Every finding on record at Future Care Cherrywood

Based on review of the medical record it was determined that the facility failed to develop a baseline care plan which included initial goals based on admission orders and the instructions needed to provide effective and person-centered care that met professional standards of quality care. This was evident for 1 (#2) of 3 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident, including, but not limited to, the resident's initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services, until a comprehensive care plan can be completed for the resident. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident. On 4/10/26 at 10:39 AM, a review of a complaint #2807352 alleged Resident #2 had not received adequate care at the facility. A review of Resident #2's medical record was conducted on 4/19/26 at 11:00 AM and revealed the resident was admitted to the facility for rehab in the beginning of March 2026 following an acute hospitalization for acute respiratory failure and a pulmonary embolism (blood clot) and with multiple diagnosis including pulmonary (lung) fibrosis (disease causing damaged, scarred lungs), chronic respiratory failure with hypoxia (low oxygen in tissues), pneumonia and diabetes. Later, in March 2026, Resident #2 had a change in condition, transferred back to the hospital and subsequently discharged from the facility. In an admission History and Physical note, on 3/11/26, the attending physician documented that prior to his/her admission to the facility, Resident #2 had been hospitalized for acute hypoxic respiratory failure and an acute pulmonary embolism and the resident's past medical history included pulmonary fibrosis, with severe restrictive pulmonary disease, Interstitial lung disease (ILD) (causes lung inflammation and scarring), and diabetes. A review of Resident #2's March 2026 medication administration record (MAR) on 4/10/26 at 2:25 PM, revealed admission orders for respiratory medications, initiated on 3/11/26 that included:- Jascayd (nerandomilast) tablet by mouth two times a day for pulmonary fibrosis- Prednisone tablet by mouth one time a day for interstitial lung disease that was initiated on 3/11/26.- Ipratropium Albuterol Solution inhale orally every 6 hours for shortness of breath/wheezing.- Sulfamethoxazole/Trimethoprim (Bactrim) tablet by mouth one time a day for pneumocystis jirovecii pneumonia (fungal lung infection) prophylaxis (prevention)- Guaifenesin (expectant) (thins respiratory mucus) ER (extended release) by mouth every 12 hours for cough The MAR also documented 3/11/26 admission medication orders that included:- Humalog (insulin lispro) KwikPen injector Inject subcutaneously, as per sliding scale, before meals and at bedtime for Diabetes.- Apixaban (Eliquis) (anticoagulant) (blood thinner) tablet by mouth 2 times a day for anticoagulant that was initiated on 3/11/26.A review of Resident #2's March 2026 treatment administration record (TAR) revealed a 3/11/26 order for Oxygen via nasal cannula at 3 LPM (liters per minute) initiated on 3/11/26 that documented the resident used oxygen continuously every day. Further review of Resident #2's medical record revealed a Baseline Care Plan Summary with an effective date of 3/11/26 at 6:29 AM that had an initial admission goal to discharge to the community, a discharge goal to return to the community, and a functional goal to improve functional status. The care plan failed to include the minimum healthcare information with initial goals and interim approaches to manage Resident #2's respiratory needs, his/her diabetes and the resident's use of an anticoagulant. Review of Resident #2's comprehensive care plans revealed a care plan for pain, falls, self-care deficit, skin integrity, and nutrition, had been developed within 48 hours of his/her admission to the facility, however there was no evidence that a care plan addressing Resident #2's respiratory status, diabetes, or use of an anticoagulant had been developed within 48 hours of the resident's admission or while s/he resided in the facility. On 4/13/26 at 2:20 PM, the above concerns were discussed with the Nursing Home Administrator (NHA) and Director of Nurses (DON). The NHA and the DON acknowledged the concerns and offered no further comments at that time.

Based on record review and staff interview, it was determined that the facility failed to ensure advance directives were offered and documented upon admission for 5 (Residents #1, #2, #5, #70, and #159) of 9 residents reviewed.The findings include:On 9/25/25 at 9:38 AM, review of the electronic medical record for 9 residents revealed that advance directive documentation could not be located for 5 residents (#1, #2, #5, #70, and #159). At 10:15 AM on the same day, surveyor requested documentation from facility staff.On 9/25/25 at 11:40 AM, an interview was conducted with Staff #10 who reviewed the residents' admission dates and facility records. Staff #10 stated:Resident #1 was admitted on [DATE] and was offered an advance directive on 9/8/25.Resident #2 was admitted on [DATE] and was not offered an advance directive until 9/25/25 after the surveyor had requested the documentation.Resident #5 was admitted on [DATE] and declined an advance directive on 8/21/25.Resident #70 was admitted on [DATE] and declined an advance directive on 8/19/25.Resident #159 was admitted on [DATE] and was not offered an advance directive until 9/25/25 after the surveyor had requested the documentation.Documentation presented by Staff #10 at this time was reviewed and the dates were confirmed to be correct.

Based on observation, interview, and record review, it was determined that the facility failed to implement infection prevention and control practices by not ensuring oxygen equipment was dated when placed into use and by not ensuring staff donned appropriate personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions (EBP). This deficient practice was evident for 2 (Residents #70 and #17) of 30 residents reviewed for infection control practices during the facility's recertification survey.The findings include: 1.) On 9/24/25 at 8:33 AM, Resident #70 was observed with an oxygen setup. The humidifier bottle and oxygen tubing attached to the resident's oxygen concentrator were noted to be in use but were not dated. At that time, Surveyor located Staff #3, who was identified as responsible for the care of Resident #70. Staff #3 confirmed the humidifier bottle and tubing were in use and acknowledged that they were not dated as required. Staff #3 then obtained a new humidifier bottle and oxygen tubing, placed them on the resident's concentrator, and marked both with the date. On 9/26/25 at 2:00 PM, the Nursing Home Administrator was informed of the above findings. 2.) Enhanced Barrier Precautions (EBP) is an infection control practice, primarily in nursing homes, that requires staff to wear a gown and gloves during high-contact resident care activities to prevent the spread of multidrug-resistant organisms (MDROs). EBP is applied to residents infected or colonized with specific MDROs, those with wounds requiring dressings, or those with indwelling medical devices. During observation on 9/26/25 at 10:00 AM, Geriatric Nursing Assistant (GNA) #22 was observed providing morning activities of daily living (ADL) care to Resident # 17 without wearing a gown. A sign posted on Resident #17's door revealed the resident was on Enhanced Barrier Precautions (EBP). GNA #22 confirmed during an interview at that time that she had not donned a gown prior to providing care. At the same time, the Charge Nurse entered Resident #19's room with supplies to perform a wound dressing change. The Charge Nurse failed to don a gown while preparing to perform the treatment, despite the posted EBP signage. The Unit Manager entered the room and instructed the Charge Nurse to put on a gown. During the observed wound dressing procedure, the Charge Nurse failed to maintain aseptic technique. The Charge Nurse was observed using a pair of scissors that had been lying on the resident's bedside table without a clean or sterile surface. This created a risk for wound contamination. During an interview conducted on 9/26/25 at approximately 10:30 AM, the Unit Manager staff #12 stated that staff are required to wear appropriate PPE and maintain aseptic technique when providing care or treatment to residents on Enhanced Barrier Precautions. This deficient practice had the potential to expose Resident #19 and other residents to healthcare-associated infections due to failure to follow infection prevention and control standards.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure that Resident #36 was provided assistance with meals in a manner that promoted dignity and respect. The failure resulted in the resident's meal tray being left unopened at bedside without staff assistance. Findings include:On 9/25/25 at 9:00 AM, during observation rounds, Resident #36 was observed with his/her meal tray on the bedside table. The tray remained unopened, and the resident made no attempt to self-feed.Interview on 9/25/25 at 9:10am with Geriatric Nursing Assistant (GNA) #19, assigned to Resident #36, revealed that she had assisted the resident with morning care but stated that the resident required assistance with meals. GNA #19 reported that she believed another GNA had been assigned to provide feeding assistance to the resident.During an interview on 9/25/25 at 9:20am, GNA #22 (identified by the facility assignment board as the GNA assigned to feed the resident) stated he was unaware that he had been assigned to feed Resident # 36. At the time of the observation, other residents' trays were being collected, while Resident #36 tray remained untouched.On 9/25/25 at 10am interviews with the Director of Nursing (DON) and Unit Manager staff #12 confirmed the resident required assistance with meals and that the staff miscommunication led to the tray being left at bedside without feeding assistance. The DON stated the issue was corrected immediately after notification.

Based on record review and facility staff interviews, it was determined that the facility failed to notify the court-appointed representative of the resident's discharge and to have that representative involved in discharge planning. This was evident for 1 (Resident #161) out of 1 residents reviewed for court-appointed guardianship.The findings include: On October 1, 2025, at 9:21 AM, the NHA and DON were interviewed in reference to the resident having a court-appointed guardian. The DON stated that the facility did not know that the resident had a court-appointed guardian. The facility had assumed that the resident was to return to the assisted living facility where he/she had previously resided. The NHA stated that the caregiver from the facility had been involved in the resident's affairs from the beginning. The caregiver had been in touch with the facility about the resident's discharge planning and was there to pick up the resident when she was discharged from the facility. The DON and NHA felt that they were familiar enough with the resident from prior admissions. The DON stated that the information on the discharge summary from the hospital stating that the resident's guardianship was complete was overlooked and not included in the resident's medical records.On October 1, 2025, a review of medical records revealed that the hospital discharge summary, on the first page, stated that the guardianship process had been completed and that the resident was not competent enough to make their own medical decisions. The resident had been admitted to the facility on [DATE], and the court order was completed on March 28, 2025. Further review revealed that on April 16, 2025, during the follow-up visit with the CRNP, she stated in her note that the resident's guardianship process had been completed during the resident's last hospitalization.During this investigation, it was determined that the facility failed to notify the court-appointed guardian of the resident's discharge.

Based on medical record review and interviews with facility staff it was determined the facility staff neglected to provide continence care to a resident who was dependent on staff for assistance. This was found to be evident for 1 (Resident #139) of 5 residents reviewed for Accidents during the facility's survey.Findings include,Resident # 139 was admitted to the facility with the following but not limited to diagnosis; Dementia (decline in cognitive function) and History of Falling.Medical record review on 9/29/25 at 10:10AM revealed the resident had a fall on 7/10/25. Review of the fall investigation provided by the facility revealed the resident was found on the floor by Geriatric Nurse Assistant (GNA # 8) on 7/10/25 at approximately 8:30AM. The resident did not sustain an injury. The resident was found to be soiled and agitated per the investigation.During an interview with the Director of Nursing (DON), on the same date at 11:20 AM, she stated that GNA (#7) who worked the night shift did not provide continence care (support management) to the resident who was incontinent (involuntary loss of urine or stool) before leaving at 7:00AM when her shift ended. She further stated that the oncoming GNA confirmed that the resident was soiled. The DON stated that GNA # 7, who worked for an agency was placed on the facility's do not return list due to resident neglect. All concerns were discussed with the Administration team at the exit conference on 10/1/25.

Based on record review and interviews, it was determined that the facility failed to maintain accurate and complete records for residents. This deficient practice was evident for 2 (Residents #139 and #161) of 3 residents reviewed during the facility's recertification survey. The findings include: 1.) Medical record review on 9/29/25 at 10:10AM revealed Resident # 139 was admitted to the facility with the following but not limited to diagnosis: Dementia and had a fall on 7/10/25. Review of the fall investigation provided by the facility revealed the resident was found on the floor by GNA (#8) on 7/10/25 at approximately 8:30AM. Further review of the resident care plan for actual falls did not have documentation of the fall or interventions. The last update to the resident care plan was dated 10/7/21. During an interview with the DON on the same date at 10:40 AM, she was asked if the resident care plan was updated after the resident was found on the floor by the GNA (#8) on 7/10/25. The DON stated that when a resident has a fall, the care plan is updated with interventions. She went on to explain that Resident # 139 care plan was closed in error on 8/25/25 and marked as resolved. She later provided documentation to the survey team of the documented error and the updated care plan. All concerns were discussed with the Administration team at the exit conference on 10/1/25. 2.) On October 1, 2025, at 9:21 AM, an interview with the facility's NHA and DON in reference to the resident's admission information. The DON stated that the facility didn't know that the resident had a guardian. The facility assumed the resident was to return to the facility where he/she was previously. They felt they were familiar with the resident from prior admissions. The DON stated that the information on the discharge summary from the hospital stating that the resident's guardianship was complete was overlooked and not included in the resident's medical records. On October 1, 2025 at 10 AM, a review of medical records revealed that the hospital discharge summary, located on the front page, stated that the guardianship process had been completed and that the resident was not competent enough to make her own medical decisions. The resident had been admitted to the facility on [DATE], and the court order was completed on March 28, 2025. Further review revealed that on April 16, 2025, during the follow-up visit with the CRNP, she stated that the resident's guardianship process had been completed during the resident's last hospitalization. Review of the face sheet showed Resident #161 was their own responsible party and that the owner of the transitional housing was the resident's friend and emergency contact.

Based in staff interviews and record review, it was determined that the facility failed to notify and coordinate with the court-appointed guardian of the resident for discharge proceedings to ensure a safe discharge. This was evident for 1 (Resident #161) out of 1 residents reviewed for safe discharge.The findings include: On October 1, 2025, at 9:21 AM, the NHA and DON were interviewed in reference to the resident having a court-appointed guardian. The DON stated that the facility didn't know that the resident had a court-appointed guardian. The facility had assumed that the resident was to return to the Assisted living facility where she had previously been. The NHA stated that the caregiver from the facility had been involved in the resident's affairs from the beginning. The caregiver had been in touch with the facility about the resident's discharge planning and was there to pick up the resident when she was discharged from the facility. The DON and NHA felt that they were familiar enough with the resident from prior admissions. The DON stated that the information on the discharge summary from the hospital stating that the resident's guardianship was complete was overlooked and not included in the resident's medical records.On October 1, 2025 at 10 AM, a review of medical records revealed that the hospital discharge summary, on the first page, stated that the guardianship process had been completed and that the resident was not competent enough to make her own medical decisions. The resident had been admitted to the facility on [DATE], and the court order was completed on March 28, 2025. Further review revealed that on April 16, 2025, during the follow-up visit with the CRNP, she stated in her note that the resident's guardianship process had been completed during the resident's last hospitalization.Review of the assisted living facility revealed that it was not a licensed assisted living facility at all and that the caregiver was the owner of transitional housing. The website for this transitional housing stated that they provide supportive housing for homeless persons, which provides them with wrap-around support services that create a continuum of care and stability.

Based on observations, medical record review and interviews with facility staff it was determined the facility staff failed to follow professional standards of practice when administering medications to a resident. This was found to be evident during medication administration observation for 1 (Resident # 20) of 49 resident's observed during the survey.The findings include: On 9/26/25 at 08:00AM a medication administration observation was done for Resident # 20. The nurse (Registered Nurse # 9) poured the resident's scheduled 8:00AM medications into a medication cup. In addition to the scheduled medications, the nurse poured Baclofen 5 mg (1) tablet into the medication cup. The nurse stated that although the medication is not scheduled until 10:00AM the resident likes to receive the Baclofen 5 mg tablet with his/her 8:00 medications.A review of the physician orders on the same date for Resident # 20 on the same date revealed the following: Baclofen 5 mg 1 tablet po (by mouth) tid (three times daily). The scheduled administration times were 10:00AM 14:00 PM (4:00PM and 22:00 (10:00PM)).An interview was conducted at 9:30AM with nurse (#9) and the Director of Nursing (DON) who was present. The nurse was asked about the Baclofen 5 mg tablet that was administered before the scheduled time and if it was the standard of practice to administer the medication outside of the scheduled time. The nurse stated that she should have called the physician first to get an order to give the medication early if the resident requested it to be given earlier than it's scheduled time. The DON confirmed that the physician should have been called for a resident request to have scheduled medication administered early, before administering the medication to the resident at the wrong time. The DON stated that re-education will be provided.The NHA was made aware of the concerns at 11:50AM.

Based on observation and interview, it was determined that the facility failed to ensure a resident's dignity, respect, and quality of life by not providing access to a call bell. This deficient practice was evident for 1 (Resident #159) of 10 residents reviewed for dignity concerns. The findings include:On 9/29/25 at 1:26 PM, Resident #159 stated he/she had been sitting in the wheelchair since 11:00 AM and did not have access to the call bell. Observation revealed the resident's call bell was wrapped around the bedrail of the bed, positioned behind the resident and out of reach.On 9/29/25 at 1:28 PM, the Director of Nursing was notified of the finding. The DON entered the room with the nurse assigned to Resident #159 and conducted bedside education on proper call bell placement to ensure resident access.

Based on record review and interviews, it was determined that the facility failed to ensure nursing staff were licensed, certified, or registered in accordance with applicable State laws. This deficient practice was evident for 1 (Staff #3) of 2 staff reviewed.The findings include:On 9/24/25 at 7:58 AM, during the initial tour of Unit 3, the dry erase board was observed to list Staff #3 as a Registered Nurse (RN) assigned to residents. At 8:33 AM the same day, Staff #3 was observed wearing an identification badge displaying RN.On 9/26/25 at 10:47 AM, review of Staff #3's personnel file revealed documentation of an active Licensed Practical Nurse (LPN) license. Verification with the Maryland Board of Nursing confirmed that Staff #3 had an active LPN license only, with no active RN license. The record indicated a prior RN application denied in 2016, with the status still listed as pending. During the same review, Staff #11 and the Nursing Home Administrator were interviewed and confirmed the discrepancy. Staff #11 stated they believed Staff #3 held a New Mexico RN license.On 9/29/25 at 1:11 PM, review of the electronic medical record revealed that Staff #3 was listed in the charting system as an RN. At 1:19 PM, the Nursing Home Administrator was notified that Staff #3 was documenting under the RN designation.On 9/29/25 at 1:50 PM, an interview was conducted with Staff #3, who stated they had been living in Maryland for about one year. Their license reflected a Maryland address with an issue date of 6/24/22, over three years ago. Staff #3 stated they had originally applied for RN licensure in Maryland in 2016, later obtained an RN license in New Mexico after moving there in 2021, and acknowledged they were required to update their license for Maryland.

Based on staff interviews and record review, it was determined that the facility failed to involve the court-appointed representative in the development of the discharge plan and failed to ensure that the assisted living facility was a licensed facility for safe discharge. This was evident for 1 (Resident #161) out of 1 residents reviewed for safe discharge.The findings include: On October 1, 2025, at 9:21 AM, the NHA and DON were interviewed in reference to the resident having a court-appointed guardian. The DON stated that the facility didn't know that the resident had a court-appointed guardian. The facility had assumed that the resident was to return to the Assisted Living facility where she had previously been. The NHA stated that the caregiver from the facility had been involved in the resident's affairs from the beginning. The caregiver had been in touch with the facility about the resident's discharge planning and was there to pick up the resident when he/she was discharged from the facility. The DON and NHA felt that they were familiar enough with the resident from prior admissions. The DON stated that the information on the discharge summary from the hospital stating that the resident's guardianship was complete was overlooked and not included in the resident's medical records.On October 1, 2025, a review of medical records revealed that the hospital discharge summary, on the first page, stated that the guardianship process had been completed and that the resident was not competent enough to make her own medical decisions. The resident had been admitted to the facility on [DATE], and the court order was completed on March 28, 2025. Further review revealed that on April 16, 2025, during the follow-up visit with the CRNP, she stated in her note that the resident's guardianship process had been completed during the resident's last hospitalization.During this investigation, it was determined that the facility failed to notify the court-appointed guardian of the resident's discharge and failed to ensure that the Assisted Living facility was a licensed facility for a safe discharge.

Based on observation, interview, and record review, it was determined that the facility failed to adhere to professional standards for food service safety. This was evidenced by the facility's failure to: 1) seal, label, and properly store food, 2) maintain proper function of the walk-in freezer, 3) monitor refrigerator temperatures, 4) monitor food temperatures, and 5) ensure the removal of expired food supplements. This was evident in the facility kitchen and 2 of 3 unit nourishment rooms observed during the survey. This had the potential to affect all residents. The findings include: 1) On [DATE] at 08:15 AM a tour of the facility's walk in refrigerator in the kitchen was conducted. There were 2 drink cups on the refrigerator shelf with amber liquid, one covered with a lid, one uncovered. There was no identification of the contents or date for either of the cups. On another shelf there was a 5 pound bag of part skim shredded mozzarella cheese that was approximately 25% full, that was gaping open. There were 2 cardboard boxes on the floor containing food. One was labeled and contained 25 pounds of fresh whole tomatoes. The other box stacked on top of the box of tomatoes contained 1 bag of celery, 1 bag of lettuce, 1 bag of red onions, and a gallon sized plastic tub with chopped green peppers. On [DATE] at 8:20 AM an interview, the Cook Supervisor (Staff #5) stated that the unlabeled cups of liquid were sugar free water and were probably from last night and he immediately removed them from the refrigerator. On [DATE] at 08:34 AM an interview with the Food Service Manager (FSM), Staff #4, was conducted in the walk-in refrigerator. When the FSM was asked about the open bag of shredded mozzarella in the walk-in refrigerator, he stated that the bag should have been closed, and confirmed that the bag of cheese was not stored properly. Also in the middle of the walk-in refrigerator was a wheeled cart which contained 1 metal pan of chopped white meat, 1 pan of cooked brussel sprouts, 1 metal pan of corn kernels, a half sheet tray of cheese sandwiches and approximately 6 peanut butter and jelly sandwiches - all unlabeled and undated. The FSM confirmed that they should be dated and labeled. He stated that the boxes of food that were stored directly on the floor were improperly stored and he moved them to the metal shelves in the refrigerator. 2) On [DATE] at 08:15 AM a tour of the facility's walk-in freezer was conducted. There was a layer of ice covering the blue heavy duty rubber floor mat. In some areas the ice was ,d+[DATE] inches thick. Many of the mat's drain holes were filled with ice. There was ice hanging from the ceiling, icicles hanging from shelves, and cardboard boxes of food products were covered with frost and ice. The freezer fans were covered with ice crystals. There was also Ice buildup on the plastic flap curtains at the entrance to the freezer. On [DATE] at 8:34 AM an interview with the FSM was conducted in the walk-in freezer. During the interview the FSM was observed moving cardboard boxes from the freezer floor to the metal shelving. When he was asked about the ice in the walk-in freezer, the FSM initially stated that maybe something spilled and caused the ice buildup. When asked about how the ice got on the ceiling, he stated that the freezer is next to a hot area of the kitchen and that when the freezer door was opened, the hot and cold air mixed and caused condensation which caused the ice in the freezer. He stated that the freezer was new as of 3 years ago. On [DATE] at 1:13 PM a request to the Nursing Home Administrator (NHA), Staff #1, was made for any work orders for repairs related to the walk-in freezer. The NHA provided a copy of the receipt for the replacement of the walk-in freezer in 2019. She also provided a copy of a Work Order for a refrigeration company dated [DATE]. The description of work read, in part, Check walk in freezer ice on ceiling due to door open to [too] long. Unit air curtain should be replaced. By the time of the exit from the facility on [DATE], no other documents regarding the walk-in freezer were provided by the facility. On [DATE] at 12:31 PM another observation of the walk-in freezer was conducted. There continued to be icicles hanging from the ceiling. 3) On [DATE] at 12:35 PM the nourishment area on Unit #3 was observed. The temperature log hanging next to the refrigerator was blank and had no dates/times, month, or any temperatures listed on it. The NHA was made aware of this finding at this time. On [DATE] at 10:10 AM the NHA provided a copy of temperature logs documented by the maintenance department. The logs contained temperature checks including Unit #3 nourishment area refrigerator dated [DATE] through [DATE]. However no temperatures were documented for [DATE]. 4) On [DATE] at 12:31 PM an observation of the lunch service tray line in the kitchen was conducted. When the surveyor requested the Cook Supervisor (Staff #5) produce the tray line food temperature logs for this meal service, the Cook Supervisor was unable to provide them. The temperature log provided for the breakfast tray line service had the date written as [DATE], although the date at the time the document was provided was [DATE]. The above was also reviewed and confirmed with the FSM during the tray line observation. 5) On [DATE] at 12:35 PM the nourishment area on Unit #3 was observed. On the counter next to the refrigerator there were 2 opened bottles of Thickener (Simply Thick). One of the bottles had a manufacturer's expiration date of [DATE]. On [DATE] at 12:47 PM an observation of the Unit #1 nourishment room was conducted. In the bottom left cabinet under the microwave was one partially full box of individual 0.14 oz packets of NutriSource Fiber with a manufacturer's expiration date written as 24 [DATE]. On [DATE] at 02:00 PM an interview with the Director of Nursing (DON), Staff #3, the DON said that she was not aware that there were expired supplements in the nourishment areas. She said that the expired products should have been checked for expiration dates and removed. On [DATE] at 11:15 AM all of the above concerns were reviewed with the Corporate Nurse (Staff #23) and the DON.

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to 1) hold/document care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan, and 2) revise residents' care plan based on their health status. This was evident for 8 (#18, #29, #40, #44, #49, #67, #111, and #115) of 10 residents reviewed for care plan meetings during the annual survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1a) During a review of Resident #115's medical record on 5/23/23 at 10:40 AM, it revealed that the resident had MDS assessment completed on 4/27/22, 5/04/22, 8/02/22, 9/22/22, 12/23/22, 1/14/23, 3/20/23, and 4/19/23. Further review revealed that Resident #115's care plan meeting was documented on 5/09/22, 8/09/23, 3/10/23, and 4/19/23. A unit manager or social worker wrote the details of care plan meetings in the resident's electronic medical record under the progress note. No care plan meeting documentation was found for December 2022. 1b) During a review of Resident #49's medical record on 5/24/23 at 9:03 AM revealed that the resident had an MDS assessment completed on 9/09/20, 12/09/21, 3/11/21, 6/11/21, 9/10/21, 3/13/22, 6/13/22, 9/11/22, 12/11/22, and 3/14/23. However, the resident's care plan meeting was documented on 3/16/21, 9/21/21, 12/23/21, 3/22/22, and 6/23/22. No documentation was found for September 2022, December 2022, and March 2023. 1c) The surveyor reviewed Resident #44's medical record on 5/24/23 at 2:57 PM. The review revealed that Resident #44 had a quarterly and annual MDS assessments on 12/10/21, 2/07/22, 5/10/22, 8/10/22, 11/10/22, 12/29/22, and 3/31/23. Further review revealed that care plan meetings were held on 12/20/21, 5/23/22, 8/16/22, 11/15/22, and 4/11/23. However, there was no evidence in the medical record that a care plan meeting had been held with the resident and the interdisciplinary team in February 2022. 44441 1d) On 5/19/23 at 9:03 AM, Resident #29 indicated in an interview that she/he did not get invited to a care plan meeting and had only gone once since admission to the facility. The resident stated that the brother who was the representative was not invited and did not attend. On 5/24/23 at 9:16 AM, a medical record review was conducted for Resident #29 and revealed that the resident was admitted to the facility in October 2022. Further review of the medical records revealed that the last documentation of a care plan meeting for Resident #29 was held on 11/1/2022. Staff #21, the Social Work Director, in an interview on 5/24/23 at 9:39 AM, indicated that care plan meetings are held quarterly and that since Covid-19, the meetings were held virtually and over the phone. She was made aware that documentation for Resident #29 related to a current quarterly care plan meeting could not be found and that the last documented care plan meeting was in November 2022. She was asked to provide the documentation. On 5/24/23 at 3:55 PM, the Administrator provided the Social Work progress notes and confirmed that there were no care plan meetings held for Resident #29 since November 2022. 15701 1e) On 5/23/23 at 10:00 AM a chart review for Resident #40 revealed the resident was admitted to the facility in September of 2021. A review of the social worker's care plan meeting documentation revealed that care plan meetings were not held quarterly (every 90 days). There was a 7-month gap between a documented care meeting on 8/16/22 and a care plan meeting on 3/28/23. On 5/25/23 the nursing home administrator provided copies of social work notes revealing care plan meetings were not held between August and March. 1f) Resident #111's medical record was reviewed on 5/22/23. A review of the social worker's care plan meeting documentation revealed that care plan meetings were not held quarterly (every 90 days). There was an 8-month gap between a documented care meeting on 8/9/22 and a care plan meeting on 4/4/23. A discussion was held with the social worker (staff #21) on 5/24/23 at 10:02 AM. The identified gaps related to the lack of care plan meetings for both resident #40 and resident #111 were discussed. 48168 1g) On 05/19/23 at 10:56 AM, in an interview with Resident #67, the resident stated that he/she did not remember being invited to, or attending, any care plan meetings, or receiving any written care plan documents, and was unaware if his/her spouse attended any care plan meetings. On 05/19/23 at 01:45 PM, an interview with Resident #18 was conducted. When asked about his/her plan of care and attendance at care plan meetings, the resident stated, I don't know what care I am supposed to get, I don't know if they have meetings or not. The resident did not know if his/her family attended care plan meetings. On 5/24/23 at 9:05 AM, a record review revealed no care plan meeting documentation for Resident #67 that corresponded to the Minimum Data Set (MDS) assessments dated 1/25/23, 12/24/22, and 9/23/22. On 5/24/23 at 9:10 AM, a record review revealed no care plan meeting documentation for Resident #18 that corresponded to the MDS assessments dated 10/3/22, 1/3/23, and 4/5/23. On 05/24/23 at 09:35 AM, an interview with the facility's Director of Social Work (Staff #21) was conducted. When asked where Resident #67's care plan meeting documentation was for the resident's MDS assessments dated 1/25/23, 12/24/22, and 9/23/22, the Director of Social Work stated that the notes would be in the Progress Notes under a Care Plan Note. When informed that these notes were not found for the corresponding dates, she stated that she did not know why they could not be found there and she would have to look into it. On 05/25/23 at 08:19 AM, in an interview with the Administrator (Staff #1), the Administrator confirmed that for Resident #67 there was no documentation of care plan meetings, including attendance, for the corresponding MDS assessments of 1/25/23, 12/24/22, and 9/23/22. On 06/02/23 at 11:25 AM, in an interview with the Corporate Nurse (Staff #23), he stated that he could not produce copies of Resident #18 ' s care plan meetings for the corresponding MDS assessments dated 10/3/22, 1/3/23, or 4/5/23 because there were no care plan meetings held for the resident for any of those assessments. 2) On 6/1/23 at 2:20 PM, a record review for Resident #18 revealed an active care plan problem for altered mood due to diagnoses of MDD (Major Depression Disorder) and bipolar disorder. However, no diagnosis of MDD or bipolar disorder appeared on the resident's active list of diagnoses in the medical record. On 06/02/23 at 09:32 AM a record review of Resident #18's MDS section I dated 4/10/23 indicates No for Bipolar disorder for question I5900. Physician evaluation notes which included diagnoses did not contain a diagnosis of depression or bipolar disorder. Review of the diagnosis list in Resident #18 ' s medical record indicated that a diagnosis of bipolar disorder was created on 10/25/17, and resolved on 12/19/2020, however the active care plan continued to list an active problem with a related diagnosis of MDD and bipolar disorder. On 06/02/23 at 11:38 AM in an interview with the DON and the Corporate Nurse, Resident #18's current plan of care and active diagnosis list was reviewed. Both the DON (Staff #3) and the Corporate Nurse acknowledged that the care plan had an active problem with a diagnosis of MDD and bipolar disorder but there was no current active diagnosis or treatment of either MDD or bipolar disorder. Neither the DON or the Corporate Nurse could explain the discrepancy. On 6/6/23 at 11:10 AM in an interview with the DON and the Corporate Nurse, they both stated that they couldn't determine why there was a care plan for inactive diagnoses.

Based on observation, record review and interview, it was determined that the facility failed to develop and implement appropriate, comprehensive, person centered care plans. The care plan was not developed for 3 (Residents #18, #53, and #356), or implemented for 2 (Resident #18 and #67) of 11 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. A contracture is a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff. 1a) Investigation of self-reported incident MD00189698 was conducted on 5/30/23 at 10:00 AM. The incident was regarding Resident #53 who was noted to have two areas of purple discoloration on the right forearm dated 03/03/23. Further review of Resident #53's medical record revealed a diagnosis of vascular dementia, schizoaffective disorder, and deep vein thrombosis. Also, it showed that Resident #53 had taken anticoagulants from 1/31/23 to 4/11/23. However, a review of Resident #53's care plan did not indicate the use of anticoagulants while the resident took the medication and after the bruising incident was reported. During an interview with the Director of Nursing (DON) on 6/01/23 at 11:40 AM, the DON reviewed Resident #53's care plan and confirmed that there was no care plan initiated regarding anticoagulation use. The surveyor shared concerns about Resident #53's intervention regarding an unknown origin injury. 1b) Portion of investigating complaint MD00173463 on 6/01/23 at 2:27 PM revealed that Resident #356 had an unknown origin broken arm on his/her left side on 10/12/21. Further review of Resident #356's medical record revealed that the resident had resided in this facility since 2018 with diagnoses that include but are not limited to hemiplegia and hemiparesis affecting the left dominant side and vascular dementia. A review of Resident #356's medical record on 6/01/23 revealed that the facility's attending physician (Staff # 45) evaluated the resident after the unknown-origin broken arm on the left side was reported. A review of the physician's note dated 10/14/21 by Staff #45 stated that the etiology of the fracture is not clear: however, most likely it seems to be due to underlying severe osteoporosis. The resident with advanced age. Also, the orthopedic office's evaluation note dated 10/28/21 documented that it was felt that the fracture was associated with his/her being osteoporotic and, as such, a pathologic fracture without trauma. However, a further review of Resident #356's care plan revealed that the facility did not initiate his/her risk of injury related to his/her current condition. During an interview with Staff #45 via phone on 6/05/23 at 8:47 AM, Staff #45 confirmed that Resident #356's medical condition was at high risk of further bone, muscle, and/or tissue injury without trauma. Staff #45 also stated that he expected the facility to provide care more carefully when they provide care. On 6/06/23 at 9:00 AM, the surveyor shared concerns with the Director of Nursing about Resident #356's care plan not being initiated after the injured incident. The DON verbalized understanding. 48168 1c) On 05/22/23 at 09:26 AM an observation and interview of Resident #18 was conducted. The resident's right hand was observed to be severely deformed with the fingers extended at an unnatural angle. The resident also had contractures of his/her right elbow and wrist. The resident stated that he/she was unable to use his/her right arm to perform any self care tasks due to the contracture. On 06/02/23 at 09:50 AM a record review was conducted for Resident #18. The record revealed that the resident was admitted to the facility with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. In lay terms, this meant that the resident had a stroke which impaired the function of the right side of the body. The record review also revealed that the facility developed a plan of care, created on 7/20/22 and revised on 4/1/23, with the problem that stated The Resident has a functional maintenance program r/t history of CVA as evident by generalized muscle weakness and dependence on caregivers. The resident's goal was written as The Resident will maintain flexibility and useful motion in the joints of the body through the review period. The interventions were written as Range of motion (active) 2X a week and INSTRUCTIONS: Seated exercises including LAQ and left hip flexion with 2#. R hip flexion with no weights. Ball squeezes. (2X10). The facility failed to identify interventions to address Resident #18 ' s right upper extremity contractures. On 06/02/23 at 11:38 AM an interview with the DON (#3) and the Corporate Nurse (Staff #23) was conducted. They were both shown Resident #18's current plan of care and asked what plan was developed for the resident's right upper extremity contracture. Both the DON and the Corporate Nurse agreed that the care plan lacked specific goals or interventions for the resident's right upper extremity contracture and said that they could not determine why this aspect of the patient's care was not included in the resident's plan of care. 2) A. On 05/18/23 at 11:21 AM an observation of Resident #67 was conducted. The resident's knees were highly bent and appeared to be propped up. On 05/26/23 at 09:24 AM a record review of the resident #67's care plan revealed an active care plan problem created on 9/23/20, and revised on 3/7/23 The Resident needs functional maintenance program r/t multiple sclerosis as evident by decreased motor control in bilateral upper extremities. The goal was written as The Resident will maintain flexibility and useful motion in the joints of the body through review period. The interventions were written as Range of motion (active): 2-3 X a week INSTRUCTIONS: 3 x 15 of LUE [left upper extremity] exercises including bicep curls, chest presses, chest pulls, and overhead presses with 2 pound and supervision/rest breaks as tolerated. Patient does not tolerate RUE [right upper extremity] ROM [range of motion]. On 05/26/23 at 09:50 AM an interview with the Director of Physical Therapy and Rehabilitative Services (Staff #28) was conducted. He stated that Resident #67 was not currently receiving physical therapy services, but he believed the resident was on a strength training program which would be under functional maintenance on the resident's care plan. The actual therapy would be done by an aide trained in restorative nursing, and he named the restorative aide, Staff #26, whom he said was trained by the Physical Therapy department to provide restorative therapy. On 05/26/23 at 10:45 AM an interview was conducted with Staff #26 and the Unit Manager (Staff #18) regarding Resident #67's restorative therapy services. When asked how restorative therapy services are scheduled, the Staff #26 stated that she had a list of people and saw the residents who were available on the days she worked. On 05/26/23 at 1:22 PM a record review was performed of the Restorative/Functional Management aide documentation for April and May 2023 for Resident #67. The task specified Range of Motion (active) 2-3 x week. The review revealed that restorative therapy services were signed off as provided to the resident only once per week, on 5/1/23, 5/8/23, 5/17/23, and 5/23/23 in May 2023 and on 4/14/23, 4/22/23, and 4/28/23 in April 2023, not 2-3 x week as per the care plan. 2) B. On 06/02/23 at 09:32 AM a record review of Resident #18's plan of care revealed that there is a problem for a Functional Maintenance Program, created on 7/20/22 and revised on 4/1/23 that listed the intervention of providing range of motion exercises 2 x week. On 06/02/23 at 11:35 AM a record review and interview with the Corporate Nurse was conducted regarding restorative therapy services for Resident #18. The Corporate Nurse provided a copy of the restorative therapy documentation that showed restorative therapy visits to the resident on 5/6/23, 5/20/23, and 5/29/23 (less than once per week). Per the Corporate Nurse, there were no restorative therapy documentation for Resident #18 prior to May 2023. The Corporate Nurse also confirmed that restorative therapy services for Resident #18 and Resident #67 were not provided as per the residents' care plans.

Based on observations and interviews with the facility staff and resident, it was determined the facility failed to ensure that a resident who chooses to go to the 1st floor to eat lunch in the main dining room and attend activities like bingo and music is aided to get prepared and transferred out of bed to a wheelchair for escort assistance. This was evident for 1 (#127) of 4 residents investigated for activities during a Medicare/Medicaid survey. The findings include: An interview was conducted with resident #127 on 5/18/23 at 10:37 AM. The resident was asked if he/she attends activities. Resident #127 pointed to a sign posted on the wall Please take downstairs for lunch, music and bingo. Review of resident #127's medical record on 5/23/23 revealed the resident was admitted to the facility on [DATE]. Review of the admission activity assessment dated [DATE] indicated that resident #127 presented with the activity potential to plan his/her own day but requires invitation, motivation, and encouragement needing escort assistance. A care plan review note dated 5/4/23 revealed that the resident started attending some group programs and communal dining. On 5/18, 5/19, 5/22, 5/23, and 5/24/23 the resident was noted to not eat lunch in the main dining area. Resident #127 was interviewed while in bed at 12:25 PM on 5/24/23. The resident indicated that they did not get him ready. He/she acknowledged not eating lunch downstairs in the main dining room for the past week. At 12:39 PM on 5/24/23, the unit manager (staff #51) was asked if she knew why resident #127 was not out of bed and downstairs for lunch. She did not have an answer and was going to find the GNA assigned to resident #127. At 12:46 on 5/24/23 the unit manager joined the conversation with the resident and asked the resident about going to the dining room for lunch. The resident stated that he wanted to go to the dining room for lunch. He/she stated that the staff does not ask him/her about going to the dining room. The surveyor pointed to the sign on the wall for the Unit manager's benefit and she indicated that she did not know about the sign. The nursing home administrator, director of nursing, and a corporate nurse (staff #36) were informed of the concern with resident #127 not being given the opportunity to attend communal dining for the first five days of the survey on 5/26/23 at 4:10 PM.

Based on reviews of a clinical record and a facility reported incident (FRI), review of the facility investigation, and interviews with the resident and staff, it was determined that the facility staff failed to treat residents with dignity and respect by not assisting a resident with toileting when requested. This was evident for 1 (Resident #50) of 24 residents reviewed for abuse during the survey. The findings include: Review of facility reported incident MD00190945 on 05/23/23 revealed an allegation that GNA #29 told Resident #50 that S/he could not use the bedpan immediately on 04/05/23. A review of the facility Resident Right's and Services policy on 06/05/23 at 10 AM, revealed section C -2 which indicated the resident has the right to receive treatment, care and services that are in an environment that promotes maintenance or enhancement of each resident's quality of life. Section C - 3 indicates a resident has the right to have a dignified existence, self-determination, and communication with access to individuals and services inside and outside the nursing facility. A review of Resident #50's medical record on 05/23/23 revealed that Resident #50 was admitted to the facility on [DATE] with diagnoses that include an overactive bladder, urinary incontinence, and anxiety. Further review of Resident #50's clinical record revealed 3 Brief Interview for Mental Status (BIMS) that occurred on the 07/18/22 annual assessment, 12/12/22 quarterly assessment, and 02/26/23 quarterly assessment where each indicated a score of 15 which indicates Resident #50 is cognitively intact during the interviews. A review of the facility investigation into Resident #50's 04/05/23 allegation, that GNA #29 would not assist him/her with toileting when requested, on 05/23/23 revealed a typed statement from Staff Member #31. Staff Member #31 documented that Resident #50 complained on 04/05/23 at 4:27 PM that GNA #29 would not allow Resident #50 to use the bathroom until 6:30 PM that evening. Staff Member #31 also documented that during the 3 PM - 11 PM, 04/05/23 shift Resident #50 also complained that staff would not answer his/her call light, further assist Resident #50 with toileting requests, and at 8:23 PM GNA #29 assisted Resident #50 with the bedpan but left him/her lying flat and stated to Resident #50 that, you will have to wait until I come back and then closed the door. In an interview with Staff Member #31 on 05/24/23 at 1:02 PM, Staff Member #31 confirmed his/her typed statement regarding Resident #50's allegations that GNA #29 would not assist Resident #50 with toileting on 04/05/23. In an interview with Staff Member #33 on 05/24/23 at 1:40 PM, Staff Member #33 stated that S/he was made aware of Resident #50's comments, that GNA #29 would not assist him/her with going to the rest room on 04/05/23, by the facility staff. Staff Member #33 stated S/he was home and drove to the facility that evening. Staff Member #33 stated S/he arrived at the facility and immediately sent GNA #29 home, reassigned Resident #50 to a different staff person, started an investigation into the allegations, and notified the facility director of nurses. A review of Staff Member #33's handwritten statement, dated 04/06/23, on 05/24/23, revealed that Staff Member #33 interviewed Resident #50 at 8:40 PM on 04/05/23. Staff Member #33 documented that Resident #50 appeared to be upset and complaint that GNA #29 was not helping him/her. Staff Member #33 documented that Resident #50 stated that S/he asked GNA #29 to use the bedpan at 3:30 PM and GNA #29 stated that Resident #50 would have to wait until 6:30 PM. Resident #50 also stated that GNA #29 was mad with Resident #50 and called Resident #50 crazy and a demented person. Resident #50 also informed Staff Member #33 that GNA #29 placed him/her on the bedpan around 8:20 PM and stated to Resident #50 that, you will have to wait until I come back. Staff Member #33 documented that the facility director of nurses was made aware of the report at 8:45 PM on 04/05/23. In an interview with Resident #50 on 05/24/23 at 1:50 PM, Resident #50 stated that S/he recalled the incident and that it happened with GNA #29 a few weeks ago. Resident #50 stated that GNA #29 made him/her feel very uncomfortable and was glad that GNA #29 no longer provides care to him/her.

Based on observation and interview, it was determined that the facility failed to ensure that resident care areas were in good repair. This was evident for 3 of 33 resident rooms located on the first floor, and 1 of 3 unit nourishment rooms. The findings include: On 05/18/23 at 11:08 AM, an observation of Resident #67's room was conducted. The privacy curtain had a hole at the top of the curtain in the netted area, which was approximately 4-5 inches in diameter. There was also a loose, displaced floor tile in the resident's bathroom next to the toilet. On 05/22/23 at 09:23 AM, an interview with Resident #18 was conducted. The resident stated that cleanliness in the room and bathroom has been an issue, but only recently. On 05/22/23 at 11:11 AM, an observation of Resident #18's bathroom was conducted. There was damaged drywall with deep scrapes on the wall next to the toilet. The drywall was puckered, and there was a hole in the drywall at the level of the cove molding, an area of approximately 8-10 inches long, 4 inches wide. On the back wall, behind the toilet, the flange where the plumbing pipe enters the wall was covered with a brown discoloration. There were also gouges into the drywall in front of the toilet approximately 8 inches from the floor. There was also a dark spot on the ceiling tile directly above the toilet that measured approximately 5 inches in diameter. On 05/22/23 at 11:05 AM an observation of Resident #99's room and bathroom was conducted. The bathroom had cracked floor tiles with dark spots in cracked areas, the wallboard next to, and directly in front of, the toilet was damaged with deep scrape [NAME] that were approximately 8 inches from the floor. The bare drywall was exposed and the paint was missing. The bathroom tile floor around the toilet was dirty and had dark brown discoloration. There was an over sink shelf in the resident's bedroom area that was not secured to the wall and the shelf was attached to the wall on only the left side. The sink counter was also not secured and could be moved up and down about 2 inches with little effort. There was one water spot on the ceiling tile in the center of the room. The windowsill had peeling paint. On 06/05/23 at 12:47 PM an observation of the Unit #1 nourishment room was conducted. There were two sinks in the nourishment room, one small, one large. The backsplash behind the large sink was spongy, had peeled veneer and had a black discoloration. The caulk around the backsplash tile was black and separated from the wall. When touched, the backsplash felt spongy. The discolored area was an approximately 3 foot section.

Based on observation, interviews, and reviews of the facility administrative records, it was determined that facility staff failed to promote care for a resident in an environment that maintains or enhances each resident's dignity and privacy. This was evident for 2 (Resident #6, #259) of 2 residents observed during the annual recertification survey. The findings include: 1) The observation was made on 5/18/23 at 3:00 PM of Resident #6 lying in bed in his/her room with three beds and staying with one other resident. Resident #6's bed faced the window, so the resident's foot showed at the room door side. At 3:04 PM on 5/18/23, an X-ray technician (Staff #41) entered the room and prepared an X-ray for Resident #6. The surveyor came out of the room and observed staff #41's care from the hallway. The surveyor observed Resident #6 was shouting help, help without any procedure being performed. At 3:07 PM on 5/18/23, a Licensed Practical Nurse (LPN #42) entered the room to help the resident. The surveyor observed Resident #6's room was widely opened, and a privacy curtain was not applied during the procedure. The surveyor saw Resident #6's legs swung during the procedure. Right after the procedure, an interview was conducted with Staff #41. He stated that he usually opened the door while preparing the process, exited the room, and closed the door to prevent radiation exposure. At 3:10 PM on 5/18/23, the surveyor shared concerns regarding the failure to keep residents privacy with LPN #42. He said okay. In an interview with the Director of Nursing (DON) on 6/06/23 at 09:00 AM, the surveyor shared concerns with the DON. 18819 2) On 05/19/23 at 9:10 AM, a nurse surveyor went to interview Resident #259 in his/her bedroom. An observation that Resident #259's door was open and the resident's privacy curtain was pulled back/open. Resident #259 agreed to the interview but stated that S/he was on the bedpan and asked if the surveyor could come back. At 9:20 AM, the nurse surveyor returned to Resident #259's room to continue the interview. Resident #259 complained that the nurse aide did not close the privacy curtain or close the door to the room. In an interview with GNA #30 On 05/19/23 at 11:46 AM, GNA #30 Stated that S/he has worked at the facility under an agency contract for 6 months. GNA #30 stated that S/he would tell the resident what S/he was going to do before assisting a resident. GNA #30 stated that Resident #259 had to prompt him/her to pull the curtain after placing the resident on the bedpan. GNA #30 Stated that S/he did not assist Resident #259 off of the bedpan earlier on 05/19/23. A review of the facility Resident Right's and Services policy on 06/05/23 at 10 AM, of section D, Personal Privacy, 2, revealed a statement that a resident has the right to privacy during personal care.

Based on clinical record review and staff interviews, it was determined that the facility failed to 1) ensure the resident/responsible party was provided information in a manner easily understood by the resident or resident representative to formulate an advanced directive and offered the opportunity to develop an advanced directive, and 2) document/file the resident's advanced directive on their medical record. This was evident for 2 (Resident #40 and #111) of 10 sampled residents for advanced directives, and one resident ( #44) of 10 residents' advanced directive reviewed during the annual survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they can no longer make decisions for themselves because of illness or incapacity. 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 (CPR) and other life-sustaining treatment options for a specific patient. 1a) On [DATE] at 10:00 AM a chart review for Resident #40 revealed the resident was admitted to the facility in September of 2021. On [DATE] resident #40 made her/his decisions on the MOLST form and on [DATE] the resident was deemed incapable of making her/his own healthcare decisions except She/he can appoint healthcare agent. The most recent quarterly Brief Interview for Mental Status ([DATE]) revealed resident #40 scored a ,d+[DATE] indicating an intact cognitive response. The social worker (staff # 21) was interviewed on [DATE] at 1:25 PM. She was asked questions about her documentation related to advanced directives. She indicated that in the admission social history, there is a section where residents are asked, and she stated that advanced directives are reviewed quarterly. Further review of resident #40's medical record revealed that there was not a quarterly advanced directive review between [DATE] and [DATE] (7 months). The advanced directive review documentation only reviewed the resident's CPR status. There was no documentation related to the resident being asked or helped to develop an Advanced directive with a selection of a healthcare agent. 1b) Resident #111's medical record was reviewed on [DATE]. Resident #111 was originally admitted to the facility in November of 2021 with diagnoses that included cerebrovascular disease, dementia, mood disturbance, and anxiety. On [DATE] resident #111 made her/his own MOLST decisions and was deemed incapable of making his/her own medical decisions on [DATE] except can appoint healthcare agent. The most recent quarterly Brief Interview for Mental Status ([DATE]) revealed resident #40 scored a ,d+[DATE] indicating moderate cognitive impairment. There was not any documentation of quarterly advanced directive reviews between [DATE] and [DATE] (8 months). Both notes indicated that the social worker met with the resident to address code status. The resident's son was listed as a surrogate decision maker as there was no documentation related to the resident being asked or helped to develop an Advanced directive with a selection of a healthcare agent. An interview was conducted with the social worker on [DATE] at 10:02 AM. Information was exchanged related to the physicians' documentation on the Physician's Certification of incapacity to make informed decisions and the 7 and 8-month gaps in her advanced directive review notes and only documentation about code status. She was asked to confirm. Copies of the Physician Certification of Incapacity to Make Informed Decisions and social work notes were requested for both residents #40 and #111. The concerns related to lack of advanced directive education and no documentation related to formulating advanced directives for residents #40 and #111 were shared with the nursing home administrator, director of nursing, and Corporate Nurse (staff # 36) on [DATE] at 4:10 PM. 43096 2) On [DATE] at 11:01 AM, a review for Resident #44 revealed the resident was admitted to the facility in [DATE] with a past medical history that included but was not limited to, hemiplegia and hemiparesis, chronic obstructive pulmonary disease, embolism, and thrombosis of deep vein of the right upper extremity. During a review of the clinical record on [DATE], the resident's MOLST was located on the paper chart. The MOLST form dated [DATE] documented, I hereby certify that these orders are entered as a result of a discussion with and the informed consent of the patient's health care agent as named in the patient's advance directive. However, there was no advance directive filed under the medical record. During an interview with the Director of Nursing (DON) on [DATE] at 9:10 AM, the DON stated that usually, facility social workers obtain/document/manage residents' advance directives. However, the DON confirmed that the facility did not have documented or advance directives for Resident #44 in his/her medical record. During an interview with the Director of Nursing on [DATE] at 09:00 AM, the surveyor shared concerns about Resident #44's advanced directive.

Based on review of medical records and other pertinent documentation and interviews it was determined that the facility failed to ensure that staff immediately reported observations of suspected abuse to the Administrator as evidenced by abuse being observed on three separate occasions by three different staff members prior to it being reported to the Administrator; failed to ensure supervisory staff reported abuse allegations to the Administrator within 2 hours after the allegation was made as evidenced by nursing supervisor waiting more than 8 hours before reporting the allegation to a Unit Nurse Manager (Resident #41); and failed to report allegations of abuse to the state survey agency (Resident #6). This was found to be evident for 2 out of the 38 residents reviewed during the survey. On (MONTH) 18, 2019 at 6:25 pm an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to protect a vulnerable resident from abuse as evidenced by the facility's failure to report observations of abuse when made; failure to conduct thorough investigation; and failure to have effective system in place to ensure family member #1 was not allowed access to the resident. Surveyors accepted the facility's plan and the immediate jeopardy was abated on (MONTH) 18, 2019 at 11:40 PM with surveyors on-site. The findings include: On 1/18/19 review of Resident #41's medical record revealed a Minimum Data Set assessment, dated 11/14/18, that assessed the resident as totally dependent on staff for activities of daily living. The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps in the planning of care. Further review of the medical record revealed Resident #41 has a court appointed guardian of person due to lacking sufficient understanding or capacity to make or communicate responsible decisions concerning his/her person. Review of the 11/9/18 primary care provider note revealed a history of a [MEDICAL CONDITION] and stated, Resident is not able to verbalize whether (s/he) is in pain or frustrated. On 1/18/19 review of the facility investigation of an abuse allegation regarding Resident #41 revealed that on 12/28/18 at 7 AM a report was made that a Geriatric Nursing Assistant (GNA) had observed the resident being inappropriately touched by (family member #1). 1. Review of the facility investigation documentation revealed an Investigation Interview Form, dated 1/2/18, which documented an interview with GNA #3 completed by Assistant Director of Nursing (ADON)#13. Review of this form revealed the following: Tell me what you saw? 'Yes @ midnight I knocked on the door. The (person) was sitting close to the bed with (his/her) hands on (resident's) chest when (s/he) saw me come into the room, (s/he) removed (his/her) hands from (resident's) chest and raised (his/her) head.' Did you report this to anyone? 'I shared it with a co-worker'. No documentation was found as to the date that GNA #3's observation was made or what co-worker she reported it to. On 1/18/19 at 5:50 PM ADON #13, who documented GNA #3's interview, reported that GNA #3 was unable to provide the date of the observation but was definite that it was around midnight. ADON #13 went on to report that the co-worker GNA #3 had shared the information with was GNA #4. On 1/22/19 at 7:13 AM GNA #3 was interviewed in the presence of the Administrator. During this interview the GNA reported that she was familiar with the resident and confirmed that the resident was dependent for all care and was unable to verbally communicate. She reported that around midnight on a night in December, unsure of the date but confirmed it was before Christmas, she opened the resident's door and observed a (person) close to the bed with (his/her) hands on the resident's chest, upon seeing the GNA the (person) quickly sat back and then moved to another chair. The GNA reported that she then took the resident's vital signs, made sure the resident was ok then she left the room. GNA confirmed that the (person) was still in the room when she left, that she did not know at the time who the (person) was and that she thought (s/he) was (the resident's) (boy/girl)friend, although no one had ever informed her that the resident had a (boy/girl)friend. When asked if she told anyone about the unknown (person) in the resident's room she responded: No, because (s/he) was already there before my shift, the (person) was kind of old, did not know it was the (family member #1). She went on to report that usually the door is open but that night the door was closed and that midnight was the first time she had entered the room that shift. At the end of the interview the GNA confirmed that in the future she would report if she were to witness anyone touching a dependent resident inappropriately. Review of the police report revealed that GNA #3 reported to police that the above referenced incident occurred around (MONTH) 20, (YEAR). Review of time sheet documentation revealed GNA #3 worked the night shifts that started on 12/19 and 12/20. Review of the Visitor Sign-In Log for Resident #41 revealed the (family member #1) had signed in on 12/18 at 7:10. No designation of AM or PM and the Departure Time section for 12/18 was observed to be blank. Further review revealed the (family member #1) signed in again on 12/19 at 4:59. No designation of AM or PM and the departure time for the 12/19 entry was also noted to be blank. Review of the medical record revealed the following nursing note, dated 12/20/18 at 4:22 AM: family member (family member #1) spent the night in the room with patient. Patient had a quiet night no yelling nor crying noted. Patient respond to some stimulus and verbal command like open your eye or open your mouth . This note was written by Nurse #18. Further review of the medical record revealed a Change in Condition Evaluation, completed 12/20/18 at 3:08 PM, that revealed that a change had occurred in the morning and included the following: resident noted with increased agitation, continuously crying, yelling, drawing up a fist. appear very angry. unable to console. no relief with pain meds. ([MEDICATION NAME] and Tylenol). The physician had been made aware of the change in condition on 12/20/18 at 1:45 PM. Further review of the Visitor Sign-In Logs revealed the Family Member #1 visited on 12/21/18; 12/22/18; 12/23/18; 12/24/18; 12/25/18; 12/26/18 and 12/27/18. On 12/26/18 the family member #1 signed in at 7:44, the departure time for 12/26/18 was noted to be blank. No other visitors signed in on 12/26/18 after 7:44, although another visitor had signed in at 4:11 and no departure time was noted for this individual either. On 12/27/18 the Family Member #1 signed in at 4:50 and signed out at 6:00. No AM or PM designation was found for these Visitor Sign-In times. During the interview with GNA #3 on the morning of 1/22/19, when asked about having discussed her observation with any other staff, GNA # 3 reported that GNA #4 had told her during a change of shift report that the resident's (family member #1) was still in the room. GNA #3 stated: I told her I thought (s/he) was the (boy/girl)friend, how come the (family member #1) touch (resident) like that? Upon review of the statement, dated 1/2/19, GNA #3 confirmed that her statement about sharing her observation with a co-worker was in regard to the discussion with GNA #4 when GNA #4 had informed her the resident's (family member #1) was in the resident's room. GNA #3 confirmed that the night that she saw the (person) in the room touching the resident was a different night than when GNA #4 reported (him/her) being in the room during change of shift report. GNA #3 did not provide a date as to when this conversation had occurred, although she did state that she had not seen the (person) again after the conversation with GNA #4. Review of staffing sheets and time card documentation revealed that GNA #4 had worked the evening shift on 12/26/18 and GNA #3 had worked the night shift that started on 12/26/18. Further review of scheduling sheets and time card documentation failed to reveal documentation that GNA #3 had worked the night shift that started on 12/27/18 and ended on 12/28/18. Time card documentation revealed GNA #3 did not work at all on 12/27 and started a shift on 12/28 at 10:55 PM. 2. On 1/18/19 further review of the facility investigation documentation revealed a statement from Geriatric Nursing Assistant (GNA) #4, dated as having been written on 12/31/18, which stated, On the evening of (MONTH) 24th, as I conducted my routine checkup of my patient upon opening the door I noticed the patient's (family member #1's) hands in (resident's) shirt around (resident's) (chest) area. I then said to (him/her), ok (sir/ma'am), I'll be back I close the door, and then reported what I had seen to my supervisor on duty that evening. Interview with GNA #4 on 1/18/19 at 3:08 PM confirmed that she was familiar with the resident and that she had reported something that she had seen. The GNA reported that on Christmas eve or Christmas day she walked in to perform care and saw the (family member #1) in the room with (his/her) hand in the resident's shirt and that she left the room and went and informed her supervisor. The GNA then reviewed her written statement and confirmed the date of (MONTH) 24, (YEAR) as the day of the observation. Review of the police report revealed GNA #4 had reported to police that the above referenced incident had occurred on (MONTH) 24, (YEAR). Review of the Visitor Sign-In Log for Resident #41 revealed Family Member #1 had arrived on 12/24 at 4:17 and departed at 8:30. No designation of AM or PM was found for these entries. Review of the staffing sheets and time card documentation for 12/24/18 revealed the supervisor on duty was Nurse Supervisor #7. No statement was found in the facility's investigation that a statement was obtained from Nurse Supervisor #7, or any other supervisor. On 1/28/19 at 2:32 PM Nurse Supervisor #7 was interviewed. Nurse Supervisor #7 denied having received any direct reports of abuse from staff. She reported the first time she heard about abuse regarding Resident #41 was when she picked up a shift on a Friday evening and the unit nurse manager #10 informed her the police would be coming into facility. (MONTH) 28, (YEAR) was a Friday. 3. On 1/18/19 further review of the facility investigation documentation revealed Nurse #18 was listed as having been interviewed, however no documentation of an interview was found. On 1/23/18 at 7:12 AM Nurse #18 was interviewed in the presence of the Unit Nurse Manager #10. Nurse #18 reported she was familiar with the resident who she reported as nonverbal and requiring total care. When asked if she had been informed of possible abuse of Resident #41 the nurse reported that she personally had seen something, stating that she had seen the (family member #1) in a compromised position rubbing the left chest and arm. She went on to report that she had immediately reported this to Nurse supervisor #14. When asked when this occurred she responded before Christmas. Nurse #18 went on to report that maybe on the 24th (12/24/18) she was at the facility, but not working at the time, and that she and GNA #4 were talking about it. She stated: When I saw it, you have a gut feeling, when I saw it the (family member #2) was there and I was like who would do that, the (family member #2) was there. And when (GNA #4) said something, we put an eye on it. Nurse #18 confirmed it was just she and GNA #4 talking about this concern. On 1/28/19 the facility provided a copy of a statement written by Nurse #18. The statement was dated 1/19/19. The statement included the following: To whom it may concern I (name of Nurse #18) Nurse on 11pm-7 am night shift. Nurse walked in the room found patient's (male/female) family member's hand under gown rubbing left side of chest area. As soon as I walked in the room (s/he) pulled back but was still rubbing the left hand. I asked (him/her) to excuse me because I was getting ready to feed patient. This was reported to supervisor (name of Nurse #14) immediately. Patient's (family member #2) was in the room when all this happened but nonverbal with eyes closed. Further review of Nurse #18's written statement failed to reveal a date as to when this observation had been made and reported. Review of the police report revealed Nurse #18 reported to police that the above referenced incident had occurred on an unknown date in (MONTH) (YEAR). 4. On 1/18/19 at 3:58 PM Nursing supervisor #14 was interviewed. She reported that GNA #4 had reported the abuse concerns to her towards the end of the evening shift of 12/27/18. Nurse #14 also reported that she had done a physical assessment of the resident. When asked where the assessment was documented Nurse #14 responded: nurses do documentation every shift and if you check the notes there should be a note from the nurse. Review of the medical record revealed a nursing note, dated 12/27/18 at 10:47 PM written by Nurse #31 which addressed basic care and medical status during the shift. Further review of the nursing notes failed to reveal documentation of an assessment during the 12/27/18 night shift or any shift on 12/28/18. A Late Entry for 12/28/18 was found, written by ADON #13, which referenced the GNAs observation of a (male/female) sitting in a chair beside the bed with (his/her) arms extended and both hands on resident's chest. This note included that the health care practitioner and responsible party were made aware but failed to include any information in regards to an assessment of the resident. Review of the medical record failed to reveal any documentation of a physical assessment of the resident by Nurse #14 on 12/27/18 or 12/28/18. The resident was not seen by a primary care provider until 1/10/19. On 1/24/19 at 10:00 AM when asked about expectations of an assessment after an allegation of abuse the Medical Director reported that he would expect a thorough assessment by nursing, then if any concerns a follow up with the doctor. Surveyor then reviewed the concern with the Medical Director, the Director of Nursing (DON) and corporate nurse that there was no documentation found in the medical record of an assessment of the resident following the abuse report. On 1/28/19 a copy of the electronic incident report, with a revision date of 1/24/19 included the following in the Immediate Action Taken: Description: Assessed. No injury found. This documentation was not found on the 1/3/19 version of the incident report originally provided on 1/18/19. On 1/28/19 the facility provided a copy of a statement written by Nursing Supervisor #14 on 1/18/19 that stated the following: (name of GNA #4) GNA 3-11 reported to this writer on the night of 12/27/18 @ about 10:50 PM that she observed (Resident #41's) (family member #1) hand in the Patient's shirt toward (his/her) (chest). (GNA #3) when talked to also testified that she had noticed on several occasions that (family member #1) was too close to the Patient but thought he was (Resident #41's) (boy/girl)friend. This writer then went in assess the Patient especially around the (chest) area, but noticed no physical sign of trauma. (Resident #41's) (resident room #) has a foley catheter that was draining clear color urine at the time. No blood noticed. This writer then reported to the Unit Manager (#10) in the AM. Also during the 1/18/19 interview, Nursing Supervisor #14 confirmed that she did not contact the DON or the Administrator about the abuse allegation on 12/27/18 but waited until the morning of 12/28/18 to inform the Unit Nurse Manager #10. Nurse Supervisor #14 reported that GNA #4 reported the incident toward the end of the shift and she didn't want to call (Unit Manager #10) so late so I waited till the next day because (family member #1) wasn't around anymore that night. It was the end of the evening shift, before (GNA #4) left. Then I talked to (GNA #3) when she came to work and confirmed everything then called (Unit Manager #10) in the morning. Further review of the investigation documentation provided by the facility on 1/18/19 revealed the following: 1/2/18 - Allegation of family member inappropriately touching resident has been substantiated by witness. On (MONTH) 18, 2019 at 6:25 pm an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to protect a vulnerable resident from abuse as evidenced by the facility's failure to report observations of abuse when made; failure to conduct thorough investigation; and failure to have effective system in place to ensure family member #1 was not allowed access to the resident. The Abatement Plan to remove the Immediate Jeopardy included the following: - Education of staff regarding Protecting vulnerable residents and reporting observations of abuse immediately; with validation competency post training. -Education of Administrator and Nursing Management regarding conducting thorough investigations; with validation competency post training. -Education of nursing staff regarding conducting and documenting a thorough physical assessment of a resident post allegation of physical abuse. -The completion of in-servicing will be monitored by comparing training records with an employee staffing roster. -Receptionist and designated relief staff re-educated. -The Administrator, Manager on Duty or Nursing Supervisor will review a list of restricted visitors maintained in the Visitor Log Book daily and update as needed. -The DON will be responsible for the implementation of the abatement plan. Surveyors accepted the facility's plan and the immediate jeopardy was abated on (MONTH) 18, 2019 at 11:40 PM with surveyors on-site. 2) On 1/18/19 at 12:10 PM during observation of the facility, a picture was noted at the nurse's station. At that time an interview was conducted with Unit Manager #24 requesting information on the picture. The staff member explained that it was a picture of a family member of Resident #6 who was no longer allowed to enter the facility due to verbal abuse directed at the Resident and a staff member a month ago. Review of the facility's investigation was conducted on 1/23/19 at 11:00 AM and it did not indicate that the incident had been reported to the state agency. During an interview on 1/23/19 at 1:36 PM with the Director of Nursing (DON), she/he was asked what the process was for suspected or known abuse of a Resident. The DON stated you must complete a self-report. When asked if this had been completed, he/she responded No.