Every finding on record at Dennett Rehab Center

Based on observations, interviews, record reviews, and review of facility investigative records and witness statements, the facility failed to provide adequate supervision and implement appropriate interventions to prevent elopement for 1 of 3 sampled residents (Resident #5) who was identified as being at risk for elopement. As a result, Resident #5 eloped from the facility and was located walking on a main road before being safely returned to the facility.The findings include:Record review conducted on 7/20/26 at 11:45 a.m. of the admission Record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of dementia, cerebral infarction, hypertension, urinary tract infection, senile degeneration of the brain, age-related cataracts, restlessness and agitation, and hoarding disorder.Record review conducted on 7/20/26 at 1:47 p.m. of the History and Physical dated 6/16/26, completed by MD16 revealed Resident #5 had severe dementia, a history of cerebrovascular accident (CVA), hoarding disorder, and cataracts. The History and Physical documented Resident #5 was upset about being admitted to the facility, was ambulatory without an assistive device, and was a limited historian.Record review conducted on 7/20/26 at 1:53 p.m. of the Elopement Evaluation Assessment completed on 6/16/26 at 12:17 a.m. by LPN12 revealed the assessment documented Home Elopement History - No, Wanders - Yes, Goal Directed - Yes, Safety - No, Privacy - No, and Recent admission - Yes, with an elopement risk score of 5.0.Record review conducted on 7/20/26 at 1:55 p.m. of the Baseline Care Plan initiated on 6/16/26 by LPN12 Resident #5 was independent with ambulation and required no physical assistance for mobility.Record review conducted on 7/20/26 at 2:00 p.m. of the June 2026 Medication Administration Record (MAR), documented by LPN12, revealed a physician's order dated 6/16/26 for a Wander Guard bracelet with instructions to check placement and function every shift. Documentation indicated the Wander Guard was applied on 6/16/26 at 6:30 p.m. and the function was documented as checked on 6/16/26 at 6:30 p.m. and again on 6/17/26 at 6:30 a.m.Record review conducted on 7/20/26 at 2:08 p.m. of the Nurses' Progress Note dated 6/17/26 at 1:07 a.m., documented by LPN12 revealed Resident #5 became irritated, wanted the power of attorney, put on a coat, picked up a backpack, and stated, I am going home. The note further documented Resident #5 walked through the East Wing looking for a telephone and looking for a door to exit. The resident's family was contacted by telephone, after which Resident #5 became calm and rested in the room.Interview conducted on 7/20/26 at 2:18 p.m. with GNA8 revealed Resident #5 repeatedly stated on 6/17/26, I want to go home, throughout the day. GNA8 stated Resident #5 ambulated independently, wore a Wander Guard bracelet, and paced throughout the facility. GNA8 stated the last time Resident #5 was observed before the Code [NAME] was at approximately 3:00 p.m., after assisting Resident #5 to the restroom.Review conducted on 7/20/26 at 4:18 p.m. of a Facility Witness Statement dated 6/17/26, completed by the Human Resources Assistant (HRA), revealed that at approximately 1:30 p.m., Resident #5 came to the front door and pushed on the door; however, it did not open. Resident #5 then walked away. The Receptionist stated that was the last time Resident #5 was observed until the elopement incident occurred.During interview on 7/21/26 at 10:47am, HRA indicated that on 6/17/26 Resident #5 walked to the front area of the facility, and was just talking to staff and other residents, and would walk back towards the hall. HRA stated that about 1:30pm, Resident #5 came back to the front area, went towards the main entrance door, wander guard alarm went off, tried to push on the door, and when it did not open, turned around, and went back walking down the hall.Review conducted on 7/20/26 at 4:18 p.m. of a Facility Witness Statement dated 6/17/26, completed by Activities Director (Act Dir), revealed that between approximately 2:00 p.m. and 2:15 p.m., Resident #5 asked if the resident could go outside. Act Dir walked with Resident #5 through the hallway to the blue double doors leading to the main dining room. Activities were playing bingo in the dining room, and the doors were closed. Act Dir attempted to open the doors but could not. Act Dir told Resident #5 that the resident could not go outside. Resident #5 then proceeded toward the last doors, when GNA8 intervened and started walking toward the [NAME] Wing with Resident #5. Act Dir then proceeded to the office to attend to paperwork and stated that was the last time Resident #5 was observed before the elopement.Review conducted on 7/20/26 at 4:18 p.m. of an additional Facility Witness Statement dated 6/17/26, completed by Receptionist, revealed Resident #5 came to the front, walked to the main door, the alarm activated, Resident #5 pushed onto the front door, and it did not open. Resident #5 then walked away. The statement documented that this occurred at approximately 1:30 p.m. and was the last time the receptionist observed Resident #5 until the elopement incident occurred.Review conducted on 7/20/26 at 4:18 p.m. of an additional Facility Witness Statement dated 6/17/26, completed by the Receptionist, revealed the Receptionist received a telephone call informing the facility that Resident #5 was walking down Broadford Road. The caller described the resident as wearing yellow pajamas. The Receptionist identified the resident as Resident #5. The Receptionist confirmed the description of Resident #5, announced Code Green, exited the facility with another staff member, and ran toward Broadford Road until locating Resident #5 with the caller. The statement documented Resident #5 was assisted into a staff member's vehicle and returned to the facility.During interview conducted on 7/21/26 at 12:16 pm, the Receptionist revealed that at approximately 1:20 p.m., Resident #5 approached the front entrance door and pushed onto the door. The Receptionist stated the Wander Guard alarm activated, and the door did not open. The Receptionist stated Resident #5 appeared a little agitated and walked away down the hallway. The Receptionist further stated that at approximately 3:20 p.m., they received a telephone call from another resident's family member, who asked if the facility was missing a resident. The Receptionist stated they replied that they did not think so. The receptionist stated that the other resident's family member then described the resident as wearing yellow pajamas. The Receptionist stated they immediately recognized Resident #5, ended the telephone call, picked up the facility phone, and announced Code Green, patient outside three times overhead. The Receptionist stated GNA10 responded, and they ran toward Broadford Road and located Resident #5 on [NAME] Drive. The Receptionist stated the other resident's family member remained with Resident #5 until facility staff arrived. The Receptionist stated the other resident's family member had been walking toward the facility when they observed Resident #5 and contacted the facility. The Receptionist stated GNA10 and LPN9 arrived, assisted Resident #5 into a vehicle, and transported the resident safely back to the facility.Review conducted on 7/20/26 at 4:18 p.m. of a Facility Witness Statement dated 6/17/26, completed by LPN9, revealed that after hearing the Code [NAME] announcement, LPN9 responded outside toward Broadford Road. The statement documented Resident #5 was located approximately 450 feet from the facility with a member of the public. Resident #5 was assisted into LPN9's vehicle and returned to the facility. Upon returning to the facility, Resident #5 was assessed and no apparent injuries were noted.During an interview on 7/20/26 at 2:31 p.m., Licensed Practical Nurse (LPN)9 indicated they were an agency nurse who had been assigned to the facility since March 2026. LPN9 stated they provided care to Resident #5 on 6/17/26. LPN9 indicated Resident #5 was confused, knew only their name, ambulated independently without an assistive device, and was physically active, frequently walking throughout the facility. LPN9 stated Resident #5 had a Wander Guard device in place upon admission. LPN9 indicated they observed Resident #5 speaking with the resident's son by telephone and noted the resident was demanding during the conversation. LPN9 stated attempts at reality orientation were unsuccessful. LPN9 indicated Resident #5 did not exhibit exit-seeking behaviors and did not make statements that caused staff to believe the resident intended to leave the facility. LPN9 stated they observed Resident #5 walking from the therapy area toward the nursing station at approximately 2:45 p.m. before the resident returned toward their room. LPN9 indicated a Code [NAME] was announced at approximately 3:20 p.m., at which time staff immediately initiated a search of the facility and surrounding grounds. LPN9 stated they searched the area outside the facility by vehicle and located Resident #5 outside the building with a family member of another resident. LPN9 indicated Resident #5 remained standing, was pleasant, denied pain when assessed, had no visible injuries, and continued to wear the Wander Guard device. LPN9 stated Resident #5 willingly entered LPN9's vehicle after Geriatric Nursing Assistant (GNA)10 approached the resident and encouraged the resident to return to the facility. LPN9 stated Resident #5 commented, It's beautiful out here. Look at the flowers. Upon returning to the facility, Resident #5 underwent a head-to-toe assessment and skin assessment, with no injuries identified. LPN9 stated Resident #5 was placed on one-to-one supervision until discharge to a sister facility with a memory care unit at approximately 7:00 p.m. LPN9 further indicated that while repairs to the exit door were being completed, a staff member was assigned to continuously monitor the affected exit door, nurses verified the remaining exit doors were functioning properly, and there had been no additional elopements since the incident.During interview on 7/20/26 at 2:44 p.m., Geriatric Nursing Assistant (GNA)10 indicated they observed Resident #5 on the day of the incident ambulating independently throughout the facility without an assistive device. GNA10 stated that at approximately 3:00 p.m., they were attending a stand-up meeting when a Code [NAME] was announced. GNA10 indicated staff were informed that Resident #5 had been observed on [NAME] Road after a family member of another resident contacted the facility. GNA10 stated they and two Assistant Directors of Nursing (Registered Nurse (RN)20 and RN21) immediately exited the front entrance of the facility and proceeded toward the right side of the building and the parking lot. GNA10 indicated Licensed Practical Nurse (LPN)9 arrived in a personal vehicle after locating Resident #5. GNA10 stated Resident #5 was standing with a family member of another resident near the first house on the left side of Broadford Road. GNA10 indicated Resident #5 appeared pleasant, mumbled about the weather, ambulated at the resident's baseline, had no visible injuries, and did not complain of pain. GNA10 stated they asked Resident #5 to ride back to the facility, and the resident willingly entered LPN9's vehicle. GNA10 stated the family member who remained with Resident #5 did not report any concerns regarding the resident's condition. Upon returning to the facility, Resident #5 was placed on one-to-one supervision. GNA10 indicated the facility also assigned staff to continuously monitor the affected exit door, increased the frequency of elopement drills to every shift, and installed secondary audible door alarms (screamers) on the same day as an additional safety measure.Interview conducted on 7/21/26 at 10:55 a.m. with RN13 revealed that after the Code [NAME] was announced, RN13, GNA10, and Receptionist responded toward Broadford Road. RN13 stated Resident #5 was located near the second house before Broadford Road and was technically on [NAME] Drive when staff located the resident. RN13 stated Resident #5 got into the vehicle with LPN9 and GNA10 and was returned to the facility. RN13 further stated that upon returning to the facility, RN13 immediately began trying to determine how Resident #5 had exited the building. RN13 stated that RN13 and SSD17 inspected the exit door located on the 600 Hall. RN13 stated the door was not closed securely. Although the door appeared to be latched, when it was pushed, it opened. RN13 stated they closed the door, and when it was closed again, it latched and did not open. RN13 stated the alarm did not activate when the door initially opened. RN13 further stated no alarm had activated for that door. RN13 stated they held the door closed for approximately 15 seconds, after which the alarm activated, and the door did not open. RN13 stated the alarms activated appropriately on the other exit doors, but not on the 600 Hall exit door.Interview conducted on 7/20/26 at 1:56 p.m. with the Maintenance Director revealed the Maintenance Director inspected all ten exit doors each morning before staff arrived and inspected the doors at approximately 7:30 a.m. on 6/17/26. The Maintenance Director stated all exit doors, magnetic locks, the Wander Guard system, and door alarms were functioning appropriately during the morning inspection. The Maintenance Director further stated that following the Code Green, the exit door located on the 600 Hall of the Far East Wing was found ajar. The Maintenance Director stated the door timer was believed to have malfunctioned, preventing the magnetic lock from securing properly. The Maintenance Director stated the Regional Maintenance Director was notified, responded to the facility on 6/17/26, repaired the door, and confirmed the locking mechanism was functioning properly.Review conducted on 7/20/26 at 4:16 p.m. of the facility's corrective action documentation dated 6/17/26 revealed Resident #5 was immediately placed on one-to-one supervision upon returning to the facility pending transfer to a secured memory care unit. The documentation further revealed the Wander Guard placement and function were rechecked; the resident's care plan and elopement risk assessment were reviewed and revised; all exit doors were inspected; secondary exit alarms were installed on all exit doors; staff received re-education regarding the facility's Wandering and Elopement/Missing Resident Emergency Procedure; and daily Code [NAME] drills were initiated.Record review conducted on 7/20/26 at 4:16 p.m. of the Care Plan initiated on 6/17/26 by the interdisciplinary team revealed Resident #5 was identified as an elopement risk/wanderer related to dementia. The Care Plan documented Resident #5 agreed to wear a Wander Guard. Interventions included checking the Wander Guard placement and function as ordered by the physician, providing one-to-one supervision until placement in a secured memory care unit was arranged, distracting Resident #5 from wandering through pleasant diversions and structured activities, and assessing internal factors when increased wandering was observed.Record review conducted on 7/20/26 at 4:16 p.m. of the Social Services documentation dated 6/17/26, completed by SSD17 revealed Resident #5's responsible party agreed to transfer Resident #5 to a facility with a secured memory care unit. The documentation further revealed Resident #5 was discharged later that day and transferred without incident.During interview conducted on 7/21/26 at 12:23 p.m. with the Administrator, it revealed that the facility reviewed new admissions each morning and knew Resident #5 had been admitted from home. The Administrator stated that at approximately 3:20 p.m., while staff were in a stand-down meeting, an overhead page announced the emergency response. The Administrator stated they did not leave the building but were informed that Resident #5 had been safely returned to the facility. The Administrator stated the resident's family and physician were notified and that Resident #5 did not sustain any injuries. The Administrator stated the facility immediately began investigating the incident and determined the 600 Hall exit door was involved. The Administrator stated staff were assigned to continuously monitor the door until repairs could be completed. The Administrator further stated the Regional Maintenance Director, who lived nearby, responded to the facility and worked with the door vendor to evaluate and repair the door.On 7/21/2026, a past compliance Immediate Jeopardy was signed by the administrator.The facility implemented measures effective for supervision and elopement prevention for all residents with cognitive impairment and /or exit seeking behaviors.Review of the corrective action to correct non compliance indicated that on 6/17/26 at approximately 3:20pm the receptionist received a phone call from another resident's family member stating a lady was outside the center. Receptionist was able to identify the lady as Resident #5 and announced a code green (elopement). On 6/17/26 at approximately 3:24pm LPN9 and GNA10 were able to locate Resident #5 on the pathway towards Broadford Road, accompanied by another resident's family member. LPN9 together with GNA10 (who had arrived at location) returned Resident #5 back to facility via LPN9's car, after LPN9 assessed resident at the location found and determined that Resident #5 had no visible injuries, no complaints of pain, was stable but with confusion.At 3:25pm on 6/17/26 Resident #5 was returned to the facility and a skin assessment, including vital signs, was performed by LPN9 with no injuries notes. Wander guard was checked and revealed to be functioning appropriately.On 6/17/26 at 3:25pm, one on one staff monitoring was immediately initiated for Resident #5.On 6/17/26 at 3:30pm, the facility immediately implemented a 100% head count in the facility with all residents accounted for. Wander guard placed on 6/16/26 (admission) was rechecked and found to be working appropriately, care plan was updated, elopement binder was updated. Resident #5's elopement risk assessment was reviewed and revised to ensure accuracy and appropriateness of interventions. All emergency exit doors were inspected for proper functioning by ADON, maintenance staff and members of management team, with one door noted on 600 hallway not to be functioning consistently, and Regional Maintenance Director contacted and arrived onsite with technical issue corrected.All exit doors continued to be monitored by staff. Designated staff member assigned to the affected door on 600 hall until technical issue corrected.On 6/17/26 Regional Maintenance Director arrived on site and fixed technical issue to the affected door.On 6/17/26 at 5:30pm to 6:00pm secondary alarms were placed on all exit doors to ensure continued coverage in the event of a door.On 6/17/26 at 6:45 pm, after facility consulting with Resident #5 representative, Resident #5 was discharged from the facility to another facility with a secured unit for continued safety. On 6/17/26 the facility initiated Systemic Changes to Prevent Recurrence. The facility implemented the following system-wide interventions:Staff were Interviewed to create a timeline as to when resident was last seen, with resident noted to have been toileted minutes prior to phone call being received. Re-education was initiated with all staff regarding Wandering and Elopement/Missing Resident Emergency Procedure. Care plans of residents identified at risk for elopement were reviewed and revised if needed. Residents with wander guards to have placement and function checked each shift for one week.The facilities Ongoing Monitoring and Quality Assurance. The facility conducted ongoing audits to ensure compliance: Vendor scheduled to be on site on 6/18/26 to perform inspection of door that had a malfunction to confirm in proper working order. Audit of all egress doors scheduled to be completed by vendor on 6/29/26 or sooner based on vendor availability. Re-education to be completed regarding Wandering and Elopement/Missing Resident Emergency Procedure prior to the employee's next shift worked. Elopement drills will be completed Daily for every shift for one week. Then weekly x 3 weeks.Results of these audits were reviewed in the Quality Assurance and Performance Improvement (QAP)) program. Any identified issues were addressed promptly with corrective action by facility.On 7/20/2026 from 11:30am to 2:44pm, eight staff were interviewed ( Housekeeping HSK3, Geriatric Nursing Assistant GNA4, Occupational Therapist Assistant COTA5, Maintenance Director, Dietary Manager, GNA8, LPN9, GNA9). All eight staff stated that the facility completed code green (elopement) drills every shift for a month, and currently twice a week, confirmed receiving and were able to reiterate education regarding wandering and elopement/missing resident emergency procedure.Based on the above actions taken by the facility and verified by the surveyor on site, it was determined that the facility's deficient practice was past non compliance with a compliance date of 6/17/2026.

Based on interview, record review, and facility policy review, the facility failed to ensure a nurse followed a physician's order for wound care for 1 (Resident #3) of 3 sampled residents reviewed for wound care.Findings included: A facility policy titled, Wound Care, revised 10/2010, revealed, 12. Remove dry gauze. Apply treatments as indicated. The policy specified, 2. Report other information in accordance with facility policy and professional standards of practice. An admission Record revealed the facility admitted Resident #3 on 04/20/2026. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had skin tear(s). Resident #3's Order Recap Report for the timeframe 04/01/2026 - 06/30/2026, revealed an order dated 05/01/2026 to cleanse the skin tear on the resident's left forearm with wound cleanser, pat dry, and apply a transparent dressing and leave in place until it falls off. Resident #3's hospital record dated 05/20/2026, revealed Pt [patient] has wounds to bilateral forearm that are not dressed. During an interview on 06/09/2026 at 12:02 PM, Registered Nurse (RN) #2 stated Resident #3 had skin tears on both of their arms. RN #2 stated the resident's skin tears appeared better, scabbed over, and dry at the time the resident was sent to the hospital. RN #2 stated the previous nurse left the skin tears opened to air. During an interview on 06/09/2026 at 12:48 PM, Geriatric Nursing Assistant (GNA) #8 stated Resident #3 had geri-sleeves applied because of skin tears on their arms. GNA #8 stated she recalled the nurse mentioned during a prior shift that she removed the dressing from the resident's skin tears to allow the skin tears to dry out. During an interview on 06/09/2026 at 12:27 PM, Licensed Practical Nurse (LPN) #4 stated Resident #3 had two skin tears on their arms. LPN #3 stated she removed a transparent dressing from one of the resident's skin tears because the dressing kept the skin tear too wet. LPN #4 stated she cleansed the resident's skin tear and left it opened to air so it could dry, even though the order indicated to leave the transparent dressing in place until it fell off. During a follow-up interview on 06/11/2026 at 12:55 PM, LPN #4 stated she should have called the physician and got an order to discontinue the dressings to Resident #3's arm so that the skin tear would be opened to air. During an interview on 06/11/2026 at 3:46 PM, the Assistant Director of Nursing (ADON) stated that if a skin tear was healing and the treatment needed to be changed, the nurse should document it on the skin sheet and notify the physician to get an order to discontinue or change the treatment. The ADON stated the nurse would not be following the plan of care if they did not replace the dressing according to the physician order. During an interview on 06/11/2026 at 2:21 PM, the Nurse Practitioner stated that if a resident had a treatment that needed to be changed due to skin healing, the nurse should call and discuss it with the provider. During an interview on 06/12/2026 at 10:50 AM, the Director of Nursing (DON) stated skin tear dressings should not be left opened to air without a physician order. The DON confirmed that when a nurse determined a treatment needed to change, the nurse should notify the provider, update the treatment plan, and obtain a new order.

Based on observation and staff interviews, it was determined that the facility failed to employ a qualified kitchen manager and/or a full-time dietician to execute the functions of the food and nutrition service. ServSafe is an accredited food and beverage training and certificate program administered by the US National Restaurant Association. The goal is to prevent foodborne illnesses based on a set of guidelines to improve safety and hygiene in food preparation.To become a Certified Dietary Manger (CDM), one must complete and pass an exam through an accredited program administered by the Association of Nutrition and Foodservice Professionals.The findings include:On 3/11/26 at 10:04 AM during observation of the kitchen, Surveyor observed the Kitchen Manger directing/instructing other kitchen staff to perform kitchen tasks. The Kitchen Manager (Staff #16) identified herself as the Kitchen Manager.During an interview, she acknowledged that she lacked qualifications and stated, I have to complete ServSafe and my CDM program. She reported that she communicates with a dietician twice a week, Tuesday and Thursday via email. On 3/12/26 at 11:23 AM, in an interview, the Nursing Home Administrator (NHA) stated that the certified dietician was never on site, she's not local to the area. She also acknowledged that the current Kitchen Manager (Staff #16) lacked training and qualifications for the role; I know we're getting a tag. Dietary is a challenge.

Based on interviews, food tray sampling, and observation, it was determined that the facility failed to provide food that was appetizing in temperature, palatability, and flavor. This was evident during random resident interviews and food tray sampling. This had the potential to impact all residents.Findings included:On 3/11/26 at 11:59 AM, during an interview, Resident #7 reported that the food served at the facility was poor. The chicken was described as tough and difficult to cut.On 3/11/26 at 10:19 AM, Resident #8 reported that food portions were small. During a subsequent interview on 3/12/26, the resident reported that the food, specifically the meat, was overcooked.On 3/13/26 at 9:50 AM, the resident council president, Resident #81, was interviewed. The resident reported that concerns had been shared during resident council meetings indicating that the food was often cold and not good.On 3/16/26, an observation of lunch tray delivery was conducted. The tray was loaded onto the food cart at 11:46 AM and left the kitchen in route to the dining room at 12:17 PM. The tray was delivered at 12:26 PM, approximately 40 minutes after the food left the steam table.On 3/16/26 at 12:28 PM, three surveyors observed and tasted the lunch tray, which consisted of pork slices, rice, and a vegetable dish. Observation revealed that the food was no longer warm and was not palatable in temperature or taste.On 3/16/26 at 12:46 PM, three residents in the dining room were interviewed regarding the lunch meal. Two of the three residents reported they did not like the food. Resident #52 reported that the rice was undercooked and did not taste good. Resident #16 reported not liking the meat. Observation of Resident #16's plate showed that only a small amount of meat had been eaten; most remained on the plate, which had been pushed away.On 3/16/26 at 12:49 PM, these concerns were discussed with the Certified Dietary Manager Consultant (Staff #26). The consultant confirmed that the delivery time of the food trays between leaving the kitchen and arriving in the dining room was excessive. The consultant stated that delivering each cart as it became ready, rather than waiting for all the carts to be ready, could reduce the time between removal of the food trays from the steam table and service to residents.On 3/16/26 at 1:30 PM, these concerns were discussed with the administrator, who reported having reviewed the issue with the Certified Dietary Manager Consultant and approved the proposed plan to reduce food delivery time.

Based on observation and staff interviews, the facility failed to store and prepare food in accordance with professional standards for food service safety. This was evident by unsanitary conditions and unlabeled food items throughout the kitchen and storage areas observed during the kitchen survey. The findings include:On 3/11/26 at 9:00 AM, the surveyor observed color-coded labels with the printed acronym [NAME] (received, opened, expired). None of the labels included the date to indicate received, opened and expired.On 3/11/26 at 10:00 AM, the surveyor and Staff #16 observed the entire kitchen and multiple storage areas.During the observation, Staff #16 verbally acknowledged the following:None of the labels included the date to indicate received, opened, and expired on most, if not all, items.A approximate sized 4'X4' patch of ice was on the freezer floorFrozen condensation on the condensing unitThe oven and stove top had significant grease and food build-upFood debris and trash was accumulated in the tracks of the cook preparation tableBoth the primary and secondary steam tables' water was contaminated with food debrisThere was juice standing in the bottom of the automatic juice dispenserThe vent covers had grease, dust build-up, and one vent had an lodged insect.There was brownish/greenish buildup on walls and ceilingsA soaking-wet mop was observed in a dirty bucket in a mop sink; there were no drying hooks to hang the mop On 3/12/26 at 8:06 AM in an interview, the Nursing Home Administrator (NHA) and the Kitchen Manager confirmed the above were a concern.

Based on observation and staff interviews, it was determined that the facility failed to maintain safe operating kitchen equipment. This was evident for the steamer equipment observed during the kitchen survey.On 3/11/26 at 10:04 AM during observation of the kitchen, it was observed that the steamer's on indicator light was dark and that no heat emanated from the steamer. In an interview, the Kitchen Manager (Staff #16) confirmed it hasn't worked for quite a while. She stated that she had verbally reported the broken equipment to the maintenance director.On 3/12/26 at 8:06 AM, during an observation of the kitchen with the Nursing Home Administrator (NHA), it was noted that the on indicator light appeared to be on.In an interview, Staff #16 reported, it doesn't work right. When you open the door hot water spills out. It's not safe.The NHA heard and acknowledged the concern.

Based on observation and interview, it was determined that the facility failed to ensure resident dignity was maintained. This was evident for 1 (Resident #74) of 1 Resident observed for dignity.The findings include: On 03/15/26 at 8:20 PM, during an evening observation, the surveyor observed Resident #74 in their bed from the hallway. The resident was unclothed, uncovered, and fully exposed. No direct care was being provided to the resident during this observation. No curtain was pulled for resident privacy or dignity. The surveyor stood further down the hallway, observing from a distance as three facility staff passed Resident #74's open door, where they remained exposed until approximately 8:35 PM.On 03/15/26 at 8:45 PM, during an interview with the nursing home administrator, they were made aware of the concern regarding Resident #74's dignity.

Based on record review and interviews, it was determined that the facility failed to ensure a system was in place to review, communicate, and implement pharmacy recommendations following a physician response. This was identified for 5 of 6 residents (#'s 17, 46, 27, 7, 66), reviewed for unnecessary medications.The findings include: 1.On 3/12/26 at 9:00 AM, a review of physician orders for Resident #17 revealed an order for Risperdal Oral Solution 1 mg/mL (risperidone), give 1 mg by mouth every morning and at bedtime for dementia. On 3/12/26 at 10:57 AM, review of the pharmacist's monthly medication review (MMR), dated 2/12/26, identified a recommendation stating the resident was receiving Risperdal for dementia without a diagnosis to support use. The pharmacist noted acceptable indications include schizophrenia, delusional disorder, bipolar disorder (mania), depression with psychotic features, and other psychotic disorders. On 3/12/26 at 10:59 AM, further review of the MMR revealed the physician documented okay and signed the recommendation on 2/12/26. On 3/12/26 at 12:05 PM, interview with Staff #24 (Psychiatric CRNP) confirmed the recommendation was reviewed; however, changes were documented only in a progress note and were not transcribed into physician orders. On 3/12/26 at 12:08 PM, record review identified a diagnosis of delusional disorder dated 1/15/26; however, the physician orders and MAR were not updated to reflect this diagnosis, and the indication was not available to the pharmacist at the time of the MMR. On 3/13/26 at 8:36 AM, interview with the consultant pharmacist (Staff #2) confirmed that accepted recommendations are expected to be reflected in physician orders and the MAR. On 3/12/26 at 12:42 PM, interview with the Director of Nursing (DON) confirmed that physician orders were not updated following acceptance of the pharmacist's recommendation. The DON stated that going forward, all MMR recommendations would be reviewed and incorporated into physician orders when accepted. 2. On 3/12/26 at 1:40 PM, review of physician orders for Resident #46 revealed an order dated 3/5/26 for Risperdal oral tablet, give 3 mg by mouth twice daily for agitation and aggression. On 3/12/26 at 8:59 AM, a request was made for the previous four MMRs. Review of these MMRs revealed no pharmacist recommendations addressing the use of Risperdal. On 3/13/26 at 10:17 AM, interview with the Medical Director (Staff #8) confirmed that the indication for Risperdal was under review and stated a preference to review pharmacy recommendations at the time they are made. On 3/13/26 at 10:50 AM, a follow-up review of physician orders revealed a revised order with a start date of 3/12/26 for Risperdal oral tablet 2 mg, give 3 mg by mouth twice daily for psychotic disorder related to traumatic brain injury 3. On 3/12/26 at 4:04 PM a review of Resident #27's medical record revealed pharmacy recommendations dated 2/13/26, 12/08/25, and 7/18/25. No other pharmacy recommendations were found in the resident's record. The Director of Nursing (DON) was asked to provide the lists from the pharmacist of the residents for whom the pharmacist had no specific recommendations, for each of the past 12 months. On 3/13/26 at 9:08 AM, a review of the lists of residents for whom the pharmacist had no recommendations for the past 12 months, failed to reveal Resident #27's name for August 2025, November 2025, December 2025. The DON was asked to provide the specific pharmacy recommendations for these 3 months for Resident #27. On 3/13/26 at 10:32 AM an interview was conducted with the facility's Medical Director in the presence of the Nursing Home Administrator (NHA). The Medical Director said she became the medical director in December 2025. When asked about her process and preference of how pharmacy recommendations were reviewed, she indicated that it was her preference to review all of them, and added that if a pharmacy recommendation was provided to her she would review and response to it. On 3/13/26 at 11:08 AM, the DON provided pharmacy recommendations for Resident #27 for August 2025, November 2025, and December 2025. A review revealed that the August 2025 recommendation stated that a clear/appropriate diagnosis was needed for the medication atorvastatin. The form lacked any physician response, rationale, or signature. A review of the November 2025 pharmacy recommendation revealed the same request from the pharmacist as the August recommendation and indicated it was a second request, and the form lacked any physician response/rationale or signature. A review of the December 2025 pharmacy recommendation, revealed a request from the pharmacist to consider a reduction in the dose of the resident's proton-pump inhibitor (PPI) , a medication that reduces stomach acid production, but no response or rationale was provided although the form was signed by a physician. When asked, the DON said she was aware of the deficiency. 4. On 3/13/26 at 9:00 AM a review of Resident #7's medical record failed to reveal pharmacy reviews for May 2025, and September 2025, and December 2025. The DON was asked to provide these documents. On 3/13/26 at 11:28 AM, a review of the documents requested revealed that the May 2025 pharmacy recommendation, which recommended gradual dose reduction (GDR) attempt for Resident #7's antidepressant medication, failed to reveal any physician signature or response. A review of the September 2025 pharmacy recommendation which recommended a GDR attempt for a different antidepressant medication also failed to reveal any physician signature or response. A review of the December 2025 pharmacy recommendation which suggested a change in the resident's insulin dosage, was signed by a physician, but contained no response or rationale. The DON was interviewed and said she was aware of the deficiencies. 5. On 3/12/26 at 11:21 AM, a review of Resident #66's record revealed recommendations from the facility's consulting pharmacist on 1/06/26 that outlined irregularities in the diagnosis for the antipsychotic drug risperidone 2 mg for 'agitation'. The pharmacist recommendations to the prescribing provider recommended information on appropriate conditions for drug indication that aligned with the Diagnositic Statistical Manual (DSM)-V and the Centers for Medicare and Medicaid (CMS) guidelines for antipsychotic medications: Schizophrenia spectrum disorders (e.g., schizophrenia, schizoaffective disorder, schizophreniform disorder), Delusional disorder, Bipolar I or Il disorder with manic, mixed, or psychotic features, Major depressive disorder with psychotic features, Refractory major depression, Brief psychotic disorder, Psychotic disorder due to another medical condition (e.g., delirium with psychotic features), Other specified or unspecified schizophrenia spectrum and psychotic disorders. On 3/12/26 at 11:33 AM, an with Staff #24 (Psychiatric Certified Registered Nurse Practitioner) was conducted. Staff #24 explained they have been a consulting provider for the facility for a little over two years and comes on site to the facility once a week. When Staff #24 was asked about recommendations from the facility's consulting pharmacist regarding monthly medication reviews, they stated that they are completed within a week. On 03/12/26 at 11:37 AM, during the interview with Staff #24, the surveyor reviewed Resident #66's monthly medication recommendations from the facility's consulting pharmacist that outlined no clear or appropriate diagnosis for Resident #66's order of risperidone 2mg. Staff #24 explained that they are not aware of a timeframe the facility has for addressing monthly medication review recommendations, but that they are completed as soon as possible. Staff #24 referenced receiving reports from the pharmacy every couple of months, and based on previous gradual dose reductions, the stability of the resident or a change in condition, Staff #24 makes adjustments to medication orders accordingly. On 03/12/26 at 12:14 PM, there is no evidence that the prescriber made changes that were provided for Resident #66 on 1/6/26 or 2/13/26 related to the order for risperidone that is written as: RisperDAL Oral Tablet 0.5 MG (Risperidone), give 1 tablet by mouth two times a day for agitation. On 03/12/26 at 12:43 PM, the Director of Nursing (DON) was interviewed regarding monthly medication reviews and the findings related to Resident #66. The DON explained that they are responsible for updating orders when there are indications for proper use or proper diagnosis, and further explained that they have been in the DON role at the facility for approximately a week and a half at the time of the survey. On 03/12/25 at 12:50 PM, the DON acknowledged the concern regarding the prescriber's undocumented actions regarding recommendations provided by the facility's consulting pharmacist.

Based on observations and interviews it was determined that the facility failed to ensure resident records were kept private. This was evident when a resident's medical record (Resident #37) was left visible on a computer screen on 1 of 4 nursing stations observed after hours during the survey.The findings include:On 3/15/26 at 8:12 PM an observation of the 600/700 hallway of the facility was conducted. The nurses station was unoccupied at the time. A large computer screen on the desk was open to Resident #37's electronic chart and visible. On 3/15/26 at 8:18 PM an interview was conducted with the Activities Director (Staff #12) who had walked up to the surveyor who was still at the 600/700 nurses station. This surveyor asked Staff #12 to make a copy of the scheduled/assignment sheet and she proceeded to remove the schedule from the wall, brought it to the nurses station printer, which was located next to the computer screen with the resident's name showing, made a copy of the assignment sheet and gave it to the surveyor, then put the original schedule back on the wall.On 3/15/26 at 8:20 PM Staff #12 returned to the nurses station to continue the interview. When she was informed that the resident information was visible on the computer screen she paused for a moment and then went to the computer and locked the screen so the resident's information was no longer visible. On 3/15/26 at 8:37 PM an interview was conducted with the Nursing Home Administrator (NHA) in her office and when asked she said that there were no specified visiting hours, visitors were allowed at any time. The NHA was then informed that Resident #37's medical record was visible on the computer screen at the 600/700 nurses station and she acknowledged the finding.

Based on record review, observations, and interviews, it was determined that the facility failed to ensure physician orders were implemented. This was evident for 1 (Resident #1) of 5 residents reviewed for accidents during the survey.The findings included: On 3/11/2026 at 11:31 AM, Resident #1, admitted to the facility for rehabilitation, was interviewed. The resident had no documented cognitive impairment and reported doing well with no complaints regarding care.On 3/12/26 at 4:30 PM, a review of Resident #1's physician orders revealed the following order: apply Tubi grips to bilateral lower legs in the morning and remove at night, everyday shift, with a start date of 1/17/2026.On 3/12/26 at 5:05 PM, Resident #1 was observed sitting up in bed, talking with a visitor, fully dressed and wearing shoes. Observation revealed the resident was not wearing Tubi grip stockings.On 3/12/2026 at 5:10 PM, Nurse Staff #17 and the surveyor observed Resident #1's legs. Nurse Staff #17 confirmed that the resident was not wearing Tubi grip stockings. The nurse searched the room but was unable to locate the stockings. The nurse reported that the resident had been wearing the stockings that morning and stated that GNA Staff #18 and GNA Staff #19 may have removed them when providing care to the resident.On 3/12/26 at 5:15 PM, during an interview, GNA Staff #19 reported not removing the Tubi grip stockings from Resident #1.On 3/12/26 at 5:20 PM, during an interview, GNA Staff #18 reported assisting GNA #19 with care for Resident #1 and stated the stockings were not removed during their care on 3/12/26.On 3/12/26 at 5:22 PM, Nurse Staff #17 was interviewed and stated that if the GNAs did not remove the stockings, rehabilitation staff may have removed them during therapy.On 3/13/26 at 8:21 AM, the Physical Therapist Assistant (Staff #21) and the Occupational Therapy Assistant (Staff #20) were interviewed. Both reported providing therapy to Resident #1 on 3/12/26, including lower extremity exercises to improve strength and balance. They also reported that therapy goals included increasing independence with activities of daily living, as Resident #1 was unable to dress the lower extremities independently. Both staff members stated they did not remove the Tubi grip stockings.On 3/13/26 at 8:24 AM, during a continued interview, the Occupational Therapy Assistant (Staff #20) reported not recalling ever seeing Tubi grip stockings on Resident #1.On 3/13/26 at 8:32 AM, a review of the Treatment Administration Record revealed documentation that Tubi grip stockings were applied every morning from March 1 through March 12, 2026.On 3/13/2026 at 11:26 AM, Resident #1 was interviewed and asked if the stockings were worn that day. The resident reported yes, and stated it was the first time wearing them, also stating that they felt comfortable.On 3/13/26 at 10:11 AM, the administrator was interviewed regarding concerns with the Tubi grip stockings. The administrator reported that the resident was wearing the stockings on 3/13/26 and acknowledged concerns that the stockings had not been applied as ordered on previous days.

Based on observation, staff interviews, and record review it was determined that the facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice. During observation of the facility narcotic books, it was observed that 2 of 3 narcotic count sheets did not accurately reconcile and document narcotic count during the survey.The findings includeThe standard of practice for narcotic reconciliation is conducted at the end-of-shift with two licensed personnel, the on-coming licensed personnel and the out-going licensed personnel, who verify the count of all controlled medications by signature on the narcotic count sheet.Reconciliation refers to a system of recordkeeping that ensures an accurate inventory by accounting for controlled medications. The reconciliation process identifies loss or potential diversion of controlled medications, minimizes the time between the actual loss or potential diversion and follow-up to determine the extent of loss. On 3/11/26 at 9:36 AM Licensed Practical Nurse (LPN #14) and this surveyor reviewed the East unit's narcotic count sheet. It revealed that LPN #15, the on-coming nurse, had signed the narcotic count sheet at 7:00 AM and at 6:30 PM as the out-going nurse. LPN #14 confirmed that the narcotic count sheet was prematurely signed. On 3/11/26 at 11:11 AM, in an interview, LPN #15 confirmed her signature and acknowledged that she had signed the narcotic count sheet dated 3/11/26 at 7:00 AM and at 6:30 PM and stated, I always sign early so that I don't forget.Further record review revealed a second narcotic count sheet that was undated and unlabeled. It lacked off-going licensed personnel signatures on 3/5 and 3/9/26.On 3/11/26 a review of the Controlled Substance Policy, Dispensing and Reconciling Controlled Substances revealed Nursing staff count controlled medication inventory at the end of each shift.The nurse coming on duty and the nurse going off duty make the count together and document.The Director of Nursing confirmed understanding that the facility's narcotic reconciliation practice failed to accurately reconcile and document controlled medications using acceptable standards of practice.

Based on observation, record review, and interview it was determined that the facility failed to ensure medications were secured and accounted for as evidenced by observation of a resident's medications which were left at the resident's bedside. Maintain and secure controlled medications in a separately locked, permanently affixed compartment. This was evident for 1 (Resident #2) during a random observation and 1 out of 3 refrigerators reviewed for medication storage during a surveyThe findings include:Controlled Medications are substances that have an accepted medical use, have potential for abuse, and may also lead to physical or psychological dependence. These medications fall under US Drug Enforcement Agency (DEA) Schedules II-V.1.) Resident #2 was re-admitted to the facility in February 2026 after a hospitalization for surgical repair of their fractured right hip. The resident's diagnoses included, but were not limited to, right neck of femur [hip] fracture and mild intellectual disability. On 3/15/26 at 8:04 PM an observation and interview with Resident #2 was conducted. The resident was seated in their wheelchair next to their bed with their overbed tray table in front of them. The table had a bowl of what appeared to be pudding, and next to the bowl was an overturned medicine cup and 6 pills that were loosely scattered on the table. When asked what the medications were, the resident pushed the pills around and pointed to one oblong pill and said I think that is my blood pressure pill. The resident could not specify what the other medications were. No staff were present in the room. A review of the resident's medical record revealed orders for the following medications to be administered at 9:00 PM: atorvastatin 20 mg (to reduce cholesterol), Montelukast 10 mg (for eczema), potassium chloride 10 mEq (for low potassium level), oxycodone 5 mg (a narcotic to treat pain), and pudding 1/2 cup to take medications. On 3/16/26 at 9:06 AM a review of the facility's medication administration policy dated April 2019, revealed a statement that said a resident may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. A review of Resident #2's physician order failed to reveal an order for the resident to self-administer their medications. The DON was asked to provide an audit of Resident #2's medication administration record for 3/15/26. On 3/16/26 at 11:58 AM an interview was conducted with the Director of Nursing (DON) to review the observation that Resident #2's medications were left on the resident's table and to review the resident's medication administration audit. The audit revealed documentation that Licensed Practical Nurse (Staff #11) signed that she administered the resident's 9:00 PM atorvastatin, Montelukast, potassium chloride, and oxycodone, in pudding at 9:01 PM. The DON confirmed the deficiency and also said that the facility would initiate disciplinary action for Staff #11 that day. 2.) On 3/11/26 at 2:21 PM Registered Nurse (RN #13) accessed the locked medication refrigerator on the [NAME] Unit. It was observed that the plastic box compartment contained Lorazepam (a controlled medication). The compartment was unaffixed. RN #13 easily removed the compartment and stated that it should be secured. On 3/11/26, the Director of Nursing (DON) provided the facility Policy for Controlled Substances which stated, in part, controlled substances are separately locked in permanently affixed compartment. On 3/11/26 at 2:41 PM, the DON and Nursing Home Administrator confirmed the finding and acknowledged the concern.

Based on record review and interviews, it was determined that the facility failed to ensure communication and collaboration on end of life care with the hospice agency. This was evident for 1 (Resident #78) of 1 residents reviewed for hospice and end of life care. The findings include:On 03/12/26 at 2:49 PM Resident #78's care plan indicated they were under Hospice of [NAME] County's care. Resident #78's care plan described they would have assistance with coping issues related to terminal illness and family would be provided emotional support to cope with the resident's decline and entry into Hospice. The care plan further indicated that the facility would update [NAME] County Hospice and the family of any changes, including significant changes, falls, and uncontrolled pain or discomfort.On 03/12/26 at 3:05 PM Resident #78's record was reviewed and revealed a progress note entered on 03/05/26 at 01:00 AM by Staff #4, a Licensed Practical Nurse (LPN), indicating: Resident #78 had been very agitated that evening. Resident #78 was yelling out in pain and requesting to go to bed. Staff members assisted Resident #78 to their to bed and made them comfortable with dignity maintained. Resident #78 continued to yell out saying, I need less pain, not more. Staff #4 administered ordered PRN doses of Morphine and Ativan, as well as a scheduled dose of Morphine. Resident #78 was resting comfortably with call bell in reach. There was no documentation that indicated the facility notified or provided an update to Hospice of [NAME] County. On 03/12/26 at 3:10 PM , a progress note entered on 03/06/26 at 10:55 AM indicated a change in condition related to Resident #78 having a unwitnessed fall, stating : [a laboratory technician] was coming up the hallway and stated that Resident #78 was starting to fall out of their bed. When staff reached the room, Resident #78 was partially on the floor and partially in the bed. Vital signs were taken and were stable. No new complaints of pain or discomfort. [Assisted] Resident #78 off floor and back into bed with no issues.There was no documentation that indicated the facility notified Hospice of [NAME] County of the incident.On 03/12/26 at 3:35 PM a telephone interview was conducted with Staff #6, a Registered Nurse (RN) from Hospice of [NAME] County, who indicated that they were Resident #78's case manager. Staff #6 stated that Staff #7, a Certified Nurse Aide (CNA), provided on-site visits to Resident #78 five days a week, and an RN provided on-site visits two days a week. Staff #6 reported that Resident # 78 had a fall at the facility on 03/06/26 at approximately 6:45 AM. Staff #6 explained staff #5, contacted them and provided an update on Resident #78's fall, and on that day of the event, 03/03/26, Staff #6 visited Resident #78. However, the most recent hospice visit note within Resident #78's medical record during the surveyor review and interview with Staff #6 was from 02/25/26. Further, the facility's progress note documentation in Resident #78's medical record did not indicate that the facility collaborated with or communicated with Hospice of [NAME] County regarding Resident #78's fall. During the phone call, the surveyor asked Staff #6 if they regularly attended the resident's care plan meetings as their case manager at the facility. Staff #6 said that hospice staff did not attend resident care plan conferences at the facility. The surveyor then reviewed with Staff #6 a care plan conference progress note for Resident #78 entered on 03/03/26, by Staff #10, the facility's social services designee, that explained Staff #7, who was in attendance stated Resident #78 would likely be coming off hospice services later that month. Staff #6 explained that Staff #7, a CNA, most likely knew this information from having been in communication with Staff #6. The surveyor asked Staff #6 if a CNA could make assessments and those types of determination statements, to which Staff #6 explained, No, they cannot.Resident #78's medical record did not indicate evidence of the facility having contacted, communicated or consulted with Hospice of [NAME] County related to events on 03/05/25 and 03/06/26. 03/13/26 at 11:40 AM ,during an interview, Staff #10 and the Nursing Home Administrator were made aware of the concern related to documented communication, collaboration, and consultation on Hospice and end of life care planning between the facility and hospice agency. No additional evidence was provided before the end of the survey.

Based on observations and staff interviews, it was determined that the facility failed to ensure that licensed personnel used proper hand hygiene during medication administration to prevent and minimize the spread of infections. This was evident for two out of three licensed personnel (LPN #23 and LPN #25) observed during the medication administration task.Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve the use of Personal Protective Equipment (PPE) such as gown and glove use during high-contact resident care activities.The findings include:On 3/11/26 at 4:00 PM the surveyor observed Licensed Practical Nurse (LPN #23) exit room [ROOM NUMBER], approach the hall medication cart, retrieve medication, re-enter the room and exit the room without proper hand hygiene.On 3/11/26 at 4:04 PM the surveyor observed LPN #23 assist Resident #56 to the restroom and to bed. An EBP sign and PPE hung on the door approximately 5' from the floor. The surveyor observed LPN #23 prepare Resident #56's medications, enter the room, administer the medications and exit the room without hand hygiene or donning PPE.On 3/11/26 at 4:20 PM the surveyor observed LPN #23 prepare Resident #8's medications, enter the room, administer the medications and exit the room without hand hygiene.On 3/11/26 at 4:30 PM the surveyor observed LPN #23 prepare Resident #2's medications, enter the room, administer the medications and exit the room without hand hygiene.On 3/11/26 at 4:42 PM in an interview, LPN #23 acknowledged that she had not performed proper hand hygiene nor donned PPE for residents on EBP.On 3/12/26 at 8:39 AM the surveyor observed LPN #25 prepare Resident #33's medications, enter the room and administer the medications without hand hygiene. In an interview, she stated, I didn't know to wash before entering.

Based on interview, record review, facility policy review, and the American Diabetes Association Guidelines, the facility failed to follow a physician's order for blood glucose monitoring and failed to assess a blood glucose level on an unresponsive resident with a known diagnosis of diabetes mellitus for 1 (Resident #8) of 4 sampled residents reviewed for diabetic management. This failure resulted in harm, as the resident was sent to the hospital unresponsive for a critical blood glucose level of 29.Findings included: A facility policy titled, Diabetes - Clinical Protocol, revised 12/2020, revealed, Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes, as well as factors that may influence glucose tolerance; for example, medications including prednisone, thiazide diuretics or some antipsychotic medications. The policy continued, Related Considerations 1. Risk of hypoglycemia should be considered in any treatment plan, as it is a significant and high-risk complication of treatment. The policy continued, under the heading, Monitoring and Follow-Up, 2. As indicated, the Physician will order appropriate lab tests and adjust treatments based on these results and other parameters such as glycosuria [glucose in the urine], weight gain or loss, hypoglycemic episodes, etc. a. Examples of blood glucose monitoring for various situations might include the following: (1) For the resident on oral medication(s) who is well controlled: monitor blood glucose levels at least twice weekly (or more frequently if there is a change in drugs or drug doses); monitor A1C on admission (if no results from a previous test are available) or when diabetes is diagnosed and every 3 to 6 months thereafter. The policy continued, 4. The physician will order desired parameters for monitoring and reporting information related to blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record and care plan. The policy continued, 6. The staff and Physician will manage hypoglycemia appropriately. The policy continued, (3) For someone who is lethargic but not comatose, treatment might include oral glucose paste rubbed onto the buccal mucosa, intramuscular glucagon, or intravenous 50% dextrose. An American Diabetes Association guideline for Hypoglycemia (Low Blood Glucose), indicated, Hypoglycemia has three levels based on blood glucose (blood sugar) levels and how serious your symptoms are. The guideline continued, Level 3 Your blood glucose has affected your ability to think or control your body so you need help to treat it. An admission Record revealed the facility admitted Resident #8 on 05/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of Stage 4 chronic kidney disease, type 2 diabetes mellitus, and morbid obesity. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2025, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required setup assistance or clean-up assistance with eating and received hypoglycemic medication during the assessment's seven-day lookback period. Resident #8's Skilled Progress Note, dated 05/13/2025 at 10:30 AM, revealed a note by the Nurse Practitioner (NP) that indicated the resident was concerned about not receiving glipizide. Per the Skilled Progress Note, the medication had been stopped while the resident was at the hospital. The Skilled Progress Note indicated the NP decided to resume the medication, as there were no renal side effects. The Skilled Progress Note further revealed, we will resume with monitoring parameters. We will monitor fasting accucheck [blood sugar check] to monitor for hypoglycemia. Resident #8's nursing progress note dated 05/13/2025 at 2:37 PM, revealed glipizide 2.5 milligrams (mg) by mouth daily and fasting blood sugar checks daily for seven days were ordered. Per the progress note, all orders were placed in the system per written order from the NP. Resident #8's Order Recap Report contained an order dated 05/13/2025, for glipizide 2.5 mg one tablet by mouth in the morning for type 2 diabetes. The Order Recap Report also contained an order dated 05/13/2025, for Fasting Accu-Chek [blood sugar checks] daily for 7 days, one time only for Type 2 diabetes until 05/21/2025 23:59, with a start date of 05/14/2025. Resident #8's Medication Administration Record [MAR] for the timeframe 05/01/2025 -05/31/2025, revealed an order entry for glipizide 2.5 mg in the morning for type 2 diabetes. Staff documentation indicated the glipizide was administered daily from 05/14/2025 through 05/18/2025. There was no evidence of an order transcription for the fasting blood sugar checks for seven days on the resident's MAR or Treatment Administration Record [TAR] for the timeframe 05/01/2025 - 05/31/2025. Resident #8's Wound TAR for the timeframe 05/01/2025 - 05/31/2025, revealed an order entry for fasting blood sugar checks daily for seven days until 05/21/2025 with a start date of 05/14/2025. There was no staff documentation to indicate this had been completed. Resident #8's nursing progress note dated 5/18/2025 at 11:50 AM revealed Licensed Practical Nurse (LPN) #21 entered the dining room and found Resident #8 unresponsive. Per the nursing progress note, a geriatric nurse aide (GNA) informed the nurse they had just taken Resident #8 into the dining room. Per the nursing progress note, the GNA took the resident back to their room, the Medical Director was notified, and an order was given to send the resident to the emergency room (ER). There was no documented evidence of a nursing assessment of the resident completed in the dining room, nor any documented nursing assessment completed after the resident was taken to their room. Resident #8's nursing progress note dated 05/18/2025 at 12:22 PM, revealed LPN #24 notified the MD at 11:50 AM, called 911 at 11:53 AM, notified the resident's family at 12:00 PM, and emergency medical services (EMS) arrived at 12:05 PM. The nursing progress note indicated EMS left with Resident #8 on a stretcher at 12:18 PM. Per the nursing progress note, the resident remained unresponsive to staff and EMS at the time of transfer. An MD: Comprehensive Report for the 911 response on 05/18/2025 revealed in the Patient/Chief Complaint section that Resident #8 was found unresponsive at 11:45 AM, and the ambulance was dispatched at 11:58 AM. Per the Report, at 12:04 PM, EMS reported Resident #8 to be clammy, diaphoretic, [and] pale. The Report indicated that at 12:09 PM, the resident was not responsive to painful stimuli and had a recorded blood glucose (sugar) level of 29 mg/dL The Report indicated EMS provided 8 grams (gm) of buccal (oral) glucose paste and 1 mg shot of glucagon in Resident #8's left deltoid muscle. Resident #8's blood glucose level was documented as 60 mg/dL at 12:24 PM. The narrative section indicated the resident was taken out to the ambulance and was secured for transport. The resident's skin was reported to be diaphoretic and clammy, and their eyes were glassy in appearance. The narrative section indicated Resident #8 became more alert as transport continued. During an interview on 10/09/2025 at 9:28 AM, GNA #3 stated she was Resident #8's aide the day 911 was called. She stated she was told the resident needed to go to the dining room for lunch for more assistance with their meal. GNA #3 said she was alerted by the nurse that the resident needed help and was told to take the resident back to their room. GNA #3 said she stayed in the room with the resident until EMS arrived. GNA #3 stated the nurse did vital signs and sternal rubs, but she did not know if the nurse checked the resident's blood sugar. During a telephone interview on 10/09/2025 at 11:53 AM, LPN #21 stated Resident #8 was experiencing arm/shoulder pain that morning, so she assisted the resident to eat a blueberry muffin and told the resident she wanted them to eat in the dining room for lunch for assistance with their meal. LPN #21 said Resident #8 was assisted out of bed and sat beside the nurse's station for a while before lunch. LPN #21 stated she received confirmation from the x-ray company that they were coming that afternoon to x-ray the resident's shoulder. When she went into the dining room to tell Resident #8, she found the resident unresponsive. Per LPN #21, she asked a GNA to assist her to take Resident #8 back to their room and the nurse (LPN #24) at the desk called the doctor and obtained an order to send the resident to the hospital. LPN #21 said the nurse at the desk called 911, while she grabbed items to do a set of vital signs on Resident #8. LPN #21 stated when she arrived back in the resident's room, she did sternal rubs with little response and took a set of vital signs that were within the resident's normal range. LPN #21 stated that before she could have even gone out and retrieved the glucometer to check a blood sugar, EMS arrived. She stated it all happened so fast, that she did not think to check the resident's blood sugar. LPN #21 stated EMS told her as they were wheeling Resident #8 out the door that the resident's blood sugar was 26 mg/dL or 29 mg/dL; she could not remember which. She stated she did not document that blood sugar level because she did not do the blood sugar check. LPN #21 stated she did not know why she did not chart the vital signs she obtained, other than the desk nurse told her they documented in the nurse's note about notifying the doctor and calling EMS and it all ran together. She reported that later, in the evening, a family member came to the facility to collect Resident #8's belongings and stated they were not happy because the facility had not done a blood sugar on Resident #8 since the resident's admission. LPN #21 stated that since she administered Resident #8's medications that morning and had not been their nurse prior, with the [family member] present, she checked the resident's orders and did not find an order to check the resident's blood sugars. During a telephone interview on 10/09/2025 at 11:17 AM, LPN #24 stated she was the nurse at the desk at the time of the incident with Resident #8. She stated that right before lunch, LPN #21 came out of the dining room and told her Resident #8 was unresponsive and to call the doctor. LPN #24 stated she called the doctor, got an order to send the resident to the ER, and called 911 to come to the facility. She stated she got all the transfer paperwork ready for EMS and documented everything in the nurse's notes. LPN #24 stated she did not see Resident #8 until they were leaving on a gurney with EMS, and she was not aware the issue was blood sugar related. During an interview on 10/09/2025 at 12:32 PM, the Assistant Director of Nursing (ADON) stated LPN #21 called her the evening of 05/18/2025 and informed her she sent Resident #8 out by EMS due to being unresponsive. Per the ADON, the nurse told her a family member came to get the resident's belongings and was upset about the resident not getting their blood sugar check for a week. The ADON said LPN #21 told the ADON she looked and did not see an order for blood sugar checks. The ADON stated an investigation was started to determine why the blood sugar check orders were entered into the computer but were not available for the nurses to see. Per the ADON, it was discovered the order for the fasting blood sugar check had been coded to be visible on the Wound Treatment Administration Record, which was a portion of their current electronic medical record that was not available to the nurses to access. During a follow-up interview on 10/09/2025 at 5:41 PM, the ADON stated there was no protocol/standing orders for low blood sugars for the facility. She stated if a blood sugar registered below 60 mg/dL, the nurses were to call the doctor and get an order to administer glucagon. The ADON stated the expectation was for the nurse to check vital signs and a blood sugar on any unresponsive resident, regardless of a known diagnosis of diabetes. During an interview on 10/09/2025 at 12:50 PM, the NP stated that prior to going to see Resident #8 she documented to discontinue the medication, on a pharmacy recommendation, and used the diagnosis of chronic kidney disease. The NP said she had a conversation with the resident about the medication. Per the NP, Resident #8 was very alert and able to make their own medical decisions without any issue. According to the NP, the resident told her they had been on glipizide for a long time and wanted to take it again. The NP stated to comply with the resident's wishes, she ordered the medication at the smallest dose and ordered blood sugar checks for seven days. The NP stated she spoke with Resident #8 every day, and the resident did not mention at any point that the staff were not checking their blood sugar. She stated she was not aware Resident #8 had low blood sugar at the time of their transfer to the ER. She said her expectation of the nurses would be for them to check a blood sugar and obtain a set of vitals on any resident they found unresponsive. During an interview on 10/09/2025 at 7:15 AM, the Medical Director stated he had been made aware of the incident with Resident #8 having a low blood sugar of 29 mg/dL, and that the NP placed the resident back on glipizide with an order to do blood sugar checks for seven days. He stated he had a set parameter for blood sugars over 400 mg/dL and how to proceed; however, for blood sugars lower than 60 mg/dL, the nurses knew to call him for an order for glucose. He stated his expectation of the nurses was for them to follow physician's orders and to obtain vital signs and a blood sugar on all unresponsive residents, regardless of a diagnosis of diabetes. During an interview on 10/09/2025 at 7:03 PM, Corporate Nurse (CN) #28 stated she was the Director of Nursing on record at the time of the incident in May 2025 with Resident #8. She stated if a resident had a blood sugar less than 60 mg/dL, nurses were to call the doctor for orders. CN #28 stated she expected the nurses to follow physician's orders as they were written, to make sure they were put into the computer correctly for the staff to be able to see the orders, and for a blood sugar and vital signs to be completed on all unresponsive residents, whether staff knew the residents were diabetic or not. CN #28 said if the blood sugar was lower than 60 mg/dL, she expected the nurse to call the doctor for an order for glucagon. During an interview on 10/09/2025 at 12:45 PM, the Administrator stated she was not notified of the issue of low blood sugar for Resident #8. She stated the facility addressed the family member's concern and investigated the blood sugars not being done as ordered. She stated her expectation of the nurses would be for them to follow the doctor's orders, to ensure orders entered in the computer were coded correctly to show up on the MAR and TAR, and that the nurses do vital signs and a blood sugar on any unresponsive resident to find the reason for their current state.

Based on observation, interview, review of facility reported incidents and facility policy, it was determined that the facility failed to treat a vulnerable resident with respect and free from verbal abuse. This was evident during a complaint survey and a random observation of staff and resident interactions (Resident #39). The findings include: 1. During the tour and observation of resident care and staff activities on 3/3/25, Resident # 39 was observed at different times either rolling up and down the halls on all units in his/her wheelchair or scooting around on the floor on his/her buttocks. When the resident was observed on his/her buttocks previously staff had guided him/her back to his/her respective room where the resident stayed for a time before coming back out again scooting along the floor. This activity would occur repeatedly throughout the day. At approximately 1:06 PM Resident #39 was observed scooting up the hall from his/her room towards the nursing station. Staff GNA #5 at this time was heard saying here he comes again, he needs to be 1:1. At this time Resident #39 was in front of the nurse's station along with staff Licensed Practical Nurse (LPN) #3 and Geriatric Nursing Assistant (GNA) #4 and GNA #5. GNA #5 continued to state, Every freakin' hour, 365 (referring to Resident #39). Resident #39 was then picked up by GNA #5 and placed in his/her wheelchair. GNA #5 then stated, and off [s/he] goes to cause destruction to someone else, put [her/him] in the office to crawl around, [resident] will be fine, as Resident #39 turned and wheeled down the hallway. There was also another resident sitting in the immediate area, later identified as Resident #309 The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were immediately notified of the observations that occurred with GNA #5 and Resident #39. Record review on 3/3/25 at 2:00 PM revealed Resident #39 has a diagnosis including cerebral palsy, and unspecified intellectual disabilities. On 7/13/24 Resident #39 was assessed and documented as non-verbal. This was also observed throughout the survey. Review of the medical record for Resident #309 revealed diagnoses including cancer and adjustment disorder. A brief interview for mental status was conducted on 2/14/25 which revealed a score of 15 meaning that s/he is cognitively intact at the time of the incident. A review of GNA #5's employee file revealed that he had annual in-service training on abuse 11/11/24 and re-in-services that were held facility wide on 12/12/24. The concern related to GNA #5's outward verbalization of frustration related to the behaviors of Resident #39 and the lack of GNA #5's ability to provide appropriate interventions and interactions with Resident #39 secondary to his/her diagnosis of cerebral palsy was reviewed with the facility during exit on 3/5/25.

Based on the review of a facility reported incident #MD00214913, #MD00214911 and #MD00213420, medical record review, interview with facility staff and review of facility policies, it was determined that the facility failed to ensure that residents medications were secure, maintained and free from misappropriation. This was evident for 2 of 3 (#1 and #17) residents reviewed for medication misappropriation. This was identified a D of past non-compliance for facility reported incidents MD00214913 and MD00214911 for F602. The findings include: Review on 3/3/25 at 10:30 AM of the facility reported incidents #MD00214913 and #MD00214911 revealed concerns related to narcotic discrepancies and misappropriation. According to facility reported incident #MD00213420 occurring on 1/9/25, a family brought medications from home to the facility for Resident #302, which included Ativan (sedative). Unfortunately, about a week or so after they were discharged home, they alleged that the Ativan bottle they brought home no longer contained Ativan but metformin (diabetic medication). They called the facility and complained. The facility did an investigation and was unable to determine if there was a mix-up with the medication but did implement new policies for residents bringing in medications from home. This also initiated the first round of education provided to the nurses regarding narcotic medications and the increase in audits of the narcotic logs by the Assistant Director of Nursing (ADON) and Director od Nursing (DON). Interview on 3/3/35 at 11:21 AM with the facility ADON revealed that the administration started to notice a pattern with a specific nurse, so they started to watch her and the narcotic logbook closely. It was during this audit that the DON and ADON found a questionable signature on a narcotic log from 1/3/25 that LPN #14 forged. 'A pattern of incorrect documentation, missing forms, missing medication, and false documentation was identified by DON and ADON and later identified to only occur on the days when staff LPN #14 worked and completed the forms. They realized that the pharmacy sheets that came in and out were not matching and they found a pattern only where this specific nurse worked.' According to the facility investigation packet, reviewed on 3/3/25, LPN #14 was interviewed regarding the DON's findings and initially denied any wrongdoing but had confirmed that she signed another nurse's signature on one of the pharmacy narcotic forms. The facility's investigation determined that there was Tramadol (narcotic for moderate-severe pain) taken from Resident #1 and Gabapentin (anticonvulsant/nerve pain medication) from Resident #17. The facility implemented an ad hoc quality assurance and performance improvement meeting on 1/13/25 related to this concern of drug diversion with LPN #14. The plan included: Educate all nurses on the floor Do not accept any medications from a resident's home stock Two nurses need to sign for all narcotics that come into the building from pharmacy. Only the management team can destroy any controlled medications. The shift-to-shift count sheet must be completed every time the keys change hands even if the nurse leaves and goes out of the building for lunch. We are to use BLACK ink only DO not scratch out or write over any mistake made on the count sheets or shift to shift report. Cross out the mistake with one line initial and write error. DO not write over any numbers. If you write the wrong number put one line through it, initial it, write error and write the correct number. The shift-to-shift count sheets need to stay in the binders until collected by management. The controlled substance sheets, when completed need placed in the med room, in the allotted spot. Education for all nurses was completed on 2/28/25 according to the sign in log Observation of the narcotic logs with the ADON on the 100 unit on 3/3/25 at approximately 11:45 AM noted no concerns with the narcotic logs or the signatures. There were no noted holes or discrepancies for March or February for this log. On 3/4/25 at 8:35 AM Agency LPN #9 was interviewed regarding the process of completing the narcotic log, sign in and sign out with another nurse. She stated that you count the cards and the pills in the card and sign with the nurse. There was a new narcotic log implemented as per the ad hoc meeting and there were no concerns or holes or errors noted. This surveyor asked the process for discrepancies, and LPN #9 stated that they recount, look for the medication then immediately report to the ADON or DON. Interview with the DON on 3/5/25 at 10:37 AM regarding what initiated that concern with LPN #14 and the discrepancies. She stated the same as the ADON, that around 2/12/25 something seemed off. When they came in on 2/17/25 they did an audit and looked at the nurses' signatures and it appeared that one of the signatures was not that nurse's actual signature and that was the straw' then they realized paper was missing and others were remade by LPN #14. LPN #14 was terminated from the facility on 2/21/25.

Based on observation, interviews, record reviews, and policy reviews, the facility failed to follow infection control and prevention guidelines as follows: The facility staff did not don (put on) personal protective equipment (PPE) prior to entering a resident room and providing hands on care. This was evident during the random observation of staff to resident interactions and patient care. This failure had the potential to affect the spread of infections and involved Resident (39) The findings include: During the tour of the facility and observation of resident and staff practices, on 3/3/25 at approximately 12:45 PM, this surveyor observed LPN #3 in the room of Resident #39, with Resident #39 and GNA #4. Resident #39 was due for nutrition to be administrated via the gastrostomy tube (medical device that provides a direct route to the stomach for nutrition and medication). At this time s/he was very active and not responsive to the requests from LPN #3 to sit and let her administer the fluid bolus. GNA #4 was attempting to hold Resident #39's right arm and they both hollered for assistance. GNA #5 then came to the room to assist with the feeding administration. When LPN #3 saw this surveyor at the door observing the event in Resident #39's room, she yelled for the door to be closed. This surveyor waited outside the door until all 3 staff members exited the room. Upon exiting the room, this surveyor asked what PPE the 3 of the staff wore while providing care. LPN #3 stated we had our gloves and masks on, did you see he was flailing trying to head butt me? It was reviewed at that time that there was an Enhanced Barrier Precaution sign on Resident #39's door and no one was wearing the appropriate PPE, which included according to the sign and the facility policy to the donning of gowns prior to the interaction with Resident #39s' gastrostomy tube, especially if they knew the potential of his/her behaviors and potential rejection of care that LPN #3 reported upon exiting the room. The DON and NHA were notified of the observations during the survey and again during exit on 3/5/25.

Based on review of a facility reported incident, medical record review, observation and interview, it was determined facility staff failed to prevent residents assessed to be at risk for elopement from eloping from the facility (Resident #202 and #204). This was evident for 2 of 7 residents reviewed for elopement. This resulted in an immediate jeopardy for the residents at risk for elopement on 2/15/23 and again on 2/6/24. After the elopement for both incidents, the facility put a plan in place to ensure that no other residents eloped from the facility. Review of the facility's plan of correction, implemented immediately after the facility gained knowledge of the elopements on 2/15/23 and 2/6/24, resulted in the citation being cited as past noncompliance. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents. The findings include: 1. Review of Facility Reported Incident MD00189063 revealed Resident #202 eloped from the facility on 2/15/23. Review of Resident #202's medical record revealed on 2/15/23 at 12:15 AM the Resident was found in the facility truck in the parking lot by Staff #2 while she was on break. The facility's investigation revealed the facility staff located the Resident's wheelchair in the hallway and believed the Resident exited out of an employee entrance. The Resident was assessed and had no injuries. Observation of all exit doors on 11/18/24 at 11:00 AM with the Maintenance Director revealed a closed employee door that was off the facility's main hallway. Through the employee door there was an employee time clock and past the time clock was a locked set of double doors with a key pad that led to the outside. Also in the main hallway was a closed door with a sign that said laundry. Through the laundry door was a locked set of double doors with a keypad that led to the outside. During an interview with the Maintenance Director on 11/18/24 at 11:00 AM, he stated after the Resident was found in the truck, the facility installed keypads on both sets of employee doors. The Maintenance Director stated before the Resident eloped the employee time clock and laundry exit doors did not have locks and were not locked. The Maintenance Director stated all other doors were locked with keypad codes prior to the incident on 2/15/23. During an interview with the Maintenance Director on 11/19/24 at 7:15 AM, he stated he immediately put a temporary motion alarm in place until the new locks were installed on the 2 employee doors. During interview with Staff #2 on 11/19/24 at 4:51 PM, Staff #2 stated she went out the employee exit on 2/15/23 for a break and saw Resident #202 sitting in a truck on the facility parking lot. Staff #2 stated she stayed with the Resident while contacting staff to assist in returning the Resident inside the facility. Staff #2 stated the Resident seemed fine and not injured. Staff #2 stated the Resident ' s wheelchair was located outside the doors in the main hallway that led to the employee exit. Review of the facility's plan of correction on 11/19/24 provided by the Administrator revealed after Resident #202 eloped on 2/15/23 the facility completed the following interventions: 1) head count for all residents in the facility 2) placed alarms on all exit doors 3) reassessed all residents at risk for elopement 4) staff educated on elopement assessment and prevention and 5) the incident was included in the facility's QAPI (Quality Assurance and Performance Improvement) plan. Interview with the Administrator on 11/19/24 at 7:36 AM confirmed Resident #202 was at risk for elopement on 2/15/23 and did elope from the facility on 2/15/23. The Administrator confirmed alarms were immediately placed on 2/15/23 and the facility was in compliance when all education was completed on 4/10/23. 2. Review of Facility Reported Incident MD00202296 revealed Resident #204 eloped from the facility on 2/6/24. Review of Resident #204's medical record on 11/18/24 revealed Resident #204 was admitted to the facility on [DATE]. On 2/1/23 a Social Services note stated the Resident had some incidents of wandering since last review. He/she continued to wear the wanderguard to provide him/her with a safe environment. Further review of Resident #204's medical record revealed a nurse's note on 11/14/23 at 3:19 AM that stated the Resident has been wandering this shift. He/she is walking all over the building. When asked where he/she is going he/she says, I'm getting out Staff is within sight of him/her at all times. Review of the facility investigation revealed on 2/6/24 at 6:30 PM the facility staff could not locate the Resident during dinner service. The facility staff called the police who arrived at the facility and were given a picture identification of the Resident and a description of the clothes the Resident was wearing. The police notified the facility on 2/6/24 at 8:30 PM that the Resident had been found in the woods and transported to the hospital without injury. Review of the facility investigation found the exit door on the 700 unit was not completely latched after a delivery of a chair earlier that day. During an interview with the Maintenance Director on 11/18/24 at 11:15 AM, he stated after the incident he created a log to show that he checks that each of the 10 exit doors are checked every morning when he comes in and again prior to him leaving each day. During an interview with the Administrator on 11/18/24 at 12:45 PM, the Administrator stated she has been the Administrator of the facility since February 2024 and there have been no additional elopements since 2/6/24. During an interview with the Maintenance Director on 11/19/24 at 7:10 AM, he was asked why the alarm didn't sound if the 700 unit exit door was ajar, the Maintenance Director stated once the code is put in the alarm does not reset until the door is shut. During interview with Staff #12 on 11/19/24 at 4:41 PM, Staff #12 stated she was working on 2/6/24 and saw the Resident sitting in a chair by the nurses' station about 30 minutes prior to delivering his/her dinner tray. Staff #12 stated when she went to deliver his/her dinner tray and the Resident wasn't in his/her room, she immediately started looking for the Resident and asking staff if they had seen him/her. Staff #12 stated when we couldn't find the Resident the facility staff began looking outside for the Resident and that is when I saw footprints outside the 700 unit exit door. Review of the facility's plan of correction on 11/19/24 provided by the Administrator revealed after Resident #204 eloped on 2/6/24 the facility completed the following interventions: 1) all facility entry and exit ways and windows were checked for security, penetration and proper function 2) head count for all residents in the facility to ensure all residents were accounted for 3) all residents reassessed for elopement 4) facility elopement binders checked for accurateness and in use wanderguards were checked for function 5) staff educated on elopement and maintenance educated on daily checks of entry and exit door ways for security, penetration and proper function 6) The incident was included in the facility's QAPI (Quality Assurance and Performance Improvement) plan. Interview with the Administrator on 11/19/24 at 7:40 AM confirmed Resident #204 was at risk for elopement on 2/6/24 and did elope from the facility on 2/6/24. The Administrator confirmed the facility was in compliance when all education was completed on 2/12/24.

Based on review of complaints, interview, and documentation review, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 9 of 21 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency. This deficient practice had the potential to affect all residents. The findings include: 1) Nine out of twenty-one complaints that the Office of Health Care Quality (OHCQ) received and reviewed on this survey alleged the facility did not having sufficient nursing staff to provide essential care to the residents that resided at the facility. Complaints consisted of geriatric nursing assistants (GNAs) having up to 20-27 residents to take care of during any given shift. There were concerns that the residents were not receiving timely care, not receiving showers, and were not getting changed or toileted every 2 hours, only twice per shift. 2) Review of the Resident Census and Conditions CMS 672 form that was completed by the Nursing Home Administrator upon request from the surveyor documented that 75 of the 75 residents in the building were either totally dependent on staff or required the assistance of 1 to 2 staff for bathing and eating. It was documented that 64 of the 75 residents were either totally dependent or required the assistance of 1 to 2 staff for dressing and 53 of the 75 residents were either totally dependent or required the assistance of 1 or 2 staff members for toilet use. 3) Staff Interviews were conducted during the 3-day survey which began on 11/18/24 and concluded on 11/20/24. On 11/18/24 at 9:49 AM an interview was conducted with the scheduler, staff #1 who stated they use agency every day and that they staff to census. Staff #1 stated they try to get as close to 3.0 PPD (per patient per day hours); that is our goal. GNA #4 was interviewed and stated they work short and can only do 2 rounds on residents during the night with 4 aides. There usually is 1 geriatric nursing assistant (GNA) for 27 residents. GNA #4 stated, it happened this past Saturday on the Far East wing. I took care of them by myself. We go in in the morning and only 2 GNAs in the building for night shift. The residents are supposed to get showers 2 times per week, and you have to take people to the bathroom. You can't get 6 showers done when you are by yourself. I can get them up but when it is time to change them, I have to find someone to help me. If I can't give a shower, I document N/A (not applicable). I did some showers the day before because I figured I would be by myself on Saturday. This past week I was by myself on Monday and Wednesday, and I split between east and new wing. They keep taking new admissions. GNA #31 was interviewed and stated there were heavier people on west wing and there was only 1 GNA on the day shift 7/7/24 and 7/24/24 Note: The surveyor validated that claim by reviewing the assignment sheets for those 2 days that were provided by the scheduler. There were 25 residents on the unit. There were residents that did not get turned and changed. Everyone got 1 round done. Just last week it was only 2 GNAs and 3 nurses. Everyone got 2 rounds that night and the nurses answered call bells. I feel we do everything we can, but I think the residents would get better care if we could get better staffing. The Nursing Home Administrator (NHA) was interviewed and stated that they did mandate staff to stay over. The NHA stated they had a STAR system and people know if they will have to stay over. They take turns. They just initiated a bonus program, use agency and just signed more contracted agency. Registered Nurse #24 was interviewed and stated, staffing is awful. Nurses call out and GNAS call out and showers aren't getting done. Sometimes showers are made up on the weekends. GNA #25 was interviewed and stated, today I have 29 residents. I can't get to bathe the residents or do all the rounds I need to do. Meals are late. Water is not passed. I can't do last rounds. Now that we have a hospitality aide that helps. Sometimes I can only do 2 rounds on residents. Interview of a complainant stated things have not gotten better since the last surveyor was out in January. I don't know how they slice it. Define 3 hours per day care or define adequate care. They can't provide the proper care. I hope you can fix this mess. There is 1 aide per floor at least 4 nights a week. GNA #14 was interviewed and stated, we work short daily. If you have help you have 12 residents each that is a good day. They will schedule me with 24 residents, and I refuse to do that. They will pull people. If we have time to do showers we will. Sometimes you have 7 to 8 showers and 2 meals, and you can't do it all. I put either N/A or partial as my documentation for showers. Partial is face, armpit, stomach and butt. We can't give the residents the care they need. We are supposed to do 4 rounds. Most of the time it is 2 or 3. GNA #15 was interviewed and stated, we work short all the time. Twenty residents on most of the East wing. Sometimes an aide will split the hall. I do what I can do by myself and then I ask one of the other girls for help. Showers are not given all the time. I document N/A if don't have time to give a shower. The administration says we can't have more staff with no applicants. But we still keep getting new admissions. GNA #26 was interviewed and stated, we work short. It is good if we only have 12 residents. It is hard when we have 27 each and that happens a lot. Weekends are hard. On night shift there is 1 GNA per hall. It is hard because we have rehab patients, bedpans, dementia. The residents don't get as much care, and we don't have time to offer as many fluids. RN #27 was interviewed and stated, sometimes we are short, and showers are a real issue. LPN #28 was interviewed and stated, we don't have enough staff. Sometimes I am both the nurse and the aide. I come to work at 6:30 PM at night and the aide doesn't show up. Sometimes I am the only nurse with no aide. There are a lot of 2 assist. They are harder and they are groggy. We do the best you can. There are a lot of times the residents can't get showers. When it is med pass time, I can't give narcotics and do GNA work both at the same time. If they are giving a shower and there is no other aide on the floor it is hard. There are 27 residents with 1 aide. On the schedule it says 2 aides, but 1 aide doesn't show up and is not replaced. LPN #21was interviewed and stated, the residents do not get the proper care. It is always rushed to care for them. Sometimes I am the other aide. We will shower the whole floor on the weekends if we can't get to them during the week. 4) Review of the facility assessment on 11/20/24 at 8:31 AM documented the following: Facility Assessment and Staffing Needs: This facility assessment will be used to: Inform staffing decision to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care. Review of the relevant information about the residents documented 55 required medical management, 13 were special high care, 13 were clinically complex, 12 had behavioral symptoms and cognitive performance, 27 had reduced physical functioning, 18 required respiratory treatments, 53 had behavioral/mental health, 76 had medication management, 14 on isolation and 14 for wound care. This was for the time period 7/23/24. For the time period 1/1/24 to 7/23/24 the average daily census was 80.55 with 69.15 being LTC (long term care) and 11.4 being skilled. The total number of nursing adjusted hours per resident day according to the facility assessment was 2.8115 per patient per day. Note that this does not meet the state minimal standards for 3.0 PPD. 5) Review of the actual worked nursing schedules for July 2024 and August 2024 revealed the facility did not meet the state minimal 3.0 PPD for 27 of 31 days reviewed in July and for 19 of 21 days reviewed for August 2024. 6) Review of Resident #1's ADLs (activities for daily living) for bathing for the time period 10/26/24 to 11/19/24; the resident had no showers and 8 bed baths. The remaining documentation was either partial or N/A. Review of Resident #31 ADLs for bathing for the time period 10/26/24 to 11/19/24; the resident had 3 showers on 10/28/24, 11/4/24, and 11/14/24. The resident's shower days were listed as Monday and Thursday. The resident did not have any complete bed baths during that time period. The remaining documentation was either partial or N/A. Review of Resident #11 ADLs for bathing for the time period 10/26/24 to 11/19/24; the resident had no showers and 3 bed baths on 10/26/24, 10/30/24, and 11/16/24. The resident's care plan documented the resident prefers no showers and only wants bed baths. The remaining documentation was either partial or N/A. Review of Resident #12's ADLs for bathing for the time period 10/26/24 to 11/19/24; the resident had 2 showers on 11/1/24 and 11/12/24, and 1 bed bath on 10/30/24. The resident's care plan documented the resident only wants showers on Friday but would be offered on Tuesday and Friday. Resident #12 did not receive a shower on 11/8/24 or 11/15/24. The remaining documentation was either partial or N/A. Review of Resident #54's ADLs for bathing for the time period 10/26/24 to 11/19/24; the resident had 3 showers on 11/1/24, 11/12/24, and 11/15/24. The resident had a bed bath on 10/30/24 and 11/5/24. The resident's shower days were Wednesday and Saturday. The remaining documentation was either partial or N/A. On 11/20/24 at 10:45 AM the NHA and Director of Nursing were informed of the staffing concerns.

Based on observation, interviews, and record review, it was determined that the facility failed to provide treatment and care in accordance with the physician's order to administer a pureed diet with honey-thickened liquids to Resident #1 and failed to follow standards of care following a life-threatening choking event. The facility's failure resulted in Immediate Jeopardy when Resident #1 on [DATE], suffered a choking episode and subsequently died . This was identified for 1 of 6 residents reviewed during a complaint survey. On [DATE] an Immediate Jeopardy (IJ) was identified. The facility Administrator received the IJ template on [DATE] at 4:10 PM and was notified that there was Immediate Jeopardy (IJ) identified due to the above failures. The facility IJ abatement plan was accepted on [DATE] at 9:45 PM. The findings include: The State Survey Agency (SA) received a complaint (MD00201673) indicating that Resident #1 had choked on food and died in [DATE]. Review of Resident #1's closed medical record revealed a Speech and Language Pathologist's (SLP) assessment summary of Resident #1 ability to safely swallow, dated [DATE], that indicated: SLP is recommending continuing with a pureed diet with honey-thickened liquids. It is not recommended to give resident cookies or finger foods by request, as this does not follow the LRD (least restrictive diet). Other options for safe and optimal nutrition may need to be considered in the future. Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for anxiety, aspiration, behavioral outbursts, compromised general health, dehydration, and further decline in function. In an interview with Staff #8, the former SLP, on [DATE] at 3:51 PM, Staff #8 stated that she recalled Resident #1 and the SLP consult results from [DATE]. Staff #8 stated that Resident #1 should have had nothing but pureed foods and honey-thickened liquids. Review of Resident #1's care plans on [DATE] revealed the nursing staff developed an ADL (activities of daily living) self-care deficit care plan on [DATE] to address Resident #1 history of cerebral palsy, epilepsy, hydrocephalus, hemiplegia, and contractures of the arms and legs. The nursing interventions documented for eating were, 1.) I eat with the help of one assistant with meals, and 2.) I require staff assistance from one to help me by spoon feeding me my meal. Further review of Resident #1's closed medical record on [DATE] revealed physician orders dated [DATE], for a regular diet, dysphagia pureed texture, with honey thick liquids. (A puree is a very smooth or blended food - like applesauce or mashed potatoes. To puree something is to blend, chop, mash, or strain a food until it reaches this soft consistency. You do not need to chew a pureed diet). A review of the cognition section of Resident #1's annual Minimum Data Set Assessment (MDS) review, with an assessment date of [DATE], revealed the question if Resident #1 should have a Brief Interview for Mental Status conducted. The facility administrator completed this section on [DATE] with a no answer due to Resident #1's being rarely/never understood. The facility MDS coordinator, staff #20, confirmed the annual assessment and submitted the annual MDS assessment for Resident #1 to CMS on [DATE]. Resident #1 was dependent upon the facility staff for all aspects of his/her care. Record documentation revealed that on [DATE] at 12:30 PM, Resident #1 was observed by staff #4 coughing and banging on his/her chest while seated in his/her wheelchair in the west wing dining room. Resident #1 was seated at the first table on the right as you entered the west wing dining room. Staff #4 called for help and attempted to perform the Heimlich maneuver on Resident #1. More staff arrived and also attempted the Heimlich maneuver. Staff moved Resident #1 to the main hallway and lowered him/her to the floor. At that time, Resident #1 became cyanotic and limp. Staff attempted to suction Resident#1's oral cavity and continued to perform the Heimlich maneuver. Staff were unsuccessful at clearing Resident #1's airway. The former Director of Nursing (DON) attempted to obtain a radial pulse and a heartbeat with the use of a stethoscope. Resident #1 was pronounced dead at the facility at 1:01 PM by the former DON (Staff #3). In an interview with staff #4 on [DATE] at 2:25 PM with the acting DON in attendance, staff #4 stated that on [DATE] during the lunch meal, Resident #1 was seated in his/her wheelchair and facing the wall at the first table of the west wing dining room. Resident #1 was seated alone at the dining table. Staff #4 stated that the new CNA, staff #5, had placed the lunch meal tray in front of Resident #1 on [DATE]. Staff #4 stated that she had served Resident #1 his/her meal trays in the past and would assist with cutting up his/her food. Staff #4 stated that Resident #1 was ordered a pureed diet with thickened liquids but would often ask for pizza and Pepsi. Staff #4 stated she was in the process of passing out the lunch meal trays to residents when she observed Resident #1 wheezing. Staff #4 stated that she called for help and lowered the back of Resident #4's wheelchair and stood him/her up. Nothing came out of Resident #1's mouth at that time. Staff #4 stated she got behind Resident #1 and attempted the Heimlich maneuver ten times. Staff #4 stated that she handed Resident #1 over to Staff #13. The former DON (Staff #3) and Resident #1's nurse, staff #6, arrived to assist. As other staff members had brought the crash cart and set up a suction machine, Staff #4 stated that the former DON (Staff #3) continued to perform the Heimlich maneuver while Resident #1 was lying on the ground. Someone checked Resident #1's medical record and stated that he/she had a do-not-resuscitate (DNR) order. Staff #4 stated that she does not get involved in assisting with CPR on residents in the facility. Nurses are the staff that perform CPR on residents. Staff #4 stated that no one asked for 911 to be called during Resident #1's choking incident on [DATE]. In an interview with staff #5 on [DATE] at 4:11 PM, staff #5 stated that she had just recently completed the class to become a Geriatric Nursing Assistant (GNA) on [DATE]. Staff #5 stated she had been working on the nursing units independently since completing the class. Staff #5 stated that someone served Resident #1 pizza that was not cut up and no staff members were paying attention to Resident #1 while he/she was eating lunch on [DATE]. Staff #5 stated that no one instructed her to call 911. In an interview with Resident #1's [DATE] Licensed Practical Nurse (LPN) #6, on [DATE] at 4:34 PM, staff member #6 stated she was alerted to someone calling her name for assistance. Staff #6 stated she arrived as staff members were performing the Heimlich maneuver. Staff #6 stated that she observed Resident #1 turning blue as she arrived to assist. Staff #6 stated that she performed a mouth sweep on Resident #1 but the food was too far down his/her throat. Staff #6 stated that someone mentioned that Resident #1 was given a whole piece of pizza at lunch and that it was not cut up. Staff #6 stated that she did not recall hearing requests to call 911 but did hear someone say that Resident #1 had a DNR order. In an interview with Resident #1's court appointed guardian on [DATE] at 12:16 PM, Resident #1's guardian stated that he was not aware of signing or being aware of any documentation that Resident #1 was able to deviate from the physician's ordered pureed diet and honey thicken liquids. In an interview with staff #14 on [DATE] at 12:40 PM, Staff #14 stated that she witnessed Staff #5 serve Resident #1 his/her lunch meal on [DATE]. Staff #14 stated that in the past she would purposefully remove any food item off of Resident #1's meal tray if the food item was not in a pureed consistency. Staff member #14 stated that she had spoken to Staff #5, days before the choking incident, about also doing the same. Staff #14 stated that Resident #1 was a resident who required staff to feed him/her. In an interview with the facility medical director on [DATE] at 1:15 PM, the facility medical director stated that he did not know why Resident #1 was getting pizza. The medical director stated that he was made aware of Resident #1's [DATE] choking episode after the fact. The facility medical director also stated that he was not asked to participate in the ad hoc, quality assurance meeting the facility staff conducted on [DATE]. In an interview with the acting DON (Staff #2), on [DATE] at 11:15 AM, the facility followed the Maryland Board of Nurses 120-day Ruling for Geriatric Nursing Assistants (GNA) in long term care. After the Certified Nursing Assistant (CNA) passes the initial GNA class and is waiting to take the State GNA exam, MBON stipulates that the CNA then may work as a nursing assistant performing all duties expected of a GNA while awaiting to take their GNA examination and the results. The total time to complete all requirements is 120 days. The facility indicated that the CNA would follow the usual nursing hierarchy and would be supervised by the licensed nursing staff during that 120-day period. The Plan of Removal for the Immediate Jeopardy was accepted on [DATE] at 12:30 AM and included the following: Step 1: A root cause analysis of the event was completed on [DATE]. The facility completed a review of events and the medical records of Resident #1. All facility residents' dietary orders were verified against meal tickets to ensure accuracy. Step 2: The facility will complete the below audits on [DATE] to prevent residents from receiving food in a form that poses a risk to their health. A house wide audit will be completed on [DATE] by the Director of Nursing (DON) to ensure the residents ordered diet and consistency/form are listed correctly on order, Plan of Care/Kardex, and Dietary Manager will ensure it is correct on the meal ticket. A house audit will be completed on [DATE] by the Nursing Home Administrator (NHA) on the next meal service to ensure proper diet and form is maintained for those on specialized formed diets and are being followed. The facility will complete the following audits on [DATE] to ensure processes are in place to involve emergency services. A house audit of residents MOLSTs will be completed on [DATE] by a QAPI nurse to ensure a MOLST is on file, and it is completed in its entirety. The MOLST Binder (located at each nurse's station) which lists residents in alphabetical order and contains a hard copy of their MOLST. An additional copy is scanned in the PointClickCare (PCC) documents module. It is noted on the care plan. The Social worker will audit to ensure the Binder MOLST is an identical match of the PCC loaded MOLST and care plan. Step 3: The facility will begin education on [DATE] with staff as follows. Identified staff will receive education prior to the next shift work with all identified staff receiving education by [DATE]. The current working staff will receive immediate education on [DATE]. Nursing staff will be educated by DON on following physician's dietary orders/form to ensure proper diet is ordered and is reflected in the resident's Plan of Care/Kardex. Dietary staff will be educated by NHA on ensuring physician ordered diet/form is reflected on meal tickets. Dietary staff, nursing staff, and activities staff will be educated by NHA on meal consistency/form levels. Staff will be educated by QAPI Nurse on ensuring the meal served on resident's tray is the accurate consistency/form according to dietary meal ticket. Nursing staff will be educated by DON on ensuring the meal assistance level needed as listed on resident's Plan of Care and/or Kardex is followed. Staff will be educated by NHA on the process of involving emergency services based on professional standards of care. Staff will be educated that resident's code status can be found through PCC Document Module or also located in an alphabet MOLST binder found at each nurse's station. Step 4: The facility will implement monitoring as follows to ensure continued compliance. An ongoing audit of new admissions will be completed by the DON to ensure the residents ordered diet and consistency/form are listed correctly on order, Plan of Care/Kardex, and Dietary Manager will ensure accuracy of meal ticket weekly x 4 weeks then monthly x 3 months. An ongoing audit of 10 residents on specialized diets will be completed by the NHA on the next meal service to ensure proper diet and form is maintained for those on specialized formed diets are being followed weekly x 4 weeks then monthly x 3 months. An ongoing audit will be completed by the NHA on all emergent health events to ensure emergency services are called if appropriate, weekly x 4 weeks then monthly x 3 months. An ongoing audit will be completed on all new admissions and readmissions by the Social Worker to ensure the binder MOLST at the nurse's stations match the PCC document loaded MOLST. Step 5: All results will be tracked and trended at facility monthly QAPI meetings. The Medical Director will be in attendance. On [DATE], based on review of credible evidence, resident medical records, and interviews, it was determined that the facility completed the plan to remove the immediacy on [DATE].

Based on policy review, job description review, medical record review, observations, and interviews, the facility failed to provide the needed assistance and supervision with meals. The facility's failure resulted in harm when Resident #1 was left alone and choked after consuming a slice of pizza. This was identified for 1 of 6 residents reviewed during a complaint survey. The findings include: The State Survey Agency (SA) received complaint allegation (MD00201673) indicating that Resident #1 had choked on food and died in [DATE]. Review of Resident #1's closed medical record revealed a Speech and Language Pathologist's (SLP) assessment summary of Resident #1 ability to safely swallow, dated [DATE], that indicated: SLP is recommending continuing with a pureed diet with honey-thickened liquids. It is not recommended to give resident cookies or finger foods by request, as this does not follow the LRD (least restrictive diet). Other options for safe and optimal nutrition may need to be considered in the future. Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for anxiety, aspiration, behavioral outbursts, compromised general health, dehydration, and further decline in function. In an interview with Staff #8, the former SLP, on [DATE] at 3:51 PM, Staff #8 stated that she recalled Resident #1 and the SLP consult results from [DATE]. Staff #8 stated that Resident #1 should have had nothing but pureed foods and honey-thickened liquids. Review of Resident #1's care plans on [DATE] revealed the nursing staff developed an ADL (activities of daily living) self-care deficit care plan on [DATE] to address Resident #1 history of cerebral palsy, epilepsy, hydrocephalus, hemiplegia, and contractures of the arms and legs. The nursing interventions documented for eating were, 1.) I eat with the help of one assistant with meals, and 2.) I require staff assistance from one to help me by spoon feeding me my meal. Further review of Resident #1's closed medical record on [DATE] revealed physician orders dated [DATE], for a regular diet, dysphagia pureed texture, with honey thick liquids. (A puree is a very smooth or blended food - like applesauce or mashed potatoes. To puree something is to blend, chop, mash, or strain a food until it reaches this soft consistency. You do not need to chew a pureed diet). A review of the cognition section of Resident #1's annual Minimum Data Set Assessment (MDS) review, with an assessment date of [DATE], revealed the question if Resident #1 should have a Brief Interview for Mental Status conducted. The facility administrator completed this section on [DATE] with a no answer due to Resident #1's being rarely/never understood. The facility MDS coordinator, staff #20, confirmed the annual assessment and submitted the annual MDS assessment for Resident #1 to CMS on [DATE]. Resident #1 was dependent upon the facility staff for all aspects of his/her care. Record documentation revealed that on [DATE] at 12:30 PM, Resident #1 was observed by staff #4 coughing and banging on his/her chest while seated in his/her wheelchair in the west wing dining room. Resident #1 was seated at the first table on the right as you entered the west wing dining room. Staff #4 called for help and attempted to perform the Heimlich maneuver on Resident #1. More staff arrived and also attempted the Heimlich maneuver. Staff moved Resident #1 to the main hallway and lowered him/her to the floor. At that time, Resident #1 became cyanotic and limp. Staff attempted to suction Resident#1's oral cavity and continued to perform the Heimlich maneuver. Staff were unsuccessful at clearing Resident #1's airway. The former Director of Nursing (DON) attempted to obtain a radial pulse and a heartbeat with the use of a stethoscope. Resident #1 was pronounced dead at the facility at 1:01 PM by the former DON (Staff #3). In an interview with staff #4 on [DATE] at 2:25 PM with the acting DON in attendance, staff #4 stated that on [DATE] during the lunch meal, Resident #1 was seated in his/her wheelchair and facing the wall at the first table of the west wing dining room. Resident #1 was seated alone at the dining table. Staff #4 stated that the new CNA, staff #5, had placed the lunch meal tray in front of Resident #1 on [DATE]. Staff #4 stated that she had served Resident #1 his/her meal trays in the past and would assist with cutting up his/her food. Staff #4 stated that Resident #1 was ordered a pureed diet with thickened liquids but would often ask for pizza and Pepsi. Staff #4 stated she was in the process of passing out the lunch meal trays to residents when she observed Resident #1 wheezing. Staff #4 stated that she called for help and lowered the back of Resident #4's wheelchair and stood him/her up. Nothing came out of Resident #1's mouth at that time. Staff #4 stated she got behind Resident #1 and attempted the Heimlich maneuver ten times. Staff #4 stated that she handed Resident #1 over to Staff #13. The former DON (Staff #3) and Resident #1's nurse, staff #6, arrived to assist. As other staff members had brought the crash cart and set up a suction machine, Staff #4 stated that the former DON (Staff #3) continued to perform the Heimlich maneuver while Resident #1 was lying on the ground. Someone checked Resident #1's medical record and stated that he/she had a do-not-resuscitate (DNR) order. Staff #4 stated that she does not get involved in assisting with CPR on residents in the facility. Nurses are the staff that perform CPR on residents. Staff #4 stated that no one asked for 911 to be called during Resident #1's choking incident on [DATE]. In an interview with staff #5 on [DATE] at 4:11 PM, staff #5 stated that she had just recently completed the class to become a Geriatric Nursing Assistant (GNA) on [DATE]. Staff #5 stated she had been working on the nursing units independently since completing the class. Staff #5 stated that someone served Resident #1 pizza that was not cut up and no staff members were paying attention to Resident #1 while he/she was eating lunch on [DATE]. Staff #5 stated that no one instructed her to call 911. In an interview with Resident #1's [DATE] Licensed Practical Nurse (LPN) #6, on [DATE] at 4:34 PM, staff member #6 stated she was alerted to someone calling her name for assistance. Staff #6 stated she arrived as staff members were performing the Heimlich maneuver. Staff #6 stated that she observed Resident #1 turning blue as she arrived to assist. Staff #6 stated that she performed a mouth sweep on Resident #1 but the food was too far down his/her throat. Staff #6 stated that someone mentioned that Resident #1 was given a whole piece of pizza at lunch and that it was not cut up. Staff #6 stated that she did not recall hearing requests to call 911 but did hear someone say that Resident #1 had a DNR order. In an interview with Resident #1's court-appointed guardian on [DATE] at 12:16 PM, Resident #1's guardian stated that he was not aware of signing or being aware of any documentation that Resident #1 was able to deviate from the physician's ordered pureed diet and honey thicken liquids. In an interview with Staff #14 on [DATE] at 12:40 PM, Staff #14 stated that she witnessed Staff #5 serve Resident #1 his/her lunch meal on [DATE]. Staff #14 stated that in the past she would purposefully remove any food item off of Resident #1's meal tray if the food item was not in a pureed consistency. Staff member #14 stated that she had spoken to Staff #5, days before the choking incident, about also doing the same. Staff #14 stated that Resident #1 was a resident who required staff to feed him/her. In an interview with the facility medical director on [DATE] at 1:15 PM, the facility medical director stated that he did not know why Resident #1 was getting pizza. The medical director stated that he was made aware of Resident #1's [DATE] choking episode after the fact. The facility medical director also stated that he was not asked to participate in the ad hoc, quality assurance meeting the facility staff conducted on [DATE]. In an interview with the acting DON (Staff #2), on [DATE] at 11:15 AM, the facility followed the Maryland Board of Nurses 120-day Ruling for Geriatric Nursing Assistants (GNA) in long-term care. After the Certified Nursing Assistant (CNA) passes the initial GNA class and is waiting to take the State GNA exam, MBON stipulates that the CNA then may work as a nursing assistant performing all duties expected of a GNA while awaiting to take their GNA examination and the results. The total time to complete all requirements is 120 days. The facility indicated that the CNA would follow the usual nursing hierarchy and would be supervised by the licensed nursing staff during that 120-day period.

Based on medical record review, facility documentation review and staff interview, it was determined that the facility staff failed to protect a resident (Resident #94), who was totally dependent on staff for all aspects of activities of daily living, from an accident with injury. The failure of staff to follow the resident's person-centered care plan after transferring the resident from the bed to the wheelchair, by not securing the vest restraint and having the second staff member stay in the room until the vest restraint was secure, resulted in the resident falling face forward onto the floor and sustaining a laceration which required 4 sutures and a likely non-displaced nasal bone fracture. Additionally, the staff failed to follow physician's orders [REDACTED].#28) who was a fall's risk. This was evident for 2 (#94, #28) of 4 residents reviewed for accidents. The findings include: Review of Resident #94's medical record on 7/10/19 revealed that Resident #94 was admitted to the facility in (MONTH) (YEAR) from an assisted living facility where the resident had a history of [REDACTED]. The 5/29/18 admission note documented, coming to this facility d/t (due to) increasing dementia. The admission note also documented that the resident wore a seat belt and that the resident had a fall on 5/19/18 with head injury. The emergency room report, dated 5/19/18, documented the resident fell from a seated position out of a wheelchair and sustained an abrasion to the scalp and a neck sprain. Subsequent nursing notes, dated 9/19/18 and 9/20/18, documented that the resident was totally dependent on staff for all care and that the resident tended to lean to the right in the wheelchair and often required repositioning. The resident had a (MONTH) (YEAR) physician's orders [REDACTED]. A vest restraint is a vest with straps that is designed to secure a patient to a seated position. Observations were made during the survey of residents wearing vest restraints where the vest was worn around the chest and the straps were wrapped around the back of the wheelchair and secured to the frame of the wheelchair. This resident was not observed as the resident was no longer in the facility. A 10/1/18 nursing note documented that the resident was in the tub room with Geriatric Nursing Assistant (GNA) #20. GNA #20 was behind the resident's wheelchair, untying the vest restraint, when the resident leaned forward and fell to his/her knees on the floor in front of the chair and then to the right side. GNA #20 was waiting for another GNA to help transfer the resident to a shower chair. It was documented that the resident's nurse that evening explained to staff, after the fall, that 2 staff members should be present when untying the resident's vest restraint. A 10/2/18 fall's investigation note documented had falls meeting with staff and discussed the event and the care plan interventions. Staff member was untying Resident #94's vest restraint getting Resident #94 ready for his/her bath when Resident #94 leaned forward and was on the floor. Two staff persons will be present when the restraint is untied. The resident had no injuries from the fall. A nursing progress note, dated 1/19/19 at 7:30 AM, documented, staff noted to place Resident #94 in his/her wheelchair and after placing him/her in wheelchair staff noted to turn to get his/her hair brush and Resident #94 lunged forward and went to the floor face first. The note continued, noted to have a laceration to forehead above left eyebrow and nose noted to be displaced. The resident was sent to the emergency room after the fall and returned to the facility later that morning. The hospital discharge summary documented the discharge as, fall; nasal bridge contusion/abrasion; [MEDICAL CONDITION]; likely non-displaced nasal bone fracture. The emergency room report documented that he/she had a 1.5 cm (centimeter) laceration over the left eyebrow gaping 3 mm (millimeter) on tension and that the resident winced with cleaning and numbing of the forehead wound in clear response to pain. The report documented that the laceration was repaired with (4) 4-0 Nylon sutures. While at the hospital, the resident had a CT scan of the head that was performed due to trauma and the findings were, an old stroke in the right occipital lobe. No evidence of intracranial bleed. The report also documented, Neuro: orientation: severe dementia. no report of AMS (altered mental status) per nursing home. He/She answers every question with 'no.' Continued review of Resident #94's medical record revealed a third fall on 3/5/19 at 5:55 PM. The GNA stated that she attempted to take the resident to the bathroom by herself, untied the vest restraint, then opened the door to call for help with standing the resident. The resident pushed him/herself forward in the wheelchair and slid out of the wheelchair on to his/her buttocks on the bathroom floor. The resident did not have any injuries. The facility's daily falls review, dated 3/6/19, documented that interventions already in place were, 2 aides, 1 staff to stand in front and 1 staff behind until vest restraint is tied and 2 staff present before untying vest restraint. The falls review documented that the fall was, preventable and if care plan had been followed this may have been avoided. Review of Resident #94's care plan for falls, which was initiated on 8/29/18, had the intervention, I want Resident #94 to have a vest restraint on at all times while in wheelchair with a pommel cushion which was initiated on 9/24/18 and a second intervention, have 2 staff members present before untying vest restraint when he/she is in the wheelchair with an implementation date of 10/1/18. A third intervention, which was implemented on 1/21/19, after the fall with a laceration to the forehead, stated, I want one staff member to stand in front of mother/father and one behind mother/father until his/her Vest restraint is tied. Review of the quarterly MDS (Minimum Data Set) with an assessment reference date (ARD) of 1/1/9, Section G, documented that the resident was an extensive assist with 2 or more staff members for bed mobility, transfer, dressing, toilet use and personal hygiene, and was a total assist with 2 or more staff members for bathing. The MDS also was coded that the resident was not steady during transfer and was only able to stabilize with staff assistance. On 7/10/19 at 1:49 PM, Staff #7 stated that she was the resident's primary GNA on 1/19/19. She stated, between 7:00 AM and 8:00 AM, we were getting him/her up for breakfast, I washed him/her up by myself, but Staff #6 came over to help me get him/her up because he/she was a 2 assist. I was supposed to tie the vest protector before anything else. I reached for a hair brush and when I turned around, he/she was on the ground. Staff #6 was at the bathroom door, on her way out. It is supposed to be tied before we put him/her in the chair. On 7/10/19 at 2:20 PM, the Quality Assurance Nurse (QA) was interviewed and stated, we monitor restraints every 3 to 6 months. The QA nurse was asked if the staff were being monitored for following the care plan and the response was, as far as monitoring, I don't know how you would monitor it. We discuss restraints in Q[NAME] The QA nurse stated that, after the 10/1/18 fall, unit staff were educated, and the QA nurse acknowledged that 2 staff must be present until the vest restraint is tied. The 1/19/19 fall was discussed, and the QA nurse stated that all units were educated. When asked if QA monitored afterwards, the response was, how would I monitor that? When asked if anyone went on units and observed the care given to resident's with vest restraints, the response was, no. I didn't do that. The QA nurse was asked about the effectiveness of the education after the 1/19/19 fall due to the resident having a third fall on 3/5/19. The QA nurse stated, what can I do. I am only 1 person. I am Q[NAME] I can't be out on the units. They hired a staff development person in November, and I think that will help as she can go out and educate one on one. On 7/11/19 at 3:16 PM, Staff#9 was asked about the 3/5/19 fall. Staff #9 stated, we were serving dinner trays and I found out he/she had to go to the bathroom, and I told the other aide that he/she had to go, and the other aide asked if I needed help and I told her no, which was bad on my part. He/She was not my resident and I had not taken care of him/her before. I was new, and I was just trying to help because it was dinner time. I was educated by QA and the educator. I was trained during orientation to look at the back of the door to see the documents, but for this incident I was just taking him/her to the bathroom. Discussed with the Director of Nursing on 7/11/19 at 1:12 PM. 2) Review of the medical record for Resident #28 on 7/12/19 revealed documentation, dated 4/30/19 at 9:00 PM which stated, Resident's roommate yelling for help as resident had fallen, resident had been in bed prior to fall, pressure pad did not activate, tab alarm was not in place. Resident found lying on his/her left side, assessed for injury with none noted. The 5/1/19 facility investigation of the fall documented, Staff reports they heard Resident #28's roommate yell, staff went into room, and found Resident #28 on the floor by his/her bed. His/her alarms did not sound, were not in place. Non-skid socks were not on at time of fall. The investigation ended with, Met with 7-3 and 3-11 GNA's, the falls care plan was gone over, aides reminded to make sure interventions are in place when in bed. Review of Resident #28's physician's orders [REDACTED]. Review of Resident #28's care plan, at risk for falls due to dx (diagnosis) of dementia, h/o (history of) falls, muscle weakness, arthritis, decreased vision and history of [MEDICAL CONDITION]. I am ordered a diuretic, [MEDICATION NAME], narcotic, and an antihypertensive had the interventions, (name) would like Resident #28 to have alarms per orders: mobility clip alarm at all times with String shortened, pressure pad alarm at all times. The care plan was initiated on 8/10/18. The falls review document was reviewed on 7/16/19 and the new intervention post fall was, aide was counseled/disciplined to place alarms as ordered. Staff #19 was interviewed on 7/16/19 at 10:16 AM about the fall and stated, it was my second 16 hour shift. I was doing (2) 16 hr. shifts and an 8 hour shift and it got overwhelming. I usually don't put him/her to bed. That night he/she was assigned to me. I put him/her to bed but was not used to putting him/her to bed, so I forgot his/her alarms and grippy socks. That night I was tired, and I just lost my train of thought. After this incident I got talked to about it and I signed a paper that I was educated.

Based on medical record review, staff interview and facility documentation review it was determined that the facility staff failed to protect a resident, who was totally dependent on staff for all aspects of activities of daily living, from an accident with injury. The failure of staff to follow the resident's person-centered care plan while turning a resident in bed resulted in the resident rolling out of bed and sustaining bilateral nasal fractures. This was evident for 1 (#33) of 7 residents reviewed for accidents. The findings include: Review of Resident #33's medical record on 4/25/18 revealed the resident had a fall on 8/24/17 and sustained bilateral nasal fractures. A nursing progress note dated 8/24/17 at 14:38 (2:38 PM) documented resident had a fall from bed during care and landed face down on floor, bleeding from facial area, resident not moved, nurse wiped blood away from nose and mouth without moving resident to aide in breathing. Resident did not lose consciousness, moaning. Physician called and new order to send to ER. Review of the emergency room documentation revealed a discharge summary dated 8/24/17 which documented [DIAGNOSES REDACTED]. The special notes documented patient needs neuro checks every 2 hours once back to nursing home. Normal medications and meals. Has bilateral nasal fractures from the fall out of bed - there is some angulation so she may need ear, nose and throat physician follow up as an outpatient in the next 1-2 weeks. Resident #33 had a [DIAGNOSES REDACTED]. Resident #33 was unable to communicate and was severely demented. Review of the MDS (Minimum Data Set) assessment with an assessment reference date (ARD) of 8/15/17, Section C, Cognitive Patterns was coded severely impaired. Section G, Functional Status, was coded total dependence with 2+ assistance for bed mobility, transfer, dressing, personal hygiene and bathing. Review of Resident #33's care plan Resident is dependent on staff for all ADL's (activities of daily living) r/t perceptual/cognitive impairment, associated with Alzheimer's dementia, impaired mobility, visual deficit, disease progression and impaired ability to communicate had the approaches 2 ½ siderails up when in bed, 2 assist with incontinence and the falls care plan resident at risk for injury due to falling r/t has poor safety awareness, poor body control, is b/c (bed/chair) confined and uses [MEDICAL CONDITION] drugs, history of falls had the intervention 2 half siderails up when in bed at all times and when providing care in bed. On 4/25/18 at 4:09 PM the surveyor requested a copy of the facility's investigation into the fall. The Quality Assurance Nurse (QA) and the Nursing Home Administrator (NHA) brought in documentation and explained that the Geriatric Nursing Assistant (GNA) did not follow the care plan which required 2 people to turn and position the resident. The NHA stated the GNA thought she could do it herself and she turned the resident too close to the edge of the bed and the resident fell out of the bed, face first onto the floor. The NHA advised the surveyor that the GNA had been terminated during the investigation. The QA nurse indicated that all staff were educated and there is now a blue card in resident rooms to indicate the number of staff for care and transfers. The QA nurse stated they did a RCA (root cause analysis). Review of the falls investigation of 8/24/17 revealed the nurse was called to the resident's room at 1:45 PM. When the nurse arrived, the resident was found face down on the floor in a pool of blood. The resident was moaning. The nurse cleared blood from the airway without moving the resident's head or neck or back. The nurse documented I inched under face just enough to clear airway because she was bleeding from nose going into mouth. Her feet were hung up on the edge of the bed. The nurse called for assistance of another nurse to do all arrangements. Staff stayed with the resident, vital signs were taken, and the resident was moaning the entire time. The GNA stated I turned the resident, her head went off the bed and I couldn't hold her. The side rail was down on my side. The side rail was up on the opposite side. The nurse, Staff #1, was not available for interview in the facility. A phone message was left for Staff #1 on 4/26/18 at 1:56 PM, however as of 4/27/18 a return call had not been received. A daily falls review was done on 8/25/17 with 6 staff members. New interventions consisted of staff education (full building). The surveyor requested a copy of the signatures of the staff that attended the education. The surveyor was given a typed memo which stated Attention all staff, All residents will now have a blue index card on their cork board letting staff know how many assist the resident is with turning and repositioning in bed. This will signify what is on the resident's care plan and should be maintained anytime you are turning or repositioning a resident in bed. B0 means the resident needs no assistance, B1 means 1 assist and B2 means the resident needs 2 assist with T&P in bed. Please ask if you have any questions. The date of the memo was 8/29/17, which was 5 days after the accident. The surveyor was supplied with 2 signed memos, 1 with 14 signatures and 1 with 17 signatures. On 4/25/18 at 6:00 PM the surveyor requested to know how many personnel were in the nursing department and the NHA advised 75 current. The NHA stated it has fluctuated between 60 and 75 staff. The Director of Nursing (DON) was asked how do you know that all staff members are aware of this memo and the DON stated I don't really. The memos are in the communication book on each unit. The DON was unable to find the memo on 1 of the units as of 6:00 PM 4/25/18.

Based on medical record review, facility documentation review, and staff interview it was determined the facility staff failed to follow a resident's care plan to prevent a fall which resulted in a major injury (laceration requiring 10 staples to the head along with a fractured finger for Resident #67 and a broken pelvis for Resident #43). This was evident for 2 of 3 residents (Resident #67, #43) reviewed for accidents. The findings include: 1. Resident #67 was a [AGE] year old female admitted to the facility on [DATE]. The resident was assessed as a falls risk, and a care plan was initiated on 10/20/15 at 13:57 (1:57 PM) for potential for injury, gait belt for transfers r/t (related to) generalized weakness, impaired vision manifested by decreased mobility, poor safety awareness. One of the nurse aide interventions stated gait belt for transfers and ambulation. Review of incident report, dated 11/15/15 at 19:20, (7:20 PM) stated that the resident fell and hit their head sustaining a 5 cm (centimeter) by 3 cm laceration. The fall happened in the resident's room and at the time the resident was walking with the nursing assistant. The resident ambulated with nurse assistant, when Nursing Assistant stopped to open bathroom door, resident began to lean backwards, tripped over own feet, Nursing Assistant attempted to catch resident, but resident fell face first onto floor between beds in room. The resident was transferred to the emergency room via 911. Review of the hospital discharge summary stated that the resident sustained [REDACTED]. Skin closed with 10 staples. Review of the written warning that was issued to Geriatric Nursing Assistant (GNA) #2 on 11/15/15, stated gait belt was not used for transfer. The violation was fall without gait belt usage - always use a gait belt when ambulating, transferring residents. The employee statement was I understand to always wear a gait belt. GNA #3 was asked by the surveyor, on 11/18/15 at 9:30 AM, how Resident #67 was to be transferred. GNA #3 stated when we get up on bedside commode 2 assist with gait belt and walker. GNA #3 continued use gait belts for any transfer, no matter what always use a gait belt. GNA #1 was asked by the surveyor on 11/18/15 at 9:45 AM how Resident #67 was to be transferred. GNA #1 stated before the fall we used 1 person with gait belt and transfers. When asked by the surveyor when are gait belts used the reply was they are used when you transfer and ambulate, it is policy. The surveyor said does that mean mandatory and the response was yes. Review of the gait belt policy given to surveyor by the Nursing Home Administrator (NHA) on 11/18/15 stated Gait and transfer belts will be utilized for all residents who ambulate, transfer or need assistance with lifting. The gait belts are made available on all floors at the nurses' station. Aides will sign them out at the beginning of the shift and return them at the end of the shift. Gait belts will be worn outside of the clothing as much as possible. A gait/transfer belt will be placed around the resident at waist level snuggly as possible without causing discomfort to the resident. On 11/18/15 at 10:45 AM, the surveyor went to the East Nursing Station and asked for the gait belt sign out book. There was not a gait belt book. The gait belts were located on the wall next to the nursing station for anyone to use. Licensed Practical Nurse (LPN) #3 stated during an interview on 11/19/15 at 10:18 AM, that GNA #2 was written up because a gait belt was not used when taking the resident to the bathroom. The NHA was advised on 11/19/15 at 10:34 AM. 2. Resident # 43 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident # 43's activities of daily living (ADL) care plan evaluation, dated 6/2/15, indicated that the resident required assistance from one staff, with wheeled walker and a gait belt, for both transfers and ambulation. Review of the fall care plan evaluation for resident #43, dated 8/20/15, revealed that the resident fell on [DATE] at 4:40 AM, while ambulating using a walker, with a staff to the restroom when the resident slipped in her own urine. In an interview on 11/17/15 at 11:00 AM, resident #43' s granddaughter stated to the surveyor that her grandmother was nearing discharge when she suffered a fall and broke her pelvis on 8/20/15. X-RAY results from 8/20/15 corroborated that resident #43 suffered a fracture to the left inferior pubic ramus and left ischial tuberosity. Review of facility documentation, completed 8/26/15 about the fall event, revealed that resident # 43 was walking with walker and a trainer to restroom, but was incontinent and slipped in her own urine. Further review of the incident investigation indicated that the possible cause was staff not using a gait belt and was unable to hold the resident and the resident fell to the floor. During a brief meeting with the administrator on 11/18/15 at 11:00 AM, he/she submitted a copy of the facility' s Gait and Transfer Belts Policy. According to the Gait and Transfer Belt Policy, belts must be utilized for all residents who ambulate, transfer or need assistance with lifting. During another interview with the administrator on 11/18/15 at 11:35 AM, he/she confirmed that the GNA did not use a gait belt when the resident was assisted to the restroom on 8/20/15. Interview of Licensed Practical Nurse (LPN) # 3 on 11/19/15 at 9:05 AM, revealed that resident # 43 fell on [DATE] and he/she then came into the resident room to assess the resident for possible injury. LPN # 3 indicated that the GNA and a trainer who cared for resident # 43 was alone with the resident and the resident fell . LPN # 3 also confirmed that resident # 43 was not wearing a gait belt and the GNA and trainer did not have a gait belt with them when resident #43 fell . LPN # 3 added that the GNA and trainer was given education about gait belt use. An interview was conducted with RN # 1, and GNA # 5 and GNA # 6 on 11/18/15 at 9:35 AM and each was asked when is a gait belt to be used. All three staff reported that a gait belt is to be used anytime when a resident is assisted with ambulation or transfers. The facility staff failed to follow the resident care plan and facility policy on use of a gait belt when ambulating a resident and this failure contributed to a resident fall with serious injury.