Every finding on record at Future Care Canton Harbor

Based on observations, record reviews and interviews with the resident family and facility staff, it was determined the facility failed to provide documentation of a resident refusal to get out of bed. This was found to be evident during observations of 1 (Resident # 6) of 2 residents reviewed for activities during the survey.Findings include:Based on record review, Resident # 6 had the following but not limited diagnosis: Nontraumatic Intracerebral Hemorrhage (Stroke)On 9/15/25 at 8:45 AM an observation was made of Resident # 6 lying in bed in the bedroom. No activities were observed. Another observation was made on the same date at 12:30PM and the resident was lying in the bed in the bedroom. No activities were observed.During a family interview conducted on 9/15/25 at 2:17 PM the family expressed concerns about staff not getting the resident out of bed. The family went on to say that they visited Resident # 6 the prior weekend, and the resident was lying in bed. They stated that there was no wheelchair available, so they were unable to take the resident out of the room during their visit.Additional observations were made on 9/16/25 at 9:00AM and 4:30PM, and Resident # 6 was lying in bed. No activities were observed at the time of the observations. Staff #16, the resident assigned GNA was in the hallway near the resident room at 4:30PM and was asked what time she gets Resident #6 out of the bed and she stated that she does not usually get the resident up.On 9/17/25 at 8:30AM an observation was made of Resident # 6 and s/he was lying in bed in the bedroom. No activities were observed. The resident's assigned GNA #14 was in the hallway at the time of the observation and was asked if she gets the resident up out of bed to the chair, and she stated that the resident does not usually get up. She went on to explain that the resident was a fall risk and if the resident was up in the chair too long, the resident would try to get up.On 9/17/25 at 9:00AM Resident #6 self-care deficit care plan was reviewed. One of the goals listed was as follows: Resident will be able to tolerate Out of Bed (OOB) in chair- 2 hours. During an interview with the DON on the same date at 10:00AM, she was made aware of the surveyor observations of the resident being in bed for the past three days and the family's concern that staff did not get the resident out of bed. The DON stated that the resident refuses to get out of bed but was unable to provide documentation of non-compliance to the survey team. The DON acknowledged that the goal was for the resident to get up out of bed and will educate her staff to get the resident up and to document any refusals.All concerns were discussed with the Administration team at the exit conference on 9/18/25.

Based on observations and interviews with facility staff, it was determined the facility failed to protect residents' personal health information from being publicly displayed. This was found to be evident for 3 (Resident # 4, # 30, and # 136) of 3 residents observed with Covid precaution signs posted during the facility's survey.Findings include: An observation was made of the 100-unit hallway on 9/15/25 at 9:00AM and the following concerns were identified:On the entrance doorway leading into Resident # 4 and Resident # 131's room, there was a sign posted indicating the following information: Stop Covid Precautions. Keep door closed. Additional instructions on personal protective equipment were also on the posted sign.On the entrance doorway leading into Resident # 30 room, there was a sign posted indicating the following information: Stop Covid Precautions. Keep door closed. Additional instructions on personal protective equipment were also on the posted sign.On the entrance doorway leading into Resident # 136 room, there was a sign posted indicating the following information: Stop Covid Precautions. Keep door closed. Additional instructions on personal protective equipment were also on the posted sign.An interview was conducted at the time of the observations with the Nurse #12 assigned to the unit and she stated that the residents in each of the rooms had Covid and that blue tape was also placed on the floor in front of each of the rooms.A subsequent interview was conducted with the Regional Clinical Nurse (RCN # 4) at approximately 1:30PM and she was made aware of the sign displaying the resident's personal health information and that it was not protected. The RCN confirmed that this was a violation of the residents' privacy and stated that the signs would be removed. A follow-up observation on the same date found the signs were replaced with droplet precaution signs.All concerns were discussed with the Administration team at the exit conference on 9/18/25.

Based on complaints, reviews of active and closed medical records, reviews of the residents' electronic medical records, and interviews with staff members, it was determined that the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident in 3 (Resident #2, #6, #10) of 11 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. 1) A review of complaint MD00204530 on [DATE] revealed an allegation Resident #2 was not being provided incontinence care timely. A review of Resident #2's closed medical record revealed that Resident #2 was originally admitted to the facility on [DATE] and then readmitted to the facility on [DATE] due to being sent to the hospital for the reinsertion of a feeding tube. Resident #2 is totally dependent upon the facility staff for all of her care and needs. Further review of Resident #2's closed medical revealed a readmission skin assessment that was documented as being performed on [DATE] at 1:36 AM. At this time, Resident #2 was identified with 4 - stage II wounds. They included: Site #1 - a new Left Gluteal Fold, Pressure Injury, Stage II, that measured 1 cm x 0.4 cm, ,d+[DATE]% epithelial skin present, with redness observed. Site #2 - a new Left Gluteal Fold, Pressure Injury, Stage II, that measured 1 cm x 0.5 cm, ,d+[DATE]% epithelial skin present. Site #3 - a new Left Inner Buttock, Pressure Injury, Stage II, that measured 1 cm x 2 cm, ,d+[DATE]% epithelial skin present, with Wound edges that are Undefined/Irregular, and redness was observed. Site #4 - a new Right Inner Buttock, Pressure Injury, Stage II, that measured 2 cm x 2 cm, ,d+[DATE]% epithelial skin present, with Wound edges that are Undefined/Irregular, and redness was observed. Greer's goo ointment was indicated as treatments for the wounds. After the [DATE] readmission skin assessment that identified the 4 different - Stage II wounds on Resident #2 skin, the staff failed to document on a skin record if the 4 different wounds healed or deteriorated before being sent to the hospital on [DATE]. Between [DATE] and [DATE], Resident #2's physician failed to document a skin assessment on the following assessment dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 11:08 AM the Nurse Practitioner documented Resident #2 was being treated with Greer's [NAME] for sacral excoriation. Resident #2 was sent to the hospital on [DATE] after a fall and did not return to the facility. A review of Resident #2's care plans on [DATE] revealed an impaired skin integrity prevention care plan related to Resident #2's fragile skin and decreased mobility. This care plan was initiated on [DATE]. The goal was to maintain Resident #2's intact skin through the review period. Nursing approaches included: to remind/assist resident to turn/reposition at least every 2 hours, apply arm/leg protectors per order, apply air mattress per order, apply barrier cream after each incontinent episode, apply a brief as needed, apply a pressure reducing cushion to chair, apply a pressure relieving mattress to bed, to avoid scrubbing and pat dry sensitive skin, clean peri-area after each incontinent episode, then apply barrier cream. After Resident #2 was readmitted to the facility on [DATE] and identified with 4 new areas of skin breakdown (4 - stage II wounds), the facility staff failed to update Resident #2's impaired skin integrity prevention care plan to an actual impairment skin integrity and update the nursing interventions on [DATE]. On [DATE], the facility wound nurse did update Resident #2's skin/wound prevention care plan. The skin/wound prevention care plan goal was to heal Resident #2's right inner buttocks, Gluteal crease moisture associated skin damage. On [DATE], Nursing approaches were updated included: monitor Resident #2's wounds for effectiveness, assist resident to turn/reposition at least every 2 hours, a nurse to perform weekly assessments, document and notify providers of changes, observe for changes and report changes to the nurse, and to provide education to resident/family/caregivers related to impaired skin integrity and plan of care. Resident #2 was sent to the hospital on [DATE] and did not return to the facility. Review of Resident #2's [DATE] readmission care plan summary that was created on [DATE] at 2:21 AM, revealed a nursing skin condition that indicated Resident #2 was readmitted with a pressure injury. Resident #2's family was not presented with the readmission care plan summary until [DATE] via a telephone call. In an interview with the facility wound nurse and the Director of Nurses on [DATE] at 11:44 AM, the facility wound nurse stated that the facility does have a Wound Care Physician that assesses residents weekly but does not see Residents Identified with Stage I or II wounds unless she asks for a consultation. The wound nurse stated that she documents resident skin/wound assessments on paper and then at a later time she will document the resident skin/wound assessments in the resident's electronic medical record. The wound nurse stated it takes time to place my skin/wound assessments into the computer. The nurse surveyor indicated that he was unable to locate any wound assessments regarding Resident #2 wounds after being readmitted on [DATE]. The nurse surveyor requested the wound nurse to locate any written/paper assessments that she may have regarding Resident #2. In an interview with the Regional Nurse Consultant on [DATE] at 12:25 PM, the Regional Nurse Consultant stated that the wound nurse could not locate any paper/written skin/wound assessments for Resident #2. The Regional Nurse Consultant also stated that the wound nurse did document in the electronic medical record that on [DATE] Resident #2's 4 - stage II wounds identified on [DATE] were moisture associated skin damage (MASD). These [DATE] wound nurse assessments were entered into Resident #2's electronic medical record on [DATE] as late entries after the Resident had been discharged from the facility. 2) A review of complaint MD00213834 on [DATE] revealed an allegation Resident #6 was not receiving quality care and being not cared for properly. A review of Resident #6's closed medical record revealed that Resident #6 was admitted to the facility on [DATE] with diagnoses that included a post-surgical orthopedic procedure due to a fractured right ankle and cystitis with pyuria. A review of Resident #6's closed medical record on [DATE] 12 PM revealed a physician order dated [DATE] at 11 PM instructing the nursing staff to apply a pressure relieving mattress to the bed every shift for skin protection and offloading. A review of Resident #6's [DATE] Treatment Administration Record (TAR) revealed that the nursing staff signed off, every shift, that a specialty mattress had been applied to Resident #6's bed starting on [DATE]. In an interview with the facility Central Supply Director (Staff Member #27) on [DATE] at 2:45 PM, The Central Supply Director stated that she does not have a supply of specialty mattresses in the facility and that a specialty mattress has to be ordered by the nursing staff through our vendor. In an interview with the facility Corporate Nurse, [DATE] at 2:45 PM, the facility Corporate Nurse stated that the facility admissions director or the nursing unit manager will order specialty mattresses for the residents. The facility Corporate Nurse presented the nurse surveyor with a mattress order receipt that indicated the facility received a specialty mattress for Resident #6 on [DATE]. The Corporate Nurse confirmed that the nursing staff were signing off the use of a specialty mattress for Resident #6's bed since [DATE] but the mattress had not been delivered and applied to Resident #6's bed until [DATE]. 3) A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must accurately and legibly complete the form and then sign and date it. This also includes correctly identifying the name of the resident at the top of the form. Voiding the Form: to void this medical order form, a physician or nurse practitioner shall draw a line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician or nurse practitioner to void the MOLST form. Keep the voided order form in the patient's active or archived medical record. In Maryland Law: Surrogates and Life-Sustaining Treatment: A surrogate may consent to the withholding or withdrawal of life-sustaining procedures if the patient's attending physician and a consulting physician certify, to a reasonable degree of medical certainty, that the patient has a terminal or end-stage condition or is in a persistent vegetative state. A surrogate may not consider a patient's pre-existing, long-term mental or physical disability in making a decision to withhold or withdraw life-sustaining procedures. A surrogate who is a guardian usually must obtain the court's permission to authorize the withholding or withdrawal of life-sustaining procedures. Review of complaint MD00210555 on [DATE] revealed an allegation Resident #10 was not receiving quality care while residing in the facility. A review of Resident #10's medical record on [DATE] at 12:56 PM revealed 2 current MOLST forms in Resident #10 paper medical record. The first MOLST form was dated [DATE] and indicated Resident #10 did not want: CPR, option a - 2, to be placed on a ventilator, did not want blood products, did not want artificial nutrition and hydration, and did not want dialysis. The second MOLST form found in Resident #10's medical record was dated [DATE] and indicated that Resident #10 wanted to be a Full Code. The back page of the [DATE] MOLST form had not been completed. The two active incongruent MOLST forms could be confusing to staff if an emergency situation arose regarding Resident #10. The facility corporate Registered Nurse (RN) was immediately made aware of the situation, she contacted Resident #10's attending physician who was in the facility. Resident #10's physician voided the [DATE] MOLST form.

Based on complaint, reviews of a closed medical record, reviews of the resident's electronic medical records, and interviews with facility staff members, it was determined that the facility staff failed to 1) update a resident's skin and wound care plan after being readmitted with actual stage II wounds, 2) document a resident's assessment timely demonstrating the healing or deterioration of a resident's Stage II wounds, and notifying the resident's physician and family of the resident's stage II wounds. This was evident in 1 (Resident #2) of 11 residents reviewed during a complaint survey. The findings include. 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 review of complaint MD00204530 on 03/20/25 revealed an allegation Resident #2 was not being provided incontinence care timely. A review of Resident #2's closed medical record revealed that Resident #2 was originally admitted to the facility on [DATE]. Resident #2 then went to the hospital on 04/07/24 and then readmitted to the facility on [DATE] for the reinsertion of a feeding tube. Resident #2 is totally dependent upon the facility staff for all of her care and needs. Further review of Resident #2's closed medical revealed a readmission skin assessment that was documented as being performed on 04/09/24 at 1:36 AM. At this time, Resident #2 was identified with 4 - stage II wounds. They included: Site #1 - a new Left Gluteal Fold, Pressure Injury, Stage II, that measured 1 cm x 0.4 cm, 25-50% epithelial skin present, with redness observed. Site #2 - a new Left Gluteal Fold, Pressure Injury, Stage II, that measured 1 cm x 0.5 cm, 51-75% epithelial skin present. Site #3 - a new Left Inner Buttock, Pressure Injury, Stage II, that measured 1 cm x 2 cm, 51-75% epithelial skin present, with Wound edges that are Undefined/Irregular, and redness was observed. Site #4 - a new Right Inner Buttock, Pressure Injury, Stage II, that measured 2 cm x 2 cm, 51-75% epithelial skin present, with Wound edges that are Undefined/Irregular, and redness was observed. Greer's goo ointment was indicated as treatments for the wounds. After the 04/09/24 readmission skin assessment that identified the 4 different - Stage II wounds on Resident #2 skin, the staff failed to document on a skin record if the 4 different wounds healed or deteriorated before being sent to the hospital on 04/28/24. Between 04/09/24 and 04/25/24, Resident #2's physician failed to document a skin assessment on the following assessment dates: 04/09/24, 04/11/24, 04/12/24, 04/15/24, 04/16/24, 04/18/24, 04/19/24, 04/23/24, and 04/24/24. On 04/26/24 at 11:08 AM the Nurse Practitioner documented Resident #2 was being treated with Greer's [NAME] for sacral excoriation. Resident #2 was sent to the hospital on 04/28/24 after a fall and did not return to the facility. A review of Resident #2's care plans on 03/20/25 revealed an impaired skin integrity prevention care plan related to Resident #2's fragile skin and decreased mobility. This care plan was initiated on 03/22/24. The goal was to maintain Resident #2's intact skin through the review period. Nursing approaches included: to remind/assist resident to turn/reposition at least every 2 hours, apply arm/leg protectors per order, apply air mattress per order, apply barrier cream after each incontinent episode, apply a brief as needed, apply a pressure reducing cushion to chair, apply a pressure relieving mattress to bed, to avoid scrubbing and pat dry sensitive skin, clean peri-area after each incontinent episode, then apply barrier cream. After Resident #2 was readmitted to the facility on [DATE] and identified with 4 new areas of skin breakdown (4 - stage II wounds), the facility staff failed to update Resident #2's impaired skin integrity prevention care plan to an actual impairment skin integrity and update the nursing interventions on 04/09/24. On 04/29/24, the facility wound nurse did update Resident #2's skin/wound prevention care plan. The skin/wound prevention care plan goal was to heal Resident #2's right inner buttocks, Gluteal crease moisture associated skin damage. On 04/29/24, Nursing approaches were updated included: monitor Resident #2's wounds for effectiveness, assist resident to turn/reposition at least every 2 hours, a nurse to perform weekly assessments, document and notify providers of changes, observe for changes and report changes to the nurse, and to provide education to resident/family/caregivers related to impaired skin integrity and plan of care. Resident #2 was sent to the hospital on 04/28/24 and did not return to the facility. The nursing staff were unable to implement these new interventions since the care plan had not been updated until 04/29/24 after Resident #2 was discharged from the facility on 04/28/24. Review of Resident #2's 04/08/24 readmission care plan summary that was created on 04/09/24 at 2:21 AM, revealed a nursing skin condition that indicated Resident #2 was readmitted with a pressure injury. Resident #2's family was not presented with the readmission care plan summary until 04/22/24 via a telephone call. In an interview with the facility wound nurse and the Director of Nurses on 03/20/25 at 11:44 AM, the facility wound nurse stated that the facility does have a Wound Care Physician that assesses residents weekly but does not see Residents Identified with Stage I or II wounds unless she asks for a consultation. The wound nurse stated that she documents resident skin/wound assessments on paper and then at a later time she will document the resident skin/wound assessments in the resident's electronic medical record. The wound nurse stated it takes time to place my skin/wound assessments into the computer. The nurse surveyor indicated that he was unable to locate any wound assessments regarding Resident #2 wounds after being readmitted on [DATE]. The nurse surveyor requested the wound nurse to locate any hand written/paper assessments that she may have regarding Resident #2's wounds. In an interview with the Regional Nurse Consultant on 03/21/25 at 12:25 PM, the Regional Nurse Consultant stated that the wound nurse could not located any hand written paper/written skin/wound assessments for Resident #2. The Regional Nurse Consultant also stated that the wound nurse did document in the electronic medical record that on 04/11/24 Resident #2's 4 - stage II wounds, identified on 04/08/24, were moisture associated skin damage (MASD). The 04/11/24 wound assessments were entered into Resident #2's electronic medical record on 04/29/24 as late entries after the Resident had been discharged from the facility.

Based on complaint and reviews of a closed medical record, it was determined that the facility staff failed to follow a physician's order to administer an antibiotic for 3 days, a total of 6 doses. This was evident for 1 (Resident #6) of 11 residents reviewed during a complaint survey. The findings include: A review of complaint MD00213834 on 03/27/25 revealed an allegation Resident #6 was not receiving quality care and not being cared for properly. A review of Resident #6's closed medical record revealed that Resident #6 was admitted to the facility on [DATE] with diagnoses that included post-surgical orthopedic procedure due to a fractured right ankle and cystitis with pyuria. A review of Resident #6's closed medical record on 03/27/25 at 12 PM revealed a physician order dated 01/18/25 at 9 AM instructing the nursing staff to administer the antibiotic, Cefpodoxime Proextill, 100 mg, orally, every 12 hours for cystitis for 3 days. A review of Resident #6's January 2025 Medication Administration Record (MAR) revealed Resident #6 did not receive a dose of the antibiotic on 01/18/25. A review of Resident #6's nursing progress notes, dated 01/18/25 at 2:11 PM revealed a nursing progress note indicating that the charge nurse had contacted the facility pharmacy and requested the pharmacy to send Resident #6's antibiotic stat. Further review revealed that Resident #6 only received 2 doses of the antibiotic on 01/19/25 and 01/20/25 (4 doses). The nursing staff failed to administer a total of 6 doses of the antibiotic Cefpodoxime Proextill to Resident #6 every 12 hours over 3 days for a total of 6 doses. The facility administrator and corporate nurse were made aware of the finding during the exit conference on 04/01/25 at 1:30 PM.

Based on medical record review, administrative record review, and staff interview; it was determined that the facility failed to protect a cognitively impaired resident (resident #1) from physical abuse from a facility staff member. This was evident for 1 of 5 residents reviewed for abuse during a complaint survey. This failure to protect residents from physical abuse by a facility staff member resulted in an Immediate Jeopardy. However, the facility developed, initiated, and completed an acceptable plan of correction to prevent further abuse which met all elements of past noncompliance. The period of noncompliance began on 2/12/24 and ended on 2/20/2024. The findings include: The following terms are defined for comprehension of the investigative findings: Minimum Data Set (MDS): The Minimum Data Set (MDS) is a comprehensive assessment of a resident completed by facility staff. The MDS is a multi-discipline tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain, and medications to name a few] to be addressed. The MDS assessment is part of the broader Resident Assessment Instrument (RAI) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive status. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. A score of 99 indicates the facility was unable to complete the assessment. The findings include: On 4/8/24 at 9:00 am, surveyor review of resident #1's medical record revealed resident #1 was admitted to the facility alert and oriented x3 with a BIMS 15/15 documented in the quarterly MDS assessment dated [DATE]. On 4/8/24 at 10:00 am, surveyor review of facility reported incident intake MD#00202562, dated 2/13/2024, revealed that on 2/12/24 resident #1 alleged that he/she was punched in the nose by Agency GNA #1. On 4/8/24 at 10:30 am, surveyor review of related complaint MD#00204268, dated 4/2/2024, alleged resident #1 received improper treatment by the facility. On 4/8/24 at 11:00 am, surveyor review of the facility's investigation of the incidents that occurred on 2/12/24 revealed the facility's investigation contained a witness statement from Agency LPN#4, dated 2/13/24, which revealed that on 2/12/24 at approximately 5:00 pm resident #1 required care after Agency LPN #4 observed resident #1's room was soiled from urine and stool after resident #1 detached his/her colostomy bag. On 2/12/24 at approximately 5:15 pm, Agency LPN#4 asked Agency GNA #1 to assist resident #1 with his/her care while Agency LPN #4 finished necessary nursing tasks. On 2/12/24 at approximately 5:30 pm, Agency LPN #4 then stated in the witness statement that Agency GNA #1 came to him/her and reported that resident #1 hit him/her in the mouth while he/she was providing care. On 2/12/24 at approximately 5:45 pm, Agency LPN #4 and RN Night Supervisor #5 entered resident #1's room and found resident #1's nose bleeding. Agency LPN #4 stated that he/she immediately provided treatment by applying ice to resident #1's nose to stop the bleeding. Agency LPN #4 also stated that resident#1 told him/her that he/she was punched in the nose by Agency GNA #1. On 4/8/24 at 11:30 am, surveyor review of witness statements from GNA #2 and GNA #3, both dated 2/13/24, revealed that GNAs #2 and #3 observed resident #1 entering Unit 3's dining room on 2/12/24 at approximately 6:15 pm. GNA #2 and GNA #3 observed that resident #1 had scant bleeding from his/her nose when he/she stated that a GNA punched him/her in the nose. GNA #2 and #3 observed Agency GNA#1 enter Unit 3's dining room on 2/12/24 at approximately 6:20 pm. GNA #2 and #3 stated in their witness statements that they heard resident #1 apologize to Agency GNA #1 for hitting him/her in the mouth and resident #1 added, .but you hit me first. Further review of the facility investigation on 4/8/24 at 11:45 am revealed facility nursing staff failed to inform the facility's DON or the Executive Director after the discovery of the alleged abuse of resident #1. Agency LPN #4 and GNA #3 contacted RN Night Supervisor #5 to report the alleged abuse of resident #1 on 2/12/24 by approximately 6:30 pm. The Director of Nursing (DON) discovered the alleged abuse of resident #1 on 2/13/24 when he/she viewed local hospital records of resident #1's emergency room visit. Continued review of the facility investigation on 4/8/24 at 11:50 am revealed resident #1 self-contacted law enforcement on 2/12/24 at approximately 10:30 pm. According to the witness statement from RN Night Supervisor #5, resident #1 told local law enforcement that he/she was not being treated well in the facility and he/she was also having chest pains. Resident #1 requested to be transferred to the local hospital for treatment. On 4/8/24 at 12:30 pm, surveyor review of local hospital records detailing resident #1's admission assessment on 2/13/24 at 9:22 pm revealed the hospital assessed the resident and found mild soft tissue swelling in the left nose area after taking a maxillofacial CT scan. On 4/8/24 at 1:59 pm, surveyor interview with Agency LPN#4 confirmed the written statement in the facility investigation. Agency LPN #4 also added that resident #1's nose was not bleeding prior to care being provided by Agency GNA#1 on 2/12/24 at approximately 5:15 pm. After care was provided by Agency GNA #1, Agency LPN#4, and RN Night Supervisor #5 observed resident #1 was bleeding from his/her nose that required treatment to stop on 2/12/24 at approximately 5:45 pm. Agency LPN #4 confirmed that he/she treated resident #1's nosebleed with ice. Agency LPN #4 also added that resident #1 was not violent or uncontrollable when he/she made contact with the resident after his/her contact with Agency GNA #1 on 2/12/24 at approximately 5:45 pm. Resident #1 told Agency LPN #4 on 2/12/24 at approximately 5:45 pm that Agency GNA #1 punched him/her in the nose. On 4/8/24 at 2:55 pm, surveyor interview with Agency GNA #1 confirmed that Agency GNA #1 was in resident #1's room on 2/12/24 at approximately 5:30 pm. Agency GNA #1 also confirmed the statements made by GNAs #2 and #3. Agency GNA #1 stated that he/she entered the Unit #3's dining room on 2/12/24 at approximately 6:15 pm where two other GNAs (GNAs #2 and #3) were feeding residents. Agency GNA #1 stated that resident #1 approached him/her and stated . I know I punched you in the mouth, but you punched me first. Agency GNA #1 stated resident #1 was winking at him/her when the statement was made in the Unit 3 dining room. Agency GNA #1 then stated that he/she turned to GNAs #2 and #3 and stated, Did you see that he/she (resident #1) winked when he/she said that to me? Agency GNA #1 stated that GNAs #2 and #3 did not respond to her statement about resident #1. On 4/9/24 at 11:45 am, surveyor interview with the Executive Director, DON, Regional Director of Operations, and Regional Clinical Services Manager revealed that Agency GNA #1's last day working at the facility was 2/12/24. The DON stated that Agency GNA #1 was placed on the Do Not Call list on 2/15/24 when he/she refused to return to the facility on [DATE] for re-training on abuse prohibition. The Regional Executive Director provided proof of abuse and prohibition education that was given to all nursing staff. Medical record review on 4/9/24 at 12:30 pm revealed resident #1 had care plans which contained interventions for behavior that included resident swinging at staff and physically and verbally abusing staff since 1/22/24. On 4/11/24 at 11:30 am, the DON provided the surveyor with facility reports on all agency staff that worked in the facility from 2/12/24 to the present. The DON also provided proof that all agency staff received abuse prohibition training from their agency and refresher training from the facility prior to their first shift. Review of the information given by the DON revealed that the facility employed agency staff from 2 nursing agencies, Agency A and Agency B. Agency GNA #1 was employed by Agency B. The DON provided proof of a background check (dated 4/25/23), completion of abuse prohibition training by Agency B (dated 12/4/23) and completion of abuse prohibition training by the facility (dated 11/3/23). The information obtained from Agency B also contained confirmation that Agency GNA #1 worked in the facility on 2/12/24 at 3:00 pm to 2/13/24 at 7:00 am. On 4/11/24 at 1:30 pm, interview with the DON, Executive Director, Regional Director of Operations and Regional Clinical Services Manager revealed the RN Night Supervisor #5 failed to remove Agency GNA #1 from the building after resident #1 alleged Agency GNA #1 hit him/her in the nose. RN Night Supervisor #5 told Agency GNA #1 that resident #1 was no longer assigned to him/her. The interview also revealed the resident was transferred to the local hospital after his/her complaint to local law enforcement on 2/12/24 at approximately 10:00 pm. The surveyor asked the facility administration team why the RN Night Supervisor #5 failed to remove Agency GNA #1 from the facility after resident #1 alleged that he/she was punched in the nose by Agency GNA #1. None of the facility administration team was able to explain why Agency GNA #1 was allowed to work the remainder of the shift on 2/12/24 (after 6:00 pm) to 2/13/24 at 7:00 am. The surveyor also asked the DON when he/she became aware of resident #1's allegation of abuse. The DON stated that he/she became aware of the abuse allegation when he/she reviewed local hospital records for resident #1's status on 2/13/24. The local hospital records documented that resident #1 alleged that he/she was punched in the nose on 2/12/24. The DON further stated that he/she started the abuse investigation on 2/13/24. The DON stated that he/she suspended Agency GNA #1 from all of his/her scheduled shifts until completion of the abuse investigation. On 4/12/24 at 12:00 pm, the Executive Director, DON, Regional Director of Operations and Regional Clinical Services Manager were notified by the surveyor that the facility failed to protect a cognitively impaired resident (resident #1) from physical abuse from a facility staff member (Agency GNA #1). The facility's failure to remove Agency GNA #1 from the facility on 2/12/24, after nursing supervisory staff became aware of the allegation of abuse, placing all residents in the facility in immediate jeopardy. Agency GNA#1 was allowed to continue working from 2/12/24 at approximately 6:00 pm to 2/13/24 at 7:00 am. The facility's corrective actions included: Suspending all up-coming scheduled shifts for Agency GNA #1 as of 2/13/24 at approximately 2 pm. Agency GNA #1 was also placed on the facility's Do Not Call List as of 2/15/24 due to his/her refusal to return to the building for one-on-one abuse prohibition training. Creating a QAPI plan to prevent future errors in adherence to CMS abuse procedures including re-education of all nursing staff (including agency staff) by 2/20/24, auditing all abuse complaints to ensure the facility adhered to the 2 hours time limit for reporting of alleged abuse by 4/1/24. A review of the facility records and staff interviews revealed that the facility completed corrective actions on 2/29/24. This deficient practice was cited as past noncompliance with Federal and State requirements with a compliance date of 2/20/24.

Based on tour, observation, and interview, it was determined that the facility failed to secure and monitor chemicals in an active resident area. This was evident during a random tour on the 3rd floor of the facility. The findings include: During a tour on the 3rd floor of the facility at 12:44 PM on 4/11/24 revealed a maintenance cart with 4 cans of Ultra Power Foam for stripping and cleaning the floors. It was observed and noted at this time that multiple rooms were being deep cleaned. An additional can of the Ultra Power Foam was sitting on the railing next to room [ROOM NUMBER]. This surveyor continued observations through 12:53 PM when the facility Assistant Director of Nursing arrived on the floor and made the same observations. The chemicals remained on the floor as 2 residents were observed rolling down the hall. Resident #6 stopped at all the items and stated 'wow there is a lot of stuff here.' Their medical records were reviewed on 4/12/24 at 10:20 AM. Resident #6 was documented with a brief interview of mental status (BIMS) 3 meaning severe cognitive impairment according to his/her 3/2024 MDS and Resident was documented with a BIMS of 15, according to the 2/2024 MDS, meaning that s/he is cognitively intact. Staff #13, identified as a floor tech, was interviewed at 1:05 PM on 4/11/24. He acknowledged that he was responsible for the chemicals that were left on the floor. This surveyors' observations and concerns were reviewed with him at that time. He took the cart, moved it to a corner and placed a 'wet floor' sign in front of it. These concerns were reviewed with the facility DON on 4/11/24 at approximately 1:30 PM

Based on review of facility reported incident investigations and interview, it was determined the facility staff failed to thoroughly investigate allegations of abuse. This was evident for 1 (Resident #2) of 5 residents reviewed for abuse during a complaint survey. The findings include: 1) On 4/11/2024 at 9:30 AM, review of Facility Reported Incident (FRI), MD00202778, revealed that Resident #2's sister reported on 2/19/2024 that the resident told her a couple of weeks ago that Geriatric Nursing Assistant (GNA # 11) told him/her To shut up and was rough with care. Further review of the facility investigation report of the incident on 4/11/2024 at 11:00 AM, revealed that there were interviews /statements from staff and other residents. However, some of the interview statements on file did not indicate the titles nor identify the persons completing the forms and/or the date the statements were obtained. There was no interview statement of the resident, resident's roommate and/or statements from other residents. The investigation was not thorough. On 4/11/2024 at 12:50 PM, in an interview with the Director of Nursing (DON) in the presence of the Regional Clinical Services Manager (Staff #7), the surveyor asked if DON had documentation of residents' interviews. DON stated that she did not have. Surveyor informed them that the investigation was not thorough as interview statements were incomplete and did not identify the persons completing the interviews, no statements from the resident, resident's roommate, and/or other residents on file. 2) On 4/11/2024 at 1:15 PM, review of Facility Reported Incident (FRI), MD00202775, revealed Resident #2 alleged that staff took their call bell from them and shut the door. Further review of the facility investigation report of the incident on 4/11/2024 at 1:50 PM, noted resident and staff interviews. However, only staff statements/interviews were on file. There was no interview statement of the resident, resident's roommate, and/or other residents on file. The investigation was not thorough. On 4/11/2024 at 2:05 PM, in an interview with the Director of Nursing (DON), they were informed that the investigation of the above allegation was not thorough: No evidence of Resident #2, resident's roommate and/or any other residents' interviews on file. DON provided no new/additional information to validate that the above allegation was thoroughly investigated.

Based on medical record review, administrative record review, and staff interview; it was determined that the facility failed to report the alleged abuse of a cognitively impaired resident (resident #1) to the proper authorities. This was evident for 1 of 5 residents reviewed for abuse during a complaint survey. The following terms are defined for comprehension of the investigative findings: Minimum Data Set (MDS): The Minimum Data Set (MDS) is a comprehensive assessment of a resident completed by facility staff. The MDS is a multi-discipline tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain, and medications to name a few] to be addressed. The MDS assessment is part of the broader Resident Assessment Instrument (RAI) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive status. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. A score of 99 indicates the facility was unable to complete the assessment. The findings include: On 4/8/24 at 9:00am, surveyor review of resident #1's medical record revealed resident #1 was a long-term care resident admitted to the facility on [DATE] with diagnoses that include but are not limited to Bipolar Disorder, Heart Disease, and Colostomy status. The resident was admitted to the facility alert and oriented x3 with a BIMS 15/15 documented in the quarterly MDS assessment dated [DATE]. On 4/8/24 at 10:00am, surveyor review of facility reported incident intake MD#00202562, dated 2/13/2024, revealed that on 2/12/24 resident #1 alleged that he/she was punched in the nose by Agency GNA #1. On 4/8/24 at 10:30am, surveyor review of related complaint MD#00204268, dated 4/2/2024, alleged resident #1 received improper treatment by the facility. On 4/8/24 at 11:00am, surveyor review of the facility's investigation of the incidents that occurred on 2/12/24 revealed the facility's investigation contained a witness statement from Agency LPN#4, dated 2/13/24, which revealed that on 2/12/24 at approximately 5:00pm resident #1 required care after Agency LPN #4 observed resident #1's room was soiled from urine and stool after resident #1 detached his/her colostomy bag. On 2/12/24 at approximately 5:15pm, Agency LPN#4 asked Agency GNA #1 to assist resident #1 with his/her care while Agency LPN #4 finished necessary nursing tasks. On 2/12/24 at approximately 5:30pm, Agency LPN #4 then stated in the witness statement that Agency GNA #1 came to him/her and reported that resident #1 hit him/her in the mouth while he/she was providing care. On 2/12/24 at approximately 5:45pm, Agency LPN #4 and RN Night Supervisor #5 entered resident #1's room and found resident #1's nose bleeding. Agency LPN #4 stated that he/she immediately provided treatment by applying ice to resident #1's nose to stop the bleeding. Agency LPN #4 also stated that resident#1 told him/her that he/she was punched in the nose by Agency GNA #1. On 4/8/24 at 11:30am, surveyor review of witness statements from GNA #2 and GNA #3, both dated 2/13/24, revealed that GNAs #2 and #3 observed resident #1 entering Unit 3's dining room on 2/12/24 at approximately 6:15pm. GNA #2 and GNA #3 observed that resident #1 had scant bleeding from his/her nose when he/she stated that a GNA punched him/her in the nose. GNA #2 and #3 observed Agency GNA#1 enter Unit 3's dining room on 2/12/24 at approximately 6:20pm. GNA #2 and #3 stated in their witness statements that they heard resident #1 apologize to Agency GNA #1 for hitting him/her in the mouth and resident #1 added, .but you hit me first. Further review of the facility investigation on 4/8/24 at 11:45am revealed facility nursing staff failed to inform the facility's DON or the Executive Director after discovery of the alleged abuse of resident #1. Agency LPN #4 and GNA #3 contacted RN Night Supervisor #5 to report the alleged abuse of resident #1 on 2/12/24 by approximately 6:30pm. The Director of Nursing (DON) discovered the alleged abuse of resident #1 on 2/13/24 when he/she viewed local hospital records of resident #1's emergency room visit. The DON informed the State of Maryland's Office of Health Care Quality (OHCQ) of the alleged abuse on 2/13/24 at 5:24pm, the Baltimore City Department of Aging on 2/13/24 at 5:59pm, and local law enforcement on 2/13/24 at 6:00pm. Continued review of the facility investigation on 4/8/24 at 11:50am revealed resident #1 self-contacted law enforcement on 2/12/24 at approximately 10:30pm. According to the witness statement from RN Night Supervisor #5, resident #1 told local enforcement that he/she was not being treated well in the facility and he/she was also having chest pains. Resident #1 requested to be transferred to the local hospital for treatment. On 4/8/24 at 12:30pm, surveyor review of local hospital records detailing resident #1's admission assessment on 2/13/24 at 9:22pm revealed the hospital assessed the resident and found mild soft tissue swelling in the left nose area after taking a maxillofacial CT scan. On 4/8/24 at 1:59pm, surveyor interview with Agency LPN#4 confirmed the written statement in the facility investigation. Agency LPN #4 also added that resident #1's nose was not bleeding prior to contact with Agency GNA#1 on 2/12/24 at approximately 5:15pm. After contact with Agency GNA #1, Agency LPN#4 and RN Night Supervisor #5 observed resident #1 was bleeding from his/her nose that required treatment to stop on 2/12/24 at approximately 5:45pm. Agency LPN #4 confirmed that he/she treated resident #1's nosebleed with ice. Agency LPN #4 also added that resident #1 was not violent or uncontrollable when he/she made contact with the resident after his/her contact with Agency GNA #1 on 2/12/24 at approximately 5:45pm. Resident #1 told Agency LPN #4 on 2/12/24 at approximately 5:45pm that Agency GNA #1 punched him/her in the nose. On 4/8/24 at 2:55pm, surveyor interview with Agency GNA #1 confirmed that Agency GNA #1 was in resident #1's room on 2/12/24 at approximately 5:30pm. Agency GNA #1 also confirmed the statements made by GNAs #2 and #3. Agency GNA #1 stated that he/she entered the Unit #3's dining room on 2/12/24 at approximately 6:15pm where two other GNAs (GNAs #2 and #3) were feeding residents. Agency GNA #1 stated that resident #1 approached him/her and stated . I know I punched you in the mouth, but you punched me first. Agency GNA #1 stated resident #1 was winking at him/her when the statement was made in the Unit 3 dining room. Agency GNA #1 then stated that he/she turned to GNAs #2 and #3 and stated, Did you see that he/she (resident #1) winked when he/she said that to me? Agency GNA #1 stated that GNAs #2 and #3 did not respond to her statement about resident #1. On 4/9/24 at 11:45am, surveyor interview with the Executive Director, DON, Regional Director of Operations, and Regional Clinical Services Manager revealed that Agency GNA #1's last day working at the facility was 2/12/24. The DON stated that Agency GNA #1 was placed on the Do Not Call list on 2/15/24 when he/she refused to return to the facility on [DATE] for re-training on abuse prohibition. The Regional Director of Operations and the Regional Clinical Services Manager admitted the facility failed to report the alleged abuse timely to the State of Maryland's Office of Health Care Quality (OHCQ), the Baltimore City Department of Aging and local law enforcement. The Regional Executive Director provided proof of abuse and prohibition education that was given to all nursing staff. Medical record review on 4/9/24 at 12:30pm revealed resident #1 had care plans which contained interventions for behavior that included resident swinging at staff and physically and verbally abusing staff since 1/22/24. Resident #1 also had a care plan for bleeding as a side effect of anticoagulation medication since 5/24/21. On 4/11/24 at 11:30am, the DON provided the surveyor with facility reports on all agency staff that worked in the facility from 2/12/24 to the present. The DON also provided proof that all agency staff received abuse prohibition training from their agency and refresher training from the facility prior to their first shift. Review of the information given by the DON revealed that the facility employed agency staff from 2 nursing agencies: Agency A and Agency B. Agency GNA #1 was employed by Agency B. The DON provided proof of a background check (dated 4/25/23), completion of abuse prohibition training by Agency B (dated 12/4/23) and completion of abuse prohibition training by the facility (dated 11/3/23). The information obtained from Agency B also contained confirmation that Agency GNA #1 worked in the facility on 2/12/24 at 3:00pm to 2/13/24 at 7:00am. On 4/11/24 at 1:30pm, interview with the DON, Executive Director, Regional Director of Operations and Regional Clinical Services Manager revealed the RN Night Supervisor #5 failed to remove Agency GNA #1 from the building after resident #1 alleged Agency GNA #1 hit him/her in the nose. RN Night Supervisor #5 told Agency GNA #1 that resident #1 was no longer assigned to him/her. The interview also revealed the resident was transferred to the local hospital after his/her complaint to local law enforcement on 2/12/24 at approximately 10:00pm. The surveyor asked the facility administration team why the RN Night Supervisor #5 failed to remove Agency GNA #1 from the facility after resident #1 alleged that he/she was punched in the nose by Agency GNA #1. None of the facility administration team was able to explain why Agency GNA #1 was allowed to work the remainder of the shift on 2/12/24 (after 6:00pm) to 2/13/24 at 7:00am. The surveyor also asked the DON when he/she became aware of resident #1's allegation of abuse. The DON stated that he/she became aware of the abuse allegation when he/she reviewed local hospital records for resident #1's status on 2/13/24. The local hospital records documented that resident #1 alleged that he/she was punched in the nose on 2/12/24. The DON further stated that he/she started the abuse investigation on 2/13/24. The DON stated that he/she suspended Agency GNA #1 from all of his/her scheduled shifts until completion of the abuse investigation. The DON then contacted OHCQ on 2/13/24 at 5:24pm, the Baltimore City Department of Aging on 2/13/24 at 5:59pm and local law enforcement on 2/13/24 at 6:00pm. On 4/12/24 at 12:00pm, the surveyor expressed concern to the Executive Director, DON, Regional Director of Operations and Regional Clinical Services Manager surveyor that the facility failed to report the alleged abuse of a cognitively impaired resident (Agency GNA #1). The facility administrative staff understood.

Based on observations, interviews with facility staff and review of facility records it was determined that the facility failed to: 1) store food in accordance with professional standards for food service and safety, and 2) keep complete kitchen records. This was found evident of 1 of 4 kitchen observation and 2 of 3 kitchen record reviews during the annual survey. The findings include: 1) On 8/28/23 at 8:35 AM, the surveyor conducted an initial tour of the facility's kitchen. The surveyor observed the facility's Certified Dietary Manager (CDM) Staff #10 walk into the kitchen's walk-in refrigerator. The surveyor conducted an interview at this time. Staff #10 stated she usually comes to the kitchen in the morning to check the dates labeled on the food. The surveyor asked Staff #10 what was in the square clear container on the shelf. Staff #10 stated it was pudding and that it was just made but agreed it had no label to indicate what it was or when it was made. Staff #10 explained that different items have different discard dates depending on the product. The date that it was received and opened should be on the label. On further observation of the walk-in refrigerator, the surveyor observed a container, with no label to identify what the contents were, or no label to indicate when the substance was opened. Staff #10 stated it was Italian dressing and was opened the date it was received, pointing to a label indicating the bottle was received on. Additionally, the surveyor observed a bag of slaw received on 8/3/23 with darker liquid at the bottom of the bag, Celery received on 7/11/23 wilted with a fuzzy substance on one of the stalks and a bag of cut lettuce received on 8/17/23 with liquid leaking from the bag when lifted. Staff #10 stated she expects that all food should be inspected before use and would throw all those items out. The surveyor noted a bag of onions on the lower shelf, and within the bag was an onion, identified by Staff #10, cut in half, wrapped with aluminum foil. Staff #10 stated that the partial onion should not have been stored with the bag of onions but on the shelf labeled and designated for opened items. On 8/28/23 at 9:08 AM, the surveyor observed the walk-in freezer along with Staff #10. The surveyor noted an open bag with no label on it. The item was covered in frost. Staff # 10 identified the item as waffles and stated that the waffles did not belong in the freezer and would get rid of them. On 8/28/23 at 9:19 AM, the surveyor observed the dry storage room accompanied by Staff #10. The surveyor noted six, 6-pound 11-ounce cans of corn beef hash with an expiration date of December 2022. Staff #10 stated the cans must have rotated in from the emergency supply and that she would discard them. On further observation the surveyor reviewed the emergency supply section that was covered by a plastic drape. This section contained: A box of pudding snack packs received on 9/9/22 with a best used by date of 8/10/2023. A box of Mott's apple sauce 4-ounce containers received 9/6/22 with a best used by date of 8/26/23. A box of apple cinnamon Nutri Grain bars receive on 9/6/22 with an expiration date of 3/5/23. A box of Pineapple tidbits 4-ounce containers received on 9/6/22 with expiration of 12/23/22. After the observations Staff #10 stated, the kitchen employees will always check expiration dates before using and that inventory is done twice a week. She stated all these items need to be thrown out. The surveyor observed an additional section of the dry storage. The items below had no received dates or expiration dates: 1 one-gallon honey mustard and dip. 3 one-gallon bottles of relish with dust noted on the top. 4 six pound five-ounce cranberry sauce jars. After this observation, Staff #10 stated she would toss these items because she could not indicate how old the items were. On the same shelf the surveyor observed 7 unopened boxes of one pound confectioners' sugar with a best by date of 12/20/22. An additional box was opened with a label written, opened on 1/3/23. The best by date was 12/20/22. This indicated that the package was opened after the best buy date. Staff #10 stated that the kitchen staff should check the date before opening and education would need to be done with the kitchen staff. 2a) On 8/28/23 at 9:08 AM, the surveyor observed the temperature logs for both refrigerators and the walk-in freezer with Staff #10. Staff #10 stated they check the temperature log times three times a day with meal prep. The freezer log was missing a logged temperature on 8/26/23 in the designated time for lunch schedule and was also missing documentation in the morning. The log was also missing lunch and afternoon time slots on the date 8/27/23. Staff # 10 stated the cook is responsible for documenting and would do further education. 2b) On 9/7/2023 at 10:09 AM, the surveyor observed the kitchen dishwashing area. The surveyor observed dietary aide/cook Staff #27 rinsing dishes with a spray hose, placing them in a tray, and sending them through the dishwasher. The surveyor noted the digital screen below the dishwasher was blinking and displayed, GF wash temp but no reading, and then the screen switched and read rinse, with a reading 2 PSI. The surveyor asked Staff #27 how they would know if the dishwasher was reaching sanitization temperatures. Staff #27 stated she didn't know because it was not reading but believed that Dietary Aide (Staff #29) had checked it before using it this morning. On 9/7/23 at 10:13 AM, the surveyor interviewed the Food Service Manager, Staff #62. Staff #62 reported she was filling in for Staff #10 while she was out. Staff #62 stated she was unaware that the temperature gauge was not reading a temperature. The surveyor and Staff #62 reviewed the temperature log for the dishwasher. No temperature was documented for 9/7/23 in the morning time slot. Staff #62 stated the expectation is that the temperature is taken before use to ensure the dishes are sanitized. On 9/7/23 at 10:19 AM, the surveyor interviewed Dietary Aide, Staff #29. Staff #29 stated that he took the temperatures and chemical checks for the three-compartment sink but he was not responsible for the dishwasher. On 9/7/23 at 10:20 AM, the surveyor conducted an interview with Maintenance Director, Staff #2. During this interview Staff #2 stated that he had a replacement part for the temperature gauge. He also reported that when the temperature gauge got wet from the spray hose, the digital temperature gauge on the dishwasher was affected and lost the ability to display the temperature reading. On 9/7/23 at 10:23 AM, Staff #2 returned to the kitchen and produced a temperature strip. The strip had 3 boxes indicating a temperature range of 160 degrees Fahrenheit (F), 170 degrees F, and 180 degrees F. The surveyor observed the strip go through the dishwasher and no box changed to indicate that the temperature reached the levels on the strip. Staff #2 continued to place 2 additional strips, one after another, through the dishwasher which all had the same results. There was no indication the temperature reached the described levels. On 9/7/23 at 10:40 AM, Staff #2 returned to the dishwasher with a different supply of temperature strips. Staff #2 placed the new strip through the dishwasher. The temperature registered within the 180-degree F box. On 9/7/23 at approximately 10:42 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During that interview it was determined that the facility would use paper products until the dishwasher was fixed.

Based on observation and interview with facility staff it was determined that the facility failed to serve food at appetizing temperatures. This was evident during 1 of 1 food test tray samples reviewed during an annual survey. The finding include: On 9/15/23 at 11:57 AM, the surveyor observed the facility's kitchen staff assemble food trays for the lunch mealtime. The surveyor requested a sample tray be placed on the food cart that was scheduled to be delivered to the 1st floor. Further observation revealed a log of recorded temperatures taken from the foods that were contained on the steam table assembly line in preparation for the lunch meal. The temperatures were: Entree (Chicken Salad)- 37 degrees Fahrenheit (F) Vegetable (buttered beets)- 37 degrees F Soup (Cream of Broccoli)- 198 degrees F Mechanical soft meat- 41 degrees F Pureed Meat -30 degrees F Pureed Vegetable- 38 degrees F Dessert- 41 degrees F Juice- 41 degrees F On 9/15/23 at 12:33 PM, the surveyor observed the food cart delivered to the 1st floor. On 9/15/23 at 12:46 PM, all the trays were delivered and only the test trays were left. The surveyor observed the following temperatures taken, from the regular food tray, by the Certified Dietary Manager (Staff #10): Apple juice- 56 degrees F - 15 degrees increase from recorded kitchen temperature. Berries- 67 degrees F - 26 degree increase from recorded kitchen temperature. Cream of broccoli soup- 122 degrees F -76 degree decrease from the recorded kitchen temperature. Chicken salad- 43 degrees F - 6 degrees increase from the recorded kitchen temperature. Beets-55 degrees F- 18 degree increase from the recorded kitchen temperature. Following the Regular tray, temperatures were taken from the pureed (blended) food tray. The temperatures were as follows: Cream of Broccoli soup-110 degrees - 12 degrees cooler than the regular soup temperature. Pureed strawberries- 67 degrees - 26 degree increase the kitchen and same as the regular tray. Puree beets-63 degrees - 25 degrees increase from the recorded kitchen temperature. Puree-chicken salad- 67 degrees- 37 degrees increase from recorded kitchen temperature. After recording all of the temperatures, the surveyor reviewed the concerns with Staff #10. The hot soup had cooled significantly and the cool foods had risen, both producing non desirable food temperatures.

Based on reviews of a Facility Reported Incident (FRI) and interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse. This was evident for 6 (#4, #21, #57, #55, #106, & 455) out 21 residents reviewed for abuse. The findings include: 1) During review of a FRI on 9/11/23 at 9:00 AM, the surveyors found interviews of 5 residents cared for by Geriatric Nurse Assistant (GNA) # 40), a staff member under investigation for allegations of abuse. The report of the resident's interviews stated GNA # 40 was not physically abusive to them however the interview comments read: Resident # 4 stated, it is GNA # 40's way or no way, Resident # 57 stated GNA # 40 is not good to work with and sometimes rude, Resident # 21 stated, I feel that GNA # 40 is mad at me, she is not always polite and does not socialize with me. No follow-up was found in the FRI regarding these comments. During an interview on 9/14/23 at 7:15 AM, the Director of Nursing (DON) was shown the above report of the statements made by residents regarding GNA # 40. The DON was asked what follow up was done with these concerns and she stated she would have to review her files to make sure but thought GNA # 40 had Customer Service training and Anger and Dementia response training. 09/15/2023 at 7:27 AM interview with the DON, Regional Clinical Service Manager and the Administrator, the surveyors asked about the follow up on the interviews with the other residents (#4, #21, #57). The DON responded that she would get back to the surveyors with more information. The DON provided Psychiatric notes to the surveyors from Residents # 4, # 21, and # 57 on 9/15/23 at 1:00 PM. When the surveyor questioned the timing of the notes, the DON acknowledged that the notes were routine, not related to the incident and, one of the notes was written prior to the incident. 45733 2) On 9/1/23 at 1:18 PM, a review was conducted of the Facility Reported Incident (FRI) # MD 00191424. The report stated that, on 3/18/23 at 6:35 PM Unit Manager (UM) #58 heard Residents #55 and #106 argue in the dining room. The UM entered the dining room and found Resident #55 attempted to strike Resident #106 with a magazine. On 9/1/23 at 2:00 PM, review of the Facility's Incident Investigation file revealed one interview from the UM Nurse #58 and one intervew from Resident #55. No other interviews were conducted for the staff on duty and residents from that nursing unit. During an interview conducted on 9/1/23 at 2:10 PM, the DON was unable to explain why only staff UM #58 and Resident #55 were interviewed, but no other residents and other staff members on that day were interviewed. 37277 3) On 09/11/2023 at 1:18PM, a record review revealed that a FRI involving Resident #455 was received by the Office of Healthcare Quality on 09/06/2022 at 12:19 PM. Further review on the FRI conducted on 09/11/23 at 1:18 PM revealed the facility's investigation was missing two key components: Only 1 staff member interview was conducted and no other residents, including the roommate, were interviewed. On 09/11/2023 at 1:30 PM, the Director of Nursing (DON) acknowledged that only one staff member had been interviewed. Per the DON, the roommate had not been interviewed due to having cognitive impairment.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that infection control practices and guidelines were followed. This was found to be evident for 3 (resident #474, 475 and #110) out of 65 residents reviewed for infection control. The findings include: 1) On 08/31/23 at 09:28 AM, an observation was conducted in Resident #475's room. The Surveyor observed Geriatric Nursing Assistant (GNA) #8 obtain Resident #474's blood pressure. She (#8) did not disinfect the shared blood pressure cuff prior to taking Resident #475's blood pressure. During an interview conducted on 08/31/23 at 09:35 AM, the surveyor asked GNA #8 how she provided infection control when using a shared blood pressure cuff. The GNA admitted that she did not apply the infection control practices properly in terms of disinfecting the shared blood pressure cuff. An interview with the Regional Clinical Service Manager (RCSM, Staff #5) on 08/31/23 at 11:18 AM confirmed that the expectation was for all staff to consistently apply the infection control practices on shared equipment. The RCSM provided the surveyor with GNA #8's one to one education for infection control in regards to shared equipment and in service for nursing unit staff. 44440 2) On 8/29/23 at 8:22 AM, the surveyor observed Geriatric Nursing Assistant - GNA (Staff #9) walk in and deliver Resident #110's breakfast tray. On further observation the surveyor noted after Staff #9 delivered Resident #110's breakfast tray, she helped reposition the resident. Next Staff #9 returned to the hallway and headed back to the food cart. On 8/29/23 at 8:25 AM, the surveyor interviewed Staff #9. During the interview Staff #9 stated that she did reposition Resident #110 and after providing care to the resident she should have sanitized her hands but did not.

Based on interview and record review it was determined that the facility failed to administer pain medications consistent with professional standards. This was found evident of 1 of 5 (Resident # 41) residents reviewed for pain management during the annual survey. The findings include: On 8/31/23 at 12:41 PM, the surveyor reviewed Resident #41's medical record. The review revealed Resident #41 had a past medical history of polyneuropathy (multiple nerves damaged causing pain in different areas of the body), surgical amputation, diabetes type 2 with foot ulcer and muscle weakness. A care plan is a guide that addresses the needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Further review of the record revealed Resident #41 had a care plan for chronic pain related to diabetic neuropathy (damaged nerves that cause pain) and arthritis. On 9/5/23 at 9:54 AM, the surveyor reviewed Resident #41's hospital discharge summaries. The review revealed a hospital discharge summary from a hospital stay Resident #41 had in early July 2023. The discharge instruction titled chronic pain states to continue oxycodone (narcotic pain medication) and wean (slowly decrease) as tolerated. On 9/5/23 at 11:05 AM, the surveyor reviewed the July 2023 Medication Administration Records (MAR) for Resident #41. The review revealed oxycodone was prescribed to be given with pain parameters starting on 7/13/23. The instructions in all the oxycodone orders after 7/13/23 were written to give oxycodone for assessed pain of 7 through 10 on a 1-10 pain scale rating. The surveyor noted several administrations on the MAR that were given outside of the pain rating parameters, such as: Oxycodone 10 mg was documented as given on 7/13/23 with a pain assessment of 6. Oxycodone 10 mg was documented as given on 7/14/23 twice with a pain assessment of 6 both times. Oxycodone 10 mg was documented as given on 7/17/23 with a pain assessment of 6. Oxycodone 10 mg was documented as given on 7/19/23 twice, once with a pain assessment of 5 and another with a pain assessment of 6. Oxycodone 5 mg was documented as given on 7/22/23 with a pain assessment of 6. Oxycodone 5 mg was documented as given on 7/23/23 with a pain assessment of 5. On 9/12/23 at 2:05 PM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #21. During this interview Staff #21 stated that if a resident is having severe pain, she would administer a narcotic (controlled pain prescribed by doctors to treat severe pain) and give as ordered. She further stated she would give something like Tylenol for mild pain. She further stated both medications can be given together if it is part of the resident's plan of care. On 9/13/23 at 2:18 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated a resident is expected to be assessed using a pain scale and pain medications should be given as ordered. The DON further stated that if a pain assessment falls outside of the prescribed administer parameters the nurse would be expected to clarify the orders with the provider and provide the appropriate pain medication. The surveyor reviewed the July 2023 MAR with the DON and agreed the medications were given outside of the prescribed parameters.

Based on interviews and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 1 out of 5 (Resident #128) residents reviewed for respiratory care during an annual and complaint survey. The findings include: Pulse oximeter - a device that uses a light source to analyze the light that passes through a finger and can determine the percentage of oxygen in the red blood cells, referred to as a pulse ox. Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels. On 8/30/23 at 10:25 AM, the surveyor observed Resident #41 resting in bed noted to have oxygen being delivered via nasal cannula. On 9/6/23 at 8:58 AM, the surveyor reviewed Resident #128's medical records. The review revealed that Resident #128 was admitted to the facility in early 2022 and had a past medical history of, acute pulmonary edema (fluid on the lungs), Chronic Obstructive Pulmonary Disorder (COPD), and lung cancer. Further review revealed Resident # 41's care plan stating impaired gas (oxygen) exchange related to COPD as evident by shortness of breath and wheezing. On 9/6/23 at 11:13 AM, the surveyor observed Resident #128 again resting in bed with oxygen being delivered via nasal cannula. On 9/8/23 at 9:33 AM, the surveyor reviewed Resident #128's orders. The review revealed an order for oxygen via nasal cannula at 2 Liters per Minute (LPM) as needed to keep oxygen saturation 90% or greater. On 9/8/23 at 11:33 AM, the surveyor conducted an interview with Registered Nurse Staff #37. During the interview Staff #37 stated she would check the order before applying oxygen. She further stated that if a resident is receiving oxygen the expectation is that the pulse oximeter be monitored. On 9/11/23 at 12:38 PM, the surveyor reviewed the most recent pulse oximeter reading for Resident #128. The review revealed the last documented pulse oximeter reading was on 8/29/23. No additional documentation was found even though Resident #128 continued to have oxygen administer. On 9/12/23 at 8:38 AM the surveyor interviewed the Director of Nursing (DON). The DON confirmed that Resident #128's oxygen level was not monitored and added that Resident #128's vitals may have been adjusted after hospice care was started. The DON confirmed that Resident #128's oxygen order required monitoring for determining oxygen therapy. That respiratory care could not be followed as written if the pox was not taken.

Based on record review and staff interview, it was determined that the facility staff failed to ensure skin alterations were documented in the medical record. This was evident for 1 (#451) of 65 residents reviewed during the recertification survey. It was determined that the facility's failure to document the skin alterations resulted in past non-compliance which existed from 01/12/2023 until 01/29/2023. The findings include: On 09/12/2023 at 9:00 AM, a record review revealed that on 01/18/2023 the facility received a complaint from Resident #451's son alleging that the resident had obtained a wound on [his/her] right hip where a previous wound had been healed. When investigating the concern, facility staff members were interviewed. Staff #59 recalled that Resident #451's right hip had a dark spot, like a bruise. Staff #61 also remembered a dark area on the right hip. Staff #61 stated that it wasn't new and that it was darker but was there before. Staff #60, a nurse that cared for Resident #451 on the day of discharge, admitted that she did not assess the resident completely. She wrote I didn't look at his skin. A review of Resident #451's medical record revealed that from the date of admission on 01/12/2023 through discharge on 01/17/2023, there was no documentation of skin discoloration on the right hip. On 09/12/2023 at 10:00 AM the findings were brought to the attention of the Director of Nursing (DON). The DON acknowledged that it is the expectation for staff to document any skin alterations, including discoloration. The DON provided documentation proving that after the facility completed their investigation, the facility provided education to nurses and GNA's related to properly documenting and reporting skin alterations. Additionally, all residents were audited to ensure that skin checks were completed.

Based on interviews and resident record reviews, it was determined that the facility failed to provide scheduled showers to residents. This was evident of 2 of 2 residents (Resident #398 and #108) reviewed for Activities of Daily Life (ADL) care on an annual and complaint survey. The finding include: Activities of Daily Living (ADLs) are everyday routine activities that are done to take care of oneself. 1a) On 8/28/23 at 12:13 PM, the surveyor conducted an interview with Resident #398. During this interview Resident #398 stated that they had been here over a week and hadn't gotten a shower. On 9/5/23 at 10:58 AM, the surveyor reviewed Resident #398's electronic medical record. This review revealed that Resident #389 had been admitted to the facility in the middle of August 2023 and had a past medical history that included, difficulty in walking, weakness, history of falling, and cerebral infarction (disruption of blood flow to the brain). On 9/6/23 at 10:52 AM, the surveyor interviewed Geriatric Nursing Assistant (GNA) Staff #22. During this interview Staff # 22 stated the GNA's are aware of who is scheduled to get a shower on what day by the shower book located in the nursing station. Staff #22 further stated, we check the book before we start our shift and would document if a shower was refused. On 9/6/23 at 1:30 PM, the surveyor requested shower documentation for Resident #398. On 9/6/23 at approximately 2:30 PM, the surveyor reviewed the second-floor shower schedule along with the shower documentation. The surveyor reviewed the ADL shower section for August of 2023, where the question is asked: Did the resident receive a shower? y-yes n- no. The date after Resident #398's admission was coded with NA (non-applicable) and the next 5 days were coded as N, for no shower given. The surveyor next reviewed the most current floor shower schedule and noted all residents were on a shower schedule twice per week. Resident #398's dates were Wednesday and Saturday. On 9/7/23 at 10:45 AM, the surveyor reviewed the nursing admission assessment. The review revealed that Resident #398 expressed his/her preference was to receive showers. On 9/8/23 at 11:15 AM, the surveyor conducted an interview with the Director of Nursing (DON). The DON agreed that showers were not documented as given per the resident's schedule. 1b) On 8/28/23 at 12:20 PM, the surveyor interviewed Resident #108. During this interview Resident #108 stated he/she has scheduled shower days but had only had a shower twice since admission. On 9/5/23 at 1:49 PM, the surveyor reviewed Resident #108's medical record. The review revealed that Resident #108 was admitted to the facility in late October 2022. Further review of the record revealed that Resident #108 had a care plan for self-care deficit related to musculoskeletal impairment as evidenced by left sided hemiplegia (loss of movement of one side of the body). The goal stated, Resident will perform ADLs with minimum level of assistance through review period. On 9/6/23 at 1:30 PM, the surveyor requested shower documentation for Resident #108. On 9/6/23 at approximately 2:30 PM, the surveyor reviewed the second-floor shower schedule along with the shower documentation from August of 2023. The ADL shower section asked the question: Did the resident receive a shower? y-yes n- no. On 8/7/23 and 8/14/23, y was coded for yes. On 8/10/23, 8/21/23, 8/23/23, and 8/30/23 NA was coded. On 8/17/23, and 8/26/23 n was coded for no. Only 2 showers were documented as given for the month of August 2023. Review of the floor shower schedule revealed that all residents were on a shower schedule twice per week and Resident #108's dates were Tuesday and Friday. On 9/7/23 at 10:45 AM, the surveyor reviewed the nursing admission assessment. The review revealed that Resident #398's expressed he/she had a preference to receive showers. On 9/8/23 at 11:15 AM, the surveyor conducted an interview with the Director of Nursing (DON). The DON agreed that showers were not documented as given per the resident's schedule.

Based on interview and medical record review it was determined that facility staff failed to provide an explanation in the resident's medical record to demonstrate the absence of the resident from their care plan meetings and 2) update a resident's care plan to reflect a new diagnosis with recommended treatments. This was evident for 1 (Resident #99) out of 3 residents reviewed for care planning during the investigation portion of the survey. The findings include: A care plan is a guide that addresses the needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. In a care plan meeting, staff and residents/families talk about life in the facility-meals, activities, therapies, personal schedule, medical and nursing care, and emotional needs. Residents/families can bring up problems, ask questions, or offer information to help staff provide care. The Brief Interview for Mental Status (BIMS) assessment is a 15-point cognitive screening used to screen and identify the cognitive condition of residents. It's a structured evaluation aimed at evaluating aspects of cognition in elderly patients. The BIMS score interpretation is, 0 - 7: Severe cognitive impact, 8 - 12: Moderate impairment, 13 - 15: Intact cognitive response. 1) On 8/31/2023 at 7:00AM A record review was conducted for Resident #99 which revealed diagnoses including dementia, major depressive disorder, mood disturbance and psychotic disturbance. The resident's BIMS score on 5/22/2023 was 12 out of 15. During a tour of the unit on 8/31/2023 at 8:45 AM, the surveyor conducted an interview with Resident #99 who revealed I do not see the social worker. They (the facility staff) change the social workers often so I am not sure who the person is, and I was told I can only see her on Mondays. I ask for her every day, but she is never here. When I have a problem, I can't talk to anyone. On 8/31/2023 at 10:00 AM Surveyor conducted a review of Resident #99's social services notes and plan of care notes dated from 10/22/2022 through 06/16/2023 which revealed no mention of Resident # 99's invitation or refusal to attend care plan meetings. During an interview with the Social Work Director staff #7 on 8/31/2023 at 1:28 PM, it was revealed that the resident had two certifications of incapacity related to a diagnosis of dementia and she was not familiar with Resident #99's current care plan meeting attendance. The Social Work Director recalled the resident had a history of refusing to attend care plan meetings and deferred to the social work assistant, Staff #67, for answers to questions about Resident #99's care plan meeting attendance. 09/01/23 at 07:26 AM, the surveyor reviewed Care Plan meeting sign in sheets for Resident #99 and the facility's Care Planning Process policy. During review, it was revealed under Section D- 3 of the policy, it read the resident and his/her family member/significant other shall be notified of the care planning process on admission and shall be notified in advance of each care plan conference. Review of care plan meeting attendance sign in sheets with dates ranging from 07/15/2021 to 03/10/2023 revealed no signatures from Resident #99. During an interview on 09/07/23 at 08:44 AM Staff #67 stated, I visit the resident at least weekly. I met with Resident #99 and invited the resident to his/her next care plan meeting. If the resident refuses to attend, I will document it in his/her chart and then attempt to reschedule it. During an interview on 09/07/23 at 12:00 PM with Staff #5 and the Social Work Director confirmed that there was no documentation of Resident #99's invitation/refusal to or attendance at his/her care plan meetings since 11/12/2021 and Resident #99 was invited to attend his/her next scheduled care plan meeting. 2) On 8/31/2023 at 10:30 AM the surveyor requested Resident #99's care plan. On 09/01/23 at 09:17 AM surveyor reviewed Resident #99's medical record for hospitalization s. Resident #99 had the hospital admitted s of 4/01/2023, 5/02/2023, and 5/10/2023. A nurse's note #18 revealed that Resident #99 was hospitalized on [DATE] due to complaint of chest pain and the physician ordered the resident to go to the emergency department. Review of the hospital discharge note dated 4/06/2023 revealed the resident had a mental status change and solemnness due to a urinary tract infection (UTI) and was treated with antibiotics. The resident was discharged from the hospital back to the facility on [DATE]. The discharge summary also stated the resident was to begin taking an oral antibiotic which was to start on 4/07/2023. Review of the resident's care plan showed no update to include the new diagnosis and treatment plan. An electroencephalogram (EEG) is a test that measures electrical activity in the brain using small, metal discs (electrodes) attached to the scalp. Brain cells communicate via electrical impulses and are active all the time, even during sleep. This activity shows up as wavy lines on an EEG recording. Further review into Resident #99's medical record revealed another hospitalization on [DATE]. A nurse's (#18) note dated 5/02/2023 at 5:27 PM stated the resident complained of chest pain. The chest pain was unrelieved, and the facility's interventions were ineffective, so the Nurse Practitioner (#68) ordered to send Resident #99 out for evaluation and treatment. Review of the resident's hospital discharge summary revealed the resident was treated for a UTI and discharged from the hospital on 5/05/2023. The summary gave instructions for the resident to take Macrobid 100mg capsule, to treat the UTI, Flomax 0.4 mg 24-hour capsule for possible benign prostatic hyperplasia (BPH), maintain good perineal hygiene, and avoid catheterization. Resident #99's care plan showed no update to include the UTI diagnosis and treatment plan. In addition, further review into Resident #99's medical record revealed another hospitalization dated 5/10/2023. The resident was sent to the hospital for observed seizure activity by a staff member. The hospital discharge summary noted that seizure activity was not seen on the electroencephalogram (EEG). During Resident #99's hospital stay, he/she was treated for 5 days on an antibiotic for a UTI and discharged on [DATE]. Resident #99's care plan showed no update to include the UTI diagnosis and treatment plan. On 9/01/2023 at 12:05 PM the Director of Nursing (DON) provided a care plan for impaired elimination related to incontinence; created on 2/11/2020. Review of the care plan revealed no updates that correlated with the UTI diagnosis on hospital admissions dated 4/01/2023, 5/05/2023, and 5/10/2023. On 9/08/2023 at 11:15 PM an interview was held with the DON and Staff #5 who confirmed Resident #99's care plan was not updated. Cross Reference (F655 and F656)

Based on interviews and record reviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs. This finding was evident for 2 of 4 residents (#103 and #146) review for care plan. The findings include: 1) During an interview conducted on 8/29/23 at 10:45 AM, Resident #103 stated that he/she was upset because the staff did not provide continent care when needed and had been left soiled for long periods of time. The resident further stated that when my son came to visit he would change my soiled diaper routinely. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strength and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 9/11/23 at 12:02 PM a review of resident #103's medical records showed a MDS assessment for Urinary Continence which was coded a 2 for frequently incontinent. A care plan is an ongoing, regular assessment of a resident's condition to see if their health status has changed. Further review of resident #103's medical record did not reveal an incontinent care plan. On 9/11/23 at 03:00 PM the surveyor conducted a phone interview with the Resident #103's son. The son stated that he had changed the resident's soiled diaper during their visit almost 3 times per week. During an interview conducted on 9/12/23 at 9:00 AM, the Director of Nursing (DON) and surveyor reviewed resident #103's care plan. The DON confirmed the resident did not have a care plan for incontinent care. 47758 2) The surveyors reviewed the care plan for Resident # 146 on 9/12/23 at 11:44 AM. There was no intervention found in the care plan for combative behaviors. The surveyors requested a care plan for combative behaviors from the Regional Clinical Service Manager (RCSM) on 9/14/23 at 9:00 AM. It was not received prior to the survey exit. The surveyors interviewed the RCSM # 5 on 9/15/23 at 12:30 PM, about the concern that Resident # 146 did not have a care plan for combative behaviors. She responded that there should have been care plan for combative behaviors.

Based on observations and interviews with staff, it was determined that the facility failed to store medication in a locked compartment. This was found evident on 2 of 2 random observations. The findings include: 1) This surveyor observed on the second floor an unlocked medication cart on 9/6/23 at 10:42 AM. The cart was located by room [ROOM NUMBER] and across from room [ROOM NUMBER]. Five different staff members, including nursing staff, walked past the cart without securing it. They continued down the hallway without maintaining eye contact with the medication cart. Staff at the nursing station were not looking at the cart. There were no residents in the vicinity. This surveyor checked the drawers at 10:57 AM. Every medication except the controlled substances which were in a locked drawer within the cart were accessible. A nurse (Staff #37) walked up to the cart at 10:58 AM and locked it. This surveyor approached and informed her that the cart has been under observation. I asked if it was her assigned medication cart and she replied yes. This surveyor informed her that the medication cart had been unlocked. She replied that she didn't know it was unlocked. I mentioned to her that she had just locked it and she replied oh, I didn't know. Staff #5 was interviewed on 09/15/23 at 8:00 AM. She was informed of the findings. This surveyor emphasized that five staff members walked past the medication cart and not one secured the medication cart. She replied that she understood the importance of ensuring the medication carts are locked and secured. She also stated that she was made aware by nursing shortly after Staff #37 was informed of the unlocked cart. 44440 2) On 9/6/23 at 11:20 AM, the surveyor observed a medication cart that was unattended and unlocked located on the first floor hallway located just outside room [ROOM NUMBER]. At this time no staff were in the hallway. On 9/6/23 at 11:32 AM, the surveyor observes the Unit Manager Staff #19 walk over and lock the unlocked medication cart. The surveyor asked Staff #19 if she was aware of who was responsible for that medication cart. Staff #19 stated it was assigned to Registered Nurse (RN) Staff #20. She further stated she was not unsure why the medication cart was left open, and the expectation is that when a medication cart is not in use it should be locked. On 9/6/23 at 11:38 AM, the surveyor conducted an interview with Staff #20. During the interview Staff #20 stated that she was busy working with a resident when Licensed Practical Nurse (LPN) Staff #21 offered to help by obtaining a blood glucose (blood sugar) level on another resident who had a critical laboratory value. Staff #20 stated that Staff #21 took her keys to the medication cart in order to get the blood glucose machine and must have left it open. Staff #20 confirmed that Staff #21 had her own medication cart and was aware of the expectations of a medication cart. On 9/6/23 at 11:42 AM, the surveyor interviewed Staff #21. Staff #21 confirmed she left the medication cart open and stated that the medication cart should always be locked when not in use and unattended.

Based on review of the medical record and facility email, as well as interviews with the laboratory staff, it was determined that the facility failed to: address abnormal blood laboratory test results from 3/24/14 - 3/31/14; obtain a urine culture and sensitivity and; observe and assess the resident's sacrum when the resident complained of shingle symptoms. This resulted in the resident being transferred to the emergency room and admitted to the hospital for treatment of [REDACTED]. This was evident for 1 of 5 residents's selected for review. The findings included the following. On 4/3/14, 4/8/14, 4/9/14, 4/10/14, 4/11/14 and 4/15/14, the surveyor reviewed the resident's medical record, hospital admission and emergency room record as well as communication via interview and email communication with the facility. In addition, on 4/15/14, the surveyor interviewed the medical technician at the laboratory used by the facility. By way of history resident #3 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was assessed and noted to be alert, oriented and own decision maker. On 3/8/14, according to the monthly physician progress notes [REDACTED]. The primary [DIAGNOSES REDACTED]. Blood laboratory test results were reviewed by the physician. He reviewed the earlier results dated 9/12/13. The blood urea nitrogen (BUN) was within normal limits at 26 (the normal range was 6-26) and the creatinine was slightly elevated at1.42 (the normal range was 0.52-1.04). These results can indicate hydration and kidney function. At the time of that visit, the physician noted that the BUN and creatinine were 26 and 1.43, respectively. Resident #3's sodium (Na+) was 129 (the normal range was from 137-145) and the physician noted that was "usual". The resident's medications were also reviewed and noted to be, "all ok". Resident #3's medication regime included: [MEDICATION NAME] with [MEDICATION NAME] for [MEDICAL CONDITION]; calcium with vitamin D for supplement; [MEDICATION NAME] and [MEDICATION NAME] for high blood pressure; and, an antacid - calcium [MEDICATION NAME] - Tums for indigestion. The resident continued to receive these medications as ordered through 3/31/14, per the medication administration record. On 3/20/14 at 12:41 pm, blood laboratory test results were reported to the facility. The resident's BUN and creatinine were high at 78 and 2.20, respectively. The calcium was high at 11.6 (the normal range was 8.4-10.2); potassium (K+) was high at 5.7 (the normal range was from 3.5-5.1). At 7 pm, according to the laboratory test result, the physician was notified of the abnormal test results and as a result ordered: Kayexelate, a medication to reduce the elevated K+ level; the [MEDICATION NAME] with [MEDICATION NAME] which had been ordered on [DATE] for the treatment of [REDACTED]. The surveyor reviewed the medical record and email responses from the facility administrator from 4/3/14-4/11/14. There was no evidence that the facility staff administered increased fluids as ordered. On 3/24/14 at 11:50 am, the resident's blood laboratory test results were reported to the facility. The resident's BUN was high at 86, creatinine was high at 2.71 and calcium was high at 11.1. The bottom of the laboratory test result had a note written by nurse #3: "paged MD x 4 (0 with a line through it) response". The surveyor reviewed the medical record and email responses from the facility administrator from 4/3/14-4/11/14. There was no evidence that the physician was notified of the abnormal blood test results. There were no new physician orders [REDACTED]. The medical record and email correspondence with the facility administrator failed to reveal that the physician was notified of the 3/24/14 abnormal blood test results. On 3/28/14 at 7:30 am, the physician was notified of the results of a complete blood count (CBC) done every Thursday to assess the resident's [MEDICAL CONDITION]. (These blood test results would not include the abnormal blood tests done on 3/24/14 and there was no evidence that the physician was notified of the abnormal blood test results dated 3/24/14 at that time). The CBC results included an elevated white blood count (WBC) of 11.4 (the normal range was from 4.0-10.8). This elevation could indicate an infection. The physician ordered a urinalysis and culture and sensitivity (C&S) to rule out a urinary tract infection. At 11:59 am, according to the laboratory test result, the facility received the results of the urinalysis. The results were abnormal: the clarity was cloudy (normal was clear); the leukocytes, [MEDICATION NAME] and blood were positive (the normal was negative); the red blood count (RBC) was high at 11 (the normal range was 0-4); the WBC was high at 163 (the normal range was 0-5); and there were WBC clumps and bacteria (the normal was none). The urinalysis results were abnormal and the physician chose not to make new orders but asked that the C&S remain flagged. Results of a C&S identify the bacteria growing and the antibiotic that would be best for treatment. When there is bacterial growth preliminary C&S results are available at 24 and 48 hours. The final results are available at 72 hours. There were no C&S results in the medical record. The surveyor interviewed the med technician at the laboratory on 4/15/14 at 6:15 pm. She reviewed the resident's information and told the surveyor the C&S was never ordered and therefore not done. At 2:55 pm, according to the concurrent review, the resident complained of having a shingles outbreak on the sacrum. The [DIAGNOSES REDACTED]. The resident received the medication [MEDICATION NAME] and was isolated from others. The facility failed to assess the area on resident's sacrum prior to the [DIAGNOSES REDACTED]. On 3/29/14 and 3/30/14, there was no evidence that the physician was aware of the abnormal blood laboratory results on 3/24/14 nor any evidence that the physician was notified that the urine C&S had not been done. On 3/31/14 at 3:02 pm, according to the concurrent review, the resident had decreased activities of daily living (ADL), a sore throat, decreased meal and fluid intake, cloudy urine, and the family wanted the resident sent to the emergency room (ER) for further evaluation. The resident was assessed, treated and admitted at the hospital. The [DIAGNOSES REDACTED]. According to the hospital history and physical, the resident was thirsty with extremely dry mucous membranes and sunken eyes. The resident complained of chest and neck pain and a headache. The resident's laboratory test results were abnormal. Resident #3's BUN and creatinine were elevated at 110 and 2.4; which would indicate dehydration and kidney failure. The WBC was 12.57; which would indicate an infection. The calcium was 14.2 which would need to be monitored and the troponin level was at 1 which could indicate cardiac changes. The plan was to hydrate the resident with intravenous (IV) fluids, monitor blood laboratory test results and increase oral intake. The calcium with vitamin D supplements were stopped as was the [MEDICATION NAME] as they affect the kidney function. the resident was started on an antibiotic, [MEDICATION NAME], for a urinary tract infection. The physician noted that the resident had been treated for [REDACTED]. The area on the sacrum was assessed at the hospital and the area was a Stage II pressure ulcer. The facility failed to notify the physician of abnormal blood laboratory test results, obtain a urine C&S, and observe the resident's sacrum when the resident described changes. This resulted in the resident's hospitalization for dehydration, acute [MEDICAL CONDITION], elevated calcium, troponin, and white blood cell count levels, an untreated urinary tract infection and a misdiagnosed /treated stage II pressure ulcer on her sacrum.