Every finding on record at Elkton Nursing and Rehabilitation Center

Based on record review and interview, it was determined that the facility failed to allow residents the right to choose their attending physician. This was evident for thirteen (Residents #2, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, and #24) of the fourteen residents interviewed regarding this change.The findings include:Facility admission Packet (page 7)- 4. Your Rights as a Resident- As a resident of this Facility, you have many rights under Federal and State law. Some of those rights are listed in this section. You will be given a written description of all your rights. B Selection of a Doctor or Other Provider- You may select your own doctor and other health care providers. Your doctor and other health care providers must follow our policies. If your doctor and other health care providers do not follow facility policies and procedures, the Facility will ask you to choose other providers.On 7/14/26 at 10:40 AM, the surveyor reviewed complaints [IQIES #3051803 and IQIES #3075025] in which the central issue was the facility changing the attending physician team without allowing the residents to choose their attending physician.During an interview on 7/15/26 at 2:03 PM, SW#10 (social worker) stated, I gave the letter (about the change in physicians happening on July 9th) that the NHA wrote to the residents. If they (the residents) have a low BIMS, I mailed or emailed it to their representative. I never gave the residents any further paperwork. I wrote exactly what was in the NHA letter in my notes (in the EMR) on 6/12/26. There is only one attending in the facility now [MD #23] and his NP. They are here everyday which is way more than the other group. The residents really don't have a choice since there is only one doctor in the building.During an interview on 7/15/26 at 1:40 PM, Resident #12 stated, I would rather have stayed with [MD # 7].Bottom line- I would like to have [MD #7].During an interview on 7/15/26 at 1:45 PM, Resident #13 stated, No one asked me my permission about changing my doctor. I would want to keep [MD #8]. I don't know my new doctor's name or how to get in touch with him.During an interview on 7/15/26 at 2:25 PM, Resident #10 stated, No, I did not want to change doctors. I want [MD #5] back. I have known him for years. He treats me well.During an interview on 7/15/26 at 2:30 PM, Resident #11 stated, I would rather stay with my old doctor [MD # 8] and his/her NP. I never signed anything to change doctors. We [MD #8 and I] had real conversations. They get me. This new guy.he came around to introduce himself. I never said I wanted to change doctors.During an interview on 7/16/26 at 7:40 AM, Resident #14 stated, I am extremely pissed off about it. They (the facility) were supposed to give us a list of doctors with a writeup about them. We never got it. By the 9th of July, we were all thinking we would get a letter about the doctor choices. On the 9th of July, I found out my doctor had been changed on my paperwork to [MD #23]. I had blood work on 7/7 and no one has followed up with me about it. I had the nurses print out a copy of the labs. There are a lot of abnormalities on it. But no one has gone over it with me. I would rather stay with [MD #7] because he/she knows me. Had I been given the opportunity to get to know about the new doctor, things may have been different. [MD #23] has yet to see me.During an interview on 7/16/26 at 7:55 AM, Resident #21 stated, I didn't like it. I have been here 3 years. I can't keep switching doctors. I would prefer to stay with [MD #7]. My situation is a bit different from most. I am from Arizona; I came here to see the specialists at [Baltimore hospital]. I have a disease caused by Valley Fever. Most docs don't know much about it. I have no idea who my new doctor is. It has been a few weeks and I have not met him. I never got a piece of paper to choose my new doctor.During an interview on 7/16/26 at 8:16 AM, Resident #2 stated, I really don't have any strong feelings because I rarely saw my doctor. I would have liked to have kept my old doctor [MD#7] for reasons of familiarity and shared knowledge. I was not given a choice. I don't know the new doctor's name and have not met him.During an interview on 7/16/26 at 8:20 AM, Resident #18 stated, I am not happy with how it was done. [MD #5] told me today is my last day. That was the first that I heard about it. I did not get a flyer about the new doctor. I have not seen, heard or met the new doctor. I haven't been seen by the new doctor, don't know nothing about him.During an interview on 7/16/26 at 8:55 AM, Resident #15 stated, I was shocked and surprised. No one explained to me why this is happening. [MD #7] has kept me alive for the past three years. I was on hospice service and he/she got me well enough to get off hospice. There was a general letter about the physicians changing. I did not get a personal letter. I did not realize that it would affect me and my doctor. I did not get a letter to choose a new doctor. I was just given a new doctor, [MD#23]. He/ she came to see me this week. He/she seemed nice. I felt like I was betraying [MD #7] when I was talking to him/her (MD #23). It has upset me. But I was not given a choice to pick him/her. He/she said that my old physician was not managing me correctly. I explained that my ammonia level are always that high. He/she said he/she is now here and he/she is going to get me fixed up.During an interview on 7/16/26 at 9:10 AM, Resident #24 stated, I just think we had a relationship with our doctors. I did not get a chance to say who I wanted as a doctor During an interview on 7/16/26 at 9:45 AM, Resident #16's representative stated, Absolutely, I was not given any notice. I have medical and financial power of attorney. My grandmother passed away 2 years ago. The facility should have a copy of the transfer of the decision-making. I do not even know who is seeing my mom now as a physician.During an interview on 7/16/26 at 10:05 AM, Resident #17 stated, I have no idea how that process (changing the doctors) worked. My NP and [MD #7] were really nice. I did not get a letter saying the docs were changing. I don't know who my new doctor is. I have not seen any doctor recently. I would like to see a doctor. I am in need my hydrocortisone ointment reordered. They gave hydrocortisone cream instead. The cream does not really work with my skin condition it dries up and flakes off and does not relieve the itch.During a telephone interview on 7/16/26 at 10:23 AM, Resident #19's representative stated, I have not received any notice about a change in physician. [Resident #19] has been there 15 years. I am currently in the court system in Maryland to get guardianship. I really did not care too much for the old doctor. But I do not know the name or contact for the new doctor. I was not even aware that the doctor had been changed.During an interview on 7/16/26 at 1:13 PM, the NHA stated, . I already told you that I did not give the residents a choice for their physician at this time. There is only one physician coming into the facility currently. Once he assesses everyone, he will recommend to the residents the other physicians on this team that he thinks will be a good fit for them. Then the facility will give the residents a sheet with a list of the physicians available for them to choose from.

Based on record review and interview, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by failing to arrange or schedule physician-ordered specialist consults, procedures, diagnostic tests, or labs. This was evident for 4 (Resident #2, #4, #3, and #26) of 4 residents reviewed for consults, diagnostic tests, and labs during the complaint survey.The findings include:On 07/15/2026 at approximately 8:05 AM, in review of Intake # 3069061, there were noted concerns related to critical physical health concerns, denied oncology tests, and insurance-related procedure refusal. On 07/15/2026 at approximately 2:00 PM, in review of intake #3074558, a noted concern related to a fall with a fracture was raised.1) On 07/15/2026 at 9:47 AM, during an interview, Resident #2 expressed concerns regarding follow-up appointments, the procedure of a nephrostomy tube change, and follow-up appointments and tests that needed to be completed.On 07/15/2026 at 8:59 AM, during a review of Resident #2's medical record, a 05/06/2026 hospital discharge summary was revealed, directing an oncology follow-up within 2 weeks and a brain magnetic resonance imaging (MRI) without contrast. Corresponding physician orders included a brain MRI (05/06/2026), an oncology consult for melanoma (05/07/2026), and a vascular consult for right superficial femoral artery (SFA) occlusion (05/28/2026). However, there was no evidence that the oncology follow-up, brain MRI, or vascular consultation was scheduled or completed.On 07/15/2026 at approximately 9:05 AM, continued review of Resident #2's medical records revealed a 06/11/2026 physician order for an Interventional Radiology (IR) consult for nephrostomy tube replacement.On 07/15/2026 at 11:20 AM, further review of Resident #2's medical record revealed a 07/02/2026 progress note indicating the resident attended an IR appointment for tube replacement due to stitch dislodgement, but it was not replaced due to insurance issues. Although the progress note indicated the unit clerk was notified to reschedule, there was no evidence the procedure was rescheduled.On 07/15/2026 at 10:51 AM, Staff #11 (Unit Manager Registered Nurse) stated that required consults and testing are identified from the hospital discharge summary, scheduled by the unit clerk, documented under health status notes, and uploaded to miscellaneous documents. She verified that Resident #2 had no consults, tests, or nephrostomy tube change procedures scheduled, followed up on, or completed.2) On 07/16/2026 at 8:30 AM, a review of Resident #4 revealed a progress note dated 06/20/2026 at 9:38 AM indicated a new physician order to repeat an electrocardiogram (EKG). Further review of Resident #4's medical record revealed a corresponding physician order dated 06/20/2026 at 8:09 AM to repeat EKG related to abnormal findings. However, there was no evidence in Resident #4's medical record to confirm that the EKG was completed.On 07/16/2026 at approximately 8:35 AM, a review of Resident #4's medical record revealed a 06/25/2026 physician note documenting three diarrhea episodes, one formed stool, Imodium initiation, and a pending C. diff test. However, the test-a laboratory analysis of a stool sample used to diagnose Clostridioides difficile infection, which causes watery diarrhea and severe inflammation of the colon-was not actually ordered until 06/28/2026 at 10:46 PM and returned positive on 06/29/2026, four days after the note indicated it was awaiting results.On 07/16/2026 at 11:05 AM, during an interview, Staff #13, a Licensed Practical Nurse (LPN), stated the process for obtaining an EKG requires a physician order, entry into the electronic medical record, and contacting the diagnostic testing company. If a physician orders a C.diff test via progress note, they typically notify the nurse to enter the order. Staff #13 confirmed that the 06/20/2026 EKG order was not completed and the C. diff test was delayed until four days after the physician ordered it.3) On 07/16/2026 at 3:08 PM, a review of Resident #3's census report revealed he/she was out to the hospital on [DATE] and returned to the facility on [DATE].On 07/16/2026 at 3:25 PM, a review of Resident #3's hospital discharge summary noted instructions for outpatient cardiology with a repeat echocardiogram in 2-3 months to monitor left ventricular heart function, otolaryngology follow-up within 2-7 days, and orthopedic surgery follow-up in 2-4 weeks for a chronic left proximal humerus fracture, including therapy and left arm non-weightbearing restrictions. However, Resident #3's medical record contained no evidence of these scheduled appointments, tests, or the non-weightbearing status.On 07/16/2026 at 3:35 PM, during an interview, Staff #20 (Unit Manager, Registered Nurse) stated that Unit Managers review hospital discharge summaries to have the unit clerk schedule appointments or tests, which are then documented in physician orders along with any weight-bearing status changes. She verified that no follow-up was completed related to the appointments or tests scheduled for Resident #3, and his/her weight-bearing status was not updated in the medical record.4) On 07/16/2026 at 4:09 PM, a review of Resident #26's medical record revealed physician orders from 5/25/2026 for an urgent breast center referral (breast mass) and a vascular surgery consult (peripheral vascular disease) and from 5/15/2026 for a vascular consult. However, there was no evidence of scheduling or completion found in the record in relation to the referral or consults.On 07/16/2026 at 4:11 PM, during an interview, the Director of Nursing (DON) stated her expectation that all consults, tests, procedures, or referrals must be completed in accordance with physician orders and recommendations, adding that staff are required to notify her of any difficulties encountered. At this time the concern was shared with the DON.

Based on record review and interview, it was determined that the facility failed to implement and maintain an effective training program regarding nephrostomy tube care. This was evident during staff interviews while reviewing complaint #3067494 regarding nephrostomy tube flushing.The findings include:The National Library of Medicine documented that the standard of care for the procedure of flushing a nephrostomy tube requires a specific physician order to flush the tube to prevent clogging and requires strict aseptic (sterile) technique by the staff performing the procedure. The procedure requires the nurse to wash his/her hands thoroughly, disinfect the port with an alcohol swab and gently instill 5 to 10 mls (milliliters) of sterile normal saline. (2026)Review of the complaint #3067494 for Resident #4 revealed the presence of a nephrostomy tube (a thin, flexible tube inserted in a patient's back directly into the kidney to drain urine). Resident #4 was hospitalized from [DATE] to 6/17/26 with fever and vomiting and was with acute pyelonephritis (a medical term for a kidney infection). E#21 (hospital consultant Infectious Disease) documented on Resident #4's hospital consult acute pyelonephritis related to nephrostomy tube. No other symptoms to suggest an alternative cause.During an interview regarding the procedure for flushing a nephrostomy tube on 7/15/26 at 10:54 AM, Registered Nurse (RN #16) stated, We just unscrew the tube, clean it with alcohol and flush with 10 mls of normal saline solution (NSS). We use standard precautions. I don't use sterile gloves, just regular gloves. In an effort to observe a nephrostomy tube flush, an interview with Licensed Practical Nurse (LPN) #13 occurred. On 7/15/26 at 11:27 AM, LPN #13 stated, I already flushed Resident # 2's nephrostomy tube. It is a sterile procedure. You have to use sterile gloves and wash the tube off with alcohol. Then you use a sterile syringe flush with 10 ml of NSS and watch it drain back out into the nephrostomy bag. I was trained by the [staff development nurse]. She showed me how to do it. I am not sure if there was a competency check off. I have been here awhile so it was a few years ago that I was trained to do it.During an interview on 7/15/26 at 11: 40 AM, the Director of Nursing (DON) stated that the Staff developmental nurse no longer works there and she was covering that role. The DON stated that she would look for nephrostomy flushing procedure checkoffs for the nursing staff.During an interview on 7/16/26 at 11:15 AM, the Nursing Home Administrator (NHA) confirmed that the facility did not have any Nephrostomy flushing procedure competency check offs for the nursing staff. He also confirmed that the role of staff development was vacant and currently the DON was covering that role along with the Infection Preventionist role too.The facility failed to provide evidence of an effective training program regarding nephrostomy tube care and flushing procedure.

Based on interview, and record review, it was determined the facility failed to ensure that residents were provided with necessary medical supplies timely. This was evident for 3 (Resident #2, #8, and #9) of 3 residents reviewed for colostomy care during the complaint survey.The findings include:1) On 07/15/2026 at approximately 11:35 AM, a review of Intake #3053477 was conducted regarding a concern that the facility failed to provide colostomy bags, requiring the resident to use their own bags from home.On 07/15/2026 at approximately 2:00 PM, a review of Resident #2's physician orders revealed two orders dated 06/02/2026: one for an afternoon colostomy appliance change every 3 days, and another to change the colostomy bag as needed. On 07/15/2026 at 1:03 PM, during an interview, Resident #2 reported experiencing difficulties obtaining colostomy supplies. Resident #2 stated that a couple of weeks prior, staff had to scout for supplies, and on a previous occasion, there had been a multi-day wait. Additionally, Resident #2 reported that staff once placed a towel over the colostomy site due to a lack of available supplies on hand.2) On 07/15/2026 at 1:24 PM, a review of Resident #8's medical record revealed a physician order dated 7/9/2026 for a colostomy appliance change every day shift every 3 days.On 07/15/2026 at 12:53 PM, during an interview, Resident #8 reported using personal supplies brought from home for about a week. A girl stated she would order them, but no updates have been received since.3) On 07/15/2026 at 1:26 PM, a review of Resident #9's medical record revealed a physician order dated 7/9/2026 for a colostomy appliance change every 3 days.On 07/15/2026 at 12:57 PM, during an interview, Resident #9, who has been at the facility for a week, stated they brought 2 or 3 appliances from home but only have 1 left. He/She submitted a written request for a supply order last week but has received no updates since.On 07/15/2026 at 1:08 PM, during an interview, Staff #13, a Licensed Practical Nurse (LPN), stated that colostomy supplies are resident-specific and ordered through central supplies when low. The facility must provide all necessary supplies, and residents should not use their own supplies.On 07/15/2026 at 12:38 AM, Staff #12 (Central Supply Clerk, formerly in admissions) stated that colostomy/urostomy supplies are only ordered on a monthly basis through Gentell, a supply company. Staff #12 further noted that for residents arriving from the hospital, a 1-2 day supply is provided by the hospital because it takes 1-2 days for the facility's orders to be delivered.On 07/15/2026 at 2:28 PM, during a second interview, Staff #12 (Central Supply Clerk) clarified the process for ordering colostomy supplies for hospital admissions: admissions identify the specific type and notify Central Supply for next-day delivery. She provided an email from 07/15/2026 at 2:13 PM confirming supplies were just ordered for Residents #2, #8, and #9. The concern was shared at this time.

Based on review of complaint IQIES #3067494, record review and interviews, it was determined that the facility failed to accurately assess the facility's nursing staff needs and nursing staff competency needs during the annual and/or update of the Facility Assessment. This deficient practice has the potential to affect all residents in the facility.The findings include:A facility assessment is conducted annually to determine what resources are necessary to care for the residents competently during daily operations and emergencies. The assessment must include staff competencies necessary to provide the level and types of care needed for its resident population.Resident #4 was admitted to the facility on [DATE] with a nephrostomy tube (a thin, flexible tube inserted in through the patient's back directly into the kidney to drain urine) in place.A review of the Facility's Assessment report was conducted on 7/16/26 at 9:15 AM. That Facility Assessment was documented as being updated and reviewed by QAPI (Quality Assurance and Performance Improvement) committee on 11/27/25. In Part 2. Services and Care/Offered Based on Resident Needs, the assessment did not address the need for nursing staff training regarding nephrostomy tube care, in particular for training regarding the aseptic procedure of flushing a nephrostomy tube.During an interview on 7/16/26 11:00 AM, the Director of Nursing confirmed that the Facility assessment made no mention of nephrostomy tubes or the care of this device in Part 2. Services and Care/Offered Based on Resident Needs.The facility assessment did not accurately and completely address the nursing staff's educational and competency needs with regard to caring for residents with Nephrostomy tubes.

Based on a review of facility documents and interviews, it was determined the facility failed to maintain an effective grievance system. This was evident for 3 of 3 months of grievance forms from the months of May through July of 2026 reviewed during the complaint survey. The findings include:On 07/16/2026 at 3:50 PM, a review of the facility's grievance forms from the last 3 months (May through July of 2026), provided to the surveyor by the Administrator revealed the following:Review of the grievance forms for the month of May of 2026 noted a concern regarding frequently delayed (until 10:00 AM) or undelivered breakfast meals.Review of the grievance forms for the month of June 2026 noted multiple areas of concern regarding care issues surrounding a hospital transfer and a subsequent refusal to return to the facility, staff members not introducing themselves, absence of paper towels in restrooms, cold food service, medication administration errors, requests for female-only care providers, delayed responses to call bells, extended wait times for pain medication, failure to provide suctioning on a regular basis, missing clothing, staff shortages due to overlapping break times, cleanliness of the shower room, inadequate ventilation, and oxygen supply being turned off for prolonged periods.Review of the grievance forms for the month of July of 2026 noted concerns regarding soiled bed linens and improper care of a central line. However, for the 3 months of May, June, and July of 2026, documentation lacked investigative actions, conclusion summaries, resolution dates, corrective measures, and evidence of how dispositions were communicated to the complainants.On 07/16/2026 at 4:25 PM, during an interview, the Administrator (the grievance officer) stated he lacks access to the online grievance portal. He acknowledged the facility had not addressed grievance forms, and the concern was shared with the Administrator at this time.

Based on record review and interview, it was determined that the facility failed to provide adequate nutrition, hydration, and life-sustaining medications. Consequently, Resident #10 continued to reside in the facility without receiving any nutrition, hydration, or medications from 7/31/2026 to 8/3/2026. This was evident for 1 (Resident #10) of 3 residents reviewed during the revisit survey. This failure resulted in immediate jeopardy.The findings include:According to [NAME] Medicine, a gastrostomy tube (G-tube) placement inserts a tube through the abdominal wall into the stomach to provide an alternative route for feeding, fluids, and medication. It is used for long-term nutritional support or when swallowing difficulties make oral intake unsafe or inadequate.Under the Health Care Decision Act, if a resident lacks an advance directive or appointed health care agent, a surrogate decision-maker is designated to advocate for them. This surrogate may consent to withholding or withdrawing life-sustaining procedures if both the attending and a consulting physician certify that the patient has a terminal or end-stage condition or is in a persistent vegetative state.The Medical Orders for Life-Sustaining Treatment (MOLST) is a portable, enduring form detailing a patient's wishes regarding CPR and other life-sustaining options. This includes Do-Not-Resuscitate (DNR) orders, created by a doctor with the patient or health care agent, instructing providers to initiate or withhold CPR. The Maryland MOLST form communicates preferences to health care professionals regarding artificial ventilation, blood transfusions, hospital transfers, medical workups, antibiotics, artificially administered fluids and nutrition, and dialysis.The Minimum Data Set (MDS) is a comprehensive resident assessment that provides necessary facility information to develop, deliver, and modify a personalized care plan. This care plan serves as a guide to address each resident's unique needs and to plan, assess, and evaluate the effectiveness of their care.The Brief Interview for Mental Status (BIMS) is a mandatory screening tool used upon admission to long-term care facilities to assess a resident's cognitive condition. Typically administered by a social worker, the assessment uses numerically scored questions totaling 0 to 15 points to categorize cognitive status into three groups: Intact (13 to 15: normal thinking and memory), Moderate (8 to 12: moderate problems), and Severe (0 to 7: severe problems). Rather than diagnosing illnesses like dementia or Alzheimer's, it helps staff detect early symptoms and identify the need for further evaluation.On 08/03/2026 at 10:25 AM, a review of Resident #10's medical diagnosis list consisted of cerebrovascular accident (CVA), cardiomyopathy, heart ejection fraction (EF 15%), esophageal obstruction, status post S/P GT (gastrostomy tube), ventricular tachycardia (a life-threatening abnormal heart rhythm), and an intracardiac thrombosis (a dangerous condition of a blood clot inside a heart chamber or valve). It can block blood flow or travel to the brain or lungs, causing a stroke or pulmonary embolism.On 08/03/2026 at approximately 2:40 PM, a review of Resident #10's medical record revealed a form dated 02/04/2026. Signed during hospitalization at the hospital's request, this Affidavit for a friend or other acquaintance as the surrogate decision-maker stated that a long-time family friend was willing to serve as Resident #10's decision-maker.On 08/03/2026 at 10:11 AM, a review of Resident #10's medical record revealed two physician certifications regarding decision-making capacity that indicated Resident #10 lacked capacity (including for life-sustaining treatments) due to a stroke/CVA. These documents were completed by the attending physician on 03/13/2026 and another certifying practitioner on 03/26/2026.On 08/03/2026 at 10:07 AM, a review of Resident #10's MOLST form dated 04/07/26 showed an X by the patient's surrogate, authorized under the Health Care Decisions Act, selecting to attempt CPR, hospital transfer, and artificial hydration.On 08/03/2026 at approximately 9:30 AM, a review of Resident #10's physician orders revealed the following active orders: a nothing by mouth (NPO) diet (ordered 03/22/2026); Osmolite 1.5 Cal, 300 mL via G-tube as a bolus 4 times daily (1200 mL/day total) with 60 mL water flushes before and after each bolus (ordered 07/20/2026); and a free water flush of 210 mL twice daily for added hydration (ordered 07/20/2026). Further review of Resident #10's physician orders revealed medications of Eliquis (an anticoagulant that lowers the risk of stroke or blood clots), 5 mg, 1 tablet via G-tube twice daily (ordered 03/21/2026); and Amiodarone (an antiarrhythmic medication used to treat and prevent life-threatening irregular heartbeats, such as ventricular tachycardia or ventricular fibrillation.) 200 MG, 1 tablet via G-tube daily in the afternoon (ordered 03/21/2026).On 08/03/2026 at 10:15 AM, a review of Resident #10's quarterly MDS dated [DATE] was conducted. Section K showed the resident received 51% or more of total calories and an average daily fluid intake of 501 CC or more via parenteral or tube feeding. Section C revealed a BIMS score of 7 indicating that the resident had severe cognitive impairment.On 08/03/2026 at 9:49 AM, a review of Resident #10's progress notes revealed a change in condition on 07/31/2026 at 7:11 PM. The progress note indicated that medications and enteral feedings could not be administered via the blocked and displaced G-tube, which was leaking from a split at the insertion site. Resident #10 refused Emergency Department transfer; the Primary Care Provider advised monitoring and educating Resident #10 on the importance of hospital transfer for tube replacement. Due to an ongoing tube malfunction, Resident #10 did not receive critical medications or tube feeding nutrition on 07/31/2026, 08/01/2026, 08/02/2026, and 08/03/2026. There was no evidence that Resident #10's surrogate was notified of the continued malfunction from 08/01/2026 through 08/03/2026. Furthermore, the facility allowed Resident #10 to make medical decisions despite lacking the mental capacity.On 08/03/2026 at approximately 9:52 AM, a review of Resident #10's medical record revealed a physician progress note dated 08/02/2026 at 12:59 PM. The note indicated that Resident #10's G-tube is split at the tip and leaking, preventing feeds, flushes, or medications. Resident #10 refused transfer for replacement, rejecting tube feeds and essential medications (apixaban, amiodarone) despite being informed of the risk of death. He expressed a desire to die but denied a suicidal plan or intent. The providers' plan outlined an urgent psychiatry consult for severe depression and capacity evaluation (next-business-day in-person assessment); a speech therapy swallowing reassessment for potential oral administration or limited by-mouth trials; and an Emergency Department (ED) transfer if refusal persists or if aspiration or clinical decline occurs. Nursing should notify the physician immediately of any changes or transfer acceptance.On 08/03/2026 at 11:27 AM, during an interview with Staff #9, the agency-registered nurse (RN) stated in relation to Resident #10, staff reported the G-tube was leaking, but the resident refused hospitalization. Staff #9 confirmed that for 3 days the G-tube had met resistance and was non-functioning, preventing feeding or medication administration.On 08/03/2026 at 11:30 AM, during an interview, Staff #18, Licensed Practical Nurse (LPN), stated Resident #10's G-tube has a slit and is meeting resistance, preventing it from flushing. Staff have tried to get Resident #10 to go to the hospital, but Resident #10 refused.On 08/03/2026 at 12:03 PM, during an interview with a speech therapist (ST), it was revealed that Resident #10 has an esophageal blockage; he can chew and swallow, but food gets stuck in the esophagus and does not reach the stomach. She further stated Resident #10 is to receive nothing by mouth with no alternative nutritional intake but to receive it via tube.On 08/03/2026 at 11:49 AM, during an interview, the Assistant Director of Nursing (ADON) stated she assumed staff would send a resident to the hospital if a G-tube were nonfunctioning. On 08/03/2026 at 1:21 PM, during an interview, the Medical Director (MD) confirmed that Resident #10's G-tube was blocked and required replacement. The MD noted that due to an oral stricture, nothing can be administered by mouth, as it cannot pass into the stomach. Withholding tube nutrition and critical medications-such as Eliquis for an intracardiac thrombus and Amiodarone for arrhythmias-presents an immediate risk, with total deprivation of nutrition and fluids expected to cause severe dehydration within 5 days. Furthermore, the MD stated that Resident #10's surrogate had not been notified and that a chart review was necessary to determine if Resident #10 had an established POA, surrogate, or capacity status.On 08/03/2026 at approximately 4:45 PM, after surveyor intervention, a review of Resident #10's progress notes dated 08/03/2026 at 4:30 PM revealed that the provider signed an emergency evaluation petition at 4:30 PM to hospitalize the resident for a G- tube clogged since 07/31/2026 due to refusals. Despite being previously deemed incapacitated for medical decisions, Resident #10 was referred for an emergency psychiatric evaluation without documented surrogate notification. This resulted in an incapacitated resident being sent for evaluation regarding a medical decision they lacked capacity to make. These identified concerns were brought to the attention of the facility's Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON) on 08/03/2026, and an immediate jeopardy was called on 08/03/2026 at 5:15 PM related to failure to provide (R#10) adequate nutrition and life-sustaining medications. The facility developed a plan sufficient enough to remove immediacy, which was reviewed and accepted after 3 attempts at 8:30 PM on 08/03/2026 while surveyors remained onsite. The facility's abatement plan was accepted by the OHCQ at 2:20 PM on 08/05/2026.The plan included:1. Immediate Correction ActionNotify the attending and medical director of the current status: no nutrition, hydration, amiodarone, or Eliquis since 7/31. Obtain an order for emergency transfer and PEG replacement.Transfer Resident #10 to the Emergency Department for G-tube replacement and evaluation, consistent with the MOLST and the 08/01/2026 physician plan. If the surrogate declines transfer, obtain that decision in writing, notify the medical director, and initiate ethics/legal review before any further delay.Document every attempt, refusal, notification, and clinical finding contemporaneously in the medical record.Pull the current enteral feeding roster (PEG / G-tube / NG).For each, a four-question check: (a) Is the tube patent and flushing per order? (b) Were feedings and medications administered in the last 24 hours? (c) Are capacity status and the decision maker documented? (d) Does the MOLST match?The center will identify residents who are currently on antiarrhythmics and anticoagulants.2. Systematic changeAny resident who misses two consecutive scheduled tube feedings, or any scheduled dose of a cardiac or anticoagulant medication, triggers immediate notification of the attending physician and the DON/administrator. The event stays on the 24-hour report until resolved, not carried shift to shift.A refusal by a resident who lacks capacity is not a valid refusal. Before honoring any refusal of life-sustaining treatment (transfer, feeding, medication), the nurse must check the capacity determination and the MOLST. If the resident lacks capacity, the surrogate or agent must be notified.3. Education1. Audience of all licensed nurses. Agency and PRN staff are educated by documented phone calls with attestation before their next shift. Content on Rule 1 and Rule 2 above is delivered by the Staff Educator. Education received a sign-in sheet with the Conducted by line completed and signed. No nurse works a shift before being educated.2. Audience of Medical Providers: The attending physician and CRNP delivered to the administrator of the content the need to send the patient to the hospital when the resident misses two consecutive scheduled tube feedings or two consecutive days of an antiarrhythmic or anticoagulation medication. 4. Monitoring5 times a week x 14 days: The DON or designee reviews the enteral feeding roster for missed feedings.Daily x 14 days: a random sample of 5 residents who may have missed anticoagulants or antiarrhythmics.Weekly x 4, then monthly x 2: same review, plus an audit of any documented refusal of life-sustaining treatment checked against the capacity determination and MOLST.Results reported to the QAPI committee monthly for review and comment.

Based on observation, interviews, review of facility documents, and record reviews, it was determined that the facility failed to provide interventions consistent with the resident's needs and professional standards of practice, causing an accident that led to severe pain and an emergency room (ER) transfer. This was evident for 1 (Resident #1) of 3 residents reviewed for falls during the complaint survey. This resulted in actual harm to Resident #1. The findings include:Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, toileting, transferring, and mobility.A pain scale is a 0-10 numerical tool for assessing pain severity, with zero representing no pain and 10 the worst pain imaginable. According to the Mayo Clinic, pain scores from 1-3 are mild, 4-6 are moderate, and 7-10 are severe.On 06/16/2026 at 9:00 AM during an observation/interview, Resident #1 was observed with a flaccid left side and reported a concern of being dropped by two aides during a bed-to-wheelchair pivot transfer. The resident stated a Hoyer lift should have been used and complained of left knee pain.On 06/16/2026 at 10:25 AM, during an interview, Resident #1's complainant reported dissatisfaction regarding an incident where the resident was dropped during a transfer from bed to wheelchair. The complainant noted that staff failed to utilize a Hoyer lift for the transfer because the equipment could not be located at the time.On 06/16/2026 at 9:22 AM, a review of Resident #1's care plan (created 08/08/2023; revised 01/17/2024) revealed activity of daily living (ADL) assistance was required due to slurred speech, unsteady gait, history of CVA, stroke, falls, syncope, and weakness. Resident #1's care plan included a 2-person assist mechanical lift transfer intervention (created 08/22/2023; revised 04/11/2025).On 06/16/2026 at 8:50 AM, a review of Intake #3043744 revealed that the facility called 911 at 3:30 AM, 15 hours after Resident #1 was allegedly dropped by staff who refused to use a Hoyer lift around noon the previous day. Resident #1 claimed an aide told her, Do not say anything; I will be fired, and reported that the facility denied his/her requests for an X-ray or transport. Resident #1, who is unable to use his/her left side, noted it was the third time he/she had been dropped by staff at this facility.On 06/16/2026 at 12:35 PM, a review of the facility investigation forms revealed 2 written statements from Geriatric Nursing Assistant's (GNA) Staff #7 and Staff #3 regarding Resident #1's transfer that resulted in a fall on 06/14/2026 at 11:30 AM. Staff #7 reported that because Hoyer lift batteries were uncharged, they attempted a standing pivot transfer, during which Resident #1's left leg gave out, resulting in pain to Resident #1's left leg. Staff #3 stated she was told by Staff #7 that there were no hoyer lifts available and felt uncomfortable with the pivot transfer since Resident #1 could not stand. Resident #1 fell during the transfer and was returned to bed using a Hoyer lift and pad.On 06/16/2026 at 9:31 AM, review of Resident #1's medical record revealed a change in condition dated 06/15/2026 at 3:20 AM that indicated Resident #1 reported 10/10 left leg pain after falling on her knees during a bed-to-chair transfer. A physician recommended as-needed Tylenol and an ER evaluation. Further review of Resident #1's medical record revealed a physician progress note dated 06/15/2026 at 4:36 AM detailing acute pain after being dropped during a transfer without a Hoyer lift. Assessment noted 10/10 left knee pain, limb-length swelling, a bluish foot with no palpable pulse, and warmth to the touch.On 06/16/2026 at approximately 9:40 AM, a review of Resident #1's progress notes dated 06/15/2026 at 11:46 PM revealed Resident #1 returned from the ER at 10:20 AM with two attendants. Resident #1 reported 3/10 left knee pain and noted receiving pain medication at the hospital.On 06/17/2026 at 12:44 PM, a review of Resident #1's June 2026 pain summary indicated pain scores were consistently 0 until the fall on 06/14/2026. Subsequently, a review of Resident #1's post-fall documentation indicated pain scores rose to 1-10 with persistent left knee pain.On 06/17/2026 at approximately 12:50 PM, a continued review of Resident #1's medical record revealed a medical note from 06/17/2026 at 12:25 PM: Seen today for pain management after a recent fall with left knee/leg pain, detailing new routine orders for oxycodone 5 mg, a 5% lidocaine patch, and Tylenol 1000 mg for pain management. Further review of Resident #1's medication administration record (MAR) confirmed Resident #1 did not require or receive any pain medications for left knee pain in June prior to the fall.On 06/16/2026 at 2:38 PM, during an interview with the Director of Nursing (DON), transfer protocols were discussed, explaining that staff determine a resident's transfer status by reviewing the care plan and referring to the Kardex. The DON stated her expectation that staff adhere to these designated statuses, such as the use of a Hoyer lift. It was confirmed that Staff #7 and Staff #3 were both aware that Resident #1 required a Hoyer lift for transfers. The concern was shared at this time.

Based on record review, observations and interview, it was determined that the facility failed to have prevent involuntary seclusion. This was evident for three (Resident #2, Resident #7 and Resident #8 ) out of three residents reviewed during the survey.The findings include:Involuntary seclusion is defined as separation of a resident from other residents or from his/her room, or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident representative.MDS (Minimum Data Set) is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions.BIMS (Basic Inventory of Mental Status) is a structured assessment tool aimed at evaluating cognition of the elderly. A BIMS score of 0-7 is reflective of severe cognitive deficit, a score of 8-12 reflects a moderate cognition deficit and a score of 13-15 score is reflective of normal cognition.1). Resident #2 was admitted on [DATE] with diagnoses including but not limited to, respiratory failure with hypoxia and bipolar disorder.During an interview on 6/16/26 at 8:40 AM, NHA (Nursing Home Administrator) #1 stated, I don't believe there is a policy for determining who gets the code to the door on 2 West.A review of Resident #2's medical record on 6/16/26 at 10:50 AM revealed an admission Nursing Collection Tool note written by LPN (Licensed Practical Nurse) #5 on 5/29/26 at 6:33 PM stated, Cognitive state on arrival: Cognitively intact, oriented to person, oriented to place, oriented to time. Further review revealed a Health Status Note written by LPN #5 on 5/30/26 at 3:21 AM that stated, .Resident arrived alert and responsive, able to make needs known.A review of the facility's investigation file for the fall that is mentioned in complaint # 3030738 on 6/16/26 at 12:15 PM revealed that the fall occurred in close proximity to the unit's secured doors. Ongoing review of Resident #2's EMR (electronic medical record) revealed a progress note by APN (Advanced Practice Nurse) #8 that stated, .History of Present Illness: 72 yo (year old) female.was attempting to elope from the facility and was trying to get out the door when she fell backward hitting her head on the ground. She sustained a hematoma to the back of her head and was unable to get up off the ground due to low back pain.A review of complaint #3030738 documented that Resident #2 stated that a nurse at the nursing home.would not let her leave (the unit).During an interview on 6/16/26 at 2:03 PM, DON (Director of Nursing) #2 stated that nursing unit 2 [NAME] is where the dementia residents reside but it is not a certified dementia unit. There are residents on that unit who do not carry the diagnosis of dementia. It is a secure unit. Anyone who is alert and oriented gets the code for the doors to the unit (2 West). Of course, if they are an elopement risk, they don't get the code. [Resident #2] was only in the facility for less than 24 hours so we did not do an elopement evaluation on her prior to the fall.During a telephone interview on 6/17/26 at 9:46 AM, RN (Registered Nurse)#6 stated, To the best of my knowledge, most of the residents (on 2 West) are confused. I cannot say which ones are allowed to have the code to the door.No, there is no list (of residents who have the door code) that I am aware of. If a resident tries to get out, we just redirect them. The code to get out of the unit is different from the code to get in the unit.During a telephone interview on 6/17/26 at 9:55 AM, LPN #5 stated, .You need the code to get out of the unit (2 West). Residents on the unit usually do not have the code to leave the unit. Depending on their evaluation, the residents are determined if they are eligible to have the code. I believe MDS Coordinators evaluate their eligibility. It is not the floor nurse who does that. I am not sure where it is documented that the resident has been given the door code.I have seen residents that have been given the code to leave the unit. Leave the unit to go smoke or whatever after punching the code in.During an interview on 6/17/26 at 11:08 AM, LPN #4 stated, We assess the residents to determine if they can leave the unit. We look at the BIMS score. But you can usually tell after a conversation with the resident. No, there is not a list of the residents that are allowed to leave the unit alone. I don't think it is written down anywhere. LPN #9 and I are here all the time (weekdays) so we know who can go and who cannot. To be honest, most of the oriented residents don't want the code. It is just something else to remember and they know that we will let them out. On weekends, a lot of the staff are agency (nurses who do not work for the facility) and they would not know who is allowed to leave independently, so they don't let the residents out. If a resident is admitted on a weekend and does not get assessed, they are not allowed off the unit until Monday when they are assessed.2). Resident #7 was admitted to the facility on [DATE] with diagnoses that include, but not limited to heart failure and cirrhosis. A review of Resident #7's EMR revealed a quarterly MDS with ARD (Assessment Reference Date) dated 4/14/26 with a documented BIMS score of 15. Resident #7's EMR also contained an Elopement Risk Tool dated 4/23/26 with a score of 1.0 and stated Resident #7 was a low elopement risk.During an interview on 6/17/26 at 10:20 AM, Resident #7 stated, No, I have never been given the door code. I have to get someone to let me out the doors when I want to go to activities.3). Resident #8 was admitted on [DATE] with diagnosis including but not limited to, bipolar disorder.A review of Resident #8's EMR revealed an annual MDS with ARD dated 3/24/26 with a documented BIMS score of 15 . Resident #8's EMR also contained an Elopement Risk Tool dated 6/21/26 with a score of 0.0 and stated Resident #8 was a low elopement risk.During an interview on 6/17/26 at 10:30 Am, Resident #8 stated that she/he did not have the code to the unit door and she/he had to ask staff to let her/him out if she/he wanted to leave the unit.

Based on interview, record review, and staff interview, it was determined that the facility failed to notify Resident #1's emergency contact representative and physician in a timely manner after a significant change in condition related to a fall. This was evident for 1 (Resident #1) of 1 residents reviewed for falls during the survey. The findings include:On 06/16/2026 at 10:25 AM, during an interview, Resident #1's complainant reported dissatisfaction regarding an incident where the resident was dropped during a transfer from bed to wheelchair that occurred in the early afternoon of 06/14/2026. Resident #1's complainant was frustrated that notification of the fall was delayed until 06/15/2026 at approximately 3:30 AM, when the resident was sent to the emergency room (ER).On 06/16/2026 at 9:31 AM, a review of Resident #1's progress notes revealed a change in condition dated 06/15/2026 at 8:03 AM. Following a fall during a transfer on 06/14/2026 at 11:30 AM, Resident #1 presented with a swollen, warm left leg and reported pain at a level of 10/10. Further review of Resident #1's medical record showed an eINTERACT Transfer Form dated 06/15/2026 at 3:24 AM that indicated notification to the physician and emergency contact for Resident #1 did not occur until approximately 16 hours after the fall.On 06/16/2026 at 2:38 PM, during an interview with the Director of Nursing (DON), a delay in notifying the physician and emergency contact following Resident #1's fall was confirmed. The DON verified that nurses are responsible for these notifications after post-falls. The concern was shared at this time.

Based on review of medical records, observation, and interviews with residents and staff, it was determined the facility failed to report an allegation of resident neglect. This was evident for 1 (Resident #1) of 1 residents reviewed for neglect during the survey. The findings include: The Office of Health Care Quality (OHCQ), an agency within the Maryland Department of Health, monitors care quality in Maryland's health care facilities and community-based programs. Allegations of abuse, neglect, or property misappropriation must be reported to OHCQ. Neglect, is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.On 06/16/2026 at 9:22 AM, a review of Resident #1's care plan (created 08/08/2023; revised 01/17/2024) revealed activity of daily living (ADL) assistance was required due to slurred speech, unsteady gait, history of CVA, stroke, falls, syncope, and weakness. Resident #1's care plan included a 2-person assist mechanical lift transfer intervention (created 08/22/2023; revised 04/11/2025).On 06/16/2026 at 9:00 AM during an observation/interview, Resident #1 was observed with a flaccid left side and reported a concern of being dropped by two aides during a bed-to-wheelchair pivot transfer. The resident stated a Hoyer lift should have been used and complained of left knee pain.On 06/16/2026 at 9:31 AM, a review of Resident #1's progress notes revealed a change in condition dated 06/15/2026 at 8:03 AM. Resident #1 reported 10/10 pain and a swollen, warm left leg following a fall during a bed-to-chair transfer on the day shift. On 06/16/2026 at 12:35 PM, a review of the facility investigation forms revealed 2 written statements from Geriatric Nursing Assistant's (GNA) Staff #7 and Staff #3 regarding Resident #1's transfer that resulted in a fall on 06/14/2026 at 11:30 AM. Staff #7 reported that because Hoyer lift batteries were uncharged, they attempted a standing pivot transfer, during which Resident #1's left leg gave out, resulting in pain to Resident #1's left leg. Staff #3 stated she was told by Staff #7 that there were no hoyer lifts available and felt uncomfortable with the pivot transfer since Resident #1 could not stand. Resident #1 fell during the transfer and was returned to bed using a Hoyer lift and pad.On 06/16/2026 at 2:38 PM, during an interview with the Director of Nursing (DON), it was explained that staff must follow care plans and the Kardex for transfer protocols, such as using a Hoyer lift for Resident #1. Although Staff #7 and Staff #3 were aware of this requirement, they failed to comply, leading to Staff #7's suspension pending investigation. The DON confirmed this failure to follow the plan of care constituted neglect and was a reportable occurrence. However, the DON acknowledged that these specifics regarding Resident #1 were not reported to the Office of Health Care Quality (OHCQ).

Based on surveyor review of administrative records and interview, the facility failed to ensure the Infection Preventionist (IP) participated in the first quarter 2026 Quality Assurance Performance Improvement (QAPI) meeting. The findings include:A review of the monthly QAPI sign-in sheets from February 2026 to July 2026 on 8/5/26 at 10:30 AM revealed that the IP did not attend in January, February and March of 2026.During an interview on 8/5/26 at 10:10 AM, NHA (nursing home administrator) #1 stated that he/she was not able to locate the QAPI meeting sign-in sheets for the months of January 2026 and May 2026. Therefore there was no evidence of the IP attending a QAPI meeting in January 2026.During an interview on 8/5/26 at 12:15 PM, ADON (assistant director of nursing) #3 stated that IP#21 was the IP from January to March 2026. ADON#3 confirmed that IP#21's signature was not on the February and March 2026 QAPI sign-in sheets.

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician ordered parameters when administering blood pressure medications. This was evident for 3 (#300, #304, #303) of 3 residents reviewed during a complaint survey. The findings include: 1) On 1/29/26 at 8:35 AM a review of Resident #300's medical revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, a fracture of the left pubis, diabetes mellitus with diabetic neuropathy and hyperglycemia, anemia, and orthostatic hypotension. Review of a 1/6/26 medical progress note documented that Resident #300 had a recent hospitalization from 12/9/25 to 1/6/26 for acute metabolic encephalopathy, infection, and acute kidney injury. The note documented that Resident #300 had, significant deconditioning impaired mobility, chronic pain, orthostatic hypotension, nutritional deficits, and high fall risk and was admitted to subacute rehabilitation for continued physical therapy, occupational therapy, nutritional optimization, pain management, and medical monitoring prior to safe long-term disposition. A 1/13/26 medical progress note documented the visit was a follow-up for a recent fall with head strike, right heel ulcer care, pain control, glucose trends and blood pressure variability. The note documented, recent head injury after unwitnessed fall on anticoagulation: maintain fall precautions with environment optimization including keeping urinal and call bell within reach. Orthostatic hypotension with variable BP (blood pressure) on midodrine/fludrocortisone. Continue holding midodrine parameters and avoid evening doses to reduce supine hypertension, monitor BP trends symptoms and volume status. The medication Midodrine is used to treat symptomatic orthostatic hypotension (sudden blood pressure drop upon standing). It works by constricting blood vessels to increase blood pressure, reducing dizziness, lightheadedness, and fainting.Review of January 2026 physician's orders for Resident #300 revealed the order for Midodrine 5 MG, give 3 tablets by mouth three times a day for hypotension (low blood pressure); hold for systolic blood pressure (SBP) greater than 120. SBP is the top number of the blood pressure reading. This was ordered on the day of admission, 1/6/26.Review of Resident #300's January 2026 Medication Administration Record (MAR) documented the Midodrine was given on the following days when outside of physician ordered parameters:1/6/26 at 6 AM for b/p 132/881/9/26 at 12PM for b/p 128/661/14/26 at 4 PM for b/p 122/68 Furthermore, on 1/11/26 at 6 AM the blood pressure was 118/69 and the Midodrine was held. The Midodrine should not have been held because the SBP was below 120.On 1/14/26 Resident #300 was sent to the hospital for a fall and returned to the facility on 1/27/26. After Resident #300 returned from the hospital the Midodrine order was changed to 10 mg. three times per day for hypotension. Hold if SBP is greater than 120.Review of the January 2026 MAR documented the Midodrine was given on 1/28/26 at 2 PM for a b/p of 128/74. The Midodrine should have been held per physician ordered parameters.On 1/29/26 at 10:00 AM the surveyor requested a list of all residents on Midodrine.On 1/29/26 at 11:08 AM the Director of Nursing (DON) was informed about the Midodrine being given outside of parameters. The DON stated, I just saw that when you asked about it. 2) Review of Resident #304's medical record revealed physician's orders for Midodrine 5 mg., give 1 tablet by mouth one time a day for hypotension: Hold for SBP greater than 120.Review of Resident #304's December 2025 MAR documented the Midodrine was given on the following days when outside of physician ordered parameters: 12/01/25: 121/6812/14/25: 166/8412/15/25: 132/7112/17/25: 126/7212/20/25: 121/7112/22/25: 134/6012/23/25: 121/7112/29/25: 126/7612/31/25: 132/78 Review of Resident #304's January 2026 MAR documented the Midodrine was given on the following days when outside of physician ordered parameters: 1/10/26: 134/551/11/26: 123/621/27/26: 132/74 3) Review of Resident #303's medical record revealed a physician's order for Midodrine 5 mg., give 1 tablet by mouth 3 times a day for hypotension. Hold for SBP greater than 110. Review of Resident #303's December 2025 MAR documented the Midodrine was given on the following days when outside of physician ordered parameters:12/04/25: 121/62 at 12 PM12/04/25: 119/72 at 6 PM12/09/25: 132/77 at 6 PM12/13/25: 126/72 at 6 AM12/14/25: 118/60 at 6 AM12/14/25: 112/70 at 6 PM12/15/25: 118/68 at 12 PM12/16/25: 120/61 at 6 PM12/28/25: 118/73 at 2 PM12/31/25: 126/78 at 6 AM12/31/25: 119/78 at 8 PM Review of Resident #303's January 2026 MAR documented the Midodrine was given on the following days when outside of physician ordered parameters:1/04/26: 125/74 at 6 AM1/09/26: 122/74 at 6 AM1/06/26: 118/74 at 2 PM1/06/26: 121/77 at 8 PM1/11/26: 115/72 at 8 PM1/25/26: 113/65 at 6 AM1/25/26: 119/741/27/26: 118/70 at 6 AM On 1/4/26 at 8 PM the resident's blood pressure was 97/58 and staff did not administer the Midodrine when they should have administered as the SBP was below 110. On 1/29/26 at 1:15 PM an interview was conducted with the medical director who confirmed that facility staff failed to follow the physician's ordered parameters. The medical director stated that he had concerns when the medication was administered outside of parameters.On 1/29/26 at 1:30 PM the concern was discussed with the DON who stated that she would begin in-servicing staff.

Based on medical record review and staff interview, it was determined that the facility staff failed to obtain laboratory tests as ordered by the physician for residents (#300 and #302). This was evident for 2 of 3 residents reviewed for laboratory services during a complaint survey.The findings include: 1. Review of Resident #300's medical record on 1/29/26 revealed the Resident was admitted to the facility in January 2026 with diagnosis to include diabetes and anemia. Review of Resident #300's physician orders revealed the Resident was ordered a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and Magnesium level on 1/5/26 to be completed on 1/6/26. Further review of Resident #300's medical record on 1/29/26 revealed the Resident did not have any laboratory results on 1/6/26. Review of the Resident's nurses' notes revealed no documentation on why the laboratory tests were not completed. Interview with the Director of Nursing on 1/29/26 at 1:45 PM confirmed the facility staff failed to obtain laboratory tests ordered by the physician on 1/5/26 for Resident #300. 2. Review of Resident #302's medical record on 1/29/26 revealed the Resident was admitted to the facility with a diagnosis to include pneumonia. Further review of Resident #302's medical record revealed the Resident was seen by the Physician's Assistant (Staff #24) on 1/7/26 for abnormal laboratory results. At that time Staff #24 documented to repeat CBC (Complete Blood Count) in the AM. Further review of Resident #302's medical record revealed a nurse's note by Staff #25 on 1/7/26 at 10:57 PM that stated: Labs from 1/7/26 reviewed by PA (Staff #25) resident already has order for CBC in am. Review of Resident #302's laboratory results revealed no lab tests were drawn on 1/8/26. The Resident was discharged from the facility on 1/13/26 without the lab tests completed. Interview with the Director of Nursing on 1/29/26 at 10:28 AM confirmed Resident #302 did not have a CBC laboratory test on 1/8/26 as ordered by the physician.

Based on medical record review and staff interview, it was determined that the facility staff failed to administer medications as ordered by the physician (Resident #302). This was evident for 1 of 5 residents reviewed during a complaint survey.The findings include:Review of Resident #302's medical record on 1/29/26 revealed the Resident was admitted to the facility with a diagnosis to include pneumonia.Review of Resident #302's January 2026 Medication Administration Record with the Director of Nursing on 1/29/26 revealed no documentation the following medications and treatments were administered to the Resident per physician's orders:PICC (peripherally inserted central catheter) line flush every shift on 1/7/26 night shift and 1/10/26 day shiftAcetylcysteine Solution 10 ml inhale orally every 6 hours on 1/8, 1/9 and 1/10/26 at 6 AM, 1/11/26 at 12 PM and 6 PM and 1/12/26 at 6 PMAlbuterol Sulfate Inhalation 3 ml via nebulizer every 6 hours on 1/8, 1/9 and 1/10/26 at 6 AMPiperacillin 4.5 gram intravenously every 6 hours for pneumonia on 1/8, 1/9 and 1/10/26 at 6 AMInterview with the Director of Nursing on 1/29/26 at 10:28 AM confirmed the Surveyor's findings.

Based on record review, observation, and interview, it was determined the facility staff failed to ensure interventions for safety were in place for a resident with a history of falls. This was evident for 1 (#300) of 3 residents reviewed during a complaint survey.The findings include: On 1/29/26 at 8:35 AM a review of Resident #300's medical revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, a fracture of the left pubis, diabetes mellitus with diabetic neuropathy and hyperglycemia, altered mental status, severe protein-calorie malnutrition, anemia, and orthostatic hypotension. Review of a 1/6/26 nursing admission note documented that Resident #300 was alert and oriented times 2. Review of a 1/6/26 medical progress note documented that Resident #300 had a recent hospitalization from 12/9/25 to 1/6/26 for acute metabolic encephalopathy, infection, and acute kidney injury. The note documented that the resident arrived at the hospital alert and oriented times 2 and had some confusion. The note documented that Resident #300 had a recent fall at rehabilitation that resulted in a head injury. The resident reported a severe concussion with transient loss of consciousness and significant memory impairment. The note documented that the resident reported inability to walk, intermittent difficulty speaking, left eye visual loss, and poor appetite. The note documented that Resident #300 had, significant deconditioning impaired mobility, chronic pain, orthostatic hypotension, nutritional deficits, and high fall risk and was admitted to subacute rehabilitation for continued physical therapy, occupational therapy, nutritional optimization, pain management, and medical monitoring prior to safe long-term disposition. Review of a 1/9/26 at 17:36 (5:36 PM) change in condition note documented Resident #300 had a fall and was transported out of the facility to the hospital. A 1/9/26 at 18:18 health note documented that Resident #300 had an unwitnessed fall out of bed. The resident reported that he/she hit his/her head and was receiving the blood thinner Eliquis twice a day. The nurse reported that the resident had altered mental status and increased aggression that was not at the resident's baseline. A 1/10/26, 72-hour post fall documentation of note documented the resident was back in the facility and interventions were currently in place to prevent additional falls such as the bed in low position and the call light within reach. A 1/13/26 medical progress note documented the visit was a follow-up for a recent fall with head strike, right heel ulcer care, pain control, glucose trends and blood pressure variability. The note documented, the patient appears alert but disorganized, with tangential speech during interview. [He/she] is disoriented to time, unable to accurately state the current date, month, or year, and believes the year is 2000. The note documented, recent head injury after unwitnessed fall on anticoagulation: maintain fall precautions with environment optimization including keeping urinal and call bell within reach. Orthostatic hypotension with variable BP (blood pressure) on midodrine/fludrocortisone. Continue holding midodrine parameters and avoid evening doses to reduce supine hypertension, monitor BP trends symptoms and volume status. The medication Midodrine is used to treat symptomatic orthostatic hypotension (sudden blood pressure drop upon standing). It works by constricting blood vessels to increase blood pressure, reducing dizziness, lightheadedness, and fainting.On 1/14/26 a change in condition note documented the resident had a fall after an episode of combative and agitated behavior. Resident #300 was sent to the hospital and returned to the facility on 1/27/26. On 1/29/26 at 8:50 AM observation was made of Resident #300 lying on his back in bed eating breakfast. The resident's call bell was observed lying under the bed and not within reach. The resident's urinal was hanging off the second drawer handle of the night stand which was not within reach and was at least 4 feet away from the right side of the bed. There were no fall mats next to the bed. On 1/29/26 at 8:50 AM an interview was conducted with Resident #300. Resident #300 stated that he/she had trouble standing up. Resident #300 stated he/she had fallen and broke his/her pelvis and sternum. Resident #300 stated he/she had 2 cracks in his/her skull because he/she fell and went unconscious. On 1/29/26 at 8:50 AM Licensed Practical Nurse (LPN) #23 was asked to come into Resident #300's room. At that time the surveyor showed LPN #23 where the call bell was located. LPN #23 stated, what is it doing under there. LPN #23 picked up the call bell and was holding the end of it and said, I don't know who was supposed to put it on the bed. At that time the surveyor showed LPN #23 where the urinal was and that the resident could not reach it.Continued review of Resident #300's medical record revealed a care plan, the resident is at risk for falls and fall related injury r/t weakness, diabetes, orthostatic hypotension, pain in left hip, anemia, use of cardiovascular and psychotropic medications. Interventions on the care plan included, Ensure urinal is within reach, place bed in lowest position while resident is in bed, place common items within reach of the resident, and remind the resident to use their call light to ask for assistance with ADLS.Review of physician's orders revealed the order for Midodrine 10 mg. to be given 3 times a day for hypotension. The order stated if the systolic blood pressure (SBP) (top number of blood pressure) is greater than 120, the medication should be held. Review of Resident #300's January 2026 Medication Administration Record (MAR) documented the Midodrine was given on 1/28/26 at 1400 (2 PM) for a blood pressure of 128/74. The Midodrine should have been held because it was outside of physician ordered parameters. Cross Reference F757.On 1/29/26 at 11:08 AM with the Director of Nursing (DON), Resident #300 was observed with the bed in medium high position. The DON confirmed the bed was not in low position. The DON via bed remote lowered the resident's bed. The DON was asked if Resident #300 should have fall mats next to the bed. The DON stated it depended on what therapy assessed as the resident just came back from the hospital. The DON was informed at that time about the Midodrine being given outside of parameters. The DON stated, I just saw that when you asked about it. The DON was also informed of the morning's observations of the urinal on the night stand drawer handle and the call bell under the bed.On 1/29/26 at 11:37 AM an interview was conducted with Occupational Therapist (OT) #21. OT #21 stated that Resident #300 was a fall's risk. OT #21 stated that when she saw Resident #300 this morning that Resident #300 was a little more sedated than yesterday. Prior to going out to the hospital the resident had a urinary tract infection and then had the behaviors and altered mental status and had previous falls. I feel like fall mats are a good idea. OT #21 stated that she felt that when the resident's underlying medical conditions arise then it places the resident at more of a risk for falls. OT #21 stated that Resident #300 was also impulsive, so if Resident #300 could not reach things the resident would try to get out of bed which the resident knew was not safe to do.On 1/29/26 at 1:15 PM an interview conducted with the medical director confirmed that the Midodrine should have been held.

Based on medical record review and staff interview, it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers. This was evident for 1 (#300) of 3 residents reviewed for pressure ulcers during a complaint survey.The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). On 1/29/26 at 8:35 AM a review of Resident #300's medical revealed the resident was admitted to the facility on [DATE] with diagnoses that included a fracture of the left pubis, type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, and severe protein-calorie malnutrition. Review of a 1/6/26 nursing admission note documented Resident #300 was admitted with a pressure ulcer on the right heel. A 1/6/26 medical progress note documented that Resident #300 had an active right heel pressure injury and staff were to, offload right heel continuously with boots and pillows and avoid pressure on affected area. A 1/8/26 skin and wound note documented the right heel pressure ulcer was stage 3 and the assessment/plan was, float heels while in bed with use of the facility's preferred equipment, pillows/boots, etc. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels. Review of Resident #300's January 2026 Treatment Administration Record (TAR) documented the physician's order, offload heels with green boots as tolerated every shift. On 1/28/26 the boots were signed off as worn each shift. On 1/29/26 at 8:50 AM Resident #300 was observed in bed lying on his/her back eating breakfast. Resident #300's feet were observed lying directly on the mattress of the bed and the heels were not elevated. Resident #300 was wearing gray slipper socks and did not have heel boots on their feet. Resident #300 was asked if the staff ever elevated his/her feet off the mattress and the response was, sometimes but there is nothing there now. On 1/29/26 at 9:30 AM a second observation was made of Resident #300, and his/her heels were still lying directly on the mattress. On 1/29/26 at 11:04 AM a third observation was made of the resident, and a pillow was under the bottom of his/her legs. Resident #300 was wearing gray slipper socks. The Director of Nursing (DON) came to the room with the surveyor and observed the resident's feet. The DON was informed of the previous observations and was informed that nursing staff had been signing off that heel boots were being worn, however there were no heel boots in the resident's room. The DON confirmed the finding and stated she would have someone get heel boots on the resident.

Based on review of medical records, facility investigation and interviews, it was determined that the facility failed to ensure that a resident who required a Hoyer lift for transfer was transferred with a Hoyer lift which resulted in harm to Resident #156 who sustained a fracture of the distal femur. This was evident for 1 (Resident # 156) out of 11 residents reviewed during the annual survey. The findings include: Review of Resident #156's medical record on 09/30/2025 at 3:30 PM revealed Resident #156 had a Brief Interview of Mental Status (BIMS) score of 15/15 on 07/29/2025, and a Care Plan with a focus of Short-Term Care: the resident requires assistance with their activities of daily living due to impaired mobility; dated 07/20/2025 with inventions dated 07/22/2025 for transfers: Hoyer Lift Assist x 2; Ambulation: unable.Further review revealed a Radiology Results Report dated 09/15/2025 of Resident #156's right knee with the following findings: Previous arthroplasty with grossly displaced fracture of the distal femur extending to the arthroplasty hardware. Review of Facility Reported Incident Investigation on 10/02/2025 at 2:00 PM revealed that that the facility had verified Resident #156 having a witnessed fall while transferring to bed from a wheelchair sustaining a right acute fracture of the distal femur on 09/15/2025 due to Geriatric Nursing Assistant (GNA) staff #28 failing to identify transfer status of Resident #156 to be a mechanical lift assist of 2 persons for all transfers. The facility interviewed Geriatric Nursing Assistant (GNA) #28 on 09/17/2025 and GNA #28 statement stated that on 09/15/2025 at 10:50 AM therapy had gotten Resident #156 out of bed into a wheelchair, and he/she requested to go back to bed. GNA #28 stated to Resident #156 that he/she was going to put him/her in bed but Resident #156 stated, No I do not need help, stood to take a step and went down on his/her right knee, turned to his/her buttocks leaning back toward the bedside table. The facility interviewed resident #156 on 09/15/2025 and resident statement stated that he/she was trying to transfer from the wheelchair to his/her bed and that the bed was lowered for him/her to get in, he/she had been working with therapy for stand and pivot and did a car transfer the other day with therapy. He/she stated he/she stood, his/her feet would not move almost like glue to the floor, and he/she fell on to the right knee, then his/her buttocks then fell back and hit their head on the floor. The resident stated that the caregiver was at the foot of the bed near the window and the resident stated that he/she was trying to get into bed on the side closest to the door. Further review revealed that GNA #28 was terminated by the facility on 09/24/2025 for violation of company policy. During interview with 10/02/2025 at 2:10 PM Director of Nursing staff #2 stated that, [GNA #28] attempted to assist [Resident #156] with a transfer without a Hoyer Lift or a second person, did not try and stop resident from transferring, did not try and get help or clarification from the resident medical chart or ask a nurse regarding [Resident #156] transfer status. He/she should have known and did not. Director of Nursing staff #2 further stated, [GNA #28] was reported to the Maryland Board of Nursing.During an interview on 10/02/2025 at 4:31 PM Director of Rehabilitation staff #30 stated, [Resident #156] was a 2 person transfer with a Hoyer lift at the time of injury/fracture on 09/15/2025. Staff #30 also provided a PT Recert, Progress Report and Updated Therapy Plan Current dated 8/21/2025 revealing that Resident #156 was Substantial/ maximal assistance for chair/bed transfers. Staff #30 further stated, staff should have used a Hoyer lift with 2 persons assist with [Resident #156] on the day that he/she was transferred and sustained a fracture. Review of facility staff education on 10/03/2025 at 11:20 AM revealed that the facility completed all facility nursing staff, including agency staff, education as of 09/22/2025 regarding transferring a resident safely, checking Kardex for transfer status prior to transfer, and notifying nurse if resident insists on transferring in a manner inconsistent with safe transfer status. During an interview on 10/07/2025 at approximately 8:05 AM Director of Nursing stated that, audits were started on 09/29/2025 to ensure staff are able to demonstrate where the transfer status is found in the clinical record and that the residents that require a mechanical lift for transfer are transferred appropriately. During review of facility documentation on 10/07/2025 at 8:10 AM the facility audit sheets revealed a start date of 09/29/2025.

Based on interview and record review it was determined the facility failed to ensure the hospice pain management orders for Resident #179 were followed which resulted in harm to the Resident due to unmanaged pain. This was evident for 1 out of 9 residents reviewed for pain management during the facility's recertification survey.The findings include: On 10/7/25 at 8:26AM the surveyor conducted a review of complaint #319265 submitted to the Office of Health Care Quality which alleged that on 6/15/25 evening shift and overnight shift into 6/16/25, Resident #179 suffered with pain that was not appropriately managed by facility staff.Review of the medical record by the surveyor on 10/7/25 at 8:31AM revealed that on 6/10/25 Resident #179 was admitted to hospice care with a terminal illness. The following hospice medication order for Resident #179 were observed to be actively in effect from 6/13/25 to 6/16/25: Morphine Sulfate Oral Solution 100/MG/5ML Give 0.75ml by mouth every 4 hours for pain/dyspnea if asleep wake pt. for med administration. Surveyor review of the medication administration record of Resident #179 revealed pain medication orders for both scheduled and hourly as needed Morphine medication for pain. On 6/15/25 at 1:55PM Resident #179 was given an as needed dose of pain Morphine medication. Further surveyor review of the medical record revealed that after the 6/15/25 1:55PM dose, no further Morphine pain medication was administered to the resident for approximately 18 hours and 39 minutes until 6/16/25 at 8:34AM. On 10/7/25 at 11:32AM the surveyor conducted an interview with Staff #47 who reported they were made aware of the hospice nurse's arrival to the facility on the morning of 6/16/25 at which time the narcotic medications were found to not be logged according to how they should've been given. Staff #47 reported to the surveyor that there were two forms of documentation, they didn't match, and the resident was not receiving the morphine pain medication as ordered, which resulted in the resident having a pain crisis. Staff #47 reported the resident's family communicated their concern to them for Resident #179's unmanaged pain. Staff #47 reported that an occurrence report was documented regarding Resident #179's pain crisis. Staff #47 reported that the resident was foaming at the mouth, medications were ordered routinely and medications were not being given routinely, and no prn (as needed) pain medication was being given. Staff #47 reported that because the pain had not been managed according to orders, more orders were needed to then achieve pain control for the resident. Review of medical record documentation on 10/7/25 at approximately 12:00PM which was provided in response to the surveyor's request, revealed a client occurrence report dated 6/16/25 which detailed the following information regarding the medical care of Resident #179: Nature of occurrence: untoward outcome, Pt (patient) in pain crisis, tremoring, foaming at mouth, minimally responsive, moaning. The report additionally detailed 6 witnesses to the occurrence which included Staff #47, Physician #48, Certified Registered Nurse Practitioner (CRNP) #49, Unit Manager #50, ADON #45, and LPN Charge Nurse #46, and documented the date of physician notification about the occurrence as 6/16/25 with the following physician response to the pain crisis of Resident #179: medication dose and frequency increased (multiple prn doses given.)During surveyor's review of Resident #179's medical record on 10/7/25 at 1:45PM the June 2025 Medication Administration Record was observed documented as signed off by nursing staff as Morphine having been documented as administered, however, surveyor review of the facility's narcotic log revealed no controlled narcotic medication was logged as administered and reconciled in the facility's narcotic log from after 6/15/25 at 1:55PM until 6/16/25 at 8:34AM. Morphine orders for the resident were observed to be crossed out and re-written with different types of orders on 3 out of 3 morphine logs instead of new sheets having been started to account for the medication order changes, and only 1 out of 3 morphine logs was found to document an RX#. Further review of the medical record revealed a medical progress note documented by CRNP #49 with a service date of 6/16/25 which included the following information: Called to the unit for uncontrolled pain; Patient was seen and assessed at the bedside for uncontrolled pain. Hospice staff were also present at the time of evaluation, and we collaborated to address [his/her] significant discomfort. Review of the medication administration record indicated no breakthrough morphine was given overnight, contributing to [his/her] current level of pain. On 10/7/25 at 1:51PM the surveyor conducted an interview with LPN #46 who reported that Resident #179 was placed on morphine which started out as prn (as needed) then went on to a standard scheduled dose with prn's (as needed) for breakthrough pain, and the last few days when [Resident #179's] pain exacerbated I was working with the hospice nurse to manage [his/her] pain. I reached out to [hospice nurse] and asked them to review [Resident #179's] dose. The times I was not here, I'm sorry but [his/her] pain wasn't managed, [s/he] wasn't getting the doses. The family [of Resident #179] came in and spoke about the disgust of [Resident #179's] pain not managed. When the surveyor inquired to LPN #46 how they knew the resident wasn't receiving the pain medication doses they stated: I saw the book, (LPN #46 pointed to the narcotic log) and the count and you can see the gap in administrations. Family told me he wasn't getting [his/her] medications overnight. I learned the morning after when I came in for my shift. Oh I called hospice right away, [s/he] came every day and we made sure pain was managed. LPN #46 reported to surveyors that on the morning of 6/16/25 they found Resident #179's mouth filled with froth and when his/her mouth was cleaned s/he was moaning in pain and they observed the resident with facial grimacing. LPN #46 stated that after they reached out to hospice and the resident's primary care physician in the early morning on 6/16/25, the narcotic log was then observed by the hospice nurse. LPN #46 observed the narcotic log with surveyors and stated: usually we have separate logs for different administrations, but I don't think we got the medication from pharmacy. The surveyor asked for LPN #46 to show where in the narcotic log that the medication had been administered and they stated: It's not there, you won't see it. When the surveyor inquired as to if the concern was brought to facility staff they stated: Hospice spoke to the ADON. When the surveyor inquired as to if any further action was taken by the facility to prevent future occurrence or if any action was taken to address the overnight nurse/staff and medication administration, they stated: Not that I know of, no one was addressed. On 10/8/25 at 8:14AM the surveyor further reviewed the June 2025 medication administration record (MAR) of Resident #179 and compared this to the facility's narcotic log which revealed the following additional information: 1. the 6/15/25 9:00AM scheduled dose of Morphine was documented as given 1 hr and 28 minutes later at 10:28AM, and the narcotic log revealed there was only 0.5 ml left in bottle and a 0.5ml dose was given which was not the full dose of 0.75ml which was ordered for the resident's scheduled morphine for pain control,2. the 6/15/25 17:00PM scheduled dose of Morphine was documented as given at 16:55PM on the MAR, however, was not accounted for as having been given on the narcotic log, 3. the 6/15/25 21:16PM 0.75ml dose q 4hrs was documented as given per the MAR, however, was not accounted for as having been given on the narcotic log, 4. the 6/16/25 1:00AM scheduled dose of Morphine was documented as given on the MAR at 4:55AM, however, was not accounted for as having been given on the narcotic log, 5. the 6/16/25 5:00AM scheduled dose of morphine was documented as given per the MAR at 5:35AM, however, was not accounted for as having been given on the narcotic log, and6. the 6/16/25 scheduled 9:00AM Morphine dose was documented as given per the MAR at 8:21AM, however, was not accounted for as having been given on the narcotic log. On 10/8/25 at 8:50AM the surveyor conducted an interview with the facility's Director of Nursing (DON). When the surveyor inquired as to if Resident #179's pain crisis had been brought to their attention, they reported they were not aware and that no information had been provided to them from facility staff regarding the situation. Surveyors observed the narcotic log with the DON who reported that they did not know who had crossed out the orders on the narcotic log and stated that they shouldn't have crossed all that out and it's not matching the MAR (medication administration record). When the surveyor inquired to the DON as to how she would know the pain medications had been given, she stated I don't, it has to be signed on both the MAR and narcotic log, I wouldn't know, I assume the pain medication was not given. The DON further informed surveyors that routine and as needed medications both go on the narcotics log and if the dose is changed a new page is started. The DON stated to surveyors: No, procedure was not followed. When the surveyor inquired as to if documented pain crisis is typical for a resident receiving hospice services, they stated: No, it (pain) should be controlled. On 10/8/25 at 9:08AM the surveyor conducted an interview with ADON #45 regarding the incident of pain crisis of Resident #179. ADON #45 reported I don't remember, I thought that happened on an off shift, 3-11 or 11-7. When the surveyor inquired to ADON #45 as to whether the facility took any actions in response to Resident #179's situation to prevent further occurrence, they stated the following: It should've been fixed, but whether it did or not I don't know, the unit manager should have done that. On 10/8/25 at 11:45AM the surveyor shared the harm level concern with the facility's Director of Nursing and the facility's Administrator who both acknowledged and confirmed understanding of the surveyor's concerns. At this time the surveyor additionally provided an opportunity for any and all further documentation to be provided by the facility for surveyor review. The Director of Nursing stated to surveyors that there was no further documentation to be provided.

Based on observations, record reviews, and interviews with residents and staff, it was determined that the facility failed to maintain a system to ensure that resident council concerns were acknowledged and addressed timely, resolutions were communicated, and interventions were effective. This failure had the potential to affect all residents.The findings include: Resident Council is a group of residents that meets regularly on the behalf of all residents in the facility to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life. Facility staff are required to consider residents' views and act upon grievances and recommendations. Facility staff must consider these recommendations and attempt to accommodate them, to the extent practicable. On 9/28/2025 at 11:15AM, during an interview with representatives from the resident council, the Surveyor was informed that concerns discussed during the resident council meetings are not addressed and acted upon timely. The resolutions are usually unclear because the issues still occur. The residents feel like nothing is being done to address their majority of their concerns. On 10/3/2025 at 2:05PM, a review of the resident council minutes for July 15, 2025, failed to reveal a review of administrative resolutions and what was resolved from last meeting. There was a social service concern that residents are not sure the process to fill out grievances outside of regular business hours and resident rights were reviewed. An additional review of resident council minutes from August 12, 2025, failed to reveal a review of administrative resolutions (states none at this time) and what was resolved from last meeting. New concerns included: new tray times discussed, the front door will be locked at all times, GNA/nurses are not knocking or announcing themselves when they enter the room, residents request more outside time other than smoke breaks, problems with ants and flies in their room, and resident rights were discussed. An additional review of resident council minutes from September 16, 2025, failed to reveal a review of administrative resolutions (states none at this time) and what was resolved from last meeting. The Nursing Home Administrator (NHA), the Administrator in Training (AIT), and the Director of Nursing (DON) were at the meeting. New concerns included: staff members taking breaks during mealtimes, resident snacks are hidden behind the nurses' station making them less accessible, and residents would like to have more variety of snacks. On 10/7/2025 at 12:00PM, during an interview with the residents from the resident council group, the Surveyor was informed that the concerns/grievances process should be completed and discussed with the residents within 5 days. Grievance forms should be located outside the social services office, and they are not. Residents are demanding resolutions to their concerns expressed at the meetings and the facility staff are not updating them. On 10/8/2025 at 8:51AM, during an interview with the DON, the Surveyor was informed that the concerns addressed during the resident council meetings are forwarded to that specific department to review and provide a resolution for. The resolutions are sent back to the activity (the staff that take the resident council minutes) department to discuss with the president and the group during the next meeting. Each department is responsible for following up with their concerns and resolutions. On 10/8/2025 at 12:05 PM, during an interview with Director of Recreation (DOR) #10, the Surveyor discovered that after the resident council meetings the concerns/grievances are entered into a computer system to be managed by the administrator. After the review process, the Grievance Summaries are completed and attached to the Resident Council Minutes to be discussed at the next meeting. On 10/9/2025 at 8:00AM, during an interview conducted with the AIT, the Surveyor informed the AIT that after a review of the Grievance Summaries from July, August, and September 2025, the Surveyor had the following concerns: grievances from resident council are not reported on the same date the grievance was recorded by staff; grievances are not addressed timely; resolutions are not always communicated to the resident council; and, interventions are not monitored to ensure they are effective. The Surveyor also expressed the concern that the facility failed to ensure grievance forms were available outside the social service office and there was no bin or mailbox labeled for grievances. During the survey, some nursing staff still failed to knock/ask permission before entering the resident's room, flies and ants were observed throughout the facility as well as in resident's rooms, and snacks were placed behind the nurses' station on Unit 2 and not passed out to residents. These were all concerns addressed by the resident council and have continued with no effective resolution.

Based on interview and record review, it was determined that the facility failed to ensure that residents only smoked in areas outside of the facility and in a safe manner. This was evident for 1 (Resident #2) of 28 residents who smoked at the facility. As a result of this deficient practice, immediate jeopardy was declared at the facility on 8/24/23 and was abated on 8/25/23. The findings include: On 8/24/23 at 9:54 AM, Staff #8, who worked on Unit 2, stated that she knows staff have caught residents smoking in their rooms on the unit. She stated, you can smell it even if you don't see it. On 8/24/23 at 10:00 AM, Unit Manager #6 denied that any residents on the 2nd Unit had been caught smoking in an inappropriate location such as inside their room. On 8/24/23 at 10:07 AM, Resident #1 stated that his/her roommate (Resident #2) smokes in the bathroom attached to the bedroom. Although Resident #1 was bed bound and could not get out of bed to witness Resident #2 smoking in the bathroom, Resident #1 stated that Resident #2 would go in the bathroom at night or early in the morning, turn on the faucet, and would stay in there for long periods of time. The resident would then leave the bathroom and the smell of smoke would fill the bedroom. Resident #1 expressed concern about the roommate smoking because Resident #1 has significant respiratory disease, breathes through a tracheostomy, and receives continuous oxygen therapy. Resident #1 stated that maintenance staff have found cigarette filters in the toilet as recently as a week ago, and that Resident #2 most recently smoked in the bathroom yesterday (8/23/23) morning. On 8/24/23 at 10:13 AM, Staff #4 stated that, a few months ago, she had caught Resident #2 right after he/she smoked in the room. I could smell it in the room. Staff #4 indicated she reported this to UM #6 and that it went up the chain of command, but that nothing was done because there wasn't enough evidence. Staff #4 stated that she was the second person to catch Resident #2, that an agency Geriatric Nursing Assistant (GNA) had previously caught Resident #2 and reported it. When asked to identify the agency GNA, Staff #4 was unable to, saying I'm sorry, I don't know her name. On 8/24/23 at 10:18 AM, Staff #3 stated that she witnessed Resident #2 smoking in the 2nd floor dining room. Staff #3 stated it happened the first part of this week. Staff #3 had been informed by a GNA from the night shift that Resident #2 was smoking in the dining room. Staff #3 found the resident still smoking in the dining room, confronted the resident, reminded the resident that he/she could only smoke outside, and ensured the resident extinguished the cigarette. Staff #3 stated she reported the incident to the night nurse, Licensed Practical Nurse (LPN) #9. Staff #3 was not sure what happened with the investigation after that. On 8/24/23 at 10:25 AM, when asked if he/she had ever seen someone smoke unsafely, Resident #4 stated that Resident #2 has been caught smoking in the bathrooms. He/she is always smoking in the bathrooms but nothing has been done to him/her. On 8/24/23 at 11:44 AM, the surveyor interviewed the Administrator. During the interview, the Administrator stated that he was only aware of one time that Resident #2 had been witnessed smoking somewhere inappropriately, that it was in the 1st floor dining room (not the 2nd floor) about 2-3 months ago. The Administrator described the resident as having propped open an outside door and was smoking right next to the open door but still inside the building. The Administrator said he had a conversation with Resident #2, reminding him/her of the facility policy to only smoke outside in designated areas. The Administrator stated this conversation was not written down anywhere and that no further disciplinary action had been taken against Resident #2. During the interview, the Administrator also stated that Resident #6 has complained of Resident #2 smoking in his/her bathroom. Resident #6 resided in the room next to Resident #2 and the two rooms share a bathroom. Resident #2's medical record was reviewed on 8/24/23 at 12:08 PM. The review failed to reveal any progress notes in 2023 that addressed Resident #2's behavior of smoking inside. Review of the care plan failed to reveal any care plan topic addressing Resident #2's behavior of smoking inside. Resident #2's smoking care plan was last modified on 11/22/22. Further review of Resident #2's record revealed that the resident's three most recent smoking assessments (3/8/22, 11/22/22, and 2/14/23) all documented that the resident was determined to be able to smoke independently and that the resident has no risk factors for unsafe smoking. The assessments all documented that the patient understands that smoking may only take place at designated times and in designated smoking areas. The resident had a documented Brief Interview of Mental Status (BIMS) score of 15/15, indicating that the resident had no cognitive impairment. The facility's smoking policy was reviewed on 8/24/23 at 12:20 PM. The policy stated, the center maintains a policy of no smoking within the building by anyone at any time. During an interview on 8/24/23 at 12:34 PM, LPN #9 denied ever having received report from Staff #3 about Resident #2 smoking in the 2nd floor dining room. On 8/24/23 at 2:20 PM, Maintenance Staff #10 stated that the maintenance team had to plunge Resident #2's toilet several times (as recently as one week ago) because it became stopped up with discarded cigarette filters. There were times when the filters were still visible in the toilet bowl. The maintenance staff recalled having seen Resident #2 with a cigarette in his/her hand in the bathroom one time. On 8/24/23 at 2:22 PM, the Maintenance Director confirmed Maintenance Staff #10's statement. The Maintenance Director stated that the clogged toilet had been reported to the Maintenance department by Geriatric Nursing Assistants (GNA) who worked with the resident. The Maintenance Director also stated that he had reported this to nursing staff during morning meeting, roughly a month ago. Nursing staff stated to him that they would have a discussion with the resident. On 8/24/23 at 2:50 PM, review of the maintenance log for Unit 2 for June - August, 2023, revealed that, on 8/9/23, Resident #2's toilet was reported to be flushing slowly. No other reports were found related to Resident #2's toilet. As a result of these findings, it was determined that immediate jeopardy existed in the facility related to the facility's failure to address Resident #2's behavior of smoking inside the building. Immediate Jeopardy was declared on 8/24/23 at 3:00 PM. The facility submitted their first version of a plan to remove the immediacy at 4:52 PM but it was rejected at 5:20 PM. The facility submitted their second plan at 5:42 PM but it was rejected at 5:50 PM. The facility submitted their third plan at 6:10 PM and it was accepted on 8/24/23 at 6:20 PM. The date of compliance of the accepted plan was 8/25/23. The plan to remove the immediacy contained the following corrective actions: Re-education of Resident #2 regarding the smoking policy, alleged completed 8/24/23. Resident #2 was placed on continuous observation (1:1) by a dedicated staff member, alleged completed 8/24/23. Resident #2 was re-evaluated for safe smoking and was determined to require supervision when smoking, alleged completed 8/24/23. Resident #2 was re-educated on the risks of smoking and offered smoking cessation material including use of a nicotine patch, alleged completed 8/24/23. An ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the root cause of this incident and to develop and implement corrective actions, alleged completed 8/24/23. Resident #2's roommate was offered a room change, alleged completed 8/24/23. All staff, including contracted staff who were permitted to work in the building, received education regarding immediately extinguishing smoking material if found lit inside and immediately reporting any incident in which smoking in the building was witnessed or suspected. Education occurred in person or by telephone, alleged completed 8/24/23. All residents who smoke were re-educated regarding safe smoking (especially not smoking inside) by the Administrator, Director of Nursing (DON), or the Assistant DON, alleged completed 8/25/23. The DON or Administrative Nurse will inspect resident living quarters weekly for 90 days and refer results to QAPI, alleged complete 11/22/23. On 8/25/23 at 3:00 PM, the surveyor reviewed the credible evidence provided by the facility for the above corrected actions. The credible evidence included a log that nursing staff completed for the 1:1. The log documented that staff assisted Resident #2 outside to smoke twice on the night of 8/24/23 - 8/25/23, once at 2:30 AM and again at 5:30 AM. The facility was found to be in compliance at that time and the IJ was declared to be abated on 8/25/23 at 3:20 PM.

Based on observation, interview, and medical record review, it was determined that the facility failed to have a process in place to: 1.) Effectively manage and evaluate the process of the 'leave of absence' (LOA) of residents in the facility. This was evident for two dependent residents of seven reviewed (Resident #4 and Resident #15) that were able to leave the facility for an undetermined Amount of time and has the potential to affect all residents assigned a LOA in the facility. 2.) Have an effective way to ensure residents who were assessed as needing supervision and/or assistance or assistive devices with smoking are provided a safe environment to smoke while residing in the facility even when signed out LOA and remaining on the facility property. This was evident for 1 of 7 residents reviewed for safe smoking practices (#15). 3.) Continually monitor the [NAME] and [NAME] of residents signing in and out of the facility on LOA. This was evident during the review of a 30-day period affecting all residents with LOA orders. These deficient practices resulted in the finding of immediate jeopardy, which was identified on September 22, 2021, at 5:35 PM. The facility provided an initial plan of removal on 9/22/2021 at 8:45 PM that was not accepted. A second plan of removal was provided on 9/22/21 at 10:15 PM that was not accepted. A final plan of removal was accepted on 9/23/21 at 12:15 AM. The Immediate Jeopardy was removed on 9/28/21 at 11:00 AM after validation that the plan had been implemented. 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 extended survey was completed on September 28, 2021. The findings include: A Leave of Absence (LOA) is defined as when a resident has permission to leave the facility for a few hours or days to spend time visiting with friends and/or family. Such leave of absence must be arranged in advance with nursing home staff so they have time to prepare any medications the patient will need as well as instructions for the temporary caregivers. 1. A review of complaint # MD 727 sent to the State Survey Agency was conducted on 09/20/21 at 7:45 AM. The complainant, an officer at the local police department stated that the facility allowed on several occasions, (4/11/21, 6/14/21, 8/13/21 and 9/7/21) for Resident #4 to sign themselves out of the facility unattended even though the resident could not walk or talk very well. On June 14, 2021, the facility called 911 to report the patient missing, after several hours since the patient was last seen. According to the complaint report, the patient was not found until the next morning, several hours after the report was taken. The patient had fallen in the woods, just a few hundred feet from the facility and was unable to walk. The same patient was reported missing again on August 13, 2021, for the same reasons. The officer added that there have been four documented incidents of a similar nature since April of 2021, and several additional calls concerning the resident being allowed to leave the facility but refusing to return. The most recent incident occurred on the morning of September 7, 2021. On 9/21/21 at 8:00 AM an interview was conducted with the Director of Nursing (DON). Surveyor requested to receive the investigative notes regarding the facility's reports of Resident # 4 being missing from the facility on 4/11/21, 6/14/21, 8/13/21 and 9/7/21. The DON replied There are no incident reports because he was not considered missing on those dates. She also stated that the resident was on a Leave of Absence so, there were no incidents to investigate. She went on to say that she educated staff that if a resident was on a LOA no one from the facility should be documenting that the resident was missing or go out to look for them since it is not the facility's responsibility to monitor resident's whereabouts or their times of return. A review of the medical records for Resident # 4 was conducted on 09/21/21 at 08:20 AM. The resident was admitted to the facility with a diagnosis that included a [CONDITION(S)] (a stroke) that left the resident paralyzed on the right side of their body and required the use of a cane for walking or a wheelchair for mobility. In addition, the injury caused the resident to not be able to verbally express ideas or words effectively to others. A review of the Resident's February 2021 Quarterly Assessment revealed a Brief Interview for Mental Status (BIMs) score of 9. (The BIMS test is a required screening tool used in nursing homes to get a quick snapshot of how well a person is currently functioning cognitively. The score of 9 indicated that the resident was mildly impaired. Further review of the assessment found the resident was unsteady for moving from a sit to stand position, and for walking surface to surface transfer and required the use of a cane. In review of Resident #4's court ordered Physician Certificate of Incapacity dated 5/3/19 the physician described the causes of the resident's mental impairment as not reversible, along with the somatic factors of hearing, vision, speech impairments are not reversible and the impairment of memory, cognitive, and executive functioning as severe. Regarding everyday functioning, it was documented that Resident #4 had a non-ability to understand, perform, or participate in decision making. In the professional opinion of the physician Resident #4 had a disability which prevented him/her from making or communicating any responsible decisions concerning their person. However, further review revealed a Certificate of Capacity dated 4/12/21 completed by the resident's attending physician stated that the resident had adequate decision capacity to include decisions regarding life-sustaining treatments. However, there was no note by the physician that addressed the change of capacity. During an interview with the officer of the local police department (PO#1) conducted on 9/21/2021, at 12:05 PM, it was revealed that on 04/11/21 the officer was called back to the facility later that day because the resident was again trying to leave the facility, but the staff refused to allow them to go. After the officer spoke to the resident, s/he was taken to the local Emergency Department for evaluation because of the suicidal thoughts expressed to the officer. A review of a physician order dated 4/14/21 at 3:22 PM indicated that the Resident May go on LOA, however further review of the medical records failed to indicate any established parameters for tracking the resident's [NAME] and [NAME] from the facility. There was no documentation found to show the duration, purpose, and location of where the resident would spend the LOA. In addition, there was no documentation found to support that the resident was assessed prior to leaving the facility or if the resident had their cane or wheelchair with them to assist them in traveling to and from the facility. According to the interventions put in place after the 4/11/21 elopement, the facility's investigation concluded that Resident #4 did not utilize the sign-out book on 4/11/21, was educated to sign-out when on leave, and was able to demonstrate the capacity to do so during the instruction. A review of the facility's LOA policy on 9/21/2021 at 10:30 am revealed that Each resident leaving the premises must be signed out and must be signed in upon return to the facility. Additionally, restrictions noted on the resident's chart concerning who may or may not sign the resident out must be honored. An interview with PO#1 was conducted on 9/21/2021 at 12:05 PM. The officer stated that on June 15, 2021, at 12 AM, the facility called 911 to report Resident #4 had signed out of the facility at 7:30 PM on June 14, 2021 and had not been seen for several hours. The officer stated that a search team was dispatched and after several hours the resident was detected by way of their phone's GPS (Global Positioning System) and found by the local authorities in a nearby wooded area a few hundred feet from the facility. The resident's ankle was injured, and the resident was unable to Ambulate independently. The officer stated he was familiar with the resident since he had been dispatched to the facility several times since April 2021 for the same type of incidents. They added that the resident was consistently allowed by the facility to leave the facility unattended although the resident could not walk or talk very well. A review of nursing documentation conducted on 09/21/21 at 11:15 AM revealed nursing staff documented Resident #4 as unaccounted for during the 4 incidents reported by the complainant: On 4/11/21 at 1:15 AM, Nurse# 38 documented that Resident #4 had left the facility and was bought back after being found in the local area by facility staff. At 3:53 PM Nurse #41 documented that Resident # 4 was encouraged to use the Wanderguard (a device worn on the ankle or wrist to alarm whenever a resident approaches an exit in a facility), but s/he refused. In addition, documentation dated from 4/11/21 through 04/14/21, on Change in Condition Follow up forms indicated that Resident #4 was assessed for presenting symptom of Absent. A Change in Condition follow up form dated 4/11/21 at 1:40 PM stated the presenting symptom of leaving the facility. Further review found the resident's physician indicated in a progress note dated 4/12/21 that he was informed the resident had sneaked out of the facility and was found hours later drinking at a local bar. Further review found that although the 4/14/21's LOA order was given to the DON verbally on 4/14/21 at 5:22 PM it indicated it was effective on 4/13/21 at 3:22 PM. On 6/15/21 at 01:09 AM, Nurse #37 documented that Resident #4 signed out of premises at 19:23 (7:30 PM). At 11:00 PM the staff started to search the building for him, Supervisor was notified, and a sweep of the parking lot and local business were conducted. Phone calls were made to a local tavern, to the resident's and their friend's cell phones with no response. Nurse #37 added that after checking nearby the emergency room , the local police department was notified, and a missing person report was filed with the Sheriff's office. Nurse #40 indicated in their note dated 6/14/21 at 11:44 PM, that a code pink was initiated by their supervisor. A code pink was identified as a resident elopement by the DON during an interview on 9/22/21 at 11:15 PM. Further review found a nurse's note text dated June 15, 2021 at 06:51 revealed a call received by the facility at 9630 stated that the Resident was found at the back of the Shell gas station and was taken to the ER for evaluation. A June 15, 2021 Health Status Note revealed that Resident #4 returned to facility from the ER at about 12:30 PM. Resident #4 transferred to the bed from the wheelchair without incident, vital signs were taken, had no complaints of pain at that time and was observed in bed with eyes open watching TV. Further review revealed that Change in Condition Assessments were conducted from June 15 - June 21, 2021. Documentation under Symptoms on June 15, 16, 17, 19, and 21, 2021 were noted as S/P Elopement and on June 20, 2021, the symptoms documented indicated S/P outing. A review of the June 15, 2021's Transfer Evaluation revealed Partial weight bearing- can provide assistance with transfers and repositioning - not independent. A June 15, 2021 Clinical Admission Evaluation revealed under the category Functional: Resident #4 not able to move all extremities and Impairment on one side. Gait is unsteady with use of cane indicated and a June 15, 2021, assessment under: Evaluation of present condition indicated the resident was stable with the Progress note summary that stated, Continue to monitor resident for S/P Elopement, Resident remains asleep most of the shift will continue to monitor. A review of the resident's May 19, 2021 Quarterly Assessment revealed a BIMs score of 0. Scores closer to 0 indicate severe cognitive impairment. Review of Nurse #37's progress note dated August 26, 2021, at 11:36 PM revealed Resident #4 had left earlier on a trip to a department store and had not returned. The nurse added that multiple attempts to reach the resident by cell phone were unsuccessful and supervisor notified. Review of the resident's August 19, 2021Quarterly Assessment revealed a BIMs score of 0. Review of Staff # 36's documentation on September 7, 2021, at 7:20 PM revealed that upon their arrival to the facility for their shift, Nurse #39 reported to them that Resident #4 had signed themselves out at 7:30 PM and had been missing since that time. A review of a note written by the 11:00 PM overnight shift Licensed Practical Nurse (LPN # 66) on 09/07/21 at 7:22 PM indicated that upon their arrival to the unit for work that evening, she was informed that Resident #4 had signed themselves out around 7:30 PM and had been missing since that time. She also stated that this action has been a pattern of Resident #4 so she waited a while longer before initiating a search for the Resident. The resident was later found hidden in the bushes across from a gas station, intoxicated, upset, and refusing to re-enter the facility so the nurse called the police to assist them with the resident. (Cross Reference with F 609) During an interview on September 21, 2021, at 12:05 PM the complainant re-iterated their reported concerns and added that on midnight on 9/7/21 they were contacted by the facility that Resident #4 was missing. Law enforcement conducted a searched of the area. With no success after several hours, PO#1 contacted the resident's cell phone carrier and activated the phone's location device to assist in the search. The device pinpointed the resident at 6:00 AM in a wooded area with an injured ankle, was unable to walk, and was transferred to the Emergency Department. During an interview with the DON and the Administrator conducted on 9/21/21 at 11:00AM the Administrator stated that since the Resident was on LOA's, the incidents did not require notification to the state agency. The DON added that staff should not have documented the incidents as an elopement, nor contacted the police, or conducted a search for the resident because the resident was on LOA. When surveyors showed the reviewed nursing documentation to support that the staff were identifying the incidents as elopements, the DON stated that staff was educated regarding their error in calling a code pink as the resident was on LOA and there was no need. The DON added during a follow-up interview on 9/22/21 at 1:15 PM, that Resident #4 often left the facility for several hours including overnight and for multiple consecutive days believing that they stayed over at a friend's home. A review of the June, August, and September 2021 Midnight Census Reports on 09/21/21 at 12:40 PM indicated that although on September 7, 2021, Resident #4 was indicated to be in the facility, nursing documentation, and police report statements said the resident was not present in the building during that time. (A Midnight Census is the number of residents occupying nursing home beds in a nursing facility at midnight of each day. Midnight census is defined as the number of patients occupying a bed in each nursing unit at midnight) 2. During observation of residents smoking out front of the facility on 9/21/2021 at 9:40 AM Resident #19 was interviewed. Resident #19 was observed wheeling up to the facility in his/her motorized wheelchair carrying coffee and a bag of items, including cigarettes for another resident s/he purchased from the gas station up the street. Resident #19 stated that they were the 'runner' and was the one with the motorized wheelchair that made it easier to get across the street as it is 'busy,' when they go every day. Observations were conducted by surveyors during arrival and leaving the facility on 9/20/21 and 9/21/21. Observation of the most direct path from the facility's exit to the gas station revealed approximately 400 feet of a two-lane paved road. that connected the nursing home's driveway exit lead to the nearest driveway entrance into the gas station's lot. Further review failed to find a sidewalk on either side of the two-lane road and the only crosswalk observed was at the far end of the gas station about 50 feet beyond the immediate driveway's entrance and located at the intersection's traffic light. According to the facility Director of Nursing (DON) and Administrator, who were interviewed on 9/21/2021 at 10:15 AM, the residents that were found out front of the facility go out there to smoke as they refuse to follow the facility smoking protocols. They have signed a facility form that states they refuse to follow the facility/CDC/government guidelines and therefore need to sign out of the facility making them LOA to go smoke. However, review of the facility form had no listed guidelines on it. Review of the Resident #19 Smoking Safety Evaluation conducted on 09/21/21 at 12:30 PM revealed the resident displayed balance problems while sitting or standing, total or limited Range of Motion (ROM) in arms and hands and failed to follow facility's policy on location and time of smoking. Further review revealed documentation on assessment on 7/19/2021 indicating Resident's #19's BIMS score of 15, which indicates resident was cognitvely intact. In addition, further review of the facility's Smoking Safety Evaluation form revealed the statement: Note: Supervision will be required for all Residents during designated smoking times. This evaluation will be utilized for the Resident's smoking care plan on admission and as indicated. Multiple residents were observed smoking on 9/21/2021 at 9:45 AM at the front of the facility, including Resident #20, #21, #22 and #24. They were asked about the smoking process at the facility and signing in and out. They stated that they often travel off the property and go to the gas station or other places but did not elaborate. This was happening unbeknownst to the staff who were documenting on the sign-out form that the resident was outside smoking or chilling. The staff, therefore, did not actually know where the residents are when they sign out on LOA. A review of the sign in/out forms on 9/21/2021 also failed to show that residents were consistently signing back in, and staff were not following up to see when or if residents were back in the facility. A review of the progress note for Resident #15 on 9/21/2021 at 1:30 PM revealed that on 9/19/2021 the resident left the facility after signing out to smoke and was found at the gas station. The nursing progress note documented that staff alerted this writer resident had gone across the street to the store, staff members were able to wheel resident back to facility, educated to inform staff prior to leaving, verbalize understanding. Further review of Resident #15's medical record revealed that s/he is his/her own representative, was cognitively intact, however, was documented as a wanderer and an unsafe smoker requiring supervision and an apron as s/he was at risk of burning him/herself according to the smoking assessment completed on 8/20/2021 and the most recent care plan. According to the resident's care plan s/he is also at risk for falls. Review of Resident's #15's June 15, 2021, Quarterly Assessment indicated a BIMS score of 15, indicating cognitively intake but required supervision for bed mobility and transfers, limited assistance walking, limited assistance locomotion on and independent locomotion off unit, no issues with ROM, use w/c and walker. A review of the resident's 9/15/21 Assessment indicated a BIMs score of 05, which indicated severe cognitive impairment. Review of Resident #15's Smoking Safety Evaluation revealed the resident demonstrated total or limited ROM in arms and hands. During the assessment the resident [CONDITION(S)] skin, clothing, furniture ,or other, drop ashes on self, and failed to follow facility's policy on location and time of smoking. Further reviewed revealed concerns noted during the evaluation that the resident was unable to light safely, unable to hold cigarette safely, unable to extinguish a cigarette safely, and unable to use ashtray to extinguish a cigarette. Based on the evaluation, the clinical suggestions for the resident were for Resident #15 to use a smoking apron. When the DON was interviewed on 9/21/2021 about the incident when Resident #15 was found at the gas station on 9/19/2021 and needed assistance returning to the facility, she was unaware. When the DON was asked about safety concerns related to the resident smoking, she stated that the resident had an apron in his/her room. The DON also stated that once a resident signs out of the facility it is not the facility's responsibility to monitor the resident anymore. Resident #15 was interviewed on 9/22/2021 at 3:24 PM and indicated they go outside 3 times a day to smoke. The resident was asked if they had to wear anything over their clothing when they went outside to smoke, and the resident said no. Observation of the resident failed to reveal any smoking apron. In addition, it was noted that his/her shirt and pants were covered with the appearance of burn holes. According to the LOA sign out papers Resident #15 signed out to smoke' on August 30, September 10, September 11th multiple times, and September 12th, 2021, multiple times with inconsistent signing in upon return to the facility. Resident #15 was observed smoking outside on 9/22/2021 at 3:55 PM . He was found by surveyors in the front of the facility smoking without an apron and unmonitored. In addition, he was noticed with [CONDITION(S)] on his clothing. The DON was notified of the observation and stated she would look into it to see if they refused the apron. At about 4:00 PM on 9/22/2021 after the observation/interview, surveyors went to the resident's room and found an smoking apron present. 3. On 9/21/2021 at 9:18 AM surveyor approached the front desk to review the process for residents signing in and out to go on LOA. Staff #36 were there and stated that residents will sign out to smoke but really go to the gas station or the store. Multiple residents were observed smoking on 9/21/2021 at 9:45 AM at the front of the facility, including #20, #21, #22 and #24. They were asked about the smoking process here at the facility and signing in and out. They stated that they often travel off the property and go to the gas station or other places and did not elaborate. This is happening unbeknownst to the staff who are documenting on the sign-out form that the resident is outside smoking, or chilling. The staff, therefore, do not actually know where the residents are. Surveyor requested to see the sign in and out sheets from June 2021 to the present. Staff # 36 stated that she would have to look in the file and stated that the sign-out sheets get pulled from the binder and filed away. She would pull them and get them to the survey team. During follow up with Staff #36 at 10:42 AM on 9/21/2021, she provided the team with the sign in sheets from 8/29/2021 to 9/21/2021. Surveyor asked where the other sign-in sheets were, and she stated that I guess we threw them out at the end of the month. Immediate review of the sign-in sheets provided to the survey team revealed that there were multiple days on the sign-out log for short term leave from the facility consistently failed to have the residents full name and, failed to have sign-in times for all the residents. In addition, under Resident name it stated to print legibly, which on multiple occasions resident names were not legible or discernible as to which resident had signed out on the form. Review of the sign in sheets revealed: on 8/29/2021 there were 23 of 42 times when only the residents first name was signed out. On 8/30/2021 there were 10 of 29 instances where there was no documentation that a resident that signed out signed back in. On 9/7/21 there were 26 of 54 incidents where residents were not documented as signing back in after signing out for an LOA. This pattern continued through the review up to the date of 9/21/2021. There was no noted pattern for specific residents that failed to sign back in, it was across the board for any residents noted signing out. The identified issues of the missing sign in sheets and the lack of information on the sign in sheets was reviewed with the DON and Administrator on 9/21/2021 at 12:00 PM. On 9/21/2021 at 12:27 PM staff #16, a hospitality aide working the front desk was interviewed about residents that had signed out on the resident sign-out log on 9/21/2021. A resident name was noted on the sign-out form. This resident was noted to have signed out to smoke; however, the resident named did not exist in the facility as was reviewed on 9/21/2021 at 12:00 PM, and the name could not be found in the facility's computer. However, the last name identified on the form was a resident that was identified as a smoker, Resident #15. Staff #16 was asked who was outside, and she stated the name written on the form. The concern that there was no resident in the facility with that name was verbalized to staff # 16 so she proceeded to call the nursing station upstairs and was notified that Resident #15 was indeed the resident outside and the name was corrected on the sign-out form. She stated I don't know why [Resident #15]said that was [his/her]name after she called the nursing unit. The DON was interviewed on 9/21/2021 at 12:40 PM. The concern was that staff were not always aware who was outside according to the resident sign-out sheet and were not following up when residents that sign-out LOA were returning to the facility was reviewed at that time. Because of these findings, an Immediate Jeopardy was called on 09/22/2021 at 5:35 PM related to resident safety when leaving the facility on a leave of absence and safety of residents while smoking. The facility provided an initial plan of removal on 9/22/2021 at 8:45 PM that was not accepted. A second plan of removal was provided on 9/22/21 at 10:15 PM that was not accepted. A final plan of removal was accepted on 9/23/21 at 12:15 AM to remove the immediacy of the IJ for F689 alleging compliance as of 9/24/21. The Immediate Jeopardy was removed on 9/28/21 at 11:00 AM after validation that the plan had been implemented. The provisions of the plan to remove the immediacy included the following: Residents #4 and #15 will be reassessed for ability to have LOA privileges based on functional ability and cognitive ability. Until reassessments can be completed, a staff member will accompany resident #4 and resident# 15 when outside on facility property. If the resident #4 leaves the property, MD and RP will be notified (if applicable). If resident #15 decides to smoke while outside, staff will ensure safety. If a resident conducts themselves in any manner that puts themselves or any other resident at risk those residents will be issued a behavior contract and/or a discharge notice. Resident #15 was reassessed for safe smoking. Resident re assessment remains smoking with supervision. All residents with active LOA orders will be reviewed to ensure residents were allowed privileges based on functional ability and cognitive ability. If the residents have a change in condition, we will reevaluate for the resident's ability to have LOA privileges. Residents will be reassessed quarterly and at a significant change. A reassessment will be completed by the IDT team for functional and cognitive status. Residents deemed safe for LOA will not be specific for smoking. The LOA list was updated and placed at the front desk. All smoking residents will be reassessed for safe smoking practices. Front desk receptionists were educated by the Administrator and HR on LOA policy and the new LOA log which asks residents the anticipated location and anticipated duration of LOA. Any staff members that do not receive the education by the compliance date will be educated via phone with 2 witnesses and/or education at the front door prior to the start of their next scheduled shift. Current LOA Eligible Residents and/or Responsible Parties will be educated by the IDT team on the new LOA log which asks residents the anticipated location and anticipated duration of LOA. All licensed nurses will be reeducated by the ADON and Unit Managers to inform the physicians and responsible party (if applicable) regarding incidents while resident is on LOA. Any licensed nurses that do not receive the education by the compliance date will be educated via phone with 2 witnesses and/or education at the front door prior to the start of their next scheduled shift. All facility staff will be educated by the NHA, DON, and Admin Team on the new LOA log and LOA policy which includes the anticipated location and duration of LOA. Any staff members that do not receive the education by the compliance date will be educated via phone with 2 witnesses and/or education at the front door prior to the start of their next scheduled shift. The Medical Director will educate the Attending Physicians on the LOA policy and log and the Physician role in determining LOA appropriateness. Any staff members that do not receive the education by the compliance date will be educated via phone with 2 witnesses and/or education at the front door prior to the start of their next scheduled shift. The Administrator will audit the LOA book weekly for 12 weeks to ensure the front desk Receptionists are filling out the LOA book properly. The Director of Nursing will audit 10 LOA eligible residents weekly for 4 weeks and then 20 residents monthly for 2 months to ensure residents with LOA orders are appropriate. If the DON sees any discrepancies, she will notify the Physician. The Director of Nursing will audit 10 smoking residents weekly for 4 weeks and then 20 residents monthly for 2 months to ensure residents with Smoking orders are appropriate. If the DON sees any discrepancies, she will notify the Physician. These audits will be reviewed by the QAPI meeting for 3 months and determined if any further action is necessary.

Based on observation of residents and the environment, interviews with facility staff, review of elopement risk information and medical records, it was determined that the facility failed to consistently implement interventions for residents assessed to be at risk for elopement. This resulted in an Immediate Jeopardy for the residents at risk for elopement ( # 1, # 4, # 6, # 7, # 8, # 14, # 15, # 16, # 17, # 18, # 20, # 21, # 22, # 23, # 24, # 25, # 26, # 27, # 28, # 29, # 30). The findings included the following: On 2/19/14 at 9 am, the surveyor met with the director of nursing (DON) and reviewed the facility reported incident (FRI) information. FRI MD 856/MD 956 was dated 12/3/13 and 12/6/13. These were submitted to the Office of Health Care Quality by the facility. The facility reported that resident #31 had eloped on 12/1/13. He had been located at another facility across the parking lot from the facility. The interventions implemented by the facility to decrease the risk of elopement included the application of a wander guard bracelet. A wander guard bracelet is applied to the person and will alert the staff when a resident approaches an exit that is armed with a wander guard pad. An alarm will sound and the exit will not function until disarmed. The bracelet and the pad need to be tested to assure function. The surveyor requested a list of residents assessed as an elopement risk from the DON. At approximately 9:30 am, the DON provided a list dated 2/19/14 with 14 residents listed. Observation completed at 10:00 am revealed that the main entrance was equipped with a wander guard pad. The reception area/front desk was located to the right of the entrance. The surveyor interviewed the receptionist at that time. She stated that she had a book at the desk with photographs and information on the residents that were at risk for elopement. She added that these residents had wander guard bracelets in place. She described her responsibility to be to look in the book for the resident's information and alert the correct unit when the wander guard alarm sounded at the main entrance. The surveyor reviewed the information located in the book. The book contained the facility elopement management program. The program required that residents were assessed before and during the admission process, daily, weekly, and quarterly according to the MDS assessment schedule and as needed. The first form to be used included an elopement risk identification form - which was to be placed in binders at the front desk and on each unit. The information on the form was to include the resident's room number, a photo, distinguishing characteristics and emergency contact information as well as urgent medications. The surveyor reviewed the information in the elopement risk book located at the front desk. While the book had the same list of 14 residents provided by the DON in the front pocket, there were 15 residents not on the list with pages in the book identifying them to be at risk for elopement. There was 1 resident on the list without a page in the book and there were 3 residents with pages in the book that were not on the current list. There were 2 residents that had no last name or room number on the form. Residents #15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30 had elopement risk identification forms with photographs in the elopement risk book but were not on the elopement risk list provided by the DON and in the book at the front desk. Residents #7, 23, and 27 had elopement risk identification forms with photographs in the elopement risk book but they were not on the current daily resident roster. Resident #1 was on the elopement list but did not have a photograph or identification form in the book. Residents #29 and #30 had only their first name on the form and no room number listed. The surveyor toured the facility with the DON and reviewed the elopement risk books on units I, II, and III. During the tour, at approximately 12:30 pm, 7 residents that had been identified to be at risk for elopement were observed without their wander guard bracelets in place. The residents assessed to be elopement risks without bracelets in place were #1, 6, 14, 15, 18, 25, and 30. There were 3 residents listed as an elopement risk that had their wander guard bracelets on either their wheelchair or walker. Resident #4 and #8 had their bracelets on their wheel chairs and resident #28 had hers on her walker. The tour and observations included the following: Unit I was the only unit on the ground floor. It was located down the hall from the main entrance. According to interviews with the DON, the receptionist, and the maintenance director, the front desk was closed after 5 pm and unit I covered the front door if the wander guard alarm went off. Unit I had a book with the same list in the front which noted only 14 residents. The surveyor reviewed the pages with resident elopement risk pages there were 5 current residents (#1, 18, 4, 25, and 28) that were not in the book. and the same 3 residents (#7, 23, and 27) not on the current roster were in the book. There was one resident (#16) that had been evaluated to be at risk for elopement with an intervention of application of a wander guard bracelet. Nurse #2, during surveyor interview at 1 pm, stated that she looked to see if the bracelet was in place but did not test it to see if it functioned. Unit II was located upstairs requiring the use of the elevator or stairs. Unit II had a book on the unit as well. The list in the front of the book had 14 residents listed, the same as the one provided by the DON. Only the 4 residents on unit II with elopement risk forms were in the book. Observation of the residents on the unit revealed that 2 of the 4 residents (#25 and 14) assessed to be elopement risks with wander guard bracelet placement as an intervention, failed to have them in place. Nurse #4, during surveyor interview at 2 pm, stated that she took the resident near the exit/elevator to test the bracelets function. Unit III was a locked unit which required a key code for entrance and was also located upstairs. The book on the unit failed to reveal 5 residents (#16, 1, 18, 14, and 25) listed in the book at the front desk. In addition the same list of 14 resident and the 3 residents not on the current roster were in the book. On Unit III observation of the residents revealed that 5 of the 21 residents (#1, 6, 15, 18, and 30) assessed to be elopement risks with wander guard bracelet placement as an intervention failed to have them in place. There were 21 residents identified to be elopement risks and one of the interventions to prevent elopement included application of wander guard bracelets. During rounds and observations with the DON, there were 7 residents listed that had been assessed to have been provided with wander guard bracelets as an intervention to prevent elopement who failed to have them in place. Those identified included 2 of 4 residents on unit II and 5 of 21 residents on unit III. As a result of the elopement/safety risk of the residents, an immediate jeopardy was called at 3:45 pm due to the facility's failure to protect them. The facility provided a plan of correction which included: a house wide assessment of residents at risk for elopement as well as documentation of a plan of care for monitoring resident changes; monitoring of devices applied and wander guard pads; updating elopement risk manuals with reviews on a regular basis; maintenance of the monitoring devices and wand ordering and ongoing audits of outcomes, interventions and educations. The immediate jeopardy was abated on 2/19/14 at 4:45 pm.

Based on medical record, facility fall investigation, and bariatric bed/ equipment use manual review as well as observation and interviews with the resident, the facility staff and the bariatric bed manufacturer, it was determined that the facility failed to maintain an environment for safe transfers. The resident made an assisted transfer from the bedside commode to the bed. The bed moved, the resident fell ; this resulted in a fractured femur. This was evident for 1 of 7 residents selected for review. The findings included the following. On 6/18/13, 6/19/13 and 6/20/13, the surveyor reviewed resident #7's information. Review of the medical record and facility investigation: By way of history: Resident #7 was admitted to the hospital from 3/17/13 to 3/19/13 following bilateral knee replacements with chronic knee and hip pain. She was having problems walking and this was worsening. She was placed on pain control, evaluated for therapy, and transferred to the facility for sub acute rehabilitation. Her [DIAGNOSES REDACTED]. On 3/19/13, she was admitted to the facility for rehabilitation and placed in a bariatric bed. On 4/2/13 at 3:50 pm, according to the facility fall investigation worksheet, the resident was transferring off of the bed side commode with the assistance of GNA #3. The resident grabbed the bed rail, the bed moved; the resident fell and landed on her buttocks. Her left leg was extended and her right leg was turned at an "odd angle". The resident complained of pain, was unable to move her leg, and 911 was called. The X-ray for that date in the medical record noted that the resident had a deformity/ fracture of the posterior distal femur. On 4/3/13, the director of nursing (DON) had recommended having maintenance check the brakes on the bed to prevent further falls. On 6/18/13, the surveyor interviewed the administrator (ADM), DON, resident #7, and geriatric nursing assistant (GNA) #3, regarding the transfer which resulted in the fall. The ADM and DON agreed that the resident had fallen because the bed was unlocked. The resident stated the transfer had been done the regular way. She described transferring to include the GNA placing the bedside commode (BSC) close to the bed; she (resident #7) would stand, hold the side rail and pivot into the bed. She said she stood, grabbed the side rail and the bed moved. She recalled screaming, "Oh .... the bed moved". She said she fell and her right leg was bent under her. She said she yelled and screamed, "Words that people probably had never heard before", because the pain was "horrible". She described the feeling like taking an uncooked piece of pasta and breaking it in half. She felt as though she "blacked out" for a little while because the next thing she remembered was the paramedics standing over her. She added that the paramedics had to move her leg to get her to get her on the stretcher. She said she knew they had to do that but it was horrible pain. The GNA that had assisted with the transfer, GNA #3 agreed that the transfer was regularly done as the resident had described. GNA #3 stated that the day of the fall when she (resident #7) went to get on the bed, the bed moved. She described resident #7 ' s leg as bent beneath her. Resident #7 was described to be screaming and cussing AND apologizing the whole time. In closing she said she didn 't know what happened, the bed just moved and she fell . Nothing was different during the transfer. On 6/19/13, the surveyor and the assistant DON, DON, and staffing coordinator observed another bariatric bed in the facility. All attempted to move the bed when it was locked - it did not move. On 6/20/13, the surveyor reviewed the manual provided by the ADM regarding locking the bariatric bed used by resident #7. The manual noted that all four wheels needed to be aligned with the bed frame when locked; there was a picture noting the placement. The surveyor interviewed the bariatric bed manufacturer consultant, provided by the ADM, provider #4. He stated that if the wheels were not lined up properly the bed could move. The surveyor observed resident #7 ' s bed. The wheels were turned and not lined up with the bed frame. GNA #7 was providing ADL care to the resident. The surveyor asked her if the wheels were locked - she observed the wheels and responded " yes " . The DON and OTA #5 were also asked and responded, " Yes " after observation. The wheels were not aligned. In summary: Resident #7 was admitted for rehabilitation. She was in the facility from 3/19/13 - 4/2/13 and transferred to and from bed without incident. On 4/2/13, she was transferred using the normal routine and the bed moved. She fell to the floor which resulted in a fractured femur and pain. The facility failed to maintain an environment for safe transfers. The resident attempted an assisted transfer from the bedside commode to the bed. The bed moved, the resident fell ; and this resulted in a fractured femur and pain.