Every finding on record at Devlin Manor Nursing and Rehabilitation Center

Based on record review and interview it was determined the facility staff failed to report an allegation of abuse to the local law enforcement authorities. This was evident for 1 (#3) of 2 residents reviewed for abuse.The findings include:Investigation documentation and facility reported incident (FRI) #3022768 was reviewed on 6/26/26 at 12:30 PM. The review revealed that on 5/22/26 at approximately 9:00 PM, Resident #3 reported to Licensed Practical Nurse (LPN) #3 that s/he experienced pain while receiving evening care from Geriatric Nursing Assistant (GNA) #4; and the GNA failed to stop when Resident #3 repeatedly told her to stop because she was causing pain. GNA notified the nurse. The resident spoke to a family member immediately after the encounter. The family member telephoned the facility and spoke to the nurse.The resident was assessed by LPN #3 at that time, no injuries were found, and the report of an allegation of abuse was submitted to the state agency. GNA #4 was suspended pending the outcome of the facility's investigation.The facility's self-report indicated that the police were not notified.A handwritten witness statement dated 5/26/26 reflected an interview the Social Worker (SW) #5 conducted with Resident #3. The resident described the incident from 5/22/26 and indicated: s/he told the GNA that it was really hurting and she was pulling at his/her skin. S/he asked her to stop but she kept pulling. At the end of the interview it noted: *I asked (Resident #3) if s/he felt s/he was abused? Resident stated Yes. In an interview on 6/25/26 at 2:30 PM Resident #3 recalled the incident and his/her conversation with the Social Worker. S/he indicated the Social Worker asked do you think it was abuse? Yes or no? I thought about it for a minute, I didn't feel the aide intended to hurt me, but I felt that when I told her to stop and she didn't, it was abusive, so I told the Social Worker yes. LPN #6 was interviewed on 6/29/26 at 11:22 AM. She indicated that she was the Administrative nurse on call the evening of 5/22/26. She indicated she received a phone call from the nurse that Resident #3's family member wanted to talk to the administrative nurse, so I called her. She was upset, indicated Resident #3 called him/her and indicated that staff had abused the resident. I decided to come to the facility to see the resident. LPN #6 indicated that once the resident made the accusations, she suspended GNA #4. No documentation was found in the investigation documentation or Resident #3's medical record to indicate that facility staff notified local law enforcement of an allegation of abuse. During an interview on 6/29/26 at 12:15 PM the Director of Nursing confirmed that the police were not notified. She stated, there wasn't any injury when we assessed him/her, so we didn't notify the police.

Based on record review and staff interviews, it was determined that facility staff failed to 1) ensure advance directives and decision-making authority were established and maintained for a resident who lacks decision making capacity and 2) document that residents were informed of their right to formulate Advance Directives upon admission. This deficient practice was evident for 4 (Resident #4, #1, #10 and #11) of 4 residents reviewed for Advance Directives during the annual survey. The findings include: 1) On 03/25/26 at 9:40 AM, a review of Resident #4's medical record indicated the resident lacked decision making capacity at the time of admission in March 2024. The resident's medical record failed to show evidence the facility obtained documentation of an authorized decision-maker, including advance directive for the resident. During an interview with the Director of Social Services (DSS) #14 on 03/25/26 at 10:15 AM, she reported that the resident's family member had been making decisions since 2024; however, no legal documentation was present to support the family member's authority. On 03/25/2026 at 10:34 AM, the DSS #14 reported that no documentation exists showing attempts made by the facility to establish a authorized decision-maker or to ensure completion of advance directive document from admission through 03/23/2026. 2) On 03/24/25 at 10:45 AM, a review of the residents' electronic records revealed Maryland Orders for Life Sustaining Treatment (MOLST) were completed as follows: Resident #1 MOLST completed on 02/24/26. Resident #10 MOLST completed on 06/11/24. Resident #11 MOLST completed on 09/09/25. The records failed to reveal that Advance Directives were discussed with residents and/or responsible representatives. On 03/24/26 at 10:45 AM during an interview the Director of Social Services reviewed the clinical records of Residents #1, #10 and #11 and reported that she could not find documentation to indicate that information on Advance Directive was discussed with the residents and/or responsible representatives.

Based on observation and interview, the facility failed to process and store linens in a manner to maintain infection prevention. This was evident during 1 of 1 observation of the laundry room during an annual survey.The findings include:On 03/24/26 at 9:02 AM, an observation of the hallway by the clean and dirty laundry rooms revealed two uncovered clothing racks which appeared to be full of resident linen.At the same time, further observation of the hallway revealed a room which had a singular washer and dryer next to one another. Further observation of the room revealed an uncovered clothing rack labeled, unlabeled clothing, and a medium sized basket on the floor of various rags/cloths.On 03/24/26 at 9:03 AM, an interview with Housekeeping Aide (Staff #16) revealed that only resident linen was washed, dried, and sorted in the room where there was a singular washer and dryer. She further indicated they have separate clean and dirty laundry rooms for bed linen, towels, and other items other than resident clothing. During the same interview, the surveyor asked Staff #16 what the basket of rags/cloths were on the floor in the room and she indicated they were from the kitchen and also get cleaned in the room that was indicated to only be used for resident clothing/linen. On 03/24/26 at 9:05 AM, further interview with Staff #16 revealed that clean resident clothes were sorted in the resident clothing laundry room and hung up on the rack outside in the hallway. On 03/24/26 at 9:06 AM, an interview with Housekeeping Director (Staff #17) regarding the separate clean and dirty laundry rooms, as well as the resident clothing specific room, revealed it was the only facility she knew of that processed linens as such. During the same interview, she confirmed that resident clothing gets processed (dirty resident clothing gets washed and clean resident clothing gets dried and sorted) in the resident clothing only room, and that bed linens, towels, and other items were processed in the clean and dirty laundry rooms. She further indicated that the facility has no room for the clean resident clothing racks and that was why they were out in the hallway.On 03/27/26 at approximately 9:30 AM, the surveyor reviewed the concern with the Nursing Home Administrator. He indicated that he understood and that the exposed clean resident clothing rack had since been moved after surveyor intervention.

Based on review of medical records and interviews with facility staff, it was determined that the facility staff failed to develop a 48-hour baseline care plan upon admission. This was evident for 1 (Resident # 106) of 20 residents reviewed for care plans during the annual re-certification survey.The findings include: On 03/24/26 at 1:53 PM Resident #106 medical records were reviewed and revealed that Resident #106 was admitted to the facility on [DATE]. The baseline care plan could not be found in the Matrix, the facilities electronic health records (EHR).On 03/24/26 at 2:43 PM Staff #5, the Regional Clinical Director of Nursing (CDON) was asked to provide a copy of Resident #106's 48-hour baseline care plan.On 03/24/26 at 2:58 PM Staff #2, the Director of Nursing (DON) and Staff #5 CDON were interviewed and asked if they had documentation that Resident #106's 48-hour base line care plan was completed. The DON stated that they did not do the 48-hour care plan for Resident #106. Both the DON and the CDON verbalized understanding that the base line care plan should have been completed within 48 hours of Resident #106's admission.

Based on observation, record reviews, and interviews, it was determined that facility staff failed to ensure effective communication by not addressing hearing impairment for a resident identified with hearing loss. This deficient practice was evident for one (Resident #82) resident of two residents reviewed for vision and hearing during the annual survey.The findings include:On 03/24/26 at 10:08 AM, during an interview with Resident #82, the resident reported difficulty hearing and asked the surveyor to stand on the left side of the bed since hearing is better with the left ear. The resident also reported they did not have hearing aids.Review of the care plan dated 02/06/2025 identified hearing loss and included interventions such as facing the resident and speaking clearly. A review of the minimum data set (MDS) dated [DATE] indicated minimal hearing difficulty. The most recent MDS dated [DATE] indicated a decline in hearing to moderate hearing difficulty. Further review of the medical record failed to show evidence of an audiology screening or evaluation.On 03/26/2026 at 10:04 AM, during an interview, the Director of Nursing (DON) confirmed that the resident has not been assessed for hearing loss and could not provide an explanation for lack of referral or evaluation.

Based on observations, staff interviews, and record review, it was determined that the facility staff failed to revise the comprehensive care plan to reflect the resident's need for oxygen therapy. This deficient practice was evident for one (Resident #19) resident reviewed for care plans during the annual survey.The findings include:On 03/23/2026 and 03/24/2026, the surveyor observed Resident #19 in bed receiving oxygen at 2 liters via nasal cannula.A review of the resident's comprehensive care plan failed to include the use of oxygen therapy, monitoring, or interventions related to respiratory needs.On 03/24/2026, during an interview, the Director of Nursing (DON) acknowledged that the care plan should have been updated to reflect the resident's oxygen use following the hospitalization in October 2025 and November 2025.A review of the hospital discharge summaries dated October 2025 and November 2025 confirmed ongoing oxygen therapy needs; however, the care plan was not updated to reflect these changes in condition.

Based on observations, record review and interviews, it was determined that the facility failed to ensure that a dependent resident's grooming needs were met. This was evident in 1 (Resident# 10) of 1 resident reviewed for Activities of Daily Living (ADL).The findings include:On 03/23/26 at 11:36 AM the surveyor observed Resident #10 sitting at the side of his/her bed, with a disheveled appearance and facial hair about a quarter of an inch long.On 0/23/26 a review Resident #10's most recent MDS ARD 02/11/26 revealed a Brief Interview Mental (BIMS) score of 6 indicating severe cognitive impairment. A further review of the clinical record and care plans did not find evidence that the resident refused care, including shaving and grooming.On 03/23/26 at 2:28 PM in an interview GNA #19 stated that she was not assigned to the resident at the time of the interview, but she had a good relationship with the resident. She indicated that whenever she provided care the resident did not refuse grooming.On 03/24/26 at 1:10 PM the surveyor again observed the resident with unshaven facial hair sitting on his/her bed. The surveyor interviewed the Unit Manager #18 who accompanied the surveyor to the resident's room and confirmed the findings. On 03/24/2026 at 1:30 PM during an interview the Director of Nursing stated that she was made aware of the surveyor's concerns. However, Resident #10 sometimes refused care, but the refusal of care was not mentioned on the resident's care plans. She further stated that the Unit Manager was in the process of updating the resident's care plan.On 03/24/26 at 1:51 PM Unit Manager #18 reported to the surveyor that the resident's facial hair was shaved, and the care plan had been updated.

Based on observations, staff interviews, and record review, it was determined that the facility failed to ensure physician orders were obtained and implemented for oxygen therapy. This deficient practice was evident for one resident (Resident #19) reviewed for professional standard of practice during the annual survey.The findings include:On 03/23/2026 and 03/24/2026, the surveyor observed Resident #19 in bed receiving oxygen at 2 liters via nasal cannula.On 03/24/2026, during an interview, the Registered Nurse (RN) #12 confirmed the resident was receiving oxygen. Both the surveyor and RN #12 reviewed the resident's medical record which failed to reveal an order for oxygen. The RN acknowledged the order was missing and stated the resident should have an oxygen order.A review of the resident's hospital discharge documents dated October 2025 indicated the resident was to be weaned to 1 liter of oxygen, and hospital discharge documents dated November 2025, indicated a history of hypoxia (low oxygen) requiring 3 liters of oxygen via nasal cannula.On 03/24/2026, the Director of Nursing (DON) stated, the admitting nurses are responsible for copying hospital discharge orders into the facility system. She acknowledged that Resident #19 was hospitalized in October 2025 and November 2025 and returned on oxygen; however, the admitting nurse failed to enter an oxygen order upon readmission.

Based on resident record review and staff interview, it was determined that the facility failed to conduct a comprehensive Minimum Data Set (MDS) assessment within 14 days of a significant change. This was evident for 1 (Resident #52) of 3 residents reviewed during the annual re-certification survey.The findings included:On 03/23/26 at 10:28 AM, during the initial observation, Resident #52 was observed lying in bed on her back and her left hand was contracted.On 3/25/26 at 7:38 AM, Resident #52's medical records were reviewed and revealed that Physical Therapy (PT) assessed contractures of her right and left ankle upon their admission assessment on 3/1/23.Occupational Therapy (OT) notes revealed Resident #52 had contracture of muscle in their left hand on 4/26/24.The MDS assessments were then reviewed and revealed that in section GG functional limitation in range of motion on 6/7/2024, 9/5/2024, and 12/6/24, the upper extremities (shoulder, elbow, wrist, and hand) were documented as no impairment, even though Resident #52 was being treated by OT for left hand contraction since 4/26/24.On 03/25/26 at 2:05 PM, the Director of Nursing (DON) was interviewed because the MDS nurse was on vacation. The DON was shown the OT progress notes from 4/26/24 and the MDS assessments for 6/7/24, 9/5/24, and 12/6/24, which documented that Resident #52 had no upper extremity impairment when her left hand was contracted since April 2024.The DON acknowledged that the MDS documentation regarding Resident #52's left hand being contracted was a significant change and should have been documented timely.

Based on record review and staff interview, it was determined that facility staff failed to make sure a legal decision maker was in place for a resident in a timely manner. This deficient practice was evident for one resident (Resident #4) reviewed for decision making capacity during the annual survey.The findings include:On 03/25/26 at 9:40 AM, a review of Resident #4's medical record revealed an admission date of 03/06/2024, with multiple diagnoses, including dementia. Further review indicated that no advance directives were documented for the resident. On 05/31/2024, the attending physician, and on 06/03/24 the nurse practitioner, certified that Resident #4 lacked decision making capacity. The medical records failed to show evidence of a court appointed legal healthcare decision maker.On 03/25/26 at 10:15 AM, during an interview, the Director of Social [NAME] (DSS) #14 stated that when a resident is admitted without decision-making capacity, the facility contacts the resident's family and advises them to seek legal guidance to establish a decision maker. The surveyor inquired about Resident #4's appointed decision maker. The DSS #14 stated she was unsure whether the facility had obtained the required documentation but reported that the facility was currently in the process of obtaining guardianship. The surveyor requested that the DSS review the medical records to determine whether documentation of a court appointed decision maker was present and to provide any available guardianship documents.On 03/25/2026 at 10:34 AM, the DSS #14 provided the surveyor with a progress note dated 03/23/2026 at 1:25PM, which indicated that certification for guardianship had been submitted to the physician and provider for completion. The DSS #14 further stated that the facility did not have documentation of any prior attempts to obtain an appointed healthcare decision maker since the resident's admission in 2024.

Based on record review and interview, it was determined that the facility staff failed to monitor a resident with abnormal lab findings. The failure to do so, resulted in harm to the resident since the resident had to be hospitalized for treatment. This was evident for 1 (#6) of 2 residents reviewed for quality of care. The findings include:Cirrhosis of the liver is a condition in which the liver becomes scarred and unable to work properly. Ascites is a complication in which the liver does not produce protein in the blood causing fluid to build up in the abdominal cavity and if left untreated it can cause the resident to have trouble breathing. Esophageal varices is a complication that is caused by increased pressure in the portal (liver) vein that results in weak blood vessels in the esophagus. These weak blood vessels bleed easily and are the cause of 1/3rd of the deaths from cirrhosis. Lastly, with endstage liver disease, the liver cannot rid the body of waste and allows ammonia to build up in the blood. The high ammonia levels cause hepatic encephalopathy as evidenced by changes in behaviors, agitation, combativeness, irrationality, and muscle tremors. If left untreated a hepatic coma occurs which has a mortality rate of 90%. (Gerontologic Nursing, 7th Edition 2025). On 3/17/26 at 9:36 AM a medical record review for Resident #6 (R6) revealed a progress note dated 2/9/26 at 1:22 PM that read the resident's cancer center appointment was cancelled for tomorrow and to continue with the nurse practitioner's (NP) order for labs which included an ammonia level. A visit conducted by the attending physician on 2/10/26 revealed the resident the following but not limited to diagnoses: pancreatic cancer and cirrhosis of the liver with ascites and esophageal varices. A review of the lab results for the ammonia level drawn on 2/11/26 revealed the ammonia level was 76 with a reference range of 9-35, next to the results was a (H) indicating that the level was high. The result was circled and NNO (no new orders) written next to it. Above it was handwritten that there was no previous ammonia level. It was signed by Physician Assistant (PA) #1. A review of the progress notes and orders confirmed that PA #1 had not ordered any treatment or monitoring for the high ammonia level. Furthermore, there was no corresponding progress note. A progress note dated 2/18/26 revealed the resident was sent to the emergency department (ED) for further evaluation due to the resident's family member insisting that the resident was sent. A review of R6's acute hospital records on 3/19/26 at 12:06 PM for the ED visit on 2/18/26 and the subsequent hospitalization revealed in the ED notes that the resident had a change in mental status and abdominal pain. An ammonia level was obtained on 2/18/26 and the results were 180 with a reference range of 9-35. The primary diagnosis was hepatic encephalopathy. R6 was treated with lactulose which causes the resident to get rid of the excess ammonia by having multiple bowel movements in a day. The resident spent 6 days in the hospital and was discharged on 2/24/26. The R6's attending physician, who was the facility's Medical Director was interviewed on 3/17/26 at 11:06 AM. He reported that the resident had an elevated ammonia level and PA #1 had missed it. He reported that on 2/18/26 the resident had an altered mental status and the family insisted that the resident was sent to the ED, for which he was glad because of the ammonia level. He stated that the family was not happy and rightly so. He reported that he had extensive conversations with the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding the medical error. He reported that he reported the error to the provider staffing agency that he and PA #1 work for. During an interview with PA #1 on 3/17026 at 1:55 PM she confirmed that she reviewed the ammonia level for R6 on 2/11/26 and had not written any orders and she was unable to find a previous ammonia level for the resident. When asked her rationale for no new orders, she reported that the resident did not have a history of hepatic encephalopathy and the nurses had not reported a change in mental status, so she decided not to treat the resident. She stated that she wrote no monitoring orders to assess the resident for a change in mental status because it was a normal part of nursing care. Furthermore, stated without a change in mental status she felt the resident did not need treatment. When asked if she had anyone had questioned her decision not to write any new orders related to the ammonia levels. She stated that she had a meeting with her boss, who told her that her rationale was well thought out. The concerns were reviewed with the NHA and DON on 3/18/26 at 10:05 AM. When asked what the facility had done when the Medical Director had reported the concern to them. The DON mentioned that they had an action plan to address lab results. However, she admitted that it was a plan to ensure the facility received results in a timely manner which was not the concern with this incident. The DON reported that the staffing agency that contracted PA #1 had initiated a performance improvement plan (PIP) for the error. However, they had not conducted a root cause and analysis and implemented intervention to ensure the deficient practice did not occur again. An interview with the Medical Director of the staffing agency that contracted PA #1 on 3/18/26 at 11:14 AM revealed what he found throughout his investigation of the incident. He reported that PA #1 provided a written explanation of her rationale to not take action when she received the lab results. According to the MD, she had reviewed the resident's medical record and found that the resident was having 2-3 large bowel movements a day. She decided against treatment with lactulose because the goal of this treatment was to make the patient have 2-3 bowel movements a day and that was already occurring. He reported that she wrote in her statement that she planned to recheck the ammonia level in a couple of days, but failed to enter the order in the resident's medical record. The failure to write this order caused harm to the resident by resulting in 6 days of hospitalization.

Based on record review and interview, it was determined that staff failed to recognize and report allegations of abuse to the State Agency within the required timeframe. This was evident for 1 of 4 facility reported incidents reviewed.The findings include:On 3/19/26 at 10:01 AM a review of the facility's investigation file for the facility reported incident #2726923 revealed on the initial report form it was indicated that the Director of Nursing (DON) became aware of an allegation of abuse on 1/21/26 at 9:32 AM. However, further review of the investigation file revealed that GNA #3 verbally abused Resident #6 on 1/20/26 during the evening shift. It was witnessed by facility staff who failed to report the abuse. The email confirmation read the report was sent to the State Agency (SA) on 1/21/26 at 12:42 PM. An interview with Certified Medicine Aide (CMA) #5 on 3/19/26 at 3:15 PM revealed she was present when the abuse occurred and confirmed it was on 1/20/26 between 8:00 PM - 8:30 PM. The concerns were reviewed with the DON on 3/19/26 at 1:34 PM. She reported that she thought the 2-hour timeframe to report to the SA started when she was notified of the allegation of abuse. Cross reference: F600 and F610

Based on record review and interview, it was determined that facility staff failed to ensure that a resident had the medications they needed upon admission and throughout their stay. This was evident for 1 (#6) of 2 residents reviewed for quality of care concerns.The findings include:A medical record review on 3/17/26 at 9:36 AM for Resident #6 (R6) revealed the discharge summary from the hospital for 11/25. According to the record the resident had cancer of the pancreas (an organ that secretes enzymes to assist with digestion and absorption of nutrients) and had a Whipple procedure (a procedure in which the head of the pancreas, the first part of the small intestines, the gallbladder and the bile duct is removed) to treat the cancer. Further review of the discharge summary revealed the resident was on Creon, which was a medication with three pancreatic enzymes to assist with digestion and absorption of nutrients and was usually taken with every meal. A review of the resident's orders revealed the resident was ordered Creon 24,000-76,000-120,000 unit; administer 1 capsule by mouth 3 times a day on 11/19/25. A review of the medication administration record (MAR) for November 2025 revealed facility staff were to administer Creon to the resident at 8:00 AM, 12:00 PM, and 5:00 PM every day. According to the record the resident was not given the medication on 11/19/25 at 5:00 PM and the nurse noted the drug was not available from the pharmacy and was pending an evaluation from the attending physician to be ordered from the pharmacy. A review of the MAR for January 2026 revealed the resident was not administered the Creon on 1/7/26 at 12:00 PM and 5:00 PM and the nurse noted that the medication was not available to give. A review of the MAR for February 2026 revealed the resident did not receive Creon on 2/16/26 at 5:00 PM or on 2/17/26 at 8:00 AM, 12:00 PM, and 5:00 PM. The nurses noted each time that the medication was on order from the pharmacy. On 3/17/26 at 3:40 PM a review of the information sent from the pharmacy regarding how much Creon they had dispensed for the resident and when revealed the following: on 11/24/25 (5 days after admission) they sent 100 capsules, on 1/8/26 they sent 100 capsules, and on 2/17/26 they sent 100 capsules. These dates coincide with the dates that the resident had missed doses of the medication because facility staff allowed it to run out before the next order arrived. An interview with the Director of Nursing (DON) on 3/18/26 at 12:15 PM revealed she reviewed most new admissions. She reported she reviewed R6 prior to admission and gave the ok to admit the resident. She reported she was aware the resident was on Creon and acknowledged the importance of the medication to be taken with each meal. When asked why she had not ensured the facility had the medication to administer to the resident upon admission, she reported that they asked the family to provide the medication until they can get it in. She further explained that this medication required her signature to order and because it was not in stock at the pharmacy it took longer to get it in. She agreed that it was not the responsibility of the resident and/or family to provide medications that the resident needed in the facility. She was asked to provide evidence that family were asked to bring the medication upon admission by the hospital case manager. A review of the facility's Ordering and Receiving Medications from the Pharmacy policy and procedure on 3/18/26 at 12:30 PM revealed there was no implementation date noted. In addition, there were no provisions for special order medications included.On 3/18/26 at 1:03 PM an interview with Registered Nurse (RN) #2 revealed she was assigned to R6 the day that s/he was admitted . She stated that she was unable to administer the Creon because it had not been ordered from the pharmacy. She reported she called the DON and asked what she needed to do. She reported she was given the directive to call the resident's family and asked them to bring the medication from home. She stated that the DON told her that the attending physician needed to evaluate the resident to ensure if s/he needed the medication. (This was why she noted that on MAR on 11/19/25 for the missed 5:00 PM dose. She reported that resident's family brought the medication in the next day.During a subsequent interview with the DON on 3/19/26 at 1:34 PM. She reported she was unable to provide evidence that the case manager at the hospital had spoken to the resident and/or family regarding the need to bring the medication with them. She reported she consulted with the admission Coordinator too. She stated that even though they knew it took longer to get special order medications from the pharmacy, they had no process in place to order the medications prior to admission, so it was available when the resident arrived. Reviewed the days that the resident had missed doses because the refills had not arrived. She reported that there was no provision in place to ensure that refills were received before the pills ran out. She acknowledged the concerns and reported that she was going to implement provisions to have the medications ordered prior to admission and to order them 7 days in advance when they needed reordered.

Based on record review and interview, it was determined that facility staff failed to that a staff member who was observed abusing a resident, no longer had access to vulnerable residents to ensure there was no further abuse. This was evident for 1 (#4) of 1 resident review for abuse.The findings include:A medical record review for Resident #6 (R6) on 3/19/26 at 9:50 AM revealed a minimum data set (MDS) with an assessment reference date of 12/18/25 that read the resident had a diagnosis of dementia and was severely cognitively impaired.During a review of the facility's investigation file for the facility reported incident #2726923 on 3/19/26 at 10:01 AM revealed that GNA #3 abuse Resident #6 (R6) on 1/20/26 during the evening shift. While GNA #3 and GNA #4 was putting the resident back to bed GNA #3 stated to the resident, Do not fucking hit me. However, facility staff failed to recognize the abuse, and it was not reported to the Director of Nursing (DON) until 1/21/26 at 9:32 AM. On 3/20/26 at 9:30 AM staff assignment sheets for 1/20/26 and 1/21/26 were reviewed. Based on these documents GNA #3 worked evening shift starting at 2:30 PM on 1/20/26 and continued to work until 1/21/26 at 6:30 AM. This was confirmed by reviewing GNA #3's time punches for those days. An interview with Certified Medicine Aide (CMA) #5 on 3/19/26 at 3:15 PM revealed she was present when the abuse occurred and confirmed it was on 1/20/26 between 8:00 PM - 8:30 PM. This confirms that GNA #3 worked approximately 10 hours with vulnerable residents after she was overheard verbally abusing resident #6. The concerns were reviewed with the DON on 3/19/26 at 1:34 PM. Cross reference: F600 and F609

Based on record review and interview, it was determined that the facility failed to ensure their residents were free from abuse. This was evident for 1 of 2 residents reviewed for abuse.The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 1/23/26.The findings include:MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A medical record review on 3/19/26 at 9:50 AM for Resident #4 (R4) revealed a Minimum Data Set (MDS) that documented the resident had no behaviors, severe cognitive impairment, unclear speech, and s/he understood what was being said sometimes. Furthermore, it was documented that the resident relied on staff to provide most ADLs (activities of daily living include but are not limited to the following: bathing, dressing, eating, and toileting). On 3/19/26 at 10:01 AM a review of the facility's investigation file for the facility reported incident #2726923 revealed the initial report form. Review of the form revealed that on 1/21/26 Geriatric Nursing Assistant (GNA) #6 reported to the Director of Nursing (DON) that she heard GNA #3 report to the oncoming dayshift GNA that R4 had hit her and she stated, fucked [his/her] ass straight up and [his/her] is a fucking retarded gimp Further stating that s/he will be nice now because s/he realized which one it was and s/he won't be getting any more ice cream from her. Review of the interview the DON had with Certified Medicine Aide (CMA) #5 revealed on 1/20/26, during the evening shift, she was in the hallway at the medicine cart near R6's room where GNA #3 and GNA #4 were putting the resident back in bed. She stated she heard GNA #3 state, don't fucking hit me. The statement read that she reported the door to the R6's room was closed so she could not see what was going on. Review of the interview that the DON had with GNA #4 revealed she confirmed she was assisting GNA #3 with putting R6 back to bed on 1/20/26 with the mechanical lift. She stated that GNA #3's voice was raised during the incident, but she could not remember if she cursed at the resident. Review of an interview that the DON had with GNA #3 revealed that R6 hit her and she held his/her arm down. The DON had not asked GNA #3 what she said to the resident. Further review revealed evidence that GNA #3 was terminated and when she was told she was terminated she admitted to cursing at R6. Evidence showed she was reported to the state licensing agency. Review of the education provided revealed that all facility staff were educated on Abuse Prevention, Recognizing, and Reporting. A mitigation plan for staff failing to report allegations of abuse timely was initiated on 1/21/26. On 3/20/26 at 9:30 AM reviewed the staffing assignment sheets for 1/20/26 and 1/21/26 which revealed GNA #3 worked evening shift starting at 2:30 PM on 1/20/26 and continued to work until 1/21/26 at 6:30 AM. This was confirmed by reviewing GNA #3's time punches for those days. On 3/19/26 at 10:55 AM the surveyor attempted to interview GNA #3 by phone and was unsuccessful. On 3/19/26 at 10:59 AM the surveyor attempted to interview GNA #4 by phone but was unsuccessful. During an interview with CMA #5 on 3/19/26 at 3:15 PM revealed that on 1/20/26 around 8 - 8:30 PM she was standing at her medication cart near R6's room. She stated that GNA #3 and GNA #4 were getting R6 out of his/her wheelchair in the hallway with the mechanical lift. She had her back to them, but overheard GNA #3 state, Don't fucking hit me. She reported she failed to report the abuse because she thought GNA #3 said this to GNA #4 and not to the resident. On 3/19/26 at 11:42 AM the concerns were reviewed with the DON. She stated that she determined it was abuse and implemented the following plan of correction: the employee was terminated and reported to the state licensing agency, and education on recognizing and reporting abuse was provided to all staff in the facility. A mitigation action plan was developed and implemented to follow in their Quality Assurance and Performance Improvement committee. Based on the above actions taken by the facility and verified by surveyor on site, it was determined that the facility's deficient practice was past noncompliance with a compliance date of 1/23/26. Cross reference: F609 and F610

Based on record review and interview, it was determined that the facility failed to ensure they had an effective Quality Assurance and Performance Improvement Program to include the development and implementation of polices and procedures for the program. This was evident during the revisit survey.The findings include:During a complaint survey on 3/20/26, the facility was determined to be out of compliance with CMS regulation 483.30(b) physician visits and it resulted in harm to a resident.A medical record review for Resident #1 on 5/13/26 at 12:18 PM revealed a hospital Discharge summary dated [DATE] documenting the resident had multiple duodenal (first section of the small bowels) ulcers. The resident was listed as NPO (nothing by mouth) for their diet and was receiving TPN (total parenteral nutrition - nutrition through an intravenous line) and the resident was to receive medications orally. The list of discharge medications included but were not limited to a proton pump inhibiter (decreases gastric juices for digestion) and a gastrointestinal protectant (given to prevent additional ulcers from forming). However, a review of the resident's physician orders revealed the medications on the discharge summary had not been ordered for the resident. There were no notes that indicated the reason for these medications not being continued by the admitting nurse, Registered Nurse (RN) #4. Nor were there any notes or orders entered by PA #5 who had reviewed the discharge with RN #4 per his progress note. On 5/7/26 the resident had a history and physical assessment by Physician #6. The notes read that the resident's full plan of care, to include the resident's medication orders, had been reviewed. In the medical decision-making section, the physician wrote for the duodenal ulcers that the resident was to continue the proton pump inhibitor and the gastrointestinal protectant. The note failed to indicate that the physician was aware that the resident had no bowel sounds at the time of admission, that the resident had reported they were not on oral medications in the hospital, and that he [the physician] was aware that the resident's medications listed on the discharge summary had not been ordered. Through interviews with RN #4 and PA #4 it was determined that there was confusion with the resident's discharge summary, and the resident was supposed to be NPO until they were examined by the physician the next day. However, this information was made part of the medical record.An interview with Physician #6 on 5/13/26 at 3:28 PM revealed he thought the resident was on the medications as they were listed on the discharge summary. He stated that if the medications had not been entered into the computer and he failed to hand write them on the paper record then that was his mistake. The failure to review the resident full plan of care to include their medications was deficient practice and the facility continued to be out of compliance with 483.30(b).An interview with the Director of Nursing (DON) on 5/14/26 at 1:46 PM revealed that they were not auditing the physician notes to ensure the full plan of care and medications had been reviewed at each visit. The facility's plan of correction and Quality Assurance tools failed to ensure compliance with all the components of the regulation. Cross Reference: F711.On 5/14/26 at 1:09 PM a review of the facility's QAPI program policies and procedures revealed there was no date of completion of the police, it's implementation date, or the date it was last reviewed located on the document. The document was titled, Leadership Polices and Procedures with subject, Quality Assurance and Performance Improvement (QAPI) Program. Under procedures it read that the QAA (Quality Assessment and Assurance) committee was chaired by the Administrator and they would designate a person to lead the committee meeting in their absence. The procedure further noted that the committee was responsible for developing feedback mechanisms but failed to indicate what they were and how they were obtained. They were to establish benchmarks but failed to show what was established. They were to assign a person responsible for collection, reporting and analysis of data and development of an action plan, however, they failed to indicate the title of the role of the person responsible. They failed to include the mechanisms for communication of QAPI indicators, initiative, strategies, and results. The policy stated the facility was to implement systems to monitor care and services provided to residents and listed what it should include, and not what their established system included. There was a second document titled the same as above except it noted that it was the guidelines for the committee. This document was instructions as to what the facility should include in their QAPI plan and the scope of the QAPI plan but failed to reveal the facility's QAPI plan.An interview with the Quality Assurance coordinator on 5/14/26 at 1:22 PM revealed she was aware there were no established policies and procedures for the QAPI program. She reported that she knew what was expected to be done based on policies and procedures that were developed in other facilities that she worked at. She reported that she was the one who set up the Quality Acceptance and Assurance (QAA) committee meetings and ran the meetings.The Nursing Home Administrator (NHA) was interviewed on 5/14/26 at 1:54 PM regarding his role as a QAPI committee member. He stated that he was a participant in the meeting, but it was run by the QA coordinator. When asked, he was unable to give more details about his role on the committee other than stating he monitored the meeting, asked the appropriate questions, and monitored the quality improvement. However, the policy/procedure provided by the facility read he was the chair of the committee and that he was to appoint a designated person to hold the meeting in his absence and failed to include that the QA coordinator ran the meeting. The concerns were reviewed with him, and he failed to provide a rationale for the repeat deficiency and the lack of QAPI program policies and procedures. Cross Reference: F865

Based on record review and interview, it was determined that the facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program. This was evident during the review of the QAPI program for the revisit survey.The findings include:A QAPI plan is the written plan containing the process that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.On 5/14/26 at 1:09 PM a review of the facility's QAPI program information provided by the Quality Assurance (QA) coordinator failed to reveal the facility's QAPI plan. An interview with the Director of Nursing (DON) and QA Coordinator on 5/14/26 at 1:20 PM revealed that they were unaware of the regulatory requirements for the development of a QAPI plan and unsure if the facility had developed one. The DON reported she would need to contact their corporate consultants to determine if they had a QAPI plan. The QA coordinator reported that she was responsible for overseeing the program and conducting the QAA [Quality Acceptance and Assurance] committee meetings, however had no established QAPI plan to guide her in these duties.On 5/14/26 at 1:46 PM during a subsequent interview with the DON, she reported that their corporate consultant informed her that a QAPI plan was not required to be written out. Reviewed the regulation with the DON and she verbalized she understood and confirmed they had no QAPI plan in writing.An interview with the Nursing Home Administrator on 5/14/26 at 1:54 PM revealed he was unaware of the required QAPI plan. The concerns were reviewed with him.Cross Reference F867

Based on interview, record review, facility document review, and facility policy review, the facility failed to timely assess and implement interventions after a change of condition for 2 (Resident #2 and Resident #4) of 3 residents reviewed for change of condition. The failure resulted in a delay of assessment and treatment for Resident #2 and Resident #4. Findings included: A facility policy titled, Physician and Other Communication/Change in Condition, revised 05/05/2023, specified To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. The policy also indicated, The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. Changes and new approaches will be reflected in the individualized care plan. 1. A Resident Face Sheet indicated the facility admitted Resident #2 on 03/01/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of dementia with mood disturbance and stiffness to the left and right shoulder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/07/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent for toileting hygiene and substantial/maximal assistance to roll left and right while in bed. Resident #2's Care Plan included a problem area, start date 04/26/2025 and edited 09/02/2025, that indicated the resident required assistance with activities of daily living (ADLs). Interventions indicated the resident required extensive assistance with bed mobility. Resident #2's Progress Notes dated 08/30/2025 revealed Registered Nurse (RN) #21 was notified by the resident's family that the resident had a cut on their hand. The note indicated RN #21 observed a deep laceration between the resident's right thumb and index finger approximately one inch wide. The note indicated the Certified Registered Nurse Practitioner (CRNP) was in the facility and assessed the resident and determined the resident needed to be sent to the emergency department for sutures. The note indicated the resident was transported to the hospital around 4:50 PM. Resident #2's Progress Notes by the CRNP dated 08/30/2025 revealed the resident had an open three-centimeter laceration wound to the skin of the right hand between the thumb and fourth finger with no active bleeding observed. The progress note indicated the wound was cleansed with normal saline and a dressing secured with gauze wrap was applied. The note indicated that the resident was transferred to the emergency department via emergency services for further evaluation and treatment of the right-hand laceration wound. Resident #2's Progress Notes dated 08/31/2025 indicated the resident returned to the facility with six sutures in place to the right hand between the thumb and index finger. Resident #2's Patient/Resident Incident/Accident Investigation Worksheet dated 08/30/2025 at 4:20 PM indicated the resident had a deep one-inch laceration between the right thumb and index finger. The investigation indicated the resident stated they were holding onto the side rail when staff tried to roll them. The investigation indicated the resident was sent to the emergency department for sutures, and the side rails were removed. Review of a witness statement of Geriatric Nursing Assistant (GNA) #7 obtained via telephone by the Director of Nursing (DON) dated 08/20/2025 revealed that when she came in for her shift, GNA #23 and GNA #8 gave her report and let her know that Resident #2 had sustained a skin tear to the resident's right hand during care. The statement indicated that when GNA #7 was providing care, they did not notice any bleeding to the resident's right hand on the first rounds but did notice dried blood in between the resident's right thumb and right index finger during her second rounds. Review of a witness statement of GNA #23 obtained via telephone by the DON dated 09/01/2025, revealed that while she was providing care for Resident #2 with GNA #8, the GNAs were turning the resident using a draw sheet, and the resident reached back and grabbed the side rail. The statement indicated they stopped turning the resident and noticed blood to the resident's right hand. The statement indicated they washed the blood off, placed a wet washcloth to the area, and told Licensed Practical Nurse (LPN) #22. Review of a witness statement of GNA #8 obtained via telephone by the DON, dated 08/30/2025, revealed that while she was providing care to Resident #2 with GNA #23, the GNAs were turning the resident with a draw sheet, and the resident tried to hit them and grabbed hold of the side rail. The statement indicated the resident sustained a skin tear to their right hand, and GNA #23 told LPN #22 about the incident. During an interview on 09/09/2025 at 10:26 AM, GNA #7 stated she came into work and got report from GNA #23 and GNA #8. She stated they told her that during the shift, Resident #2 became combative and hard to change and was fighting with them and then grabbed hold of the railing, and when they tried to roll the resident, it caused a skin tear. She said they told her they reported it to LPN #22. She stated that when she did her first rounds, she did not notice any bleeding. When she went to do her next rounds, the resident's family was in the room and the resident complained of the area and that was when she noticed that it was a cut, not just a skin tear, so she told the nurse. During a phone interview on 09/09/2025 at 10:35 AM, GNA #23 stated she went in with GNA #8 to change Resident #2. The resident was agitated and fussing at them, and when they tried to turn the resident, the resident grabbed hold of the side rail. Once they got the resident to let go of the rail, they noticed blood, so they finished changing the resident and then got a wet washcloth and put it in the resident's hand and told LPN #22. She stated she did not know if the nurse followed up. She stated she was questioned by the facility and gave a statement. During a phone interview on 09/09/2025 at 10:51 AM, RN #21 stated she was at the nurses' station, and the resident's family came up and asked what happened to the resident's hand. She stated she was not aware of anything, and when she went into the resident's room, she noticed a laceration between the thumb and index finger that was not bleeding at the time. She stated she noticed dried blood on the left side rail, and the resident told her that they were holding onto the side rail while the girls were changing them. She stated she grabbed the provider, who was in the building, and got orders to send the resident to the emergency room for sutures. She stated she was not sure what happened. She stated the DON did an investigation and she gave her witness statement. During an interview on 09/09/2025 at 11:13 AM, GNA #8 stated that at about 2:30 in the morning during rounds, Resident #2 started cussing and getting combative and calling them names because the resident was mad about being woke up to be changed. She stated that when they went to turn the resident, the resident grabbed the rail and started screaming at them. She stated GNA #23 gently pried the resident's hand off the rail, but they did not notice anything until they were done, and then she saw the blood. She stated the resident had a skin tear to their hand. She notified LPN #22 that it had happened, and the nurse said she was going to check the resident out. During an interview on 09/10/2025 at 10:51 AM, the Physician Assistant (PA) stated she would expect the nurse to assess the area, provide wound care, and put on a bandage until it could be further assessed by a provider to see if sutures were needed. During an interview on 09/10/2025 at 11:41 AM, Family Member #24 stated Resident #2 told them that they hurt themself on the bed bar. The family member stated they were just concerned when they saw how deep the cut was. During an interview on 09/10/2025 at 12:08 PM, the Director of Nursing (DON) stated she received a call on 08/30/2025 that staff had found a laceration on Resident #2's hand and they needed to figure out what happened, so they started an investigation. She stated she talked to the RN on duty, and they had not noticed anything and had not been told anything in report. She stated GNA #7, the day aide, stated she got report that the resident sustained a skin tear to their hand. She stated the GNA did not see any bleeding on her first rounds, but she saw dried blood on her second rounds when the resident's family was in the room. She stated RN #21 assessed the area and had the PA assess the area, which needed sutures due to the placement of the cut. She stated that when she was finding the root cause during the investigation, she found out that GNA #23 and GNA #8 were using a draw sheet to turn the resident, and the resident grabbed the side rail. She stated that when they saw the blood, they cleaned it with a washcloth and told LPN #22. She stated LPN #22 stated she did not recall the GNAs telling her about the skin tear, only that the resident was giving them a hard time. She stated she suspended LPN #22 pending the investigation and gave her a final written warning for failure to assess and complete the documentation. The DON stated she did an in-service with the other nurses on when a change of condition was reported, they should follow up. She also educated about injuries of unknown origin and what to do about a resident becoming combative during care. She stated she did a mitigation plan on 08/30/2025. During another interview on 09/11/2025 at 12:55 PM, the DON stated she was not able to say how she would monitor to ensure that changes of condition reported to the nurse by the GNAs were being followed up on. She stated the change of condition should be put on the 24-hour report and the GNA. During an interview on 09/10/2025 at 1:27 PM, the Administrator stated the laceration was reported by the family, but they then found out that it had been reported to the previous nurse. He stated that nurse should have followed up on it when she was told. He stated he knew that the nurse was suspended and given a final written warning and education was provided. During an interview on 09/12/2025 at 9:10 AM, the Medical Director stated if a resident got an injury where the skin was broken, then it should have a bandage applied. He stated the nurse should have addressed Resident #2's wound and provided wound care. He stated it was not their practice to wait to assess an injury and provide first aid. He stated it should have been done right away. Multiple attempts were made to contact LPN #22 during the survey without a response. 2. Resident #4's Face Sheet indicated the facility admitted the resident on 05/01/2025. According to the Face Sheet, the resident had a medical history that included diagnoses of Alzheimer's disease, repeated falls, and osteoarthritis.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. Per the MDS, Resident #4 had no fall history upon admission. Resident #4's Care Plan included a problem statement, edited 09/09/2025, that indicated a risk for falling related to wandering behaviors and poor safety awareness. Interventions directed staff to apply hipsters for safety, bowel and bladder training, non-skid socks or proper footwear while out of bed, and to keep personal items and frequently-used items within reach. Resident #4's progress notes dated 05/23/2025 revealed Licensed Practical Nurse (LPN) #4 was at the nurses' station after lunch speaking with Registered Nurse (RN) #10 when Geriatric Nursing Assistant (GNA) #12 approached the desk notifying them that Resident #4 had discoloration to their forehead. Further review indicated LPN #4 noted Resident #4 had yellowish-green discoloration to their mid-forehead, which looked to be old bruising in the healing stage. LPN #4 further noted she was unaware of any recent falls, and Resident #4 denied having a fall at that time. LPN #4 also noted the resident's assigned nurse at that time, LPN #9 was also at the desk, looked at Resident #4, and then continued down the hallway. Resident #4 was alert to person only, ambulated independently, and did not appear to be in any distress at that time.Resident #4's progress notes dated 05/24/2025 revealed RN #18 noted that at approximately 11:00 AM, Resident #4 was alert and standing at the nurses' station conversing with staff. Staff then observed dark purple discoloration to the resident's bilateral periorbital area and the bridge of the nose with yellowish-green discoloration and swelling to the mid-forehead. RN #18 assessed Resident #4, with no other injuries noted.Resident #4's progress notes dated 05/24/2025 revealed the Medical Director (MD) wanted Resident #4 sent to the emergency room for x-rays to rule out any facial fractures.Review of a Facility Reported Incident Initial Report Form dated 05/24/2025 indicated Resident #4 had an injury of unknown origin. GNA #7 notified RN #18 of bruising around the resident's eyes and a hematoma to their forehead. RN #18 then completed a head-to-toe review, which revealed bruising bilaterally to the resident's eyes and a 4-centimeter (cm) x 4 cm hematoma to their forehead. Resident #4 denied any pain, and neuro checks were at the resident's baseline. RN #18 asked Resident #4 what had happened, and the resident stated, I fell yesterday. Facility staff were unaware of Resident #4 having a fall the previous day. Nursing staff then notified the resident's family member and the MD. Resident #4 was then sent to the emergency room, where no further injury was identified. During an interview on 09/09/2025 at 11:07 AM, GNA #8 stated she worked the evening shift the day Resident #4 started to have bruising to their face, and when she saw it, she notified LPN #4 and RN #10. GNA #8 further stated staff were unaware of what happened to the resident, and a medical provider came in to assess the resident sometime after the bruising was identified. During an interview on 09/09/2025 at 11:13 AM, LPN #9 stated she administered Resident #4's morning medications on 05/23/2025 and noted nothing out of the ordinary occurred on her shift while taking care of Resident #4. LPN #9 further stated her shift on 05/23/2025 ended at 3:00 PM, and LPN #4 relieved her that evening. LPN #9 further stated no one notified her of the bruising to Resident #4's face, and she never saw any discoloration to the resident's face on 05/23/2025. During an interview on 09/09/2025 at 11:23 AM, RN #10 stated she remembered when GNA #12 came to the nurses' station and notified her, LPN #4, and LPN #9 of the bruising to Resident #4's face on 05/23/2025. RN #10 further stated Resident #4 was assigned to LPN #9 at that time, and she thought LPN #9 was aware of the bruising and took care of it once notified. Per RN #10, once an injury of unknown origin was identified, it should be reported immediately and addressed if any further medical care was needed. RN #10 then stated she did not know if Resident #4's injury of unknown origin was reported and addressed timely. During an interview on 09/09/2025 at 11:48 AM, GNA #7 stated she noticed the bruising to Resident #4's face on 05/24/2025 when she took the resident their breakfast tray, and the bruising must have come from an incident the previous day. GNA #7 further stated no one knew how Resident #4 obtained the bruising to their face, and the resident was unable to tell them how it happened due to their cognitive status. During an interview on 09/09/2025 at 12:52 PM, GNA #12 stated she notified the nurses at the nurses' station in the evening of the bruising to Resident #4's face but could not remember who was present at that time. GNA #12 further stated she was not sure what occurred after she notified the nurses of the bruising. During an interview on 09/09/2025 at 1:13 PM, LPN #4 stated she worked as a GNA on 05/23/2025 when another GNA approached the nurses' station stating Resident #4 had bruising to their face. Per LPN #4, the discoloration to the resident's forehead could have been bruising that looked like it was healing, but it did not look like a new bruise. LPN #4 further stated it was right after lunch when the bruising was initially identified and LPN #9 was assigned to the resident and notified of the bruising. LPN #4 further stated she was not sure what was done after the bruising was brought to LPN #9's attention, but when there was an incident, the assigned nurse should assess, take vital signs, notify the MD and family, and address any injuries. During an interview on 09/09/2025 at 2:45 PM, Unit Manager (UM) #17 stated LPN #9 was Resident #4's nurse at the time the bruising to the resident's face was identified. UM #17 further stated the assigned nurse should have notified the MD on 05/23/2025 when the bruising was first identified. Per UM #17, LPN #9 stated to her that she did not remember seeing or hearing anything about Resident #4's facial bruising on 05/23/2025. UM #17 further stated RN #18 notified everyone of the bruising the next day on 05/24/2025 and then started neuro checks.During an interview on 09/09/2025 at 4:05 PM, UM #17 stated if an injury of unknown origin was brought to either nurse on duty's attention, one of them should have assessed the resident and notified the MD. Per UM #17, the nurses usually took care of only the residents on their assigned hall, but one of the nurses should have done something on 05/23/2025 when the bruising was first identified. During an interview on 09/10/2025 at 11:25 AM, the Director of Nursing (DON) stated she received a call from UM #15 on 05/24/2025 that RN #18 observed bruising around Resident #4's eyes. Per the DON, she instructed UM #15 to interview the staff that worked with Resident #4 to determine what happened and found out the bruising was reported to LPN #4 and RN #10 the previous day. During the follow-up investigation, there was some confusion. LPN #4 thought the bruising was reported to LPN #9 and that LPN #9 assessed the resident and did the required reporting prior to LPN #4 taking over LPN #9's hall on 05/23/2025. Per the DON, Resident #4 denied falling on 05/23/2025 when initially asked. The DON further stated RN #18 was on duty 05/24/2025 and asked Resident #4 how they obtained the facial bruising and the resident stated, I fell yesterday, but could not give any details. Per the DON, Resident #4 was independently ambulatory and could get up on their own if they did have a fall. The DON further stated the incident should have been identified and reported on 05/23/2025. Following the incident, the DON provided re-education to all nurses on identifying changes in condition and communication between the nurses to ensure any medical needs were addressed timely. During an interview on 09/10/2025 at 12:14 PM, the Administrator stated he expected nursing staff to notify the provider in a timely manner when they identified a resident's change in condition.During an interview on 09/11/2025 at 1:10 PM, LPN #4 stated she worked as a GNA when Resident #4's bruising was initially reported on 05/23/2025, and LPN #9 was present during that time. LPN #4 further stated LPN #9 looked at the resident at that time, and LPN #4 thought LPN #9 would have called the provider and done an assessment. LPN #4 further stated nothing related to Resident #4 was passed on in report on 05/23/2025 because she thought LPN #9 would have taken care of that during her shift, so she took no further actions during her shift as a nurse on 05/23/2025. During an interview on 09/11/2025 at 3:54 PM, GNA #20 stated staff did not know what happened to Resident #4's face on 05/23/2025, but they first noticed yellow and black bruising around the resident's eyes around dinner time that day. GNA #20 further stated LPN #4 monitored the resident that shift, with no further concerns noted.During an interview on 09/12/2025 at 9:09 AM, the MD stated he expected nursing staff to report to a provider of a possible head injury right away. The MD further stated his medical group should have been notified of Resident #4's facial bruising on 05/23/2025 instead of the next morning. Per the MD, Resident #4 should have been sent to the emergency room right away to rule out any further injury beyond bruising.

Based on interviews, record reviews, and facility policy review, it was determined the facility failed to report an allegation of misappropriation of property timely to the state survey agency for 1 (Resident #6) of 5 facility-reported incidents for allegations of abuse, neglect, and misappropriation of property. Specifically, Resident #6 alleged to have $230 missing in January 2025, and the facility did not report the allegation to the state agency until April 2025.Findings included:The facility's undated policy, titled, Abuse, Neglect, Exploitation, or Mistreatment, indicated, The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately.Resident #6's Face Sheet indicated the facility admitted the resident on 03/03/2022. According to the Face Sheet, the resident had a medical history that included diagnoses of congestive heart failure, type II diabetes mellitus, and acute respiratory failure with hypoxia.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A Facility Reported Incident Initial Report Form, dated 04/26/2025, indicated the facility was informed of the allegation of misappropriation on 01/15/2025 but did not notify the state survey agency until 04/26/2025. The facility submitted the required 5-day investigation report to the state agency on 05/01/2025, which was not compliant with the required timeframe. Further review indicated Resident #6 reported to the Social Worker (SW) that they were missing $225 on 01/15/2025, and it was unknown of the date and time the money went missing. Following the allegation, staff placed a lock on Resident #6's bedside dresser, and statements were obtained from the staff and the other residents on the hall with decision-making capacity. Staff searched for the money in January 2025 and again in April 2025 when the allegation was made, but that amount of money was not found. The facility was unable to substantiate whether the resident ever had that amount of money.During an interview on 09/09/2025 at 9:57 AM, Geriatric Nursing Assistant (GNA) #5 stated that in January 2025, Resident #6 asked her to look in the resident's bedside drawer for money because the resident wanted to order some food. Per GNA #5, she looked in the resident's drawer, but there was no money there. GNA #5 asked the resident how much money was supposed to be there, and the resident stated $300. GNA #5 then stated she searched the resident's room but did not find the missing money, so she reported it to the nurse, who then searched the resident's room but did not find the money. The missing money was then reported to the Director of Nursing (DON). GNA #5 further stated she never knew Resident #6 to have that sum of money, but following the allegation, the facility provided the resident with a lock box for their valuables.During an interview on 09/09/2025 at 1:31 PM, the Social Worker (SW) stated Resident #6 reported money missing on 01/15/2025, but staff could never confirm the resident ever had the money. Following the allegation, the facility provided the resident with a lock box for valuables, but the resident never locked the drawer. The SW further stated they disregarded the allegation in January 2025 because no staff saw the resident with a large amount of money. Per the SW, the allegation related to missing money came up again in April 2025, so the facility chose to report the allegation to the state agency.During an interview on 09/09/2025 at 2:11 PM, Unit Manager (UM) #15 stated Resident #6 alleged to have money missing in January 2025 and staff checked the resident's room thoroughly without finding the money. Staff then placed a lock box in Resident #6's bedside table, but the resident never locked up their valuables. UM #15 further stated staff were not aware of Resident #6 having the amount of money they claimed was missing. Per UM #15, when Resident #6 expired, staff cleaned out their belongings and did find money in their lock box. Staff inventoried the resident's belongings and passed them on to their power of attorney (POA).During an interview on 09/09/2025 at 2:45 PM, UM #17 stated she did the state reportable related to Resident #6's missing money. Per UM #17, she received a call from compliance notifying her of Resident #6's missing money not being addressed, so she called her nursing consultant, who instructed her to report the allegation to the state agency. UM #17 further stated that after Resident #6 expired, staff found around $300 throughout their room. Staff inventoried the resident's belongings and gave them to the SW, who then gave them to the resident's family.During an interview on 09/10/2025 at 11:25 AM, the DON stated that in January 2025, Resident #6 alleged they were missing money, but staff were unable to determine if the resident ever had the amount of money they alleged was missing. The DON further stated Resident #6's concern related to their missing money came up again in April 2025, so they made the decision to report the allegation of misappropriation to the state agency at that time.During an interview on 09/10/2025 at 12:14 PM, the Administrator stated that as the abuse coordinator, they reported any allegation of abuse, neglect, or misappropriation to the state agency within two hours of the allegation being made. The Administrator further stated Resident #6 alleged to have a large amount of money missing at one time, but facility staff treated it more as a grievance as opposed to an allegation of misappropriation because staff could not verify the resident ever had the amount of money alleged to be missing. The Administrator further stated the decision was made to make the reportable in April 2025 because Resident #6 again brought up the large amount of missing money, but facility staff had to again unsubstantiate it because they could not verify the resident ever had the money.

Based on interview, record review, and policy review, the facility failed to develop a care plan related to anticoagulant medication for one (Resident (R)28 residents in the sample of 28 residents. The deficient practice had the potential to cause an adverse reactions from receiving an anticoagulant medication. Findings include: 1. Review of R28's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R28 was admitted to the facility on [DATE] with diagnoses that included unspecified disorders of the brain-cerebral ventriculomegaly, and paroxysmal atrial fibrillation. Review of R28's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/24 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated R28 was moderately impaired for decision-making. This MDS assessment further indicated R28 receives an anticoagulant. Review of R28's Physician Orders dated 10/16/23 in the EMR under the Orders tab indicated Eliquis 5 milligram (mg) tablet by mouth two times a day. Review of R28's Comprehensive Care Plan, located in the EMR under the Care Plan tab did not show a focus, measurable goals, or interventions for anticoagulant medication use. During an interview with the MDS Coordinator (MDSC) on 01/16/25 at 3:30 PM, the MDSC stated that the care plans are updated or revised by her during each quarterly assessment. The MDSC stated that the anticoagulant should have been on the care plan. During an interview with the Director of Nurses (DON) on 01/16/25 at 3:42 PM, the DON stated that R28 does receive Eliquis which is an anticoagulant. The DON also stated this information should be included in the Care Plan. Review of the facility's policy titled Nursing Policy and Procedures dated 05/05/23 indicated, .developing a comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care.

Based on a facility reported incident and the investigation, reviews of a closed medical record, and staff interviews, it was determined that the facility staff failed to maintain a safe environment by leaving a storage door open by allowing a resident (Resident #7) to enter and gain access to a box cutter. Resident #7 subsequently lacerates his/her arm with the box cutter in a suicide attempt. This was evident for 1 of 19 (Resident #7) residents reviewed during a complaint survey. This incident was identified as past non-compliance at a harm level. The findings include: Review of facility reported incident MD 005 on 11/15/2016 revealed Resident #7 was observed by a GNA with a bleeding left wrist on 06/19/2016 at 9:10 PM. The GNA was alerted by a bed alarm sounding. A box cutter was found in Resident #7's bed at this time and immediately removed from the room. Resident #7 was also noted with 12 superficial lacerations to the left dorsal forearm and left wrist. The facility investigation indicated Resident #7 stated he/she found the box cutter in the supply room on the third floor nursing. Resident #7 stated to the nurse that he/she was hoping to be dead by morning. In an interview with the facility director of nursing DON) on 11/23/2016 at 12:22 PM, the DON stated that the facility did not have a policy on what doors need to be secured. The door to the supply room, that Resident #7 gained access to and found the box cutter, can only be opened with a key. The door is only accessible by key or if the door is not closed all of the way. The DON was unaware as to why the supply room had a box cutter in the room. A tour of the third floor nursing unit revealed cognitively impaired ambulatory residents. Review of the facility investigation into facility reported incident MD 006 on 11/15/2016 revealed the following interventions were put into place: On 6/19/16, the facility immediately placed Resident #7 on 1:1 supervision. Resident #7' s physician and family were notified about the incident. Resident #7 received first aide to his/her left arm lacerations by the facility nursing staff. Resident #7 was sent and admitted to the hospital. The facility staff swept all of the units to ensure all of the storage closets were closed. Facility initiated policy for nursing staff to complete every shift rounds to ensure all of the closet doors were locked. The facility initiated weekly quality assurance audits to make sure all of the storage closets were locked. The staff were able to identify the person who left the supply closet door open. All of the facility staff were educated on the new policy by 8/13/16.

Based on review of a facility reported incident, medical record review, and resident and staff interview, it was determined that the facility staff failed to 1) provide a resident with a safe environment and enough supervision during care to prevent the resident from receiving a second degree burn from a piece of equipment, and 2) remove a resident off of a bed pan timely. This occurred for 2 (#2, #5) of 6 residents reviewed during a complaint survey. The findings include: 1) Review of facility reported incident MD 947 on 03/23/2015 revealed an allegation that Resident #2 was found with a nebulizer machine under the covers laying against his/her right stump on 03/12/2015 at 4:20 AM. Initially, the skin was only reddened, but later the skin had developed fluid filled blisters on both of Resident #2's right and left stump. Nurse #2 documented on the report that Resident #2 was noted with reddening to the right stump measuring 7.2 cm x 14.2 cm with two blisters, one measuring 1 cm x 1.2 cm with clear fluid filled, and the second blister measuring 1.7 cm x 1.9 cm with clear fluid filled. Nurse #2 documented that Resident #2's left stump proximal side had redness measuring 3.5 cm x 1.5 cm. Nurse #2 documented that Resident #2 also had redness to the left stump medial side that measured 1.5 cm x 4 cm, with one blister measuring 1.5 cm x 1.2 cm. Review of Resident #2's medical record, on 03/23/2015, revealed that Resident #2 received nebulizer treatments every four hours as needed related to shortness of breath. Further review of Resident #2's medical record revealed that nurse #1 signed off as administering a nebulizer treatment to Resident #1 on 03/12/2015 at 4:37 AM. In an interview on 03/23/2015 at 5:53 PM, GNA #1 stated that he/she was alerted to Resident #2's room on 03/12/2015 at approximately 5:15 AM, by Resident #2's call light. GNA #1 stated that Resident #2 told him/her that the nebulizer machine felt hot. GNA #1 stated that he/she lifted off the bed covers and went to remove the nebulizer machine. GNA #1 stated that the nebulizer machine was hot and he/she could not almost hold it, because it was so hot. GNA #1 stated that he/she had to switch hands to lower the nebulizer machine to the floor due to the nebulizer machine being so hot. GNA #1 also stated that this was when he/she noticed the reddened area of Resident #2's right stump. GNA #1 stated that he/she did not know how the nebulizer got into Resident #2's bed. GNA #1 stated that when he/she arrived in the room, Resident #2 had the nebulizer mask raised onto his forehead. GNA #1 stated that Resident #2's call bell has an emergent call with a quick repeating signal to alert staff quickly to Resident #2's room. In an interview on 03/24/2015 at 9:03 AM, nurse #1 stated that Resident #2 had the nebulizer machine in his/her bed and that Resident #2 covered up the nebulizer machine with his/her blankets. Nurse #1 stated that he/she was passing morning medications when he/she was alerted by GNA #1 that the nebulizer machine was found in Resident #2's bed. Nurse #1 stated that he/she checked on Resident #2 frequently during the 03/12/2015 4 AM scheduled nebulizer treatment. Nurse #1 stated that he/she did not know what time the nebulizer machine was removed from Resident #2's bed because the facility computer system had been down. In an interview on 03/24/2015 at 11:30 AM, Resident #2 stated that he remembered when his/her stump got burned. Resident #2 stated that nurse #1 plugged the nebulizer machine into the socket next to the window, and then placed the nebulizer onto the bed. Resident #2 stated he/she has a specialty mattress with raised edges to prevent him/her from falling out of bed. Resident #2 stated that nurse #1 did not place the nebulizer machine on a bedside table or the windowsill. Resident #2 stated he/she had fallen asleep and then woke up and alerted the staff with his/her call bell. Resident #2 stated that was when the staff found out the nebulizer machine had burned him. The facility staff failed to provide Resident #2 with a safe environment and enough supervision during care, to prevent Resident from receiving a second degree burn to the right and left stump area from an overheated nebulizer machine that was placed in Resident #2's bed. 2) Review of facility reported incident MD 369 on 03/23/2015 revealed an allegation that Resident #5 was left on a bed pan for more than an hour and fifteen minutes on 02/15/2015 at approximately 5 PM. Resident #5 was noted with a pink ring on his/her buttock area which was blanchable. In an interview on 03/24/2015 at 10:45 AM, nurse #2 stated that Resident #5 was left on a bedpan for one hour and fifteen minutes and did not have any skin breakdown. Review of Resident #5's closed medical record on 03/24/2015 did not reveal any skin breakdown as a result of being left on a bedpan for one hour and fifteen minutes on 02/15/2015. The nursing staff failed to care for Resident #5 by assisting the resident off the bedpan timely to prevent any skin breakdown.

Based on complaint, review of a closed medical record, and staff interview, it was determined that the facility staff failed to follow a resident's wishes regarding the performance of CPR . This was evident for 1 (#6) of 6 residents reviewed during a complaint survey. The findings include: Review of complaint MD 194, on [DATE], revealed an allegation that the facility staff did not perform CPR (cardiopulmonary resuscitation) in accordance to Resident #6's wishes. Review of resident #6's closed medical record, on [DATE], revealed a completed MOLST (Medical Orders for Life-Sustaining Treatment), dated [DATE], which was completed by Resident #6's physician upon readmission to the facility. (The MOLST form is used for documenting a resident's specific wishes related to life-sustaining treatments prior to resident suffering cardio-pulmonary arrest and other treatments.) Resident #6's [DATE] MOLST form indicated that Resident #6 was to be a Full Code which means administering CPR, and may use intubation and artificial ventilation indefinitely, may give any blood products, transfer to hospital for any situation requiring hospital-level care, perform any medical tests indicated to diagnose and/or treat medical condition, may give chronic [MEDICAL TREATMENT] for end-stage kidney disease if medically indicated, but do not provide artificially administered fluids or nutrition. On [DATE] at 12:10 AM, Resident #6 was assessed by nurse #1 and was found without a pulse or respirations. Nurse #1 failed to initiate CPR on Resident #6 at that time. In an interview on [DATE] at 12:14 PM, Resident #6's attending physician stated that Resident #6's new MOLST form was completed and placed in Resident #6's medical record on [DATE] after returning from the hospital, and that the [DATE] MOLST was correct. Resident #6's attending physician stated that Resident #6's [DATE] MOLST did not make it to the MOLST binder on the nursing unit. In an interview on [DATE] at 12:45 PM, nurse #1 stated that the residents MOLST forms are kept on a binder on the nursing units, and a copy of a resident's MOLST is scanned into the computer. Nurse #1 stated that Resident #6's MOLST form, (that was located in the binder on the nursing unit), indicated that Resident #6 was a No Code/No CPR. Nurse #1 stated he/she was alerted, later in the morning of [DATE] by the facility administrative aide, that Resident #6 was to be a Full Code/CPR according to the new [DATE] MOLST form. The facility staff failed to indentify and follow the wishes created by Resident #6 on the [DATE] MOLST form, which indicated that Resident #6 wanted to be a Full Code/CPR, on [DATE] at 12:10 AM, and failed to perform CPR on Resident #6 at that time.