Every finding on record at Ellicott City Healthcare Center

Based on facility investigative record review, medical record review, and staff interviews, it was determined that the facility failed to ensure a cognitively impaired resident remained free from sexual abuse. This was evident for 1 (Resident #22) of 7 residents reviewed for abuse during the complaint survey. This deficient practice resulted in Immediate Jeopardy. However, the facility developed, implemented, and completed corrective actions prior to the start of this survey. The facility's plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 4/10/2026.The findings include:The Minimum Data Set (MDS) is a comprehensive assessment completed by facility staff that evaluates a resident's cognition, behaviors, functional abilities, and care needs.The Brief Interview for Mental Status (BIMS) is an assessment used to determine a resident's cognitive status. A score of 13-15 indicates cognitively intact, 8-12 indicates moderate cognitive impairment, and 0-7 indicates severe cognitive impairment.A review of Facility Reported Incident (FRI) #2974322 on 7/7/2026 at 10:06 AM revealed an allegation that Resident #23 engaged in sexual activity with Resident #22 on 4/2/2026. A review of related Complaint #2972968 on 7/7/2026 at 10:38 AM, revealed an allegation of sexual assault involving Resident #22.A review of the facility's investigative documentation on 7/7/2026 at 11:15 AM revealed that on 4/2/2026, multiple facility staff members observed Resident #23 engaged in sexual activity with Resident #22. The facility's investigation revealed that staff who observed the sexual activity exited the room, closed the privacy curtain, or closed the room door without immediately intervening or separating the residents. Continued review revealed the incident was subsequently reported to facility administration, law enforcement was notified, Resident #23 was placed on one-to-one supervision until law enforcement arrived, and Resident #23 was removed from the facility on 4/2/2026. The facility's investigation verified the allegation through witness statements obtained during the investigation.A review of Resident #22's clinical record revealed diagnoses including vascular dementia, cognitive communication deficit, major depressive disorder, post-traumatic stress disorder, and hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke). Review of Resident #22's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment.Continued review of Resident #22's clinical record revealed two Physician Certifications Related to Medical Condition, Decision Making and Treatment Limitation forms dated 1/30/2024 and 2/20/2024. The forms revealed Resident #22 lacked decision-making capacity, including the ability to make medical treatment decisions.Continued review of Resident #22's nursing documentation dated 4/2/2026 revealed that the resident's responsible party (RP) requested the resident be transferred to the emergency department (ED) for further evaluation following notification of the incident. The attending physician was notified, and Resident #22 was transferred to the ED after law enforcement responded.Further review of Resident #22's psychiatric consultation dated 4/3/2026 revealed the resident was guarded, irritable, reluctant to engage, and declined to discuss the reported incident. The consultation documented the resident responded, Maybe I do, maybe I do not, when questioned about recall of the event.Review of Resident #22's physician progress note dated 4/14/2026 revealed Resident #22 returned from the emergency department following forensic evaluation. The physician documented no acute injuries were identified and further documented Resident #22 lacked capacity due to dementia, had impaired judgment, impaired short- and long-term memory, and relied upon the RP to make healthcare and financial decisions.On 7/7/2026 at 11:45 AM, Resident #23's clinical record was reviewed to reveal Resident #23's admission MDS assessment which documented a BIMS score of 15, indicating cognitively intact Review of Physical Therapy Aide (PTA) #20's witness statement dated 4/2/2026 revealed that at approximately 12:00 PM, PTA #20 entered Resident #22's room for scheduled therapy and observed Residents #22 and #23 engaged in sexual activity while both residents were in bed. The witness statement further documented that PTA #20 exited the room without intervening.On 7/7/2026 at 12:16 PM, an interview with PTA #20 confirmed the written witness statement. PTA #20 stated he/she exited the room, asked a GNA in the opposite room whether they knew what was occurring, continued providing therapy according to her schedule, and did not report the incident to the Director of Rehabilitation until approximately two hours later.On 07/08/2026 9:35 AM in an interview with GNA #21, it was revealed that on 4/2/2026 she was picking up breakfast meal trays when she entered Resident #22's room and found the door closed and the curtain drawn which was unusual for Resident #22. GNA #21 stated that when she pulled the curtain back, she saw Resident #23 sitting on top of Resident #22's face. GNA #21 stated she could not see all of Resident #22's face and Resident #23 was smiling. The GNA further stated that she closed the curtain, left the room and closed the door. GNA #21 stated she did not intervene or separate the residents before leaving the room. GNA #21 also stated that she reported the incident to the nurse on duty, LPN #22.On 07/08/2026 at 9:58 AM, in an interview, LPN #22 stated that she did not see what happened between Residents #22 and #23 and that she only became aware of the incident when the former DON asked for her statement. LPN #22 further stated that no GNA reported the incident to her.Review of Maintenance Assistant #3's witness statement dated 4/2/2026 revealed Maintenance Assistant #3 transported Resident #22 to their room to be cleaned up. When Maintenance Assistant #3 returned to check on Resident #22, he observed Resident #23 sitting on Resident #22's face. The witness statement further revealed that Maintenance Assistant #3 informed GNA #23 of what he observed.On 07/08/2026 at 10:05 AM, an interview with Maintenance Assistant #3 confirmed the written witness statement. Maintenance Assistance #3 stated he wheeled Resident #22 to his/her room so that staff could help him/her get cleaned up. Maintenance Assistant #3 stated that when he went back about thirty minutes later to check to see if Resident #22 was still in his/her room, he saw Resident #23 sitting on Resident #22's face. Maintenance Assistant #3 stated he told GNA #23, who he thought was assigned to Resident #22, and then he went and shut the door. Maintenance Assistant #3 did not intervene or separate the residents.On 07/08/2026 at 10:50 AM, in an interview, GNA #23 stated that Resident #22 was not in her assignment, but that Maintenance Assistant #3 asked her to go look in Resident #22's room. GNA #23 stated that when she got to the room she observed Resident #23 sitting on the edge of Resident #22's bed with his/her clothes on. GNA #23 further stated that this happened right before lunch and when she found the nurse, she was already aware of the incident.On 7/9/2026 at 11:59AM, in an interview, Social Worker #25, stated an unknown GNA reported to her that they saw Resident #23 sitting on top of Resident #22. Social Worker #25 further stated that when she contacted the former DON via phone about the incident, the former DON stated that this was the second time this had happened today.On 7/7/2026 at 12:39 PM, an interview with the Director of Nursing (DON) revealed that at the time of the alleged incident, 4/2/2026, she served as the facility's Regional Nurse and was not notified of the incident until 4/5/2026 by the former DON. The DON stated that Resident #23 was removed from the facility on 4/2/2026 and Resident #22 received medical evaluation and psychological services following the incident. The DON further stated staff should have intervened immediately once the interaction was observed and should have separated the residents.On 7/09/2026 at 2:00 PM, the Executive Director and DON were notified that the facility failed to protect a cognitively impaired resident (Resident #22) from sexual abuse after multiple staff members observed Resident #23 engaging in sexual activity with Resident #22 and failed to immediately intervene to stop the abuse. Facility staff acknowledged observing the sexual activity but exited the room, closed the curtain, or shut the door without separating the residents. The facility's failure to immediately intervene allowed the sexual abuse of Resident #22 to continue after multiple staff members observed the incident and demonstrated facility staff failed to protect residents from abuse.The facility's corrective actions included: Placing Resident #23 on one-to-one supervision until law enforcement arrived on 4/2/2026. Removing Resident #23 from the facility on 4/2/2026. Transferring Resident #22 to the emergency department for evaluation and completing a forensic examination. Completing a psychological evaluation of Resident #22 following return to the facility. Conducting an Ad Hoc Qualtiy Assurance and Performance Improvement (QAPI) meeting on 4/7/2026 to address staff response to resident-to-resident sexual abuse and reporting expectations. Completing facility-wide education regarding abuse prevention, reporting requirements, and immediate staff intervention. Providing resident council education regarding reporting concerns and resident safety. Implementing admission audits and ongoing monitoring to identify and address residents at increased risk for abuse.A review of facility documentation and staff interviews revealed the facility completed corrective actions on 4/10/2026. This deficient practice was cited as past noncompliance with Federal and State requirements with a compliance date of 4/10/2026.

Based on observation, medical record review and interview, it was determined the facility staff failed to document in the residents' medical record if notification of a room change was made to residents and the residents' representative. This was evident for 4 (Resident #28, #29, #30 and #31) of 9 residents reviewed for room transfers during a complaint survey. The findings include:Review of a facility reported incident 3063858 was conducted on 7/7/26 regarding a plumbing backflow on the Magnolia Unit.Observation of Rooms 111 through 125 on 7/7/26 at 7:55 AM revealed the Rooms were behind 2 closed doors, the middle of the hallway floor tile had been removed and cement was exposed. At the time 2 contractors were in the affected area providing repairs. During interview of Contractor #5 at that time, he stated the plumbing work had been completed and they were there to work on the floor replacement and clean up.Further observation of the affected area on 7/7/26 revealed no residents were residing in Rooms 111 through 125, there were no odors, the sinks and toilets were functional and no water backup was noted from the shower drains.Review of facility documentation provided by the Director of Nursing on 7/7/26 revealed on 6/28/26 21 residents were relocated in the facility due to the backup of drainage water in the hallway and shower drains for Rooms 111-125, part of the Magnolia Unit.Nine of 21 residents' medical records were reviewed on 7/14/26 for documentation of notification to the resident and the representative after the residents were relocated on 6/28/26. Residents #28, #29, #30 and #31 did not have a Notification of Room Change evaluation completed.During interview with the Director of Nursing (DON) on 7/14/26 at 10:14 AM, the DON stated the Social Worker was supposed to ensure that the Notification of Room Change was completed for all 21 residents affected. The DON added the Social Worker is currently on leave.Interview with the DON on 7/14/26 at 10:30 AM confirmed the facility staff failed to document if Residents #28, #29, #30, #31 and the residents' representatives were notified of the room change that occurred on 6/28/26.

Based on review of medical records, facility documentation review and interviews, it was determined the facility failed to provide documentation that allegations of abuse, neglect and injury of unknown origin were thoroughly investigated. This was evident for 6 (Resident #1, #3, #4, #17, #8, #6) of 16 residents reviewed for facility reported incidents during a complaint survey. The findings include: 1) A review of facility reported incident 2745896 was conducted on 7/7/26 regarding Resident #1's allegation that LPN (licensed practical nurse) #39 purposely delayed the administration of his/her medications to cause him/her anguish. Review of the facility investigation documentation provided by the Director of Nursing on 7/7/26 revealed no statement from Resident #1, LPN #39 or any other staff. Although 10 residents were interviewed, they were only asked if they had been abused. There is no indication the 10 residents were interviewed regarding the delay in medication administration by LPN #39. Interview with the Director of Nursing on 7/9/26 at 1:05 PM confirmed the investigation for facility reported incident 2745896 was incomplete. 2) A review of facility reported incident 2783643 was conducted on 7/10/26 regarding Resident #3 allegation he/she heard GNA (geriatric nursing assistant) #27 state: I am not getting him/her up. It's my day off and I only came in today for the bonus they offered. Review of the facility's investigation documentation on 7/10/26 provided by the Director of Nursing revealed there were no staff or resident interviews to see if anyone witnessed GNA #27's alleged statement. Interview with the Director of Nursing on 7/10/26 at 8:45 AM confirmed the investigation for facility reported incident 2783643 was incomplete. 3) A review of facility reported incident 2784272 was conducted on 7/9/26 regarding Resident #4's allegation that when he/she called the nurse's station for assistance the staff were laughing about his/her request. Review of the facility's investigation documentation on 7/9/26 provided by the Director of Nursing revealed there were no staff statements or interview of Resident #4 regarding the allegation. Further review of the investigation documentation revealed there was no evidence that facility submitted the required Follow-up Investigation Report Form to the Office of Health Care Quality. Interview with the Director of Nursing on 7/9/26 at 2:00 PM confirmed the investigation for facility reported incident 2784272 was incomplete and the facility had no evidence they had submitted the required Follow-up Investigation Report Form to the Office of Health Care Quality. 4) On 7/9/26 at 8:55 AM a review of facility reported incident 3025308 and Resident #17's medical record was conducted. Review of the investigation revealed Resident #17 told the speech therapist on 5/27/26 at approximately 10:50 AM that he/she had his/her gown ripped off and was raped and beaten. The investigation revealed a written statement from Geriatric Nursing Assistant (GNA) #40 that documented on 5/27/26 at around 9:30 AM Resident #17 told her that another resident tried to rape him/her last night. Further review of the facility's investigation revealed that seven staff members who worked on the first floor during the 3:00 PM to 11:00 PM shift and the 11:00 PM to 7:00 AM shift were not interviewed or did not have documented written statements. Review of the assignment sheets provided to the surveyor by the Director of Nursing (DON) showed a staff member's name on the sheet, but that staff member was not on the schedule. GNA #41 was assigned to the resident on 5/26/26 for 3:00 PM to 11:00 PM however there was no written statemen from GNA #41. On 7/9/26 at 1:07 PM the DON was interviewed and stated that the previous DON and Nursing Home Administrator (NHA) were not following the process of sending the 5-day report and investigation to the regional team, preventing the regional team from following up to ensure the investigation was complete. The DON confirmed the surveyor's findings. 5) On 7/10/26 at 7:30 AM a review of facility reported incident 3001828 and Resident #8's medical record was conducted. Review of the investigation revealed Resident #8 alleged that GNA #42 said to the residents at the elevator, I am tired of these [expletives]. A review of the facility's investigation failed to produce staff interviews regarding the incident and GNA #42. There was no documentation of how GNA #42 worked with the residents. There was only 1 resident statement. On 7/14/26 at 1:01 PM the DON was interviewed about the completeness of the investigation. The DON confirmed that there were no other staff interviews about GNA #42's credibility about how she treated other residents and if she ever had any outbursts of profanity towards the residents. The DON confirmed that the investigation only included 1 resident statement and not the other 2 residents who were supposedly at the elevator when the incident occurred. The DON stated it would have been necessary to get the witness and the other resident statements. 6) On 7/14/26 at 9:24 AM a review of facility reported incident 2968971 and Resident #6's medical record was conducted. Resident #6 had alleged abuse. The NHA was unable to provide the surveyor with an investigation. The only documentation was on the 5-day report that OHCQ received, however it was not a detailed investigation. The facility was unable to provide the surveyor with resident assessments, interviews, or any staff member interviews regarding the incident. On 7/14/26 at 1:35 PM the NHA confirmed to the surveyor that he never found the initial report, the 5-day report, or the investigation. The NHA stated, I gave you everything I have.

Based on medical record review, observation and interviews, the facility staff failed to ensure a resident's call bell was in reach. This was evident for 1 (Resident #12) of 5 residents observed for call bells during a complaint survey. The findings:Review of Resident #12's medical record on 7/7/26 revealed the Resident was admitted to the facility in 2017 and has a diagnosis to include legal blindness.During interview of Resident #12 on 7/7/26 at 9:46 AM, the Resident stated he/she needed assistance repositioning in bed, the Resident was asked at that time if he/she knew where his/her call bell was to alert staff. The Resident stated he/she was legally blind and did not know where his/her call bell was.Observation of the Resident's call bell on 7/7/26 at 9:46 AM revealed it was sitting on top of the Resident's oxygen concentrator approximately 2 feet from the Resident's bed and not in the Resident's reach.The Surveyor asked Unit Manager #9 to come to the Resident's room. Unit Manager #9 arrived at the Resident's room on 7/7/26 at 9:49 AM. At that time Unit Manager #9 confirmed the Resident's call bell wasn't in reach of the Resident.Unit Manager #9 advised the Surveyor on 7/7/26 at 10:10 AM he had put a clip on the Resident's call bell to ensure it was in reach for the Resident.The Surveyor advised the Director of Nursing of the Surveyor's findings on 7/9/26 at 10:57 AM.

Based on review of facility reported incident, documentation review, and interviews, it was determined the facility failed to report an alleged abuse immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #17) of 16 residents reviewed for facility reported incidents during a complaint survey.The findings include: On 7/9/26 at 8:55 AM a review of facility reported incident 3025308 and Resident #17's medical record was conducted. Review of the investigation revealed Resident #17 told the speech therapist on 5/27/26 at approximately 10:50 AM that he/she had his/her gown ripped off and was raped and beaten. The investigation revealed a written statement from Geriatric Nursing Assistant (GNA) #40 that documented on 5/27/26 at around 9:30 AM Resident #17 told her that another resident tried to rape him/her last night. There was no evidence that GNA #40 immediately told administration about the allegation.Continued review of the facility's investigation revealed the initial report was not filed until 5/27/26 at 12:43 PM, which was past the 2 hours for initial reporting. Additionally, the facility could not produce documentation that the final 5-day report was sent to OHCQ. On 7/9/26 at 9:45 AM an interview was conducted with Licensed Practical Nurse (LPN) #22 who stated that she did not know about the incident until the Director of Nursing (DON) called her up to ask her about it. LPN #22 stated that she worked the whole shift and was shocked that the GNA did not say anything to her. On 7/9/26 at 1:07 PM the DON stated that the previous DON and Nursing Home Administrator (NHA) were not following the process of sending the 5-day report and investigation to the regional team, therefore no follow-up could happen to ensure that the reports were sent timely to OHCQ.

Based on review of complaints, medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (Residents #16, #24, #17) of 28 residents reviewed during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 7/7/26 at 9:20 AM a review of facility reported incident 3044112 and Resident #16's medical record was conducted.Review of a 5/29/26 at 7:35 AM nurse's note documented, pt. refused a.m. lab.Review of a 5/30/26 at 13:49 (1:49 PM) behavior note documented, resident made several attempts to elope.Review of Resident #16's MDS assessment with an assessment reference date (ARD) of 5/31/26, Section E Behavior, coded none. This was incorrect as the resident rejected a blood draw for labs and made several attempts to elope.On 7/14/26 at 10:25 AM an interview was conducted with the MDS Coordinator. The MDS coordinator stated that she could not log into the computer system so she would have the regional MDS coordinator check for her.On 7/14/26 at 11:36 AM the MDS Coordinator confirmed the errors.2) On7/8/26 at 11:54 AM a review of complaint 2749436 and Resident #24's medical record was conducted.Review of Resident #24's admission assessment dated [DATE] documented that Resident #24 had an ileostomy. An ileostomy is a surgical procedure that diverts stool out of the body by connecting the lower part of the small intestine to an opening in the abdominal wall called a stoma. Stool is then collected in an external pouch.Review of Resident #24's quarterly MDS assessment with an assessment reference date (ARD) of 6/12/26, Section H0400 bowel continence, was coded (2) frequently incontinent. That was incorrect as it should have been coded as not rated due to having an ileostomy.Continued review of the quarterly MDS, section J, documented that the resident did not receive any pain medications during the look back period. In Section N, High-Risk Drug Classes, medications, it was coded that the resident did receive a hypnotic but not a diuretic medication.Review of Resident #24's June 2026 Medication Administration Record (MAR) revealed the resident received Gabapentin 100 mg (2) 3 times per day for neuropathic pain. Additionally, the MAR failed to produce documentation that Resident #24 received a hypnotic medication. The June 2026 MAR however did document that the resident received a diuretic medication which was Lasix. Section N in the MDS assessment failed to capture the diuretic medication. The MDS assessment also coded that the resident received a hypnotic medication when the resident did not.On 7/14/26 at 11:36 AM the MDS Coordinator confirmed the errors.3) On 7/9/26 at 8:55 AM a review of facility reported incident 3025308 and Resident #17's medical record was conducted.Review of Resident #17's May 2026 MAR documented the use of the hypnotic medication Ramelteon every night.Review of Resident #17's MDS assessment with an ARD of 5/14/26, Section N Medications, N0415, High-Risk Drug Classes, failed to capture the use of the hypnotic.On 7/14/26 at 11:36 AM an interview was conducted with the MDS Coordinator who confirmed the errors.

Based on record review, observation, and interview, it was determined that facility staff failed to administer medications in accordance with nursing practice standards. This was evident for 1 (Resident #6) of 16 residents reviewed for facility reported incidents during a complaint survey. The findings include:On 7/14/26 at 9:24 AM a review of facility reported incident 2968971 and Resident #6's medical record was conducted.Review of a 4/30/26 nurse practitioner (NP) progress note documented that Resident #6 had cognitive decline that was worsening and likely had frontal temporal dementia. Frontotemporal dementia is a group of progressive brain disorders that damage the frontal and temporal lobes of the brain. Review of Resident #6's most recent BIMS (Brief Interview of Mental Status) dated 6/15/26 was 6. A score of 6 falls into the lowest tier, which indicates severe cognitive impairment or problems with thinking and memory.On 7/14/26 at 11:55 AM the surveyor went to visit Resident #6 and observed Resident #6 lying in bed. Resident #6 appeared confused and was holding a 30 ml. plastic medication cup that contained 3 white pills. Three other pills were observed lying on the resident's chest. Two of the 3 pills were broken in half.On 7/14/24 at 12:23 PM a review of Resident #6's July 2026 Medication Administration Record (MAR) documented the medication that Resident #6 had in the medicine cup and on top of his/her chest. They were the 9 AM medications: Lasix (diuretic), (2) potassium tablets, carvedilol (blood pressure and heart failure) to be received twice per day, duloxetine (antidepressant), and buspirone (anti-anxiety) to be received twice per day. The Director of Nursing (DON) was called to the resident's room after the observation and confirmed the findings. The DON confirmed the standard of nursing practice was the nurse was to stay with the resident, especially with the resident's cognitive status, and observe that the resident had taken all of the medication when administered. The DON stated the nurse was not to leave any medication at the bedside.

Based on review of a complaint, medical record review, and interview, it was determined that the facility failed to ensure that residents requiring dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #21) of 28 residents reviewed for complaints during a complaint survey.The findings include: On 7/10/26 at 8:11 AM a review of complaint 2976233 was conducted and alleged that Resident #21 had not received needed dental care. On 7/10/26 at 8:11 AM Resident #21's medical record was reviewed and revealed a 4/24/26 at 16:35 (4:35 PM) change in condition note that documented that the resident complained of pain in the left side of the mouth. The physician was called and ordered an antibiotic and a dental consult. A review of a 5/1/26 physician's progress note documented the reason for the visit was a follow-up for dental pain status. The physician documented that the resident completed the antibiotic that was prescribed for left tooth pain. The physician documented, Dental consult was ordered. Awaiting dental evaluation for definitive care. A review of a 6/15/26 nurse practitioner (NP) note documented the reason for the consult as, Management of antibiotics for tooth infection. The note stated, Reports tooth ache is improving. However, expressed frustration of not able to see the dentist. The NP documented, Possible dental infection. Will need to follow up with dentist for source control. On 7/10/26 at 9:01 AM the complainant was interviewed and stated, Has never seen a dentist. They overlook doctor's appointments. On 7/10/26 at 9:20 AM Resident #21 was interviewed and stated, I have not seen the dentist. On 7/10/26 at 10:09 AM Licensed Practical Nurse (LPN) #9, the unit manager was interviewed and stated that the resident was supposed to be seen through a certain vendor, but the resident's insurance got dropped and the resident did not have insurance. LPN #9 stated, we have been trying to set it up through the [name of vendor] for dental. We used to have somebody that makes the appointments, but they let that person go and the unit manager has to make the appointments now. LPN #9 stated that the business office was responsible for obtaining the insurance through the state. On 7/10/26 at 11:08 AM the business office manager (BOM) #30 was interviewed and stated they had issues with his/her insurance. She stated that Medicaid was approved at the end of October 2025, and the resident could see any specialty services. BOM #30 stated that staff were aware and there was no reason that he/she should not have been seen by the dentist. I was not aware that the appointments were not scheduled. On 7/10/26 at 1:35 PM the issue was discussed with the Director of Nursing (DON) and she confirmed the findings and stated that they would get the dental appointment made.

Based on complaint, medical record review, and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 3 (Residents #21, #6, #35) of 34 residents reviewed for complaints during a complaint survey.The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 7/10/26 at 8:11 AM a review of complaint 2976233 alleged that Resident #21 had not been seen by the podiatrist or the ophthalmologist in over one year. Review of Resident #21's medical record failed to produce any evidence that the resident was seen by podiatry or ophthalmology. On 7/10/26 at 12:25 PM the Director of Nursing (DON) was interviewed and stated that they were in the process of having a new person upload all documents into the electronic medical record. On 7/10/26 at 12:35 PM Licensed Practical Nurse (LPN) #9 stated that Resident #21's chart was thinned. LPN #9 stated that the records should have been scanned into the system, but at the time of the visits they did not have someone in medical records, but now they did. On 7/10/26 at 1:35 PM the DON was able to find some of the documents to validate Resident #21 was seen by podiatry and ophthalmology. She did confirm that the documents should have been scanned into the medical record. 2) On 7/14/26 at 9:24 AM a review of facility reported incident 2968971 and Resident #6's medical record was conducted. Resident #6 had alleged abuse. Review of Resident #6's medical record revealed a 3/30/26 at 12:21 PM care plan note that documented the resident reported being thrown against the wall and held down while the Geriatric Nursing Assistant (GNA) forcefully changed his/her brief. Review of a 4/30/26 nurse practitioner (NP) progress note documented that Resident #6 had cognitive decline that was worsening and likely had frontal temporal dementia. On 7/14/26 at 11:55 AM the surveyor went to visit Resident #6 and observed Resident #6 lying in bed. Resident #6 appeared confused and was holding a 30 ml. plastic medication cup that had 3 white pills in it. There were 3 other pills lying on top of the resident's chest. Two of the 3 pills were broken in half. On 7/14/24 at 12:23 PM a review of Resident #6's July 2026 Medication Administration Record (MAR) documented the medication that Resident #6 had in the medicine cup and on top of his/her chest. They were the 9 AM medications: Lasix (diuretic), (2) potassium tablets, carvedilol (blood pressure and heart failure) to be received twice per day, duloxetine (antidepressant), and buspirone (anti-anxiety) to be received twice per day. The medications were not signed off as administered at 12:23 PM. Review of the Administering Medications Policy that was given to the surveyor on 7/14/26 at 12:39 PM revealed #20; the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. The DON was called to the resident's room after the observation and confirmed the findings. The DON was informed that the resident's MAR was not signed. 3) On 7/20/26 at 11:30 AM, a review of complaint #3094426 and Resident #35's medical record was conducted. Resident #35 experienced a respiratory distress event and was transferred to the hospital per responsible party's (RP) request. Review of Resident #35's medical record revealed a Late Entry Change in Condition note with an effective date of 7/14/26 at 11:00 AM, created on 7/15/26 at 12:09:06 PM by Licensed Practical Nurse (LPN) #46, the assigned nurse for Resident #35. The note documented the resident experienced respiratory distress and was transferred to the emergency department. During the complaint investigation, an interview with the complainant on 7/20/26 identified LPN #44 as the nurse who initially responded to Resident #35's respiratory distress and notified the hospice team. On 07/20/26 at 1:41 PM, an interview with LPN #44 revealed Unit Manager (UM) #9 and Registered Nurse (RN) Night Supervisor #45 also responded to Resident #35's respiratory distress event. Interviews with UM #9 and RN Night Supervisor #45 on 7/22/26 confirmed the interventions they performed during Resident #35's respiratory event included elevating the head of the bed, discontinuing the tube feeding, performing oral suction, administering oxygen via non-rebreather mask, notifying the hospice team, and coordinating the resident's emergency response. Review of Resident #35's medical record failed to include complete documentation of the nursing assessments and interventions performed by staff who initially responded to Resident #35's respiratory distress documented in the medical record. On 7/23/26 at 9:43 AM, during an interview, the Director of Nursing (DON) was made aware of concerns regarding the lack of documentation. The DON confirmed there was no additional nursing documentation in PointClickCare (PCC), the facility's electronic medical record, related to the responding staff's interventions during Resident #35's respiratory distress event. The DON further stated each staff member who intervened should have documented how the resident was found and the care they provided. The DON stated she would follow up with the responding staff. Review of the facility's Change in a Resident's Condition or Status policy on 7/24/26 revealed, under Policy Interpretation and Implementation, Item #8, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. On 7/24/26, during a follow-up interview, the DON stated all staff who intervened during Resident #35's respiratory distress event should have documented the care they provided in the medical record, and the documentation should not have been left to the assigned nurse alone . The DON stated UM #9 believed LPN #46, the assigned nurse, would document the event. The DON subsequently provided written statements from UM #9 and RN Night Supervisor #45 describing their involvement in Resident #35's care on 7/14/26. The statements described interventions, including discontinuation of the tube feeding, oral suctioning, oxygen administration via non-rebreather mask, and coordination of the resident's emergency response, which were not documented in the medical record.

Based on observation, pertinent document review, and interview it was determined that the facility failed to maintain a safe, comfortable and homelike environment. This was evident for 7 (Resident #1, #8, #40, #66, #90, #127, #140) of 15 residents reviewed during the environmental task, in addition to multiple random observations of elevated hot water in resident rooms on both floors of the facility which put all residents at risk of being affected by this deficient practice.The findings include: 1) On 2/10/26 at 9:35 AM, the surveyor interviewed Resident #127 and observed that the resident's bathroom had a loose plastic threshold on the floor of the shower and a shower chair with a jagged piece of plastic protruding in the area that a person would sit. The surveyor also noted the sink is extremely discolored with a brown circular stain and is cracked. The drywall had multiple gouges. During this observation, GNA #27 confirmed the surveyor's observations. On 2/10/26 at 10:00 AM, the surveyor interviewed roommates (Residents #66 and #90), who pointed out a large, thick area of thick spackle on the wall that was rough in texture (had not been sanded) and without paint. They also identified several additional areas around the bedroom and bathroom with unsanded or unpainted spackling, gouges in the drywall, sink and toilet stains, and gouges in the toilet bowl. The surveyor noted a gap in the wall near the pipes under the sink. On 2/10/26 at 1:02 PM, during an interview with Resident #1, the surveyor observed their bathroom, noting extensive drywall damage with gouges, rough spackling, and holes around the piping under the sink. On 2/10/26 at 10:33 AM, Resident #8 pointed out that their bedroom had wear and tear, with paint and drywall pulling away, and a handle on their dresser drawer was coming off (it was hanging by one screw). Multiple areas of chipped paint were observed, and the bathroom sink had cracks and discoloration. On 2/10/26 around 11:00 AM, the surveyor noted during the initial screening that the sink in Resident #40's room was slow to drain, cracked, and stained. On 2/13/26 at 4:08 PM, the surveyor interviewed the Maintenance Director (MD #8) regarding the process for keeping the building in good repair and whether environmental rounds are conducted. He stated that they are trying to play catch-up for needed repairs and are aware of many walls that need paint and drywall repair, but there is no planned date to complete these repairs. Regarding gaps around several bathroom pipes, he reported a plan to install plastic pieces that snap around the pipes, but no timeline was provided. He also noted that several sinks were cracked and stained and stated they would only be replaced if they started to leak. On 2/13/26 at 4:25 PM, the surveyor interviewed the Nursing Home Administrator (NHA), who expressed awareness of areas needing paint and acknowledged concerns about gaps around piping. He stated that corporate painters come periodically but was unsure when they would return. On 2/17/26 at 12:00 PM, the surveyor toured rooms with the NHA, who confirmed concerns in each area: -Resident #8: Wall damage and loose drawer handle -Residents #66 and #90: Damage to multiple walls, rough spackle without sanding, missing paint, sink and toilet cracks/discoloration, pipes exposed under sink -Resident #127: Cracked/stained sink, cracked shower chair (immediately removed by NHA), loose threshold, exposed pipes -Resident #40: Cracked/stained sink When asked if he wanted to look at Resident #1's room, the NHA stated, No, I believe this is a concern. 2) On 2/10/26 at 9:25 AM, during the initial screening process, Resident #140 stated that the facility is often out of soap, towels, and washcloths, impacting their ability to get a bath or shower. On 2/17/26 at 12:38 PM, the surveyor asked the NHA if he was aware of the facility being short of linens such as washcloths or towels. He stated that he was not aware and reported that he had recently purchased washcloths. On 2/17/26 at 12:40 PM, the surveyor interviewed GNA #27, who reported frequent shortages of washcloths and towels and reported delays in providing ADL (Activities of Daily Living) care, stating, I try to plan ahead and improvise since this has been an issue. On 2/17/26 at 12:44 PM, the surveyor interviewed GNA #37, who reported very often a shortage of towels and washcloths, impacting her ability to give bed baths and showers. On 2/17/26 at 12:46 PM, the surveyor informed the NHA that residents had complained about linen shortages and that GNA staff confirmed these shortages were impacting timely care. The NHA acknowledged that the issue might be related to laundry rather than supply but stated that a systemic change was needed. On 2/19/26 at 11:39 AM, the surveyor reviewed environmental concerns with the NHA and at 12:15 PM reviewed the concerns with the Director of Nursing (DON). Both confirmed that the findings were issues and reported they were working on changes. On 2/19/26 at 1:48 PM, the NHA stated he was unable to find a policy about maintaining a home-like environment or conducting environmental rounds but would continue looking. At survey exit, no policy was provided to the surveyor. 3)On 2/10/2026 at 10:55 AM, the water temperature was taken in the bathroom of resident room [ROOM NUMBER]. The temperature was 125 degrees Fahrenheit. On 2/10/26 at 10:56 AM, the water temperature was taken in the bathroom of resident room [ROOM NUMBER]. The temperature was 126.3 degrees Fahrenheit. On 2/10/26 at 10:59 AM, the water temperature was taken in the bathroom of resident room [ROOM NUMBER]. The temperature was 123.7 degrees Fahrenheit. On 2/10/26 at 11:06 AM, maintenance staff (Staff #44) was interviewed. Staff #44 reported checking water temperatures in one room on every unit early each morning. Staff #44 stated that water temperatures should be maintained between 110 and 120 degrees Fahrenheit. Staff #44 reported taking water temperatures on the morning of 2/10/26 and provided a copy of the readings to the survey team. Staff #44 confirmed the temperature readings were in Fahrenheit. Staff #44 stated that the temperatures taken that morning had not been reported to the supervisor or the facility administrator. Staff #44 could not recall the specific rooms tested. On 2/10/26 at 11:08 AM, review of the water temperature document taken the morning of 2/10/26 revealed the following readings, which Staff #44 confirmed were degrees Fahrenheit: Apple Blossom Unit: 124.5Cherry Unit: 120.9Cedar Unit: 126.7Dogwood Unit: 125.1 On 2/10/26 at 1:13 PM, during a brief interview, the Administrator and the Maintenance Director reported they were unaware of the temperatures taken by Staff #44. On 2/10/26 at 1:14 PM, the surveyor, Administrator, and Maintenance Director observed the water temperature in room [ROOM NUMBER]. The temperature was 122 degrees Fahrenheit. The Maintenance Director confirmed that water temperature checks were conducted first thing each morning. On 02/10/26 at 1:33 PM, the Administrator reported that the water temperature at the boiler had been lowered and that a plumbing company had been contacted to resolve the issue. On 2/11/26 at 12:00 PM, a request was made to the Maintenance Director for a copy of the morning water temperatures. The Maintenance Director reported that morning temperatures had not been taken. On 2/11/26 at 1:00 PM, the surveyor obtained random bathroom sink water temperatures in resident rooms using a calibrated digital thermometer. The following temperatures were recorded: room [ROOM NUMBER]: 128.9 degrees F room [ROOM NUMBER]A: 124.3 degrees F room [ROOM NUMBER]A: 127.4 degrees F At 1:09 PM, Resident #140 stated, Be careful if you are checking the water temperatures, implying the water became excessively hot. On 2/11/26 at 1:40 PM, the Maintenance Director provided water temperature log dated 2/11/26 at 1:40 PM. Review of the log revealed the following: room [ROOM NUMBER]: 125 degrees [NAME] 142: 137 degrees [NAME] 222: 127 degrees F On 2/11/26 at 2:20 PM, the surveyor returned to the unit to recheck water temperatures after the facility announced the hot water system was being shut down for repair. The following temperatures were recorded: room [ROOM NUMBER]: 121.8 degrees [NAME] 200: 120.9 degrees F On 2/11/26 at 4:57 PM, the Administrator confirmed that the hot water had been shut off; however, some residual hot water remained in the pipes. The Administrator reported that staff were aware of the issue. He reported that the hot water would be shut of until the repairs have been completed. On 2/17/2026 from 10:37 AM to 11:38 PM, the Administrator reported that all plumbing repairs had been completed. Surveyors and the Administrator took water temperatures in rooms on every unit in the facility. All temperatures were within normal limits of 110-120 degrees Fahrenheit.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure medication carts were kept secured and failed to ensure controlled medications were stored in an affixed lock box. This was found to be evident during one random observation; and for five of five medication storage refrigerators reviewed during the medication storage task.The findings include: 1) On 2/13/26 from 1:21 to 1:30 PM this surveyor observed various staff and residents pass by an unattended and unlocked medication administration cart on the Dogwood Unit. At 1:30 PM Licensed Practical Nurse (LPN #6) confirmed the unlocked medication cart. He stated, this is not my unit. He, then, informed Dogwood's Unit Manager, LPN #10; she confirmed it was unlocked and then locked the cart. The Director of Nursing was made aware of the concern. 2) 483.45(h)(2) requires that the facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976. On 2/13/26 at 7:54 AM, the surveyor, accompanied by Licensed Practical Nurse (Nurse #42), observed the medication refrigerator in the medication storage room on the Magnolia Unit. The surveyor requested that Nurse #42 demonstrate how controlled medications were secured. She pulled out Lorazepam, which was not secured, and attempted to place it in a lock box. The box was not permanently affixed to the refrigerator, and the medication did not fit within the box. Nurse #42 confirmed that medications are expected to be secured in a lock box but stated she did not realize the box needed to be permanently affixed. A second locking-type box was also observed in the refrigerator. Nurse #42 removed it and showed the surveyor that the lid was broken, making it impossible to use for securing medications; this box was also not permanently affixed. On 2/13/26 at 8:08 AM, the surveyor observed the medication storage room on the Apple Unit. Registered Nurse (Nurse #43) opened the refrigerator and removed a bubble-wrapped narcotics lock box. She stated it was a new box that had never been unwrapped from its packaging and was not affixed to the refrigerator. She further stated, Only nurses are allowed in the medication refrigerator, so it doesn't matter if the narcotics box isn't locked. On 2/13/26 at 10:43 AM, the surveyor interviewed the Director of Nursing (DON) regarding the expectation for locking controlled medications. The DON stated that controlled medications should be secured with a double lock. When asked if it was acceptable to have a loose box for storing narcotics, she stated she would need to check the policy but acknowledged that it should likely be secured. The surveyor and DON toured all five medication storage rooms (Dogwood, Cedar, Cherry, Magnolia, and Apple Units) and the DON confirmed that none of the facility's medication storage refrigerators contained permanently affixed and locked storage containers for controlled medications. The DON further confirmed that controlled medications, including Lorazepam and Methadone, were placed loosely in the refrigerators or in boxes that could be removed. She also confirmed that one box was broken and that the bubble-wrapped box had never been permanently affixed. The DON acknowledged that this represented a regulatory concern.

Based on staff interviews, review of pertinent documentation, and survey findings, it was determined the facility failed to ensure that an effective Quality Assurance Performance and Improvement (QAPI) program was in place to identify Quality concerns and develop effective plans of correction.This has the potential to affect all residents.The findings include:Review of the statement of deficiencies for the past two recertification surveys and the findings for the current survey revealed that deficient practice was identified during each of these surveys in the following areas:F 550 Resident RightsF 582 Beneficiary Protection NoticeF 600 AbuseF 656 Comprehensive Care PlansF 657 Care Plan Revision and TimingF 679 ActivitiesF 684 Quality of CareF 761 Medication StorageF 880 Infection ControlReview of the Plan of Correction for the survey ending 9/10/24 revealed the plan related to F 582 for failure to provide the appropriate beneficiary protection notices stated the social service department was educated on the importance and need to issue the Beneficiary Protection Notices. There was no indication in the plan that any systemic change to the facility's process regarding the issuing of these notice was going to occur. The plan indicated Quality Assurance auditing was going to be conducted by the Social Service Director, thus auditing his/her own work.Review of the Plan of Correction for the survey ending 9/10/24 revealed the plan related to F 656 for the failure to develop comprehensive care plans indicated the Social Service Director would re-educate the Interdisciplinary team members on the need and importance of developing comprehensive care plans for residents. There was no indication in the plan of correction that there was going to be any systemic change to the facility's process in developing care plans.On 2/19/26 at 3:08 PM the Nursing Home Administrator (NHA) reported the Assistant Director of Nursing, who left the facility in December, was certified in Quality Assurance. He went on to report that at the last QA meeting, held in January, that he requested training for all the departments in quality assurance. Surveyor reviewed the concern that deficient practice has been identified for the third time in a row for multiple regulations and that the plans of correction have failed to actually address the identified issues and QAPI program has failed to adequately monitor.

Based on observations, interviews, and medical record review, it was determined that facility staff failed to follow infection control protocols of the laundry process, maintain laundry dryers in a sanitary and hazard-free condition, and retain a copy of the original manufacturer's instructions for the washer and dryer; failed to ensure staff donned personal protective equipment and prevented other residents from entering the rooms of residents on contact precautions; and failed to perform hand hygiene during medication administration. These findings were evident in two of two dryers observed during the infection control task, for one (Resident #150) of eight residents reviewed for infection control, and for one (Nurse #41) of two staff observed during the medication administration task.The findings include: 1)During an observation of the laundry service on 02/17/26, at 1:06 PM, it was noted that no washer/dryer service logs or original commercial manufacturer handbooks were available in the laundry room. There were 2 dirty laundry karts covered waiting to be washed. An interview was conducted on 02/17/26 at 1:10 PM with the Environmental Manager (Staff #7). During our discussion, the manager described the protocol for transferring covered dirty linens from the floors to the laundry area. This process includes sorting and washing items based on their classification, specifically distinguishing between contaminated and dirty linens. Additionally, it was noted that once the wash cycle is complete, yellow carts are used to transfer the wet, clean items to the dryer room. In the dryer room surveyor noticed dryers inside drums with melted diapers and multiple objects, presenting a safety hazard and unsanitary condition. the Environmental Manager Staff #7 acknowledged this as an omission of service, noting that the drums have not been cleaned. Requested last three of the washer/ dryers' service records and the original manufactory handbooks as for the facility to follow. During a record review conducted on 02/17/26 at 2:10 PM, service records indicated that dryer ductwork cleaning and inspections were performed on 08/04/25, 11/13/25, and 02/05/26. However, the records show no service was conducted on the dryer drums. Additionally, the original manufacturer handbooks were unavailable for review. Interview with Maintenance Manager (Staff #8) on 02/17/26 at 3:30 PM, it was confirmed that debris with melted diapers and multiple objects were present in the dryers' drums. The Maintenance Manager agreed that the laundry service has failed to maintain the equipment in a sanitary and hazard-free condition and lacked keeping the original manufacturer handbooks to follow the regular maintenance and care. All above deficient practice is a significant concern that needs to be addressed. On 02/17/26 at 3:50 PM, the Administrator was made aware above finding as a deficiency practice. 2) Personal Protective Equipment (PPE) refers to protective items such as masks, gowns, gloves, eye protectors, shoe covers, hair caps worn to protect the body or clothing from hazards and to protect residents and staff from cross-transmission. Contact precautions are infection control measures used to prevent the spread of bacteria and viruses transmitted through direct or indirect contact with a diseased person or contaminated surface. On 2/12/26 at 10:46 AM Resident #150 was in bed watching TV. Licensed Practical Nurse (LPN #17) was in the hall preparing to administer this resident's medications. Surveyor observed LPN #17 enter the resident's room without gloves, without a gown and without washing hands before and after administering the medications. Surveyor observed a contact precaution sign posted on the resident's door and PPE supplies and dedicated patient-care equipment outside of the room. On 2/12/26 at 10:57 AM in an interview, LPN #17 acknowledged that the resident recently returned from the hospital with a diagnosis Clostridioides difficile (C-diff) that required Resident #150 to be on contact precautions. She conveyed that contact precautions required gloves, gown and handwashing with soap and water. LPN #17 confirmed that she failed to don PPE and wash her hands. On 2/12/26 at 11:02 AM Resident #150 reported a diagnosis of C-diff that required isolation. During resident interview, the Activities Director (Staff #13) entered the room without PPE. The Infection Preventionist (Nurse #4) was made aware of the above. On 2/12/26 at 3:29 PM surveyor observed Resident #150 and Resident #107 in Resident #150's room. Resident #107 was in an unusual kneeling position while in a wheelchair. This positioning placed Resident #107's head and upper body in very close proximity to Resident 150's person and bed. Resident #107 did not wear any PPE. On 2/12/26, two facility staff, LPN #17 and the Infection Preventionist Nurse #4, confirmed Resident #107 was in the isolation room without PPE. On 2/13/26 at 9:15 AM the Activities Director (Staff #13) confirmed that she had entered the room previously without donning PPE and acknowledged the resident's infectious disease requires PPE when entering the room. The Director of Nursing was made aware of the concern. 3) The Centers for Disease Control and Prevention (CDC) recommend that hand hygiene be performed immediately before resident contact, before preparing or administering medications, after removing gloves, and between each resident contact during medication administration. On 2/13/26 at 8:16 AM, the surveyor conducted a medication administration observation of Licensed Practical Nurse (Nurse #41). During medication preparation, a pill fell from the packet onto the cart. Nurse #41 applied gloves, retrieved the pill, disposed of it, and removed the gloves without performing hand hygiene. She handled multiple other pill packets while preparing medications, touching each without performing hand hygiene. She then prepared medications for Resident #122, handed the resident a medication cup, discarded the empty cup in the trash, and proceeded to the next resident without performing hand hygiene. Hand sanitizer was observed on top of the medication cart and readily accessible. At 8:45 AM, while administering medications to Resident #129, Nurse #41 prepared 14 medications and was observed touching multiple surfaces, including pill packets, the computer keyboard, the medication cart, keys, and medication cups, without performing hand hygiene. She administered the medications, discarded the empty cup in the trash, and again did not perform hand hygiene. At 9:09 AM, the surveyor asked Nurse #41 when hand hygiene should be performed. She stated the surveyor threw her off by observing the medication pass and said, I normally do it, but did not identify appropriate hand hygiene intervals. On 2/13/26 at 1:55 PM, the surveyor reviewed these concerns with the Director of Nursing, who confirmed that staff are expected to perform hand hygiene at multiple points throughout medication administration.

Based on medical record review and staff interview it was determined the facility failed to provide the resident, and the resident's representative, in writing of the required transfer documents when the resident was transferred/discharged from the facility to an acute care facility. This was evident for two (Resident #14 and #150) of four residents reviewed for hospitalization during the survey.The findings include:1) Review of Resident #14's medical record revealed that as of 9/25/25 the resident was determined to be incapable of making informed decisions regarding the provision, withholding or withdrawing of all treatments due to vascular dementia. Further review revealed there were family members involved in the residents care planning. Review of the medical record revealed that the resident was transferred to the hospital due to a mental status change on 1/21/26. Further review of the medical record failed to reveal documentation to indicate a written notice of transfer or a bed hold policy was provided to either the resident or a responsible representative. On 2/17/26 at 4:39 PM Unit Nurse Manager #16 was interviewed in regard to documentation provided at time of transfer. Surveyor discussed the concern that record review failed to reveal documentation that a bed hold or a transfer notice was provided. The Unit Manager #16 indicated they do provide resident's bed hold policy at transfer, but did not indicate that she was aware there was a need to provide a written notice of transfer. On 2/18/26 surveyor requested documentation of the Bed Hold Policy and the Transfer notice for the 1/21/26 hospitalization from the Director of Nursing. Review of the Bed Hold Authorization Form, provided in response to surveyor request, revealed the following statement: This serves as your notice of bed hold days the resident currently has remaining that will be paid by Medicaid: 30 days. Maryland Medicaid stopped paying for bed holds in July of 2012. Further review of the Bed Hold Authorization Form revealed it was dated 1/27/26 and included Resident #14's name (last name written first) in the signature section. No documentation was found to indicate a responsible representative was informed or provided the hold policy for the 1/21/26 hospitalization. No documentation was provided to indicate a Notice of Transfer was provided to either the resident or a responsible representative. The written notice of transfer is required to include: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. On 2/19/26 at 3:30 PM after surveyor reviewed the concern regarding the failure to provide a Notice of Transfer, the Director of Nursing reported that Social Work was suppose to be doing that. 2)On 2/11/26 at 12:35 PM a record review of Resident #150's electronic health record revealed the resident was hospitalized on [DATE]. Further review revealed two unsuccessful attempts to contact the resident's family via phone regarding the hospital transfer. On 2/13/26 at 8:54 AM a review of the resident's electronic health record and paper chart lacked documentation of the hospital transfer documents and bed hold notice. On 2/13/26 at 9:37 AM Licensed Practical Nurse (LPN #26) stated when a resident gets transferred to the hospital, the nursing staff should print the paperwork which included: MOLST, Face sheet, medications, Care Plan, recent labs, a bed hold policy and orders to transfer. The nurse should document by completing an electronic Interact form in the electronic health record at time of transfer. LPN #26 and surveyor reviewed and confirmed the electronic Interact form was red and yellow that indicated it was incomplete. On 2/13/26 at 9:50 AM Social Work Designee (Staff #22) acknowledged social work was responsible for sending a written notice via certified mail to the family representative post hospital transfer. Staff #22 stated that she could not find Resident #150's paperwork and was unable to provide a certified mail receipt. On 2/13/26 at 3:05 PM in an interview, the Director of Nursing confirmed incomplete documentation, and that written notice of the bed hold was not provided to the resident/ resident representative.

Based on interviews, observation, and record review, it was determined that the facility failed to ensure: consults were scheduled as ordered; and that medications and treatments were administered and documented as ordered. This was evident for one (Resident #2) of one reviewed for urinary catheter use; one (Resident #44) of one resident reviewed for non-pressure skin conditions; one (Resident #7) out of one reviewed for insulin use; one (Resident #8) of three reviewed for pain management and one (Resident #127) of seven reviewed for general investigations.The findings include:1)Review of Resident #2's medical record revealed the resident was cognitively intact and their own responsible party. On 2/19/26 at approximately 10:00 AM Resident #2 reported a concern regarding physician ordered referrals not being followed up on by staff. After the 2/19/26 interview. review of the medical record revealed the following physician orders for specialty consultations: 1/8/26 order for infectious disease consult 1/14/26 order for referral to urology1/14/26 order for referral to neurology2/3/26 order to arrange neurosurgery follow-up Further review of the medical record failed to reveal documentation to indicate what, if any, progress was made in scheduling these appointments. On 2/19/26 at 11:58 AM the Unit Nurse Manager #16 was interviewed in regard to the process for scheduling ordered non inhouse specialist appointments. The Unit Manager #16 reported the order is put into communications (indicating a computer system) for the secretary to arrange for the appointment. She went on to report that they use to have a secretary that arranged for the appointments but that position was currently open. After checking for the four orders listed above, the Unit Manager reported that she saw the orders and that they were put in the communications to be done, but was unable to provide information to indicate that any of the four appointments was scheduled. She indicated she would follow up with the Director of Nursing about scheduling the appointments. On 2/19/26 at 3:30 PM surveyor reviewed the concern with the Director of Nursing regarding the failure to ensure the scheduling of specialist appointments. 2) Review of Resident #44's medical record revealed the resident was seen by the wound specialist Nurse Practitioner #46 on 2/5/26. This note revealed: Erythema (redness) rash to peri area and under bilateral (both) breast, recommend nystatin powder BID (two times a day) for 14 days. A corresponding order was found, with a start date of 2/5/26, for the Nystatin External Powder 100000 Unit/GM: Apply to groin and left breast topically two times a day for rash for 14 days. No documentation was found as to why the order was put in for the powder to be applied to the left breast, when NP #46's assessment indicated the rash was under both breasts. Review of the February 2026 Medication Administration Record (MAR) revealed staff were documenting the administration of the Nystatin two times a day as ordered. However, the section of the MAR to document the location on the body where the Nystatin was administered revealed the following:2/5 AM both breasts; but failed to document that it was applied to the groin area2/5 PM both breasts; but failed to document that it was applied to the groin area2/6 AM both breasts; but failed to document that it was applied to the groin area2/6 PM groin and other2/7 AM left breast and groin*2/7 PM groin; but failed to document that it was applied to under the breast2/8 AM groin; but failed to document that it was applied to under the breast2/8 PM groin; but failed to document that it was applied to under the breast2/9 AM groin; but failed to document that it was applied to under the breast2/9 PM groin; but failed to document that it was applied to under the breast2/10 AM groin; but failed to document that it was applied to under the breast On 2/10/26 at approximately 2:20 PM Resident #44 requested the surveyor inform staff that the resident had a rash under the breasts and the resident wanted to be seen by the wound nurse. On 2/10/26 at approximately 3:00 PM surveyor informed Nurse #45 of the resident's report of a rash and request to be seen by the wound nurse. Further review of the section of the MAR to document the location on the body where the Nystatin was administered revealed the following: 2/10 PM groin; but failed to document that it was applied to under the breast2/11 AM groin; but failed to document that it was applied to under the breast2/11 PM groin; but failed to document that it was applied to under the breast2/12 AM both breasts and groin2/12 PM groin; but failed to document that it was applied to under the breast2/13 AM groin; but failed to document that it was applied to under the breast2/13 PM groin; but failed to document that it was applied to under the breast2/14 AM groin; but failed to document that it was applied to under the breast2/14 PM groin; but failed to document that it was applied to under the breast2/15 AM groin; but failed to document that it was applied to under the breast2/15 PM both breasts, but failed to document that it was applied to the groin area2/16 AM left breast and groin*2/16 PM both breasts, but failed to document that it was applied to the groin area2/17 AM right breast, but failed to document that it was applied to the groin area2/17 PM both breasts, but failed to document that it was applied to the groin area2/18 AM left breast, but failed to document that it was applied to the groin area On 2/18/26 at 11:08 AM, after surveyor had reviewed the February MAR, the Unit Nurse Manager #16 was interviewed in regard to the Nystatin order. The Unit Manager #16 reported that, according to the order, the Nystatin was to be administered to the groin and left breast. After reviewing the location documentation Unit Manager #16 stated: they keep switching from breast to groin, every specific area on the body is supposed to have its own order. She confirmed the expectation is that staff read the whole order. Further review of the section of the MAR to document the location on the body where the Nystatin was administered revealed the following:2/18 PM both breasts, but failed to document that it was applied to the groin area For the 28 occasions for this medication to be administered, only on two occasions was it administered as ordered: to the left breast and groin area. Staff failed to apply the Nystatin to the area under the breast from the evening of 2/7 through the evening of 2/11; and again, from the evening of 2/12 through the morning of 2/15. On 2/19/26 at 3:30 PM surveyor reviewed the concern with the Director of Nursing regarding the failure to administer the medication as ordered. 3) On 2/10/26 at 11:26 AM Resident #7, a long-term resident receiving treatment for diabetes was interviewed. During the interview s/he reported that s/he had been a resident at the facility for over 8 years. Resident #7 stated that during his/her stay she had received daily insulin injections, however, s/he had not received his/her insulin injection for the past couple weeks. Resident #7 Minimum Data Set assessment, dated 11/12/25, was reviewed on 2/19/26. Review revealed that the Resident was cognitively intact. On 2/10/26 at 12:08 PM review of Resident #7 medication administration record revealed documentation that the resident was administered his/her insulin daily 2/01/26 through 2/09/26. On 2/11/26 at 1:14 PM an interview was conducted with the nurse (Staff #9) at a medication cart with a computer on top. Nurse #9 reported that the medication cart contained the medications for Resident #7. The nurse was asked by the surveyor what insulin medication were ordered for Resident #7. Nurse #9 reported that one of the insulin medications ordered for Resident #7 was Tresiba Subcutaneous 100 ml 3 units to be given at bedtime. The surveyor requested that Nurse #9 locate the Tresiba Subcutaneous 100 ml 3 units in the medication cart. Nurse #9 was unable to locate the medication in the medication cart or the unit medication refrigerator. On 2/11/26 at 1:16 PM Nurse #9 asked her unit manager to assist with locating the Tresiba Subcutaneous 100 ml 3 units. Unit Nurse Manager #10 was unable to find the medication. On 2/11/26 at 1:32 PM Unit Nurse Manager #10 confirmed she could not find the residents Tresiba medication and the last time a pharmacy request for the medication was in December 2025. On 2/12/26 at 7:30 AM review of medication administration record (MAR) revealed that on 2/11/26 a check on the MAR that revealed that Tresiba Subcutaneous 100 ml 3 units was administered in the evening. Further review revealed documentation that nurse #11 administered the medication subcutaneously to the left deltoid. On 2/12/26 at 7:41 AM the Unit Nurse Manager #10 was interviewed. She reported that the Tresiba Subcutaneous 100 ml 3 units did not arrive yesterday and that the physician had changed the order. On 2/12/26 at 10:00 AM the Director of Nursing (DON) was interviewed. She confirmed that the Tresiba was not available to be administered to Resident #7 on the evening of 2/11/26. The DON reviewed the medication administration record and confirmed the documentation indicated that Tresiba was administered to the Resident #7 on 2/11//26 On 2/12/26 at 10:18 AM a phone interview was conducted with Nurse #11, who had provided care to the resident on the evening shift of 2/11/26 and documented the administration of Tresiba. He reported that he did not administer the medication and put in a note indicating. To be administered upon deliver therapeutic interchange was affected by pharmacy and will be delivered instead. He reported that he had to check the box that indicated the medication was administered because that was the only way to remove the medication form being in the red. He reported he was not aware of another code he could document to indicate the medication was not given. Nurse #11 did not address his documentation in the MAR that indicated that the Tresiba medication was administered Sub Q (under the skin) in the left deltoid. No further documentation was found in the progress notes indicating if the medication was delivered and administered. On 2/12/26 at 11:04 AM discussion with DON after reviewing the note in progress notes. She confirmed the concern that it was not communicated that the medication was not administered. She reported it was an education issue because there is a code that should be used to indicate the medication was not given. On 2/13/26 at 9:05 AM interview with Resident #7. When the Resident was asked if s/he had been receiving his/her insulin injections the resident stated yes, s/he started receiving them yesterday (9/12/26). 4) Resident #8 has a medical history of chronic pain, heart-related conditions including hypertension, atrial fibrillation, coronary artery disease, and peripheral vascular disease, diabetes, and chronic obstructive pulmonary disease. On 2/10/26 at 1:14 PM, during the initial screening of residents, Resident #8 reported that the facility runs out of their pain medication every eight days and often must wait several days for the medication to be refilled. The resident stated they are always in pain and need their medication every day. On 2/12/26 at 2:21 PM, the surveyor reviewed Resident #8's physician orders (treatments and medications ordered by the physician) and identified multiple dates with no documentation to indicate that the orders had been completed. The review revealed the following: On 2/2/26 no documentation that the ordered medications (Ammonium Lactate lotion, Calcitriol, Ferrous Sulfate, Finasteride, Tamsulosin, and Eliquis) were administered and that vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturation) were obtained. On 2/4/26, 2/9/26, and 2/11/26 no documentation that Aquaphor was applied. On 2/9/26 and 2/11/26 no documentation of monitoring for bleeding related to blood thinner use, monitoring for antidepressant side effects, or monitoring of pain. Further review of January 2026 orders revealed 23 additional instances in which staff did not document medication and treatment orders. On 2/12/26 at 2:25 PM, the surveyor's review of progress notes failed to reveal a reason for the lack of documentation. On 2/12/26 at 2:57 PM, during an interview, the Director of Nursing (DON) stated, Generally, if there are gaps to an assigned medication or treatment, it means it was not done. The surveyor informed the DON that Resident #8 had multiple gaps in order documentation. On 2/12/26 at 4:27 PM, during a follow-up interview, the DON stated that gaps in the order record indicate that the care was not provided or not documented, if it was provided. She stated she would determine who was responsible and agreed it was a concern, stating, The expectation is that they document as they provide the medication or treatment. 5) Resident #127 has a medical history of a recent cholecystectomy (gallbladder surgery) and has a drainage bag, a medical collection device used to collect bile and fluids drained from the gallbladder. On 2/10/26, at approximately 9:30 AM, the surveyor conducted an initial resident screening as part of the recertification survey. Resident #127 reported feeling frustrated because the nurse who had performed care on their cholecystostomy bag had left it open, resulting in leakage onto the bed. The surveyor observed yellowish-brown liquid on the resident's sheets. On 2/18/26, at 12:38 PM, the surveyor conducted a record review and identified a care plan for Resident #127. The care plan included multiple goals for managing the cholecystectomy drainage bag, including, in part: - Resident is at risk of complications related to cholecystectomy - Monitor amount of drain On 2/18/26, at 12:46 PM, the surveyor reviewed the medication administration record (MAR) and noted there was no documentation to support that the following interventions had been performed on 2/4 and 2/15/2026: -Document cholecystostomy output each shift -Empty abdominal drain every shift and record output On 2/18/2026, at 1:11 PM, the surveyor interviewed the Director of Nursing regarding the gaps in care on 2/4 and 2/15. The Director confirmed that the lack of documentation indicates that care was not provided or not recorded on the Medication Administration Record (MAR).

Based on review of staff records and a staff interview, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received annual performance evaluations. This was evident for two (GNAs #28 and #29) of two GNA employee records reviewed during the survey. The findings include:During the survey, two Geriatric Nurse Assistants (GNA #28 and #29) employee files were reviewed. The records reviewed on 2/17/26 revealed GNA #28's hire date was 4/22/19 and GNA #29's hire date was 3/12/23. Both of the employee files lacked annual performance evaluations. In a subsequent interview, the Director of Nursing acknowledged that GNA performance evaluations had not been completed and stated, they're in Workday, its on my list.

Based on staff and resident interviews, record review and observations, it was determined that the facility failed to have a process in place to separate the Arbitration Agreement from the admission Agreement and failed to ensure that the person signing the Arbitration Agreement was cognitively capable or had legal authority. This was evident for three (Residents #6, #41, #52) of six residents reviewed for arbitration agreements.An arbitration agreement is a legal document used in long-term care facilities. It requires that disputes or injuries be resolved through private arbitration instead of through the court system. By signing, a resident waives their constitutional right to have a judge or jury decide the case. The arbitrator's decision is usually final and cannot be appealed.A Brief Interview for Mental Status (BIMS) is quick assessment that indicates how well you think, learn and remember. Scores range from 0 to 15. Low scores 0-7 indicate severe cognitive impairment.The findings include:On 2/10/26 at 10:19 AM the Nursing Home Administrator (NHA) confirmed that the facility had Arbitration Agreements but denied that any residents were bound by it. He also reported that the admission Office would be responsible for implementing the Arbitration Agreement. On 2/18/26 at 3:30 PM in an interview, the Clinical admission Director (Staff #39) stated that Arbitration Agreement was completed during the admission process. She stated the admission and Arbitration Agreements were together in one packet. She explained that she verbally reviewed/read the packet while the resident follows along using an electronic tablet. She said, all residents sign the Agreements except those who are not cognitively capable. On 2/19/26 at 9:01 AM the NHA and Regional Sales Manager (Staff #38) provided signed Arbitration Agreements for Residents #6, #41, #52. 1) On 2/19/26 at 12:16 PM in an interview, Resident #6 stated that s/he would need to carefully read the Arbitration Agreement before signing it and that s/he had no recollection of seeing or signing an Arbitration Agreement before. On 2/19/26 at 1:02 PM a review of Resident #6's Arbitration Agreement revealed electronically printed initials on the signature line of the last page. In a follow-up interview at 1:29 PM, Resident #6 confirmed that they were her/his initials but added, I don't remember that part. I thought it was just the admissions. On 2/19/26 at 3:35 PM surveyor asked Clinical Admissions Director #39 since resident stated s/he did no know that they signed an Arbitration Agreement, can you check with the resident because it its still within 30 days of original Agreement. On 2/19/26 at 3:41 PM surveyor observed the admission Director verbally read and review a hard copy of the Arbitration Agreement to Resident #6. Resident #6 acknowledged that s/he does not agree to the terms and declined to enter into the Arbitration Agreement and reported to the Clinical admission Director #39, that when the first lady came around, I did not know I was signing an Arbitration Agreement. On 2/19/26 at 4:04 PM a review of the document confirmed by Resident #6's signature that the resident did not agree to arbitration. 2) On 2/19/26 a review of Resident #41's record revealed: a face sheet that showed admission was 10/12/23, physician certification that indicated the resident lacks adequate decision-making capacity dated on 10/13/23, and an admission BIMS of 5 that indicated severe cognitive impairment. Resident #41's Arbitration Agreement was dated 10/13/23 and revealed her/his electronic signature. 3) On 2/19/26 AM a review of Resident #52's record revealed: a face sheet that showed initial admission was 6/12/24, physician certification that indicated the resident was unable to comprehend information and make decisions dated on 11/26/25, and an admission BIMS of 7 that indicated severe cognitive impairment. Resident #52's Arbitration Agreement was dated 6/24/24 and revealed an electronic signature of an unknown person. On 2/19/26 at 11:27 AM in an interview, the Regional Sales Manager #38 stated, I don't have any documents indicating signing authority for [Resident #52.] On 2/19/26 at 1:42 PM in a telephone interview, a temporary admission Director (Staff #40) confirmed that she was working at [NAME] City January 6- January 23, 2026. She explained that residents use a tablet to accept the contract by signing a one-time electronic signature at the first screen-page of the contract. The software then auto populates and fills in all other signature lines throughout the packet. She also acknowledged that it is possible for others to check the agree/disagree boxes throughout the packet without the resident's awareness. On 2/19/26 at 1:52 PM the Clinical Admissions Director #39 verified the process above. The Director of Nursing and NHA were made aware of the concern.

Based on observation, interview and record review, it was determined that the facility failed to maintain the call light/bell system in working order to allow residents to request assistance when needed. This was evident during environmental observation on 2 of 2 nursing units. The findings include: 1) On 2/10/26 at 3:35 PM review of complaint # 2682304 revealed a concern that from 11/28/25 through 12/2/25 Resident # 159 resided in a room without a call light or a tap bell. Review of census revealed that Resident #159 was assigned to a room that currently did not have a working call light/ bell system. Further observation of the room revealed a silver tap bell. On 2/18/26 at 12:48 PM Interview with the Maintenance Director (Staff #8) reported that he distributes the tap bells to the nursing staff, and the nursing staff distributes them to the residents that do not have working call lights. He reported that he first started giving them out only a couple weeks ago. He cannot remember the exact date that he started to give them out. 2) On 02/10/26 at 1:50 PM, during an interview, Resident #165 reported that her/his call light/bell broke today, and that s/he was waiting to get it fixed, Resident #165 reported that s/he was not given anything to use in place of the failed call light system. At the time of the above interview, an observation in resident #165's room failed to reveal a tap bell or call light system. The place on the wall for the call bell revealed that the call light was missing from the wall. On 2/11/26 at 9:14 AM, the light over Resident #165's room was on with no audio alert. During a brief interview, Resident #165 reported to the surveyor and the Corporate Senior Activity Director (Staff #50) that when s/he uses the bell no one comes, s/he does not think the staff can hear the bell. On 2/11/2026 11:57 AM An observation of the hall call light/bell was made. The bell was rung with the residents' permission on 2/11/2026 11:58 AM. The bell rang 5 times in row. On 2/11/26 at 12:15 PM LPN Staff #41 was the nurse working on the floor at the time that Resident #165 rang her/his light/bell. She reported she was in another resident's room with a provider and was unable to hear the bell. 3) On 2/10/26 at approximately 9:45 AM, the surveyor interviewed Resident #127, who expressed concerns that the wall call [NAME]/light did not work in the bathroom. The resident stated that they are often left on the toilet for at least 30 minutes because staff cannot hear the manual bell when it rings. The surveyor observed a manual hand bell on the bathroom sink counter and confirmed the wall-mounted call bell system did not activate when pulled. GNA #27 later entered the room and confirmed that the wall call bell had not been working. On 2/10/26, between 10:00 and 11:00 AM, during the initial screening of residents, Residents #10 and #67 reported non-working call bells. On 2/11/26 at 10:04 AM, the surveyor interviewed Resident #10 and observed a call bell tied to the bed rail. While discussing call bell/light response time, the resident pointed out that staff had tied a non-working call bell to the bed rail. The surveyor observed that the wall end of the call bell was not plugged into the wall and was instead draped over a wheelchair. On 2/11/26 at 12:39 PM, the surveyor interviewed GNA #30 regarding Resident #10's call bell. She stated that it falls out of the wall. The surveyor observed her pick up the disconnected box and reinsert it into the wall. When asked if she had ever reported the issue, she stated that she had not. When asked about the process for reporting broken equipment, she stated that she might tell a manager, but she usually just plugs it back into the wall. When asked if she was aware of the facility's TELS system for reporting broken equipment, she stated that she was not sure. The surveyor followed GNA #30 to the nurse's station, where GNA #31 asked if assistance was needed. GNA #30 explained that Resident #10's call bell had been falling out of the wall. GNA #31 stated, I will put it into the TELS system now. When asked whether all staff had received training on the TELS system, GNA #31 stated she was unsure and said, I just know that I know how to do it. GNA #30 again stated that she had never been shown how to use the system. On 2/13/26 at 3:35 PM, the surveyors interviewed the Nursing Home Administrator (NHA). He confirmed that it is the facility's expectation that all call bells/lights be functional and stated that because call bells are vital to resident safety, broken bells should be immediately reported and either fixed or escalated to management rather than relying solely on the TELS system. When asked what staff had been instructed to do when call bells were not functioning, he stated that residents were to be provided with manual bells. He acknowledged that staff had received only verbal instruction and confirmed that no formal education or in-service had been provided. The surveyor informed him that residents reported staff could not hear the manual bells and had experienced delays in assistance, including being left on the toilet for extended periods. He stated that he was not aware of those concerns and would instruct staff to make more frequent rounds. Regarding the scope of the issue, he stated that the facility became aware that multiple rooms had non-functioning call bells/lights just a few days prior to the survey entrance on 2/10/26. He explained that the facility has two separate call systems requiring specific parts and that one system would require reprogramming. He stated that a quote had been obtained and parts had been ordered but was unsure if this had been completed prior to surveyor entrance or around the time of entrance. On 2/13/26 at 4:08 PM, the surveyor interviewed the Maintenance Director (MD #8) and asked how he is notified when something needs repair. He stated that unit managers put things in TELS and that he might also notice issues himself. When asked about formal environmental rounds, he stated that rounds focus on items such as fire safety or vents. When asked whether he had assessed the call bells, he stated that he had been made aware of an issue and had informed the regional director. On 2/17/26 at 10:36 AM, the surveyor interviewed the Nursing Home Administrator (NHA) for clarification regarding when the call bell/light issue was first identified. He stated that it had been an intermittent issue since approximately July 2024 when he first arrived at the facility, but it became significantly worse about one week prior to the start of the survey. He stated that a full facility audit had been completed and would be provided to the surveyors. On 2/18/26 at 1:30 PM, Resident #127 asked to speak with the surveyor and reported, I was left on the toilet again this weekend. The resident stated that they had to use their personal cell phone to call the nurses' station because no one responded when they rang the manual bell. The resident showed the surveyor the call log on their cell phone, which reflected an outgoing call to the facility on 2/14/26 at 10:27 PM. On 2/18/26 at 1:38 PM, the surveyor notified NHA and the Director of Nursing (DON) of Resident #127's report. Communicating that they had been left on the toilet over the weekend and had used their personal phone to call the facility for assistance. Both acknowledged that this was a concern. On 2/19/26 at 11:39 AM the surveyor spoke with the NHA, and at 12:15 PM with the Director of Nursing to review concerns identified during the recertification survey. Both confirmed that the call bell system issues were valid concerns. 4) On 2/12/26 at 10:17 AM, the surveyor observed that the call bell indicator light above Resident #2's door was on. Nurse #17, who was at the medication cart located near Resident 2's room, reported that the light malfunctions, indicating it was always on. When asked, if the residents needed assistance, how they would alert staff. Nurse #17 responded that the resident would come out to the hall. Review of Resident #2's medical record revealed that the resident had resided in the current room for more than 4 weeks prior to the start of the survey. The resident's diagnosis included paraplegia, which means the resident is unable to stand or walk. On 2/12/26 at 12:47 PM Resident #2 reported that the call bell has been broken since they were moved into the current room. The resident also reported s/he did not have a wheelchair for mobility on the first night they were in the room. On The administrator provided an invoice by an outside company for the repair and parts for the call bell/light system. The quote was dated 2/10/2026 and an invoice date of 2/12/26.However, the residents' complaints regarding the broken call light systems began to be documented in November 2025. The administrator reported that the facility has installed a temporary call light system for the first floor on the weekend of February 14th and 15th. On 2/13/2026 3:56 PM, during an interview with Administrator, he reported that the facility is still working on repairing the call light system. He confirmed the concern that multiple rooms on each nursing unit had call light/bell system not in working order.

Based on observation, record review and resident and staff interviews, it was determined that the facility failed to provide quality care that promotes resident respect and dignity. This was evident for one (Resident #67) out of five residents reviewed for dignity during the survey.The findings include:On 2/11/26 Resident #67 was observed sleeping in bed. Fingernails were long and unkept with dark build up underneath.On 2/13/26 at 1:26 PM this surveyor observed Resident #67's uncovered foot and noted exceptionally long toenails. The resident stated, I want them cut. They hurt me.On 2/13/26 at 1:29 PM this surveyor observed Licensed Practical Nurse (LPN #26) assess Resident #67 toenails. The resident pulled the foot away and stated, that hurts.In a follow-up interview, LPN #26 verified that the toenails are very long. He reported that the process to schedule a podiatry appointment was to verbally report it to social work.On 2/13/26 at 3:12 PM in an interview, Director of Social Service (DSS #21) explained the process to schedule a podiatry appointment for a resident. He stated that nurses should retrieve a Health Drive form from his office, complete it, have it signed by a Physician or Nurse Practitioner and also get a nurse signature and return it to his office. He, in turn, uploads the completed form to Health Drive and waits to receive an email confirming receipt of the request. If completed accurately and financial clearance is verified, then Health Drive schedules the appointment. He confirmed that he had not received any Health Drive forms today.On 2/17/26 at 9:15 AM this surveyor observed Resident #67's toenails remained very long. On 2/17/26 at 9:17 AM in an interview with DSS #21 confirmed that a completed Health Drive form was received and uploaded; Resident #67's podiatry appointment was scheduled for 2/20/26.

Based on resident and staff interviews, record review and observation, it was determined that the facility failed to demonstrate prompt action in response to residents' grievances; provide a written response to residents of the grievance outcome; ensure an anonymous means to submit grievances; and post the Grievance Official name and contact information. This was evident for six of six Activities Team's grievances that were reviewed during this survey. The findings include: On 2/12/26 at 10:01 AM in an interview with the Resident Council President (Resident #129,) the following was reported: Resident Council meetings held every second Tuesday of each month at 3:00 PM On average 25 residents attend Staff are invited to the meetings, but often they don't attend, especially nursing leadership Minutes are recorded by me (Resident #129) and kept in my personal journal On the day before the meeting, I (Resident #129) personally and physically go throughout the building via wheelchair to verbally invite residents to the meeting. It was stated; the facility won't allow posted signs from residents. Resident #129 referred to the minutes in her/his journal and complained about the following as persistent grievances: Geriatric Nurse Assistants are disrespectful Call bell response is slow- sometimes hours Food is cold, nobody answers the phone to change orders, dirty utensils Elevator walls are dirty Some people (residents) run out of medications Resident #129 stated that to make a grievance, a concern form gets filled out, and goes to Social Work, after that, nothing happens! Resident #129 was not aware of the Grievance Official's (GO) name or contact information. On 2/18/26 at 1:28 PM Social Work Assistant (Staff #22) acknowledged that she attended the meetings when invited and confirmed Resident #129 extended an invitation to last meeting. She was unable to identify the process for responding to residents' grievances discussed at the meetings. On 2/18/26 at 1:34 PM, an interview with newly hired Activities Director (Staff #13) confirmed the information provided by Resident #129. She stated that she took attendance of residents and staff. She noted that the last regularly scheduled Resident Council meeting was in November 2025. When the grievances listed above were discussed, she reported that she completed concern forms and submitted them to the Director of Social Work (Staff #21). They have 7 days to investigate and mitigate the grievance and return it to Director of Social Work. He, in turn, gives the completed forms to me and I file them with the minutes. On 2/18/26 at 2:11 PM Director of Social Work (Staff #21) stated that the residents do not receive written resolutions, but they should. He identified himself as the GO. He stated, residents stay informed about the grievance process I guess by education, although he, himself, denied educating residents. He indicated that grievance forms are located outside of Social Service door and at the main entrance door. He confirmed that his contact information identifying himself as the GO was not posted next to the grievance forms. When asked, how does one file a grievance anonymously, he stated, they give the form to me or my assistant. On 2/18/26 at 2:33 PM, on the first floor, this surveyor observed no grievance bins or posters; on the second floor, this surveyor observed a plastic bin with grievance forms outside of Director of Social Work #21's door with a Compliance poster, but without the GO contact information. A similar plastic bin labeled grievance was observed to the right of the main entrance door without any poster or contact information. Next to this bin, hung a small black locked metal box. An interview with the receptionist, whose desk was directly in line of sight, reported that she had never seen anyone access that box, denied knowing the purpose of it and acknowledged that she didn't know it was there. In subsequent interviews, the Director of Nursing and Nursing Home Administrator acknowledged that they were unaware of the location of grievance boxes. A review of the Grievance Policy approved on 2/3/26 revealed, in part, the facility will prominently post and make information available to all residents the right to file grievances orally and in writing; the right to file grievances anonymously; contact information of the Grievance Official (GO); a reasonable time frame for review; the right to obtain a written decision regarding the grievance; etc. It continued: Section 1. b. The facility will maintain a secure box for reporting grievances in writing anonymously. Multiple boxes may be required to ensure all residents are able to exercise their right to file grievances in writing or anonymously. Grievance forms and instructions for using the box will be posted near or on the grievance box. The box will be checked daily during business hours, at a minimum, by the GO or designee. Section 4. b. The GO will complete a written grievance decision that includes specific criteria such as a summary of pertinent findings or conclusions regarding the concerns; whether the grievance was confirmed or not; and whether corrective action is taken and why and what that action is; and the date the written decision was made. Section 4. c. The GO will meet with the resident and inform the resident of the results of the investigation and how the resident's grievance was resolved or will be resolved. 4.c.i. A copy of the written grievance decision will be provided upon request. On 2/19/26 a review of Concern forms dated 2/11/26 revealed partial completion of the form; it included date, name of resident, person presenting the concern, a description of the concern and the department representative to notify. The information not included was actions taken to resolve the concern, investigator's signature and Administrator's signature. Further review of the Grievance form dated 2/11/26 revealed incomplete information and that it was resubmitted on 2/18/26, still incomplete. In an interview, Director of Social Work #21 acknowledged that the process didn't work. And the Activity Director #13 stated, sometimes, I have to hound them to get things done.

Based on medical record review, observations, and interviews with facility staff and residents, it was determined that the facility failed to: 1.) protect Resident #32 and Resident #29 from Resident #144 who had a documented history of combative, verbal, and physically aggressive behavior towards staff and other residents. This failure led to physical abuse, emotional distress, and psychosocial harm to Resident (#32) and physical abuse to Resident (#29) and 2.) keep residents free from abuse by staff (Resident #9), (Resident # 259) and (Resident #308). This was evident for 3 of 15 residents reviewed for abuse. The findings include: 1. On 9/12/2022 at 10:00 AM, a review of Resident #32's medical record revealed the resident had two certifications of incapacity to make informed decisions (2/2/2022 and 2/5/2022 respectively). On 2/1/22 the facility initiated a care plan for Resident #32 to address the following: Dementia with behavioral disturbance and was revised on 9/5/2022 to include Psychosocial well-being related to resident-to-resident altercation. According to the care plan, Resident #32 goal was to feel safe, comfortable, and well cared for. Intervention: When conflict arises, remove the resident to a calm safe environment and allow them to vent/share his/her feelings. Further review of Resident #32's medical record revealed the resident was ambulatory and that on 6/22/22 the facility's staff documented the outcome of the resident's Brief Interview for Mental Status (BIMS) as a 7 out of 15, which indicates the resident had severe cognitive impairment. A review of the medical record for Resident #144 on 9/12/22 at 1:30 PM revealed the resident was admitted to the facility in August of 2022 with a diagnosis including Dementia with behavioral disturbance, impulse control, insomnia, and Delirium. According to Resident #144's medical record, the resident had two certifications of incapacity to make informed decisions (8/11/22 and 8/26/22 respectively). On 8/12/22 the facility initiated a care plan for Resident #144 to address the following: Dementia with behavioral disturbance; resident is at times combative with staff and residents while being re-directed. Further review of Resident #144's medical record revealed the resident was ambulatory and that on 8/16/22 the facility's staff documented the outcome of the resident's Brief Interview for Mental Status (BIMS) as a 99 out of 15, which indicates the resident was unable to complete the interview. Continued review of Resident #144's medical record on 9/12/22 at 2:30 PM revealed multiple documentation notes of combative, verbal, and physically aggressive behavior toward staff and other residents between 8/24/2022 and 9/8/2022 when Resident #144 was removed from the facility. On 8/24/22 at 7:36 PM, a change in condition report documented around 4 PM to 5 PM, Resident #144 was noted with increased agitation, banging, and forcing the exit door to open, resident kicked the main entrance door opened and exited times three, staff had to struggle to redirect him/her back on the unit. Further documentation noted that when Staff #25 attempted to shave Resident #144 s/he became upset and moved his/her head and sustained a small cut to the left cheek. NP was made aware, and an order was obtained for treatment. On 8/26/22 at 9 AM, a change in condition report documented that Resident #144 was very combative and aggressive with staff, holding knives, kicking doors with his/her shoulders and head, seeking an exit, impossible to re-direct and the resident was a danger to self, staff, and other residents, going into residents' rooms trying to unplug air-conditioners. The attending physician was made aware during a visit on 8/26/22, and the physician attempted to calm the resident down to no avail. An order was given to Emergency Petition the resident via 911 to the nearest ER for further evaluation and treatment. On 8/26/22 at 10:51 AM, a Behavioral care note indicated: Resident very agitated and combative during rounds this morning, attempts to calm the resident down proved fruitless. The attending physician was immediately made aware during rounds, and support and encouragement were provided by both physician and facility social worker to no avail. Resident held his/her breakfast tray utensil kicking other residents' doors on the unit with his/her shoulders and head seeking exit off the unit, danger to self and others. Became impossible to re-direct residents. The new recommendation is given by the attending physician based on the resident's behavior to Emergency Petition resident out via 911 to the nearest emergency room for further evaluation and treatment. On 8/27/22 at 5:00 AM, a nurse's note documented Resident #144 returned from the emergency room at around 3:30 AM, per the emergency room psychiatric practitioner, Inpatient psych was not recommended, and the resident was cleared by the psych NP to return to the facility. No changes in medication were recommended. The resident was stable with no threat to staff or other residents. The physician was made aware and recommended a follow-up with a psych consult. On 8/27/2022 at 11:58 AM a nurse's note documented that Resident #144 attacked another resident (Resident#29) with a shoe and stole his/her belongings. 911 was called and a one-to-one sitter had been assigned to the resident until 911 arrived. On 8/27/2022 at 12:45 PM, a nurse's note documented that Police arrived and refused to take the resident to the hospital for evaluation. An Officer stated that because the resident went to the hospital on 8/26/22, he/she didn't need to go again, and the resident's combative behavior was a part of normal dementia behavior. The Nurse informed the officer that an emergency psychiatric evaluation was needed. The Nurse asked the officer to call for his supervisor. Due to the police refusing to take the resident to the hospital. The nurse called 911 so an ambulance transferred the resident. On 8/27/22 at 1:30 PM a nurse's note documented: Police, Paramedics, and a mobile Crisis team came for Resident #144. The nurse explained to them that the resident was displaying altered mental status evidenced by him/her attacking another resident (#29) with a shoe and stealing his/her personal belongings. The nurse explained that the resident's doctor wanted him to go to a hospital inpatient psychiatric unit for evaluation. Police, Paramedics, and the mobile crisis team concluded that the resident did not need to be evaluated because this combative behavior was part of normal dementia and refused to take Resident #144 to the hospital and left the facility. The officer's supervisor never showed up or contacted the nurse. A one-to-one facility staff member was assigned to Resident #144. The resident was alert and verbally responsive, still having intermittent pacing, going to other residents' rooms, and needed constant redirections for safety. On 8/29/22 at 3:42 AM, a nurse's note documented Resident #144 was alert and oriented as per baseline. The resident had one on one care and monitoring for aggressive behavioral disturbance, combativeness, and wandering to other residents' rooms and the resident denies any distress or pain. On 9/1/22 at 5:16 AM, a change in condition note documented: Resident hit his/her right shin against an air conditioner in the hallway when trying to get out of the unit and sustained some bruise on the area. On 9/4/22 at 12:00 PM, a nurse's note documented: The resident attacked his/her one-to-one sitter. The resident was attempting to break into another resident's room. The one-to-one sitter attempted to redirect the resident from the other resident's room. The resident attacked the one-to-one sitter with a water bottle and hit him in the head with the water bottle and threw water at him. The violent attack caused the one-to-one sitter's glasses to break. Despite being attacked and having water thrown on him, the sitter was able to redirect Resident #144 and keep him/her calm. The resident was documented as being a danger to himself, the staff, and the other residents. On 9/5/22 at 2:30 PM, a nurse's note documented: Patient remains stable at this time, medicated as scheduled, 1 to 1 monitoring continues for aggressive, combative, and wandering behaviors. No behavioral issues were noted during this shift, nursing continues to monitor with one-on-one nursing staff members. On 9/5/22 at 3:00 PM, a change in condition report documents: Resident#144 pushed another resident (#32) who sustained a hematoma to the back of his/her head from the incident, Resident #144 was immediately removed from the area and was monitored by 1 on 1 nursing staff to prevent a future incident. Resident #32 was assessed, and a small hematoma was noted on the back of his/her head. 911 was called incident report number is given (22-77731). Resident #32 refused hospital transfer. A recommendation was made to send Resident #144 out for treatment due to aggressive behaviors. On 9/5/22 at 4:00 PM, a nurse's note documented: 911 arrived on the Dementia (Cherry) unit and refused to transfer the resident due to the resident needing proper documentation to be transferred to an appropriate facility for his/her behaviors and not the emergency room . A private ambulance service was called to transport the resident. On 9/5/22 at 8:05 PM, a nurses note documented: Private ambulance transportation arrived at the unit and refused to take the resident due to behaviors stating it was against their company ethics to transfer a resident to the emergency room with such behaviors and directed the facility to call 911 so the physician updated of their refusal to transfer the resident to ER. The physician gave new order for Olanzapine (antipsychotic) 5mg 1tab every AM and to continue with 1:1 monitoring. During observation rounds on 9/8/22 at 10 AM, Resident #144 was observed pacing up and down the hallway of the Dementia Unit (Cherry). GNA (Geriatric Nursing Assistant) #24 was attempting to redirect the resident. GNA #24 stated that she was assigned to the resident to do one-to-one monitoring due to his/her aggressive behavior. On 9/8/22 at 12:30 PM, while entering the Dementia Unit surveyor witnessed Resident #32 sitting outside of his/her room yelling and screaming, Get that [Resident #144, s/he] has already hit me and knocked me down. I have a knot on my head from [him/her.] Resident #144 was observed walking aggressively down the hallway toward Resident #32. Resident #144 then stopped and began trying to snatch a clear plastic display board off the wall that was being held in place with metal hardware. Resident #32 then jumped up and ran into his/her room and slammed the door. Resident #32 continued to yell thru the door, this is my home, and I am afraid of [him/her]. I am telling you, I am going to hurt that [Resident #144]. GNA #26, GNA #29, and GNA #31 were observed standing in the hallway each stating, this [Resident #144] is abusive, we are afraid of [him/her]. When asked where was the one-to-one sitter, GNA #24 (who was assigned to Resident #144), GNA #28 stated GNA #24 left the unit after stating Resident #144 hit GNA #24 in the face. When asked who was monitoring Resident #144, GNA #28 stated the resident did not currently have a one-to-one sitter. Resident #144 continued to pace up and down the hallway grabbing Resident #32's lunch off his/her tray on the table that was sitting outside of Resident #32's room and entering other residents' rooms, walking behind the nurse's station, and attempting to open doors behind the nurse's station. GNA's #26, #29, and #31 remained on the unit but were unable to redirect Resident #144. The Charge Nurse, LPN #25, and the Acting Administrator #35 were immediately notified by the surveyor. At 12:45 PM, GNA #34 arrived on the Dementia Cherry Unit from the Dogwood unit and was able to redirect Resident #144 off of the unit. At 1:00 PM the Nurse Practitioner (NP) attempted to redirect and/or assess Resident #144; however, the resident pushed and poured water in the NP's face from a cup s/he was holding. At that time an order was obtained to Emergency Petition Resident #144 to the hospital. At 1:30 PM, 911 staff arrived and Resident #144 became very aggressive toward the police officers and had to be handcuffed and escorted out of the facility. 9/8/22 2:56 PM, a Nurse Practitioner note documented: Seen and evaluated for abnormal behavioral disturbances. Per the report, at about 12:45 PM, the resident was very combative and aggressive towards staff, hitting, kicking doors, and pouring ice water on staff and residents. S/he was very difficult to re-direct, medications were recently increased, but his/her behaviors continued to be getting worse and uncontrolled. The NP documented that while attempting to redirect Resident #144, he pushed the NP and poured ice water on her face. The resident was a threat to himself, the staff, and residents, and needed to be sent out to the ER for further evaluation so an order was written. Two policemen were in the building at 1:45 PM obtained a report and removed the resident from the facility at 2:05 PM. During an interview on 9/8/22 at 2:45 PM with Resident #32, she stated this is my home and this [Resident #144] comes after me every day. I am sick of it. I am going to hurt him/her. During an interview on 9/12/22 at 9 AM with Resident #29, s/he was unable to recall being hit with a shoe. S/he stated there was a crazy [man/woman] that lives at the facility. During an interview on 9/12/22 at 10 AM with GNA #24 (who was assigned to Resident #144 1:1 on 9/5/22) she stated she left the unit to go on break and informed the Charge Nurse #25, the Certified Medication Aide CMA #26 and GNA's #28 and #44 that she was leaving. When she returned 5 minutes late, Resident #144 had pushed Resident #32 down and the staff was trying to redirect Resident #144. During an interview on 9/12/22 at 10:30 AM with CMA#26 she stated, I was sitting at the nursing station about 3 PM and heard screaming coming from Resident #32's room. I found the resident lying on the floor. I called the [Charge Nurse #25] and I left. During an interview on 9/10/22 at 11 AM with Charge Nurse (#25) he stated, At about 3 PM on 9/5/22, I received a call from [CMA #26] who stated, 'we have a situation on Cherry hurry up and come.' When I got to the unit, I found [Resident #32] on the floor in [his/her] room, and [Resident # 144] was in the hallway at the door with staff trying to get in [his/her] room. I assessed [Resident #32] and noted a hematoma in the back of [his/her] head. I asked [Resident #32] what happened, and [s/he] stated that the man (Resident #144) pushed me. During an interview on 9/12/22 at 2:30 PM with the Director of Nurses (DON), she stated Resident #144 should have not been left without a 1:1 on sitter on 9/5/22 or 9/8/22. She stated all staff was currently being in-serviced on the facility 1:1 policy. During an interview on 9/19/22 with the Director of Operations, she stated the policy for 1:1 is to never leave the resident without being relieved by another staff member. During an interview on 9/27/22 at 1 PM with Resident #32 s/he stated, [Resident #144] is gone. I now feel safe. 30440 2. The facility failed to keep residents (Resident #9), (Resident # 259) free from abuse by staff. MD00183691 was reviewed on 9/20/22 at 10:00 AM for an allegation of staff abuse towards resident #9. A review of the resident medical record revealed the resident had the following but not limited diagnosis: Chronic Kidney Disease, Pain in the Right and left Knee, and Gait/Mobility Abnormalities. On 9/20/22 at 11:45 AM Ombudsman #61 advised that on 8/4/22 Resident #9 requested to have the toilet plunged in the bedroom. Ombudsman #61 visited the facility on that date and upon entering the resident room, a male who was in the room stated to the resident, did you do this? Ombudsman #61 stated that the resident appeared to be upset by the male staff's comment. Ombudsman # 61 reported the concern to the Maintenance Director (MD) #12. The MD #12 identified the male staff as Staff #11. An interview was conducted with MD #12, on the same date at 12:15 PM and he confirmed that the Ombudsman reported the incident to him. MD #12 went on to say that the Ombudsman reported male staff #11 spoke to Resident #9 forcefully. MD #12 stated he did not report this because the Ombudsman was vague in the description of the incident and stated that it was more of a dignity concern and not abuse. An interview was conducted with the administrative team on 9/20/22 at 1:15 PM and they were asked if these concerns were reported by the MD #12 and they stated, no. On 9/23/22 at 11:00 AM the facility Administrator #62 provided a copy of the initial self-report that was sent to the office of Health Care Quality on 9/20/22. He stated that the facility was currently investigating the concern. On 10/13/22 at 2:30 PM the Divisional Director #9 spoke to the survey team and stated the facility concluded the investigation and found that the allegation of abuse was substantiated. She stated that Staff #11 was terminated. 3. MD00161046 was reviewed on 9/29/22 at 11:00 AM. Intake information was provided to the Office of Health Care Quality by the facility of a staff-to-resident allegation of abuse that occurred on 11/28/21. According to the documentation, Staff #63 smacked Resident #259 on the hand, as the resident was going behind the nurse station. During the facility's investigation, the abuse allegation was substantiated and Staff # 63 was terminated. An interview was conducted with the Corporate Staff on 9/29/22 at 11:45 AM and they were asked to provide documentation of the facility's investigation. The Divisional Director #9 stated that the facility does not have an investigation for this incident that occurred on 11/28/21. The administration team confirmed that the facility was responsible for conducting a thorough investigation to include documentation of resident and staff interviews and that they were unable to provide the survey team with this information. All concerns were discussed at the time of exit on 10/14/22 at 6:00 PM. 42782 4. The facility failed to keep a resident (Resident #308) free from verbal abuse. On 09/30/22 at 1:43 PM a review of the Facility Reported Incident (FRI) MD00139186 revealed Resident #308 reported being verbally abused by a Geriatric Nursing Assistant (GNA). The GNA was suspended pending investigation. The GNA's employee file revealed he/she had a pre-employment background check done as well as Abuse Training. A review of the facility's investigation revealed the GNA admitted to verbally abusing the resident. On 09/30/22 at 3:15 PM Assistant Director of Nursing #7 reviewed the investigation and confirmed the GNA verbally abused the resident and was terminated.

Based on observation, interview with staff and review of residents' medical records, facility policy, quality assurance and performance review (QAPI) material, it was determined that the facility failed to prevent Resident #321 from leaving the facility without supervision as evident by the facility's failure to: 1. monitor the resident after exhibiting exit seeking behavior, 2. initiate a care plan for elopement with interventions to prevent the resident from leaving, and 3. failure of the front desk staff to prevent a high-risk resident from leaving the facility although the resident photo was in the elopement binder. This was evident for 1 out of 9 residents (#321) reviewed for elopement. Additionally, there were three other examples related to the facility's failure to have a system in place to deter a monitor resident's at risk of elopement from exiting attempting or exiting the facility without knowledge. This was evident for 3 of 9 residents (#122, #163, and #74) reviewed for elopement. As a result of these findings, an Immediate Jeopardy situation was identified on 8/30/19 at 11:37 AM related to Resident #321 and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 8/30/19 around 3:30 PM and the State Agency was unable to accept this plan. The facility submitted an additional plan around 4:00 PM on 8/30/19. The facility's removal plan was accepted by the State Agency at 5:11 PM. The immediate jeopardy was removed on 9/10/19 at 12:50 PM after confirmation of all staff training, care plan updates, BIM's reassessment, updating of elopement risk and wandering drills. After removal of the immediacy, the deficiency remained with potential for minimal harm at a scope and severity of D. The findings include: Review of the medical records revealed that Resident #321 was initially transported to an acute care hospital from home on 12/27/18 after experiencing a fall. During the resident's emergency room stay, he/she required chemical restraints due to his/her agitation, aggressive behavior, and trying to exit the hospital by walking out of the emergency room . As a result, he/she was transferred out to a psychiatric hospital on [DATE] for behavior monitoring and treatment secondary to his/her [MEDICAL CONDITION] and aggressive behavior. Review of the specialty hospital psychiatric hospital discharge summary revealed a plan for 24-hour supervision and follow-up by a psychiatrist secondary to the resident's [DIAGNOSES REDACTED]. Resident #321 was discharged to Nursing Home #1 on 1/7/19. However, at the family members request, he/she was transferred to the current facility. On 1/7/19 Resident #321 was admitted to the facility from a different skilled nursing facility. Review of the medical records revealed a nursing admission wandering observation tool and a cognitive status/orientation that was completed by a licensed practical nurse (LPN) #7 on 1/7/19 which revealed the following: 1. The resident and family voiced concerns that indicated the resident may tend to leave, 2. The resident expressed anxiety / apprehensive to leave the facility, and 3. The resident has risk factors for elopement. The cognitive status revealed that the resident was not able to report the correct year, the resident was not able to report the correct month and was not able to report the correct day. The wandering observation tool that LPN #7 completed on 1/7/19 included the following: .10. Does resident have Rick Factors for elopement or unsafe wandering? Yes; 11. If Risk Factors are present proceed to care plan. Review of Resident #321's Base Line Care Plan dated 1/7/19 did not reveal any interventions or notations related to his risk for elopement. The section on the care plan entitled safety was left blank. Review of the admission Brief Interview for Mental Status or BIMS (a test given by medical professionals that helps determine a patient's cognitive understanding). A BIMS score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. Reveal that the resident scored a 13. Review of the Psychiatric nurse practitioner (NP) note dated 1/14/19 revealed the resident was being seen for behavioral disturbances; agitation and threatening to leave the facility. Review of the assessment and recommendation reveals the following; Resident alert to self only, feeling frustrated and irritable with staff. Resident also stated, I want to go home, they conspired to bring me here, I don't belong here. A facility self-report dated 1/15/19 documented the following: Patient was last seen in the facility at approx. 5:00 pm. (on 1/14/19). At approx. 5:20 pm we were notified that a patient was noted walking down the street by an employee while driving. Employee made a u-turn and was unable to locate the resident. Search by staff completed of area and facility unsuccessfully. Police were called at 5:42 pm and was located and returned to the facility at approx. 6:05pm with no noted injury. Resident was noted wearing a [NAME]et and a hat. Resident had an initial BIMs of 13 and is his own responsible party. Resident has a [DIAGNOSES REDACTED]. Resident was assessed with [REDACTED]. Psych consult obtained. Investigation is ongoing to determine how/why resident left facility. A nursing head to toe assessment was completed with no injury noted. Resident was appropriately dressed. 1 on 1 was initiated and a psych evaluation was completed. The outcome of the psych evaluation was to continue the 1 on 1. Wanderguard was placed on the resident after the incident. A repeat BIMS was completed with a score of 8. Staff in serviced on resident elopement. The resident was able to leave the facility and travel 2.2 miles down a busy roadway through a roundabout at rush hour. Review of the facility plan regarding elopement revealed the following: 1. Deal with elopements from investigation through the creation of a credible evidence binder, 2. Update exit seeking binder book to include face sheet, care plan, identifier etc., 3. Inservice staff on elopement risk management by heightening the awareness of staff. Review of the geriatric nursing assistants (GNA) written statements all dated for 1/15/19 after the resident had been returned, revealed the following: on 1/15/19 GNA #45 witnessed the resident put on his/her [NAME]et and GNAs #46 and #7 were informed by the resident that he/she was leaving to visit his/her mother. GNAs #34 and #46 were also informed by the resident that he/she was leaving. The GNAs indicated they thought the resident was a visitor. Review of the facility investigative notes dated 1/15/19 revealed that the receptionist received a call from an employee at 5:20 PM on 1/14/19 informing her where the resident was located which is 2.2 miles away from the facility. The receptionist statement revealed that the charge nurse was made aware. Review of the investigative note dated 1/16/19 reveals that the BIM's score is in question due to the resident most recent cognitive status/orientation and the [DIAGNOSES REDACTED]. Review of the assessment and wandering observation tool dated 1/7/19, reveal that the resident had potential risk factors due to his/her [DIAGNOSES REDACTED]. The resident also had definitive risk factors as evidence by family voiced concerns that would indicate wandering tendencies and the resident has expressed to leave the facility. Further review of the wandering observation tool reveal that since the resident has risk factors for elopement a care plan should be initiated. Further review of the clinical records revealed that no care plan with interventions to prevent the resident from elopement was put in place until after the resident eloped from the facility on 1/15/19. Review of the facility's current list of residents who had been identified with wandering behaviors and interview with staff, revealed a lack of consistent care planning for keeping residents who wander safe from harm. Only 6 of the 34 residents on the wandering list had a plan of care for wandering/elopement. During an interview with GNA #34 on 8/28/19 she revealed that the resident always put on his/her coat and hat she also revealed that the resident reported that he/she was going home. The surveyor asked if she told anyone about the resident leaving, and she replied 'no, I thought (he/she) was a visitor.' During interview with the evening supervisor registered nurse RN #10 on 8/28/19, she revealed she saw the resident with his/her coat and hat but did not do or say anything. An interview with the resident's nurse LPN #7 on 8/28/19 she revealed that she saw the resident when she started her shift around 3:00 PM. She further revealed that when she observed the resident, he/she was dressed in a coat and hat. LPN #7 also revealed that she was passing out evening medication around 5:00 PM and she did not see the resident, and someone told her the resident went downstairs. She verbalized that she went downstairs to look for the resident, but could not locate him/her, so she called the code and called the police. During an interview with the receptionist (staff #47) on 8/30/19, the surveyor asked how she knew which residents needed to be in the elopement binder. The Staff #47 indicated that the nurse would call her and tell her which residents needed to be in the elopement binder. She further revealed that once the nurse gives the name of the resident, she would print the face sheet and the nurse would fill out the information for the binder. Review of the current elopement binder revealed thirty-four residents identified as wandering residents. The survey team was informed that the wandering binder was not accurate, and that there were only 9 wandering residents. During an interview with the Director of Nursing (DON) on 8/30/19 the survey team requested the elopement binder that was completed when the resident eloped, however the DON failed to provide the binder. Further interview with the DON revealed that the facility-initiated education in (MONTH) for heightened awareness for elopement and wander drills. The surveyor asked if the facility was 100% compliant, meaning were all the employees educated, and the DON replied, no she, did not think so. As a result of these findings, an Immediate Jeopardy situation was identified on 8/30/19 at 11:37 AM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 8/30/19 around 3:30 PM and the State Agency was unable to accept this plan. The facility submitted an additional plan around 4:00 PM on 8/30/19. The facility's removal plan was accepted by the State Agency at 5:11 PM. The facility's abatement plan included the following: -Resident# 321 placed on a 1:1 monitoring 01/15/19 after elopement and continued through 1/17/2019 19:30 hours when resident was Emergency Petitioned for Increased agitation towards staff and was not re-directable; -Resident# 321 Care plan initiated to reflect new interventions. 1/15/19 -Resident #321, Wander guard placement on 1/15/19 -Facility Staff education on the elopement process and heightened awareness for potential elopement initiated on 1/15/19 and 1/16/19. Date to be completed: 9/2/19 -Elopement Drills initiated on 1/15/19, 1/16/19, 08/29/19 and ongoing Door checks were completed on 1/15-1/25 and are ongoing -Ad Hoc QAPI meeting conducted to review updated Elopement Processes on 01/15/19 Resident seen by Psych services on 1/16/2019 -Resident Wander Observation was reassessed and inaccurately completed on 1/16/19 BIMS reassessed on 1/16/19 -AD Hoc QAPI completed on 01/15/19 and 8/28/19 and 8/29/19 in relation to elopement process and need for updates of Elopement Risks/ exit seeking/ Wander Observation Tool/ Care plan and orders. -8/28/19 wander observation tool report was initiated for review. 8/29/19 wander observation tools were updated Identification of Others: -Residents Wandering Observation Tools were initiated on 8/29/19 for facility and 9 residents were identified as elopement risks. The Elopement binder was updated by Clinical Management team. -Care plans updated to reflect the most current assessment 8/29/19 for the 9 residents identified -Physician orders [REDACTED]. -Wander guard bracelets orders not needed. Education: -Facility Staff education on elopement process and heightened awareness/ risk factors and potential of exit seeking behavior was initiated on 1/15/2019, 01/16/2019 and 08/29/19. To be completed by: 09/02/19 --Facility initiated education on Elopement process on 01/15/19, 8/29/2019 and ongoing (completion: 09/2/19.) Elopement drills were held on 8/29/2019 3-11 and 11-7 shift with management oversight and input without issues. 7-3 to be conducted on Saturday 8/31/2019 by management team. -Heightened awareness/signs of exit seeking behaviors education initiated on 8/30/2019 with all disciplines. (Completion 09/2/19) -ED in-serviced receptionist on proper process for the elopement book that is housed at the front desk on 8/30/19. -Education SMS sent to Licensed Nurses on 8/29/19 with initial reminder for elopement education. -Relias education for facility staff for Elopement was set and uploads on 2/2019 and 8/30/2019. Licensed Nurse Education on the completion and update of the Wander Observation Tool, initiation/ update of care plan and physician orders [REDACTED]. (Completion date: 09/2/19) System Change: -Newly admitted /readmitted residents discharge summaries will be reviewed by the Nursing Supervisor upon admission to the facility. The Nursing supervisor will then identify if the residents is an elopement risk or exhibit exit seeking behaviors. The Nursing Supervisor then will delegate the completion of an individualized care plan, obtain appropriate physician orders [REDACTED]. Residents that are experiencing a change in condition will be evaluated by the Nursing supervisors to identify if they are an elopement risk or exhibiting exit seeking behaviors. If needed, individualized care plan, obtaining appropriate physician orders [REDACTED]. -Discharge Summaries for newly admitted /readmitted residents to the center will be reviewed in conjunction with the 24-hour summary report to identify any resident that may be an elopement risk or exhibiting exit seeking behaviors 5 days a week x 4 weeks and monthly for 3 months by nursing supervision. -Nursing Supervisors will be responsible for updating the facility elopement binders. Monitoring: -Nursing, Supervisors will audit discharge summaries of new admissions/readmits 5 days a week x 4 weeks and then monthly for three months to identify residents that are an elopement risk or have behaviors of exit seeking to ensure they have appropriate physician orders, accurate assessment, care plan and monitoring. -Nursing supervisors will audit the 24 hour summary reports for residents that have been identified with an acute change in condition to identify if they are an elopement risk or have exit seeking behaviors if needed have appropriate physician orders, accurate assessment, care plan and monitoring 5 days a week x 4 weeks then monthly 3. -QA Nurse will audit the Facility Elopement Binders to ensure they are accurate and current based on the wandering observation tool weekly x 4 weeks and then monthly times 3. -Audits will be reviewed at QAPI and once it has been determined that the enhanced systems and monitoring have been made, the frequency of the auditing process will be determined. 2. A review of Resident #122's clinical record revealed that the resident was admitted to the facility as an elopement risk. The resident had a care plan for (name of resident) is an elopement risk/wanderer: Resident wanders aimlessly. The interventions listed are: apply wanderguard, check function everyday, assess for fall risk, and complete elopement risk assessment quarterly and as needed. A review of the Investigation Report revealed that on 9/3/19 at 10:35 PM, Resident #122 was seen going into his/her room. The Resident was found at 10:55 PM in the parking lot by facility staff. He/She was brought back into the nursing home at 11:03 PM and was assessed. A one to one sitter (1:1) was initiated at 11:05 PM on 9/3/19. The facility's Investigative Report included the following: This resident was assessed to be a wanderer on the unit and is at risk for elopement. Resident has a WanderGuard bracelet on the right ankle. Patient this evening at 10:55 was found outside the parking lot. Patient stated he/she went through the window to get out the facility. Patient stated, I broke the bracket on the window then pushed the window screen down, then I climbed on the window ledge and jumped to the ground which is 3-4 inches from the window. The resident then said, I walked straight and then made a left turn and when I get to the front parking lot I saw someone in his car, and I thought it was the nurse (name of nurse) and I said to myself Ha I am in (expletive) now. Staff asked resident why did he/she leave the facility. The resident replied I wanted to go get some cigarettes and snacks. Per staff who found patient in the parking lot stated he/she was easily redirected back to the facility. When resident came through the front door with facility staff the wander guard alarmed. The WanderGuard bracelet was still on the right ankle. Resident was educated on not leaving the facility. Resident was immediately placed on 1:1 sitter with staff, all windows on the first floor and the locked unit was checked for any broken brackets. Maintenance Director was called to come into facility. The resident complained of pain in left knee, so an order was obtained for a stat x-ray via a mobile x-ray company. The resident was medicated with Tylenol for pain. Survey team observed resident on 9/04/19 at 8:12 AM. The resident was laying in bed facing window with feet near headboard. The 1:1 staff was not present. The survey team spoke with the resident. The resident said he/she left to get cigarettes and that leaving the facility was easy. Resident said opening the windows was not a problem. This surveyor observed a table knife underneath a washcloth on the windowsill. The Administrator and the Director of Nursing (DON) were interviewed on 9/4/19 at 8:28 AM. The DON initially stated that there was a person in the room. Surveyors replied that they had been in the room and no one was there. The survey team, the Administrator and the DON went to Resident #122's room. GNA #15 was interviewed on 9/4/19 at 8:35 AM. She stated that she was told to be the 1:1 staff person. While in that capacity she was asked by her supervisor to leave the room to help with food trays. When she was done, she came back to the room. She said she saw the survey team leaving the room and enter a neighboring room. The Maintenance Director was interviewed on 9/6/19 at 9:00 AM. He informed the survey team that a housekeeper found a window [MEDICATION NAME] underneath the resident's bed a few days earlier. He could not remember exactly when or the name of the housekeeper. He said he just replaced the lock and did not know the resident was at risk for elopement. The Administrator was interviewed on 9/6/19 at 9:38 AM. She confirmed that there should have been a 1:1 sitter. She stated staff assumed the resident was asleep but agreed that was not an excuse for the 1:1 sitter to leave the room. The facility obtained an order for [REDACTED]. 3. The wanderguard alarm sounded outside the business office at 3:30 PM on 9/10/19. Staff from the business office (#5 and #38) left their office to locate the source of the alarm. A floor tech (#39) was observed to have walked past the WanderGuard sensor with a trash bin. They looked around to verify a resident was not in the vicinity. They had the floor tech (staff #39) move the trash bin back and forth to confirm the source of the alarm. Staff identified that a WanderGuard bracelet with device attached had been thrown in a trash bag which was placed in a trash can. Staff began a head count of residents. Staff #5 went to the front desk to have Dr. Wanderer called overhead. A review of staff statements revealed that Resident #163 had removed a WanderGuard sometime in the morning of 9/10/19. The Maintenance Director replaced it and activated the new one. At 3:30 PM he was asked for two more WanderGuard bracelets and gave them to nursing. 4. Review of the medical record for Resident #74 on 8/25/19 at 1:04 PM revealed [DIAGNOSES REDACTED]. Resident #74 was initiated for further review and during review on 8/30/19 at 2:05 PM, a nursing note was reviewed from 8/25/2019 at 1:04 PM that documented the following: at 10:00 AM Resident #74 asked to sign out, as is the facility procedure, to go out front of the facility to meet a family member to talk. The note further stated: At 11:45 AM assigned charge nurse went outside to look for Patient for routine medicine and other care, but Patient was not around. Charge nurse Call the Patient Cell phone but was not reachable. Charge nurse spoke with Sister and stated that, I don't know where he is, but I will find out and return to you. Charge nurse received call back from sister who stated that he left with his daughter and he should return by 6pm. Patient left the facility without LOA (leave of absence) Order. A progress note entered on 9/2/19 at 7:53 PM documented as a late entry, noted that Resident #74 was educated on the facility policy of signing out and informing staff when s/he is leaving the facility vs. sitting out front of the building. On 9/6/19 at 9:35 AM surveyor spoke with the facility Corporate MDS (minimum data set) coordinator, Nurse #11, regarding Resident #74 who unknowingly left the facility and the subsequent steps that Nurse #48 took after the resident was noted missing. Nurse #48 documented first calling the sister, did not notify the supervisor and after calling the sister waited for a return call and still did not call for a 'Dr. Wanderer' and notify his supervisor of the potential missing resident. Nurse #11 verbalized agreement that Nurse #48 should have followed protocol regarding the resident elopement procedure for Resident #74 when the resident was not found in his/her last known location and family was not immediately aware of where s/he was. The facility was aware of the concerns related to the findings for Resident #74 as there was an ongoing immediate jeopardy regarding an elopement during the occurrence with Resident #74 and this incident was reviewed with them repeatedly during the survey in relation to the ongoing immediate jeopardy proceedings.

Based on observation, interviews with residents and staff and medical record review it was determined that the facility failed to implement the pain management regimen according to the resident's needs, rights and choices by not carrying out the physician's orders [REDACTED]. This was evident for 1 of 5 residents (Resident #162) reviewed for pain in the investigative portion of the survey. The findings include: Review of the medical records revealed that the resident was admitted to the facility on [DATE] at 11:30 PM for rehabilitation and pain management. Review of the hospital discharge medication list provided to the facility revealed the following [MEDICATION NAME] HCL 5 milligram tablet 1 tablet PO (by mouth) Q6H PRN (every 6 hours as needed) for severe pain 7-10 on scale, in addition to the acute care hospital sent the prescription for the pain medication. Review of the admission orders [REDACTED]. Give 1 tablet by mouth every 6 hours as needed for pain, pain scale 7-10. Review of the Medication Administration Records (MAR) revealed [MEDICATION NAME] 5 mg order. Review of the resident's care plan which was initiated on 8/9/19 revealed the following: The resident has acute pain related to Right humerus fracture, the goal is adequate relief of pain. The interventions included; administer [MEDICATION NAME] (pain) medications as per orders, give ½ hour before treatments, and anticipate need for pain and respond immediately. Review of the initial Physical Therapy (PT) plan of care notes written on 8/9/19 revealed the resident was reporting a pain level of 9 out of 10 to the right upper arm and that it had severe effect on function. Further review of the PT note failed to reveal that nursing was made aware of the pain. Review of the 8/9/19 nurses note, and MAR failed to reveal any note referencing the resident having pain or pain medication given to the resident. On 8/12/19 PT documented that the resident was reporting pain to the right upper arm, nurse notified, and session terminated due to pain. Review of the nurses note dated 8/12/19 revealed the following: medicated for pain as ordered. Review of the MAR and the controlled drug administration records failed to reveal any signature indicating pain medication was given. Review of the physician note written on 8/12/19 revealed that the resident was having pain, and the physician renewed the order for [MEDICATION NAME]. Further review of the PT notes revealed that on 8/13/19 PT documented that the resident was reporting pain in the R(right) arm nursing administered pain medication and resident agreeable to bedside treatment. Review of the nursing notes and MAR for 8/13/19 failed to reveal any documentation that the resident was having pain and that pain medication was administered. Observation of Resident #162 on 8/2719 during the initial stage of the survey revealed a swollen and bruised right hand and fingers. During an interview with the resident on 8/27/19 the surveyor asked the resident if he/she was having any pain. The resident verbalized I am doing okay now, but when I was having pain when I first got here. Resident #162 medical records were reviewed on 9/9/19. This review revealed that the resident was admitted to an acute care hospital with a comminuted [MEDICAL CONDITION] proximal (near shoulder) and of the mid shaft (mid arm above elbow) humerus. A comminuted fracture is the type of fracture in which the bone has been broken into pieces and can be very painful. The resident also developed a hematoma at the fracture site (hematoma is generally defined as a collection of blood outside of blood vessels). During an interview with PT (Staff #50) on 9/10/19 she revealed that she remembered the resident, because on the initial evaluation date the resident had pain. She also revealed that the resident had pain on 2 other days of therapy. The surveyor asked if the resident received therapy every day, she replied we did an initial evaluation and then put the resident on caseload starting 8/11/19. The surveyor asked when residents have pain what is the process. The therapist replied, I usually stop therapy and go tell the nurse. The surveyor asked the therapist if he/she remembered whether or not they told the nurse when the resident expressed pain, and he/she stated, I believe I told the nurse. During an interview with LPN #27 the surveyor asked her about the note where she medicated the resident for pain, she revealed she wrote it in error, she could not remember giving the resident any pain medication. During an interview with the Administrator on 9/9/19 the surveyor requested a copy of any [MEDICATION NAME] 5 mg that was removed from the Omnicell and administered to the resident. The administrator provided the surveyor with documentation revealing that no [MEDICATION NAME] was removed from the Omnicell and that the only prescription was received on 8/12/19 and the required clarification was received on 8/13/19 and the medication was sent on 8/13/19 at 9:35 PM. During an interview with the resident on 9/10/19, the surveyor asked about the pain management on admission and the resident revealed that before coming to the facility the hospital medicated her/him for pain. The resident also revealed that it was done because the facility may take a while before they could get pain medication from the pharmacy. The surveyor asked the resident why he/she did not ask for pain medication but the resident revealed, he/she did ask every day, two to three times a day because his/her arm was really hurting. The resident also revealed that staff kept saying they were waiting for the doctor to come and write the prescription for pain. The concern regarding the failure to implement the pain management regimen by not carrying out the physician's orders [REDACTED].

Based on review of medical records and interview with facility staff it was determined that the facility failed to have a system in place for accurate documentation of the administration of medications within physician ordered parameters. Specifically, Resident #141, #133, #196, #301, #182, #189 received the medications [MEDICATION NAME] or Carvedilol on multiple occasions with documented blood pressures or heart rates outside of physician ordered parameters. As a result, a total of 58 medication errors were evident for 5 out of 37 residents reviewed during Stage II of the survey process. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy and the facility was notified of this determination at 5:10 PM on 1/19/17. The facility provided a plan to remove the immediacy while the surveyors were on site, which was accepted by the OHCQ at 6:41 PM, on 1/19/17. The plan included immediately auditing on 1/19/17 orders for- all residents in the facility that were on [MEDICAL TREATMENT] and receiving [MEDICATION NAME]. The orders and parameters were revised under consultation with the attending physician and the nephrologist. All nurses received training immediately on 1/19/17 or either prior to their next shift on following physician ordered parameters. The plan also included weekly audits and monthly quality assurance committee monitoring of [MEDICAL TREATMENT] residents' medical records to ensure that [MEDICATION NAME] was being administered per physician orders. After removal of the immediacy, the deficient practice remained with a potential for more than minimal harm at a level E. The findings Include: Review of Resident #141 ' s record on January 17, 2017 revealed that Resident #141 is was [AGE] year old with a history of Hepatic [MEDICAL CONDITION], End Stage [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITIONS], A-Fib, Hepatic Failure and Diabetes. During review of the Resident's Medication Administration Record [REDACTED]. Resident #141 was prescribed 5 mg of [MEDICATION NAME] (a medication that helps to increase a person's blood pressure) give 3 tabs three times per day for [MEDICAL CONDITION] (low blood pressure). The nurse was to hold the medication if the Resident's systolic blood pressure (SBP - the first number of a blood pressure reading) was greater than 120. On January 4, 2017 Resident #141's blood pressure was 137/88, the [MEDICATION NAME] was administered at 5:00 PM. On January 5, 2017 the blood pressure was 126/79, the medication was administered at 5:00 PM. January 6, 2017 the blood pressure was 139/76, the medication was administered at 6:00 A.M., and on January 11, 2017 the blood pressure was 124/70, the [MEDICATION NAME] was administered at 1: 00 PM. In December 2016 another order written for [MEDICATION NAME], to be given 1 tablet by mouth 2 times a day for [MEDICAL CONDITION] HOLD FOR SBP greater than 120 or heart rate greater than 60 min. On December 2, 2016 the blood pressure (BP) was 128/80, [MEDICATION NAME] was administered at 9:00 A.M. On December 20, 2016 Resident # 141's blood pressure was 124/80 with a pulse of 94. The medication was administered at 5:00 PM. On December the 28, 2016 the heart rate was 85. At 9:00 A.M. the [MEDICATION NAME] was given. In November 2016 an order read [MEDICATION NAME] HCL 10 mg, give 1 tablet by mouth 2 times a day HOLD FOR SBP greater than 120 or heart rate greater than 60. On November 24, 2016 the pulse was 72, on November 25, 2016 the blood pressure was 127/72 with a pulse of 98. Both times the [MEDICATION NAME] was given to Resident #141 on the 24th and the 25 respectfully, at 9:00 A.M. There was no documentation in the clinical record that the physician authorized the administration outside of the parameters. In addition, there was no documentation in the clinical record that the nurse documented a rationale for administering the medication or documented that the medication had been given. Review of Resident #133's record on January 17, 2017 revealed that Resident #133 was a [AGE] year old with a history of stroke, and ([MEDICAL CONDITION]). Review of Resident #133's medical record on January 19, 2017 revealed, on 11/23/2016 the resident was prescribed [MEDICATION NAME] 5 mg to be administered prior to [MEDICAL TREATMENT] as related to [MEDICAL CONDITION], hold for systolic blood pressure (SBP) > 120 administer 30 minutes prior to [MEDICAL TREATMENT]. On November 25, 2016 the blood pressure (BP) was documented as 124/72. On December 9, 2016 the BP was documented as 125/66, and on December 23, 2016 the BP was documented as 123/71. The medication was documented as administered against the doctors ' parameters to hold the medication on all three identified dates. Staff #3, who documented on December 9, 2016 for administering [MEDICATION NAME] outside of prescribed parameters, was interviewed on January 19, 2017 at 11:50 AM. When asked about administering the medication outside of the prescribed parameters, Staff #3 initially disputed the fact that the initials were hers. The nurse explained that [MEDICAL TREATMENT] lowers the blood pressure and it is the nurses ' judgment to give [MEDICATION NAME]. The nurse did not have any further explanation as to why she gave medication outside of the prescribed medication order. There was no documentation in the clinical record that the physician authorized the administration outside of parameters. In addition, there was no documentation that the nurse documented a rationale for administering the medication or documented that the medication had been held. A record review conducted on January 13, 2017 at 9:30 AM revealed that Resident #196, a [AGE] year old with a history of heart failure and hypertension (high blood pressure), was ordered Carvedilol, a medication that is used to treat heart failure and hypertension. The order, which was active at least from October 2016 through the time of the survey, was written for 3.125 MG to be administered one time a day for hypertension and to hold for a systolic blood pressure (BP) below 120 or a heartrate (HR) below 60. The Medication Administration Record [REDACTED]. In November the medication was documented as administered on November 12, 2016 with a BP 116/68, November 13, 2016 with a BP 116/66, November 19, 2016 with a BP 116/64, and November 20, 2016 with a BP 116/64. In December on the 16, 2016 the medication was documented as administered with a BP of 118/70. On January 2, 2017 the medication was documented as administered with a BP of 118/74, January 4, 2017 with a BP 110/68, and January 5, 2017 with a BP 112/64. There was no documentation in the clinical record that the physician authorized the administration outside of parameters. In addition, there was no documentation in the clinical record that the nurse documented a rationale for administering the medication or documented that the medication had been held. On January 13, 2017 at 11:20 AM the Director of Nursing (DON) acknowledged that she recognized that there were issues documenting the administration of medications outside of the doctor's ordered parameters. A record review conducted on January 17, 2017 at 11:00AM revealed that Resident #301, a [AGE] year old with a history of stroke, hypertension, and ([MEDICAL CONDITION]), was ordered [MEDICATION NAME], 5 mg to be administered every Tuesday, Thursday, and Saturday prior to [MEDICAL TREATMENT] for low SBP and to be held for SBP above 110 and heartrate above 60. The Medication Administration Record [REDACTED]. In January the medication was documented as administered on January 5, 2017 with a BP of 145/74 and HR 87, and January 7, 2017 with a BP of 135/77 and HR 85. On January 13, 2017 a new order was written with a new parameter of hold for SBP > 120. On January 17, 2017 this medication was documented as administered with a BP of 133/67. An interview was conducted on January 19, 2017 at 11:20 AM with staff #2, the nurse who documented having administered the [MEDICATION NAME] to Resident #301, outside of the ordered parameters on December 24th 2016 and January 5, 2017 and 7, 2017. Staff #2 stated When blood pressure is not according to parameters I don't give it. For all those dates I should have put a note that [MEDICATION NAME] was not given. I did not give the medication on those days because I would not have given it to him. Staff #2 could not give an answer as to why on the dates in question the medications were not documented as held. There was no documentation in the clinical record that the physician authorized the administration outside of parameters. In addition, there was no documentation in the clinical record that the nurse documented a rationale for administering the medication or documented that the medication had been held. s Review of Resident #182's Medication Administration Record [REDACTED]. On December 12, 2016 through December 14, 2016 the heart rates were 80, 82, and 80 the medication was given. On December 18, 2016 the HR was 76 when the medication was given. From December 20, 2016 through December 22, 2016 the heart rates were 86, 80, and 67, again the [MEDICATION NAME] was given. December 26, 2016 through December 28, 2016 the heart rates were 80, 70, and 64 when the resident was given [MEDICATION NAME]. On December 30, 2016 and December 31, 2016 the heart rates were 82 and 96, when the Resident was given [MEDICATION NAME]. On December 8, 2016, Resident #182 had a BP of 129/77 with a HR of 76, and on December 9, 2016 the BP was 129/68 with a pulse of 80. Both times the [MEDICATION NAME] was given. On December 10, 2016 the Resident's BP was 132/56, and on December 15, 2016 the Resident had a BP of 127/72, again the medication was given. On December 16, 2016 the Resident had a BP of 131/70 and on December 17, 2016 the BP was 127/70, each day the [MEDICATION NAME] was administered. The medication was given on December 19, 2016 when the Resident had a BP of 125/72, December 24, 2016 with a BP of 123/56, December 25, 2016 with a BP of 136/80, and again on December 29, 2016 with a BP of 125/68. There was no documentation in the clinical record that the physician authorized the administration outside of parameters. In addition, there was no documentation in the clinical record that the nurse documented a rationale for administering the medication or documented that the medication had been held. Resident #189 is a [AGE] year old with a history of [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] and hypertension. On November 21, 2016, the resident was prescribed [MEDICATION NAME] 2.5 mg to be given thirty minutes prior to [MEDICAL TREATMENT], with an order to hold the medication for systolic blood pressure (SBP) greater than 120. The Medication Administration Record [REDACTED]. The medication was documented to be given when it should have been held on the following days: December 17, 2016 when the Resident's SBP was 125. On December 22, 2016 when the resident had a SBP of 122. The [MEDICATION NAME] was given on December 31, 2016 when the Resident's SBP was 130. On January 10, 2017 the Resident's SBP was 148 again, the medication was administered. There was no documentation in the clinical record that the physician authorized the administration outside of the parameters. In addition, there was no documentation in the clinical record that the nurse documented a rationale for administering the medication or documented that the medication had been held. Administering medications according to the parameters set by the physician in the orders is a professional standard in healthcare that helps to safeguard the resident.

Based on medical record review it was determined the facility staff failed to implement interventions to prevent Resident #5 from acquiring an avoidable pressure ulcer. This was evident for 1 of 10 sampled resident's selected for review. The findings include: The resident's medical record was reviewed on 3/23/15 and 3/24/15. Resident #5 was admitted to the facility on [DATE] after being hospitalized for [REDACTED]. Review of the hospital medical record revealed that on 9/21/14 the Physical Therapist documented that the resident required the assistance of 2 staff members for bed mobility. The resident's admission physician's orders [REDACTED]. An abduction pillow is a large foam pillow placed between the legs. The purpose of the device is to help decrease the risk of a dislocation. The use of an abduction pillow can make it difficult for a person to turn themselves in bed. Facility medical record review revealed that on 9/24/14 the Physical Therapist documented in the initial assessment that the resident required moderate to maximum assistance (50% to 75% assist) for bed mobility - rolling side-to-side. Review of the Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 9/30/14 revealed that the resident was at risk for developing pressure ulcers. On 10/1/14, the facility staff developed a care plan due to the resident's activities of daily living self care performance deficit due to limited mobility related to a [MEDICAL CONDITION]. Interventions included the requirement of staff participation to reposition and turn the resident in bed. Review of the Treatment Administration Record (TAR) revealed that there is no documented evidence that the facility staff implemented interventions to relieve pressure from bony prominences when the resident was in bed or sitting in a wheelchair. On 10/3/14 the nurse completed a concurrent review which revealed the resident was assessed with [REDACTED]. The depth of the wound was 0.1 centimeters. The physician was notified and gave a telephone order to have the resident assessed by the Wound Nurse secondary to the sacral pressure ulcer. On 10/6/14 a late entry for 10/3/14 was entered in the physician's orders [REDACTED]. Further medical record review revealed that the facility staff failed to revise the resident's care plan related to the development of a sacral pressure ulcer. Also, the facility failed to implement interventions for pressure relief to the resident's bony prominences even after the resident developed a pressure ulcer on 10/3/14. Medical record review revealed on 10/8/14 the resident's sacral pressure ulcer measured 5 centimeters x 3.8 centimeters and was unstageable. An unstageable pressure ulcer indicates full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (devitalized tissue). The physician was notified and gave an order for [REDACTED]. On 10/14/14 the resident was seen by the Orthopaedic Physician for a follow up evaluation of the [MEDICAL CONDITION]. The physician documented in recommendations "Needs aggressive care of sacral decub (decubitus = pressure ulcer)." On 10/15/14 the resident was evaluated by the wound care physician. The nurse documented that the resident is turned and positioned every 2 hours with positioning devices in place. The nurse further documented that teaching was done with the resident regarding the importance of turning and repositioning. The resident verbalized understanding, but voiced a concern that it was not easy to move in bed due to the softness of the specialty mattress. The physician gave a new order on 10/15/14 for a gel cushion to the resident's wheelchair. As of 11/18/14 the resident's pressure ulcer was healed. The resident was, subsequently, discharged to home after completing rehabilitation therapy.

Based on medical record review and interview of facility staff it was determined the facility staff failed to prevent a resident from falling out of bed resulting in an injury. This was evident for 1 of 3 sampled residents selected for review. The findings include: Resident #1 is a [AGE] year old with [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 11/8/2012. Review of the Minimum Data Set, an assessment tool, revealed that as of 9/9/12 the resident required extensive assistance for bed mobility. On 10/10/12 at approximately 10:35 p.m., the geriatric nursing assistant (GNA), Staff #1, was providing incontinence care. Review of the GNA's written statement revealed the following: "I was taking care of my incontinent patient. I had everything on the bed to change her. The patient usually jerks towards you, but this time she went the opposite direction and fell off the bed." Interview of the GNA, Staff #1, on 11/13/12 at 11:55 a.m. revealed that when the GNA cleaned the resident or changed her bed, she would turn the resident on her side, but the resident does not stay on her side will "jerk back toward you." The nurse notified the nurse practitioner of the resident's fall from the bed on 10/10/12. The nurse practitioner gave a telephone order for an x-ray of the resident's bilateral hips and pelvis. On 10/11/12 the x-ray revealed that the resident had a nondisplaced fracture of the right hip. The resident was subsequently transferred to the hospital and underwent surgical repair of the right hip fracture. Despite the resident's high risk for falls due to a history of muscle spasms, a history of a seizure disorder and the tendency to "jerk" toward the caregiver when turned on her side, the GNA failed to prevent the resident from falling from the bed resulting in a fracture to her right hip. The resident was readmitted to the facility on [DATE]. Further review of the resident's medical record revealed [REDACTED].

Based on medical record review, it was determined the facility staff failed to protect a resident with a jejunostomy tube from injury. This evident for 1 of 8 sampled residents selected for review. The findings include: Resident #2 was a [AGE] year old with multiple [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. A jejunostomy is the surgical creation of a permanent opening into the jejunum. The jejunum is the second portion of the small intestine. Nutrition, hydration and medication is provided to the resident via a jejunostomy tube. This resident's tube was inserted by a physician. The Transfer Summary from the hospital indicated that the resident had a jejunostomy tube placed during hospitalization , although under medications it instructed that drugs were to be given through the PEG tube. The nursing home failed to reconcile this conflicting information and correctly identify the location and type of tube that the resident had in place. When the attending physician at the facility examined the resident at the facility on [DATE], the physician referred to a PEG (percutaneous endoscopic gastrostomy). This is differs from a jejunostomy in that a PEG is the surgical creation of a permanent opening into the stomach versus the jejunum. The physician failed to correctly identify the resident's jejunostomy tube. review of the resident's medical record revealed [REDACTED]. Review of the hospital emergency room record revealed that the resident's feeding tube was replaced in the emergency room and the resident returned to the facility. Review of the resident's nursing home medical record revealed that on [DATE] at 12:50 p.m., the nurse documented that the resident was found on the floor beside the bed. Upon assessment of the resident, the nurse documented that the resident's feeding tube had become dislodged. The nurse documented that the physician was notified and an order was given to place a new feeding tube. The nurse replaced the resident's feeding tube with a Foley catheter and filled the balloon with 24 ml of fluid. A nurse with no specialized training in feeding tubes is not qualified to replace a jejunostomy tube On [DATE] at 9:45 p.m., the nurse documented that the resident was vomiting. The physician was notified and an order was given to transfer the resident to the hospital. On [DATE] at 4:30 a.m., the nurse documented that the resident returned from the hospital and continued to vomit. The physician was notified and gave a new order for the medication [MEDICATION NAME] 10 mg. every 6 hours as needed. [MEDICATION NAME] increases peristalsis in the gastrointestinal tract. On [DATE] at 11:15 a.m., the nurse documented that the resident vomited a large amount of coffee ground emesis. The physician was notified and gave an order to send the resident to the hospital via 911. The resident was subsequently admitted to the hospital. Review of the resident's hospital medical record revealed that the resident was taken to the operating room for an exploratory laparotomy on [DATE]. The surgeon documented in the operative report that a hole was discovered in the jejunum at the jejunostomy site. The surgeon further documented: "The Foley catheter was deflated with a syringe and 24 ml of water were removed from the balloon. The balloon had ruptured through the posterior aspect of the jejunum at the jejunostomy site."The resident subsequently expired on [DATE] due [MEDICAL CONDITION] due to a jejunal perforation.