Every finding on record at Future Care Cold Spring

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service and safety. This was evident in 2 of 3 kitchen observations and 2 of 2 nourishment room observations during an annual survey. The findings included: On 9/29/25 at 8:10 AM, the surveyor made an initial tour of the facility's kitchen. Upon entering the kitchen, the surveyor noted dripping from the ceiling outside of the walk-in refrigerator/freezer. A bread cart was next to the refrigerator/freezer door, and a spice rack was across from it. Two containers collected the dripping water on the floor. On 9/29/25 at 8:17 AM, the surveyor interviewed the Food Service Director Staff #1. During the interview, Staff #1 stated he believed the dripping was from condensation. On 9/29/25 at 8:34 AM, the surveyor asked the Nursing Home Administrator if he was aware of the dripping from the kitchen ceiling. The NHA stated he was not but would follow-up. On 9/29/25 at 10:34 AM, the surveyor conducted a follow-up interview with the NHA. During the interview, the NHA stated that the leaking in the ceiling was due to a pinhole leak in the hot water return line and that the line was fixed. He further stated that they disposed of the bread and spices out of an abundance of caution. On 10/6/25 at 11:16 AM, the surveyor observed the 3rd floor nourishment room located close to the elevator. The surveyor observed a resident's food tray that appeared to have had a resident eaten from it on the counter in the nourishment room. Licensed Practical Nurse (LPN) #24 stated that she would dispose of the contents from the tray. On 10/6/25 at 11:23 AM, the surveyor observed the 2nd floor nourishment room located close to the elevator. Again, the surveyor noted a resident's left-over food trays on the counter in the nourishment room. The surveyor updated Unit Manager #12 of the observation. On 10/6/25 at 11:35 AM, the surveyor observed the lunch meal assembly at the steam table line in the main kitchen. On further observation, the surveyor noted a cell phone on the stainless-steel table parallel with the steam table assembly next to the coffee maker. When asked if there was a reason for the cell phone to be out, Dietary Aide #20 left the steam table assembly and removed the phone from the area. On 10/6/25 at 12:21 PM, the surveyor interviewed the NHA. During the interview, the surveyor revealed the observation from the kitchen. The NHA confirmed that personal items such as a cell phone should not be in the kitchen during meal preparation or meal assembly.

Based on observations, interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This was found evident in 3 (Resident #124, #127 and #137) out of 51 residents reviewed during the recertification survey. The findings include: 1) On 10/01/25 at 9:05 AM a review of the facility's investigation of an incident pertaining to Resident # 124 revealed the staffing sheet dated 06/25/25 Unit 3B on 06/25/25 7:00 AM -3:00 PM shift indicated Geriatric Nursing Assistant (GNA) #8 had an assignment on the unit. The surveyor asked the Administrator where the statement from GNA #8 was since he/she worked on the unit where the alleged incident occurred. The Administrator verbalized GNA #8 assignment was changed, and he/she was moved to Unit 3B. The surveyor asked the Administrator when the GNA assignment changed should the staffing sheet have been updated. The Administrator verbalized, yes. On 10/01/25 at 10:02 am a review of the Change in Condition Evaluation for Resident #124 dated 06/26/25 was completed by Registered Nurse (RN)#10 revealed the evaluation was not completed in totality. RN #10 failed to complete the section related to pain, Code Status, and whether the resident had medication changes within the past week. The surveyor reviewed the evaluation with Regional Clinical Services Manager #5. The surveyor asked was RN #10 supposed to complete the form entirely. Regional Clinical Services Manager #5 verbalized yes. On 10/07/25 at 11:15 am a review of Resident #127 electronic health record revealed the resident had a fall on 05/21/25. The resident sustained an abrasion to the forehead but there was no documentation to verify the location and size of the abrasion. The surveyor asked Assistant Director of Nursing (ADON) #25 should the nurse have documented where the abrasion was located and the size. ADON #25 verbalized yes. 2) On 9/29/25 at 9:11 AM, the surveyor observed Resident #137's Peripherally Inserted Central Catheter (PICC) line in his/her right upper arm. The dressing covering the site was dated 9/20/25. On further observation, the dressing to Resident #137's left posterior thigh was off, and the wound was exposed to the bed. The surveyor noted that the drainage was observed into the bed linen. Resident #137 stated that the wound dressing had come off after transferring to the wheelchair and then back to bed last evening. Resident #137 further stated that the staff yesterday evening was aware and told him/her that they would re-dress the wound later. On 9/29/25 at 9:15 AM, the surveyor conducted an interview with Resident #137's assigned nurse, Licensed Practical Nurse (LPN) #2. During the interview, LPN #2 stated that a PICC line dressing should be changed every 7 days. She further stated she was not aware that Resident #137's left leg dressing needed to be dressed and would follow up with the Resident. On 9/29/25 at 12:49 PM, the surveyor reviewed Resident #137's September 2025 Treatment Administration Record (TAR). Nowhere on the TAR was there an order or a place to document the PICC line dressing change. On further review, the dressing changes to Resident #137's two left leg wounds were documented as changed on the scheduled change on 9/28/25; however, the as-needed dressing change was left blank. On 9/30/25 at 6:38 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview, the DON stated that she had spoken to the nurse that took care of Resident #137 on the afternoon of 9/28/25. She further stated that Resident #137 refused to have both his/her PICC line dressing changed and wound re-dressed and that the nurse wrote a late entry to capture these events. The DON confirmed that the nurse should have documented at the time the resident refused and notified the provider of refusals of care.

Based on observations and interviews, the facility failed to maintain practices to help prevent the transmission of infections. This was evident in 1 (Resident #137) of 9 residents reviewed for indwelling medical devices/wounds and observations of the laundry area during the recertification survey.The findings include:Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO, as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).1) On 9/29/25 at 9:11 AM, the surveyor observed that Resident #137 had a Peripherally Inserted Central Catheter (PICC) line in his/her right upper arm, a foley catheter, multiple pressure ulcers, and an ostomy. The surveyor further observed no sign or indication to staff that they should be utilizing EBP while performing any high-contact care for Resident #137 related to Resident 137's multiple indwelling medical devices. On 9/29/25 at 12:49 PM, the surveyor reviewed Resident #137's September 2025 Treatment Administration Record (TAR). An order was written for Resident #137 to have Enhanced Barrier Precautions. On 9/30/25 at 9:44 AM, the surveyor conducted an interview with Resident #137's assigned nurse, Licensed Practical Nurse (LPN) #2. During the interview, LPN #2 stated Resident #137 was not in EBP and confirmed that he/she did not have a sign on the door. On 9/30/25 at 11:10 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview, the DON confirmed that Resident #137 was in EBP. The surveyor relayed the interview with LPN #2. The DON stated that Resident #137 should have a sign on their door to indicate the precautions staff should provide. She further stated that the order for EBP was updated on 9/29/25 to indicate the rationale for the precautions. 2) On 10/06/25 at 2:39 pm during a tour of the facility's laundry room the surveyor observed the door where the clean laundry was stored was opened, the laundry shoot was ajar with four bags of soiled laundry inside the shoot, three bags of soiled laundry were on the floor, and a yellow gown & googles were on top of the paper towel dispenser. Also, the chemicals used to clean the laundry were caked on the raised area where they were stored. On 10/06/25 at 2:45 pm when the door was closed to the clean laundry room, dust particles were floating in the air. The surveyor asked Environmental Services Director (EVS) #28 were they aware the door to the clean area is supposed to be closed, EVS Director #28 verbalized they were not aware. EVS Director #28 verbalized the floor tech would clean up the spilled chemicals. On 10/07/2025 at 10:32 am during an interview with EVS Director #28 the surveyor asked what the expectations of the staff in relation to infection control and cleanliness of the laundry room are. EVS Director #28 verbalized the laundry staff would be in-serviced on keeping the laundry room clean. The staff are not supposed to have bags of laundry on the floor and before the bin gets full, they must remove the dirty laundry. They are supposed to dust and clean the laundry area daily. The personal protective equipment (PPE) was removed and the area where the chemicals were was cleaned.

Based on observations and interview it was determined that the facility failed to maintain adequate conditions of equipment. This was evident during 2 of 3 observations of ice machines and 1 of 1 of the laundry room. The findings include:On 10/6/25 at 11:16 AM, the surveyor observed the 3rd floor nourishment room located close to the elevator. Upon opening the door, the surveyor noted water on the floor just below the ice maker machine, and the ice machine's tray was filled to the top with water. Next, the surveyor interviewed Licensed Practical Nurse (LPN) #24 and asked if she was aware of the ice machine's condition. She stated she was not and would let maintenance know. On 10/6/25 at 11:23 AM, the surveyor observed the 2nd floor nourishment room located close to the elevator. The surveyor noted moist tan particles at the bottom of the ice machine's tray. The Regional Director of Nursing (RDON) was on the floor and the surveyor asked if the ice machine was clean. The RDON stated she believed that cleaning could not remove some of the white areas seen on the tray. Next, the surveyor removed the tray and wiped the bottom of the ice tray. A tan substance smeared on the paper towel. The surveyor updated Unit Manager #12 of the observation. On 10/6/25 at 12:54 PM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview, the NHA administrator stated that maintenance serviced the floor ice machines every 4 months. He further stated that the Environmental Service (EVS) was responsible for cleaning the outside of the machine every day. The surveyor revealed the concern that both ice makers reviewed in the nourishment rooms were being utilized even with poor cleaning and working conditions. The NHA stated that maintenance had already fixed the clog that was causing backup in the 3rd floor ice maker and would update EVS.

Based on record reviews and interviews, it was determined that the facility failed to develop and implement patient-centered comprehensive care plans to meet the needs of residents. This was evident for 2 (Residents #1 and #4) out of 51 residents reviewed during the annual survey.The findings include:A care plan is a formal document that outlines a nursing home resident's medical and personal care needs. 1) During a record review of Resident #1's Care Plan on 10/01/2025 at 12:17 PM, a care plan problem was identified that read, (SPECIFY Impaired memory / cognition) r/t (SPECIFY neurological disorder) as evidenced by ______. The Regional Clinical Service Manager (RCSM) was asked about the expectation was for filling in brackets when creating care plans. The RCSM stated Social Services was responsible for that entry and the expectation was that details should be documented when the care plan is written. Social Worker #3 acknowledged on 10/02/2025 at 12:09 PM that the care plan should be patient-specific and the bracketed information needed to be patient-centered. During an interview on 10/02/2025 at 12:11 AM, the Director of Nursing (DON) and the RCSM acknowledged the concerns related to the care plan not being patient centered. Need to be filled in. 2) On 10/1/25 at 8:17 AM, the surveyor reviewed Resident #4's medical record. The review revealed a note written by Physician # 27 on 9/25/25 that stated Resident #4 was recently admitted to the facility after functional decline in ambulation and Activities of Daily Living (ADLs) due to a fall with fractures and right upper extremity weakness. On further review, the surveyor noted a care plan created on 8/24/25 that stated Resident # 4 had pain related to. 11 days later, a care plan was added on 9/5/25 that stated Resident #4 was at risk for pain related to chronic physical disability. Additionally, a care plan created on 8/24/25 stated Resident #4 was at risk for falls related to. On 8/27/25, a new care plan was added that stated Resident #4 had an actual fall as evidenced by the resident was observed being on the floor. On 10/1/25 at 12:02 PM, the surveyor conducted an interview with Regional Clinical Service Manager Staff #5. During the interview, Staff #5 stated that the care plans created on 8/24/25 were not person-centered and should have been specific to Resident #4's plan of care.

Based on staff interviews and record reviews, the facility failed to maintain acceptable parameters of nutrition for residents and address significant weight gain. This was evident for 1 (Resident #8) out of 5 residents reviewed for nutrition during the annual survey. Significant weight change is defined as a gain or loss of 5% of a person's weight within 30 days, 7.5% within 90 days, or 10% within 180 days. Significant weight change requires clinical evaluation and, if the change is not beneficial, intervention. The findings include: On 10/1/25 at 12:42 AM, the surveyor reviewed the medical record for Resident #8. The review revealed that Resident #8 was admitted to the facility in January of 2024. Resident #8's past medical history included major depressive disorder, peripheral vascular disease, acquired absence of the leg above the knee, and dementia. Further review of Resident #8's medical record revealed weights taken:9/1/25 212.6 Pounds (lbs)8/13/25- 211 lbs8/8/25- 202.8 lbs7/31/25- 203.4 lbs7/2/25- 203.2 lbs6/24/25- 203.26/17/25- 211.2 lbs6/11/25- 212.3 lbs6/6/26- 209 lbs5/1/25- 202.4 lbs4/9/25- 197 lbs3/6/25- 171.8 lbs2/8/25- 171.3 lbs1/13/25- 171.5 lbs12/5/24- 171 lbs11/11/24-164.5 lbs10/3/24- 154.6 lbs From 10/3/24 to 3/6/25, approximately 6 months, Resident #8 had an 11.13% weight gain.From 3/6/25 to 9/1/25, approximately 6 months, Resident #8 had a 23.75% weight gain. Next, the surveyor reviewed the dietary progress notes. On 10/3/24, a quarterly assessment note written by Dietitian #31 indicated that the weight on 9/3/24 was most likely an error. She further stated that Resident #8 had an above-the-knee amputation in July and requested a reweight. On 10/22/24, a note written by Dietitian #31 acknowledged the re-weigh done on 10/3/24 with the plan to continue to monitor weights. On 11/19/24, a readmission note written by Dietitian #31 for nutrition assessment documented Resident #8's weight on 11/11/24 was 165.5 lbs. She further stated this triggered a 6.5% weight gain over one month and requested a reweight to confirm weight change. The surveyor noted the next weights completed on 12/5/24- 171 lbs. This was one month after the request. On 2/18/25, a quarterly assessment note written by Dietitian #31 noted the resident was triggered for an 11.8% weight gain and stated it was likely related to fluid shifts or scale discrepancy and noted the weight at 171.3 lbs on 2/8/25. The plan was to continue to monitor monthly weights. On 5/23/25, a quarterly assessment note written by Dietitian #31 questioned a 37 lb weight gain x 3 months, with no edema or congestive heart failure noted. She further stated the weight gain might be due to a possible scale discrepancy and noted the weight of 202.4 lbs on 5/1/25. The plan was to monitor weight trends and labs. On 6/10/25, a note written by Dietitian #31 acknowledged a Minimum Data Set assessment that documented a 10% weight change over 180 days. She further requested a reweight to confirm, with the next weight taken the next day on 6/11/25- 213.3lbs. On 6/12/25, a note written by Dietitian #31 confirmed weight gain from the reweight obtained and wrote she continued to question a +41 pound weight gain in 6 months. She wrote the provider was to be made aware by nursing. On 6/13/25, a readmission note written by Dietitian #31 asked for a weight to be obtained and also to obtain weights weekly. The next weight was obtained on 6/17/25-211.2lbs, 4 days after the request. On 6/25/25, a note written by Dietitian #31 documented a weight loss, however questioning 6/6- 6/17 weights as possible outliers with the plan to monitor weight trends. On 7/4/25, a note written by Dietitian #31 documented questioning weight gain x 6 months for a possible scale discrepancy. Dietitian #31 wrote Resident #31 was on mirtazapine (also known as Remeron) (an atypical antidepressant used primarily to treat major depressive disorder and can have an appetite-stimulating effect). Dietitian #31 suggested considering discontinuing this medication. On 8/13/25, a quarterly assessment note written by Dietitian #31 documented a trigger for weight gain x 6 months with weights trending up. The stated goal was for weight maintenance and again documented to consider discontinuing the appetite stimulant mirtazapine. On 10/3/25 at 9:14 AM, the surveyor interviewed Dietitian #31 along with Regional Clinical Service Manager Staff #5. During the interview, Dietitian #31 stated that she was aware of Resident #8's weight gain and documented the monitoring. She stated that her assessments and recommendations should be communicated to the physician by the nursing staff. She further stated that re-weights were not always completed by nursing, but she continued to request them if not performed. The surveyor relayed concerns that the resident continued to gain weight after the same monitoring was happening for months and when re-weights and medication adjustments were requested they were not acted on. Additionally, there was no follow-up to inquire if the scales utilized were calibrated and accurate. Staff #5 confirmed that scales utilized were validated quarterly. At the time of exit no documentation was proved to the surveyor to indicate that Resident #8's weight gain was according to his/her plan of care and/or intervention were adjusted or acknowledged. Cross reference F710

Based on observations, staff interviews and clinical record review, it was determined that the facility staff failed to ensure that a tube feeding bag was labeled. This was evident for 1 resident ( #89) of 3 residents reviewed for tube feedings during the annual survey. The findings include: On 09/29/2025 at 10:57 AM during an initial observation of Resident #89, both the tube feeding formula bag and the flush bag were found hanging on the tube feeding pump. The formula bag was full, and the flush bag was half full. Neither bag was labeled with the resident's name, the type of formula, the date and time the bag was hung, or the name/initials of the staff member who hung them. On 09/29/2025 at 11:15 AM Staff #6, a Registered Nurse (RN), confirmed that Resident #89 receives daily tube feedings. When shown the unlabeled bags and asked about the formula, the recipient, the hanging time, and the staff member responsible, Staff #6, RN stated, I am not sure if Resident #89 received the tube feeding because another shift hangs the bag and night shift takes the bag down by 6:00 AM. Staff #6, RN also added, I am not sure what formula this is or when it was hung because there is no label on the tube feeding bag. Following this, Staff #6, RN removed both the tube feeding and flush bags. On 09/30/2025 at 10:50 AM a review of Resident #89's medical records revealed an order from September 11, 2025, for Jevity 1.5 at 35ml/hour for 10 hours from (8 PM to 6 AM) or until a total nutrient volume of 350ml was infused. The order specified administering the enteral feeding once daily, with downtime at 6 AM or until the total volume of 350ml was administered, and to hang the enteral tube feeding at 8 PM each day. The tube feeding was observed the day before still hanging at 10:57 AM. On 10/7/2025 at10:34 AM, Staff #25, the Assistant Director of Nursing (ADON), was interviewed regarding the facility's procedure for nurses hanging tube feedings. The ADON explained that nurses should verify the order, perform hand hygiene, and label the tube feeding with the resident's name, formula type, date, time hung, and their initials or name. The same procedure applies to the flush bag and syringe. The ADON was informed that this procedure was not followed for Resident #89, raising concerns about potential errors in administering the correct formula to the right resident at the right time, as well as the risk of infection due to untimely disposal of the formula. The ADON acknowledged and understood these concerns.

Based on review of Geriatric Nursing Assistant personnel files and staff interview, it was determined that the facility failed to complete required annual performance reviews for Geriatric Nursing Assistants (GNAs) at least once every 12 months. This finding was identified for 2 of the 3 GNA staff members (GNA #22 and #23) reviewed during the annual survey. The findings include: On 10/6/2025 at 9:45 PM, annual competencies for three random GNA's were requested. Record reviews revealed that Staff #22, GNA and Staff #23, GNA did not have their annual performance reviews for 2024 and 2025. On 10/06/2025 at 11:56 AM Staff #5, the Regional Clinical Service Manager (RCSM), was interviewed and asked if any additional documentation could be provided for Staff #22 and Staff #23's annual GNA performance reviews. Currently, Staff #22's last annual GNA performance review was on 6/27/2023 and Staff #23's last annual GNA performance review was on 6/29/2023. Staff # 5 RCSM stated what I have given you is all the documentation that I have for these staff members. Staff #5, the RCSM, verbalized understanding that GNA's should have competencies/performance reviews annually.

Based on observations, record reviews, and interviews, the facility staff failed to 1) obtain and administer medications according to procedures and, 2) failed to accurately and safely to conduct and apply before each meal's insulin sliding scale. This was evident for two residents (#133 and #43) out of 10 reviewed for medications. The findings include:1) On 10/6/25, at 1:06 PM, the surveyor reviewed Resident #133's medical record. The Medication Administration Record (MAR) for May 2024 indicated that four different medications were coded 9 (other, see progress notes) in the administration documentation. Three of those medications had progress notes that stated the medication was ordered, but the pharmacy still needed to deliver them to the facility. The medications were: Famotidine (start date of April 9, 2024) coded 9 on May 3, 2024. Levothyroxine (start date of December 2, 2023) coded 9 on May 29, 2024. Nasal Moist Nasal Solution (start date of May 25, 2024) coded 9 on May 26, 2024. On 10/6/25, at 1:02 PM, the surveyor interviewed Staff #5, the Regional Clinical Service Manager. During the interview, the surveyor reviewed the concern that Resident #133 did not receive his/her medication as ordered on multiple occasions because the medications were unavailable. Staff #5 stated that the pharmacy dispensed medications with three days' worth and replaced them accordingly. She further stated that the medications should have been available for administration. A review of the facility's policy, Medication Administration- Timeliness, revealed that the expected outcome stated, Medications will be administered within appropriate time frames. 2) On 10/2/2025 at 8:30 AM, this surveyor was on the floor to observe the medication administration with Registered Nurse (RN) Staff #16; noticing the residents' breakfast cart was arrived around 8:30 AM. Resident #43 had a standing order started 8/29/2025 for Humalog Kwikpen Subcutaneous Solutions pen- injector 100 Unit/ML (Insulin Lispro) injections as per sliding scale of the blood sugar (BS) fingerstick: if 0-200 =0, 201-25-=2, 251-300=4, 301-350=6, 351-400=8, 401+ =10 Notified MD if less than 60 or greater 400, subcutaneously before meals and at bedtime for Diabetes mellitus type 2. Humalog Kwikpen Insulin lispro U-100 (Humalog ) is a short-acting insulin which Onset: 10-15 minutes Peak: 1-3 hours Administer 30-60 minutes before meals. Fingerstick is a method used to test blood glucose by using a puncturing device (like a lancet) to take a small sample of blood from the finger. Diabetes mellitus type 2 is a chronic metabolic disorder characterized by persistent high or low blood sugars. It may be due to impaired insulin secretion, resistance to peripheral actions of insulin, or both. Observed Staff #16 was giving Resident #43's morning medications, he did not conduct the before breakfast BS check nor provided the proper coverage as an omission error. Noted on the Medication Administration Record (MAR) standard meals and before sleep hours BS checks were set for 6:30 AM, 11:00AM, 16:00 PM & 20:00 PM which it was also a concern. Record Review, on 10/2/2025 at 09:05 AM, MAR revealed that there was a discrepancy of breakfast sliding scale time set at 6:30 AM, however, the breakfast cart did not arrive until 8:30AM which it still required a before meal BS check to this resident. Interview, on 10/2/2025 at 09:20 AM, Unit Manager Staff #15 reviewed the MAR and stated that the night shift RN Staff #32 did a one time BS check around 6:00 AM the reading was 287 and she mistakenly utilized the before meal breakfast regiment then she covered Resident #43 with 4 units of Humalog Kwikpen Subcutaneous which it was an error. The day shift Staff #16 did not check at 8:30 AM when breakfast was served because he saw the before breakfast BS check was already filled in as 287 -2 hours ago. Staff #15 stated that the breakfast for that floor was always the last cart from the kitchen around 8:30 AM. Staff #15 was to correct all the before meal BS check times on MAR immediately to align with the actual meal serving times, to educate the nursing staff to conduct before meal time insulin scaling scale correctly and not to utilize the before meals insulin regiment for one time BS check needs. Interview, on 10/3/2025 at 10:00 AM, shared above finding with the Regional Clinical Service Manager Staff #5 as a practice concern. And she recognized that the above finding was a practice deficiency.

Based on a review of the medical record and interviews with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists. This was evident for 1 (#12) of 51 residents reviewed during the annual survey.The findings include:During a review of the consulting pharmacist's monthly recommendations for Resident #12 on 10/03/2025 at 8:30 AM, it was recommended that the prescriber document a rational for use and a duration date for lorazepam. The physician reviewed the recommendation and signed that they would refer to end of life consultant. The current order read, LORazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml by mouth every 6 hours as needed (PRN) for anxiety, agitation end of life care -Start Date08/05/2025 1045. No end date was written. The review was signed as completed by Physician #30. During an interview Physician #30 acknowledged on 10/03/2025 at 11:40 AM, that although the recommendation for the indication for end of life care was made, there was no stop date added as recommended by the Clinical Pharmacist. On 10/03/2025 at 11:41 AM, the Regional Clinical Service Manager (RCSM) acknowledged the concern that there was no stop date for PRN medications. She later confirmed that there was no stop date on the record and stated it would be corrected. The Director of Nursing is responsible for following up with the Clinical Pharmacist recommendations.

Based on a record review and interviews, the facility failed to obtain laboratory services in a timely manner. This was found evident of 1 (Resident #2) of 1 resident reviewed for laboratory services reviewed during the annual survey The findings include: On 10/1/25 at 11:47 AM, the surveyor reviewed Resident #2's medical record. The review revealed Resident #2 had a past medical history of dementia and behavioral disturbances. Resident #2's care plan listed a risk for complications related to aphasia and apraxia, affecting response to care, and noted refusal of laboratory (Lab) samples. Next, the surveyor reviewed the progress notes. On 9/26/25, Registered Nurse (RN) #29 documented that a Basic Metabolic Panel (BMP) result was cancelled due to a missing date of birth (DOB) identifier. The note further states that the provider was informed, and a new order for a BMP for Monday 9/29/25 was given. On 10/1/25 at 12:59 PM, the surveyor reviewed Resident #2's orders. No order was found for a redraw of the BMP lab. On 10/2/25 at 1:46 PM, the surveyor interviewed the Director of Nursing (DON) and asked for the lab results from the redraw that was described to have occurred on Monday 9/29/25. On 10/3/25 at 6:59 AM, the surveyor conducted a follow-up interview with the DON. During the interview, the DON stated that an order should have been placed to communicate the redraw, and it was missed. She further stated that the order was now entered, and the lab would be drawn.

Based on record reviews and interviews it was determined that the facility staff failed to ensure two Geriatric Nursing Assistants (GNA) received Dementia training upon hire and failed to complete an annual employee evaluation. This deficient practice was evidenced in three GNA records reviewed during the recertification survey. The findings include: On 09/30/25 at 2:47 pm a review of Geriatric Nursing Assistant (GNA) #17 employee training record revealed the GNA was hired in March 2025 and did not receive Dementia training. On 10/01/25 at 2:22 pm a review of GNA #18 employee training record revealed there was no documentation to verify the GNA received Dementia training. The GNA was hired on 07/08/24 and was terminated on 04/04/25. A review of GNA #36 employee record revealed the GNA was hired on 04/24/24 and is currently working in the facility. The GNA did not have their annual evaluation after one year of employment. On 10/01/25 10:06 am during an interview with Regional Director of Operations #37 verbalized they don't have evidence to verify GNA#17 received Dementia training, but they do Dementia training throughout the year. On 10/03/25 at 10:40 am during an interview with Regional Clinical Service Manager #5 reported GNA #18 started the Dementia training but did not complete the course. When asked if a GNA is supposed to have a yearly evaluation. Regional Clinical Services Manager #5 verbalized yes. On 10/03/25 at 12:10 pm during an interview with Director of Education #19 the surveyor asked GNA's required to have Dementia training. Director of Education #19 verbalized Dementia training must be completed within the first 90 days of employment. The course should be completed In Health Stream. The facility staff are responsible for ensuing the training was completed.

Based on record review and interviews, it was determined that the facility failed to determine if a Resident had an Advanced Directive and/or offer to help formulate one if determined not to have one. This was evident in 2 (Resident #138 & #4) of 3 residents reviewed for Advanced Directives during an annual survey. The findings included: 1a) On 9/30/25 at 8:11 AM, the surveyor reviewed the paper medical record for Resident #138. The paper medical record did not contain Advanced Directives (AD)s. On 9/30/25 at 10:36 AM, the surveyor interviewed the Social Service Director, Staff #3. During the interview, the surveyor asked if Resident #138 was asked about AD or offered to make them. Staff #3 stated she had met with the resident and was not sure. She stated that recently she had help from the corporate social workers to help review residents' ADs and would follow back up. On 10/1/25, Staff #3 wrote a progress note related to reaching out for ADs. However, this was documented after the surveyor requested this documentation. At the time of exit, no documentation was provided to indicate the ADs were addressed prior to the surveyor's request. 1b) On 9/30/25 at 7:55 AM, the surveyor reviewed the paper medical record for Resident #4. The paper medical record did not contain Advanced Directives (AD)s. On 10/1/25 at 8:17 AM, the surveyor reviewed Resident #4's electronic medical record. The review revealed Resident #4 was admitted into the facility in the middle of August 2025. The review revealed no documentation to note if the Resident had ADs and needed to be obtained or if Resident #4 was offered the opportunity to create an AD on admission if he/she did not have them. On 10/2/25 at 10:34 AM, the surveyor interviewed the Social Service Director, Staff #3. During the interview, the surveyor asked if Resident #4 was asked about AD or offered to make them. Staff #3 stated she would review her documentation and follow up. On 10/2/25 at 11:29 AM, the surveyor conducted a follow-up interview with Staff #3, where she confirmed that there was no documentation to support that Resident #4 was asked about ADs or the opportunity to create one.

Based on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent Residents. This was evident in 1(Resident #4) out of 2 Residents reviewed for Activity of Daily Living (ADL) care. The findings included: On 10/1/25 at 8:17 AM, the surveyor reviewed Resident #4's medical record. A note written by Physician # 27 on 9/25/25 stated Resident #4 was recently admitted to the facility after functional decline in ambulation and Activities of Daily Living (ADLs) due to a fall with fractures and right upper extremity weakness. On 9/30/25 at 9:35 AM, the surveyor observed Resident #4 in the lounge area in a reclining chair. The surveyor noted long nails on all of Resident's left fingers which all appeared to be 1/2 inch long and had a dark substance under them. The surveyor reviewed the TASK documentation for Activity of Daily Living (ADL) cares for personal hygiene for Resident #4 for the month of September. Resident #4 was documented as dependent for ability to maintain personal hygiene. No refusals were noted in the documentation. On 10/1/25 at 12:02 PM, the surveyor conducted an interview with Regional Clinical Service Manager Staff #5. During the interview, the surveyor reviewed the TASK documentation and asked if maintaining and cleaning fingernails would be included in ADL care. Staff #5 confirmed that it would be part of the care. The surveyor reviewed the observations of Resident #4's nails and the concern that nail cares were not provided. On 10/2/25 at 7:53 AM, the surveyor conducted a follow-up interview with Regional Clinical Service Manager Staff #5. During the interview, Staff #5 stated that she had a regional nurse look at the nails and the nurse described them as needing some care and that the nails were addressed.

Based on record review and interviews it was determined that the facility staff failed to follow the standard of practice for nurses as evidenced that a nurse failed to notify the physician when a resident refused a treatment and a nurse completed a Change in Condition Evaluation 11 days after the change occurred. This deficient practice was evidenced in 2 (#124 & #125) of 5 resident records reviewed during the recertification survey. The findings include: On 09/30/25 at 11:35 AM a review of Resident #124 electronic health record (EHR) revealed Registered Nurse (RN) #10 completed a change in condition evaluation on 07/07/25 and the form was back dated to 06/26/25. On 09/30/25 at 12:13 PM during an interview with the Director of Nursing (DON) the surveyor asked when the staff are expected to document when a change occurs with a resident. The DON verbalized a change in condition evaluation form should be completed before the end of the shift. The Unit Managers or supervisors are supposed to ensure the staff completes documentation in a timely manner. On 10/03/25 at 8:55 AM a review of Resident #125 electronic health record revealed Licensed Practical Nurse #35 documented on 8/5/2025 at 11:21 PM the resident refused care of their suprapubic catheter. Further review of the EHR revealed on 08/10/25 at 11: 12 PM LPN #35 documented the resident refused care of their suprapubic catheter. On 10/03/25 at 10:44 AM during an interview with Regional Clinical Service Manager #5 the surveyor asked when a resident refuses care what the staff are expected to do? Regional Clinical Service Manager #5 verbalized the staff should offer care to the resident again, call the family for assistance, and educate the resident about the implications of refusing care. The physician should be notified when a resident refuses care.

Number of residents sampled: Number of residents cited: Based on record review and interviews it was determined that the facility staff failed to notify the state agency within the two-hour allotted time frame. This deficient practice was evidenced in 2 (#124 & #126) of 3 facility reported incident investigations reviewed during the recertification survey. The findings include: On 09/30/25 at 12:59 PM a review of the facility's investigation of the facility reported incident related to Resident #124 revealed the facility staff became aware of the alleged incident on 06/26/25 at 6:50 AM. The incident was reported to the state agency on 06/26/25 at 9:23 AM which was outside of the two-hour allotted timeframe for reporting incidents. On 10/01/25 at 1:50 PM a review of the facility's investigation of the facility reported incident related to Resident #126 revealed the facility staff became aware of the alleged incident occurred on 03/27/25 at 1:40 PM. The incident was reported to the state agency on 03/27/25 at 03/27/25 at 3:51 PM, which was outside of the two-hour allotted timeframe for reporting incidents. On 10/02/25 at 9:44 AM the surveyor reported to Regional Clinical Service Manager #5 both incidents were reported to the state agency outside of the two hour allotted timeframe. During an interview with the Administrator on 10/06/25 at 12:21 PM the surveyor asked who is responsible for reporting incidents to the state agency and what is the timeframe when incidents should be reported. Incidents are reported to the state agency by the Administrator, Director of Nursing (DON) or the Assistant Director of Nursing (ADON). Allegations of abuse are reported to the state agency as soon as possible; within two hours.

Based on record review and interview it was determined that the facility failed to appropriately prescribe psychotropic medication for a resident without documented need for one. This was found evident in 1 (Resident #4) out of 5 residents reviewed for unnecessary medications. The findings include: Psychotropic medications are used to treat mental health disorders and are considered any drug that affects behavior, mood, thoughts, or perception. There are five main types of psychotropic medications, and each type has its own specific uses, benefits, and side effects. The five main types are: antidepressants, anti-anxiety, stimulants, antipsychotics and mood stabilizers. On 10/1/25 at 7:30 AM, the surveyor reviewed Resident #4's medical record. The review revealed that Resident #4 was admitted on [DATE] and was ordered Quetiapine (also known as Seroquel) (an atypical antipsychotic medication used to treat mental health conditions like schizophrenia, bipolar disorder, and major depressive disorder) 50 mg at bedtime for depression with a start date of 8/16/25 and an additional order for Quetiapine 25mg twice a day for depression. On further review it was noted that Resident #4 was seen by Physician #33 in 8/18/25 and Olanzapine (also known as Zyprexa) (an atypical antipsychotic medication used to treat schizophrenia and bipolar disorder) 5mg daily as needed for anxiety. There is no end date to the psychotropic medication. Physician #33 noted Resident #4 was on both Olanzapine and Quetiapine and asked for psychiatry (psych) to follow up. Next the surveyor reviews the Psych consult note written on 8/29/25 by psych Nurse Practitioner (NP) #34. NP #34 list Resident's Olanzapine dosage at 25mg twice a day for psychosis and Quetiapine 50mg once a day for depression. She further stated to continue these medications as ordered. These doses were incorrect, and an addendum to the note is made on 9/5/25 to the correct orders written for Quetiapine, however Olanzapine is written as daily, not as needed as actually prescribed. On 9/5/25 NP #34 recommends discontinuing Quetiapine bedtime dose and tapering Olanzapine over 5 days and then discontinuing. On review of Resident #4's Medication Regimen Review conducted on 9/3/25 it stated, Resident was admitted on Olanzapine as needed. Per regulatory guidelines, order for as needed antipsychotic medication as needed must be limited to 14 days with no exceptions. It further stated, please add a stop date to the current order or consider discontinuing medication. On the MRR form, the providers agreed, and the signature followed with a date o 9/10/25. On 10/1/25 at 8:01 AM, the surveyor reviews the order for the as needed Olanzapine started on 9/18/25 and notes it was discontinued on 9/8/25. On 10/01/25 at 12:02 PM, the surveyor interviewed Regional Clinical Service Manager Staff #5. During the interview, the surveyor reviewed the concern that an as-needed psychotropic medication was written without an end date of 14 days and continued to be ordered even after a pharmacy review requested a change on 9/3/25 and psych requested a change on 9/5/25. The order was finally adjusted on 9/8/25.

Based on record review and interviews it was determined that the facility staff physically/verbally abused a resident. This deficient practice was evidenced in 1 (#126) of two facility reported incidents reviewed for alleged abuse during the recertification survey. The findings include:On 10/01/25 at 10:22 AM the surveyor reviewed the investigation related to Resident #126 allegation of abuse. According to the investigation on 03/27/25 Maintenance Assistant #38 reported he/she witnessed Geriatric Nursing Assistant (GNA)# 18 pull their hand back and swung hitting the resident on the left shoulder. The swung had enough force that Resident #126 stumbled back into the wardrobe armoire behind them. Director of Social Services #3 interviewed Resident #126 roommate who was in the room during the time of the alleged incident. The roommate did not see the incident but verbalized they heard Resident #126 yell, why did you hit me, and they heard a stumble. GNA #18 denied hitting the resident but told Resident #126, I'm going to bop you. Director of Social Services #3 interviewed Resident #126 and verbalized GNA #18 hit them with their key holder because he/she was not dressed. Further review of the investigation revealed GNA #18 was suspended pending investigation and terminated on 04/04/25. GNA #18 was also reported to the Maryland Board of Nursing. The complaint read on 03/27/25 GNA #18 was observed by Maintenance Assistant #38 strike Resident #126 with their fist in the chest inside the residents' room. A review of an Employee Disciplinary Form dated 03/27/25 revealed GNA #18 was late for work 15 times and was a No Call/No Show 20 times. The Incident Description read on 03/27/25 GNA #18 was observed by another employee strike Resident #126 with their fist in the chest inside the resident's room. The form was signed by Assistant Director of Nursing (ADON) #25 and dated/signed 04/04/24.On 10/02/25 at 11:26 AM during an interview with Regional Director of Operations # 37 verbalized the result of the investigation was inconclusive. They had concerns because Resident #126 told them GNA #18 did not hit them on the shoulder. They reported the incident to the board for further investigation. They know something happened; the resident was trying to walk out of the room naked, and the GNA was trying to redirect him. Resident #126 verbalized the GNA tapped me. They didn't know if Maintenance Assistant #38 had some type of interaction with the GNA. It could have happened the way Maintenance Assistant #38 reported. On 10/07/25 at 10:56 AM during an interview with Maintenance Assistant #38 the surveyor asked did he/she witness the GNA #18 hit Resident #126. Maintenance Assistant #38 verbalized yes. The surveyor asked did he/she have anything against GNA #18. Maintenance Director #38 verbalized they did not socialize; he/she just saw her around in the workplace.

Based on observations and interviews, the facility failed to provide a resident with a reasonable accommodation of need, as evidenced during one (Resident #138) random observation on the survey. The findings included: On 9/29/25 at 10:07 AM, the surveyor interviewed Resident #138 and his/her family member. Resident #138 stated the facility recently removed his/her side rails, and he/she was not able to move in the bed. On 9/29/25 at 1:32 PM, the surveyor interviewed the Nursing Home Administrator (NHA). The NHA confirmed that the facility removed the side rails from Resident's beds and was reassessing if they needed them. He further stated that the facility was ensuring assessments were completed, and that residents were care planned for side rails. The surveyor requested Resident #138's side rail assessment. Next, the surveyor reviewed Resident #138's side rail assessment, completed on 9/20/25. The assessment recommended 1/4 siderail assist handles to serve as an enabler to promote independence. On further review, the surveyor noted in Resident #138's physical therapy evaluation that Resident #138 was documented as being bedbound for several years due to weakness. The rationale for treatment was to decrease the level of assistance from caregivers. On 9/29/25 at 2:41 PM, the surveyor interviewed the Director of Nursing (DON). The surveyor reviewed the concern that Resident #138 was assessed to need the side rails, yet they were removed after assessing the need. The DON stated that the side rails would be replaced.

Based on interviews and record review, it was determined that the facility's physician failed to acknowledge and/or address recommended interventions for a resident with significant weight gain. This was evident in 1 (Resident #8) out of 5 residents reviewed for nutrition. The findings included: On 10/1/25 at 12:42 AM, the surveyor reviewed the medical record for Resident #8. The review revealed that Resident #8 was admitted to the facility in January 2024. Resident #8's past medical history included major depressive disorder, peripheral vascular disease, acquired absence of the leg above the knee, and dementia. Further review of Resident #8's medical record revealed weight changes over a year. Resident #8 had an 11.13% weight gain from 10/3/24 to 3/6/25 during this 6-month time period, and a 23.75% weight gain from 3/6/25 to 9/1/25, during this 6-month time period. Next, the surveyor reviewed the dietary progress notes. On 6/12/25, a note written by Dietitian #31 confirmed weight gain from the reweight obtained and stated she continued to question a +41 pound weight gain in 6 months. She wrote the provider was to be made aware by nursing. On 7/4/25, a note written by Dietitian #31 documented questioning weight gain x 6 months for a possible scale discrepancy. Dietitian #31 wrote Resident #31 was on mirtazapine (also known as Remeron) (an atypical antidepressant used primarily to treat major depressive disorder and can have an appetite-stimulating effect). Dietitian #31 suggested considering discontinuing this medication. On 8/13/25, a quarterly assessment note written by Dietitian #31 documented a trigger for weight gain x 6 months with weights trending up. The stated goal was for weight maintenance and again documented to consider discontinuing the appetite stimulant mirtazapine. On 10/2/25 at 1:48 PM, the surveyor conducted an interview with the Regional Clinical Service Manager Staff #5. During the interview, the surveyor reviewed concerns that the dietitian's recommendations related to weight gain were not being acknowledged or implemented by the physician. The surveyor requested medical notes that addressed the weight gain. On 10/3/25 at 9:14 AM, the surveyor interviewed Dietitian #31 along with Regional Clinical Service Manager Staff #5. During the interview, Dietitian #31 stated that she was aware of Resident #8's weight gain and documented the monitoring. She stated that her assessments and recommendations should be communicated to the physician by the nursing staff. On 10/3/25 at 11:35 AM, the surveyor conducted an interview with Resident #8's Physician #30. During the interview, Physician #30 stated she was monitoring Resident #8's weight gain through labs and a heart failure workup. When the surveyor asked for documentation that addressed the weight gain and response to the dietitian's recommendation, Physician #30 stated she did not have that documented. The surveyor reviewed the concern that the dietitian documented quite often Resident #8's continual weight gain and recommended discontinuing mirtazapine in July and in August, and in both months the resident continued to gain weight. Nowhere in the medical records is it noted that these notifications or recommendations were addressed. Cross reference F692

Based on observation, record review, and interview it was determined that the facility failed to ensure resident #92 received adequate supervision and failed to prevent elopement. This was evident for 1 of 2 residents reviewed for accidents during the facility's recertification survey. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy. After the incident, the facility developed, initiated, and completed a plan of correction to prevent further elopement of residents. Therefore, this deficiency will be cited as past non-compliance. The date of correction was 1/28/2022. The findings include: On 3/4/24 at 12:46 PM the surveyor reviewed the facility's self-report form sent to the Office of Health Care Quality for an incident that occurred on 1/26/22 regarding Resident #92. The self-report form indicated the facility's Administrator (during that time) received a call from the hospital regarding the resident having been found by EMS walking in the facility neighborhood and was brought to the emergency room . At this time, the surveyor began a review of the facility's complete investigation file for the 1/26/22 incident. On 3/4/24 at 12:46 PM the surveyor reviewed the facility's follow up self-report form dated 2/2/22 which noted the date/time of the incident occurrence was 1/26/22 at 2:18PM. The form additionally reported: After video surveillance and maintenance check of wander guard system; it was determined that Resident #92 had a functional wander guard in place (was checked prior to and after the incident and found to be functional.) There was a noted equipment malfunction of the system at the main entrance which resulted in no alarm sounding as Resident #92 exited the facility. Surveyor review of the medical record revealed the resident's care plan upon their admission in 2021 which included they were at risk for elopement, diagnosis of dementia, and exhibited wandering behavior. Further review of the medical record revealed a plan of care note dated 1/26/22 at 6:00 PM for Resident #92 which included the following information: Patient left the building with functioning wander guard in place on [his/her] left ankle. Further review of the medical record revealed a nurse note dated 1/26/22 at 10:09 PM which included the following information: Resident was able to elope from facility earlier today, approximately at 1400 hours. Upon surveyor's review of the Medication Administration Audit Report for 1/26/22 the following information was revealed: 1.) behavior monitoring by the nurse for wandering every shift which was scheduled to occur at 3:00PM on 1/26/22 had no documentation or staff sign off present, 2.) the following nursing care for the resident scheduled to occur on 1/26/22 at 3:00PM was documented by Staff #63, Licensed Practical Nurse (LPN,) on 1/27/22 at approximately 11:04PM, approximately 32 hours after their 3-11 shift on 1/26/22 began: vital signs task, turn and reposition every 2 hours, pain level, barrier cream application, pressure reducing wheel chair cushion while out of bed, wander guard to right ankle, check for placement, and wander guard for elopement risk every shift, 3.) medications and nursing care scheduled to be given on the 3-11 shift on 1/26/22 at 4:30PM, 5:00PM, 5:30PM, 8:00PM, 9:00PM, and 10:00PM, were documented as administered by Staff #63, LPN, on 1/27/22 at approximately 1:13AM. On 3/8/24 at 10:40 AM the surveyor shared their concerns as to the dates/times on the Medication Administration Audit Report to the Director of Nursing, Administrator, Staff #54, Corporate Director of Operations, and Staff #11, Regional Corporate Nurse. No further clarification of the dates/times of care/medication sign-off was provided at that time. On 3/8/24 at 11:38 AM the Director of Nursing informed surveyors that there was no documentation during the 3-11 pm shift on 1/26/22. They further reported that later, on 1/27/22 staff input documentation for 1/26/22. They further stated: When they realized [Resident #92] was gone, they should have begun documenting from that point on and I talked to IT and they should have backdated the documentation to 1/26/22 when they input it on 1/27/22. They didn't backdate it. The surveyor further inquired to the DON if they would expect staff to backdate documentation if it had not been performed, to which they replied: No, but from the time they realized they should have begun documenting. Upon surveyor review of the facility's investigation interview form for Staff #57, Licensed Practical Nurse, it was documented that they reported they had worked on 1/26/22 on the 3-11 pm shift, did not see Resident #92 on that date, and: I cannot remember seeing [him/her] The documentation further revealed Staff #57 did not notice Resident #92 was missing, and was assigned to Resident #92 on 1/26/22. Upon surveyor review of the food cart delivery schedule, the unit the resident resided on was scheduled to receive dinner at 5:15 PM. Review of the facility's documented interview with Staff #56, Geriatric Nursing Assistant, (GNA) on 1/26/22 revealed they reported no when asked if they took Resident #92's dinner tray into the resident's room, and reported they had not seen the resident on 1/26/22, although they confirmed working the 3-11pm shift on 1/26/24 and were the GNA assigned to Resident #92 for that shift. On 3/4/24 at 1:26PM the surveyor was provided with January and February 2022 documentation logs of wander guard checks having been performed after the incident on 1/26/22, however, the surveyor noted that there were 29 days of checks signed off as occurring in the month of February 2022, which should have only had 28 days of checks within that month. January and February check logs were reviewed and found to be consistently completed at the current time, for 2024. On 3/4/24 at 1:32 PM, the surveyor concluded rounding with Staff #10, Director of Maintenance, which included observations and testing of the facility's exit doors, coded keypads, and testing for the function of two wander guard system units, one which was located near the front lobby elevator and one which was located at the interior set of front doors to the facility in the lobby. On 3/4/24 at 2:16 PM the surveyor conducted an interview with the facility Administrator, who reported that to their knowledge, there had been no other elopements since 1/26/22. When the surveyor requested documentation of wander guard system checks performed leading up to 1/26/22 they indicated the documentation may be located in storage. On 3/4/24 at 2:39 PM, the facility Administrator brought Staff #55, Maintenance Assistant to the surveyor, unsolicited by the surveyor. At this time, the surveyor conducted an interview with Staff #55 who reported information that conflicted in nature with the self-report made by the facility to the Office of Health Care Quality regarding the incident on 1/26/22. Staff #55 reported they had been asked to review the security footage of the incident and their understanding of the event was that Resident #92 followed someone out the door immediately behind them. Staff #55 further reported that the security footage they found, they showed to the previous facility Administrator. Staff #55 additionally reported that they believed the documentation of their maintenance checks of the wander guard system prior to 1/26/22 was located within the building in the file cabinet. The Administrator stated: We are still seeing if we can locate that documentation. Staff #55 stated regarding locating the documentation: I am not aware my director has yet, I believe s/he has. Staff #55 was not aware at the time of the interview of an equipment malfunction having occurred. Staff #55 reported the upgrades,which were made after the elopement, to the surveyor. On 3/4/24 the surveyor noted there was no evidence included in the facility's complete investigation file as to any repairs having been made on 1/26/22 in response to the mechanical failure having occurred. On 3/4/24 the surveyor reviewed the facility's incident investigation form. Documentation on the form under section 8c revealed a place to document if a protective device was ordered, which was checked no, and a place to document if the protective device was in place at the time of the incident, which was checked as n/a. Further review of the form revealed the following: Resident left unattended on 1/26/22 at approximately 2:15 PM. Despite the fact that resident's wander guard was intact and functional, entrance door to facility did not alarm. On 3/6/24 at approximately 12:09 PM the surveyor received and reviewed the hospital discharge summary for Resident #92 which documented the following: Encounter for medical screening examination; Abrasion of knee; At risk for elopement from healthcare setting. Further review of the documentation revealed the resident arrived at the Hospital Emergency Department on 1/26/22 at 5:45 PM however, no details could be found to provide clarification of events leading up to the resident's arrival. The surveyor requested for the facility to provide further documentation. On 3/7/24 at 1:23 PM, the surveyor received the Hospital Emergency Department Clinical Summary dated 1/26/22 which detailed the following information regarding Resident #92: Patient stated complaint: Encounter for medical screening; Accidental fall, Wondering Person/[NAME]. On 3/7/24 at 1:23 PM, the surveyor additionally received Resident #92's Hospital Emergency Department Clinician Note which included the following information: found wandering in the street after eloping from NH (nursing home). On 3/4/24 at 8:04 AM the surveyor observed Resident #92 near the facility's front desk engaged in exit-seeking behavior, carrying a bag packed with personal items, with various staff present attempting to re-direct the resident. At this time, the surveyor confirmed the Resident's name with the Unit Manager 3rd Floor, Licensed Practical Nurse Staff #12 On 3/4/24 at 8:04 AM the surveyor observed the front desk was staffed with security personnel, who when asked by the surveyor, were able to immediately refer the surveyor to a log kept at the front desk for documentation of checks being performed for the current functioning of the wander guard system. On 3/4/24 at 8:04 AM the surveyor observed a posting behind the front desk which included photos of facility residents considered at risk for elopement. On 3/4/24 at approximately 8:04 AM the surveyor was able to hear an audible noise present indicating the resident was within proximity of the wander guard device located near the front desk. On 3/4/24 at approximately 8:04 AM the surveyor conducted an interview with Staff #51, Human Resources, who confirmed with the surveyor that the audible noise heard was the wander guard system alarm. On 3/7/24 at 9:10 AM the surveyor conducted an observation of the facility's front door systems with Staff #55, Maintenance Assistant. The front door wander guard systems were audible and the mag-lock system was found to be engaged appropriately during testing. On 3/7/24 at 11:05 AM the surveyor communicated the concern of Immediate Jeopardy and concerns to the following facility staff: Administrator, Director of Nursing, Staff #54; Corporate Director of Operations, and Staff #11, Regional Corporate Nurse. At this time, the surveyor requested all documentation of measures/actions the facility took and/or put into place to prevent further incidents. Staff #54, Corporate Director of Operations, reported to surveyors that the facility did not have any camera footage of the incident, and there was no audio capability. On 3/7/24 at 1:23 PM, the surveyor was provided with copies of emails from Staff #57, Corporate Director of Facility Maintenance and Safety Operations, who reported that on 1/26/22 they received a call notifying them around 6 pm and they reported to the facility to check the wander guard system. The surveyor noted that in an email dated 1/27/22, Staff #57 communicated the following information: Wander guard system still seems to be working OK. On 3/14/24 the surveyor reviewed and verified the completion of the facility's plan of action which was formulated in response to the 1/26/22 incident which included the following interventions completed by1/28/2022. 1. Assessment of the resident for injury on return and document any skin breakdown on skin sheets. 2. Notify guardian. 3. Update wandering assessment and elopement careplan for incident upon resident's return. 4. Complete incident report. 5. Interview staff on duty 7-3 and 3-11 shift 1/26/22 6. Check wanderguard system to ensure door alarms when wanderguard present. 7. Audit current residents identified at risk for elopement to ensure that device is in place, within expiration date, has MD orders, is being signed off qshift as in use and qd as functioning, is care planned, on GNA kardex, and picture at front desk 8. Ensure that adequate supply of wanderguards are in house and staff know where they are located. 9. Re-assess current residents' wandering assessments to ensure any elopement risk is clearly identified. 10. Initiate a careplan for at risk for elopement if any new at risk residents identified. 11. Re-educate staff on the policy for missing resident and nursing staff on making rounds at the start of every shift. 12. Educate receptionists/security guards on the contents of the wanderguard book and importance of notifying staff if a resident is attempting to leave the facility unattended. 13. Educate receptionists on the use of equipment to check the function of the front door wanderguard system qshift. 14. Review residents with wanderguards daily x2 weeks, then weekly x 2weeks, then monthly for 3 months to ensure MD orders are written, function is checked qd and documented on TAR, placement is checked q shift and documented on TAR, assessments and care plans are up to date and wander guard is functional and within expiration date. 15. Report results of the wander guard audits monthly x 4 months to the QAPI committee which will determine whether any need for further audits and/or action plans. 16. Documentation of staff education 17. Evidence of work performed to upgrade the front door locking system on 1/28/22. 18. Documentation of initial assessment confirming all residents were accounted for. 19. Documentation of ongoing performance improvement audits. 20. Documentation of 2024 weekly maintenance inspections of fire/exit doors and wander guard system.

Based on medical record review and interviews with facility staff, it was determined that the facility staff failed to recognize and follow a written physician order [REDACTED]. This is evident for 2 of 32 resident's selected for review in the Stage 2 survey sample. The findings include: 1. The facility staff failed to recognize and follow a written physician's orders [REDACTED]. Resident #143 was admitted with multiple [DIAGNOSES REDACTED]. Diabetes is a disease where the body does not produce the chemical insulin to control blood sugar levels. The blood sugar levels must be controlled with insulin injections. Failure to control the blood sugar levels can lead to unresponsiveness and death. Normal blood sugar levels are 70 - 100 but it is the physical symptoms that determine if nursing action is needed. A blood sugar of 98 with the person feeling fatigued or drowsy may be too low for that person and require food high in sugar to be given. Therefore, diabetes is controlled by monitoring both blood sugar levels and the symptoms the person is experiencing to determine whether insulin is needed or not. On admission, for Resident #143, the physician ordered blood sugar levels to be obtained at 6:30 AM, 11:30 AM, 5:00 PM, and 9:00 PM. Depending on the blood sugar level various amounts of Humalog insulin, short acting insulin, were to be given to maintain normal blood sugar levels. If the blood sugar level was below 60 or greater than 400 the physician was to be called. At 9:00 PM Resident #143 was to be given long acting insulin, [MEDICATION NAME]. On 5/13/14 at 6:30 AM the blood sugar was noted as 53 and Resident #143 was without signs and symptoms of low blood sugar. The physician was not notified and staff followed the low blood sugar protocol and repeated the blood sugar and obtained a result of 66. On 5/14/14 at 6:30 AM Resident #143 had a blood sugar of 36, unable to swallow crackers or liquids and the physician was called and ordered a [MEDICATION NAME] injection. [MEDICATION NAME] is a drug that is given by an injection to increase the blood sugar level. The resident's blood sugar increased to 74. On 5/14/14 at 11:30 AM the blood sugar was 256. The Nurse Practitioner (NP) noted on a progress note of 5/14/14 that Resident #143 was having blood sugar fluctuations and drowsiness and that the resident liked to sleep all day. The NP also noted Resident #143's appetite was fair. The NP wrote on 5/14/14 an order to change the [MEDICATION NAME] injection from every evening to every morning. The NP was interviewed on 9/9/14 at 8:20 AM and stated the [MEDICATION NAME] order change was to prevent the low morning blood sugars and decrease drowsiness. At 5:00 PM on 5/14/14 Resident #143 was found on the floor in their room. Resident stated that they had fallen from their wheelchair and no injuries were noted. The blood sugar was noted at 5:00 PM on 5/14/14 to be 99 and at 9:00 PM to be 98. At 9:00 PM on 5/14/14 Resident #143 was given the [MEDICATION NAME]. The NP's order to change the time to morning from evening had not been recognized by the nursing staff and not placed in the Medication Administration Record. At 2:30 PM on 9/9/14 the Director of Nursing confirmed the [MEDICATION NAME] change ordered had not been followed by the facility nursing staff. On 5/15/14 at approximately 5:00 AM Resident #143 was found unresponsive with a blood sugar level of 20, [MEDICATION NAME] injection given and cardiopulmonary resuscitation was initiated. Nine One One (911) was called at 5:03 AM and paramedics arrived at 5:09 AM. Paramedics ceased resuscitation efforts on Resident #143 at 5:34 AM. Failure to recognize and follow the written [MEDICATION NAME] time change order put Resident #143 at risk for dangerously low blood sugar and unresponsiveness. 2. The facility staff failed to thoroughly assess and obtain abdominal girth measurements ordered by the physician. Review of resident # 2's record revealed on 3/24/14 the physician ordered: abdominal girth monthly. Abdominal girth is the measurement of the distance around the abdomen at a specific point. Measurement is most often made at the level of the belly button (navel). Abdominal girth is used to diagnose and monitor obesity but not limited to. Review of the Medication Administration Record [REDACTED]. On 6/5 14 on the 3-11 shift, the facility staff failed to document the abdominal girth for the resident and on 8/5/14 the facility staff documented the abdominal girth as obtained; however, failed to document the distance. Interview with the Director of Nursing on 9/9/14 at 10:00 AM revealed that the facility staff failed to thoroughly assess and obtain abdominal girths as ordered by the physician.