Every finding on record at Forestville Rehabilitation and Wellness Center

Based on record review and staff interview, the facility failed to provide residents, who gave permission to allow the facility to manage their SSI/SSA funds, access to surplus SSI/SSA fund on demand for the month of April 2026. This was evident for 3 of 14 residents (Resident #3, #11, & #13) reviewed during a complaint survey. The findings include: Surveyor review of a complaint 2981750 on 5/29/26 at 9:40am that was sent to OHCQ on 4/13/26 and updated on 5/5/26 alleged the facility failed to provide resident surplus SSI/SSA funds when requested. Interview with Resident #3 on 5/29/26 at 10:40am reveal Resident #3 alleged that he/she was denied his/her surplus SSI/SSA funds when requested for the month of April 2026. Resident #3 stated that he/she was aware of the change in ownership as of February 2026. The facility did not make the resident aware that he/she wouldn't be able to access surplus SSI/SSA funds for the month of April 2026. Additionally, 2 residents' (Resident #11 and #13) complaints that the facility failed to provide access to surplus SSI/SSA funds for the month of April 2026 were also reviewed. Interview with the Administrator on 6/1/26 at 3:30pm regarding the residents' complaints of the facility's failure to provide access to surplus SSI/SSA funds for the month of April 2026 revealed that the Administrator was unaware of any financial issues with resident's accounts and resident funds are managed through the Business Office Manager. Interview with the Business Office Manager #17 on 6/2/26 at 7:40am confirmed that the facility's Business Office are responsible for all resident's funds and distribute resident surplus SSI/SSA funds for residents that gave permission to have the facility manage their SSI/SSA funds. Business Office Manager #17 also confirmed that he/she has been employed with the facility for 8 years and he/she is still employed as the Business Office Manager when the facility changed owners on 4/1/26. The surveyor asked Business Office Manager #17 if the facility had a issue with providing resident's access to their surplus SSI/SSA funds in April 2026. Business Office Manager #17 confirmed the facility was unable to distribute access SSI/SSA to residents because the former owner didn't send the facility resident's SSI/SSA funds until 4/17/26. Any surplus of resident funds was not available to the resident until 5/1/26. The Surveyor asked Business Office Manager #17 about the availability of residents receiving checks for the balance of their surplus funds. Business Office Manager #17 admitted the facility under the new owners could not issue checks until 6/1/26. Business Office Manager #17 provided the survey team with the financial statements for Residents #3, #11, and #13. The financial statements confirmed resident's SSI/SSA funds were not available for facility use until 4/17/26. The financial statements also confirm that the first disburse of surplus SSI/SSA funds was not until 5/1/26.

Based on record review and staff interview, the facility failed to timely report an alleged verbal abuse of a resident (resident #6) by facility nursing staff to OHCQ. This was evident with 1 of 14 resident records reviewed during a complaint survey. The findings include: Record review on 5/28/26 at 9:30am revealed an incident report sent by the facility 3006910 to the State of Maryland's Office of Health Care Quality on 5/7/26. In this incident report, the facility alleged LPN # 10 verbally abused Resident #6. On 5/13/26, the facility completed its investigation of the alleged verbal abuse incident and determined LPN #10 did not verbal abuse Resident #6. Interview with Resident #6 on 5/29/26 at 8:40am confirmed the alleged verbal abuse incident occurred on 5/7/26 at approximately 7:30am. Record review of the facility investigation on 6/2/26 at 7:30am confirmed the alleged verbal abuse incident took place on 5/7/26. The facility's initial investigation report sent to OHCQ revealed that the alleged verbal abuse incident occurred at breakfast on 5/7/26 and staff informed the facility administration of the alleged verbal abuse incident at 9:55am. The facility reported the alleged verbal abuse incident at 10:28 am on 5/7/26. Interview with LPN #10 on 6/2/26 at 9:50 am confirmed he/she had a verbal altercation with Resident #6 on 5/7/26 at approximately 7:30am. Interview with Social Services Director #8 on 6/2/26 at 10:30am revealed that Social Services Director #8 observed the alleged verbal abuse incident on 5/7/26. Social Services Director #8 stated that he/she heard a verbal altercation on 5/7/26 at approximately 7:30am. Social Services Director #8 then stated that he/she reported the altercation between LPN #10 and Resident #6 at approximately 9:30am to the Regional Director of Clinical Operations # 18 in morning meeting. Regional Director of Clinical Operations #18 made Social Services Director #8 aware of the time constraints involved with reporting alleged abuse to OHCQ and later given a refresher training on abuse reporting. Interview with Unit Manager #7 on 6/2/26 at 12:02pm confirmed the alleged verbal abuse incident occurred 5/7/26 at approximately 7:30am. Unit Manager #7 calmed LPN #10 and resident #6. After LPN #10 was calmed, Unit Manager #7 called the Director of Nursing (DON) to report the altercation. Interview with the Administrator and Regional Director of Clinical Operations #18 on 6/3/26 at 10:30am confirm that Social Services Director #8 reported the verbal abuse allegation on 5/7/26 in the 9:30am morning meeting. Regional Director of Clinical Operations #18 stated that he/she immediately started the facility investigation at the time Social Services Director #8 reported the incident in morning meeting. The Administrator stated that he/she was informed of the alleged verbal abuse incident at approximately 10:00am on 5/7/26 by the DON. The surveyor informed the Administrator and Regional Director of Clinical Operations #18 Unit Manager #7 stated she called the DON after the alleged verbal abuse incident on 5/7/26 at approximately 8:00am. The Administrator clarified his/her former statement regarding DON. The Administrator stated the DON stated informed him/her of the conversation he/she had with Unit Manager #7 earlier in the day about LPN#10's request to leave for the day. Unit Manager #7 failed to inform the DON of the alleged verbal abuse incident. The DON became aware of the alleged verbal abuse incident when Social Services Director #8 reported the alleged verbal abuse incident in morning meeting on 5/7/26.

Based on record review and staff interview; it was determined that the facility failed to protect a resident (resident #6) from verbal abuse by a facility staff member. This was evident for 1 of 14 residents reviewed during a complaint survey. The findings include:Record review on 5/28/26 at 9:30am revealed an incident report sent by the facility 3006910 to the State of Maryland's Office of Health Care Quality on 5/7/26. In this incident report, the facility alleged LPN # 10 verbally abused Resident #6. On 5/13/26, the facility completed its investigation of the alleged verbal abuse incident and determined LPN #10 did not verbal abuse Resident #6. Interview with Resident #6 on 5/29/26 at 8:40am confirmed LPN #10's verbal abuse of Resident #6 on 5/7/26. Resident #6 stated he/she left his/her room on 5/7/26 at breakfast time (approximately 7:30am) upset that he/she did not receive the ADL (Activities of Daily Living) assistance requested earlier in the morning. LPN #10 told Resident #6 that his/her robe wasn't covering his/her backside. Resident #6 then had a heated conversation with LPN #10 which resulted in LPN #10 loudly saying obscenities to Resident #6. Resident #6 then stated that Social Services Director #8 intervened in the argument between Resident #6 and LPN #10 and attempted to calm both Resident #6 and LPN #10 by standing between them. Unit Manager #7 took LPN #10 into his/her office. Social Services Director # 8 took Resident #6 into his/her office and asked Resident #6 if he/she felt safe in the facility. Resident #6 stated that he/she felt safe and then complained that nursing staff failed to assist with his/her ADL care. Resident #6 also stated that he/she felt that if nursing staff had assisted with the requested ADL care, the resident wouldn't have come out of his/her room with his/her backside exposed. Record review of the facility investigation on 6/2/26 at 7:30am confirmed the alleged verbal abuse incident took place on 5/7/26. The facility's investigation summarized the alleged verbal abuse incident as follows: [Resident #6] came out of his/her room on 5/7/26 partially covered with a robe. Nursing staff attempted to re-direct the resident. The resident responded with obscenities. LPN#10 attempted to calm down the resident at first but Social Service Director #8 observed LPN #10 screaming at the resident. Unit Manager #7 calmed Resident #6 and LPN #10 down from the verbal altercation. The facility's investigation contained written statements from LPN #10, Social Service Director #8, Unit Manager #7 and Resident #6, as well as other written statements from other nursing staff present during the alleged verbal abuse incident. Interview with the Assistant Director of Nursing (ADON) on 6/2/26 at 9:00am revealed LPN #10 was suspended without pay from 5/7/26 to 5/17/26. The ADON provided the surveyor with payroll records to confirm the dates of suspension. Interview with LPN #10 on 6/2/26 at 9:50 am confirmed LPN #10 was scheduled to work from 7am to 3:00pm on the 2nd floor of the facility on 5/7/26. LPN #10 also confirmed he/she had a verbal altercation with Resident #6 on 5/7/26 at approximately 7:30am. LPN #10 stated that he/she observed Resident #6 leaving his/her room partially covered with a robe. LPN #10 then stated that Resident #6 was screaming obscenities about nursing staff when nursing staff attempted unsuccessfully to calm resident. LPN #10 then stated that he/she attempted to calm Resident #6 and cautioned other nursing staff not to interact with the resident. Resident #6 then directed his/her obscenities toward LPN #10. LPN #10 denies screaming at Resident #6 or saying any obscenities to Resident #6. Unit Manager #7 calmed Resident #6 and took LPN #10 away from the resident into his/her office. Unit Manager #7 suspended LPN #10 pending investigation of verbal abuse. Interview with Social Services Director #8 on 6/2/26 at 10:30am revealed Social Services Director #8 observed the alleged verbal abuse incident on 5/7/26. Social Services Director #8 stated that his/her office is located on the 2nd floor by the nurses' station. Social Services Director #8 stated that he/she heard a verbal altercation on 5/7/26 at approximately 7:30am. Social Services Director #8 left his/her office and observed Resident #6 and LPN #10 standing close to each other with their fingers pointed into each other's face. Social Services Director #8 also heard Resident #6 and LPN #10 screaming obscenities at each other. Social Services Director #8 attempted to remove LPN #10 from the altercation but he/she refused to move. Eventually, Unit Manager #7 calmed Resident #6 and LPN #10. Unit Manager #7 took LPN #10 into his/her office and Social Services Director #8 took Resident #6 into his/her office to ensure the resident felt safe in the facility. The resident stated that he/she felt safe and explained nursing staff failed to assist the resident with ADK care when requested. Social Services Director #8 escorted Resident #6 back to his/her room. Social Services Director #8 then stated that he/she reported the altercation between LPN #10 and Resident #6 at approximately 9:30am to the Regional Director of Clinical Operations # 18 in morning meeting. Regional Director of Clinical Operations #18 made Social Services Director #8 aware of the time constraints involved with reporting alleged abuse to OHCQ and later gave Social Services Director #8 a refresher training on abuse reporting. Interview with Unit Manager #7 on 6/2/26 at 12:02pm confirmed the alleged verbal abuse incident occurred 5/7/26 at approximately 7:30am. Unit Manager #7 stated that he/she heard LPN #10 yelling obscenities to Resident #6 after Resident #6 insulted LPN #10. Unit Manager #7 calmed LPN #10 and Resident #6. LPN #10 stated that he/she wanted to turn in the unit keys and go home. Unit Manager #7 took LPN #10 into his/her office to calm the nurse. After LPN #10 was calmed, Unit Manager #7 called the Director of Nursing (DON) to report the altercation. The DON stated LPN #10 would need to be suspended pending facility investigation of the alleged verbal abuse incident. Interview with the Administrator and Regional Director of Clinical Operations #18 on 6/3/26 at 10:30am confirm that Social Services Director #8 reported the verbal abuse allegation on 5/7/26 in the 9:30am morning meeting. Regional Director of Clinical Operations #18 stated that he/she immediately started the facility investigation at the time Social Services Director #8 reported the incident in morning meeting. The Administrator stated that he/she was informed of the alleged verbal abuse incident at approximately 10:00am on 5/7/26 by the DON. The surveyor informed the Administrator and Regional Director of Clinical Operations #18 Unit Manager #7 stated she called the DON after the alleged verbal abuse incident on 5/7/26 at approximately 8:00am. The Administrator clarified his/her former statement regarding the DON. The Administrator stated the DON informed him/her of the conversation he/she had with Unit Manager #7 earlier in the day about LPN#10's request to leave for the day. Unit Manager #7 failed to inform the DON of the alleged verbal abuse incident. The DON became aware of the alleged verbal abuse incident when Social Services Director #8 reported the alleged verbal abuse incident in morning meeting on 5/7/26 at 9:30am.

Based on investigation into a complaint, observation, and staff interview, the facility failed to maintain a homelike environment for residents. This was evident for 1 of 1 resident bathrooms reviewed during the complaint investigation.The findings include: On 06/02/26, a review of Complaint #3001489 revealed allegations related to facility maintenance and environmental conditions.On 06/04/26 at 12:38 PM, during a random tour of the facility, observation of the shared bathroom serving residents in room [ROOM NUMBER] revealed the following environmental concerns: One of three light fixtures above the sink was missing a cover; The wall surrounding the grab bar and toilet tissue dispenser contained unfinished wall repairs with visible patching material; Unfinished wall repairs with visible patching material and gaps were also observed beneath the sink, along with gaps at the base of the wall; and The ceiling contained one displaced ceiling tile and three ceiling tiles with brown water stains. On 06/04/26 at 1:45 PM, during an interview, the Maintenance Director confirmed the environmental concerns observed in the bathroom serving residents in room [ROOM NUMBER], including the missing light fixture cover, unfinished wall repairs, stained ceiling tiles, and displaced ceiling tile. The Maintenance Director stated he would come up with a plan to address the concerns.At the time of exit conference, no additional information was provided by the facility.

Based on record review and staff interview, the facility failed to protect a resident's dignity (resident #6) by failing to assist the resident with requested adl tasks resulting in the resident leaving his/her room with his/her lower body being partially unclothed. This was evident in 1 of 14 residents reviewed during the facility's complaint survey. The findings include:Interview with Resident #6 on 5/29/26 at 8:40am revealed Resident #6 stated he/she left his/her room on 5/7/26 at breakfast time (approximately 7:30am) upset that he/she did not receive the ADL (Activities of Daily Living) assistance requested earlier in the morning. LPN #10 told Resident #6 that his/her robe wasn't covering his/her backside. Resident #6 then had a heated conversation with LPN #10 which resulted in LPN #10 loudly saying obscenities to Resident #6. Resident #6 then stated that the Social Services Director #8 intervened in the argument between Resident #6 and LPN #10 and attempted to calm both Resident #6 and LPN #10 by standing between them. Unit Manager #7 took LPN #10 into his/her office. Social Services Director # 8 took Resident #6 into his/her office and asked Resident #6 if he/she felt safe in the facility. Resident #6 stated that he/she felt safe and then complained that nursing staff failed to assist with ADL care. Resident #6 also stated that he/she felt that if nursing staff had assisted with the requested ADL care, the resident wouldn't have come out of his/her room with his/her backside exposed. Record review of Resident #6's medical records on 6/2/26 at 9:00am revealed the resident had a diagnosis of hemiparesis/hemiplegia which is the paralysis of one side of the body. The resident's diagnosis required the resident to need assistance with ADL care. Interview with LPN #10 on 6/2/26 at 9:50 am confirmed LPN #10 observed Resident #6 leave his/her room partially covered with a robe. LPN #10 then stated that Resident #6 was screaming obscenities about nursing staff when nursing staff attempted unsuccessfully to calm Resident #6. LPN #10 then stated that he/she attempted to calm Resident #6 and cautioned other nursing staff not to interact with the resident. Resident #6 directed his/her obscenities toward LPN #10. LPN #10 denies screaming at Resident #6 or saying any obscenities to Resident #6. Unit Manager #7 calmed Resident #6 and took LPN #10 away from the resident into his/her office. The surveyor asked LPN #10 if any of the nursing staff attempted to assist Resident #6 with covering his/her body. LPN #10 did not remember. During an interview with the Assistant Director of Nursing (ADON) on 6/2/26 at 1:30pm, the surveyor asked the ADON of the facility policy on how nursing staff would protect a resident's dignity. The ADON stated that nursing staff would protect a resident's dignity by respecting the resident's right to have personal preference in their daily lives. The surveyor informed the ADON that Resident #6 felt that his/her dignity was violated on 5/7/26 when nursing staff failed to assist the resident with requested ADL tasks and per Resident #6 felt nursing staff failure to assist with requested ADL tasks led to the altercation with LPN #10 on the morning of 5/7/26.

Based on investigation of a complaint, record review and interviews, it was determined that the facility failed to ensure physician documentation accurately reflected the resident's dietary plan of care. This was evident for 1 (Resident #2) of 10 residents reviewed during the complaint survey.The findings include: On 06/02/26, a review of Complaint #3001489 related to care concerns involving Resident #2 was conducted.On 06/03/26 at 9:37 AM, review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE] for continued care and rehabilitation following hospitalization.Review of Resident #2's physician orders revealed an order for a regular diet, regular texture, and thin liquids with a start date of 03/04/26. The order was electronically signed by the Medical Director. Further review of Resident #2's clinical record revealed a physician assessment (History and Physical) dated 03/05/26 that included a plan of care to continue medications as ordered and a pureed diet with aspiration precautions. The assessment was electronically signed by the Medical Director.Review of Resident #2's nutritional assessment dated [DATE] revealed the assessment was completed by the Registered Dietitian (RD) based on a regular diet, regular texture, and thin liquids.On 06/04/26 at 11:09 AM, during an interview, the RD stated that she based her nutritional assessment on the dietary orders entered in Resident #2's electronic clinical record.On 06/04/26 at 11:25 AM, during an interview, the Medical Director reviewed Resident #2's clinical record and confirmed that he electronically signed the physician orders dated 03/04/26 for a regular diet, regular texture, and thin liquids and the physician assessment dated [DATE] documenting a pureed diet with aspiration precautions. The Medical Director stated the resident was on a regular diet and that the pureed diet with aspiration precautions documented in the physician assessment was entered in error.

Based on investigation into a complaint, closed record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to address residents' individualized care needs. This was evident for 1 (Resident #2) of 5 residents reviewed for care plans during the complaint survey. The findings include: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.On 06/02/26, a review of Complaint #3001489 revealed allegations related to the care provided to Resident #2.On 06/03/26 at 9:37 AM, a review of Resident #2's closed record revealed that the resident was admitted to the facility on [DATE] with diagnoses that included Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris and Heart Failure, Unspecified.Review of Resident #2's emergency room (ER) Discharge summary dated [DATE] revealed the resident had chronic systolic heart failure with an ejection fraction of 30% to 35%.Review of Resident #2's comprehensive care plan failed to reveal goals or interventions developed to address the resident's cardiac diagnoses, including Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris and chronic systolic heart failure.On 06/04/26 at 1:37 PM, during an interview, the Assistant Director of Nursing (ADON) reviewed Resident #2's comprehensive care plan and confirmed there was no care plan developed to address the resident's cardiac needs. The ADON stated that residents' care plans are expected to address their individualized care needs.At the time of exit conference, no additional information was provided by the facility.

Based on the facility bed licensure, staff interviews, and a review of the facility staff roster, it was determined that there were no qualified or licensed social worker or qualified social services designee employed on a full-time basis for this 162 licensed bed facility. This was observed during the recertification/complaint survey and has the potential to affect all residents.The findings include:Facilities licensed for more than 120 bed capacity must employ a qualified social worker on a full time basis. A qualified social worker is defined as an individual with a licensed in social work or a bachelor's degree in a related human services field and at least one year of supervised social work experience in a health care setting. A social worker contributes to the well-being and quality of life of the residents by addressing the emotional, social, and psychological needs of the residents.When conducting a state survey, if the facility is licensed for over 120 beds and does not have a full time licensed social worker, or a qualified social services designee, an extended survey must be conducted to identify areas of substandard quality of care. This involves further review of the facility policies and procedures related to the deficiencies found during the standard survey.During the review of the facility entrance documentations on 1/5/2026 at 0900, it was noted that the facility is licensed for 162 beds with a current census of 147.On 1/6/26 at 10:26 AM, when the Director of Nursing (DON) was asked about the social worker, The DON stated that staff #1 is the Social Services Director (SSD), but she/he is not licensed, and the previous licensed social worker had resigned. An interview with the Nursing Home Administrator (NHA) on 1/6/2026 at 12:38 PM revealed that the previous social worker worked at the facility for 4.5 months and the regional social worker came to the facility monthly. There was no evidence provided to show when the regional social worker came to the building.On 1/12/26 at 11:32 AM a review of the SSD employee file failed to reveal a degree of any type.The Human Resources Director (HRD), staff #32 stated on 1/12/26 at 11:39 AM that she spoke to the SSD and confirmed that she/he did not have a college degree. On 1/12/26 at 11:46 AM, in an interview with the SSD when asked if she/he had a bachelor's degree she/he stated, no, but is working towards an SSD certification. On 1/12/2026 at 12:15 PM, the DON and NHA were made aware that not having a full-time employed qualified social worker at the facility is a concern and had resulted in an extended survey. The DON and NHA acknowledged the concern and stated that there was a hiring request made for a qualified and licensed social worker.

Based on a review of resident council meeting minutes and interviews with residents and facility staff, it was determined the facility failed to give adequate responses to grievances that were presented by the resident council. This was evident for 6 of 6 months of the Resident Council meeting minutes reviewed during the recertification/complaint survey. The findings include: The Resident Council is a group of residents that meets regularly on the behalf of all residents in the facility to discuss concerns about facility policies and procedures affecting residents' care, treatment, and quality of life. Facility staff are required to consider resident and family group views and act upon grievances and recommendations. This may include developing or changing policies affecting resident care and life. Facility staff should discuss their decisions with the resident and/or family group and document in writing its response and rationale. The facility must be able to demonstrate their response and rationale.On 01/07/2026 at 8:45 AM, during an interview, Resident #155 voiced a concern that the facility does not respond to concerns expressed during the Resident Council meeting; therefore, the concerns keep recurring.On 01/07/2026 at approximately 11:00 AM a review of the most recent 6 months' Resident Council meeting minutes was conducted. However, the documentation lacked identified resident information pertaining to the concerns, evidence that individual residents' concerns were addressed, or proof of a resolution/action taken to resolve the concern, including notification of that resolution to the resident. A review of June 2025's Resident Council meeting minutes revealed the following concerns: missing/delayed laundry returns, slow call light response, lack of access to the eye doctor, poor staff attitude, and inadequate training for new Geriatric Nursing Assistants (GNAs).A review of July 2025's Resident Council minutes revealed three concerns: Residents had inquired about the status of the bus for summer outings. Geriatric nursing assistants reportedly refuse to assist residents not assigned to them, often turning off call lights and stating they will notify the assigned aide. A third concern was the timely ordering of medications.A review of August 2025's Resident Council meeting minutes revealed the following concerns: residents who smoke are not going out on time; a continued concern of GNAs turning off call lights without addressing resident needs; staff speak a different language; and excessive noise occurs during the 11 PM to 7 AM shift change. A review of September 2025's Resident Council meeting minutes revealed the following resident concerns: long wait times for staff assistance, poor staff attitudes, excessive noise during the 11:00 PM to 7:00 AM shift change, inability to watch football during the season, delayed smoker outings, staff speaking non-English languages, and staff using Bluetooth devices.A review of the October 2025 Resident Council meeting minutes revealed the following concerns: staff still being on their phones, call lights still not being answered timely, and persistent staff attitudes.A review of November 2025's Resident Council meeting minutes revealed the following concerns: call lights not being answered timely. On 01/07/2026 at 11:40 AM, during an interview with Staff #34 (Activity Director) stated the Resident Council grievances/concerns are documented individually on a concern form and sent to the relevant department (e.g., laundry concerns go to Laundry). The department returns the form to her, and she keeps them in a binder in her office; however, the binder is missing. The Activity Director was informed of this concern. On 01/07/2026 at 2:49 PM during an interview, the Administrator, who is also the Grievance Officer, described the grievance process: concerns are submitted on a form to him, then assigned to the relevant department for resolution. The resolution is documented on the form, communicated to the complainant, and returned to the Administrator. The Administrator was informed of the concern at this time.

Based on observation and interview, it was determined that the facility failed to store and maintain food in accordance with professional standards for food service. This was evident during an initial tour of the kitchen during the recertification/complaint survey. The findings include:On 01/05/2026 at 7:37 AM during an initial tour of the kitchen accompanied by Staff #9 (Dietary District Manager) in a large walk-in refrigerator, the following items were found: 3 clear medium-sized containers of fruit with a use-by date of 01/04/2026, 1 large container of vegetable soup with no date, and French toast in a steel container with a date of 12/29. Staff #9 was not able to determine if the date for the French toast was an open or a use-by date. On 01/05/2026 at approximately 7:45 AM, a continued observation in the large walk-in refrigerator revealed a small steel container of fish with no date, 1 large container of sliced cheese with a prep date of 10/23/2025 and a use-by date of 12/23/2025, and one clear container of cantaloupe with a prep date of 12/23/2025 and a use-by date of 12/30/2025.On 01/05/2026 at approximately 7:50 AM, a further observation of the kitchen revealed that under the food tray line was a large bin labeled Starch with a use-by date of 12/28/2025.On 01/07/2026 at 8:35 AM, during an interview, Staff #9 (Dietary District Manager) confirmed food should be labeled with a date and discarded on the expiration date. At this time, he was notified of the concern. On 01/09/2026 at approximately 3:30 PM the Administrator and Director of Nursing was made aware of the concern.

Based on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received mandatory communication training. This was evident for 4 (LPN #45, GNA #46, GNA #47, GNA #48) out of 6 direct care staff employees reviewed during the Extended Survey portion of the facility's recertification survey.A facility must include effective communications as mandatory training for direct care staff. Direct care staff are defined as those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Effective communication helps staff understand what a resident is trying to communicate so staff can appropriately respond. It also helps staff to effectively provide information to residents. This helps to ensure that residents are provided with information in a language and manner they can understand. On 1/8/26 at 11:32 AM in an interview with Human Resources Director (HRD #32) and the Infection Preventionist/Staff Educator (IP/SE #10), when asked if HRD #32 handles any of the staff training, HRD #32 stated, I get staff set up with a background check and orientation paperwork. I do not personally complete any trainings. IP/SE #10 acknowledged and confirmed this. On 1/8/26 at 11:34 AM in an interview with IP/SE #10 when asked the different ways trainings were provided to staff, she stated staff completed Relias training that was scheduled from corporate and that from me personally, I do handwashing, PPE (personal protective equipment), and [resident] falls in-services. When asked if there was any mandatory training all staff received, she stated, Yes, the ones in Relias. During the interview she stated on the first day employees completed onboarding paperwork and there was no training and on the second day they did their Relias, PPD (tuberculosis skin test), and flu. Then employees were scheduled to do floor orientation. When asked how long the two orientation days were, she stated 8 hours. When asked if there were any mandatory trainings all staff received upon and/or within 90 days of hire, she stated, Yes, handwashing, donning and doffing PPE, and that is more or less it. When asked how the facility kept track of staff participation in the required trainings/education/in services, she stated, We have a form that when we have an in-service, they have to sign for it, an attendance sheet. When asked where those attendance sheets are stored, she stated, I have a binder when I have in-services and it's stored in my office. The surveyor requested all in-services and any other training/education related documentation for staff for 2024 and 2025. The surveyor and IP/SE #10 walked to her office and she provided a white, 3-ring binder titled 2025 In Service that had monthly dividers from January through December and five manilla folders with attendance sheets. When asked if there was any further documentation to provide as evidence of facility staff trainings, education, in-services, et cetera, she stated no. When asked if there was any competency documentation for GNAs she stated, I told you it's in Relias. When asked if there was any competency documentation for nurses, she pulled one manila folder from the pile provided, titled Med Pass Completed. When asked if this was for nurses, she stated yes. When asked if every nurse needed to complete this she stated yes. When asked if all nurses had completed it, she said, I want to say 80% did because I have not seen them all. When asked how she could verify all nurses or GNAs competed a training, in-service, education, et cetera, she stated I have a staff roster, and I check it off. When asked if she could share one example, IP/SE #10 flipped through the manilla folder. The surveyor asked if she saw the staff roster she had mentioned and she stated no. In a dual observation, the surveyor and IP/SE #10 looked through the remaining manilla folders and she verified there was no staff roster check off completed to ensure all staff received the offered education, training, and/or in services. On 1/8/26 at 12:32 PM review of Licensed Practical Nurse (LPN #45's) employee files revealed she was hired on 8/19/25; however, failed to reveal communication training.On 1/8/26 at 1:12 PM review of Geriatric Nursing Assistant (GNA #46's) employee files revealed he was hired on 6/26/24; however, failed to reveal communication training.On 1/8/26 at 1:22 PM review of GNA #47's employee files revealed he was hired on 6/5/24; however, failed to reveal communication training.On 1/8/26 1:42 PM review of GNA #48's employee files revealed she was hired on 6/5/24; however, failed to reveal communication training.On 1/12/26 at 10:36 AM review of all training, education, in-services from the white, 3-ring binder ( 2025 In Service) revealed the following required trainings:12/6/24 Effective Communication Training12/19/24 Abuse/Neglect/Mistreatment/MisappropriatingFrom 8/25 through 12/25 there were no attendance sheets in the binder for any of those monthsOn 1/12/26 at 11:44 AM review of the four manilla folders revealed attendance sheets for the following training and dates:Folder #1 Med pass observations completed in 10/2025 and 12/2025Folder #2 G-tube observations completed in 10/2025Folder #3 Perineal Care 8/2025, Pain meds 10/2025, Identifying Substance Abuse 10/2025, Nurses documenting order after orders are written 11/2025, Identifying residents with a history of overdose or overdosing 11/2025 Folder #4 Abuse 9/2025, Discard sharps in room [ROOM NUMBER]/5/26, Hand hygiene 7/2025, 9/2025, 10/2025, 11/2025 and 1/2026, Perineal Care 6/2025, Dating Nebulizer Treatment 9/2025, E. coli in urine 6/2025, IDT Fall Assessment after a fall 12/2025, Infection Prevention- Ice Scoop 10/2025, Fill out inventory sheet properly 11/2025, No medical documents placed in shower book 12/2025, Nurses Not to do Sternal rub on residents complaining of chest pain 11/2025, Nurses to administer meds timely 11/2025, Narcotic signing and hand off 12/2025, Alert Charting 12/2025, Bed locked 12/2025, Dignity to residents 11/2025, Get resident out of bed every day 12/2025, HIPPA 12/2025, and Dialysis Assessment Pre and Post Dialysis 10/2025. Folder #5 PPE 10/2025, Timely call bell response times 10/2025, Staff Introduction at beginning of shift 10/2025, Town Hall Meeting 9/2025, Hot Beverages 9/2025, Disaster Plan 9/2025, Label Resident Urinal 10/2025, No Gloves in Hallway 10/2025, Room Cohorting 10/2025, Perineal Care 10/2025, Staff to Knock before Entering 10/2025, Linen Carts 10/2025, Surgical Mask wearing properly 10/2025, Foley empty before Resident leaves for appt 10/2025, Tube Feeding 10/2025, Med Pass 10/2025, Nursing admission Evaluation 10/2025, Glucometer 10/2025, Perineal Care 10/2025, 1-1 Monitoring for RM [ROOM NUMBER] A 10/2025, Address abnormal vital signs 4/2025, Staff answer call bell timely 4/2025, Staff not using cell phone while providing care to residents 7/2025, Bed Safety 7/2025, 24 hour report 7/2025, Check sites (IV, G-tube, peg tube, trach, etc.) and communicate changes 7/2025, Perineal Care 12/2025, Fall Prevention and Management 11/2025, Transfer to Hospital: Bed Hold, MOLST, Med List 6/2025, Heat Advisory 6/2025, Resident Falls 6/2025, Ice Machine 6/2025, Dementia 6/2025, O2 (oxygen) tubing, nebulizer, filters 6/2025, Nurses not to label water bottles on G-Tube 6/2025, ADT 6/2025 (ADT= Electronic System where you bring residents in or discharge them out and shows their status in the facility (Admission, Discharge, Transfer), Signing Off Medications 6/2025, Staff to Report any occurrences on the Resident and Report to the Nurse 6/2025, Wound Interventions and Shower Documentation 4/2025.Review of all manilla folders failed to reveal any communication training.On 1/12/26 at 2:08 PM in an interview with IP/ SE #10, she verified and confirmed as second time, that the 5 manilla folders and white 3-ring binder provided included all the training, in-services, and education for facility staff outside of the Relias trainings which were provided as transcripts for the employees.On 1/12/26 at 4:26 PM in an interview with IP/ SE #10, a dual observation was conducted of the Relias trainings staff completed upon hire. There were three pages provided for Licensed Staff and three pages for GNAs. When asked if any of the upon hire Relias training included communication training listed, she stated for nurses there was Expanding your Communication Skills training, and it would be on the staff's Relias transcript if they completed it. She verified and confirmed that the Relias training required for GNAs did not include communication training.On 1/12/26 at 4:30 PM in an interview with IP/ SE #10, a dual observation was conducted of each employees' Relias transcript along with the attendance sheets from the 3-ring binder and manilla folders. During the interview and observations, when asked if there was evidence for: LPN #45 of communication training, she stated no. When asked how many hours of cognitive impairment/mental illness training direct patient care staff needed to complete annually, she stated, I'm not really sure. When asked how many hours of cognitive impairment/mental illness training direct patient care staff needed to complete within 90 days of hire, she stated, 30 minutes quarterly based on this paper. GNA #46 of communication training, she stated no. GNA #47 of communication training, she stated no. GNA #48 of communication training, she stated, No, I'm not sure who's scheduling these modules. There's no consistency. The surveyor pulled out and shared the 2025 Annual Relias Course & Skills 2 page document provided by the facility and shared that based on these documents, there were communication trainings listed such as Expanding Your Communication Skill Set; however, not all employees were completing the courses. When asked whose responsibility it was to ensure assigned modules were monitored to ensure that staff were completing them timely, IP/SE #10 stated, I don't assign the modules, someone from corporate does that. The surveyor shared that some employees who were hired the same month and for the same position had a different number of courses completed. When asked whose responsibility it was to ensure staff completion of the assigned modules, IP/SE #10 stated, Myself, the nurse managers, but usually it's myself that checks.The surveyor shared these findings were concerns. The IP/SE #10 verbalized and acknowledged understanding of the concerns.

Based on a review of medical records and staff interviews, it was determined that facility staff failed to provide and document appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for one resident (Resident #66) of three reviewed for urinary catheter care during this annual survey.The findings include:A Foley catheter is a thin, flexible tube inserted through the urethra into the bladder to drain urine, used for urinary retention, incontinence, or during/after surgery, kept in place by an inflated balloon at the tip. Foley catheter sizes are measured in French (Fr) units, indicating the tube's outer diameter, with larger numbers meaning a thicker catheter.During an interview on 1/05/26 at 11:37 AM, Resident #66 reported that their indwelling catheter had come out several times within one month. The resident stated, I felt like someone was pulling out the catheter.A review of medical records on 1/08/26 at 7:55 AM revealed that Resident #66 has a chronic indwelling catheter due to a diagnosis of paraplegia (spinal level T2). Progress notes indicated multiple incidents of the Foley catheter being dislodged in December 2025:12/02/25 (8:15 AM): Nursing staff noted that a Geriatric Nursing Assistant (GNA) reported the catheter had come out at approximately 6:00 AM. After an assessment, a new 16 Fr catheter was inserted. Telehealth was notified, and a voicemail was left for the Responsible Party (RP).12/06/25 (10:36 PM): Documentation showed the catheter came out and a new one was inserted.12/13/25 (3:37 PM): A progress note indicated that an 18 Fr Foley catheter was inserted and the balloon inflated with 10 cc of sterile water.12/23/25 (10:41 PM): Nursing staff observed the catheter in the trash. The resident stated it had come out and they had discarded it. A 16 Fr catheter was re-inserted.12/24/25 (4:48 PM): A note documented another dislodgment and subsequent re-insertion.A review of the Treatment Administration Records (TAR) on 1/09/26 at 9:13 AM revealed no records of the Foley catheter re-insertions and no documentation from medical providers addressing these recurrent issues.In an interview on 1/09/26 at 9:24 AM, Licensed Practical Nurse (Staff #35) stated that a physician's order is required to re-insert a Foley catheter unless a PRN (as needed) order is already in place.During an interview with the Director of Nursing (DON) on 1/09/26 at 9:31 AM, the surveyor asked about the expected protocol when a catheter is dislodged. The DON explained that nurses are expected to notify providers, assess and document the resident's condition, and follow provider orders regarding the specific catheter size. When asked if Resident #66 was scheduled for a urology evaluation regarding recurrent issues, the DON confirmed that no consult was planned, stating, We do not schedule for urology follow-up just because a Foley catheter came out.The surveyor shared concerns that the catheter size was changed from 16 Fr to 18 Fr and then back to 16 Fr without a specific provider order, noting the potential for urethral trauma. The DON validated these concerns.

Based on review of the medical record and interviews with facility staff, it was determined that the facility failed to provide residents with information to formulate an advanced directive and ensure that a current copy of residents' advanced directives was in the residents' medical record. This was evident for 1 (Resident #1) out of 5 residents reviewed during the facility's recertification/complaint survey. The findings include:An advance directive is a set of written instructions that allows you to make decisions about your future medical care, and/or to designate somebody to make those decisions for you if you are no longer able to do so because of illness, injury, or incapacity. It includes the appointment of a health care agent or advocate, your healthcare instructions, and a signature page where you and two witnesses sign the form to make the document official. Essentially, it is a way to ensure everyone knows what you want and that your healthcare preferences are followed, even when you cannot communicate them directly. MOLST (Medical Orders for Life-Sustaining Treatment) is a form for right now, not for the future. The MOLST form is followed as soon as the form is completed. It is a portable and enduring medical order form (similar to a prescription) that relays instructions between health professionals about a patient's care. It translates a patient's end-of-life care wishes into specific, actionable medical orders signed by a doctor, ensuring their preferences for treatments such as CPR, intubation, or feeding tubes are followed across different healthcare settings.The MOLST form is not an advance directive because it is a medical document that contains actionable medical orders that are effective immediately based on a patient's current medical condition. Advance directives, including living wills, are legal documents that are effective only after the patient has lost capacity. In other words, a health care representative can make decisions for a person only after he or she has been determined to lack capacity; a living will is relevant only after the patient can no longer be consulted. A MOLST form, on the other hand, is a medical document signed by both the clinician and the patient, and is effective as soon as it is signed, regardless of a patient's capacity to make decisions.On [DATE] at 9:54 AM review of Resident #1's medical record failed to reveal an advance directive and/or documented evidence or information indicating that an opportunity to formulate an advance directive was provided to the resident. Further review revealed a bolded heading under the Miscellaneous tab in the electronic medical record titled, Advance Directives; however, there was no advanced directives documentation observed and under the heading were two MOLST's (Medical Orders for Life-Sustaining Treatment, a form is used for documenting a resident's specific wishes related to life-sustaining treatments). On [DATE] at 9:34 AM an interview was conducted with the Social Services Designee (SSD#1). During the interview when asked about the process for advance directives in the facility, she stated when a resident was admitted to the facility, they are asked if they have advance directive. She stated, If they say yes, they'll give it to us, and we upload it in PCC (Point Click Care, facility's electronic medical record). If they don't have one, we'll do one if they are alert and oriented. If they're not alert and oriented, we do a health care surrogate form. When asked if this process was documented, SSD #1 stated, It should say if they have an advance directive or if they refused to do one. It would be documented as a social services note. When asked if she could provide a copy of Resident #1's advance directive, she stated, I have to check on [previous Social Worker's first name]'s desk. He just left last Friday. The surveyor shared that Resident #1 was admitted to the facility on [DATE] and when asked if it would have been scanned and uploaded in almost a year's time, SSD #1 stated, Yeah, it should have been done. On [DATE] at 9:49 AM review of Resident #1's medical record revealed five social services notes; however, failed to reveal any social services note indicating that an opportunity to formulate an advance directive was provided to the resident. On [DATE] at 10:18 AM in an interview with the Director of Nursing (Director of Nursing) when asked if she could provide a copy of Resident #1's advance directive, she stated, I don't think he/she has an advance directive. He/she's alert and oriented and has the capacity to make his/her own decisions. When asked about advance directives, she stated it was a federal form for what to do when you become incapacitated. Additionally, she stated that some people do not have it, so we do certifications. When asked to explain more, she stated, We have physicians evaluate if they have capacity. If a resident did not have capacity, a surrogate would be signed, if that person accepted the responsibility. Furthermore, she stated Resident #1 does not have one [an advance directive], but he/she's alert and oriented times three, has a MOLST, and has not been deemed incapable, so he/she does not need one. The surveyor shared this was a concern. The DON acknowledged understanding of the concern. On [DATE] at 10:55 AM review of the facility's policies and procedures for Advance Directive (Resident's Right to Choose) revealed, It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. On admission, the facility will determine if the resident has executed an advance directive and if not, determine whether the resident would like to formulate an advance directive. Additionally, the review revealed, The facility will provide the resident or resident representative with information on how to formulate an advance directive.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure each resident's medication regimen was free from unnecessary medication/chemical restraints. This was evidenced by the facility utilizing psychotropic medication without appropriate assessment and documentation. This deficient practice was identified in one (Resident #17) of five residents reviewed for unnecessary medication regimens during the recertification/complaint survey.The findings include:Psychosis is a symptom involving a loss of contact with reality (e.g., hallucinations or delusions) that can occur in various conditions.Schizophrenia is a chronic mental health disorder characterized by psychosis and additional symptoms such as disorganized thinking and impaired daily functioning lasting over six months.Risperidone (Risperdal) is an atypical antipsychotic medication primarily indicated for schizophrenia, bipolar disorder, and irritability associated with autism. It functions by balancing dopamine and serotonin levels to stabilize mood and behavior.On 1/07/26 at 7:32 AM, the surveyor reviewed Resident #17's medical records. The review revealed that the resident had diagnoses including, but not limited to, anxiety and unspecified psychosis not due to a substance or known physiological condition. However, as of 10/22/25, the resident was prescribed Risperdal 1ml by mouth twice daily for a diagnosis of Schizophrenia. The records confirmed that Resident #17 did not have a clinical diagnosis of Schizophrenia to support the use of Risperdal for that indication.A review of the Minimum Data Set (MDS) assessments for Resident #17 on 1/07/26 at 1:00 PM revealed inconsistent coding for Schizophrenia:-12/03/24: Schizophrenia was coded.-05/25/25, 08/21/25, and 09/09/25: Schizophrenia was NOT coded.-12/13/25: Schizophrenia was not coded, but psychotic disorder was coded.On 1/09/26 at 7:59 AM, the MDS Coordinator (Staff #3) stated that Resident #17 had a diagnosis of Schizophrenia upon admission. Staff #3 explained, The corporate office directed us to inactivate schizophrenia diagnoses for residents due to a CMS memo. We were told to complete a new schizophrenia evaluation before re-activating the diagnosis. Since the psychiatrist has not completed the evaluation yet, I coded it as 'no schizophrenia.'The facility provided a copy of CMS Memorandum QSO-23-05-NH issued 01/18/23, which outlines audits to verify the accuracy of schizophrenia diagnoses. The memo addresses concerns that facilities may erroneously code schizophrenia to mask high antipsychotic use, as these residents are often excluded from quality measures.On 1/09/26 at 11:43 AM, the Psychiatrist (Staff #11) confirmed that the corporate office required a full re-assessment for all residents with a schizophrenia diagnosis. Staff #11 noted that while Resident #17 had a Provider Attestation for Schizophrenia form completed on 10/20/22, the corporate mandate required a new evaluation, which was currently in process.In a review of Risperdal administration on 1/09/26 at 1 PM showed the dosage and indication fluctuated frequently between 11/09/23 and 1/09/26 without consistent clinical justification. Notably:-From 11/09/23 to 10/11/25, 0.5mg by mouth twice a day (BID) for unspecified psychosis-From 10/12/25 to 10/14/25, 1mg BID for unspecified psychosis.-From 10/14/25 to 10/18/25, 0.5mg BID for unspecified psychosis.-From 10/22/25 to 1/09/26, 1mg BID for schizophrenia.-From 1/09/26, 0.5mg BID for unspecified psychosis.On 1/12/26 at 9:38 AM, the surveyor reviewed all psych notes from January 2025 to current. The review revealed that:-On 1/20/25, the initial mental health visit in-person by Staff #12 documented that Resident #17 had diagnosis of Schizophrenia and Risperidone 0.5mg BID was used for Schizophrenia.-On 4/16/25 and 6/18/25, follow up assessment by Staff #44 (Psych NP) documented no schizophrenia but history of present illness narrative contained Risperdal 0.5mg BID for schizophrenia.-On 8/13/25, 8/25/25, 9/01/25, 9/11/25,and 9/15/25, psych notes written by Staff #12 showed that there was no diagnosis of Schizophrenia but Risperdal was used for Schizophrenia.-On 9/23/25, a psych note written by Staff #12 documented as this is a facility requested mental health assessment to review resident's mental health diagnosis. Staff reports ongoing concerns regarding disorganized thoughts and behaviors noted over the past several months. No documentation of a schizophrenia diagnosis was found in the chart, despite the current use of Risperidone.Presentation does not meet full criteria for schizophrenia, Assign diagnosis: Unspecified psychosis not due to a substance or known physiological condition. Also, the indication of current medication for risperidone was changed to unspecified psychosis.-On 9/30/25 and 10/08/25, psych notes written by Staff #12 documented that Resident #17 was on Risperdal 0.5mg BID for psychosis, however, no diagnosis of psychosis.There was no documentation around 10/12/25, regarding increasing Risperdal dose from 0.5mg BID to 1mg BID.-On 10/13/25, Staff #12 wrote a note with adjusting risperidone to 0.5mg BID.-On 10/31/25, Staff #12's note included Risperdal 1mg BID for psychosis, however no evaluation/assessment documented about increasing dose from 0.5mg to 1mg started on 10/22/25.On 1/12/26 at 10:00 AM, the Director of Nursing (DON) was informed of the concerns regarding the lack of proper, timely assessment and documentation for Resident #17's antipsychotic medication. The DON validated these findings.

Based on review of pertinent documents and interview with facility staff, it was determined that the facility failed to timely report to the State Survey Agency, the Office of Health Care Quality (OHCQ), an allegation of suspected resident abuse, and an allegation of misappropriation. This was evident for 2 (Resident # 164 and #163) of 2 residents reviewed for abuse during the recertification/complaint survey.The findings include:The OHCQ is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are to be reported to the OHCQ in a timely manner.1) On 01/07/26 at approximately 1:35 PM, a review of the facility concern forms for the month of October 2025 revealed a concern form dated 10/30/2025 filed by Resident #164 of a concern that an assigned geriatric nursing assistant was roughly handling Resident #164. The facility's resolution was that the assigned Geriatric Nursing Assistant was removed from the assignment, and the Director of Nursing was made aware. However, the facility failed to report this allegation of abuse/neglect to the Office of Health Care Quality. 2) On 01/07/26, at approximately 1:45 PM, a review of October 2025 facility concern forms revealed an allegation dated 10/15/25 from Resident #163's complainant regarding a missing wallet/purse and wigs. The facility's resolution was searching the room, and Staff #21 (Unit Manager RN) requested a receipt from the complainant. However, the facility failed to report this alleged misappropriation to the Office of Health Care Quality. On 01/07/26 at 2:49 PM, during an interview with the administrator, he identified himself as the Grievance Officer responsible for handling concerns. He outlined the following grievance process: A resident, family member, or staff member completes a form detailing the concern, which is then submitted to him. He subsequently distributes the form to the relevant department for follow-up and resolution. The complainant should then be notified of the resolution. However, the Administrator acknowledged that while allegations of abuse, neglect, or misappropriation should be reported to the Office of Health Care Quality (OHCQ), the specific allegations concerning Residents #163 and #164 were not reported. On 01/08/26 at 11:06 AM, during an interview, the Director of Nursing (DON) confirmed that both the rough handling of a resident (constituting physical abuse) and a missing purse or wallet (constituting misappropriation) are mandatory reportable events to the Office of Health Care Quality and were not reported. The concern was communicated at the time of the interview.

Based on review of facility records and interview with staff it was determined the facility failed to thoroughly investigate an allegation of suspected resident abuse and an allegation of misappropriation. This was evident for 2 (Resident # 164 and #163) of 2 residents reviewed for abuse during the survey. The findings include:1) On 01/07/2026 at approximately 1:35 PM, a review of the facility concern forms for the month of October 2025 revealed a concern form dated 10/30/2025 filed by Resident #164 about a concern that an assigned geriatric nursing assistant was roughly handling Resident #164 and was not assisting with dinner. The facility's resolution was that the assigned geriatric nursing assistant was removed from the assignment, and the Director of nursing was made aware. However, the only accompanying documentation was a statement from the alleged geriatric nursing assistant perpetrator, which solely addressed not receiving assistance with the dinner meal.2) On 01/07/2026, at approximately 1:45 PM, a review of October 2025 facility concern forms revealed an allegation dated 10/15/2025 from Resident #163's complainant regarding a missing wallet/purse and wigs. The facility's resolution was searching for the room, and Staff #21 (Unit Manager RN) requested a receipt from the complainant. However, there was only a Personal Effects Inventory sheet for Resident #163 dated 08/18/2025 attached to the concern form that indicated Resident #163 had belongings of a pocketbook and wig. On 01/09/2026 at 9:21 AM during an interview, the Director of Nursing (DON) described the investigation process: The DON/Administrator reports to the Office of Health Care Quality; the social worker interviews residents and screens the affected resident for psychosocial effects; nursing assesses the resident; police, the responsible party, and the physician are notified; staff are interviewed; and any staff perpetrator is removed from the schedule. In-service training is completed if applicable. For misappropriation, the facility searches and interviews staff, family, roommates, and other residents; notifies police; and provides in-service training if applicable. The DON further stated staff must immediately report any allegation of abuse, neglect, or misappropriation to the Administrator or DON, and an investigation would need to occur. The DON confirmed a thorough investigation did not occur for Resident #163's misappropriation allegation or Resident #164's abuse allegation. This concern was shared with the DON at this time.

Based on record review and interviews, it was determined that the facility failed to provide documented evidence to support that the facility notified a representative of the Office of the State Long-Term Care Ombudsman that the resident was discharged . This was evident for 1 (Resident #162) of 2 Residents reviewed for discharge during the recertification/complaint survey process.Findings Included:On 01/09/2026 at 8:39 AM, a review of Resident #162 medical records revealed that the resident was discharged to home on [DATE]; however, there was no documented evidence to support that the facility notified the State Ombudsman's Office in writing.On 01/09/2026 at 9:35AM, in an interview with the Director of Nursing (DON), she was asked who was responsible for transfer and discharge notification to the Ombudsman and she explained that the social worker was responsible for ombudsman notification and it was done via email.On 1/9/2026 at 11:05 AM, in an interview with the social work designee (Staff #1), she explained that the previous social work designee (SWD) was responsible for notifying the ombudsman of Resident's transfer and discharge for the month of November 2025 and she was not copied on the ombudsman notification email sent by the previous SWD. Therefore, she was unable to verify if the ombudsman was notified of Resident #162's discharge. She stated that she tried to call the ombudsman to verify but she was not available. On 1/9/2026 at 11:35AM the surveyor called and left a voice message for the ombudsman to call back. The facility was unable to provide documentation to support that the Ombudsman was notified of Resident #162's discharge.

Based on review of the medical record and interview with facility staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect a resident's status. This was evident for 2 (Resident #8 and #17) out of 32 residents reviewed during the facility's recertification survey.The findings include:The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's functional, medical, psychosocial, and cognitive status. It is administered to all residents at admission, quarterly, annually, and whenever a significant change in an individual's condition occurs. It is the foundation for creating an individualized care plan and ensures the appropriate care and services are provided to each resident. MDS assessments must be accurate to ensure each resident receives the personalized and resident specific care they need.Psychosis: A symptom involving a loss of contact with reality (e.g., hallucinations or delusions).Schizophrenia: A chronic mental health disorder characterized by psychosis, disorganized thinking, and impaired daily functioning lasting over six months. 1) On 1/5/26 at 9:56 AM review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Further review revealed the following weights: 12/9/24 214.0 lbs (pounds) 6/8/25 181.6 lbs The above weights reflected that Resident #8 experienced a 32.4lb or 15.14% weight loss in 6 months. On 1/8/26 at 9:06 AM review of Resident #8's 8/17/25 MDS revealed Section K0300 'Weight Loss'- Loss of 5% or more in the last month or loss of 10% or more in the last 6 months was coded as no. On 1/9/26 at 9:59 AM in an interview with the MDS Coordinator (MDSC #3) when asked if she had a dashboard when she logged into PCC (Point Click Care, the facility's electronic medical record) she stated yes. During the interview when asked what type of alerts and/or information was on the dashboard, she stated, I don't look at alerts because it doesn't affect my department, but yes, there are alerts on the dashboard. When asked if any alerts and/or notifications related to a resident's nutritional status showed on her dashboard she stated, No, I do not see if a resident loses weight on my dashboard. When asked if she was part of the facility's interdisciplinary team (IDT) she stated yes. When asked if she attended the daily clinical meetings, she stated yes and confirmed that residents' weight loss was discussed at those meetings. When asked what information she used to code she stated, Remember the MDS is an IDT approach so there are different sections applied to different disciplines. When asked if she reviewing the medical record was part of the process before completing the MDS she stated, Absolutely, and depending on the section you have a look back period. A dual observation was conducted of Resident #8's weights, weight loss, and 8/17/25 MDS. When asked why she coded Resident #8 as no for weight loss she stated, The dietician did that. You'll have to ask her why she did that. On 1/9/26 at 10:14 AM in an interview with the Registered Dietician (RD #20) when asked Resident #8's weight on 12/9/24, she opened her laptop, pulled up the resident's chart, and stated 214 lbs. When asked his/her weight on 6/8/25 she stated 181.6 lbs. When asked if from 12/9/24 through 6/8/25 the resident had weight loss she stated yes. When asked what percentage weight loss she stated 15% and verified and confirmed it was significant weight loss. During the interview a dual observation of Resident #8's 8/21/25 MDS was conducted and it was noted that Section K0300 'Weight Loss'- Loss of 5% or more in the last month or loss of 10% or more in the last 6 months was coded as no. When asked if that was accurately coded she stated no. When asked what it should have been coded as she stated, number 2. Yes, and the resident is not on a prescribed weight loss regimen. The surveyor shared this was a concern. RD #20 verbalized and acknowledged understanding of the concern. 2) On 1/07/26 at 7:32 AM, a review of Resident #17's medical records revealed diagnoses of anxiety and unspecified psychosis. As of 10/22/25, the resident was prescribed Risperdal (1ml twice daily) specifically for a diagnosis of Schizophrenia. However, clinical records confirmed that Resident #17 did not have a verified diagnosis of Schizophrenia to support this indication. A review of MDS assessments conducted on 1/07/26 at 1:00 PM revealed inconsistent coding for Schizophrenia: 12/03/24: Schizophrenia was coded. 05/25/25, 08/21/25, and 09/09/25: Schizophrenia was not coded. 12/13/25: Schizophrenia was not coded, though psychotic disorder was captured. On 1/09/26 at 7:59 AM, the MDS Coordinator (Staff #3) stated that the resident was admitted with a Schizophrenia diagnosis. Staff #3 explained, The corporate office directed us to inactivate schizophrenia diagnoses due to a CMS memo. We were instructed to complete new evaluations before re-activating the diagnosis. Since the psychiatrist has not completed the evaluation yet, I coded it as 'no schizophrenia.' On 1/12/26 at 9:38 AM, a review of psychiatric notes from January 2025 to the present revealed: 1/20/25: Initial assessment (Staff #12) documented a Schizophrenia diagnosis. 4/16/25 and 6/18/25: Follow-up assessments (Staff #44, Psych NP) excluded Schizophrenia from the ICD codes, yet the narrative history continued to list Risperdal for Schizophrenia. 8/13/25 through 9/15/25: Notes (Staff #12) showed no Schizophrenia diagnosis, despite continuing Risperdal for that indication. 9/23/25: Staff #12 updated the records to change the indication for Risperdal from Schizophrenia to unspecified psychosis. 9/30/25 through 11/14/25: Notes continued to document Risperdal use for psychosis. On 1/12/26 at 10:00 AM, the Director of Nursing (DON) was informed that Resident #17's active diagnoses were not accurately coded on the MDS. The DON validated these findings.

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP) and documented in the medical record. This was evident for 2 (Resident #1 and #8) out of 52 residents reviewed during the facility's recertification survey.The findings include:A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and current medication list must be given to the resident and/or RP and there must be evidence in the medical record that it was provided. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission.On 1/6/25 at 9:44 AM review of Resident #1's medical record revealed he/she was admitted to the facility on [DATE]. Further review of the medical record failed to reveal a BLCP and/or evidence from the medical record that a copy was given to the resident and/or RP.On 1/6/26 at 9:56 AM review of Resident #8's medical record revealed he/she was admitted to the facility on [DATE]. Further review of the medical record failed to reveal a BLCP and/or evidence from the medical record that a copy was given to the resident and/or RP.On 1/6/26 at 10:07 AM in an interview with the Director of Nursing (DON) when asked the facility's process for BLCP's she stated, when residents are admitted we do a BLCP from whatever triggered from the initial assessment. There are four major BCLP's: pain, fall, skin, ADLs (activities of daily living), and if anything else triggered that would be included. She stated it was completed within 24-48 hours. When asked where the survey team could find residents' BLCPs, she stated it was in PCC [Point Click Care, the facility's electronic medical record (EMR)]. When asked what it was called she stated there was not a specific document called the BLCP. In a continued interview, the DON stated that the nurse would complete a Nursing Assessment Evaluation for any new admission or readmission and that evaluation would trigger care plans. Additionally, she stated those care plans were reviewed by the supervisor or manager to ensure that the four basic care plans were there. When asked if the BLCP was resident specific, she stated, We make sure it's resident specific before we print it and give it to the resident and family. When asked if there was evidence from the medical record that a copy was provided to the resident and/or RP, she stated, Yes, there is evidence from the medical record that the care plan is given to the resident, a signature sheet with the date. When asked whose responsibility it was to provide the resident with the BLCP and obtain their signature, she stated the Unit Managers or the Assistant Director of Nursing. She stated, They should give them the copy and have them sign. The signature sheet would be in their paper chart. When asked who was ultimately responsible for ensuring the completion of this process, she stated, From the supervisors and managers to me, the DON.On 1/6/25 at 12:05 PM review of Resident #1's paper chart and EMR failed to reveal a signature page from around the time of his/her admission to the facility.On 1/6/25 at 12:09 PM review of Resident #'8s paper chart and EMR failed to reveal a signature page from around the time of his/her admission to the facility.On 1/6/25 at 12:10 PM in an interview with Licensed Practical Nurse (LPN #14) when asked how long she had worked at the facility, she stated 5 years. When asked if she provided residents with copies of their BLCP and documented that, she stated, I'm not too sure. No, I'm not saying I give the BLCP. But I will say, resident was educated. But as far as giving them a copy of the BLCP and documenting that in the medical record, no. On 1/6/25 at 12:15 PM in an interview with LPN #24 when asked how long she had worked at the facility she stated about 2 months. When asked if she completed a BCLP when a resident was admitted , she stated yes. When asked if she was provided training on the BLCP, she stated, I wouldn't remember. When asked if she provided a copy of the BLCP to the resident and/or RP she stated yes. When asked if she was trained/instructed by the facility to document in the medical record when she provided a copy of the BLCP and/or have the resident and/or RP sign off that they had received it, she stated no.On 1/7/26 at 8:38 AM in an interview with the Director of Nursing she stated she did not see a BLCP for Resident #8 or Resident #1, but that they might be in medical records. On 1/7/26 at 8:45 AM in an interview with Medical Records (MR #19), he and the surveyor went to his office. MR #19 looked through file cabinets for a several minutes and then stated there were no records for Resident #1 or Resident #8. When asked if there was any other location the records might be stored, he stated, No, there is no other place in the building where medical records were stored. The DON entered the medical records office and looked on MR #19's computer; however, was unable to provide a BLCP or evidence from the medical record that one was provided to Resident #1 or Resident #8. The surveyor shared this was a concern. The DON acknowledged understanding of the concern.

Based on a review of complaints, medical records, and staff interviews, the facility failed to ensure a resident received necessary treatment and services to promote their highest practicable well-being: evidence by failing to 1) follow Physician orders for Gastrointestinal interventions related to appointments, and 2) arrange a critical diagnostic test and a specialty consultation as ordered by the provider. This was evident for 2 (Resident #19 and #145) of 8 residents that were reviewed during this recertification/complaint survey.The findings included:According to [NAME] Medicine, a gastrostomy tube (G-tube) is a medical procedure in which a tube is inserted through the abdominal wall and into the stomach to provide an alternative route for delivering nutrition, fluids, and medications directly into the stomach, bypassing the mouth and esophagus. A modified barium swallow study (MBSS) is a real-time X-ray (fluoroscopic) procedure that evaluates how a patient swallows different liquids and foods to determine the cause of swallowing difficulties (dysphagia) or aspiration (food/liquid entering the lungs). 1) On 01/06/26 at 1:59 PM, a review of Resident #19's medical record revealed a physician order dated 11/12/25 to please schedule a gastrointestinal (GI) appointment for evaluation for gastrostomy tube (G-tube) removal. On 01/07/26 at 9:25 AM, further review of Resident #19's medical record indicated a physician order dated 08/13/25 for a modified barium swallow study (MBSS). On 01/07/26 at 9:56 AM, during an interview, the Director of Nursing (DON) explained the process for appointments: a nurse would receive the order from the physician and give it to the Unit Secretary to be scheduled. On 01/07/26 at 12:22 PM, during an interview with Staff #21 (Unit Manager Licensed Practical Nurse LPN), described the appointment process: The unit secretary schedules the appointment after receiving the request from the nurse. The nurse is then informed of the scheduled appointment, notifies the resident/family, updates the order to include the Physician, date and time, and the Unit Secretary would schedule transportation. On 01/08/26 at 8:44 AM, during an interview with Staff #28 (Unit Secretary), the appointment scheduling process was described. A nurse provides the necessary appointment or consultation information on a form, which the secretary then uses to schedule the appointment. Following scheduling, the secretary returns the appointment details to the nurse for the ordered appointment update. Staff #28 explicitly stated that she never received a request for Resident #19's MBS or GI consult and was not aware these appointments needed to be scheduled. She further explained she only became aware of these required appointments on 01/07/26 and began making calls to schedule. On 01/09/26 at approximately 3:30 PM the Director of Nursing and Administrator were made aware of the concern. 2) A portion of investigating complaint 2689147 on 1/05/26 at 10:30 AM, the surveyor conducted a phone interview with complainant. The complainant claimed that the ENT (ear, nose, throat) appointment was scheduled more than 2 months after the hospital recommended for follow up which was delayed Resident #145's diagnosis, and active treatment had not been provided by the facility while he/she was in waiting. On 1/07/26 at 8:29 AM, the surveyor reviewed Resident #145's medical record. It was revealed that the resident's provider assessed him/her on 10/30/25 and ordered neck ultrasound: the test was performed at the facility on 10/30/25 with result of left neck solid mass measuring 3x2x2 cm. Recommendation for CT neck and chest. The CT neck order was placed on 10/30/25 at 11:11 PM, however it was not scheduled till the resident transferred to the hospital on [DATE]. Further review of Resident #145's medical record revealed that the resident was transferred to the hospital on [DATE] at 6:30 AM per the family's request to manage neck pain. During the hospital stay from 11/10/25 to 11/11/25, Resident #145 received a CT scan of the neck. The results indicated enlarged, partially necrotic, and enhancing left-sided level 2 and 3 lymph nodes measuring 3.4 x 2.4 x 3.7 cm, suspicious for metastatic lymphadenopathy. An ENT evaluation and possible biopsy were recommended. Additionally, the hospital discharge summary noted: You must call each provider to make/verify your appointment with [ENT doctor's name] within one week. The facility's provider wrote order for an ENT appointment and possible biopsy on 11/12/25; however, the appointment scheduled for 1/22/26. In an interview with Staff #28 (appointment scheduler) on 1/08/26 at 8:07 AM, the staff stated that 1/22/26 (more than 70 days later than the order placed) was the earliest possible date. When asked how she managed consultations requiring a specific time window, she stated she would inform the doctor's office, allowing the offices to communicate and adjust the schedule. Staff #28 verified she communicated the details of this case to the Unit Manager. On 1/08/26 at 8:48 AM, Staff #43 (Unit Manager) stated, I updated Resident #145's family member regarding the earliest ENT appointment, and the family member stated they would search for an earlier appointment themselves. Since they said that, I took no additional action to adjust the schedule. However, a progress note written by Staff #43 on 11/14/25 stated: [Resident's family member] was updated about the upcoming ENT appointment on 1/22/26, which is the earliest we can get at this time. In a phone interview on 1/12/26 at 8:53 AM, the family member stated, The nurse called me and said if I was able to look into it myself, I could seek an earlier appointment. The family member insisted they never indicated they would handle the scheduling entirely on their own. A further review of the medical record on 1/08/26 revealed the resident was transferred back to the hospital on [DATE] for neck pain management. During that visit, a biopsy was conducted, resulting in a diagnosis of oropharyngeal cancer. On 1/12/26 at 10:00 AM, the Director of Nursing (DON) validated concerns that the diagnostic CT scan and ENT consultation were not arranged in a timely manner.

Based on resident interviews, record review, review of other pertinent documentation, and staff interviews, it was determined that the facility failed to treat a resident who complained of severe pain resulting in harm to the resident. This was evident for 1 of 8 (Resident #91) residents reviewed for pain management. The findings include: During observation rounds on 5/20/24 at 10 am, Resident #91 stated while s/he was being transferred from his/her bed to the chair by the Physical Therapist (PT) #49, s/he heard a popping sound and I told her you broke my leg. S/he stated prior to the transfer s/he told staff #49; You cannot pick me up by yourself, it takes 2 people. The resident stated there were 2 Geriatric Nursing Assistants (GNA) in the room at the time; but Staff #49 told them Not to touch me. It is her job. After the resident was transferred into the chair, the resident told the nurse and the [Physical Therapist Staff #49], I was feeling pain in my right leg; however, neither one responded. When asked by the surveyor when this incident occurred the resident stated around November 22nd or the 23rd. The resident stated, I remember this because it was prior to Thanksgiving. The resident went on to state that s/he called 911 on 12/1/23 due to the pain in his/her right leg; however, the facility told 911 s/he had dementia, and they were not needed. On 5/28/24 at 9:00 am, the review of Resident #91's orders revealed Resident #91 was receiving Tramadol 50mg BID for pain (start date 11/9/23), Gabapentin 300mg three times a day for Neuropathic Pain (start date 11/9/23), Lidocaine Patch 4% (apply to right leg topically in the morning) and Cymbalta 20 mg in the evening for depression/pain (ordered 11/9/23). The resident was also ordered two 325 mg Acetaminophen Oral Tablet every 6 hours as needed for pain (ordered 12/12/22). The resident was receiving diathermy for chronic knee pain and to improve functional performance (ordered on 5/10/23). On 5/28/2024 at 9:45 am, the Medical Administration Record (MAR) was reviewed. The MAR revealed that Licensed Practical Nurse (LPN) #43 documented he administered a Tylenol 650 mg oral tablet on 11/22/23 at 5:29 am for a pain level of 2/10 pain. The following dates and times were documented by LPN #43: Tylenol 650 mg tablet given at 5:29 AM on 11/22/23 for a pain level of 2. Tylenol 650 mg tablet given at 5:48 AM on 11/23/23 for a pain level of 2. Tylenol 650 mg tablet given at 5:59 AM on 11/24/23 for a pain level of 2. Tylenol 650 mg tablet given at 5:05 AM on 11/25/23 for a pain level of 2. Tylenol 650 mg tablet given at 5:50 AM on 11/28/23 for a pain level of 2. Tylenol 650 mg tablet given at 5:36 AM on 11/30/23 for a pain level of 2. Tylenol 650 mg tablet given at 5:19 AM on 12/2/23 for a pain level of 2. Tylenol 650 mg tablet given at 5:16 AM on 12/3/23 for a pain level of 2. It should be noted that prior to 11/22/23 the resident had not requested Tylenol since September 9, 2023. Continued review of the medical record on 5/28/24 revealed the following: On 12/3/23 at 2:21 pm, the physical therapist (Staff #50) documented that Resident #91 reported a 10/10 pain level for right leg pain during the therapy session. There was no evidence that the pain was treated or that the pain was reported to the nursing staff. On 12/5/2023 at 3:34 pm, the Physical Therapist (Staff #49) documented that Resident #91 reported an 8/10 pain level for right leg pain during the session. There was no evidence that the pain was treated or that the pain was reported to the nursing staff. On 12/7/2023 at 3:33 pm, the Physical Therapist (Staff #49) documented that Resident #91 reported a 6/10 pain level for right leg pain during the session. There was no evidence that the pain was treated. Further review of the medical record on 5/29/24 at 10 am, revealed a physician progress note dated 12/13/23 at 3:12 pm which revealed the following: The resident reports right knee pain. S/he reports s/he hit her knee on the floor while working with a physical therapist. The physical therapist and nursing staff reported no fall and knee injury. The resident states his/her right knee was very swollen, and it has improved now. S/he reports the injury happened more than a week ago. S/he reports severe knee pain. Right knee is tender to touch, per resident. We will do right knee X Ray. Continue pain management. On 5/29/2024 at 2 pm, an interview was done with the physical therapist (PT), Staff #49. Staff #49 stated she does transfer the resident while performing therapy. Staff #49 stated the resident complained of pain as she documented. She stated, I notified the charge nurse on 12/5/23 and 12/7/23 that the resident was complaining of pain to his/her right leg. When asked by the surveyor if she documented notifying the nursing staff of Resident #91's pain, she responded no. Staff #49 also stated the fracture in question was declared to have happened on 11/30/2023 by the facility. On 5/29/24 at 3 pm, an interview was conducted with LPN #7. LPN #7 stated that no one reported to her that Resident #91 was in pain. Staff #7 stated the first time she knew of the incident was 12/13/23, when the physician ordered an x-ray. LPN # 7 was the day shift nurse who cared for Resident #91 on 11/21/2023 through 11/26/2023, 12/5/23, 12/7/23, 12/13/23, and 12/14/23 as documented on daily staffing sheets. On 5/29/24 at 3:30pm, An interview was conducted with LPN #43. When asked about the administration of the PRN Tylenol, LPN #43 stated, the resident was complaining of pain, and I was not sure if s/he received their pain medication as scheduled. When a resident complains of pain, I give them medication if it is ordered. When asked if he contacted the doctor since the resident was requesting PRN pain medication on top of the scheduled pain medications, he said No, maybe I should have.

Based on facility investigation review and interviews, it was determined that the facility staff failed to keep a resident free from sexual assault. This was evident for 1 of 6 residents (#1) selected for review. This incident resulted in actual harm to the resident. Review of the facility's plan of correction, implemented immediately after the facility gained knowledge of the incident, resulted in the citation being cited as past noncompliance. The findings included the following: On 7/18/16, the surveyor reviewed the facility investigation regarding an alleged sexual abuse reported to the Office of Health Care and Quality. The intake number was MD 346. Record review, on 7/18/16, revealed that Resident #1 was alert and oriented to person and place. Behaviors included smearing food and stool on the environment within reach, as well as staff members. According to GNA #1's written statement (6/20/16) as well as surveyor interview (on 7/22/16), revealed that on 6/20/16, at around 4:30 am GNA #1 walked into resident #1's room and observed the contracted laboratory technician on the resident's bed between her legs, he was described to have his face toward her private parts. The laboratory technician was described to stop and leave the room, and exited the facility. GNA #1 then described observing and interviewing resident #1. According to GNA #1, the resident's incontinent pants were on the floor next to the bed; the GNA added that this was not unusual behavior for this resident. The resident was taken to the bathroom and then back to bed. The GNA described the resident to be in her normal state. GNA #1 went and got another GNA (#3) and they completed their shift together; they did not report what was observed to anyone else. On 6/20/16, after 7 AM, GNA #1 called and reported to Human Resource personnel the assault she had witnessed on resident #1 earlier that day. Immediate actions taken by the facility, on 6/20/16, included: Resident #1 was immediately assessed by nurse practitioner, there were no signs of physical trauma and resident's mood was reported to be appropriate for the resident. The resident was transferred to a hospital emergency department, and underwent a forensic sexual assault assessment. The police were notified and initiated an investigation. A 100% audit was completed on all residents receiving laboratory draws, to ensure that those with orders for draws were not affected; no other residents were identified as being affected; this was completed on 6/20/16. All residents were assessed, and interviewed, if possible; there were no other residents identified or concerns noted, on 6/20/16. The facility suspended, on 6/20/16, and then terminated both GNAs for not reporting the incident. After hour entrance (8:30 PM to 8 AM) into the facility is supervised/permitted by the assistance of the Supervisor and/or Security. The perpetrator was a laboratory technician employed by the laboratory contracted by the facility. The laboratory technician was immediately barred from entering the facility. The technician was subsequently arrested. All other employees of the laboratory were escorted while in the facility. The facility immediately began a search for another laboratory contractor. A new laboratory was contacted for service commencement possibilities the day after the incident and contract with new provider began 8/26/16. All other contractors providing services in the facility were contacted, on 6/20/16, to confirm that criminal background checks had been conducted, and that abuse education/training had occurred with all employees. The Staff Development Educator, Director of Social Services, Unit Managers, and Supervisors in-serviced staff on allegation of abuse, neglect and misappropriation of property to ensure compliance with reporting and keeping resident safe. This training was completed on 6/21/16. Daily huddles with nursing staff were initiated, on 8/10/16 per shift to discuss, monitor, and implement corrective actions as needed on incidents that should be immediately reported. Unit Managers and Supervisors would monitor for compliance monthly and report findings to Quality Assurance (QA) Committee. Additionally, the QA committee would be reviewing any changes to response and/or contractor changes.