Every finding on record at Hidden Waters Rehabilitation and Wellness Center

Based on resident record reviews, staff interviews, and facility record reviews, it was determined that the facility failed to adhere to professional standards of quality of established clinical practices, physician orders, or facility policies regarding medication administration. This was evident for 11 residents (Resident # 11, #17, #3, #62, #119, #232, #76, #9, #57, #50, and #8 ) out of 28 residents reviewed for medications during the annual recertification survey. Facilities must ensure that all care and services, including medication administration, adhere to accepted standards of clinical practice. This is often interpreted through established guidelines like the six rights of medication administration: right patient; right medication; right dose; right route; right time; and right documentation. It is a standard of nursing practice to document administered medications immediately after administration. Failing to do this results in an inaccurate record where it cannot be determined when a medication was given and has the potential to result in medication errors (such as a resident receiving a dose twice, or two doses of a medication being given too close in time). The surveyors reviewed resident medication administration records (MARs) and the medication administration audit report for the following residents: 1. On 12/11/2025 at 8:46 AM, the surveyor reviewed Resident # 11's medical records. The resident record review revealed that Resident #11's Medication Admin Audit Report indicated that the resident received the following morning medications late on 12/5/25: Aspirin Oral Tablet Chewable 81 MG, for cerebrovascular accident prophylaxis, was scheduled for 7:00 AM, administered at 2:03 PM, and documented at 2:04 PM; Metformin HCl Oral Tablet 1000 MG, for diabetes mellitus, was scheduled for 7:00 AM, administered at 2:03 PM, and documented at 2:04 PM; Jardiance Oral Tablet 10 MG (Empagliflozin), for diabetes, was scheduled for 7:00 AM, administered at 2:03 PM, and documented at 2:04 PM; Duloxetine HCl 20 MG Capsule delayed release particles was scheduled for 7:00 AM, administered at 2:03 PM, and documented at 2:04 PM; Tramadol HCl Oral Tablet 50 MG (Tramadol HCl), for inguinal pain, was scheduled for 7:00 AM, administered at 2:03 PM, and documented at 2:04 PM; Baclofen Oral Tablet 10 MG, for muscle spasm, was scheduled for 7:00 AM, administered at 2:03 PM, and documented at 2:04 PM; Carvedilol Oral Tablet 12.5 MG, for hypertension, was scheduled for 7:00 AM, administered at 2:04 PM, and documented at 2:04 PM; Gabapentin Oral Capsule 100 MG, for neuropathic pain, was scheduled for 7:00 AM, administered at 2:03 PM, and documented at 2:04 PM; and Sinemet Oral Tablet 25-100 MG (Carbidopa-Levodopa), for Parkinson, was scheduled for 10:00 AM, administered at 1:56 PM, and documented at 2:04 PM. 2. On 12/11/2025 at 9:38 AM, the surveyor reviewed Resident # 17's medical records. The resident record review revealed that Resident #17's Medication Admin Audit Report indicated that the resident received the following morning medications late on 12/5/25: Amlodipine Besylate Oral Tablet 10 MG, for hypertension, was scheduled for 7:00 AM, administered at 2:29 PM, and documented at 2:29 PM; Aspirin Oral Tablet Chewable 81 MG, for atrial fibrillation, was scheduled for 7:00 AM, administered at 2:29 PM, and documented at 2:29 PM; Jardiance Oral Tablet 10 MG (Empagliflozin) was scheduled for 7:00 AM, administered at 2:29 PM, and documented at 2:29 PM; Polyethylene Glycol 3350 Oral Powder 17 GM/SCOOP, for bowel regimen, was scheduled for 7:00 AM, administered at 2:29 PM, and documented at 2:29 PM; Chlorhexidine Gluconate Mouth/Throat Solution 0.12 %, was scheduled for 7:00 AM, administered at 2:29 PM, and documented at 2:29 PM; Metformin HCl Oral Tablet 500 MG, for A1c of 8.0, was scheduled for 7:00 AM, administered at 2:29 PM, and documented at 2:29 PM; Lisinopril Oral Tablet 20 MG, for hypertension, was scheduled for 7:00 AM, administered at 2:28 PM, and documented at 2:29 PM; and Metoprolol Tartrate Oral Tablet 50 MG, for hypertension, was scheduled for 7:00 AM, administered at 2:28 PM, and documented at 2:29 PM. 3. On 12/11/2025 at 9:52 AM, the surveyor reviewed Resident # 3's medical records. The resident record review revealed that Resident #3's Medication Admin Audit Report indicated that the resident received the following morning medications late on 12/5/25: Aripiprazole Tablet 5 MG, for psychosis, was scheduled for 7:00 AM, administered at 12:47 PM, and documented at 12:49 PM; Acetaminophen Tablet 325 MG, for pain, was scheduled for 7:00 AM, administered at 12:46 PM, and documented at 12:49 PM; Artificial Tears Ophthalmic Solution 0.2-0.2-1 %, for dry eyes, was scheduled for 9:00 AM, administered at 12:46 PM, and documented at 12:49 PM; and Aspirin Oral Tablet Chewable 81 MG, for peripheral artery disease and cerebrovascular accident prophylaxis, was scheduled for 9:00 AM, administered at 12:46 PM, and documented at 12:49 PM. 4. On 12/08/2025 at 10:30 AM, the surveyor reviewed the medication administration audit report via the electronic medical record. Resident # 62 on 11/27/25 was scheduled to receive Carvedilol Oral tablets at 1700; the documentation reflects that staff #31 documented and signed the MAR at 19:35 PM. Resident #62 on 12/03/25 was scheduled to receive Carvedilol Oral tablets at 1700. The documentation reflected by staff # 10 was an administration time of 19:24 and a documentation time of 19:35. Resident #62 on 12/03/2025 was scheduled to receive Eliquis 5mg two times per day for DVT, due at 1700, administration time of 19:23 and a documentation time was 19:30. 5. On 12/08/2025 at 10:30 AM, the surveyor reviewed the medication administration audit report via the electronic medical record. Resident #119 on 11/27/25 was scheduled to receive Levetiracetam Oral tablet 500mg, 1 tablet at 17:00, the administration time reflected, and the documentation time were 19:35. 6. Review of the medication administration audit report revealed Resident # 232 was scheduled on 11/27/25 to receive Carvedilol Oral tablet, 625 mg two times a day for hypertension, take one tablet by mouth two time daily with meals, the scheduled time was 17:00, the documented administration time was 19:57 and the documented time by staff #30 was 19:57. The surveyor reviewed the MAR audit report for 12/03/25. Resident # 232 was scheduled to receive Carvedilol Oral tablet, 625 mg two times a day for hypertension, take one tablet by mouth two times daily with meals. The scheduled time was 17:00, the administration time documented was 19:44, and the documentation time was 19:45. The surveyor reviewed the documented administrative times for medications provided to the residents on the 1 [NAME] clinical unit for a seven day period. 7. On 12/8/2025 at 8:01 AM during the Medication Administration facility task for resident #76 with LPN staff #8, this Surveyor observed staff #8 prepare the following six medications: Plavix 75mg, 1 tab; Amlodipine 10mg, 1 tab; Sertraline 25mg, 2 tabs for a dose of 50mg; Levetiracetam 750mg, 1 tab; MultiVitamin, 1 tab; and Cholecalciferol 0.1mg, 1 tab; for a total of 7 tabs that this Surveyor observed placed in the medication cup. While still at the medication cart, this Surveyor then asked LPN staff #8 how many pills they had placed in the cup; staff #8 stated '7', thus confirming the number of tabs pulled for this administration. LPN staff #8 proceeded to resident #76's bedside, administered the medications, returned to the medication cart, and began to chart the medications given. This Surveyor observed staff #8 select the 6 medications above and then selected 'Aspirin 81mg, 1 tab', and marked them all as given, despite not preparing the Aspirin medication along with the other medications. This Surveyor shared with the LPN staff #8 that only the 6 medications above were pulled, placed in the medication cup, and then confirmed with the staff member before going to the bedside for administration. This Surveyor then asked the LPN staff #8 again, how many pills were stated before administration, again, staff #8 stated '7'. LPN staff then stated, I did give it, removed the Aspirin bottle from the standard medication drawer. This surveyor did not observe staff #8 preparing the Aspirin during the initial setup of the medications. 8. On 12/8/2025 at 8:15 AM during Medication Administration facility task for Resident #9 with LPN staff #8, this Surveyor observed staff #8 prepare the following three medications: Acetaminophen 325mg, 2 tabs for dose of 650mg; Ascorbic Acid 500mg, 1 tab; the medications were crushed, placed in a medication cup and then approximately 5mL of Liquicell (liquid modular protein) was poured from a large multi-use bottle on top of the medication cart, added to the medication cup and mixed with the crushed powder. Then, Oxycodone Hydrochloride 5 MG/5 ML Oral Solution was added to another medication cup; the medication was not signed out of the Narcotic Count book before preparation. Before entering the resident room, this Surveyor asked was the Liquicell that was used to mix the crushed medications was considered a medication; LPN staff #8 stated 'Yes'. When asked if this resident was ordered for this medication, staff #8 stated, 'We use it to mix the medications and give it to the residents.' Staff #8 then proceeded to resident bedside, administered the medications by spooning the medications into the resident's mouth, exited the resident's room, returned to the medication cart and began charting the medications given. Staff #8 selected 'Acetaminophen Rectal Suppository 650 MG' as given despite giving oral Acetaminophen to the resident. The Surveyor then observed staff #8 proceeded to prepare for the next resident; however, this Surveyor intervened and asked at what point the narcotic was given to Resident #9 would be signed out of the Narcotic Book; staff #8 stated, the resident sometimes may not take the medication'. Staff #8 then obtained the book and signed the medication entry after the medication administration was completed. When asked if the medication protocol is to sign out the narcotic first and then what to do if the resident refused, staff #8 stated, the medication should be signed out first, and if not taken, discarded with 2 nurse staff members'. Additionally, during record review for Resident #9, the following medications were due and omitted during this administration: Modular Protein, 30 mL with 120 mL water/beverage (Liquicell is the facility substitute); and Zinc Sulfate 220 MG, 1 Capsule. 9. On 12/8/2025 at 8:38 AM during the Medication Administration facility task for Resident #57 with LPN staff #5, this Surveyor observed staff #5 prepare the following medications: Donepezil hydrochloride 10MG, 1 Tablet; Cholecalciferol 0.025MG, 1 Tablet; empagliflozin 25MG (Jardiance), 1 Tablet; Magnesium Oxide 400MG, 1 Tablet; Metformin Hydrochloride 500MG, 1 Tablet; Vitamin B12 1 MG, 1 Tablet; a total of 6 medications. Staff #5 went to the bedside, administered the medications, and returned to the medication cart to chart the medications as given. During this time, staff #5 selected the 6 medications, and in addition selected 'Fluticasone-Salmeterol 100-50 MCG/ACT Aerosol Powder, breath activated' and then marked all of them as given despite not actually giving the resident the inhaler. At this time, staff #5 stated, 'Oh, I missed the inhaler, and I needed a fingerstick.'; LPN staff #5 then asked LPN/MDS Coordinator staff #8, who was also present at the medication cart, to obtain a fingerstick. This Surveyor then observed staff #8 offer to administer the inhaler, staff #5 gave the inhaler to staff #8; staff #8 then went to the bedside to administer the medication, returned to the medication cart, and stated 'I got the fingerstick, it is 119, and I gave the inhaler'. This surveyor asked LPN staff #5 what the expectation is on charting on medications not given and then giving the medication to someone else to administer, staff #5 stated, this nurse was sent to help today, they are not new, they are a nurse too'. Additionally, during record review for resident #57, 'Dulaglutide Subcutaneous Solution Auto-injector 1.5MG/0.5ML (Dulaglutide) Inject 1.5 mg subcutaneously was due at 8:00 AM'; it was given late, and this was after the resident consumed their meal and a late fingerstick that was performed. On 12/8/2025 at 9:39 AM, during staff interviews with the Regional Director of Process Improvement, staff #14, DON staff #2, and NHA staff #1, this Surveyor shared the above findings that were observed during the medication administration facility task. When asked about the expectation for signing out narcotics, late medications, charting on medications not given, and charting medications but allowing other staff members to administer the medication, DON staff #2 stated, 'These behaviors are not our policies or expectations for safe medication administration.' 10. On 12/8/25 at 8:47 AM, during review of the medication administration audit report for Residents #50 and Resident #8, it was noted that several medications were documented as late delivery to the residents. Resident #50 had the following medications on 12/5/25 that were late: Lantus insulin was due at 7 AM, administered at 1:08 PM, and documented at 3:08 PM. Compression stockings were due at 9 am and were administered at 4:12 PM. Flasp insulin was due at 4:30 PM and was administered at 11:09 PM. Baclofen due at 5 PM, administered at 11:09 PM; Metformin due at 5 PM, administered at 9:39 PM; and Compression stockings due at 9 PM, administered at 11:15 PM. 11. Resident #8 had the following medications on 12/5/25: Amlodipine, Folic Acid, Cyanocobalamin, Nephro-Vite, and Quetiapine were due at 7 AM, and all of them were signed off at 11:08 AM. On 12/8/2025 at 9:01 AM, the surveyors interviewed the Director of Nursing, staff #2. During the interview, the surveyor asked staff #2 what the expectations of staff are when administering medication to residents. Staff #2 stated that the expectation is that staff sign and document medication administration immediately after administering medication to the resident. On 12/8/2025 at 1:30 PM, the surveyors reviewed the facility's Medications Administration policy and procedure. The facility's Medications Administration policy and procedure stated that medications will be charted when given and medications will be administered within the time frame of one hour before up to one hour after time ordered.

Based on record reviews and staff interviews, it was determined that the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections based on an established infection prevention and control program. This was evident for 2 (residents #158 and #9) out of 46 residents observed during initial review for Infection Prevention & Control during the annual survey.Findings include:1. On 12/04/2025 at 8:16 AM during initial observation rounds, resident #158 urinary catheter/Foley bag was observed resting on the floor at the resident's bedside.On 12/04/2024 at 12:00 PM during an interview, NHA staff #3 and DON staff #2 were notified of the findings and infection control concerns for observing the resident urinary catheter/Foley bag on the floor next to the resident's bed.On 12/10/2025 at 12:51 PM during record review for resident #158, it revealed physician orders for the resident urinary catheter/Foley, placed 7/11/25 for acute urinary retention and worsening function; resident later diagnosed w/Obstructive Uropathy.On follow-up observations completed on 12/5/2025 at 11:51 AM and 12/12/2025 at 9:18 AM, now after Surveyor intervention, resident #158 urinary catheter/Foley bag was observed hooked to the lower portion of the resident bed, away from the floor.2. On 12/8/2025 at 8:15 AM during the Medication Administration facility task for resident #9 with LPN staff #8, this Surveyor observed staff #8 walk into the resident room with the prepared medications. The resident room had the following sign displayed: 'Enhanced Barrier Precautions', which indicated 'STOP: EVERYONE MUST: Clean their hands, including before entering and when leaving the room'. Staff #8 proceeded to the bedside, spooned the medications into the resident mouth without performing hand hygiene before or after administration or wearing protective gloves during the administration.On 12/8/2025 at 9:39 AM during staff interviews with Regional Director of Process Improvement staff #14, DON staff #2, and NHA staff #1, this Surveyor shared these findings with the administrative team, that were observed during the medication administration facility task.

Based on observations and interviews, it was determined that the facility failed to maintain the resident right to a dignified existence, by leaving visibly soiled linens on the resident's bedside during their meal while at bedside. This was evident for 1 (resident #122) out of 1 resident observed for Resident Rights during the annual survey.Findings include:On 12/4/2025 at 8:24 AM during initial observation rounds of resident #122, there were visibly soiled linens-a sheet and washcloth, with brown stains and a strong odor of stool noted, partially rolled up and positioned toward the end of the bed. The resident, a bilateral above-the-knee amputee, was observed sitting in a wheelchair at bedside, with the bedside table partially across the bed. When asked about the linens left at the end of the bed, the resident stated, 'I clean myself every morning and leave the linens there for staff to collect it'. Surveyor asked the resident did they asked a staff member this morning to remove the soiled linens; the resident stated, 'the linens were there when the aide came to get my breakfast tray, and I do this every morning'. The resident was then asked at what time the linens get removed, the resident stated, 'it's moved usually around 9a or 10a'.On 12/4/2025 at 9:39 AM during an interview with DON staff #2 and NHA staff #3, this Surveyor shared the findings of soiled linens left at bedside in a resident room and the resident stating they cleaned themselves daily and the linens remain there even after the meal tray is removed by staff. The Surveyor asked was this the expectation to leave visibly soiled linens at bedside, even if tray distribution or pickup is in progress; DON staff #2 stated 'No'.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure the safety of the resident room environment by not limiting the presence of potential hazards. This was evident for 5 (rooms 227, 229, 234, 235, and 237) of 26 resident rooms observed during the annual survey.Findings include:On 12/4/2025 at 7:57 AM during initial observation rounds wall-mounted thermostats were observed without outer protective covers with the internal elements exposed in rooms 234 & 237. Additionally, in rooms [ROOM NUMBER], resident dressers were observed with broken/missing doors compartments. On 12/4/2025 at 9:30 AM during the entrance conference with NHA staff #3 and DON staff #2, findings shared about thermostats that were observed without outer protective covers and broken dresser doors that were observed in the resident rooms.On 12/12/2025 at 9:23 AM during follow-up observation rounds, the thermostats without protective coverings and internal elements and the broken/missing dresser doors were again observed.On 12/12/2025 at 9:55 AM during follow-up interview with DON staff #2, this Surveyor updated facility on the follow-up observations; staff #2 stated 'the plan is to provide temporary covers to the exposed thermostats within the resident rooms and replace the dressers'.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure medications were administered in accordance with physician orders for 6 of 26 opportunities reviewed. This deficient practice resulted in residents receiving medications contrary to physician orders and a medication error rate of 23.08%.Findings include: 1. On 12/8/2025 at 8:01 AM during the Medication Administration facility task for resident #76 with LPN staff #8, this Surveyor observed staff #8 prepare six medications for a total of 7 tabs that this Surveyor observed placed in the medication cup. While still at the medication cart, this Surveyor then asked LPN staff #8 how many pills they had placed in the cup; staff #8 stated '7', thus confirming the number of tabs pulled for this administration. LPN staff #8 proceeded to resident #76's bedside, administered the medications, returned to the medication cart, and began to chart the medications given, however one error was observed. 'Aspirin 81mg, 1 tab' was selected and charted as given, despite not preparing or giving the Aspirin medication along with the other medications. This Surveyor shared with the LPN staff #8 that the Aspirin was never pulled with the original 6 medications (for 7 tabs) that were placed in the medication cup and confirmed with the staff member prior to going to the bedside for administration. This Surveyor then asked the LPN staff #8 again how many pills were stated prior to administration, again staff #8 repeated '7'. LPN staff #8 then stated, 'I did give it', at which point staff #8 then removed an Aspirin bottle from the standard medication drawer. This Surveyor did not observe staff #8 preparing the Aspirin during the initial set-up of the medications. 2. On 12/8/2025 at 8:15 AM during Medication Administration facility task for resident #9 with LPN staff #8, three errors were observed. First, Acetaminophen 325mg, 2 tabs for dose of 650mg was crushed and given orally, however was charted as given as a suppository rectally, the wrong route. Second, Zinc sulfate 220MG, 1 Capsule was omitted. Third, despite staff #8 using Liquacell (Modular Protein) 5mL to mix with the crushed oral medications, per physician orders resident #9 was written for 'Modular Protein, 30 mL w/120 mL water/beverage' also to be given during the morning medications; however, this medication dose as written was omitted.3. On 12/8/2025 at 8:38 AM during the Medication Administration facility task for resident #57 with LPN staff #5, two errors were observed. First, 'Fluticasone-Salmeterol 100-50 MCG/ACT Aerosol Powder, breath activated' was selected and charted as given by LPN staff #5; however, the medication was omitted during the initial medication administration. Second, 'Dulaglutide Subcutaneous Solution Auto-injector 1.5MG/0.5ML (Dulaglutide) Inject 1.5 mg subcutaneously in the morning, at 8AM' was not given per physician orders on time, this medication was charted as given at 9:14 AM, over an hour after it was due.On 12/8/2025 at 9:39 AM during staff interviews with Regional Director of Process Improvement staff #14, DON staff #2, and NHA staff #1, this Surveyor shared with the administrative team these findings observed during medication administration facility task.

Based on record reviews and staff interviews, it was determined that the facility failed to maintain proper records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and, failed to properly dispose of medications of a discharged resident. This was evident for 2 (residents #119 and #230) out of 2 residents reviewed for medication labeling and storage review during the annual survey.Findings include: 1. On 12/8/2025 at 1:57 PM during medication storage observation rounds with LPN staff #10 of the 1W Medication Cart #2 Narcotic Book-Team 2, it revealed the following entry for page No. 117: Resident #119; Oxycodone 5mg/5mL solution; Date: 11/15/25; Time: 14:00; Amount on Hand: 30mL; Amount Used: 0; Method: 0; and Amount Left: 30mL; however, the medication was not present in the narcotic locked box of Cart #2 as the Narcotic Book-Team 2 indicated. When asked about the location of this medication, staff #10 stated, 'this resident is on the other side of the (1W) unit and this medication was transferred to the other cart (Cart #1)'; however, the narcotic sheet did not reflect this transfer at the bottom of the sheet in the 'MEDICATION TRANSFERRED' section. Staff #10 stated 'I notified the LPN Unit Manager #4 on yesterday' (Sun, 12/7/25). This Surveyor completed a record review of Resident #119's room census with staff #10, which revealed resident #119 was admitted to room [ROOM NUMBER]A on 11/12/25 and then transferred to room [ROOM NUMBER]A on 11/14/25; however, the controlled medication was maintained on Cart #2 Narcotic Book-Team 2. This Surveyor then completed medication storage observation rounds of 1W Medication Cart #1 Narcotic Book-Team 1 with LPN Unit Manager staff # 4, it revealed an entry on page No. 139 for this same resident (resident #119). Page No. 19 revealed: Oxycodone 5mg/5mL solution; Date: 12/5/25; Time: 3p; Amount on Hand: 30mL; Amount Used: (-); Method: (-); and Amount Left: 30mL. The medication was observed in the locked medication box of Cart #1, sealed and unused. The prescription label on the bag revealed: Rx#14490599, NS: 1W, Rm: 112-A, Date: 11/14/25, Dt Wrt: 11/14/25, Res #119, OXYCODONE 5mg/5mL SOLN. When asked why this medication was reflected in two places as an active controlled substance medication that was transferred on 12/5/25, despite the resident room change on 11/14/25; staff #4 stated the medicine was not properly reconciled out of the other Narcotic Book (Team 2) when the medication was moved to this cart (Cart #1)'. On 12/8/25 at 2:28 PM during follow-up observation and interview with DON #2, this Surveyor shared the findings. When asked was the process correctly followed and what the expectation of transferring medications for transferred residents; this Surveyor was told 'the expectation is to transfer the medication at the time the resident is transferred, and to complete the page in the Narcotic book.' 2. On 12/9/2025 at 11:51 AM during observation rounds with Charge RN staff #15 of the 1W Medication Storage Room and Refrigerator this Surveyor observed medications for resident #230; the label appeared old and was fading, it read: Rx# 12578636, Dt Wrt: 02/11/25, [NAME]: 03/05/25, LATANOPROST 0.005% OPTH SOLN; the remaining label was partially ineligible. This Surveyor asked staff #15 was this resident (#230) still a resident at the facility; staff #15 stated No. When asked who reconciles the medication refrigerator for discharged residents; staff #15 stated, I don't know, possibly the manager'. On 12/9/2025 at 12:40 PM during follow-up observation and interview with DON #2, when asked was this the expectation of reconciling medications of discharged residents from the facility; this Surveyor was told 'No, the expectation is to remove the medications and return them to Pharmacy as per protocol.' 3. On 12/8/25 at 11:00 AM, during a medication storage check of the 3 [NAME] unit, the surveyor observed lacosamide 150 mg tablets in the resident's narcotic box. Review of the Narcotic Count Log revealed 12 tablets remaining, although a dose had been administered. During an interview, Nurse Staff #36 stated she administered the medication but forgot to sign it off. This resulted in an inaccurate narcotic count, compromising medication record integrity and controlled-substance accountability.

Based on observation, interview, and record review, the facility failed to ensure residents received the menu-specified type and required portion size of juice during the breakfast meal service. Specifically, residents on 2 [NAME] unit were provided with less than the required 4 ounces of juice, and at least one resident (#106) received a juice type inconsistent with their dietary order. This failure had the potential to negatively affect 2 west residents' nutritional intake, preferences, and compliance with physician-ordered diets.Findings include:On 12/4/25 at approximately 8:00 AM, during observation of the breakfast meal service on 2 West, the surveyor observed GNA Staff #34 placing clear plastic cups on top of the meal cart and pouring approximately 2 ounces of apple juice into each of approximately 15 cups prior to tray delivery.Review of the facility's posted breakfast menu for that date indicated residents were to receive 4 ounces of juice with breakfast.During continued observation, Resident #106 was observed with two clear plastic cups of apple juice on the breakfast tray. Each cup contained approximately 2 ounces of juice. When interviewed at that time, the resident stated, I don't like apple juice.Review of the dietary slip for Resident #130 revealed the resident was ordered to receive 4 ounces of orange juice with breakfast. There was no documentation to indicate a substitution, refusal, or resident preference change that had been made.During an interview on 12/4/25 at approximately 8:15 AM, GNA Staff # 34 stated, The juice is poured into cups before we serve the trays to make sure there is enough for everyone.During an interview on 12/5/25 at approximately 10:00 AM, the Regional Dietary Manager stated, There is enough juice sent to the units for each resident. We send 6-ounce cups to 2 West, and the nursing staff is to administer 4 ounces of juice as ordered to each resident. When asked if cups were sent to the unit on 12/4/25 during breakfast, the Regional Dietary Manager stated that the cups were not sent in error.

Based on observation and interview with residents and facility staff, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents on the 3 [NAME] clinical unit who eat food prepared by the facility. The findings include:On 12/05/2025 9:22 AM Resident #92 stated the food is okay but food items arrive cold such as potatoes and eggs. The temperature testing of the facility lunch meal on 12/11/2025 12:15PM inside the facility kitchen revealed the following: the internal temperatures of the food items to be served to the residents on unit 3 [NAME] did meet the standards of professional practice. However, the subsequent temperature testing of the selected test tray sent to the 3 [NAME] clinical unit did not meet the standard of practice for internal temperatures of the meat and vegetables.On 12/11/2025 at 12:15 PM staff # 33, the regional dietary director performed the temperature testing on the preparation trays held the following food items: regular barbeque pork: 179 degrees, grilled cheese sandwich: 145.9 degrees, tater tots: 140.7 degrees, lima beans: 177 degrees, macaroni noodles: 166.8 degrees, brown gravy: 158 degrees, pureed mashed potatoes: 186 degrees, pureed lima beans: 157.7, shredded pork: 177 degrees. The three portable food carts designated to the 3 [NAME] clinical unit began leaving the facility kitchen at 12:25 PM and the last food cart arrived on the unit at 12:30 PM on 12/11/2025. The test tray was placed on the third food cart.On 12/11/2025 the surveyor at 12:35PM observed that all three portable food carts utilized to deliver the lunch meal to the residents on 3 [NAME] did not possess external doors which prevented the food trays from having additional protection from heat loss while traveling through the facility, the elevator, and while on the clinical unit prior to staff distributing the lunch meal. The surveyor discussed the concern of the portable food carts whose doors had been with staff #33 and he stated that repair orders had been submitted to the facility maintenance director several months ago but no action had been taken at this time. The test tray temperature results for the lunch meal served on unit 3 [NAME] on 12/11/2025 at 12:45 PM were as follows: fruit punch: 40.7 degrees, hot water: 146.7 degrees, peaches: 44.2 degrees, lima beans:124.0 degrees, tater tots: 113 degrees, shredded barbeque pork:120 degrees.The facility failed to maintain a holding temperature above 135 degrees for the lima beans, the tater tots, and the shredded barbeque pork which would directly impact the palatability and preferred temperature of the residents.The results of the test tray temperatures were reviewed with the regional dietary director, staff #33, the administrator, and the DON on 12/11/2025 at 2:15 PM.

Based on record reviews and staff interviews, it was determined that the facility staff failed to maintain medical records for a resident in accordance with accepted professional standards and practices to contain accurate documentation. This was evident for 1 (resident #15) out of 1 resident reviewed for accurate identifiable information during the annual survey.Findings include:On 12/5/2025 at 12:03 PM during observations and interviews, resident #15 complained of wounds and discomfort to their bilateral heels. The resident was observed supine in bed, socks on both feet that were resting directly on the mattress with no pillow or heel-relieving device being used. This Surveyor asked resident #15 if they were instructed to elevate their heels off the bed for some relief; resident #15 stated, No. Resident #15 then offered to show this Surveyor their heel wounds and was able to remove their own socks. This Surveyor observed both heels, which revealed an approximate 3cm x 2cm open area to the Left-heel and a 2cm x 1.5cm open area to the Right-heel. This Surveyor then shared the residents' concerns and findings with LPN staff #6, who was on the unit upon exiting the resident room that day.On 12/11/2025 at 9:00 AM during record review of resident #15, it was revealed that after Surveyor intervention, a wound care assessment and treatment recommendations were completed, per the HP SKIN AND WOUND NOTE, dated 12/8/25 at 21:53. Additionally, resident #15 Care Plan Report reflected interventions for the bilateral heels as well. However, the 'Weekly Skin Check - V3' form, completed by resident #15 primary nurse, LPN staff #7, was answered as follows: Skin Check, 1. Has resident refused skin check? -'No'; 1a. Are there any skin area(s) noted? - 'No'; Signature, 1. Nurse completing this UDA: staff #7; signed by staff #7; Signed Date: 12/8/25. Based on these findings it appeared that, despite resident #15 having wounds to the bilateral heels, the weekly skin sheet completed by the LPN staff #7 on 12/8/2025 did not accurately reflect the resident's current medical condition of wounds to the bilateral heels, as being consistent with the remaining records.On 12/11/2025 at 12:00 PM during an interview with LPN staff #7, when asked what was the Weekly Skin Check - V3' form was used for; staff #7 stated, 'for the weekly skin assessment of the resident'. This Surveyor then asked was a skin assessment required when completing this form; staff #7 stated 'Yes'. The Surveyor then discussed the 'Weekly Skin Check - V3' form completed by staff #7 on 12/8/25 and asked about their reply to the skin check question (1a. Are there any skin area(s) noted?' answered as 'No'; staff #7 stated, I thought it referred to new skin areas, I am aware the resident has heel wounds and I answered incorrectly'.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure residents are not in public view and to provide a privacy curtain to prevent exposure of resident body parts. This was evident for 1 (resident #10) out of 1 observed without a privacy curtain between bed A and bed B in a 3-bed room during the annual survey.Findings include:On 12/04/2025 at 7:50 AM during initial observation rounds, this Surveyor observed resident #10 lying in the middle bed (Bed B) of the room, that was occupied by 3 residents. During this observation, resident #10 (Bed B) was positioned parallel to Bed C bed to the right closest to the window, while Bed A bed was positioned perpendicularly to the left and closest to the door. There was no privacy curtain observed between resident #10 (Bed B) and the resident occupying Bed A.On 12/04/2025 at 12:00 PM during an interview with NHA staff #3 and DON staff #2, this Surveyor notified the team of the findings. When asked what the expectation for privacy curtains in the 3-occupant rooms was, DON staff #2 stated, 'the expectation is for a privacy curtain to be present between each resident'.On 12/05/2025 at 11:28 AM during follow-up observation rounds, a privacy curtain was observed between resident #10 in Bed B and Bed A; this was completed after surveyor intervention.

Based on a review of survey results binders, and interviews, it was determined that the facility failed to protect the privacy of residents' information. This was found evident in 2 of 2 survey results binders. The findings included: On 10/28/25 at 8:17 AM, the Director of Nursing (DON) brought the surveyor the survey results binder that belonged in the front lobby. On 10/28/25 at 8:33 AM, the surveyor reviewed the survey results binder. The review revealed nine pages of residents' names along with their attending physicians, totaling 232 residents' names and physicians' names. On 10/28/25 at 8:42 AM, the surveyor interviewed the Director of Nursing (DON). During the interview, the DON confirmed that the list of residents and their physicians should not have been in the book because the survey results binders are available for anyone to review. The DON stated he had an additional survey results binder on one West. On 10/28/25 at 9:09 AM, the surveyor reviewed the binder from one West. The review revealed that the same nine pages with 232 residents' names along with their physicians were located in this survey results binder as well. On 10/28/25 at 9:18 AM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview, the NHA confirmed that that list of residents and their physicians would be removed from both survey results binders. He confirmed that they should not have been placed there in the first place.

Based on observation, review of survey results binders, and interview, the facility failed to 1) have readily accessible the survey results and 2) have the results from the last survey available for review. This was found on entry into the building and of 1of 2 survey result binders. The findings include: 1) On 10/28/25 at 8:13 AM, the surveyor requested to review the survey results from the last survey from the front desk receptionist Staff #22. Staff #22 stated that the survey binder was normally kept at the front desk but she was not able to find the book. On 10/28/25 at 8:17 AM, the Director of Nursing (DON) brought the surveyor the surveyor result binder. The DON explained that the Regional Director of Clinical Operations was reviewing the book yesterday and did not return the book to its normal location behind the front reception desk. 2) On 10/28/25 at 8:18 AM, the surveyor reviewed the survey results binder. The results from the survey that was completed in December of 2024 were in the binder; however, the results from the survey completed in June of 2025 were not. On 10/28/25 at 8:42 AM, the DON confirmed that a survey was completed in June of 2025. He stated that the facility had an additional binder on the one [NAME] unit and he would see if that binder had the most recent results. On 10/28/25 at 9:09 AM, the surveyor reviewed the binder from one West. The review revealed that the surveyor results from June 2025 were in the binder. The DON confirmed that he would update the front lobby survey results binder and that the binder was returned to the front for accessibility.

Based on record review and interviews, the facility failed to have an appropriate reason to involuntarily discharge a resident and failed to permit that resident to remain in the facility, and not discharge, while the appeal for discharge was pending. This was found evident in 1 (Resident #21) out of 1 Residents reviewed for involuntary discharges. The findings included: On 11/3/25 at 8:54 AM, the surveyor reviewed intake #2657616 that was submitted to the Office of Health Care Quality (OHCQ). The intake alleged that the facility inappropriately discharged Resident #21. It further stated that Resident #21 had an appeal for his/her discharge and the reason for discharge (non-payment) was inaccurate. It further stated that the facility was aware an appeal was filed and an email had been sent to the social worker to inform the facility. On 11/3/25 at 10:54 AM, the surveyor requested Resident #21's appeal for involuntary discharge from the Director of Nursing (DON). On 11/3/25 at 11:15 AM, the surveyor reviewed Resident #21's discharge summary and noted that Resident #21 was discharged from the facility on 10/23/25 accompanied by his/her parent with plans to go to a relative's home. On further review, a discharge note was written on 10/23/24 at 2:14 PM documenting these same plans. On 11/3/25 at 12:12 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview, the DON presented the notice given to Resident #21 titled: RE: Notice of Proposed Involuntary Discharge or Transfer. The notice was dated 9/22/25 and indicated that Resident #21's proposed discharge date , for home, was 10/23/25. The reason given was: You have failed, after reasonable and appropriate notice, to pay (or to have paid under Medicare or Medicaid) for a stay at this facility. The DON stated he was unaware of an appeal and after talking to the Business Office Manager (BOM) believed that Resident #21 did not have an outstanding bill with the facility. On 11/03/25 at 12:22 PM, the surveyor conducted an interview with BOM #6. During the interview, BOM #6 stated that she prepared the involuntary discharge letter for the previous Nursing Home Administrator (NHA). She stated that she had been monitoring and advising Resident #21 that he/she was close to going over the 18 Leave of Absences (LOA)s days. This being the threshold Medicaid allows while in Long Term Care. The BOM confirmed that Resident #21 did not have a current outstanding bill for his/her stay and that Resident #21 was discharged because Medicaid would not be paying for his/her stay due to going over the 18 LOAs. BOM#6 stated she had been out of the office around 10/23/25 and returned on 10/29/25. She further stated she had not seen the an appeal to the involuntary discharge come through the business office for Resident #21. On 11/03/25 at 12:56 PM, the surveyor interviewed Director of Social Service # 5. DSS #5 stated that she had helped Resident #21 with the discharge and was not aware of any appeal that was filed to contest the discharge. On 11/4/25 at 8:23 AM, the surveyor conducted an interview with Resident #21. During the interview, Resident #21 stated he/she had filed an appeal with the help of the Ombudsman. Resident #21 stated he/she had to stay at a relative's house because his/her residence had a fire and was not able to be occupied at the time of discharge. He/she stated that he/she informed the facility he/she was not ready to leave. On 11/4/25 at 11:38 AM, the surveyor reviewed the appeals letter sent to the Office of Administrative Hearings. The letter was dated 10/17/25 but the email was sent to the office on 10/21/25. The surveyor noted that the letter was also addressed to the facility's previous NHA, the Resident and the Ombudsman. Next, the surveyor asked SSD #6 to provide any recent emails the Ombudsman had sent her. On 11/4/25 at 11:45 AM, the surveyor conducted an interview with the SSD #6. During the interview, SSD #6 brought email correspondence from the Ombudsman dated 10/21/25 at 3:10 PM. In the email the Ombudsman requested a face sheet and inquired about wheelchair repairs, she then wrote: Also, (Resident #21) has filed an appeal to the notice of Involuntary Discharge. SSD#6 responded to the requests in the email on 10/23/25 at 10:06 AM. This was prior to Resident #21's discharge. The surveyor asked SSD#6 how she communicated this information about Resident #21's appealed to the administration. She stated it was discussed during Daily Department Stand Up meetings but could not remember what day or if it was with the old NHA or the current one. The surveyor requested notes taken during the meeting from 10/21/25-10/23/25. On review of the meeting notes on 10/23/25, the Business Office section had noted, one discharge appealed. In the Social work section, it was noted, One appeal for 30 day discharge. On 11/4/25 at 1:21 PM, the surveyor interviewed the Assistant Nursing Home Administrator (ANHA) #20. During the interview, the surveyor relayed the concern that the facility was aware Resident #21 appealed his/her involuntary discharge and that the Resident was still discharged from the facility, as well as the concern that the rationale for involuntary discharge was not valid. Resident #21 did not have an outstanding bill. At the time of exit, no additional information was provided.

[NAME] ' s example: Harm Based on record review and interview, it was determined that the facility failed to ensure that adequate supervision to prevent accidents/hazards was provided 1) during care which resulted in a fall causing harm to Resident #55. This was evident for 1 of 38 residents reviewed for complaints. The findings include: Review of complaint intake MD00212102 on 6/3/25 at 10:30am revealed that resident #55 ' s family alleged that the facility neglected to provide adequate supervision to the resident. This lack of supervision resulted in the resident having a fall incident. Review of resident #55 ' s medical record revealed a care plan that stated that the resident had ADL self-care performance deficit due to his/her immobility as of 7/3/2017. The care plan ' s interventions for the resident ' s self-care performance deficit was to have staff provide assistance with ADL care. Further review of resident #55 ' s medical record revealed an MDS assessment (Section GG) dated 10/11/24 which assessed the resident as being dependent on staff for ADL care and bed mobility which included being rolled from left to right from a lying position. On 6/4/25 at 11:00am, the DON provided the surveyor with a copy of the November 2024 GNA Kardex for resident #55. Review of the GNA Kardex for November 2024 revealed that the resident was totally dependent on nursing staff for toileting hygiene and being rolled from left to right on 11/20/24 (the day of the fall incident). Also, the resident required two person assistance for both toileting hygiene and being rolled from left to right on 11/20/24. Further review of resident #55's medical record revealed a change in condition document dated 11/20/24 which reported that the resident had a fall incident at approximately 2:30pm. The change in condition stated that GNA #18 was providing ADL care for the resident when the fall incident occurred. GNA #18 was turning the resident when he/she slid off the bed onto the floor. Another change in condition document dated 11/20/24 at 5:47pm stated that the resident complained of pain in both legs after the fall incident. The facility transferred the resident to the local hospital for further evaluation. Interview with the Director of Nursing (DON) on 6/4/25 at 9:30am confirmed that resident #55 had a fall incident on 11/20/24 that resulted in the resident being transferred to the local hospital for evaluation. The DON also confirmed that the facility did not report the fall incident because facility nursing staff witnessed the fall incident. The DON provided the surveyor with the fall incident investigation. Review of the facility fall investigation on 6/4/25 at 10:00am revealed that the fall investigation contained two witness statements from GNA #18 and RN Unit Manager #19, a copy of the resident ' s care plan, and a copy of the change in condition documents from 11/20/24. The witness statement from GNA #18 dated 11/20/24 stated that he/she was providing ADL care and asked resident #55 to assist him/her in turning the resident to his/her left side. GNA #18 was standing on the resident ' s right side and turning the resident to his/her left side when the resident slid from the bed to the floor. GNA #18 stated that he/she lowered the bed and called for help to assess the resident. The witness statement from RN Unit Manager #19 stated that GNA #18 was re-educated on how to call for help at all times during resident care. On 6/4/25 at 10:12am, the surveyor interviewed GNA #18. During the surveyor interview, GNA #18 confirmed that he/she witnessed resident #55 fall from his/her bed on 11/20/24 when GNA #18 was turning resident #55 onto his/her left side during ADL care. GNA #18 also confirmed that he/she raised the height of the resident ' s bed to his/her waist, which was at least 30 inches from the floor, to make changing the resident easier for the GNA. GNA #18 stated he/she asked the resident to use the upper bed rails (enablers) to assist with turning the resident to his/her left side. GNA #18 then stated that he/she witnessed the resident continue to roll toward the left side with the resident ' s legs sliding off the bed. GNA #18 stated that he/she tried to stop the resident from rolling off the bed but he/she was unable to stop the resident because the resident was a big person. GNA #18 then stated that he/she called for help and RN Unit Manager #19 came into the resident ' s room to assess and assist with the resident after the fall. GNA #18 then stated that RN Unit Manager #19 assessed the resident for damage. The resident complained of pain to his/her knee. GNA #18 and another staff member used the hoyer lift to transfer the resident from the floor to the bed. GNA #18 stated that he/she was later educated on how to roll a resident and that the resident was a 2 person assist. Surveyor interview with RN Unit Manger #19 on 6/4/25 at 12:10pm confirmed that resident #55 was known to require 2 person assistance when the resident needed to be turned. RN Unit Manager #19 stated, the resident is heavy .and needs to have two people assisting .when the resident needs to be turned. The other person can stop the resident from falling off the bed . Interview with MDS Coordinator #20 on 6/4/25 at 2:49pm confirmed that the resident required two personal assistance for toileting hygiene, personal hygiene and rolling left to right. On 6/4/2025 at 10:05am, the DON provided the surveyor with the emergency room report from the local hospital for resident #55 ' s visit on 11/20/24. Review of the emergency room report from the local hospital revealed that the resident was sent to the local hospital after a fall on 11/20/24 and complaining of pain to the left hip. The local hospital assessed the resident and found that the resident had a fracture to the left leg. The surveyor informed the Executive Director and the DON on 6/5/25 at 9:30am of the deficient practice of failing to provide adequate supervision that caused harm to resident #55 on 11/20/24.

Based on medical record review and interview, the facility failed to make prompt efforts to resolve a resident's grievance and also failed to keep the resident appropriately apprised of the progress toward resolution. This was evident for 1 (#25) of 55 residents reviewed in a complaint survey. The findings include: Review of a complaint MD 00217656, sent to the Maryland's Office of Health Care Quality (OHCQ), on 5/22/25 at 8:00 AM revealed that the complaint was sent by the Ombudsman alleging that the facility failed to promptly resolve resident #25's grievance of reimbursement for a missing prosthetic leg. Review of resident #25's medical record on 5/22/25 at 8:30 AM revealed no evidence that the facility misplaced the resident's prosthetic leg. Interview with the Ombudsman on 5/22/25 at 12:15 PM revealed that resident #25's prosthetic leg was missing since 1/2025. The Ombudsman stated that the resident complained to the facility that his/her prosthetic leg was missing from his/her belongings since 1/2025. The resident received no updates on the location of the prosthetic leg and decided to contact the Ombudsman for assistance in 3/2025. The Ombudsman contacted the facility in 3/2025 about the missing prosthetic leg and received no updates on the location of the prosthetic leg. The Ombudsman sent an email to the facility's social worker director on 4/29/25 about the resident's missing prosthetic leg. The facility provided no updates on the location of the missing prosthetic leg nor solutions for replacing the missing prosthetic leg as of the time of the interview. Interview with the Executive Director on 5/27/25 at 8:30 AM confirmed that the facility was aware of resident #25's missing prosthetic leg. The Executive Director admitted that the resident's prosthetic leg was possibly misplaced as of 11/2024 when the facility was evacuated due to loss of heat. As of the date of the interview, the facility had failed to find the resident's prosthetic leg. The Executive Director also admitted that no efforts were made to reimburse or replace the resident's prosthetic leg until the resident returned from medical treatment. The surveyor pointed out that the resident returned to the facility on 5/22/25. The Executive Director stated that the facility would work on replacing the missing prosthetic leg.

Based on review of facility documents and staff interview it was determined the facility failed to report an allegation of abuse immediately but not later than 2 hours after an allegation was made. This was evident for 1 (#21) of 19 residents reviewed for abuse during a complaint survey. The findings include: On 5/22/25 at 1:09 PM, a review facility reported incident, MD00205036, which alleged that Resident #21 sustained a scratch to his/her face during an altercation with Resident #2, resulting in Resident #21 being transferred to the hospital emergency department for further evaluation. The facility's investigation documented the incident had occurred on 4/3/24 at 6:30 PM. The facility's investigation did not include documentation as to when the incident was sent to OHCQ or when the final report was sent. The above concern was discussed with the Director of Nurses (DON) on 5/22/25 at approximately 1:30 PM and the surveyor requested email confirmation of when facility report sent to state office. On 5/22/25 at 2:18 PM, the DON reported to the surveyor that email confirmations of when above facility reported incident was sent to OHCQ were permanently deleted and no longer available for the DON to provide to the surveyor.

Based on record review and staff interview, it was determined that facility staff failed to develop resident-centered comprehensive care plans for their residents. This was evident for 3 (#8, #27, and #53) of 38 residents reviewed for complaints. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Elopement is defined as a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. 1) On 5/28/25 at 3:46 PM during a review of the facility report incident investigation file for incident #MD00206569 it was revealed that on 6/12/24, facility staff were unable to find Resident #8 and s/he was found the next day at a nearby shopping center parking lot. A review of the resident's statement revealed that s/he had paid someone to push them in their wheelchair to the nearby shopping center, however, due to the resident's physical limitations s/he was unable to get back to the facility. An electronic medical record review on 5/28/25 at 4:17 PM, for Resident #8 revealed under the assessment tab the resident was assessed for elopement risk on admission and quarterly and found to be no risk. A review of the physician's orders revealed the resident had an order dated 10/19/22 that read the resident could go on a leave of absence with supervision. The MDS with the assessment reference date of 5/31/24 revealed the resident had no cognitive impairment and was wheelchair bound. Further review revealed that after the incident on 6/12/24, the elopement risk assessment conducted on 6/21/24, the nurse documented the resident had not eloped in the past. The facility failed to develop a care plan for elopement and implement interventions to ensure this incident does not occur again. On 5/28/25 at 4:17 PM an interview with the Director of Nursing (DON) revealed he failed to recognize the incident on 6/12/25 as an elopement because of the resident cognitive status and failed to ensure that interventions were put into place to prevent further elopements. An interview with the Nursing Home Administrator (NHA) on 5/29/25 at 8:42 AM revealed she failed to recognize this incident as an elopement. 2) A medical record review for Resident #27 on 5/27/25 at 1:31 PM revealed in the progress notes that the resident was discharged from the facility, however, there was no discharge care plan included. On 5/22/25 at 9:46 AM an interview with Social Worker Designee Staff #23 revealed she initiated a care plan for each new admission that was assigned to her. She confirmed that Resident #27 was assigned to her, however, she had no rationale as to why she failed to initiate a discharge care plan for the resident. The concerns were reviewed with the Director of Nursing (DON) on 5/28/25 at 4:37 PM and he acknowledged the concerns. 3) Review of complaint MD00207518 on 6/2/25 at 10:48 AM sent to the Office of Health Care Quality (OHCQ) revealed that Resident #53 was malodorous from the facility nursing staff failing to change the resident and provide ADL care. Review of Resident #55's medical record on 6/2/25 at 11:10 AM reveal no care plan for incontinence. A document dated 6/20/24 titled bowel elimination pattern assessed the resident has being bowel incontinent. MDS assessments dated 6/19/24 and 2/10/25 assessed the resident has being frequently incontinent of bowel and bladder. During an interview with the Director of Nursing (DON) on 6/3/25 at 8:00 AM, the surveyor informed the DON that the facility failed to provide an incontinence care plan for Resident #53.

Based on record review and interview, it was determined that facility staff failed to notify a resident in writing of a pending discharge and failed to ensure that the discharge was documented in the medical record. This was evident for 1 (#27) of 1 resident reviewed for discharges. The findings include: On 5/21/25 at 1:10 PM a review of complaint #MD00213157 revealed the complainant alleged Resident #27 had not received appropriate notice of the facility's intent to discharge him/her. A medical record review for Resident #27 on 5/27/25 at 1:31 PM revealed in the progress notes that the resident was discharged from the facility, however, there was no written notice of discharge. In Addition, staff failed to document discussion with the resident regarding discharge planning, the resident's input regarding the discharge, and the reason for the discharge. On 5/22/25 at 9:46 AM an interview with Social Worker Designee Staff #23 confirmed she worked with Resident #27 regarding discharge planning. She reported she had discussions with the resident about discharge and the resident was not sure where to go upon discharge. She reported the resident was not asking to be discharged and the reason for the discharge was because the resident's insurance was ending. When asked if she had issued a 30-day discharge letter to the resident she reported that the business office would handle that. An interview with the Business Office Manager on 5/22/25 at 10:19 AM revealed she received a notice from their corporate office Social Worker that the resident's insurance was ending on 12/4/24, however they did not issue a written 30-day notice to the resident. The resident was told verbally and was given the option to appeal. She stated this was the facility's normal practice to not issue a 30-day notice in writing when the resident's insurance was ending. This was reviewed with the Nursing Home Administrator on 6/5/25 at 9:20 AM. She acknowledge the concern.

Based on medical record review and interview with facility staff and the review of a facility reported incident (FRI), it was determined that the facility staff failed to 1. thoroughly investigate an injury (bruising) of unknown origin and 2. failed to thoroughly investigate allegations of abuse. This was evident during the review of 2 of 19 facility reported incidents. Residents (#20 and #21) The findings include: 1. Review of the facility reported incident #MD208608 on 6/2/25 at 12:57 PM revealed a concern related to a new discoloration observed around Resident #20's right upper eye lid. Secondary to Resident #20's diagnosed intellectual disabilities s/he was unable to give a verifiable account of what happened to cause this newly identified injury. According to an electronic medical record review, Resident #20 is also diagnosed with muscle weakness and lack of coordination. Further review at this time of the facility investigation report revealed that the facility determined that the allegation of abuse was 'unsubstantiated' after reviewing all documents and witness statements. A comparative review was completed on 6/3/25 at 12:00 PM of the staff schedules from 8/7, 8/8 and 8/9/24 to the staff that were interviewed. There were 8 identified staff that marked 'no' for all 3 questions related to the investigation into the alleged abuse of Resident #20, including 1. Did you work with [Resident #20] on 8/7, 8/8 or 8/9, that were assigned to work with Resident #20 according to the scheduled assignments provided to the surveyor by the DON on 6/3/25. Surveyor interviewed the unit manager staff LPN #16 on 6/4/25 at 8:28 AM regarding the interviews that she conducted on 8/12/24. She was asked about her process in determining who to interview during an investigation and she stated that she will look at the schedule as to who was assigned to the resident. The statements from the FRI for Resident #20 were reviewed concurrently at this time with staff #16. The concern that there were multiple staff assigned to Resident #20 between 8/7-8/9 that marked 'no' when in fact they did care for Resident #20 was discussed. She was then asked if she reviewed the acquired statements and interviews and she stated 'yes.' At this time the actual schedules of the staff for 8/7-8/9 were reviewed. The concern that there were staff assigned to Resident #20 whose statements stated 'no' regarding caring for Resident #20 during that same time frame was reviewed and shown to staff #16. Staff #16 was also asked if it was standard practice to interview yourself for an abuse investigation as she had completed an interview and signed her name as the witness and name/title of the person taking the statement, she had no response. The conclusion into the facility allegation of abuse of Resident #20 was that Resident #20 bumped his/her eye on the radiator that was located next to his/her bed as this resident, according to the investigation, nodded his/her head yes/no when asked specific questions, although the statements gathered were false and not verified. This concern was reviewed at this time with staff #16 and was previously reviewed with the facility DON on 6/3/25 and again during exit on 6/5/25. 2. On 5/22/25 at 1:09 PM, a review of the facility's investigation file for self-report MD00204541, which was an allegation of abuse related to a resident-to-resident altercation, was conducted. The initial self-report documented that on 4/3/24, staff heard a noise coming from the 2nd floor dining room and found Resident #21, and Resident #2 involved in an altercation in the dining room and separated the 2 residents. Resident #21 sustained a scratch to his/her left face, caused by Resident #2 during the altercation, 911 was called, and Resident #21 was transferred to the ER (emergency room) for evaluation of the scratch on his/her left face. The self-report further documented that Resident #21 returned to the facility after having a CT (computed tomography) scan (medical imaging procedure) and no abnormalities were seen and documented that after reviewing all documents, including statements, the allegation was substantiated The self-report documented the incident occurred on 4/3/24 at 6:30 PM, however there was no documentation found in the self-report to indicate the name of the staff who first became aware of the incident. The self-report indicated that Resident #21 and Resident #2 were not able to accurately describe what happened or caused the altercation and no one witnessed the altercation, however when staff arrived in the dining room, staff observed Resident #21 holding Resident #2's wheelchair and a scratch was visible on Resident #21's left face. Continued review of the facility's investigation revealed the facility failed to thoroughly investigate the resident-to-resident altercation. The facility's investigation included 6 Witness Statement forms which were completed by staff. On the forms, the Name And Title Of The Witness, the Name/Title Of Person Taking the Statement, and the Date of Occurrence, were printed on the forms with a space for the witness to fill in the information, followed the heading Summary of Statement', and the questions 1. Were you present during the altercation with both residents?, 2. Did you work with this resident today?, 3. Did you suspect any concerns with the two residents in question? If yes, who did you report to? What was going on?, and 4. If you heard a noise in the dining room, were residents separated?. Following each question, the potential response of Yes and No was printed Review of the witness statements revealed that 6 of the 6 staff documented the date the incident occurred was 4/4/24, which contradicted the facility's self-report which documented the resident-to-resident altercation occurred on 4/3/34. In response to the question, were you present during the altercation with both residents, 6 of 6 staff circled the response no, indicating the staff member had not witnessed the altercation. In response to the question . If you heard a noise in the dining room, were residents separated?, 5 of 6 staff circled no, and 1 staff did not answer the question. All of the witness statements documented that none of the employees were present during the alteration. with both residents. There were no statements from the staff heard the noise coming from the 2nd floor dining room, the staff who responded to the noise in the dining room or the staff that separated the residents and determined an altercation between Resident #21 and Resident #2 had occurred. The facilities investigation included Abuse Questionnaire forms that asked residents Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse:? Did you tell staff? Have you seen any resident here being abused? and Did you tell staff?, The facility's investigation included 2 Abuse Questionnaire forms that indicated 50 residents were interviewed for abuse, however, there the abuse questionnaire forms failed to include any resident names, only room numbers and there was no documentation on the forms to indicate who interviewed the residents. The facility's investigation included 12 Weekly Comprehensive Head to Toe Skin Assessment Report forms which had a space to document the resident's name, room number, the employee name, the date, a place to check whether the skin was normal or abnormal, and the statement if abnormal, record site of affected area(s) followed by an outline of the back and front person to document any skin irregularities. Review of the Skin Assessment Report forms revealed the resident's name, and his/her room number were handwritten on each of the assessment forms. The statement, No Skin Issues was handwritten on 11 of the 12 assessment forms included with the facility's investigation, and one form had no documentation to indicate the status of a resident's skin. There was no date documented on 10 of the 12 assessments to indicate when the assessment had been completed, and the name of the employee(s) that completed the skin assessments was not documented on 12 of the 12 assessments A skin assessment form for the scratch on Resident #21's left face was not found with the facility's investigation. Review of Resident #21's medical record revealed, on 4/3/24 at 7:31 PM in a Skin Grid Non-Pressure note, the nurse documented Resident #21 had a new non-pressure wound, and documented the wound was a scratch to left face that was red, moist grainy, optimal granulation with no exudate. The area to document the size of the wound was blank. Continued review of the facility's self-report and the resident's medical record medical record failed to reveal documentation of the size, depth and width of the scratch on Resident #21's left face which warranted a transfer to the hospital emergency room. The above concerns were discussed with the Director of Nurses (DON) on 5/22/25 at 3:05 PM and the DON acknowledged the concerns at that time.

Based on record review and staff interview; it was determined that the facility failed to protect their residents from verbal abuse from a facility staff member. This was evident for 1 (#46) of 55 residents reviewed during a complaint survey. The findings include: Review of facility reported incident (FRI) MD00217347 on 5/29/25 at 8:00 AM revealed the FRI alleged that Geriatric Nursing Assistant (GNA) #13 verbally abused Resident #46 while providing ADL care. Review of Resident #46's medical record on 5/29/25 at 8:30 AM revealed a care plan for psychosocial well-being. The intervention for this psychosocial well-being was listed as encouragement for communication. The Director of Nursing (DON) provided the surveyor with the facility investigation of the alleged verbal abuse incident. Review of the facility investigation on 5/29/25 at 10:00 AM revealed the incident occurred on 5/2/25. GNA #13 made comments about the number of bowel moments being made by resident #46. The facility investigation determined that the allegation of verbal abuse was unsubstantiated. The facility's investigation also contained a statement from GNA#13 which admitted that GNA#13 told resident #46 that he/she shouldn't be in the facility but in a hospital. The facility investigation also contained a list of nursing staff that received re-education on abuse prohibition. The list of nursing staff did not contain GNA #13. Interview with the DON on 5/29/25 at 11:10 AM revealed that Resident #46's family reported that the resident was upset about the statements made by GNA #13 when she/he was providing ADL care on 5/2/25. The surveyor asked why did the facility consider the allegation of verbal abuse as unsubstantiated? The DON confirmed that GNA #13 admitted to the statements that upset resident #46 but the DON stated that GNA #13 did not mean to hurt the resident's feelings and provided adequate ADL care after the incident. The surveyor pointed out that verbal abuse is based on how the resident feels about the incident and the resident believed that he/she was verbally abused.

Based on observation, record review and staff interview, it was determined that the facility failed to maintain a safe temperature of 71-81 degrees Fahrenheit (F). This was evident for 3 of 3 floors in the facility. The findings include: The Center for Disease Control's (CDC) Preventing Hypothermia publication on 2/7/24, read that victims of hypothermia are often: older adults with inadequate heat. www.cdc.gov. On 12/2/24 at 1:00 PM an observation in the lobby of the facility revealed it felt cold, and residents and staff were wearing coats, hats, and gloves. During an observation of the 1st floor nursing unit on 12/2/24 at 3:45 PM it felt cold on the unit. There were large heating units located sporadically in the hallways. Residents were observed wearing coats, hats, gloves, and some had extra blankets on the bed. During the observation Resident #1 was lying in bed wearing a sweatshirt with the hood pulled up and an extra fleece blanket covering them. The resident reported that they were cold. An observation in the hallway revealed there was no portable heating unit near this room. On 12/2/2024 at 4:05 PM an observation of Unit 2 revealed Resident #2 lying in bed with the covers on, but no extra blankets were on the bed. Resident #2 stated s/he was cold but was getting used to it. Furthermore, the resident reported that it was cold in the building when they were admitted to the facility before Thanksgiving Day. An observation of the hallway outside the resident ' s room revealed there was no portable heater within sight of this room. On 12/2/24 around 7:50 PM the temperature of Resident #2 ' s room was taken and found to be 50 degrees F. On 12/2/24 at 4:30 PM the temperature logs the facility provided revealed that they were taking a temperature on each floor every hour and failed to check the resident ' s room temperatures. The facility had the capacity to house 247 residents and there were 40 - 50 rooms on the 2nd and 3rd floors. The first floor had approximately 15 rooms. The surveyors conducted individual room temperatures on each unit with maintenance staff taking the temperatures on 12/2/24 at 7:50 PM. Temperatures were obtained on the 3rd floor in 51 resident rooms and 1 day room of the ceiling and the floor. The temperatures ranged from 45 - 61.1 degrees. room [ROOM NUMBER] had the coldest temperature of 45 degrees F. This room was occupied by 3 residents at the time the temperature was obtained. Temperatures were obtained on the 2nd floor in 50 rooms of the ceiling and floor. The temperatures ranged from 46.3 - 69.3 degrees. The temperatures were obtained on the 1st floor in 15 rooms of the ceiling and the floor. The temperatures ranged from 56 - 66.4 degrees. An interview with the Divisional Facility Manager Staff #3 on 12/2/24 at 1:44 PM revealed he had typed a timeline of the events. Review of the timeline was conducted during the interview. According to the timeline following occurred: facility staff determined on 11/30/24 at 8:30 PM there was a leak in the boiler system causing the heat to go out; portable heaters were installed in the facility on 11/30/24 by 11:00 PM; on 11/30/24 at 9:15 PM the first attempt was made to fix the problem; on 12/1/24 at 10:00 AM the facility identified the boiler had low pressure and was still not working; On 12/1/24 at 7:00 PM, they determined a pipe was broken and needed to be replaced ; and on 12/1/24 at 9:00 PM they scheduled contractors to come to the facility and fix the pipe. Staff #3 reported that facility staff were obtaining room temperatures starting on 11/30/24 at 8:00 PM and continued to take them hourly. However, a later review of these temperatures on 12/2/24 at 4:30 PM revealed the temperatures were not taken in each room, but on each floor. On 11/30/24 starting at 8 pm and ongoing each hour the temperature ranges were as follows: 1st floor 60- 61 degrees, 2nd floor 58 - 61 degrees, and 3rd floor 57 - 60 degrees. On 12/1/24: 1st floor 51 - 62 degrees, 55 - 64 degrees, and 3rd floor 58 - 65 degrees. He reported that the contractors had identified the issue on 12/2/24 and was onsite fixing it at the time of this interview. Included in the timeline was that the Director of Nursing (DON) had interviewed all the residents, and they declined to evacuate, however this was later found to be inaccurate as he had interviewed 8 residents. On 12/2/24 at 2:33 PM An interview with the DON and Nursing Home Administrator (NHA) revealed he had interviewed a few residents on 11/30/24 to determine if they wanted to be evacuated from the building. He stated he had not documented this information in the resident ' s medical records but had recorded it on a census sheet that had been printed. A review of the census report he provided revealed he asked 8 of 233 residents. He failed to contact any resident representatives for residents who were incapable of making decisions and/or were unable to verbalize what they wanted. When asked what interventions he initiated to keep the residents safe, he stated they offered coats, hats, gloves, and blankets to the residents. An interview with Registered Nurse (RN) #7 on 12/2/24 at 8:30 PM revealed that she was working on the day the heat went out and reported there were no blankets to offer the residents, and they had to give them extra fitted sheets. She stated she was wearing her winter jacket to work on the unit over the weekend. A subsequent interview with the NHA on 12/2/24 at 3:19 PM revealed they failed to start the evacuation process until 12/2/24 at 8:30 PM and had evacuated 11 of their 233 residents at the time of the interview. When asked her rationale for waiting to evacuate residents from a building with no heat source she reported that all the residents had been interviewed and did not want to evacuate. When asked if she had called any resident representatives to ask them about evacuating their residents, she stated she had not. Reminded the NHA that in the previous interview with the DON, he reported he had only asked a few residents and did not call any resident representatives. The NHA stated that some residents told staff they would leave if the heat was not fixed by Monday, 12/2/24, and this was why she decided to evacuate today. However, the facility was unable to provide any documentation that residents had been asked about evacuation and said they would leave on Monday. She reported the evacuation plan was to send all the residents to sister facilities. She reported the sister facility had identified 100 beds, but they were still getting responses. She reported that if their sister facilities did not have enough beds, they would start reaching out to other facilities we have contracted with. However, they had not established any contracts with other local facilities for an evacuation if needed except for sister facilities. She reported they had not secured a place close by that would allow them to immediately evacuate all the residents to one place in the case of an emergency. Furthermore, she had not reached out to the local emergency management system for assistance. She was estimating that it would be 12/3/24, 3 days after the loss of their heat source, before all residents would be transferred out. On 12/2/24 at 1:07 PM Regional Nurse Staff #1 reported they had 103 residents who had DC Medicaid and was waiting for approval from DC Medicaid to move the residents to a facility that did not accept DC Medicaid. In addition, they were reviewing the resident ' s insurance coverage to send them to a facility that accepted the insurance. These delays were later found to be because they had not set up provisions for an emergency evacuation plan as required. A review of the evacuation plan on 12/2/24 at 4:30 PM revealed that the NHA had the authority to evacuate the residents. However, the facility had failed to set up contracts with other locations to allow for immediate evacuation of their residents in case of an emergency, such as a gymnasium or community center until they could relocate each resident to another nursing care facility. Furthermore, their plan failed to include contracts with local facilities that could take their residents to provide care in the case of an emergency regardless of their payor source. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 12/2/24 at 9:15 PM and an IJ summary tool was provided to the facility at that time. The facility submitted a plan to remove the immediacy on 12/3/24 at 1:00 AM and the facility ' s written plan to remove the immediacy was accepted on 12/3/24 at 1:12 AM with an alleged date of compliance of 12/3/24. The provisions of the plan to remove the immediacy included the following: 1) Residents in rooms number 247, 117 and 335 were moved to a warmer area of the facility. 2) Assessments of current residents completed by regional and divisional teams to assure residents had no signs and symptoms of vascular changes related to temperatures. 3) The Executive Director [Nursing Home Administrator] will educate all current staff (nursing, rehab, EVS, laundry, maintenance, dietary, laundry, administrative) to organization Emergency Preparedness Plan, Relocation Plan, Extreme Cold Temperature Protocol, Temperature monitoring of facility, temperature monitoring of residents, and HVAC mediation plan, Notification of change to residents, physicians, and resident representatives. Education to be completed by 12/3/24. 4) We have relocated approximately 50 residents while repairs to our heating system have been made. We now feel we can maintain proper temperatures throughout the facility. 5) Remaining residents will be located in rooms that have reached the range of 71-81 degrees Fahrenheit by 12/3/2024 at 3 a.m. Current resident temperatures will be monitored hourly and documented on the unit census sheet by Unit Managers. Facility environmental temperatures will be monitored hourly and documented on a temperature log by the Maintenance Director. If it is found that we are still experiencing temperature issues we will look to relocate our remaining residents. 6) Executive Director to review audits daily x 12 weeks to assure temperatures of facility and residents remain within acceptable temperature parameters. On 12/4/24 and 12/5/24, an onsite visit was conducted. After validation of the implementation of the facility ' s plan of removal, which included staff interviews, record reviews and direct observation, it was determined the facility met the minimum standards of compliance to remove the findings of an Immediate Jeopardy on 12/5/24 at 5:30 PM with a compliance date of 12/5/24 and not 12/3/24 as stated in the plan.

Based on the review of a facility-reported incident, record review, and interviews it was determined that the facility failed to prevent a cognitively impaired resident with a history of wandering from eloping. This was evident for 1 of 6 (Resident #211) Residents reviewed for elopement risk during an annual and complaint survey. The Maryland Office of Health Care Quality (OHCQ) determined that the concern met the Federal definition of Immediate Jeopardy. However, the facility developed, initiated, and completed an acceptable plan of correction to prevent further elopements which met all elements of past noncompliance. The period of noncompliance began on 12/21/22 and ended on 12/25/22. The facility was notified verbally on 5/4/2023 at 8:29 AM that the non-compliance was determined to be an Immediate Jeopardy past non-compliance. The findings include: On 4/20/23 at 10:16 AM, the surveyor reviewed Resident #211 ' s medical record. The review revealed that resident #211 was admitted to the facility on [DATE] with a past medical history that included but is not limited to, schizoaffective disorder, bipolar, unspecified dementia, and a cognitive communication deficit. Further review of Resident 211 ' s medical record revealed a progress note from Licensed Practical Nurse (LPN) Staff #12 that documented Resident #211 was admitted at approximately 9:57 PM from a medical center. Staff #12 further described Resident #211 as self-ambulating (walking) and adjusting to the new environment. The surveyor reviewed Resident #211 ' s admission initial evaluation assessment documented by staff LPN #13. In the section labeled Cognitive Status/Orientation, Resident #211 was documented as missing the correct year by more than 5 years, missing the correct month by more than one month, and unable to identify the day of the week. In the section labeled Behavioral Status, Resident #211 was documented as having delusions (misconceptions or beliefs that are firmly held), contrary to reality. Question 4. Asked; Has the resident exhibited exit-seeking since admission? The answer; Behavior not exhibited. The surveyor further reviewed the admission initial evaluation and noted a section labeled, Elopement Wandering Evaluation. Staff #13 answered yes to; Does the resident have a history of wandering and is there a pattern tied to the resident's past? However, on the last question in the elopement section: Based on the responses above, is the resident at risk for elopement or unsafe wandering? Staff #13 documented no. On 04/20/2023 at approximately 10 AM, a surveyor review of the Facility Reported Incident that was reported to the Office of Health Care Quality on 12/21/22, revealed that Resident #211 was admitted to the facility on [DATE], placed on 1:1 supervision, and had eloped from the facility in the early morning on 12/21/22. On 04/20/2023 at 1:26 PM, the surveyor interviewed the Director of Nursing (DON). In this interview, the DON stated the nursing supervisor was the one that established the 1:1 intervention. He also stated that it was his expectation that when a Resident is on 1:1 supervision the staff always has eyes on the resident. When asked what happened with Resident #211, the DON stated that the Geriatric Nursing Assistant (GNA) did not have eyes on the resident during a short period of time and the resident was able to walk away. The DON thought the resident left around 6 AM. On 04/21/2023 at 6:06 AM, the surveyor interviewed the night supervisor Staff #10, who had been working the night of the elopement and who determined that a GNA should be assigned to Resident #211 for a 1:1 assignment. Staff #10 stated she assigned GNA Staff #14 to have the 1:1 supervisor assignment for resident #221. During the interview staff #10 stated Resident #211 was walking around and with his/her history of dementia and his/her adjusting to a new environment it was decided it would be best to have the staff monitor Resident #211 on a 1:1. Staff #10 confirmed that there was no order for a 1:1 and no documentation of 1:1 monitoring in the medical record. On 4/21/2023 at 9:55 AM, the surveyor conducted a phone interview with GNA Staff #14. During this interview staff #14 stated that when she exited the elevator to begin her shift on the 2nd floor, Staff #10 asked her to be on a 1:1 supervision assignment with Resident #221. Staff #14 stated she was instructed to go to the third floor and try to bring Resident #221 back down to 2nd floor, where Resident #221 had been admitted . Staff #14 was able to get Resident #221 onto the elevators after stating she would get him/her a snack. After getting a snack from the first floor, Staff #14 stated she and Resident #221 returned to watch a movie in the dining room on the second floor. Staff #14 reported Resident #221 was constantly getting up and moving to different chairs. Staff #14 then stated Resident #221 eventually sat behind her and about 10 minutes after Resident #221 switched chairs to behind her a coworker walked by and asked, where was Resident #221. GNA staff #14 stated she immediately searched the 3rd, 2nd, and first floors. When Resident #221 could not be found she notified Staff #10. A review of the facility investigation stated Resident #221 was found by the Prince [NAME] County (PGC) police up the street at a shopping center. An assessment was completed with no injuries noted. A new order for a wander guard was placed and a 1:1 was ordered for increased supervision. On 4/20/23 at 10:05 AM, the surveyor interviewed the DON. The DON confirmed the police found Resident #221 at the Walmart where the Resident would have had to have crossed a 4-lane highway at a busy intersection. Resident #221 was brought back to the facility around 11 AM. The DON stated after the facility found out about the elopement, they immediately addressed the issue. They conducted a complete room search, activated the missing person code including a head count, searched the parameter then the neighborhood, all doors and alarms checked, the physician called, hospitals called, and notified police of the missing Resident and attempted to call the Resident ' s family member. The DON stated they had an AD-HOC meeting (an unscheduled meeting in response to a situation that needs to be addressed timely) The DON stated he would bring the documentation of what was completed in response to the elopement. On 4/20/23 at approximately 11 AM, the surveyor reviewed the elopement documents. The documents contained an abatement plan and education documents. The abatement plan contained immediate actions as described by the DON and documentation of headcount, doors, and alarms checked. Following the immediate actions. All staff on duty were asked to fill out a statement form. The forms were attached. Elopement assessments were completed on all Residents. The assessments were provided. Education was provided to receptionists, and education was completed on wandering risk assessments. Continuity of care for residents Inservice- sign-in sheet was provided. Per the interview with DON, all education was completed by 12/25/23. The monitoring included auditing new admission for elopement risks. The audits were provided. Nurse managers review notes for behaviors. Elopement drill to be completed on each shift. Drills were provided. Audits of 1:1 documentation provided. On 4/21/23 at 6:22 AM, the surveyor interviewed the front door receptionist Staff #76. Staff #76 confirmed she received education on elopement risk residents. The surveyor reviewed the book and all current elopement risk Residents identified by the facility and confirmed they were in the book. On 4/21/23 at 9:55 AM, the surveyor confirmed the elopement education was given to GNA staff #14. On 5/4/23 at 8:29 AM, the surveyor reviewed the immediate jeopardy elopement concern with the DON. The facility identified the problem at the time it occurred, implemented corrective actions, and was compliant after completing all corrective actions and education as of 12/25/22.

Based on review of resident medical records, interview with facility staff and residents, and observation of resident care, it was determined that the facility failed to ensure that Resident #11, who was cognitively impaired and exhibited physically disruptive behaviors, was protected from abuse as evidenced by the resident being involved in a physical altercation that led to the resident sustaining a wrist fracture. Further, the facility continued to put Resident #11 at risk of physical and/or mental abuse as evidenced by two more physically aggressive incidents occurring that involved Resident #11 and had the potential for causing additional physical harm. This was evident for 1 of 5 residents involved in facility reported incidents. This deficient practice rose to the level of actual harm. The findings include: The facility's investigation into Facility Reported Incident (FRI) #MD 548 was reviewed on 3/5/20 at 12:40 PM. The review revealed that, at 1:40 AM, Resident #4 approached the nurses' station on his/her unit and spoke with the Licensed Practical Nurse (LPN) #1 and Geriatric Nursing Assistant (GNA) #2, informing them that his/her roommate, Resident #11, was touching him/her inappropriately. This was the second night that Resident #11 was at the facility. LPN #1 and GNA #2 then began following Resident #4 back to his/her room. However, before staff reached the room, Resident #4 and Resident #11 began a physical altercation that resulted in Resident #11 sustaining a skin tear to Resident #11's upper eyelid area. Then, because Resident #11 continued to have pain in his/her left wrist, an x-ray was performed on Resident #11's left wrist the next day on 11/29/19 at 11:00 AM. The x-ray resulted on the same day at 3:13 PM and showed that Resident # 11 had an acute wrist fracture. Resident #11's medical record was reviewed on 3/5/20 at 1:00 PM. The review revealed that Resident #11 was admitted to the facility on [DATE] at 9:00 PM with [DIAGNOSES REDACTED]. Alert but not oriented to time, place, or situation. The nursing admission assessment for Resident #11 dated 11/27/19 scored Resident #11 with a Brief Interview of Mental Status (BIMS) score of 5/15, which indicates severe impairment to cognitive function. A nursing note written on 11/27/19 and dated/timed at 7:43 AM was found that stated, Resident keeps going into other residents' rooms and corners messing with their stuff, and that makes other residents irritated and trying to confront him/her. Also, a psychiatry note was found written by Certified Registered Nurse Practitioner (CRNP) #3 and dated 11/27/19 that documented the following: Paces / wanders. Poor Attention. Poor eye contact. Anxious Affect. Sad mood. Poor problem solving. Poor judgement. Confused thought process. Poor concentration. Diagnoses: [REDACTED]. Adjustment disorder with mixed anxiety and depressed mood. Recommendations: monitor mood and redirect behaviors. Resident #4's medical record was reviewed concurrently. The review revealed a nursing note written on 11/28/19 at 2:44 PM that stated, Resident was visited this morning post having an altercation with roommate (Resident #4) during the early hour of the night. Resident #4 alleged that Resident #11 grabbed his/her private parts while s/he was sleeping. Resident #4 tried to push Resident #11 away and the resident hit him/her. Resident #4 hit back, causing a skin tear to Resident #11's upper eyelid area. No other evidence could be found in the medical record that Resident #4 had a history of [REDACTED]. LPN #1 was interviewed by the survey team on 3/6/20 at 9:08 AM. During the interview, LPN #1 stated that she worked as the night nurse on the night of 11/27/19 into 11/28/19 from 11:00 PM to 7:00 AM. She stated that when she began her shift, she found both Resident #4 and Resident #11 asleep in their beds in the room they shared. LPN #1 then reported that, at 1:40 AM, Resident #4 came out of his/her room, approached the nurses' station, and claimed that Resident #11 was touching him/her. LPN #1 stated that she acknowledged Resident #4 and proceeded to follow him/her back to his/her room. However, Resident #4 returned to his/her room more quickly than LPN #1 did and LPN #1 started hearing commotion. She stated that she hurried to the room and found Resident #4 and Resident #11 fighting. Staff separated them and Resident #4 appeared uninjured. However, Resident #11 had a skin tear to his/her upper eyelid area. LPN #1 stated that Resident #11 was moved to another room that morning. Resident #4 was interviewed on 3/6/20 at 7:35 AM. During the interview, Resident #4 confirmed the altercation between himself/herself and Resident #11 that happened on 11/28/19. Resident #4 stated that Resident #11 had acted strangely and was off his/her rocker since admission on 11/26/19 at 9:00 PM. Resident #4 stated that Resident #11 would sit on Resident #4's bed, would use the toilet right after I had cleaned it for myself, and would go into other people's rooms and bother them. Resident #4 then said that s/he woke up at around 1:30 AM in the morning of 11/28/19 and found Resident #11 standing next to him/her, was naked, and was touching Resident #4 inappropriately. Resident #4 stated that s/he immediately went to the nurses' station and talked to LPN #1. But Resident #4 also stated that LPN #1 didn't take me seriously when s/he went to talk to her. Resident #4 stated that s/he felt bad that Resident #11's arm got broken. Resident #4 said, I didn't want to fight him/her, but s/he threw the first punch because I had told on him/her. Resident #11 was observed in his/her room on 3/6/20 at 7:45 AM. The resident was laying in bed and would not respond to surveyor questions. GNA #4 was, also, in the room and was interviewed. GNA #4 stated that she was performing one-to-one with Resident #11 in which she never left Resident #11 out of her sight. GNA #4 stated that this had been ordered because of Resident #11's aggressive behaviors. Although Resident #11 was observed lying quietly in bed at that time, GNA #4 stated that s/he could get feisty quickly and will sometimes curse you out. Resident #11's medical record was further reviewed on 3/9/20 at 8:25 AM. The review revealed that Resident #11 was moved to another room on 11/28/19 where s/he became roommates with Resident #12. It was, also, found that Resident #11 was moved again on 1/17/20 in response to an allegation made by Resident #12 on 1/16/20 that Resident #11 punched Resident #12 in the face in the middle of the night. A nursing note dated 1/14/20 (two days prior to this allegation) was found that stated, Resident demonstrating strength (of wrist fracture) by punching into hand. A follow up interview was conducted with Resident #11 on 3/9/20 at 9:48 AM. Again, the resident did not answer questions by the survey team. The resident was noted to still be on one-to-one supervision at this time. GNA #6 was in the room providing that supervision and stated to the survey team that Resident #11 did not often speak or make sense when s/he did. GNA #6, also, stated that Resident #11 had aggressive behaviors in the past, including punching at his/her mirror. The mirror in the room over the sink was noted to be covered with cloth. Investigative material was obtained from the facility for facility reported incident (FRI) #MD 310 on 3/9/20 at 10:30 AM regarding Resident #12's accusation that Resident #11 punched him/her. During the review of this material, it was found that Resident #12's allegation was unsubstantiated by the facility. There were no witnesses to the event, Resident #12 did not have any visible injury to his/her face, and Resident #12 retracted his/her allegation when interviewed by Staff #5 on 1/16/20 at 2:30 PM. Nevertheless, Resident #11 was moved to another room the next day on 1/17/20. Resident #12 was interviewed by the survey team on 3/9/20 at 12:54 AM. During the interview, Resident #12 refused to discuss the incident from 1/16/20 or his/her impressions of Resident #11 as a roommate, except that s/he was glad (Resident #11) is in a different room. Further review of Resident #11's medical record on 3/9/20 at 1:00 PM revealed that Resident #11 became roommates with Resident #13 when Resident #11 was relocated on 1/17/20. A nursing note dated 1/18/20 was found that stated, Mirror in resident's room covered with sheet papers to prevent chance of fighting with the mirror. Another nursing note dated 1/27/20 and timed 7:41 AM was found that stated, Resident is alert but continues talking to himself/herself, saying how s/he is going to beat somebody up. Resident saw his/her shadow on the window and started hitting the window, stating, 'I am going to kill that mother f**er.' Resident was redirected and the window blind was closed. Resident keeps going back and forth to the window. Each time, resident is redirected back to his/her bed. The review, also, revealed that another altercation occurred involving Resident #11. In a nursing note dated 1/26/20 and timed 1:10 AM, Registered Nurse (RN) #6 wrote, At 12:10 AM charge nurse reported that (Resident #11) had an altercation with his/her roommate (Resident #13), and she separated them . When asked what had happened, (Resident #13) stated (Resident #11) was peeing on the floor in the room and s/he reported him/her. (Resident #11) got mad and swung at him/her and s/he did the same. Head to toe assessment done on both, no injuries noted. Investigative material was obtained from the facility for FRI #MD 307 on 3/9/20 at 1:12 PM regarding this incident between Residents #11 and #13. Review of the material revealed a statement made by LPN #7 who was at the nurse's station at the time of the incident. The statement said, At 12:10 AM, residents were in the hallway exchanging words with their roommates. The writer rushed to separate them. (Resident #13) stated, 'my roommate urinated on the floor in the bathroom and I told him/her not to and my roommate swung at me and I did the same.' A statement was found written by GNA #8 that stated, 'On 1/26/20, residents were in the hallway and exchanged words with each other. The charge nurse separated them; (Resident #11) to the nurses' station, (Resident #13) into the bedroom and later was transferred to another room with all his/her belongings. And lastly, a statement was found written by GNA #9 that stated, Residents were in the hallway talking loudly to each other. The nurse came and separated them from having any confrontation. The matter was reported to the supervisor who advised us to transfer them to separate rooms. The investigative material, also, demonstrated that neither resident showed signs of injury or reported pain. Room change information supplied in the investigation demonstrated that the residents were immediately separated and roomed apart. An attempt was made to interview Resident #13 on 3/9/20 at 1:30 PM and on 3/10/20 at 8:45 AM. The resident was not available for an interview either time. Resident #13's medical record was reviewed on 3/9/20 at 1:45 PM. The review revealed that Resident #13 was admitted to the facility in June of 2019 with [DIAGNOSES REDACTED]. The most recent BIMS score for Resident #13 was 15/15 as recorded in his/her Quarterly MDS assessment with an assessment review date of 12/15/19. The Director of Nursing (DON) was interviewed on 3/9/20 at 2:15 AM. During the interview, the DON stated that Resident #11 may have benefitted from being in a single occupancy room after the first and second incident, but that no single occupancy room was available either time. She stated that the room changes that were made were based on rooming Resident #11 with other residents that the clinical team deemed compatible.

Based on staff interviews and review of medical records, facility policies, and other pertinent documentation, the facility failed to ensure an effective system to ensure that the nutritional needs of residents were met. This was evident for 5 of 19 sampled residents selected for review. Resident #1, Resident # 13, Resident #18, Resident #17 and Resident #19 were affected by the deficient practice. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy and the facility was verbally notified of this determination at 2:00 P.M. on [DATE]. The facility provided a plan to remove immediacy while the surveyor was onsite, which was accepted by the OHCQ at 8:20 P.M. on [DATE]. The plan included auditing all residents in the facility receiving tube feeding to ensure that appropriate goal weights and rates of tube feeding were in place; implementing process changes including basing weight calculations on ideal body weight; providing Minimum Data Set (MDS) assessment, coding, and care planning education to interdisciplinary team members; and auditing, modifying, and updating MDS assessment documentation and care plans. The plan also included monitoring actions including reviewing residents receiving tube feeding in daily clinical standup meeting and tracking residents with weight loss in a weekly nutritional risk meeting. After removing immediacy the deficient practice continued at a pattern level of harm (H). The findings include: 1. The facility staff failed to ensure that a tube fed resident (Resident #1) received adequate nutrition for 17 months. Review of the hospital medical record on [DATE] revealed that Resident #1's weight on [DATE] was 70 pounds. Review of the nursing home record revealed that one month later, when Resident #1 was first admitted to the nursing home from the hospital on [DATE], he/she was extremely thin with weight of 57.4 pounds (57.4 pounds had not been his/her baseline weight). Review of physician order [REDACTED].#1 to receive 50 mL/hr. of Glucerna 1.2 tube feed formula to run for 18 hours daily providing 900 mL total volume and 1,080 daily calories (1.2 * 900 mL = 1,080 calories). Review of the medical record on [DATE] revealed that on [DATE], the nursing home attending physician wrote an order to refer Resident #1 to hospice and on [DATE] Resident #1 was then accepted to receive hospice services. Consistent with the nursing home [DATE] admission weight of 57.4 pounds, the hospice initial certification assessment (signed [DATE]) corroborated that Resident #1 was severely cachectic (underweight and malnourished) at the time of the initial hospice evaluation. Later assessments in the hospice record further documented that the resident remained profoundly, profoundly cachectic throughout his/her admission. Review of the medical record revealed that in each of six MDS assessments completed for Resident #1 between the [DATE] admission and his/her [DATE] death, staff documented that the resident was in hospice care without any condition that supported that the resident had a life expectancy of less than six months. Nonetheless, Resident #1 was placed into hospice care. The MDS assessment reference dates were [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of all care plans in the medical record for February 2016 revealed that after placement into hospice services, no hospice care plan was ever developed and implemented to provide staff guidance on goals and/or expectations for hospice care or for how care would be coordinated between and amongst the hospice and nursing home staff. With no plan defining reasons, goals and objectives for hospice services, the facility Dietitian developed a nutritional care plan based in part on her assumptions about hospice care. Review of the nursing home medical record on [DATE], revealed that Resident #1 received all nutrition through a gastrostomy tube ([DEVICE]) and was totally dependent on staff for nutrition. Dietary Services Policy last revised in [DATE] revealed that nutritional assessments will be completed prior to developing the resident's MDS and care plan. On [DATE] interview with the Dietitian, she added that nutritional assessments for residents on tube feeding must be completed within 24 hours of admission. Neither of these occurred when Resident #1 was admitted : the first nutritional assessment for Resident #1 was not completed prior to the admission MDS assessment and was not completed within 24 hours of admission. The first nutritional assessment was documented six weeks after admission on [DATE] and the nutrition care plan (labeled pressure ulcer but focused on nutrition) was created on the same date [DATE]. However, computer system documentation revealed that when the care plan was created on [DATE], it was backdated to indicate it had been initiated on [DATE], six weeks before it was created. This care plan documented the goal that resident will have adequate nutrition/hydration status. Review of the medical record on [DATE] revealed that interventions in the nutrition care plan documented to continue [DEVICE] feeding as ordered, flushes as ordered, and monthly weights for hospice re-evaluation. No goal weight was defined in the nutritional care plan. With no documented hospice care plan defining expectations for hospice care, in interview with the Dietitian on [DATE] at 4:00 P.M., she reported that she established a dietary plan to only maintain the resident's current weight because the resident had been placed on hospice. She indicated that if the resident had not been on hospice she would have been much more aggressive with his/her nutritional goals. In the [DATE] interview, the Dietitian indicated that her goal was met because the resident's weight did in fact remain stable. Corroborating the Dietitian report in interview, the record revealed that the resident's weight was maintained in a stable but severely underweight status throughout his/her 17-month admission with no modifications to his/her tube-feeding rate. Weights were documented in the record that ranged between 56 and 63 pounds throughout the resident admission and the hospice physician repeatedly documented that the resident continued in a profoundly, profoundly cachectic condition (cachectic is a severely underweight and malnourished state). Nutritional progress notes revealed that Tesident #1 tolerated tube feeds well and no evidence was found in the record of any concern that would have contraindicated increasing the resident's tube-feed intake. In the first documented nutritional assessment on [DATE], the Dietitian did not establish any goal weight for Resident #1, did not document an ideal body weight, did not document the reason for tube feeds; and did not establish any long-term plan to evaluate and reassess his/her progress in gaining weight given the severely cachectic state he/she arrived in. In interview on [DATE], the Dietitian reported that there was no plan to help the resident gain weight because the resident was on hospice, and that all that needed to be done was to maintain the resident's current weight and to continue to get monthly weights to re-evaluate continued authorization for hospice care. On [DATE], a dietary late entry was entered into the progress notes section of the record and was labeled an initial nutrition assessment. As was evident with the nutrition care plan, according to computer system documentation, this assessment note was created on [DATE] but was backdated such that it appeared in the medical record as the initial nutrition assessment dated more than two months earlier on [DATE]. Narrative comments within this note, also, referenced to see the [DATE] nutrition assessment. In the [DATE] assessment (the one dated [DATE]) the Dietitian calculated that Resident #1's ideal weight for his/her height would have been 81 pounds but there was no evidence of any assessment of the resident's baseline weight from the hospital or from the family, and this [DATE] assessment again did not establish any goal weight or any strategy to address the resident's still cachectic state more than two months after admission. Review of the nursing home medical record revealed that over his/her 17-month admission, the Dietitian wrote many brief notes indicating that the resident was stable, was on hospice and that staff were to continue on the same plan and were to continue to obtain monthly weights for hospice recertification. Dietary notes included the [DATE] note entered on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]). Very brief earlier notes were entered into the medical record on [DATE] and [DATE] but the initial assessment had not yet been documented as completed. Regarding the related area of skin ulcers, the record for Resident #1 revealed that during his/her admission, Resident #1 had numerous wounds including but not limited to pressure ulcers. Poor nutritional status contributes to pressure ulcer risk and therefore review of these plans should have been coordinated as required during each quarterly MDS assessment. A care plan for skin integrity was created and initiated by nursing staff upon admission on [DATE]. The intervention to record percentage of meal consumed was initiated on [DATE] in this plan and remained in place until [DATE] after Resident #1's death. Resident #1 received all nutrition through tube feeding so he/she never consumed any meal and therefore no percentage of meals consumed could have ever been accurately recorded. No staff member ever re-evaluated and revised this inaccurate intervention documented in the care plan for pressure ulcers throughout the entire admission. Facility Dietary Services Policy last revised [DATE] revealed that nutritional assessments will be reviewed at least quarterly and revised as necessary. This did not occur. Although the quarterly MDS screening questions were filled out, at the time of each quarterly assessment, no interdisciplinary team member ever recognized, questioned or addressed the unmet nutritional needs of Resident #1. After seventeen months with an ongoing and active strategy to maintain the resident at his/her severely malnourished state, with no strategy to actually address Resident #1's profound cachexia, with no contraindications to try, and with no coordinated interdisciplinary planning input as required, on [DATE], Resident #1 experienced a change in condition and died in the nursing home. At admission to the nursing home on [DATE] Resident #1 weighed 57.4 pounds. On [DATE], Resident #1 still weighed only 56 pounds. During this same 17-month time frame that Resident #1 was not receiving adequate nutrition, Resident #1 developed skin and pressure ulcers, the Dietitian continued to document that the resident was stable, and the hospice physician continued to document that the resident was profoundly, profoundly cachectic. No interdisciplinary process identified the longstanding concern and no action was ever taken to address his/her nutritional needs. Failure to Thrive is a condition where despite best efforts a resident declines and the condition is often associated with weight loss or an inability to gain weight back. After 17 months of nutritional neglect, on [DATE], the nursing home Medical Director signed the death certificate indicating the cause of Resident #1's death was Failure to Thrive. Reference Federal Tags F0155, F0279 & F0280 2. The facility staff failed to ensure that a tube fed resident (Resident #18) received adequate nutrition to prevent weight loss. Resident #18's medical record was reviewed on [DATE] and [DATE]. Medical record review revealed Resident #18 had resided at the facility since 1997. Medical record review revealed that Resident #18 received all nutrition via a gastrostomy tube ([DEVICE]) and was totally dependent on facility staff for nutrition. Medical record review revealed that between [DATE] through [DATE] Resident #18's weights ranged between 168 and 175 pounds. The resident's body mass index (BMI) ranged between 25.5 - 26.6. The BMI is the measure of body fat based on height and weight. BMI categories are as follows: less than 18.5 - underweight; 18.5 - 24.9 normal; 25 - 29.9 overweight. Medical record review revealed that on [DATE] a quarterly nutrition assessment was completed by the Dietitian. The Dietitian calculated the resident's caloric needs were 2,143 calories per day. Medical record review revealed that on [DATE] the resident's weight was documented as 168.1 pounds which reflected a BMI of 25.6. As of [DATE] the resident had been receiving [MEDICATION NAME] 1.5 82 ml. per hour x 18 hour per day which provided 2,214 calories per day. ([MEDICATION NAME] is a specific tube feeding formula). Medical record review revealed that on [DATE], the physician's assistant (PA) examined the resident and assessed the resident with [MEDICAL CONDITION] secondary to drainage from the [DEVICE] site. The PA gave an order for [REDACTED]. Medical record review revealed that on [DATE] the nurse documented that the resident was noted manipulating/playing with [DEVICE]. [DEVICE] was noted detached from feeding pump and formula wasting on floor. Medical record review revealed that on [DATE] the resident was examined by the PA for follow-up of the [MEDICAL CONDITION]. The PA documented that nursing had reported there was no improvement in the [MEDICAL CONDITION]. Additionally, the resident was assessed with [REDACTED]. The resident was transferred to the hospital for evaluation and treatment. The resident was subsequently admitted to the hospital and was treated for [REDACTED]. The resident was readmitted to the facility on [DATE]. Medical record review revealed the resident's weight was documented as 125.8 pounds on [DATE], which represented a BMI of 19.1. Between [DATE] and [DATE] the resident's documented weight fell from 168.1 pounds on [DATE] to 125.8 pounds on [DATE]. This represented a 42.3 weight loss and represented 25% of the resident's body weight; additionally, the resident's BMI fell from 25.6 on [DATE] to 19.1 on [DATE]. On [DATE] the Dietitian completed a nutritional assessment of the resident. The Dietitian documented that the resident's ideal body weight was 154 pounds and estimated the caloric needs were 2,130 - 2,380 calories per day. The Dietitian noted the resident's weight loss of 42.3 pounds and documented the weight loss was related to leakage at the [DEVICE] site and infections. The Dietitian recommended continuing [MEDICATION NAME] 1.5 80 ml. per hour x 18 hours which provided 2,160 calories per day. This was 54 calories less per day than the resident had been receiving prior to the resident's discharge to the hospital on [DATE]. Medical record review revealed the resident was again hospitalized [DATE] through [DATE] for [DEVICE] malfunction, and [DATE] through [DATE] for acute abdominal wall infection and [DEVICE] malfunction. The resident was then readmitted to the facility on [DATE]. The resident's readmission tube feeding order was lowered to [MEDICATION NAME] 1.5 at 60 ml. per hour x 18 hours, which only provided 1,620 calories. On [DATE] the resident's weight was documented as 118.2 pounds. The Dietitian did not assess the resident until 5 days after the resident was readmitted to the facility. For 5 days the resident received 540 calories less per day than he/she was receiving prior to the hospitalization on [DATE]. On [DATE] the Dietitian completed a nutritional assessment of the resident. The Dietitian noted the resident's weight loss and determined that the present feeding was not meeting the established nutritional needs and recommended increasing the rate of feeding to [MEDICATION NAME] 1.5 85 ml. per hour x 18 hour which would provide 2,295 calories. Medical record review revealed the resident was hospitalized on [DATE] through [DATE] for [DEVICE] malfunction. The resident was readmitted to the facility on [DATE]. On [DATE] the resident's weight was documented as 124.4 pounds. On [DATE] a physician's orders [REDACTED]. per hour x 18 hours which would provide 2,025 calories per day. The amount of tube feeding had been decreased by 270 calories per day. Medical record review revealed that on [DATE], 6 days after the resident was readmitted to the facility, the resident was evaluated by the Dietitian. The Dietitian noted the resident's weight of 124.4 pounds. The Dietitian documented that the resident's ideal body weight was 154 pounds and the estimated caloric needs were 1,865 - 2,115 calories per day. This calculation was significantly less than the 2,130 - 2,380 calories per day calculated for the same resident on [DATE]. The Dietitian further documented on [DATE] that the resident's weight loss was previously addressed in diet assessment on [DATE] and that the present feeding was appropriate. As noted above, the resident was receiving 270 calories less per day than he/she received prior to [DATE]. The resident continued to receive [MEDICATION NAME] 1.5 75 ml. per hour x 18 hours [DATE] through [DATE]. Medical record review revealed the resident's weights were documented as follows: [DATE] 122 pounds and [DATE] 119 pounds. Medical record review revealed on [DATE] the resident's tube feeding was increased to [MEDICATION NAME] 1.5 80 ml. per hour x 18 hours which provided 2,160 calories per day. Medical record review revealed that on [DATE] a new tube feeding order was given for [MEDICATION NAME] 1.5 1 can (237 ml) 4 x per day which would provide 1,422 calories per day. Medical record review revealed that on [DATE] the Dietitian completed a nutritional assessment for the resident. The Dietitian documented that the resident's ideal body weight was 154 pounds, the estimated caloric needs were 1,865 - 2,115 calories per day. This calculation of caloric needs was significantly less than the Dietitian's calculation documented on [DATE] which was based on the same ideal body weight of 154 pounds. At that time the estimated caloric needs were documented to be 2,130 - 2,380 calories per day. The resident was now receiving 873 calories less per day than he/she was receiving [DATE] through [DATE], and 738 calories less per day than he/she was receiving [DATE] through [DATE]. Medical record review revealed that on [DATE] the resident was admitted to hospice care. Review of the hospice care nurse's progress notes revealed that the documented: (He/She) appears very emaciated and cachectic with all bones protruding, temporal wasting and ill fitting cloths. Medical record review revealed that the resident continued to receive [MEDICATION NAME] 1.5 1 can (237 ml) 4 x per day. The resident's weights were documented as follows: [DATE] 93 pounds, [DATE] 96 pounds, [DATE] 99 pounds, [DATE] 97 pounds, [DATE] 99 pounds. On [DATE] the Dietitian completed a nutritional assessment for the resident and made no changes. On [DATE] the resident's weight was documented as 81 pounds. The resident had gone from 99 pounds on [DATE] to 81 pounds on [DATE] which represents a weight loss of 18 pounds which is 18% of the resident's body weight. There is no documented evidence that the Dietitian intervened on [DATE]. Between [DATE] through [DATE] the resident had lost a total of 87.1 pounds, 52% of the resident's body weight. The resident's BMI had gone from 25.6 on [DATE] to 12.3 on [DATE]. After surveyor intervention, on [DATE] the Dietitian assessed the resident and noted the resident's weight of 87 pounds on [DATE]. The Dietitian recommended increasing the resident's tube feeding to [MEDICATION NAME] 1.5 1 can (237 ml.) 5 times per day. 3. The facility staff failed to ensure the Dietitian intervened when Resident #17 experienced significant weight loss, developed pressure ulcers and then experienced additional significant weight loss subsequent to have a gastrostomy tube placed. Resident #17 has a [DIAGNOSES REDACTED]. Resident #17's medical record was reviewed on [DATE] and [DATE]. Medical record review revealed that the resident had maintained a weight between 169 - 172 pounds from [DATE] through [DATE]. Review of the weight summary flow sheet revealed that on [DATE] the resident's weight was 169 pounds and on [DATE] the resident's weight was 158 pounds. This represents an 11-pound weight loss, 6.5% of the resident's body weight. The physician was notified and ordered a speech therapy evaluation. On [DATE] the Speech Therapist recommended downgrading the resident's diet to a mechanical soft diet with puree meats and a physician's orders [REDACTED]. On [DATE] the Speech Therapist obtained a telephone order from the physician to provide feeding assistance as needed for optimal meal intake. Review of the dietary progress notes revealed that the resident was last evaluated by the Dietitian on [DATE]. There is no documented evidence that the Dietitian evaluated the resident when the resident experienced an 11 pound weight loss documented on [DATE]. Medical record review revealed that on [DATE] a wound evaluation was completed. The resident was assessed with [REDACTED]. The wound bed was described as 100% scab with no drainage noted. The staff that completed the wound evaluation on [DATE] documented that the Dietitian was updated on [DATE]. Medical record review revealed that on [DATE] the resident had laboratory blood work, which revealed that the resident's serum [MEDICATION NAME] was 2.8 which is low. Although the resident had been assessed with [REDACTED]. Medical record review revealed that on [DATE], based on the Dietitian's recommendation, a telephone order was given by the resident's physician for vitamin C 500 mg. daily for supplement. Vitamin C is frequently prescribed for wound healing. Review of the weight summary flow sheet revealed that on [DATE] the resident's weight was 159 pounds. Medical record review revealed that on [DATE] the Dietitian addressed the resident's weight loss which was initially documented on [DATE]. The Dietitian documented the following weights in the progress note: [DATE] 158 pounds; [DATE] 160 pounds; [DATE] 167 pounds and [DATE] 165.2 pounds. The Dietitian acknowledged that there was a weight discrepancy. Medical record review revealed that on [DATE] the resident was evaluated by the wound specialist. The wound specialist documented that the resident's heel wound had deteriorated and there was now 100% thick, adherent devitalized necrotic tissue with moderate serous exudate. The wound care specialist recommended vitamin C 500 mg. two times per day and zinc [MEDICATION NAME] 220 mg. one time per day for 14 days. TheNurse documented in the progress note that the Dietitian was updated on [DATE]. There is no documented evidence that the wound specialist's recommendations were implemented. The resident continued to receive vitamin C 500 mg. 1 time per day. Review of the weight summary flow sheet revealed that on [DATE] the resident's weight was down to 149.5 pounds. The resident had experienced an additional weight loss of 9.5 pounds since [DATE]. Between [DATE] and [DATE] the resident had lost a total of 19.5 pounds, 11.5% of his/her body weight. Review of the wound evaluation record revealed that on [DATE], the resident was assessed with [REDACTED]. The Nurse documented that the Dietitian was updated. Medical record review revealed that on [DATE] the resident was transferred to the hospital secondary to a change in medical condition. The resident was readmitted to the facility on [DATE]. While hospitalized , a gastrostomy tube had been placed secondary to the resident's poor appetite. Review of the hospital discharge summary revealed the hospital Dietitian recommended [MEDICATION NAME] 1.5 60 ml. per hour. The resident was also readmitted with a stage III sacral pressure ulcer that measured 3.0 x 1.0 x 0.3 cm and an unstageable left heel pressure ulcer that measured 1.0 x 0.8 x 0.3 cm. The resident's admission weight on [DATE] was 158.6 pounds. Medical record review revealed that on [DATE] the resident was evaluated by the Dietitian. The Dietitian documented that the resident's estimated caloric needs were 2,170 calories per day and estimated protein needs were 72 grams per day. The Dietitian documented that the resident was started on [MEDICATION NAME] 1.5 at 60 ml. per hour x 18 hours, which did not meet the documented needs of the resident but rather would provide only 1,620 calories and 69 grams of protein per day. The Dietitian further documented that he/she would review the feeding, monitor tolerance and would possibly increase the feeding rate to meet the estimated calorie needs. However, review of the physician's orders [REDACTED]. per hour x 18 hours which would provide 1,080 calories per day and 46 grams of protein per day. This was 1,090 calories less per day than the resident's estimated caloric needs. Additionally, based on the resident's actual body weight of 158.6 pounds, the resident's protein requirement to aid in healing of pressure sores was 87 - 108 grams of protein per day for wound healing. The resident was receiving 41 - 62 grams less than what was required for wound healing (the National Pressure Ulcer Advisory Panel recommended range of protein needs associated with healing a pressure ulcer is between 1.2 to 1.5 grams of protein per kilogram of body weight per day). On [DATE], based on the Dietitian's recommendation, Prosoure 30 ml. per day was added to supplement the resident's protein intake. Together with the tube feeding, this provided the resident with a total of 61 grams of protein per day, which was still less than what was required for wound healing. Medical record review revealed that on [DATE] the Dietitian assessed the resident. The Dietitian documented that the resident's weight on [DATE] was by then down to 142 pounds. The Dietitian calculated the resident's estimated caloric need as 1,600 calories per day. This was still significantly less than the Dietitian's calculation on [DATE] of 2,170 calories per day. The resident had lost 17.2 pounds in less than 4 weeks since readmission to the facility on [DATE]. The Dietitian documented that the weight loss may have been related to calories not meeting needs. The resident's tube feeding was increased to [MEDICATION NAME] 1.5 60 ml. per hour x 18 hours which would provide 1,620 calories per day. Also, on [DATE] Prosource was increased from 30 mL every day to 45 mL every day. Together with the tube feeding, the resident was receiving 91.5 grams of protein per day. Medical record review revealed that on [DATE] the resident's weight was down to 136.8 pounds. Between [DATE] through [DATE] the resident lost an additional 5.2 pounds, indicating a significant 3.7% total body weight loss over a 2 week period. Medical record review revealed that on [DATE] the resident's sacral wound was evaluated and had worsened status. The Nurse documented that the wound bed was 100% necrotic tissue with moderate serous drainage, and that the wound had deteriorated as evidenced by increased necrosis. The Nurse documented that the Dietitian was updated on [DATE]. However, there was no evidence the Dietitian evaluated the resident's nutritional needs at that time. As of [DATE] there was no documented evidence that the Dietitian evaluated the resident since [DATE] despite worsening of the resident's sacral pressure sore and additional weight loss. After surveyor intervention, the Dietitian assessed the resident in February ,[DATE]. The resident's tube feeding was increased to [MEDICATION NAME] 1.5 70 ml. per hour x 18 hours. 4. Resident #19's medical record was reviewed on [DATE] and [DATE]. Medical record review revealed Resident #19 has resided at the facility since 2004. Resident #19 receives nutrition, hydration and medications through a gastrostomy tube. The resident also has a physician's orders [REDACTED]. Review of the MDS dated [DATE] revealed the resident is totally dependent on staff for nutrition. Review of the weight summary sheet revealed that the resident's weights ranged between 142.7 - 147.2 between [DATE] through [DATE]. On [DATE] the resident's weight was documented as 142.7 On [DATE] the resident's weight was documented as 118.4 pounds. This represents a 24.3 pound weight loss over a one month period, 17% of the resident's body weight. Further review of the medical record revealed that there is no documented evidence that the physician was notified of the resident's rapid, significant weight loss. Medical record review revealed on [DATE] the Dietitian completed a quarterly nutritional assessment for Resident #19. The Dietitian documented that the resident's most recent weight was 142.7 pounds on [DATE]. The Dietitian failed to note the weight of [DATE] of 118.4 pounds. The Dietitian further notes that the resident had a weight loss of 4.8 pounds x 3 months and 4.2 pounds x 1 month, but no significant loss overall and that the weight for July is pending. The Dietitian recommended increasing the resident's tube feeding secondary to the resident's weight loss trend. Medical record review revealed that it was not until [DATE] that nursing and the dietitian noted the resident's significant weight loss of 24.3 pounds that was documented on [DATE]. It was not until [DATE] that the resident was evaluated by the attending physician for weight loss. 5. Resident #13 had a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on [DATE] and [DATE]. Medical record review revealed that between [DATE] through [DATE] the resident's weights ranged between 101 and 110 pounds. Review of the weight summary sheet revealed that on [DATE] the resident's weight was 93 pounds, [DATE] 93 pounds and [DATE] 86.2 pounds. Medical record review revealed that the last comprehensive dietary assessment was on [DATE]. Review of the dietary progress notes revealed that on [DATE] the resident was evaluated by the Dieitian. The Dietitian noted the resident's weight of 93 pounds and that the resident had lost 17 pounds over a 30 day period. The Dietitian documented that the resident was under hospice care and weights are done monthly for hospice re-evaluation. Review of the dietary progress notes revealed that on [DATE] the resident was evaluated by the Dietitian for weight change. The Dietitian noted the resident's weight of 86 pounds on [DATE] and documented that the resident was under hospice care and weight loss fluctuations were anticipated. Again, the Dietitian documented that monthly weights would be continued for hospice re-evaluation. On [DATE] the Dietitian noted in the dietary progress note that the resident had lost 7.5% of his/her total body weight over a 30 day period and weight decline was expected. That was the last dietary progress note. Medical record review revealed that on [DATE] the resident was hospitalized for [REDACTED]. Review of the hospital discharge summary dated [DATE] revealed that the resident was very emaciated. <b

Based on medical record review it was determined the facility staff failed to provide care and services necessary to prevent the development of pressure ulcers and/or prevent the deterioration of existing pressure ulcers. This was evident for 4 of 19 sampled residents selected for review. Resident #1, Resident #10, Resident #17 and Resident #13 were affected by the deficient practice. The findings include: 1. Review of a local hospital medical record on 2/16/16 revealed that Resident #1's weight on 6/11/14 was 70 pounds. Review of the nursing home record, on 2/11/16, revealed that one month later, when Resident #1 was first admitted to the nursing home from the local hospital on [DATE], he/she was extremely thin with weight of 57.4 pounds (57.4 pounds had not been his/her baseline weight). Despite the resident's severely malnourished state, review of the medical record and interview with the nursing home Dietitian revealed that the Dietitian developed a nutritional plan to only maintain the resident's weight on admission. In interview, the Dietitian stated that the rationale to provide only a minimum amount of nutrition to Resident #1 was because Resident #1 was in hospice. No hospice care planning was evident in the medical record and with no guidance on hospice planning, interview with the Dietitian revealed that she assumed it was acceptable to leave the resident in a severely malnourished condition. Inadequate nutrition placed Resident #1 at increased risk for new skin ulcers and for worsening of existing skin ulcers. Review of the medical record on 2/16/16 revealed that Resident #1 was admitted on [DATE] with facial wounds that were difficult to heal because consistently picked at these wounds. Record review on 2/16/16 revealed that the care plan for pressure/skin ulcers for Resident #1 was labeled ulceration or interference with structural integrity of layers of skin caused by prolonged pressure . This care plan included only three interventions which were utilizing an alternating pressure ulcer mattress to relieve pressure, keeping resident nails trimmed to prevent injury when attempting to scratch self, and recording percentage of meals consumed. When the resident developed new skin ulcers during the 17-month admission the record revealed that no care plan changes were documented. When first created, the care plan for skin integrity was also inaccurate but no staff ever recognized and revised the plan as required during the periodic Minimum Data Set (MDS) assessments. The intervention to record percentage of meal consumed was initiated on 7/11/14 in this plan. Resident #1 received all nutrition through tube feeding so he/she never consumed any meal and therefore no percentage of meals consumed could have ever been accurately recorded. In six opportunities during MDS assessments (reference dates 7/21/14, 10/19/14, 1/19/15, 4/21/15, 7/22/15 and 10/22/15), no staff member ever revised this inaccurate intervention that remained in the care plan without revision until 12/13/15 after Resident #1's death when all care plans were discontinued. A 12/21/14 nursing progress note indicated an open blister was noted during activities of daily living (ADL) care and the charge nurse was notified. A change in condition note was also entered about this open blister on 12/21/14 but neither note indicated the location of this open blister, it's characteristics or if it met the definition of a Stage 2 pressure ulcer. Both the physician and responsible party were notified, but no evaluation of, or revisions to the care plan were evident. On 12/25/14 a wound evaluation note indicated that Resident #1 had by then developed a sacral wound measuring length 1.0 x width 1.0 by depth 0.1 and exudate was present. This wound care note documented diaper [MEDICAL CONDITION] to sacral areas. A similar note was documented for the same wound with the same measurements on 12/29/14. The record indicated that over the next approximately two months this wound worsened significantly and persisted until finally healing by 2/23/15. With severely compromised nutritional status and this significant wound evident, the MDS assessment with reference date of 1/19/15 did not capture the wound and therefore did not lead to evaluation of, or revisions to the care plan. Nor, did this persistent wound lead to evaluation of the nutritional risk factor where Resident #1 was not receiving adequate nutrition but no staff acted to meet the resident's nutritional needs. The record revealed an 8/31/15 note indicating there had been a clinical change in condition that required relieving pressure from the resident's heels. As was evident with the blister identified months before (on 12/21/14) the change in condition note did not document what the actual change in the resident's heel(s) was. The actual change in condition was not found in wound care sheets, was not found in progress notes, and was not found in care planning documentation. Given the anatomical location, the resident's known high risk, the resident's nutritionally compromised state, and that the intervention selected was one to address pressure concerns, it was very likely that the resident had developed one or more heel pressure ulcer(s) but whatever the clinical concern was, no care plan was revised to reflect any change in care services to meet the resident's changed skin integrity status. Review of the medical record on 2/16/16 revealed that on at least three different occasions Resident #1 had wounds labeled as blisters and/or open blisters. On 11/26/15 a progress note indicated that one of these blisters was associated with pressure from the use of a soft helmet that had been employed to keep Resident #1 from scratching at his/her face. This blister therefore met the definition of a facility acquired pressure ulcer. This ulcer was not documented as a pressure ulcer in skin sheets, was not staged as a pressure ulcer, and was not care planned. The use of the soft helmet associated with this pressure ulcer was not documented or addressed in any care plan. After this stage-2 pressure ulcer was identified, a new intervention was employed using a wedge cushion to protect the resident from pressure to the same area. Like all the above, this intervention addressing the pressure ulcer concern was not included in the skin integrity care plan to ensure that all staff would know what the plan of care was. On 9/21/15 Resident #1 required cauterization of abnormal granulation tissue performed on left lateral side of face. On 10/20/15 Resident #1 was seen by a Podiatrist to perform a procedure for left lateral great toe in-grown nail. With this new surgical wound, no changes were entered into the plan of care. Despite all these concerns with skin ulcers, no staff adequately assessed the resident's needs during the required assessment windows and no revisions were ever forthcoming in the resident's related care plans. With risk factors of immobility and severely compromised nutritional status, Resident #1 developed numerous skin ulcers for which cohesive and comprehensive assessments were never done and for which care planning was never accomplished. Although a consulting wound team followed the resident, care was not managed holistically with any clear planning efforts that might have otherwise identified and addressed the related concerns of skin ulcer development, skin ulcer worsening, and nutritional neglect. 2. Resident #10 was admitted to the facility on [DATE] for rehabilitation after being hospitalized with a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 2/16/16, 2/17/16, 2/18/16 and 2/19/16. Medical record review revealed that the resident received nutrition via a gastrostomy tube. The resident was dependent on facility staff for nutrition. Review of the Initial Nutrition History/Assessment revealed that the dietitian evaluated the resident on 7/24/15. The dietitian documented that the resident's height was 62 inches and the resident's weight was 169 pounds. The dietitian noted that the resident had a history of [REDACTED]. There is no documented evidence that the dietitian calculated the resident's total caloric needs, estimated protein needs or estimated fluid needs. The National Pressure Ulcer Advisory Panel recommended range of protein needs associated with healing a pressure ulcer is between 1.2 to 1.5 grams of protein per kilogram of body weight per day. Based on the resident's weight of 169 pounds, the resident required 92 - 115 grams of protein per day. Medical record review revealed that on 7/24/15 the dietitian recommended a tube feeding formula of Glucerna 1.5 at 50 ml. per hour for 18 hours which would provide 1,350 calories and 75 grams of protein which is 17 - 40 grams less protein than the resident required for wound healing. Medical record review revealed that on 7/27/15 the resident had blood chemistries drawn which revealed a serum [MEDICATION NAME] level of 2.4 gm/dl (the normal range is 3.5 - 4.7 gm/dl. [MEDICATION NAME] is a protein found in the blood. A low serum [MEDICATION NAME] level is associated with risk for development of pressure ulcers, as well as, poor healing of pressure ulcers. There is no documented evidence that the facility staff consulted with the dietitian regarding the resident's low [MEDICATION NAME] level. Medical record review revealed that the admission Minimum Data Set (MDS - an assessment tool) dated 8/4/15 revealed that the Resident had 2 stage 4 pressure ulcers, present on admission, and 1 unstageable pressure ulcer, present on admission. The resident was assessed to be at risk for developing pressure ulcers. The MDS documentation on 8/4/15 revealed that there were no nutrition or hydration interventions in place. The resident was assessed as needing extensive assistance with bed mobility. Medical record review revealed that on 8/10/15 the resident was evaluated by the wound care specialist. The wound care specialist noted the resident's serum [MEDICATION NAME] of 2.4 on 7/27/15 and stated: Labwork reviewed and considered in wound care plan. However, as stated above, there is no documented evidence that the dietitian addressed the resident's low serum [MEDICATION NAME] level. Medical record review revealed that on 8/17/15 the resident was evaluated by the wound care specialist. The wound care specialist documented that the resident was receiving vitamin C and zinc supplements. However, medical record review revealed that the resident did not have a physician's orders [REDACTED]. Medical record review revealed that the resident continued to receive Glucerna 1.2 50 ml. per hour x 18 hours through 9/14/15 which continued to provide 75 grams of protein. The dietitian never followed up and reassessed the resident's nutritional needs related to the pressure ulcers after the incomplete nutritional assessment of 7/24/15. Medical record review revealed that on 9/14/15 the resident was evaluated by the wound care specialist. The wound care specialist documented that the resident's sacral pressure ulcer had deteriorated and was found to have increased necrosis (devitalized tissue) and evidence of infection. The resident was subsequently transferred to the hospital and admitted for treatment of [REDACTED]. Review of the resident's care plan revealed that the facility staff failed to initiate appropriate nutritional goals and interventions to prevent pressure ulcers from worsening. On 7/24/15 a care plan was initiated related to the resident triggered secondary to DM-2 (diabetes mellitus), Decub (pressure ulcer) III and iv per hospital paper, [MEDICAL CONDITION] and GT (gastrostomy tube). The only intervention was tube feeding as ordered. Review of the resident's treatment administration record revealed that from the time the resident was admitted to the facility on [DATE] through the resident's discharge to the hospital on [DATE], there is no documented evidence that resident was being turned and positioned to prevent further development of pressure ulcers and/or deterioration of existing pressure ulcers. 3. Resident #17's medical record was reviewed on 2/19/16 and 2/22/16. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed that the resident requires the extensive assistance of 2 staff members for bed mobility. Medical record review revealed the resident experienced an 11 pound weight loss between 8/1/15 and 9/1/15. Medical record review revealed that on 9/20/15 a wound evaluation was completed. The resident was assessed with [REDACTED]. The wound bed was described as 100% scab with no drainage noted. The staff that completed the wound evaluation on 9/20/15 documented that the dietitian was updated on 9/21/15. Medical record review revealed that on 9/28/15 the resident had laboratory blood work which revealed that the resident's serum [MEDICATION NAME] level was 2.8 which is low. Although the resident had been assessed with [REDACTED]. Medical record review revealed that on 10/5/15, a telephone order was given by the resident's physician for vitamin C 500 mg. daily for supplement. Vitamin C is frequently prescribed for wound healing. Review of the weight summary flow sheet revealed that on 10/6/15 the resident's weight was 159 pounds. Medical record review revealed that on 10/27/15 the dietitian addressed the resident's weight loss which was initially documented on 9/1/15. The dietitian documented the following weights in the progress note: 9/8/15 158 pounds; 9/16/15 160 pounds; 9/23/15 167 pounds and 9/28/15 165.2 pounds. The dietitian acknowledged that there was a weight discrepancy. The dietitian failed to address the weight of 10/6/15 which was 159 pounds and there was no evidence that the dietitian had the resident re-weighed. Medical record review revealed that on 11/2/15 the resident was evaluated by the wound specialist. The wound specialist documented that the resident's heel wound had deteriorated and there was now 100% thick, adherent devitalized necrotic tissue with moderate serous exudate. The wound care specialist recommended vitamin C 500 mg. two times per day and zinc sulfate 220 mg. one time per day for 14 days. The Nurse documented in the progress note that the dietitian was updated on 11/2/15. There is no documented evidence that the wound specialist's recommendations were implemented. The resident continued to receive vitamin C 500 mg. 1 time per day. Review of the weight summary flow sheet revealed that on 11/8/15 the resident's weight was 149.5 pounds. The resident had experienced an additional 9.5 pound weight loss since 9/1/15. Between 8/1/15 and 11/8/15 the resident had lost a total of 19.5 pounds, 11.5% of his/her body weight. Review of the wound evaluation record revealed that on 11/18/15, the resident was assessed with [REDACTED]. The Nurse documented that the Dietitian was updated. Review of the resident's care plan revealed that the facility staff failed to initiate a nursing and/or nutritional care plan with appropriate goals and interventions to prevent pressure ulcers and/or prevent pressure ulcers from deteriorating. Medical record review revealed that on 11/20/15 the resident was transferred to the hospital secondary to a change in medical condition. The resident was readmitted to the facility on [DATE]. While hospitalized , a gastrostomy tube had been placed secondary to the resident's poor appetite. Review of the hospital discharge summary revealed the hospital Dietitian recommended [MEDICATION NAME] 1.5 60 ml. per hour. The resident was also readmitted with a stage III sacral pressure ulcer that measured 3.0 x 1.0 x 0.3 cm and an unstageable left heel pressure ulcer that measured 1.0 x 0.8 x 0.3 cm. The resident's admission weight on 11/28/15 was 158.6 pounds. Medical record review revealed that on 11/30/15 the resident was evaluated by the Dietitian. The Dietitian documented that the resident's estimated caloric needs were 2,170 calories per day and estimated protein needs were 72 grams per day. The Dietitian documented that the resident was started on [MEDICATION NAME] 1.5 at 60 ml. per hour x 18 hours which would provide 1,620 calories and 69 grams of protein per day. The Dietitian further documented that he/she would review the feeding, monitor tolerance and would possibly increase the feeding rate to meet the estimated calorie need. Review of the physician's orders [REDACTED]. order was given on 11/30/15 to start [MEDICATION NAME] 1.5 at 40 ml. per hour x 18 hours which would provide 1,080 calories per day and 46 grams of protein per day. This is 1,090 calories less per day than the resident's estimated caloric needs. Additionally, based on the resident's actual body weight of 158.6 pounds, the resident's protein requirement to aid in healing of pressure ulcers was 87 - 108 grams of protein per day for wound healing. The resident was receiving 41 - 62 grams less than what is required for wound healing. The National Pressure Ulcer Advisory Panel recommended range of protein needs associated with healing a pressure ulcer is between 1.2 to 1.5 grams of protein per kilogram of body weight per day. On 12/17/15, based on the dietitian's recommendation, Prosource 30 ml. per day was added to supplement the resident's protein intake. Together with the tube feeding, this provided the resident with a total of 61 grams of protein per day, which was still less than what is required for wound healing. Medical record review revealed that on 12/24/15 the dietitian assessed the resident. The dietitian documented that the resident's weight on 12/21/15 was 142 pounds. The dietitian calculated the resident's estimated caloric need as 1,600 calories per day. This is still significantly less than the dietitian's calculation on 11/30/15 of 2,170 calories per day. The resident had lost 17.2 pounds in less than 4 weeks since readmission to the facility on [DATE]. The dietitian documented that the weight loss may have been related to calories not meeting needs. The resident's tube feeding was increased to [MEDICATION NAME] 1.5 60 ml. per hour x 18 hours which would provide 1,620 calories per day. Also, on 12/25/15 Prosource was increased from 30 ml every day to 45 ml every day. Together with the tube feeding, the resident was receiving 91.5 grams of protein per day. Medical record review revealed that on 1/4/16 the resident's weight was 136.8 pounds. Between 12/21/15 through 1/4/16 the resident lost an additional 5.2 pounds. Medical record review revealed that on 1/11/16 the resident's sacral wound was evaluated. The nurse documented that the wound bed was 100% necrotic tissue with moderate serous drainage, and that the wound had deteriorated as evidenced by increased necrosis. The nurse documented that the Dietitian was updated on 1/11/16. However, there is no evidence the Dietitian evaluated the resident's nutritional needs at that time. As of 2/19/15 there is no documented evidence that the resident had been evaluated by the Dietitian since 12/24/15 despite worsening of the resident's sacral pressure sore and additional weight loss. After surveyor intervention, the Dietitian assessed the resident on 2/20/16. The resident's tube feeding was increased to [MEDICATION NAME] 1.5 70 ml. per hour x 18 hours. Refer to CMS F 279 and F 325. 4) Resident #13 had a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 2/18/16 and 2/19/16. Medical record review revealed that the resident was readmitted to the facility on [DATE] after being hospitalized and treated for [REDACTED]. Review of the wound evaluation note dated 8/7/15 revealed that the resident had a stage IV sacral wound, and 2 unstageable wounds to the left ankle and left elbow. The wound evaluation note stated that the dietitian was updated on 8/7/15. The resident was evaluated on 8/21/15, 8/28/15 and 9/4/15. Each time the resident was evaluated it was documented that the dietitian was notified on 8/7/15. There is no documented evidence that the resident was ever evaluated by the dietitian related to the resident's pressure ulcers.

Based on staff interviews and review of medical records, facility policies, and other pertinent documentation, the facility failed to revise care plans when inaccurate and ineffective care plans had been developed, but during five required Minimum Data Set (MDS) assessment windows, staff failed to correct and revise the plans in order to effectively meet resident needs. This failure to plan and thereby deliver effective care constituted neglect and contributed to an immediate jeopardy situation (reference Federal Tag F 325) when Resident #1 suffered nutritional neglect and then died . This was evident for 1 of 19 residents reviewed. The findings include: Review of the hospital medical record on [DATE] revealed that Resident #1 ' s weight on [DATE] was 70 pounds. Review of the nursing home record revealed that one month later, when Resident #1 was first admitted to the nursing home from the hospital on [DATE], he/she was extremely thin with weight of 57.4 pounds (57.4 pounds had not been his/her baseline weight). Review of the nursing home medical record on [DATE], revealed that Resident #1 received all nutrition through a gastrostomy tube ([DEVICE]) and was totally dependent on staff for nutrition. A nutrition care plan (labeled pressure ulcer) was initiated for Resident #1 and indicated the goal, resident will have adequate nutrition/hydration status. The only interventions listed were to continue [DEVICE]s as ordered, flushes as ordered, and obtain monthly weights for hospice re-evaluation. Computer system documentation revealed that this care plan was created on [DATE] more than a month after Resident #1's admission but staff backdated the care plan to have been initiated on [DATE]. After Resident #1 developed his/her first skin ulcer, Vitamin C and a protein supplement were added to the plan during [DATE]. The nutrition care plan documented no goal or target weight for Resident #1. In interview on [DATE] at 4:00 P.M., the Dietitian reported that the goal for nutrition was to just maintain the resident's admission weight, which unfortunately left the resident in a severely malnourished state, which the hospice physician repeatedly documented as a profoundly cachectic (severely malnourished) state. In the same [DATE] interview, the Dietitian reported that if the resident had not been on hospice she would have been much more aggressive with his/her nutritional goals. With an undocumented goal, the Dietitian provided only enough nutrition to keep Resident #1 in a severely malnourished state and the interdisciplinary team never recognized or questioned why Resident #1 was receiving inadequate nutrition for so long. Record review on [DATE] revealed that the care plan for pressure/skin ulcers for Resident #1 was labeled ulceration or interference with structural integrity of layers of skin caused by prolonged pressure . This care plan included only three interventions which were utilizing an alternating pressure ulcer mattress to relieve pressure, keeping resident nails trimmed to prevent injury when attempting to scratch self, and recording percentage of meals consumed. The record revealed an [DATE] note indicating there had been a clinical change in condition that required relieving pressure from the resident's heels. The change in condition note did not however document what the actual change in the resident's heel(s) was. The actual change in condition was not found in wound care sheets, was not found in progress notes, and was not found in care planning documentation. Given the anatomical location, the resident's known high risk, the resident's nutritionally compromised state, and that the intervention selected was one to address pressure concerns, it was very likely that the resident had developed another pressure ulcer, heel (s), but whatever the clinical concern was, no care plan was revised to reflect any change in care services to meet the resident's changed need(s). Review of the medical record revealed that on at least three different occasions Resident #1 had wounds labeled as blisters and/or open blisters. On [DATE] a progress note indicated that one of these blisters was associated with pressure from the use of a soft helmet that had been employed to keep Resident #1 from scratching at his/her face. This blister therefore also met the definition of a pressure ulcer. This ulcer was not documented as a pressure ulcer in skin sheets, was not staged as a pressure ulcer, was not captured in MDS documentation as a pressure ulcer, and was not care planned. The use of the soft helmet associated with this pressure ulcer was not documented or addressed in any care plan. After this stage-2 pressure ulcer was identified, a new intervention was employed using a wedge cushion to protect the resident from pressure to the same area. Like all the above, this intervention addressing the pressure ulcer concern was not included in the skin integrity care plan to ensure that all staff would know what the plan of care was. In addition, the plan for ulceration or interference with structural layers of skin integrity was also inaccurate but no staff recognized and revised the plan to address this during the periodic MDS assessments. The intervention to record percentage of meal consumed was initiated on [DATE] in this plan. Resident #1 received all nutrition through tube feeding so he/she never consumed any meal and therefore no percentage of meals consumed could have ever been accurately recorded. In six opportunities during MDS assessments (reference dates [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]); no staff member ever revised this inaccurate intervention that remained in the care plan without revision until [DATE] after Resident #1's death when all care plans were discontinued. In [DATE] interview, the Dietitian revealed that when completing section K (Nutrition) in each MDS assessment, she assumed there was no need to provide any care and services to do anything more than maintain the resident's admission weight specifically because the resident had been placed into hospice. And based on the assessment and care planning documentation, when completing and assessing section M (Skin Conditions) staff did not identify inaccuracies, did not capture important ulcer data, and did not revise care plans to ensure that the interventions were meeting resident needs. The failure to ensure that care plans were re-evaluated, revised and current in order to drive effective care delivery processes contributed to harm when Resident #1 developed pressure ulcers while receiving inadequate nutrition for 17 months.

Based on medical record review and review of the facility's investigation of a fall with injury it was determined the facility staff failed to protect Resident #6 from injury. This was evident for 1 out of 9 sampled residents selected for review. The findings include: Resident #6 had a [DIAGNOSES REDACTED]. The resident required extensive assistance with bed mobility. The resident was receiving Coumadin, an anticoagulant medication. Resident #6's medical record was reviewed on [DATE] and [DATE]. Review of the facility's fall investigation report revealed that on [DATE] at 6:45 A.M., the Geriatric Nursing Assistant (GNA) was providing care to the resident. The GNA reported that the resident appeared to be increasingly confused and was attempting to climb out of the bed. The GNA further reported that the resident was agitated and combative, so the GNA lowered the bed, raised the siderails and left the resident's room to get assistance from the charge nurse. When the GNA returned to the resident's room, the GNA observed the resident's lower body hanging from the bed and before the GNA could reach the resident, the resident's entire body rolled out of the bed and on to the floor. The resident sustained [REDACTED]. The physician was notified and gave an order to send the resident to the hospital for evaluation. Medical record review revealed that on [DATE] at 8:36 P.M. the nurse documented that the resident returned from the hospital with a [DIAGNOSES REDACTED]. The nurse documented that the physician was notified and neurological checks were in progress. The resident continued to receive the anticoagulant medication, Coumadin 4 mg. every evening. An adverse effect of Coumadin is bleeding. Medical record review revealed that on the morning of [DATE] the Unit Manager was called to the resident's room by the Charge Nurse due to a change in mental status and bleeding from the mouth. The Unit Manager documented that upon further assessment of the resident, a small amount of dark red drainage was coming from the resident's mouth and the resident was unresponsive to verbal and tactile stimuli. The resident's pupils were fixed and non-reactive to light. The resident was transferred to the hospital via the Emergency Medical System, 911, for further evaluation. Review of the hospital medical record, which was provided to the surveyor on [DATE], revealed that the resident arrived at the emergency department on [DATE] at 11:25 A.M. CPR was in progress when the resident arrived at the hospital. The resident was placed on life support in the emergency department. A CT scan revealed extensive intracranial hemorrhage and diffuse subarachnoid hemorrhage. The resident was diagnosed with [REDACTED]. The resident expired in the intensive care unit on [DATE] at 8:30 P.M.

Based on medical record review, observation, and staff interviews, it was determined that the nursing staff failed to promptly notify a physician of a resident's abnormal laboratory result and the facility staff failed to notify the physician and all appropriate nursing staff that a resident did not return from a leave of absence (LOA) in two of 37 sampled resident records in the Stage 2 review. 1. The nursing staff failed to promptly notify a physician of a resident's White Blood Count. A White Blood Count (WBC) is a laboratory test obtained by blood sample. A WBC is used to determine the presence of an infection. It is also used to help monitor the body's response to various treatments. White Blood Counts that continue to rise to abnormal levels indicate that the condition is getting worse. Counts that return to normal indicate improvement. A normal WBC range is 3.7 to 10.6 . Review of the facility's investigation, inservices, and action plan related to this incident resulted in this deficiency being cited as past non-compliance. The findings included: Resident #312 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Osteo[DIAGNOSES REDACTED] is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Osteo[DIAGNOSES REDACTED] can also begin in the bone itself if an injury exposes the bone to germs. Review of the medical record revealed the following interdisciplinary Plan of Care: [DATE]: "Resident is at risk for abnormal Lab(laboratory) values related to disease process". An approach included: "Monitor for s/s (signs and symptoms) of infection, report abn. (abnormal) findings to M.D. (physician)". By way of history, this resident on [DATE], had a WBC of 13.9 . In response to this laboratory value the nurse practitioner ordered a follow up WBC to be performed on [DATE]. Review of the medical record revealed that the blood sample was obtained on [DATE] at 4:00 p.m. and was received at the hospital at 8:53 p.m. that same day. Review of the medical record revealed the following nursing note: [DATE] ,[DATE] shift: ... " Abnormal lab (laboratory) results of WBC 22.4 ... in resident chart." (Physician) called X 2, message left on answering service phone, awaiting return call. Report given to night nurse to F/U (follow up) C (with) (physician)." Review of the medical record revealed no notification of this resident's WBC of 22.4 for the next 3 days. Review of the medical record revealed the following nursing note: [DATE] at 10:00 a.m.: "@ (at) about 8:40 a.m. resident noted (with) c change in mental status, unable to feed self, physical functioning is total dependence. Resident mood tired c little energy. Further assessment done ...". The attending physician and nurse practitioner was made aware of this nursing assessment and the abnormally high WBC. The nurse practitioner wrote the following on [DATE]: " Labs - WBC 22.4 Pt (patient) (with) non healing R (right) foot wound, osteo[DIAGNOSES REDACTED] R foot . Pt followed by wound MD, vascular Surgeon. Per last vasc. (vascular) consult recommended's R transmetatarsal amputation or R BKA (below knee amputation). Per nursing pt c confusion, poor intake. ...". In response to the nurse practitioner assessment she ordered at 10:55 a.m. on [DATE], during [MEDICAL TREATMENT] [MEDICATION NAME] (a potent antibiotic) 1 Gram intravenously, blood cultures and various other laboratory testing including a WBC. On [DATE] at 8:50 p.m., the nursing staff documented they were in receipt of this resident's laboratory test and noted the resident now with a WBC 40.7 . The physician was made aware of this resident's laboratory results and gave no new orders. On [DATE] at 6:51 a.m. the nursing staff found the resident unresponsive, initiated CPR and the resident was transferred to the hospital were he expired. The nursing staff failed to promptly notify a physician of an abnormally elevated WBC, for this severely compromised resident and this three day delay contributed to this resident's death. 2. The facility staff failed to notify the physician and all appropriate nursing staff that a resident did not return from a leave of absence (LOA). The findings included: On [DATE], during the entrance conference the facility staff provided an alphabetical census list which indicated resident #319 was in the facility. On [DATE], this surveyor went to retrieve resident #319's record from the nursing unit and was told by nursing staff that the resident had been discharged . The resident's medical record was obtained on [DATE] from the medical records department at 11:35 AM. Review of the medical record revealed that the last physician order [REDACTED].#319 an LOA (overnight) beginning [DATE] . The LOA book showed that the resident ' s daughter had signed resident #319 out for an LOA on [DATE] at 10:50 AM. Nursing notes on [DATE] stated daughter was given medications and a lengthy explanation on how to administer these medications while on LOA. Last nursing note in the medical record was written on the night shift of [DATE] which stated the resident was on an LOA. Review of the 24 hour nursing report for Unit 1 West on [DATE] and [DATE] indicated resident #319 was on LOA. During an interview on [DATE] at 11:25 AM, with Unit nurse #1, this surveyor questioned whether or not resident #319 was in the facility. Nurse #1 responded "She is on LOA. Would you like me to call her family and find out where she is?" On [DATE] at 11:30 AM resident #319's assigned bed was observed by this surveyor. The resident ' s bed was made and her possessions were in the bedside table, locker, and on bedside tray. On [DATE] at 11:40 AM Nurse #2, who was assigned resident #319, had stated that she noticed on the resident ' s vital sign paper that the resident was on LOA. Not until [DATE] was the facility staff able to confirm that the resident had been taken to the hospital on [DATE], by the daughter, for a change in condition. She was admitted to the hospital on [DATE]. The nursing supervisor on the ,[DATE] shift on [DATE] was aware of the resident ' s status but had failed to report the change to the physician or to other appropriate facility staff. When facility staff are made aware of a change in a resident ' s status from LOA to hospital admission the facility staff should notify the physician and inform all appropriate facility staff .