Every finding on record at Good Samaritan Nursing Home Operator, LLC

Based on review of facility reported incidents, medical record review, and interview, it was determined the facility failed to report an allegation of abuse immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #10) of 6 residents reviewed for facility reported incidents during a complaint survey.The findings include: Review of facility reported incident 3070081 was conducted on 8/6/26 regarding Resident #10 alleged a staff member inappropriately touched him/her on 7/4/26 at approximately 11:30 PM. Review of the facility investigation revealed a statement from RN #16 that GNA #17 reported that Resident #10 stated he/she was inappropriately touched during incontinence care. RN #16 stated during his assessment of the Resident, he/she stated that while 2 staff members were changing him/her, he/she was touched inappropriately around the buttocks area. Review of Resident #10's medical record on 8/6/26 revealed the Resident was admitted to the facility in June 2026 with a diagnosis to include dementia. Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Further review of Resident #10's medical record revealed on 7/5/26 at 12:46 AM, RN #16 documented the on-call provider was notified due to the Resident noted on 7/4/26 at 11:30 PM with intermittent confusion and change in baseline mental status. Review of the Facility Reported Incident Initial Report Form provided by the Director of Nursing to the Surveyor revealed the incident was not reported to the Administrator until 7/6/26 at 11:15 AM and not reported to OHCQ until 7/6/26 at 1:15 PM. Interview with the Regional Nurse on 8/6/26 at 11:55 AM confirmed the facility staff failed to report an allegation of abuse to the Administrator and the Office of Health Care Quality timely.

Based on medical record review and interview, it was determined that the facility failed to involve the resident's representative in the discharge planning process in a timely manner. This was evident for 1 (Resident #11) of 3 residents reviewed for discharge planning during a complaint survey.The findings include:Review of Complaint 3040092 was conducted on 8/5/26 regarding the facility's timely communication with Resident #11's representative (RP) regarding discharge planning. Review of Resident #11's medical record on 8/5/26 revealed the Resident was admitted to the facility on [DATE]. During interview with Resident #11's RP on 8/5/26 at 9:53 AM, the RP stated the Resident lives with the RP. The RP also stated no one from social services reached out to him/her regarding discharge planning until 6/9/26 and told him/her at that time the Resident was going to be discharged the next day on 6/10/26. The RP stated this did not give him/her enough time to ensure he/she was available to transport the Resident home and have everything was in place for the Resident. At that time the RP stated he/she filed an appeal for discharge that day and it was granted changing the Resident's discharge date until 6/13/26. Further review of Resident #11's medical record revealed no communication from social services with the RP regarding discharge planning until 6/11/26. Although the RP provided the Surveyor with email communication he/she had with Social Services Assistant #1 beginning 6/9/26. Interview with the Director of Nursing on 8/5/26 at 12:45 PM confirmed the facility staff failed to communicate with the Resident #11's RP in a timely manner for discharge planning.

Based on record review and interview it was determined that the facility failed to ensure that a baseline care plan was provided to the resident and the resident's representative within 48 hours of admission to the facility. This was evident for 1 (Resident #11) of 3 residents reviewed for baseline care plans during a complaint survey.The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident including initial goals, physician orders, therapy services, dietary services and social services. Review of Complaint 3040092 was conducted on 8/5/26 regarding the facility's lack of communication with Resident #11's representative (RP). Review of Resident #11's medical record on 8/5/26 revealed the Resident was admitted to the facility on [DATE]. Further review of Resident #11's medical record revealed a baseline care plan was completed by facility staff on 6/2/26, 20 days after admission and only signed by the Resident. During interview with the Director of Nursing (DON) on 8/5/26 at 10:40 AM the DON was asked what the facility's process is for baseline care plans. The DON stated it is completed by nursing as part of the admission process and reviewed with the resident within 48 hours of admission. The DON added it is given to the RP if the Resident chooses. Interview with the DON on 8/5/26 at 12:45 PM confirmed the facility staff failed to complete a baseline care plan within 48 hours of admission for Resident #11 and failed to provide the baseline care plan to the Resident #11's RP.

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Resident #2 and #9) of 11 residents reviewed during a complaint survey.The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1.The facility staff failed to accurately document a Resident's guardians in the medical record.Review of Complaint 3016578 was conducted on 8/5/26 regarding the facility staff honoring one of Resident #2's guardian's rights.Review of Resident #2's medical record on 8/5/26 revealed the Resident had listed Emergency contact #1 as Guardian of person and Emergency contact #2 as Guardian of property.A guardian of the person makes physical, medical, and daily care choices for an individual. A guardian of the property manages that same individual's money, bills, and financial assets.Further review of Resident #2's medical record revealed a court document dated 3/11/24 entitled, Order Appointing Co-Guardians of the Person. Review of that document revealed Emergency contact #1 and #2 were appointed as Co-Guardians of the Person with all the rights, duties and powers set forth in Md Code, Estates & Trusts 13-708 and Md Rule 10-206.Interview with the Regional Nurse on 8/10/26 at 7:45 AM confirmed Resident #2's medical record inaccurately listed the Resident's guardians, and it would be updated.After Surveyor intervention, Resident #2's medical record was changed to list Emergency contact #1 and Emergency Contact #2 to be Co-Guardians and both Emergency Contact #1.2.The facility failed to document a) the correct indication for a medication and b) administration of medications for Resident #9.Review of Complaint 3072988 was conducted on 8/5/26 regarding care concerns.Review of Resident #9's medical record on 8/5/26 revealed the Resident was admitted to the facility in May 2026 and discharged in June 2026 with a diagnosis to include hypothyroidism and hypertension.Review of Resident #9's June 2026 Medication Administration Record revealed the following:a) The Resident was ordered to receive Levothyroxine sodium 75 mcg daily for GERD (gastroesophageal reflux disease).Levothyroxine sodium is a medication used to treat hypothyroidism (an underactive thyroid) not GERD. Interview with the Regional Nurse on 8/10/26 at 7:50 AM confirmed Resident #9's medical record incorrectly indicated Levothyroxine sodium was for GERD and should have listed hypothyroidism.b) The facility staff failed to document the administration of Levothyroxine 75 mcq daily on 6/13 and 6/14/2026 and also failed to document the administration of Hydralazine 10 mg every 8 hours on 6/1 at 2 PM and 6/13, 6/14/2026 at 6 AM.Hydralazine is a medication used to treat hypertension (high blood pressure).Interview with the Regional Nurse on 8/10/26 at 7:50 AM confirmed the facility staff failed to document the administration of Resident #9's Levothyroxine on 6/13, 6/14/26 and Hydralazine on 6/1, 6/13, 6/14/26.

Based on observation, record review, and interviews with facility staff, it was determined that the facility failed to ensure that residents' personal hygiene needs were adequately met, timely assistance was provided for incontinence care, and assistance with meals was provided. This was evident for 5 (Resident #5, #9, #49, #39, and #1) of 7 residents reviewed for Activities of Daily Living (ADLs) during the recertification/complaint survey. The findings include: Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, toileting, and mobility. 1) On 04/27/2026 at 8:25 AM, during an observation of Resident #5, brown substances were noted present under the fingernails of the right hand. Resident #5 stated a need for the nails to be cleaned and trimmed.On 04/27/2026 at 11:41 AM, Staff #6 (Unit Manager Registered Nurse RN) verified Resident #5 had a brown substance under the fingernails of the right hand and stated she would inform the other Unit Manager.On 04/28/2026 at approximately 2:00 PM, a review of Resident #5's care plan titled ADL self-care performance deficit related to stroke as evidenced by requiring total assistance from nursing staff for ADL care was originally created on 06/26/2018 and last revised on 04/07/2025. 2) On 04/27/2026 at 9:32 AM, an observation revealed that the fingernails on Resident #9's right hand were soiled with a dark brown/black substance. On 04/27/2026 at 11:39 AM, Staff #6 (Unit Manager Registered Nurse) verified Resident #9's nails with dark brown/black substances and stated she would have staff soak his/her nails later. On 04/28/2026 at approx. 2:30 PM, a review of Resident #9's care plan noted a self-care deficit (impaired balance, inability to complete daily tasks independently) related to CVA and generalized weakness. Created: 01/10/2022. Revised: 05/29/2024. 3) On 04/27/2026 at 11:17 AM, during an observation of Resident #49, noted fingernails were noted to be long and untrimmed.On 04/27/2026 at 11:34 AM, during an interview, Staff #6 (Unit Manager Registered Nurse) shared that residents' care of fingernails is completed as needed, and on shower days, the facility does clip and file residents' nails. Staff #6 verified Resident #49's nails were long and needed to be trimmed.On 04/27/2026 at approximately 11:40 AM, in review of Resident #49's care plan for Activity of Daily Living (ADL), Resident #49's noted self-care performance deficit related to activity intolerance, impaired balance, and cognitive impairment as evidenced by his dependency on staff for all needs. Created on: 08/14/2020 Revision on 07/14/2025. On 04/29/2026 at 10:56 AM, during an interview, the Assistant Director of Nursing (ADON) stated that Activities of Daily Living (ADL) care included nail care and that staff are expected to trim and clean long fingernails or those with brown/black substances underneath. This concern regarding nail care was shared with the ADON at that time. 4) On 04/27/2026 at 9:20 AM, during an observation, an odor was noted in the hallway near Resident #39's room. A brown substance was observed on Resident #39's bed, wheelchair, and call light. Unknown staff members continued to walk past the room. On 04/27/2026 at 10:06 AM, during a second observation, the brown substance remained present on Resident #39's bed, wheelchair, and call light. On 04/27/2026 at 10:07 AM, during an interview with Staff #4, Licensed Practical Nurse (LPN) confirmed that she informed the assigned Geriatric Nursing Assistant (GNA) that it smelled down there, after which the GNA went on break. Staff #4, LPN, then knocked on Resident #39's bathroom door and asked if the resident was okay. The LPN stated Resident #39 requested assistance with a brief and clothing change. However, Staff #4's assistance was provided about 47 minutes after Resident #39's incontinent episode and only following the surveyor's intervention in notifying Staff #4. On 04/27/2026 at 2:48 PM, a review of Resident #39's care plan of self-care deficit related to dementia and glaucoma (impaired vision, difficulty walking). The initial plan, dated November 29, 2022, and revised on November 30, 2022, specifies that one staff member is required to assist the resident with dressing (per the 11/29/2022 plan), as well as toileting and transfers (both revised on 10/02/2024). On 04/29/2026 at 10:56 AM, during an interview, the Assistant Director of Nursing (ADON) discussed ADL care. The ADON stated that if a nurse reported an odor of incontinence, indicating a resident might need assistance, they would expect a staff member to assist the resident. The ADON also noted that she has observed that Resident #39 has now started to require more assistance. At this time the concern was shared with ADON.5) On 04/30/2026 at 8:37 AM, during an observation of Resident #1 lying in bed with a breakfast tray in front of him/her, there was no staff present.On 04/29/2026 at 3:00 pm, review of Resident #1's care plan, created 03/30/2025 and revised 01/13/2026, indicated imbalanced nutrition related to diabetes, hypertension, hyperlipidemia, and recent weight loss. An intervention for 1:1 meal assistance was created/revised on 11/25/2025.On 04/30/2026 at 8:46 AM, Staff #20 (Regional Clinical Nurse) was interviewed. She stated a speech therapist determines if feeding assistance is needed, which would then be documented in a care plan and noted on the Kardex and assignment sheet. She clarified that 1:1 meal assistance requires a staff member to be present and are to assist with the meal. She confirmed no staff was assisting Resident #1 with the required 1:1 meal assistance. The concern was shared at this time.On 05/01/2026 at approximately 1:30 PM, the concerns were shared with the Administrator and Regional Clinical Services Manager.

Based on observation, record review, and interview, it was determined that the facility failed to provide necessary respiratory care that consistent with professional standards of practice. This was evident for 4 Residents (Resident #7,#49, #88 and #89) of 4 residents reviewed for respiratory care during the recertification survey.The findings include: A nebulizer mask is a medical device used to deliver medication directly into the lungs in the form of a fine mist. A nasal cannula is a lightweight, flexible plastic tube with two small prongs placed just inside the nostrils to deliver supplemental oxygen. 1) On 4/27/2026 at 8:31 AM, the surveyor observed a nebulizer mask resting on top of Resident #88's soiled breakfast tray, creating a potential for contamination of respiratory equipment. An unused portable oxygen cylinder was also observed beside the nightstand. Registered Nurse (RN) #10 was immediately notified. On 4/29/2026 at 7:27 AM, a review of Resident #88's medical record revealed: -No physician order oxygen for therapy; and -An active order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 milliliters (ml) inhale orally every 6 hours for shortness of breath for 7 days, with an end date of 5/1/26. (liquid medications used to relax and open airways to improve breathing). On 4/29/2026 at 9:40 AM, the portable oxygen cylinder remained in Resident #88's room. RN #14, confirmed that Resident #88 was not receiving oxygen therapy and was unsure why the oxygen tank was stored in the room. On 4/29/2026 at 11:00 AM, the Assistant Director of Nursing (ADON) confirmed there was no oxygen order and stated oxygen tanks should be stored in the designated oxygen storage area when not in use. On 5/01/2026 at 10:19 AM, review of the facility policies confirmed: -Medical gas safety and storage requires equipment to be returned to its proper storage location when not in use; and-Handheld nebulizer equipment is to be stored in a clean plastic bag and maintained ready for use. 2) On 4/27/2026 at 9:03 AM, the surveyor observed Resident #89's oxygen tubing and humidifier bottle were not labeled, increasing the risk for improper use and infection control concerns. RN #10 was notified at that time. On 4/28/2026at 11:36 AM, medical record review revealed active physician orders to: -Change the humidifier bottle every night shift on Mondays; and-Change oxygen tubing weekly on night shift on Mondays. On 4/29/2026 at 8:57 AM, Licensed Practical Nurse (LPN) #24 stated that staff are expected to change and label oxygen tubing weekly and replace the humidifier bottle as ordered. LPN #24 further stated that respiratory equipment should be stored in a clean clear bag when not in use. On 4/29/2026 at 9:20 AM, Resident #89's nasal cannula was observed hanging uncovered on the side of the bed, exposing the equipment to environmental contamination. RN #14 was notified. On 4/29/2026 at 11:06 AM, the ADON was notified of the above concerns. 3) On 04/27/2026 at 09:54 AM, during the initial tour of Resident #7's room the surveyor observed resident on oxygen via a nasal cannula, upon closer inspection it showed that the resident was on 1.5 liters of oxygen. On 04/27/2026 at 09:56 AM, in an interview with Registered Nurse (RN) #14, she was asked how many liters of oxygen the resident was ordered and she reported 2 liters after confirming with the resident's medical record. The surveyor asked her to take a look at the resident's current oxygen administration, and she confirmed that the resident was on 1.5 liters. She reported that she would increase the dose as ordered. The nurse was notified that the mentioned finding was a concern. On 04/27/2026 at approximately 10:15 AM, the nurse was observed removing an oxygen concentrator from the resident's room. She reported that the oxygen concentrator machine was broken and was just replaced. On 04/29/2026 at approximately 11:10 AM, the surveyor reviewed Resident #7's medical orders which confirmed that resident had an order for oxygen via Nasal Cannula at 2 Liters Per minute every shift. Start Date04/08/2026. On 04/29/2026 at approximately 11:03 AM the Assistant Director of Nursing was notified of the concerns found. 4) On 04/27/2026 at 11:15 AM, during an observation of Resident #49, it was noted that the oxygen tubing was on the floor while Resident #49 was lying in bed. The oxygen concentrator was on, set at 3 liters per minute. On 04/27/2026 at 11:26 AM, Resident #49 was observed accompanied by Staff #4, Licensed Practical Nurse (LPN). Resident #49's oxygen concentrator was on and set to 3 liters per minute, but oxygen was not being delivered because the tubing was lying on the floor. Staff #4 acknowledged the oxygen tubing on the floor and the oxygen setting, stating she would retrieve new oxygen tubing. On 04/28/2026 at 10:38 AM, a review of Resident #49's medical record revealed a physician order from 11/20/2020 for oxygen at 2 liters per minute continuously every shift. On 04/28/2026 at 10:42 AM, a continued review of Resident #49's medical record revealed a care plan (created 04/29/2025, revised 04/17/2026) for impaired gas exchange (shortness of breath/hypoxia) with an intervention for continuous oxygen at 2 liters via nasal cannula. On 04/29/2026 at 10:59 AM, during an interview with the Assistant Director of Nursing (ADON), the following protocol was discussed: the oxygen concentrator's liter setting must align with the physician's order. If the oxygen tubing is found on the floor, it should be immediately discarded and replaced with new tubing. The expectation is that the resident would consistently receive oxygen as ordered. The concern was shared with the ADON at this time.

Based on record reviews, observations and interviews, it was determined that the facility failed to ensure that pain management was provided to each resident in a way that was consistent with the professional standards of practice, residents goals and preferences. This was evident for 8 Residents (#80, #7,#97, #2, #4, #10, #127, #12) of 8 Residents reviewed for pain management during the recertification/complaint survey. The finding include: Non-pharmalogical interventions are identified as an alternative method of treatment for a medical concern without the use of medication. This could include physical, psychological, and lifestyle interventions designed to reduce pain and improve quality of life. The CDC's 2022 Clinical Practice Guideline for Prescribing Opioids emphasizes non-pharmacological, non-opioid therapies as the first line of treatment for subacute and chronic pain. The Minimum Data Set (MDS) is a standardized comprehensive assessment tool that measures health status in nursing home residents. Oxycodone is a strong painkiller from a group of medicines called opiates, or narcotics used to treat moderate to severe pain. 1) On 4/27/2026 at 08:28 AM during the screening process of the annual survey, Resident #4 stated that she/he received pain medication for the pain in his/her legs, ankles, and sacral area, but it still hurts. During record review on 4/29/2026 at 1:18 PM, it was noted that resident had the following pain medications ordered: -Oxycodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for Pain written on 11/18/2025 -Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Pain *Use caution w/ APAP total daily dose greater than 3,000mg* written on 11/17/2025 Further record review on 4/29/2026 at 1:38 PM of the resident's care plan created on 3/28/2025, revealed that resident had actual pain related to wound on sacrum as evidenced by need for pain management, with intervention to implement non-pharmacological approaches every shift. On 04/29/2026 at 10:43 AM, the Assistant Director of Nursing (ADON) was interviewed regarding the pain management process. The ADON stated that pain assessments are completed every shift and documented on the Treatment Administration Record (TAR), but nonpharmacological methods are not documented, because they are in the care plan. The surveyor asked how the staff would know what nonpharmacological interventions were used prior to the administration of pain medications. The ADON stated that the nurse would write it in a progress note. In addition, the surveyor informed ADON that the pain medications ordered did not indicate which to use for mild, moderate, or sever pain, to which the ADON agreed. On 4/30/2026 at 07:40 AM, the Regional Clinical Services Manager stated that after further review of the pain management guidelines, he agreed that nonpharmacological measures used for pain management should be documented on the TAR or written in the progress notes. He also stated that the facility would initiate an Inservice to the staff regarding pain management. 2) On 04/27/2026 at 8:46 AM, during an interview, Resident #10 reported that their current pain medication was inadequate for managing their pain. On 04/28/2026 at 1:33 PM, a review of Resident #10's medical record revealed a 04/17/2026 physician order for Tramadol HCl 50 mg: 1 tablet by mouth every 12 hours as needed for pain scale 4-10 AND every 12 hours for pain. A 02/06/2026 order was for Acetaminophen Extra Strength 500 mg: 2 tablets by mouth every 6 hours as needed for pain scale 1-3. On 04/28/2026 at 1:50 PM, continued review of Resident #10's medical record revealed a care plan (created 08/09/2025, revised 11/20/2025) for Risk for pain related to diabetes. The interventions section (created 08/14/2025, revised 11/20/2025) included implementing nonpharmacological approaches like relaxation, guided imagery, music, distraction, and massage before, after, and, if possible, during painful activities or before pain occurs. On 04/28/2026 at 1:54 PM, a review of Resident #10's medication administration records (February-April 2026) showed multiple instances where Tramadol was given for pain with no documentation of non-pharmacological interventions before the administration of Tramadol for pain: 7 times in February, 5 in March, and 4 in April. On 04/29/2026 at 10:43 AM, the Assistant Director of Nursing (ADON) was interviewed regarding the pain management process. ADON stated that pain assessments are completed every shift and documented on the treatment administration record. For new-onset pain, a pain evaluation (including non-pharmacological interventions) should be documented in a progress note or the pain assessment/evaluation. If a resident requests pain medication, the nurse may not do non-pharmaceutical interventions; they are typically done for new-onset expressed pain. On 04/30/2026 at 7:40 AM, the Regional Clinical Services Manager (Staff # 19) agreed that nonpharmacological pain management should be documented on the treatment administration record (TAR) or in a progress note. Staff #19 confirmed an Inservice for nurses starts today to ensure documentation of nonpharmacological methods. On 05/01/2026 at approximately 1:30 PM, the concern was shared with the Regional Clinical Services Manager and the Administrator. 3) On 04/27/2026 at 09:18 AM, in an interview with Resident #80, the resident reported that he/she was experiencing pain management issues for 4 days. The resident explained that the nurse last night did not know how much pain medication he/she should have or the name of the medication. Resident #80 expressed that the pain sometimes prevents him/her from participating fully in physical therapy and expressed concern that he/she will be able to meet the goals of physical therapy before discharge date . The resident stated that the pain level is 10/10 and medication only takes the pain level to 8/10. The surveyor observed the resident grimacing at this time. On 04/27/2026 at 10:06 AM, the Registered Nurse (RN)#14 was made aware of the resident's concern. On 04/29/2026 at 12:24 PM, a review of Resident #80's Medication Administration Record (MAR) revealed that resident had orders for oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl) Controlled Drug Give 1 tablet by mouth every 4 hours as needed for pain level 1-5 and OxyCODONE HCl Oral Tablet 15 MG (Oxycodone HCl) Controlled Drug Give 1 tablet by mouth every 4 hours as needed for pain level 6-10. However, on 04/24/2026 at 05:19 AM resident reported pain level at an 8/10 but oxycodone 10mg was administered. On 04/29/2026 at approximately 2:43 PM, in an interview with the Assistant Director of Nursing (ADON) and Regional Clinical Services Manager, they were notified that oxycodone was administered on 4/24/2026 for pain level of 8 when resident also had a 15 mg that was ordered but not given and the resident expressed that pain was unmanaged. The finding was acknowledged and they stated that they will further investigate the concern. On 4/30/2026, during further review of Resident #80's MAR with the ADON, she clarified that resident received 10mg of oxycodone for a pain level of 8/10 and she acknowledged that the medication was not administered according to the physician's order. She was notified then by the surveyor that the above-mentioned findings was a concern. 4) On 04/29/2026 at 10:43 AM, the Assistant Director of Nursing (ADON) was interviewed regarding the pain management process. The ADON stated that pain assessments are completed every shift and documented on the Treatment Administration Record (TAR), but nonpharmacological methods are not documented, because they are in the care plan. The surveyor asked how the staff would know what nonpharmacological interventions were used prior to the administration of pain medications. The ADON stated that the nurse would write it in a progress note. On 04/29/2026 12:13 PM, a review of Resident #80's Medication Administration Record and Treatment Administration Records revealed no documented evidence to support that the facility provided non-pharmacological intervention to support resident who had pain concerns and required pain medication as needed. Further review of the resident's medical record revealed that on 04/27/2026 a pain care plan was created identifying that resident had pain related to a surgical procedure (right hip replacement) as evidenced by medication and resident verbalization. The care plan identified that non-pharmacological intervention were to be implemented to manage pain, however, there was no evidence that the facility used any non-pharmacological intervention approaches to help with the resident's pain management. On 04/29/2026 at 02:43 PM, In an interview with the Regional Clinical Services Manager Nurse and the ADON, they were asked about the non-pharmacological interventions used to assist Resident #80 with better pain management and they explained that the non-pharmacological intervention was addressed on the care plan but did not specify what interventions were used. They were also unable to verbalize the type of resident specific non-pharmacological intervention used for the resident's pain. On 04/29/2026 at 3:10 PM, a review of Resident #80 MDS (section J) completed on 04/29/2026 at 08:36 AM that Resident #80 received scheduled and PRN pain medication; however, did not receive non-pharmacological interventions for pain. ON 04/30/2026 at 7:40 AM, in an interview with the Regional Clinical Services Manager nurse, he stated that he reviewed information concerning pain management last evening and agreed that nonpharmacological measures should be implemented for pain management and should be documented on the TAR or during a progress note. 5) On 04/27/2026 at 9:27 AM, in an interview with Resident #7, the resident expressed concerns about pain management. On 04/30/2026 at 8:42 AM, a review of Resident #7's care plan created on 04/16/2026 revealed that resident was identified as at risk for pain and implement non-pharmacological interventions such as relaxation, guided imagery, music, distraction and massage before, after and if possible during painful activities or before pain occurs. On 04/30/2026 at 8:52 AM, a review of Resident #7's MAR and TAR revealed that the resident has an order for oxyCODONE HCl Oral Tablet 15 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Pain; however, there was no documented evidence to support that the non-pharmacological interventions identified on the care plan were implemented to assist with the resident's pain management needs as planned. On 05/01/2026 at approximately 12:30 PM, in an interview with the ADON, she was notified that the facility failed to have documentation to support non-pharmacological interventions were in place to manage resident pain. 6) On 04/27/2026 at approximately 11am, the surveyor made a second attempt to conduct an interview with Resident #97; however, the resident appeared drowsy and lethargic at that time and unable to be fully engaged in a conversation. RN # 14 was made aware of the resident lethargy and she explained that the resident was receiving several medications for pain due to his/her disease process. On 04/28/2026 at 1:49 PM, Resident #97 was observed resting in bed and appeared to be in distress, when asked the resident reported that he/she needed pain medication and the pain was not managed well. The resident nurse, Licensed Practical Nurse (LPN#24) was made aware. On 04/30/2026 at 10:43 AM, a review of Resident #97's care plan revealed that resident had actual pain related to chronic disease process. On 05/01/2026 at approximately 11:30 AM, a review of Resident #97's MAR and TAR revealed that resident had an order for several pain medication including opioids and non-opioids medication (both scheduled and as needed) to treat the resident's pain; however, there was no documented evidence to support that the facility took additional measures to offer other non-pharmacological interventions to treat the resident's pain. On 05/01/2026 at approximately 12:30 PM, in an interview with the ADON, she was notified that the facility failed to have documentation to support non-pharmacological interventions were in place to manage resident pain as needed. 7) On 4/29/2026 at 12:41 PM, a review of the active physician orders revealed that Resident # 2 was prescribed: Oxycodone Hydrochloride (HCl) 10 milligrams (mg) orally every 4 hours as needed for pain rated 4-6; andOxycodone HCl 15 mg (administered as three 5mg tablets) orally every 4 hours as needed for pain rated 7-10. A review of the Medication Administration Record (MAR) for April 2026 indicated that Resident #2 received: Oxycodone 10 mg a total of 32 times; andOxycodone 15 mg a total of 9 times. Resident #2's care plan created on 3/12/26 indicated Implement nonpharmacological approaches imagery, relaxation and deep breathing techniques. However, there was no evidence that these non-pharmacological interventions were implemented or documented. 8) A review of Resident #127's clinical record revealed that the resident was prescribed Morphine Sulfate (concentrate) solution 20mg/ml to be administered 5 mg by mouth every 4 hours as needed for pain, Acetaminophen Rectal Suppository 650 mg to be administered every 6 hours as needed, and Acetaminophen 325 mg to be administered as two tablets for 650 mg every 6 hours as needed for pain. Further review revealed the absence of non-pharmacological measures being attempted prior to the use of medications to relieve pain. The survey team brought the issue of not finding non-pharmacological measures in residents' clinical records to the attention of Staff #19 on 4/29/26. Staff #19 stated that the facility nursing staff used non-pharmacological measures, but they are noted in the resident care plans but not documented on either the Medication Administration Record or the Treatment Administration Record. A member of the state survey team interviewed Staff #19 on 4/30/26 at 7:40 AM. He stated that he reviewed information concerning pain management last evening. He agreed that nonpharmacological measures should have been implemented for pain management and should have been documented on the Treatment Administration Record. 9) A review of Resident #12's clinical record revealed that the resident was prescribed Acetaminophen 325 mg to be administered as two tablets for 650 mg every 6 hours as needed for pain. Further review revealed the absence of non-pharmacological measures being attempted prior to the use of medications to relieve pain. The survey team brought the issue of not finding non-pharmacological measures in residents' clinical records to the attention of Staff #19 on 4/29/26. Staff #19 stated that the facility nursing staff used non-pharmacological measures, but they are noted in the resident care plans but not documented on either the Medication Administration Record or the Treatment Administration Record. A member of the state survey team interviewed Staff #19 on 4/30/26 at 7:40 AM. He stated that he reviewed information concerning pain management last evening. He agreed that nonpharmacological measures should have been implemented for pain management and should have been documented on the Treatment Administration Record.

Based on observation and interviews with facility staff, it was determined the facility failed to provide an environment that promotes resident respect and dignity. This was evident for 2 (Resident #9 and #39) of 2 residents reviewed for dignity during the recertification/complaint survey.The findings include:1) On 04/27/2026 at 9:32 AM, an observation of Resident #9 lying in bed showed the linen on the bed had multiple areas of yellow dried substance and an odor of urine. On 04/27/2026 at 2:07 PM, an observation/interview was conducted with Staff #8 and Staff #9, both Geriatric Nursing Assistants (GNAs). The staff stated that resident linens are changed every other day or when they are soiled. However, GNA #8 verified that Resident #9's fitted sheet, top sheet, and white blanket had multiple dried yellow areas. GNA #9 confirmed both the presence of an odor of urine and the dried, yellow-stained condition of Resident #9's linens.2) On 04/27/2026 at 9:20 AM, during an observation, an odor was noted in the hallway near Resident #39's room. A brown substance was observed on Resident #39's bed, wheelchair, and call light. Unknown staff members continued to walk past the room.On 04/27/2026 at 10:06 AM, during a second observation, the brown substance remained present on Resident #39's bed, wheelchair, and call light. On 04/27/2026 at 10:07 AM, during an interview, Staff #4, Licensed Practical Nurse (LPN), confirmed that the brown substance was bowel and was considered a dignity issue. On 04/29/2026 at 10:56 AM, during an interview, the Assistant Director of Nursing (ADON) stated that staff are expected to change residents' linen daily and as needed. The ADON agreed that soiled linen constitutes a dignity issue for residents. The concern was shared with the ADON at this time.

Based on interviews and record review, it was determined that the facility failed to assess the resident's right to self-administer medication. This was evident for 1 resident (#111) of 1 resident reviewed for medication self-administration during the recertification/complaint survey.Findings Included:On 04/30/2026 at 2:20 PM, in an interview with Resident #111, the resident explained that he/she kept medication (inhaler) at the bedside because he/she alleged that the staff failed to administer medication in a timely manner. The resident explained he/she had a respiratory illness and as a result the resident required his/her respiratory medication timely. The resident reported that he/she has received a lot of opposition from the nurses for keeping the inhaler at the bedside. The resident reported that he/she has capacity to administer their own medication and as a result should be allowed that right to keep medication for safety and comfort reasons.On 05/01/2026 at approximately 8:00 AM, a review of a progress note written on 04/25/2026 at 05:55 AM, revealed: Resident complain of shortness of breath and was given a nebulizer treatment. The resident requested the inhaler, and the nurse went into the medication room to check for the resident medicine, medication was not available. Resident used their own inhaler at bedside and shortness of breath has decreased.On 05/01/2026 at 10:31 AM, a review of Resident #111's medical record was completed and revealed that there was no physician's orders for self-administration, no care plan and/or progress notes to support that the resident was appropriately assessed for self-administration of medication. However, resident reported that medication was kept at the bedside at all times.On 05/01/2026 at 11:02 AM, during an interview with the Assistant Director of Nursing (ADON), the ADON was questioned about residents who self-administered medication. She explained that the facility had no residents who self-administered medication within the last month. When asked to describe the process for assessing a resident's ability to self-medicate, she explain that the resident's cognitive ability to self-administer their own medication would be assessed and if a medication assessment was completed it would be documented in the nursing note. The ADON confirmed that keeping medication at the bedside was not permitted unless the resident was assessed as capable, and that the Medication Administration Record (MAR) would identify the medication as self-administration. The ADON was subsequently notified that the facility failed to properly assess residents for self-administration ability to ensure that the resident was able to safely administer his/her own medication as desired.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure that call bells were consistently maintained within residents' reach. This was evident for 2 (Residents #61 and #78) of 133 residents observed during the recertification survey. The findings include: Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. 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. 1) On 4/27/2026 at 9:00 AM, Resident #61 was observed seated in a wheelchair and requested assistance to turn on the room light. At that time, the call bell was observed on the floor across the room, inaccessible to the resident. Registered Nurse (RN) #10 was immediately notified of the observation. On 4/29/2026 at 11:57 AM, a review of the medical record revealed that Resident #61 utilized a wheelchair for mobility and required supervision and staff assistance with ADLs. The resident's care plan indicated a self-care deficit as evidenced by functional decline, indicating a need for accessible assistance. 2) On 4/27/2026 at 9:31 AM, Resident #78's call bell was observed on the floor and not within reach. The surveyor notified RN #11 at the time of the observation. On 4/29/2026 at 8:57 AM, during an interview with Licensed Practical Nurse (LPN) #24, he/she stated that staff are expected to ensure that call bells are placed within residents' reach at all times. On 4/29/2026 at 12:12 PM, a review of medical record revealed that Resident #78 required the use of a walker for mobility and was dependent on staff for ADLs. The resident's care plan also identified a self-care deficit, indicating the need for assistance. On 4/30/2026 at 11:33 AM, the Assistant Director of Nursing (ADON) was informed of the above findings and acknowledged the concerns.

Based on record review, complaint # 2991568 and interviews, it was determined the facility staff failed to report alleged violations related to neglect and/or abuse, including injuries of unknown source with major injuries to the Office of Healthcare Quality as required. This was evident for 1 (Resident #97) of 39 residents records reviewed during the recertification survey process. The findings include: On 04/27/2026 at approximately 11am, a review of complaint #2991568 alleged that Resident #97 was being accused of verbally threatening his/her roommate, with no proof of the alleged abuse. On 04/27/2026 at 2:43 PM, in an interview with Resident #97, the resident reported that he/she was accused of threatening to kill his/her roommate (Resident #166). Resident #97 stated that the staff alleged that Resident #166 reported the alleged threat to the staff and they called the police on him/her; however, Resident #97 denied threatening the roommate (Resident #166). On 4/30/2026 at 11:45 AM, a review of Resident #97's care plan created on 03/24/2026 revealed that Resident #97 had a diagnosis of Mood disturbance related to Depression as evidenced by fluctuations in mood. On 04/30/2026 at 11:54 AM, a review of a change in condition evaluations completed on 04/21/2026 at 11:43 PM revealed that Resident #97 became verbally aggressive toward his/her roommate after accusing the roommate of eating his/her food. It was alleged that Resident #97 stated, I will kill you, in the presence of a staff. The police were called to evaluate the situation. On 04/30/2026 at 12:13 PM, in an interview with Assistant Director of Nursing (ADON) and the Regional Clinical Services Manager, they were asked if the above-mentioned incident was submitted to the Office of Health Care Quality (OHCQ) and the ADON stated no. They were asked what the expectation of the facility was, if a resident threatens to kill another resident. They acknowledged that the facility should have reported the incident to OHCQ.

Based on a review of facility investigative materials, medical records, and staff interviews, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This was evident for one (Resident #161) of three residents reviewed during this recertification/complaint survey.The findings include:On 4/30/26 at 7:53 AM, the surveyor reviewed a self-reported incident #340529. The review revealed that on 5/01/25 at approximately 1:00 AM, Resident #161 was found with their head hanging off the side of the bed while their lower body remained on the mattress. The resident sustained a skin tear on the right lateral leg, which required transfer to the hospital and seven superficial Prolene sutures. The facility's internal investigation concluded that because the fall was unwitnessed, the cause could not be determined.Further review of Resident #161's medical record revealed that the resident's most recent Brief Interview for Mental Status (BIMS), dated 4/18/25, resulted in a score of 13 out of 15, indicating intact cognitive function. Despite the resident's intact cognitive status, the facility's investigative packet contained no written statement from Resident #161 regarding the cause of the injury.During an interview on 4/30/26, the Regional Clinical Services Manager (Staff #19) provided a statement from Licensed Practical Nurse (LPN) #23, who performed the initial assessment. LPN #23 claimed the resident did not know what happened because they were asleep.Review of the hospital visit notes dated 5/01/25 revealed a different account. The resident told hospital staff they were standing on the side of the bed when an aide came in to help, and noted they had been sleeping prior to calling for staff assistance.On 5/01/26, these concerns were presented to the Assistant Director of Nursing, the Regional Clinical Services Manager, and the Nursing Home Administrator. The facility leadership validated these findings.

Based on observation, record review, and interview, it was determined that the facility failed to develop and implement a comprehensive care plan addressing the use of a nebulizer and an arm sling. This was evident for 1 (Resident #88) of 36 residents reviewed for care planning during the recertification 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. The care plan consists of focus, goal and interventions. A nebulizer is a medical device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs through a mouthpiece or face mask.On 4/27/2026 at 8:31 AM, the surveyor observed a nebulizer mask resting on top of Resident #88's soiled breakfast tray. Resident #88 was seated in a wheelchair with a sling applied to the left arm and reported discomfort. Registered Nurse (RN) #10 was immediately notified of the observation.On 4/29/2026 at 7:27 AM, a review of Resident #88's medical record indicated the following physician orders:Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 milliliters (ml) inhale orally every 6 hours for shortness of breath for 7 days, with an end date of 5/1/26. (liquid medications used to relax and open airways to improve breathing).Left arm in sling at all times except for hygiene every shift.A change in condition note dated 4/24/26 confirmed that Resident #88 experienced shortness of breath (SOB) and was initiated on breathing treatments. Further review indicated the resident was admitted on [DATE] with a closed fracture of multiple ribs, requiring the use of a sling to the left arm. Despite these identified needs and physician orders, there was no evidence in the medical record that a care plan was developed or implemented to address SOB and the use of a nebulizer treatments, and the use and management of the left arm sling. On 4/29/2026 at 11:00 AM, during an interview with the Assistant Director of Nursing (ADON), she confirmed that care plans are initiated upon admission by supervisors or Unit Managers and subsequently reviewed and completed by the Interdisciplinary Team (IDT). The ADON further stated that care plans are updated with new physician orders, falls, and changes in condition, as well as during routine quarterly reviews. The ADON confirmed that there was no care plan addressing the resident's SOB or the use of nebulizer treatments. On 4/30/2026 at 1:38 PM, the ADON also confirmed that there was no care plan in place addressing the use of sling.

Based on record review and interviews, it was determined that the facility failed to revise the comprehensive care plan to reflect the resident's current treatment needs. This was true for 1 (Resident #97) of 36 residents reviewed for care planning during the recertification survey. Findings Included:On 4/29/2026 at 11:00 AM, during an interview with the Assistant Director of Nursing (ADON), she confirmed that care plans are initiated upon admission by supervisors or Unit Managers and subsequently reviewed and completed by the Interdisciplinary Team (IDT). The ADON further stated that care plans are updated with new physician orders and changes in condition, as well as during routine quarterly reviews. On 04/30/2026 at 11:54 AM, a review of Resident #97's progress report written on 04/22/2026 at 07:01 AM revealed that the resident who was alert and oriented was observed by staff ambulating/standing by the nursing station in his/her underwear only.On 04/30/2026 at 11:54 AM, a review of a change in condition evaluation form completed on 04/21/2026 at 11:43 PM revealed that Resident #97 became verbally aggressive toward his/her roommate after accusing him/hers of eating his/her food. Resident stated, I will kill you, in the presence of a staff. The police were called to evaluate the situation.On 4/30/2026 at 12:22 PM, in an interview with the Nursing Home Administrator (NHA), she was informed that Resident #97 had multiple behavioral issues such as non-compliance with treatment orders, verbal altercation with two different roommates and inappropriately dressed at the nursing station; however, the facility failed to revised the care plan to reflect that the resident had the above mentioned behavioral issues, the NHA acknowledged the findings.On 05/01/2026 at approximately 12:30 PM, the ADON was notified of the above-mentioned findings and it was acknowledged and no additional documentation was provided at that time.

Based on complaint investigations, medical record reviews, and staff interviews, it was determined that the facility failed to assess and/or document the onset and management of unusual changes in resident condition. This deficiency was evident for one resident (Resident #153) out of three reviewed for injuries of unknown origin during the recertification/complaint survey.The findings include:On 4/30/26 at 8:00 AM, the surveyor reviewed self-reported incident #2720156. The report indicated that on 1/17/26, Resident #153 underwent an X-ray due to complaints of right hip pain, which revealed an acute fracture of the right femoral neck.At 8:34 AM on 4/30/26, a review of the resident's medical record revealed a Change in Condition note dated 1/17/26 at 1:33 PM. While the note acknowledged the X-ray results and the fracture, the record lacked any prior documentation regarding the resident's pain, including: the specific time of onset for the unusual pain, which staff member performed the initial clinical assessment, the interventions implemented to manage the pain while awaiting the X-ray, and the specific details of the report to the physician prior to the receipt of the X-ray results.During an interview on 4/30/26 at 9:39 AM, the Assistant Director of Nursing (ADON) and the Regional Clinical Nurse Manager reviewed these findings. They validated that there was no documentation of a pain assessment or nursing interventions leading up to the diagnostic imaging.

Based on complaint investigations, medical record reviews, and staff interviews, it was determined that the facility failed to ensure appropriate wound care, timely specialist consultation, and necessary medication adjustments. This was evident of one (Resident #157) out of five residents reviewed for pressure ulcers during the recertification/complaint survey.The findings include:Moisture-Associated Skin Damage (MASD) is an umbrella medical term for skin inflammation, irritation, and erosion (breakdown) caused by prolonged exposure to moisture, such as urine, stool, wound exudate, sweat, or saliva. A stage 2 pressure ulcer is a partial-thickness skin loss involving the epidermis and/or dermis, appearing as a shallow, pink/red, moist, open ulcer or a ruptured/intact blister. On 4/28/26 at 8:09 AM, the surveyor reviewed complaint regarding Resident #157. The review revealed that the complainant submitted on 1/09/26 had concerns regarding Resident #157's care: the resident did not receive appropriate care and acquired a stage 2 bedsore.In a review of Resident #157's medical record on 4/28/26 at 9 AM, it was revealed that the resident admitted on [DATE]. The first skin assessment documented on 9/11/25 showed that he/she had Moisture Associated Skin Damage (MASD) on sacrum area. The follow up skin assessment was documented on 9/15/25 with sacrum skin issue measured as 5.5 X 2.5 X 0.1 (cm) as MASD. However, the wound specialist's documentation dated 9/15/25 stated signing off on patient who remains in the facility. A week later on 9/22/25, skin assessment and wound specialist documented as stage 2 pressure ulcer documented with size of 3.0 X 1.0 X 0.1 (cm).In an interview with Wound Nurse #22 on 5/01/26 at 8:04 AM, she explained the facility's protocol: the admission nurse performs the initial assessment, which the wound nurse then confirms. The wound nurse rounds weekly with a contracted physician and provides daily care. Additionally, Wound Nurse #22 clarified that MASD requires treatment with zinc ointment, which is a medicated treatment that must be ordered by a physician, unlike standard barrier creams.Upon a joint review of the medical record, Wound Nurse #22 confirmed there was no evidence to prove Resident #157 received treatment with zinc ointment between the initial discovery of MASD and its progression to a Stage 2 pressure ulcer. The nurse further acknowledged that the wound physician's note on 9/15/25 indicated the resident was not actually evaluated by the provider during that visit.On 5/01/26, these findings were presented to the Assistant Director of Nursing (ADON). The ADON validated that the facility failed to obtain the necessary treatment orders and specialist oversight required to prevent the MASD from deteriorating into a pressure ulcer.

Based on a complaint investigation, medical record reviews, and staff interviews, it was determined that the facility failed to ensure a resident received psychotropic medication as recommended by psychiatric consultants. This deficiency affected one resident (Resident #162) out of five reviewed for behavioral health during the recertification/complaint survey.The findings include:On 4/29/26 at 8:59 AM, the surveyor reviewed a complaint alleging that Resident #162 did not receive appropriate treatment for mental health issues during their stay at the facility.Further review of medical records for Resident #162 revealed that the resident was admitted to the facility on [DATE]. An initial psychological evaluation on 4/22/25 recommended Depakote 125 mg twice daily for mood and behavioral disturbances. Subsequent psychiatric consultations on 4/23/25 and 4/29/25 confirmed the ongoing need for this treatment.On 4/29/26 at 11:30 AM, a review of Resident #162's medication orders revealed that on 4/25/25, Depakote 125 mg was started three times daily rather than the recommended twice daily. The Medication Administration Record (MAR) for April 2025 showed the resident received this incorrect dose seven times between 4/26/25 and 4/28/25. On 4/28/25, an order for Depakote 125 mg twice daily was briefly entered and then immediately discontinued. As a result, the medication was never restarted, leaving the resident without the recommended treatment.During an interview on 4/29/26, the Assistant Director of Nursing (ADON) reviewed the records with the surveyor. The ADON confirmed that the resident received the incorrect dosage from 4/26/25 to 4/28/25 and validated that the correct order was discontinued without an accompanying clinical assessment or justification.

Based on observations of the facility's kitchen and food services, it was determined that the facility failed to maintain sanitary food service operations. This deficiency was identified during multiple observations of kitchen and food service areas throughout the recertification/complaint survey. The findings include: During the initial tour of the kitchen on 4/27/26 at 7:50 AM, the surveyor noted a beverage cart containing apple juice, cups of milk, and cups of water that did not have dates marked on their lids. When asked how staff or residents would know when these beverages were prepared, Dietary Manager #25 stated, Everything in this kitchen is supposed to have a date. She then instructed a dietary aide to label the lids. On 4/28/26 at 7:28 AM, the surveyor inspected the nourishment rooms on the first floor. Accompanied by Geriatric Nursing Aide (GNA) #26, the surveyor found a paper bag containing food labeled with Resident #76's name in the refrigerator; however, it lacked a storage date. Additionally, the refrigerator contained an undated plate of cornbread and an unmarked dragon fruit. The interior of the refrigerator also exhibited dust and dark stains. GNA #26 validated these findings.During a follow-up tour of the kitchen on 4/30/26 at 11:50 AM, it was noted that Kitchen Aide #27 was not wearing a beard cover while handling food for service. Dietary Manager #25 confirmed that staff are required to wear hairnets and beard always covers while in the kitchen.In an interview with the Nursing Home Administrator (NHA) on 4/30/26 at 1:42 PM, the surveyor shared the aforementioned concerns. The NHA validated the findings.

Based on record review and interview, it was determined that the facility failed to ensure that staff COVID-19 vaccination status was consistently monitored and documented. This was evident for 2 Geriatric Nurse Assistants (GNA) #18 and #9 of 5 randomly selected staff members reviewed during the recertification survey. The findings include: A COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease. On 5/01/2026 7:26 AM, a review of the employee health records for GNA #18 and #9 revealed no documented evidence of COVID-19 vaccination status.On 5/01/2026 at 8:04 AM, in an interview with the Assistant Director of Nursing (ADON), she stated that the facility offers COVID-19 vaccinations to all staff during on-site clinics; however, she acknowledged that vaccination status had not been consistently documented. On 5/01/2026 at 9:06 AM, the ADON provided an email correspondence with a community pharmacy indicating that 3 employees had expressed interest in receiving the COVID-19 vaccine during a 2024 clinic. No documentation was provided to confirm whether these vaccinations were administered or recorded in the employees' health records.

Based on an observation and facility staff interviews, it was determined that the kitchen failed to store food items, so as to maintain the integrity of the specific item. This was evident during the initial tour of the kitchen, by noting expired food items and undated opened items, observed by the surveyor during the recertification/complaint survey. The findings include: On [DATE] at 8:19 AM observations with the Food Service Director (FSD) revealed the following: In the kitchen dry storage room on at 8: 25 AM, Extra heavy half full one gallon Mayonnaise container without an open date. Several snack cups were on the floor under the storage shelves, Magic cup dessert, (2) vanilla (3) chocolate (2) and wild berry (1). Complete butter milk pan cake mix expired on [DATE]. On [DATE] at 09:32 AM, the walk-in freezer had ice built up on the floor, noted hanging icicles under the condenser. Corn beef, wrapped in plastic wrap, was found in the kitchen fridge without an open date. On [DATE] at 09:06 AM Interview with dietary staff # 33 revealed that kitchen staff date the left over food items after they are opened, and discard after 72 hrs. On [DATE] at 9:30 AM reviewed with Food Service Director all the above findings and he/she validated the findings.

Based on medical record and facility investigation review as well as interviews with the director of nursing (DON) and the resident (resident #2), it was evident that the facility failed to provide care and services in accordance with the comprehensive plan of care. This resulted in the resident falling/being lowered to the floor, sustaining an abrasion and persistent lower back pain. This deficiency is cited as past non-compliance as the facility provided information supporting a correction date prior to 4/19/16. This was evident for 1 of 9 residents selected for review. The findings included the following: On 4/19/16, the surveyor reviewed the allegations in complaint #MD 286 regarding resident #2's quality of care in the facility. The complainant alleged that on 1/9/16 a nurse transferred and toileted resident # 2 by herself when there should have been 2 staff members present. This resulted in the resident falling, injuring an area above her left eye and new onset back pain. The back pain was eventually diagnosed as a compression fracture. The complainant further alleged that the nurse left the resident alone after the fall and that when she arrived to visit the next afternoon she was the one who noticed the abrasion above the resident's eye. The complainant further alleged that when the resident was discharged from the facility, the dosage on the prescription for an anti-coagulant was incorrect, (refer to F 281). The surveyor reviewed the facility's investigation and the resident's medical record as well as interviewed the DON regarding the event. By way of history, according to the hospital discharge summary, resident #2 was hospitalized for [REDACTED]. Prior to the stroke the resident had been independent for activities of daily living. On 12/20/15 and 12/31/15, according to the minimum data set (MDS) assessment and care plans the resident required the assistance of 2 staff members for transfers and toileting. On 1/9/16 at 11 pm, per the facility investigation, nurse #1, transferred resident #2 from the wheel chair to the toilet, by herself, and when she attempted to transfer the resident from the toilet back to the wheel chair, by herself, the resident fell / had to be lowered to the floor. The nurse left the resident in the bathroom alone and went to get help - she did not use the call bell/call for assistance. On 1/10/16 at 2 pm, per the facility investigation, 15 hours after the fall, resident #2's family came to visit the resident and noted an abrasion above the resident's left eye brow. The charge nurse assessed the area and notified the certified nurse practitioner (CRNP). At 3:20 pm, according to the physician order [REDACTED]. At 6:40 pm, according to the X-ray results, the resident had [MEDICAL CONDITION] joint disease in the lower back. At 6 pm and 7 pm, per the facility investigation, the DON interviewed geriatric nursing assistant (GNA) #2 and nurse #1. In the statements they described the resident leaning on her left side against the hamper with her head almost on the floor in the bathroom following the fall. Per the facility's investigation nurse #1 failed to stay with the resident and use the call bell to seek assistance, assess and document the injury above the resident's left eye, and notify the resident's family of the fall/injury, (refer to F 157). On 1/11/16, according to the physical therapy (PT) notes, the resident complained of lower back discomfort at a level of 9/10 (a scale of 1-10, with 10 being the worst) with movement. The treatment was changed to include external stimulation to decrease the pain. On 1/12/16, according to the POS, a non-steroidal anti-[MEDICAL CONDITION], [MEDICATION NAME] 600 milligrams (mgs) was ordered every 8 hours for pain. On 1/14/16, per the CRNP assessment, the resident complained of lower back pain following the fall at a level of 7/10. The [MEDICATION NAME] was discontinued and an opioid, [MEDICATION NAME] 25 mg three times per day was ordered as well a topical cream, [MEDICATION NAME], to the lower back three times per day for pain. At 8:15 am, according to the nursing assessment, the resident's pain was 3/10 in the lower back. Pain was described to be at a 9 when it was its worst and that the resident had described being unable to eat her breakfast because the pain was so bad. At an undocumented time, according to the occupation therapy (OT) assessment the resident's family stated that the resident gets worried/anxious at night about having to go to the bathroom and that the resident had acute back pain from a recent fall that became intermittently severe with any movement causing interference with her ability to function normally. On 1/15/16, according to the POS, a CT scan of the back was ordered because of post fall persistent complaints of pain. On 1/19/16, per the CRNP assessment, the resident's back pain following the fall had been at a level of 8/10. On 1/20/16, per the CT impression, the resident had a mild chronic compression [MEDICAL CONDITION] (L2) area. The CT scan was done 5 days after being ordered for persistent complaints of back pain, (refer to F 510). On 1/21/16, per the CRNP assessment, the resident had pain at a level of 10/10 with activity. On 1/26/16, per the CRNP assessment, the resident continued with intermittent back pain. On 2/22/16, per the CRNP discharge summary, the resident had been in the facility for rehabilitation following a stroke, had a fall which resulted in lower back pain and that a CT scan revealed a mild compression fracture of L2 and would require follow up with the orthopedist as an outpatient. On 4/22/16, the surveyor contacted the DON for additional information; she was unable to provide any. On 4/28/16 at 10:30 am, the surveyor interviewed the resident. The resident described falling in the bathroom when the nurse tried to transfer him/her off of the toilet without help. During the fall the resident recalled hitting his/her head and being left alone in the bathroom for what seemed like a long time. During that time she/he described back pain that made him/her cry. Following the fall he/she described increased nervousness with further transfers/toileting to the point that he/she shook because of the fear of falling again. On 4/28/16 at 12:30 pm the surveyor called the facility DON, she was unable to provide additional information. The facility failed to provide care and services in accordance with the resident's comprehensive plan of care. This resulted in the resident falling/being lowered to the floor, sustaining an abrasion and lower back pain.

Based on medical record review and resident interview, it was determined that the facility staff failed to manage Resident #1's pain. This was evident for 1 of 3 residents selected for review. The findings include: On 8/21/14, the surveyor reviewed a complaint sent to The Office of Health Care Quality (on 7/24/14) and Resident #1's medical record. Record review revealed that on 7/17/14 at about 6 pm Resident #1 was admitted to the facility. Resident #1 had been readmitted to the hospital on [DATE] after being discharged home following a right total knee repair (the surgery had been done on 6/24/14). While in the hospital Resident #1 was treated for [REDACTED]. According to the nursing admission assessment completed by LPN #1 at approximately 6:10 pm, Resident #1 described constant, excruciating pain in the right knee at a rate of 10/10 (on a scale of 1-10). According to the physician order [REDACTED].#1 had orders for the administration of routine and as needed medication to treat pain and muscle spasms. However, the facility staff failed to administer the medications until the next morning. The medications included: [MEDICATION NAME] 10 milligrams (mg) with breakfast, lunch and at bedtime for spasms; [MEDICATION NAME] 50 mg 4 times a day (6 am, 12 pm, 6 pm and 12 am) for pain and [MEDICATION NAME] 10 mg, as needed for pain every 3 hours. On 7/18/14 at 4:40 am, according to the POS, MAR and nursing note, Resident #1 received the first dose of pain medication, [MEDICATION NAME], for "excruciating" pain in the right knee. On 7/18/14 at 6 am, according to the MAR, the resident received the first dose of [MEDICATION NAME]. Review of the MAR revealed the [MEDICATION NAME] was not administered. Record review revealed that on 7/18/14 at 9:20 am, Resident #1 was transferred to the hospital for complaints of chest pain. Resident #1 was interviewed by the surveyor on 8/26/14 at 8:20 am. Resident #1 stated that he was in so much pain the evening/night that he spent at the facility that he thought he would die. The facility failed to manage resident #1's pain from the time of admission through 7/18/14 at 4:40 am, a total of 4 and 1/2 hours without pain medication despite Resident #1 indicating the pain was 10/10.

Based on complaint intake, medical record and facility investigation review, tour and observation of the facility including the loading dock deck area, and interviews with the administrator, director of nursing, and maintenance supervisor it was determined that the facility staff failed to maintain an environment free of accident hazards and provide adequate supervision to prevent an accident. This was evident for 1 of 9 residents selected for review. The findings included the following: The facility staff failed to close the garage type door that led to the loading dock deck in an unsupervised area which resulted in resident #1 falling 4 feet from the deck to the ground; this resulted in the resident sustaining lacerations to his face and a fractured leg. On 9/26/12 and 9/27/12 the surveyor investigated a complaint sent to the Office of Health Care Quality (OHCQ) by resident #1 ' s son. On 8/9/12 the resident's son's complaint was received by OHCQ. His son alleged that his father had wheeled himself, while seated in a wheel chair, through an unsupervised area to an outside loading dock deck on 8/4/12. The complaint further noted that the resident had wheeled himself off of the loading dock deck and fallen 4 feet to a concrete driveway which resulted in a head injury and fractures of the right leg. The resident ' s son added that his father had been discovered on the ground outside of the facility by a visitor. On 8/16/12 the OHCQ received a report from the facility administrator (ADM) of "neglect". His information supported the resident's son's complaint allegations. The report summary, written by the facility ADM, noted that on 8/4/12 at 5:15 PM resident #1 went to the loading dock area and fell off the dock. According to the ADM investigation notes, the hospital report reflected that the resident had sustained a fractured hip and facial lacerations. The report further noted that the resident had self propelled through a secured door, which was not functioning properly, which led to the hallway and to the loading dock area. The ADM report added that it appeared that the resident may have been assisted through the door and preceded to the loading dock area. The garage like door which led outside to the loading dock deck, had been left open by an employee (employee #3) when he was emptying trash. The facility had surveillance cameras which captured portions of the events as described. On 9/26/12 at 10:30 AM the surveyor toured the area described to be the exit route taken by resident #1 with the DON and then the ADM. The tour of the exit route began by walking down the hall from the nurse's station; the station where the facility staff caring for the resident reported. The door down the hall to the left opened to the hallway that led to the loading dock are. The door had been equipped with a round door knob instead of a handle as noted at the time of the resident ' s exit. The touch key pad had to be used prior to opening the door; this was not working at the time of the resident ' s exit. The door was heavy and difficult to open. Once through the door, down the hallway up to the left was a surveillance camera. The hallway had several exits/ entrances and housed employee lockers and vending machines. The employee lounge was down the hall to the left. The next door, used by the resident at the time of his exit, was down the hall passed the employee lounge employee lockers, and vending machines, was to the right. This door opened with ease to the area in front of the garage type door which led to the loading dock; there were many supplies and equipment stored in this area. There was an unlocked un-alarmed door to the left of the garage type door which also led to the loading dock area; the ADM and maintenance supervisor secured this exit following surveyor intervention/ observation. The DON opened the garage type door using a red button located high up on the wall to the left of the door. The button had to be held to keep the door going up. Once the door was opened the surveyor and DON walked through floor length plastic flaps to the loading dock deck. The deck was about 4 feet off of the ground and surrounded by various dumpsters and equipment. The ground below the deck was cement/ concrete and could be accessed by driving/ moving down the facility driveway which led to parking areas. The ADM met the surveyor and DON at this point and the areas were re-observed and an interview with the ADM took place. During surveyor interview with the ADM he stated that when the incident occurred employee #3, per his written statement and interview with the ADM, had been emptying trash off of the loading dock and left the area leaving the " garage type " door open and unsupervised. Employee #3 alleged that he had gotten a personal phone call and went to the employee lounge to take it. He alleged that he got called back to the kitchen and saw the resident coming down the hall. The ADM stated that he had watched the video from the surveillance camera available at that time. It showed the hallway that led to the loading dock area, up to a point. The video, per the ADM, showed employee #3 walk down and into the employee lounge. It also showed the resident coming down the hall. He stated that when the door at the end of the hall was open there was light into the hall. The ADM and surveyor walked to the door and he held it open and noted how heavy the door was and how difficult it would be for someone to hold it open when seated in a wheel chair and pass through. He said that when he watched the video from the surveillance camera he felt that the door was open for over 15 seconds and he believed that someone held the door open while the resident passed through it; this was the door that led to the hallway to the loading dock area. The surveyor reviewed employee #3' s employee file, with the human resource staff ' s supervision. The file included 2 written counseling ' s and statements. On 8/9/12 employee #3 was placed on administrative leave because he left the door to the loading dock open and unsupervised, on 8/4/12, which resulted in resident #1 falling and sustaining injuries. On 8/13/12 another employee counseling was done and employee #3 was dismissed. The surveyor interviewed the maintenance supervisor. He had documentation which supported that the door to the hallway leading to the loading dock had a broken handle and alarm system at the time of the resident's entrance to the hallway which led to the loading dock deck area. The surveyor reviewed the resident' s medical record: By way of history resident #1 had been in the hospital prior to admission to the facility. Per the discharge summary, he had lived at home with assistance prior to the admission. His transfer summary noted that he had been admitted to the hospital on [DATE]. He had come with symptoms of speech changes. The assessments/ consultations had ruled out a stroke and the changes were thought to be due to a severely low magnesium level - likely due to overuse of constipation meds. His other [DIAGNOSES REDACTED]. He was receiving medication for his current [DIAGNOSES REDACTED]. His discharge instructions included activity as tolerated with fall precautions On 7/28/12 he was admitted to the facility and fall precautions were ordered as well as the medications and treatments noted on the transfer summary. The surveyor reviewed the facility investigation: On 8/4/12 at 5:25 pm the receptionist was alerted by a visitor that the resident was on the ground outside in front of the loading dock deck. She ran to alert the nursing staff about what the visitor reported. The resident was discovered on the ground, bleeding from his head and lying on his right side with his wheel chair folded closed at his feet. Pressure was applied and ice to stop the bleeding from his head. He complained of pain to the head and right hip/ thigh and was calling, " help me, help me ". The resident was transferred 911 to the hospital. The facility staff left the garage type door to the loading dock deck open and unsupervised. The resident self propelled in his wheel chair out the door and fell 4 feet to the pavement/ concrete driveway. A visitor observed him on the ground outside the loading dock and alerted the facility staff. He was assessed to have bleeding from the head, pain in the right leg and was calling "help me, help me". He was transported to the hospital 911. His son placed a complaint noting neglect and that his father had suffered a fractured leg and head lacerations as a result of the fall. The facility investigation and interviews with the DON and ADM supported the allegations.