Every finding on record at Frederick Villa Healthcare

Based on record review and interview, it was determined that facility staff failed to implement a grievance process for their residents. This was evident for 1 (#8) of 6 residents reviewed for complaints.The finding include:MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A review of the facility's Grievance Policy dated 5/15/26 and last reviewed on 11/23/25 revealed that it was the policy of the facility that grievances could be received verbally and by telephone. Further review revealed that the policy was to document the receipt of the grievance, initiate investigations promptly, interview involved parties, review records, statements, evidence, to determine a resolution, and report it to the resident or family.On 8/4/26 at 10:35 AM a review of complaint #3046405 that was received on 6/17/26, revealed the complainant alleged that they had contacted the Nursing Home Administrator (NHA) regarding care concerns and maltreatment of Resident #8. The complainant stated that the NHA told them that he would address the grievances.A medical record review on 8/5/26 at 11:19 AM revealed a minimum data set with the assessment reference date of 6/10/26. A review of section C revealed the resident had no cognitive impairment.On 8/6/26 at 11:47 AM the grievance notebook was reviewed for 5/26, 6/26, and 7/26 and there was no grievance form completed regarding the complainant's concerns.There was no contact information provided for the complainant. There were 3 attempts to interview Resident #8 during the survey on 8/4/26 at 11:47 AM, 8/4/26 at 1:00 PM, and 8/5/26 at 11:12 AM with no success. An interview with the NHA on 8/7/26 at 12:21 PM revealed that when he receives complaints that he will handle them directly or if they involve specific discipline then he will complete a grievance form. When asked if he had received complaints regarding Resident #8, he stated that he had spoken to family on numerous occasions in 6/26. He stated that the concerns were mainly focused on the resident's discharge plan, but there may have been other concerns raised. Reviewed the concern that he had not followed the grievance policy. He stated that he wanted to check his files for documentation of the concerns and report back. On 8/7/26 at 12:53 PM the NHA reported back that he had not documented the concerns reported to him regarding Resident #8. He stated that he had addressed the concerns and the resident had no further complaints because he visited the resident frequently. However, he stated that he could not recall everything that was reported because he had not documented the concerns. He was unable to provide a rationale as to why he had not ensured that any person who reported care concerns regarding a resident was given the right to the grievance process.

Based on record review and interview, it was determined that facility staff failed to report an allegation of abuse to the State Agency (SA) within the required timeframe. This was evident for 1 (#2) of 1 resident review for an allegation of abuse.The findings include:On 8/7/26 at 11:45 AM a review of the facility's investigation file for facility reported incident #3037870 revealed the initial report form. According to the form the facility was notified by the Ombudsman on 6/8/26 at 12:00 PM of an abuse allegation for Resident #8. The allegation was that on 6/5/26 during the 11:00 PM - 7:00 AM shift the nursing assistant was rough with the resident. The allegation was reported to the State Agency on 6/8/26 at 1:57 PM. However, further review of the investigation revealed a statement written by Registered Nurse (RN) #15 on 6/8/26. According to the statement he had cared for the resident on 6/6/26 during the 3:00 PM - 11:00 PM shift and the resident's family member had reported this allegation of abuse to him. RN #15 wrote that he spoke with Certified Nursing Assistant (Aid) #16 and she reported to him that she had been in Resident #8 room and each time she had to move the resident to the middle of the bed to ensure the resident safety.An interview with RN #15 on 8/7/26 at 2:00 PM confirmed that he had received the allegation that Aid #16 was rough with Resident #8 during care and he failed to report it to Administration. On 8/7/26 at 1:29 PM an interview with the Director of Nursing (DON) revealed that RN #15 should have reported the allegation of abuse to her or the Nursing Home Administrator (NHA) immediately.The concerns were reviewed with the NHA on 8/7/26 at 2:15 PM.Cross Reference: F610

Based on record review and interview, it was determined that facility staff failed to ensure the safety of vulnerable residents and conduct a thorough investigation after an allegation of abuse. This was evident for 1 (#2) of 1 resident review for an allegation of abuse.The findings include:On 8/7/26 at 11:45 AM a review of the facility's investigation file for facility reported incident #3037870 revealed the initial report form. According to the form the facility was notified by the Ombudsman on 6/8/26 at 12:00 PM of an abuse allegation for Resident #8. The allegation was that on 6/5/26 during the 11:00 PM - 7:00 AM shift the nursing assistant was rough with the resident. The allegation was reported to the State Agency on 6/8/26 at 1:57 PM. A discipline form was included for Certified Nursing Assistant (Aid) #16 suspension on 6/8/26 until the allegation was investigated. However, further review of the investigation revealed a statement written by Registered Nurse (RN) #15 on 6/8/26. According to the statement he had cared for the resident on 6/6/26 during the 3:00 PM - 11:00 PM shift and the resident's family member had reported this allegation of abuse to him. RN #15 wrote that he spoke with Aid #16 and she reported to him that she had been in Resident #8 room and each time she had to move the resident to the middle of the bed to ensure the resident safety. A review of the final report form revealed the Nursing Home Administrator (NHA) was the investigator of this incident. Further review of the form revealed that he failed to determine that this allegation was reported to RN #15 on 6/6/26 and he failed to report it to him or the Director of Nursing immediately and that Aid #16 continued to care for vulnerable residents. A review of the resident interviews revealed that 4 residents were interviewed and not all the residents who had the same nursing assistant as Resident #8.On 8/7/26 at 5:00 PM a review of the assignment sheets revealed Aid #16 was not on duty on 6/5/26 on the 11:00 PM - 7:00 AM shift when Resident #8 alleged the abuse occurred. She was on duty on 6/7/26 during the 3:00 PM - 11:00 PM shift. It was unclear if the facility identified the correct Certified Nursing Assistant.An interview with RN #15 on 8/7/26 at 2:00 PM confirmed that Resident #8's family member reported an allegation that Aid #16 was rough with the resident during care. He stated that he talked to the resident and Aid #16 and that he felt that there was no abuse. He stated that he had not removed Aid #16 from resident care areas but asked her to stay out of Resident #8's room.On 8/7/26 at 1:29 PM an interview with the Director of Nursing (DON) revealed that she was unaware that RN #15 had received the allegation of abuse on 6/6/26 and failed to report it to her or the NHA. The NHA was interviewed on 8/7/26 at 2:15 PM and he confirmed that he had not determined that the allegation of abuse was not reported immediately to him or the DON on 6/6/26. When asked about the resident interviews, he stated that they choose a sample of residents and they do not interview or assess all the residents assigned to the staff member accused of abuse. The concerns were reviewed with him.Cross Reference: F609

Based on observations during tour and interview with facility staff, it was determined that the facility staff failed to ensure that resident medications and supplies. This was a single observation over an extended period on 1 of 3 units. The findings include: During initial tour of the facility at 8:05 AM on Lilly Lane, a treatment cart was identified as unlocked. This surveyor was able to go through the cart and identify wound care supplies for Resident #1. One unidentified staff member asked this surveyor if I needed any assistance. I stated who I was and the purpose for my visit. The cart remained unlocked. This surveyor continued to monitor the cart. At 8:07 AM this surveyor looked down at the end of the hall and saw a medication cart sitting in the middle of the hall with the drawer wide open with no staff around. This surveyor walked towards the open medication cart. From the right a staff member exited a resident room and as this surveyor was introducing herself, the yet unidentified staff member stated her name then stated what, you just going to stand there, what do you want me to say? I was wrong. This surveyor then asked if the treatment cart up the hall belonged to her and she stated, Have a nice day, bye.This surveyor proceeded up the hall and continued observations of the still unlocked treatment cart. At 8:11 AM, this staff now identified as RN#14, came up to the nursing station where the treatment cart was located, took her personal items and locked them up, passing the treatment cart twice in the process, never locking it. Continued observations of staff surrounding the treatment cart revealed; the morning breakfast cart was set up for morning delivery with staff standing there the entire time, the facility MDS coordinator was also seen passing by the cart at 8:20 AM along with multiple other aides yet no one made an attempt to lock the cart or notify a nurse to lock the cart.At 8:25 AM the facility DON came down the hall and introduced herself to the surveyor. The ongoing observations of the open medication cart in the middle of the unit and lack of response from RN #14 after it was directly brought to her attention 18 minutes earlier of the unlocked treatment cart was reviewed at this time and again prior to exit again with the DON and NHA.

Based the review of facility reported incidents (FRI) related to injuries of unknown origin and interview with staff, it was noted that vital signs documented for the incidents had been previously documented in the medical record and not reflective of the resident's current status, this was evident during the review of 2 of 6 facility reported incidents (FRI) (Resident #7, and Resident #1) Additionally, staff charted on a resident while they were in the hospital. This was evident for 1 of 1 (Resident #7).The findings include: 1. Review of the FRI and medial record of Resident #7 on 11:03 AM on 8/4/26 revealed a fall from the bed, resulting in multiple fractures, occurring on 7/3/26. A situation, background, assessment, and recommendation (SBAR) was completed on 7/3/26 at 12:34 PM for Resident #7 prior to being sent to the hospital. Directions on the SBAR include: 'at the time of the evaluation resident/patient vital signs were:' however, the documented assessment included vital signs from 6/17/26. Review of the FRI for Resident #1 on 8/5/26 at 7:03 AM revealed that an SBAR was completed on 7/20/26 at 1:28 PM and again on 7/20/26 at 4:17 PM related to an identified change in condition for a newly identified fracture. However, the vital signs documented on both SBAR's were from an assessment completed on 7/2/26.2. Continued review of the medical record for Resident #7 on 8/4/26 at 11:30 AM revealed that an updated wound care note was documented on 7/7/26. This note document that it was update from the wound care visit completed on 6/8/26. However, on 7/3/26, Resident #1 was sent out to the hospital and had not yet returned. The facility ADON was interviewed on 8/5/26 at 1:42 PM regarding his documentation and entry into Resident #7's medical record. He acknowledged entering the wound care note late and that he should have put 'late entry,' in addition to the resident not being in the facility at the time the entry was made.

Based on resident interviews, record review, reviews of other pertinent documentation, and staff interviews, it was determined that the facility failed to treat a resident who complained of severe pain resulting in harm to the resident. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey.The findings include:In an interview with Resident #1 and a family member on 05/04/26 at 11:07 am, Resident #1 complained of pain in the groin area. Resident #1 moaned in pain with any movement while seated during the interview. Resident #1's family member stated that Resident #1 is in constant pain and that the medications the staff are providing are not working.A review of Resident #1's clinical record on 05/04/2026 at 11:30 am revealed that on 11/25/25, Resident #1's physician gave orders to the nursing staff to administer the pain medication Tylenol, Oral Tablet, 325 mg, give 2 tablets by mouth, every 4 hours as needed for pain.A review of Resident #1's clinical record revealed a monthly progress note date 04/07/26 at 5:47 pm from Resident #1's attending physician (staff member #5) that Resident is requiring Morphine Sulfate ER (Extended Release) for their diagnosis of chronic pain. Resident #1's attending physician also indicated that Resident #1 has tried several other medications, including NSAIDS, OTCs, and topical pain relievers without any improvement. Resident #1's attending physician also indicated that he did not suspect any abuse or addiction and that he will constantly re-evaluate the need for this medication at each visit. The 04/07/26, 5:47 pm progress note indicated Resident #1 had declined an assessment of their groin area.In an interview with the Resident #1's attending physician on 05/04/26 at 12:17 pm, Resident #1's attending physician stated that he was just contacted by the nursing staff 10 minutes ago about Resident #1's pain management and that currently Resident #1 had no complaints of pain. Resident #1's attending physician stated that the nursing staff were applying an ointment to the resident's genitals approximately a month ago. Resident #1's attending physician stated that Resident #1 was admitted to the hospital in December 2025 and has chronic infections (cellulitis) of the genitals. Resident #1 also has a history of genitalcellulitis. Resident #1's physician stated that he just gave orders to the nursing staff that included: to wash resident #1's groin area three times a day with soap and water, administer an antibiotic orally daily for 7 days, and to apply a topical ointment to Resident #1's genitalia for 7 days.A review of the facility Pain Management Policy on 05/04/26 revealed that all residents will receive individualized pain management using both pharmacological and non-pharmacological interventions. Pain will be assessed, treated, monitored and documented consistently. Assessment requirements included the nursing staff will perform a pain assessment upon admission, quarterly, and with significant change and post-intervention. The staff will use standardized pain scales appropriate to a resident's cognitive status. The nursing staff will assess location, intensity, duration, quality, and impact on function. Administer medications per provider orders, including PRN (as needed). Residents receiving PRN pain medications will document effectiveness and side effects. Pain management will be care planned and incorporated into the interdisciplinary care plan. The nursing staff are to document a pain assessment, interventions, response and follow-up including refusal, adverse reactions and provider communication.Further review of Resident #1's clinical record revealed a nursing progress note (written by RN#3) dated 05/02/25 at 3:25 pm that indicated Resident #1 was complaining of severe chronic pain in the groin / genital area with a pain of 10/10 on pain scale (1-10). On assessment Resident #1's genitals noted to be swollen, tender to touch. RN#3 documented the medication podofilox 0.5% gel had been applied as per physician order. Podofilox 0.5% gel is a prescription topical medicine used to treat external genital and perianal warts caused by Human papillomavirus (HPV). The medication works by destroying wart tissue. Common reactions include burning, stinging, inflammation, itching, pain, and skin redness. RN#3 documented that Resident #1's pain was reassessed and his pain was still noted to be 10/10 after application of topical gel. RN#3's nursing progress note indicated the facility nursing supervisor was notified who reached out to Resident #1's provider/physician. A new verbal telephone order was received on 05/02/26 at 4:09 pm that instructed the nursing staff to apply Lidocaine External Cream, 4% cream, to Resident #1's genitals, topically, one time a day. Lidocaine External Cream is used on different parts of the body to cause numbness or loss of feeling for patients having certain medical procedures. Lidocaine skin patch is used to relieve nerve pain caused by herpes zoster or shingles (postherpetic neuralgia). Lidocaine belongs to the family of medicines called local anesthetics. This medicine prevents pain by blocking the signals at the nerve endings in the skin.In an interview with RN#3 on 05/05/26 at 1:10 pm, RN#3 stated that he recalled taking care of Resident #1 on 05/02/26. RN#3 stated that Resident #1 was complaining of 10/10 pain on 05/02/26. RN#3 stated that he administered Resident #1's morning dose of Morphine 15 mg orally during the morning as ordered. RN#3 stated that he applied the Podofilox 0.5% gel to Resident #1's genitalia . RN#3 stated that Resident #1's genitalia was observed on 05/02/26 and noted to be swollen and without any open areas. RN#3 stated Resident #1's physician was notified who ordered the Lidocaine gel to be applied. RN#3 confirmed that a dose of Lidocaine gel was not administered on 05/02/26 because it had not been delivered from the pharmacy. RN#3 stated that he administered a dose of Tylenol to Resident #1 at 2 pm on 05/02/26. A review of Resident #1's May 2026 medication administration record (MAR) on 05/05/26 at 1:30 pm failed to reveal any documentation Resident #1 was administered a PRN dose of Tylenol for pain between 05/01/26 thru 05/04/26 at 11 am. In an interview with the facility dispensing pharmacist on 05/05/26 at 11:47 am, the dispensing pharmacist confirmed a physician's order that Resident #1 was receiving regular Morphine 15 mg, orally, twice a day and not extended release (long acting) Morphine. The dispensing pharmacist confirmed the use for the Podofilox 0.5% gel was for use to the affected areas (warts) only and that the medication was not a pain-relieving medication.In an interview with the facility director of nurses (DON) on 05/04/26 at 12 noon, the DON stated that the expectation for managing a resident's pain includes the nursing staff completing a pain assessment, using a 0 - 10 pain scale, documenting a pain scale number every shift, documenting non-pharmacological interventions used to help a resident's pain, if the resident is receiving a PRN pain medication, a pre and post administration assessment will be documented using the pain scale.In an interview with the facility Regional Clinical Nurse Educator on 05/04/26 at 1:20 PM, Employee #5 stated the expectation for the nursing staff is to document a change in condition progress note, conduct a new pain assessment, document if resident is being assessed with a verbal or non-verbal pain scale by documenting a 0 - 10 scale (0 = no pain, 10 = the worst pain). The nurse surveyor indicated that the nursing staff were just signing off a pain assessment that was completed every shift but there was no documentation of a pain scale being utilized. The Nurse Educator reviewed Resident #1's medication administration record and confirmed that the nursing had not been documenting a numerical pain scale. The Nurse Educator stated that when the physician's order to perform a pain evaluation every shift was placed into the system on 11/25/25, the nurse did not include the supplemental documentation tab in the computer. The Nurse Educator indicated this would only allow the nursing staff to sign off the physician order for the pain assessment but there would be no documentation of Resident #1's verbal or non-verbal response to the pain assessment question.

Based on complaint, reviews of clinical records and all pertinent administrative records, and staff interview, it was determined that the facility staff failed to promptly notify the ordering physician or clinical practitioner of a laboratory result. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey.The findings include:During the start of the complaint survey at the facility on 05/04/26 at 11:07 am, the facility administrator escorted Resident #1 and their family member to the facility conference room and introduced them to the nurse surveyor. An interview with Resident #1 then proceeded. During a private interview with Resident #1 and their family member, Resident #1 and their family member brought a complaint against the facility indicating that Resident #1 was complaining of continuous pain in the groin area and the facility staff were not providing quality of care to Resident #1.During a review of Resident #1's clinical record on 05/04/26, Resident #1's attending physician assessed Resident #1 on 04/07/26 at 5:47 PM and noted Resident #1 was complaining of discomfort during urination. Resident #1's attending physician also documented that Resident #1 declined to have a genitourinary examination at that time and that Resident #1 was to be seen by an Infectious Disease Doctor in May 2026 (May 4, 2026, at 9:30 am). Resident #1's attending physician's plan included orders to obtain a urinalysis and a urine culture.Further review of Resident #1's chart revealed the nursing staff obtained a urine sample and sent the specimen to the lab on 04/08/26. On 04/08/26 at 9:53 am, the facility laboratory forwarded the results of Resident #1's urinalysis. The urinalysis report noted abnormal findings. Upon the results being reported to Resident #1's attending physician on 04/08/26 at 9:26 PM, Resident #1's attending physician gave new orders to the nursing staff to administer the antibiotic Ciprofloxacin, 250 mg, orally, twice daily, for 7 days due to Cystitis (bladder infection). Resident #1 received the first dose of Ciprofloxacin on 04/08/26.On 04/11/26 at 10:01 am, the facility laboratory forwarded the results of Resident #1's urine culture. The urine culture report noted abnormal findings that included the antibiotic Ciprofloxacin that was resistant to the organism identified in Resident #1's 04/11/26 urine culture results.Further review of Resident #1's clinical record revealed a nursing progress note dated 04/13/26 at 11:04 am indicating Resident #1's attending physician was made aware of Resident #1's urine culture results. At 2 pm on 04/13/26, Resident #1's attending physician discontinued the antibiotic Ciprofloxacin and initiated the antibiotic Keflex, 500 mg, orally, twice a day for 7 days due to a urinary tract infection. Resident #1 received an additional 4 doses of the antibiotic Ciprofloxacin (4/11 - 9 pm dose, 4/12 - 9 am and 9 pm doses, and 4/13 - 9 am dose) after the facility was notified by the facility laboratory on 04/11/26 at 10:01 am that the organism identified in the urine culture was resistant to the antibiotic Ciprofloxacin. Resident #1 received the first dose of Keflex 500 mg orally on 04/13/16 at 9 pm.Cross reference to F 697

Based on complaint, reviews of a clinical record and all pertinent documentation, and staff interview, it was determined that the facility failed to follow a physician's order to obtain a timely infectious disease and urology consult. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey. The findings include: 1) In an interview with Resident #1 and a family member on 05/04/26 at 11:07 am, Resident #1 complained of pain in his groin area. Resident moaned in pain with any movement while seated during the interview. Resident #1's family member stated that Resident #1 is in constant pain and that the medications the staff are providing are not working.A review of Resident #1's clinical record on 05/04/2026 at 11:30 am revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that are not limited to: dementia with behavioral disturbance, a stroke with right sided weakness, Immunodeficiency disease, chronic pain syndrome, papillomavirus, expressive aphasia, and genital herpes. On 03/17/26, Resident #1's physician gave an order for Resident #1 be seen by one of the local infectious disease physicians in the community. An appointment of 05/04/26 at 9:30 AM was obtained for Resident #1. On 03/19/26 the facility staff conducted a BIMS test on Resident #1 and determined that Resident #1 had a score of 3/15 which indicated severe cognitive impairment.A review of Resident #1's clinical record on 05/04/26 at 12 noon revealed that the infectious disease physician appointment for 9:30 am this morning had been cancelled and needed to be rescheduled.In an interview with Staff Person #12 at the infectious disease physician's office on 05/04/26 at 3:48 pm, Staff Person #12 indicated a staff member from the facility called and cancelled Resident #1's appointment at 8:16 am this morning due to the facility of not being able to send a staff member (CNA) with Resident #1. Staff Person #12 was also informed by the facility staff member that Resident #1 could not go to an appointment without a staff member (CNA).In an interview with the facility scheduler (Staff Member #4) on 05/04/26 at 4:13 pm, Staff Member #4 confirmed cancelling Resident #1's infectious disease physician appointment this morning (05/04/26). Staff Member #4 stated that there was not an available nursing aide to go with Resident #1 to the physician appointment.2) Review of Resident #1's clinical record on 05/04/26 at 12 noon revealed a physician's order dated 12/02/25 instructing the nursing staff to Schedule a urology consult to follow up regarding the diagnoses of penile cellulitis, and chronic HSV (Herpes simplex virus) infection with condyloma acuminata (commonly known as genital warts).In an interview with the facility scheduler (Staff Member #4) on 05/04/26 at 4:13 pm, Staff Member #4 stated that Resident #1 was seen by a urologist while in the hospital in early November 2025 and that it was decided then that Resident #1's genitourinary issues were not of a urological concern. Staff Member #4 was unable to produce any urology consult progress notes or state why the physician's order for a urologist had not been discontinued by Resident #1's attending physician.Cross reference to F 697

Based on complaint, reviews of a clinical record and all pertinent documents, and interviews with facility staff, it was determined that the nursing staff failed to 1) follow the physician ordered parameters when documenting a resident's lung sounds every shift, and 2) obtain a resident's pacemaker check every shift for proper functioning. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey. The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. In an interview with Resident #1 and a family member on 05/04/26 at 11:07 am, Resident #1 complained of pain in his groin area. Resident #1's family member stated that Resident #1 is in constant pain and that the medications the staff are providing are not working.A review of Resident #1's clinical record on 05/04/26 at 12 noon revealed the following 2 physician orders:1) On 11/25/25 at 12 noon, please document lung sounds once a day 1 = clear 2 =rales 3 = rhonchi4 = wheezing, one time daily for monitoring. 2) On 11/25/25, obtain a Pacemaker Check every shift for proper functioning. A review of Resident #1's April and May 2026 medication administration records (MAR) and treatment administration records (TAR) on 05/04/26 at 12 noon revealed that nursing staff are only signing off (initialing) that both lung checks and a pacemaker check had been completed. The nursing staff are not following the physician parameters for lung sounds nor obtaining a result that Resident #1's pacemaker is still functioning appropriately daily. In an interview with the facility director of nurses (DON) and the regional clinical educator on 05/04/26 at 1:20 pm, the regional clinical educator stated that Resident #1 goes out to the cardiologist's office to have his pacemaker checked. They have the equipment to perform the test there. We do not use the telephone method to check Resident #1's pacemaker function. Resident #1 had his pacemaker last checked in July 2025 and has a current appointment on 05/13/26 to have the pacemaker rechecked.

Based on complaint, reviews of a clinical record and all pertinent documentation, and staff interviews, it was determined that the facility failed to obtain the staff needed to escort a resident to an outside physician's office visit. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey. The findings include: In an interview with Resident #1 and a family member on 05/04/26 at 11:07 am, Resident #1 complained of pain in his groin area. Resident moaned in pain with any movement while seated during the interview. Resident #1's family member stated that Resident #1 is in constant pain and that the medications the staff are providing are not working.A review of Resident #1's clinical record on 05/04/2026 at 11:30 am revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that are not limited to: dementia with behavioral disturbance, a stroke with right sided weakness, Immunodeficiency disease, chronic pain syndrome, papillomavirus, expressive aphasia, and genital herpes. On 03/17/26, Resident #1's physician gave an order for Resident #1 be seen by one of the local infectious disease physicians in the community. An appointment of 05/04/26 at 9:30 AM was obtained for Resident #1. On 03/19/26 the facility staff conducted a BIMS test on Resident #1 and determined that Resident #1 had a score of 3/15 which indicated severe cognitive impairment.Further review of Resident #1's clinical record on 05/04/26 at 12 noon revealed that the infectious disease physician appointment for 9:30 am this morning had been cancelled and needed to be rescheduled.In an interview with Staff Person #12 at the infectious disease physician's office on 05/04/26 at 3:48 pm, Staff Person #12 indicated a staff member from the facility called and cancelled Resident #1's appointment at 8:16 am this morning due to the facility of not being able to send a staff member (CNA) with Resident #1. Staff Person #12 was also informed by the facility staff member that Resident #1 could not go to an appointment without a staff member (CNA).In an interview with the facility scheduler (Staff Member #4) on 05/04/26 at 4:13 pm, Staff Member #4 confirmed cancelling Resident #1's infectious disease physician appointment this morning (05/04/26). Staff Member #4 stated that there was not an available nursing aide to go with Resident #1 to the physician appointment.Cross reference to F 697

Based on record review and interview, it was determined that the facility failed to ensure the baseline care plan reflected the resident's current medications at the time of admission. This was evident for 1 (Resident #10) out of 10 residents reviewed during the complaint survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive.Xarelto is an anticoagulant (blood thinner) medication used to prevent blood clots and lower the risk of stroke.Eliquis is an anticoagulant (blood thinner) medication used to lower the risk of blood clots and stroke in certain heart conditions.On 03/19/2026 at 9:37 AM, review of Resident #10's clinical record revealed that he/she was admitted to the facility on [DATE] with diagnoses including, but not limited to, ST elevation myocardial infarction (STEMI), congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. Review of Resident #10's hospital Discharge summary dated [DATE] revealed a hospital course note that stated the resident was changed from Eliquis to Xarelto and was started on a loading dose of Xarelto 15mg twice daily on 12/7/2025 with a planned transition to Xarelto 20mg daily on 12/29/2025. Review of Resident #10's physician orders revealed anticoagulant medication (Xarelto) was ordered upon admission to the facility.Review of Resident #10's baseline care plan dated 12/10/2025 revealed the plan did not include anticoagulant medication as part of the resident's current medications and did not include a care plan addressing anticoagulant therapy.On 03/23/2026 at 1:02 PM, an interview with the Director of Nursing (DON) confirmed that Resident #10 was taking anticoagulant medication (Xarelto) at the time of admission and that his/her baseline care plan did not include a plan to address anticoagulant therapy. The DON stated that Resident #10's anticoagulant medication should have been included in the baseline care plan.

Based on medical record review and interview, it was determined that the facility staff failed to develop a comprehensive person-centered care plan for a resident with extensive pressure ulcers. This was evident for 1 (Resident #5) of 2 residents reviewed for pressure ulcers during a complaint survey.The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.A pressure ulcer, also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III ( full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full-thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed).A wound vacuum (wound vac) is a specialized medical device used in negative-pressure wound therapy. It applies gentle, consistent suction to the wound bed which reduces swelling, drains excess fluids, removes debris, and promotes blood flow, often allowing patients to heal faster with fewer dressing changes. On 3/17/26 at 11:45 AM a review of Resident #5's medical record was conducted and revealed Resident #5 was admitted to the facility in November 2025 with diagnoses that included, but were not limited to, paraplegia due to a motor vehicle accident, stage 4 pressure ulcers to the left buttock, sacral region, and left ankle, local infection of the skin and subcutaneous tissue, and unspecified severe protein-calorie malnutrition. Review of Resident #5's medical record revealed a care plan, has pressure ulcer of the sacral area, and on posterior left leg, right heel, and diabetic ulcer on left ankle r/t (related to) impaired mobility with a date created and initiated on 11/18/25. The goal on the care plan was, will be free for signs of infection and improve by next review date. The interventions on the care plan were, carefully dry between toes but do not apply lotion between toes; position resident off affected area; change position every 2 hours and PRN; WOUND/DRESSING: as Order. Observe dressing (SPECIFY FREQ). Change dressing and record observations of site (SPECIFY FREQ). The care plan for Resident #5 who was admitted to the facility with Stage IV pressure ulcers was not comprehensive or resident centered. The care plan did not specify the wound/dressings or state the frequency. The care plan failed to document interventions for how to prevent further worsening of the heels, such as elevating heels and heel boots. There was nothing mentioned about the wound vac that was ordered for the resident to promote wound healing. There was nothing about monitoring for an intact seal, assessing for infection, bleeding, or fluid leakage. There was nothing about the type of mattress the resident should have been lying on.On 3/23/26 at 10:16 AM the pressure ulcer care plan for Resident #5 was reviewed with the Director of Nursing (DON). The DON was asked if she expected other interventions to be on the care plan and she acknowledged that the care plan was not comprehensive for the type of pressure wounds that the resident had when admitted to the facility.

Based on medical record review and staff interview, it was determined the facility failed to administer an antibiotic for an infection as prescribed in the discharge instructions from the hospital. This was evident for 1 (Resident #6) of 10 residents reviewed during a complaint survey.The findings include:On 3/18/26 at 8:38 AM a review of Resident #6's medical record was conducted and revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side. Review of the 1/5/26 hospital discharge summary documented that Resident #6 was diagnosed with a urinary tract infection while in the hospital and was started on an antibiotic. The discharge summary also had a list of medications that were prescribed to Resident #6 upon discharge. Resident #6 was to continue Amoxicillin 500 mg. 3 times a day for 5 additional days.Review of Resident #6's January 2026 Medication Administration Record (MAR) failed to produce evidence that the Amoxicillin was administered to Resident #6 upon admission to the facility.On 3/19/26 at 12:07 PM the Director of Nursing (DON) was interviewed about the missed antibiotic. The DON stated that she reviewed the discharge summary and that the resident received the antibiotic in the hospital. The DON was shown the discharge summary where it documented the Amoxicillin was to continue for an additional 5 days.On 3/20/26 at 9:48 AM Staff #7 was interviewed and reviewed the January 2026 MAR along with the discharge summary. Staff #7 stated our process is when we get a new admission we do a second day chart check to make sure we got everything. I believe it was missed.On 3/20/26 at 1:30 PM the concern was discussed with the DON. The DON confirmed the error and stated they were already looking at their admission process.

Based on record review and staff interview, it was determined that the facility failed to ensure residents remained free from significant medication errors. This was evident for 1 (Resident #10) out of 10 residents reviewed during the complaint survey. The findings include:Xarelto is an anticoagulant (blood thinner) used to prevent blood clots and lower the risk of stroke.Eliquis is an anticoagulant (blood thinner) used to lower the risk of blood clots and stroke in certain heart conditions.On 03/19/2026 at 9:37 AM, Resident #10's clinical record was reviewed to reveal the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, ST elevation myocardial infarction (STEMI), congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. Review of Resident #10's hospital Discharge summary dated [DATE] revealed a hospital course note that stated the resident was changed from Eliquis to Xarelto and was started on a loading dose of Xarelto 15mg twice daily on 12/7/2025 with a planned transition to Xarelto 20mg daily on 12/29/2025. Review of Resident #10's December 2025 physican orders revealed Xarelto was ordered upon admission. The record also revealed multiple Eliquis orders were entered and discontinued on 12/10/2025, 12/11/2025 and 12/15/2025.On 03/19/2026 at 12:07 PM, an interview with the Director Of Nursing (DON) revealed that Resident #10's Eliquis order was stopped and restarted to change the indication from DVT (deep vein thrombosis) to A-fib (atrial fibrillation).On 03/19/2026 at 3:12 PM, an interview with Licensed Practical Nurse (LPN) Supervisor #17 revealed that he was the supervisor when Resident #10 was admitted and that Eliquis orders dated 12/10/2025, 12/11/2025 and 12/15/2025 were created by the pharmacy. LPN Supervisor #17 confirmed the orders were verified after contacting the provider but could not explain the why the Eliquis orders were created for Resident #10.Review of Resident #10's December 2025 medication administration record (MAR) revealed that Resident #10 received Eliquis 5mg on 12/16/2025 during the 9:00 AM medication administration while also receiving Xarelto 15mg as ordered. The administration of both anticoagulant medications increased Resident #10's risk for bleeding.On 03/20/2026 at 9:12 AM, an interview with Registered Nurse (RN) #7 revealed that he was the Unit Manager when Resident #10 was admitted in December 2025 and was responsible for reviewing resident orders. RN #7 stated that Resident #10 was supposed to be on Xarelto per hospital discharge orders and identified that Eliquis orders were entered in error on 12/10/25, 12/11/25 and 12/15/25. RN #7 contacted the provider to verify the correct Xarelto order and discontinued the Eliquis order each time. RN #7 could not explain why the Eliquis orders for Resident #10 continued to appear on the MAR.On 03/20/2026 at 11:22 AM, an interview with LPN #18 revealed that she administered Eliquis 5mg to Resident #10 on 12/16/2025 during the 9:00 AM medication administration along with Xarelto, as evidenced by documentation in the MAR. On 3/20/2026 at 2:15 PM, an interview with the DON confirmed that Resident #10 should have remained on Xarelto per hospital discharge orders and not Eliquis. The DON stated that she would follow up to determine why Eliquis was ordered.On 3/23/2026 at 10:17 AM, during a follow up interview, the DON reviewed Resident #10's December 2025 MAR and confirmed that on 12/16/2025, the resident received both Xarelto and Eliquis during the 9 AM medication administration.The findings were discussed with the Director of Nursing, Administrator and the Regional Director of Clinical Operations at the time of exit conference.

Based on medical record review, complaint review, and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Resident #5, #4) of 10 residents reviewed during a complaint survey.The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.1a)On 3/17/26 at 11:45 AM a review of Resident #5's medical record was conducted and revealed Resident #5 was admitted to the facility in November 2025 with diagnoses that included, but were not limited to, paraplegia due to a motor vehicle accident, stage 4 pressure ulcers to the left buttock, sacral region, and left ankle, local infection of the skin and subcutaneous tissue, and unspecified severe protein-calorie malnutrition.Review of Resident #5's medical record revealed the resident was seen weekly by the wound care physician/wound care nurse. Initially, the only wound notes in the medical record for wounds were dated 11/21/25, 11/29/25, and 2/12/26.On 3/20/26 at 8:33 AM an interview was conducted with the Wound Care Nurse Practitioner, Staff #21 who stated she has worked at the facility since December 2025. Staff #21 stated that they changed systems in December 2025 which went from wound expert to doc now. Staff #21 stated it did not look like any of the wound expert notes pulled into PCC (electronic medical record system) from doc now. Staff #21 stated that she would let their office manager know so she could send the notes over to the facility. Staff #21 was able to show the surveyor the weekly visits in her computer system.After interview with Staff #21, the Director of Nursing (DON) was interviewed and gave the surveyor the wound care notes that were printed off for dates of service 12/12/25, 12/19/25, and 12/26/25. The DON confirmed the notes were not initially in the medical record.1b) Review of Resident #5's medical record revealed a 2/18/26 change in condition note that documented Resident #5 was sent to the hospital for hypotension and critical labs. The vital sign section of the form documented the respiratory rate was 18 and the oxygen saturation was 97 percent on room air. There was no documentation of trouble breathing on the change in condition form or on the hospital transfer form. However, review of the hospital emergency room documentation dated 2/18/26 documented patient also reports some shortness of breath. The note documented on 2/18/26 at 14:45 the resident was on a non-rebreather mask receiving oxygen at 15 liters a minute. On 3/20/26 at 9:04 AM an interview was conducted with Staff #7 who stated he was the RN that sent the resident to the hospital. Staff #7 stated the resident was having respiratory issues and that the blood work was abnormal and the hematocrit and hemoglobin was low. Staff #7 stated that normally the resident would reject being sent to the hospital for a blood transfusion but this time the resident was having respiratory issues, so the physician wanted the resident sent out. Staff #7 confirmed that he failed to document that the resident had respiratory issues prior to being sent out. On 3/20/26 at 11:28 AM an interview was conducted with the DON about the documentation not reflecting the resident's condition. The DON agreed that the nurses needed to expand on the change in condition form as to what was actually going on with the resident and that they would need to educate the staff.1c) Review of geriatric nursing assistant (GNA) tasks for bowel movements for Resident #5 documented bowel movements were monitored every day that the resident was in the facility in December 2025, January 2026, and February 2026. There were, however, some blank spaces for some of the shifts. It was also noted that Resident #5 had a colostomy and was ordered to have bowel movements monitored every shift for output. A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall, bringing a portion of the large intestine to the surface to allow stool to exit the body into an attached, replaceable bag.Review of the December 2025 GNA task record for bowel movements was blank for the 7:00 AM to 3:00 PM shift on 12/9/25, 12/13/25, and on the 3:00 PM to 11:00 PM shift on 12/20/25, 12/21/25, and 12/28/25. Review of the January 2026 GNA task record for bowel movements was blank for the 7:00 AM to 3:00 PM shift on 1/11/26, and the February 2026 record was blank on the 11:00 PM to 7:00 AM shift on 2/6/26 and 2/9/26. On 3/20/26 at 11:28 AM an interview was conducted with the DON who stated, if it was not signed off it was not done.1d) Review of complaint 2790378 alleged that Resident #5 could not keep any food down. Review of nursing progress notes and change in condition forms did not reveal that Resident #5 had any nausea or vomiting.Review of February 2026 physician's orders for Resident #5 revealed the order Ondansetron 4 mg. to be given every 8 hours as needed for nausea and emesis (vomiting) on 2/16/26 at 1831 (6:31 PM). On 3/19/26 at 8:56 AM Staff #12 was interviewed about Resident #5 and stated that Resident #5 did vomit one morning, and they gave him/her something and he/she was able to eat lunch.On 3/19/26 at 9:25 AM physician #14 was interviewed and stated that Resident #5 did vomit but never told anyone and I did not find out about it until several days later, but I don't remember any of the details about it. There was no documentation in the medical record that Resident #5 had nausea or vomited.On 3/20/26 at 11:28 AM an interview was conducted with the DON. Informed the DON that there was no documentation of Resident #5 having nausea and/or vomiting, however an order was written for Ondansetron (anti-nausea medication). The DON stated that the nurses needed to expand more on their documentation.1e) Review of complaint 2790378 alleged that the facility failed to hold mandated care plan meetings. Review of Resident #5's medical record revealed a letter that invited the family to a care plan meeting on 2/11/26, however there was no documentation in the medical record that validated that the meeting took place.On 3/23/26 at 9:58 AM an interview was conducted with the Regional Social Worker, Staff #25, who was able to provide an attendance record of the meeting. Staff #25 did confirm there were no social work notes in the medical record, and the meeting should have been documented in the assessment section of the medical record that day.2)On 3/23/26 at 11:11 AM a review of Resident #4's medical record was conducted and revealed Resident #4 was admitted to the facility on [DATE]. Review of the medical record failed to produce documentation that a care plan meeting was held with the resident after admission. Review of the miscellaneous section of the electronic medical record (Emr) revealed there was a care plan invitation letter for a care plan meeting for 1/21/26, however there was nothing noted for October 2025 or November 2025.On 3/23/26 at 12:54 PM an interview was conducted with Staff #25, who validated that there was no documentation related to the care plan meeting after admission. Staff #25 stated she could only find the meeting notes from the care plan meeting that took place on 1/21/26. Staff #25 stated that the facility changed the policy after they found the issue of care plan notes that had not been put into the medical record. She stated that the current social worker was out, and they could not find any of the notes.On 3/23/26 the Nursing Home Administrator and the DON were informed of the documentation concerns at the exit conference.

Based on facility documentation and an interview, it was determined that the facility failed to have a qualified Infection Preventionist (IP). This failure has the potential to affect all residents in the facility.The findings include:An Infection Preventionist is responsible for assessing, developing, implementing, and monitoring a facility's Infection Prevention and Control Program to prevent and control infections.During an interview with the Director of Nursing (DON) on 8/26/25 at 12:38 PM, the DON stated that Staff #29 (regional Assistant Director of Nursing and Infection Preventionist) was collaborating as the IP for the facility. The DON clarified that until she completes IP training, Staff #29 is a resource person who comes to the facility once a month.A phone interview was conducted with Staff #29 on 8/26/2025 at 1:12 PM. She confirmed that she is an employee of a regional company and is working as a resource person to cover the vacancy of a qualified IP. She started this role at the end of March 2025. Staff #29 stated that she comes to the facility once a month and is available when the current DON needs help.In an interview with the DON and the Nursing Home Administrator (NHA) on 8/27/25 at 7:30 AM, the DON confirmed that the facility failed to have an IP onsite.

Based on review of complaint 337259 and the facility's pest problem logs and interview with facility staff, it was determined that the facility failed to maintain an effective pest control program. This deficient practice had the potential to impact all residents.The findings include:Review of complaint 337259 on 8/25/25 at 12:13 PM revealed that the facility was infested with roaches and rodents.The surveyor requested the facility's pest logs from 2025 on 8/27/25 at 7:42 AM. Review of the Pest Problem Log on 8/27/25 at 9:42 AM revealed the following entries in patient care areas:11/13/24 room [ROOM NUMBER]: roaches, mice11/13/24 room [ROOM NUMBER]: roaches, mice1/21/25 room [ROOM NUMBER]: roaches2/6/25 Medication room [ROOM NUMBER], 2, 3: ants, roaches, mice, mice droppings4/21/25 Rooms 118, 115, 120, 116, 117: roaches4/21/25 Rooms 217-220: roaches, mice4/22/25 Rooms 105, 106, 111, 112: roaches4/23/25 Break room: ants4/25/25 Front area: roaches5/2/25 Rooms: 207-209: water bugs5/2/25 Rooms: 100, 109: mice5/15/25 Rooms 204: spiders5/20/25 Unit 3 nurse's station: ants 5/20/25 room [ROOM NUMBER]: roaches 5/25/25 Rooms 211, 220: ants5/26/25 room [ROOM NUMBER]: bugs5/27/25 room [ROOM NUMBER]: bugs5/29/25 Rooms 211, 220: ants5/31/25 room [ROOM NUMBER]: spiders5/31/25 room [ROOM NUMBER]: ants6/1/25 room [ROOM NUMBER]: spiders6/1/25 room [ROOM NUMBER]: roaches 6/2/25 room [ROOM NUMBER]: spiders6/2/25 Rehab: roaches6/4/25 Rooms 102, 104, 106: ants, roaches6/4/25 room [ROOM NUMBER]-120: ants, roaches6/24/25 Laundry room: roaches7/16/25 Conference room: roaches, mice8/6/25 Rooms 202, 208, 314, 315: roaches, mice8/6/25 room [ROOM NUMBER]: roaches, mice8/6/25 Shower rooms 1, 2, 3: ants, roaches, mice8/8/25 room [ROOM NUMBER]: gnats8/12/25 room [ROOM NUMBER]: flies, gnats8/15/25 room [ROOM NUMBER]: flies On 8/27/25 at 8:21 AM in an interview with the Nursing Home Administrator (NHA) when asked if he has seen roaches and rodents in the facility he stated, Yes, we live in the state of Maryland and so I have seen roaches and rodents in the facility. We do have a pest management company. On 8/27/25 at 9:16 AM in an interview with the NHA, the surveyor shared the concerns that there was a complaint filed regarding the roaches and rodents, that the logs show sightings of roaches and rodents, and that he verified and confirmed that there are roaches and rodents in the facility. During the interview, the NHA stated this building was an old building and being surrounded by woods and water, it was a continuous effort to keep the pests and rodents out of the building. The surveyor shared this issue was a concern and the NHA stated, sure, I understand.

Based on a review of resident medical records, and interviews with facility staff, it was determined that the facility failed to: 1) review and revise the resident's care plan as required, 2) hold or document interdisciplinary team care plan meetings at the time of quarterly revisions, and 3) to ensure participation in the care planning process by the required interdisciplinary team (IDT) members. This was evident for 7 (Resident #10, #74, #8, #13, #15, #68, and #130) of 34 residents reviewed during the investigation phase of the facility's recertification/complaint survey. The findings included: Care plans are developed to guide the care residents receive and must be created within seven days of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). An interdisciplinary team, including the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (when practicable), is required to develop and revise these plans. 1) On 08/19/2025 at 12:01 PM, Resident #10 reported to the surveyor that I have a broken tooth and its hurting. I have a few broken teeth. I have been seen by a dentist, and they said I might have to get some of the teeth pulled out. It's been about 2 years since I've seen the dentist. On 08/20/2025 at 1:20 PM, in an interview with Staff #12, she explained that she was responsible for scheduling resident's appointments and if a consult or referral was recommended while the resident was in the facility, the doctors would give the nurse an order- then order goes to medical records, then she would schedule the appointment. For residents with dental concerns, if they have Medicaid the dental insurance Medicaid will cover dental, if they had no dental insurance facility will pick up the cost. She stated that the dentist that comes into the facility, if asked to see a resident the dentist will see them no matter their insurance. For tooth aches the dentist will see and make recommendations usually in the middle of the month.Staff #12 was asked if she was aware of any dental concerns for Resident #10 and if the resident had any scheduled dentist appointment and she stated that she was not aware of any dental appointment for Resident #10. On 08/20/2025 at 2:06 PM, a review of Resident #10's dental exam completed on 9/21/2024 revealed that the resident presented with missing restoration on tooth #30 with poor restorability and mobility on tooth #12 and #13. Referral Date: September 21, 2024. Reason For Referral: Extraction tooth #30, #12 and #13. On 08/20/2025 at 2:13 PM, a review of the 10/3/2024 progress notes in Resident #10's chart revealed that the resident had a referral for dental consult at the University of Maryland Medical Center, for oral and maxillofacial surgery and for extraction of tooth #30, #12 and #13. The note stated that the medical records department was contacted for follow up. The Physician and resident were both informed. On 08/20/2025 at approximately 5:58 PM, a review of the resident care plan revealed that the facility failed to review and update the care plan at least quarterly. The dental care plan was initiated on 12/01/2023 and it stated the resident will be free of pain in the oral cavity and that the facility will coordinate arrangements for dental care, transportation as needed/as ordered. However, the resident had an active dental referral as of 9/21/2024 for tooth extraction and was using lidocaine gel for tooth ache, the facility failed to update the care plan to reflect the resident's change in dental status for approximately 11 months. On 08/19/2024 at approximately 1:45 PM, during the initial pool phase the Resident #74 was observed to have a black eye and when the resident was asked what happened he/she stated that he/she fell; surveyor asked the resident if he/she would answer some question regarding the fall and the resident stated he/she was not up to talking to the surveyor. 08/27/2025 at approximately 5:00 PM, a review of Resident #74's medical records revealed that on 8/13/2025 at approximately 8:08 PM, the resident was observed laying on the floor lateral on the left side. The resident was observed to have a small hematoma on the left side of the face. The resident was alert and oriented and reported to staff that he/she fell from the wheelchair and hit his/her head on the floor. The resident was sent to the emergency room due to the fall. CT scan was completed and negative. On 8/14/2025 at approximately 9:54 PM the resident returned from the hospital with new orders: Apply ice to the left eye if swelling increases; Tylenol Oral Tablet 325 MG, give 3 tablet by mouth every 8 hours as needed for headache and continue neuro checks for 24 hours and a follow-up care appointment with a medical doctor. On 08/28/2025 8:13 AM, a review of the resident care plan revealed that the facility failed to review and revise the care plan to include that the resident had an actual fall with injury on 8/13/2025 and there were also no documented interventions identified after the 8/13/2025 fall on the resident's care plan. On 8/28/2025 1:30 PM, the Director of Nursing (DON) was notified that the facility failed to provide documented evidence to support that they reviewed and revised Resident #74's care plan after the 8/13/2025 fall and the DON verbally acknowledged the issue brought to her attention by the surveyor. 2) On 08/27/2025 at 10:53 AM, a review of Resident #10 care plan meeting revealed that the facility failed to conduct an interdisciplinary care plan meeting at least quarterly as required. Care plan meetings were completed a total of 3 times between January 2024 to survey date (1/2/2024, 9/27/24 and to survey date). On 08/27/2025 at 1:52 PM Interview with Staff #6 (social worker), the social worker was notified that Resident #10 care plan meetings were not completed as required, she was asked how often care plan meetings should be conducted, she stated that the goal was to have care plan meetings quarterly. Staff #6 stated that the missing care plan meetings was an oversight. On 8/28/2025 at approximately 1:30 PM, the Director of Nursing (DON) was notified, and she acknowledged the issue brought to her attention. On 8/19/25 at 11:10 AM, a review of Resident #8's medical record revealed the resident has been at the facility for more than 10 years. The most recent two years of MDS assessment reports showed that the resident's quarterly assessments were completed on 7/28/23, 1/08/24, 4/09/24, 7/10/24, 1/08/25, 4/10/25, and 7/08/25. Annual assessments were completed on 10/08/23 and 10/08/24. A further review of Resident #8's progress notes revealed that the facility held care plan meetings on 7/10/24, 10/10/24, and 1/13/25. During an interview with Staff #6 (Social Worker) on 8/20/25 at 11:25 AM, she stated that the care plan meetings were arranged by the facility's social worker after the MDS assessment and should be documented in the progress notes. When the surveyor asked why Resident #8's care plan meetings weren't documented in the progress notes, Staff #6 replied, I have them in my notes. She confirmed that those were not part of the official medical record. On 8/28/25 around 4 PM, the surveyor informed the Director of Nursing (DON) of these concerns, and she validated the findings. On 08/19/2025 at 8:33 AM, in an interview with Resident #13, the resident stated he/she was unaware of what a care plan meeting was and has not had one. On 08/21/2025 at 10:53 AM, a review of Resident #13's medical records revealed he/she has resided in the facility since 2019. Further review of Resident #13's MDS (Minimum Data Set is a comprehensive, federally mandated assessment tool used to evaluate a resident's functional, cognitive, and health status to create individualized care plans, monitor quality of care, and support reimbursement for Medicare and Medicaid certified facilities.) assessments showed that the facility staff completed quarterly assessments on 11/19/2024, 04/15/2025 and 07/16/2025, and an annual assessment on 01/15/2025. However, only one care plan meeting note was documented in the resident's electronic medical record titled care conference for 11/21/2024. On 08/19/2025 at 1:51 PM in review of Resident #15's medical records revealed care plan meetings were held on 10/2/2024 and 07/09/2025, with a nine-month interval between them. On 08/21/2025 at 10:35 AM, continued review of Resident #15's medical records revealed he/she has resided in the facility since 2023. Further review of Resident #15's MDS assessments showed that the facility staff completed quarterly assessments on 01/15/2025, 03/11/2025, 04/01/2025 and 07/02/2025 and an annual assessment on 12/29/2024. However, only two care plan meeting notes were documented in the resident's electronic medical record titled care conference for 10/02/2024 and 07/09/2025. On 08/20/2025 at 11:25 AM, in an interview with the Social Worker (Staff # 6), she stated that residents' care plan meetings were scheduled according to when the MDS was due. The care plan meeting was documented in the resident's electronic medical record under the title care conference. On 08/21/2025 at 1:37 PM, Staff # 46 confirmed that care plan meetings were not held and that corresponding documentation was missing from the residents' ( Resident #13 and #15) electronic medical records. On 08/28/2025 At 3:00 PM the Director of Nursing (DON) was made aware and understood the concerns. A review of Resident #68's medical records on 8/26/2025 at 2:44 PM revealed care conference notes done on 1/22/2025 and 7/10/2025 for care plan meetings held by the Interdisciplinary Team (IDT). [of note: These care conferences were 6 months apart instead of 3 months (quarterly)]. Further review of Resident #68's medical record on 8/26/2025 at 2:54 PM revealed that Resident #68 had a quarterly MDS assessment completed on 1/15/2025 and 4/16/2025, and an Annual MDS done on 6/26/2025. Based on the MDS assessments, the resident should have had a care plan meeting following the 4/16/2025 quarterly MDS assessments. However, there was no evidence in the medical records that a care plan meeting had been held with the resident and the IDT in April 2025 following the 4/16/2025 quarterly MDS assessment. The surveyor interviewed the Social Worker (Staff #6) on 8/27/2025 at 9:15 AM. During the interview, Staff #6 indicated that social services staff were responsible for coordinating the care plan meeting with residents. She stated that care plan meetings were scheduled based on MDS /ARD (Assessment reference date) and added that care plan meetings were to be held at least quarterly with long-term care residents. The surveyor requested that Staff #6 provide the survey team with any evidence of care plan meetings held in 2025 for Resident #68. In a follow up interview with Staff #6 on 8/27/2025 at 9:55 AM, she presented documentation that showed Resident #68 was invited to care plan meetings in January and July of 2025, including documentation of the care plan meetings held on 1/22/2025 and 7/10/2025. However, there was no invitation letter and/care plan meeting documentation for April 2025. When asked if there was a care plan meeting in April 2025, Staff #6 stated she was going to find out. In an interview with Resident #68 on 8/27/2025 at 12:50 PM, the resident was asked if s/he was invited to and/or attended a care plan meeting in April 2025, the resident said no. In another interview with Staff #6 on 8/27/2025 at 1:59 PM, she confirmed that there was no care plan meeting scheduled for Resident #68 in April 2025. On 8/27/2025 at 3:25 PM, during an exit conference, surveyor informed the Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional Clinical Educator of the missed care plan meeting in April 2025. No additional information was provided to the surveyor. 3) On 8/27/25 at 8:02 AM review of complaint 337226 revealed a care plan meeting for Resident #130 was held on 7/19/23 that did not include a nurse, nurse practitioner, or doctor. On 8/27/25 at 9:33 AM review of social services documentation revealed a care plan meeting was held on 7/19/23. On 8/28/25 at 9:15 AM in an interview with the Director of Nursing (DON), the surveyor requested all documentation related to Resident #130's July 2023 care plan meeting. On 8/28/25 at 10:04 AM review of the Education Attendance Record for Resident #130 and dated 7/19/23 failed to reveal a staff member from nursing (a nurse and/or nurse aide), physician or dietary representative had attended the care plan meeting. On 8/28/25 at 10:05 AM in an interview with the Nursing Home Administrator (NHA), a dual observation of the Education Attendance Record was conducted and the surveyor noted there was not a staff member from the nursing or dietary department or a physician. The NHA verified and confirmed the findings. When asked if the expectation was that a physician and nursing staff members attended care plan meetings, the NHA stated yes. When asked if there was evidence that a nurse or physician attended this care plan meeting, he stated no.

Based on a medical record review, facility investigation review, and staff interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse in a timely manner. This was evident for 5 residents (Resident #86, #143, #71, #131 and #73) of 8 residents reviewed for abuse during this recertification/complaint survey.The findings Included: 1) On 08/19/2025 at 9:04 AM, during the initial screening phase of the survey, Resident #86 reported to the surveyor that “on the recent Sunday night shift (8/17/2025) a nurse was very mean to her during care and when the nurse’s attitude was brought to the nurse’s attention, she just left the room and never came back. When asked if the incident was reported to anyone, Resident #86 stated “no”. The resident’s roommate (Resident #143) confirmed that the nurse was rough with her during care. The nurse was described as “African” by both residents. On 08/19/2025 at approximately 9:10 AM, during the initial screening phase Resident #143 reported to the surveyor that the staff were “mean, and they have very bad attitude, they refuse to attend to our needs when we need help. They get mad when we ring the call bell.” On 08/19/2025 at approximately12:28 PM, unit manager (RN #13) was made aware of Residents #86 and #143 above-mentioned concerns. RN #13 stated that he would talk with the residents. On 08/21/2025 at 11:45 AM, the DON was notified that Residents #86 and #143 had concerns that were reported to RN #13 by the surveyor on 8/19/2025; however, there was no evidence to support that additional steps were taken to report or investigate the resident’s claims, the DON stated that RN #13 was pulled of the unit and sent home for a unrelated incident. The surveyor clarified if the residents’ concerns depended on RN #13 ‘s return to the facility and the DON explained that the investigation can be completed by other staff. On 8/26/25 at 8:20 AM interview with DON, she was asked, what was the expectation if an abuse incident was reported to staff. The DON explained that they would start an investigation, if a staff member was involved, they would be removed; for resident- resident we would separate them. Conduct the follow up investigation immediately assessment the residents (skin sheet or any kind of notes under assessment section). On 08/26/2025 at 1:45 PM, in a follow-up interview with RN#13, he stated that he was removed from the unit for a few days and therefore he was unable to complete the investigation. RN #13 stated that he would typically immediately report allegations of abuse to his supervisor but in this case, it was not done. He stated that he planned to continue with the follow-up investigation upon his return to work the next day; however, he was then pulled off the unit and sent home for an unrelated issue. Therefore, he could not complete the investigation. RN #13 provided the surveyor with a one page document titled “Statement form” where an apparent interview was conducted with Resident #86, however, there was no additional documents provided to the surveyor to support that a thorough investigation was completed in a timely manner for resident #86 and #143 to prevent further alleged abuse, neglect, exploitation and mistreatment from occurring while the investigation was in progress. The facility failed to provide documented evidence to support that they conducted investigations related to Resident #86 and #143's allegations. 2) On 08/25/2025 at 3:35 PM, in an interview with Resident #71, the resident alleged to the surveyor that the Geriatric Nursing Aides (GNAs) in the facility “have bad attitudes, especially when we need to get to the hoyer lift.” The resident alleged that on one particular occasion, a GNA made some hurtful statements to Resident #71 while providing personal care about a month ago. The resident alleged that the GNA stated to the resident that he/she was “too fat, his/her thighs are too heavy, and he/she needed to lose weight because you are hurting my back”. The resident alleged that sometimes they are afraid to call for help.” Resident #71 reported that GNAs were sometimes using their cellphones while providing care to residents. The surveyor did not observe any concerns for abuse or neglect during the survey process. A review of the facility’s documentation titled “concern and comments revealed that on 6/5/2025 Resident #71 reported to NHA that a GNA was rude to the resident and told the resident that he/she needed to lose some weight. However, there was no documented evidence to support the fact that the facility conducted a thorough investigation and in a timely manner. The facility provided no documentation to suggest that the resident was assessed by a nurse and or a healthcare provider such as a physician, mental health provider, social worker, etc). There was also no documentation to suggest that the facility conducted resident and staff interviews in a timely manner, reported the incident to the appropriate agency, provide additional abuse training to the alleged perpetrator (GNA#47). On 08/26/2025 at 9:57 AM, the NHA reported that the incidents were not reported to him as a case of abuse. NHA stated he saw the resident in the hallway, and it was expressed more as a customer service issue and not abuse. We did go back to check the schedule and found that the GNA was accidentally in the resident’s room again. The NHA stated that he spoke to the unit supervisor to ensure the GNA was not sent back or assigned to Resident #71’s room again. The GNA was also educated not to enter the residents room again. On 08/26/2025 at 10:55 AM, in an interview with the NHA, the NHA was notified by the surveyor that the facility failed to thoroughly investigate the allegation of abuse and he acknowledged the concern. 3) On 8/20/25 at 12:42 PM, the surveyor reviewed the facility’s investigative packet for Self-Reported Incident, 337232. It was indicated that Resident #131 called 911 on 1/01/24 at 11:40 AM to report being aggressively grabbed by a nurse. The Nursing Home Administrator (NHA) was made aware of the incident on 1/02/25 at 9:45 AM and stated he began an investigation immediately. However, a review of Resident #131's medical records showed that assessments including a skin check, a Braden assessment, pain evaluation, and change in condition were not conducted until after 10:00 PM on 1/02/25, more than 12 hours after the NHA was notified. The NHA validated this delay. 4) A facility-reported incident (ID #337256) stated that a family member of Resident #73 reported a Geriatric Nursing Aide (GNA) was providing aggressive care on 2/04/25. The initial report was submitted on 2/04/25 at 4:00 PM. However, Resident #73's medical records showed that the resident's assessment for pain, Braden score, and change in condition was not completed until 2/05/25. In an interview with the Director of Nursing (DON) on 8/26/25 at 8:20 AM, she confirmed that no assessment was completed on the day the incident was reported and validated that all such incidents should be investigated immediately.

Based on review of facility reported incidents (Intake #2578127, # 337212 and #337236), record review, and interview, it was determined that the facility failed to ensure that all alleged resident violations were reported in a timely manner, including: abuse, neglect, exploitation or mistreatment. This was evident for 6 (Resident #86, # 143, #71 #101, #2, and #140) of 76 Residents that were part of the survey sample.The findings included: 1) On 08/19/2025 at 9:04 AM, during the initial screening phase of the survey, Resident #86 alleged to the surveyor that “on the last Sunday night shift (8/17/2025) a nurse was very mean and rough with the resident during care and when her attitude was brought to her attention by Resident #86, she just left the room and never came back. When asked if the incident was reported to anyone, Resident #86 stated “no”. The resident’s roommate (Resident #143) confirmed that nurse was rough with her during care pushing Resident #86 roughly towards the bedrail. The nurse was described as “African” by both residents. On 08/19/2025 at approximately 9:10 AM, during the initial screening phase Resident #143 reported to the surveyor that the staff were “mean and they have very bad attitude, they refuse to attend to our needs when we need help. ‘They get mad when we ring the call bell.” On 08/19/2025 at approximately12:28 PM, unit manager (RN #13) was made aware of Residents #86 and #143 above-mentioned concerns. RN #13 stated that he would speak with the residents. On 8/21/2025 at approximately 11:45 am, the Director of Nursing (DON) was notified that the unit manager (RN #13) was made aware of Resident #86 and #143 concerns; however, there was no documented evidence to support that a follow-up investigation was initiated and reported to the Office of Health Care Quality (OHCQ) in a timely manner. On 08/25/2025 at 3:20 PM, the Regional Director of Clinical Operations (RDCO) was notified that Resident #86 and #143’s concern was reported to RN #13 by the surveyor on 8/19/2025 and the Director of Nursing (DON) was notified of the concern on 8/21/2025. However, there was no report was made to OHCQ. The RDCO stated that she will look into it further. On 8/26/25 at 8:20 AM interview with DON, she was asked, when an abuse incident is reported what was the expectation. The DON reported they start an investigation, if a staff member was involved, they would be removed from the unit; for resident- resident we would separate them. Conduct the follow up investigation immediately; assessment of the residents (complete skin sheet or any kind of notes under assessment section). On 08/26/2025 at 1:45 PM, in a follow-up interview with RN#13, he stated that he was removed from the unit for a few days and therefore he was unable to complete the investigation. RN #13 stated that he would typically report concerns of abuse to his supervisor immediately but in this case, it was not done. He stated that he planned to continue with the follow-up investigation upon his return the next day. However, he was then pulled off the floor for an unrelated issue and was immediately sent home. He stated that he could not complete the investigation. He was notified by the surveyor that there was a concern in regard to late reporting to OHCQ for allegations of abuse and or neglect. RN #13 provided the surveyor with a one page document titled “Statement form” where an apparent interview was conducted with Resident #86, however, there was no additional documents provided. On 08/27/2025 at approximately 10:14 AM, a review of the documentation provided revealed that the facility conducted an internal investigative form; however, there was no documentation to suggest that the allegation of abuse was filed with OHCQ as required. On 08/28/2025, the DON was once again informed that the facility failed to report the allegations of abuse/neglect for Resident #86 and #143 to OHCQ in a timely manner. 2) On 08/25/2025 at 3:35 PM, in an interview with Resident #71, the resident alleged to the surveyor that the Geriatric Nursing Aides (GNAs) in the facility have bad attitudes, especially when we need to get to the hoyer lift. The resident alleged that on one particular occasion, a GNA made some hurtful statements to Resident #71 while providing personal care about a month ago. The resident alleged that the GNA stated to the resident that he/she was “too fat, his/her thighs are too heavy, and he/she needed to lose weight because he/she was hurting the GNA’s back”. The resident alleged that sometimes they are afraid to call for help.” Resident #71 reported that GNAs were sometimes using their cellphones while providing care to residents. The resident also reported that on a separate incident he/she had an episode of incontinence and a GNA told Resident #71 to wait until the next shift, the resident stated that they waited from 2pm to 6pm before help was provided. The resident’s roommate Resident#7) confirmed the above-mentioned concerns. Resident #71 stated that a manager was notified about the concerns and asked that the GNA did not return to the resident’s room; however, the GNA returned to the resident’s room once after the complaint was made to the manager. On 08/25/2025 at approximately 3:45 PM, the Regional Director of Clinical Operations (RDCO) was informed by Resident #71 of the concerns shared with the surveyor. The RDCO stated that the issues would be addressed. On 08/26/2025 at 9:13 AM, in a follow-up interview with the RDCO, she was asked if the complaints were reported to OHCQ and she stated they were not reported. She stated that the staff were educated on reportable events. She stated that the concern was investigated and the GNA stated that she was not talking to Resident #71 about their weight, she was talking to someone on the cellphone. The RDCO stated that the GNA was educated on customer service and cellphone policy by the administrator. On 08/26/2025 at 9:48 AM, a review of a facility’s internal document revealed that Resident #71 made an official complaint to the facility that on 6/5/2025 at 11pm- 7am shift, the assigned GNA (GNA #47) was rude and told Resident #71 that the resident needed to lose some weight. A signed human resource statement revealed that “GNA #47 changed her work status to PRN (as needed). GNA #47 has not worked at the facility since July 28, 2025 and she is not currently schedule to pick up any shifts for this month (august) or the next (September).” A review of another internal document revealed that on 8/22/2025 Resident #71 reported to the facility that on about 7 -3pm shift, a GNA refused to provide personal hygiene care and the GNA told the resident to wait until next shift. Resident reported that he/she was not changed until 6 pm that evening. This incident was reported by the resident to the Nursing Home Administrator (NHA). On 08/26/2025 at 10:55 AM, in an interview with the NHA, the NHA was notified that the facility failed to report the allegation of abuse/neglect to OHCQ as required and he acknowledged the surveyor’s concerns. The NHA reported that the incidents were not reported to him as a case of abuse. NHA stated he saw the resident in the hallway, and it was expressed more as a customer service issue and not abuse. The NHA stated that they did go back to check the schedule and found that the GNA was accidentally in her room again after the reported incident. The NHA stated that he spoke to the unit supervisor to ensure the GNA was not sent back or assigned to Resident #71’s room again. He stated that the GNA was also educated not to enter Resident #71’s room again. When asked if there was any documented evidence to support that the unit supervisor and GNA were notified of the resident’s request he stated that it was communicated verbally to both of them. 3) On 08/27/2025 at approximately 10:16 AM, a review of a facility reported intake # 2578127 revealed that Resident #101 reported to the facility that his/her cellphone went missing on Sunday 9/8/2024 at around 1PM from his bed. Further review of the facility’s documentation related to this report revealed that a staff member was notified of the Resident’s alleged missing cellphone on 9/8/2024 at approximately 2:30pm; however, documentation suggests that the alleged incident was reported to the Office of Health Care Quality (OHCQ) on 9/9/2024 at 4:57 PM, which was more than 24 hours after the facility was made aware of the incident. On 08/28/2025 at 10:07 am, in an interview with the Nursing Home Administrator (NHA), the NHA was notified the facility failed to report the alleged incident to OHCQ in a timely manner. He acknowledged the surveyors’ concern, and he stated that he was not notified by Staff until 9/9/2024 at 9:30 AM (the following day) as a result the report to OHCQ was submitted late. 4) On 8/26/2025 at 1:34 PM, a review of facility reported incident 337212 was conducted and revealed Resident #2 alleged that he/she was pushed into bed and forced to lie down by GNA #45. Review of the facility’s investigation revealed that the incident was reported to the Social Worker, Staff #46 on 4/20/2023. The initial self-report was emailed to OHCQ on 4/24/2023, which was not within 2 hours of the alleged abuse. On 8/26/2025 at 2:40 PM, an interview was conducted with the Director of Nursing (DON) who stated that an allegation of abuse must be reported to OHCQ within 2 hours of the allegation. However, DON stated she was not employed at the facility during that time. The DON confirmed the findings. 5) This surveyor investigated intake #337236 on 8/26/25 and 8/27/25. As part of the investigation, this surveyor asked Resident #140, Are you getting along with your roommate? The resident responded by shaking their head no and pointing towards the roommate (privacy curtain was pulled to allow for privacy). Resident #140 said that the roommate did foul things to them. This surveyor asked if he/she told anyone and they replied that they told one of the board ladies. This surveyor asked if they meant one of the GNA's (Geriatric Nursing Assistant) and the resident shook their head up and down. This surveyor asked when did they tell the GNA and they replied about two months ago. This surveyor told the Director of Nursing (DON) on 8/26/25 at 8:35 AM that the resident alleged the roommate does foul things to the resident. She said she would investigate. This surveyor emailed the state survey agency on 8/27/25 and was informed that no self-report was sent. The Administrator was interviewed on 8/28/25 at 9:10 AM. He was informed of the resident’s allegation and that this surveyor told the DON. He replied that he would find out what happened. The Administrator was interviewed on 8/28/25 at 10:00 AM. He said the social worker followed up and the resident agreed to a room change. This surveyor stated that it was not reported to the state reporting agency, and any allegation needs to be reported. It is up to our office to decide if we are going to investigate. Telling a surveyor or getting an allegation from a surveyor does not constitute notification. He replied he understood.