Every finding on record at Forest Haven Nursing and Rehabilitation CTR

Based on observation and interview it was determined the facility failed to ensure a safe, clean, comfortable, homelike environment. This was evident pervasively throughout all resident floors of the facility's building.The findings include: 1. On 9/4/25 at 8:14AM the surveyor observed ripped areas in the flooring material in resident room # 202.2. On 9/4/25 at 8:26AM the surveyor observed resident room [ROOM NUMBER] with windows with a cloudy, unclean appearance and chipping wall paint.3. On 9/4/25 at 8:30AM the surveyor observed resident room # 110 with 2 out of 2 windows with a cloudy, unclean appearance and the surveyor noted the window glass in 1 out of 2 windows in the room had a large v-shaped crack present, and the privacy curtain was observed to have an unclean appearance with multiple brown stains, and chipping wall paint was observed. One area of plank type flooring was observed to be mismatched and gray in color with the surrounding brown flooring.On 9/4/25 at 9:20AM the surveyor conducted an interview with the facility Administrator and shared the concerns at which time they acknowledged the surveyor's concerns and reported the following information: Let me call maintenance right away.4. On 9/4/25 at 9:30AM the surveyor observed gray marks on the Station 3 hallway walls. 5. On 9/4/25 at 9:35AM the surveyor observed resident room [ROOM NUMBER] with loose covering to the lower portion of the room door which was protruding with a bowed appearance and gray marks with a broken piece of the covering which was protruding outward. 6. On 9/4/25 at 1:15PM the surveyor observed resident room [ROOM NUMBER] with broken blinds.7. On 9/10/25 at 10:43AM the surveyor observed an area of brown colored peeling tape approximately 5 feet across and 2 inches wide with exposed wall mesh type material present above the facility's interior lobby doors.8. On 9/10/25 at 10:45AM the surveyor observed a missing end cap on the lower wall molding of the hallway near room [ROOM NUMBER].9. On 9/10/25 at 10:45AM the surveyor observed four areas of white spackling present on the wall next to the interior lobby doors and two different wall paint colors were both present with paint roller type marks present on the wall.10. On 9/10/25 at 10:48AM the surveyor observed the ceiling area by the interior lobby doors with approximately a 6 inch crack in the ceiling tile, multiple scratch marks present on the ceiling tiles, and a lifted ceiling tile.11. On 9/10/25 at 10:51AM the surveyor observed the community area next to the lobby with chipped paint present on the wall molding, a section of mismatched flooring, areas of white spackle present on the wall paint, 1 of 4 sitting chairs were observed to have a severely worn appearance with pieces of vinyl material hanging off and exposed under cloth material present, 1 out of 1 cushioned chair was observed with a severely worn appearance with the surface material worn off and peeling exposing the under cloth of the cushion with the seat cushion observed to be slanted and smushed down, and 1 out of 1 couch was observed soiled with black, brown, and red staining present on the material throughout.On 9/10/25 at 10:57AM the surveyor observed red stains present on the floor in front of the couch furniture in the community area next to the lobby.On 9/10/25 at 11:00AM the surveyor conducted an interview and a dual observation and shared concerns with Director of Housekeeping #8 who acknowledged and confirmed understanding of the surveyor's concerns and stated the following information to the surveyor: I see what you are seeing.12. On 9/10/25 at 11:05AM the surveyor observed 32 unpainted white spackled areas on the walls throughout the Station 3 hallway. Gray marks, scraping, and chipping paint were observed to be present around the elevator and molding near the elevator was observed to be damaged as well as the flooring in front of the elevator which had a worn and damaged appearance and was mismatched in color as compared to the surrounding flooring.13. On 9/10/25 at 11:08AM the surveyor observed areas of gray scrapes on the hallway walls between resident rooms #117 and # 119 and between resident rooms # 115 and # 117.14. On 9/10/25 at 11:09AM the surveyor observed a hallway handwashing sink with an unclean appearance and no trim molding present along the floor, with a cupboard which was missing hardware with 2 screws and holes present in the cupboard doors. Caulk material was observed surrounding the sink with a brown and unclean appearance.15. On 9/10/25 at 11:10AM the surveyor observed gray scrapes on the wall paint between resident rooms #107 and 109.16. On 9/10/25 at 11:12AM the surveyor observed a crack approximately 4 inches long in the ceiling tile in the hallway near resident room [ROOM NUMBER], and a lifted ceiling tile that was not flush with the ceiling.17. On 9/10/25 at 11:13AM the surveyor observed a ceiling tile which was bowed in appearance near resident room # 113 and a ceiling tile which was lifted in appearance near resident room [ROOM NUMBER], and a ceiling tile with a dark brown circular stain with a hole present in it near resident room [ROOM NUMBER]. A circular metal plate was observed screwed to the ceiling with an unclean gray appearance.Resident room # 111 was observed to have chipped areas of paint and black and gray marks on the lower portion of the room's door covering material.18. On 9/10/25 at 11:14AM the surveyor observed scrapes present on ceiling tiles located outside of resident room [ROOM NUMBER].19. On 9/10/25 at 11:16AM the door to resident room [ROOM NUMBER] was observed to have an area of damage to the wood.20. On 9/10/25 at 11:22AM the surveyor observed the windows in resident room [ROOM NUMBER] to be unclean and cloudy in appearance, and the wall behind the headboard of the bed was observed to have paint worn off in various areas.21. On 9/10/25 at 11:23AM the surveyor observed resident room [ROOM NUMBER] continued with broken and bent blinds. Unpainted/unfinished sections of wood wall molding which was mismatched in color to the existing painted section of molding present next to it were observed. Metal registers were observed below the windows to be bent and falling out of place with surrounding rusty brown metal material exposed. A pillow was observed laying on the floor and with no pillowcase. An interview of Resident #58 was conducted at this time and Resident #58 expressed to the surveyor that the conditions in the room had been present for a long time.On 9/10/25 at 11:26AM the surveyor shared concerns with Registered Nurse #11 who after surveyor intervention, stated: I'm putting in the TELS (computer program utilized by staff to inform maintenance of concerns) system.22. On 9/10/25 at 11:27AM the surveyor observed broken blinds in resident room # 107.On 9/10/25 at 11:27AM the surveyor observed that after surveyor intervention, cleaning was being performed to the community area furniture by Director of Housekeeping #8 and housekeeping staff.23. On 9/10/25 at 11:30AM surveyors observed an air conditioning unit in room [ROOM NUMBER] with duct tape present on each side of the air conditioning unit and a board which was taped to the window which had a dirty appearance with black, brown, and gray matter present on it. The residents' window view was unclean and cloudy in appearance with weeds observed within the window space. An electric vent labeled split-system heat pump with a buildup of gray matter within it was observed affixed to the wall. The flooring near the resident's bed was observed to be cracked.24. On 9/10/25 at 11:36AM surveyors observed a 6-inch x 3 inch area in resident room [ROOM NUMBER]'s door covering to be cracked. Further observation of room [ROOM NUMBER] revealed chipped paint present within the room, and a patchwork area on the lower portion of the wall near the bathroom which was approximately 3 feet tall x 2 feet wide with pieces of cove molding adhered to the wall in several areas with areas of smeared adhesive type material with cove molding at the base with a bowed appearance. An exposed area of broken drywall type material was observed present next to the patchwork area. The bathroom was observed to have gray scrape marks on the doors and along the wall across from the commode. Spackled screw holes and an unpainted area was observed on the wall next to the toilet paper dispenser, and the seam along the wall was observed to be brown in appearance. The caulk surrounding the toilet base was observed to be missing in some areas and areas of dark brown staining were present. One ceiling tile in the bathroom was observed to have brown staining covering approximately 70% of the tile's surface. The wall behind the commode was observed to have an unclean appearance with various brown speckles present and a section of dry wall material to the right of the bathroom sink was observed to be in disrepair with a bubbled appearance and an area that appeared to be cut exposing a different material underneath and a smeared area of adhesive/spackle type material.25. On 9/12/25 at 9:19AM the surveyor observed pieces of the severely worn cushioned chair's surface material present on the floor in the community area next to the facility's lobby. The surveyor noted that multiple stains and discoloration of the couch's fabric throughout continued to persist after housekeeping staff had previously performed cleaning of the material in response to the surveyors sharing of concerns.Surveyors completed a tour of the facility to share maintenance concerns on 9/12/25 with Maintenance Director #18 beginning at approximately 9:45AM, in addition to other prior tours additionally performed with them. 26. On 9/12/25 at 10:43AM surveyors observed resident room [ROOM NUMBER]. The resident's sink vanity was observed to have a square shaped piece of wood material which was worn in appearance, attached to the front of the vanity by nails. Cracked areas were observed present between the vanity and the wall. The materials on the front of the vanity were observed to be mismatched. [NAME] cove molding was observed to be bowed in appearance and did not cover the flooring surface beyond where the flooring material ended. One bathroom ceiling tile was observed to be lifted in appearance and the metal grid holding the ceiling tiles was observed to have discolored areas with a rusty brown appearance. The bathroom lighting was observed to have a light fixture with two different colored bulbs present, one which was fluorescent and one which was a warm color. The cove molding in the bathroom was observed to be separated from the wall with duct tape present on it. Another section of the cove molding in the bathroom was observed to have various pieces of duct tape securing it to the wall. The handle covers present on the resident's toilet seat riser were observed with areas of worn off material.27. On 9/12/25 at 10:47AM surveyors observed resident room [ROOM NUMBER]'s bathroom which had wet brown liquid and areas of missing caulk surrounding the base of the commode. Cobwebs were observed in the corner of the ceiling in the resident's bathroom. The sink vanity was observed to have a worn appearance with two cupboard doors, one of which was missing a handle. Cove molding was observed at the base of the vanity to have a bowed appearance exposing flooring area with dark debris present. The light fixture located above the vanity was observed to have a pull cord approximately 2 inches in length which was difficult for the resident to reach. Surveyors observed a light fixture mounted on the wall located next to the resident's bed, however, the pull cord for the fixture was on the opposite side of the fixture, located away from the resident's bed and was not within reach of the resident when the resident was in bed. 28. On 9/12/25 at 10:50AM surveyors observed the room signage to resident room [ROOM NUMBER] with chipped areas present. 29. On 9/12/25 at 10:50AM surveyors observed a damaged area of ceiling with cracking present with a stained appearance surrounding the crack and staining and a bubbled appearance below the area on the wall in the hallway outside of resident room [ROOM NUMBER].On 9/12/25 at 10:50AM surveyors observed the room number signage to resident room [ROOM NUMBER] to be worn in appearance with splattering of white paint and chipping areas observed on it.On 9/12/25 at 10:50AM surveyors observed three different colored mismatched areas of handrails located across from resident room [ROOM NUMBER].30. On 9/12/25 at 10:55AM surveyors observed 18 out of 18 call bell light covers located in the 2A hallway with discoloration and brown staining present.31. On 9/12/25 at 10:50AM surveyors observed the 2A day room. Chipped paint and black marks were observed on wall surfaces, three tray tables were observed, one tray table with brown stains present and a dirty straw, one tray table with cracks present in the surface and crumbled areas along the edges of the tray table, and one tray table which was holding metal equipment and trash bags. The blinds were observed with a worn appearance with areas of chipping paint present on them. An unused bulletin board with staples present was observed sitting against the wall on the floor, and another bulletin board was observed to be blank with a torn paper covering present on it. A black plastic piece was observed secured to the wall with no phone present. A toilet seat riser and a hoyer lift were observed stored in the day room. One ceiling tile was observed with a brown half circle shaped stain present.32. On 9/12/25 at 10:51AM surveyors observed electrical panels on the first floor of station 2A containing breakers were openly accessible within the resident hallway and with a plastic container of personal protective equipment was located directly in front of the breaker box which had a sign posted which read the following information: CAUTION area in front of this electrical panel must be kept clear for 36 inches.33. On 9/12/25 at 10:52AM surveyors observed a dented doorknob in the first-floor hallway located on station 2A.34. On 9/12/25 at 10:54AM surveyors observed a section of missing ceiling tile in the hallway outside of resident room [ROOM NUMBER].35. On 9/12/25 at 10:54AM surveyors observed multiple resident room doors with various areas of worn sticker type adhesive present in the hallway of room [ROOM NUMBER].36. On 9/12/25 at 10:58AM surveyors observed dark brown staining present on ceiling tiles located just beyond the double door locked entrance to Station 1 (house). The interior surface of the double doors was observed to have large areas of scraping and missing paint present. The window to the nursing station visible from the resident's dining area was observed to have a peeling film appearance with the backs of nursing papers and tape and adhesive visible. Chipping wall paint was observed below the window area.37. On 9/12/25 at 10:58AM surveyors observed blue drip marks approximately 2 feet in length present along the hallway's mural on Station 1 (house).38. On 9/12/25 at 10:58AM the surveyors observed a bare appearing community room area which opened into and was visible from the resident community area with one table, no chairs or other furniture, 2 vending machines, a hand sanitizer fixture, and Heimlich maneuver poster. The room included several windows with a view of overgrown weeds, an exterior door with a rust-colored appearance, broken metal objects, a large wooden board which appeared to have partially rotted, and a piece of pvc pipe lying on the ground outside. 39. On 9/12/25 at 11:00AM surveyors observed an area of flooring on the first floor of Station 1 (house) near the elevator and outside of the bathroom with flooring which was observed to be in disrepair to include chipping areas with pieces missing, and lifting/bowed. The flooring material was felt to be movable when surveyors walked on it. Areas of the walls in this area were observed to be unfinished with paint and missing cove molding and peeling paint.40. On 9/12/25 at 11:06 AM surveyors observed the flooring in the hallway of the first floor of station 1 which had an area of disrepair and mismatched flooring. Observation of the first floor station 1 community area next to the nursing office was observed to have flooring that was severely worn with the surface color worn and chipping areas, and missing and broken blinds were present, and a window which had a white piece of board taped in place to cover the lower portion of the window was observed to have a bent metal covering to the windowsill which was separated from the windowsill. Window drapes at the top of the windows were observed to be hung in a bunched and uneven manner. [NAME] spackling was present on the wall in several areas next to the community room's bathroom. The nurses' station glass windows were observed to be unclean with a cloudy appearance. The ceiling was observed to be bowed in appearance with brown staining present on the ceiling tile where the metal sprinkler was located. Interior front doors to the station 1 house were observed to have areas of scraping and worn off paint. The flooring in front of the interior front doors to the station one house were observed to be mismatched in color and type and an area was missing a piece of flooring. A vent was observed above the interior front doors to the station one house which was covered in gray matter.41. On 9/12/25 at 11:14 AM surveyors observed resident room # 2 with broken blinds and no privacy curtains for two out of two residents in the room. One light fixture was observed to be loose hanging from the wall with a 2-inch cord present. Areas of scraping and chipped paint were observed on the walls of the room and on a door located within the room which did not have a door handle present and where the door handle would be located, a hole was observed. Screens on both sides of the air conditioning unit located within the window of the room were observed to have open areas unscreened to the outside. The glass type material in the windowpane of the window was observed to be cracked. Flooring tiles were observed by surveyors to be lifted out of their areas and laying on the floor.42. On 9/12/25 at 11:15 AM surveyors observed cracking in the wall above the glass window in the hallway near the nurse's station. Walls located next to the nursing station in the hallway were observed to have areas of different colored paint and several walls were unclean in appearance with brown drip marks present and multiple plastic anchors were observed protruding from the wall.43. On 9/12/25 at 11:16 AM surveyors observed a nutrition area located in the resident hallway of station 1, floor 1, which included a wall mounted cupboard with doors which were nailed shut and a seam on the wall below the cupboards was exposed. A mismatched piece of wood was observed nailed to the front of the nutrition station area below the countertop, next to the nutrition refrigerator. A section of flooring below the nutrition refrigerator was observed to be missing exposing other flooring type with broken materials.44. On 9/12/25 at 11:16 AM surveyors observed a hand washing sink area located in the hallway of station 1, floor 1 which was observed to be in disrepair with crumbling slash peeling areas and missing hardware. The wall located behind the faucet was observed to be discolored and unclean in appearance. Cracking was observed in the caulk surrounding the hand washing countertop. The corner molding next to the hand washing sink was observed to be separated. A large crack was observed in the wall of the resident hallway extending from the molding upward above the fire pull station and worn paint was observed on the wall in this area.45. On 9/12/25 at 11:17AM surveyors observed white plastic corner molding hanging loosely off of a wall corner in the station 1, floor 1 resident hallway near resident room [ROOM NUMBER]. Flooring tiles within resident room [ROOM NUMBER] were observed to be mismatched in color, and there was no threshold strip located between where the hallway flooring ended and the square tile flooring to the resident room began. The doorway area to resident room [ROOM NUMBER] was observed to have an unclean, dark worn adhesive type material present. Resident room [ROOM NUMBER]'s window glass was observed to be cloudy and unclean in appearance. Metal material was observed sticking upward from the windowsill. Dark areas of staining were observed on the surrounding window surface. One white, jagged piece of white colored hard material was observed nailed to the corner of the windowsill, and worn duct tape was observed extending from the window sill upward. Areas in the corners of the window were observed with cracking and peeling. A gray cobweb approximately 1 foot in length was observed hanging in the corner of the ceiling of the room. Pieces of unfinished wood were observed screwed to the ceiling supporting the metal for the privacy curtain to hang on.46. On 9/12/25 at 11:23AM surveyors observed the second floor of station 1 (house). Flooring was observed with areas where the surface color was worn off, and areas of chipping.47. On 9/12/25 at 11:23AM surveyors observed resident room [ROOM NUMBER] which had an area of mismatched, uneven, wood filler type material smeared with a rough appearance on the resident's door and over the area below the door hinge. Splintered wooden areas were observed to be present on the door frame to the room. Surveyors observed cracked and broken flooring leading to the entrance to the resident's room, with approximately a 0.5-inch depressed area. The flooring leading into the room was observed to have an unclean appearance with grey and brown debris present. A piece of furniture with a visibly worn surface was observed in the room with one drawer mismatched in color to the remaining four drawers with one drawer missing the handle with a broken piece of handle protruding from the drawer. Several areas of paint were observed to be worn off on the wall near the light fixture.48. On 9/12/25 at 11:24AM surveyors observed the resident bathroom located near resident room [ROOM NUMBER] which was observed to be unclean in appearance with brown debris on the wall, the toilet was observed to be mounted diagonally and close to the wall. Paint on the walls was observed to be patched with different colors, and chipping paint was observed to be present. [NAME] debris was observed present on the bathroom floor and surrounding the entrance to the bathroom and along the wall which was observed with no cove molding present. Dark stained areas were observed to be present surrounding the base of the commode. Molding located behind the toilet was observed to be cracked with separation present. The upper portion of the side of the bathroom vanity was observed to be damaged with separated covering material with exposed particle board type material with a white fuzzy substance observed within it. The lower portion of the side of the bathroom vanity was observed to be damaged and lifted upward. No sink stopper was present within the sink.49. On 9/12/25 at 12:12PM surveyors observed a handrail next to the 2A community room with no cap, exposing a sharp metal surface. Surveyors shared the concern with Director of Maintenance # 18 who observed, acknowledged and confirmed understanding of the concern.50. On 9/12/25 at 12:14PM surveyors observed the shower room located near the elevator on the first floor of station 1 (house) which was observed to be in disrepair. The handwashing sink vanity was observed to have an area of damaged wood laying beneath it with dark debris present. An area of disrepair was observed to the right of where the handwashing sink was attached to the wall with a dark gray and rough appearance, the left side of the vanity was observed to be separated from the sink top, with a crumbled and peeling appearance, the area above the entrance to the restroom on the wall was observed to have cracking present and white spackled areas. The area of wall located next to the fire extinguisher signage was observed to be cracked extending from the door frame to the ceiling.51. On 9/12/25 at 12:15PM surveyors observed a hallway electrical outlet with no cover present, with gray matter present. A wall corner was observed in the hallway with a cracked and damaged appearance with exposed metal present.52. On 9/12/25 at 12:16PM surveyors observed countertop covering to the side of the countertop above the nutrition refrigerator on the first floor of station 1 (house) was broken.53. On 9/12/25 at 12:19PM surveyors observed broken wood covering present on the lattice within the station 1 community area.54. On 9/12/25 at 12:20PM surveyors observed room [ROOM NUMBER] on the first floor of station 1 (house) with broken blinds, crumbled areas on the furniture surface, a cracked window pane, the window was observed and felt to be movable and not secured, a piece of bent metal flashing hanging from the base of the window sill near the floor which was protruding outward next to the resident's bed. The overbed table was observed to have an unclean surface. A damaged thermostat was observed mounted on the wall with a plastic covering hanging off of and lifted out of the wall with plastic anchors visible. room [ROOM NUMBER]'s signage did not identify which bed the resident was located in. 55. On 9/12/25 at 12:21PM surveyors observed an area outside of resident room [ROOM NUMBER] on the wall with an area of peeled and missing paint in which the brown wall board was exposed.56. On 9/12/25 at 12:21PM surveyors observed resident room [ROOM NUMBER] with mismatched colors of flooring which appeared to be unclean with brown debris present. A section of flooring was observed to be lifted and out of its place, laying on the floor. Broken and splintered wood was observed on a lattice type covering within the room. Chipping and cracked paint were observed in several areas within the room to include a pipe running along the floor, the wall below the windowsill and additional wall areas. Blind panels were observed to be broken and with missing sections of panels. Resident wardrobe furniture was observed to be missing a drawer and hardware, and the bottom of the furniture appeared to be in disrepair as well as the drawer that existed was observed to be broken. Surveyors observed that two out of three residents had no privacy curtain present. Bent areas of metal windowsill material were observed. An area was openly exposed to the outside between the window and the covering extensions of the window ac unit. Dark debris was observed on areas of the window and windowsill. Window glass privacy covering was observed with scratched off areas.57. On 9/12/25 at 12:23PM surveyors observed broken ceramic pieces sticking out several inches long from the wall in the resident hallway on the first floor of station 1 (house).58. On 9/12/25 at 12:23PM surveyors observed the fluorescent lighting in the ceiling next to the stained ceiling tile containing the metal sprinkler on the first floor of the station 1 community area. The fluorescent lighting was observed to be lifted in the area with the bowed appearance in the ceiling which exposed approximately an inch of metal that was observed with a black, thick layer of debris present.59. On 9/12/25 at 12:24PM surveyors observed cove molding missing on a wall corner near the room labeled Station 1 Unit Manager.60. On 9/12/25 at 12:25PM surveyors observed that room [ROOM NUMBER] had no signage except the number 12 written in pen on the wall which was surrounded by chipping drywall material and ripped areas of brown exposed wallboard. room [ROOM NUMBER] was observed to have denting in the walls and an area of damage which included cracked paint and drywall, and depressions in the wall. Blinds were observed to be damaged and missing in sections. The light fixture above the bed was observed to have speckled areas of rust color. The mirror type material on the wall was observed to be unclean with various gray smears present.61. On 9/12/25 at 12:27PM surveyors observed two diagonal cracks present in the wall and separation present between where the wall met the ceiling on the second floor of station 1 (house) resident hallway.62. On 9/12/25 at 12:27PM surveyors observed an area between a door frame and the wall to have multiple broken and crumbled several inch sized pieces of building material present on the second floor of station 1 (house).63. On 9/12/25 at 12:28PM surveyors observed the second-floor station 1 (house) shower room signage in the resident hallway with missing letters and a worn appearance in areas on the surface of the door and door frame. Black scraping was observed to be present on the wall next to the shower room. Within the shower, a metal folding chair with plastic was observed to be situated in the shower for a seat. The vent labeled NuTone within the bathroom was observed to be covered with a layer of thick grey debris. The soap dispenser was observed to have rust-colored stains present.64. On 9/12/25 at 12:29PM surveyors observed the second-floor station 1 (house) bathroom which was observed to have dark areas present surrounding the base of the commode, the side of the bathroom vanity with exposed particle type board present, and 1 of 2 knobs was present on the vanity doors.65. On 9/12/25 at 12:29PM surveyors observed a ceiling tile in room [ROOM NUMBER] with a dark brown stain present.66. On 9/12/25 at 12:30PM surveyors observed room [ROOM NUMBER] with cracking in the wall's surface which extended upward from near the floor to near the ceiling. Cracks were observed in the ceiling and where the wall met the ceiling. Flooring near this area was observed to have a bowed appearance. A small nightstand piece of furniture was observed with wear to the wood-colored surfaces. Sections of flooring in the room were observed to be mismatched in color and cracking was observed within the wall which held a wooden fireplace mantel. Above the mantel was an area of wall damage present with chipping paint and exposed brown material. Sections of window blinds were observed to be missing. Another crack in the wall was observed extending above the resident's light fixture up toward the ceiling. Cracking in the wall was observed above the resident's bedroom window.67. On 9/12/25 at 12:32PM surveyors observed an uncovered area in the resident hallway below the signage to room [ROOM NUMBER] with uncovered wiring. Gray marks were observed on the wall.68. On 9/12/25 at 12:32PM surveyors observed broken and mismatched areas of flooring in the resident hallway outside the shower room near room [ROOM NUMBER].69. On 9/12/25 at 12:32PM surveyors observed the flooring to room [ROOM NUMBER] to be sloped and felt soft when walked upon. Flooring tiles located near the window sill were observed to have darker staining present.70. On 9/12/25 at 12:33PM surveyors observed and felt areas of flooring material which were raised with an uneven surface outside of the resident bathroom on the second floor of the station 1 (house) hallway. Throughout the tour with Maintenance Director # 18 they acknowledged and confirmed understanding of the surveyor's concerns.On 9/15/25 at 9:25AM surveyors conducted a tour of the facility including the facility's Administrator and Maintenance Director #18 to share surveyor concerns. During the tour, surveyor concerns were acknowledged by both the facility Administrator and Maintenance Director #18.On 9/15/25 at 9:25AM the facility Administrator stated that the flooring located on floor 1, station 1 outside the elevator got replaced not long ago. The handle to the shower water was observed and felt to be movable and separating from the wall, at which time the facility Administrator stated: I'm seeing that now moving, so we are going to fix that.On 9/15/25 at 9:30AM after surveyor intervention, the Director of Maintenance stated to the Administrator in the presence of surveyors that they (facility staff) are working on hanging privacy curtains now. After surveyor intervention, the Administrator informed a staff member that the window to the nursing station needed cleaning, to which they replied: Housekeeping does that. 71. On 9/15/25 at 9:35AM a metal plate with a cut out sharp edge was observed on a door within the first floor station 1 (house) hallway and both the Administrator and Director of Maintenance #18 confirmed with surveyors that this

Based on observation and interview it was determined the facility failed to: 1.) ensure proper sanitation and food handling practices, 2.) properly monitor the temperatures of nourishment refrigerators, and 3.) ensure labeling and dating of food products and monitoring for expiration of food product. This was evident during the surveyor's tours of the facility's kitchen during the facility's recertification survey. The findings include: 1. On 9/4/25 at 7:46AM the surveyor conducted an initial tour of the facility's kitchen. On 9/4/25 at 7:47AM the surveyor observed the reach in refrigerator with an unclean appearance. Black debris and food crumbs were observed in the bottom of the reach in refrigerator and the racks holding containers of food items were observed to have missing areas of paint. The surface of the walls within the reach in refrigerator had an unclean appearance with brown debris present. The handles to the reach in refrigerator were missing coverings revealing sharp edges. One unlabeled container of salad was observed to be present on the shelf within the reach in refrigerator with a condiment packet within it resting on the lettuce. At this time, the surveyor requested and conducted a dual observation of concerns with Dietary Director #5. On 9/4/25 at 7:49AM the surveyor observed the walk in refrigerator's exterior thermometer to be in broken condition and reading below -40 degrees. On 9/4/25 at 7:49AM a container of Worcestershire sauce was observed to have dark rings within the container and white debris present on the outside of the container. On 9/4/25 at 7:51AM the surveyor observed an air filter with a thick layer of gray fuzzy debris located directly above the ice chest in the kitchen where ice was observed to be stored below it. Dietary Director #5 observed and acknowledged the concern. On 9/4/25 at 7:52AM the surveyor observed individual plastic bags of lunchmeat and cheese sandwiches marked with use by dates of Tue 9/03 with condiment packages inside the packaging resting against the sandwich bread which was located within the walk in refrigerator. On 9/4/25 at 7:52AM the surveyor observed a plastic container of hard boiled eggs with speckled debris on the top of the outside of the container which was labeled USE BY [DATE] Sat 25 in the walk in refrigerator. Dietary Director #5 observed and acknowledged the concern. On 9/4/25 at 7:54AM the surveyor observed two unlabeled saran wrapped packages within the walk in refrigerator, one containing hot dogs, and one containing French fry wedges. Dietary Director #5 acknowledged the concern, confirmed there was no labeling present, and was observed throwing the items away into the trash can. 2. On 9/4/25 at 8:01AM the surveyor observed a layer of brown and black debris and food crumbs present on the food serving line equipment on the shelving located below the steam table. A layer of tan crusted food debris was observed just below the food service line on the surface of the equipment. 3. On 9/4/25 at 8:03AM the surveyor observed a plumbing pipe below the three compartment sink which was dripping into a plastic hot food cover which was filled with clear liquid. 4. On 9/4/25 at 8:04AM the surveyor observed a layer of gray fuzzy matter present on various piping extending over and near the food service line. 5. On 9/4/25 at 9:36AM the surveyor observed a layer of gray and black debris present on a vent near the food serving line. All concerns were shared with Dietary Director #5 and dual observations of concerns were made with them. On 9/5/25 at 1:56PM the surveyor conducted an interview with Dietary Director #5 who after surveyor intervention, reported to the surveyor that they had cleaned the areas below the steam table and that the dripping pipe in the kitchen needed to be sealed by maintenance and he needed to check the status of the repair.6. On 9/11/25 at 9:38AM the surveyor observed debris continued to be present on the vent near the food serving line which was holding containers of food below it. A dual observation was conducted of the concern with Dietary Aide #31 who acknowledged and confirmed understanding of the concern. A dual observation was then subsequently conducted by the surveyor with Cook/Supervisor #32 who observed the concern and also acknowledged and confirmed understanding of the concern. 7. On 9/11/25 at 9:41AM the surveyor observed brown liquid pooling in the bottom of the reach in refrigerator.On 9/11/25 at 9:42AM the surveyor conducted a dual observation of the concerns within the reach in refrigerator with Cook/Supervisor #32 who observed, acknowledged, and confirmed understanding of the concerns.8. On 9/11/25 at 9:45AM The surveyor conducted a dual observation of concerns with Dietary Director #5. On 9/11/25 at 9:51AM the surveyor conducted a dual observation with Dietary Director #5 and observed the walk-in refrigerator to have a dirty and unclean appearance to the flooring, with areas of black and brown matter, thick areas of food debris, and small pieces of trash present on the floor. Areas of chipped paint were observed on the walls of the walk in refrigerator. Separated areas along where the walls met the ceiling were observed with black and brown matter present. A crack was present in the ceiling of the walk in refrigerator and the ceiling was observed to have black speckled areas of matter present. 9. On 9/15/25 at 12:15PM the surveyor requested and conducted a dual tour of nutrition rooms with Dietary Director #5. On 9/15/25 at 12:18PM the surveyor observed the Unit 2A nutrition refrigerator which held outside resident foods with meat and dairy in disposable containers, cartons of juice, and other food items. On 9/15/25 at 12:21PM the surveyor noted the Unit 2A nutrition refrigerator was observed with no temperature log present. When the surveyor inquired to Dietary Director #5 as to how they monitored temperatures of nutrition room refrigerators, they reported to the surveyor that the nursing staff was responsible for the monitoring. Dietary Director #5 was observed asking Licensed Practical Nurse (LPN) #33 where temperature logs were located, at which time they proceeded to the medication cart and unlocked it, and removed the temperature log to show the surveyor and Dietary Director #5. On 9/15/25 at 12:21PM the surveyor and Dietary Director #5 observed the nutrition refrigerator log for Unit 2A which revealed the temperature log was labeled Medication Storage Monthly Temperature Log (v June 2021). The following information was observed to be handwritten on the top of the log: Nourishment log 2A September 2025. Further review of the log revealed the following temperature range guidelines on the sheet in which the surveyor noted included temperatures above 40F: Refrigerator temperature acceptable range 36F-46F, record exact temperature twice daily if too warm or too cold record in other section and notify DON, If frig temp is out of range, call vaccine manufacturer (see package insert in product box) for vaccines and for all other items call the pharmacy for guidance. At this time, the surveyor conducted an interview with LPN #33 who confirmed with and reported to the surveyor that a range of 36F to 46F was acceptable for the nutrition refrigerator temperatures with food in them. When the surveyor inquired to LPN #33 as to what types of items were stored in the nutrition room refrigerators, they reported that outside resident food, nutrition supplements, milk, and other food items were stored in them. At this time the surveyor conducted an interview with Dietary Director #5 who acknowledged that the temperature range being monitored was not acceptable for food storage and acknowledged understanding of the surveyor's concerns. On 9/15/25 at 12:37PM the surveyor conducted a dual tour of the Station 1 (house) nutrition refrigerator with Dietary Director #5. LPN #35 provided the temperature monitoring log for the refrigerator for Station 1 which revealed the temperature log was labeled Medication Storage Monthly Temperature Log (v June 2021). The following information was observed to be handwritten on the top of the log: Nourishment Station 1 September 2025. Further review of the log revealed the following temperature range guidelines on the sheet in which the surveyor noted included temperatures above 40F: Refrigerator temperature acceptable range 36F-46F, record exact temperature twice daily if too warm or too cold record in other section and notify DON, If frig temp is out of range, call vaccine manufacturer (see package insert in product box) for vaccines and for all other items call the pharmacy for guidance. At this time, the surveyor conducted an interview with LPN #34 who reported to the surveyor that the appropriate range for the nutrition refrigerator was 36F to 46F and showed the surveyor where that was written on the log. LPN #34 stated that anything above this range, we let maintenance know by using the TELS [system for reporting maintenance concerns to maintenance staff] system. When the surveyor inquired as to LPN #34 if they need to let the kitchen know when a refrigerator is out of the temperature range on the form, they stated to both the surveyor and Dietary Director #5: No we don't let the kitchen know, it gets put in TELS. LPN #34 reported the nourishment refrigerator was used if residents needed to store food, for juice, and sometimes milk. On 9/15/25 at 12:43PM the surveyor conducted a dual tour of the Station 2B nourishment refrigerator with Dietary Director #5. Frost build up was observed within a compartment of the refrigerator with brown staining present on a portion of the build up. An area of brown liquid was present within the refrigerator. Yogurt was observed stored within the refrigerator. At this time, the surveyor conducted an interview with LPN #35 who reported that the temperature range considered out of range and necessary to report for the nourishment refrigerator was below 40F, 40F or below, and 48F and above. On 9/15/25 at 12:44PM the surveyor observed the Station 4 nourishment refrigerator with Dietary Director #5. Two different temp logs were observed to be in use at the same time with two different temperature ranges listed on them for September 2025. The surveyor noted that both temperature logs were observed to be incomplete. Upon observation by the surveyor and Dietary Director #5 of the thermometer located within the Station 4 nourishment refrigerator, it was noted that the thermometer read 46F. Frost build up was observed within a compartment of the refrigerator with brown staining present. Yogurt was observed to be stored within the refrigerator. The surveyor conducted an interview with LPN #36 and inquired to them as to what temperatures would be considered out of range for the nourishment refrigerator in which they would need to alert someone, to which they replied: above 40F, 46F, anything below 36F, and above 46F. At this time, Dietary Director #5 stated to the surveyor that they would be letting maintenance know, and the contents of the refrigerator would be discarded. On 9/15/25 at 12:53PM the surveyor observed the Station 3 nourishment refrigerator temperature log with Dietary Director #5, which revealed the temperature log was labeled Medication Storage Monthly Temperature Log (v June 2021). The following information was observed to be handwritten on the top of the log: Nourishments #3 [DATE]. Further review of the log revealed the following temperature range guidelines on the sheet in which the surveyor noted included temperatures above 40F: Refrigerator temperature acceptable range 36F-46F, record exact temperature twice daily if too warm or too cold record in other section and notify DON. If frig temp is out of range, call vaccine manufacturer (see package insert in product box) for vaccines and for all other items call the pharmacy for guidance. Both the surveyor and Dietary Director #5 observed that recorded on 12 occasions throughout September 2025, the temperature of the nourishment refrigerator was recorded by nursing staff on 3 occasions at 42F. Two thermometers were observed to be present in the Station 3 nourishment refrigerator, one which was observed to read 46F, and another which was observed to read 52F. The surveyor asked for Registered Nurse (RN) #11 to read one thermometer temperature, and RN #11 reported to the surveyor that it was at 46F. Milk, juice, yogurt, previously opened supplements, and other items were observed stored within the refrigerator. On 9/15/25 at 1:00PM a carton of milk with an expiration date of 9/12/25 was observed within the refrigerator. Dietary Director #5 stated to the surveyor: It's out of date, and everything needs to be discarded, and was observed removing the carton of milk from the refrigerator. Dietary Director #5 observed and acknowledged and confirmed understanding of the surveyor's concerns and stated the following information to the surveyor: I'm going to take the refrigerator out of service and let maintenance know, as soon as I walk downstairs.

Based on observations, staff interviews and review of facility documents, it was determined the facility failed to implement, complete and accurately reflect a Facility Assessment regarding the facility's physical environment, equipment, and other physical plant considerations that are necessary to care for its population, as well as an evaluation of the facility building maintenance capital improvements, or structures. This was evident during survey with the potential to affect all residents. The findings include the following: During observational rounds of the facility and interview on 09/12/2025 at approximately 9:45 AM with Maintenance Director staff #18, the surveyor asked if there was a preventive maintenance plan in place for replacement or repairs of resident beds, resident furniture, electrical switches/outlets, painting of facility walls, condition of walls, condition of ceilings, conditions of floors, condition and functionality of showers, condition of building foundation, functionality of resident call bell systems and monitoring of decline of the overall facility environment. Maintenance Director staff # 18, responded to the surveyor's question by stating, no.During an interview on 9/15/25 at 11:23AM with Administrator staff #3 with the Director of Maintenance staff #18 present, the surveyor inquired as to if the facility had a preventative maintenance program, to which the Administrator replied in the presence of the survey team: No, we don't have one. During review of the Facility Assessment on 09/15/2025 at 3:45 PM revealed the facility is performing a Routine Preventive Maintenance Schedule on a daily, weekly and monthly basis. However, the facility could not provide evidence that this was being completed. Further review revealed that the Facility Assessment did not include an evaluation of building maintenance capital improvements or structures.

Based on observation and interview with staff, it was determined that the facility failed to: 1) ensure clean linen was handled and transported in a safe and sanitary manner. The was evident for 1 clean linen transportation cart observed; and 2) establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice was evident for the Water Management Plan investigated during the survey.The findings include: 1. On 9/5/2025 at 6:30AM, the Surveyor observed Staffing Coordinator #24 pulling a 2-shelf cart with blankets piled one on top of the other on the top and bottom shelf of the cart. The blankets were uncovered and 2 brown blankets, on the bottom shelf, were dragging on the floor as the staff pulled the cart onto the basement elevator. The Surveyor asked, Are the blankets clean? Staffing Coordinator #24 responded Yes. The Surveyor asked, Should the blankets be covered? Staffing Coordinator #24 replied, I know, I know. She's getting me a bag. The Surveyor observed another staff member give Staffing Coordinator #24 a large, clear plastic bag and remove the 2 brown blankets, that were observed dragging on the floor, from the bottom shelf of the cart. On 9/5/2025 at approximately 9:30AM, during an interview with the Nursing Home Administrator (NHA), the Surveyor expressed the concern that clean blankets were being transported uncovered and 2 brown blankets were observed dragging on the floor as staff #24 entered the basement elevator. On 9/8/2025 at approximately 2:00PM, the Surveyor reviewed an In-Service Summary and Attendance form completed on 9/5/2025 with the subject: Clean Linen Transportation. The in-service stated Clean linen must be transported in linen carts with covers in place. Only clean linen should be in linen carts. No personal items in linen carts. Nursing staff provided signatures on the form. 2. On 09/12/2025 2:50PM during facility record review of the 'Infection Control Log' received and interview with the ADON/Infection Preventionist Staff #4, it revealed the following for reporting period 7/1/25-7/31/25 with 3 episodes of pneumonia, and for reporting period 8/1/25-8/31/25 it revealed a potential spike of 6 episodes of pneumonia. Surveyor asked Staff #4 were they aware of water testing at the facility and the results; surveyor was told Yes. On 09/12/2025 3:00PM during facility record review of the Water Management plan received from Maintenance Director Staff #18 for the Infection Control Facility Task it revealed 'Legionella Analytical' water test results dated 7/17/25 of water sampled on 7/1/25 detected Total Legionella for 3 of the 7 sample areas reported as follows: 1st Fl. Kitchen Sink (Hot) at 12 CFU/ml; 2nd Floor Main Shower Room (Cold) 18 CFU/ml; and 1st Fl. Kitchen Sink (Cold) >300 CFU/ml. On 09/15/2025 11:04 AM during record review the of the Water Management Plan received at the Entrance Conference on 09/04/25 from NHA Staff #3 and a duplicate copy from Maintenance Director Staff #18 on 09/12/25 3:00 PM, after surveyor request for an updated copy if available. The 18-page document revealed the following items per page: 1. Water Management Program Team Roster 2. Water Management Program: Facility Information (listing Forest Haven Nursing Home demographic details, such as Name, Facility Description, Address, etc.) 3. Water Safety Management Assessment & Plan (Date of Assessment: 11/20/21) 4. Water System Narrative Description: Detailed Pages 5-12. Water Flow Diagrams (8 pages of non-specific data for Forest Haven) 13. Water Management Program Control Measures Pages 14-15. Diagrams (2 pages of non-specific data for Forest Haven) 16. Water Management Program Validation Techniques On 09/15/2025 11:45 AM during interviews with Maintenance Director Staff #18 and NHA Staff #3, surveyor discussed concerns regarding the Flow Diagrams on pages 5-12 and 14-15 and asked were the diagrams specific to Forest Haven water flow system; Maintenance Director Staff #18 stated No. Surveyor asked if there was any other description of building water system using text and/or flow diagrams; Maintenance Director Staff #18 stated No, there are no Forest Haven specific flow diagrams. Surveyor expressed concern about the date of the assessment listed on page 3: Water Management Assessment & Plan as 11/20/21, despite the statement listed on the form Program review required at least annually and with qualifying event. On page 1: Water Management Program Team Roster reflects the responsible parties as follows: the NHA Staff #3 as Administrator, Maintenance Director Staff #18 as Maintenance Director, and ADON/Infection Preventionist Staff #4 as Infection Preventionist. Of note, surveyor was informed of the hire dates of the responsible parties on the Team Roster as follow; NHA Staff #3 stated NHA Staff #3 arrival-[DATE]; Maintenance Director Staff #18-May 2025; and ADON-Infection Preventionist Staff #4-[DATE]. Surveyor asked when the last water management plan reviewed, or assessment was completed; Maintenance Director Staff #18 stated site water testing was recently completed on 7/1/25 by EcoLab and results received on 7/17/25 revealed 3 of 7 samples with positive findings of Legionella detected. Surveyor asked Maintenance Director Staff #18 once the results were known, was this considered a qualifying event and was the Water Management Program reviewed or updated at that time; surveyor was told No, I was told to run the water daily and retesting was recently completed on 9/2/25, we are waiting results. Of note, the facility was unable to provide further evidence whether the facility implemented adequate prevention and control measures once the water testing issue was identified. Additionally, the facility was unable to provide an updated Water Management Plan or Flow Diagrams specific to facility.

Based on observation, record review, and interviews, it was determined that the facility failed to: 1) maintain laundry equipment in safe operating conditions. This deficient practice was evident for 1 of 4 washers and 4 of 5 dryers within the Laundry Room; and 2) maintain patient care equipment in a safe operating condition. This was evidence for 1 out of 4 Automatic External Defibrillators reviewed. The findings include: 1. On 09/12/2025 9:00 AM during record reviews and interviews pertaining to Complaint #309947 received on 5/21/25, it revealed the washing machine was broken, and we had to take the clothes home to wash them. During the interview the family stated that they were told during this time the machines were down but was never informed that the facility could still wash the resident clothing. Additionally, the family also shared they were never informed when the services resumed. On 09/12/2025 9:38 AM during observational rounds and interviews with the Director of Housekeeping/Laundry Account Manager Staff #8 in the Laundry Room, it revealed 1 of 4 washers and 4 of 5 dryers were out of service. The surveyor asked about the length of time the machines have been out of service. Staff #8 stated one washer has been out of service for over 3 years and of the remaining 4 washers, a 2nd washer was down from 5/9/25 to 5/13/25 for 5 days. During the days the washer was down and only 2 were working, the facility activated an off-site laundry plan. Currently 3 washers of the 4 are working. Staff #8 also advised for the dryers, 3 of 5 dryers have been out of service for over 3 years and are used just for spare parts. Another dryer (Dryer #1) went out of service on 7/10/25, the Maintenance Director (Staff #18) was notified. On 9/10/25, after a vendor service call, we were told the dryer needed several repaired. Currently there is no date of when the dryer will return to service, and 1 dryer is in use. The surveyor asked how the down machines impact the washing of resident personal clothing and Staff #8 stated resident clothing could still be cleaned, but there may have been delays. The surveyor shared the family concerns of Complaint #309947 and family being told machines were down. The Surveyor asked how updates about laundry services are communicated to the staff and families; Staff #8 stated I inform the nurse of the unit, not the GNAs or families. On 09/12/2025 1:25 PM during interview Maintenance Director Staff #18, surveyor shared concerns of multiple dryers and the 1 washer currently down. The surveyor requested the preventative maintenance logs or repair logs of the laundry equipment; none was provided for further review. On 09/15/2025 6:15 PM during interview with NHA Staff #3 the surveyor shared concerns regarding the multiple dryers and the 1 washer currently down and the lack of preventive maintenance or repair logs. Staff #3 stated those machines have been down for over 3 years; they are just used for spare parts. The facility could not provide any further supportive evidence about the length of time the equipment was not being used or plans to support the continued laundry needs of the facility. 2. Automatic External Defibrillator (AED) is a device that delivers an electric shock to the heart to restore a normal rhythm during a sudden cardiac arrest. On 9/10/2025 at 12:28PM, during a tour of Station 3, the Surveyor discovered an AED device located inside a locked container hanging on the wall outside of the nursing station. The container cabinet window had a clear, transparent, glass-like material which was cracked with sharp edges. The AED was inside the container in a blue case. There was no visible expiration date. The status indicator or ready green light was not on. Instead, there was a red indicator with a black X on it. On 9/10/2025 at 12:33PM, during an interview with Unit Manager/ Licensed Practical Nurse (LPN) #6 on Station 3, the Surveyor was informed that the maintenance department was responsible for routine inspections of the AED devices to ensure they are ready to use. There were 4 AED devices located by the nurses' stations on Station 2A, 3, 2B, and 4. The Surveyor and LPN #6 viewed the AED device on Station 3 and confirmed by visual inspection, the AED was not ready to use. The visual readiness indicator green light was not on and the red indicator with the black X was present. The glass-like material of the container window was cracked and broken with sharp edges. LPN #6 stated that she did not know the AED was not ready to use and container window was broken and would inform the maintenance department. On 9/10/2025 at 1:16PM, the Surveyor observed Maintenance Assistant #7 repairing the AED container window on Station 3. The Surveyor asked the status of the AED inside the container. Maintenance Assistant #7 was unsure how to check the status of the AED, did not know what the red indicator with the black X meant, and could not tell the Surveyor if it was ready to use. Maintenance Assistant removed the AED from the container. The AED made a beeping noise. During an interview with Maintenance Director #18 and the Director of Nursing (DON) at Station 3, the Surveyor informed the staff of the AED findings on that unit. The Surveyor, Maintenance Director #18, and the DON visually inspected the AED. The Surveyor expressed the concern that the visual readiness green light indicator was not on, there was a red indicator with a black X, there was no visual expiration date, and there was a beeping noise which indicated a problem and the AED would not be ready to use in the case of an emergency. The DON opened the blue case the AED was in. The chest pads needed to be replaced. The Surveyor confirmed the AED was not ready to use. The DON stated that the maintenance department was responsible for completing visual inspections of the AED's throughout the facility. The Surveyor stated that Maintenance Assistant #7 stated he did not know how to check the status of the AED devices and was could not tell the Surveyor when an AED is ready to use. The Surveyor also informed the staff that maintenance assistant #7 just fixed the container window which was cracked with broken, sharp edges. Maintenance Director #18 informed the Surveyor that he had been aware of the condition of the container window. Maintenance Director #18 stated that he would address the concerns with the AED promptly.

Based on observations and interviews with staff, it was determined that the facility failed to ensure that the resident's call system was functioning properly. This was found to be evident for 2 resident rooms (room [ROOM NUMBER] and #218) out of 17 rooms observed at Station 4 and 3 resident rooms (room [ROOM NUMBER], #2 and #8) out of 13 rooms observed at Station 1. The findings include: 1. On 9/12/2025 at 2:47PM, 4 Surveyors toured Station 4 nursing unit. An observation was made of the call system at the nursing station and room [ROOM NUMBER]. A Surveyor observed the nursing station call system, there was an audible beeping noise coming from the call system, but no room number illuminated to indicate which room needed assistance. As the other Surveyors walked through the hallway, no light above any room illuminated to indicate which resident room needed assistance. Geriatric Nursing Assistant #23 was observed walking out of room [ROOM NUMBER], Resident #107's room. The Surveyor asked GNA #23 if Resident #107 had pressed the call bell for assistance. GNA #23 stated that the resident did press the call bell and the GNA was responding to the call to see if the resident needed assistance. The Surveyor requested the GNA #23 to ask Resident #107 to press the call bell again. Resident #107 pressed the call bell. The Surveyor, at the nursing station by the call system, could hear the beeping noise but there was no room number illuminated to identify which resident room needed assistance. The other 3 Surveyors in the hallway did not see any lights above any resident rooms light up to identify what resident in what room needed assistance. During an interview with GNA #23, the Surveyor was informed that the GNA knows that Resident #107 in room [ROOM NUMBER] needs assistance when they can hear the beeping noise at the nursing station and do not see a light illuminated above any other room. All other rooms light up, except room [ROOM NUMBER], when the resident presses the call bell. The Surveyor expressed the concern that the call system at the nursing station failed to illuminate for room [ROOM NUMBER]; however, there was an audible noise heard at the call system. The Surveyor also expressed the concern that the light above room [ROOM NUMBER] failed to light up when the resident pressed the button. GNA #23 confirmed the Surveyor's findings and stated that the light at the nursing station call system and above room [ROOM NUMBER] had not been working properly for months now. The light above room [ROOM NUMBER] would work on and off, but not consistent and Maintenance had been made aware. 1a. On 9/12/2025 at 2:50PM, during a continued observation of the call system at Station 4 nursing station, the Surveyors tested the call bells for other rooms. A Surveyor pressed the call bell for room [ROOM NUMBER], and the light above the room illuminated. Another Surveyor observed the call system at the nursing station. An audible beeping noise was heard from the call system at the nursing station; however, room [ROOM NUMBER] illuminated on the call system. GNA #23 and the Surveyors confirmed that when the call bell was pressed in room [ROOM NUMBER], room [ROOM NUMBER] illuminated on the call system. There was no room [ROOM NUMBER] on the call system at Station 4 nursing station. 1b. During a tour of Station 4 and interview with Maintenance Director #18 and the Nursing Home Administrator (NHA) on 9/15/2025 at 10:37AM, the Surveyor expressed the concern that when Resident #107 pressed the call bell for room [ROOM NUMBER], the call system at the nursing station failed to illuminate; however, there was an audible beeping noise heard coming from the call system. The Surveyor also expressed the concern that the light above room [ROOM NUMBER] failed to light up when the resident pressed the call bell. During the interview, the Surveyor observed Maintenance Assistant #7 exiting room [ROOM NUMBER]. Maintenance Assistant #7 stated that the light above the door was fixed. Maintenance Assistant #7 and Maintenance Director #18 stated that they will address room [ROOM NUMBER] failing to illuminate on the call system at the nursing station. During a continued interview with Maintenance Director #18 and the NHA, the Surveyor informed the staff that when the call bell was pressed in room [ROOM NUMBER], room [ROOM NUMBER] illuminated on the call system. There was no room [ROOM NUMBER] on the call system at Station 4 nursing station. The NHA and Maintenance Director #18 confirmed the Surveyor's findings. 2. On 9/12/25 at 11:17AM surveyors observed Room # 4 on the first floor of station 1 and randomly tested the call bell nearest to the room's entrance door and observed that the call bell was not in working order, when the call bell button was pressed, it did not light the hallway call system. Director of Maintenance # 18 acknowledged understanding of the concern and reported to surveyors that they would get the call light fixed. 2a. On 9/12/25 at 12:20PM Surveyors observed room [ROOM NUMBER] on the first floor of station 1 (house). The call bell indicator light above the doorway in the resident hallway did not have a cover on it, the small light bulb was observed protruding from the mounted system. 2b. On 9/15/25 at 10:31AM surveyors observed the Station 1 second floor call bell system located in the resident hallway and observed that several call bell indicator lights on the system were missing plastic caps and failed to identify which room was calling for assistance which included room [ROOM NUMBER]. room [ROOM NUMBER]'s call light indicator had no cap and additionally, no light bulb present. On 9/15/25 at 10:31AM Certified Medication Aide #38 observed the call light system concerns with surveyors and acknowledged and confirmed understanding of the surveyor's concerns. During an interview on 9/15/25 at 11:23AM the surveyor inquired to the facility's Administrator with the Director of Maintenance #18 present, as to if the facility had a preventative maintenance program, to which the Administrator replied in the presence of the survey team: No, we don't have one. The Administrator stated the following information in response to the surveyor's inquiry as to if they felt that two maintenance staff were enough to cover the facility's environment needs: Well, the structure of the building is old, it's not an excuse, we've always run the maintenance department with two staff, we have two and a half people now, but we've always run it with two. At this time the surveyor offered to the Administrator and Director of Maintenance an opportunity for any questions regarding environmental concerns and they had no questions regarding the surveyor's environmental concerns.

Based on observation, record review, and interviews with staff, it was determined that the facility failed to ensure the exterior facility environment was maintained to be safe, sanitary. This was evident throughout the surveyors' tour of the exterior facility. The findings include: On 9/10/25 at 9:13AM the surveyor conducted a tour of the facility's exterior environment. 1a. On 9/10/25 at 9:13AM the surveyor observed a piece of white painted wooden board affixed to the front of the facility's entrance with visible black nails around the perimeter of the board, and several weeds sticking out from the side of the board. 1b. On 9/10/25 at 9:13AM the surveyor observed uneven depressed areas of missing and misplaced bricks at the entrance to the facility's main parking lot with weeds present, and felt movable bricks upon walking in the parking lot leading up to the concrete sidewalk near to the front doors of the facility. Weeds were observed present along the concrete sidewalk at the front entrance of the facility. 1c. On 9/10/25 at 9:14AM the surveyor observed sections of fencing along the front of the facility in disrepair and damaged in multiple areas. Broken railings were observed, railings were observed falling out of place with some resting on the ground, and some were observed to be half in place and half resting onto the ground. Various caps to the fencing were mismatched in appearance with some being flat, and some being pointed. One fence cap was observed to be broken with sharp edges protruding upward. [NAME] matter was observed on the white fencing. A broken area of white fencing post was observed sticking out of the ground along the front of the facility. A fence post was observed to be falling onto the ground next to the facility's tattered job fair signage affixed to the fencing. 1d. On 9/10/25 at 9:15AM the surveyor observed brown plant matter which was dry in appearance protruding upward from the facility's gutter above the facility signage on the front of the building. 1e. On 9/10/25 at 9:16AM the surveyor observed a broken glass window with tape on it from the facility's exterior grounds. Weeds were observed protruding from the facility's shrubs in front of resident room windows. 1f. On 9/10/25 at 9:16AM the surveyor observed an area on the roof of the facility with lifted and missing shingles with shingles hanging down from the roof with areas of black roofing material and an area of wood exposed. Resident and community area windows were visibly soiled and cloudy in appearance from the exterior. Dried brown vines were observed on the exterior of the facility's wall. Approximately ten cobwebs were observed on the exterior of the second floor window where the vending machine was observed. Broken blinds were observed from the facility's exterior. One window screen was observed on the ground below a window with no screen present in it. 1g. On 9/10/25 at 9:19AM the surveyor observed the carport type area in front of the facility to have a gray film present with columns which were observed to have cracked and chipping areas of paint and orange rust colored spots. 1h. On 9/10/25 at 9:20AM the surveyor observed various plastic covers below resident windows with a thick layer of brown debris present on them, and a dirty brief resting on the ground. An area beneath a resident window was observed with white fencing missing on the top railing, and a pile of broken railing pieces and debris was observed on the ground with a gray colored wood piece resting against the side of the facility. On 9/10/25 at 9:43AM the surveyor requested and completed a tour of the exterior facility environment and shared concerns with the Director of Maintenance #18 and the facility's Administrator. During the tour, both the Director of Maintenance and facility Administrator acknowledged understanding of and observed the surveyor's concerns. Director of Maintenance #18 reported to the Administrator that brackets needed to be put back into the fencing because when they put the fencing rails back into place, they fall back out. The facility Administrator stated to the surveyor that a quote for gutter cleaning had been obtained last month, however, this was not scheduled. The facility Administrator stated to the surveyor during the tour that they will have the windows cleaned inside and out, and a power washing company would be contacted to clean the building's exterior, and a lawn company would be called for the weeds, and the front door area was a work in progress. Director of Maintenance reported to the surveyor in response to the groundskeeping regarding weeds that they would have to call the landscaping company, and would remove the pile of broken fencing and wood. In response to the sharing of the shingles in disrepair, the Administrator stated the following information: I haven't taken notice to it. During an interview on 9/15/25 at 11:23AM the surveyor inquired to the facility's Administrator with the Director of Maintenance #18 present, as to if the facility had a preventative maintenance program, to which the Administrator replied in the presence of the survey team: No, we don't have one. On 9/15/25 at 11:26AM the surveyor attempted a phone call to the facility's Regional Director of Maintenance and no response was received. As of 9/22/25, there continued to be no response received.

Based on observation and interview it was determined the facility failed to ensure a handrail was firmly secured. This was evident for one handrail during a random observation on Station 3 during the surveyor's initial tour of the facility. The findings include: On 9/4/25 at 9:30AM the surveyor observed a handrail with a sharp edge present with a metal screw protruding from the wall in the hallway next to room [ROOM NUMBER]. The cap to the handrail was observed sitting on the opposite railing across the hall. Upon further inspection of the handrail the surveyor found the handrail to be loose and movable. On 9/4/25 at 9:34AM the surveyor conducted an interview and shared concerns with Unit Manager, Licensed Practical Nurse #6 who observed, acknowledged, and confirmed understanding of the surveyor's concerns and stated to the surveyor: Okay let me get maintenance, they replaced all this recently.On 9/4/25 at 9:36AM the surveyor shared concerns and conducted an interview with Maintenance Assistant #7, and after surveyor intervention, they reported the following information to the surveyor: We just fixed them, and they broke, We're gonna take care of that right now.

Based on record review and interview with staff, it was determined that the facility failed to facilitate timely care plan meetings after a resident's quarterly assessment. This was evident for 1 (Resident #14) out of 4 residents reviewed for care planning during the annual survey.The findings include:A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs.Interdisciplinary team (IDT) is a team of medical professionals that provide specific patient centered care to the residents within a facility. On 9/8/2025 at 2:00PM, the Surveyor conducted an interview with Social Services Director #1. The Surveyor was informed that care conference (care plan) meetings are held at admission, quarterly (every 90 days), for a significant change, or as requested by the resident or resident representative. Care conference meetings are usually held during the timeframe of the MDS assessment, and the interdisciplinary team participate in the meetings.On 09/11/2025 at11:16AM, during a review of Resident #14's electronic medical record, the Surveyor discovered that the last care conference was 5/15/2025 and the next care conference was due on 8/27/2025. Further review revealed a quarterly MDS assessment completed 8/5/2025. An additional review of the resident's medical record failed to reveal documentation of a care conference meeting during the timeframe of the quarterly MDS assessment on 8/5/2025. During an interview with Social Services Director #1 on 9/12/2025 at 2:12PM, the Surveyor expressed the concern that the last care conference meeting was 5/15/2025, greater than 90 days, and there was no documentation to verify Resident #14 had a care conference meeting during the timeframe of the quarterly MDS assessment on 8/5/2025. Social Services Director #1 confirmed the Surveyor's findings. The Surveyor requested any evidence that a care conference meeting had taken place for Resident #14 since the last meeting 5/15/2025.As of the survey team exit on 9/15/2025 at approximately 6:30PM, no documentation of Resident #14's care conference meeting since 5/15/2025 had been provided.

Based on record review and interviews with staff, it was determined that the facility failed to complete residents Pre-admission Screening and Resident Review (PASRR) forms according to professional standards of practice. This was evident for 1 (Resident #2) out of 6 resident PASRR's reviewed during the annual survey.The findings include:The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders(MD) or intellectual disabilities(ID) and related conditions. This initial pre-screening is referred to as PASARR Level I, and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility.PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has MD, ID or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs.On 9/8/2025 at 8:13AM, during a review of Resident #2's electronic medical record, the Surveyor discovered that the resident had diagnoses of, but not limited to, bipolar disorder, dementia, depression, and post-traumatic stress disorder (PTSD). Further review revealed physician's note dated 8/31/2023 which stated that the resident had multiple prior inpatient mental health hospitalizations, including 9/2022 and a placement at a Geri psych facility for stabilization prior to admission to the facility on 8/29/2023.On 9/8/2025 at 8:30AM, additional review of Resident #2's electronic medical record revealed a PASRR form dated 8/29/2023 and was completed by Social Service Assistant #2 upon admission to the facility. Section C #3 asks, In the past 2 years, has the individual had psychiatric treatment more intensive than outpatient care more than once (e.g.,partial hospitalization) or inpatient hospitalization, and the Social Service Assistant #2 answered No. However, the resident had been hospitalized for psychiatric treatment in 9/2022 and a placement at a Geri psych facility for stabilization prior to admission to the facility on 8/29/2023. Additionally, Social Service Assistant #2 failed to answer the follow up question to Section C Is the individual considered to have a serious mental illness? Social Service Assistant #2 proceeded to complete Section D with all No responses which indicated that the resident must be referred to Adult Evaluation & Review Services (AERS) for a Level II evaluation. Social Service Assistant #2 failed to follow up with the local AERS office.During an interview conducted with Social Service Director #1 on 9/9/2025 at 10:30AM, the Surveyor informed her of multiple concerns with Resident #2's PASRR completed on 8/29/2023. The Surveyor requested documentation to verify contact with AERS after completion of the PASRR. Social Service Director #2 asked to review Resident #2's PASRR and she would get back to this Surveyor.On 9/9/2025 at 11:10AM during an interview conducted with Social Service Director #1, she confirmed the Surveyor's findings and acknowledged that the PASRR was filled out incorrectly and AERS was not notified of the positive PASRR Level I.

Based on observations, record review, and interview with staff, it was determined that the facility failed to ensure that residents were properly assessed for the safe use of bedrails, failed to obtain consent from the resident or resident representative prior to use of bedrails, and failed to complete a device assessment for the use of bedrails. This was evident for 2 (Resident #15 and # 65) out of 8 residents reviewed for accidents during the survey.The findings include: Bedrails, also known as side rails, are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. A Resident or Resident's Representative should be provided with the risks and benefits along with a signed consent obtained before the use of bedrails. 1. On 9/4/2025 at 8:15AM, during a tour of Station 4, the Surveyor observed Resident #15 in his/her room sleeping. The head of the bed was raised about 30 degrees and there were quarter side rails raised at the top of the bed on both sides. The resident was observed sleeping with his/her head leaning on the right-side bedrail. On 9/4/2025 at 11:21AM, during an interview with Resident #15, the Surveyor observed Resident #15 laying in bed, with the head of the bed elevated about 30 degrees and quarter bedrails raised at the top of the bed on both sides. The resident was leaning to the right side with his/her head and shoulder resting on the right-side bedrail. On 9/8/2025 at 11:30AM, a review of Resident #15's electronic medical record revealed an active physician's order dated 2/25/2025 for the resident to have quarter rails to bed for turning and positioning every shift, first, second, and third. A review revealed treatment administration records for February 2025 through September 2025 where staff documented that quarter rails were in place. Resident #15 was care planned for use of bedrails. Further review of the medical record failed to reveal a bedrail assessment, resident or resident representative consent for the use of bedrails, and a device assessment for quarter bedrails. On 9/8/2025 at 11:42AM, during an interview conducted with the Director of Nursing (DON), the Surveyor was informed that the facility uses quarter bedrails as enablers for the residents' bed mobility. The DON stated that the facility was not completing the bedrail assessments for any resident who utilized bedrails for mobility and would be initiating bedrail assessments that day. On 9/8/2025 at 12:30PM, the DON reviewed the Siderail Review and Consent form with the Surveyors. The form would be completed quarterly to assess residents for functional need and risk potential and ensure there is a physician's order and consent from the resident or resident representative for the use of bedrails. 2. On 09/04/2025 at 1:57 PM, the surveyor observed Resident #65 lying in bed with bedrails raised on the upper sides of the bed. The resident stated the bedrails were in place to assist with bed mobility. On 09/08/2025 at 11:42 AM, the Director of Nursing (DON) was interviewed and stated that the facility had not completed bedrail assessments but would begin doing so. On 09/08/2025 at 12:40 PM, the DON presented a completed bedrail assessment for Resident #65 that was created on 09/08/2025 at 11:52 AM.

Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were administered in accordance with physician orders for 2 of 26 opportunities reviewed. This deficient practice resulted in residents receiving medications contrary to physician orders and a medication error rate of 7.69%.The findings include:On 09/09/25 at 8:53AM, during the morning medication pass, Resident #21 was administered Topamax in a crushed form by Staff #14. During review of the resident's electronic medical record at 9:40AM it was revealed that the physician's order read for headache no crush, indicating the medication was to be given whole and was not to be crushed.On 09/10/25 at 8:22AM, during the morning medication pass, Resident #128 was administered Ferrous Sulfate 325 mg without food. Review of the physician's order indicated the medication was to be given with meals. Staff #15 was asked about the resident being given the medication without food and they stated the food trays were on their way. The surveyor observed that the resident was not served until 8:52AM.

Based on review of the facility's Facility Reported Incidents and interviews, it was determined that the facility failed to timely report an allegation of abuse (Resident #54). This was evident for 1 out of 7 residents reviewed for abuse during the survey. The findings include: Surveyor's review of the medical record of Resident #54 on 9/8/2025 at 1:45PM revealed the following allegation of abuse made by Resident #54 was documented by Physician #39 on 6/18/25 at 12:45PM: Patient seen today for monthly evaluation, reports two females verbally abused him/her stating shut the f*** up, reports s/he wants to go home, states s/he feels safe here but wants to go home. On 9/8/2025 at 2:07PM the surveyor conducted an interview of the facility's Administrator regarding the allegation documented in the 6/18/25 progress note, and inquired to them as to if the facility had a self-report for the documented verbal abuse allegation, to which the Administrator replied: Let me check on this. On 9/8/25 at 2:19PM the surveyor conducted an interview with Social Services Assistant Director (SSAD) #2 who confirmed with surveyors that Resident #54 had previously reported an allegation of abuse which included verbal abuse. During the interview, SSAD #2 stated regarding the Resident's allegation: It was definitely reported to the Administrator. On 9/9/2025 at 9:18AM the surveyor conducted an interview of the Administrator as to why the allegation of abuse was not timely reported to the Office of Health Care Quality until after surveyor intervention. The Administrator reported to the surveyor: Because administration didn't know about it. During the interview the Administrator reported to surveyors that Physician #39 did not them know about the allegation as they are the abuse coordinator. After surveyor intervention, the Administrator informed surveyors that because the allegation was not reported, they had instituted education in agreement with the facility's medical director for physicians and practitioners to be educated on reporting directly to the abuse coordinator, that was she can streamline and ensure communication reaches her to be reported. On 9/9/2025 at 9:18AM the surveyor shared the concern for the allegation of abuse from 6/18/25 not having been timely reported to the Office of Health Care Quality. At this time, the Administrator acknowledged and confirmed understanding of the surveyor's concern.

Based on record review, observation, and interviews, it was determined that the facility failed to ensure resident personal and medical information was not publicly disclosed without consent. This deficient practice was evident for 3 of 3 residents reviewed (Residents #20, #45, and #65).The findings include:On 09/12/25 at 9:14 AM, review of the facility's website foresthavennursingcenter.com revealed testimonials posted with full resident names, photos of the residents, and information related to medical diagnoses for Residents #20, #45, and #65. At 9:30 AM, the surveyor brought the website up for the Director of Nursing (DON) to see and requested to review the consents from the residents to use their information on a publicly accessible website.At 10:05 AM, review of the electronic medical record showed all three residents had a Brief Interview for Mental Status (BIMS) score of 15, indicating they were cognitively intact.At 10:45 AM, the DON was unable to produce consents for Residents #45 and #65. A consent for Resident #20 was provided but was incomplete and verbally consented to by the resident's responsible party. The language used in the consent only granted permission for the resident's photo to be used on the website.At 11:01 AM, Resident #65 was interviewed and stated they were unaware their information was on the website and did not recall consenting to it.At 11:03 AM, Resident #20 was interviewed and stated they were unaware their information was on the website and did not recall consenting to it.At 11:08 AM, Resident #45 was interviewed and was unaware their information was being used on the website and did not recall consenting to it.At 11:59 AM, all three residents were asked if they were agreeable to having their information posted. Residents #45 and #65 stated they were not ok with it and wished for the information to be taken down. Resident #20 stated they had no issue with it.At 2:09 PM, an interview was conducted with the Nursing Home Administrator (NHA), who stated they were unaware of the website and would follow up after the surveyor expressed concerns.On 09/15/25 at 11:15 AM, an interview was conducted with the NHA, who remained unclear on where to locate the information and was provided the website address. No consents were produced at that time, and the NHA was still unable to identify who was managing the website. At 1:45PM, the information was noted to be taken down from the website.

Based on record reviews and interviews, it was determined that the facility failed to notify the medical director of recent testing results of the facility when there was a need to alter treatment or testing significantly. This was evident for 2 (#113 and #1) residents out of 6 residents investigated during the survey.The findings include:On 09/12/2025 2:50PM during facility record review of the 'Infection Control Log' received from the ADON/Infection Preventionist Staff #4 for the Infection Control Facility Task, it revealed the following for reporting period 7/1/25-7/31/25 with 3 episodes of pneumonia with onset dates of 7/8/25; 7/16/25; and 7/21/25. For reporting period 8/1/25-8/31/25 it revealed a potential spike with 6 episodes of pneumonia reported with onset dates of 8/1/25; 8/4/25; 8/8/25; 8/14/25; 8/15/25; and 8/26/25.On 09/12/2025 3:00PM during facility record review of the Water Management plan received from Maintenance Director Staff #18 for the Infection Control Facility Task it revealed 'Legionella Analytical' water test results dated 7/17/25 of water sampled on 7/1/25 detected Total Legionella for 3 of the 7 sample areas reported as follows: 1st Fl. Kitchen Sink (Hot) at 12 CFU/ml; 2nd Floor Main Shower Room (Cold) 18 CFU/ml; and 1st Fl. Kitchen Sink (Cold) >300 CFU/ml.On 09/15/2025 3:30PM during record review and interviews with ADON/Infection Preventionist Staff #4 the surveyor requested documentation for the increased August 2025 pneumonia cases and any communication regarding the Water Management water testing results received on 7/17/25. Staff #4 stated a flu outbreak was reported to Baltimore County Health Department and provided surveyor email entries of discussion of flu outbreak. Staff #4 provided email communication with Public Health Investigator, Baltimore County Health Department between Monday, August 11, 2025, 12:30 PM to Friday, August 15, 2025, 3:16 PM regarding 'Forest Haven Flu Outbreak #2025-1157'. The emails revealed concerns discussed for the presence of pneumonia data in addition to the Flu Outbreak data within the reporting.An email dated Thursday, August 14, 2025, 9:35 AM the Public Health Investigator noted Please send copies of respiratory panel results and CXR for the residents on the outbreak. It was reported H.H. and W.W. (lines 4 and 9) had a positive CXR [chest x-ray]- please confirm the status of Legionella Urine Antigen [LUA] test. Friendly reminder, LUAs must be conducted for any resident with non-aspiration pneumonia concerns. The next entry, an email reply dated Thursday, 14, 2025 2:22 PM, sent by ADON/Infection Preventionist Staff #4 read Note there are only 3 positive cases currently in house not clear. Two residents had CXR/positive for PNA with no signs/symptoms that warrants Legionella urine antigen test as discussed with Medical Director. These residents are being monitored and to report to the MD/NP for any symptoms noted. Currently no signs/symptoms noted at this time. Of note, upon review of this entire email communication there was no discussion of the recent facility's Legionella Analytical water test results of 7/17/25. Additionally, no follow-up emails between Baltimore Health Department were offered regarding the additional pneumonia cases with onset dates after the email end date of 8/15/25.On 09/15/2025 5:01PM during a phone interview with Medical Director Staff #26, the surveyor asked why the residents in question were not tested as recommended upon request from the Public Health Investigator, Baltimore County Health Department; Staff #26 states the Legionella Urine was not done because the residents did not present with any clinical symptoms or elevated lab work consistent with that potential diagnosis. Surveyor then asked staff #26 was aware of the recent Legionella Analytical water test results of 7/17/25; staff #26 stated No. Surveyor asked Staff #26 is notified of facility testing results or concerns; staff #26 stated this would have been discussed at the Risk meetings, but I was not informed of that at the recent Risk meeting. Of note, Staff #26 could not recall the last Risk meeting exact date during the phone call. Surveyor asked Staff #26 if aware of additional pneumonia cases and stated No, I was never informed of additional pneumonia cases. Surveyor asked Staff #26 if the water test results were known when asked to complete the recommended Legionella Urine test and the increase in pneumonia cases, would a different clinical approach have been taken; Staff #26 stated Yes.On 09/15/2025 5:15PM during interview with Nursing Home Administrator (NHA) Staff #3, surveyor discussed concerns of increased pneumonia cases, recent Legionella Analytical testing with detected results reported on 7/17/25, and Medical Director staff #26 stating no knowledge of these findings or discussion at most recent Risk meeting. Surveyor requested date of last Risk meeting, meeting minutes, and any communication regarding water findings with the Medical Director staff #26. Staff #3 stated we did inform the Medical Director, likely at the Risk meeting.On 09/15/25 6:15PM during follow-up interview with NHA Staff #3, stated the last Risk meeting was held on 8/28/25 and confirmed Medical Director staff #26 was present; however, there were no meeting minutes from that meeting. Surveyor asked NHA Staff #3 if the Medical Director was notified of the recent water test results of 7/17/25; staff #3 stated that the Medical Director (staff #26) was informed of the water test results around the time the Public Health Investigator, Baltimore County Health Department requested the follow-up urine studies. Surveyor asked NHA Staff #3 if there any documentation to support this conversation or notification to Medical Director Staff #26; Staff #3 stated No.

Based on observation, record reviews and interviews, it was determined that the facility failed to ensure resident self-determination for bathing preferences such as methods and times. This was evident for 1 (#114) resident out of 8 residents investigated during the survey.The findings include:On 09/04/2025 at 11:30 AM during initial observation and interviews, Resident #114 was observed in bed and shared with surveyor of never being allowed to shower and that staff always give a bed bath. Surveyor asked Resident #114 when they ask for a shower, what happens; resident stated they are told, there is no shower chair large enough and the bathing area is too small. Surveyor asked Resident #114 if they have ever been taken to the shower, Resident #114 stated no, I am only bathed in the bed and often the sink water is cold or not warm enough.On 09/09/2025 2:49 PM during record review it revealed on the Matrix POC (Point of Care) for the period of 8/10/25-9/9/25, only complete or partial bed baths were noted as being completed or offered. During this same time only one refusal of a bed bath was documented. The record review of the Care Plan entry for ADLs, revealed it was initiated on 8/25/19 and indicated no preference between bath and shower; no changes or updates to this non-preference or desire to shower were documented during subsequent reviews of the Care Plan for ADLs. Additionally, the record review of Shower schedule for Resident #114, indicated Monday and Thursday as shower days.On 09/09/2025 2:54 PM during observation and interviews with GNA staff #25 and LPN staff #27, surveyor shared Resident #114 concerns of request to take a shower and repeatedly told there was no shower chair to fit resident and bathroom area was too small. Surveyor accompanied GNA staff #25 and LPN staff #27 to Unit 2A shower room. Surveyor observed shower chair in room and LPN staff #27 stated this shower chair is regular sized and Resident #114 is unable to fit this chair or in this room. Surveyor asked if there was a larger shower chair and area for resident use if needed. Surveyor was then taken around the corner to Unit 3 and shown what was used as the larger shower area that is designated for the Bariatric Shower chair. Surveyor observed that the shower area had narrow doors like the initial shower area on Unit 2A, however there was a larger sized chair observed in the shower area; of note, this chair appeared too wide for the doors of the shower room. Surveyor asked how the Bariatric chair could fit through the doorway, LPN staff #27 stated after the resident is hoyered or assisted to the Bariatric chair, the chair is then turned sideways to enter the shower area for residents to be bathed. Surveyor asked if this had been attempted or offered for Resident #114, specifically on their assigned Monday and Thursday shower schedule days; GNA staff #25 stated no, that resident is always bathed in bed and never offered or taken for a shower. Surveyor asked LPN staff #27 if Resident #114 been offered to shower; stated that resident has history of refusing showers previously in the past when they were a resident on Unit 3. Surveyor asked LPN staff #27, how long had Resident #114 been on the current unit, LPN staff #114 stated a few months.

Based on observation, interview, and record review it was determined the facility failed: 1) to ensure Resident (#117) was provided assistance necessary for an activity of daily living necessary to maintain proper nutrition. This was evident during a random observation; and 2) ensure that a resident who was unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene. This was evident for 1 (#114) resident out of 8 residents investigated during the survey. The findings include: 1. On 9/15/25 at 1:05PM the surveyor observed Resident #117 in the hallway sitting in their wheelchair at an overbed tray table with their lunch situated on it, with their face down to their plate licking carrots with their tongue off of their plate to get them into their mouth to eat them. Resident #117 was subsequently observed with their face down to their pudding container licking the pudding out of the container to eat it. No staff were observed to be assisting or providing supervision for the resident during this time. The surveyor went to find staff and observed Geriatric Nursing Assistant (GNA) # 37 passing a tray of food into a resident room. The surveyor conducted an interview and shared concerns with GNA #37 who reported to the surveyor that they supervise Resident #117 and reported that the resident could feed themself if they have the utensil placed in their hand. After surveyor intervention, GNA #37 was then observed walking over to the resident and then placed the utensil into Resident #117's hand, and then Resident #117 began to be able to feed themself from their plate and eat their meal using the utensil. At this time, the surveyor shared their concern additionally with Dietary Director #5 who acknowledged understanding of the surveyor's concern. On 9/15/2025 at 1:13PM the surveyor shared concerns with the facility Administrator who confirmed understanding of the concern. Review of Resident #117's care plan by the surveyor on 9/15/25 at 3:30PM revealed the following information was present: (Resident #117) requires assist with ADL care and eating: assist and continue to assess periodically for changes in cognition; adjust approaches to offer more assistance as needed. Review of Resident #117's medical record by the surveyor on 9/15/25 at 3:30PM revealed the following active medical order dated as beginning on 11/4/2024: Eating with assist of 1. 2. On 09/04/2025 at 11:30 AM during initial observation and interviews, Resident #114 was observed in bed and shared with surveyor of never being allowed to shower and that staff always give a bed bath. Surveyor asked Resident #114 when they ask for a shower, what happens; resident stated they are told, there is no shower chair large enough and the bathing area is too small. Surveyor asked Resident #114 have you ever been taken to the shower, Resident #114 states no, I am only bathed in the bed and often the sink water is cold or not warm enough. On 09/09/2025 2:49 PM during record review it revealed on the Matrix POC (Point of Care) for the period of 8/10/25-9/9/25, only complete or partial bed baths are noted as being completed or offered. During this same time only one refusal of a bed bath was documented. The record review of the Care Plan entry for ADLs, revealed it was initiated on 8/25/19 and indicates no preference between bath and shower; no changes or updates to this non-preference or desire to shower were documented during subsequent reviews of the Care Plan for ADLs. Additionally, the record review of Shower schedule for Resident #114, indicates a Monday and Thursday shower days. On 09/09/2025 2:54 PM during observation and interviews with GNA staff #25 and LPN staff #27, surveyor shared Resident #114 concerns of request to take a shower and repeatedly told there was no shower chair to fit resident and bathroom area was too small. Surveyor asked if was there a Bariatric chair for resident to be showered; LPN staff #25 stated yes. Surveyor asked if it had been attempted or offered for Resident #114, specifically on their assigned Monday and Thursday shower schedule days; GNA staff #25 stated no, that resident is always bathed in bed and never offered or taken for a shower. Surveyor asked LPN staff #27 has Resident #114 been offered to shower; stated that resident has history of refusing showers previously in the past when they were a resident on Unit 3. Surveyor asked LPN staff #27, how long has Resident #114 been on the current unit 2, LPN staff #114 stated a few months.

Based on observations and staff interviews, the facility failed to maintain an environment that is free from risks of accident hazards. This was evident for 1 (Resident #110) out of 6 residents reviewed during the survey. On 9/04/25 at 8:34 AM, during observation rounds, the surveyor observed Resident #110's toilet leaking water from the base. There was a large puddle of water on the bathroom floor surrounding the toilet. Also, the bathroom floor was slippery when walking on it. On 9/04/25 at 10:10 AM, the Director of Nursing staff #13 was interviewed. During the interview, the surveyor made staff #13 aware that Resident #110's toilet was leaking water from the base, and that there was a large puddle of water on the floor surrounding the toilet. Staff #13 mentioned that she would have maintenance repair Resident #110's toilet, and the puddle of water mopped from the floor.

Based on record reviews and interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and including the right to refuse treatment. This was evident for 1 (#1) resident out of 3 residents investigated for complaints during the facility's annual survey.The findings include:On 09/12/2025 11:00 AM during record review of Resident #1, it revealed the face and beard were being shaved against the family/POA preferences for resident; this occurred on more than one occasion. Resident #1 was admitted on [DATE]. Resident record review of Care Plan dated 05/28/25 revealed interventions for ADLs Functional Status/Rehabilitation Potential, started 11/20/2023, which (Resident #1) requires assistance with ADL's R/T cognitive deficit; and Cognitive Loss / Dementia, started 12/06/2023, which stated (Resident #1) is unable to make daily decisions without cues/supervision R/T diagnosis of dementia.A progress note, dated 05/03/2025 11:33 AM revealed Received resident Alert and responsive, ADL care provided as indicated, Family request LOA, when resident daughter came to pick up resident, resident is dress nice and clean, and shaved by Aid, daughter states that her mother do not want resident to be shaved by staff, updates 24 hrs report for IDT [interdisciplinary team] follow, resident left in a stable condition with no issue noted.On 09/15/2025 2:04 PM interview with Resident #1, Daughter at bedside, and wife/POA via daughter's cellphone. Surveyor observed various signage posted on resident closet, dated November 2024, with request not to shave resident and other resident preferences. Surveyor asked could family recall the initial concern when Resident #1 was shaved; daughter stated, the time was around June 2024. Family asked was the resident preferences discussed at Care Plan meetings in the past; wife/POA stated, yes, multiple times at various meetings.On 09/15/2025 6:30 PM during exit interview NHA Staff #3 notified of family concerns of repeated shaving against resident and family preferences, and Care Plan 05/28/25 not updated with resident-specific preferences.

Based on record review and interview with staff, it was determined that the facility failed to provide the written notification of transfer to the resident representative, provide written notification of the facility's bed hold policy upon transfer to the hospital to the resident representative, and ensure the local ombudsman was notified of a facility-initiated transfer to the hospital. This was evident for 1 (Resident #15) out of 4 residents reviewed for hospitalization during the annual survey.The findings include:Bed Hold is holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization.On 9/5/2025 at 9:24AM, during a review of Resident #15's electronic medical record, the Surveyor discovered that the resident was transferred to the hospital on 6/23/2025 and 7/28/2025. On 9/8/2025 at 10:45AM, a review of Resident #15's electronic and paper medical record failed to reveal documentation to verify Resident #15's resident representative had been provided with written notification of the transfer to the hospital and the facility's bed hold policy upon transfer to the hospital on 6/23/2025 and 7/28/2025. There was also no documentation that the ombudsman was informed of the resident's hospital transfer on 6/25/2025 and 7/28/2025.On 9/8/2025 at 12:02PM, during a review of Resident #15's electronic medical record, the Surveyor discovered that the resident was transferred to the hospital on 9/5/2025. Further review, including the paper medical record, failed to reveal documentation to verify Resident #15's resident representative had been provided with written notification of the transfer to the hospital and the facility's bed hold policy upon transfer to the hospital on 9/5/2025. There was also no documentation that the Ombudsman was informed of the resident's hospital transfer on 9/5/2025.On 9/8/2025 at 2:28PM, the Surveyor conducted an interview with Social Services Director #1 and Social Services Assistant Director #2. During the interview, the Surveyor discovered that the Bed Hold Policy form and the Notice of Discharge or Transfer form are filled out by the social work department. The documents would then be sent to some resident representatives via email with the documents attached, and other resident representatives via certified mail. The Surveyor was informed that the social services department is responsible for informing the Ombudsman of the facility's transfers and discharges via email every month. A copy of all documents should be maintained in the residents' medical record. The Surveyor expressed the concern that there was no documentation to verify that Resident #15's resident representative was provided with written notification of the residents transfer to the hospital and the facility's bed hold policy upon transfer to the hospital on 6/23/2025, 7/28/2025, and 9/5/2025. There was also no documentation that the Ombudsman was notified of the resident's transfer to the hospital on 6/23/2025 and 7/28/2025. The Surveyor requested documentation.On 9/9/2025 at 11:10AM, during an interview with Social Service Director #1, the Surveyor was informed that as of 9/8/2025 the nursing staff would now complete the Bed Hold Policy form and Notice of Discharge or Transfer form at the time of transfer to the hospital and give a copy to the social service department. The social service department would then send the notification to the resident representative via email or certified mail. The Ombudsman would be notified of a resident transfer via email.Social Service Director #1 was unable to provide documentation that Resident #15's resident representative was emailed or sent a copy of the bed hold policy or transfer notification for the hospital transfers on 6/23/2025 and 7/28/2025. The Surveyor was provided with a copy of the email receipt to the Ombudsman for notification of all transfers and discharges, including Resident #15, for the months of June 2025 and July 2025. Social Service Director #1 stated that she was unaware the resident was out of the building to the hospital on 9/5/2025 and would complete a Notice of Discharge or Transfer form and Bed Hold Policy form and email a copy to the resident representative and the Ombudsman On 9/10/2025 at 8:00AM, the Surveyor reviewed a copy of Resident #15's Bed Hold Policy form and Notice of Discharge or Transfer form completed 9/9/2025 for the transfer to the hospital on 9/5/2025 and the email receipt to the resident representative and the Ombudsman on 9/9/2025 at 4:16PM.

Based on clinical record review and staff interviews, it was determined that the facility staff failed to ensure 1) adequate supervision while positioning a resident in bed during the provision of care and 2) residents did not have access to medications. This was evident for 2 of 30 residents (#13 and #26) reviewed for complaints and resulted in harm to Resident #13. The findings include: 1. On 4/21/25 at 9AM, a record review was conducted which revealed that Resident #13 had diagnoses which included, but were not limited to, respiratory failure with hypoxia, heart failure, wedge compression fracture of fourth thoracic vertebra, Hospice, and dementia. The MDS (Minimum Data Set) is a screening tool that is utilized to ensure each resident's individual needs are identified. A review of the MDS assessment, with an assessment reference date of 4/22/2023, identified that to turn from side to side and position body when in bed, the resident was extensive assistance on staff for the activity and required 2 staff persons to physically assist. According to the facility report MD00203380 notes dated 03/07/2024 at 11:25 AM, Resident #13 fell from bed during activities of daily living (ADL) care and as a result, he/she sustained a fracture to the left superior pubic ramus. The facility incident report described how Staff #1, a Geriatric Nursing Assistant (GNA) and the only witness to the fall, had been providing care without the assistance of another staff member. Staff #1 left the resident unattended on her left side in bed to get additional supplies to care for the resident. When Staff #1 returned to the bed Resident #13 was on the floor on his/her left side. On 4/22/25 at 8:30 AM it was discovered that Staff #1 no longer works at the facility and his/her last day of employment was 3/28/2024. The phone number provided from Human Resources was disconnected, so the Staff was not interviewed. Resident #13 remained in the facility and staff followed hospice recommendations for pain management and the daughter's wishes. During an interview the Administrator confirmed the facility staff failed to provide supervision for Resident #13 according to the ADL policy. 2. An observation on 4/23/25 at 11:50 AM of Resident (R)26's room revealed the resident had the following medications sitting out in the open on his/her over-the-bed table: 1 can of medicated spray, a container of Desitin (diaper rash cream), Pepto Bismol ultra, liquid [NAME] pectate, severe congestion liquid medication, cough syrup. During this observation R26 was interviewed. The resident reported that s/he has these medications at his/her bedside because facility staff refused to get them for the resident. The resident reported that a family member purchased the medications and brought them to him/her. An interview with the Director of Nursing (DON) on 4/29/25 at 11:04 AM revealed that residents were not allowed to have medications at their bedside. She reported that she was not aware that R26 had medications in their room. The DON reported that R26 will cover the over-the-bed table with magazines and paper to hide what was on it. During this interview on 4/29/25 at 11:15 AM an observation of R26's room was made with the DON present. The DON confirmed that the medications were on the over-the-bed table. The DON reported that facility staff had a meeting with R26 and his/her family to discuss behavioral concerns in 9/2024, and denied the medications were on the table at that time. Social Services staff #8 was interviewed on 4/30/25 at 9:38 AM. He confirmed a meeting was held with R26 and his/her family on 9/24/24, in the resident's room, to discuss behaviors. He reported that he has seen medications on the resident's over-the-bed table on multiple occasions. He reported he has seen Pepto-Bismal and cough syrup. He confirmed that medications were in the room during the meeting on 9/24/24. An interview with the attending physician on 4/30/25 at 10:39 AM revealed he was aware that R26 had medications at his/her bedside. He reported that he has discussed this issue with the resident on multiple occasions and offered to prescribe them for the resident, so staff could administer them. When asked if he had assessed the resident for self-administration, he stated that he felt the resident would take excessive amounts of the medication and not adhere to the prescribed dose. Furthermore, he stated the administrative team had discussed this issue on multiple occasions but were not sure how to handle it. Facility staff continued to allow the resident to keep the medications at the bedside and self-administer the medications when it was deemed unsafe to do so. The concerns were reviewed with the Nursing Home Administrator (NHA) and Clinical Services Director #10 on 5/1/25 at 3:15 PM. The scope severity for Example #2 remained at a D.

Based on review of medical records, facility documentation, complaint MD00205968 and staff interviews, it was determined the facility failed to ensure all residents were free from abuse. This was evident for 3 (Resident #2, #3, and #4) of 4 residents reviewed for abuse during a complaint survey. The findings include: Abuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse, is defined at S483.5 as non-consensual sexual contact of any type with a resident. Misappropriation of resident property, as defined at S483.5, means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. A review of Resident #1's closed medical on 05/28/24 revealed Resident #1 was admitted into the facility with diagnoses that included but not limited to dementia, mood disturbance, psychotic disturbance, and bipolar disease. On 01/09/24, Resident #1's attending physician certified that Resident #1 was unable to make any medical, treatment, and financial decisions due to dementia. Review of Resident #1 medical record revealed a behavior care plan, initiated on 01/17/24, that identified a problem: Resident #1 has a behavior problem (refusing care, sad mood, tearfulness, hoarding, setting fires, wandering into other residents rooms, sexually inappropriate, disrobing in front of others, false accusations, verbal and physical aggression, exit seeking, packing belongings, yelling at others, playing in feces, smearing feces, placing briefs in toilet) r/t dementia with behaviors, insomnia, and depression Further review of Resident #1's closed medical record revealed a nursing progress note, dated 01/24/24 at 4:30 PM, where Staff member #16 was doing rounds and looking for Resident #4. Resident #4 was found in Resident #1's room, seated in a chair. Staff member #16 observed Resident #1 standing in front of Resident #4, stroking Resident #4's head with Resident #1's genitals exposed. Staff member #16 immediately informed the nurse of Resident #1's inappropriate sexual behavior and separated the two residents. Resident #1's physician was notified of Resident #1's inappropriate sexual behavior and instructed the nursing staff to obtain a psychiatric consult. On 01/25/24, Resident #1 was evaluated by nurse practitioner, Staff Member #17, for sexually inappropriate behavior. Staff member #17 documented the 01/24/24 incident and indicated speaking to Resident #1's family member. Resident #1 had been moved to a different floor on 01/24/24. In the interview, Resident #1's family member informed Staff member #17 that Resident #1 had a history of deviant sexual behavior including fondling a comatose patient in the past and exposing his private parts in public. Staff member #17's 01/24/24 treatment plan for Resident #1 was to: provide mindfulness training and family support, staff to approach patient respectfully and be clear about upcoming nursing care. In an interview with the facility director of nurses (DON) on 05/29/24 at 1:40 PM, the DON indicated the facility had not investigated nor notified the State agency of the allegation of sexual abuse on 01/24/24. Further review of Resident #1's closed medical records revealed a nursing progress note that documented on 03/27/24 at 7:20 AM, Resident #1 had taken Resident #3's personal letters and other items. Resident #3 was noted to be crying and very upset. Resident #3 suffers from quadriplegia, a stroke, anxiety, difficulty speaking, aphasia, and is totally dependent upon the nursing staff for all his/her care needs. The staff indicated that the facility administrator was made aware of the incident. At 10:45 AM on 03/27/24, Resident #1 was observed by a therapy staff member digging into Resident #3's Vaseline and then observed Resident #1 hit Resident #3 in the arm. In an interview with the facility director of nurses on 05/29/24 at 1:40 PM, the DON stated that the facility had not investigated, obtained witness statements, nor notified the State agency of the allegation of abuse on 03/27/24. Review of complaint MD00205968 on 05/28/24 revealed an allegation that, on 05/18/24, Resident #1 was sent to the emergency room under emergency petition due to being witnessed for the second time in a 10-day period fondling the same female resident (hands down the resident's diaper) who was bed bound and demented on 05/08/24. Review of Resident #2's medical record on 05/28/24 revealed that Resident #2 was admitted to the facility on [DATE] with diagnoses that include but not limited to: Traumatic [NAME] Injury, depression, anxiety, and intellectual disabilities. Resident #2 was totally dependent upon the nursing staff for all their care needs. Further review revealed that on 05/08/24 at approximately 6:30 am, Resident #1 was observed inappropriately touching Resident #2 by Staff member #7. In an interview with Staff member #7 on 05/30/24 at 2:30 PM, Staff member #7 stated s/he recalled observing Resident #1 inappropriately touching Resident #2 in Resident #2's room on 05/08/24. Staff member #7 stated that s/he observed Resident #1 with his/her hand in Resident #2's diaper and it appeared that Resident #1 was digging in Resident #2's diaper with his/her hand. The staff documented that Resident #1's physician was notified, and the nursing staff implemented Q 15-minute observations. Resident #2 was unable to recall the incident when interviewed by the facility staff. On 05/18/24 at approximately 7:20 AM, Resident #1 was again observed in Resident #2's room. Resident #1 was observed by Staff member #5 inappropriately touching Resident #2 again. (hands in his/her diaper). In an interview with Staff member #5 on 05/30/24 at 2:39 PM, Staff member #5 stated that s/he observed Resident #1, in Resident #2's room on 05/18/24 at approximately 7:20 AM. Staff member #5 stated s/he observed Resident #1 with his/her hand in Resident #2's diaper and Resident #1 appeared to be rubbing Resident #2 in a circular motion. The facility staff initiated an investigation, placed Resident #1 on 1:1 supervision, and notified Resident #1's physician. Resident #1 was ultimately emergency petitioned to the hospital emergency roiagnom on [DATE].

Based on medical record review, administrative record review, and staff interview; it was determined that the facility failed to protect a cognitively impaired resident (Resident #56) from verbal and physical abuse from a facility staff member. This caused harm to Resident #56. This was evident for 1 of 10 residents reviewed for abuse during an annual recertification survey. The findings include: Minimum Data Set (MDS): The Minimum Data Set (MDS) is a comprehensive assessment of a resident completed by facility staff. The MDS is a multi-discipline tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain, and medications to name a few) to be addressed. The MDS assessment is part of the broader Resident Assessment Instrument (RAI) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive status. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. Medical record review on 7/25/2022 at 7:10 AM revealed Resident #56 was alert and oriented x2 with a BIMS assessment score of 3/15, indicating severe cognitive impairment documented in the quarterly MDS assessment dated [DATE]. Review of the facility reported incident MD 543, dated 3/19/2022, revealed that on 3/16/2022 the facility received an accusation of witnessed abuse. The witness also provided video of the abuse incident involving GNA #20 and Resident #56. The facility investigation substantiated that GNA#20 violated facility policy by committing gross misconduct as shown in the video footage of the 3/16/2022 abuse incident. The facility terminated GNA #20 and reported GNA#20 to the Maryland Board of Nursing (MBON). The facility's investigation contained a written statement from Witness #21 dated 3/17/2022 that reported that on 3/16/2022 at approximately 2:15pm, he/she witnessed Resident #56 in a wheelchair in the doorway of his/her room without clothing below the waist. Witness #21 then reported that GNA #20 yelled at Resident #56 to get the [expletive] back in your room at least two times and then GNA #20 got behind Resident #56's wheelchair, positioned the wheelchair near the bed, and dumped the resident into his/her bed by picking up the wheelchair by its handles. Witness #21 then witnessed GNA#20 leave Resident #56's room. Witness #21, using a cell phone to capture the incident, videotaped GNA #20 coming back into Resident #56's room to continue the employee/resident interaction. The facility's investigation also contained a resident accident investigation worksheet dated 3/16/2022 which reported that the facility assessed the resident for injuries at 2:30pm. The facility staff found no physical injuries and Resident #56 reported no injuries to the facility staff at the time of the assessment. The facility also reported that staff closely monitored the resident for safety. The facility's investigation also contained a written statement from Social Services Director #32, dated 3/17/2022 which reported that he/she interviewed Resident #56 after the incident on 3/16/2022 and Resident #56 reported not feeling safe in the facility. Resident #56 also reported that his/her back and nose hurt. Social Services Director #32 also reported that Resident #56 had an average BIMS score of 3, indicating severe cognitive impairment, had cognitive deficits, and had a family member representative, who makes decisions on behalf of Resident #56. On 7/26/22 at 7:10 AM, review of the facility investigation revealed the reported abuse incident dated 3/16/2022. The investigation packet contained GNA #20's training transcript for the time he/she worked in the facility. The training transcript revealed that GNA #20 had not had the required abuse, neglect, or exploitation training since 7/1/2020. On 7/26/22 at 10:30 AM, review of the progress notes revealed no notes for 3/17/2022 regarding the Resident #56's complaint of pain in his/her back and nose. On 7/26/22 at 10:40AM, review of the Resident #56's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #56 received a 1 mg [MEDICATION(S)] every 8 hours for Anxiety (scheduled for 6am, 2pm and 10pm) daily. This medication can also be used to treat pain as well as Anxiety. Review of medical records revealed that resident #56 had the [MEDICATION(S)] order prior to the 3/16/2022 abuse incident. On 7/26/22 at 10:50 AM, review of the psychiatric assessment performed on 3/17/2022 revealed that the resident was interviewed for distress following the 3/16/2022 abuse incident. The assessment found that the resident was not in any distress at the time of the interview. The assessment also stated that the resident's short-term memory was severely impaired, so the resident did not remember the incident with GNA #20. The facility's investigation documentation also contained a suspension pending investigation form dated 3/17/2022 which was signed by GNA #20 on 3/17/2022. The facility investigation also contained a termination form for GNA #20 dated 3/18/2022 which was signed by the Administrator and Director of Human Resources #31. On 7/26/22 at 11:42 AM, Witness #21, was interviewed by telephone. The surveyor asked Witness #21 to recall the abuse incident witnessed on 3/16/2022. Witness #21 stated he/she was visiting on the 2nd floor (Unit 4) of the facility and observed GNA #20 speaking harshly (cursing) at Resident #56 in a wheelchair. Witness #21 further stated that he/she witnessed GNA #20 get behind Resident #56's wheelchair, push Resident #56 in his/her room, position the wheelchair near the bed, picked the wheelchair up (with the back wheels off the floor) and dump the resident on the bed. After GNA #20 dumped Resident #56 on the bed, he/she then exited the room. Witness #21 then reported that he/she felt that GNA #20 was not done with Resident #56, so I took out my phone and started to record. Witness #21 reported that he/she videotaped GNA #20 returning to Resident #56's room a short time later, pushed Resident #56's bedside table into the resident's bed with force, and then kicked resident #56 in the leg. The surveyor asked Witness #21 to recall the time when he/she reported the incident to the facility. Witness #21 stated that he/she reported the abuse incident to the Administrator at 2:30 PM on 3/16/2022 in a cell phone text. Witness #21 also sent the video to the Administrator's cell phone at that time. On 07/26/22 at 12:06 PM, the surveyor interviewed the Administrator and Director of Nursing (DON) regarding the witnessed abuse incident on 3/16/2022. The Administrator and the DON confirmed that GNA #20 was the staff member alleged to have abused Resident #56 in the video sent by Witness #21. The surveyor asked the Administrator and the DON to recall the incident as seen on the video. The Administrator stated that GNA #20 kicked the resident's bed, pushed the bedside table on to Resident #56's legs while his/her bed was in the lowest position. The Administrator stated that the facility had no abuse allegations concerning GNA #20 prior to the abuse allegation on 3/16/2022. The Administrator further stated that when he/she interviewed the GNA #20 during the facility's investigation of the 3/16/2022 abuse incident, GNA #20 denied the incident occurred. GNA #20 changed his/her statements regarding the 3/16/2022 abuse incident when the Administrator informed GNA #20 of the video and GNA #20 confessed to kicking the bed rails on the resident's bed as an attempt to stop the resident from kicking GNA #20. The Administrator confirmed that he/she received the video from Witness #21 at 2:30 PM on 3/16/2022. The Administrator also reported that Witness #21 reported that the abuse incident occurred on 3/16/2022 between 2:15 PM to 2:30 PM. The Administrator revealed that GNA #20 provided direct care to Resident #56 on 3/16/2022 at Unit 4 of the facility. The Administrator also revealed GNA #20 was suspended pending facility abuse investigation on 3/17/2022. The Administrator revealed that GNA #20 was not suspended on 3/16/2022 because GNA #20 had left for the day before contact was made with the DON regarding the abuse allegation. The Administrator also revealed that GNA #20 was terminated on 3/18/2022 for gross misconduct based on the video submitted by Witness #21. The DON revealed that he/she reported GNA #20 to the Maryland Board of Nursing on 3/19/2022. On 7/26/22 at 12:15 PM, the Administrator provided the survey team leader with a copy of the video sent from Witness #21 on 3/16/22. The surveyor viewed the video, and it confirmed the Administrator's description of the video. Cross Reference F943

Based on medical record review, observation and interview, the facility staff failed to prevent a resident from being abused (Resident #4). This was evident for 1 ( Resident #4) out of 5 residents reviewed during a complaint survey. The findings include: Review of Resident #4's medical record revealed the Resident was admitted to the facility in (MONTH) 2014 from the hospital with a [DIAGNOSES REDACTED]. An assessment was completed by the facility staff on 10/18/19. The facility staff documented on 10/18/19 a BIMS (Brief Interview for Mental Status) Summary Score of 9/15. A score of 9 indicates moderate cognitive impairment. Review of facility reported incident MD 131 revealed the facility submitted a report on 10/23/19 to OHCQ (Office of Health Care Quality that,on 10/22/19, Resident #4 was assessed to have a swollen lip with laceration. The Resident reported to the Administrator at that time that they were hit by an employee. The Resident identified GNA (geriatric nursing assistant) #2 as the employee that hit them. Review of Resident #4's medical record revealed a nurse's note on 10/22/19 at 11:37 PM that stated, Resident noted with skin tear, bruise and swollen left upper lip on this shift during round about 4 PM. When asked, (Resident #4) said a staff member hit them on the lip. Upon head to toe assessment, no other skin issue found. Patient is stable and denies pain or any other discomfort. Doctor notified. Nurse communicated with responsible party. New order to apply [MEDICATION NAME] daily and left open to air until resolve. [MEDICATION NAME] is an antibiotic cream used to prevent skin infections caused by small cuts, scrapes or burns. Review of the Resident's physician orders [REDACTED]. Apply ice pack every 4 hours for 15 minutes to lips for 24 hours. review of the resident's medical record revealed [REDACTED]. Patient today reported to me that they have intermittent pain along top lip. Denied any further bleeding. Further review of the resident's medical record revealed [REDACTED]. The nurse practitioner documented, Unit Manager reports patient stated a female nursing assistant hit them in their mouth causing them to have a swollen cut upper lip on Monday (MONTH) 21, 2019. Patient was seen today in room sitting up in chair, no acute distress. Patient alert and oriented times 2. When asked how they were doing, patient showed me the inside of their left upper lip, it was slightly swollen with a small healing laceration noted. When asked what happened, patient stated that girl hit me in my mouth. When asked if she hit with her hand or an object patient looked around and looked down at the floor and stated she hit me with my shoe. During interview with the Administrator on 11/21/19 at 10:10 AM the Administrator stated on 10/22/19 while he was doing rounds, he noticed that Resident #4's lip was swollen. The Administrator stated the Nursing Supervisor was called and an investigation began immediately. During interview with the Nursing Supervisor on 11/21/19 at 12:55 PM, she stated I was called to the unit on 10/22/19 by LPN (licensed practical nurse) #3. He told me the Administrator made him aware Resident #4 had a swollen lip. I went in and assessed Resident #4. Their lip was swollen and had a cut on the same side of the lip that was swollen. I asked him/her how he/she got the injury and he/she told me someone punched him/her in the lip a couple days before. He stated the person had white short hair and said let me take you and I will show you to her. (Resident #4) held my hand and when we got to the nurses' station, they immediately pointed to her and said that is the b**** that did it to me. The Resident pointed to GNA #2. The Nursing Supervisor then stated she made the Administrator aware and the Administrator told GNA #2 she had to go home. During interview with Resident #4 on 11/21/19 at 10:49 AM, when asked if they remembered an incident that happened recently, the resident stated, I was hit in the mouth. It's all well now. When asked who did it, the Resident reported the person was no longer at the facility. When asked if they could describe the person, the Resident stated, Hair was light. She was light skinned. When asked if she was African American, the Resident stated yes. The Resident stated, I was sitting on my bed and I think she picked up a shoe and hit me. When asked if it hurt, the Resident stated, It hurt some. During interview with Resident #4 on 11/22/19 at 8:11 AM, the surveyor asked the Resident to describe the shoe that was used. The Resident opened the bedside cabinet and pulled out a white FILA tennis shoe and said that was it, but it was on the ground. The Resident then pointed to the floor next to the bottom of the bed. During interview with the Director of Nursing (DON) on 11/22/19 at 9:40 AM, she stated that, after watching multiple days of video, they discovered on 10/21/19 the incident had occurred. The DON was asked to state what was seen on the video. The DON stated, Resident #4 came out of their room, went to the left and then you can see the resident carrying linen back to their room. Before the resident got to the door, GNA #2 appeared and she was running to the Resident. There was a struggle over the linen and the Resident would not give her the linen, looks like the Resident strikes out, but can not tell if they hit GNA #2. Then you see GNA #2 push the Resident from the front back into their room. The DON stated at that time when she interviewed Resident #4, the resident said they were pushed onto the bed. During interview with GNA #1 on 11/22/19 at 11:26 AM, she stated that she worked 10/21/19 when she went to Resident #4's room, she saw GNA #2 and the Resident. She stated GNA #2 seemed frustrated, her phone was on the floor and I asked if okay and she didn't answer. During interview with CMT (certified medication technician) #2 on 11/22/19 at 1:11 PM, she stated she was on the back hall passing medications on 10/21/19 and she heard a commotion. It appeared that Resident #4 had GNA #2 against the wall. I wasn't sure what was going on, so I closed my medication cart and went down the hall. By the time I got there the Resident was in bed. I could tell GNA #2 was upset and the Resident was breathing heaving. GNA #2 seemed overwhelmed, her phone was on the floor in 3 pieces. CMT #2 stated the Resident didn't say anything to me about being hit. During interview with the Director of Nursing and Administrator on 11/25/19 at 2:15 PM, they confirmed the facility substantiated abuse by GNA #2 against Resident #4 on 10/21/19. Cross Reference F609

Based on taking water temperatures with the Director of Maintenance on 8/23/18 at 11:35 AM, it was determined that the facility failed to maintain safe water temperatures as evidenced by temperature readings that ranged from 124 degrees to 132.8 degrees Fahrenheit in multiple locations throughout the building, that included resident rooms, bathrooms, and bathrooms in the dining area, which placed residents at risk for injury and posed an Immediate Jeopardy. An Immediate Jeopardy was called on (MONTH) 23, (YEAR) at 3:00 PM. The surveyors remained onsite until the Immediate Jeopardy was abated on (MONTH) 23, (YEAR) at 6:00 PM after an acceptable plan to remove immediacy was implemented. Based on observations in the Station 1 nursing unit, which housed cognitively impaired residents either due to [MEDICAL CONDITION], Dementia or Psychiatric Illness, it was determined that the facility failed to keep the environment safe, as evidenced by multiple observations of an unlocked supply room which contained disposable razors, shampoos, body washes and other items which were considered harmful to residents that were at risk for self-harm, (Resident #106) and residents that were known to consume non-food items (Resident #79). The unlocked and unattended supply room posed a risk for the residents on the unit which resulted in a second Immediate Jeopardy. The second Immediate Jeopardy was called on (MONTH) 29, (YEAR) at 3:30 PM. The facility developed a plan sufficient to remove immediacy, which was reviewed and accepted at 4:56 PM on (MONTH) 29, (YEAR) while surveyors remained onsite. The findings include: 1) On 8/23/18 at 10:50 AM, the surveyor noticed the water that was coming out of a sink in the Station 1 unit felt hot. On 8/23/18 at 11:35 AM, the surveyor asked the Maintenance Director to take water temperatures in the Station 1 unit. The Maintenance Director calibrated a thermometer before testing room [ROOM NUMBER]. The water temperature was 129.1 Fahrenheit. Resident #95 resided in room [ROOM NUMBER] and had the [DIAGNOSES REDACTED]. Resident #95 had a BIMS (Brief Interview of Mental Status) score of 0, dated 7/19/18, which indicated severe cognitive impairment. On 8/23/18 at 11:42 AM, the water temperature that was taken in room [ROOM NUMBER] was 129.1 degrees Fahrenheit. Resident #106 resided in room [ROOM NUMBER] and had the [DIAGNOSES REDACTED]. Resident #106 had a BIMS score of 0. Other water temperatures that were taken by the Maintenance Director in the bathroom sink across from room [ROOM NUMBER] read 132.8 degrees Fahrenheit (F) and the bathroom sink next to room [ROOM NUMBER] read 129.6 F. The bathroom in the first floor sitting/back dining area had a water temperature of 132.4 F and the bathroom next to the elevator had a water temperature of 127.7 F. The bathroom next to the elevator was the closest bathroom to the front dining room. Multiple residents on the unit were seen going in the bathroom next to the elevator. On station 2 in room [ROOM NUMBER], the water temperature was 124 F. A second surveyor checked water temperatures with a calibrated thermometer and found the following. 8/23/18 at 11:17 AM room [ROOM NUMBER]/107-bathroom water temperature was 128 F. 8/23/18 at 11:22 AM room [ROOM NUMBER]-bathroom water temperature was 128 F. 8/23/18 at 11:27 AM room [ROOM NUMBER] water temperature was 128 degrees F. 8/23/18 at 11:42 AM room [ROOM NUMBER] water temperature was 124 F and did not have much pressure 8/23/18 at 12:33 PM The sink in the hallway across from the nurse's station 2B temperature was 128F. 8/23/18 at 1:48 PM room [ROOM NUMBER]-bathroom water temperature was 130 F. The Maintenance Director stated, during an interview on 8/23/18 at 12:05 PM, that temperatures were normally kept between 100 to 110 degrees Fahrenheit. The Maintenance Director stated a water temperature check is done one time in the morning and if the water temperature is too hot, the mixing valve will be adjusted. Maintenance Employee #2 stated that, on 8/23/18 at 12:07 PM, the water temperatures were not checked on the morning of 8/23/18 due to a leak in another part of the building. The Maintenance Director advised that the older mixing valve fluctuates a lot in the morning. The morning temperature will be one temperature and in the evening the temperature will spike, therefore, an adjustment would have to be made. The Maintenance Director also stated that water temperatures were not recorded in the evening. The Maintenance Director advised the surveyor he would check the mixing valves. On 8/23/18 at 2:45 PM, the Maintenance Director stated to the surveyor, the temperatures are fluctuating, but I have a plumber coming in. I adjusted the mixing valve. I have the guys going through each room right now to check the temperature of every room. They're going to write down their results and give them to me. As a result of the elevated water temperatures throughout the building that contained vulnerable residents who were cognitively impaired, with decreased reaction time and psychiatric illnesses, a condition of Immediate Jeopardy to residents was declared on 8/23/18 at 3:00 PM and the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON) were advised at that time and signed the Immediate Jeopardy summary on 8/23/18 at 3:13 PM. The NHA advised that a plumber was on the way to the facility. The NHA stated, they're not using any hot water right now. The staff has sanitary wipes and bottled water and that's what the staff are using. Nobody will use the hot water until the plumber comes. The surveyors went back on the units to ensure that the staff were aware of the hot water temperatures. Staff #23, who was working on Station 2, stated on 8/23/18 at 3:40 PM, the water is hot today. My hand is still tingling. On 8/23/18 at 4:57 PM, the surveyor spoke to the plumber who stated, the internal thermostat broke and new valves are needed. On 8/23/18 at 5:02 PM, the NHA told the surveyor, 2 valves failed. All rooms (100%) and common areas are being checked. They are adjusting the valves and running water out and will continue to add cold water. Review of the plumber's invoice, Service Order on 8/23/18, documented the following: found mixing valves for nursing station 1, 3 and 4 had failed. Gained approval from (NHA) to replace. Picked up materials. Returned. Replaced both mixing valves. Performed CO test for water heater serving Station 3 and 4. Found Recirc loop is inadequate. Hot water supply for mixing valve is inadequate. Need to redesign system. The NHA submitted a plan to the surveyors to remove immediacy by 1) calling in a plumber to investigate and fix the problem 2) adjusting water temperatures and continuous monitoring 3) bottled water provided to residents in order to wash hands and tend to personal hygiene 4) sanitary wipes were distributed 5) immediate staff education to all personnel working each shift 6) implemented the emergency preparedness plan and 7) held an Ad Hoc Quality Assurance Performance Improvement meeting regarding the plan. The plan to remove immediacy was accepted and the Immediate Jeopardy was terminated at 6:00 PM on 8/23/18. 2) On 8/23/18 at 10:01 AM, 2 surveyors observed that the supply room door was unlocked and unattended on the secured unit, Station 1. The supply room was in the short hall, in between the common use bathroom and the elevator that residents used to get up to the second and third floor. In the supply room were bottles of mouthwash, [MEDICATION NAME] swabs, alcohol prep pads, manicure sticks, 1 pack of disposable razors, 5 Foley catheter kits and 6 bottles of body wash. Staff #24, the nurse on the unit, walked up at that time, wiped a liquid puddle off the floor at the entrance of the supply room along with a roach. The surveyor advised Staff #24 that the door was unlocked. Staff #24 proceeded to lock the door. A second observation was made of the supply room door on 8/23/18 at 3:15 PM. The door was unlocked and unattended with residents walking in the hall, using the adjacent bathroom and elevator. There were 41 residents who resided on the unit. The surveyor went to find the nurse, Staff #25, and advised that it was the second observation made that day of an unlocked and unattended supply room. Staff #25 proceeded to lock the door and put a sign up stating Keep door locked at all times. On 8/24/18 and 8/28/18, the supply room door was observed locked. During an environmental tour with the NHA and the Director of Maintenance on 8/29/18 at 1:35 PM, the supply room door on Station 1 was unlocked and unattended, and the sign had been removed. The supply room contained, at that time, (4) packages of disposable razors which contained 10 razors in each pack, (23) 8-ounce bottles of Medline Sooth and Cool Cleanse Shampoo and Body Wash, 1 large fingernail clipper, 4 Foley Catheter Insertion Kits, multiple [MEDICAL CONDITION] adhesives, (2) sterile inhalation waters for respiratory care, along with other supplies such as juice and Ensure. The surveyor advised the NHA at that time that it was the third time the room was observed unlocked and unattended. The NHA was called into the conference room on 8/29/18 at 3:30 PM where notification was made that an Immediate Jeopardy existed to the vulnerable residents on Station 1. The NHA stated he was anticipating the Immediate Jeopardy and had already put measures in place. The NHA stated we already started education, checked all supply room doors, held an impromptu QAPI meeting and notified the Medical Director. The NHA stated we are having every 2-hour checks on the supply room door and showed the surveyor the signatures of staff that were currently in the building that had already received education. Review of medical records of 2 of the residents on the unit revealed that Resident #106 had [DIAGNOSES REDACTED]. The care plan was updated on 8/28/18. Resident #79, who had [DIAGNOSES REDACTED]. The note continued is difficult to assess thoughts due to muteness and language barrier and continues to eat non-food items including trash/diapers/gloves. On 8/29/18 at 4:56 PM, the plan to remove immediacy was accepted and the Immediate Jeopardy was abated.

Based on administrative and medical record review, staff and consultant interviews it was determined the facility restrained a cognitively impaired resident (Resident #15) without an order to allow a consulting staff member to perform a non-emergent procedure. This was evident for 1 of 15 residents reviewed during this complaint survey. The facility had identified these concerns prior to the start of the survey and had instituted substantial corrective actions to prevent recurrence of similar events, therefore this deficiency is being cited as past non-compliance harm. The findings include: Surveyor review of an incident (#MD 893) revealed an allegation that on 6/9/16, Staff #9 held Resident #15's arms down to allow Consultant #1 to swab the resident's mouth in preparation for a dental assessment. Resident #15 was admitted to the nursing home in July 2006 with [DIAGNOSES REDACTED]. The quarterly MDS assessments completed on 3/14/16 and 6/14/16, Section E Behavior E0800 Rejection of Care indicated the resident demonstrated rejection of care behaviors during those assessment periods. Review of Section C- Cognitive Patterns, C1000 revealed the resident was coded as being severely cognitively impaired and in C0100 staff indicated the resident is rarely or never understood. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. Surveyor review of one of Resident #15's care plans, revised on 8/22/14, addressed refusal of care, kicking, hitting and cursing at staff. One of the interventions included in the plan instructed staff that if the resident is resistive or aggressive, allow the resident 20-30 minutes to calm down and then re-approach. If the resident was still aggressive after the waiting period, staff were to leave the resident in a safe place, report to the nurse (nursing assistants) and re-attempt later.A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.Further medical record review revealed that on 5/6/16 the resident's family member reported to nursing staff that the resident struck him/her in the face twice during a visit. On 6/9/16 a nursing progress note reported the resident threw a carton of milk, a spoon and plastic bowl at his/her roommate's visitor and used a derogatory term to describe the visitor. The psychiatric nurse practitioner noted on 6/13/16 that the resident demonstrated increased agitation and combativeness and ordered [MEDICATION NAME] (antianxiety) 0.25 milligrams every six hours as needed for agitation. Review of the facility's investigative documentation revealed a written statement from Staff #9 that noted on 6/9/16 he/she heard Consultant #1 say to the resident, don't hit me. Staff #9 reported he/she saw the resident swinging at the Consultant #1 and offered to help. Staff #9 reported that he/she asked the resident to hold her/his arms out and he/she, put her/his hands on the resident's arms, holding her/his arms still.During an interview with the surveyor on 8/10/16 at 12:47 PM Consultant #1 stated he/she was attempting to swab the resident's mouth with a [MEDICATION NAME] (anti-[MEDICAL CONDITION] / antibacterial solution) swab prior to starting to clean the resident's mouth. Consultant #1 stated he/she did not ask staff for help with the resident because when he/she encounters residents that are resistive he/she usually waits and talks to the residents and if they continue to offer resistance does not perform any services. Consultant #1 further stated that Staff #9 just came to the resident's bedside grabbed the resident's arms and folded them over the resident's chest. He/she stated it happened very quickly and at that point he/she stopped trying to work with the resident, packed his/her belongings and left the room. Consultant #1 stated she/he reported concerns about Staff #9's actions to Social Services staff.In interview with the surveyor on 8/10/16 at 1:42 PM the Director of Nursing (DON) stated Consultant #1 should never have entered the room without notifying staff prior to attempting to work with the resident. When asked if they direct staff to hold resident's hands to perform care/tasks, the DON and Administrator responded no, the approach is to wait, and re-approach.During an interview with the surveyor, on 8/10/16 at 3:15 PM, Staff #9 stated when he/she finished providing care for Resident #15's roommate and he/she observed the resident swinging at Consultant #1 and asked if she/he needed help. Staff #9 stated the resident had his/her arms crossed over her/his chest and she/he (Staff #9) held the resident's arms/wrists while Consultant #1 swabbed the resident's mouth. He/she stated after the swab Consultant #1 packed up he/his equipment and left the room. Staff failed to follow the individualized care plan and instead restrained Resident #15 without an order. Facility staff failed to consider the potential for psychosocial harm suffered by a resident that was unable to give consent to a procedure and what the reasonable expectation would be for a resident who was not cognitively impaired.Incident #MD 893 was substantiated and a past-noncompliance Actual Harm was determined to exist related to the restraint of a resident during a non-emergent procedure. The facility had identified the concern and had implemented an acceptable plan of correction before the survey. The plan of correction included the nursing assistant involved in the incident being re-educated regarding dealing with difficult residents, and the resident was re-evaluated by the psychiatric nurse practitioner.

Based on administrative record review, medical record review and interviews with facility staff, it was determined the facility staff failed to monitor their radiator heater temperatures. As a result, the resident sustained [REDACTED]. This was evident for 1 (#142) of 35 residents reviewed during stage 2 of the survey.Findings include:Review of a facility reported incident #MD 501 and associated complaint #MD 699, revealed Resident #142 sustained multiple burns located at the left upper back, mid back and left buttock area.Resident #142 was admitted to the facility with the following but not limited to Diagnosis: [REDACTED].According to the facility investigation, the Director of Nursing (DON) was notified on 12/6/2015 at 10:57 PM by the weekend supervisor (Nurse Supervisor), that the said resident #142 was observed at approximately 10:30 PM by a GNA (Geriatric Nurse Assistant) lying partially on the roommate's bed and on the floor in the space between the heater and the bed. Upon assessment of resident #142, it was noted that he/she sustained multiple burns to his/her body; #1-left buttocks 12 cm (centimeters) x 12 cm, #2-left upper back 2 cm x 2 cm and #3-red discoloration from the mid to upper back. There were no other areas of compromise upon head to toe assessment. The resident vital signs at the time were stable, as well as oxygen saturation level. Resident #142 presented with facial grimacing and groaning, so was medicated with 650 mg of prn (as needed) Tylenol. A call was placed to physician who ordered the resident to be transferred 911.An interview was conducted with the Maintenance Director (MD) on 2/25/16 at 12:42 PM. The MD explained that he/she received a call from the facility and was asked to come in and check all the heating systems due to an accident that involved Resident #142. He/she stated that the facility used an outside engineering company that serviced the heating system. The outside company was called on 12/7/15 at 8:44 AM and came into the facility on [DATE], according to the call summary sheet and work code documentation submitted by the MD. The MD further explained that the system that in place was a steam heat radiator system that could generate steam between 200-230 degrees Fahrenheit. The MD also offered that the facility did a modification to all of the heaters in the building, in which they extended the top covered surface and covered the front metal frames to prevent the residents from the steam. The MD additionally offered, the facility staff implemented hourly monitoring of the thermostats throughout the facility after the incident, to ensure that it was maintained at a low setting of 2. The MD stated that no previous monitoring of the thermostats were done prior to the incident.A tour of the room where Resident #142 resided at the time of the incident was conducted on 2/26/16 at 2:00 PM with the Surveyor, Administrator and the MD. The Administrator explained, that at the time of the incident, Resident #142's roommate's bed was pushed over closer to the heater, decreasing the space between the heater and the roommates bed. The administrator was able to show the modification that was made to the radiator heat system inside of the room. Additionally, the administrator pointed to the nightstand, that was now mounted down in place, and explained that the night stand created a space between the bed and the heater.A telephone interview was conducted with the nurse supervisor on 2/27/16 at 12:10 PM. The nurse supervisor stated, I was making my rounds at 10:40 PM when I received a call indicating there was an incident. The nurse supervisor went on to state that a GNA found Resident #142 lying on the floor between his/her roommate's bed and the heat unit. The nurse supervisor further explained that Resident #142's back was resting on the heat unit, according to the GNA who found the resident. The resident was moved immediately. The nurse supervisor stated that when he/she arrived to the resident's room, a GNA and a nurse were with the resident. Resident #142 was assessed by the nurse supervisor and was found to have redness noted to the left upper back and the left upper buttock was all red. Resident #142 was able to respond to his/her name. There was no other mental status changes noted. The nurse supervisor further stated that he/she noticed that upon arriving to the resident's room, the room was very hot and warmer than usual. The nurse supervisor went on to say that he/she checked the thermostat and realized that it was set at 6, which was higher than the normal setting of 2-3. The nurse supervisor reported, 'the thermostats are now enclosed and locked, however, they were not enclosed and locked prior to this incident.'Review of hospital documentation revealed Resident #142's, left lower back, just above the gluteal region 2% area of burn, peripheral area is blanching, pink, moist, central area pale, dry and leathery, small area left upper back with epidermal sloughing and pink, moist, blanching tissue.The facility failed to ensure that Resident #142 was safe and free of accidents and injury when the resident skin came in contact with the metal frame of the facility's radiator heat system, when he/she was found by staff with his/her back against the radiator metal surface. Additionally, the facility staff failed to ensure that the thermostat inside of Resident #142 room, was maintained at a low setting of 2. As a result, Resident #142 sustained burns to 2% total body surface area (TBSA),resulting in harm to the resident.

Based on record review, observations, and interview with staff, it was determined that the facility staff failed to provide adequate supervision in the shower room to prevent a fall which resulted in the resident sustaining a fractured nose requiring stitches and the administration of narcotic pain medication. This was evident for 1 out of 35 residents (#167) reviewed in stage two of the survey. The findings include: On 11/6/14 at 12:08 PM Resident #167 was noted by surveyor to have old bruising on to the face below both eyes and an abrasion on the bridge of the nose. On 11/10/14 Resident #167's medical record was reviewed. This review revealed that the resident was [AGE] years old and had [DIAGNOSES REDACTED]. The resident had a care plan initiated in February 2014 for Risk for Fall/Injuries related to wandering, unsteady gait and poor safety awareness. Review of the care plan revealed the following falls: 8/25/14-- the resident lost balance in the dining room and fell on the floor; 9/12/14-- resident noted on floor beside bed, skin tear to bridge of nose; 10/4/14-- resident found on floor in bedroom beside bed; 10/11/14-- resident found on the floor in the hallway, skin discoloration to the left side of cheek bone; and 10/22/14-- resident observed on the floor in a sitting position at bedside. Review of the resident's Minimum Data Set (MDS: a standardized assessment form used to assist in the planning of resident care) dated 10/6/14 revealed that the resident required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person for transferring and walking in the room and corridor. This MDS also indicated that for bathing the resident was totally dependent requiring one person physical assist and that in regard to balance during transitions and walking the resident was not steady, but able to stabilize without staff assistance. For the Cognitive Pattern question: C0100 Should BIMS (brief interview mental status) be conducted? this was answered No (resident rarely/never understood). Further review of the medical record revealed that several physical therapy screens were completed for the resident in October and included the following comments: -10/6/14: On screen resident has decline functionally and needs increasing assistance for transfers and the gait is very unstable; -10/11/14: Rehab is working with (him/her) to improve dynamic balance in order to improve stability in standing and walking. On screen resident is at her baseline both physically and functionally. Educated resident on safety during transfer and during ambulation and going to insist on safety measures in every session of rehab; -10/22/14: Resident is working with PT (physical therapist) and working on improving gait pattern, dynamic balance and postural awareness in standing. Educating resident on safety and will continue to reinforce safety precautions during every session of rehab. Review of the nursing notes revealed that on 10/27/14 at 9:05 AM the resident was ambulated (walked) into the shower room with the geriatric nursing assistant (GNA staff #10) who reported turning around to turn the water on and the resident was heard falling to the floor. Upon assessment Resident #167 was noted with discoloration to both knees, a laceration (cut) to forehead and across the bridge of the nose. Ice packs were applied with pressure dressing to assist with bleeding and neuro checks were started. The physician was contacted and an order was obtained to send the resident to the hospital for evaluation. Review of the hospital record revealed that the resident sustained [REDACTED]. Further review of the nursing notes revealed that the resident returned to the facility on [DATE] around 5:30 PM. The physician was notified and orders were obtained per the hospital recommendations for Amoxicillin (an antibiotic) 500 miligrams (mg) three times a day for 7 days to prevent infection; Oxycodone (a narcotic pain reliever) 5 mg every 4 hours, and Bacitracin ointment to nasal laceration two times a day for 7 days. Review of the medication record (MAR) for October 2014 revealed that the resident received the Oxycodone on 10/28/14 at 12:00 AM, 4:00 AM, and 8:00 AM. The order was changed on 10/28/14 to every 6 hours as needed for pain post nasal fracture/laceration and the resident received the medication for pain related to the nasal fracture on 10/29/14 at 9:37 AM, 10/30/14 at 8:59 AM and 8:44 PM, and 10/31/14 at 12:40 PM. Review of the November MAR revealed that the resident continued to receive oxycodone for nasal fracture pain through 11/4/14. The October and November MARs also revealed that the resident continued to receive a regularly scheduled dose of Tylenol (pain reliever) every 8 hours during this time period. On 11/10/14 when asked if GNA (staff #10) would be working later in the week the director of nursing (DON) reported that the GNA had been terminated. On 11/12/14 at 2:40 PM review of staff #10's employee file revealed that she had been terminated on 10/27/14. Review of the Payroll Change Notice form included the following under the remarks: Failure to ensure resident safety - see disciplinary action dated 10/27/14. The Disciplinary Action Record revealed that employee had violated personnel policy number 19 page 50. Review of the signed statement from the GNA revealed that she had walked the resident from her room to the shower room, "I turned around to turn the water on and then she was on the floor." On 11/12/14 at 11:30 AM the GNA (staff #11) assigned to the resident for that day was interviewed. She reported that the resident needs total assistance for bathing, was a fall risk and that she uses the wheelchair to take the resident to the shower room then transfers the resident to the shower chair. The GNA went on to report that the GNAs have the option to look at the care plan but that most of the information about a resident's care needs are obtained through a verbal report at the beginning of the shift. On 11/12/14 at 2:35 PM surveyor reviewed with the administrator and the DON concerns regarding Resident #167's fall on 10/27/14 due to records indicating the resident was a fall risk with an unsteady gait that had been assessed by OT and PT for this issue; and that no information was found in the current fall care plan addressing safety measures during bathing for this resident. The DON reported that staff education did occur after the incident. On 11/12/14 at 2:58 PM the facility provided evidence that the GNA and nursing staff had received an in-service: on "Showering an Ambulatory Resident." This in-service training occurred between 10/28/14 - 11/1/14. Included in this training was the following: If ambulating a resident to the shower room, the resident must be safely seated either in a shower chair or the shower bench PRIOR to performing any preparation (e.g. turning on the water, ensuring proper water temperature, etc.) needed in the shower room.