Every finding on record at Green Acres Nursing and Rehab

Based on an investigation into a complaint, record review, and staff interviews, it was determined that the facility failed to ensure a resident remained free from abuse. This deficient practice was evident for 1 (Resident #5) of 5 residents reviewed for abuse during the complaint survey.The findings include:According to CMS, the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.The Brief Interview for Mental Status (BIMS) is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. A series of standardized questions in the BIMS are scored and when added result in a total score between 0-15. The numeric value falls into one of three cognitive categories: Intact which is 13 to 15 points, Moderate which is 8 to 12 points or Severe cognitive impairment which is 0 to 7 points.A review of complaint intake #2977399 on 5/13/2026 revealed concerns related to an alleged incident of resident-to-resident sexual abuse that reportedly occurred on 3/15/2026 involving Residents #5 and #8.A review of the facility's timeline of events and investigative documentation on 5/13/2026 at approximately 1:00 PM revealed the following: On 3/15/2026 at approximately 5:20 PM, while delivering meal trays, CMA #16 observed Resident #8 in Resident #5's room with their pants pulled down to thigh level exposing their genitals while Resident #5 was in bed. Facility investigative documentation further revealed CMA #7 reported observing Resident #8 rubbing Resident #5's stomach underneath the blanket.A review of Resident #5's clinical record revealed diagnoses including Dementia, Anxiety Disorder, Difficulty Walking, Generalized Muscle Weakness, and Need for Assistance with Personal Care. Review of Resident #5's admission MDS assessment dated [DATE] revealed a BIMS score of 0. Facility documentation revealed Resident #5 was unable to provide responses regarding the incident.A review of Resident #8's clinical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Dementia, Psychotic Disturbance, Anxiety, Cerebral Infarction, and Amnesia. Further review confirmed Resident #8 was an emergency discharge from the facility on 3/17/2026 following the 3/15/2026 incident.On 5/13/2026 at 12:51 PM, during an interview, the local Ombudsman stated the facility had prior awareness of concerns related to Resident #8's sexual behaviors before the 3/15/2026 incident. The Ombudsman stated that on 3/17/2026 she received email notification of Resident # 8's emergency discharge from the facility following the incident on 3/15/26. The email titled Emergency Discharge Documentation included three attachments: the emergency discharge letter, incident summary and the facility's timeline of events. Review of the the timeline included an investigation background that indicated the facility was contacted by a public defender on 8/5/2025 regarding concerns about whether the facility was equipped to manage Resident #8. The public defender did not provide further details about the legal matter and instructed the facility to contact Resident #8's Resident Representative (RP) for more information. On 08/05/2025, the facility contacted Resident #8's RP to request more information. On 08/07/2025, Resident #8's RP returned the call and stated that in August 2023, s/he was contacted by Resident #8's previous facility with an allegation that Resident #8 had been involved in an inappropriate sexual act. The Ombudsman provided copies of the documentation to the surveyor for review.Further review of the facility's investigative documentation revealed the facility became aware in August 2025 of prior allegations involving inappropriate sexual behavior related to Resident #8 at a previous facility. The facility's investigative documentation further confirmed the information obtained during the Ombudsman's interview.A review of Resident #8's care plan on 5/13/2026 at 2:09 PM revealed a care plan related to sexually inappropriate behavior was initiated on 3/16/2026 following the incident. Prior to the incident, there was no documented care plan related to sexually inappropriate behavior, increased supervision, monitoring related to sexual behaviors, or interventions related to Resident #8 entering other residents' rooms without permission.Continued review of Resident #8's clinical record revealed a nursing progress note dated 3/9/2026 documented Resident #8 entered other residents' rooms without permission and required staff redirection.On 5/13/2026 at 3:15 PM, during an interview, the Administrator stated that facility was aware of prior concerns related to Resident #8's sexual behaviors before the 3/15/2026 incident. The Administrator further confirmed there were no additional monitoring or supervision interventions in place related to sexual behaviors prior to the incident because Resident #8 had not displayed sexual behaviors in the facility before 3/15/2026.On 5/13/2026 at 3:32 PM, during an interview, the Director of Nursing (DON) confirmed Resident #8's genitalia was exposed during the incident and confirmed interventions related to sexually inappropriate behavior were initiated following the incident.On 5/15/2026 at 11:18 AM, during an interview, CMA #7 confirmed observing Resident #8 in Resident #5's room with their pants pulled down, exposing genitalia, while Resident #5 was in bed. CMA #16 further stated Resident #8's hand was underneath Resident #5's blanket on their stomach.A subsequent review of Resident #5's clinical record did not reveal evidence that Resident #5 displayed any emotional or behavior changes related to the 3/15/2026 incident.On 05/15/2026 1:42 PM, during an interview, Resident #5's RP stated I can't say. I know s/he is mouthy when asked how Resident #5 would have responded to the incident prior to his/her dementia diagnosis. The RP further stated Resident #5 was not modest at all prior to his/her dementia. When the surveyor asked how Resident #5 would have responded to unwanted physical contact, the RP stated Resident #5 would not have wanted to be touched. The RP further stated she had not observed any emotional or behavioral changes in Resident #5 following the incident.The Administrator and Director of Nursing were made aware of the findings at the time of exit conference.

Based on investigation into a complaint, record review, and staff interviews, it was determined that the facility failed to ensure allegations of abuse were reported to the Office of Health Care Quality (OHCQ) as required. This deficient practice was evident for 1 (Resident #5) of 5 residents reviewed for abuse during the complaint survey. The findings include:A review of complaint intake #2977399 on 5/13/2026 revealed concerns related to an alleged incident of resident-to-resident sexual abuse that reportedly occurred on 3/15/2026 involving two dementia residents, Residents #5 and #8.Further review of the facility's internal investigation documentation revealed the facility contacted local law enforcement regarding the incident and a police report was generated.On 5/13/2026 at 3:15 PM, during an interview, the Administrator confirmed the incident was not reported to OHCQ because the facility did not consider the incident reportable based on the information available at the time. The Administrator stated the facility notified law enforcement because Resident #8's genitalia was exposed during the incident and just to be on the safe side.On 5/13/2026 at 3:32 PM, during an interview, the Director of Nursing (DON) confirmed the facility did not report the 3/15/2026 incident to OHCQ at the time of occurrence.On 5/14/2026, during a follow-up interview with the Administrator, it was revealed that the facility submitted a Facility Reported Incident (FRI) related to the 3/15/2026 incident to OHCQ on 5/13/2026 at 11:23 PM following surveyor inquiry during the complaint investigation.The findings were discussed with the Administrator and DON during the exit conference.

Based on observations and staff interviews it was determined the facility failed to store food in accordance with professional standards for food safety and failed to ensure that the facility dishwasher provided safe heat sanitization. The findings include the following: 1. An initial tour of the facility kitchen was completed on 01/14/2026 at 08:05 AM with staff #4 the following items were found to be missing an expiration date on the product: a) One 36 OZ Lemon Meringue Pieb) One large bag of chicken tendersc) Several spice containers of spices d) Several 4 OZ Orange Juice containerse) One platter containing slices of tomatoes and cucumbers f) Two 1-gallon containers of Heavy-Duty Mayonnaise During the tour interview on 01/14/2026 at 08:05 AM with staff #4 he/she confirmed and stated that the above items did not have an expiration date on them, and staff are supposed to label all food items with an expiration date. During interview on 01/14/2026 at 8:30 AM staff #5 stated that all food items are to be labeled by staff with delivery and/or expiration date upon being received. 2. During observation rounds on 01/14/2026 at 12:20 PM with staff #6 the facility High Temperature Dishwasher (heat sanitization) monitor device was flashing a warning screen indicating that the wash temperature was low and reading 128.4F. Staff #6 verified this reading and stated that he/she would call and have this fixed. During an interview on 01/14/2026 at 12:45 PM with staff #5 stated that the facility was going to use paper products for all meals until the dishwasher was fixed. After surveyor intervention, during interview and review of facility documentation on 01/15/2026 at 12:00 PM staff #1 provided a invoice indicating that the facility dishwasher was serviced and fixed.

Based on observation and staff interview during facility environmental observations, it was determined that the facility failed to ensure a safe, clean, comfortable, homelike environment. This was evident for 13 (rooms 102, 103, 104, 107, 111, 112, 115, 116, 118, 117, 119, 120, and 122) out of 24 resident rooms observed for Homelike Environment during the annual survey.The findings include: 1. On 01/14/2026 at 8:22 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom there was caulking missing and brown discoloration was present at the base of the toilet. 2. On 01/14/2026 at 8:25 AM the Surveyor observed resident room [ROOM NUMBER], upon entering the bathroom the left wall had scrapes and chipped paint areas to the lower half of the wall just above the Cove base area.3. On 01/14/2026 at 8:26 AM the Surveyor observed resident room [ROOM NUMBER], upon entering the bathroom the left wall had scrapes and chipped paint areas to the lower half of the wall just above the Cove base area. 4. On 01/14/2026 at 8:36 AM the Surveyor observed resident room [ROOM NUMBER], there were incomplete wall repairs noted to 2 of 3 of the walls within the bathroom with areas of dry spackle present; there were no signs indicating 'work in progress'. Additionally, between Bed A & B the wall area had heavily scuffed and chipped areas to the paint. 5. On 01/14/2026 at 8:45 AM the Surveyor observed in resident room [ROOM NUMBER], within the bathroom there was caulking missing and brown discoloration was present at the base of the toilet; and the left wall had scrapes and chipped paint areas to the lower half of the wall just above the Cove base area.6. On 01/14/2026 at 8:57 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom there was missing caulking and brown discoloration was present at the base of the toilet; and the left wall had scrapes and chipped paint areas to the lower half of the wall just above the Cove base area.7. On 01/14/2026 9:01 AM the Surveyor observed resident room [ROOM NUMBER], between Bed A & B there were incomplete wall repairs with dry spackle areas and multiple paint colors on the wall. Additionally, within the bathroom, the caulking was missing and brown discoloration was present at the base of the toilet, and the far wall with the toilet paper dispenser had dry spackle repair areas that appeared to be incomplete; there were no signs indicating 'work in progress'.8. On 01/14/2026 at 9:09 AM the Surveyor observed resident room [ROOM NUMBER], upon entering the bathroom the left wall had scrapes and chipped paint areas to the lower half of the wall just above the Cove base area.9. On 01/14/2026 at 9:10 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom there were 5 open holes and the outline of a dispenser that was possibly affixed to the wall just adjacent to the mirror, there was no evidence of repairs in progress; the area was left unrepaired. Additionally, there was missing caulking, and brown discoloration was present at the base of the toilet.10. On 01/14/2026 at 9:14 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom the caulking was missing, and brown discoloration was present at the base of the toilet. Additionally, the left wall had scrapes and chipped paint areas to the lower half of the wall just above the Cove base area and the far wall with the toilet paper dispenser had an area of dry spackle present near the bottom of the wall where it meets the Cove Base area; there were no signs indicating 'work in progress'.11. On 01/14/2026 at 11:00 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom there was caulking missing and brown discoloration was present at the base of the toilet. Additionally, the left wall had scrapes and chipped paint areas to the lower half of the wall just above the Cove base area.12. On 01/14/2026 at 11:02 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom there was caulking missing and brown discoloration was present at the base of the toilet. Additionally, the left wall had scrapes and chipped paint areas to the lower half of the wall just above the Cove base area. Additionally, between Bed A & B the wall area had chipped and lifting areas to the paint.13. On 01/14/2026 at 11:04 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom there was missing caulking and brown discoloration was present at the base of the toilet. The bathroom floor tiles appeared heavily stained. Additionally, the left wall had an area of dry spackle present scrapes and chipped paint areas near the bottom of the wall where it meets the Cove Base area; there were no signs indicating 'work in progress'.On 01/14/2026 at 11:30 AM during interviews with the LPN Manager staff #22, the Surveyor shared the resident room findings. When asked how do needed repairs or room concerns get reported; staff #22 stated everyone is responsible for speaking about room repair concerns, and the orders are placed in the Maintenance system called TELS.On 01/14/2026 at 12:00 PM during interviews with NHA staff #1, this Surveyor shared the resident room findings. After Surveyor discussion, NHA staff #1 stated the rooms will be reviewed for repairs.

Based on observation, record review and interview, it was determined that the facility failed to develop and implement a baseline care plan for a resident, requiring patient-centered Dementia Care, that meets the professional standards of quality care. This was evident for 1 (resident #4) out of 7 residents investigated for Care Planning during the annual survey.The findings include:On 01/14/2026 at 9:07 AM during the initial observation, resident #4 was observed in bed and eating breakfast, being fed by GNA #24 while seated. Resident #4 was relaxed, smiling at and able to respond to this Surveyor interaction. Resident #4 denied any discomfort and concerns, yet was unable to answer detailed questions and appeared pleasantly confused.On 01/15/2026 at 11:18 AM during record review it revealed resident #4 had diagnoses of 'UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F03.90)'. Review of the Minimum Data Set (MDS) Resident Assessment and Care Screening Annual review, dated 12/11/25, revealed a Brief Interview for Mental Stats (BIMS) score of '0', indicating sever cognitive impairment and no behaviors. Additionally, review of the Quarterly assessment, dated 9/11/25, revealed an impaired cognitive status and no behaviors. However, review of resident #4 Care Plan Report, Baseline initiated, 12/4/24 did not have a patient-centered comprehensive care plan written for Dementia Care.On 01/15/2026 at 2:00 PM during an interview with DON staff #2 and NHA staff #1, the Surveyor shared these findings and reviewed the care plans with the facility; both agreed no Care Plan was present for Dementia care and concern.

Based on observation, record review and interview, it was determined that the facility failed to develop and initiate a comprehensive person-centered care plan for residents residing in the facility. This was evident for 1 (resident #4) out of 7 residents investigated for Care Planning during the annual survey.The findings include:On 01/14/2026 at 9:07 AM during the initial observation, resident #4 was observed in bed and eating breakfast, being fed by GNA #24 while seated. Resident #4 was relaxed, smiling at and able to respond to this Surveyor interaction. Resident #4 denied any discomfort and concerns, yet was unable to answer detailed questions and appeared pleasantly confused.On 01/15/2026 at 11:18 AM during record review it revealed resident #4 had diagnoses of 'UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F03.90)'. Review of the Minimum Data Set (MDS) Resident Assessment and Care Screening Annual review, dated 12/11/25, revealed a Brief Interview for Mental Status (BIMS) score of '0', indicating severe cognitive impairement and no behaviors. Additionally, review of the Quarterly assessment, dated 9/11/25, revealed an impaired cognitive status and no behaviors. However, review of resident #4 Care Plan Reports, Baseline initiated 12/4/24, revisions initiated 3/1/25 and 5/26/25, and the current plan, initiated 8/22/25, did not have a patient-centered comprehensive care plan written for Dementia Care: demonstrating four missed opportunities to provide Dementia patient-centered care for the resident.On 01/15/2026 at 2:00 PM during an interview with DON staff #2 and NHA staff #1, the Surveyor shared these findings and reviewed the care plans with the facility; both agreed no Care Plan was present for Dementia care and concern.

Based on record reviews and interviews, it was determined that the facility failed to: 1) ensure that each member of the interdisciplinary team was involved in updating the residents' care plans. This was evident for 2 residents (Resident #16 and Resident #65) out of 14 residents reviewed; and 2) develop and implement person-centered care plans with specific, individualized interventions to address residents' diagnosed conditions. This deficient practice was evident for 2 (Residents #10, #109) of 7 residents reviewed.The findings include: 1a) On 01/20/2026 at 10:12 AM, the surveyor reviewed Resident #16's records. The resident record review revealed that the resident had a Care Plan Meeting Attendance Sheet, dated 11/26/25, for a care plan meeting that occurred on 11/26/25. It was documented on the care plan meeting attendance sheet that the following interdisciplinary team members attended the resident's care plan meeting on 11/26/25: Nursling, Dietician, Activities, Social Services, resident's wife via telephone, and Resident #16. According to the Care Plan Meeting Attendance Sheet for the meeting that occurred on 11/26/25, the physician and the nursing aide, who had responsibility for the resident, did not participate in updating Resident #16's care plan on 11/26/25. On 01/20/2026 at 11:27 AM, the surveyor asked the Nursing Home Administrator staff #1 and the Director of Nursing staff #2 for any progress notes from the physician and nurse aide, with responsibility to the resident, about their input on the resident's care plan, since according to the Care Plan Meeting Attendance Sheet dated 11/26/25, they were not in attendance. Staff #1 and staff #2 mentioned that they would check Resident #16's progress notes for documentation communicating the attending physician's and nurse aide's updates to Resident #16's care plan. On 01/20/2026 at approximately 4:35 PM, at the end of the exit conference, the surveyor had not received the copies of the progress notes indicating the physician's and nurse aide's updates to Resident #16's care plan meeting. 1b) During Resident #65's record review on 01/15/2026 at 1:18 PM revealed a Care Plan Meeting Attendance Sheet, dated 12/09/2025, for a care plan meeting that did not include the attendance of the resident's physician and the nursing aide, who has responsibility for Resident #65. During an interview on 01/16/2026 at 1:30 PM staff #1 Nursing Home Administrator and staff #9 verified that the care plan meeting did not occur with physician and the nursing aide, who has responsibility for Resident #65. 2) On 1/15/26 at 1:56 PM, record review revealed that Resident #109's most recent care plan was dated 8/22/25 and had not been reviewed and updated on a quarterly basis. The care plan was due for review three months from that date and had not been updated for approximately five months, failing to reflect the resident's current condition. On 1/15/26 at 2:49 PM, the Director of Nursing (DON) was informed of the overdue quarterly care plan review for Resident #109. 3) On 1/20/26 at 11:38 AM, record review revealed that Resident #10 and Resident #109 both had a diagnosis of dementia; however, their care plans lacked specific, individualized interventions to address cognitive impairment, safety needs, or dementia-related behaviors. At 11:45 AM, the surveyor requested that the DON review the care plans for Residents #10 and #109 to identify and provide individualized, measurable interventions addressing dementia-related needs, including but not limited to supervision, redirection, communication approaches, or safety precautions. At 4:27 PM, the concerns regarding the lack of dementia-specific care plan interventions were again discussed during the exit conference. The DON did not provide additional information, documentation, or clarification regarding care plan updates or interventions for either resident.

Based on observation, record review and interview, it was determined that the facility failed to ensure nursing services were provided in accordance with professional standards of practice related to medication preparation and administration. This deficient practice was evident for 1 of 5 residents reviewed (Resident #122) and had the potential to affect resident safety and clinical outcomes.The findings include:On 01/16/26 at 9:35 AM, during observation of a medication pass, Staff #21, a licensed nurse, was observed crushing and preparing divalproex sodium 125 mg delayed-release (DR) for administration to Resident #122. Delayed-release medications are formulated to release medication over time and should not be crushed, as doing so alters the medication's delivery mechanism and may increase the risk of adverse effects. On 01/16/26 at 9:47 AM, during the same medication pass, Staff #21 administered Humalog insulin to Resident #122 via injection into the deltoid region. Insulin is intended for subcutaneous administration at appropriate sites to ensure proper absorption and glycemic control. Administration into the deltoid muscle is inconsistent with accepted nursing practice and may result in altered absorption and unpredictable blood glucose response.On 01/16/26 at 10:40 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the findings. The DON acknowledged the concerns and stated that in-service education would be provided to nursing staff

Based on observations, record reviews, and interviews, it was determined that the facility failed to document that informed consent was obtained and retained from residents and/or their resident representatives prior to the use of bedrails. This was evident for 6 out of 6 residents observed (Resident #83, #103, # 118, #10, #13 and #14) during the survey conducted at the facility. 1) On 01/14/2026 at 08:25 AM the surveyor observed that the beds in room [ROOM NUMBER] A and B both had 1/4 length bedrails in place on both sides of the bed. The residents, # 83 and # 118 agreed to be interviewed by the surveyor. On 01/15/2026 at 1:30 PM a review of the electronic medical record of both residents #83 and #118 failed to reveal a consent form for bedrail installation. On 01/14/2026 at 08:35 AM the surveyor observed that the bed assigned to resident # 103 had 1/4 length bedrails in place and up on both sides of the bed. A review of the electronic medical record on 01/15/2025 at 2:00 PM failed to reveal a consent form for bedrail installation. On 01/15/2026 at 10:30 AM the surveyor observed during a tour of unit three, that all three residents' beds had 1/4 siderails in place. On 01/15/2025 at 2:50 PM the director of maintenance, staff # 11 stated that the bedrails are attached to bed when the beds arrive at the facility. The last bed rail inspection was completed in October 2025. The director of maintenance, staff #11 stated that he does not fill out a formal form used for each bed railing assessment. On 01/16/2026 at approximately 07:30 AM the surveyor was informed by the Director of Nursing staff #2 that the resident representatives had been contacted by telephone and that approval of the 1/4 siderails were obtained verbally or by email the evening of 01/16/2026. On 01/16/2025 at 1:30 PM staff #2 stated that there are no signed consents for the bed railings currently in any of the resident's charts. The DON was notified that this was considered a potential deficiency. 2) On 01/14/2026 at 9:25 AM, the surveyor observed bedrails in use for Residents #10, #13, and #14 during the initial tour of the nursing unit. On 01/15/2026 at 1:12 PM, the surveyor requested documentation for the bedrails in place for the three residents observed. During an interview with the Nursing Home Administrator staff #1, she stated that maintenance staff installs bed rails when requested and that the documentation would be provided. At 2:56 PM, staff #2 informed the surveyor she was still working on providing the informed consent documentation authorizing the use of bed rails for the residents. On 01/20/2026 at 11:45 AM, the facility was requested to provide informed consent documentation for the use of bed rails for Residents #10, #13, and #14. On 01/20/2026 at 12:11 PM, the facility provided informed consent forms for all three residents, which were dated 01/15/2026, indicating the consents were completed after the bed rails were already in use.

Based on observation, record review, and interview, it was determined that the facility failed to ensure medications were properly removed and disposed of when no longer appropriate for use, including after resident discharge and upon expiration. This deficient practice was evident for 2 of 3 medication rooms reviewed.The findings include:On 01/16/2026 at 12:38 PM, during an observation of the Unit 400 medication room, a vancomycin solution labeled for Resident #166 was observed stored in the refrigerator door. During interview at the time of observation, Staff #8 stated she did not believe the resident was still in the facility. At 12:43 PM, review of the electronic medical record revealed Resident #166 had been discharged from the facility on 12/13/2025. The medication had not been removed from the medication refrigerator following the resident's discharge.At 1:22 PM, during an observation of the Unit 100 medication storage room, a medication labeled for Resident #97 was observed stored in the refrigerator. Review of the medication label revealed the medication was expired 04/2025 and had been filled on 09/27/2023.At 1:26 PM, the Director of Nursing (DON) was notified of the above findings. The DON acknowledged the concerns about expired medications and medications for discharged residents kept in the storage rooms and stated the issue would be addressed.

Based on observation and interview, it was determined that the facility failed to ensure medications were administered in accordance with professional standards of practice, resulting in an overall medication administration error rate of 11.54%. This deficient practice was evident for 3 of 26 medication administrations observed. The findings include:On 01/16/26 at 9:35 AM, during observation of medication administration, Staff #21 was observed crushing divalproex sodium 125 mg delayed-release (DR) and preparing it for administration to Resident #122. Delayed-release medications are not to be crushed due to alteration of the medication's intended release properties.At 9:47 AM, Staff #21 administered Humalog insulin to Resident #122 via injection into the deltoid region, rather than the recommended subcutaneous injection site on the back of the arm, inconsistent with accepted medication administration practices.At 9:52 AM, Staff #21 prepared and attempted to administer medication to Resident #152 immediately after administering medication to Resident #122 without performing hand hygiene between residents.At 10:40 AM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were informed of the medication error concerns and cumulative medication error rate of 11.54% observed during the medication pass. The DON and NHA stated that in-service education would be conducted immediately with nursing staff.

Based on record reviews and interviews, it was determined that the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are accurately documented the resident current medical diagnosis. This was evident for 1 (resident #4) out of 7 residents' Care Plans reviewed during the annual survey.The Findings include:On 01/14/2026 at 9:07 AM during the initial observation, resident #4 was observed in bed and eating breakfast, being fed by GNA #24 while seated. Resident #4 was relaxed, smiling at and able to respond to this Surveyor interaction. Resident #4 denied any discomfort and concerns, yet was unable to answer detailed questions and pleasantly confused.On 01/20/2026 at 11:18 AM during record review it revealed resident #4 has the following diagnosis of: PAROXYSMAL ATRIAL FIBRILLATION (I48.0), CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE (I50.32), ESSENTIAL (PRIMARY) HYPERTENSION (I10), VITAMIN D DEFICIENCY, UNSPECIFIED (E55.9), DEPRESSION, UNSPECIFIED (F32.A), NEURALGIA AND NEURITIS, UNSPECIFIED (M79.2), OTHER HYPERLIPIDEMIA (E78.49), ESSENTIAL TREMOR (G25.0), OTHER CONSTIPATION (K59.09), PRESSURE ULCER OF SACRAL REGION, STAGE 4 (L89.154), UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F03.90), ANTIPHOSPHOLIPID SYNDROME (D68.61), PRESENCE OF CARDIAC PACEMAKER (Z95.0), CHRONIC EMBOLISM AND THROMBOSIS OF UNSPECIFIED VEIN (I82.91), ANEMIA, UNSPECIFIED (D64.9). However, review of resident Care Plan Report initiated 8/22/25, a Focus entry later added, read: [Resident #4] is prescribed a psychotropic medication (specify medication(s)) for alteration in mood/behavior related to Schizophrenia. Date Initiated: 10/28/2025; despite this resident not having an active diagnosis for Schizophrenia.On 01/20/2026 at 2:00 PM during an interview with DON staff #2, the Surveyor shared these findings and reviewed the care plans with staff #2, who agreed the listed diagnosis was not an active diagnosis for resident #4.

Based on observation and interviews, it was determined that the facility failed to: 1) maintain infection prevention and control by not ensuring a sanitary and comfortable environment within the resident care areas. This was evident for 6 (rooms 101. 102, 108, 119, 121, and 123) out of 24 resident rooms observed; and 2) ensure staff performed appropriate hand hygiene during medication administration, placing residents at risk for cross-contamination. This deficient practice was evident for 1 of 5 medication administration observations.The findings include: 1) On 01/14/2026 at 8:20 AM the Surveyor observed resident room [ROOM NUMBER], the hand sanitizer dispenser on the wall near the door designated for staff use, was empty. On 01/14/2026 at 8:22 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom, a pair of discarded plastic clear gloves were observed on the floor near the rear base of the toilet. On 01/14/2026 at 8:41 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom, a soiled, yellow-stained wash cloth was observed on the floor. On 01/14/2026 at 9:06 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom a stack of open paper towels was observed placed on the safety grab bar attached to the wall, despite an intact paper towel holder mounted on the wall. On 01/14/2026 at 9:14 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom the soap dispenser was empty. On 01/14/2026 at 9:15 AM the Surveyor observed resident room [ROOM NUMBER], within the, a pair of discarded plastic clear gloves were observed on the floor near the base of the toilet. On 01/14/2026 at 11:30 AM during interviews with the LPN Manager staff #22, the Surveyor shared the resident room findings. When asked, was this the expectation of discarding items or maintaining a clean environment, staff #22 stated 'No'. 2) On 01/16/26 at 9:52 AM, during observation of medication administration, Staff #21 prepared and attempted to administer medication to Resident #152 immediately after giving an insulin injection to Resident #122 without performing hand hygiene between residents. The surveyor intervened prior to the medication being administered to Resident #152. The prepared medication was disposed of, and Staff #21 performed hand hygiene before continuing the medication pass. On 1/16/26 at 10:40 AM, the Director of Nursing staff #2 and the Nursing Home Administrator staff #1) were informed of the infection control concerns related to failure to perform hand hygiene between residents during medication administration. Staff #2 stated that there would be in-service training performed in response to the observations.

Based on observation and interview, it was determined that the facility failed to post required nurse staffing ratio information in a visible and accessible location on resident units. This deficient practice was evident for 3 of 4 units reviewed (Units 100, 200, and 300) during the recertification survey.The findings include:On 1/14/26 at 7:56 AM, during the initial tour of the facility for the recertification survey, observation revealed that Unit 200 did not have nurse staffing ratio information posted on the unit. Additionally, on the secured side of Unit 200, there was no visible staffing board, and residents in the secured area were unable to see any nurse staffing information. At 9:17 AM, observation of Unit 100 revealed that the nurse staffing ratio was not posted on the unit's staffing board.On 1/15/26, observations were conducted on multiple units and revealed the following:At 8:38 AM, no nurse staffing ratio was posted on the staffing board on Unit 200.At 8:42 AM, no nurse staffing ratio was posted on the staffing board on Unit 300.At 8:44 AM, no nurse staffing ratio was posted on the staffing board on Unit 100.At 9:47 AM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) accompanied the surveyor to the units. During the tour, the DON stated that the nurse staffing ratio was located on a separate paper posted on a bulletin board further down the hallway on Unit 100. Observation of the referenced document revealed that the sheet was not filled out. During the same tour, concerns were discussed regarding the lack of visibility and accessibility of the staffing ratio information for residents. It was further observed that Unit 200 did not have a staffing ratio sheet posted at all. Additionally, concerns were discussed that residents located in the secured area within Unit 200 were unable to view the staffing board. The current staffing board was only visible through a small window in the door of the secured area and the distance made it difficult to read. The NHA stated that a staffing board would be installed for the secured area.

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had an Advance Directive or was offered the opportunity to create one. This was evident for 5 residents (#21, #98, # 286, # 287, and # 296) out of 52 in the survey sample. The findings include: 1. A review of Resident #21's clinical record on 8/6/24 revealed the resident did not have a copy of an Advance Directive in either the current electronic health record or the previous record used by the former nursing home company. A progress note dated 7/21/23 listed, Patient states POA [Power of Attorney] is in progress of being completed. No evidence of follow up to this request. The DON and Administrator were interviewed on 8/16/24 at 1:20 PM. They were informed that an Advanced Directive could not be located, and that the resident started the process but there was no follow up. They said they understood the findings and would review the electronic records and speak with the Social Worker. 2. A review of Resident #98's electronic clinical record on 8/8/24 at 10:00 AM revealed there was not an Advance Directive located there. A progress note on 1/3/23 stated that the resident requested one at admission but the facility did not follow up. The Social Worker was interviewed on 8/9/24. She confirmed that there was not an Advance Directive in the chart, but the resident was offered one at admission. The DON and Administrator were interviewed on 8/16/24 at 1:42 PM. They were informed that an Advanced Directive could not be located, and that the resident started the process but there was no follow up. They said they understood the findings and would review the electronic records and speak with the Social Worker. 47758 During a record review on 08/08/24 at 08:10 AM, the surveyor was unable to locate Advanced Directives on the charts of Residents # 286, # 287, and # 296. The facility was asked to provide documentation that Advanced Directives were offered to the residents. An interview was conducted with Social Worker (SW) #6 on 08/09/24 at 09:40 AM. SW #6 stated she did not see where advanced directives were offered to Residents # 286, # 287, and # 296. She stated the process is that we offer to the Resident or Responsible Party (RP) if a resident is not able to make decisions. If a family member stated they had Advanced Directives, I ask them to bring them in and, follow up in about a week if I don't receive them. I document this in the Interdisplinary Team (IDT) note or social services note. I did not find documentation for Residents # 286, #287, and # 296. The Director of Nursing further stated that the facility was working on the Advance Directives process.

Based on facility investigations, record reviews, interviews and observations, the facility failed to protect residents from abuse and neglect. This was found to be evident for 5 (# 7, # 27, # 50, # 62, # 82) out of 38 residents investigated during the annual survey for abuse and neglect. The findings include: 1. A review of a facility investigation on 08/14/24 at 3:37 PM for an allegation made by the Responsible Party (RP) for Resident #7 revealed the following. On 9/29/23, the RP arrived at the facility at 11:00 AM. The RP dressed the resident and then placed the resident in bed but on top of the sheets. The RP arrived the next day at 12 noon. The resident was still on top of the bedsheets and still dressed in the clothes from the day before. Bed sheets were folded under the resident and the resident's catheter bag was full. The RP asked the nurse about being dressed in the same clothes, but she did not know for sure since she had not worked the day before. RP asked the Geriatric Nursing Assistant (GNA) who had worked the day before. She said the resident was dressed like this when she started the day, and the resident was on top of the bed laying on the bedsheets. RP said the resident was wearing the same clothes as the day before and had not been changed for 23 hours. RP also said the resident's brief was cold and urine soaked. The Unit Manager (#15) was interviewed on 8/15/24 at 1:43 PM. She said the GNA assumed the 11-7 shift changed the resident and left him/her in bed. The GNA was unaware that 2 shifts had gone by after RP changed him/her into the clothes and place him/her in bed. RP told her of the incident after he went straight to the Administrator and the Director of Nursing (DON). She said she was left out of the loop but there have been no incidents since this one. The DON and administrator were interviewed on 8/16/24 at 1:20 PM. This surveyor went over the incident and expressed concern regarding the failure of staff to place the resident in bed and then change him/her into clean clothes. The administrator and the DON said they understood the findings and would review. As of 08/20/24 at 1:27 PM there was no additional information presented to the survey team. 42783 2. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. A BIMS score can range from 0 to 15, with lower scores indicating a decline in cognitive performance. A BIMS score 0 to 7 points suggests severe cognitive impairment, 8 to 12 points suggests moderate cognitive impairment, and 13 to 15 points suggests that cognition is intact. On 08/16/2024 at 11:00 AM a review of the Facility Reported Incident (FRI) investigation was conducted for an allegation of neglect. The review of the investigation revealed a witness statement from the facility's Maintenance Worker #22. The Maintenance Worker stated that he witnessed Geriatric Nursing Assistant (GNA) # 23 push Resident #50 in a wheelchair and kick the resident in the foot after repeatedly telling the resident to put his/her feet up. The facility stated in their investigation that there was limited video that showed the resident being pushed to the dinning room without foot pedals, and GNA did use her feet to lift the residents leg and pushed her to the table. The investigation also included a statement from GNA #23 who denied kicking the resident. The GNA stated that the resident decided to put [resident's gender] feet down so she slid her leg under [resident's gender] to lift it and then pushed [resident gender] under the table. The investigation further stated that the Resident was assessed to have a BIMS of 09 and was unable to recall the incident. The facility found evidence to support neglect because the employee failed to provide services such as foot rest or repositioning appropriately while pushing [resident gender]. During an interview conducted on 08/16/2024 at 11:17 AM, Resident #50 stated he/she remembered that his/her foot was kicked and that it hurt but could not recall when, why or who kicked his/her foot. During an interview conducted on 08/19/24 at 09:59 AM, the Assistant Director of Nursing (ADON) stated she no longer had access to the video. The ADON stated that she reviewed the video at the time of the incident and observed GNA #23 pushing the resident down the hallway towards the day room of the 200-nursing unit, the GNA stopped at the double doors prior to the day room walked to the side of the resident and lifted the resident legs up with her leg and then continued to push the resident to the dayroom table. The ADON stated she did not see the GNA #23 kick the resident on the video. 3. On 08/21/2024 at 10:30 AM a review of the Facility Reported Incident (FRI) investigation file for an allegation of neglect was conducted. The investigation revealed a statement from GNA #14 that advised the facility that she observed Resident #27 soiled in urine, dry feces, laying on urine-stained sheets and was wearing the night gown from the previous day. Another statement from Unit Manager # 15 also advised that she observed the Resident #27 soiled in urine, dry feces, laying on urine-stained sheets. During an interview conducted on 08/21/2024 at 11:00 AM, Resident #27 did not respond when asked if he/she had experienced abuse, neglect or had a concern with his/her care. A record review of Resident #27's medical record conducted on 08/21/2024 at 11:19 AM revealed a BIMS assessment score of 07. On 08/21/2024 at 12:14 PM an interview was conducted with Unit Manager #15. The Unit Manager stated that GNA #14 had made her rounds and noticed that Resident #27 was soiled in urine, dried fecal matter and stained sheets. The GNA reported the incident to the Unit Manager who went to the Resident's room and confirmed the resident was soiled in urine, dry feces and urine soiled sheets. The Unit Manager also stated that she immediately had care provided to the resident and investigated the incident. The Unit Manager stated that she discovered that 2 GNAs went against their assignment and switched residents and as a result Resident #27 was missed and did not receive care on the day shift. 47758 4. During a review of intake # MD00191221 on 8/16/24 at 07:34 AM, Resident # 82 was found on the floor next to his/her wheelchair. There were no witnesses, and this was determined to be an unwitnessed fall until the next morning when Resident # 82 told staff s/he had been pulled out of her wheelchair by another resident. The facility reviewed video footage that showed Resident # 49 rolling his/her wheelchair up to Resident # 82 and pulling him/her out of his/her wheelchair and kicking him/her. No injuries were found on assessment of Resident # 82. 5. During a review of intake # MD00192185 on 08/19/2024 at 1:24 PM, the facility reported that Resident # 318 was observed slapping Resident # 62 across the face by staff. This appeared to be an unprovoked attack when observed by the facility on video. No injuries were found on assessment of Resident # 62. When the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were interviewed on 08/20/2024 at 7:12 AM, regarding the concern of abuse, resident to resident, they questioned how an altercation was considered abuse when Residents # 49 and #318 were deemed mentally incompetent. The surveyor told them that any willful act was considered abuse regardless of the mental status of the perpetrator and that all residents have the right to be free from abuse. The surveyor referred the DON and NHA to the F600 tag and interpretive guidelines for clarification. The NHA stated they would be exploring options to improve practice.

Based on observation and interviews it was determined the facility failed to respect the resident's dignity as evidenced by the resident meal tray taken away before the meal was finished. This was evident for 1 out of 1 resident (resident #50) reviewed for dignity. The findings include: During an observation conducted on 08/06/2024 at 07:51 AM, this surveyor observed Resident #50 in bed with an empty cold cereal cup on the tray table and a breakfast casserole that sat directly on top of the tray table. This surveyor asked the resident if he/she had a plate that the food was on, the resident stated yes, they took his/her plate and left the resident with casserole. On 08/06/2024 at 07:53 AM an interview was conducted with Licensed Practical Nurse (LPN) #5. During the interview the LPN asked Resident #50 if he/she was done with the breakfast casserole. The Resident stated yes, and the LPN removed the breakfast casserole off the tray table with a napkin. The LPN further stated that she would find out who the Geriatric Nurse Assistant (GNA) was that removed the resident's meal tray and speak to them. During an interview conducted 08/14/24 11:05 AM, this surveyor advised the Nursing Home Administrator (NHA) of the observation. The NHA stated she would find out who the GNA was and investigate. On 08/16/2024 at 11:12 AM the NHA provided this surveyor a copy of a Grievance/Complaint form. The summary of pertinent findings section stated: GNA caring for [Resident's name] on above date states when she removed breakfast tray from the room resident had the breakfast casserole in [resident's gender] hand feeding [gender self]. The section Resolution of Grievance/Complaint had a box checked off for Yes, describe resolution for was grievance/complaint resolved. The section had a statement that read Resident stated [resident's gender] was okay [resident's gender] likes to hold [resident's gender] plates/bowls close to [resident's gender] mouth sometimes when [resident's gender] eats. However, the resident plate and meal tray was removed from the resident although the resident had not finished the breakfast casserole.

Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to honor resident choices with showering. This was evident for 2 (#21 and #73) out of 52 residents in the survey sample. The findings include: 1. Resident #21 was interviewed on 8/6/24 at 11:26 AM. The resident stated that they do not always get 2 showers each week. The resident stated that their scheduled days are Tuesday and Friday, but they will not get a shower unless there are 4 or more geriatric nursing aides (GNA's) on duty. A review of the electronic health record revealed the last documented shower was on 9/19/23. The Administrator and Director of Nursing (DON) were interviewed on 8/16/24 at 1:25 PM. The resident allegation of no showers was presented to them. They said they understood the findings and would review both electronic medical records as well as review the shower sheets. 2. Resident #73 was interviewed on 8/08/24 at 09:00 AM. The resident stated that they do not receive showers and only get bed baths. The resident had a very distinct odor suggesting the lack of bathing. A review of the clinical records revealed that the resident only received a shower on 8/11/24 and 8/15/24 based on a 30 day look back period with no refusals noted. The Administrator and Director of Nursing (DON) were interviewed on 8/16/24 at 1:33 PM. The resident allegation of no showers was presented to them. They said they understood the findings and would review both electronic medical records as well as review the shower sheets.

Based on interviews and record review it was determined that the facility failed to ensure the Power of Attorney (POA) was notified of a pressure ulcer. This was found to be evident for 1 (Resident #29) out of 1 resident reviewed for notification. The finding include: Pressure ulcers are an injury that breaks down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They are sometimes known as bedsores or pressure sores. Pressure ulcers are categorized into four stages based on the extent of skin damage: Stage 1: The skin is intact but may appear red, even when no pressure is applied. It may also feel warmer or colder, softer or harder, or more sensitive to pain than the surrounding tissue. Stage 2: The upper layers of the skin are damaged, and there may be a blister, scrape, or bruise. The skin may appear as a shallow open ulcer with a red or pink wound bed. Stage 3: The skin is completely damaged, and the ulcer may extend to the subcutaneous fat. The lesion may be foul-smelling, and slough or eschar may be visible. Stage 4: The skin and much of the surrounding tissue is damaged and has died . The ulcer may extend through the fascia and involve muscle, bone, tendon, or joint. During an interview conducted on [DATE] at 11:33 AM, the POA stated she had not been notified that Resident #29 had a stage 2 sacrum pressure ulcer. A record review conducted on [DATE] at 11:45 AM revealed a wound evaluation dated [DATE]. The evaluation showed a stage 2 sacrum pressure ulcer that was acquired prior to re-admission to the facility on [DATE]. No record of POA notification. During an interview conducted on [DATE] at 3:06 PM, Licensed Practical Nurse (LPN) #16 stated that she notified Resident #29's POA in person of the stage 2 sacrum pressure ulcer. When asked if it was documented in the resident's medical record that she had notified the POA the LPN stated no. The LPN further stated that the facility's policy was to notify the Resident Representative of a change and to document the notification in the resident's medical record.

Based on family interview, staff interview, and clinical record reviews, it was determined that the facility failed to ensure that allegations of missing money was reported to the State Survey Agency (Maryland Department of Health - Office of Healthcare Quality) and neglect were reported within the required time frame. This was evident for 2 (#7, #136) out of the 52 residents reviewed for reporting of alleged violations. The findings include: 1. A review of a facility investigation on 08/14/24 at 3:37 PM for an allegation made by the Responsible Party (RP) revealed the following. On 9/29/23, the RP arrived at the facility at 11:00 AM. The RP dressed the resident and then placed the resident in bed but on top of the sheets. The RP arrived the next day at 12 noon. The resident was still on top of the bedsheets and still dressed in the clothes from the day before. Bed sheets were folded under the resident and the resident's catheter bag was full. The RP asked the nurse about being dressed in the same clothes, but she did not know for sure since she had not worked the day before. RP asked the Geriatric Nursing Assistant (GNA) who had worked the day before. She said the resident was dressed like this when she started the day, and the resident was on top of the bed laying on the bedsheets. RP said the resident was wearing the same clothes as the day before and had not been changed for 23 hours. RP also said the resident's brief was cold and urine soaked. The facility submitted the initial report to the Office of Healthcare Quality (OHCQ) on 10/1/23 which was the day the RP reported it, but the final report was not sent until 10/23/23. The final investigation needed to have been reported within 5 days. The Unit Manager (#15) was interviewed on 8/15/24 at 1:43 PM. She said the GNA assumed the 11-7 shift changed the resident and left him/her in bed. The GNA was unaware that 2 shifts had gone by after RP changed him/her into the clothes and place him/her in bed. RP told her of the incident after he went straight to the Administrator and the Director of Nursing (DON). She said she was left out of the loop but there have been no incidents since this one. The DON and Administrator were interviewed on 8/16/24 at 1:20 PM. This surveyor went over the incident and expressed concern regarding the failure of staff to place the resident in bed and then change him/her into clean clothes. The Administrator and the DON said they understood the findings and would review. 49815 2. On 8/14/2024 at 7:30 AM the surveyor reviewed the facility investigation file for the Facility Reported Incident (FRI) dated and timed for 8/14/2023 2:38 PM (initial self-report) and 8/21/2023 11:33 AM (final self-report) for Resident #136. Review of this investigation file revealed that Resident #136 reported initially missing $100, and then changed to missing $160. In this facility investigation file, there were 6 employee interviews documented on employee statement forms that were conducted on these dates: 11/19/2023, 11/20/2023 and 11/22/2023; a copy of a check dated 8/30/2023 for $160, pay to the order of Resident #136; a copy of two check requests, one dated 8/22/2023 for $160 and one dated 11/22/2023 for $110; and a copy of emails dated and timed for 8/14/2023 at 3:16 PM and 8/22/2023 at 11:37 AM that the Nursing Home Administrator (NHA) sent to the Office of Health Care Quality (OHCQ) with the initial self-report and the final self-report as attachments. Further review of the facility investigation file on 8/14/2024 revealed that the facility had reported the allegation of Resident #136 missing money in August of 2023 to the Office of Health Care Quality (OHCQ), but the facility failed to report the allegation of Resident #136 missing money in November of 2023 to the Office of Health Care Quality (OHCQ). At 10:07 AM on 8/14/2024 the surveyor interviewed the Nursing Home Administrator (NHA) and the NHA confirmed that the facility investigation file that was provided to the surveyor was a complete investigation file for Resident #136 for the allegation of missing money in August of 2023. The surveyor reviewed with the Nursing Home Administrator (NHA) that there were two allegations of missing money for Resident #136 included in this facility investigation file, one from August 2023 and one from November 2023 for Resident #136. The Nursing Home Administrator (NHA) stated that she would have to look into this. In a follow-up interview with the Nursing Home Administrator (NHA) at 1:10 PM on 8/14/2024, the NHA stated that the allegation of the missing money in November of 2023 for Resident #136 was not reported to the Office of Health Care Quality (OHCQ). The Nursing Home Administrator (NHA) further stated during the interview that there was not a complaint form for Resident #136 for the November 2023 allegation of missing money. The Nursing Home Administrator (NHA) provided the surveyor with a copy of a check dated 12/5/2023 in the amount of $110 pay to the order of Resident #136. Facilities are required to submit an initial first self-report to the Maryland Department of Health - Office of Health Care Quality (OHCQ) for abuse, neglect, injury of unknown origin and misappropriation of resident property within 2 hours if serious bodily harm resulted, all others within 24 hours, and to forward investigation results, final follow-up self-report within 5 business days. The record review on 8/14/2024 of the facility investigation file for Resident #136 further revealed that the allegation of missing money in August of 2023 was not reported to the Office of Health Care Quality (OHCQ) by the Nursing Home Administrator (NHA) in the required time frame. The Nursing Home Administrator (NHA) submitted the initial self-report attached to an email on 8/14/2023 at 3:16 PM to the Office of Health Care Quality (OHCQ), but the final self-report attached to an email was not submitted to the Office of Health Care Quality (OHCQ) until 8/22/2023 at 11:37 AM by the Nursing Home Administrator (NHA).

Based on medical record review and interview it was determined that the facility failed to provide adequate supervision to prevent accidents as evidenced by failure to provide stand by assist and contact guard assist as indicated by the Physical Therapist (PT) for a resident with a newly acquired merry walker. The staff allowed the resident to utilize the merry walker without assistance prior to the physical therapist's (PT) final determination of the appropriateness of the use of the device vs other Assistive devices and in the absence of a physician order for the use of this device. This was found to be evident for 1 out of 23 residents (Resident #20) reviewed during the survey. This deficient practice resulted in actual harm to the resident which included a brain bleed and fracture of facial bones. The findings include: On 4/19/21 review of Resident #20's medical record revealed the resident had resided at the facility for more than one year and whose diagnosis included but not limited to dementia, depression and [CONDITION(S)]. Review of the 4/14/2020 and 9/3/2020 Minimum Data Set assessments revealed the resident required limited assistance of one person for walking in the corridors (hallways) on unit. Limited assistance means resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance. Further review of the medical record revealed the resident had six falls between 6/1/2020 and 7/30/2020. Review of the resident's care plan addressing High Risk for Falling, originally initiated 1/22/2020, revealed the following update on 8/4/2020: several falls noted in lookback, no injuries, screen sent to therapy, ordering [NAME] [sic] walker therapy will work with resident once [NAME] [sic] walker received. A merry walker is an enclosed walker system with wheels that allows for increased ambulation of residents with clinical mobility concerns. It includes a seat for the resident to rest when needed. Review of the facility policy related to Assistive Devices, with an effective date of 10/18/2015, revealed It is the policy of [name] to assess and utilize assistive devices. The purpose is to provide an outline of available resident equipment that may help improve balance, increase mobility, reduce pain and increase confidence. The Procedures included the following: 1. Equipment: canes, walkers, including standard, platform, rolling, and Merry Walker 2. Review medical history for appropriateness of treatment, including history of falls and fall risk. 3. Refer to therapy department for recommendations on type of assistive device to use when and as necessary. Therapy will screen or evaluate for appropriateness of device 4. Keep device clean. During an interview on 4/20/21 at 12:30 PM neither the Director of Nursing (DON) or the therapy program manager were able to provide a date as to when the merry walker arrived at the facility. As of time of exit on 4/21/21 no information was provided as to the date the merry walker arrived in the facility. During the interview on 4/20/21 at 12:30 PM the therapy program manager revealed discussion about trying a merry walker would occur at the weight, wounds and falls meeting. She reported we try them out and do the evaluation and that some people don't do well, some people try to climb out of them. The therapy program manager went on to report that once a merry walker arrives it is set aside for a time for evaluation, is adjusted and they see how the resident does with it. She indicated that at first the resident uses the merry walker just with the therapist and once the therapist feels safe, they provide educate to the staff. When asked when a resident would be allowed to just use the merry walker, she reported it was at the therapist's discretion. On 4/20/21 review of the physical therapy notes revealed that on 9/1/20 the Physical Therapist (PT #13) evaluated the resident. Review of the note for this evaluation revealed the following: Reason for Referral: This [age] year old [female/male] presents to therapy to assess for safety in rocking w/c [wheelchair] vs in merry Walker as Pt Demo [patient demonstrates] tendency to ambulate holding on to sides of rocking w/c even if rocking w/c is reclined back and had falls while trying to get out of rocking w/c. Nursing already ordered merry Walker for Pt.[patient] GNA [geriatric nursing assistant] staff used merry Walker few days ago and pt was found ambulating side ways, so nursing staff transferred Pt back to rocking w/c, however, morning regular GNA reported that yesterday, pt was in merry Walker almost all day and tolerated merry Walker well. Patient requires skilled therapy in order to improve safety and functional mobility, decrease fall risk: rocking w/c vs merry Walker. Review of the PT Daily Treatment Note for 9/1/20 revealed Nursing/ GNA staff already had Pt in merry Walker this morning. On 4/20/21 during the 12:30 PM interview, the therapy program manager confirmed that the physical therapist note indicated the resident had been using the walker prior to the 9/1/20 evaluation. Further review of the PT notes revealed the resident ambulated in the merry walker and CGA [contact guard assistance] was provided for safety secondary to cognitive deficits. With CGA the assisting person has one or two hands on the body of the resident but provides no other assistance to perform the task. The contact is made to help steady the resident or help with balance. Further review of the 9/1/20 PT note revealed Supervision/CGA recommended during fnal [functional] transfers and functional mobility in merry walker for safety. Nursing made aware. Review of the PT - Therapist Progress & Discharge Summary, dated 9/3/2020 and signed by PT #13 revealed the following: Skilled Services Provided since Last Report: Gait training in merry walking CGA/min-A, pt/caregiver education provided regarding Pt's current level of participation and providing SBA (stand by assist)/CGA during fnal [functional] mobility in merry walker. On 4/20/21 at 1:30 PM the Physical Therapist (PT Staff #13) was interviewed. She confirmed that the Geriatric Nursing Assistant (GNA) had the resident in the merry walker prior to her arrival for the evaluation. The PT also reported she did not know when the merry walker had arrived in the facility. When asked about her recommendations the PT stated: I told the nursing staff that [s/he] needs supervision and contact guard whenever in the merry walker. Further review of the medical record revealed the following progress note dated 9/2/20 at 2:20 PM: fall - Nursing: Loud boom heard in day room and when assessed pt [patient] noted laying on left side of body on the floor with [NAME] walker on side as well. Pt assessed and noted to have hit her head. Neuros [neurological checks] done immediately and at baseline pupil equal and reactive. Blood noted coming from inside of mouth and nose. Pt denied any pain and ROM [range of motion] done before moving resident off of floor. ROM at baseline and no objective s/s [signs or symptoms] of pain when limbs moved. Pt assisted off the floor using hoyer lift and put into chair. Swelling noted to left side of face including eye. inside of mouth bleeding from tongue and lip looks to have been bitten during fall. Nose bleeding and stopped with pressure and cold rag. No other open abrasions or bruising noted at this time. Ice pack applied to left side of face secured with cling wrap. unit manager notified along with MD and RP [responsible party name]. New order given for x ray to left side of face. PRN [as needed] tylenol given for pain. Review of the PT Daily Treatment Note, dated 9/2/20 and signed by PT #13 revealed the following: Pt had a fall in merry walker this morning as per nursing unwitnessed in the day room. Review of the medication administration record revealed the resident received regularly scheduled dose of 81 mg of aspirin on the morning of 9/3/20. Aspirin increases the risk of bleeding. Further review of the medical record revealed the nurse practitioner saw the resident on 9/3/20. Review of this note revealed the x-ray had been negative for fracture, the resident had been stable throughout the evening and night although continued to attempt to get out of bed overnight. The resident appeared comfortable in no acute distress and stated she felt okay. Neuro check and vital signs remained stable. The family had requested a CT (computerized tomography) scan, so the resident was being sent to the hospital for escalation of care and CT scan and daughter's request. Review on 4/20/21 of the investigation documentation, provided by the DON regarding the 9/2/20 fall, revealed a reiteration of the above referenced 9/2/20 nursing note; the x-ray results report, a synopsis of the nurse practitioner's note from 9/3/20, a statement that the resident was admitted to the hospital and a list of current fall interventions. There was also a statement that, Resident is highly demented with no safety awareness, does not retain safety precautions, still wants to remain mobile. Further review of the investigation documentation failed to reveal interviews with staff regarding the fall. Further review of the investigation documentation failed to reveal a date as to when this document was created or by whom. On 4/20/21 at 12:30 PM surveyor reviewed the concern with the DON that the investigation failed to include any interviews. The DON indicated she would follow up with the unit manager. She also reported that there should be video surveillance documentation, as well. Later in the afternoon the DON reported that the video is only available for 30 days and presented the Surveyor with a typed sheet of paper titled: Camera surveillance on fall 9/2/2020. The document included the following: Resident was pacing the hall walking with the [NAME] walker about 10:45 AM suddenly [s/he] tripped and fall sideways to the left, prior to that staff member spoke with 5 minutes before the incident. Steps to try prevent further falls resident will use geri chair to seat in day room and have body alarm for significant movement to alert staff. The statement included the name of the unit director (Staff #5) but was not signed. The resident's name was not included in the video surveillance documentation. On 4/20/21 at 3:08 PM the unit nurse manager (Staff #5) was interviewed. He confirmed having reviewed the video surveillance which showed a staff member spoke to the resident a few minutes prior to the fall. He reported the resident fell sideways. He also reported that a GNA was down the hallway watching the resident but was not walking with the resident and not providing assistance. Based on this report by the unit nurse manager (Staff #5) CGA could have been provided at the time of the fall since it requires actual physical contact with the resident. When asked about the nursing note that indicated the fall was not witnessed, the unit nurse manager reported that the nurse did not see the fall but that the GNA was in the hallway. He went on to report that the GNA who was in the video no longer works at the facility. The unit nurse manager also reported that the merry walker had not been on the unit until the day before the fall. The DON was present during this interview and reported they do not use merry walkers often. The DON confirmed during the survey that no other residents were using merry walkers at this time. Further review of the medical record failed to reveal a physician order for the use of the merry walker. On 4/21/21 at 9:15 AM an interview was conducted with the DON and the Administrator. The DON reported that the resident had been unable to ambulate without the use of the walker. The DON confirmed there had been no physician order for the use of the merry walker and indicated that they obtain an order after a trial period and once therapy determines that the merry walker is appropriate then they would get an order for its use. During this interview surveyor reviewed with the Administrator and DON the concern regarding the failure to provide adequate supervision while using the merry walker. The Administrator acknowledged that the PT's recommendation included CGA during merry walker mobility. Further review of the medical record revealed that on 9/3/20, after being sent to the local hospital for the CT scan the resident was transferred to another hospital for further evaluation. Review of the History & Physical note from the second hospital, date 9/4/2020 at 12:53 AM, revealed the following: Head CT from OSH [outside hospital] found to have right frontoparietal subdural hematoma [bruise to the brain] measuring about 3 mm in thickness with no associated mass effect or midline shift, with associated traumatic SAH [sub arachnoid hemorrhage - brain bleed] and right parietal contusion. CT Max/Face showed fractures in left maxillary [MEDICATION(S)], the left orbital floor and the left zygomatic arch [broken facial bones]. The resident was admitted to the second hospital for two weeks.

F880 Based on observation, staff interview, review of documentation including medical records and State and Federal guidance, the facility failed to develop and implement an effective infection prevention and control program and contain a COVID-19 outbreak as evidenced by the following interrelated system failures. The facility failed to 1) sufficiently establish doffing stations and ensure staff followed isolation precautions; 2) ensure effective systems to separate COVID negative and COVID positive residents as much as possible during an infectious outbreak; 3) ensure that staff followed accepted standards of practice for hand hygiene during the declared health emergency; 4) ensure that staff utilized personal protective equipment in a manner that met minimum standards and minimized risk for infectious spread; and 5) develop and implement an effective system to both obtain and clinically respond timely to critical laboratory results. As a result of this noncompliance, at the time the survey began, all residents, staff and visitors had been placed at risk, 92 residents had become positive for COVID-19, and 29 of these residents had died . As a result of these findings, an immediate jeopardy was declared on [DATE] at 9:40 AM. The facility submitted a plan of removal at 6:27 PM and it was accepted by the State Agency at 6:45 PM. After removal of the immediacy, the deficiency remained at a potential for more than minimal harm and at a scope and severity of E. The findings Include: On [DATE], the Maryland Secretary of Health issued a Directive and Order Regarding Nursing Home Matters Pursuant to Executive Order No. [DATE]-01 I. The order stated: Staff Assignments: Nursing homes shall immediately implement, to the best of their ability, the following personnel practices: - Establish a cohort of staff who are assigned to care for known or suspected COVID-19 residents. - Designate a room, unit, or floor of the nursing home as a separate observation area where newly admitted and readmitted residents are kept for 14 days on contact and droplet precautions while being observed every shift for signs and symptoms of COVID-19. - Designate a room, unit, or floor of the nursing home to care for residents with known or suspected COVID-19 A person under investigation (PUI) for COVID-19 per the Centers for Disease Control and Prevention (CDC) Guidance originally posted on [DATE], Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, is to be kept in isolation in the same manner as a resident who is positive for COVID-19. The document also indicates that, when caring for residents suspected of COVID-19, staff should follow standard precautions, wear an N95 respirator, a face shield or goggles, gloves, and an isolation gown. Staff are to dispose of their isolation gown and gloves prior to leaving the resident's room. To complete this disposal, a doffing station including a trash can must be placed inside the resident's room directly next to the door. In order to alert staff of a resident who requires isolation precautions for known or suspected COVID-19, the CDC has provided signage to be placed outside of a resident's room. CMS defines cohorting as the practice of grouping residents infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible residents. 1.0 The facility failed to sufficiently establish doffing stations and ensure staff followed isolation precautions 1.1 COVID positive test results had been obtained for multiple residents on or before [DATE] and the facility designated that Units 100 and 200 would be dedicated for COVID positive residents and Units 300 and 400 would be dedicated for COVID negative residents. Resident #2 resided on a unit the facility had designated as COVID negative. Review of the medical record on [DATE] at 4:45 PM, revealed that Resident #2 became symptomatic [DATE] with a fever, and then developed a cough and shortness of breath on [DATE]. Further medical record review revealed that, on [DATE], Resident #2 was tested for COVID-19 and results when obtained on [DATE], were positive. Only when the positive test result was obtained, were isolation precautions initiated. Although a known outbreak was evolving in the building, for 7 days Resident #2 was symptomatic but remained on the unit designated for COVID positive residents without isolation precautions. During tour on [DATE] at 7:11 PM, the surveyor observed staff hanging the isolation precaution sign on Resident #2's door. Additionally, the surveyor observed that Resident #2's room door was open, Resident #2 was not wearing a mask, and no station was set up for staff to take off personal protective equipment. 1.2 Medical record review revealed that Resident #1 was symptomatic. Observation on [DATE] at 7:10 PM, revealed that a precaution sign was hung at his/her doorway, but the door to the room was left open, the resident was not wearing a mask, and no station had been set up for staff to safely take off personal protective equipment. 2.0 The facility failed to ensure effective systems to separate COVID negative and COVID positive residents as much as possible during an infectious outbreak. The Centers for Medicare & Medicaid Services (CMS) issued COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers with an effective date of [DATE]. The waivers were reviewed during survey on [DATE] at 12:00 PM. CMS had waived the requirements in 42 CFR 483.10(e)(5), (6), and (7) solely for the purposes of grouping or cohorting residents with respiratory illness symptoms and/or residents with a confirmed [DIAGNOSES REDACTED]. This action waived the facility's requirements to, provide notice and rationale for changing a resident's room and to provide for a resident's refusal of a transfer to another room in the facility. Consistent with the above noted Federal waiver, on [DATE] the State of Maryland Secretary of Health issued a Directive and Order Regarding Nursing Home Matters. This State Order required that Maryland nursing homes immediately implement, to the best of their ability, the following personnel practices: o Establish a cohort of staff who are assigned to care for known or suspected COVID-19 residents. o Designate a room, unit, or floor of the nursing home as a separate observation area where newly admitted and readmitted residents are kept for 14 days on contact and droplet precautions while being observed every shift for signs and symptoms of COVID-19. o Designate a room, unit, or floor of the nursing home to care for residents with known or suspected COVID-19. 2.1 Upon entry into the facility on [DATE] at 6:40 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed about cohorting of residents. They reported that they had established separate units for residents that were positive for COVID-19, and for residents that were negative for COVID-19. Units 300 and 400 were designated as negative units. However, observations during the survey revealed that resident cohorting was not consistently implemented. Observations of the 300 and 400 Units on [DATE] at 6:45 PM, revealed that there were COVID-19 positive residents that were allowed to remain on these otherwise negative units. 2.2 In a [DATE] interview at 7:00 PM, the nursing home Administrator indicated that the facility's 400 Unit had no residents that were COVID-19 positive. However, this was not accurate as in interview on [DATE] at 7:06 PM, licensed practical nurse (LPN) #6 indicated that there were two COVID positive residents (Resident #1 and Resident #2) on the otherwise negative unit. 2.3 Two days later, in [DATE] interview at 8:25 AM, the Unit 400 Unit Manager indicated there was still one COVID-19 positive resident (Resident #1) on the otherwise negative unit. Review of the medical record revealed that Resident #1 had tested positive on [DATE]. The Unit Manager stated that Resident #1's remained on the unit as family did not want him/her moved. In interview on [DATE], the DON corroborated that Resident #1's family and resident refused to allow moving the resident from his/her room. The DON added that staff was continuing to encourage family to support the room change. Later, on [DATE], after the two-day delay, Resident #1 was moved off the Covid-19 negative unit. In a [DATE] interview with the DON, she indicated she was not aware of the CMS waivers in place during the health emergency. However, the facility Nursing Home Administrator (NHA) was aware of the CMS blanket waivers. On [DATE], the NHA submitted a request to the State Survey Agency to utilize the facility's closed adult medical daycare center space for cohorting residents. Thus, despite the CMS waiver supporting moving COVID-19 positive residents to isolate them away from negative residents, and despite the State Directive mandating these actions, the facility failed to timely move Resident #1 who was positive for COVID-19; and instead elected to delay the move off of the otherwise negative unit for two days after confirmed [DIAGNOSES REDACTED]. 2.4 On the second negative unit, another resident was not isolated and was also not moved timely as required under the State Directive. In an interview on [DATE] at 11:10 AM, the DON indicated that after a lengthy delay she obtained results for COVID testing for Resident #4 on [DATE] and the results were positive. Three days later, with the known positive [DIAGNOSES REDACTED].#4 was still on this otherwise negative unit. In addition to not being moved off the negative unit, at 8:30 AM on [DATE], the Surveyor observed that Resident #4 was being fed by Geriatric Nursing Assistant (GNA) #18 in the communal dining area on the negative unit. Furthermore, Resident #5 who was COVID negative was observed at the other end of the same table during the same meal. When asked, the GNA stated that the two residents (#4 and #5) ate meals in the dining room daily. 2.5 On [DATE], more than two weeks after the [DATE] testing, the facility still had not developed a working plan on how to manage resident cohorting for residents who had tested positive and then recovered and cleared to negative status. In a [DATE] interview, the DON stated that they had not yet developed a plan but were working on developing one. 3.0 The facility failed to ensure that staff followed accepted standards of practice for hand hygiene during the declared health emergency. Surveyors made multiple observations where facility staff members were not performing hand hygiene, as necessary. For example: 3.1 On [DATE] at 8:40 AM, registered nurse (RN) #22 was observed going into a resident room on the 300 Unit with medications. RN #22 was observed kneeling on the floor while administering medications to the resident in bed A. RN #22 exited the resident room carrying a medication container and sat the container onto the medication cart. RN #22 then removed the gloves she was wearing and pulled out a new pair and applied them without washing her hands. RN #22 then sanitized the new gloves with hand sanitizer. 3.2 On [DATE] at 8:45 AM, surveyors observed two staff picking up trays on the 300 unit. A facility Social Worker was observed entering a resident room, picking up a tray and placing it on the cart. The Social Worker then did not wash her hands but sanitized the same gloves and then entered the next room. During an interview, she stated she was not told to conserve gloves and was not told to sanitize them between residents. Following a different process, geriatric nursing assistant (GNA) #18 reported that she changed gloves and sanitized her hands before going to the next resident to pick up the tray. 3.3 Surveyors observed LPN #12 touching contact surfaces without gloves on [DATE] at 7:30 PM. 3.4 Surveyors observed a facility Floor Tech touching contact surfaces without gloves on [DATE] at 9:00 AM. 3.5 During the 6:35 PM tour on [DATE], the surveyors observed that on entry to the 200 unit (a unit designated as COVID positive) neither the Administrator nor the Director of Nursing (DON) put on protective gowns and they were both observed in close proximity (within 3 - 5 feet) to staff working with residents and with residents that were in the main hallway. 3.6 During the 6:35 PM tour on [DATE], the surveyors observed that on entry to the 100 Unit (a unit with positive residents) the Director of Nursing (DON) did not put on a protective gown and gloves. 4.0 The facility failed to ensure that staff utilized personal protective equipment in a manner that met minimum standards and minimized risk for infectious spread. In CDC Guidance, Recommendations for Use of Personal Protective Equipment When Caring for Patients with Confirmed or Suspected COVID-19 that was released on [DATE], the guidance indicates that if the facility has established a designated unit for cohorting COVID-19 positive residents, then staff are to follow droplet precautions for the entire unit and don and doff prior to entering and exiting the unit accordingly. Surveyors made multiple observations where facility staff were not following isolation precautions. 4.1 Observations from [DATE], [DATE], and [DATE] revealed that there was no donning or doffing station located at the entrances to either the 100 or 200 unit, both of which were designated COVID-19 positive units. During a [DATE] observation at 11:45 AM on the COVID positive 200 unit, the DON and other nursing staff at the nurses' station identified that a box on the floor of the nursing station that contained multiple forms of personal protective equipment (PPE) was the unit's donning station. It was noted that there was no trash receptacle designated for doffing. On the other positive unit, on [DATE] at 11:50 AM the surveyor observed a donning and doffing station was located on an over-the-bed table (table on wheels that can be placed over a table for resident access) at the nursing station. However, there was no trash receptacle located nearby for doffing of PPE. Doffing at the nursing station would require staff to walk through the unit with contaminated protective equipment after exiting any resident room. 4.2 On [DATE] at 9:00 AM, the surveyor observed GNA #20 in the 200 hallway and she removed her isolation gown to leave the unit. She stood at the exit doors and removed her gown, rolled it up and tucked it under her right arm against her uniform to carry it to the nursing station to throw it in the trash. The nursing station was centrally located on the unit at an intersection of 3 hallways and it was approximately 30 - 50 feet from the exit where GNA #20 removed her gown. Again, the trash at the nursing station was not designated for doffing of contaminated protective equipment. Further, there were no trash receptacles located near the exit door for staff to safely doff their isolation gowns and in this specific example any pathogens transferred from the gown could then be carried off this unit on the GNA clothing. 4.3 On [DATE] at 7:35 PM, licensed practical nurse (LPN) #12 was observed opening a door when exiting a room on a COVID positive unit, closed the door, and then went up the hall to the nursing station. LPN #12 was then observed touching the computer without changing gloves or sanitizing her hands. As was true with staff rolling up a gown and carrying it across the unit, these staff actions also carried any pathogen from the last resident room into the common area of the unit when touching the computer in the common area. 4.4 With two independent observations of staff breaking infection prevention and control standards in a manner that failed to maintain a clean environment in the common areas of the unit, during [DATE] tour, at 6:35 PM the surveyors observed that on entry to the COVID positive 200 unit neither the Administrator nor the Director of Nursing (DON) put on protective gowns. Further, without protective gowns, both the Administrator and DON were then observed on the unit in close proximity (within 3 - 5 feet) to two COVID-19 positive residents who were not wearing masks. 4.5 In another observation during the 6:45 PM tour on [DATE], on entry to the 100 Unit (a unit with positive residents), the Director of Nursing (DON) did not put on a protective gown and gloves. 5.0 The facility failed to develop and implement an effective system to both obtain and clinically respond timely to critical laboratory results resulting in delays implementing isolation precautions and delays in cohorting positive residents off negative units. Resident #4 was tested for COVID on [DATE]. Review of the medical record on [DATE] at 11:33 AM, revealed a [DATE] nursing note entered by the Director of Nursing (DON) at 11:07 AM. This nursing note indicated Per (Resident's Primary Physician), resident (#4) was tested for COVID-19 today. Results pending. During a joint interview on [DATE] at 10:30 AM, the Administrator and DON both indicated that the facility had decided to have all residents in the facility tested for COVID-19 on [DATE]. During a later [DATE] interview at 1:03 PM, the DON stated that for some reason Resident #4's results had not been obtained and when on [DATE] the family asked for test results and we couldn't find them. The DON reported that she then contacted the laboratory and obtained the positive test result on [DATE]. In a [DATE] nursing note entered at 1:30 PM, the DON documented that she updated Resident #4's representative on his/her s COVID positive results. No earlier documentation regarding the test results was found in the medical record. During an interview on [DATE] at 6:30 PM, the Administrator described the facility process for obtaining lab results. She indicated that test results were received by nursing staff, and when received, each nurse was then responsible for reporting the results to their unit managers, the residents' attending physicians, and to residents' responsible parties. The Administrator acknowledged there was no master list or other process developed to track and ensure that results from all the critical COVID lab tests sent to the lab were reported back to the nursing home timely. During [DATE] interview at 9:45 AM, the Administrator indicated that results from the [DATE] testing of all residents in the facility were received beginning on [DATE] and up to [DATE]. The Administrator indicated that she would verify those dates, however final confirmation of those dates was never provided to the survey team. With no system to ensure all COVID test results were obtained timely, the COVID positive result for resident #4 was missed. Only when family requested the results did staff discover they had not been obtained. Resident #4 remained on the otherwise negative unit during the lengthy delay after he/she had been tested [DATE] and before staff obtained the test results on [DATE]. This system failure increased the risk for transmission of the potentially fatal infectious agent to all residents, staff and visitors. As a result of these findings, a state of immediate jeopardy (IJ) was declared on [DATE] at 9:40 AM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy at 1:00 PM and it was not accepted. The facility submitted 3 additional drafts that were not accepted. The fifth draft was submitted at 6:27 PM and it was accepted by the state agency at 6:45 PM. The provisions of the plan to remove the immediacy included the following: 1. Any resident noted to be on the COVID negative unit that has not met criteria for symptom-based recovery would be moved to a COVID positive neighborhood. The facility has just completed universal testing again, now per Governor Hogan's directives, the testing was completed yesterday [DATE]. The facility has maintained CDC guidance and will move residents to appropriate neighborhoods based on the latest universal testing results. For individuals under investigation (PUI) residents' doors will remain closed and signage placed outside the room. A resident has been identified and has been moved from a private isolation room to a COVID neighborhood. 2. A review of current residents diagnosed as positive for severe acute respiratory syndrome COVID-19 will be completed and compared with the daily room and board census as completed by the Director of Nursing. Any residents noted as necessary for a room change to a COVID positive neighborhood will be moved. Room changes regarding necessary moves is communicated via email and or verbally from the Director of Nursing to Unit Managers. If the facility cannot move a COVID positive patient to a COVID positive neighborhood for lack of bed availability the facility will work with local agencies to determine an alternate location. 3. The facility will review the state required line listing daily against the facility census for assurance room placements are per CDC guidance, this will be completed by the Director of Nursing. The facility will re-educate staff on the process of proper precautions and signage for (Persons Under Investigation for possible COVID-19 exposure or infection or PUIs), including hand sanitizing gloves and washing hands in between gloves changes and donning and doffing PPE, this will be completed by the Infection Preventionist. Staff noted in the statement of deficiency will be given additional education beyond the standard process to assist them in understanding the importance of following the CDC guidance. Audits will be completed by the Infection Preventionist daily and during off shifts. In addition, the Unit Managers will be tasked with completing additional audits in support of the infection preventionist. 4. This line listing and bed census review will be sent to the facility Medical Director weekly for confirmation and review. These weekly and daily reviews will then be shared with the Quality Assurance Performance Improvement Committee (QAPIC). Facility will complete routine monitoring of staff PPE practices, donning and doffing per CDC adherence. The aforementioned Infection Preventionist audits will equally be surrendered to QAPIC. The facility will review the monitoring of PPE, hand washing, donning and doffing techniques for any additional education necessary for staff and complete QAPIC reviews. This will continue to inform and allow the QAPIC to make any necessary recommendations. The Immediate Jeopardy was removed on [DATE] at 9:10 AM after confirmation of the completion of the facility's plan of removal by the surveyor who was on site at the facility. Cross Reference Federal Tags F-835 and F-770, and CO[DATE], 1410 and 2940

F-770 Based on observation, staff interview, and review of resident medical records, the facility failed to ensure an effective process was implemented to ensure critical lab results were received timely, resulting in a more than 10 day delay in obtaining COVID testing results for Resident #4 who was COVID positive. The system failure increased the risk for the spread of the potentially fatal infectious agent from unidentified positive residents to all other residents in the highly vulnerable nursing home population, as well as to staff and visitors. As a result of these findings, a state of immediate jeopardy was declared on 4/29/2020 at 4:36 PM. The facility submitted an acceptable plan of removal at 11:04 PM on 4/29/2020 and it was accepted by the state agency at 11:20 PM. After removal of the immediacy, the deficient practice remained for the potential for more than minimal harm and at a scope and severity of D. The Findings include: CMS defines cohorting as the practice of grouping residents infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with other susceptible residents. Resident #4 was tested for COVID on 4/6/20. Review on 4/24/20 at 11:33 AM, of the medical record for Resident #4, revealed a 4/6/20 nursing note entered by the Director of Nursing (DON) at 11:07 AM documenting per (Resident's Primary Physician), resident was tested for COVID-19 today. Results pending. During a joint interview on 4/23/20 at 10:30 AM, the Administrator and DON both indicated that the facility had decided to have all residents in the facility tested for COVID-19 on 4/6/20. During a later 4/28/20 interview at 1:03 PM, the DON stated that for some reason Resident #4's results had not been obtained when on 4/20/20 the family asked for test results and we couldn't find them. The DON reported that she then contacted the laboratory and obtained the results on 4/20/20. In a 4/20/20 nursing note entered at 1:30 PM, the DON documented that she updated Resident #4's representative on his/her s COVID positive results. No earlier documentation regarding the test results was found in the medical record. During an interview on 4/29/20 at 6:30 PM, the Administrator described the facility process for obtaining lab results. She indicated that test results were received by nursing staff, and when received, each nurse was responsible for reporting the results to their unit managers, the residents' attending physicians, and to residents' responsible parties. The Administrator acknowledged there was no master list or other process developed to track and ensure that results from all the critical COVID lab tests sent to the lab were reported back to the nursing home timely. During 5/1/20 interview at 9:45 AM, the Administrator indicated that results from the 4/6/20 testing of all of the other residents in the facility were received beginning on either 4/8/20 or 4/9/20 and up to 4/11/20 (the facility provided 4/8 and 4/9 contradictory dates and the Administrator indicated that she would verify the dates but no confirmation was ever provided to the survey team prior to the survey exit). With no system to ensure all COVID test results were obtained timely, the COVID positive result for Resident #4 was missed. Only when family requested the results did staff discover they had not been obtained. Resident #4 remained on the otherwise negative unit during the lengthy delay after he/she had been tested on [DATE] and before staff obtained the test results on 4/20/20. This system failure increased the risk for transmission of the potentially fatal infectious agent to all residents, staff and visitors. As a result of these findings, a state of immediate jeopardy was declared on 4/29/2020 at 4:36 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy at 6:25 PM and it was not accepted. The facility submitted the second draft at 8:26 PM and it was also not accepted. The third draft was submitted at 11:04 PM and it was accepted by the state agency at 11:20 PM. The provisions of the plan to remove the immediacy included the following: Immediate review of all residents tested for COVID-19 to ensure that no other resident's result was not entered into the medical record or communicated with the resident's responsible party. A master list will be maintained by the director of nursing that documents when a resident is tested for COVID-19 and when the result becomes available. The Director of Nursing and the infection Preventionist will be educated by the Administrator regarding this new process. The Unit Managers will be educated by the DON that, upon testing of a resident for COVID-19, they will communicate that test to the DON so that an entry may be made into the master list. All lab test results will go straight to the DON who will enter the result into the master list at that time and communicate the result to the Unit Managers. The DON will review the master list daily to monitor for delays in return of lab reports. The master list will be surrendered to the Quality Assessment Performance Improvement (QAPI) committee by the DON for review and adjustments as needed. This will happen monthly for three months. The Immediate Jeopardy was removed on 5/1/20 at 12:00 PM. Cross Reference Federal Tags F835 and F880, and State CO[DATE] and 1410

Based on medical record review, staff interview and family interview it was determined that facility staff failed to prevent a resident from sustaining second degree burns. This was evident for 1 of 4 residents reviewed (Resident # 1) during the complaint investigation. The findings include: Complaint #MD 500 was reviewed on 9/25/2018. The complaint states that on 9/23/2018, Resident # 1 was transferred from the facility to an acute care hospital. Prior to transfer, facility staff applied McKesson Medi-Pak Instant Hot Compresses to Resident # 1's back. When Resident # 1 arrived at the hospital (he/she) was found with a large second degree burn on (his/her) back. The McKesson Medi-Pak Instant Hot Compress Instructions were reviewed on 9/25/2018 at 5:00 PM. The instructions state: Shake contents until hot. Wrap in a soft cloth or towel and apply. Discard after single use. Caution: Peak temperature may reach 160 degrees once activated. Avoid contact with skin. Use cloth or towel for protection. Do not use for more than 30 minutes. Resident # 1's medical record was reviewed on 9/25/2018. Medical record review revealed the following Nursing Progress Note, entered into the medical record on 9/23/2018. The note reads: Patient noted confused. Rectal temp (temperature) registered at 91 (degrees). Patient laying on right side, warm packs placed on bed around patient with clothing, in between clothes. Temp rechecked 91.7 F. On-call made aware. RP (responsible party) made aware. Registered Nurse (RN) # 1 was interviewed on 9/25/2018 at 4:00 PM. RN # 1 stated: That day (Resident # 1) was more confused than normal. The tech (Geriatric Nursing Assistant/Technician) got all of (his/her) vitals except for the temperature. I checked Resident # 1's temperature rectally and it was 91.6. (Resident # 1) was cold to the touch. I called the Nurse Practitioner and told her the temperature. I was concerned [MEDICAL CONDITION], with the altered mental status and (his/her) temp being so low. I got a few warm compresses, the kind that you press and shake. I used about three of them. I lined them up along (his/her) back, away from (his/her) skin. (Resident # 1) was wearing a nightgown that closed in the back. The nightgown was in between (his/her) skin and the hot packs. (Resident # 1) said that (she/he) was cold, so I was trying to keep (him/her) comfortable until EMS (Emergency Medical Services) arrived. The hot packs were still there about 5 -10 minutes later when EMS arrived. I think I told EMS that (Resident #1) had the hot packs around (him/her). I told the one EMS worker who arrived first, the rest were still on their way. When the rest of them arrived the EMS, workers pulled (Resident # 1) into the stretcher on (his/her) back. They took everything, the blankets and the hot packs. They swooped everything up into the stretcher and left. RN # 1 stated that she did not wrap the hot packs in a towel or cloth prior to placing them around Resident # 1's back. When asked to clarify the contents of the Nursing note written on 9/23/2018 RN # 1 stated: I wrote Patient laying on right side, warm packs placed on bed around patient with clothing, in between clothes. What I meant was that I put the warm packs on the bed, in between the patient's clothes and the bed. I did not put the warm packs against (Resident # 1's) skin or in between (his/her) clothes and (his/her) skin. Resident # 1's daughter was interviewed on 9/25/2018 at 3:00 PM. The daughter stated: (His/Her) temperature went down. I guess they (staff) kind of panicked maybe. They were trying to get (his/her) temperature up. When I came in they had heat packs all around (him/her). They didn't have anything or a towel over the heat packs. Then they (facility staff) decided they were going to send (him/her) to the hospital because (his/her) temperature dropped down. When EMS arrived, they came in and picked up my (parent) and everything underneath (him/ her); the sheets, blankets, everything and put them along with (him/her) on the stretcher. We get to the hospital and (he/she) kept saying my back hurts, my back hurts. We thought (he/she) was out of (his/her) head because (his/her) temp was so low. We knew they took a rectal temperature and thought that's what (he/she) meant by 'my back hurts'. (He/She) was laying on (his/her) back in the ER for a while and after that they moved (him/her) from that stretcher into an ER stretcher. One of the packs was stuck to the back of (his/her) nightgown and now (he/she) has second [MEDICAL CONDITION] it, from (his/her) shoulder blade to the middle of (his/her) back. I don't think this should have happened at all. All I know is that my (parent) is in in a lot of pain and they have to keep treating the burn so that it doesn't get infected. Resident # 1's hospital record was reviewed on 9/26/2018. Record review reveals an ER Nursing Note entered on 9/23/2018 which reads: This RN called to bedside. Patient' s family is stating patient's back is red. Patient with noted second degree burn to right upper back. Blistering x 2. Burn measuring approximately 12. 5 cm (centimeters) x 15 cm. (Doctor) called to bedside for evaluation. Upon arrival patient had multiple McKesson Medi Pak Instant hot compresses removed by patient's family on right side and this RN and a second RN on patient's left side. Unknown time hot compresses were applied to patient by nursing home staff. Continued record review revealed a wound consult note entered into Resident # 1's medical record on 9/24/2018 that read: The wound is assessed above a 2nd degree burn. The area appeared to have blistered, initially, than ruptured. There are no s/s (signs and symptoms) of infection, however we will continue to monitor the area for [DIAGNOSES REDACTED] (redness) as (he/she) is high risk for poor healing and infection. The findings were shared with the Director of Nursing (DON) on 9/25/2018 at 4:00 PM. The Director of Nursing stated that she would not expect staff to apply heat packs when a resident presents with a low temperature and complains of cold. The DON stated that nursing staff were not educated by the facility on the use of heat therapy and heat packs. In interview on 9/25/2018 at 5:00 PM the DON stated that all McKesson Medi Pak Instant Hot Compresses had been removed from the facility and placed on the Do Not Order List.

Based on medical record review and interview of facility staff it was determined the facility staff failed to protect a resident from injury. This was evident for 1 of 2 sampled residents selected for review. The findings include: Resident #1 was a [AGE] year old with a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on [DATE]. Additional information was provided by facility staff on [DATE]. Review of the Maryland Monthly Assessment, an assessment tool, and interview of the director of nursing, Staff #3, revealed that the resident was dependent on staff for activities of daily living and required the assistance of 2 staff members for bed mobility. The director of nursing, Staff #3, further indicated that the geriatric nursing assistants (GNAs) utilize "Team Sheets" which provide information related to the care requirements of residents on the GNAs' assignment. Review of the Team Sheet for Resident #1 revealed that it is noted that the resident requires the assistance of 2 GNAs during care at all times. On [DATE] the facility reported to the Office of Health Care Quality that the GNA, Staff #1, was providing care to Resident #1 and the resident rolled out of bed to the floor and sustained injuries. Review of the facility's incident investigation revealed the following written statement by the GNA, Staff #1: "I was in (name of resident)'s room to change her. After I got sheets and a pad to change her bed. I unsnapped her diaper and turned her on her left side. As I began to change her linen I noticed her legs starting to fall over. I tried to catch her. Unfortunately she proceeded to roll over rail and side of bed." Review of the nursing progress notes revealed that on [DATE] at 10:00 p.m. the GNA, Staff #1, assigned to Resident #1 called for help to the resident's room. Upon arrival, the nurse, Staff #2, observed Resident #1 lying on the floor face down with a laceration on the top of her head. Pressure was applied to the laceration to stop the bleeding until the emergency medical technicians (EMTs) arrived. When the EMTs turned the resident over, the resident was noted with a puncture wound on her right thigh. The resident was transferred to the hospital emergency room . Review of the hospital medical record revealed that Resident #1 was admitted to the hospital for care and comfort after experiencing a fall while at the nursing facility. The fall resulted in an arterial laceration of the right leg along with fracture of the right leg and a head laceration. The resident was started on a morphine drip in the emergency room . The family was made aware of the resident's critical state. The resident subsequently expired on [DATE] at 10:50 a.m. Interview of the director of nursing, Staff #3, revealed that the GNA, Staff #1, was suspended from work pending the outcome of the investigation. The facility determined that the GNA, Staff #1, was providing care to the resident, however, the GNA did not follow the written instructions for resident care. The GNA, Staff #1, received disciplinary action. Further interview of the director of nursing, Staff #3, revealed that subsequent to the incident involving Staff #1, the director of nursing, Staff #3, met with GNAs and nurses on [DATE] to discuss team sheet importance, safety issues, bed mobility, ongoing resident care meetings with the nurses, GNAs and the unit director. The team sheets are being reevaluated to clarify residents' needs. The staff development nurse is reevaluating unit orientation for GNAs to emphasize team sheets and resident safety. The facility has established a new ongoing bi-weekly resident care meetings on the unit to include the GNA, nurse and unit director.