Every finding on record at Fox Chase Healthcare

Based on record review and interviews it was determined the facility staff failed to develop and implement a system to ensure accurate accountability of controlled substances by 1) failing to have a system to accurately identify staff reconciling and signing out controlled substances upon receipt, shift audits and administration; 2) failing to identify a discrepancy in the controlled substance inventory; and 3) failing to maintain accurate record keeping, when controlled substances were removed from the inventory. This was evident for 1 (Resident #1) of 5 residents reviewed during the complaint survey.The findings include: A controlled substance is a drug or chemical whose production, use, and possession are strictly regulated by the government because it carries a risk of abuse, misuse, and physical or psychological dependence.Governments place these chemicals into five categories, called schedules, based on their medical use and danger level:Schedule I: High abuse risk and no safe, accepted medical use.Schedule II: High abuse risk, but with accepted medical uses.Schedule III-V: Lower abuse risks with accepted medical uses and decreasing levels of danger.Proper handling of controlled substances requires strict adherence to security, accurate recordkeeping, and safe disposal protocols.Accurate recordkeeping includes:Real-time logs: Record every receipt, administration, transfer, or dose change immediately.Shift audits: Conduct physical inventory counts during every staff change or shift rotation.Discrepancy reporting: Investigate and log any count mismatch right away. The facility staff utilized Medication Monitoring Control Records - forms that reflected the supply of each controlled substance provided by the pharmacy. Spaces were provided on the form for the staff administering the medication to document their name, date, time, amount given, and the number of tablets remaining of each medication in the corresponding medication blister card. 1) Resident #1's medical record was reviewed on 7/21/26 at 12:45 PM during review of Facility Reported Incident #3056055 and complaint #3056055. The record revealed Resident #1 had physician orders for: Alprazolam (Xanax) [a Schedule IV controlled substance] 0.5 mg (milligrams) 1 tablet 4 times/day for anxiety, and 1 mg every night for anxiety; and Oxycodone HCl (hydrochloride) [a Schedule II controlled substance] 30 mg by mouth every 4 hours for Chronic Pain. Resident #1's paper record contained numerous completed Medication Monitoring Control Record forms. The entries in the column designated for the name of the person who administered the medication contained illegible, unidentifiable handwritten signatures and initials. It failed to clearly identify the name and title of the person who administered the medication. Further review of the record failed to reveal a staff signature page or other means to identify the handwritten signatures/names/initials. Review of the June 2026 Controlled Drug-Controlled Substance Record for Cart #2 revealed handwritten signatures of the oncoming and off going licensed nurses responsible for counting and reconciling the controlled substances at the change of each shift. There was no identification of the signatures of the nurses who conducted the counts and reconciliation of the controlled substance records. The surveyor requested a copy of a staff signature identification list on 7/21/26 at 12:52 PM. On 7/21/26 at 2:07 PM the Chesapeake Unit Manager (UM) Registered Nurse (RN) #4 and the Potomac UM RN #5, provided a list identifying the electronic medical record (EMR) usernames of the staff. It did not identify the handwritten signatures. Upon further inquiry they indicated the facility did not have a way to identify staff signatures/initials and acknowledged the surveyor's concern. 2) Further review of Resident #1's medical record on 7/23/26 at 8:00 AM revealed a Medication Monitoring Control Record [#15] for Resident #1 for Alprazolam tablets 0.5 mg give 1 tablet four times daily for anxiety. The date received was 05/12/2026 The amount received indicated 24 with a line through it and 23 written beside it with 1 set of unidentified initials. There was no indication that a second person reconciled the amount received and verified the discrepancy. The final line in the sequence of signed out tablets was dated 6/7/26 9 pm. The form reflected 4 tablets remaining in the corresponding blister card. There was no documentation to indicate the disposition of the 4 remaining tablets from the blister card. On 7/23/26 at 3:10 PM the surveyor observed the medication cart containing Resident #1's medication with Licensed Practical Nurse (LPN) #6 and UM #5. LPN #6 was asked to reconcile Resident #1s controlled medications with the surveyor. The reconciliation was done twice and failed to reveal a blister card containing the 4 tablets of Alprazolam 0.5 mg as reflected on the Medication Monitoring Control Record [#15]. 3) However, on 7/23/26 at 3:10 PM the reconciliation with LPN #6 revealed: -Resident #1's Alprazolam 0.5 mg [Card #98B] Control Sheet indicated 12 tablets remained, the blister card contained 10 tablets. 2 tablets were unaccounted for. LPN #6 indicated that she did not sign off the 9 AM or 1 PM doses that she administered.-The Control Sheet for Pregabalin (Lyrica) 225mg [Card #103B] indicated 29 tablets remained. However, 28 tablets were in the blister card. 1 tablet was missing. LPN #6 indicated that she did not sign off the 9 AM dose that she administered.-The Control Sheet for Oxycodone 30 mg [Card#101A] indicated there should have been 7 tablets remaining, the blister card contained 5 tablets. LPN #6 indicated she did not sign off the doses she administered at 9 AM and 1 PM.LPN #6 signed off each dose from the corresponding control logs at that time. When asked when medications should be signed off she stated, when I give them. UM #5 was present and immediately made aware of the above concerns. The Administrator was made aware of the missing controlled medications on 7/23/26 at 4:10 PM and began an investigation. An interview was conducted with the facility's clinical pharmacy consultant #7 on 7/24/26 at 2:33 PM. He indicated that a team which included a pharmacist and a nurse among other disciplines came to the facility close to every month. They conducted reviews/audits which included but were not limited to: Med storage including audits of controlled drugs and narcotic sheets (Control Sheets). Medication carts were opened and audited and included checking for correct counts, and double locks. When asked if there was a policy/procedure for signing out controlled medications, he indicated that it was more of a facility responsibility. He was asked if there was a policy/procedure related to how the medication monitoring control records should be utilized. He stated, we are a vendor, we don't write policy but have input into the facility's policy, but it's up to the facility to have a policy/procedure. The Director of Nursing (DON) was made aware of the above findings on 7/28/26 at 1:20 PM.

Based on observation and interview it was determined the facility staff failed to implement standard infection control measures for a resident with an indwelling urinary catheter. This was evident for 1 (Resident #5) of 5 residents reviewed during the complaint survey. The findings include: During a tour of the facility on 7/27/26 at 11:05 AM Resident #5 was observed propelling his/her motorized wheelchair from the hallway near the nurses' station toward the Administrator's office. A urinary catheter drainage bag was lying on the foot pedals between Resident #5's feet. The drainage tubing was dragging on the floor between the foot pedals. During an observation on 7/28/26 at 11:45 AM Resident #5's bedroom door was open. From the hallway, the surveyor observed Resident #5 lying in bed, a urinary catheter drainage bag containing a moderate amount of urine was lying on the floor beside the foot of the bed facing the door and was visible from the hallway. The surveyor knocked on the door however Resident #5 appeared to be asleep and did not answer. Another observation was made on 7/28/26 at 1:00 PM. Resident #5 was in bed, and the urinary catheter drainage bag was in the same location on the floor visible from the hallway. Licensed Practical Nurse (LPN) #2 was standing at a medication cart in the hallway a few doors away. She confirmed she was the nurse providing care for Resident #5. LPN #2 indicated that the nurses and the aides were responsible for emptying the urinary drainage bags and caring for the urinary catheters. She was shown Resident #5's urinary drainage bag and confirmed it was not acceptable for the drainage bag to be on the floor per infection control standards. She indicated that it must have fallen. She was made aware that the surveyor observed the bag lying on the floor in the same location at 11:45 AM. LPN #2 again indicated that the drainage bag should not have been on the floor. She indicated that the plastic hook for hanging the bag was broken/missing and staff were using an exam glove to tie the drainage bag to the bed frame. The Director of Nursing (DON) was made aware of the above findings and acknowledged the concerns on 7/28/26 at 1:20 PM.

Based on surveyor observation, interview and record review it was determined the facility staff failed to implement measures as per the resident's Plan of Care and standards of nursing practice to promote dignity for a resident with an indwelling urinary catheter. This was evident for 1 (Resident #5) of 5 residents reviewed during the complaint survey.The findings include: During a tour of the facility on 7/28/26 at 11:45 AM the surveyor observed Resident #5's bedroom door was open. From the hallway, the surveyor observed Resident #5 lying in bed, a urinary catheter bag containing a moderate amount of urine was lying on the floor beside the foot of the bed. The surveyor knocked on the door however Resident #5 appeared to be asleep and did not answer. Review of Resident #5's medical record on 7/28/26 at 12:48 PM revealed a plan of care created 11/21/24 for Indwelling Catheter; and 3/2/26 for Indwelling suprapubic catheter. The interventions/tasks included but were not limited to: Apply dignity bag to cover the urine bag q (every) shift; and Position catheter bag and tubing below the level of the bladder and away from entrance room door. Another observation was made at 1:00 PM on 7/28/26. Resident #5 was in bed, and the uncovered urinary catheter bag was in the same location, visible from the hallway. A Licensed Practical Nurse (LPN #2) was standing at a medication cart in the hallway and confirmed she was the nurse providing care for Resident #5. When asked who was responsible for providing urinary catheter care she explained that the aides and the nurses empty and maintain the urinary bags. She was shown and confirmed that Resident #5's urinary bag was uncovered and visible from the hallway. When asked if the facility utilized dignity bags or other privacy covers for the urinary drainage bags, she explained that the bags utilized by the facility were made with a panel that prevented the contents of the bag from being visible. She obtained a new bag to show the surveyor. She explained that Resident #5 returned from a recent urology appointment several days prior, where his/her urinary drainage bag was changed to the current bag which did not include a dignity cover. She was unable to explain why the facility staff did not cover the bag upon the resident's return to the facility. The Director of Nursing (DON) was made aware of the concern on 7/28/26 at 1:20 PM.

Based on observation, interview, and record review, the facility failed to revise the care plan of 1 (Resident #2) of 19 sampled residents.Findings included: An admission Record revealed the facility admitted Resident #2 on 07/28/2022. According to the admission Record, the resident had a medical history that included diagnoses of osteoarthritis of the knee, reduced mobility, difficulty in walking, and a history of falling. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #2 sustained one fall with no injury since re-entry or admission. Resident #2's progress note dated 01/09/2026 at 4:19 PM, indicated while the resident was in the activity room, they leaned to the left, tipped their wheelchair over, and fell to the floor. Per the progress note, the immediate intervention to prevent further falls was staff placed a gel cushion in the resident's wheelchair. Resident #2's Care Plan Report, included a focus area initiated 03/09/2026, that indicated the resident was at risk for falls related to poor safety awareness related to cognitive impairment. The Care Plan Report revealed no evidence of an intervention that directed staff to place a gel cushion in the resident's wheelchair. During an observation on 04/15/2026 at 9:40 AM, Resident #2's was observed in their wheelchair and the wheelchair had a gel cushion in place. During a telephone interview on 04/13/2026 at 9:40 AM, Registered Nurse #22 stated if a resident fell, the nurse assigned to care for the resident was to place an intervention on the resident's care plan to keep the resident from falling again and the unit managers were supposed to update the resident's care plan. During an interview on 04/14/2026 at 2:07 PM, the Director of Nursing stated the nurses were expected to place interventions at the time of a resident's fall to prevent further falls and then the supervisors were responsible for adding the new intervention to the resident's care plan.

Based on interview, record review, and facility policy review, the facility failed to coordinate vision services for 1 (Resident #2) of 19 sampled residents.Findings included: A facility policy titled, Vision Services Policy, dated 03/12/2024, indicated, The facility shall ensure that each resident receives appropriate vision care and services to maintain the highest practicable level of functioning. An admission Record revealed the facility admitted Resident #2 on 07/28/2022.According to the admission Record, the resident had a medical history that included a diagnosis of macular degeneration. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2026, indicated Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #2's vision was adequate without the use of corrective lenses. Resident #2's Care Plan Report included a focus area revised 01/29/2026, that indicated the resident had impaired visual function related to macular degeneration. Interventions directed staff to arrange consultation with the eye care practitioner as required. Resident #2's Consult Form dated 03/10/2025 directed the staff to please schedule the resident an appointment with a cataract surgeon. [NAME] a telephone interview on 04/08/2026 at 9:15 AM, Resident #2's family member stated the resident's eye appointments had been missed due to no one at the facility followed up on them.During an interview on 04/11/2026 at 11:00 AM , the Medical Records Director stated he had not called recently to schedule Resident #2's surgery because he was backed up with other work. During an interview on 04/16/2026 at 11:45 AM, the Administrator stated she was unaware of the order to schedule the cataract surgery for Resident #2. During an interview on 04/21/2026 at 1:25 PM, the Medical Director stated if there was a request for surgical appointment to be made for the removal of cataracts for Resident #2, he expected the Social Services Director to make the arrangements and schedule transportation.

Based on interview, record review, document review, and facility policy review, the facility failed to investigate an allegation of misappropriation of resident property for 1 (Resident #1) of 8 sampled residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect and Exploitation, reviewed 10/12/2025, indicated, V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. An admission Record revealed the facility admitted Resident #1 on 04/25/2025. According to the admission Record, the resident had a medical history that included a diagnosis of quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2026, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of email correspondence dated 03/09/2026, from Resident #1 to the Administrator revealed $85.00 was taken from their wallet while they were out of the facility. An email confirmation from The Maryland Department of Health - Office of Health Care Quality revealed the facility reported the allegation on 04/09/2026 at 8:55 PM. During an interview on 04/09/2026 at 10:44 AM, Resident #1 stated money was taken out of their wallet while they were in the hospital and they immediately reported the incident to the Administrator. Resident #1 stated they had not received any response from the Administrator about their money. During an interview on 04/23/2026 at 9:37 AM, the Administrator stated she was aware of the email sent on 03/09/2026 by Resident #1 wherein Resident #1 expressed that $85.00 in cash was taken from their wallet while they were in the hospital. The Administrator stated she did not investigate the resident's allegation, but she should have.

Based on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of misappropriation of resident property to the state survey agency for 1 (Resident #1) of 8 sampled residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect and Exploitation, reviewed 10/12/2025, indicated, VII. Reporting/Responses A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. An admission Record revealed the facility admitted Resident #1 on 04/25/2025. According to the admission Record, the resident had a medical history that included a diagnosis of quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2026, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of email correspondence dated 03/09/2026, from Resident #1 to the Administrator revealed $85.00 was taken from their wallet while they were out of the facility. An email confirmation from The Maryland Department of Health - Office of Health Care Quality revealed the facility reported the allegation on 04/09/2026 at 8:55 PM. During an interview on 04/09/2026 at 10:44 AM, Resident #1 stated money was taken out of their wallet while they were in the hospital and they immediately reported the incident to the Administrator. Resident #1 stated they had not received any response from the Administrator about their money. During an interview on 04/23/2026 at 9:37 AM, the Administrator stated she was aware of the email sent on 03/09/2026 by Resident #1 wherein Resident #1 expressed that $85.00 in cash was taken from their wallet while they were in the hospital. The Administrator stated she did not report the allegation of misappropriation of resident property, but she should have.

Based on observation, staff interviews, and resident interviews, the facility failed to provide comfortable room temperatures for 5 (Resident #1, #3, #5, #6, and #7) of 72 residents and 12 rooms and 3 common areas reviewed for comfortable room temperatures impacting resident activities and comfort. Findings included: Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 was coded as cognitively intact. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 was coded as cognitively intact. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #5 was coded as cognitively intact. Documentation on the entry Minimum Data Set assessment dated [DATE] revealed Resident #6 was coded as cognitively intact. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #7 was coded as cognitively intact. Observations of rooms and hall temperatures with the interim Maintenance Manager (MM) on 12/15/2025 at 10:45 a.m. revealed: 47.6 degrees in room [ROOM NUMBER]; 50.0 degrees in room [ROOM NUMBER]; 39.5 degrees in room [ROOM NUMBER]; 37.7 degrees in room [ROOM NUMBER] and 49.6 in hall 3. Observation of room and halls temperatures on 12/16/25 at 10:22 a.m. revealed: room [ROOM NUMBER] at 63 degrees; room [ROOM NUMBER] at 53 degrees; room [ROOM NUMBER] at 61.9 degrees; room [ROOM NUMBER] at 53.8 degrees; room [ROOM NUMBER] at 66.0 degrees; room [ROOM NUMBER] at 48.0degrees; Hallway 2 at 58.5 (near room [ROOM NUMBER]); Hallway 3 at 64.8 (near room [ROOM NUMBER]); room [ROOM NUMBER] at 49.5 degrees; room [ROOM NUMBER] at 58.3 degrees and the Activity Room at 65.5 degrees. An interview was conducted with R7 on 12/15/25 at 9:34 a.m. R7 stated the facility had been cold since thanksgiving day. R7 stated that his/her room had been cold on and off and he/she was told the facility was working on it, but the room continued to be cold. R7 stated he/she had to use extra blankets to keep warm. R7 explained that they heard a big heater was placed in the hallway, but it did not help much. In an interview with R1 on 12/15/25 at 10:30 a.m. she stated that the facility had been cold and his/her family had to bring him/her extra blankets and a space heater. R1 explained that the heat broke down about a month ago. R5 was observed on 12/15/25 at 10:42 a.m. in his/her room seating in a wheelchair while covered in multiple blankets. R5 stated that the facility had been cold for a long time and stated that the cold was unbearable. In an interview with R3 on 12/15/25 at 10:44 a.m. he/she stated that the facility had been cold for a long time. R3 stated that they needed to wear a hoodie and be covered in multiple blankets to keep warm. In an interview with the Resident Council president (R6) on 12/15/25 at 12:48 p.m. revealed that the facility has been cold right after Thanksgiving Day this year. R6 explained that they were not doing any activities because the activity room was freezing. R6 further revealed that the heat was repaired last Saturday but broke down again. R6 stated that it was so cold that residents had to sleep in a thick hoodie and multiple blankets, and even then, could not get warm enough. R6 revealed that the heat issue had been a problem on and off for the last 3 years. During an interview with the interim maintenance manager on 12/15/25 at 9:55 a.m. he stated that he was covering the facility for only that day. He stated that he came to the building that morning and found the temperatures low as the heat has not been working properly since last week. He stated that two brand news heat units were installed on the roof last Saturday and one boiler was working but the other boiler was broken. He stated the broken part was ordered and he is not sure it will be fixed today. The facility Administrator was interviewed on 12/15/25 at 10:52 a.m. The Administrator explained that they have been experiencing problems without heat. She stated that [heating company], who take care of their boilers, 5 weeks ago brought bulbs that turned out to be the wrong size, and the next week they brought the correct size. She explained that the following week, they brought in the correct connector and bulb, but it still did not work. She explained that boiler 1 was working and that boiler 2 was not. She explained that they have 4 units, and 2 roof units did not work, serving the west hallway and rooms. She stated that one week ago, the facility paid money for a rooftop unit. She stated that the past Saturday, 12/13/25, morning, it was put on. She stated that the facility acquired temporary rental heat units for the 3 halls. She stated that they installed it on Saturday morning, 12/13/25, and everything was working right. She stated that on Sunday night and this morning it's cold again. She revealed that the owner of the heating company was coming in personally to figure out what was happening. She stated that the facility provided residents with additional blankets and served hot tea and coffee. She stated that there were no clinical concerns with the residents. She revealed that the room temperature on Saturday was 81 degrees. She stated that the heating company says there are more parts that need to be replaced. She stated that they are constantly on the phone with the heating company. She stated that both burner parts for both units have been located and will likely be placed today. She stated that she was not sure whether the product is local or far, but that they are using a courier to pick up the part.During a further interview with the Administrator on 12/17/25 at 2:52 p.m., the Administrator explained that steps had been taken to provide adequate heating for the residents. She stated that the boiler gas valves went bad. The boiler company immediately ordered, but upon receipt and attempted installation, all the required materials were missing. She stated that the entire gas valve set was received; however, upon installation, it was discovered that the required fittings for connecting to the boiler were not included. She stated that, now that the proper gas valve material and fittings are installed, the boiler exhibited signs that it needed cleaning to run as safely as possible without a fire. She stated that the boiler was cleaned out to prevent fires. During the clean-out and preventive maintenance, it was discovered that a new boiler assembly was required. She stated that the boiler company, contacted the sales rep to create a new boiler assembly for boiler number 2. Another one was ordered for boiler number 1 as a redundancy, although it may not be required for now. She stated the parts were picked up from the manufacturer in Pennsylvania and are due to be installed on 12/18/2025. The Administrator stated that during this time, the facility rented large, commercial heaters for the halls, going from 4 to 6, to provide adequate heating. She revealed that temperatures have been taken throughout the community at sporadic times, and additional items have been provided where additional warmth was needed or requested. Resident temperatures and observations were conducted to ensure safety and comfort, and thankfully, no negative outcomes were observed. She revealed that rental heat units for each room were ordered and received but not installed because State and Federal approval was not obtained, although county permission from the fire department was granted.The facility provided documentation on a typed spreadsheet on 12/18/25 that listed room temperatures, dates, and hallway temperatures. The report stated that, since yesterday, the average temperature in all rooms has been above 72 . As of this morning, residents complained the building was too hot, and everything was being adjusted by boiler mechanics. The documentation stated that boiler number 2 is fully functional, currently set to 120 and 144 degrees. She explained that Boiler 1 is also contributing to the temp, and that the same work is now being completed (cleaning and new burner assembly). The units' temps are at 120 degrees, and the climbing facility is comfortable. She revealed that the technicians will be here the rest of the day to monitor and adjust Boiler 2 (if needed) and that the above temperature satisfaction is due to the installation yesterday of the boiler #2 corrective action, i.e., placement of the new custom-made boiler assembly. As mentioned above, the custom-made boiler assembly was being installed on boiler #1. She stated that, as a result, residents and staff are all expressing warmth and comfort with the facility's temperatures in their rooms, halls, and the common area.

Based on observations, record review and interview, it was determined that the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental and psychological well-being of each resident. This was evident for all residents. The findings include: On 03/04/25 at 11:00AM and 03/05/25 at 10:40AM, the surveyor observed residents sitting in the hallways, sitting in the dining room areas without supervision, and walking around common areas in the nursing units. The surveyor observed no forms of activities or engagement in the units, the dining room, nor in the common areas. On 03/05/25 at 8:11AM a review of the list of the facility's key personnel, which was provided to the surveyor by the Administrator, revealed that the position of Activities Director was vacant. On 03/05/25 at 1:04PM the surveyor interviewed Activities Assistant, Staff # 8 who stated that she was employed by the facility from September 2024 on a part-time basis for 20 hours per week including every other weekend. Also, there was another part-time activities staff who work on alternate weekends. Staff #8 stated that the Activities Director resigned in November 2024 and since then, the facility had not filled the position. Further, on her days off, Thursdays and Fridays, there is no activity staff available to engage the residents in activities. The facility does not maintain an activity participation log and activities are not documented. Activities are not provided for residents who stay in their rooms and need one-on-one interaction with the activity staff. On 03/06/25 at 8:18AM in an interview, the Administrator stated that a new Activities Director was hired and would assume duties on March 17th, 2025. The Administrator confirmed that since the Activities Director left in November 2024, no formal activities were provided for the residents when the part time assistants were off two days per week and there was no full-time activities staff. Further, no activities were provided for vulnerable residents who require 1:1 visit. The Administrator started the truth is, I do not have the staff. The Administrator stated that she experienced difficulties filling the position of Activities Director and she reached out to her corporate office for an Interim Activities Director but was not successful in obtaining one.

Based on observation and interview, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents who eat food prepared by the facility. The findings include: On 03/04/25 at 11:57 AM, the surveyor conducted a lunch tray line observation and requested the Certified Dietary Manager (CDM) to include a test tray on the last cart that was going to the unit. Six dietary aids were observed preparing a total of 4 meal carts. The first cart was brought out to the dining room and the last cart was completed at 12: 34PM. On 03/04/25 at 12:38 PM, the surveyor and the CDM followed the last cart that was brought out to the unit to conduct the test tray. The cart was parked in one area in the hallway while the nursing staff were walking back and forth to the cart and to the residents' rooms until the last tray was distributed at 12:55 PM. The CDM proceeded to test the food on the test tray using the facility's food thermometer. The temperatures were as follows: Potato-134.6 F Carrots-134.7 F Chopped steak-136 F Dessert: pudding-48.5 F The CDM was informed of the concern and confirmed that the facility was expected to serve hot food items at 135 F and 41 F for cold food items. On 03/05/25 at 8:05 AM, during an interview with Licensed Practical Nurse Staff #1, she stated that the nursing staff were expected to distribute the meal trays as soon as the meal carts were brought to the floor. On 03/05/25 at 8:45 AM, the Director of Nursing was made aware of the food temperature concern.

Based on observation and staff interview, it was determined that the facility failed to store and label food item to maintain the integrity of the specific item. This was evident during the initial tour of the kitchen. This deficient practice has the potential to affect all residents. The findings include: On 03/03/25 at 8:13 AM, the surveyor conducted an initial tour of the kitchen with the assistance of the Certified Dietary Manager (CDM). The surveyor observed 1 large carton (approximately 0.5 gallon) of an opened lactose free milk inside the kitchen refrigerator. The carton had a letter R and 2/12/25 written on it using a black permanent marker, however, it did not contain any label as to when the item was opened and when the contents should have been used. The CDM stated that for dairy food items, the facility had 7 days to discard the item from the time it was opened. He confirmed the carton had no label and took it out from the refrigerator and discarded it in the trash bin. On 03/03/25 at 9:00 AM, the CDM followed the surveyor on the unit and verified that letter R meant received and indicated that the milk was received on 02/12/25. The surveyor informed the CDM that the carton had no date when the milk was actually opened. On 03/05/25 at 8:45 AM, the Director of Nursing (DON) was made aware of the concern.

Based on record review and interview, it was determined that the facility failed to provide documentation whether Residents had an advance directive and/or wished to formulate an advance directive. This was found to be evident for 4 (Resident #27, #28, #54 and #56) out of 4 Residents reviewed for advance directives. The findings include: An advance directive is a legal document that specifies a person's wishes for end-of-life healthcare. It also specifies who should make healthcare decisions on your behalf if you are unable to do so yourself. On 03/04/25 at 12:40 PM the surveyor conducted record reviews of Resident #27, #28, #54 and #56's medical record. During the record review of Resident #27, #28, #54 and #56's medical record, specifically the social services progress notes and assessments, it was revealed that there was no documentation to determine if Residents #27, #28, #54 and #56 had an advance directive and/or determine whether the Residents wished to formulate an advance directive. A MOLST (Medical Orders for Life-Sustaining Treatment) is a standardized form that outlines a patient's medical treatment preferences, including resuscitation and other life-sustaining interventions, ensuring those wishes are respected across all healthcare settings. The surveyor interviewed the Director of Nursing (DON) on 03/05/25 at 10:40 AM. The surveyor asked the DON for documentation of advance directives and offering of advance directive information for Residents #27, #28, #54 and #56. The Director of Nursing (DON) stated that the Residents had a MOLST in the medical charts and that it was the responsibility of the Social Services Director (SSD) for documentation of advance directives. The Social Services Director (SSD) #9 was interviewed by the surveyor at 02:40 PM on 03/05/25 and asked what the process was for documentation of advance directives. The SSD #9 stated that she was responsible for the documentation of advance directives for the Residents. The surveyor asked the SSD #9 if Residents #27, #28, #54 and 56 had advance directives and/or were offered information to formulate advance directives. The SSD #9 stated that Residents #27, #54 and #56 did not have advance directives and were not asked if they wanted to formulate an advance directive. The SSD #9 stated that she was in the process of providing Resident #28 with the information for formulating an advance directive. The SSD #9 further stated that she was new to the facility but was aware of the expectation for documentation of advance directives which included asking Residents if they had an advance directive and if not, did the Residents wish to formulate an advance directive. At the time of survey exit, no additional information on advance directives was provided by the facility.

2) On 03/3/25 at 8:30AM a tour of the facility revealed a cool to cold temperature. The residents were noted to have multiple blankets covering them. The conference room where the surveyors were instructed to work was cool to cold. On 03/3/25 at 10AM, complaints MD00214952 and MD00207551 were reviewed and revealed that the residents' rooms' temperature was not at a comfortable level. On 03/3/25 at 11:30AM an interview with the Maintenance Director revealed that Temperatures logs were maintained daily on random rooms. A review of the temperature logs revealed the following: On 02/18/25, room [ROOM NUMBER] temperature was recorded at 70 degrees. On 02/29/25, Rooms #22, # 26, and #41 temperature were recorded at 70 degrees. On 02/21/25, Rooms #10, # 16, #32 and #41 temperature were recorded at 70 degrees. On 03/4/25 at 11:23AM, The Maintenance Director was informed that the residents' room temperature did not meet the Federal and state regulations to maintain a minimum design air temperature.Based on observation and interviews, it was determined that the facility failed to provide 1) a safe, clean, comfortable, homelike environment and 2) an environment that included comfortable temperature levels. This finding was found to be evident on a tour of the laundry department, 3 (Rooms #25, #26 and #28) of 8 resident rooms observed for safe, clean, comfortable, homelike environment and 2 of 15 complaints reviewed during the recertification survey. The findings include: 1) On 03/03/25 at 08:15 AM the surveyor observed Residents' rooms with items in disrepair on the initial tour of the nursing unit: the dresser was cracked with chipped wood and a wooden mouse trap with a metal spring was behind the door on the floor in room [ROOM NUMBER]; the door frame and door cracked in room [ROOM NUMBER]; bathroom sink faucet loose, water basin on bathroom floor, doors marred, dressers marred with chipped wood and black writing on one of the dresser tops in room [ROOM NUMBER]. The Director of Nursing (DON) was interviewed at 10:10 AM on 03/03/25 and asked about the mouse trap in room [ROOM NUMBER]. The DON observed the mouse trap and stated that she was not aware that this type of mouse trap was used in the facility and that she would notify housekeeping and maintenance. During the tour of the laundry department on 03/05/25 at 06:56 AM with the Environmental Services Director (EVSD) #16 the surveyor observed the following in disrepair in the clean laundry area: chipped and missing floor tiles; missing ceiling panel; chipped and loose doorframe; loose baseboard pulling away from the wall; missing door to the cabinet. In an interview on 03/05/25 at 08:15 AM with the Environmental Services Director (EVSD) #16 he acknowledged the disrepair in the laundry department, and he stated that maintenance was notified. In an interview with the Maintenance Director for follow-up at 08:30 AM on 03/05/25 he stated that he was notified by the Director of Nursing (DON) and the Environmental Services Director about the mouse trap in the Resident room, and the concerns in the laundry department. The Maintenance Director stated that the mouse trap was removed, and that the facility does not use this type of mouse trap. Additionally, the Maintenance Director stated that he replaced the missing ceiling panel.

Based on observation, interview, and record review it was determined the facility failed to use appropriate infection control practices for 1) conducting ongoing surveillance for infections and 2) urinary catheter maintenance and ensuring that staff observed appropriate practices for enhanced barrier precautions during a high contact care for residents with indwelling urinary catheters and with pressure ulcer. This was found to be evident on the tour of the laundry department, during a record surveillance for infections and for 3 (Resident #48, #58 and #272) of 44 residents reviewed for infection control during the recertification survey The findings include: 1) On 03/05/25 at 06:56 AM the surveyor toured the laundry department in the basement of the facility with the Environmental Services Director (EVSD) #16 and the Laundry Aide #17. During this tour of the laundry department with EVSD #16 and Laundry Aide #17 the surveyor observed the following: staff personal items in clean laundry area (coat on chair, water bottle, bottle of tea and coffee cup on folding table), cardboard box of socks directly on the floor in clean laundry area, and a small refrigerator with staff personal items in the clean laundry area. Additionally, in an area directly adjacent to the clean and dirty laundry rooms the surveyor observed the following: cardboard box of personal protective equipment on top of a linen cart against a water pipe, 4 plastic bags of personal clothing directly on the floor and personal clothing in a barrel next to a maintenance paint cart. The EVSD #16 acknowledged the surveyor and stated, thank you for bringing these concerns to my attention and that he would take care of these concerns. The surveyor at 07:55 AM on 03/05/25 conveyed to the Nursing Home Administrator (NHA) several of the findings that were observed in the laundry department. On follow-up to the laundry department at 08:15 AM on 03/05/25 the surveyor observed the EVSD #16 and the laundry aide #17 addressing the identified concerns from the initial tour of the laundry department. On 03/05/25 at 09:15 AM the surveyor reviewed the Infection Prevention & Control Program dated 2001 and the Surveillance for Infections Policy which was dated 2001 and revised 2017. At 09:45 AM on 03/05/25 in an interview with the Director of Nursing (DON) and the Infection Preventionist (IP) #2 who were responsible for the Infection Control Program, specifically the surveillance for infections revealed that the facility did not have a system in place for conducting ongoing surveillance for infections. Additionally, there was no documentation for gathering surveillance data, data collection and recording, calculating infection rates, and interpreting surveillance data for the year 2024. The surveyor asked the DON and IP for monthly infection surveillance for the 3 months (January, February and March) of 2025. The DON stated that she was working on that but was unable to print the reports. On follow-up interview with the Director of Nursing (DON) at 03:00 PM on 03/06/25 the surveyor asked again for the monthly infection surveillance for 2025. The DON presented the surveyor with a 2-page computer generated list of Residents with antibiotic orders for the past year totaling 16 orders and a 1-page written log titled monthly infection surveillance for this year (2025) totaling 7 infections which was incomplete. The surveyor asked the DON for the monthly infection surveillance for 2024, and the DON acknowledged that there were no monthly infection surveillance logs for 2024. No further information was provided by the facility at the time of exit. 50502 2) An indwelling urinary catheter is a thin, flexible tube inserted into the bladder through the urethra to collect and drain urine. It remains in place for an extended period, typically days or weeks. Per Centers for Disease Control (CDC), Enhanced Barrier Precautions (EBP)are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 2a) On 3/03/25 at 9:01 AM, the catheter drainage bag of Resident #48 was observed on the floor. Licensed Practical Nurse (LPN #1) was made aware and confirmed that the drainage bag should be off the floor. On 3/03/25 at 9:08 AM, an EBP sign was observed posted outside Resident #48's room, however, there was no cart for Personal Protective Equipment (PPE). LPN #1 confirmed that the EBP sign was for foley catheter use and that he/she had not seen the PPE cart. On 3/06/25 at 6:50 PM, a review of Resident #48's medical record revealed a care plan initiated on 5/11/2023 which indicated Indwelling Catheter: Neurogenic bladder, however, the active physician orders revealed no evidence that an EBP order was written. 2b) On 3/03/25 at 9:32 AM, a review of Resident #58's active physician orders revealed an order written on 11/20/2024 which read, Maintain foley or suprapubic catheter for Neurogenic bladder. The care plan that was initiated on 11/21/2024 also indicated has Indwelling Catheter for Neurogenic bladder, however, Resident #58 had no EBP order, no EBP sign and no PPE cart outside his/her room. On 3/03/25 at 9:40 AM, the Unit Manager (UM) stated that the facility is expected to put up EBP signs and ensure that PPE carts were placed outside the residents' rooms when caring for residents with indwelling medical devices and wounds. The UM was notified that Resident #48 had no PPE cart outside the room and Resident #58 had no PPE cart as well as no EBP sign. On 3/03/25 at 9:44 AM, Geriatric Nurse Assistant (GNA #3) was observed placing a PPE cart outside Resident #48's room. He/she stated that if there was an EBP sign outside the room, he/she would only wear mask and gloves when providing close contact care to the residents, however, he/she added that he/she would wear gown, gloves and mask if a contact isolation (a medical practice used to prevent the spread of infections that can be transmitted through direct or indirect with a patient or environment) sign was up. On 3/03/25 at 9:47 AM, the UM was observed putting up an EBP sign outside the room of Resident #58. On 3/03/25 at 10:26 AM, in an interview with Resident #58, he/she confirmed that the staff were not wearing gown when giving direct contact care to him/her. He/she added that the nursing staff would only wear gloves and sometimes would wear masks. 2c) On 3/3/2025 at 9:27 AM, the surveyor observed no EBP sign and PPE cart outside Resident #272's room. On 3/03/25 10:03 AM, the UM was observed putting up an EBP sign and PPE cart outside Resident #272's room. The UM confirmed that the EBP sign was for Resident #272's wounds. On 3/06/25 at 9:40 AM, a review of the wound visit dated 3/6/25 confirmed that Resident #272 had a stage 3 pressure ulcer to the buttocks which resolved on 3/6/25 and a surgical wound of the right groin. On 3/06/25 at 10:40 AM, a review of the active physician orders revealed treatment to the wounds, however, an EBP order was not written. On 3/07/25 at 7:55 AM, in an interview with GNA #13, he/she stated that when an EBP sign was posted outside the resident's room, it meant that the resident was on oxygen and that the staff should put on gloves and mask when care was being given to the resident. He/she added that only when a resident was on contact isolation, that's when the nursing staff were expected to wear gown. On 3/07/25 at 8:24 AM, in an interview with LPN #1, he/she stated that when residents were placed on EBP for wounds and urinary catheters, nursing staff were expected to wear PPE, such as mask, gown and gloves when providing care. On 3/07/25 at 8:31 AM, in an interview with the Director of Nursing (DON), she stated that per the facility's policy, residents who had feeding tubes, wounds , foley catheters should be placed on EBP. She added that once the residents were identified, the nursing staff put up EBP signs and placed PPE carts outside the residents' rooms. The DON was made aware of the concerns. On 3/07/25 at 10:37 AM, a review of the facility's EBP policy indicated the following: Gloves and gown are applied prior to performing the high contact resident care activity. EBPs are indicated for residents with wounds and indwelling medical device. Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside the resident rooms. Residents, families and visitors are notified of the implementation of EBPs throughout the facility.

Based on observations, interviews, and record reviews it was determined that the facility failed to ensure medications were properly stored and labeled. This was evident for 2 of 2 medication carts observed for medication storage. The findings include: During an observation of the Potomac Hall medication cart on 3/04/25 at 11:39 AM with Licensed Practical Nurse (LPN) #5 it was revealed to contain expired medications. The following medications were found: Oxycodone 5 mg Tablets had expired on 12/05/24 for Resident #25. Two boxes of Albuterol Sulfate Inhalation Solution vials 0.083% 2.5mg/3mL had expired February 2025 for Resident #36. During an observation of the Chesapeake Hall medication cart on 03/04/25 at 1:59 PM with LPN #1 it was revealed to contain expired, unrefrigerated, and undated open medications. The following medications were found: An Insulin Lispro Injection 100 unit/mL vial is unopened, not dated, or refrigerated for Resident #11. A Lantus Solostar 100 unit/mL pen is opened with no opening date for Resident #11. A Basaglar Injection 100 unit pen is unopened, not dated or refrigerated and the packaging says to refrigerate for Resident #45. Percocet Tablets 5-325mg expired on 7/10/24 for Resident #40. Percocet Tablets 5-325 mg expired on 2/12/24 for Resident #40. During an interview with the Director of Nursing (DON) on 03/04/25 at 2:39 PM she advised the expectations for medications are that nurses should remove them from the cart when they are expired, or the resident is discharged . She added Insulin should be kept in the refrigerator until ready to be used and then dated when removed per policy. During a review of the Storage of Medications Policy on 03/05/25 at 10:32 AM it identified Nursing staff as being responsible for maintaining medication storage. The policy stated, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed and it advised medications requiring refrigeration are stored in a refrigerator in the drug room. During a review of the Discarding and Destroying Medications Policy on 03/06/25 at 09:24 AM, it stated Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation by the resident.

Based on record review and interview, it was determined that the facility failed to 1) revise the resident's comprehensive care plan, 2) hold care plan meetings, 3) Reassess the effectiveness of the care plan approaches and 4) have quarterly care plan meetings with the Interdisciplinary Team. This was evident for 5 (Resident #27, #48, #58, #52 and #46) of 44 residents reviewed for care plan timing and revision during the recertification survey. The findings include: An arteriovenous (AV) fistula shunt is a surgical procedure that creates a direct connection between an artery and a vein. This allows blood to flow from the high-pressure artery into the low-pressure vein, increasing blood flow in the vein. AV fistula shunts are primarily used to provide long-term vascular access for hemodialysis, a treatment for chronic kidney disease. According to CMS (Centers for Medicare and Medicaid Services), a care plan meeting is a structured, interdisciplinary conference where staff, residents, and families discuss and review the resident's care plan, ensuring needs are met and goals are achieved. In long-term care facilities, care plans should be reviewed and updated at least every 90 days, or more frequently if a resident's condition changes significantly. 1) During the initial tour of the nursing unit on 03/03/25 at 08:30 AM the surveyor observed Resident #27 with an AV fistula shunt to the left upper arm. Resident #27 stated that he/she goes to dialysis every Tuesday, Thursday and Saturday. The surveyor conducted a record review of Resident #27's medical record at 11:45 AM on 03/5/25. Review of the medical record revealed that Resident #27 had a care plan for 11 staples in the left forearm area and 10 staples in the left arm fistula site with an initiation date of 10/21/24. The care plan had a revision on date of 01/06/25; however, this problem remained on the care plan and was still on the care plan as of the record review date by the surveyor. An interview was conducted with the Director of Nursing (DON) on 03/10/25 at 9:05 AM. The surveyor conveyed to the DON that Resident #27 had a care plan dated 10/21/24 for staples to the left forearm and the left arm AV fistula shunt with a revision date of 01/06/25, and that this problem was still on the care plan. The DON acknowledged the surveyor. No additional information was provided by the facility at the time of exit. 50502 2) On 03/03/25 at 8:52 AM, Resident #48 stated that he/she has not been involved in any care plan meetings. On 03/06/25 at 8:21 AM, a review of Resident #48's medical record revealed that he/she was readmitted on [DATE]. His/her BIMS (Brief Interview for Mental Status) score was 14, which indicated he/she was cognitively intact. A review of progress notes revealed no supporting documentations that care plan meetings occurred for Resident #48. On 03/06/25 at 8:35 AM, in an interview with the Social Worker (SW), she described that when scheduling a care plan meeting, the facility notified the residents and the resident representatives either by calling or by talking to them personally. She added that starting March of this year, she started sending meeting notifications. She stated that she scheduled the meeting according to cycle or to the Assessment Reference Date (ARD) of the Minimum Data Set (MDS) schedule and for new admissions, she stated that the facility conducted a baseline care plan meeting within 72 hours. She checked Resident #48's medical record for any documentation related to any care plan meetings and she confirmed that there were none. On 03/06/25 at 8:42 AM, the Director of Nursing (DON) was made aware of the concern. On 03/07/25 at 11:49 PM, the DON confirmed that the facility had no record to prove that care plan meetings were held for Resident #48. 3) On 03/04/25 at 3:05 PM, a review of Resident #58's medical record revealed that he/she was readmitted on [DATE]. Also, the medical record indicated that a care plan was initiated on 11/23/2024 which stated, uses antidepressant medication Seroquel related to Depression, however, the resident was not on Seroquel (a type of medication used to treat mental health conditions.) On 03/05/25 at 8:27 AM, in an interview with the DON, she stated that care planning was done by the Interdisciplinary Team (IDT) and that she updated most of the care plans. She was made aware that the care plan of Resident #48 for psychotropic medication was not updated. She confirmed the findings and stated that she would make the necessary changes/ updates to the resident's care plan. 51491 4) During a telephone interview with the Legal Guardian for Resident #52 on 03/03/25 at 4:08 PM, it was revealed Resident #52 had not attended any recent care plan meetings and the guardian felt a Care Plan meeting could have been beneficial for the Resident. During a review of Medical Records on 03/03/25 at 7:37 PM it was discovered that Resident #52 required total care from the facility and the last Care Plan Meeting was 7/17/24. The attendees for the meeting included the resident, legal guardian, nursing, and activities. During a review of Resident #46 Medical Records on 03/04/25 at 6:27 PM it was discovered that Resident #46 required total care from the facility and the last Care Plan Meeting was 7/31/24. The attendees included the Resident, nursing, rehab, activities, and social services. During an interview with the Social Worker on 03/05/25 at 9:16 AM she advised she has only been with the facility for 3 months and doesn ' t think care plan meetings are caught up. She reports when the meetings are completed she puts a note in the Social Services electronic medical records. She confirmed Residents #52 and #46 had not had a recent Care Plan Meeting. She reported the staff that would usually attend would include the nurse manager, Director of Nursing, Director of Rehab, and dietician.

Based on record review and interviews, it was determined that the facility failed to provide written notification of the Resident's transfer or discharge to the Resident or Resident Representative and the facility Ombudsman. This finding was found to be evident for 3 (Resident #2, #27 and #54) of 3 residents reviewed for notice requirements before transfer or discharge to the hospital. The findings include: On 03/06/25 at 07:30 AM the surveyor conducted a record review of a closed medical record for Resident #2. The review of the medical record revealed that Resident #2 was transferred to the hospital 02/23/25, 02/25/25 and 02/27/25. Further review of the medical record on 03/06/25 revealed that the INTERACT Transfer assessment form was completed by nursing and that the responsible party was notified of Resident #2's transfers to the hospital, but there was no evidence that written notification of transfers was provided to the Resident or the Responsible Party and the facility Ombudsman. On 03/3/25 at 10:05 AM the surveyor interviewed Resident #27. The Resident stated that I have been to the hospital in the past year. At 08:30 AM on 03/06/25 the surveyor conducted a record review of Resident #27's medical record. The review of the medical record revealed that Resident #27 was transferred to the hospital 10/15/24 and 12/10/24. According to the documentation in the progress notes of the medical record the family was notified of the Resident transfer to the hospital but there was no evidence that written notification of transfers was provided to the Resident or the Responsible Party and the facility Ombudsman for Resident #27. The surveyor interviewed Resident #54 on 03/03/25 at 01:40 PM and the Resident stated, I transferred to the hospital for high blood pressure. On 03/6/25 at 09:30 AM the surveyor conducted a record review of Resident #54's medical record. The review of the medical record revealed that Resident #54 transferred to the hospital on [DATE] for abnormal lab values. Further review revealed that the INTERACT Transfer assessment form was completed 07/24/24 and indicated that the Responsible Party was notified of the transfer to the hospital and the clinical condition of Resident #54. There was no evidence that written notification of the transfer was provided to the Resident or the Responsible Party and the facility Ombudsman for Resident #54. At 07:50 AM on 03/07/25 the surveyor interviewed the Director of Nursing (DON) and asked the DON who was responsible for providing written notification to the Resident and Responsible Party and the facility Ombudsman of transfers to the hospital. The DON stated that the Social Services Director (SSD) #9 was responsible for these notifications. In an interview with the Social Services Director (SSD) #9 at 08:20 AM on 03/07/25 the surveyor asked the SSD #9 what the expectation was for providing written notification to the Ombudsman and the Resident or Responsible Party when a Resident is transferred to the hospital. The SSD #9 stated that she was notified last week that her department was responsible for this notification. No additional information was provided by the facility at exit.

Based on medical record review and interview, the facility staff failed to thoroughly investigate a facility reported incident of resident-to-resident abuse. This was evident for 1 (Resident #330) of 44 residents reviewed during survey. The findings include: Review of Residents #330 and Resident #333's facility reported incident (MD 00181638) on 03/6/25 at 10:05AM revealed the Resident #330 alleged that Resident #333 touched his/her private area. Review of the facility investigation documents on 03/6/25 at 10:10AM revealed that the facility was unable to substantiate abuse. Further review of the facility investigation documents revealed that the facility failed to interview other residents and staff members regarding abuse before concluding that the alleged resident-to-resident abuse was unsubstantiated. During an interview with the Director of Nursing on 03/6/25 at 11:00AM, the DON confirmed that the facility failed to thoroughly investigation Resident #330's allegation of abuse

Based on observation and staff interview, it was determined that the facility failed provide a family meeting to discuss grievances regarding the care of a resident. This was evident for1 (Resident #336) of 44 residents reviewed during the recertification survey. The findings include: On 03/3/25 at 9:56AM, the surveyor reviewed a complaint (MD#00201345) from Resident #336's family stating that they requested a family meeting with the facility's social service department regarding grievances regarding inadequate care of Resident #336. The review of the resident's medical record on 03/3/25 at 10:00AM revealed no evidence that the facility social services department provided the resident's family with a family meeting. During a interview with the Director of Nursing (DON) on 03/6/23 at 7:58AM, the DON reviewed Resident #336's medical record and confirmed that the resident's family did not receive the requested meeting.

Based on record review and interviews, it was determined that the facility failed to provide written notification of the bed hold policy for Residents that were transferred to the hospital. This finding was found to be evident for 3 (Resident #2, #27 and #54) of 3 residents reviewed for notice requirements of bed hold policy before or upon transfer to the hospital. The findings include: A Bed Hold is the act of holding or reserving a Resident's bed while the Resident is absent from the facility for therapeutic leave or hospitalization. It must be provided to all facility Residents regardless of payment source. The Bed Hold policy should be disclosed in the admission packet during an initial admission to the facility and it should be disclosed to Resident/Resident Representative at the time of transfer. On 03/06/25 at 07:30 AM the surveyor conducted a review of the closed medical record for Resident #2. Review of the record revealed that Resident #2 was transferred to the hospital on [DATE], 02/25/25 and 02/27/25 for evaluation of a medical emergency. There was no documented evidence that the facility sent a bed hold policy to Resident #2's responsible party upon transfer of Resident to the hospital. At 08:40 AM on 03/06/25 the surveyor reviewed the Bed Hold Notice of Policy and Authorization form that was given to Residents and Responsible Party upon transfer to the hospital. In an interview with the Director of Nursing (DON), she stated that these forms are kept at the nursing station and the nursing staff completed the form and provided the form to the Resident upon transfer to the hospital and made a copy of the signed form for the Resident's medical record. The surveyor conveyed to DON that Resident #2 did not have any Bed Hold notices in the closed medical record and the DON acknowledged and no additional information was provided. On 03/06/25 at 08:30 AM the surveyor conducted a record review of Resident #27's medical record. Review of the medical record revealed that Resident #27 was transferred to the hospital on [DATE] and 12/10/24. Further review of the medical record revealed that the Bed Hold Notice and Authorization form was signed by Resident #27 and a copy was in the medical record for the 10/15/24 transfer to the hospital, but there was no evidence of a Bed Hold Notice form for the 12/10/24 transfer to the hospital. In an interview on 03/10/25 at 09:45 AM with the Unit Manager #2 on the nursing unit, she acknowledged that there was not a Bed Hold Notice form located in the medical record for Resident #27's transfer to the hospital on [DATE]. The Unit Manager provided the surveyor with a copy of the Bed Hold Notice form for Resident #27's transfer to the hospital on [DATE] and no additional information was provided. On 03/06/25 at 08:45 AM the surveyor conducted a record review of Resident #54's medical record. Record review revealed that Resident #54 transferred to the hospital on [DATE]. Further review of the medical record revealed that Resident #54 transferred to the hospital due to abnormal lab values, but there was no evidence that the Resident or Resident Responsible party received the Bed Hold policy notice. In an interview with the DON at 10:50 AM on 03/06/25 it was conveyed to the DON that there was not a copy in Resident #54's medical record of the signed Bed Hold Notice form for the hospital transfer on 07/24/24. The DON acknowledged and no additional information was provided.

Based on a facility-reported incident, reviews of administrative, resident, and other pertinent documentation, and interviews with facility staff, it was determined that the facility failed to have a system in place to: 1) Ensure that all cognitively impaired residents, with exit seeking behaviors, do not leave the building, unauthorized; 2) Ensure that all exit doors were secure, consistently lock and closed; and 3) Ensure that residents with exit seeking behavior have an Alert Bracelet in place to alert the staff when a resident is near an exit door. This was found to be evident for 1 of 6 residents (Resident #4) reviewed for elopement during a complaint survey and resulted in an immediate jeopardy declared on 03/06/23 at 1:25 PM. The findings include: Review of Resident #4 ' s record on 3/2/2023 revealed the resident was admitted to the facility from the hospital on 01/19/22 with diagnoses that include alcoholic cirrhosis, an elevated ammonia level, bipolar disorder, dementia, encephalopathy, and cognitive communication deficit. A BIMS (Brief Interview for Mental Status) was conducted during the 10/25/22 Quarterly assessment and on the 11/28/22 Annual assessment for Resident #4. The summary for both BIMS assessments equaled 99. The summary score for a BIMS interview includes adding the scores for each question and fill in the total score (00-15). 99 is entered as a score if the resident was unable to complete the interview. A review of Resident #4's medical record revealed 2 physician certifications that indicated Resident #4 was certified incapable to make all medical decisions due to dementia. These certifications were dated 05/09/22 and 05/10/22. A review of facility-reported incident MD00175159 on 03/02/23 at 10 AM, revealed that Resident #4 was brought back to the facility by the local police department on 02/11/22 at 7:40 AM. The facility determined that Resident #4 left the facility through a window to leave the facility. The facility fixed the windows by adding a device to the window track which prevented the windows from opening all of the way. A review of facility-reported incident MD00186329 on 03/02/23 at 10 AM, revealed that Resident #4 was found by a staff member in the back parking lot on 12/15/22 at approximately 4:50 PM. Resident #4 was returned to the facility. The facility determined that Resident #4 had gone through the back door due to the door not locking after staff had exited through the door. The facility staff determined that Resident #4 had also removed his/her Alert Bracelet before exiting the facility through the back door. The facility contacted a vendor who repaired the back door latch that was determined to be in disrepair. A review of facility-reported incident MD00189418 on 03/02/23 at 10 AM, revealed that Resident #4 was observed in the back parking lot on 02/23/23 at approximately 2:30 PM, by therapy staff. Resident #4 was safely returned to the facility without incident. The facility Director of Nursing (DON) documented an interview with Resident #4 on 02/23/23 at 2:30 PM in which the facility staff member asked why Resident #4 was outside and Resident #4 stated that s/he wanted to get fresh air because the sun was shining. The DON documented that Resident #4 was not wearing his Alert Bracelet on his/her leg. The DON asked Resident #4 what happened to the Alert Bracelet to which Resident #4 replied that s/he cut it off and put it on the dresser. Resident #4 stated that s/he did not want the Alert Bracelet. An Alert Bracelet is part of a facility-wide wandering management prevention system. The bracelet is placed on a resident that emits a signal. If a resident ambulates too close to a sensor, the system may emit an audible signal to staff and may also secure an exit door preventing a resident from leaving the facility unattended. In an observation and interview with Resident #4 on 03/02/23 at 9:55 AM, Resident #4 was observed lying in his/her bed watching television. Resident #4 was observed with a functioning Alert Bracelet attached to his/her left ankle. Resident #4 was interviewed regarding eloping from the facility on 02/23/23. Resident #4 stated that s/he could not recall why s/he left the building but thought it to be nightfall. Resident #4 could not recall if it was daytime or nighttime. Reviews of Resident #4's medical record on 03/02/23 revealed an elopement prevention care plan was initiated on 02/08/22. The elopement care plan was created due to staff identifying Resident #4's was observed wandering aimlessly, disoriented to place, and a history of removing his/her Alert Bracelet. On 02/08/22, the goal of Resident #4's elopement prevention care plan was: to maintain Resident #4's safety and prevent leaving the facility unattended. Nursing interventions included: apply an Alert Bracelet and monitor placement Q shift and function daily, distracting Resident #4 from wandering by offering pleasant diversions, structured activities, food, conversation, television, reading books, and to identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something? Does it indicate the need for more exercise? On 02/11/22, additional nursing interventions were initiated that included: Provide structured activities: toileting, walking inside and outside, use reorientation strategies including signs, pictures and memory boxes and staff need to be hyper-vigilant to maintain resident's safety. On 02/14/22, additional nursing interventions were initiated that included: Resident has been in the past, a person of routine. He/she enjoys coffee in the morning and reading the newspaper. The daughter will get him/her a subscription to the newspaper to establish a similar past routine of reading the paper daily, coffee is included as a beverage choice and will continue to have a routine similar to his/her past experiences. On 05/23/22, another nursing interventions was initiated that included: Staff to identify Resident #4 removing Alert Bracelet, check placement and proper function, and any others identified. Review of Resident #4 ' s medical record revealed documentation staff were monitoring Resident #4 for removing the Alert Bracelet. A review on 03/03/23 of the facility investigation for the 02/23/2023 elopement of Resident #4 for facility-reported incident MD00189418 revealed that the interior door to the former Rehabilitation area became stuck in the open position due to the door meeting the floor when the door was opened all the way. Observations of the door on 03/02/23 at 3:15 PM with the facility Administrator revealed that the former Rehabilitation interior room door was able to become stuck in an open position when fully opened and then getting stuck on the floor. The door was a safety hazard to any wandering residents entering the former Rehabilitation area where exit doors were located. Since the Rehabilitation room door was an interior door, once Resident #4 was able to go gain access through the door, Resident #4 was able to gain access to the exterior leading door in the room which led to the back parking lot. There was no type of working alarm system on the Rehabilitation room exterior leading door at the time of Resident #4 ' s 02/23/23 elopement. The facility investigation identified environmental service staff members (EVS) that were in the area just prior to Resident #4 eloping through an unsecured door to the back parking lot on 02/23/23. In an interview with EVS #3 on 03/03/23 at 10 AM and in the presence of the facility Administrator, EVS #3 staff member stated that s/he was hired in early January 2023 and had not received any education on maintaining the former Rehabilitation door in a closed position. In an interview with the facility EVS Director on 03/03/23 at 11:58 AM in the presence of the facility Administrator, the EVS director stated that s/he started working in the facility in mid-November 2022 and was responsible for educating the EVS staff on the specifics of the facility. The EVS Director stated that the facility's EVS services are contracted through an outside vendor. The EVS Director stated that s/he does not keep a written record of any education presented to the EVS staff. Most of the education is hands-on. The EVS director stated that s/he speaks to the EVS staff about abuse and other topics but does not keep any written records. In an interview on 03/06/23 at 12:25 PM with the 02/23/23 day shift Nurse #16, escorted by the facility Administrator and DON, Nurse #16 stated that s/he started working in the facility on 01/30/23 and had a week of nursing orientation. Nurse #16 stated that s/he worked approximately 2 weeks with Resident #4 before the 02/23/23 elopement. Nurse #16 stated that s/he was first alerted to Resident #4's elopement on 02/23/23 by other facility staff members. Nurse #16 stated that s/he last observed Resident #4 during an 11 AM medication pass and at 1 PM. Nurse #16 stated that s/he had not noticed if Resident #4 had his/her Alert Bracelet on his/her wrist. In an interview with the DON during this interview with Nurse #16, the DON stated that the facility staff could not locate Resident #4's Alert Bracelet that s/he was wearing prior to the 02/23/23 elopement. In an interview with the facility DON and Administrator on 03/03/23 at 2:40 PM, the DON presented the surveyor with nursing documentation that the 02/23/23 day shift nurse, documented that s/he signed off that Resident #4 was wearing his/her Alert Bracelet at 2:49 PM. The facility DON stated that at 2:49 PM, the day shift nurse placed and secured another Alert Bracelet onto Resident #4. In an interview and observation with the facility administrator and DON on 03/02/23 at 3:15 PM, the Administrator demonstrated that the interior rehabilitation room door was still able to be open widely to the point where the door would become stuck in the open position. After surveyor intervention, the facility staff completed securing the interior Rehabilitation room door by: 1) adding a door bumper, secured on the floor, behind the door which prevented the door from fully opening, and 2) shortening the length of the upper door bracket to also prevent the door from fully opening. This was completed and verified on 03/02/23 at 3:50 PM. On 03/09/23 at 1:30 PM, the Corporate Chief Nurse #31 supplied a copy of the shopping receipt which was dated 03/02/23 at 2:42 PM, indicating the date and time the facility maintenance director had purchased the door bumper to secure the interior Rehabilitation room door. Reviews of the facility documentation after Resident #4 eloped from the facility on 02/11/22 and 12/15/22 revealed that the facility completed education with the entire staff on elopement prevention. The facility took steps to secure the windows from opening fully and repaired the back door lock mechanism. Daily door checks were also put into place. After Resident #4 ' s 02/23/23 elopement, the facility had not fully secured the interior Rehabilitation room door until 3/2/2023 after surveyor intervention and had not completed facility-wide staff education regarding residents at-risk for elopement until 03/03/2023. As a result of these findings, an immediate jeopardy was declared on 03/06/23 at 1:25 PM and the immediate jeopardy template was provided. The facility submitted an initial plan of action on 03/06/23 at 6:30 PM which was rejected and returned. Additional plans of action were received at 8:38 PM and 10:15 PM and both were rejected and returned. The facility submitted a final plan of action on 03/06/23 at 11:31 PM, which was accepted. The Immediate Jeopardy was abated on 3/8/2023 at 3:45 PM. After removal of the Immediate Jeopardy, the deficiency remained for the potential for more than minimal harm at a scope and severity of E. The facility plan of correction was as follows: Corrective Action - Resident #4 has an alert bracelet in place as of 02/23/23. Exit doors were evaluated and a maglock is in place as of 03/06/23. The internal old Rehab door on 02/23/23 the readjusted with an additional door stopper on 03/02/23. The facility revised the Elopement policy on 03/06/23 to include the following: This facility will ensure that cognitively impaired residents with exit-seeking behaviors do not leave the building unattended without an order for discharge or leave of absence as well as ensure that all exit doors are maglocked, secure, locked and closed. Identification - The Director of Nurses reviewed current residents to evaluate if there are any wandering residents in the last 30 days who are cognitively impaired to evaluate if an alert bracelet has been applied for safety. Date of compliance 03/03/23. A total number of 8 cognitively impaired residents, who have wandering behaviors have alert bracelets in place, care plans have been updated, and behavior monitoring orders initiated. Date of compliance 03/03/23. System Correction/Education - The Director of Nurses educated the licensed nurses on 02/24/23 with a completion date of 03/06/23 on the importance of monitoring the presence of the alert bracelet on residents to ensure they are in place and if not in place to ensure a timely replacement for safety. The Director of Nurses educated the licensed nurses on the revised Elopement policy. Date of completion 03/06/23. Those licensed staff who have not been trained will be removed from the schedule and unable to work until in-serviced. The Administrator educated the Maintenance Director on 03/06/23 on the importance of completing the inspection of exit doors to ensure they are secure, locked, and closed when the resident is near as well as on the importance of completing weekly audits of the Maglocks, Accucheck system at the exit doors. The Regional Director of Clinical Services educated the Administrator and the Director of Nurses on 03/06/23 on the revised Elopement policy including but not limited to ensuring that a secure system is in place for wandering residents. Staff education has been re-initiated as of 03/06/23 with a completion date of 03/06/23 with the exception that those not retrained today will be removed from the schedule and unable to work until in-serviced. Monitoring - The Maintenance Director completed and will continue weekly audits of the exit doors to validate they are secure, locked, and closed as well as a complete weekly audit of Maglocks, and Accucheck systems at exit doors. Audits will be completed weekly for four weeks then monthly for three months. Date of compliance 03/06/23. The Director of Nurses completed and will continue to complete an observational round for wandering residents who are cognitively impaired to validate that they have an Alert bracelet in place. Audits will be completed weekly for four weeks then monthly for three months. Date of compliance 03/06/23. Audits will be submitted to the QAPI Committee for review and further recommendations as necessary. Date of completion 03/06/23. A copy of the new Elopement Policy and Procedure was provided by the facility and reviewed by the survey team.

Based on a complaint, reviews of a closed record, reviews of administrative records, and interviews with staff, it was determined that the facility staff failed to 1) follow the physician's tube feeding orders, and 2) prevent a totally dependent resident from a severe weight loss. This was evident for 1 (Resident #3) of 11 residents reviewed during a complaint survey. The findings include: A review of complaint MD00174985 on 03/03/23 revealed an allegation that Resident #3 was not receiving the correct tube feeding and had lost weight. A review of Resident #3's closed medical record on 03/03/23 revealed that Resident #3 was admitted to the facility on [DATE] with diagnoses that included: diffuse traumatic brain injury, hemiplegia, seizure disorder, extremity contracture, and a gastrostomy tube for tube feeding. Resident #3 was totally dependent on the nursing staff for all of his/her care needs including nutrition and hydration. Resident #3 was not able to participate in a Brief Interview for Mental Status (BIMS) interview upon admission. Severe weight loss is defined as a weight loss of greater than 5% in one month. A review of Resident #3 ' s charted weights revealed the following: 10/05/21 at 7:28 PM - 188.0 pounds. 11/04/21 at 6:38 AM - 187.8 pounds. 12/16/21 at 6:36 PM - 151.0 pounds. 01/12/22 at 3:26 PM - 165.0 pounds. 02/04/22 at 10:40 AM - 175.8 pounds. Further review of Resident #3's closed record revealed a Dietician note, dated 11/11/21 at 3:53 PM, that indicated Resident #3's family member requested that Resident #3's tube feeding administration route be changed from bolus to continuous. The facility dietician #3 documented Resident #3's family request was for a continuous tube feeding versus a single administration bolus feeding several times a day. The facility dietician documented that Resident #3 weighed 187.8 pounds at that time. A new physician order was obtained on 11/11/21 for Resident #3's tube feeding. The new order instructed the nursing staff to start tube feeding, Jevity 1.5, to run on a continuous pump, at 115 ml/hour for 12 hours. The tube feeding infusion was to start at 6 PM and end at 6 am the next day. The total volume would equal = 1380 milliliters. The total calories would be 2070 kcal. A further review of Resident #3's nursing progress notes after 11/11/21 revealed that the nursing staff was continuing to document that Resident #3 was receiving receive bolus tube feedings on the following days: 11/14/21 at 8 AM 11/16/21 at 4:13 AM 11/19/21 at 6:44 AM 11/21/21 at 7:37 AM 11/22/21 at 6:57 AM 11/27/21 at 6:53 AM It was not until 11/29/21 that the nursing staff started documenting the current physician order for Resident #3's tube feeding (Jevity 1.5, 115 milliliters/hour, for 12 hours) on a pump from 6 PM until 6 am. A review of Resident #3's November 2021 medication administration record (MAR) revealed that the nursing staff was documenting that Resident #3's tube feeding was now infusing on a pump. A review of #3 weight records revealed that between 11/04/21 and 12/16/21, Resident #3 was identified with a 36.8-pound (19.5%) weight loss. A review of the former facility dietician ' s assessment, dated 12/21/21 at 10:15 AM, revealed no answers as to the possible cause for the significant weight loss. A weight was obtained on Resident #3 on 01/12/22 at 3:26 PM which indicated Resident #3 weighed 165 pounds. In an interview with the former facility dietician #31 on 03/07/23 at 2:06 PM, the former dietician stated that S/he could not recall what could have been the cause as to Resident #3's significant weight loss from 12/16/21. In an interview with the facility director of maintenance on 03/08/23 at 11 AM, the facility director of maintenance stated that the facility scales were being checked monthly without any signs of errors. The director of maintenance presented documentation that indicated the facility scales had been tested monthly and were determined to be functioning accurately on 10/31/21, 11/30/21 and 12/31/21.

Based on surveyor observation, review of the clinical record and staff interviews, it was determined that the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure ulcers and failed to ensure treatment to promote healing of pressure ulcers. This finding was evident in 3 of 31 sample resident selected in the stage 2 reviews. (#64, #49, #102) Definitions: A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. A pressure ulcer is usually over a bony prominence, as a result of pressure, or pressure in combination with shearing. A Stage I pressure ulcer is an area of intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage 2 pressure ulcer is a partial thickness loss of the skin presenting as a shallow open ulcer with a red pink wound bed, without slough. A stage 2 pressure ulcer may also present as an intact or open/ruptured fluid-filled or blood filled blister. A Stage 3 pressure ulcer is a full thickness skin loss in which fat is visible in the ulcer and granulation tissue (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) and rolled wound edges are often present. Slough and/or eschar may be visible. An unstageable pressure ulcer is full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. 1. The nursing staff failed to adequately monitor and treat a pressure ulcer of resident #64 present on admission which resulted in the resident's sacral ulcer worsening. On 01-20-17, review of the closed clinical record revealed resident #64 was admitted with an unstageable pressure ulcer on the sacrum. Review of the initial admission nursing assessment dated [DATE] for resident #64 revealed an open area on the right upper buttock, measuring 5.7 x 6.0 x 0.3 cm., 25% necrosis, with no other information about the other 75%. Further review revealed no initial treatment orders for this open area until August 9. Resident #64 was seen by the wound consultant on 08-04-16 who wrote continue hydrogel and gauze to all wounds as directed upon adm(ission). There is no evidence these orders were ever transcribed from admission. Review of resident #64's TAR (treatment administration record) for July 2016 and through August 9, 2016 revealed no evidence of any treatment for [REDACTED]. On August 9 an order was written to cleanse the sacral wound with normal saline, apply santyl ointment (a [MEDICATION NAME] agent), cover with maxsorb and secure with border gauze daily and PRN(as needed). Further slough record review of resident #64 revealed that from 07-30-16 to 08-05-16 the sacral/right upper buttock pressure area increased in size from 5.7 x 6 x 0.3 cm. to 6.5 x 7.5 x 0 cm with 75% slough and 25% granulation according to the skin sheet initiated on admission. A treatment was ordered on 08-09-16, 10 days after admission. There is no correlating physician or NP (nurse practitioner) note on that date. There was no mention of a dressing change, physician visit or order change for the sacral wound in the progress notes. The facility staff failed to provide any treatment to an unstageable pressure ulcer that was present on admission for resident #64. In addition, no care plan was ever initiated for the pressure ulcers for resident #64 or for the prevention for further development of pressure ulcers throughout the resident's stay in the facility. an order for [REDACTED]. On 01-23-16 at 4 PM, the surveyor requested to interview the staff that were documenting care in the progress notes the days after resident #64's admission to clarify if any treatment was done on the open areas. An interview on 01-25-17 at 4 PM with staff #4 via telephone revealed she was unable to remember this resident. She had only documented the administration of pain medication. The one staff member who documented in the progress notes wound treatment done on 08-02-16 at 12:33 AM was unavailable for interview. No other staff who cared for resident #64 from admission 07-30-16 through 08-09-16 documented any wound or dressing changes being performed. The NP on 08-01-16, which was the same NP as the wound consultant, wrote under Objectives: skin: wound location; sacrum, left buttock and left BKA (below knee amputation) with no measurements or assessment documented for resident #64 . Under assessment with ICD (coding mechanism of problems) it revealed pressure ulcer of sacral region, unstageable and pressure ulcer of left buttock, unstageable, no further information. The physician saw resident #64 on 08-02-16 for a History and Physical. The review of systems had no mention of pressure sores. Under Objectives- no mention of skin. Again under assessment the ICD for the same pressure sores there was no mention of actual size or appearance. On 01-24-16 at 11 AM, interview of the DON revealed no additional information. On 01-24-16 at 2 PM, interview of the medical director revealed no additional information. B. In addition, on the initial nursing assessment of resident #64 dated 07-30-16, 4 areas were identified as pressure sores/ wounds: a. pressure ulcer with 25% necrosis on right upper buttocks measuring 5.7 x 6 x 0.3 cm, b. open area with 50% slough underneath left stump along the surgical incision line 2.5 x 1 cm., c. right inner buttocks ulcer #2 measures 5 x 2.5 x 0.1 cm., d. left buttocks open area with 75% slough 1.5 x 0.1 cm. Only the right upper buttock and the area under the incision line were monitored using a skin sheet. The other areas were not monitored nor did they have any treatment ordered. Review of the initial nurse practitioner (NP) note dated 08-01-16 revealed resident #64 had a sacral wound, left buttock wound and left BKA ([MEDICAL CONDITION]) site. There was no description of the size or appearance of these wounds. On 08-02-16, the attending physician did a history and physical for resident #64 and documented a pressure ulcer of the sacral region, unstageable, and pressure ulcer of the left buttock, unstageable. Again no size or physical description of the 2 areas. There was no skin sheet initiated for the left buttock. On 08-04-16 when the wound consultant saw resident #64 there was documentation of 3 areas: sacrum pressure ulcer discussed above, a right buttock wound stage II (partial thickness skin loss) and the left BKA. There was no evidence of any wound on the left buttock. On 08-16-16 a different NP saw resident #64 and again under assessment wrote pressure ulcer of sacral region, unstageable and pressure ulcer of left buttock, unstageable, with no further description. On 01-23-17 at 11AM, interview with this NP revealed she/he indicated maybe the wounds merged into one another. On 01-24-17 at 1 PM, interview with the DON revealed no additional information. 2. On 01-20-17 at 1 PM, observation of a dressing change for resident #49 with staff #6 on the right malleous (ankle) revealed a healed area to be protected from re- injury. The dressing was changed the prior day 01-19-17. The dressing was [MEDICATION NAME] which provides a second layer of protection over areas that have recently healed from surface trauma. The [MEDICATION NAME] dressing is also self-adhesive and will mold to the unique surface of the wound. Further review revealed an order dated 11-14-16 by the wound consultant to use [MEDICATION NAME] every 5 days and PRN (as needed) on the right malleous until healed. The dressing was changed every 5 days for resident #49. This is the appropriate way to use the dressing. On 01-16-17, resident #49 was seen by the wound consultant who revealed the wound was healed and ordered to continue [MEDICATION NAME] x (for) 7 days for protection, area healed right malleous. This type of dressing is not to be changed daily as it disrupts the protective action of the dressing. However, the order when written on 01-16-17 by the nursing staff, it was transcribed as to change the dressing daily for 7 days. By removing the dressing daily, more damage could be done to the healing wound. Staff #6 on interview at 1 PM on 01-20-17 revealed she was following the order as written. This order was not clarified and the treatment was not done as ordered. In addition, there was no evidence of a skin sheet for the right malleous that revealed the weekly progress of this area for resident #49. On 01-20-17 at 3 PM interview with the DON revealed no additional information. 3. On 01-20-17 surveyor review of the clinical record for resident #102 revealed a nurses note written on 12-14-16 that stated the resident had a change in skin integrity as evidenced by ulcer-pressure. The following areas and measurements were listed: left heel blister 10 x 5.2 cm, left outer leg blister 2.8 x 1.4 cm, and right inner ankle redness 3 x 2.8 cm. This note repeats the areas and measurements, however the second description described redness on the right outer ankle measuring 3 x 2.8 cm. It was unclear if there were areas on the inner and outer right ankle. Surveyor review of the skin sheets dated 12-14-16 revealed the description of a stage 1 pressure area on the right inner ankle measuring 3.0 x 2.8 cm. There was no skin sheet for an area on the right outer ankle. Further review of the nurses notes revealed that on 12-19-16 resident #102 was noted to have new blisters on the right lateral foot measuring 1.8 x 3 cm, the left inner ankle measuring 2 x 1 cm, the left upper shin shin measuring 0.8 x 1.2 cm, and on the left lateral heel measuring 3 x 5.5 cm. Surveyor review of the wound care consult report written on 12-19-16 revealed resident #102 was seen on wound rounds for multiple wounds. Documentation for Wound #1 was Location: left medial heel and Type: Pressure Ulcer. There was no further description or measurement of this wound or of any other wounds. However, documented under recommendations was skin prep heels left heel, left shin, right (ankle), left (ankle)/right daily. Further review of the skin sheets of resident #102 revealed that on 01-03-17 the left heel blister opened. However, there was no evidence of a change in treatment plan until 01-08-17. In addition, review of the skin sheets dated 01-16-17 revealed the following: -left heel pressure ulcer was unstageable with 90% eschar -left lateral lower leg did not have a stage listed but was described with 30% slough and 70% pink -left inner ankle did not have a stage listed but was described as necrotic -right inner ankle was described as a stage 2 but necrotic -right lateral foot (outer ankle) was described as a stage 3 with 100% slough Further review of resident #102's clinical record revealed new orders written by the wound care consultant dated 01-16-17 for pressure ulcers on the left heel, left lateral leg, left outer ankle, right inner ankle, and right outer ankle. However, there was no wound consult note for 01-16-17 available to review. Surveyor review of resident #102's treatment administration record revealed no evidence of any treatment to the left lateral leg pressure ulcer on 01-17-17 and 01-18-17. On 01-20-17 at 2:30 PM surveyor observation of wound care to resident #102 revealed the following: Staff #5 applied a dressing soaked in Dakins solution to the left heel of resident #102 and then wrapped the area with kerlix (gauze wrap) as ordered. Then Santyl was applied to the right outer ankle as ordered. Skin prep was then applied to the areas on the left outer leg, and right inner ankle. However, Santyl was ordered to be applied to both of those areas. In addition, Santyl was ordered to be applied to the left inner ankle however, this was not done as ordered. On 01-23-17 at 2:30 PM surveyor interview with the DON provided no additional information.

Based on closed record review, surveyor observation, review of facility policy and procedures, and facility staff interview, it was determined that the facility failed to maintain a safe environment and adequate supervision for a resident with exit seeking behavior and an attempted elopement. After the elopement of a cognitively impaired resident, the facility failed to develop and implement a quality assurance plan to maintain a safe environment for residents who are at risk for elopement. This finding was evident for 1 of 8 residents identified as at risk for elopement. (#1) An immediate jeopardy to residents' health and safety was determined by the State Office of Health Care Quality on 08-03-16 at 4:20 PM. The immediate jeopardy was abated on 08-03-16 at 9:15 PM following the facility's implementation of corrective actions to ensure the health and safety of all residents that are at risk for elopement. This finding is related to facility reported incident MD 322 and is valid. The findings include: On 08-03-16, surveyor review of the admission nursing assessment for resident #1 written on 03-18-16, revealed that resident #1 was alert and oriented to person and place with a moderate alteration of judgement/insight. There was no evidence of desire to leave , exit seeking, or wandering on the admission assessment. Review of the admission MDS (Minimum Data Set) assessment for resident #1 completed on 03-25-16, section C Cognitive Patterns revealed that resident #1 had a Brief Interview for Mental Status (BIMS) score of 5/15, indicating severe cognitive impairment. Additionally, the delirium assessment indicated that resident #1 had Inattention- easily distracted, out of touch or {had} difficulty following what was said and Disorganized thinking- rambling or irrelevant conversation, unclear or illogical flow of ides, or unpredictable switching from subject to subject. The assessment indicated that these behaviors were continuously present, does not fluctuate. The MDS is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and health problems to assist nursing home staff to provide appropriate care. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. Further review of the clinical record revealed a progress note on 03-31-16 that stated resident #1 wanted to leave, but could not formulate a plan. Surveyor review of a psychiatric consult on 04-01-16 revealed that resident #1 had impaired concentration, insight, and judgement. On 04-03-16, a progress note was written that revealed resident #1 had a social service assessment completed resulting in a BIMS (Brief Interview for Mental Status) score of 8. A BIMS score of 8/15 indicates moderate cognitive impairment. In addition, on 04-14-16, a care plan meeting note stated resident #1 really wants to return to a neighborhood that she is more comfortable with but that if given the chance to stay, she was ok with it for now. Surveyor review of resident #1's progress notes,written on 04-25-16 and on 04-27-16, as late entry notes for 04-25-16 revealed the following events on 04-25-16: 10:00 AM - the social worker heard resident #1 say she wanted her medicines in order to leave the facility 11:45 AM- resident #1 attempted to elope from the facility, but was stopped outside of the building by staff and returned inside with the social worker. The resident stated she wanted to smoke and was hungry. The social worker gave the resident two cigarettes and a sandwich, then took her outside to the smoking area. (There were no staff documented as present at the time in the area. This area is not secured and leads to the parking lot) 12:52 PM- nursing staff looking for resident to administer an anti anxiety medication and apply a wander guard bracelet but was unable to locate resident #1. As staff began to look for the resident, the activities director came to the nursing station to report she had just seen the resident at the bus stop as she was driving back to the facility after lunch. Law enforcement was called to report the elopement. 4:00 PM- the social worker called shelter where resident previously resided in an attempt to locate the resident, but was unsuccessful. Further review of the progress notes revealed a note written on 04-26-16 at 8:40 AM which stated the facility was notified that resident #1 was at a health clinic next to the shelter, and was safe. Resident #1 returned to the facility on [DATE]. The facility failed to maintain a safe environment and adequate supervision of resident #1 who had exit seeking behavior and an attempted elopement. After the elopement of resident #1, the facility failed to develop and implement an adequate quality assurance plan to maintain a safe environment for residents who are at risk for elopement. (Refer to F520) Surveyor interview on 08-03-16 at 3 PM with the administrator and DON (director of nursing) provided no additional information. b. On 08-03-16, review of the clinical record revealed that resident#1 had a smoking evaluation performed on 04-28-16 which revealed the resident was not a safe smoker and needed supervision to smoke. This evaluation was performed after a re-admission nursing assessment dated [DATE] revealed the resident was a current smoker. When a resident is admitted and is a smoker, they must be assessed for their ability to smoke safely. Further review revealed that resident #1 was initially admitted on [DATE]. Review of the admission assessment revealed that resident #1 was not a tobacco user and did not smoke. A smoking assessment was not performed at this time due to the admission assessment revealing the resident was not a tobacco user. A cognitive assessment was done by the social worker on 03-25-16 which revealed that resident #1 was cognitively impaired with a BIMS score of 5 out of 15. Resident #1 was also noted to have inattention and disorganized thinking on a continuous basis. However, on 04-01-16, the resident was seen by the psychiatric nurse practitioner who documented under social history that resident #1 was a current everyday smoker. In addition, resident #1 was also seen by a psychologist on 04-05-16 and 04-12-16, who also noted that resident #1 was a current everyday smoker. However, there was no evidence that a smoking assessment was performed on the initial admission due to the nursing assessment noting that resident #1 was not a smoker. Further review of the clinical record revealed that, on 04-25-16 when resident #1 had attempted to leave the facility and was returned by the social worker, the resident was provided 2 cigarettes and assisted to the smoking area. The resident was left in the smoking area unsupervised and noted to be socializing with other residents in the smoking area. Review of these notes revealed that resident #1 was a smoker prior to the readmission on 04-26-16. However, there is no evidence the resident was assessed for smoking safely while in the facility from 03-19-16 through 04-25-16. On 08-03-16 at 3 PM, interview with the ADON and administrator revealed they thought resident #1 had not smoked in the facility until that day 04-25-16 when she asked for 2 cigarettes to calm down. The resident was admitted with cognitive deficits, was not identified as a smoker by facility staff. Resident #1 was identified as a current smoker by both the psychiatrist and psychologist during the initial admission. The resident was given cigarettes and placed in the smoking area without supervision or any assessment of smoking safely on 04-25-16, the day the resident eloped from the facility. On return, 04-26-16, resident #1 was noted to be a current smoker, and a smoking evaluation was done. Resident #1 was deemed an unsafe smoker and could only smoke with supervision. However, on initial admission on 03-19-16 there was no evidence of a smoking evaluation being done. The resident was left alone to smoke on 04-25-16 , the day of elopement.