Every finding on record at Hagerstown Healthcare Center

Based on complaints, a facility reported incident (FRI), reviews of a clinical record, reviews of facility investigation documents, and staff interview, it was determined that the facility staff failed to provide adequate supervision to Resident #5 to prevent Resident #5 from entering other resident rooms. On 07/01/26, Resident #5 was left unsupervised which allowed him to enter Resident #4's room and expose his groin area to Resident #4 and his family member. This was evident for 1 (Resident #5) of 8 residents reviewed during a complaint survey. The findings include: In an interview with Resident #4 on 07/15/26 at 3:16 PM, Resident #4 complained that at the beginning of the month Resident #5 entered Resident #4's room and exposed his groin area to Resident #4 and his visiting family member. A review of Resident #5's clinical record on 07/16/26 revealed Resident #5 was ordered to have a 1:1 sitter at all times due to a history of behavioral disturbances and that he cannot recall events. In an interview with GNA#3 on 07/16/26 at 11:49 AM, GNA#3 stated that they were assigned to watch Resident #5 at all times on 07/01/26 during the evening shift. GNA#3 stated that Resident #5 was pacing back and forth and kept asking for a pepperoni pizza. GNA#3 stated that she called in an order to a local restaurant asking for the restaurant to deliver a small pepperoni pizza to the facility. When the delivery service arrived, GNA#3 stated she spoke to the nursing supervisor and requested that he please take her place sitting with Resident #5. The nursing supervisor stated yes and GNA#3 went to the front door to pay for Resident #5 pepperoni pizza. GNA#3 stated this is when Resident #5 exited his room and entered Resident #4's room and exposed his groin area to Resident #4 and the family member. On 7 /17/26 at 11:17 AM, the Office of Health Care Quality also received a facility reportable incident (FRI) of an allegation of resident-to-resident abuse. The allegation included information that Resident #5 had exposed his groin area to other residents and family members. A review of the Facility Reported Incident documents for 3096790 on 07/20/26 at 3 PM, revealed that on the evening of 07/01/26 at approximately 5 PM, Resident #5 entered Resident #4's room and exposed his groin area to Resident #4 and Resident #4's visiting family member.

Based on complaint, observation, record review, and interviews, it was determined that the facility failed to ensure that a resident was served a meal according to a predetermined menu that incorporated the resident's preferences. This was evident for 1 (Resident #3) of 8 residents reviewed during a complaint survey. The findings include: On 06/24/26 at 4:50 PM, the Office of Health Care Quality received a complaint regarding the lack of quality of care Resident #3 is receiving while residing in the facility. Review of Resident #3's clinical record on 07/15/26 revealed Resident #3 was currently receiving Hospice services since 02/05/26. The current plan for Resident #3 was to be transferred to another SNF that their spouse was currently residing in. An observation made on 7/15/26 at 12:47 PM found Resident #3 sitting in the dinning room being assisted with the lunch meal. GNA#1 was assisting Resident #1 with the lunch meal. A review of Resident #3's 07/15/26 lunch meal ticket revealed the Resident #3 received a mechanical soft diet with nectar thickened liquids. The meal ticket also included that Resident #3 likes additional gravy and to use a translucent small sip cup with 2 handles. Observation of Resident #3's meal tray against the 07/15/26 meal ticket failed to reveal 3 additional items that should have been included on the meal tray. Missing were pureed cranberry crunch bar, 1 serving of a frozen nutritional treat (8 ounces of cranberry juice), and 1/2 cup of mandarin oranges. When asked, GNA#1 was not aware why all of the food items listed on Resident #3's meal ticket were not sent on the lunch meal tray. On 7/15/26 at 1:17 PM, RN#1 brought in the additional 3 missing items for Resident #3's lunch meal. At 1:23 PM, GNA#1 was continuing to assist Resident #3 with their lunch meal. In an interview with the facility Dietician on 07/15/26 at 1:52 PM, the facility Dietician confirmed that Resident #3 had physician ordered dysphagia mechanical ground regular diet with nectar thickened liquids. The facility Dietician stated that the facility speech language pathologist (SLP) evaluated and cleared Resident #3 to receive fruit like mandarin oranges and bananas for meals. The facility Dietician also provided the nurse surveyor documentation for Resident #3 that listed the following: Diet-[NAME], Mechanical textures, nectar thick liquids, Adaptive equipment included a scoop plate, two handled cup, weighted utensils, Supplements included a frozen nutritional treat once a day and Medpass 2.0, 120 milliliters once a day, Fruit included chilled pears at dinner, mandarin oranges at lunch, and a banana at breakfast. The facility Dietician also produced a copy of Resident #3's nutritional care plan that listed all of the meal choices and adaptive equipment listed during the interview.

Based on interview and record review, the facility failed to ensure a grievance received was documented, entered into the facility grievance log, tracked, investigated, and followed up according to the facility's grievance process for 1 (Resident #1) of 1 residents reviewed for grievances. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: cerebrovascular accident (CVA) and aphasia. Review of the resident's record revealed the resident was non-verbal and unable to independently communicate care concerns to facility staff.On 6/16/26, the surveyor reviewed a complaint submitted to the agency by Resident #1's representative. The complaint alleged concerns about the resident's room temperature, skin integrity, and the facility's failure to respond to multiple grievances submitted by Resident #1's representative.On 6/16/26 at 11:32 AM, during a review of the facility's grievance log from May 2026 through current, an entry was revealed for a written grievance submitted in June 2026. The grievance log did not contain an entry for a verbal grievance received on 6/2/26.On 6/16/26 at 12:13 PM, during an interview with Staff #5, the Social Services Assistant stated that they assist residents and families, participate in care plan meetings, and follow up on grievances when filed. When asked who the facility's grievance official was, Staff #5 stated they were unsure. Staff #5 stated that when they receive a written grievance, they provide it to Staff #6, the Director of Social Services. Staff #5 stated they were aware of a verbal concern from Resident #1's representative on 6/2/26 and a written grievance submitted on 6/12/26. Staff #5 stated they did not know the complainant wanted follow up related to the 6/2/26 verbal concern and stated they were relatively new to the role and did not know what type of follow-up should be provided.On 6/16/26 at 12:31 PM, during an interview with Staff #6, the Director of Social Services, stated that grievances may be submitted by residents, family members, or staff, verbally or in writing. Staff #6 stated that grievances are reviewed by Social Services and the interdisciplinary team, and that the facility attempts to resolve them within five days. Staff #6 identified the Executive Director/Nursing Home Administrator(NHA) as the facility's grievance official.On 6/16/26 at 12:43 PM, during an interview, Staff #6 confirmed awareness of care and environmental concerns raised by Resident #1's representative on 6/2/26 and 6/12/26. Staff #6 stated the 6/2/26 concern was verbal and the 6/12/26 grievance was written. Staff #6 stated the grievance log is maintained by Social Services. Staff #6 was unable to provide documentation that the 6/2/26 verbal grievance was documented, entered into the grievance log, investigated, assigned for follow-up, resolved, or followed up with the complainant.On 6/16/26 at 1:09 PM, during interview, the NHA confirmed the facility had received a verbal complaint from Resident #1's family member on 6/2/26. The facility was unable to provide evidence that the verbal complaint received by Staff #5 on 6/2/26 was documented, entered into the facility grievance log, referred to Staff #6 for tracking, investigation, assigned for follow-up, or followed up with the complainant within the facility's stated five-day grievance follow-up practice.Review of a nurse's note dated 6/16/26 revealed documentation of a telephone call to the resident's responsible party regarding a grievance submitted on 6/11/26 related to the resident's skin care. The note documented the provider had been made aware of the skin concern, hydrocortisone was ineffective, and mometasone furoate external cream 0.1% was ordered on 6/12/26. The note also documented a discussion of the resident's shower schedule and room move request, and stated that the responsible party agreed with the interventions and expressed satisfaction.However, the 6/16/26 nurse's note did not reference the verbal grievance received by Staff #5 on 6/2/26, did not evidence that the 6/2/26 verbal grievance was entered into the grievance log or assigned for investigation, and did not evidence follow-up within the facility's five-day grievance follow-up practice. Additionally, the individual identified in the 6/16/26 note was documented as the resident's responsible party, rather than the complainant known to the surveyor, who was listed as emergency contact #2 and durable power of attorney and who submitted the complaint to the agency.Although the facility provided documentation of follow-up related to a written grievance submitted in June 2026, the facility did not provide evidence that the verbal grievance received by Staff #5 on 6/2/26 was processed through the facility's grievance system. The 6/16/26 nurse's note documented follow-up regarding a grievance submitted on 6/11/26; however, it did not reference the 6/2/26 verbal grievance, did not show the verbal grievance was entered into the grievance log, and did not show the verbal grievance was investigated or followed up within the facility's stated five-day grievance follow-up practice.On 6/16/26 at 3:05 PM, during an interview with the NHA, they acknowledged concerns regarding the grievance process.

Based on record review and interview, it was determined that the facility failed to thoroughly investigate a self-reported incident. This was evident for 1 facility reported incident (FRI #2969278) of 2 FRIs reviewed.The findings include:Resident #3 was admitted to the facility in October 2025 with diagnoses that included, but were not limited to, opioid dependence, pain, heart failure, and a history of stroke. FRI #2969278 was a facility report of an incident when the resident became minimally responsive and was subsequently given Narcan, a drug used to reverse an opioid overdose.On 5/14/26 during the entrance conference for the survey, the Nursing Home Administrator (NHA) was interviewed and asked to provide the facility's investigation file for FRI #2969278.On 5/14/26 at 3:21 PM the facility's investigation file was reviewed. The review failed to reveal any witness statements or clinical note from the provider who evaluated the resident and ordered the Narcan to be given. Further review failed to reveal any investigation of the possible presence of non-prescribed drugs or substances.On 5/15/26 at 8:44 AM an interview was conducted with the Assistant Director of Nursing (ADON) to review the incident. She reviewed the facility's investigation file and then described the resident who she said was frail, had Type 1 diabetes with brittle blood sugars and a history of substance abuse, and who at the time of the incident became very lethargic. She said the resident's blood sugar was checked and it was okay. A call was placed to the on call provider who ordered one dose of Narcan which was administered and the resident initially became more alert but by morning the resident was still not back to baseline, so the provider instructed staff to send the resident to the hospital. The ADON further explained that the resident had a history of taking an illegal substance at the facility in 2025 and that incident resulted in a police investigation that the facility cooperated with. The ADON was asked whether any witness statements, room search, or investigation of the facility visitor log was done for the recent incident, and she said she did not think so because the recent incident was believed to be related to the resident's medical condition only.On 5/18/26 at approximately 4:20 PM the ADON brought a copy of a provider note, which was not present in the investigation file, dated 3/30/26 which was a video-visit note of the provider's evaluation of the resident during the episode, which included orders and other recommended interventions. It stated, in part, of note [resident #3 was transferred to this particular floor several months ago after [resident #3] was found to be in possession of drugs and drug paraphernalia on the previous floor. The note also included the instruction to search the resident's room for drugs and or evidence of drugs.On 5/18/26 during the exit conference, the finding that the facility's investigation was incomplete was reviewed with and acknowledged by the NHA and ADON.

Based on interviews and record review, the facility failed to ensure safe transport practices for 1 (Resident #8) of 6 residents reviewed during the complaint survey. This failure resulted in actual harm to Resident #8.The findings include:During record review it was revealed that on 1/13/26, Resident #8 (R#8) was transported off campus for an appointment in a wheelchair without leg rests, although the resident normally required stretcher transport due to limited ability to lift or maintain leg position. Shortly after transport began, the resident's left foot became caught under the wheelchair frame, and the resident reported immediate pain.During an interview on 3/3/26 at 10:14 AM, R#8 stated that Geriatric Nursing Assistant (GNA) #12 appeared to be in a hurry and did not use leg rests. The resident reported yelling stop when their leg became caught and stated that GNA #12 did not initially assess them for injury. Another staff member later attached the leg rests, and the resident was transported to the appointment without further assessment. The resident reported increasing pain throughout the day, and an X ray dated 1/15/26 revealed a fracture.Record review revealed R #8's Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact (C score 15/15), used a wheelchair for mobility, and was dependent for toileting, and dressing.Diagnostic imaging included an X ray on 1/15/26 showing chronic fractures with a possible acute femur fracture, and a computed tomography (CT)/ magnetic resonance imaging (MRI) on 1/19/26 confirming a nondisplaced femoral condyle fracture. Medical orders dated 1/23/26 required a left knee immobilizer every shift.Review of the resident's care plan and transportation assessment showed that R#8 typically required stretcher transport due to limited leg mobility. The facility did not follow the resident's assessed needs and did not ensure the use of appropriate assistive devices.The facility's investigative report dated 1/19/26 documented that GNA #12 transported the resident in a wheelchair without leg rests and was written up. During an interview on 3/3/26 at 1:44 PM, GNA #12 acknowledged that leg rests should have been used because the resident could not self propel. GNA #12 stated they asked the resident to hold their legs up and began pushing the wheelchair approximately two doorways before the resident yelled out. GNA #12 stated they retrieved leg rests and asked the resident if they were okay before continuing transport and reported being re educated and disciplined.During an interview on 3/5/26 at 11:50 AM, the Director of Nursing (DON) stated that residents transported in wheelchairs must have leg rests unless they refuse. The DON stated that R#8 was normally transported via stretcher and that GNA #12 should have known this by reviewing the Kardex. The DON stated that the resident did not report pain until the night shift, at which time the physician and family were notified. Diagnostic imaging confirmed a nondisplaced femoral fracture.

Based on the review of a facility reported incident 2699068, medical record review, and interviews with facility staff, it was determined that the facility failed to ensure that residents were free from exploitation. This was evident for 1 (Resident #7) of 1 allegation of exploitation reviewed during the complaint survey.The findings include:The facility reported incident #2699068, which was investigated starting on 3/2/26 at 9:00 AM. According to the incident summary, Resident #7 (R#7) came to the Administrator's office and stated h/she and Geriatric Nursing Assistant (GNA) #13 had been in an on-and-off relationship for a year and stated they had had sexual intercourse many times. The relationship was determined to be consensual, occurred intermittently over an extended period, and did not involve any observed concern related to supervision, care delivery, or resident safety on units. GNA #13 also asked for approximately $400.00 in August 2025, and s/he gave willingly. R#7 had been deemed capable and had a Brief Interview Mental Status (BIMS) score of 15/15. The resident is alert and oriented, has decision-making capacity, and has denied feeling coerced, threatened, or physically harmed. Staff witness statements were reviewed, and 2 staff members had suspicions about the relationship between R#7 and GNA #13 but did not report it. A review of R#7's statement summary dated 12/22/2025 revealed h/she wanted to speak to Admin2. The Resident stated h/she heard that GNA13 had reported allegations regarding drugs being present in their room. H/she stated those allegations were untrue and h/she wished to clear the air. H/she stated h/she and GNA #13 had been in an on-and-off relationship for one year. The relationship included sexual encounters that occurred on multiple occasions, including within the facility, in h/she's room, as well as at a motel. The relationship was consensual, never felt forced or pressured. H/she was never raped and did not regret the relationship and would not change what occurred if given the opportunity. H/she initiated physical contact and did not want law enforcement involved. R#7 also stated that around August 2025, approximately $400.00 was given to GNA #13. The money was given voluntarily, and it was recorded in text messages.A review of the text messages to and from GNA #13 and R#7 showed that the staff member's number was given to the facility upon hire. A text message dated 8/29/2025 at 12:03 PM revealed that GNA #13 asked to borrow $400.00, and R#7 agreed to give the employee the money. There were other text messages that revealed GNA #13 was planning to go to see R#7 and included explicit language that indicated there was a sexual relationship between the two.A telephone interview with GNA #13 was unsuccessful.An interview with Director of Nursing (DON)2 was conducted on 3/5/26 at 12:44 PM. The DON stated the resident was alert and oriented, had a mutual relationship with R#7, and was not coerced. There was evidence from text messages from the two that revealed a sexual relationship. She also stated that she expected the staff to keep it professional with Residents, not engage in sexual relations, and not receive or give money to Residents. An interview with Executive Director (ED)1 was conducted on 3/5/26 at 1:12 PM. He stated that all staff are expected to remain professional. They are not to have relationships with residents and/or give or accept any money from the residents.

Based on record review and interview, the facility failed to timely report an injury of unknown origin and an incident of resident exploitation to the State Survey Agency. This was true for two (Resident #7 and #8) of six residents sampled for reporting during the complaint survey.The findings include: 1) Based on record review, Resident #8 reported left leg pain on January 14, 2026. The resident was evaluated by the facility provider, and an X ray was ordered. The X ray completed on January 15, 2026, showed: Chronic fractures of the proximal tibia and fibula. A possible acute fracture of the distal fibula. A recommendation for follow up imaging or magnetic resonance imaging (MRI). The facility's administrative staff confirmed during interviews that they were aware of the radiology findings on January 15, 2026. Review of the facility's incident reporting log showed that the facility did not submit a report to the State Survey Agency until January 19, 2026, four days after becoming aware of the fractures. Interview on 3/5/26 at 12:51PM Director of Nursing (DON) stated that reportable for Resident #8 was reported late to the state. DON stated they should have reported immediately. DON stated the incident occurred on 1/14/26 and that they were notified by the floor nurse on 1/15/26. DON stated that an X-ray was ordered on 1/15/26, but the facility wanted to clarify whether the injury was pre-existing. DON stated they did not report the incident until 1/19/26, four days after being notified. 2) The facility reported incident 2699068 was investigated starting on 3/2/26 at 9:00 AM. According to the incident summary, Resident #7 came to the Administrator's office and stated h/she and Geriatric Nursing Assistance (GNA) #13 had been in an on-and-off relationship for a year and stated they had had sexual intercourse on occasions. The relationship was determined to be consensual, occurred intermittently over an extended period, and did not involve any observed concern related to supervision, care delivery, or resident safety on units. GNA#13 also asked for approximately $400.00 in August 2025, and h/she gave willingly. Resident #7 had been deemed capable and had a Brief Interview Mental Status (BIMS) score of 15. There were two witness statements that stated they felt there was a sexual relationship between the Resident and a staff member and did not report it. A review of a witness statement from HK19, dated 12/22/2025, revealed that she was aware GNA #13 was having an inappropriate personal relationship with Resident #7 and did not answer the question of whether she had reported it prior to today. HK19 did not return calls for an interview. A review of a witness statement from Licensed Practical Nurse (LPN) #8, dated 1/1/26, revealed that she heard a rumor of an inappropriate relationship between Resident #7 and GNA #13 last week. An interview was conducted with LPN #8 on 3/5/26 at 11: AM. She stated she should have reported it when she first heard the rumors to protect the residents from harm. She did not think it was an issue because the resident was alert and oriented. An interview with Director of Nursing (DON) #2 was conducted on 3/5/26 at 12:44 PM. The DON stated she believed since Resident #7 was alert and oriented and had a mutual relationship with GNA #13, it was not coerced. She also stated she expected the staff to keep it professional with Residents and not to receive or give money to or from residents. The DON also stated LPN #8 should have reported the rumor to her or the Executive Director (ED) when she first heard about it. An interview with ED1 was conducted on 3/5/26 at 1:12 PM. He expected the staff to report concerns as soon as they saw or heard anything to rule out abuse.

Based on observations, interviews, and record reviews, it was determined that the facility failed to label and date foods stored in facility refrigerators, ensure cleanliness of the kitchen environment and equipment, and maintain safe food storage temperatures in the walk-in refrigerator. This was evident during kitchen tours conducted throughout the facility's annual survey.The findings include:A. On 11/19/25 at 8:24 AM, the Surveyor conducted a brief initial tour of the facility kitchen. Upon stepping inside the walk-in refrigerator, the Surveyor observed multiple food items that were not labeled and/or not dated, including:Ground meat in a container labeled only freeze by 10/21/25, with no description of the food item or date when it was moved to the refrigerator. Shredded cabbage in a clear container with no date or label.Chocolate pudding in a metal container covered in plastic wrap with no name label.After leaving the walk-in refrigerator, the Surveyor opened the reach-in refrigerator and observed a container holding a pureed, orange-colored food item. The Surveyor asked Dietary Aide (DA #12) to identify the item. She stated, I think it's oranges, and immediately labeled the container as oranges with the date 11/19/25. When asked how she knew it was from that date, she stated she was unsure and would need to find out. She later returned and reported, It was probably from yesterday. When asked if it was appropriate to label an item with today's date if it was from yesterday, she stated, No, and confirmed that items should be labeled and dated when placed in the refrigerator.During this observation, a gentleman approached and identified himself as a Dietary Manager (DM #13) who was in the facility to help. The Surveyor showed him the undated and unlabeled food items in the walk-in refrigerator. He agreed that the items should have been labeled and dated and acknowledged that the practice was unsafe. He stated that many staff members were new and still learning. When asked whether the ground meat had been removed from the freezer to thaw for the day's meal or whether it was expired, he was unsure.On 11/21/25 at 11:50 AM, the Surveyor conducted an interview and performed a walk-through of the kitchen with the Dietary Manager (DM #14) and expressed concerns that there were food items stored in the refrigerators that were not dated and/or labeled. He stated that the other DM (#13) had advised him of the Surveyor's concerns, and he also agreed that the expectation is for foods to be both dated and labeled for storage. The Surveyor observed that the food items had been discarded after making DM #13 aware of the concerns.On 11/24/25 at 10:50 AM, the Surveyor conducted an interview with the Regional Dietary Manager (RDM) and expressed concerns about the unlabeled and undated food items, and he agreed that it is the expectation to label and date all food items in the refrigerators.On 11/24/25 at 1:42 PM, the Surveyor conducted an interview with the Nursing Home Administrator (NHA) and expressed concerns that the staff had missed labeling and/or dating several food items in both the walk-in and reach-in refrigerators. She stated that staff had made her aware of the Surveyor's findings and that there had been recent staff turnover but that they are working to ensure regulatory compliance.On 11/26/25 at approximately 8:30 AM, the Surveyor reviewed the facility's Dining Services policy titled Food Storage: Cold Foods (revised 2/2023), which states:All time/temperature control for safety foods, frozen, and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.All foods will be stored, wrapped, or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination.B. On 11/19/25 at 8:24 AM, during the initial tour of the kitchen, the Surveyor observed the following:Multiple carts lined along the kitchen entrance containing dirty food plates, cups, and utensils positioned next to a water cart holding what appeared to be clean cups, straws, and sugar packets.Floors visibly soiled with scattered food debris, spills, and unidentified substances.The stove and backsplash coated with black residue consistent with grease and grime; burners and surrounding areas had similar buildup.The adjacent griddle was covered with accumulated grease and grime.The food warmer with splattered substances, hazy residue, dried white drips on the exterior, and food debris inside the unit.Both food steamers with hazy glass doors, visible food particles, and grime on interior and exterior surfaces.A cart used to store clean cups containing dirt particles.The reach-in refrigerator exterior covered with streaks and dried food-like substances.The iced tea cart soiled with splashes and buildup of unidentified substances.During this observation, DM #13 approached the Surveyor. When the Surveyor asked about cleaning checklists, he reported that he was only assisting during survey, did not normally work in the facility, was unsure where cleaning logs would be kept, and would inform DM #14 that the Surveyor asked about the cleaning schedule upon his arrival.On 11/21/25 at 11:50 AM, the Surveyor toured the kitchen with DM #14 and discussed concerns regarding the stove, griddle, steamer, warmer, reach-in refrigerator, clean-storage rack, iced tea area, and overall uncleanliness. DM #14 stated that the facility contracts with a company to clean the floors and suggested the stove may appear dirty due to age, but agreed that cleanliness is an issue and stated that they are working with new staff that need to be trained. The Surveyor requested the facility's daily cleaning logs.On 11/21/25 at 12:13 PM, the Surveyor interviewed the Registered Dietitian (RD) and asked her about her role. During the conversation, the Surveyor asked if she had concerns over the cleanliness of the kitchen, and she stated that she performs sanitation audits in the kitchen and that one of the concerns was that the kitchen needed deep cleaning.On 11/21/25 at 1:40 PM, DM #14 provided the Surveyor with a blank cleaning checklist titled Daily Cleaning Assignments - Week of ____. The list is extensive and includes multiple cleaning responsibilities for the staff for all shifts. Additionally, the document states: All cleaning assignments must be completed and checked by the food service director or supervisor before you leave. The Surveyor asked for the completed log for November, and he stated that the log had not been filled out by the staff for any days of November 2025.On 11/24/25 at 10:50 AM, the Surveyor conducted an interview and tour with the Regional Dietary Manager (RDM) and expressed concerns about the cleanliness of the kitchen. He stated that DM #14 was in over the weekend and that he cleaned the stove and asked the Surveyor to look at it. The Surveyor observed that the stove backsplash had been thoroughly cleaned and that all the black residue had been removed. The Surveyor showed the RDM the photos taken the first day of the survey that demonstrated how dirty the stove and backsplash, warmer, steamer, reach-in refrigerator doors, clean dish cart, and iced tea cart were during the initial tour. He acknowledged that it should never get to that state of uncleanliness.During the tour, the Surveyor noted that the shelf under the iced tea maker had grime buildup and needed to be cleaned and pointed it out to the RDM. The Surveyor expressed concerns that the cleaning checklist had not been completed for the month of November, and he stated that there has been a lot of turnovers with staffing but that they are working on stability and would be implementing the cleaning checklists. He added that the kitchen floors were deep cleaned over the weekend.On 11/24/25 at 1:42 PM, the Surveyor interviewed the NHA and shared photos from the initial tour. She agreed the kitchen should not have reached that level of uncleanliness if cleaning checklists had been completed regularly. She acknowledged that DM #14 had notified her that cleaning checklists were not completed for November and stated they were working on new processes to ensure the kitchen is cleaned.On 11/26/25 at approximately 8:30 AM, the Surveyor reviewed the following Dining Services policies and procedures:Environment (revised 9/2017) All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.Food: Preparation (revised 2/2023) All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use.Equipment (revised 9/2017) All food service equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. All staff members will be properly trained in the cleaning and maintenance of all equipment. All food contact equipment will be cleaned and sanitized after every use. All non-food contact equipment will be clean and free of debris.C. A walk-in refrigerator for long-term care facilities must be maintained at 41 F or below to ensure safe food storage. Temperatures between 41 F and 140 F are considered the danger zone, where bacterial growth accelerates.On 11/19/25 at 8:24 AM, the Surveyor observed that the walk-in refrigerator door latch was not closing properly, and the door was not sealing. Dietary Aide (DA #17) reported it had been that way for a while. The Surveyor observed the exterior thermometer read 44 F, and the interior thermometer read 42 F, confirmed with a second thermometer. When reviewing the temperature log, the Surveyor observed that the PM shift on 11/18/25 had not recorded the temperature, and the morning shift on 11/19/25 recorded 41 F.The Surveyor expressed concerns to DM #13 and he stated that he was only assisting during the survey and would notify DM #14 of the Surveyor's concern when he arrived.On 11/21/25 at 11:40 AM, DM #14 stated that the latch on the walk-in refrigerator had been repaired. The Surveyor expressed concerns that it was unknown whether temperatures had remained safe due to the unsealed door and the missed PM log entry on 11/18/25. The Surveyor also expressed concern regarding the above-41 F temperatures observed on 11/19/25. DM #14 stated he was aware and commented that new staff were being trained and new processes implemented.On 11/24/25 at 10:50 AM, the RDM stated he was made aware of the concern about the refrigerator temperatures and stated that the facility was working on implementing changes due to recent staff turnover.On 11/24/25 at 1:42 PM, the NHA reported that she was aware of the concerns with the refrigerator temperature and that they were working to ensure compliance with safe food-storage temperature requirements.On 11/26/25 at approximately 8:30 AM, the Surveyor reviewed the Dining Services policy titled Food Storage: Cold Foods (revised 2/2023), which states:All time/temperature control for safety foods will be stored in accordance with the FDA Food Code.All perishable foods will be maintained at 41 F or below, except during preparation and service.A written record of daily temperatures will be maintained.

Based on observations, policy review, and interviews, the facility failed to prevent the spread of infection, as evidenced by the failure of licensed nursing staff to perform hand hygiene during medication administration for 3 (Residents #10, #11, and #85) of 4 residents observed. On 11/19/2025 at 8:15 AM, the surveyor arrived on the first floor and observed medication administration by CMA #2, who dispensed medication for Resident #10. Hand hygiene was not performed as the CMA began pulling blister packages from the medication cart for this resident. Hand hygiene was also not performed before administering medications to Resident #10. On 11/19/2025 at 8:30 AM, Hand hygiene was not performed when Nurse #1 approached the medication cart and administered a PRN medication (oxycodone 5) for Resident #11. At 0835 on 11/19/2025, when the CMA #2 began administering medications to Resident #85, hand hygiene was not performed. 11/21/2025 8:23 AM, the facility's Infection Prevention and Infection Control Program policy was reviewed. An IP (Infection Preventionist)/ designee will coordinate and be responsible for surveillance and the reporting of infectious outbreaks 1. The IP designee is a nurse in the facility with knowledge of the geographic population and with the rules and regulations of LTC infectious concerns Surveillance of Infections: i. There is ongoing monitoring of infections for residents and employees, and follow-up documentationii. Prevention of spread of infections is accomplished by education and implementation of the use of hand hygiene, standard precautions, and transmission-based precautions as appropriate, with treatment and follow-up, and employee work restrictions for illness. 11/21/2025 1:45 PM, a review of the facility's Medication Administration policy revealed section II, bullet: f, h'Preparation': a. Prepare a clean work surfaceb. Prepare liquids and foods to be used with medications i. Maintain proper temperature ii. Check dates on food products iii. Keep food or liquid products covered or closed when not in usec. Obtain appropriate supplies, including but not limited to: i. Gloves ii. Cups iii. Straws iv. Sharps containerd. Identify the resident by picture and state their name e. Provide for dignity and privacyf. Perform appropriate hand hygiene before beginning medication administrationg. Observe Standard Precautions, including safe sharp useh. Perform hand hygiene before and after each resident's medication is administered 11/21/2025 3:00 PM An interview was conducted with Staff #11. She was asked how infection prevention is accomplished for staff who administer medications. Staff #11 stated, Routine in-service education is provided to nursing staff on standard infection control practices monthly. Following up on the monthly in-service education, the surveyor asked whether hand hygiene observation audits were conducted and documented as outlined in the provided policy. Staff #11 stated, I routinely make observations of medication passes on the units and will engage verbally with nursing staff in a teachable moment if they are observed not to perform hand hygiene, but I do not track or document the observations or audits. During the interview, the surveyor disclosed to Staff #11 that Nurse #1 and CMA #2 were observed not performing hand hygiene during medication administration for Residents #10, #11, and #85. She acknowledged the deficiency. On 11/26/2025, during an interview at approximately 10:45 AM, the Nursing Home Administrator and Director of Nursing were made aware of observations and findings.

Based on record review and interviews, it was determined that the facility failed to complete Significant Change in Status Minimum Data Set (MDS) assessments within 14 days following a significant decline in the Residents' condition. This was evident for 1 (Resident #5) of 1 Resident reviewed for Hospice, and 1 (Resident #10) out of 5 Residents reviewed for Unnecessary medication regimen review The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected on the MDS drives Resident care planning decisions. The nursing home should complete a Significant Change in Status MDS assessment within 14 days of a major decline or improvement in a resident's status after the determination that a significant change has occurred.1) A record review for Resident #5 on 11/24/2025 at 2:25 PM included a hospice admission note that indicated that the Resident was admitted to hospice care effective 7/31/25. The continued review contained a Significant Change in Status MDS assessment dated [DATE] for Resident #5. The MDS assessment was completed and signed in sections Z0500B & V0200B2 on 8/20/25, 21 days after admission to hospice care and 6 days late.In an interview on 11/25/2025 at 12:10 PM, staff #18, an MDS Coordinator, confirmed that the Significant Change in Status MDS assessment for Resident #5, dated 7/31/25, was completed late.2) Record review for Resident #10 on 11/25/2025 at 7:22 AM showed that the Resident was readmitted from the hospital to the facility on [DATE].Further review included a Significant Change in Status MDS assessment for Resident #10 dated 10/7/25. The MDS assessment was completed and signed in sections Z0500B & V0200B2 on 10/27/25.During an interview on 11/25/2025 at 10:30 AM, staff #18 reported that Resident #10 had a change in his/her ability to transfer, warranting a Significant Change in Status MDS assessment. Staff #18 continued to state that the determination date for Resident #10's Significant Change in Status was 10/5/25, the day of readmission to the facility. However, an earlier review showed that the Significant Change in Status MDS assessment for Resident #10 dated 10/7/25 was completed on 10/27/25, 22 days after readmission to the facility and 8 days late.Staff #18 confirmed that Resident 10's Significant Change in Status MDS assessment was completed late.

Based on record review, observations, and interviews, it was determined that the facility failed to provide an assistive device to residents during smoking breaks to prevent accidents. This was evident for one Resident (Resident #40), who was reviewed for accidents.The findings include:A review of a smoker log report provided by the director of nursing (DON) showed that Resident #40 was a smoker and required an apron and staff supervision while s/he smoked.A continued review of a smoking assessment completed on 11/6/25 and provided to the surveyor by DON for Resident #40 showed that the Resident needed an apron and staff supervision during his/her smoking times.On 11/19/2025 at 1:01 PM, during the facility's scheduled smoke break, Resident #40 was with other residents outside the building at the facility's designated smoking area, with staff #3, an activities assistant, in attendance. Resident #40 was observed smoking without an apron. The Resident was asked where his/her apron was and reported that no one had ever offered him/her an apron. Staff #3 was asked about Resident #40's apron and stated she was unaware that the Resident had to wear an apron for smoking.During a subsequent observation of the facility's scheduled smoke break on 11/21/2025, at 9:13 AM, Resident #40 was noted smoking without wearing an apron. Staff #10, an activity assistant, was present and asked about Resident #40's apron. Staff #10 reported that he was unaware that the Resident needed to wear an apron during smoking breaks. Staff #10 was questioned about his process for determining which Resident needed an apron, and he responded that he relied on the facility's smoker log report. Staff #10 then checked the smoker log and confirmed that Resident #40 was on it; however, he was unaware that the Resident had to wear an apron during smoking breaks.In an interview on 11/21/2025 at 9:20 AM, the DON stated that the facility's Activity Department was responsible for supervising residents during scheduled smoking breaks and providing aprons. The concern about Resident #40 not wearing an apron during smoking breaks was shared with the DON, who indicated that Resident #40 refused to wear one. However, the interview failed to show supporting documentation of the Resident's refusal of the apron during smoking breaks.In a subsequent interview on 11/21/2025 at 11:35 AM, the DON reported that the smoker log report and Resident #40's care plan had been updated to reflect Resident #40's refusal to wear an apron during smoking breaks after the surveyor's intervention.

Based on interviews and record review, it was determined that the facility failed to notify a Resident's representative of a documented change in the Resident's condition. This was evident for one (Resident #22) out of one Resident reviewed for Notification of change.The findings include:In an interview on 11/19/2025 at 9:51 AM, the representative for Resident #22 stated that the Resident had wound dressings on both legs; however, she was unaware of the onset of the wounds or their type.A review of Resident #22's record included a change in condition evaluation form completed on 6/26/24 that recorded that Resident #22's bilateral legs and feet has dry flakes and open areas with purulent discharge with an odor. The review showed that the change began on 6/26/24 and was reported to the attending provider for Resident #22 on that date. The section of the change in condition evaluation form that documented the name of the family/health care agent notified was left blank.A continued review showed a skin/wound note dated 6/26/24 that stated that Resident #22 was seen by wound/ treatment nurse per request of floor nurse. Bilateral lower legs has open wounds. Areas cleansed with normal saline, xeroform applied, and covered with rolled gauze. MD/NP (attending provider) made aware. However, the review failed to show that Resident #22's representative was notified of the Resident's change in condition.In an interview on 11/21/2025 at 1:58 PM, the director of nursing (DON) said that any change in a resident's condition should be reported immediately to the Resident's attending provider and the representative. The DON checked the completed change in condition evaluation form for Resident #22 on 6/26/24, the clinical notes, and confirmed that the Resident's representative was not notified of the change in condition on 6/26/24.

Based on interviews and record review, it was determined that the facility failed to accurately reflect a resident's discharge plan on their individualized care plan. This was evident for one (Resident #32) of three residents reviewed for discharge planning.The findings include: Based on interviews and record review, it was determined that the facility failed to accurately reflect a resident's discharge plan on their individualized care plan. This was evident for one resident (Resident #32) of three residents reviewed for discharge planning. The findings include: Resident #32 has medical diagnoses of Cerebral Palsy, a neurological disorder that affects movement, posture, and muscle tone due to permanent brain damage occurring during fetal development or infancy, and Fragile X Chromosome, which prevents the production of a protein crucial for brain development. This can lead to a range of intellectual, developmental, and behavioral problems, including learning disabilities, speech difficulties, and autistic-like behaviors. A care plan is a personalized document that outlines a resident's specific medical, social, and personal needs, developed with the resident and their family. The care plan guides staff in providing comprehensive and individualized care. The plan is not static; it is based on comprehensive assessments and is regularly reviewed and updated to reflect the residents' changing needs. On 11/20/25 at 11:25 AM, the surveyor conducted an interview with Resident #32's family member, who expressed concerns that although they feel the facility provides good care, the facility does not have the capability to meet Resident #32's specific needs. The family member stated that they had previously discussed these concerns with the facility and were told the facility would work on arranging a transfer to a more appropriate setting based on the residents' required level of care. They stated that the facility was supposed to follow up with them, but they had not received any additional information. On 11/21/25 at 3:52 PM, the surveyor conducted a medical record review. The care plan, which had been revised on 11/13/25, stated, I have no plans for discharge secondary to LTC (long-term care). The surveyor was unable to find documentation to support that there was a plan to discharge the resident to a different facility. On 11/25/25 at 9:06 AM, the surveyor conducted further review of the resident's records, which showed notes from a care plan meeting stating that the desire was for the resident to discharge to a Developmental Disabilities Administration (DDA) group home. The care plan meeting note specified: Resident/family does voice desire to discharge to a DDA group home. Letter was sent to [name withheld] County DDA to add resident to wait list. Social work to follow up. The Developmental Disabilities Administration is a state-level agency that provides services and support to individuals with developmental disabilities. A developmental disability is a severe, chronic disability that makes independent living difficult without support. On 11/25/25 at 9:40 AM, the surveyor interviewed the Director of Social Services (DSS) and asked if she participates in care planning with residents. She stated that she does. The surveyor asked what her process is for developing a discharge plan. She stated that long-term care residents are reviewed upon admission, quarterly, annually, and with a change in condition. She stated that the plan is individualized for each resident and incorporated into the care plan. The surveyor then asked about Resident #32's plan for discharge, and the DSS stated that she is in the process of coordinating approval of a waiver with DDA. She stated that she had sent a letter to notify DDA that the resident is now stable at the facility and is able to discharge into DDA services. The surveyor asked if it would be expected that the care plan reflects these wishes and the steps (goals) required to make that happen, and the DSS stated yes, the care plan should have been updated. The surveyor showed the DSS that the care plan, updated on 11/13/25, stated that the plan was for Resident #32 to remain in long-term care. She stated that the progress notes reflect the accurate plan but acknowledged, You are correct, the care plan should have carried over the new discharge plan. She stated that she would work on getting it updated. She also stated that Resident #32 needs care that the facility cannot meet to have the best quality of life specific to their needs. On 11/25/25 at 12:16 PM, the NHA provided the surveyor with an updated care plan for Resident #32 and stated that the DSS had shared the surveyor's findings regarding the care plan not reflecting the resident's discharge plan and that it had been corrected.

Based on observation, record reviews, and interviews, it was determined that the facility failed to provide an ongoing program of activities that met residents' needs and preferences. This was evident for 1 (#10) out of 2 residents reviewed for activities.The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care.During an initial tour of the first-floor unit on 11/20/2025 at 10:30 AM, Resident #10 was observed lying in bed and not involved in any activity.A record review on 11/25/2025 at 7:22 AM included a hospital discharge summary that recorded that Resident #10's diagnoses included Altered mental status with underlying Dementia.Further review of Resident #10's MDS assessment dated [DATE] showed that it was very important to him/her to keep up with the news and go outside for fresh air when the weather was good.A review later that day of Resident #10's activity care plan focus initiated on 9/10/24 and revised on 8/27/25 stated, [Resident #10] has little or no activity involvement. [Resident #10] wishes to participate in more activities when feeling better. The goals of the care plan said, [Resident #10] will participate in activities of choice and [Resident #10] will show engagement in activities of interest. The interventions recorded on the care plan stated, Encouraging attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities, provide 1:1 in-room visits if unable to attend out-of-room events, provide a schedule of activities available. The care plan was not person-centered and failed to reflect the activity preferences identified on Resident #10's MDS assessment on 6/6/25.A review of activity logs for Resident #10 for August 1 - November 25, 2025, was completed. The review showed that the activities provided to the resident included 1:1 visits, sleep, Talk, TV, and four refusals.Further review of the facility's policies and procedures for Activities Program stated that the Activity Program consists of individual and small and large group activities which are designed to meet the needs and interests of each resident and reflect the schedules, choices and rights of the resident. However, earlier review of activity logs failed to show that Resident #10 engaged in activities, such as going outside for fresh air when the weather was good, which were previously documented as his/her activity preferences on his/her MDS assessment. In an interview on 11/25/2025 at 9:36 AM, staff #7, the Activity Director, expressed understanding of the concern and stated she would update the activity care plan to be more person-centered and would incorporate more of Resident #10's activity preferences in the activities offered.

Based on record review and staff interview, it was determined that the facility failed to provide medically related social services to a resident triggered for required PASARR screening. This finding was evident for one (Resident #54) of three residents reviewed for PASARR screening during the survey. The findings include: A Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care and/or ensure the most appropriate care setting to meet their needs. Brief Interview for Mental Status (BIMS) is an evaluation tool that indicates one's cognitive (thinking) ability ranging from 0 to 15. Zero represents no cognitive ability and 15 represents intact cognitive ability.On 11/19/25 at 9:23 AM Resident #54 was observed awake in bed; it was in the lowest position and had clean linens. Resident was alert, dressed and appeared to be agitated. The resident stated, my black slacks are missing. Surveyor observed two stuffed clear bags on the floor. Eventually, the resident discovered the slacks in one of the bags. Resident refused assistance to place the belongings in the closet or dresser.On 11/19/25 a review of Resident #54's medical record revealed a recent admission on [DATE] post hospitalization after a recent fall. Diagnosis included high blood pressure, hemorrhagic brain bleed, Alzheimer, anxiety and depression. The resident's brief interview mental status (BIMS) was 9, that indicated moderate impairment to one's thinking ability. A signed certification dated 10/23/25 revealed that the resident lacked capacity. On 11/25/25 at 7:59 AM a review of the PASARR I outcome completed on 10/10/2025 read: Letter Rationale: 30-day Provisional Hospital Exempt PASARR, valid electronic health document form attached. If nursing facility stay extends past 30 days (11/9/25) a new PASARR will be required.On 11/25/25 at 8:29 AM in an interview, the Director of Social Service, (Staff #4) after reviewing the PASARR I outcome, stated, I missed it, and acknowledged that the facility was required to complete a second PASSAR. On 11/25/25 at 2:18 PM the Nursing Home Administrator and Director of Nursing were made as of the concern. On 11/26/2025 at 10:40 AM Staff #4 confirmed PASSAR was completed after surveyor intervention.

Based on observation, record review and staff and resident interview, it was determined that the facility failed to accurately document a resident's status on the Minimum Data Set (MDS) assessment for 1 resident (Resident #81) of four residents reviewed for accidents during the survey.The findings include:The MDS is a federally mandated assessment tool that gathers information on each resident's needs that helps determine care planning decisions. Accurate MDS assessments should reflect the quality care that each resident receives. The assessment reference date (ARD) is the specific date used to assess a resident's current status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 11/19/25 at 8:37 AM Resident #81 was observed in bed. Talkative and pleasant. Personal items, fresh water, call bell observed within reach and 1/4 bilateral bedrails observed attached to the bed. On 11/21/25 at 12:55 PM a review of Resident's #81 last weight was 347.2 lbs. The care plan revealed on 2/24/24, an intervention was initiated for bilateral 1/4 siderails to bed to promote independence. Further review of MDS with ARD of 9/29/25, Section P, did not reflect Resident #81 had bedrails. On 11/21/25 at 1:04 PM, during an interview, MDS nurse (Staff #6), indicated that data used to complete the MDS assessment was gathered from the medical record which included: nurses notes, census, medication records, appointments, physician orders and the care plan. It was acknowledged that bedrails were part of the care plan and the MDS, Section P, did not document bedrails. Staff #6 acknowledged that Resident #81's MDS assessment was inaccurately documented. On 11/21/25 at 1:20 PM the surveyor confirmed observation of bedrails on Resident #81's bed and the resident stated, I need those to move in bed.On 11/25/25 at 2:17 PM the Nursing Home Administrator and Director of Nursing were made as of the concern.

Based on record reviews and interviews, it was determined that the facility failed to complete the residents' Matrix accurately. This was evident during the recertification survey. The findings include:The Matrix is used to identify pertinent care categories for: 1) newly admitted residents in the last 30 days who are still residing in the facility, and 2) all other residents. The facility completes the resident name, resident room number, and corresponding care categories. All information entered on the form should be verified by a staff member knowledgeable about the resident population. Information must be reflective of all residents as of the day of the survey.After the initial entry to the facility for this survey on 11/19/25, the director of nursing (DON) presented a completed matrix dated 11/19/25 at 10.01 AM to the survey team for all residents.A review of the Matrix showed that Residents #35, #57, and #76 received parental feedings (a method of providing nutrients directly into a person's bloodstream through an intravenous (IV) catheter when they cannot eat or receive nutrition through their gastrointestinal (GI) tract).Continued review of the Matrix also noted that Resident #94 received Hospice care.However, further review of a list of Residents receiving hospice care and parental feedings, provided by the DON, failed to show that Residents #35, #57, and #76 received parental feedings, or that Resident #94 received hospice care.In an interview on 11/20/2025 at 4:03 PM, the director of nursing (DON) reported that Resident #94 had been discontinued from hospice care before the surveyors' initial entry into the facility.However, the Matrix was not updated with the change. The DON also confirmed that Residents #35, #57, and #76 did not receive parental feedings. In a subsequent interview on 11/21/2025 at 7:46 AM, the DON reported that she corrected the Matrix after the surveyor's intervention.

Based on staff record review and interviews, it was determined that the facility failed to ensure that a Geriatric Nursing Assistant (GNA) was provided education based on issues identified during the employee's annual performance evaluation. This was evident for one staff member (Staff #8) out of six employees reviewed for sufficient and competent staffing.The findings include:Long-term care facilities are required to provide nurse aide (NA) in-services and education that address areas of weakness identified in the NA's performance reviews.On 11/19/25 at 4:25 PM, the surveyor reviewed employee performance evaluation records, which indicated that Staff #8, a GNA in the facility, had received a verbal warning. The evaluation did not include any details regarding the reason for the warning.On 11/24/25 at 1:45 PM, the surveyor conducted an interview with the Nursing Home Administrator (NHA), who stated that she was unsure of the reason for Staff #8's corrective action because she is new to the facility, but that she would look into it. The surveyor asked the NHA to identify the reason for the corrective action and to provide evidence of any in-service or education that was provided as a result of the deficiency noted during the annual performance evaluation.On 11/24/25 at 4:06 PM, the NHA provided the surveyor with a document titled Employee Corrective Action Form, dated 10/7/25, which indicated that Staff #8 had received a verbal warning on 9/8/25 and was subsequently written up again on 10/7/25 for insubordination, stating, Employee behavior was very unprofessional yelling at clinical manager and not following direction. The NHA stated that there was no evidence to support that education or any follow-up training was provided to Staff #8 as required following employee performance evaluations when issues were identified. The NHA acknowledged understanding that this is a requirement.

Based on interviews and record review, it was determined that the facility failed to ensure interdisciplinary care plan meetings were conducted following the completion of Minimum Data Set (MDS) assessments. This was evident for 3 ( Resident #11, #5, and #10) out of 41 Residents reviewed during the recertification survey.The findings include:A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. It must be developed within 7 days of completion of a resident's comprehensive Minimum Data Set (MDS) assessment. It must be reviewed and revised by the interdisciplinary team (IDT), including the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the Resident, and the Resident's representative (as practicable) after each assessment, including both the comprehensive and quarterly review assessments.The Minimum Data Set (MDS) assessment is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. The information collected is used in the Resident's care planning decisions. 1) In an interview on 11/19/2025 at 3:38 PM, Resident #11 was asked if s/he participated in his/her care plan meetings. The Resident responded that s/he has had very few care plan meetings since residing in the facility. A review of Resident #11's record showed that s/he had resided in the facility since September 2022. A continued review included care conference notes for Resident #11 from January to November 2025, which recorded that the IDT conducted reviews of the Resident's care plans and care plan meetings were held on 4/8/25, 6/17/25, and 9/16/25. Further review of the MDS history for Resident #11 noted that the following MDS assessments were completed for Resident #11:-A quarterly MDS dated [DATE]-A quarterly MDS dated [DATE]-A quarterly MDS dated [DATE]-An annual MDS dated [DATE]-A quarterly MDS dated [DATE].The review lacked documentation indicating that an IDT care plan meeting had occurred following the completion of the MDS assessments dated 1/13/25 and 9/20/25.In an interview on 11/24/2025 at 10:01 AM, staff #4, Social Services Director, reported that IDT care plan meetings were scheduled for Residents based on their MDS schedules. However, the interview and earlier record review lacked documentation that care plan meetings had occurred following Resident #11's MDS assessments in January and September 2025.During a subsequent interview on 11/24/2025 at 1:20 PM, staff #4 confirmed that there was no documentation to show that care conference meetings had occurred following Resident #11's MDS assessments dated 1/13/25 and 9/20/25.2) A record review for Resident #5 on 11/24/2025 at 2:25 PM showed that the Resident was admitted to hospice care effective 7/31/25. The continued review contained a Significant Change in Status MDS assessment dated [DATE] for Resident #5. The MDS assessment was completed and signed in sections Z0500B & V0200B2 on 8/20/25.However, the review failed to show that an IDT care plan meeting had taken place after the Significant Change in Status MDS assessment was completed for Resident #5's admission to hospice care.In an interview on 11/25/2025 at 12:10 PM, staff #18, an MDS Coordinator, reviewed Resident #5's medical record and confirmed that there was no documentation indicating that an IDT care plan meeting had occurred following his/her admission to hospice care.3) Record review for Resident #10 on 11/25/2025 at 7:22 AM included a Significant Change in Status MDS assessment for Resident #10 dated 10/7/25 and completed on 10/27/25.A continued review of care conference notes for Resident #10 lacked documentation for an IDT care plan meeting held after the Significant Change in Status assessment was completed.An interview with staff #18 on 11/25/2025 at 10:30 AM revealed that a Significant Change in Status MDS assessment was completed for Resident #10 due to a change in his/her ability to transfer. A subsequent interview on 11/25/2025 at 12:24 PM with staff #18 confirmed that no care conference meeting occurred following the completion of the MDS for Resident #10's Significant Change in Status on 10/27/25.

Based on medical record review and interview it was determined the facility staff failed to 1) follow physician orders and 2) implement resident's non-pharmacological interventions prior to administration of pain medication and identify individualized non-pharmacological interventions for behaviors. This was evident for 2 (#1 and #3) of 3 residents reviewed during the survey.The findings include:1) Low Blood Pressure (hypotension) occurs when the blood pressure is less than 90/60 Hg and can be caused by dehydration, certain medications and underlying health conditions such as heart disease, diabetes, thyroid problems, or severe infection (sepsis). On 10/21/24 at 9:23 AM, a review of complaint #2641697 alleged the facility did not provide Resident #3 with adequate care prior to sending the resident out for an appointment with a vascular (vein) specialist on 10/8/25. The complaint alleged when Resident #3 arrived for his/her vascular appointment on 10/8/25, the resident was lethargic, there was blood in his/her urinary drainage bag, and his/her blood pressure was 80/44. The complaint alleged Resident #3's blood pressure remained dangerously low and the resident required emergency care, that 911 was called and the resident was transported to the hospital by ambulance. Upon review of the complaint, Resident #3's electronic medical record (EMR) revealed that Resident #3 was initially admitted in July 2025 with complex medical needs, including diagnoses of diabetes, dementia, peripheral vascular disease, and vascular wounds. The medical record further documented two readmissions: once at the end of September 2025, and again on October 12, 2025, each following a brief hospitalization. Since the most recent readmission, Resident #3's condition has changed, and they were currently hospitalized . Review of Resident #3's October 2025 Medication Administration Record (MAR) revealed an order for a vascular appointment on 10/8/25 at 2:00 PM, that was signed off indicating the resident went to the appointment. Review of Resident #3's progress notes failed to reveal any documentation to indicate the status of the resident at the time s/he left the facility for the vascular appointment or that prior to leaving the facility, the resident had been assessed. In an Alert Charting Observation note, on 10/8/25 at 5:46 PM, the nurse indicated that during a phone call, s/he was informed when Resident #3 went to the vascular appointment, s/he was sent to the emergency room due to low blood pressure and blood in the urine. On 10/8/25 at 9:16 PM, in an Alert Charting Observation note the nurse wrote that Resident #3 had been admitted to the facility for sepsis (serious condition in which the body responds improperly to an infection). Continued review of Resident #3's October 2025 MAR revealed an order for vital signs (VS) every shift for 72 hours then daily every evening shift, with a start date of 9/25/25 at 2:30 PM. The order was documented as done every evening, from 10/1/25 to 10/7/25, indicating vital signs had been obtained on those dates, however no VS were documented on the MAR. In the EMR, VS results and the date and time they are entered in the EMR are documented under the Weights and Vitals Summary tab. Review of Resident #3's blood pressure results listed under the Weights and Vitals Summary tab failed to reveal documentation to indicate Resident #3's blood pressure had been obtained on the evening shift on 5 (10/1, 10/2, 10/3, 10/6, 10/7) of 7 days in October 2025. This was in contradiction to the documentation in the MAR which indicated his/her vital signs had been obtained. Failing to follow physician orders to obtain vital signs every evening shift as ordered put Resident #3 at risk. On 10/22/25 at 3:30 PM, the above concerns were discussed with the Nursing Home Administrator (NHA) and Infection Preventionist. The NHA acknowledged the concerns at that time and indicated that sometimes VS were documented in the wrong place, and she would look into it. No further documentation was provided to the surveyor by the time of exit from the survey on 10/23/25. 2) Resident #1's medical record was reviewed on 10/22/25 at 9:00 AM. The record revealed physician orders and MAR (Medication Administration Record) included but were not limited to 3 orders related to pain management every shift: One order was for Acetaminophen (Tylenol) 500 mg (milligrams) 2 tablets every 8 hours as needed (PRN) for pain, another order was to monitor pain level each shift with instructions for monitoring and included, Document non-pharmacological pain intervention prior to PRN pain medication administration, and a third order for Non-Pharmacological interventions 1. Repositioning, diversion activities, snacks and fluids, ice 2. Diversion activities 3. snacks and fluids 4. relaxation techniques as needed for pain. The Medication Administration Record (MAR) revealed that the resident received PRN Acetaminophen 1000 mg by mouth 16 times from October 1 – 21/2025. However, staff failed to attempt non-pharmacological pain interventions prior to administering the PRN pain medication as ordered by the physician. Staff #2 the nurse caring for Resident #1, was interviewed on 10/23/25 at 10:00 AM. She was asked how she would know which non-pharmacological interventions to implement prior to administering Resident #1's PRN pain medication. She reviewed the resident's MAR and stated, I usually work upstairs and haven't given [Resident #1] pain medication. She acknowledged that staff failed to document that non-pharmacological interventions were attempted prior to administration of PRN pain medication in October. Resident #1's Physician orders and Behavior Monitoring record revealed: A) Has resident exhibited the following behavior any time during the shift? 1) crying/sadness/excessive worrying 2) accusations against staff/residents 3) Calling 911 on (his/her) own B) Number of times? C) Which Non-Pharmacological Interventions were attempted during the shift? 1) 2) 3) D) Effective? every shift for Behaviors. Spaces labeled A, B, C, D were provided For day, evening and night shift to enter the assessment and intervention information as well as a space for staff to sign off as completed. The order failed to identify individualized non-pharmacological interventions staff should implement to assist the resident if he/she displayed behavior problems. During the interview on 10/23/25 at 10:00 AM, Staff #2 reviewed Resident #1's behavior monitoring. She acknowledged that it did not identify the non-pharmacological interventions staff should implement when resident #1 was exhibiting behaviors. When asked what she would do, she stated I would talk to him/her, redirect him/her, or offer something to read. When asked how she would know what Resident #1's individualized interventions were, she stated, Well, I know the resident I know what [he/she] likes. You gotta know your residents. When asked how someone who isn't familiar with the resident would know what to attempt, she stated I don't know, it should be written in the behavior monitoring record. On 10/23/25 at 11:08 AM the above concerns were reviewed with the Administrator, the Mobile Director of Nursing, and Staff #1 the Infection Prevention Nurse.

Based on interviews and record review it was determined that the facility failed to provide sufficient supervision to prevent an avoidable accident from occurring by not following appropriate safety procedures while using a Hoyer lift (a mechanical device used to transfer and to lift Residents). As a result, Resident (R#7) suffered a fall with harm (fractures to collarbone and femur). This was evident for 1 (R#7) of 34 residents reviewed during a complaint survey. Findings Include: Record review of the facility undated policy titled “Mechanical Lifts and Transfer” documented, it was the facility policy to “provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the Residents. Safety is a primary concern of our residents, staff and visitors. The use of mechanical lifts requires a competent and skilled user and requires the use of two (2) employees to perform the lift safely, for both residents and employees. The policy is to provide general guidance for the use of mechanical lifts, including manually operated Total Lifts, also known as (Hoyer Lift), fully mechanized total lifts, and Sit-to-Stand Lifts.” The policy further stated, “Lifts are utilized to provide a safe and ergonomic method to assist residents to transfer, stand, and toilet without physically or manually lifting them. Manual lifting can cause injury to both residents and staff and should be avoided. Staff are required to visually inspect slings, pads, belts, or chains and inspect prior to use. The policy documented, staff were not required to use a mechanical lift when there was evidence of broken, bent, or torn pieces of equipment that might render the device unsafe. “ 1.Record Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed R#32’s had a Brief Interview of Mental Status (BIMS) was a score of 14/15, which indicated the resident was cognitively intact. During an interview on 7/18/2025 at 10:48 AM, R#32 stated s/he was the roommate of R#7, and they had been roommates for several months. R#32 stated s/he remembered when staff used a Hoyer lift and dropped R#7 on the floor. R#32 stated R#7 cried in pain and was sent to the hospital. 2. Record review of R#7s face sheet showed an admission date of 10/06/2023, diagnoses included End Stage Renal Disease stage five, Dependence on Renal Dialysis and Chronic Pain. Record review of R#7s care plan, initiated on 12/9/2021, documented R#7 required assistance with activities of daily living (ADL) and had a Self-Care Performance deficit. The care plan directed staff to use a Mechanical lift (Hoyer Lift) with two staff during transfers. Record Review of the quarterly MDS dated [DATE], revealed R#7s had a BIMS score of 15/15. R#7 was impaired on one side and required total assistance with ADLs. Record review of R#7s progress notes dated 10/13/2024 at 11:04 AM, showed Registered Nurse (RN)#7 documented that she was called to R#7s room by staff and was informed R#7 was on the floor. RN#7 found R#7 lying on iron bars which supported the Hoyer lift. R#7s shoulder and head were on the iron bars supporting the Hoyer lift. R#7 complained of leg pain in her left leg. R#7 stated she hit her shoulder. R#7 was verbal, alert and oriented. R#7 was in pain and distress. R#7s daughter was present and was aware of the fall. R#7s physician was notified and R#7 was sent out to the emergency department for further evaluation. Record review of the facility, Employee Corrective Action Form (ECAF) dated 10/14/2024 documented GNA#10 was suspended after GNA#10 dropped R#7 on the floor when she used a Hoyer lift to transfer R#7 without assistance from another staff and caused a fracture of the shoulder. Record review of the facility ECAF, dated 10/16/2024 documented GNA#10 was terminated after GNA#10 violated facility policy regarding safety and carelessness. Record review of R#7s progress notes dated 10/17/2024 at 01:00 PM, showed Nurse Practitioner (NP)#27 documented she made a follow up visit after R#7 experienced a fall from a Hoyer lift over the weekend and wrote the fall resulted in a left femoral condylar fracture and a left clavicle fracture. During an interview on 7/18/02025 at 10:13 AM, RN#7 revealed she was familiar with R#7 and worked with her in the past. RN#7 stated she recalled sometime in October 2024; she was called to R#7s room when GNA#10 dropped R#7 while she attempted to transfer R#7 from her bed to the chair. RN#7 stated GNA#10 was the only staff member in the room when the accident occurred. RN#7 explained R#7’s daughter was in the room visiting. RN 7 explained, the sling was not properly fastened and hooked and stated the Hoyer lift did not malfunction. According to RN#7 the Hoyer lift functioned properly and she concluded one of the Hoyer slings was not properly fastened when it came off and caused R#7 to hit the floor. During an interview on 7/18/2025 at 1:31 PM, the Human Resources Manager (HRM)#11 revealed that GNA#10 was terminated when she violated facility policy and explained GNA10 attempted to transfer R#7 using a Hoyer and dropped R#7 on the floor. According to HRM#11, GNA#10 did not request help from other staff during the transfer. During interview and observation on 7/21/2025 at 8:45 AM, R#7 was observed in her bed and stated she recalled sometime in October 2024, GNA#10 dropped her from the Hoyer lift, and she landed on the iron bars and broke her leg and collarbone. R#7 stated she spent several months in pain. During interview and observation on 7/21/2025 at 9:15 AM, Maintenance supervisor (MS)#13 revealed all the mechanical lifts were properly serviced and were in good working condition. During an interview on 7/21/2025 at 10:30 AM, GNA#15 revealed that GNA#10 did not ask for help. She stated she was on duty and worked on the same floor when GNA#10 dropped R#7 on the floor using a Hoyer lift. GNA#15 stated facility policy required two staff persons when assisting residents with a Hoyer at all times. During an interview on 7/22/2025 at 2:38 PM, GNA#10 explained on 10/14/2024 she used a Hoyer to transfer R#7 from the bed to the chair by herself. She stated she raised R#7 approximately six feet from the ground and the strap came loose and R#7 landed on the floor. According to GNA#10, R#7 cried and stated her leg was in pain. According to GNA#10, she was suspended immediately and was terminated the next day. GNA#10 stated she asked for help, and no-one came to assist her. During an interview on 7/22/2025 at 1:15 PM, Administrator#1 revealed facility policy required two staff persons to assist residents when using a Hoyer lift. Administrator#1 stated GNA#10 should have requested assistance from another staff member and concluded the accident was avoidable. Administrator stated Quality Assurance and Performance Improvement (QAPI) will be ongoing. During an interview on 7/25/2025 at 8:30 AM, the Director of Nursing (DON)#2 stated the accident was avoidable as R#7 was a two-person assist with transfers. During an interview on 7/25/2025 at 8:30 AM, DON 2 stated the facility will continue with ongoing audits and monitoring staff during resident transfers and concluded all staff were in serviced and continuous education will be provided. Record review of facility in-service record dated 10/14/2024 showed staff were in serviced on how to use a Hoyer lift with two staff at all times. Record review of facility in-service record dated 10/17/2024 showed staff were in serviced regarding a Hoyer lift size guide and how to properly use a Hoyer lift with two staff at all times. Based on the above actions taken by the facility and verified by surveyors on site, it was determined that the facility's deficient practice was past-noncompliance with a compliance date of 10/17/24.

Based on medical record review and staff interview, facility staff failed to implement interventions to prevent a vulnerable, cognitively impaired resident (resident #2) from experiencing a fall that resulted in harm. This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Review of resident #2's medical record on 8/18/23 at 1:30 PM revealed the resident was admitted to the facility on [DATE] for long term care after receiving a diagnosis of Alzheimer's Disease and Dementia. The diagnosis of Dementia describes a group of symptoms affecting memory, thinking and social abilities severe enough to interfere with the daily life of a resident. Further review of resident #2's medical record revealed the resident was assessed by two physicians on 5/1/2020 to lack adequate decision-making capacity. Continued review of resident #2's medical records on 8/18/23 at 2:00 PM revealed the resident had an unwitnessed fall with major injury on 6/25/23 at 8:30 PM. The post-fall evaluation dated 6/25/23 revealed the resident was found on his/her back with the resident's bed in a high position. LPN #3 assessed the resident and discovered a skin tear to the left hand. Resident #2 reported no pain and was able to move all extremities. The resident's injury to the left hand was cleansed and bandaged. Resident #2 was assessed by provider #5 in a video/telehealth visit on 6/25/23 at approximately 8:50 PM. Provider #5 documented that the resident expressed no pain and LPN #3 reported no other injuries other than the left hand injury. LPN#3 documented that the resident received scheduled pain medications of a 625 mg tablet of Tylenol and a Lidocaine patch for any possible post fall pain. Provider# 5 gave orders to perform neurological checks based on facility post-fall protocols and to monitor the resident's progress. Provider #5's notes revealed the resident had no apparent sign of head injury noted during the telehealth assessment including bruising or lacerations. Provider #5 also documented, based on LPN#3's report, that the resident was found with his/her bed at a height that was approximately 3 feet from the floor. Additional review of resident #2's medical record revealed Unit Manager #4 documented on 6/25/23 at 8:58 PM that facility nursing staff heard a loud bump from resident #2 's room, went to the resident 's room to check on the resident, and found the resident on his/her back on the floor. Nursing staff assessed the resident, cleaned the left hand skin tear, and provided comfort care. When Unit Manager #4 attempted to assess the resident after LPN #3 's initial assessment, resident #2 was moaning and angry at any attempts to assess injuries sustained from the fall but denied any pain. Unit Manager #4 also stated no other injuries were found other than the left hand skin tear. Review of resident #2's medical record on 8/18/23 at 2:45 PM revealed LPN #7 assessed the resident at 11:38 PM and discovered the resident's pillow had blood on it from a wound behind the resident's left ear. LPN #7 also documented that the resident refused care because of extreme pain to the right leg which appeared swollen, red and displaced. LPN #7 called the on-call provider and received orders to send the resident out to the local hospital for emergency treatment. Hospital discharge records dated 6/26/23 revealed the resident was seen at the local hospital 's emergency roiagnom on [DATE] at 12:30 AM. The discharge record documented the resident was noted to have a small laceration to the left side of his/her head near the ear. The discharge record also documented the resident sustained a fracture of the right tibia (shinbone/lower leg) which required the resident to use a knee immobilizer to the right knee and to avoid placing weight on the injured leg. The immobilizer is a leg brace that is used to stabilize the knee to assist in the healing process. Review of resident #2's medical record on 8/18/23 at 3:00 PM revealed the resident sustained changes to his/her functional status due to the fall on 6/25/23. Resident #2 was evaluated as requiring extensive assistance for bed mobility (movement) and transfers (from the bed to his/her wheelchair) on 5/1/23, which was prior to the 6/25/23 fall. On 8/1/23, which is after the 6/25/23 fall, the resident now requires total dependence on facility nursing staff to transfer. Interview with Regional Director of Nursing (DON) #2 on 8/18/23 at 3:15 PM confirmed resident#2 sustained a fall with injury on 6/25/23 at approximately 8:30 PM. Regional DON #2 reviewed resident #2's medical records and confirmed the resident sustained harm from facility nursing staff failing to implement interventions to prevent a fall. Interview with the Regional Administrator #1 and Regional Director of Clinical Services #6 at 8/18/23 at 4:00 PM confirmed the resident sustained injuries from a fall from his/her bed on 6/25/23 that was higher than the lowest position. Interview with LPN #3 on 8/18/23 at 4:50 PM revealed the resident sustained a fall on 6/25/23 at approximately 8:30 PM after the resident fell from the bed being in the high position, approximately 2 feet from the floor. LPN #3 stated that the resident normally doesn't attempt to get out of the bed without assistance. LPN#3 was unable to determine why the resident attempted to get out of bed. LPN #3 could not recall any other injuries other than what was documented in the electronic record. During an interview with Regional Administrator #1 on 8/21/23 at 12:00 PM, the surveyor expressed concern that the facility failed to adequately supervise resident #2 which led to a fall incident where the resident sustained injuries that required transfer for emergency treatment. Regional Administrator #1 provided no new information regarding the deficient practice.

Based on record review, and interviews of staff and residents, it was determined that the facility failed to ensure that residents were free from abuse. This was found to be evident for 1 (Resident #88) out of 11 residents reviewed for resident to resident abuse and 4 (Resident #20, #38, #16, #8) of 40 residents reviewed for facility reported abuse allegations. As a result, actual harm was identified for the facility's failure to ensure that resident # 88 was free from physical abuse and injury due to another resident's aggressive behavior. The findings include: An FRI (facility reported incident) is a self- report with investigations conducted by nursing home facilities. 1) On 01/05/23 at 08:47 AM, the surveyor interviewed the residents #72 and #74. Resident # 72 stated that, on 01/01/23 at around 10:00 AM, another resident, #73, entered his/her room and grabbed his/her left forearm, scratched the skin, twisted his/her wrist, and left bruising on the left forearm below the elbow. On 01/05/23 at approximately 10:30 AM, the surveyor requested that the Administrator provide a copy of the FRI related to Resident #72 and the surveyor completed the review of the FRI at approximately 2:30 PM on 01/05/23. A review of the medical record revealed documentation by LPN # 4 that, on 01/01/23 at 11:35 AM, Resident #73 entered another resident's room, grabbed their arm and caused discoloration. The Nurse practitioner (NP) on call was made aware and the resident's family members were updated on the situation. The surveyor reviewed the FRI for resident #73 which included an interview completed around 12 noon on 01/01/23 by the facility staff with Resident #88 who stated that he/ she went to their room to sit on the bed. Resident # 73 entered the room and was trying to take things from her roommate in bed #1 and the resident in bed #1 was telling resident #73 to stop. Resident # 73 proceeded to walk to bed # 2 and take something off the bed. Resident #88 told Resident # 73 to not bother the resident in bed 2 and to leave her things alone. Resident # 73 then walked to the window ledge and picked up Resident # 88's bible. Resident #73 proceeded to hit Resident #88 in the face with the bible and then exited the room. Resident # 88 stated that they went to the hallway and saw Licensed Practical Nurse (LPN) # 40 and informed them of the physical altercation. Resident # 88 was physically assessed and noted to have blood present on the bridge of the nose and a bruise on the forehead. Notifications were made to the on-call medical doctor and the nurse practitioner (NP). GNAs were instructed to watch/monitor Resident # 73 prior to a hospital transfer to the emergency room . A review of the S-BAR, Change in Condition document that was written on 01/01/23 at 11:17 AM by LPN #48, revealed that Resident #73 appeared to be agitated with a diagnosis of dementia and psychosis.The recommendations for nursing were to continue to monitor Resident #73. Primary care provider : Recommendations: monitor. Written by LPN # 48. New Intervention Orders: Removed Resident and de-escalated situation. During a telephone interview with LPN # 48 on 01/13/23 at approximately 2:52 PM, the surveyor asked: What preventive measures were instituted after the first display of aggressive behavior was demonstrated by Resident #73 around 10:00 AM on 01/01/23? LPN # 48 stated that staff (GNAs) were told to monitor Resident #73 and to shut all the other residents' door to discourage Resident #73 from wandering into the other resident's rooms. LPN # 48 also stated I did use de-escalation techniques with Resident # 73. and that All staff were assigned the task of monitoring resident #73 in the hallway. During an interview at 1:24 PM on 01/13/22, the DON stated: The resident should have been placed on 1:1 after the first display of aggressive behavior. The surveyor asked : Has any staff education been provided since related to resident/resident abuse? The DON responded: I provided an in-service to all staff on 01/02/23. During the in-service, I emphasized that any aggressive residents should be placed on 1:1 immediately in order to prevent potential harm to other residents or staff. On 01/12/23 at approximately 2:22 PM, the surveyor reviewed a FRI for a second resident-to-resident physical altercation that occurred on 01/01/23 at approximately 12 noon, that involved the same perpetrator, Resident # 73. The second victim of alleged resident to resident physical abuse was Resident #88. On 01/13/23 at 1:23 PM, the surveyor reviewed the progress notes related to Resident #73, written on 01/01/23 beginning at 12:18 PM. Staff # 50 wrote the following: Diagnosis: Altercations, Change in mental status, possible infection, UTI. Notified that resident has had x2 altercations with 2 other residents. The aggressive resident caused a bruised area to upper extremity during the first altercation, but no skin tears were noted. After the second altercation involving Resident #73, Resident #88 sustained injuries described as blood on the bridge of the nose and bruising to the forehead. Aggressive resident is typically calm and cooperative. She/he was alert and oriented x1 with known aphasia. She/he is currently aggressive toward other residents and now with staff. During video assessment, Resident #73 was verbally aggressive, yelling and charging at staff. Due to significant change in behavior and to provide safety to staff, NP recommended transfer of Resident #73 to the ER. NP felt she/he may be experiencing an infection such as UTI. On 01/13/23 at 1:32 PM, the surveyor reviewed the medical record related to resident #88. A change in progress notes written by LPN #40 at 12:18 PM on 01/01/23 revealed the resident had a skin condition change that involved the top of the scalp with redness and mild bruising to the forehead. Also, there was a second skin assessment signed by LPN #2 on 01/03/23 but dated for 01/01/23. The second skin assessment stated that Resident #88 had a new red colored abrasion that measured 0.2 X 0.2 (LxWxD) on the face/forehead. On 1/13/23 at 10:30 AM, a review of the electronic medical record revealed that, on 01/01/23, Resident #73 was transferred to Meritus Hospital. The change of condition form included the following information: Reason for transfer: Resident to be evaluated for the changes in mental status and physical aggression displayed towards other residents. The two resident/resident physical abuse allegations were substantiated by the facility. Resident #73 was identified as the aggressor in both facility investigations. In summary, the facility failed to ensure that resident # 88 were free from physical abuse due to resident #73's aggressive behavior. At 1:30 PM on 01/13/23, the Nursing Home Administrator and the DON were interviewed regarding the two FRI's submitted to OHCQ (the Office of Healthcare Quality) related to resident # 73. Additionally, both the Nursing Home Administrator and the DON were notified of the potential harm related to Resident #73, during the exit conference on 01/13/23 at 4:00 PM. 40927 A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) test is used to get a quick snapshot of cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. 2. A medical record review on 12/28/22 at 9:24 AM for Resident #20 revealed the resident had been in the facility for approximately 2 years. A progress note written for a visit conducted on 1/4/22 by Certified Nurse Practitioner (CRNP) #6 revealed that Resident #20 suffered from many health issues to include, but not limited to diabetes, high blood pressure, chronic kidney disease, and bipolar disease. CRNP #6 documented that Resident #20 used a wheelchair to get around the facility. A review of the progress notes and administration records for medication and treatment for 12/21 revealed one documented behavior of medication refusal on 12/26/21. Otherwise, staff had not documented behaviors for this Resident #20. Further review of the medical record revealed that the resident was evaluated by the facility's mental health services on 12/16/21, following a readmission to the facility. The visit was conducted by CRNP #63. She noted that Resident #20 was being seen as a follow up requested by the facility. She documented that nursing staff reported the resident had no recent behavioral or mood concerns, elopement attempts, or episodes of resisting care. The note further read that Resident #20 was cooperative with medication administration and voiced no suicidal ideations or passive death wishes per nursing. Resident had questionable judgement, limited ability to effectively problem solve, and was goal directed. Resident was to continue antipsychotic medication for treatment of bipolar disease. On 12/28/22 at 9:33 AM, a review of the facility's investigation file for self-reported incident #MD00181051 was conducted. The self-report concluded that Resident #20 had been abused by an agency Licensed Practical Nurse (LPN) #49 on 1/9/22 during the evening shift. The facility provided in-service sign-in sheets as evidence that staff were given education about the different types of abuse and abuse reporting. There were interview sheets for the residents capable of an interview and skin sheets for residents who had not been capable of an interview, and no additional abuse concerns had been identified. A review of the witness statements collectively revealed that, on 1/9/22, the facility was in a COVID 19 outbreak and as residents tested positive for COVID 19 they were being moved to the COVID 19 positive unit referred to as the red zone and there was a plastic barrier between the red zone and the rest of the unit which was considered the green zone. According to the statements, the red zone staff were to stay in the red zone and green zone staff were not to go into the red zone and so forth. However, that day staff had been crossing over into the other zones to move residents and provide care. The Nursing Home Administrator (NHA) provided an undated statement from Resident #20 (but did note the date that the incident occurred was on 1/9/22). The statement described what Resident #20 had observed on 1/9/22 regarding staff not adhering to the red zone and green zone as they moved residents to the COVID 19 positive unit and provided care. It further described that Resident #20 had attempted to address the issues/concerns with staff to which they didn't seem to be listening. As LPN #49 was transporting a resident to the red zone, he tore a hole in the plastic barrier and Resident #20 asked him about it and was told that he would fix the hole. The resident left the unit for an hour and returned to see staff sitting in the nurses' station and LPN #49 had his mask off while talking to the other staff. Resident #20 noted that the hole had not been fixed and s/he became infuriated. Resident #20 started recording on his/her cell phone the hole in the plastic and the staff sitting in the nurses' station not wearing a mask. Resident #20 reports that an argument occurred between them and LPN #49 and they were cussing at each other. LPN #49 proceeded to come out of the nurses' station towards the resident to grab the resident's phone from them. Resident #20 then alleges that LPN #49 started to punch his/her hand so the resident would let go of the phone. Resident #20 then reported that s/he started punching LPN #49. Reportedly, LPN #49 backed off and stated he was going to call the police, but then started back towards the resident. At this point the resident grabbed a pair of scissors and told LPN #49 s/he would stab him if he attacked him/her again. Resident #20 reported that s/he went to the lobby and called the police. The statement provided by LPN #49, dated 1/9/22, read that he asked Resident #20 to stop recording on his/her cell phone because of HIPAA (The Health Insurance Portability and Accountability Act of 1996 a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. www.cdc.gov) and the privacy rights of the staff. LPN #49 reported that when Resident #20 continued to record with the cell phone he went over to the resident and attempted to grab the phone from the resident. Reportedly, when Resident #20 grabbed a pair of scissors and threatened to kill him, LPN #49 walked away to call the Director of Nursing (DON). LPN #49 reported that the DON advised him to call the police. Although it was mentioned in LPN #49's statement that he reported the incident to the DON, review of the investigation file revealed no documentation from the DON regarding the date, time, and content of the conversation. A statement from agency Registered Nurse (RN) #68 confirmed that Resident #20 had been upset regarding the way staff were going from the red zone to the green zone during the shift. She reported as the resident continued to get angry, calling us names, taking pictures, and recording us she had asked LPN #49 to assist because the resident was getting out of control. RN #68's statement confirmed that she had been present and that LPN #49 had attempted to take the resident's phone from his/her hand, however, she did not report that LPN #49 was cussing and arguing with the resident, only that he had been trying to explain things to Resident #20. According to RN #68's statement, During my time at Hagerstown Healthcare Center, I have not seen or heard of any employee abusing residents therefore, she had not identified this incident of a staff member arguing, yelling, and cussing at a resident and attempting to grab a cell phone from the resident's hand as abuse. Nor had she documented she had intervened to separate the abusive staff member from the resident to protect the resident. A statement from agency Geriatric Nursing Assistant (GNA) #69, dated 1/9/22, revealed that she had words with Resident #20 regarding the red zone and green zone and that the resident had been upset. Reportedly, she had been present during the abusive altercation between LPN #49 and Resident #20, by stating that LPN #49 had told Resident #20 to stop recording and a heated argument occurred. Based on GNA #69's statement, she had not attempted to intervene when abuse occurred to protect the resident. An unsigned, undated statement from GNA #66 indicated that on 1/9/22, she had been working on the yellow unit and overheard the arguing. GNA #66 went to see what was going on and heard Resident #20 saying that the staff were trying to give the residents COVID and that s/he had been upset about the hole in the tape. Reportedly, GNA #66 had not heard everything that had been said between Resident #20 and LPN #49 but confirmed that they had been loud and LPN #49 was trying to get his point across. She reported that, when Resident #20 threatened to kill LPN #49, she had intervened to calm the resident down. Based on her statement, she had not attempted to separate LPN #49 from Resident #20 to protect the resident, when in fact she walked away and went back to the yellow unit. She recounted that LPN #49 started to follow her, so he could move another resident. Then an unidentified nurse came in to let LPN #49 know that Resident #20 was further threatening him and that was when LPN #49 called someone who had told him to call the police. GNA #66 failed to recognize this incident as abuse due to a sentence she had in her statement that read, During my time at Hagerstown Healthcare Center, I have not seen or heard of any employee abusing residents. A statement from GNA #32, dated 1/9/22, revealed that she had seen Resident #20 in the lobby holding a pair of scissors. Reportedly, when she asked the resident what s/he had been doing with the scissors, the resident responded that s/he were defending themselves. GNA #32 asked the resident to give the scissors to her and the resident complied. A medical record review on 12/28/22 at 9:24 AM revealed a progress note that Resident #20 had been seen by CRNP #106 on 1/10/22. CRNP #106 documented that the resident was seen on rounds secondary to an incident that occurred over the weekend. Patient said to have become verbally abusive towards staff and then threatened a male staff member with scissors. Resident #20 was calm this morning and stated that he had no intention to hurt anyone. The resident stated that he felt threatened at the time of the incident and was only trying to defend himself. Patient stated that he was not worried about his personal safety. However, there was no mention that Resident #20 had been abused by staff. Further review of the medical record revealed a subsequent visit from the facility's psychiatric services provider on 1/11/22 in which Resident #20 was seen by CRNP #63. She documented in the note that resident was being seen following an incident of agitation, aggressive behavior towards staff, and threatening staff with scissors. CRNP #106 doesn't mention or address that Resident #20 had been abused by a staff member. On 12/28/22, a review of LPN #49's employee and education file revealed no behavioral health training. On 12/28/22, a review of RN #68's employee and education file revealed no behavioral health training. On 12/28/22, a review of GNA #66's employee and education file revealed no behavioral health training. During the review of LPN #49, RN#68, and GNA #69's employee files, it was determined that all three staff had worked for the same staffing agency. On 1/5/23 at 12:30 PM, a review of the staffing agency's contract with the facility, dated 5/21/21, revealed that the staffing agency was responsible to ensure that staff had the appropriate training to care for the residents in the facility. However, there was no process for the facility to inform the staffing agency of the training needed to care for their residents. On 12/28/22, a review of GNA #69's employee file revealed she had been employed by the facility. She had completed the online temporary nurses' aide training on 12/17/21. The facility provided no evidence of any training completed by GNA #69, no evaluation of resident care competencies, and no evidence that she had been trained on the behavioral health needs of residents. A review on 1/5/23 at 1:00 PM of the facility's assessment tool, dated 8/20/21, revealed the facility had failed to identify the training/competency needs for the staff to care for their resident population. On 12/28/22 at 11:15 AM, an interview was conducted with LPN #49 and he reported he remembered being asked by the DON to help move residents who were COVID 19 positive to the COVID 19 positive unit. He reported that he had 30 residents on the 2nd floor and had to go to the first floor to move the residents as requested ,which he felt doubled his workload. When asked about the specific events of 1/9/22, LPN #49 stated that due to the legal battle, he did not feel comfortable discussing it with the surveyor. On 1/5/23 at 10:53 AM, surveyor reviewed the concerns with the Director of Nursing and the Regional Director of Clinical Services #22. During an interview completed on 1/11/23 at 12:35 PM with the Nursing Home Administrator (NHA) and Corporate Executive Director #29 to review the concerns, it was stated that the facility relied on the staffing agency to send them staff who were able to provide care and services for the residents at the facility. However, they reported that, once a contract was signed with a staffing agency, there was no additional information sent to them regarding changes or updates in the resident population. While discussing the concern that none of the staff intervened to protect the resident and wrote statements indicating that LPN #49 was only trying to get his point across, the NHA reported that when things like that were identified, they provided training to the agency staff who were present on the days that the training had been offered. They had not held additional training to ensure that all agency staff had been trained. When asked the rationale for the facility's determination that physical abuse had not been substantiated, the NHA stated that they had substantiated the verbal abuse because it was recorded on the resident's phone. She stated that, when LPN reached the resident, the recording stopped, but she wanted to review the investigation notes and get back to the surveyor. A subsequent interview with the NHA on 1/11/23 at 2:45 PM revealed that they reviewed and determined that the intention of the staff member (LPN #49) was to remove the phone from the resident to stop him from recording them. However, when asked if it was appropriate for a staff member to grab a phone from a resident's hands, she responded, no it is not. The NHA stated she understood what the surveyor was asking, but they had identified a problem with residents recording things on their cell phones and was concerned about the privacy of the other residents. The NHA could not provide evidence that the facility had provided any guidance to staff on how the facility wanted them to handle an incident involving a resident recording within the facility. She stated that the staff would call management and they would instruct staff on what to do at that time. 3) On 1/4/23 at 9:32 AM, a medical record review for Resident #38 was conducted. A minimum data set with the assessment reference date of 3/22/22 revealed in section C that the resident had a BIMS of 15 which indicated no cognitive impairment and section E had no documentation indicating that this resident had behaviors. Review of the progress notes revealed this resident had a visit with the attending physician on 4/18/22 and she had documented the resident had the following, but not limited to diagnoses: morbid obesity, chronic back pain and now was having bilateral knee pain. His pain was treated with a narcotic and an analgesic for break through pain. A progress note written by Registered Nurse (RN) #71 on 4/21/22 revealed that resident was having uncontrolled pain at an 8/10 over the past 5 days. On 1/3/23 at 9:25 AM, a review of the facility's investigation file regarding self-report #MD00182599 revealed they had determined that, on 4/21/22 at 11:00 AM, RN #70 had abused Resident #38. According to the documentation, it was a witnessed altercation and RN #70 was removed from the area and an investigation was started. According to the statement provided by Resident #38, the resident had been asking RN #70 for pain medication on the morning of 4/21/22. At 10:10 AM, the resident was talking to Unit Nurse Manager (UM) #2 in his/her room. While they were talking, RN #70 came in and said to Resident #38 that he had told him/her he would be with them shortly. The resident reportedly became upset and attempted to get out of bed and that was when UM #2 stepped between them to try to deescalate the situation. A statement from RN #70 read that he thought that Resident #38 had called UM #2 into his/her room to complain about RN #70's delay with getting the pain medication as requested. A statement from UM #2 read that she had been in Resident #38's room talking with the resident about the situation with the pain medication being delayed when RN #70 came into the room and started yelling at the resident. She stated she had to step between them and was asking RN #70 to leave the room. There were additional statements from other staff who had been on the unit at the time of the incident and reported hearing RN #70 yelling. As a result of the investigation, RN #70 was terminated. The facility reported their interventions were to monitor Resident #38's psychosocial wellbeing and staff from Social Services were to meet with Resident #38 to discuss disrespectful behaviors from staff. 4) A medical record review for Resident #16 was conducted on 1/11/23 at 4:06 PM. A Minimum Data Set, with the assessment reference date 5/29/22 in section C, revealed this resident had a BIMS of 15/15 which indicated no cognitive impairment. According to Certified Nurse Practitioner (CRNP) #5's progress note, dated 9/23/22, Resident #16 was in the facility for management of Chronic Obstructive Pulmonary Disease (COPD - lung disorder that is defined by a person being diagnosed with at least two of the following lung conditions: asthma, chronic bronchitis, and/or emphysema), diabetes type 2, chronic kidney disease, and depression. Review of the record failed to reveal that staff had documented that Resident #16 had behaviors. Further review revealed this resident was locomotive throughout the facility on a motorized scooter. On 12/29/22 at 3:30 PM, a review of the facility's investigation file for the self-report #MD00184946 was conducted. The facility documented on the self-report form that, on 10/26/22 at 9:00 AM, Resident #16 had been waiting at the elevator on the 1st floor with an agency Licensed Practical Nurse (LPN) #71 who proceeded to state to the resident that s/he needed to let the ambulance people go first. An argument occurred and LPN #71 was overheard calling Resident #16 a curse word. A former Unit Manager (UM) #104 and a Geriatric Nursing Assistant (GNA) #105 had witnessed the altercation. Resident #16 and LPN #71 had been separated. Statement taken from UM #104 and GNA #105 confirmed that LPN #71 had called Resident #16 a curse word. The facility had concluded that the abuse was substantiated. As a result of the investigation, the facility reportedly contacted LPN #71's staffing agency and provided evidence that the following trainings were provided for all facility staff regarding Customer Service, 7 Types of Abuse, and Behavior Management. An interview conducted on 1/11/23 at 12:35 PM with the NHA and Corporate Executive Director #29 revealed that, in review of the abuse cases since January 2022, they had not provided any type of behavior management training for staff until recently they reached out to their psychiatric service provider to give a training on how to manage residents with behavior issues. When asked to provide behavior health training that was provided upon hire and annually, they provided training for residents with dementia, however, the residents involved in these incidents had no cognitive impairment. Cross Reference: F607, F609, and F610. 37276 5) On 12/21/22 at 1:00 PM, a review of Facility Reported Incident MD00176589 revealed that, on 4/1/22, Resident #8 reported that a housekeeper, Staff #118, gave him/her the middle finger. The facility investigated the allegation and substantiated that the abuse occurred, and the employee was terminated for abuse. The substantiated abuse was discussed with the Director of Nurses (DON) on 1/3/23 at 4:07 PM.

Based on review of resident medical records, interview with facility staff, interview with the staff of contracted Hospice services, and review of facility policy, it was determined that, when the facility was unable to immediately identify a resident's end-of-life wishes upon his her/[MEDICAL CONDITION], the facility failed to perform Cardiopulmonary Resuscitation (CPR) while they attempted to clarify the resident's wishes.As a result of these findings, a state of immediate jeopardy was declared on [DATE] at 12:30 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on [DATE] at 4:00 PM and the State Agency was unable to accept this plan. The facility submitted a second plan on [DATE] at 6:30 PM and the removal plan was accepted at 7:00 PM. The immediate jeopardy was removed on [DATE] at 9:30 AM Following the removal of the immediate jeopardy finding on [DATE], the scope/severity of the tag was lowered to a D level deficiency. This was evident for 1 (Resident #327) of 3 residents reviewed for death. The findings include: Resident #327's medical record was reviewed on [DATE] at 11:25 AM. During the review, the following note was found by Licensed Practical Nurse (LPN) #28 written on [DATE] at 7:48 PM: While going to administer medications, (Resident #327) was unresponsive at 6:48 PM, with no pulse. RN made aware and hospice notified. Another note was found written by RN #21 on [DATE] at 8:53 PM that stated, Was called to 1st floor for (Resident #327) being unresponsive . Checked (Resident #327's) [NAME]land Orders for Life-Sustaining Treatment (MOLST) form and it was not clear. (Physician #23) was called immediately and s/he stated the resident was Do Not Resuscitate (DNR). Hospice was notified. Time of death 6:48 PM. RN #21 was interviewed by telephone on [DATE] at 1:00 PM. During the interview, RN #21 stated that s/he was on the second floor when s/he was called to come down to the first floor because Resident #327 wasn't breathing. Upon arrival to the unit, RN #21 stated that s/he went to the room, confirmed the resident was deceased , and then asked staff who were present in the room (doesn't recall who) if anyone knew the resident's code status. RN #21 stated that the staff all indicated they did not know. RN #21 stated that s/he then went to the paper medical record to refer to the resident's MOLST, however this form was ambiguous because both Perform CPR and Do Not Perform CPR were checked off. RN #21 stated the form had been filled out by the hospice physician (Staff #26). RN #21 stated that s/he then called the attending physician (Staff #23) who said not to do CPR because Resident #327 was on hospice and the code status had already been discussed. When asked what s/he would have done if s/he could not reach Physician #23, RN #21 refused to answer. When asked why s/he was called for this code event, RN #21 stated that, although s/he was not the supervisor, s/he was the RN on duty in the facility and is frequently called to code events to run the code. RN #21 confirmed that no CPR was performed on Resident #327. LPN #28 was called on [DATE] at 1:10 PM and stated that s/he could not recall events from a date as long ago as [DATE]. When asked about the resident, LPN #28 stated that s/he did not remember that resident. When the surveyor read him/her the above note that s/he had written on [DATE], LPN #28 stated that s/he did not remember writing that note nor the events of that night. There was no evidence in the medical record or provided by the facility to indicate that CPR was ever provided by the facility staff to Resident #327 when s/he was found unresponsive and his orders for end of life care were unclear on [DATE]. The facility provided a policy entitled, Initiate CPR, with an effective date of [DATE] to the survey team on [DATE]. The policy stated that, The facility will maintain and train staff on a communication method that will quickly alert staff as to the code status of a resident in the event heart or respirations cease. Residents found unresponsive, not breathing or without a pulse, will have staff immediately locate the Code Status and communicate this to the team. Code status will be reviewed and updated for any changes, new orders, new advance directives and with each transfer to remain current with the resident requests. The Director of Nursing (DON) was interviewed on [DATE] at 12:30 PM. During the interview, the DON stated that s/he was aware of the confusion that the MOLST dated [DATE] caused nursing staff on the night of [DATE] and had performed an investigation afterwards. The survey team requested evidence of the DON's investigation and a single page document entitled, Follow Up Investigation From (Resident), was provided on [DATE]. The investigation specified the following: Notified Medical Director - Had Med Director review chart on visit. Attending physician reviewed chart and made note regarding code status on [DATE]. Hospice Leadership accepted education and stated that they will educate their team. MOLST audit conducted on all hospice residents by Medical Director and no other residents were identified. The Follow Up Investigation did not specify any education that the DON provided to nursing staff or any education that the Medical Director provided to facility providers. As a result of these findings, a state of immediate jeopardy was declared on [DATE] at 12:30 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on [DATE] at 4:00 PM and the State Agency was unable to accept this plan. The facility submitted a second plan on [DATE] at 6:30 PM and the removal plan was accepted at 7:00 PM. The immediate jeopardy was removed on [DATE] at 9:30 AM. After determination of immediate jeopardy concerns, an extended survey was conducted from [DATE] until [DATE]. The facility's accepted plan of removal contained the following provisions: -House wide audit on [DATE] by nursing leadership to identify other residents with MOLST forms containing conflicting code status orders. -Education of all nursing and social service staff by Staff Development on [DATE] and ongoing regarding requirement of clear and accurate MOLST forms. -Education of all nursing staff by Staff Development on [DATE] and ongoing to initiate CPR if the MOLST is unclear. -Facility physicians and extenders educated by Medical Director on [DATE] with in-person education on [DATE] regarding clear and accurate MOLST. -Auditing by social worker and medical records of 10% of MOLST forms for accuracy weekly x3, monthly x3. Report to QAPI committee meeting.

Based on review of facility reported incidents and review of the facility investigations, it was determined the facility staff failed to protect residents from verbal and physical abuse, resulting in a finding of actual harm to residents #174 and #31. This was evident for 2 of 3 facility incident reports reviewed. The findings include: 1) Resident #174 was alert and oriented times 3 and dependent on staff for activities of daily living. Review of facility reported incident MD 509 and the facility investigation that was initiated on 07/14/15 revealed an investigation that determined and substantiated that Geriatric Nursing Assistant (GNA) #9 had verbally and physically abused Resident #174 on 06/19/16 and 6/20/16. The facility investigation determined, through resident and staff interview, that GNA #9 had answered the call light for Resident #174 and stated oh look at you. You got (expletive) all over you. You gotta go to the shower. You gotta get this (expletive) off of you. Resident #174 stated she was drug into the shower and stated to GNA #9 that the water was cold and asked to please wait until the water got warmer. Resident #174 stated that he/she was told to hold onto the rail and continued to be showered with cold water. Continued review of the investigation revealed that GNA #10 stated that he/she stood at the shower room door while GNA #9 showered the resident. GNA #10 stated that the resident complained the entire time the water was too cold. A second interview was conducted with Resident #174 by the Director of Nursing and Assistant Director of Nursing to clarify and obtain more information. Resident #174 stated that he/she had to use the bathroom and he/she put on his/her call light. Resident#174 stated it must have rang at least an hour and I pooped the bed. GNA #9 entered the room and said I was full of (expletive) and I'm not washing that stuff off I'm going to put you in the shower. GNA #10 just stood back and observed. Resident #174 stated they walked me down the hall with the walker, took the walker away when I reached the shower and pushed me in the shower. I said don't put me in there, it is cold.I had to stand in the shower and hold onto the handicap rail. I was thrown a towel and told to dry off. GNA #10 did not participate but stood back and observed. Further review of the incident revealed that GNA #10 was terminated for improper conduct for failing to intervene or ask for assistance, and then participated in a shower during which the resident was refusing and yelling that the water was too cold. GNA #9 was terminated for improper conduct for cursing during care. GNA #9 showered the resident after the resident requested not to be showered with cold water. GNA #9 did not adjust the water temperature or remove the resident from a shower after the resident complained the water was too cold. Discussed with the Director of Nursing on 9/20/16 at 12:30 PM. 2) On September 13, 2016, facility reported incident # MD 396 was reviewed, in which GNA #8 was witnessed making inappropriate comments to Resident #31 while giving him/her a shower on March 25, 2016 at 8:00 PM. The facility conducted an investigation and obtained a statement from the Director of Admissions (DOA) who was a witness and overheard the conversation between GNA # 8 and the resident. In the DOA's witness statement, dated March 28, 2016, she stated that, while walking past the shower room, she heard the voice of Resident #31 and her aide, GNA #8. The DOA stated that she overheard GNA #8 say to Resident #31 that it was difficult to care for her because of how fat she was. The DOA indicated that GNA # 8's tone of voice was loud and that the manner in which she was speaking to the resident was cruel and demeaning. The DOA stated that the GNA repeated several times to the resident,your stomach is too fat,no one wants to take care of you, you can't do anything for yourself, your husband can't take care of you and that you'll never get out of here. The DOA knocked on the door and when it opened, she was able to confirm who the resident and GNA were. The DOA told GNA # 8, that she heard everything and that she was going to report the incident immediately to the DON. Review of Resident #31's March 28, 2016 statement revealed that GNA # 8 was mean. Resident #31 reported in her statement that GNA #8 was grabbing and throwing me down (the resident pointed to her abdomen). Resident #31's statement indicated that she told GNA # 8 to stop grabbing and throwing her. Resident # 31's statement further indicated that GNA # 8 told her,I can grab you if I want to. The resident stated the GNA was being hateful. The resident went on to say in his/her statement that, she told the GNA, if you do it again, I'm going to slap you. The resident said GNA # 8 jumped in his/her face and said to him/her, if you hit me, I will bust you in the jaw; with her fist in my face. GNA #8 submitted a statement and to summarize it, admitted that, as she dried underneath Resident #31 belly, the resident raised her arm striking at her and said ( expletives) to her. GNA # 8 told Resident #31 that she wasn't going to (expletive) deck me. GNA # 8 told Resident #31, If I hit you, I go to jail. I'm not your slave, you can't just beat on me. GNA # 8 stated that she was ashamed of her reaction. The facility substantiated the allegations of abuse. The GNA was terminated. The State Board of Nursing was notified.

Based on medical record review, facility documentation review, resident and staff interview, it was determined that, due to inadequate supervision, a resident(#134) subsequently fell and sustained 2 hematomas to the back of the head resulting in a finding of actual harm. This was evident for 1 (#134) of 4 residents reviewed for accidents. Additionally, the facility failed to ensure that the plastic handrails in the hallways were joined together without creating sharp gaps. This was evident on 1 of 2 nursing units observed. The findings include: 1) On 9/13/16 at 10:45 AM, Resident #134 suffered a fall while unattended in the shower. According to a written statement by Geriatric Nursing Assistant (GNA) #1, GNA #1 was giving the resident a shower when another GNA came into the shower room asking for assistance with another resident who needed to be cleaned before they could go to their appointment. GNA #1 left the shower room to go help when another GNA came to GNA #1 and advised that Resident #134 was on the floor in the shower room. Resident #134 hit his/her head and sustained 2 hematomas to the back of his/her head and was transferred to the emergency room for evaluation. Resident #134 was asked on 9/16/16 at 10:29 AM to explain what happened in the shower. Resident #134 stated I should not have been alone. It's all about the quickness. She he/ took me to the shower room and I sat on a chair and the thing started rolling backwards on me. I sat down on the chair and started washing and she/he got me the rag with suds on it and I washed until 2 girls knocked on the door and they said they needed help, so the GNA left the room. I couldn't believe it. I wiped off to get dry because he/she likes to get done so fast and when he/she came back I was on the floor. The floor was slippery because of the suds. I have scoliosis in my back and my one leg is 2 inches shorter than the other. They left me on the floor until the ambulance got there. I went to the hospital and they checked my head and did a head scan. Interview of Licensed Practical Nurse (LPN) #6 on 9/16/16 at 11:20 AM revealed that LPN #6 took care of the resident the day of the fall. LPN #6 stated the GNA left the room to help another GNA with a dialysis resident who needed to be transferred and in that short amount of time the resident fell . The resident stated the floor was slippery. The resident stated he/she hit his/her head and there was a small hematoma on the back of the head. I called the doctor and the doctor wanted the resident sent out to the hospital. 2) During a tour with the Maintenance Supervisor, on 9/20/16 at 10:10 AM, on the second floor nursing unit, the plastic handrails were noted with gaps where the handrails joined together which created sharp edges. The following observations were made: The handrail next to the elevator had an approximate one quarter inch gap that was sharp.There was a gap in the handrail outside of Room #121, next to the clean utility room, there was a half inch gap. Outside Room #123, there was a quarter inch gap and the underneath section was sharp. Outside Room #131, there was a half inch gap and there was a one third inch gap at the corner of the hall on both ends of the handrail. There was a quarter inch gap outside of the showers and office and the corner outside of the janitor's closet. By the end of the hall on the corner there was a three quarter inch gap in which an index finger was able to fit through the gap. The Maintenance Director stated that the handrails would be taken care of immediately.

Based on reviews of a facility reported incident and interviews with Resident #3 and the facility staff, it was determined that the facility staff neglected to address and medicate a resident with a complaint of a headache which lead to a physical confrontation between LPN #1, LPN #2 and Resident #3. The facility investigation determined that LPN #1 and LPN #2 physically abused Resident #3 in September 2015. This was evident for 1 of 6 (Resident #3) residents reviewed during a complaint survey. The findings include: Review of facility reported incident MD 256, on 03/11/16, revealed an allegation and investigation which determined that LPN #1 and LPN #2 had physically abused Resident #3 on 09/15/15 at 11:12 PM. In an interview on 03/11/16 at 11:55 AM, Resident #3 stated that he/she wheeled his/her wheelchair to the nursing station and asked LPN #1 for a dose of [MEDICATION NAME] to relieve his/her headache on 09/15/15. Resident #3 stated that he/she had an awful pain in his/her neck that radiated into his/her neck and eye. Per Resident #3's report, LPN #1 stated that he/she could not have a second dose of [MEDICATION NAME]. Resident #3 stated that LPN #2 arrived on the unit about this same time and that LPN #1 and LPN #2 tried to pick him/her out of his/her wheelchair by grabbing his/her arms and legs. Resident #3 stated that LPN #1 and LPN #2 tried to carry him/her back to his/her bedroom but left him/her on the floor. Resident #3 stated that LPN #1 then pushed his/her wheelchair down the hall so Resident #3 could not reach it. Resident #3 stated that LPN #1 and LPN #2 left him/her sit on the floor as they walked back to the nurses' station. Resident #3 stated that 2 GNAs came and assisted him/her back into wheelchair and then back to his/her room. Resident #3 stated that he/she never received a dose of [MEDICATION NAME] or any other pain medication until the next morning. Resident #3 stated that the incident made him/her feel very angry and that he/she could not understand why LPN #1 or LPN #2 would do such an a thing. In an interview on 03/11/16 at 1:28 PM, GNA #1 stated that he/she was working on 09/15/15 during the 3 PM to 11 PM shift, and overheard Resident #3 ask LPN #1 for a pain pill at the nurses' station. GNA #1 stated that was when Resident #3 and LPN #1 got into a spat. GNA #1 stated that he/she observed LPN #1 holding Resident #3 by his/her wrists and was attempting to pull Resident #3 back to his/her room. GNA#1 stated this is when LPN #2 showed up and was also observed pulling Resident #3 back to his/her room. GNA #1 stated he/she saw marks on Resident #3's wrists. GNA #1 stated that Resident #3 was kicking and screaming NO, NO, NO loudly. GNA #1 stated that LPN #1 and LPN #2 were roughly handling Resident #3. GNA #1 stated that this incident really upset him/her. In an interview on 03/11/16 at 3:10 PM, GNA #2 stated that it was late in the evening on 09/15/15 that he/she heard all of this commotion from Resident #3 as he/she was speaking to LPN #1 at the nurses' station. GNA #2 then stated that LPN #1 came out from behind the nurses' desk and attempted to get Resident #3 to go back to his/her room. GNA #2 then stated that LPN #2 arrived on the unit, and both LPN #1 and LPN #2 tried to pull Resident #3's wheelchair back to his/her room. GNA #2 stated that he/she observed LPN #1 hold down Resident #3's arms. GNA #2 stated the next thing he/she observed was Resident #3 on the ground floundering around. GNA #2 stated that Resident #3 was asking LPN #1 and LPN #2 to look at his/her arms. GNA #2 stated that he/she observed the visible marks on Resident #3's arms. GNA #2 stated that LPN #1 and LPN #2 left Resident #3 lying on the floor. In an interview with the facility director of nursing (DON) on 03/11/16 at 3:00 PM, the DON stated that he/she did determine abuse regarding the incident between LPN #1 and LPN #2 that occurred on 09/15/15 at approximately 11:12 PM. The facility DON also stated that he/she did inform the local police and the Maryland Board of Nursing. The facility DON stated that that LPN #1 should have notified Resident #3's physician and reviewed Resident #3's continued complaint of pain with Resident #3's physician.

Based on complaint, review of a medical record, and staff interview, it was determined that the facility staff failed to provide a resident with a safe environment to prevent a resident from falling to the floor and receiving an injury on 2 different occasions. This was evident for 1 (Resident #4) of 6 residents reviewed during a complaint survey. The findings include: Review of complaint MD 398 on 03/11/16 revealed an allegation that the facility failed to protect Resident #4 from falling to the floor on two different occasions, and one of the falls required a hospital visit. 1) Review of resident #4's medical record, on 03/11/16, revealed resident #4 to be totally dependent upon the facility staff for all aspects of care and also unable to protect himself/herself from any accidents. Resident #4 requires a minimum of two staff members to transfer Resident #4 safely from one surface to the next. Resident #4 also receives an anticoagulant for a heart arrhythmia. Review of Resident #4's medical record revealed that Resident #4 fell face forward out of his/her wheelchair on 02/27/15 at 2:34 PM and sustained a laceration to his/her forehead which required a trip to the hospital for steri-stripes and an abrasion to the left knee. Further review of Resident #4's medical record revealed nursing documentation, dated 02/27/15 at 2:17 PM, indicating that Resident #4 complained of pain to his/her head after the fall. Review of Resident #4's fall care plan revealed that Resident #4 has a history of standing up out of his/her wheelchair unassisted. The nursing staff were to assess the need for footrests on Resident #4's wheelchair that were initiated on 06/30/11. In an interview on 03/18/16 at 3:22 PM, GNA #3 stated that he/she took Resident #4 to the restroom on 02/27/15. GNA #3 stated that he/she was assisted by another GNA to get Resident #4 on and off the toilet. GNA #3 stated that Resident #4's footrests were removed from the wheelchair before taking Resident #4 into the restroom. GNA #3 stated that he/she started to push Resident #4 out of the restroom when Resident #4 placed his/her feet on the ground, and fell forward out of the wheelchair striking his/her head on the floor. 2) Further review of Resident #4's medical record revealed that Resident #4 slid out of bed onto the floor and received a skin tear to the right forearm on 10/07/15 at 9:30 PM. Review of the facility investigation into resident #4's 10/07/15 9:30 PM fall revealed that GNA #4 transferred Resident #4 back to bed, without the assistance of another staff member, and was in the process of removing Resident #4's pants when GNA #4 turned away from Resident #4 and then Resident #4 slid out of bed onto the floor, and received a 4 cm x 5 cm skin tear to the right forearm. GNA #4 was not available for interview. The facility nursing staff must follow Resident #4's fall care plan to provide Resident #4 with a safe environment to prevent Resident #4 from falling to the floor and receiving an injury.

Based on review of a facility reported incident, review of a closed medical record and administrative records, and staff interview, it was determined the facility staff failed to provide a resident with all of the indicated fall precautions to prevent the resident from falling out of a wheelchair and receiving an injury. This occurred for 1 of 7 residents (Resident #2) reviewed during a complaint survey. The findings include: Review of facility reported incident MD 615, on 06/03/2015, revealed an allegation that Resident #2 suffered a fall from his/her wheelchair on 12/29/2014, was sent to the emergency room , and was diagnosed with [REDACTED]. Review of resident #2 closed medical record on 06/03/2015 revealed a physician's orders [REDACTED]. Review of Resident #2's fall prevention care plan revealed a nursing intervention instructing the nursing staff: when Resident #2 is out of bed in the wheelchair, apply the safe release belt, and release the seat belt every two hours and reposition. Review of the GNA (geriatric nursing assistant) care guide for Resident #2 revealed instructions to apply a self release seatbelt when Resident #2 is in his/her wheelchair, to check the resident every 30 minutes, and to release the self release seatbelt every 2 hours. Review of the facility investigation into Resident #2's 12/29/2014 9:15 AM fall, revealed that Resident #2 was noted to have a history of an impaired safety awareness due to a [DIAGNOSES REDACTED].#2 slid out of his/her wheelchair, and that Resident #2's self release seatbelt had not been fastened. Further review of Resident #2's post fall investigation revealed a statement from GNA #1 that indicated he/she had informed the ADON (assistant director of nursing) that he/she had forgotten to fasten Resident #2's self release seatbelt when he/she had put Resident #2 into his/her wheelchair. Review of GNA #1's employee filed revealed that GNA #1 had been hired on 12/15/2014 and received general orientation on 12/15/2014 and 12/16/2014. GNA #1 was then placed with a GNA preceptor on 12/17/2014, 12/18/2014, 12/20/2014, and 12/24/2014. GNA #1 worked without a preceptor on 12/26/2014 and 12/29/2014. GNA #1's employee file failed to reveal any documents of his/her ability to perform his/her job on the nursing unit. In an interview with the facility DON (director of nursing) on 06/04/2015 at 1:40 PM, the facility DON stated that there were no written records of what the GNA preceptors observed nor what GNA nursing education GNA #1 received during the first two weeks of employment at the facility.