse investigation. This was evident 1 of 11 facility reported incidents during the survey. The Findings include: On 7/10/24 at 10:14 AM, the surveyor reviewed the facility's investigation of an incident that took place between Geriatric Nursing Assistant (GNA) #36 and Resident #27. The review revealed that, on 5/30/23 at about 10:00 AM, GNA #36 was working with Resident #27 and was transporting him/her to the shower. During transport, the resident defecated onto the floor. The GNA responded by yelling at the resident, grabbing the resident's face and turning his/her head to the floor, saying 'Look at what you did, why would you do this?' This was witnessed by GNA #37, registered nurse (RN) #8, RN #38, ADON #4, although not all of them witnessed the GNA yelling directly at the resident or grabbing his/her face. The investigation substantiated verbal and physical abuse by GNA #36 of Resident #27 and provided evidence that GNA #36 was terminated from employment and reported to the board of nursing. On 7/10/24 at 3:00 PM, the surveyors were provided with timekeeping documentation for GNA #36. The documentation showed that GNA #36 worked a full day on 5/30/23 (8 hours), called out sick on 5/31/23, and then was placed on administrative leave until her eventual termination on 6/28/23. An interview with GNA #37 on 7/10/24 at 2:16 PM confirmed that she witnessed GNA #36 abuse Resident #27 verbally, yelling in his/her ear and swearing. GNA #37 also stated that she believed GNA #36 continued working with the resident for the rest of the day. On 7/11/24 at 9:00 AM, review of GNA task documentation revealed that GNA #36 documented % eaten for lunch on 5/30/23, suggesting that the GNA continued to work with the resident after the incident. An interview was conducted with ADON (then-Unit Manager) #4 on 7/11/24 at 9:28 AM. During the interview, the ADON stated that she arrived on the scene of the incident at 10:15 on the morning of 5/30/23. She stated that GNA #37 explained what happened and then said that GNA #36 was in the shower with the resident. The ADON asked RN #39 and an unknown GNA to come relieve GNA #36 of working with Resident #27 in the shower. The ADON instructed GNA #36 not to work with Resident #27 for the rest of the day but did not stop GNA #36 from working on the unit. The ADON requested statements from GNA #36 and #37 which were supplied to her in a short time (possibly about an hour). GNA #36 completed her shift. When asked about whether the incident as she understood it on the morning of 5/30/23 constituted abuse, she said that she felt it was verbal abuse, and that later information she gained at 2:30 PM made her believe it was also physical abuse. She stated that, instead of having the GNA continue to work on the nursing unit, she would have kept the GNA in my office and off the nursing unit if she knew that the GNA had perpetrated physical abuse as well. She explained that as a manager, I cannot relieve an employee from duty. Human Resources can only do that. Ongoing review of the facility's investigation revealed an email from the Chief Nursing Officer (CNO, Staff #29) dated 5/31/23 at 6:51 AM. In the email, the CNO writes In the past, when a situation like this occurred, the GNA was put on administrative leave until an investigation is completed . [GNA #36] should not be caring for any of our residents at this point. She called out sick today. Additionally, a letter was found dated 5/31/23 addressed to GNA #36 and written by a human resources representative that informed GNA #36 that she was being placed on administrative leave pending investigation. No evidence could be found showing that GNA #36's assignment or work hours changed on the day of the incident, 5/30/23. Review of the facilitiy's Abuse Prevention policy on 7/11/24 revealed a statement that said, In a staff-to-patient abuse allegation, the employee involved will be removed from the care of the patient immediately pending investigation and the patient will be kept safe.

Based on a review of medical records and interview with facility staff and interview with resident's family, it was determined that the facility failed to provide written notice with the reason for transfer to a resident or resident representative. This was evident for one resident (Resident #13) out of one resident reviewed for hospitalization . This findings include: On 07/11/24 at 02:29 PM, during review of Resident #13's record, surveyors discovered a nursing progress note written by registered nurse (RN) #60 on 7/7/2024 at 5:24 PM that stated that Resident #13 was transferred to the hospital for a change in mental status on that date at 4:50 PM. The note stated that the resident's representative was made aware. However, the note did not indicate that a written notice of discharge was provided to the resident or their representative at that time. No other progress note indicated that a written notice of transfer was provided to the resident or their representative. On 07/11/24 at 04:10 PM, during and interview with RN #44, she was asked about the protocols for documenting hospital transfers. She stated that nurses document about a resident's transfer in the electronic record, and that ready-made packets with the patient's demographic information, diagnoses, medications, and laboratory test results are provided to the transport team after getting the doctor's order to transfer the resident. She also stated that families are contacted mostly through phone calls and this notification is documented in a free progress note (a progress note without subheading) and also confirmed that a note is not sent with the resident or family as family members are hardly around at the time of transfer. On 07/11/24 at 04:20 PM, a record review of Resident #13's paper and electronic medical record was done and there was no evidence of written notification being provided to the resident or the resident's family. On 07/12/24 at 10:51 AM, Resident #13 was seen in bed with his/her representative at bedside. When the resident was asked if he/she was notified of his/her last hospital transfer, he/she found it difficult to respond. The resident representative was asked if he/she was notified of the recent hospital transfer, and he/she stated that he/she was called when the facility wanted to send the resident out to the hospital and was made aware verbally of the transfer. He/she stated this was also true for past hospitalization s, that they had told him/ her in person or on the phone. The resident representative denied ever being notified in writing.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to implement a process to ensure that residents and resident representatives were made aware of the facilities bed hold policy upon transfer to the hospital. This was evident for one resident (Resident #13) out of one resident reviewed for hospitalization . This findings include: On 07/11/24 at 02:29 PM, during record review, surveyors discovered a nursing progress note written by registered nurse (RN) #60 on 7/7/2024 at 5:24 PM that stated that Resident #13 was transferred to the hospital for a change in mental status at 4:50 PM of the same day. The note stated that the resident's representative was made aware and the resident was sent out via physician' s order. There was no mention of a bed hold policy noted in the note. On 07/11/24 at 04:05 PM, surveyors conducted an interview with RN #44. When she was asked about the protocol for when a patient is to be sent to the hospital, she stated that nurses document in the electronic record and a packet is given to the transport team. When she was asked about the bed hold policy, she confirmed that the bed hold policy was not given to the resident or family during the time of transfer. She confirmed that there was no copy of the bed hold policy given to Resident #13 for his/her transfer on 7/7/24. On 07/12/24 at 09:14 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When she was asked about the bed hold policy, she stated that there was an admission checklist and a bed hold policy given at the time of admission. She stated that the bed hold policy is followed when residents come back from the hospital. She confirmed that there was no written (paper) bed hold policy given to the resident or families around the time of a resident's transfer to the hospital by nursing staff. On 07/12/24 at 09:54 AM, during an interview with a licensed social worker (Staff #21), he was asked what he does during a resident's transfer to the hospital. He stated that he did only his Minimum Data Set section. He also stated that upon admission, he went over the bed hold policy with each resident. He confirmed that paper bed hold policy is not given to residents and families at the time of transfer to the hospital. Staff #21 came back at 10:13 AM to inform surveyors that a copy of the bed hold policy is not given to residents or their representatives when residents are hospitalized and that going forward, it was something they are looking into starting.

Based on medical record review and interviews it was determined that the facility staff administered a psychotropic medication that was contraindicated for Dementia, failed to monitor a resident for extrapyramidal side effects, and failed to complete a gradual dose reduction in the past year. This deficient practice was evidenced in 1 (#21) of 1 resident record reviewed for unnecessary psychotropic medications during the survey. The findings include: According to the Mayo Clinic )a not-for-profit academic medical center), Quetiapine is used alone or together with other medicines to treat bipolar disorder (depressive and manic episodes) and schizophrenia. Quetiapine extended-release tablet is also used together with other antidepressants to treat major depressive disorder. This medicine should not be used to treat behavioral problems in older adult patients who have dementia or Alzheimer disease. Quetiapine is an antipsychotic medicine that works in the brain. On 07/08/24 at 12:55 pm during observation rounds the surveyor entered Resident #21's room and observed the resident in a chair sleeping. The surveyor called Resident #21's name several times until they awakened and was able to speak with the surveyor. On 07/10/24 at 9:52 am the surveyor observed Resident #21 in bed and the surveyor was unable to arouse the resident. Unit Manager #28 entered the resident's room and was able to arouse the resident with difficulty. Resident #21 opened their eyes briefly and went back to sleep. On 07/10/24 at 11:28 am the surveyor asked Medical Director #30 when a resident is on a psychotropic medication, when is a gradual dose reduction (GDR) attempted. Medical Director #30 verbalized a GDR is attempted every 6 months; during the Mood-Behavior rounds the intent of a GDR is discussed. The multidisciplinary team such as nursing, therapy, and the Activities staff is involved during the rounds. They try to get residents off psychotropic medications. Medical Director #30 indicated residents who have Schizophrenia, Huntington's Disease, and Tourette's Syndrome, a GDR is not indicated and Resident #21 had a history of Schizophrenia. On 07/10/24 at 1:15 pm the surveyor reviewed Resident #21 EMR (electronic medical record) which revealed the resident did not have a history of Schizophrenia, but the resident did have a history of Dementia. Further review of the EMR revealed the resident was prescribed Quetiapine Fumarate 25 mg PO (by mouth) BID (two times a day). The medication was ordered on 04/18/22. Also, Resident #21 was ordered Quetiapine Fumarate 25 mg PO QD (every day) at 9:00 pm and Quetiapine Fumarate 50 mg PO QD at 9:00 pm. The start date for both medications is 04/26/23. The surveyor reviewed the progress notes and there was not documentation to verify a GDR was attempted. On 07/12/24 at 10:14 am the surveyor received a copy of Resident #21's behavioral report. The last documented behavior occurred on 01/08/24 at 11:13 pm. According to the note written by the nurse, the resident was resistive to care and medication administration. The staff had difficulty getting the resident to go to bed but was persuaded to do so. Review of Resident #21's EMR revealed the resident was not being monitored for extrapyramidal side effect related to psychotropic medication administration. On 07/12/24 at 2:45 pm during a telephone interview with Certified Registered Nurse Practitioner (CRNP) #47 they verbalized Resident #21 was admitted from a state hospital on a higher dose of Quetiapine; shortly after the resident was admitted the medication was discontinued. Resident #21 has Dementia with a lot of behaviors and physical aggression. Within the last month the resident displayed behaviors such as cursing, hollering and being belligerent. Sometimes they grab people or push them away. When asked about behavioral monitoring CRNP #47 verbalized behavioral monitoring is a nursing question. When asked about a GDR being done, CRNP #47 verbalized providing documentation the previous day that a GDR was done. The surveyor made CRNP #47 aware the documentation did not have a name of a medication, the dose, or any information to verify a GDR was attempted. CRNP #47 did not know when Resident #21 had a GDR; they believe it was last September. A GDR is done annually; twice in the first year, three months part and annually. On 07/12/24 at 3:06 pm during an interview with Medical Director #30 the surveyor reported after reviewing Resident #21's diagnoses, the resident did not have a history of Schizophrenia. Medical Director #30 verbalized reviewing the resident's medical diagnoses and agreed the resident did not have a history of Schizophrenia. Medical Director #30 verbalized the resident's medication regimen was changed once in 2022 and twice in 2023 and that they try to make sure the lowest possible dose of medication is given. Once they get them down to a certain point and behaviors occur, they must stop a GDR. Medical Director #30 was made aware the GDR documentation the surveyor received did not include a name of a medication, a dose, or any changes indicating a dose reduction of a medication occurred. There was not sufficient documentation to verify a GDR was done

Based on observation, record review, and interview with facility staff, it was determined that the facility failed to ensure the medication error rate was less than 5 percent. This was evident for 2 (#28, #42) of 4 residents observed with 32 medication administration opportunities which resulted in an error rate of 31.25% by 2 (#55, #58) of 4 staff observed. The findings include: On 7/11/24 at 8:45 AM the surveyor walked up, introduced self, and advised that they wanted to observe med (medication) pass. Registered Nurse (RN) #55 stated she just came from administering morning medications to Resident #28 who complained of 7/10 throat pain and wanted to see if he/she has a PRN (as needed) pain medication ordered. Upon scrolling through the electronic health record (EHR) she then stated, he/she does have an order for PRN acetaminophen 500mg (milligrams), 2 tablets. RN #55 dispensed the medication and at 8:47 AM entered Resident #28's room and administered the medication. On 7/11/24 at 9:20 AM, review of Resident #28's medical record revealed an order for Good Sense Pain Relief Extra Strength 500 MG Tablet, Medication Order, 500 MG, Oral, Tablet, Analgesic/Anti-Inflammatory/Migraine/Gout Agents/Anesthetics, ANALGESICS - NonNarcotic. 2 Tablet by mouth As Needed Every Eight Hours for pain 1-6/10. 55 mins Effectiveness. On 7/11/24 at 9:35 AM in an interview with RN #55 when asked about the asked the indication for the acetaminophen, she pulled up the order in the EHR and stated the indication is for pain 1-6/10. The surveyor asked what pain score the resident reported to her and the nurse stated 7. During the interview, when asked if as the order is written she should have administered the acetaminophen, RN #55 stated no. RN #55 failed to follow physician's orders. The Assistant Director of Nursing (ADON) was notified of the concerns on 7/11/24 at 9:54 AM. During a second medication administration observation that took place on 7/11/24 at 9:27 AM, Licensed Practical Nurse (LPN) #58 administered amlodipine 5mg, carvedilol 25mg, clobazam 10mg, modafinil 200mg, lacosamide 20mL (milliliters), keppra 15mL, prednisone 10mg, and lansoprazole 10mL to Resident #42. Review of Resident #42's medical record on 7/11/24 at 9:28 AM revealed that all the above medications were ordered and scheduled to be administered Every day at 8:00 AM. On 7/11/24 at 9:32 AM, in an interview with LPN #58 when asked the standard of practice for administering a medication on time, she stated it is that you administer medications up to 1 hour before or 1 hour after the scheduled time. During the interview, LPN #58 confirmed the medications were late and stated we can write a note in the MAR (medication administration record) why it [medication] was late. LPN #58 administered the medications at 9:27 AM which was 1 hour and 27 minutes after the prescribed time. On 7/11/24 at 9:54 AM, review of the facility's Medication Management Policy; Chronic Hospital and CCF Units revealed, Medications are administered to patients/residents by qualified personnel in compliance with federal and state laws and standards of professional practice. Furthermore, in the Medication Error Management Definitions section of the policy it stated, Medication Error- a discrepancy between what the physician ordered and what was reported to occur; types of errors include omissions, extra doses, wrong doses, unauthorized drugs, wrong drug form, wrong rate, wrong time, wrong administration technique, transcription. The administrative team was made aware of the findings at the time of survey exit on 7/12/24 at 4:45 PM.

Based on record review and interview with facility staff, it was determined that the facility failed to don appropriate personal protective equipment (PPE) when transferring a resident. This was evident for 1 (#4) of 21 residents reviewed during the survey. The findings include: On 7/9/24 at 9:20AM in an interview with Unit Manager (UM) #28, when asked about the Enhanced Barrier Precaution (EBP) signage (with 9B [Room # for Resident #4] written on it in black marker) she stated it is not for a current infection, but for staff to be aware of a history of infection. Furthermore, she stated, I believe [s/he] has a history of MRSA (methicillin-resistant staphylococcus aureus). During the interview, she stated yes, there is different signage for a resident on transmission based precautions (TBP) versus EBP. The surveyor made UM #28 aware that the facility matrix provided to the survey team by Staff #3 yesterday (7/8/24 at 1:06 PM) had an X for Resident #4 under TBP. UM #28 asked, Can I look that up? and pulled up the electronic health record (EHR). She then stated, the order is in as EBP and she could ask the Director of Nursing (DON) about that because they may have made an error. During the interview she stated, she could call the Infection Control Nurse (ICN) #41 which she did. After talking to ICN #41, UM #28 stated, [Resident #4] has no active infection. During the interview, the Assistant Director of Nursing (ADON) approached UM #28's office at 9:26 AM. UM #28 explained the situation and the ADON stated, it [facility matrix] was brought down to you all [survey team] quickly and there are errors. She further stated, I looked at it yesterday and saw some mistakes. In addition, the ADON stated she usually likes to look it over but was busy and that it [facility matrix] said we have an IV [Intravenous] and that is not true anymore. The ADON stated, I am going to get you an updated copy. Review of Resident #4's medical record on 7/9/24 at 10:04 AM revealed the resident was ordered, Enhanced Barrier Precautions (EBP) Treatment Order Precautions and Directions: Every eight hours Every day at Day Shift 7:00am-2:59pm, Evening Shift 3:00pm-10:59pm, Night Shift 11:00pm-06:59am. EBPs are indicated during high-contact resident care activities including; dressing, bathing, showering; transferring; providing hygiene; changing linens, changing briefs or assisting with toileting; device care e.g. indwelling catheters of any type; wound care requiring a dressing. EBP signage instructs staff on what must be done (hand hygiene, gowns, gloves) and when. On 7/9/24 at 10:12 AM UM #28 was observed performing hand hygiene and entering Resident #4's room to assist Geriatric Nursing Assistant (GNA) #35, transfer the resident to his/her wheelchair. Neither staff member were observed donning a gown. On 7/9/24 at 10:20 AM in an interview with UM #28 when asked what they were doing in Resident #4's room she stated, transferring the resident with a [NAME] lift because you must have 2 people. When asked if she had shared that the resident is ordered EBP she stated yes, and you caught that. I did not have a gown on. During the interview when asked what personal protective equipment (PPE) do EBP orders and signage state providers and staff must don when transferring, UM #28 stated, I had my gloves on and should have had a yellow gown on too. On 7/9/24 at 10:27 AM in an interview with GNA #35 when asked what she was doing in Resident #4's room she stated she washed him/her up, provided ADL (activities of daily living) care to get him/her ready for the day, and transferred the resident from the bed to his/her wheelchair and that requires 2 people. When asked what PPE staff must wear when transferring residents who are ordered EBP, GNA #35 stated, I do not know what that means. The surveyor and GNA #35 walked around the corner to the resident's room. The surveyor pointed out the EBP signage with his/her room/bed, 9B, written on the sign and GNA #35 stated she thought he was cleared by now. UM #28 (whose office is located directly next to Resident #4's room) interjected and stated no, remember he/she has a history, so we must wear a gown and gloves to protect ourselves and other residents. UM #28 stated that she did not wear one [gown] either and to make sure to tell everyone [staff] up front too. When GNA #35 was asked if she was wearing a yellow gown when transferring Resident #4, she stated no.

Based on observation, staff interview and medical record review, it was determined the facility failed to provide a dignified dining experience for two residents that needed assistance with eating lunch. This was evident for 2 residents (Residents #18, #26) observed during the lunch meal on the initial tour of the facility. The findings include: 1. Observation of the lunch meal service on the second floor on 9/3/19 at 12:40 PM revealed Resident #18 sitting at a table with the lunch meal tray sitting beside him/her and no nursing staff were assisting Resident #18 with the lunch meal. In an interview with the facility Charge Nurse #1 on 9/4/19 at 12:26 PM, Charge Nurse #1 stated that Resident #18 is totally dependent upon staff for all aspects of his/her care and requires staff to feed him/her all meals. Reviews of Resident #18's medical record revealed a nutritional care plan that included a nursing approach that instructed the nursing staff to feed Resident #18 all of his/her meals. 2. Resident #26 was seated at a different table and observed with a meal tray seated in front of him/her. Resident #26's meal tray had not been prepared, uncovered and set up, to allow Resident #26 to start the meal. In a follow up interview with Charge Nurse #1 on 9/4/19 at 12:26 PM, Charge Nurse #1 also stated that Resident #26 requires assistance to set up his/her meals and also requires the nursing staff to help Resident #26 with eating due to Resident #26's progressive hand weakness. Charge Nurse #1 stated that Resident #26 had some weight loss earlier in the year and the nursing staff updated Resident #26's care plan to assist with Resident #26's meal intake. Review of Resident #26's medical record revealed a care plan with a nursing approach that instructed the nursing staff to help with tray set up and supervision/assistance to keep utensils in proper direction.

Based on medical record review and interview, it was determined the facility staff failed to promote Resident (#8's) self-determination. This was evident for 1 of 27 residents selected for review of self-determination during the survey process. The findings include: Medical record review for Resident #8 revealed on 3/11/19 at 1:25 PM, the resident, in collaboration with the physician completed the MOLST form. The MOLST is an acronym for Medical Orders for Life-Sustaining Treatment. The MOLST is a communication process designed to improve the quality of care of residents. MOLST orders are completed at the end of a thorough conversation or series of conversations between the resident (or the Health Care Agent or Surrogate if the resident is unable to make complex MOLST decisions) and their physician or nurse practitioner. The MOLST Program is an initiative to facilitate end-of-life medical decision-making. A MOLST form is different than a health care proxy. A health care proxy appoints a person called a health care agent to make medical decisions on someone's behalf if they are unable to make such decisions. Technically, a health care proxy is considered a legal document, whereas a MOLST form is considered a medical document. And a MOLST form must be signed both by a patient and a clinician. Because of these differences, it can be advisable to both execute a MOLST form and to appoint a health care agent. Further record record review revealed on 3/11/19 at 2:37 PM the physician ordered that Resident #8 was the primary decision maker for self. On 3/13/19 the facility staff obtained consent for: authorization for treatment and consent for the resident to participate in a student learning experience; however, the facility staff obtained that consent from the resident's sister. Interview with the Nursing Home Administrator and Director of Nursing on 9/5/19 at 10:00 AM revealed that Resident #8 does not always respond to questions when asked, may only shake head yes or no and cognition of Resident #8 varies at times. Further interview with the Nursing Home Administrator and Director of Nursing on 9/5/19 at 10:00 AM revealed Resident #8's sister is involved in making decisions related to care for Resident #8; however, the facility staff failed to determine that Resident #8 in not able to make medical decisions for self prior to accepting decisions from Resident #8's sister. Record review revealed the facility staff assessed the resident on 3/18/19 and documented the resident's cognition and BIMS was 12. Cognition is the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. The BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well the resident is functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition. Because the BIMS is given every quarter, the scores can help measure if you're improving, remaining the same, or declining in cognitive ability. The numeric value can be interpreted as follows: 13 to 15 points: intact cognition, 8 to 12 points: moderately impaired cognition and 0-7 points: severely impaired cognition. Interview with the Director of Nursing on 9/5/19 at 12:00 PM confirmed the facility staff failed to promote self-determination for Resident #8 by failing to obtain for the resident's sister to make medical decisions for Resident #8.

Based on record review and staff interview it was determined that the facility failed to notify Resident #31's physician and representative in a timely manner after a significant change occurred. This was evident for 1 (#31) out of 27 residents in the final sample. The findings include: On 9/4/2019 Facility Reported Incident MD 313 was reviewed involving Resident #31. Review of the facility's investigation confirmed that a significant change in the resident's status occurred on 4/11/2019. A significant change is a decline in a resident's status that will not normally resolve itself without intervention by staff. The facility's records showed that Resident #31's physician and representative were not notified until 4/15/2019. Interview with the Director of Nursing on 9/4/2019 at 10:57 AM confirmed that the resident's representative and physician were not notified until 4 days after the incident occurred. Interview with the Administrator on 9/5/2019 at 8:48 AM confirmed that the resident representative should have been notified in the event of a significant change occurring for Resident #31. The Administrator and Director of Nursing were made aware of these findings on 9/5/2019 during the exit conference.

Based on surveyor observation, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect residents. The findings include: On 9/3/2019 at 12:27 PM during initial observations, the wall behind room [ROOM NUMBER] bed C in Heron Harbor was observed in disrepair with exposed drywall. At 12:43 PM the Heron Harbor shower room across from room [ROOM NUMBER] was observed with a pink substance and black dirt/debris on the shower floor. Further observation of the shower room revealed a large piece of plywood secured to the wall to cover a hole. The plywood was untreated and the porous surface was not easily cleanable. At 12:56 PM Elevator 3 was observed with dust, debris and a dead spider present in the square grate on the ceiling. The Administrator and Director of Nursing were made aware of these findings on 9/5/2019 during the exit conference.

Based on facility documentation review and staff interview it was determined that the facility failed to report an incident to the State Survey Agency, the Office of Health Care Quality (OHCQ), in a timely manner. This was evident for 1 (#31) of 27 residents in the final sample. The findings include: On 9/4/2019 Facility Reported Incident MD 313 was reviewed involving Resident #31. Review of the facility's investigation confirmed that a significant change in the resident's status occurred on 4/11/2019. A significant change is a decline in a resident's status that will not normally resolve itself without intervention by staff. Further review of the facility's investigation confirmed that the incident was not reported to OHCQ until 4/15/2019, which was 4 days later, not within the required 24 hours of the time of the incident. The Director of Nursing confirmed these findings during an interview on 9/4/2019. The Administrator and Director of Nursing were made aware of these findings on 9/5/2019 during the exit conference.

Based on review of the medical record and interview, it was determined that the nursing staff failed to adequately supervise a resident in order to prevent an accident which resulted in abrasions, bruising and a fractured right leg for one out of one sampled residents Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs. Resident # 1 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Review of the medical record revealed a Plan of Care, initiated 1/24/07, which identified this resident to be "Totally dependent on staff for the full performance of all ADL's (activities of daily living)". This care plan included multiple interventions used by the facility to assist the resident including - "Transfer via mechanical lift with assistance of 2 persons". This was accomplished by using a Vander Lift. A Vander Lift is a mechanical device that is used for transferring individuals who are unable to move without assistance. Continued review of the medical record revealed the following nurses notes: 8/31/10 6:45 p.m. "Resident slid from the transfer lift while transferring to bed in attendance of two aides. Sustained abrasion to left temple, left top of head, R(ight) elbow, and L(eft) ankle. ... ". 9/1/10 10:30 p.m. " ... At approximately 1700, the GNA (geriatric nursing assistant) asked me to assess residents R thigh. I found upper thigh to be very edematous and painful to touch. Leg was easier to move, not stiff as usual. ... ". At this time the resident was seen by the physician and the resident was sent to the hospital where he was found to have a fracture of the right femur. Review of the facility investigation into the resident's fall revealed the following statements: "Both (GNA's) stated that the sling was not on the patient properly before they transferred the patient, however proceeded with moving the patient that resulted in a fracture of the femur". " ... (GNA's) had the sling to(o) low on the patients back Both stated that it was too low and therefore caused the fall". Continued review of the facility investigation into the resident's fall revealed both GNA's verbalized differing accounts of the incident - both from each other and from their own initial statements. What remained clear from the interviews is both GNA's knew the resident was not properly positioned but proceeded with the transfer despite that fact. The nursing staff is deficient for failing to adequately supervise this resident during transfer which resulted in a fall causing multiple injuries.