Every finding on record at FT Washington Rehabilitation and Wellness Center

Based on record review and interview, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS) assessments within the required timeframe. This was evident for 5 (Resident #2, #9, #16, #18 and #21) of 12 residents reviewed for resident assessment during the recertification survey.The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. Nursing homes are required to submit the Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source to Centers for Medicare and Medicaid Services (CMS') Internet Quality Improvement and Evaluation System (iQIES). According to chapter 5 of the CMS'S Resident Instrument Assessment (RAI) manual, comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. On 11/19/25 at 8:47 PM, a review of the MDS assessments revealed that the following MDS assessments were not transmitted in a timely manner: 1. Resident #2- The quarterly MDS with an Assessment Reference Data (ARD) of 9/29/25 was completed on 10/13/25, however was transmitted on 11/7/25.2. Resident #9- The annual MDS with an ARD of 9/24/2025 was completed on 10/8/25, however, was transmitted on 11/3/25.3. Resident #16- The discharge return anticipated MDS with an ARD of 9/30/25 was completed on 10/14/25, however, was transmitted on 11/12/25. - The Entry MDS with an ARD of 10/7/25 was completed on 10/14/25, however, was transmitted on 11/12/25.4. Resident #18- The quarterly MDS with an ARD of 10/16/25 was completed on 10/30/25, however was transmitted on 11/19/25.5. Resident #21- The annual MDS with an ARD of 9/16/2025 was completed on 9/30/25, however, was transmitted on 10/21/25. On 11/20/25 at 12:22 PM, during an interview with MDS Registered Nurse (RN) Team Leader and MDS Coordinator Licensed Practical Nurse (LPN), they stated that the facility is expected to adhere to the CMS's timeframe for completing and submitting MDS assessments. They verified the findings and confirmed the facility's awareness of the late transmissions and assessment backlog. They stated that corporate mobile MDS nurses were assisting them.On 11/24/2025 at 8:45 AM, the Director of Nursing (DON) was notified of the late transmission of MDS assessments

Based on interview and record review it was determined that the facility failed to hold quarterly Care Plan Meetings with the Interdisciplinary Team. This was evident for 4 (Resident #21, #13, #12 and #70) of 9 Residents reviewed for care plan meetings during the recertification survey.The findings include: Care Plan meetings are meetings with a team of care providers (attending physician, a registered nurse, nursing assistant dietary services, resident, and the resident's representative if applicable) to ensure the plan is continually adjusted to meet the changing needs or concerns of residents. Care Plan meetings are required to be held quarterly. 1). During an interview with Resident #21 on 11/18/2025 at 9:30 AM he/she reported that they had not had regular care plan meetings. During a review of medical records for Resident #21 on 11/20/2025 at 12:34 PM it was discovered that the resident's care plan meetings were not being held quarterly. The last three care plan meetings occurred on 11/14/24, 4/30/25 and 9/11/25. During an interview with the Social Work Director on 11/20/25 at 1:16 PM he agreed that care plan meetings should be conducted quarterly. He confirmed that the Care Plan Meetings for Resident #21 had not been held quarterly. 2). During a phone interview with a family member of Resident #13 on 11/18/2025 at 5:31 PM he/she reported that they hadn't had regular care plan meetings for Resident #13. During a review of medical records for Resident #13 on 11/20/25 at 11:19 AM it was discovered that his/her last four care plan meetings were held on 5/16/24, 11/15/24, 3/13/25 and 9/11/25. During an interview with the Social Work Director on 11/20/25 at 1:14 PM he reported care plan meetings are completed quarterly. He agreed that Resident #13 had missed care plan meetings, and the meetings were not conducted quarterly. 3). During a review of Resident medical records on 11/19/2025 at 9:47 AM it was discovered that Resident #12 didn't have quarterly care plan meetings. The last three care plan meetings held for Resident #12 occurred on 2/01/24, 10/14/24 and 7/10/2025. During an interview with the Social Work Director on 11/20/25 at 1:11 PM he reported care plans are to be held quarterly. He agreed that Resident #12 had not had quarterly care plan meetings and that meetings were missed. 4). On 11/19/25 at 09:00 AM the surveyor reviewed Resident #70's clinical record. The review revealed that Resident #70's quarterly Minimum Data Set (MDS) assessment was completed on 12/9/24. There was no evidence in the clinical record to indicate that a care plan meeting was held with the resident and the interdisciplinary team within 7 days or around the time the quarterly MDS assessment was completed. The record revealed an interdisciplinary care plan meeting was not held until 03/06/25. On 11/21/2025 at 8:29 AM in an interview the Social Services Director reviewed the clinical record and confirmed that there was no care plan meeting was held in December 2024 or January 2025. He stated that the meeting was overlooked because the resident had recently returned from the hospital and the MDS schedule had changed.

Based on observation, interview and record review, it was determined that the facility failed to provide necessary respiratory care services by failing to label oxygen administration equipment. This was evident for 1 (Resident #163) of 1 resident reviewed for respiratory care during the recertification survey.The findings include: Oxygen therapy is a treatment that provides a person with extra oxygen to breathe in. It is also called supplemental oxygen. A nasal cannula is a thin, flexible tube that delivers oxygen through the nose. A humidifier in oxygen therapy is a device that adds moisture to dry, concentrated oxygen to prevent drying and irritation of a patient's nasal passages, throat, and lungs. These humidifiers typically consist of a bottle filled with water that attaches to an oxygen concentrator. On 11/17/25 at 11:15 AM, Resident #163 was observed receiving oxygen therapy via nasal cannula, however, the oxygen tubing and the humidifier bottle were not labeled with the date they were put into use or the date they should be replaced. On 11/17/2025 at 11:19 AM, the Director of Nursing (DON) was made aware of this finding and verified the observation. On 11/21/2025 at 8:11 AM, a review of the active physician orders indicated 02 (oxygen) at 2LPM (liters per minute) via NC (nasal cannula) continuous every shift for SOB (shortness of breath). On 11/21/2025 at 10:18 AM, during an interview with Licensed Practical Nurse (LPN #7), he/she confirmed that the nurses were expected to change the tubing weekly and the humidifier bottle as needed, and that they were expected to date the equipment when changed.

Based on observation, interview and record review, it was determined that the facility failed to ensure a medication error rate of less than 5% during the medication observation task. This was evident for 4 of 25 medications administered during the observation which resulted in a medication error rate of 16%.The findings include:On 11/20/2025 at 8:52 AM, during the medication administration observation, Registered Nurse (RN #1), crushed the following medications of Resident #90 along with other medications in 2 separate plastics for pill crusher and mixed them in apple sauce:1. 1 tablet of Aspirin 81 mg enteric coated tablet, however the Physician's order indicated that Aspirin was to be administered in a chewable form.2. 1 tablet of Ferrous sulfate delayed release 325 (65 Fe) MG (Ferrous Sulfate) tablet3. 2 tablets of Levetiracetam 750 mg tablet4. 1 tablet of Metformin 500 mg tablet RN #1 stated that Resident #90 preferred to take the medications in powdered form and mixed in apple sauce.On 11/20/2025 at 9:11 AM, while RN #1 was administering the crushed medication mixture, Resident #90 complained of the taste and subsequently vomited immediately after ingestion. RN #1 stated an intent to notify the Physician.On 11/20/2025 at 9:41 AM, in an interview with Licensed Practical Nurse (LPN #6), he/she confirmed that there was no list of do not crush medications on the medication cart. He/she stated that he/she was sure that Aspirin EC (Enteric Coated) is a do not crush medication.On 11/20/2025 at 10:29 AM, RN #5 confirmed that he/she has not seen a list of do not crush medications on the medication carts, however, he/she indicated that bubble packs should indicate the warning. He/she then pulled a blister pack to show a do not crush warning on the pack, such as the Acetaminophen 650 ER (Extended Release) tablet.On 11/20/25 at 11:18 AM, the Director of Nursing (DON) provided a copy of Med that should not be crushed trchealthcare dated April 2025- Resource #410460 from Pharmscript of Maryland confirming that the following medications were not to be crushed with the comments:- Aspirin EC- gastric irritant- Ferrous Sulfate- mucosal irritation- Levetiracetam tablet-bad taste- Metformin- modified releaseA review of the facility's Medication Administration policy indicated the following:a. Section f. Observe the five rights in giving each medication- the right medicineb. Section t. If oral solid medications cannot be given whole, work with the appropriate clinician and the resident /representative to determine the most appropriate method for administering medications which considers the resident's safety needs, medication schedule, preferences and functional ability.On 11/24/2025 at 8:45 AM, the DON was notified of the concerns and acknowledged them.

Based on clinical record review and staff interviews, it was determined that the facility failed to act upon a clinically significant medication irregularity identified by the consultant pharmacist for residents. This was evident for 1 (Resident #5) out of 5 residents reviewed for medication regimen review during the annual survey.The findings include:On 11/25/25 at 10:02 AM, a review of Resident #5's clinical record revealed a Medication Regimen Review (MRR) dated 8/11/25 that identified a clinically significant drug interaction between Eliquis 5 mg twice daily and Paxlovid. The consultant pharmacist recommended reducing the Eliquis dose by 50% during Paxlovid therapy and continuing the reduced dose for 3 days after the last Paxlovid dose due to increased bleeding risk. The physician response section of the report was blank. Continued review revealed no documentation that the recommendation was addressed by the physician, the nursing staff, or the Director of Nursing (DON). On 11/25/25 at 10:23 AM, a review of Resident #5's August 2025 Medication Administration Record (MAR) revealed that Eliquis 5 mg twice daily was administered as ordered from 8/1/25 through 8/31/25. Further review revealed that Paxlovid was administered beginning on 8/8/25 and continued through 8/13/25. Continued review revealed that the Eliquis dose was not reduced during Paxlovid therapy or for 3 days after the last Paxlovid dose, according to the pharmacist's recommendation. On 11/25/25 at 11:02 AM, a review of the facility's policy titled Medication Regimen Review revealed that urgent or clinically significant medication irregularities are to be communicated to the medical practitioner and the Director of Nursing on the day they are identified. Continued review of the policy revealed that the Director of Nursing or designee is responsible for ensuring that medication irregularity reports are addressed with the medical practitioner in a timely manner that meets the needs of the resident. On 11/25/25 at 11:41 AM, an interview with the DON revealed that the consultant pharmacist sends MRR reports via email to the DON, Assistant Director of Nursing (ADON), and Unit Managers. The DON stated that the ADON is responsible for ensuring the recommendations are followed up on. When asked about the clinically significant recommendation for Resident #5 dated 8/11/25, the DON confirmed that the recommendation was not addressed and was not sure why it was missed. On 11/25/25 at 1:15 PM, an interview with the ADON revealed that the pharmacist's recommendations are emailed to the DON, ADON, and unit managers. The ADON stated that unit managers print the recommendations and give them to the provider for review and response. When asked if she was responsible for ensuring recommendations were acted upon, she stated that each unit manager is responsible for their own unit and she only monitors if a unit manager is unavailable.At the time of exit conference, no additional documentation was provided to show that the clinically significant medication recommendation for Resident #5 was reviewed, addressed, or implemented, as required.

Based on interview, record review and observation, it was determined that the facility failed to provide dental services for residents. This was evident for 2 (Resident #13 and #122) of 2 residents reviewed for dental services during the recertification survey.The findings include: 1) During an interview with a family member for Resident #13 on 11/18/2025 at 5:43 PM he/she reported that the resident has had problems with his/her teeth and had not had any dental care. During a review of medical records for Resident #13 on 11/20/2025 at 10:26 AM it revealed that he/she had a history of dementia and was dependent on staff for care. A change in condition communication form dated 11/21/2023 was found which reported that the nurse had found Resident #13 chewing on his/her tooth that came off and the nurse noted the resident is cognitively impaired. During further review of Resident #13 medical records it was discovered that an order was placed on 11/21/23 that ordered a Dental consult secondary to his/her tooth that came out and discontinue order when consult is completed. During continued review of the medical records for Resident #13 it was found that the order for the dental consult was signed off in the Treatment Administration Record everyday from November 22, 2023 – December 31, 2023, everyday from January 1, 2024 through December 31, 2024 and everyday from January 1, 2025 through May 27, 2025. The order was discontinued on 5/27/2025. During additional medical record review it revealed that there was no documentation of a dental consult being requested or completed for Resident #13. During an interview with the Director of Nursing (DON) on 11/21/2025 at 9:26 AM she advised that referrals for consults should be completed within 24 hours and can be completed by the nursing staff. She reported the documentation for a dental consult being requested or being completed should be in the Resident's medical records. She agreed that the order for Resident #13 to have a Dental consult should have been completed. During an interview with the DON on 11/21/25 at 1:31 PM she confirmed that there was no documentation of a dental consult referral being sent or a dental consult being completed for Resident #13 During a review of the facility's Dental Services Policy it stated, The facility will assist the resident in: A: Obtaining routine Dental Services B: Obtaining 24 – hour Emergency Dental Services C: Obtaining services to the resident to meet the needs of each resident D: Making appointments. 2) Resident #122 was admitted to the facility in May 2024 and received Hospice services until July 2024 when he/she was discharged to Long Term Care. The resident's diagnoses included Alzheimer's Disease, Adult Failure to Thrive and Cognitive Communication Deficit. On 11/18/25 at 9:16AM during initial rounds the surveyor observed the resident with broken teeth that were blackish/greyish in color along with other teeth that were similarly discolored. The resident could not tell whether he/she had seen a dentist since admission to the facility. On 11/20/25 at 7:15 AM a review of Resident #122 clinical record revealed that upon admission to the facility on 5/31/24 the resident was assessed and the documentation on the Nursing admission Evaluation Form -V6, Section 3B 4 Oral Status stated Obvious or likely cavity or broken natural teeth. There was no evidence in the clinical record indicating that the resident was evaluated by a dentist while he/she resided in the facility. The surveyor noted an active physician order dated 5/31/24 which stated Consults: Audiology, Dental, Optometry, Ophthalmology and /or Podiatry as needed. Further review of the clinical record revealed that between September 2025 and November 2024 the resident had a weight loss of 16.6 lbs., and the weight loss was addressed by the Dietitian. On 11/21/2025 at 8:50 AM during an interview the Unit Manager #11 stated that a dentist visits the facility quarterly and dental services are scheduled routinely and as needed depending on the resident's condition. Unit Manager #11 reviewed the clinical record and confirmed that there was no record to show that the resident was seen by a dentist. The Unit Manager accompanied the surveyor to Resident #122's room and, after observing the resident's teeth and confirming the surveyor's findings stated, I do not know why (resident) did not see the Dentist. During an interview on 11/21/25 at 9:17 AM the Director of Nursing (DON) was notified of the surveyor's concerns regarding the Resident #122's dental care. The DON reviewed the clinical record and stated the resident should have been evaluated by a dentist and that she would conduct a further review of the records. Later, 11/21/25 at 11:45AM the DON informed the surveyor that the records confirmed the resident was not evaluated by a dentist.

Based on observations and interviews, it was determined that the facility failed to maintain 1) Food service equipment in a manner that ensures sanitary food service operations and 2) Proper sanitation for the storage of food on the nursing units. This was evident during the initial tour of the kitchen and on 1of 3 nursing units observed for food storage and sanitation.The findings include:1. On 11/17/25 at 7:59 AM during an initial tour of the kitchen with the Certified Dietary Manager (CDM), the surveyor observed on the wall outside the walk-in refrigerator a temperature log which stated 36 degrees 11/17/25 AM. The surveyor observed that the thermometer inside the refrigerator was broken and not functioning. When asked how the temperature was verified when the thermometer was broken, the CDM stated that the temperature could have been recorded before the thermometer was broken. The thermometer was replaced. Later at 8:30AM the refrigerator's temperature revealed 39 degrees Fahrenheit.The log on the wall outside the walk-in freezer read -1 degree 11/17/25 AM. There was no thermometer visible inside the freezer. The CDM said the thermometer might have been caught behind the boxes in the freezer. Dietary Aide #9 was asked to look for the thermometer. He located a broken thermometer on the floor of the walk-in freezer. The surveyor did not observe any thawing of food or build-up of ice. The CDM stated that she will immediately replace the thermometer. After the thermometer was replaced another check at 9:00AM revealed a temperature of 10 degrees Fahrenheit. In an interview conducted on 11/17/25 at 9:15 AM the CDM, who was with the surveyor during the observations, confirmed the findings and stated that she would educate the staff to ensure that thermometers in the freezer and refrigerator were visible and in working condition. 2. On 11/19/25 at 8:25AM the surveyor conducted an observation of the nourishment refrigerator on the 1st floor in the presence of Unit Manager Staff #20. Inside the refrigerator were: one 3 cup white plastic container with a red cover containing spaghetti and ground meat with no name, no date and labeled Rm#122B; one white unlabeled shopping bag containing a black dotted lunch box. The lunch box contained 2 plastic containers with rice, 1 packet brownie, 1 packet of popcorn, and 16oz bottle of water. None of the items inside the lunch box was dated or labeled. In an interview the Unit Manager Staff #20 stated that the nourishment refrigerator is used by the residents. When food items are received it is labeled with the date received, the resident's name and room number. After 72 hours the food item is discarded. The unit manager stated that she did not know to whom the unlabeled items belong and the date they were put in the refrigerator. The unlabeled and undated items were removed from the refrigerator.On 11/19/25at 9:00 AM the surveyor reviewed the facility's policy on Storage of Resident Food. Section II (C) stated Staff will date the container when food or beverages are brought into the facility and discard food when non-safe. Reheat foods only once then discard.On 11/19/25 at 9:32 AM in an interview the Director of Nursing stated that she was notified by the Unit Manager of the surveyor's findings and that the items should have been labeled and discarded after 72 hours if not used.

Based on record reviews and interviews, it was determined that the facility failed to provide a therapy screening for 1 (Resident #17) of 28 residents reviewed for therapy services during the annual survey.The findings include:During a review of medical records for Resident #17 on 11/21/2025 at 9:02 AM it was discovered that the Resident had mobility difficulties and a history of falls. A change in condition form dated 9/29/2025 revealed that the Resident was found on the floor laying on his/her back after an unwitnessed fall.During a continued review of medical records it was revealed that there was a Nursing Referral to Therapy form completed on 9/30/2025 as a result of Resident #17 having an Unwitnessed fall.During further record review it was discovered that no therapy assessment or evaluation had been completed on Resident #17 after the fall and the nursing referral.During an interview with Therapy Manager #17 on 11/21/2025 at 2:56 PM she reported that the nurses can use the Therapy Notification Referral if they see any kind of decline or concerns with the residents. She advised the goal to complete screening after a therapy referral was 48 hours. She reported Resident #17 was not currently receiving therapy and that he/she should have had a therapy screening after the Therapy Referral request was submitted. During an interview with Therapy Manager #17 on 11/24/2025 at 8:22 AM she confirmed no screening was completed after the therapy referral was made and it should have been completed. During an interview with the Administrator on 11/25/2025 at 1:43 PM he reported that the facility Interdisciplinary Team does well following up with falls and if the referral was made to therapy, it should have been followed up on.

Based on observation and interview, it was determined that the facility failed to protect and value the resident's private space by failing to knock prior to entering a resident's room. This was evident for 1 (Resident #158) of 2 residents reviewed for dignity during the recertification survey.The findings include: On 11/17/2025 at 10:19 AM, Resident #158 expressed concern about staff members do not knock before entering their room. On 11/17/25 at 10:29 AM, while the surveyor was interviewing the Resident #158, Geriatric Nurse Assistant (GNA #4) abruptly opened the bathroom door from the other side of the room. Resident stated see, that's a perfect example of what I just shared with you. On 11/24/2025 at 10:13 AM, in an interview with GNA #12, he/she stated that the staff members are expected to knock and ask permission before entering the resident's room. On 11/25/2025 at 9:53 AM, the Director of Nursing (DON) was notified and acknowledged this concern.

Based on interview, record review, and observation, it was determined that the facility failed to notify the Physician and the Resident Representative of 1) a recommendation received after an eye appointment, and 2) medication errors that occurred during medication administration observation. This is evident for 2 (Resident #130 and #90) of 2 residents reviewed during the recertification and complaint survey. The findings include:1) Latanoprost a prescription eye drop medication used to treat eye conditions like glaucoma and ocular hypertension by lowering high pressure inside the eyeball. It works by essentially opening up or relaxing the eye's natural drainage pathways, allowing more fluid to flow out of the eye and into the bloodstream. If the high pressure is left untreated, it can damage the optic nerve and lead to permanent vision loss. On 11/19/2025 at 8:14 AM, Resident #130 stated that he/she could not see clearly even with eyeglasses on. He/she added that this has been going on for several months and was bothering him/him. He/she confirmed being seen by an eye doctor in October but unsure if the facility addressed the concern. On 11/21/2025 at 8:55 AM, a review of Resident #130's medical record revealed an Eye care group visit with an exam dated 10/13/2025. The provider confirmed the complaint of blurred vision all distances, both eyes, bothersome for several months and recommended Latanoprost 0.005%, apply 1 drop, both eyes, at bedtime indefinitely; Follow-Up: 1-2 Months. However, a review of Resident #130's active and completed physician orders found no evidence of the Latanoprost medication or treatment being entered or initiated.On 11/21/2025 at 10:25 AM, during an interview with Licensed Practical Nurse (LPN #7), he/she stated that when a resident returned from an appointment, the Charge Nurse or Unit Manager would check the consultation note and would notify the attending Physician and the Resident Representative (RP) if there were recommendations. LPN #7 confirmed that the Physician and the RP were not notified of the recommendations, and the order was not implemented.On 11/24/2025 at 8:45 AM, the Director of Nursing (DON) was notified of this concern. 2) On 11/20/2025 at 8:52 AM, during the medication administration observation, Registered Nurse (RN #1), crushed the following medications of Resident #90 along with other medications in 2 separate plastics for pill crusher and mixed them in apple sauce: 1. 1 tablet of Aspirin 81 mg enteric coated tablet, however the Physician's order indicated that Aspirin was to be administered in a chewable form.2. 1 tablet of Ferrous sulfate delayed release 325 (65 Fe) MG (Ferrous Sulfate) tablet3. 2 tablets of Levetiracetam 750 mg tablet4. 1 tablet of Metformin 500 mg tablet RN #1 stated that Resident #90 preferred to take the medications in powdered form and mixed in apple sauce. On 11/20/2025 at 9:11 AM, while RN #1 was administering the crushed medication mixture, Resident #90 complained of the taste and subsequently vomited immediately after ingestion. RN #1 stated an intent to notify the Physician.On 11/20/25 at 11:18 AM, the Director of Nursing (DON) provided a copy of Med that should not be crushed trchealthcare dated April 2025- Resource #410460 from Pharmscript of Maryland confirming that the following medications were not to be crushed with its comments:- Aspirin EC- gastric irritant- Ferrous Sulfate- mucosal irritation- Levetiracetam tablet-bad taste- Metformin- modified releaseA review of the facility's Medication Administration policy indicated the following:a. Section f. Observe the five rights in giving each medication- the right medicineb. Section x. Report medication errors.On 11/23/2025 at 3:42 PM, a review of the nurses progress notes dated 11/20/2025 indicated Patient reported nausea triggered by the taste of crushed medications mixed with applesauce during the 9:00 AM medication administration. Patient vomited immediately after ingestion of medications, expelling both the administered medications and recently ingested feeds. The Physician was notified of the event and ordered to re-administer medications. However, the Physician was not notified that a medication error had occurred (crushing non-crushable medications), and the Resident Representative was not notified of either the medication error or the episode of vomiting.On 11/24/2025 at 8:45 AM, the DON was notified of these findings and acknowledged them.

Based on observations and interviews, it was determined that the facility failed to provide a safe and homelike environment. This was found to be evident for 2 (Residents #12 and #13) out of 28 resident rooms observed for the physical environment. The findings include:1. During an observation conducted on 11/18/2025 at 9:50 AM it was discovered that the electrical outlet wall plate beside the bed of Resident #13 was broken in half and the upper socket was exposed without a wall plate surrounding it. The broken half was missing.During an observation with the Nursing Home Administrator (NHA) and Maintenance Director on 11/19/2025 at 12:44 PM they confirmed the plate was broken and needed to be repaired. The HNA reported the face plate would be repaired right away.During an additional observation on 11/25/2025 at 1:43 PM it was discovered that the socket plate had not been repaired.2. During an observation conducted on 11/18/25 at 10:33 AM, it was discovered the smoke detector in the room of Resident # 12 was not secured to the wall and was hanging by it's wires coming out of the wall.During an observation with the Nursing Home Administrator (NHA) and Maintenance director on 11/19/25 at 12:39 AM. The Maintenance Director reported the detector was pulled down about two weeks ago when the fire inspector was in the facility doing inspections and that it needed to be replaced. The NHA reported they would replace the detector. During an additional observation on 11/25/25 at 1:46 PM it was discovered that the smoke detector had not been repaired and was still hanging from the wall by it's wires.

Based on clinical record review and staff interviews, it was determined that the facility failed to provide written notification to the local ombudsman when residents transferred to the hospital. This was evident for 2 (Resident #15 and #145) out of 5 residents reviewed for written notice requirements before transfer/discharge.The findings include:On 11/25/25 at 9:13 AM, a review of Resident #15's clinical record revealed that Resident #15 was transferred to the hospital on [DATE] for further evaluation of his/her medical needs. Continued review of Resident #15's clinical record revealed no documentation that the local ombudsman was notified in writing of the hospital transfer. On 11/25/25 at 09:42 AM, a review of Resident #145's clinical record revealed that Resident #145 was transferred to the hospital on 7/11/25 for further evaluation of his/her medical needs. Further review of Resident #145's clinical record revealed no documentation that the local ombudsman was notified in writing of the hospital transfer. On 11/25/25 at 09:59 AM, a review of the facility's policy titled Transfer and Discharge Policy revealed that the facility is required to send a copy of the written transfer or discharge notice to the Office of the State Long-Term Care Ombudsman. Continued review of the policy revealed that for emergency transfers, the Social Services Director or designee is required to provide notice of the transfer to the State Long-Term Care Ombudsman via a monthly list. On 11/25/25 at 10:07 AM, an interview with the Social Services Director revealed that written notification is not sent to the local ombudsman when a resident is transferred to the hospital. The Social Services Director also stated that the facility sends the ombudsman a monthly discharge calendar and emails when submitting self-reports, but not for hospital transfers. On 11/25/25 at 11:41 AM, an interview with the Director of Nursing (DON) confirmed that the facility does not send written notifications to the local ombudsman when residents are transferred to the hospital. The DON also stated that there is no current process in place to provide written notice of hospital transfers to the local ombudsman. At the time of exit conference, no additional documentation was provided to show that written notification to the local ombudsman was completed for Residents #15 and #145's hospital transfers, as required.

Based on interview and record review, it was determined that the facility failed to complete an admission comprehensive MDS (Minimum Data Set) assessment within the required timeframe. This was evident for 1 (Residents #158) of 12 residents reviewed for resident assessment during the annual survey.The findings include:Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. According to Chapter 2 of CMS's Resident Assessment Instrument (RAI) manual, the admission assessment is a comprehensive assessment for a new resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if this is the resident's first time in this facility On 11/20/25 at 12:22 PM, during an interview with MDS Registered Nurse (RN) Team Leader and MDS Coordinator Licensed Practical Nurse (LPN), they stated that the facility is expected to follow the CMS's timeframe when completing and submitting MDS assessments. They confirmed that the facility was aware of the late completion of the MDS assessments and backlog. They added that the facility has corporate mobile MDS nurses who were assisting.On 11/24/2025 at 8:26 AM, a review of Resident #158's MDS assessment revealed that the admission assessment was not completed within the required time frame. Resident #158 was admitted on [DATE]. An admission assessment was initiated with an ARD of 11/6/25, however, the assessment was still in progress at the time of review. On 11/24/2025 at 8:45 AM, the Director of Nursing (DON) was notified of the late completion of MDS assessments

Based on medical record review, observation and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #122) of 40 residents selected for review during the recertification survey. The findings include:Minimum Data Set (MDS) is part of the U.S. Federally 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 helps nursing home staff identify health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. The facility staff failed to accurately document the Oral/Dental Status of Resident #122 on a Significant Change MDS dated [DATE].Upon admission to the facility on 5/31/24, Resident #122 was assessed and the documentation on the Nursing admission Evaluation Form -V6, Section 3B 4 Oral Status stated, Obvious or likely cavity or broken natural teeth.On 11/18/25 at 9:16 AM the surveyor observed the resident lying in bed with broken teeth that were blackish/greyish in color along with other teeth that were similarly discolored. A review of the clinical record on 11/20/25 at 7:15 AM failed to reveal evidence that the resident was ever evaluated by a dentist while he/she resided in the facility.Further review of Resident #122's medical record revealed a Significant Change MDS was completed on 10/18/25. Under Section L0200 of the MDS, there were several choices for the resident's Oral /Dental Status and a notation stating, check all that apply. Among the choices was D. Obvious or likely cavity or broken natural teeth. The MDS was coded Z. None of the above were present.The MDS Team Leader was interviewed on 11/24/25 at 10:38 AM. She reviewed Resident #122's clinical record including the Nursing admission Evaluation Form dated 5/31/24 and confirmed that the MDS was incorrectly coded.

Based on medical record reviews and interviews it was determined that the facility failed to ensure a Pre-admission screening and Resident Review (PASSR) was completed. This was evident for 1 (Resident #12) out of 28 Resident's reviewed during the annual survey. The findings include:During a review of medical records for Resident #12 on 11/18/2025 at 11:24 AM it was discovered that he/she had been diagnosed with bipolar disorder, major depressive disorder and paranoid schizophrenia. A Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires the facility to Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID).During further review of the medical records for Resident #12 it was revealed that the resident did not have an updated PASSR completed. A PASSR was discovered that had been completed on 2/22/2018 and it reported that the resident did not have a documented mental illness at that time. The Resident was discharged on 1/19/2019.During further record review it was discovered that there was a History and Physical for Resident #12 that was completed on 1/22/2019 that reported the resident had Major Depressive disorder and cognitive impairment. An additional form labeled as a Provider Attestation for Schizophrenia, Schizoaffective or Schizophreniform Diagnosis was found. The form reported Resident #12 had Paranoid Schizophrenia and was taking Depakote for treatment, the form was dated 1/23/2023. There was no updated PASSR found that was completed identifying the paranoid schizophrenia or the major depressive disorder diagnosis. During an interview with the Social Work Director on 11/20/2025 at 1:21 PM he advised that he was not with the facility at the time Resident #12 was admitted into the facility but agreed that if the Resident was admitted with a mental illness then he/she should have had a PASSR that identified those mental illnesses. He confirmed that the diagnosis of schizophrenia should have been identified on the PASSR for Resident #12. During an interview with the Social Work Director on 11/21/2025 at 9:56 AM he reported that he had reviewed the PASSR for Resident #12 and confirmed his/her diagnosis were not on the residents PASSR so he submitted a new PASSR. He reported he was not with the facility at the time the resident was readmitted and is not sure why a new PASSR was not completed.During a review of the facility's Maryland PASRR policy on 11/25/2025 at 11:32 AM it stated Under PASRR, nursing facilities cannot admit or retain an individual who has a serious mental illness, intellectual disability, developmental disability or another related condition unless the Developmental Disabilities Administration (DDA) or the Mental Hygiene Administration (MHA) has determined that a nursing facility placement is appropriate for the individual.

Based on observation, record review and interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for residents with oxygen therapy orders. This was evident for 2 (Resident #163 and #145) of 36 residents reviewed for care planning during the recertification survey.The findings include: 1) 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. Oxygen therapy is a treatment that provides a person with extra oxygen to breathe in. It is also called supplemental oxygen. A nasal cannula is a thin, flexible tube that delivers oxygen through the nose. On 11/17/25 at 11:15 AM, Resident #163 was observed receiving oxygen therapy via nasal cannula that was connected to the concentrator. On 11/21/2025 at 8:11 AM, a review of the active physician orders confirmed an order of 02 (oxygen) at 2LPM (liters per minute) via NC (nasal cannula) continuous every shift for SOB (shortness of breath). On 11/21/2025 at 8:11 AM, a review of the Resident #163's medical record revealed no evidence that a respiratory care plan was initiated for the use of oxygen. On 11/21/2025 at 9:27 AM, the Director of Nursing (DON) stated that care plans were initiated by the nurse upon admission and that any nurse could add and update the care plans later. On 11/21/2025 at 9:43 AM, the surveyor received a copy of the respiratory care plan from Licensed Practical Nurse (LPN #21). The document indicated that the care plan was initiated on 11/21/25 after surveyor intervention. On 11/21/2025 at 10:18 AM, during an interview with LPN #7, he/she stated that residents' care plans were initiated upon admission. He/she added that the Nurse Managers conduct a chart review the following day and the Minimum Data Set (MDS) nurse will add the missing care plans. On 11/21/2025 at10:28 AM, the DON was notified of this concern. 2) On 11/19/25 at 12:47 PM, a review of Resident #145's comprehensive care plan did not reveal a care plan addressing the resident's oxygen therapy needs. On 11/19/25 at 1:15 PM, a review of Resident #145's physician orders revealed the resident had active oxygen therapy orders, including oxygen at 2 liters via nasal cannula as needed for shortness of breath or signs and symptoms of hypoxia, with a start date of 4/27/25. The review also revealed an order to change oxygen tubing and humidifier every 7 days and as needed, with a start date of 4/27/25. On 11/20/25 at 1:25 PM, an interview with the Director of Nursing (DON) revealed that residents with oxygen therapy orders should have a corresponding care plan. The DON confirmed that Resident #145 should have had a care plan addressing oxygen therapy. At the time of exit conference, no additional documentation was provided to show that a care plan addressing oxygen therapy was completed for Resident #145.

Based on observation, record review, and interview, it was determined that the facility failed to administer the correct ordered medication form, follow professional standards of nursing practice and use appropriate infection control practices during medication administration. This was evident for 1 (Resident #90) of 5 residents observed during the medication administration task.The findings include:On 11/20/2025 at 8:52 AM, during the medication administration observation, Registered Nurse (RN #1), removed a pill from the bubble pack and placed it in a 2 oz clear souffle cup with the other medications. After realizing that he/she already placed the same pill in the cup, he/she used fingers to pick up a tablet and returned it to the bubble pack. He/she then crushed the following medications of Resident #90 along with other medications in 2 separate plastics for pill crusher:1. 1 tablet of Aspirin 81 mg enteric coated tablet, however the Physician's order indicated that Aspirin was to be administered in a chewable form.2. 1 tablet of Ferrous sulfate delayed release 325 (65 Fe) MG (Ferrous Sulfate) tablet3. 2 tablets of Levetiracetam 750 mg tablet4. 1 tablet of Metformin 500 mg tablet RN #1 stated that Resident #90 preferred to take the medications in powdered form and mixed in apple sauce.After crushing all the medications, RN #1 grabbed a 4oz clear plastic cup and proceeded to cut it in half with unsanitized scissors taken from the medication cart drawer. He/she poured the crushed medications coming from 2 separate plastic pill containers and mixed with apple sauce. RN #7 was informed of the infection control concerns observed during the preparation of Resident #90's medication. He/she stated she will toss the medication that he/she placed back in the bubble pack On 11/20/2025 at 9:07 AM, RN #7 went inside Resident #90's room to administer the medications and left the medication cart unlocked with her back turned away from the cart, he/she returned to the cart at 9:13 AM. On 11/20/2025 at 9:11 AM, while RN #1 was administering the crushed medication mixture, Resident #90 complained of the taste and subsequently vomited immediately after ingestion. RN #1 stated an intent to notify the Physician.On 11/20/2025 at 9:41 AM, in an interview with Licensed Practical Nurse (LPN #6), he/she confirmed that there was no list of do not crush medications on the medication cart. He/she stated that he/she was sure that Aspirin EC (Enteric Coated) is a do not crush medication.On 11/20/2025 at 10:29 AM, RN #5 confirmed that he/she has not seen a list of do not crush medications on the medication carts, however, he/she indicated that bubble packs should indicate the warning. He/she then pulled a blister pack to show a do not crush warning on the pack, such as the Acetaminophen 650 ER (Extended Release) tablet, DO NOT CRUSH.On 11/20/25 at 11:18 AM, the Director of Nursing (DON) provided a copy of Med that should not be crushed trchealthcare dated April 2025- Resource #410460 from Pharmscript of Maryland confirming that the following medications were not to be crushed with the comments:- Aspirin EC- gastric irritant- Ferrous Sulfate- mucosal irritation- Levetiracetam tablet-bad taste- Metformin- modified release A review of the facility's Medication Administration policy indicated the following:a. Section f. Observe the five rights in giving each medication- the right medicineb. Section k. Do not leave medication cart unlocked.c. Section s. Do not touch the medication, either when opening a liquid or a dose packd. Section t. If oral solid medications cannot be given whole, work with the appropriate clinician and the resident /representative to determine the most appropriate method for administering medications which considers the resident's safety needs, medication schedule, preferences and functional ability.On 11/24/2025 at 8:45 AM, the DON was notified of these findings and acknowledged them.

Based on observations, interviews and medical record review, it was determined the facility failed to ensure that a dependent resident was properly groomed. This was evident for 1 (Resident #18) of 5 residents reviewed for ADLs care during the survey process.The findings include:Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.On 11/17/25 at 11:07 AM the surveyor observed Resident #18 lying in bed. The resident's fingers on both hands were contracted and bent towards each other. His/her fingernails were approximately 1/2 inch long and visibly dirty with dark substances underneath both thumbs and fingers.On 11/18/25 at 11:30 AM the surveyor reviewed the Resdent#18's care plan which was revised on 04/28/25. The care plan stated, ADL Self Care Performance deficit, requires assistance with ADL, Cognitive deficit, . Also, Resident #18's MDS assessment dated [DATE] Section GG revealed that the resident was dependent on staff for ADLs including personal hygiene. The clinical record failed to reveal documentation indicating the resident refused to have their nails cleaned and trimmed.On 11/20/25 at 10:17 AM a second observation by the surveyor revealed Resident #18 fingernails remained uncut and visibly dirty. In an interview the resident stated I eat with my hands, and I would like my nails cleaned.On 10/20/25 at 10:48 AM in an interview with Charge Nurse #10 the surveyor expressed concern regarding the condition of Resident #18's fingernails. The surveyor accompanied Charge Nurse #10 to the resident's room where the findings were confirmed. Charge Nurse #10 stated that because of the resident's contractures, she usually trims and cleans the resident's nails herself but sometimes the resident refuses. The surveyor requested documentation of Resident #18's refusals. The Charge Nurse #10 reviewed the clinical record and stated that she could not find any documentation of the refusals. The Director of Nursing was notified on 11/20/2025 at 11:13 AM of the surveyor's findings.On 11/21/2025 at 11:12 AM Resident #18 was observed lying in bed, nails cleaned and trimmed.

Based on interview, review of a complaint, and record review, it was determined that the facility failed to provide treatment/services to maintain vision. This is evident for 1 (Resident #130) of 2 residents reviewed for communication and sensory problems during the recertification and complaint survey.The findings include:Latanoprost a prescription eye drop medication used to treat eye conditions like glaucoma and ocular hypertension by lowering high pressure inside the eyeball. It works by essentially opening up or relaxing the eye's natural drainage pathways, allowing more fluid to flow out of the eye and into the bloodstream. If the high pressure is left untreated, it can damage the optic nerve and lead to permanent vision loss. On 11/19/2025 at 8:14 AM, Resident #130 stated that he/she could not see clearly even with eyeglasses on. He/she added that this has been going on for several months and was bothering him/her. He/she confirmed being seen by an eye doctor in October but unsure if the facility was addressing the concern. On 11/19/25 at 5:21 PM, a review of complaint #2565121 indicated they felt ignored by the staff and their needs are not being addressed.On 11/20/25 at 3:42 PM, a call to the complainant confirmed the allegation.On 11/21/2025 at 8:55 AM, a review of Resident #130's medical record revealed an Eye care group visit with an exam dated 10/13/2025. The provider confirmed the complaint of blurred vision all distances, both eyes, bothersome for several months and recommended Latanoprost 0.005%, apply 1 drop, both eyes, at bedtime indefinitely; Follow-Up: 1-2 Months. However, a review of Resident #130's active and completed physician orders found no evidence of the Latanoprost medication or treatment being entered or initiated.On 11/21/2025 at 10:25 AM, during an interview Licensed Practical Nurse (LPN #7), he/she stated that when a resident returned from an appointment, the Charge Nurse or Unit Manager would check the consultation note and would notify the attending Physician and the Resident Representative (RP) if there were recommendations. LPN #7 confirmed that the Physician and the RP were not notified, and the order/treatment was not entered and implemented.On 11/24/2025 at 8:45 AM The DON was notified of these concerns.

Based on review of facility documents and staff interview it was determined the facility failed to report an allegation of abuse immediately but not later than 2 hours after an allegation was made. This was evident for 1 (Resident #16) of 13 residents reviewed for a facility reported incident during the complaint survey.The findings include: On 8/4/25 at 2:32 PM, a review of facility reported incident 294211 alleged a male staff member had exposed himself to Resident #16. The facility's investigation documented the facility became aware of the incident on 10/20/24 at 8:00 AM.Review of facility documentation revealed an email confirmation that documented the facility's initial report was sent to the State Survey Agency on 10/20/24 at 11:21 AM. The facility failed to report the allegation of abuse immediately, but not later than 2 hours after the allegation was made.The concerns with the late reporting of an allegation of abuse was discussed with the Nursing Home Administer (NHA) on 8/5/25 at 9:45 AM. The NHA acknowledged the concerns at that time and indicated he would look into the concern.

Based on record review and staff interview, it was determined that the facility failed to ensure that their residents were free of accidents which resulted in harm to resident #2. This was evident for 1 (Resident #2) of 3 residents reviewed for falls. 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. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the 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 medical record review for Resident #2 on 10/10/23 at 8:45 AM revealed a care plan for contractures (a fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the associated body part) that was initiated on 11/1/21. Review of the care plan for activities of daily living (ADL - such as bathing, toileting, eating, and bed mobility) revealed an intervention that read the resident required assistance of 2 staff during ADL care that was initiated on 6/2/22. In addition, the resident had a care plan initiated on 6/3/22, that read s/he was at risk for falls related to quadriplegia and contractures. Review of a quarterly Minimum Data Set with the assessment reference date of 4/23/23, revealed documentation in section I that the resident was a quadriplegic (loss of feeling and use of muscles from the neck down) and diabetes (a condition which the body is unable to use sugar properly and it stays in the bloodstream). A review of section G revealed the resident relied on staff for extensive assistance for most ADLs. A review of the progress notes revealed a note, written on 5/9/23 at 6:18 AM, that read at approximately 5:00 AM, the nurse was told by the GNA that they were providing care and the resident slid off the bed. An assessment was completed, and the resident was found to have an abrasion on the back of his/her head. Further review revealed a note, dated 5/9/23 at 11:51 AM, that the resident was sent to the emergency room because of the fall with head injury. Review of the hospital records for 5/9/23 revealed the hospital tests determined the resident suffered a hematoma (collection of blood) under the scalp and fractured (broke) the femur bone in the hip area. It was also noted that surgery was not recommended, and the resident was discharged back to the facility on [DATE]. During an interview with the Director of Nursing (DON) and NHA on 10/10/23 at 1:45 PM, she reported that GNA #8 (agency staff) had been providing ADL care for Resident #2 on 5/9/23 without assistance of another GNA as per the care plan. She stated that the resident was difficult to handle due to the contracted condition of his/her body. The DON confirmed that GNA #8 rolled the resident away from him/her and the resident rolled out of the bed on the opposite side. The DON stated she had been newly hired at the time of the incident and a mobile DON, through the corporate office, had completed the incident report and the investigation, but they were unable to locate the file. When asked about the interventions to prevent further incidents she reported they care planned the resident as a 2 person assist for ADL care and provided education to GNA #8. However, the care plan showed that the resident had been a 2 person assist for ADLs since 6/2/22. On 10/11/23 at 8:30 AM, an interview with the Nursing Home Administrator (NHA) confirmed that they had an incident report, but no evidence of an investigation for the 5/9/23 fall and the witness statements provided to the surveyor had been recreated on 10/10/23. A review of GNA #8 ' s employee file on 10/11/23 at 2:30 PM revealed no education or competencies completed. On 10/10/23 at 8:45 AM, further review of the progress notes revealed a second incident of a similar nature occurred on 5/27/23. The nurse wrote in a progress note dated 5/27/23, that Resident #2 had been lowered to the floor by a GNA while she was providing care. On 10/10/23 at 11:00 AM, a review of the facility ' s incident report, dated 5/27/23, revealed that the GNA #9 was providing ADL for Resident #2 on 5/27/23 without another staff member present. GNA #9 wrote in her statement that she started providing the care while waiting on the other GNA to come help her. She rolled the resident towards her, but was unable to keep the resident from sliding off the bed, so she lowered the resident to the floor. She reported that In doing this, the resident's lower back was against the bed frame and caused a healed wound on the coccyx (a boney area between the lower back and upper buttocks) to reopen. Further review of the incident report revealed treatment was provided at the facility and the resident had not been transferred out. An interview with the DON and NHA on 10/10/23 at 1:45 PM regarding this incident, the DON reported that GNA #9 was aware that the resident had required 2 person assistance for ADL care and provided the care alone. She reported the GNA was agency staff and was placed on the do not return list. The DON and NHA reported that they provided education to all nursing staff after this incident and included an intervention that the resident was to have a person on each side of his/her bed during ADL care on the care plan and the Kardex (this is a snapshot of the resident ' s care needs that can be accessed by the GNAs on their point of care documentation screen). On 10/11/23 at 2:30 PM, a review of GNA #9 ' s employee file revealed the last annual in-service training was on 2/28/21 and the last clinical skills evaluation was on 2/28/21. The concerns were reviewed with the NHA on 10/11/23 at 3:18 PM.

Based on medical record review and interviews with staff, it was determined that the physician ordered the administration of [MEDICATION NAME] to a resident who had two recent episodes of coffee ground emesis and without monitoring of blood levels. Also, the nursing staff failed to question or address the physician's orders [REDACTED]. This was evident in 1of 34 sampled residents in the Stage 2 review. [MEDICATION NAME] is an anticoagulant (blood thinning medication) used to treat and prevent the formation of blood clots. [MEDICATION NAME] is monitored by a blood test called a PT/INR. A PT/INR measures the time it takes for the blood to clot. The PT/INR test results determine the [MEDICATION NAME] dosage. The desirable range for an INR is 2-3 and elevated levels increase the risk of bleeding. [MEDICATION NAME] requires this careful monitoring due to a significant risk of bleeding during treatment. Due to the physician's failure to ensure an accurate assessment for this resident and nursing failing to question or even address the order, prior to restarting [MEDICATION NAME], placed this resident in jeopardy of having continued and increased bleeding. These findings constituted an Immediate Jeopardy situation at 10:00 AM on April 29, 2013, which was abated at 4:50 PM on April 29, 2013. The findings included: Resident #171 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Due to the resident's medical [DIAGNOSES REDACTED]. [MEDICATION NAME] is also an anticoagulant that is administered through an injection and Aspirin also acts as a blood thinner thereby protecting against [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident was admitted to the facility for rehabilitation with the goal of returning home. According to the medical record the resident was alert and oriented. The resident had orders for [MEDICATION NAME] 6 mg to be given everyday at 5:00 PM and for PT/INRs to be obtained. Review of the medical record revealed that on 12/24/12 a lab report showed the PT at 37.8 and the INR at 3.89. Both values were higher than the therapeutic range. The physician was notified and ordered for the [MEDICATION NAME] to be held (no dates given) and repeat the PT/INR on 12/26/12. Review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. According to the nurse who was on duty on 12/26/12 verified that the PT/INR was changed from 12/26/12 to 12/27/12 so it could be drawn on the regular lab day. According to this statement the physician was in the facility during the evening of 12/26/12 and gave verbal orders for the [MEDICATION NAME] to be restarted on 12/26/12 and that the PT/INR could be obtained on 12/27/12. A PT/INR was obtained on 12/27/12 with a PT of 30.0 and INR of 2.87. Review of a nurse's note dated 12/28/12 at 2:57 PM revealed the resident had a moderate amount of coffee ground emesis at 2:15 PM. Coffee ground emesis is a term used for dark colored vomit containing blood. The physician was called with no response. Further review of a nurse's note revealed that same day at 2:45 PM the resident had another episode of moderate amount of coffee ground emesis. Forty five minutes after the first notification of bleeding, the physician responds at 3:00 PM and gave verbal orders to discontinue the Aspirin (ASA) 81 mg, start [MEDICATION NAME] 40 mg daily for GI [MEDICATION NAME] and continue to hold [MEDICATION NAME] until further notice. Then the order was clarified and written directly underneath the original order, same day, same time, to hold the [MEDICATION NAME] today only 12/28/12 and resume [MEDICATION NAME] 6mg starting 12/29/12. [MEDICATION NAME] is a medication that decreases the amount of acid produced in the stomach. Review of the medical record revealed the physician was going to restart the [MEDICATION NAME] the next day to a resident with two episodes of coffee ground emesis and without first obtaining or monitoring the PT/INR to ensure the resident was not at further risk of increased bleeding. At 5PM on 12/28/12 the resident was now noted, by nursing staff, to have a moderate amount of rectal bleeding in the feces. The physician was notified and a new order was received to send the resident out via emergency transportation for evaluation and treatment. The resident was then admitted to the hospital for treatment of [REDACTED]. During an interview with the physician on 4/25/13 at 11:30 AM he revealed that he would not start [MEDICATION NAME] prior to obtaining a PT/INR especially in someone with known bleeding. He continued to state that he did not know why the order was written to give the [MEDICATION NAME] without a PT/INR. Review of the physician's orders [REDACTED]. As to when the orders were signed was unknown. Despite this physician having the knowledge that this resident was having episodes of coffee ground emesis he ordered for the blood thinning agent [MEDICATION NAME] to be restarted the next day without any assessment of the resident or without any monitoring of any blood work, including an essential PT/INR. Also, even though the nursing staff were aware of the increased risk of administering [MEDICATION NAME] to a resident who is already having bleeding episodes failed to question or address the physician's orders [REDACTED].

Based on medical record review and interviews with staff, it was determined that the physician ordered the administration of [MEDICATION NAME] to a resident who had two recent episodes of coffee ground emesis and without monitoring of blood levels. Also, the nursing staff failed to question or address the physician's orders [REDACTED]. This was evident in 1of 34 sampled residents in the Stage 2 review. [MEDICATION NAME] is an anticoagulant (blood thinning medication) used to treat and prevent the formation of blood clots. [MEDICATION NAME] is monitored by a blood test called a PT/INR. A PT/INR measures the time it takes for the blood to clot. The PT/INR test results determine the [MEDICATION NAME] dosage. The desirable range for an INR is 2-3 and elevated levels increase the risk of bleeding. [MEDICATION NAME] requires this careful monitoring due to a significant risk of bleeding during treatment. Due to the physician's failure to ensure an accurate assessment for this resident and nursing failing to question or even address the order, prior to restarting [MEDICATION NAME], placed this resident in jeopardy of having continued and increased bleeding. These findings constituted an Immediate Jeopardy situation at 10:00 AM on April 29, 2013, which was abated at 4:50 PM on April 29, 2013. The findings included: Resident #171 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Due to the resident's medical [DIAGNOSES REDACTED]. The resident was admitted to the facility for rehabilitation with the goal of returning home. According to the medical record the resident was alert and oriented. The resident had orders for [MEDICATION NAME] 6 mg to be given everyday at 5:00 PM and for PT/INRs to be obtained. Review of the medical record revealed that on 12/24/12 a lab report showed the PT at 37.8 and the INR at 3.89. Both values were higher than the therapeutic range. The physician was notified and ordered for the [MEDICATION NAME] to be held (no dates given) and repeat the PT/INR on 12/26/12. Review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. According to the nurse who was on duty on 12/26/12 verified that the PT/INR was changed from 12/26/12 to 12/27/12 so it could be drawn on the regular lab day. According to this statement the physician was in the facility during the evening of 12/26/12 and gave verbal orders for the [MEDICATION NAME] to be restarted on 12/26/12 and that the PT/INR could be obtained on 12/27/12. A PT/INR was obtained on 12/27/12 with a PT of 30.0 and INR of 2.87. Review of a nurse's note dated 12/28/12 at 2:57 PM revealed the resident had a moderate amount of coffee ground emesis at 2:15 PM. Coffee ground emesis is a term used for dark colored vomit containing blood. The physician was called with no response. Further review of a nurse's note revealed that same day at 2:45 PM the resident had another episode of moderate amount of coffee ground emesis. Forty five minutes after the first notification of bleeding, the physician responds at 3:00 PM and gave verbal orders to discontinue the Aspirin (ASA) 81 mg, start [MEDICATION NAME] 40 mg daily for GI [MEDICATION NAME] and continue to hold [MEDICATION NAME] until further notice. Then the order was clarified and written directly underneath the original order, same day, same time, to hold the [MEDICATION NAME] today only 12/28/12 and resume [MEDICATION NAME] 6mg starting 12/29/12. [MEDICATION NAME] is a medication that decreases the amount of acid produced in the stomach. Review of the medical record revealed the physician was going to restart the [MEDICATION NAME] the next day to a resident with two episodes of coffee ground emesis and without first obtaining or monitoring the PT/INR to ensure the resident was not at further risk of increased bleeding. At 5PM on 12/28/12 the resident was now noted, by nursing staff, to have a moderate amount of rectal bleeding in the feces. The physician was notified and a new order was received to send the resident out via emergency transportation for evaluation and treatment. The resident was then admitted to the hospital for treatment of [REDACTED]. During an interview with the physician on 4/25/13 at 11:30 AM he revealed that he would not start [MEDICATION NAME] prior to obtaining a PT/INR especially in someone with known bleeding. He continued to state that he did not know why the order was written to give the [MEDICATION NAME] without a PT/INR. Review of the physician's orders [REDACTED]. As to when the orders were signed was unknown. Despite this physician having the knowledge that this resident was having episodes of coffee ground emesis he ordered for the blood thinning agent [MEDICATION NAME] to be restarted the next day without any assessment of the resident or without any monitoring of any blood work, including an essential PT/INR. Also, even though the nursing staff were aware of the increased risk of administering [MEDICATION NAME] to a resident who is already having bleeding episodes failed to question or address the physician's orders [REDACTED].