Every finding on record at Harmony Suites Rehabilitation and Wellness Center

Based on resident interviews, record reviews and staff interviews, it was determined that the facility failed to provide pain management according to professional standards. This was evident for 3 (Residents #59, #3, and #8) of 6 residents reviewed for unnecessary medications and pain during the annual/complaint survey. This resulted in actual harm to Resident #59.The findings include: A pain scale is a 0-10 numerical tool for assessing pain severity, with zero representing no pain and 10 the worst pain imaginable. According to the Mayo Clinic, pain scores from 1-3 are mild, 4-6 are moderate, and 7-10 are severe. 1)On 05/11/2026 at 9:49AM, during an interview, Resident #59 reported pain from head to toe and expressed that two types of pain medication, including a nightly scheduled dose, had been unavailable for days. On 05/13/2026 at 11:40 AM, a review of Resident #59's Care Plan (revised 04/30/2026) noted chronic pain from arthritis and a spinal fracture. Interventions required following physician orders and administering prescribed medications. On 05/13/2026 at 10:56 AM, a review of Resident #59's medical record revealed physician orders for Buprenorphine sublingual film, one sublingual film daily (04/30/2026), and Oxycodone 5 mg every 6 hours as needed (04/29/2026). Further review of Resident #59's medication administration record (MAR) revealed buprenorphine was last given on 05/06/2026, with subsequent entries (May 7–10) coded as 9 (other—see nurses' notes). On 05/13/2026 at 11:11 AM, a review of Resident #59's progress notes from May 7–10, 2026, revealed that buprenorphine HCl-naloxone HCl (2-0.5 mg daily) was delayed by the pharmacy; there was no explanation for the missed dose on 05/09/2026. Continued review showed there was no evidence suggesting the facility used its emergency backup medication system or contacted the provider to obtain alternative pain medications. Additionally, a review of Resident #59's pain level summary from 05/07/2026 and 05/11/2026 shows Resident #59's pain scores ranged from 2 to 7, while the buprenorphine patch remained unavailable since its last administration on 05/06/2026. On 05/15/2025 at approximately 8:50 AM, a review of Resident #59's narcotic sign-out sheets for Oxycodone indicated that Oxycodone was administered twice a day from 05/01/2026 through 05/08/2026, with the exceptions of 05/02 (one dose) and 05/03 (no doses). The last dose available was recorded on 05/09/2026. Continued review of Resident #59's medication administration record (MAR) showed that 8 doses corresponded to pain levels between 5 and 7. Additionally, a review of Resident #59's pain level summary from 05/09/2026 and 05/11/2026 revealed pain scores ranging from 2 to 5, while the oxycodone as needed pain medication remained unavailable since its last administration on 05/09/2026. On 05/13/2026 at 11:16 AM, further review of Resident #59's progress note dated 05/08/2026 at 6:59 AM revealed overnight complaints of nausea, headache, and frequent stools. Ondansetron (a medication used for nausea and vomiting) was administered for nausea but was not effective. On 05/15/2026 at 8:37 AM, an interview with Staff #15 (LPN) Staff #15 reported a system glitch with a 05/08/2026 reorder of buprenorphine and oxycodone, noting that the pharmacy failed to deliver timely despite a follow-up call by her on 05/09/2026. However, there was no evidence of a pharmacy call until 05/10/2026, noted for the buprenorphine sublingual film pain medication as awaiting pharmacy to deliver; call put in by writer. The new scripts for both pain medications arrived on 05/12/2026 at 9:00 AM—72 hours after the last Oxycodone dose and six days after the last Buprenorphine dose. On 05/14/2026 at 5:08 PM, further review of Resident #59's medical record revealed that during a 05/11/2026 Nurse Practitioner (NP) encounter (signed 05/13/2026), Resident #59 was tearful during the NP visit, reported anxiety, and requested an increase in Oxycodone for widespread pain (extremities, shoulder, back, knees, and face). Despite documenting these symptoms, the nurse practitioner discontinued oxycodone and buprenorphine HCl-naloxone HCl, maintaining only Tylenol, lidocaine, and gabapentin. While stable pain control was the goal, the NP only provided a psychiatric referral without an alternative pain management plan. Consequently, the resident called 911 for uncontrolled pain and nausea on 5/12/26. On 05/13/2026 at 11:35 AM, a review of Resident #59's medical record revealed an E-Interact form dated 05/12/2026 at 12:30 AM documented a blood pressure reading of 174/94. The documentation noted that Resident #59 personally contacted emergency services (911) because of persistent pain and nausea. The resident described the pain as being all over from head to toe, rating it at a maximum intensity of 10/10. On 05/13/2026 at 2:47 PM, during an interview, the Director of Nursing (DON) outlined the protocol for unavailable pain medication. Nurses must check the NexyS system; if the specific dosage is unavailable, they must obtain a one-time order, contact the physician for an alternative, and follow up with the pharmacy for an expected arrival time. All interventions must be documented in nursing notes. The DON emphasized that the physician should be notified immediately if a resident requires pain medications that are unavailable. The Director of Nursing was notified of the concern at this time. On 05/14/2026 at 4:59 PM, during a phone interview, the Nurse Practitioner (NP) stated there was currently no plan for Resident #59's pain management following the discontinuation of pain medications on 05/11/2026. The NP noted that Resident #59 complained that the current pain regimen was ineffective, surgery was declined, and opioids or NSAIDs were not safe due to respiratory and cardiac risks. Although she was planning to recommend outpatient non-opioid management, the resident was hospitalized , and she acknowledged the resident had been without prescribed medications for several days. On 05/15/2026 at 3:57 PM, the Director of Nursing (DON) reported that Staff #15 (LPN) confirmed the resident requested pain medication, and that is what prompted a call to the pharmacy. No further actions/interventions were documented or completed. The DON acknowledged the ongoing pain management concerns. 2) Non-pharmacological interventions are identified as the alternative methods of treatment for a medical concern without the use of medication. This could include physical, psychological, and lifestyle interventions designed to reduce pain and improve quality of life. The CDC's 2022 Clinical Practice Guideline for Prescribing Opioids emphasizes non-pharmacological, non-opioid therapies as the first line of treatment for subacute and chronic pain. On 5/13/2026 at 09:18 AM a review of Resident #3's care plan created on 04/8/2026, revealed that the resident had complaints of chronic pain and was at Risk for Pain Disease processes, Impaired mobility. Care plan intervention indicated: administer non-pharmacological interventions and evaluate the effectiveness of interventions (repositioning, diversion activities, snacks and fluids, ice / heat, music therapy, relaxation techniques, imagery). Further record review on 05/13/2026 at 11:45 AM, a review of Resident #3's Medication Administration Record (MAR) revealed: oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Pain Hold for signs of overdose, sedation and or RR less than 12 -Start Date 05/05/2026. Oxycodone 5mg orally was administered on 05/13/2026 at 09:25 AM. On 05/14/2026 at 08:15 AM, in an interview with the Director of Nursing (DON), the DON agreed that the residents should have non-pharmocological measures documented as required per the care plan. She explained that an audit of the charts for residents who were prescribed as needed pain medications were completed and the non-pharmalogical interventions were added to their records. She also explained that staff will be educated on pain management and documentation. On 05/14/2026 at 09:51 AM, in a DON interview, the DON was made aware that Resident #3 has an order for as needed pain medication and care plan documentation indicate non-pharmalogical intervention; however, there was no documentation to suggest that the facility implemented alternative treatment methods for pain as suggested on the care plan. 3) On 05/13/2026 at 3:46 PM, during record review for unnecessary medication, it was noted that resident # 8 was ordered the following medications for pain: -Acetaminophen Oral Tablet 325 MG, Give 2 tablets by mouth every 4 hours as needed for Pain, Active since 12/10/2025. -oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl). Give 1 tablet by mouth every 24 hours as needed for pain, scale 5-10. Active since 2/5/2026. The Care Plan reviewed on 5/13/2026 at 3:52 PM, noted that Resident # 8 has chronic pain related to diagnosis of paraplegia, chronic pain syndrome. Date Initiated: 12/19/2023 Revision on: 04/16/2026; in addition, administer non-pharmacological interventions (repositioning, diversion activities, snacks and fluids, ice / heat, music therapy, relaxation techniques, imagery). Date Initiated: 04/13/2025 Revision on: 04/04/2026. On 5/14/2026 at 11:32 AM, during the review of the Medication Administration Record (MAR), Treatment Administration Record (TAR) and the Behavior Monitoring Record, there were no nonpharmacological interventions listed to be used when an as needed pain medication was administered. During an interview with the DON on 5/15/2026 at 1:30 PM concerning the documentation of pain assessment and the use of nonpharmacological interventions, she stated that there was none for this resident, and that the staff will implement them as soon as possible. The DON was made aware that this was a concern related to pain management documentation. On 5/15/2026 at 2:44 PM, a review of the orders noted that Resident #8 had an order for PRN (as Needed) pain medication Non-Pharmacological Intervention Documentation: 1=Repositioning, 2=Heat application, 3=Cold application, 4=Massage of painful area, 5=Dim lights/Quiet environment, 6=Distraction/Music/TV/Books, 7=Offer Rest Period, 8=Food/Drink, 9=Did Not administer PRN this shift, for every shift written after the surveyor's intervention of concern for pain management.

Based on record review and interviews, it was determined that the facility failed to ensure that staff accurately document medication administration for each resident in accordance with accepted professional standards and practices. This was evident for 3 (Resident #16, #3, and #97) of 4 residents reviewed for medication administration during the recertification survey. The findings include: 1)During the screening process of the survey on 5/12/26 at 09:41AM, Resident #16 stated that sometimes he/she gets his/her medications and sometimes he/she does not get them, because the nurse would say they are not available. The medical records review on 5/12/2026 at 1:05 PM noted that resident has a Brief Interview of mental status (BIMS) score of 15 (indicating intact cognition) with diagnoses not limited to hypertension, chronic kidney disease, end stage renal disease with dependence on renal dialysis. Further medical record review on 5/12/2026 at 1:19 PM, found that the resident goes to dialysis on Mondays, Wednesdays, and Fridays. Further review of the residents' Medication Administration Record (MAR) revealed that there was no documentation of medications given on the following shifts that were not dialysis days for the resident: -On 4/6/2026: 6 medications were not documented for the Evening and Night shifts as administered, no vital signs were documented, and no Finger sticks with results were documented. -On 4/9/2026 and 4/23/2026: 4 medications were not documented as administered on the AM shift and 1 on evening shift. No documented Finger sticks was resulted on the before lunch shit (11 AM), no monitoring for hypo or hyperglycemia was documented, and no pain level was assed for both AM shifts. On 5/12/2026 at 2:43 PM Staff #8 was asked what the staff would do if medications were not available. Staff #8 stated that he/she would call the pharmacy to send medications stat or check the Omnicell for some of the medications not available in the medication carts; and write a progress note to explain the situation. On 5/13/2026 at 02:50 PM, a follow up interview was done with the DON who stated that it was not a matter of missing medications, but an Agency nurse was working on those days and that Agency nurse was made a Do not Return (DNR) to the facility because she failed to complete her documentation. The DON was made aware that this was a concern because no documentation is proof that the resident did not get his medications as he/she voiced. The DON agreed. 2) On 05/13/2026 at 11:45 AM, a review of Resident #3's Medication Administration Record (MAR) and orders revealed that resident had an order for Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 70 - 150 = 0 units Blood sugar (BS) less than 70mg/dl follow hypoglycemia protocol; 151 - 200 = 2units; 201 - 250 = 3 units; 251 - 300 = 4units; 301 - 350 = 5units; 351 - 400 = 6 units Blood sugar greater than 400, give 7 units, repeat BS, and call provider, subcutaneously before meals and at bedtime for DM -Start Date04/07/2026 2100. A review of Resident #3's MAR revealed that on 05/12/2026 at 11 am was BS 154 but MAR documented comment #9 (other/see nurses notes). Resident ordered to receive 2 units of insulin. On 05/09/2026 the resident's BS was 155 at 9 PM but MAR documented #9 (other/see nurses notes). On 05/08/2026 there was no documented evidence that the resident's BS was obtained on 4:30 PM and 9 PM, the MAR was blank. A review of the resident progress notes revealed that there was no documentation to explain why the resident did not receive the medication as ordered. On 05/14/2026 at 9:51 AM, in an interview with the Director of Nursing (DON), the DON explained that she spoke with nurses and they reported that Resident #3 refused to take the insulin if the blood sugar was less 200mg/dl but the DON stated that the nurses did not document the refusal. The DON stated that the Nurse Practitioner was notified and the insulin orders were updated to meet the resident's needs. 3) On 05/12/2026 at 08:43 AM, in an interview with Resident #97, the resident reported I take thyroid medication in the morning, and I missed two different doses because the doctor changed the medication and the medication time and it was not communicated to me. It was changed between May 7th-9th. On 05/13/2026 at 3:40 PM, a review of Resident #97's orders and Medication Administration record revealed: Synthroid Oral Tablet 125 MCG (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for hypothyroidism -Start Date05/06/2026 0700 -D/C Date05/08/2026'; on 5/7/2026 MAR documentation revealed: comment #9, which indicated (other/see nurses notes). Synthroid Oral Tablet 175 MCG (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for hypothyroidism -Start Date04/16/2026 0700 -D/C Date04/17/2026; on 04/16/2026 documentation revealed: comment #9 (other/see nurses notes). A review of the resident progress notes revealed that there was no documentation to explain why the resident did not receive the medication as ordered. On 05/13/2026 3:48 PM, in an interview with the DON, the DON was informed that the MAR indicated that the resident did not receive his/her medication on 5/7/2026 and 4/16/2026. She stated she will look into it further. On 05/14/2026 at 9:52 AM, the DON acknowledged that the missing medication documentation for Resident #97 was a communication issue. She explained that after following up with the nurse responsible for medication administration they explained that the Resident refused the medication because of the medication changes. The DON acknowledged that the information should have been documented in the resident's record and was not.

Based on interview, review of intake #2671457, and record review, it was determined the facility failed to provide a resident with a written notice and reason for the room change before the resident was moved. This was evident for 1 (Residents #54) of 1 who had expressed a concern regarding room changes during the recertification survey.The findings include:On 05/11/2026 at 11:50 AM, during an interview, Resident #54 expressed a concern that the facility moved him/her from one room to another with no advance notice. He/she did not want to change rooms.On 05/12/2026 at approximately 12:10 PM, review of intake #2671457 revealed Resident #54 was moved from one room to another at the facility without notice. Neither the resident nor their power of attorney (POA) received prior notification; the POA only learned of the relocation when the facility demanded advance payment for Resident #54's continued care after the room change was completed.On 05/12/2026 at 12:15 PM, a review of Resident #54's progress notes dated 10/31/2025 at 1:04 PM revealed that a room change had occurred. During this transition, all personal belongings were moved, and administrative staff addressed the concerns raised by the resident and their family members. Subsequent documentation on 10/31/2025 at 1:11 PM confirmed the completion of the room transfer. With the resident present, the social worker contacted the power of attorney (POA) by telephone; the POA agreed to visit the facility to support the resident through the transition.On 05/12/2026 at 11:58 AM, during an interview, the Administrator stated that room changes occur with the agreement of the resident or their responsible party. The roommate is notified before the change is made. This process is documented in PCC and Social Services progress notes, and written notification of the room change is provided to the resident and maintained in their paper chart.On 05/12/2026 at 12:30 PM, a review of Resident #54's paper chart was conducted in the presence of Staff #6 (Registered Nurse Unit Manager); it was determined that the record contained no evidence of a written room change notice being provided to Resident #54. The unit manager verified this finding.On 5/12/2026 at approximately 3:00 PM, the Administrator was made aware of the concern.

Based on record review and interviews, it was determined that the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of admission. This was evident for 1(Resident#104) of 2 Residents care plan reviewed for tracheostomy care during the recertification survey process. The Findings included:On 05/13/2026 at 10:32 AM, a review of Resident #104's care plan revealed that the facility created a tracheostomy care plan was initiated on Tuesday 05/12/2026; however, a review of Resident #104's care plan revealed that the resident was admitted over the weekend of May 8, 2026.On 05/13/2026 at 11:07 AM, in an interview with the Director of Nursing (DON) she was asked about the baseline care plan, and she was also asked if the facility was responsible for care plan development on the weekend shift as well. The DON explained that the baseline care plans were usually done within the first 24 hours period during the weekday and weekends. At that time the DON was made that the baseline care plan for a newly admitted resident with a tracheostomy was not completed until 5/12/2026 which was more than 48 hours from the date of admission. She reported that she will review the above concerns mentioned. No additional documentation was provided.

Based on observation, record review and interviews, it was determined that the facility failed to ensure that they provided communication services consistent with the resident's needs. This was evident for 1 (Resident #5) of 4 Residents with communication or sensory difficulty during the recertification survey.The Findings Included:On 05/11/2026 at 10:09 AM, during the initial tour of the survey process, the surveyor attempted to communicate with Resident #5. However, Resident #5 indicated that he/she was non-English speaking. Upon further observation of the resident's room there was no observation of any communication tool for the resident's use at bedside.On 05/11/2026 at 10:10 AM, the surveyor spoke with License Practical Nurse (LPN#17) about how staff communicated with Resident #5 and she explained that the Resident does know how to affirm basic needs; however, when asked how the staff would communicate a more extensive conversation, she stated that they used a language line. When asked about how the language line was used by staff, she explained that she was not sure and will need to clarify with nurse manager.On 05/11/2026 at12:43 PM, in an interview with Resident #5's representative, the resident's representative explained that he/she had concerns that the resident had communication challenges with the staff because the resident did not speak English. The representative also explained that the resident's facility issued phone in the resident's room was not working, therefore the resident was unable to communicate with family via telephone.On 05/12/2026 at 12:30 PM, in an interview with the Director of Nursing (DON), the DON reported communication was assessed upon admission and placed on the admission assessment tool form in the Electronic Health Record. If they were unable to speak, they are provided with communication boards. If someone was a non-English speaking resident and if they cannot communicate using simple phrases, they communicate using a language line. The communication language line information was posted for any caregiver to use and have access to. They do not use family members as interpreters, and they do not use any other method of communication. She reported that it is the expectation that if the residents were unable to communicate their needs even for personal care the staff should use the language line. On 05/13/2026 at 3:05 PM, a review of Resident #5 Nursing admission Evaluation completed on 04/27/2026 revealed that Resident #5 had a communication language barrier problem. Documented goals: Resident #5 will maintain /improve current level of communication function through the review date. Documented interventions indicated: Provide reading materials, movies, newspapers, and music in the resident's preferred language. Provide the following tools to aide in communication in primary language (interpreter, communication board, etc. Intervention: Utilize language line for interpreter needs.On 05/14/2026 at 08:52 AM, in an interview with Geriatric Nursing Assistant (GNA#22), she was asked how the staff communicate with residents who didn't speak English, and she explain that she used google translate on her personal cellphone or a facility issued tablet used for translation on the language line. We don't use the language line as much, because the google translate or tablet was quicker. On 05/14/2026 at 08:56 AM, in an interview with GNA #23, she was asked how she communicated with residents who did not speak English, and she explained that she would try to find out what language they speak because she was bi-lingual and spoke French. If She was unable to communicate verbally, she would also use physical cues to ask what residents' needs were. When asked about a language line she reported that she was not aware of a language line.On 05/14/2026 at 09:21 AM, a review of Resident #5's admission notes indicated that resident was alert, oriented X3 and Spanish-speaking.On 05/14/2026 at 09:22 AM, a review of Resident #5's progress notes written on 04/27/2026 at 10:56 PM revealed Resident is Spanish speaking. Upon arrival to unit, Resident was offered language interpreter services but daughter refused, she said that language interpretation service is not helpful for [the resident].On 05/14/2026 at 9:44 AM, in an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), they were made aware that there were concerns that the resident could not communicate with the staff. They were also notified that (LPN) #17 was not aware of the communication resources that would be available to the resident. They were also made aware of the representative's concern about the resident's inability to communicate his needs and their concern about the resident's phone line not working.On 05/14/2026 at 11:05 AM, the surveyor conducted an observation of Resident #5's room and the surveyor noted that the telephone was not working (no dial tone). Staff #24 (maintenance) was present during this observation, and he stated that he will need to follow up with the telephone company to address the issue. There was no evidence that the resident had a working phone line to facilitate the interpretative care and communication needs of the resident who was non-English speaking. There was also no evidence that there was a universal understanding among staff about how to communicate with residents who are non-English speaking.

Based on observation, record reviews and interviews, it was determined that the facility failed to ensure that respiratory care needs, including tracheostomy care was provided in a manner that was consistent with professional standards of practice. This was evident for 1 (Resident #104) of 2 Residents records reviewed for respiratory and tracheostomy care during the recertification survey process. The Findings Included:Tracheostomy is a surgical hole or stoma which consists of making an incision on the front of the neck to open a direct airway to the trachea. A tracheostomy allows air to pass into the windpipe to help with breathing.On 05/11/2026 at 12:15 PM, during the initial screening phase of the survey, the surveyor observed that Resident #104 was on 2 Liters of oxygen via tracheostomy.On 05/11/2026 at 2:37 PM, a review of Resident #104's orders revealed: 05/10/2026 Trach care every shift and as needed; have same size trach and one size smaller at bedside at all times; and Oxygen at 3 liters via Nasal cannula continuous every shift start on 5/10/2026.On 05/13/2026 at 10:04 AM, the surveyor conducted another observation of Resident #104's room and respiratory care needs with Registered Nurse (RN#14). The surveyor observed that the resident was on 4 liters of oxygen. RN #14 was asked how much liters of oxygen the resident was ordered to have and she reported 4 liters. At that time the surveyor informed RN#14 that resident's current oxygen order was for 3 liters. RN #14 checked Resident #104's order and confirmed that the order was for 3 liters of oxygen, not 4 liters. She then stated will adjust the resident's oxygen as ordered.The surveyor also observed that Resident #104 had a size 7 trach tube in-use and there were several unused size 7 trach tubes at the bedside; however, there was no evidence to support that there was a smaller trach size at bedside as ordered, in case of dislodgement.On 05/13/2026 at 1:44 PM, in an interview with the Director of Nursing, she was notified of the above findings. She explained that they had a smaller size trach available in the facility but acknowledge that the smaller trach size was not present at bedside as ordered and that a smaller trach size was later placed at bedside. Oxygen audit was done throughout the building, and an in-service will be completed for facility staff.

Based on review of Geriatric Nursing Assistant personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews at least every 12 months on 3 out of 5 personnel files reviewed during the recertification survey.The findings included:On 5/15/2026 at 08:45 AM, during the sufficient and competent and nurse staffing task review, the personnel file of Geriatric Nursing Assistant (GNA) #19, #20, and #21 were reviewed. There were no up to date yearly evaluations found in their personnel files. GNA#19 is missing an annual evaluation for 2025; GNA #20 is missing an annual evaluation for 2024 and 2025; and GNA #21 is missing an annual evaluation year 2025.On 5/15/2026, at 11:00 AM, when asked about the yearly performance reviews for GNAs the Nursing Home Administrator (NHA) stated that the documents are in a system called workday and she will be able to retrieve them if given time. The facility has gone through new ownership, and the new company must allow permission to retrieve the information.At the time of Exit from the survey on 5/15/2026 at 5:30 PM, the NHA didn't have the required documents and stated that they were being retrieved. The surveyor requested for the documents be sent to the office once they were retrieved or this would result in a concern for GNAs not having their yearly evaluations. On business day 2 following the survey, the requested documents were not sent to the surveyor; thus, the facility failed to provide documentation that the GNAs had completed their yearly evaluations.

Based on record review and interview, it was determined the facility failed to ensure accurate accountability of controlled medications. This was evident for 1 (Resident #59) of 4 residents reviewed for pain during the recertification/complaint survey. The findings include:According to the Mayo Clinic, oxycodone is a potent prescription opioid analgesic (pain medication) used to treat moderate to severe pain. It works by acting on the central nervous system to change how your body perceives and responds to pain. On 05/13/2026 at 10:56 AM, a review of Resident #59's medical record revealed physician orders for Oxycodone 5 mg every 6 hours as needed for pain (04/29/2026). On 05/15/2026 at 2:32 PM, Resident #59's medication administration record (MAR) for May 2026 was reviewed and compared to the narcotic count sheets for Oxycodone. 12 doses of oxycodone 5 mg were signed out on the controlled medication utilization record (count sheet) from 05/01/2026 through 05/09/2026. Only 8 of the 12 doses were documented on the MAR as administered to Resident #59.On 05/15/2026 at 3:17 PM, during an interview with the Director of Nursing (DON), expectations for the administration of narcotic medications were discussed. The DON stated that entries on the narcotic count sheet should consistently be reflected in the medication administration record (MAR). Furthermore, the DON recognized that any inconsistencies between these two sets of documentation could be an indicator of potential drug diversion. The concern was shared with the DON at this time.

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident was administered medications according to a physician's order. This evident for 1 (Resident #201) out of 3 residents reviewed for medication administration.The findings include:A review of Resident #201's clinical record on 7/29/26 revealed that the resident's primary physician wrote an order on 7/1/26 for Percocet 7.5-325 mg give every 4 hours as needed for pain at a level of 6-10 on a 0-10 scale. On 7/2/26 at 1:00 PM the resident rated their pain as 5 and was administered the medication. On 7/3/26 at 6:45 PM the resident rated their pain as 0 but was administered the medication. On 7/8/26 at 10:00 AM and at 2:54 PM the resident rated their pain as 0 on both occasions but were administered the medication. On 7/9/26 at 1:06 AM the resident rated their pain as 5 but staff administered the medication.On 7/11/26 at 7:38 PM the resident rated their pain as a 5 but staff administered the medication. The resident on 7/14/26 at 5:12 AM and at 1:46 PM rated their pain as 0 but staff administered the medication. On 7/15/26 at 12:08 PM the resident rated their pain as 5 but staff administered the medication. On 7/16/26 at 04:30 AM, at 12:37 PM and at 8:00 PM the resident rated their pain as 5 but staff administered the medication. On 7/19/26 at 4:30 AM the resident rated their pain as 3 but staff administered the medication. On 7/20/26 at 6:44 PM the resident rated their pain as a 4 but staff administered the medication. On 7/24/26 at 7:00 PM the resident rated their pain as a 5 but staff administered the medication. The resident on 7/25/26 at 3:42 AM rated their pain as a 1 and at 7:20 PM rated their pain as a 5 but staff administered the medication. The resident on 7/26/26 at 8:03 PM rated their pain as a 5 but staff administered the medication. This surveyor interviewed the Administrator, the Director of Nursing, the Assistant Director of Nursing, and the Regional Director of Clinical Services on 7/29/26 at 3:15 PM. This surveyor asked, What does it mean when an order says give one tablet when pain is 6-10? They responded that you give the medication if the resident said the pain is 6 or higher. This surveyor then asked what if the resident said their pain was a 5, do they get the medication? They responded with you don't give it. Lastly, this surveyor asked if the resident said their pain was 0 should the medication be given? They responded with you don't give it because there is no pain.

Based on observation and interview, it was determined that the facility failed to ensure safe and secure storage of medications by allowing unauthorized personnel access to the medication room and medication room keys. This was evident for 1 of 2 medication rooms reviewed during the recertification survey.The findings include: On 5/14/2026 at 9:31 AM, during a medication administration observation, Staff #11 requested the medication room keys from Licensed Practical Nurse (LPN) #13. The keys provided access to both the medication room and the medication cart. Staff #11, who was carrying a box measuring approximately 12x 12 inches, entered the medication room independently and placed the box inside the medication refrigerator. On 5/14/2026 at 9:33 AM, Staff #11 returned the keys to LPN #13. On 5/14/2026 at 9:46 AM, the surveyor inspected the first-floor medication room with LPN #13 and observed the box previously placed in the medication refrigerator by Staff #11. The medication refrigerator contained unopened insulin pens and a clear locked drawer storing Ativan vials, a Schedule IV controlled substance. During an interview, LPN #13 stated, I've watched other nurses giving the keys to other staff personnel too. On 5/14/2026 at 9:59 AM, LPN #12 stated that the medication room keys were kept by the nurses and acknowledged that staff members occasionally borrowed the keys. LPN #12 further stated that staff should be accompanied while inside the medication room. On 5/14/2026 at 10:23 AM, the surveyor inspected the second-floor medication room with LPN #17. He/she confirmed that only licensed nursing staff were authorized to enter the medication room. The refrigerator's locked medication box was observed empty at that time. On 5/14/26 at 11:04 AM, during an interview, Staff #11 confirmed bringing a box containing wound care medications to the medication room and placing it inside the refrigerator. Staff #11 stated that he/she would normally deliver the box directly to the floor nurse; however, because the nurse was unavailable, he/she requested the medication room key and independently entered the medication room to store the medications.On 5/14/26 at 11:27 AM, the Director of Nursing (DON) confirmed that only nursing staff were authorized to access the medication carts and the medication rooms. In the presence of the DON, Staff #13 demonstrated and confirmed that the set of keys provided to Staff #11 also included the key used to open the locked drawer inside the refrigerator containing controlled substances. The DON was notified of the concern and stated that staff education had been initiated.

Based on observation and interview, it was determined that the facility failed to maintain an effective infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. This was evident for 2 medication administration observations during the recertification survey.The findings include: On 5/14/2026 at 8:56 AM, during a medication administration observation, Licensed Practical Nurse (LPN) #13 obtained Resident #20's blood pressure using a portable blood pressure machine with a reusable blood pressure cuff. At approximately 9:05 AM, LPN #13 used the same portable blood pressure machine and reusable blood pressure cuff to obtain Resident #63's blood pressure. However, LPN #13 failed to disinfect the blood pressure machine and the cuff between resident use. In addition, no disinfectant wipes or sanitizing products were observed on or near the equipment to indicate supplies were readily available for cleaning between resident use. On 5/14/26 at 9:17 AM, the surveyor observed LPN #13 failed to disinfect the rubber septum or tip of Resident #94's insulin pen prior to attaching the needle for medication administration. On 5/14/26 at 9:40 AM, LPN #13 stated nurses were expected to disinfect shared equipment between resident use with disinfectant wipes and acknowledged forgetting to sanitize the rubber tip of the insulin pen prior to needle attachment On 5/14/26 at 11:27 AM, the Director of Nursing (DON) was notified of the concerns and stated staff education had been initiated.

Based on interviews, review of Intake #2801915, and facility document review, it was determined that the facility failed to provide grievance procedure information to residents or maintain an effective grievance process. This was evident during a resident council meeting and review of 2 months of grievances during the recertification survey.The findings include: On 05/14/2026 at 1:23 PM the surveyor attended a resident council meeting with six residents. During the meeting, the residents stated that they did not know how to file a grievance/concern.On 05/11/2026 at 11:05 AM, during an interview, Resident #64 reported that GNAs frequently deactivate this/her call lights and verbalize they will return-claiming administrative monitoring-but then staff fail to provide assistance for several hours afterward. Resident #64 noted he/she has reported this issue to multiple staff members.On 05/12/2026 at approximately 2:30 PM, review of Intake #2801915 identified concerns regarding significant delays in the delivery of care, as well as disrespectful, intimidating, and occasionally coercive behavior by staff members. On 05/13/2026 at 2:30 PM, a review of a grievance form dated 07/14/2025 revealed a resident called staff after having an accident. Staff came and said they would come back but did not return until 3 hours later. The form lacked investigation details, conclusions, resolution dates, corrective measures, and evidence of communication. Two grievances from 09/16/2025 detailed staff disrespect and ignored needs. In one, a resident threatened to leave the facility due to a Geriatric Nursing Assistant's disrespectful behavior; although marked resolved, the facility provided no proof of actual resolution, only noting a nurse would administer medications. In the second, a resident reported rude treatment, but the facility lacked documentation for the staff meeting allegedly held to address the concern.On 05/13/2026 at approximately 3:15 PM, during an interview, the Director of Nursing (DON) reviewed the grievance forms dated 07/14/2025 and two forms from 09/16/2025 and acknowledged that the identified concerns had not been addressed. During the discussion, the DON noted that while customer service training had been in the facility's planning stages, it had not yet been implemented. The concern was shared with the DON at this time.On 05/14/2026 at 3:42 PM, during an interview between Staff #3 Social Worker (SW) and the Administrator, the SW identified herself as the grievance officer. SW explained that residents submit grievance forms, which various departments resolve, followed by verbal notification of outcomes to residents or responsible parties. SW claimed, while residents are informed of the grievance process during care plan meetings, no formal documentation confirms this practice. The concern was shared with the Administrator/SW at this time.

Based on interviews, records review and facility investigative material the facility failed to ensure adequate supervision and failed to implement appropriate interventions to prevent one Resident (R), R16, with a history of exit seeking behaviors from elopement, when R16 exited the facility without the facility knowledge for approximately eight hours. Out of 1 of 3 sampled Residents. The census was 90. Findings Include:A review on 3/17/26 at 9:15 am of the undated facility policy Elopement Prevention and Management Overview found that elopement occurs when a resident leaves the facility or a safe area without permission or supervision, putting them at risk. If a resident who can make decisions leaves on purpose, it is not usually considered elopement unless the facility did not know the resident left or where they were.The policy documents that the interdisciplinary team plans the least restrictive interventions to promote mobility and safety, and to meet the individualized needs and goals of the Resident/patient. Components of the Elopement Prevention and Management Program include Elopement drills, environmental modifications to promote safe mobility with monitoring effectiveness, and a protected list of names and photographs of at-risk Residents/Patients. Regular rounds and structured group activities are also components.Record review on 3/16/26 at 2:30 pm of Resident #16's Face sheet showed Resident #16 was admitted on [DATE]. Diagnoses included Dementia without Behavioral Disturbance, Psychotic Disturbance, Communication deficit, and Muscle weakness with difficulty walking.Record review done on 3/16/26 at 2:31 pm of Resident #16's Nursing admission Evaluation on 8/19/2025 at 8:45 PM, documented by Staff Nurse #24, showed Resident #16 exhibited exit-seeking behaviors. Record review conducted on 3/16/26 at 2:35 pm of Resident #16's Care Plan, initiated on 8/20/2025, documented risks including unsteady gait, impaired communication, skin integrity concerns, and impaired cognitive and visual function. Notably, wandering behaviors were not addressed in the care plan until 10/25/2025, over two months after admission, when interventions for wandering were finally included.Record review on 3/16/26 at 3:30 pm of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE], recorded Resident #16's Brief Interview of Mental Status (BIMS) score was 5. This indicated that Resident #16 had memory problems. with memory. Section GG noted Resident #16 used a wheelchair for locomotion and was dependent on staff for most activities of daily living (ADLs).Record review done on 3/16/26 at 3:35 pm of Resident #16's progress notes dated 10/25/2025 at 9:13 PM, documented by Staff Nurse #3, showed Resident #16 wandered and eloped from the facility. Resident #16 was found and brought back to the facility. Upon assessment, no visible injury or signs of distress were noted; Resident #16 denied pain.Record review done on 3/16/26 at 3:35 pm of Resident #16's progress notes dated 10/27/2025, the facility Nurse practitioner (NP)8 documented he/she interviewed Resident #16 and Resident #16 described the event calmly and stated he/she waited at the back door until an opportunity arose and left when the person nearby stepped away. NP #8 documented Resident #16 reported he/she experienced a fall during the episode of elopement, stated he/she lost balance and fell while leaving the building. Resident #16 denied pain at the time.During an interview on 3/16/2026 at 10:30 AM, Staff Nurse #7 stated that Resident #16 was well-spoken. Resident #16 used a wheelchair and self-propelled without assistance. On 10/25/2025 at approximately 12:30 PM, Environmental Service Aide (ESA) 10 opened the door for Resident #16, who left the facility. Resident #16 could not remember his/her way back and ended up at the local police department. In an interview on 3/16/2026 at 11:15 AM, the Administrator said ESA 10 opened the door for Resident #16, who left while ESA 10 was cleaning the floors. Resident #16 was last seen around 12:30 PM on 10/25/2025. A citizen found Resident #16, who may have fallen by a busy street, and took them to the police. The police called emergency services, and Resident #16 went to the hospital. The Administrator was informed by the police that Resident #16 had been sent to the hospital. The Administrator said staff were retrained and actions were taken about residents leaving; these were ongoing. During an interview on 3/17/2026 at 9:58 AM, the Director of Nursing (DON) stated Resident #16 was unable to walk long distances without a wheelchair. According to the DON, the last note in Resident #16's progress notes, dated 10/25/2025, showed that Resident #16 had lunch, and staff documented that Resident #16 ate independently. According to the DON, there was no documentation showing that Resident #16 was not accounted for approximately eight hours from 1:00 PM through 9:00 PM, until the facility received notification that Resident #16 was at the local emergency department.During an interview on 3/17/2026 at 12:09 PM, the Maintenance Director said Resident #16 often tried to leave and expressed a desire to go home to see grandchildren.During an interview on 3/18/2026 at 10:20 AM, ESA 10 said Resident #16 often moved up and down the hall in a wheelchair. On 10/25/2025 at about 12:30 PM, Resident #16 asked ESA 10 to go outside. ESA 10 opened the door, and Resident #16 went outside. ESA 10 worked for less than 2 weeks at the facility and was not trained in elopement prevention. ESA 10 said he/she realized the mistake after being let go on 10/31/2025. During an interview on 03/18/2026 at 10:06 AM, the Regional Director of Clinical Services revealed that Resident #16's elopement on 10/25/2025 was preventable and concluded on 10/31/2025. All residents identified as wanderers were placed under wander guards.During an interview on 3/20/2026 at 8:30 AM, the Administrator stated that staff will be continuously educated on elopement prevention. Residents will request a pink slip before they can exit the building. Staff were unaware that Resident #16 had eloped and left the facility for several hours.On 3/18/2026, a past compliance Immediate Jeopardy was signed by the administrator.The facility implemented measures effective for supervision and elopement prevention for all residents with cognitive impairment and /or exit-seeking behaviors.Review on 3/18/25 at 7:30 am of the corrective action to address noncompliance indicated that on 10/25/2025 at approximately 4:45pm, law enforcement contacted the Administrator to notify them Resident #16 was observed on New Hampshire Avenue by a citizen who brought him/her to the police station. Law Enforcement stated they sent Resident #16 to a local hospital. The weekend supervisor, Registered Nurse (RN) 13, called the Administrator to report that Resident #16 had left the building and had been transferred to the local hospital. Maintenance Director and GNA #14 picked up Resident #16 from the hospital at approximately 8:17pm.On 10/25/25, the facility immediately implemented a 100% headcount. Resident #16 was immediately assessed following the elopement incident upon return from the hospital. Resident #16 was then placed on 1:1 care for 24 hours. Resident #16 had labs ordered, and a full body skin assessment was completed. Wander guard was placed on Resident #16's right wrist; the order was updated to reflect wander guard, the care plan was updated, and the elopement binder was updated. Resident #16's elopement risk assessment was reviewed and revised to ensure accuracy and appropriateness of interventions. On 10/25/25, an elopement drill was completed on each shift. Staff were educated regarding elopement, and statements were received.On 10/27/25, all residents in the facility were reviewed for elopement risk. Elopement assessments were completed and/or updated for current residents. Residents identified as at risk received a wander guard order, a wander guard placement, a care plan update, and behavior monitoring. The facility's elopement binder was audited and updated to ensure all at-risk residents are accurately identified and tracked.On 10/31/25, the facility initiated Systemic Changes to Prevent Recurrence. The facility implemented the following system-wide interventions: Wander guards were applied to identified at-risk residents; a Leave of Absence (LOA) pink form process was implemented, requiring the front desk to be notified before leaving the building. Staff were re-educated on elopement prevention protocols for the use of the LOA form; Elopement policies and procedures were reviewed and reinforced with all staff. The facilities Ongoing Monitoring and Quality Assurance. The facility conducted ongoing audits to ensure compliance: the elopement binder was audited continuously to ensure accuracy; LOA documentation was reviewed continuously for compliance; and a random sample of residents was audited to ensure elopement risk assessments and interventions were in place. The results of these audits were reviewed in the Quality Assurance and Performance Improvement (QAPI) program. Any identified issues were addressed promptly with corrective action by the facility.On 3/17/2026 at 1:30pm, four staff members were interviewed (Geriatric Nursing Assistant #11, Geriatric Nursing Assistant #12, Maintenance Director #9, and Environmental Aide #10). All four staff stated that the facility used a pink slip system for all residents to present to staff upon exiting.Based on the above actions taken by the facility and verified by the on-site surveyor, it was determined that the facility's deficient practice was past noncompliance, with a compliance date of 10/31/2025.

Based on record review and facility staff interviews, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's clinical status and physician-documented care for 2 of 3 sampled residents (Resident #9 and Resident #12). Facility failed to accurately code the presence of Intravenous (IV) access for Resident #9, and the administration of hypoglycemic medication, which was coded as administered when it had been placed on hold per physician orders for Resident #12. Findings included:Resident #9 was admitted to the facility on [DATE] with a diagnosis of high-grade papillary urothelial carcinoma status post chemoradiation, chronic kidney disease stage 4, and chronic obstructive pulmonary disease.Review done on 3/16/26 at 6:25 pm of admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #9 was moderately impaired with no intravenous (IV) access.Review done on 3/16/26 at 6:25 pm of the quarterly minimum data set (MDS) assessment dated [DATE] revealed that Resident #9 was moderately impaired with no IV access.Review done on 3/16/26 at 6:59 pm of hospital records (Discharge summary page 7/37 - lines/drains/airways) dated 11/20/25 at 8:25am, indicated that Resident #9 had an implanted port (adult) right chest.Review done on 3/16/26 at 6:51 pm of nurse progress notes dated 11/22/25 at 1:37 am written by Staff Nurse #23 indicated that Resident #9 had a Central IV line on the right chest, which was used for chemotherapy.Review done on 3/16/26 at 6:51 pm of history and physical dated 11/25/25 at 11:19 am, written by Medical Doctor (MD) 40, indicated that Resident #9 had a Port-a-catheter on the right upper chest.Review done on 3/16/26 at 6:51 pm of provider progress notes dated 11/27/25 at 12:59 am written by MD #34 indicated that Resident #9 had a Port-a-catheter on the right upper chest.Review done on 3/16/26 at 6:51 pm of provider progress notes dated 11/29/25 at 12:59 am, written by MD #34, indicated that Resident #9 had a Port-a-catheter on the right upper chest.Review done on 3/16/26 at 6:51 pm of provider progress notes dated 12/2/25 at 8:19 am, written by MD #34, indicated that Resident #9 had a Port-a-catheter on the right upper chest.Review done on 3/16/26 at 6:51 pm of provider progress dated 12/3/25 at 4:51 pm, written by Medical Doctor (MD) 40, indicated that Resident #9 had a Port-a-catheter on the right upper chest.During the interview on 3/17/26 at 10:56, GNA #5 indicated that she recalled Resident #9. GNA #5 indicated that Resident #9 had an IV line that was on the right chest. GNA #5 stated that Resident #9 was admitted with an IV line in place.During the interview on 3/19/26 at 9:50 am, Staff Nurse #7 indicated that they recalled Resident #9. Staff Nurse #7 stated that Resident #9 had access IV due to the presence of a port-a-catheter on his/her right chest.During the interview on 3/19/26 at 11:59 am, MDS Staff Nurse #35 indicated that she would verify why the IV access was not accurately coded on the MDS assessment. b. Resident #12 was admitted to the facility on [DATE] with a diagnosis of diabetes, chronic obstructive pulmonary disease, obstructive and reflux uropathy, chronic kidney disease, hypertension, and dementia.Review done on 3/16/26 at 8:53 pm of the significant change in status, minimum data set (MDS) assessment dated [DATE], indicated that Resident #12 was taking a hypoglycemic (including insulin) medication during the last 7 days or since admission/entry or reentry if less than 7days.Review done on 3/16/26 at 9:29 pm of physician orders dated 9/3/25 at 11:06 pm, written by MD #34, indicated that Glipizide ER (hypoglycemic) oral tablet extended release 24-hour 5mg, give 1 tab by mouth one time a day for diabetes, was placed on hold due to patient being lethargic.Review done on 3/16/26 at 9:29 pm of physician orders dated 9/19/25 at 11:34 pm, written by MD #34, indicated that Glipizide ER (hypoglycemic) oral tablet extended release 24-hour 5mg, give 1 tab by mouth one time a day for diabetes, was discontinued due to poor oral intake and risk of hypoglycemia.Review done on 3/16/26 at 9:29 pm of the Medication Administration Record (MAR) for September 2025 revealed that Glipizide ER (hypoglycemic) Oral tablet extended release 24-hour 5 mg was on hold from 9/4/25 to 9/19/25. MAR indicated that Resident #12 did not receive glipizide ER (Hypoglycemic) oral tablet from 9/4/25 to 9/19/25.Multiple attempts (3/18/26 at 10:34am, 3/18/26 at 3:36 pm, 3/19/26 at 1:13 pm) to interview MD #34 were unsuccessful.During the interview on 3/19/26 at 11:59am, MDS Nurse #35 indicated that the MDS assessment should be accurately coded to reflect the care plan.During the interview on 3/16/26 at 12:03 pm, the Administrator indicated that the MDS assessment should accurately reflect the medical record and resident plan of care.

Based on record review and staff interviews, the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's central venous access device for 1 of 3 sampled residents (Resident #9). Findings include:Resident #9 was admitted to facility on 11/21/25 with diagnosis of high-grade papillary urothelial carcinoma status post chemoradiation, Infrarenal abdominal aortic aneurysm without rapture, atherosclerotic heart disease of native coronary artery without angina pectoris, peripheral vascular disease, chronic kidney disease stage 4, syncope and collapse, gastrointestinal hemorrhage, duodenal ulcer, dysphagia, obsessive compulsive disorder, major depression, chronic obstructive pulmonary disease, respiratory failure with hypoxia, presence of cardiac pacemaker, and duodenal ulcer. Review done on 3/16/26 at 6:25 pm of the admission minimum data set (MDS) assessment dated [DATE] revealed that Resident #9 was moderately impaired. Review done on 3/16/25 at 6:31 pm of the care plan initiated on 12/2/25 indicated that Resident #9 had impaired cognitive function. Care plan initiated on 12/2/25 revealed that Resident #9 was at risk for abnormal bleeding or hemorrhage due to anticoagulant/antiplatelet use. Review of care plan initiated 11/22/25 did not reveal evidence addressing the presence of a port-a-catheter, including no interventions for site care or dressing changes, no interventions for flushing or maintenance of the line, no monitoring for complications such as infections, occlusion or dislodgement, no staff guidance regarding management of the central intravenous (IV) access lines ( Central line, or any other type of IV line access). Review done on 3/16/26 at 6:59 pm of hospital records (Discharge summary page 7/37 - lines/drains/airways) dated 11/20/25 at 8:25am, indicated that Resident #9 had an implanted port (adult) right chest. Review done on 3/16/26 at 6:51 pm of nurse progress notes dated 11/22/25 at 1:37 am written by Staff Nurse #23 indicated that Resident #9 had a Central IV line on the right chest, which was used for chemotherapy. Review done on 3/16/26 at 6:51 pm of history and physical data dated 11/25/25 at 11:19 am, written by Medical Doctor (MD) 40, indicated that Resident #9 had a Port-a-catheter on the right upper chest. Review done on 3/16/26 at 6:51 pm of provider progress notes dated 11/27/25 at 12:59 am written by MD #34 indicated that Resident #9 had a Port-a-catheter on the right upper chest. Review done on 3/16/26 at 6:51 pm of provider progress notes dated 11/29/25 at 12:59 am, written by MD #34, indicated that Resident #9 had a Port-a-catheter on the right upper chest. Review done on 3/16/26 at 6:51 pm of provider progress notes dated 12/2/25 at 8:19 am, written by MD #34, indicated that Resident #9 had a Port-a-catheter on the right upper chest. Review done on 3/16/26 at 6:51 pm of provider progress dated 12/3/25 at 4:51 pm, written by Medical Doctor (MD) 40, indicated that Resident #9 had a Port-a-catheter on the right upper chest. During the interview on 3/17/26 at 10:56, GNA #5 indicated that she recalled Resident #9. GNA #5 noted that Resident #9 had an IV line in the right chest upon admission and stated they did not know what type of line it was or how it was managed. During the interview on 3/19/26 at 9:50 am, Staff Nurse #7 indicated that they recalled Resident #9. Staff Nurse #7 confirmed that Resident #9 had IV access via a port-a-catheter and that care related to the IV access, including dressing management, was unclear due to the absence of a care plan. During the interview on 3/19/26 at 11:59 am, MDS Staff Nurse #35 stated that Resident #9 had a significant clinical condition and treatment that should have been reflected in the care plan. During the interview on 3/19/26 at 12:03 pm, the Administrator stated that the care plan should address the residents' clinical needs and guide staff in delivering care.

Based on record review and staff interviews, the facility failed to ensure a resident received necessary care and services to maintain the highest practicable physical well-being by failing to assess, monitor and obtain appropriate treatment orders for an accessed implanted port for 1 of 3 sampled residents (Resident #9). The facility failed to initiated care from admission on [DATE] until 12/15/25, when physician orders were finally obtained, placing the resident at risk for complications including infection and loss of device patency. Findings include: Resident #9 was admitted to facility on 11/21/25 with diagnosis of high-grade papillary urothelial carcinoma status post chemoradiation, Infrarenal abdominal aortic aneurysm without rapture, atherosclerotic heart disease of native coronary artery without angina pectoris, peripheral vascular disease, chronic kidney disease stage 4, syncope and collapse, gastrointestinal hemorrhage, duodenal ulcer, dysphagia, obsessive compulsive disorder, major depression, chronic obstructive pulmonary disease, respiratory failure with hypoxia, presence of cardiac pacemaker, and duodenal ulcer. Review done on 3/16/26 at 6:25 pm of the admission Minimum Data set (MDS) assessment dated [DATE] revealed that Resident #9 was moderately impaired. Review done on 3/16/26 at 6:51 pm of nurse admission progress notes dated 11/22/25 at 1:37 am, written by Staff Nurse #23, indicated that Resident #9 had a Central intravenous (IV) line on the right chest, which was used for chemotherapy. Review done on 3/16/26 at 6:51 pm of the medical record revealed that no physician orders were obtained for dressing changes, flushing protocols, or site maintenance from admission on [DATE] through 12/15/25. Review of medical records revealed there was no evidence of ongoing assessment or monitoring of the device. Review done on 3/16/26 at 6:51 pm of physician orders revealed an entry created by Staff Nurse #38 on 12/15/25 at 11:24am, signed by Nurse Practitioner (NP) #8, which indicated that IV: implanted port (venous) lumens not in use flush port lumen with 20cc of saline followed by 5cc of heparin (100u/ml) every month. one time a day. During the interview on 3/19/26 at 9:50 am, Staff Nurse #7 stated that the dressing on Resident #9's IV access was not changed, and the port-a-catheter was not flushed because no physician orders had been initiated. During the interview on 3/19/26 at 1:04 pm, NP #8 confirmed that they were notified weeks after admission that Resident #9 had no orders obtained for management of the port-a-catheter. During the interview on 3/19/26 at 2.19 pm, Staff Nurse #38 stated that, upon assessment on 12/15/25, Resident #9 had a port-a-catheter with a Huber needle in place and no prior orders for care. During the interview on 3/19/26 at 11:36 am, the Director of Nursing (DON) confirmed that the facility did not maintain IV access or perform dressing changes and acknowledged that the resident did not have physician-ordered interventions initiated on admission. During the interview on 3/19/26 at 11:49 am, the Administrator stated that the oncology provider reported that the port-a-catheter on Resident #9 was not maintained appropriately and that the lumen remained in place.

Based on record review, facility policy review and staff interviews, the facility failed to implement and maintain an effective infection prevention and control program by failing to follow established standards of practice for care and maintenance of an accessed central venous device (Port-a-catheter) for 1 of 3 sampled residents (Resident #9). These failures included not performing dressing changes, not maintaining aseptic technique, and leaving an accessed device (Huber needle- special type of needle used to access implanted ports) ) in place without proper care, placing the resident at increased risk for infection.Findings include:Resident #9 was admitted to the facility on [DATE] with a diagnosis of high-grade papillary urothelial carcinoma status post chemoradiation, chronic kidney disease stage 4, and chronic obstructive pulmonary disease.Review done on 3/18/26 at 3:00 pm of facility's policy and procedures for Central Venous Catheter, Section 5.1, effective date 2/7/20, required changes on admission, weekly, and as needed; assessment of insertion site for erythema, drainage, and edema; use of aseptic techniques during dressing changes; routine flushing protocols for accessed and non-accessed ports; regular needless connector changes.Review done on 3/16/26 at 6:25 pm of admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #9 was moderately impaired.Review done on 3/16/26 at 6:31 pm of the care plan initiated on 12/2/25 indicated that Resident #9 had impaired cognitive function. Care plan initiated on 12/2/25 revealed that Resident #9 was at risk for abnormal bleeding or hemorrhage due to anticoagulant/antiplatelet use.Review done on 3/16/26 at 6:51 pm of nurse admission progress notes dated 11/22/25 at 1:37 am, written by Staff Nurse #23, indicated that Resident #9 had a Central intravenous (IV) (catheter inserted into a vein) line on the right chest, which was used for chemotherapy.Review done on 3/16/26 at 6:51 pm of history and physical data dated 11/25/25 at 11:19 am, written by Medical Doctor (MD) 40, indicated that Resident #9 had a Port-a-catheter on the right upper chest.Review done on 3/16/26 at 6:51 pm of provider progress notes dated 11/27/25 at 12:59 am written by MD #34 indicated that Resident #9 had a Port-a-catheter on the right upper chest.Review done on 3/16/26 at 7:01 pm of the medical record revealed that Resident #9 did not have any physician orders for Central intravenous (IV) access (port-a-catheter) dressing changes, flush protocols, and site maintenance on admission.During the interview on 3/17/26 at 10:56, Geriatric Nurse Aide (GNA) 5 indicated that Resident #9 had a dressing with an IV line to the right chest upon admission. GNA #5 indicated that they had provided showers to Resident #9 and observed that the dressing remained unchanged. GNA #5 stated that they were not provided with any instructions regarding the IV site or precautions during bathing or showering. During the interview on 3/19/26 at 2.19 pm, Staff Nurse #38 indicated that they recalled Resident #9. Staff Nurse #38 stated that on 12/15/25, they observed Resident #9 with a Port-a-catheter and a Huber needle (special type of needle used to access implanted ports) in place, with the dressing not changed.During the interview on 3/19/26 at 1:04 pm, Nurse Practitioner (NP) 8 stated they were notified weeks after admission that Resident #9 had a port-a-catheter with a lumen (inside space of a tube where fluid flows) still accessed and no dressing changes performed.During the interview on 3/19/26 at 11:36 am, the Director of Nursing (DON) confirmed that the facility did not maintain IV access or perform dressing changes and acknowledged that the resident was at high risk for infection.During the interview on 3/19/26 at 11:49 am, the Administrator stated that the oncology provider reported that the port-a-catheter on Resident #9 was not maintained appropriately and that the lumen remained in place.

Based on observations, interviews and record reviews, it was determined that the facility failed to supervise and provide protective devices for Residents that smoked. This was found to be evident for 2 (Resident #18 & #61) out of 4 Residents observed for smoking. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified verbally and in writing of this determination at 4:05 PM on 01/29/25. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 8:37 PM on 01/29/25. On 01/30/25 the survey team confirmed the facility met the compliance date of their action plan and the Immediate Jeopardy was abated on 01/29/25. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents The findings include: During a random observation conducted on 01/29/25 at 11:19 AM, the Surveyors observed resident #61 in the dining room with multiple burn holes in his/her sweatpants. The wheelchair cushion appeared to have multiple burns as well. Resident #61 was also observed holding a pack of [NAME] Cigarettes and a yellow lighter. When asked if those were burn holes in his/her pants the resident stated, yes from when I smoke. The resident was asked if he/she wore an apron or other protective device when he/she smoked, the resident stated no. On 01/29/25 at 11:20 AM Residents #61 and #18 were observed outside in the designated smoking area unsupervised. Resident #18 was observed smoking a cigarette without an apron or protective device. Resident #61 was not smoking but had a pack of [NAME] cigarettes and yellow lighter in his/her hand without an apron or protective device. During the continued observations, the Activities Director (AD) at 11:29 AM, entered the designated smoking area located outside and asked Resident #68, #61, #18, & #5 if everyone was ok. The AD then exited the smoking area and returned to her office. During an interview conducted on 01/29/25 at 11:36 AM, the AD stated that Resident #68, #61, #18, & #5 currently do not require supervision, only those that are dependent require supervision. The AD further stated that only Resident #11 who at the time was not outside, required supervision and a smoking apron. A review of Resident #61's medical records conducted on 01/29/25 at 11:42 AM, revealed a care plan that stated the resident may smoke with apron and supervision. A review of Resident #61's smoking assessment dated [DATE] stated that the resident was unable to light own cigarette, required supervision, and a smoking apron. On 01/29/25 at 11:54 AM a review of Resident #18's smoking assessment dated [DATE] stated the resident was unable to light own cigarette and required supervision while smoking. A review of Resident #18's care plan conducted on 01/29/25 at 11:56 AM stated, provide supervision during designated smoke times. During an interview conducted on 01/29/25 at 12:13 PM, the Director of Nursing (DON) stated that it is the facility's policy and expectation that all smoking residents are supervised. The DON further stated that Residents that require a smoking protective device such as an apron are required to wear the device while smoking. A review of all Resident smoking assessments conducted on 01/29/25 at 1:14 PM revealed Resident #18, #9, #38, & #62 required supervision while smoking. Resident #11, #61, and 44 required supervision and a smoking apron. An immediate jeopardy was declared on 1/29/2025 at 4:05 pm. The Administrator submitted the initial plan of correction to OHCQ on 01/29/25 at 6:21 PM and it was determined to be unacceptable. The second version was submitted to OHCQ on 01/29/25 at 7:32 PM and it was determined to be unacceptable. A third version was submitted to OHCQ and was also determined to be unacceptable. A fourth version was submitted for review on 01/29/25 at 8:14 PM and was determined to be unacceptable. The 5th and final version was submitted for review on 01/29/25 at 8:29 pm and was determined to be acceptable and the immediacy was removed at 8:37 PM. The provision of the plan to remove the immediacy had a completion date of 01/29/2025 and included the following: The facility plan for the removal of the immediate jeopardy stated that staff would be educated on safety for Residents that smoked, supervision and protective devices. Corrective actions were taken to replace burnt clothing, wheelchair equipment, and skin assessments performed for residents who were not provided with protective devices while smoking. All smoking assessments were reviewed to determine the safety needs of each smoker and revised as needed. A list was created for the staff to identify all Residents that required supervision and /or a protective device. The facility also created a schedule that assigned staff to supervise the smokers during designated smoking times. The plan also stated that the Administrator, Director of Nursing, or shift supervisor will audit smoking breaks to evaluate whether supervision is being provided as required and whether aprons are being provided as required. These audits will occur during each smoking break for two days, four times a day for two weeks, and then daily for eight weeks. Negative findings will be addressed immediately. Results of these audits will be reported to the Quality Assurance/Performance Improvement Committee and considered for further action if needed.

Based on observation and interview with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This was evident during the initial tour of the kitchen during the annual survey. The findings include: During the initial tour of the kitchen conducted on 01/27/2025 at 8:52 AM, the Surveyor and Certified Dietary Manager (CDM) observed one clear bag of corn opened and undated and one clear bag of garlic bread opened and undated inside of a box labeled broccoli florets in the walk-in freezer. There was also one clear bag of Salsbury steak opened and undated on the top shelf of the walk -in freezer. In an interview conducted on 01/27/2025 at 8:58 AM, the CDM confirmed the facility's food storage policy is to securely close packages/bags once opened and to label the package/bag with an open date. The CDM stated that the printed expiration on the package/bag is used to determine when items are discarded. The CDM further stated that opened bulk food should be labeled with an open date once removed from its original box/container. During a continued tour of the kitchen at 9:02 AM, Surveyor and the CDM observed a shelf in the food preparation area with multiple containers of dried herbs and seasonings that were opened and undated. The food containers were identified as follows: 1 6 ounce bottle of Rubbed Sage, 1 6 ounce bottle of Table Ground Black Pepper and 1 6 ounce bottle of seasoning labeled Garlic Powder. The powder inside the Garlic powder seasoning bottle was observed to be red in color. In an interview conducted on 01/27/2025 at 9:05 AM with the CDM, the CDM stated that she did not know what the red colored powder was inside the garlic powder bottle and that it would be discarded. The CDM also stated that the undated dried herbs and seasonings would be labeled and dated appropriately.

Based on interviews and record review, it was determined that the facility failed to have routine care plan meetings for residents. This was evident for 5 (Resident #36, #76, #1, #50 and #52) out of 39 residents reviewed for care plan meetings. The findings include: According to Centers for Medicare and Medicaid (CMS) a care plan meeting is a regularly scheduled gathering where healthcare professionals, residents (or their family representatives), and relevant staff from a facility discuss and review a resident's individual care plan, ensuring it accurately reflects their needs, preferences, and any necessary adjustments based on their current health status; these meetings are typically held quarterly and are a key part of quality care in nursing homes. 1) During an interview with Resident #36 on 01/27/25 at 12:13 PM, when asked about attendance for care plan meetings, he/she reported that he/she did not recall being involved in care plan meetings. 2) During an interview with Resident #76 on 01/29/25 at 09:30 AM, he/she reported that he/she was never invited to a care plan meeting. A record review for Resident #36 and #76 on 01/29/25 at approximately 12:44 PM, showed there was no documentation that quarterly care plan meetings occurred for these residents. During an interview with the Director of Nursing (DON) on 02/03/2025 at 09:43 AM, when asked what her expectations are for how often the care plan meetings should occur, she stated that the first care plan meeting should be within the first seven days of the resident ' s admission. Thereafter, a care plan meeting should be held every three months or sooner if needed. On 02/03/25 at 11:36 AM, during an interview with Social Worker #23, when asked about care plan meeting occurrences, she stated that due to the turnover of new social services staff, care plan meetings have not been happening as they should have. She stated that normally she would expect a care plan meeting to occur within seven days following each Assessment Reference Date (ARD) assessment. When asked what her expectations are for residents being involved in care plan meetings, she expects all residents to be invited and that she would document in the Electronic Health Record (EHR) if the resident refused. She further explained that on the day of the resident ' s care plan meeting, she expected that the resident would be asked again if they would like to attend the meeting. If the resident refused again, then she would document this in the EHR as well. This surveyor discussed the concern with Social Worker #23 that Resident #36 and #76 reported that they had not recalled being invited to care plan meetings and a review if their medical records did not show documentation for care plan meetings. Social Worker #23 reviewed Resident #36 ' s medical record and confirmed the Resident had not received a care plan meeting since 06/28/23. The Social Worker also confirmed that Resident #76 had not received a care plan meeting since his/her admission on 10/17/24. 51491 3) During a review of Resident Medical Records on 1/28/25 at 07:34 AM it was discovered that Resident #1 didn ' t have quarterly Care Plan Meetings regularly. The last documented Care Plan Meeting was held on 1/11/24. During a telephone interview conducted on 1/29/25 at 08:42 AM, Resident #1's family member stated he/she had concerns about Resident #1 and had been unable to have his/her questions answered. He/she reported they are the Power of Attorney for Resident #1 and had not been invited to any care plan meetings. The family member is reportedly waiting for a Care plan meeting to be scheduled to discuss his/her concerns. During an interview with the [NAME] President of Social Work for Maryland on 2/03/25 at 11:38 AM, she advised Care Plan meetings should be documented in the electronic medical records. She confirmed that the facility is behind on Care Plan Meetings and stated it seems common that care plan meetings haven ' t been held and I don't believe quarterly Care Plan meetings are up to date. She confirmed Resident #1 had not had a recent Care Plan Meeting. 50504 4) On 1/30/25 at 08:55AM the surveyor reviewed Resident #50's clinical record. The review revealed that Resident #50's quarterly MDS assessment was completed on 08/22/24 and an annual assessment was completed on 11/20/24. There was no evidence in the clinical record to indicate that a care plan meeting was held with the resident and the interdisciplinary team within 7 days or around the time of either the last quarterly or annual MDS assessment. The record revealed that the most recent interdisciplinary care plan meeting was held on 07/12/23 On 01/30/25 at 08:45 AM in an interview, the DON stated that the Social Worker was out sick, and she was unable to provide the details of the care plan meetings for Resident #50. Later, on 01/30/25 at 01:45 PM the Regional Nurse RN stated he is assisting in locating the resident's records and gave the surveyor a copy of a progress note confirming the most recent interdisciplinary care plan meeting for Resident #50 was on 7/12/23. 5) On 1/27/25 at 8:40AM during an interview, Resident #52 informed the surveyor that he/she had never been to a care plan meeting. A review of Resident # 52's clinical record revealed that resident was admitted to the facility on [DATE] and the most recent interdisciplinary care plan meeting was held on 08/10/23. The records also revealed that the most recent quarterly MDS assessments were completed on 09/18/24 and 10/19/24. There was no evidence in the clinical record to indicate that a care plan meeting had been held with the resident and the interdisciplinary team after 08/10/23. On 02/03/25 at 11:30 AM the surveyors interviewed the facility's [NAME] President for Social Work (VPW). The VPW stated that the interdisciplinary care plan meetings usually follows the MDS schedule and are held within 7 days of the schedule. However, because of the staffing issues at the facility, care plan meetings were not held in a timely manner. When asked about the care plan meetings for Resident # 50 and Resident #52, the VPW confirmed that the most recent interdisciplinary care plan meeting for Resident #50 was 07/12/23 and for Resident #52 was 08/10/23.

Based on the review of resident and facility records; interviews with residents and staff; and observations, it was determined that the facility's staff failed to keep residents free from sexual, physical, and verbal abuse. This finding was evident for 2 of 7 residents (Residents #2 and #3) reviewed for abuse during a complaint survey. On Wednesday, 2/23/2022, at 10:00 p.m. an Immediate Jeopardy was called related to the facility's failure to prevent Resident #1 from sexually abusing vulnerable residents. On Thursday, 2/24/2022, the facility presented three corrective action plans (one at 12:49 a.m., 1:09 a.m., and 1:52 a.m.) to address the immediate concern related to sexual abuse. These plans were not accepted by the Office of Health Care Quality surveyors. The fourth corrective action plan was presented to the survey team on 2/23/2022 at 2:06 a.m. This plan was accepted by the surveyors and the Office of Health Care Quality at 2:21 a.m. that morning. On Friday, 2/25/2022 the surveyors verified that the facility implemented the elements of their corrective action plan. The immediacy was removed at that time. After removal of the immediate jeopardy, the deficient practice remained at the scope and severity of a G. The findings include: 1.) On 2/15/2022 at 10:00 a.m. a review of Resident #2's medical record revealed the resident was admitted to the facility in September 2019 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Resident #2's medical record, the resident had two certifications of incapacity to make informed decisions (9/10/2019 and 9/17/2019 respectively). On 10/09/2020 the facility initiated a care plan for Resident #2 to address the following: Alteration in psychosocial wellbeing, impaired decision making, impaired thought process as evidenced by sexual advances with another resident. According to the care plan, the facility implemented 15 min checks on Resident #2 as an intervention. Further review of the resident's record revealed that the resident is contracted at the knees (inward), but able to self-propel in a wheelchair with his/her feet. The continued review of Resident #2's medical record revealed that on 11/5/2021 the facility's staff documented the outcome of the resident's Brief Interview for Mental Status (BIMS) as a 0 out of 15, which indicates the resident has severe cognitive impairment. On 02/15/2022 at 11:30 a.m. a review of Resident #1's medical record revealed the resident was admitted to the facility in February 2020. According to Resident #1's record, the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . Each assessment documented Resident #1 with a BIMS of 14 out of 15. A BIMS of 14 indicates the resident is cognitively intact. On 02/15/2022 a review of a facility reported incident dated, 11/6/2021, revealed that at 3:00 p.m. that day Geriatric Nursing Assistants (GNA) #15 and GNA #16 reported Resident #1 was observed grabbing Resident #2's private area. Resident #2 attempted to remove Resident #1's hand from his/her private area, then Resident #2 hit Resident #1 with a newspaper. The residents were separated. Resident #2 had a head-to-toe assessment for injury and a pain assessment which were negative for signs of injury or pain. Both residents were placed on one-to-one monitoring that day. On 2/15/2022 at 1:14 p.m. Resident #1 was observed in a wheelchair. The resident had the ability to self-propel the chair by using his/her hands and/or feet. On 2/15/2022 at 1:15 p.m. During interview with Resident #1, he revealed that prior to 11/6/2021, Resident #2 came into his/her room and started to disrobe. When questioned about his/her response to Resident 2's actions, Resident #1 reported watching Resident #2 disrobe until staff presented and removed Resident #1 from the room. On 2/15/2022 at 3:15 p.m. in an interview, the facility's Social Worker reported that she has worked at the facility for four months. She added that each time she visited Resident #2's room the resident did not have a top (shirt) on. On 2/16/2022 at 10:30 a.m. an interview was completed with Resident #5, Resident #2's roommate. Resident #5 stated prior to 11/06/2022 Resident #1 attempted to enter his/her room on several occasions. The resident stated that staff had to redirect the Resident #1 away from the multiple times prior to 11/06/2021. On 02/16/2022 at 11:00 a.m. a review of the facility's investigation of the incident revealed staff documented Resident #1 and Resident #2 each received one to one monitoring on 11/07/2021. On 02/16/2022 at 1:00 p.m. a review of Resident #1's medical record revealed that on 11/08/2021 the resident was sent to the hospital related to a change in mental status. Resident #1 returned to the facility the same day with no new orders. Further review of Resident #1's medical record revealed that on 11/08/2021, the facility updated Resident #1's care plan by adding that the resident was at risk for impairment in psychosocial wellbeing and activity involvement related to inappropriate touching of another resident. The stated intervention was documented as one to one monitoring by nursing staff. There was no documented evidence to indicate that Resident #1 remained on one-to-one supervision between 11/08/2021 and 1/10/2022. On 2/16/2022 at 2:00 p.m. the review of a facility reported the incident revealed that on 1/10/2022 Resident #1 was observed engaging in sexual act with Resident #2 for the second time. Licensed Practical Nurse (LPN) #4 documented that on 1/10/2022 at 6:00 p.m. Resident #1 was observed in Resident #2's room. Resident #1's hands were in Resident #2's incontinence brief. LPN #4 asked Resident #1 to leave Resident #2's room. Resident #1 complied with LPN #4's request. On 2/16/2022 at 2:00 p.m. According to facility's records, on 1/11/22 Resident #1 was relocated to a room on the second floor (room [ROOM NUMBER]). On Wednesday, 2/23/2022, at 10:00 p.m. an Immediate Jeopardy was called related to the facility's failure to prevent Resident #1 from sexually abusing vulnerable residents. The Facility's Corrective Plan of Action included: Resident's #2 Head to toe assessment completed without any visible injury noted 11/6/21 and 1/10/22 Resident #2 interview conducted by social services, [CONDITION(S)] screen completed, and psych evaluation completed 11/6/21 and 1/10/22 Resident's #2 Pain assessment complete. 11/6/21 and 1/10/22 Resident's #2 MD and RP notification of incident 11/6/21 and 1/10/22 Resident #2 referred to psych 11/6/21 and 1/10/22 Resident's #2 Care plan updated. 11/6/21, 1/10/22, and 2/23/22 Resident #1 remains on one on one 2/23/22 and ongoing Police were notified of the incident. 11/6/21 and 1/10/22 Investigation initiated and initial findings sent to state per guidelines 11/6/21 and 1/10/22 Ad Hoc QAPI meeting conducted to review Abuse investigation protocol and policy. 2/24/2022 Identification of Others: All residents have the potential to be affected by this deficient practice Interview all residents to identify if similar resident abuse exists. Implement action to protect residents if similar allegations are identified. (ED and DON) 2/24/2022 Head to toe skin assessments completed on all residents 2/24/2022 Interviews conducted house-wide on 2/24/2022 on residents with BIMS 12 or greater related to staff abuse. Skin assessments were conducted house-wide on those with BIMS less than 12. Education: Educate all staff (nursing, rehab, EVS, laundry, maintenance, dietary, laundry, administrative) on organization abuse prevention policies. (ED and DON) 2/24/2022 Educate all staff (nursing, rehab, EVS, laundry, maintenance, dietary, laundry, administrative) to one-on-one guidelines and procedures. (ED and DON) 2/24/2022 Leadership team to be trained on abuse prevention and one on one guidelines and procedures during department head meetings. ED-2/24/2022 Facility Leadership team to conduct daily ambassador rounds and interviews to assure residents with potential for abuse are identified, investigation initiated, and reported to the state timely per guidelines by ED and DON 2/24/22 and ongoing System Change: Education will be provided to all new employees upon hire and annually on the Abuse policy 2/24/2022 and ongoing by HR. All supervisors will be educated on the process of when/ if a resident complains of any form of abuse, or any abuse is witnessed, staff will notify supervisor immediately and supervisor to inform ED, DON and MD. Law enforcement must be notified and a thorough investigation will be completed. 2/24/2022 by DON and ED All residents will be interviewed by social services by 2/24/2022 Social Service to educate all new residents on the Abuse policy. 2/24/2022 and ongoing Nursing supervisors will be educated to observe for signs of patient abuse in the facility when they are completing rounds. 2/24/2022 and ongoing by DON Monitoring: Executive Director to review audits daily x 12 weeks to assure residents with potential for abuse are identified, investigation initiated, and reported to the state timely per guidelines. Audits to be reviewed monthly at the quality assurance meeting x 3 months Cross Reference F689 2) A review of the facility Abuse Policy on 2/22/22 at 2:25 p.m. revealed the following: Listed under Reporting of Incidents and Facility Response, #1: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Listed under Prevention, # 4: An employee who is alleged or accused of being a party to abuse, neglect, misappropriation of property will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. On 2/17/2022 at 10:00 a.m. a review of Resident #3's medical record revealed the resident has a BIMS score of 15/15. A BIMS score of 15 indicates that the resident is cognitively intact. Further review of Resident #3's medical record revealed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 is documented as using a wheelchair for mobility. A continued review of the resident's record revealed that on 10/7/2021 the facility developed a care plan to address the following behaviors displayed by Resident #3: Non- adherent to treatment, refusing medications and wound treatment, cursing at staff during care, throwing trays, urinal on the hallway, using profanity words, refusal to participate in the care plan meeting and non-compliant with wearing a face mask, accusing staff of stealing packages, refusing psych medications, screaming/threatening and abusive language while speaking to staff. According to the care plan, interventions to address Resident #3's behavior was listed as: Approach, speak in a calm manner and Communicate with the resident or residents' representative regarding behaviors and treatment. On 10/26/2021 the interventions were revised to include the following: Encourage active support by family/ resident representatives; Encourage residents to express feelings; Encourage to maintain as much independence and control and decision making as possible; Intervene as necessary to protect the rights and safety of others; Monitor behavioral episodes, and attempt to determine underlying causes; Notify medical provider of increased episodes of behaviors; and Observe and anticipate resident's needs; thirst, food, body positioning, pain, toileting needs. On 2/17/2022 at 10:30 a.m. a review of a facility reported incident revealed that on 12/22/2021 Resident # 3 reported an alleged altercation with GNA #28. Resident #3 stated that the GNA #28 put her hands on the resident's neck in an effort to choke the resident. On 2/17/2022 at 10:45 a.m. a review of the facility's investigation into the incident revealed an interview questionnaire that was completed with GNA #28. According to the documentation, GNA#28 worked the 11:00 p.m.-7:00 a.m. shift between 12/21/2022 and 12/22/2022. Resident #3 was one of GNA #28's assigned residents during that shift. GNA #28 explained that while she was writing on the assignment board, Resident #3 came around the corner and pushed the medication cart into her without reason. She stated that the resident was angry, called her names and then reached out to hit her. GNA #28 reported that she blocked Resident #3 from hitting her. She informed the night supervisor, Registered Nurse (RN) #17 about the incident. On 2/17/2022 at 2:20 p.m. an interview was conducted with the Director of Nursing ( DON). The DON was asked about the incident between Resident #3 and GNA #28. The DON reported that she was made aware of the incident via text message received on 12/22/2021 at approximately 10:00 AM. The DON stated that on 12/22/2021 at approximately midnight, GNA#28, reported that Resident #3 was agitated and repeatedly approached her while sitting in the hallway in his/her wheelchair. GNA #28 further reported that the resident called her names and cursed at her. The DON stated that the GNA admitted to a verbal exchange of curse words between with Resident #3 and added that the nurse supervisor, RN #17, overheard a verbal exchange between them. The DON explained that she contacted the police after receiving the text message Resident #3 was interviewed by the police. The resident showed the police his/her neck and gave a description of the GNA #28. Resident #3 explained to the police that GNA #28 got into his/her face and grabbed his/her neck while the resident was sitting in a wheelchair. The police observed bruising on the resident's neck. The DON stated GNA #28 confirmed that GNA had worked until her shift ended on 12/22/2021 at 7:00 a.m. The DON further stated that the GNA was removed from the schedule and did not work again. The DON further stated that RN #17 received written discipline for not immediately removing the GNA from the building and not immediately reporting the incident to administration. On 2/18/2022 at 11:30 a.m. RN# 17 was interviewed. RN #17 was asked to give an account of the incident that occurred between Resident #3 and GNA #28. RN #17 reported that on 12/22/2021 at around midnight she overheard a verbal exchange between Resident #3 and the GNA #28. RN #17 stated that she approached the resident and the GNA and the resident began cursing at her. RN #17 confirmed that she overheard the verbal exchange of cursing between the Resident #3 and the GNA #28, but denied witnessing a physical altercation between the two of them. On 2/22/2022 at 2:15 p.m. Resident #3 was interviewed about the allegation of abuse by GNA #28. The Resident #3 explained that GNA #28 pushed a medicine cart into him/her while he/she was sitting in the hallway. The resident further explained that he/she pushed the cart back into GNA #28, then the two of them had a verbal exchange of curse words. The resident went on to say that GNA #28 pushed him/her in the forehead using her ungloved hand, then grabbed the resident by the neck. The resident stated that RN #17 came up and began to curse at him/her. According to Resident #3 when the police arrived they saw marks on his/her neck. During another interview with the DON on 2/22/2022 at 2:30 p.m. she stated that the facility substantiated the abuse allegation. The DON explained that it is the facility's policy to report abuse allegations immediately. The DON went on to say that the supervisor was written up because she did not follow through with reporting the incident immediately to administration, did not remove the GNA, and did not complete an assessment on Resident #3 at the time of the incident. The DON stated that the GNA was terminated upon completion of the investigation and that the board of nursing was notified.

Based on the review of resident and facility records; interviews with residents and staff; and observations, it was determined that the facility staff failed to provide adequate supervision of Resident #1 to prevent sexual abuse of Resident #2 on two occasions and failed to ensure Resident #1 did not have unsupervised access to other vulnerable residents (Resident #4). This was evident for 2 of 7 residents (Residents #2 and #4) reviewed for abuse during a complaint survey. On Wednesday, 2/23/2022, at 8:00 p.m. an Immediate Jeopardy was called related to the facility's failure to provide adequate supervision of Resident #1 to prevent sexual abuse of residents. Between Wednesday night and Thursday morning, the facility presented four corrective action plans (one at 10:00 p.m., 11:30 p.m., 12:45 a.m., and 1:09 a.m.) to address the immediate concern related to supervision. These plans were not accepted by the Office of Health Care Quality's surveyors. The fifth corrective action plan was submitted at 1:52 a.m. and was accepted by the surveyors and the Office of Health Care Quality at 2:07 a.m. On Friday, 2/25/2022 the surveyors verified that the facility implemented the elements of their corrective action plan. The immediacy was removed at that time. After removal of the immediate jeopardy, the deficient practice remained at the scope and severity of D- potential for more than minimal harm. The findings include: On 2/15/2022 at 10:00 a.m. a review of Resident #2's medical record revealed the resident was admitted to the facility in September 2019 with the following diagnoses: [CONDITION(S)], anxiety disorder, dementia, and [CONDITION(S)] disorder. According to Resident #2's medical record, the resident had two certifications of incapacity to make informed decisions (9/10/2019 and 9/17/2019 respectively). On 10/09/2020 the facility initiated a care plan for Resident #2 to address the following: Alteration in psychosocial wellbeing, impaired decision making, impaired thought process as evidenced by sexual advances with another resident. According to the care plan, the facility implemented 15 min checks on Resident #2 as an intervention. Further review of the resident's record revealed that the resident is contracted at the knees (inward), but able to self-propel in a wheelchair with his/her feet. The continued review of Resident #2's medical record revealed that on 11/5/2021 the facility's staff documented the outcome of the resident's Brief Interview for Mental Status (BIMS) as a 0 out of 15, which indicates the resident has severe cognitive impairment. On 02/15/2022 at 11:30 a.m. a review of Resident #1's medical record revealed the resident was admitted to the facility in February 2020. According to Resident #1's record, the resident underwent three documented BIMS assessments (dated 9/16/2021, 12/15/2021, and 2/3/2022). Each assessment documented Resident #1 with a BIMS of 14 out of 15. A BIMS of 14 indicates the resident is cognitively intact. On 02/15/2022 at 1:25 p.m., surveyor observations revealed that GNA #8, was assigned to monitor Resident #1. On 02/15/2022 at 1:30 p.m. an interview was completed with GNA #8 who confirmed that she was assigned to provide one to one monitoring for Resident #1 during that day for the 7:00-3:00 p.m. shift. On 02/15/2022 a review of a facility reported incident dated, 11/6/2021, revealed that at 3:00 p.m. that day Geriatric Nursing Assistants (GNA) #15 and GNA #16 reported Resident #1 was observed grabbing Resident #2's private area. Resident #2 attempted to remove Resident #1's hand from his/her private area, then Resident #2 hit Resident #1 with a newspaper. The residents were separated. Resident #2 had a head-to-toe assessment for injury and a pain assessment which were negative for signs of injury or pain. Both residents were placed on one-to-one monitoring that day. On 02/16/2022 at 11:00 a.m. a review of facility records revealed staff documented Resident #1 and Resident #2 each received one to one monitoring on 11/07/2021. On 02/16/2022 at 1:00 p.m. a review of Resident #1's medical record revealed that on 11/08/2021 the resident was sent to the hospital related to a change in mental status. Resident #1 returned to the facility the same day with no new orders. Further review of Resident #1's medical record revealed that on 11/08/2021, the facility updated Resident #1's care plan by adding that the resident was at risk for impairment in psychosocial wellbeing and activity involvement related to inappropriate touching of another resident. The stated intervention was documented as one to one monitoring by nursing staff. There was no documented evidence to indicate that Resident #1 remained on a one-to-one supervision between 11/08/2021 and 1/10/2022. On 2/16/2022 at 2:00 p.m. the review of a facility reported the incident revealed that on 1/10/2022 Resident #1 was observed engaging in sexual act with Resident #2 for the second time. Licensed Practical Nurse (LPN) #4 documented that on 1/10/2022 at 6:00 p.m. Resident #1 was observed in Resident #2's room. Resident #1's hands were in Resident #2's incontinence brief. LPN #4 asked Resident #1 to leave Resident #2's room. Resident #1 complied with LPN #4's request. On 2/16/2022 at 2:00 p.m. According to facility's records, on 1/11/22 Resident #1 was relocated to a room on the second floor (room 218). According to facility records, on 1/11/22 Resident #1 was relocated to a room on the second floor (Room 218). On 1/12/22, Resident #1 was reassigned to Room 205. Resident #1's care plan was updated on 1/13/22 to include one to one monitoring of the resident, but the one-to-one monitoring no longer reflected it should be completed by nursing staff only. During an interview on 02/17/2022 at 1:30 p.m. GNA #6 reported that on 1/13/2022 during the 7:00 am to 3:00 p.m. shift she observed Resident #1 at Resident #4's bedside. GNA #6 notified the LPN #20, the charge nurse, the DON, and the Social Worker of her observation. At that time the facility assigned Hospitality Aide (HA) #22 to provide one to one monitoring for Resident #1. GNA #6 further stated about two hours later while at the nursing station she observed Resident #1 entering Resident #4's room for the second time during her shift. GNA #6 looked for HA #22 (a non-nursing employee). HA #22 reported that she had gone to the bathroom and left Resident #1 temporarily unattended while she went to the restroom. On 02/17/2022 a review of Resident #4's Medical Record revealed the resident had a BIMS of 3 out of 15, indicating the resident has severe cognitive impairment. On 02/17/2022 at 3:00 p.m. in an interview the DON verified during that Resident #1 was observed by staff in Resident #4's room on two different occasions on 1/13/2021 during the 7:00 a.m.-3:00 p.m. shift. the DON stated that Resident #1 was placed on one-to-one monitoring in response to the 1/13/2022 to being found in Resident #4's room. The DON further stated that staff were in-serviced on the facility's expectation for one-to-one monitoring of residents utilizing the facility One on One Resident Care Guidelines. On 02/23/2022 at 1:00 p.m. a review of the facility's training documentation revealed that on 1/13/2022 the facility began in-servicing their staff on their One-on-One Resident Care Guidelines. A review of the facility's in-service documentation revealed that GNA #8 had not signed off as being in-serviced on the facility's expectations for one-to-one monitoring. Further review of the facility's in-servicing documentation revealed that 14 nurses and GNAs had not received in-service training regarding the facility expectations for one-to-one monitoring. There were an additional 25 non nursing employees that had not received in-service training regarding the facility's One on One Resident Care Guidelines. On 02/23/2022 at 1:30 p.m. an interview with GNA #8 revealed this employee was in-serviced on the facility's One on One Resident Care Guidelines on 02/23/2022. On Wednesday, 2/23/2022, at 8:00 p.m. an Immediate Jeopardy was called related to the facility's failure to provide adequate supervision of Resident #1 to prevent sexual abuse of residents. The Facility's Corrective Action Plan included: Resident #1 remains one to one in the facility. Resident # 2 was assessed to have no injuries on 11/6/21 and 1/10/22, care plan was updated to reflect no further need for Q15 minute checks on 2/23/22. Will continue with care plan intervention for redirection and assistance as needed. Facility staff was reeducated regarding one-to-one guidelines and procedures on 2/23/22 by the facility Director of Nursing. Reportable event was reported on 11/6/21 and 1/10/22. Ad Hoc QAPI meeting conducted to review one to one guidelines and procedures 2/23/2022 Identification of Others: All residents have the potential to be affected by this deficient practice Head to toe skin assessments completed on all non-interview able residents will be completed by 2/24/22 Interviews conducted house-wide for interview able residents with BIMS 12 or greater by 2/24/22 using the CMS tool (form CMS- ) any identified issues will be investigated Clinical Meeting interdisciplinary team will review progress notes and identify instances of potential abuse on 2/24/22. Social Services to review and update care plans for residents who have been identified at risk for needing one to one supervision begins 2/24/22 and ongoing. Education: Educate all staff (nursing, rehab, EVS, laundry, maintenance, dietary, laundry, administrative) to observation one on one by DON 2/24/22 Leadership team to be trained on one on one during department head meetings. ED-2/24/2022 Divisional Director of Clinical Educated Director of Nursing and Executive Director regarding one-to-one education process, guidelines, documentation, and need to complete all staff education prior to allowing staff to work Director of Nursing educated staff on one-to-one education process, documentation, and guidelines 2/24/22 Calls placed to facility staff to complete education on one-to-one procedure and guidelines 2/24/22 System Change: Will be provided to all new employees upon hire and annually on the one-on-one policy 2/24/2022 and ongoing The Director of Nursing and off shift supervisors to be educate facility staff prior to being allowed to proceed pass reception desk to unit to work 2/24/22 and ongoing The Director of Nursing and off shift supervisors Facility agency staff to be educated on one-to-one education process, documentation, and guidelines prior to being allowed to proceed pass reception desk to unit work 2/24/22 and ongoing Monitoring: Director of Nursing to audit current residents on one to one daily to assure each resident is appropriately supervised and one to one documentation is being completed by the assigned employee for each shift. As well as care plans updated beginning 2/24/22 Audits to be reviewed monthly by the Quality Assurance Performance Improvement Committee to assure all residents assigned to one to one are appropriately supervised and one to one documentation is being completed by the assigned employee for each shift. Beginning 2/24/22 ADHOC then Monthly x 3 months Results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for 3 months, the Committee will determine the need for further audits and/or action plans. Beginning 2/24/22 ADHOC then monthly for 3 months.

Based on closed record review, surveyor observation, review of facility policy and procedures, and facility staff interview, it was determined that the facility failed to maintain a safe environment for a resident with a history of known cognitive impairment and wandering. This finding was evident for 1(#2) of 5 residents identified as at risk for wandering/elopement. An immediate jeopardy to residents' health and safety was determined by the State Office of Health Care Quality On 07-27-16 at 3:20 PM. The immediate jeopardy was abated on 07-27-16 at 7:05 PM following the facility's implementation of corrective actions to ensure the health and safety of all residents that wander and/or are at risk for elopement. This finding is related to complaint #MD 285 and is valid. The findings include: On 07-27-16, surveyor review of the closed clinical record for resident #2 revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. Surveyor review of the Wandering Observation Tool completed on admission revealed the resident was assessed as low risk. Further review of the clinical record revealed that, 2 days after admission, resident #2 attempted to leave the facility and a wanderguard bracelet was ordered and applied to the resident. However, there was no update of the Wandering Observation Tool used to assess the resident's risk of wandering/elopement. Review of the admission MDS assessment revealed that resident #2's wandering presence and frequency was coded as occurring 1-3 days, however, nursing documentation revealed that resident #2 was wandering on 5 days between 05-07-16 and 05-13-16. In addition, the assessment of the impact of wandering did not place the resident at significant risk of getting to a potentially dangerous place and that the wandering did not intrude on the privacy of others. However, the nursing documentation revealed that, on 05-09-16, the resident attempted to leave the building through the front door and on 05-10-16 the resident was going to doors and trying to get out. Nursing notes also revealed that resident #2 was wandering into other resident's rooms on a daily basis from 05-09-16 through 05-13-16. See F272 In addition, nursing documentation in the nurses notes revealed that resident #2 was closely monitored or frequently monitored. Surveyor interview with facility staff #1 and staff #2 on 07-27-16, revealed that staff could not clarify how often the resident was observed or what the expectation was for close or frequent monitoring. Surveyor review of the care plan for resident #2 revealed that a care plan for elopement/wandering was initiated on 05-16-16, however, there were no updates to the care plan from 05-16-16 through 07-24-16, despite the resident wandering in and out of other's rooms daily and a change in the wandering observation tool score which reflected the resident was at moderate risk on 07-21-16. Further review of the care plan for elopement/wandering revealed interventions that included, know where abouts of resident and safety check PRN {as needed}. Surveyor interview with facility staff #1 and staff #2 on 07-27-16 revealed that staff could not state specifically what those care plan interventions meant or how they are implemented. There was no definitive protocol of how often the resident was observed or who was responsible for implementing the interventions. In addition review of physician progress notes [REDACTED].#2 needed constant supervision and redirection. Also on 06-07-16 the physician documented that due to the wandering and severe dementia, the resident would be better served on a locked dementia unit. Surveyor review of the facility policy and procedure for a missing resident revealed that if the resident cannot be immediately located, the nurse will organize a search of the center and surrounding grounds including: a. staff accounting of residents on their assignments b. assigning staff to search areas c. enlist help of all departments d. announce the code for missing resident through out the facility e. immediately notify director of nursing and executive director. If the search fails to locate the resident within 15 minutes notify local police, family and extend search to surrounding neighborhood. Surveyor review of the facility investigation of the elopement of resident #2 on 07-27-16 revealed the following time line of events on 07-24-16 - Resident #2 seen by activity staff on the lower level at 12:20 PM - 12:30 PM GNA notified supervisor resident could not be located for lunch - 12:30 PM inside of facility and facility grounds searched - 1:45 PM the food service director asked by nursing if I had seen resident - 1:50 PM administrator notified of missing resident - 2:00 PM Law enforcement notified of missing resident - 2:45 PM physician and family notified of missing resident Surveyor review of the clinical record for resident #2 revealed a nursing note written on 07-24-16 at 4:15 PM that stated, at approximately 12:15 PM, resident could not be located for lunch, staff searched but could not find resident in the facility, resident could not be found around the facility also, administrative staff notified, police called and resident son was also notified. This time was inconsistent with the report in the facility investigation. In addition, the the time line of events revealed the following inconsistencies with policy and procedure for a missing resident: - Facility staff failed to enlist help of all departments when the resident could not be immediately located. The resident was noted by nursing staff to be missing at 12:30 PM and the food service director was not aware of missing resident until 1:45 PM. - The director of nursing and executive director were not immediately notified of the missing resident. The administrator was not notified until 1:50 PM. 1 hour and 20 minutes after the resident was noted to be missing. - Law enforcement was not notified after 15 minutes of searching for the resident. Law enforcement was not notified until 2 PM, 1 hour and 30 minutes after the resident was noted to be missing. Surveyor review of the hospital emergency room (ER) report from 07-24-16 revealed that resident #2 arrived at the ER at 1:40 PM. EMS (emergency medical system) reported resident was picked up from the street sidewalk but the resident was did not know how he fell or how long he was down. The resident had a small abrasion to forehead and left arm. Surveyor interview of the administrator, on 07-27-16 at 11:10 AM, revealed that the supervisor called the administrator to report the resident was missing on 07-24-17 around 2 PM and that law enforcement was called around 2:20 PM. Law enforcement conducted another search of the building and grounds and put out an APB (all points bulletin) around 2:45 PM. The resident was found to be at an area hospital at 5 PM. EMS had picked up the resident at 12:50 PM about 1/2 mile from the facility where the resident was found on the ground by a passerby and 911 was called. The administrator also revealed that review of the facility's security camera tapes on 07-24-16 showed the resident wearing a red shirt walking through the parking lot at 12:32 PM. Immediate inspection of all exits and wander guard sensors revealed alarms were in working order. Administrator was unable to definitively identify how the resident left the building.

Based on surveyor review of the clinical records and interview of the facility staff and physician, it was determined that the facility staff failed to ensure that a resident who entered the facility without a pressure sore, did not develop pressure sores. This finding was evident in 1 of 30 residents selected in the stage 2 review. ( #15). This was related to complaint MD 620 and was considered valid. This finding rose to the level of harm. The findings include: On 03-31-16, review of the closed clinical record revealed that resident #15 was in the facility for rehabilitation after spinal surgery, status [REDACTED]. In addition, the resident had a balloon aortic valvuloplasty repair, also known as balloon aortic valvotomy which is the widening of a stenotic aortic valve using a balloon catheter inside the valve. The balloon is placed into the aortic valve that has become stiff from calcium buildup. The balloon is then inflated in an effort to increase the opening size of the valve and improve blood flow. Resident #15 was alert and oriented. However, the resident needed extensive assistance with 2 people for bed mobility. Further review of resident #15's record revealed the admission observation tool, dated 01-21-16, under skin, which revealed that the only wound present was a surgical incision. There was no measurements or specific area noted. A Braden Observation tool was performed to determine the risk of a pressure sore developing for resident #15 with the finding of 16 meaning a moderate risk. Under the area to document comments or interventions, none was documented. A care plan for resident #15 was initiated for incontinence which could cause possible skin integrity breakdown. The interventions included: monitor fluid intake, observe voiding patterns .call light within reach, answer promptly, pericare when incontinent, keep clean/dry, assist to bathroom, assist with hygiene. A care plan was also initiated for skin integrity to the surgical wound on the mid back. The interventions included: assist with hygiene and general skin care, keep skin clean and dry .monitor for infection, encourage to turn and reposition as tolerated There was no care plan for prevention of alteration in skin integrity for this resident using routine turning and positioning, or other assistive devices such as a chair pad or special mattress, prior to the development of the pressure sore. On 02-03-16, an open blister on the sacrum was noted during routine AM care of resident #15. It was noted to measure 2 x 2 x 0.1 cm., the wound was clean with no drainage or bleeding, the wound bed was pink in color. A call was placed to the facility's wound physician and an order obtained to place hydrogel on the open area and cover it daily. The wound specialist visited resident #15 on 02-05-16, and noted the Stage II pressure sore on the sacrum, measuring 3.0 x 4.5 x 0.1 cm with light serous exudate. A stage II pressure sore is a partial thickness, loss of dermis, presenting as a shallow open ulcer, with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. The recommendation was to offload the wound, reposition per facility protocol, and to continue the use of hydrogel daily. Skin grids are the facility staff's weekly assessment of wounds. This includes areas to describe the wound in color, temperature, site, type, measurements, stage and other pertinent notes. On 02-05-16 ,the skin grid note for resident #15 revealed that the sacral ulcer was noted to be pressure, 3.0 x 4.5 x 0.1, stage II. Seen by wound specialist - 35% skin, 65% granulation, small serous drainage, continue treatment with hydrogel. On 02-12-16, the wound specialist visited resident #15 again and noted that the wound had deteriorated and was now a Stage III pressure sore, a full thickness tissue loss. The wound measured 3.2 x 1.5 x 0.1 cm. with 50% yellow slough and 50% granulation tissue. At this time, he/she debrided the area (meaning they surgically removed subcutaneous tissue along with the necrotic (dead) tissue). For the dressings, she/he changed the treatment from hydrogel to leptospermum honey. However, there was no evidence this order was written in the physician's orders [REDACTED]. On 04-06-16 at 9:20 AM, interview with the wound specialist revealed that he/she could not remember if they had written the order on that date. In a stage III pressure sore, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (necrotic tissue) may be present, but does not obscure the depth of tissue loss. It may include undermining or tunneling. On 02-12-16, the skin grid of resident #15 was completed noting only that there was a wound on the sacrum. No measurements or further description was noted. Under the note section was documented Dressing to sacral decub(itus) intact On 02-18-16, the wound specialist noted the wound of resident #15 had again deteriorated, remained Stage III, and the measurements were 4.0 x 1.8 x 0.3 cm with light serous exudate, yellow necrotic tissue 90%, granulation tissue 10%. On this date, he/she recommended leptospermum honey and a protective dressing to be done every day. The order for honey treatment was written in the chart on this date, 02-18-16. On 02-19-16, the completed skin grid of resident #15 had no information concerning the wound, the area was blank. Under the notes mid back surgical wound with steri strips and sacral decubitus. On 02-26-16, the wound specialist noted that resident #15's wound had continued to deteriorate and was now unstageable, meaning full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (necrotic tissue) in the wound bed. The measurements were 8.0 x 5.5 x 0.3 cm.,with yellow necrosis 90%, granulation tissue 10% and light serous exudate. The treatment was changed to silver [MEDICATION NAME] twice per day. At that time, an order was written to administer Vitamin C 500 mg. twice per day and Zinc [MEDICATION NAME] 220 mg. daily for wound healing along with the new treatment order. On 02-26-16, resident #15's skin grid included: sacral ulcer, measurements 8.0 x 5.5 x 0.1 cm, which did not match the wound specialist's assessment, unstageable, skin 15%, granulation 10%, necrosis 75%, again not matching the specialist's assessment. The facility staff were not documenting any changes or measurements, other than when the wound specialist was visiting resident #15. Arginade, 2 packets per day, a protein supplement, was ordered on 03-01-16 to promote wound healing. The pressure wound for resident #15 was discovered 13 days after admission, without evidence of a plan to prevent skin breakdown. The wound continued to deteriorate and became unstageable in the following 3 weeks. No care plan was initiated for the actual wound when it occurred. On 04-06-16 at 11 AM, interview with the medical director revealed no additional information.