Every finding on record at Holly Hill Healthcare Center

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure that residents received the necessary monitoring to promote their well-being. This was evident of one (Resident #5) out of six residents reviewed during this complaint survey.The findings include:During a complaint investigation on 5/11/26 at 11:00 AM, it was revealed that Resident #5's family member noted the resident had a purple bruise under his/her eye on 2/12/26. However, the family member was not notified regarding the incident, and the facility provided two conflicting explanations for the cause of the bruise.A review of Resident #5's medical records on 5/11/26 at 1:59 PM revealed that on 2/13/26 at 7:43 AM, a nurse documented in a progress note that the resident bumped his/her head on the headboard during AM care, noting a raised knot but no bruising or discoloration. Additionally, a progress note by the facility Nurse Practitioner, service date 2/13/26 and signed on 2/15/26, stated: per GNA he/she was taking the patient to his/her room for AM care when he/she hit their face on foot board. On exam, right side face under lower eyelid swollen with large bruise.However, there was no subsequent documentation regarding the bruise's status, including its size, color changes, progression, or route cause.During an interview with the Director of Nursing (DON) on 5/12/26 at 11:21 AM, she stated that if a non-pressure skin issue is noted for a resident, it must be documented in the medical chart with the status of the bruise. The surveyor reviewed Resident #5's medical records with the DON, who validated that there was no appropriate assessment or ongoing documentation regarding Resident #5's bruise.

Based on observations, staff and resident interviews, it was determined that the facility failed to ensure that call bells were kept within reach for residents to utilize. This was found to be evident in 5 (Residents #26, #9, #3, #43, and #46) of 36 residents reviewed during the investigation phase of the annual survey.The findings include:On 10/1/2025 at 8:56 AM, Resident #26's call bell was observed hanging on the wall left of the resident's bed wrapped around the call bell plug outlet and not within reach. The call bell was again observed at 10:34 AM in the same position not within reach of Resident #26.On 10/1/2025 at 10:28 AM, Resident #9's call bell was observed underneath the resident's bed, not within reach of resident lying in bed.On 10/1/2025 at 10:29 AM, Resident #3's call bell was observed hanging in a basket behind the resident's bed, not within reach of the resident lying in bed. When Resident #3 was asked if their call bell is usually within reach, they stated no.On 10/01/2025 at 10:44 AM, Resident #43's call bell was observed hanging in a basket behind the resident's bed, not within reach of the resident lying in bed.On 10/1/2025 at 10:47 AM, Resident #46's call bell was observed hanging in a basket behind the resident's bed, not within reach of the resident lying in bed.On 10/1/2025 at 11:10 AM, Licensed Practical Nurse (LPN) #3 toured resident rooms where call bells were observed not to be within reach of the residents #26, #9, #3, #43, and #46 with surveyor. LPN #3 placed call bells next to residents and stated that it is the facility's expectation that call bells are always within reach of the residents.The Nursing Home Administrator (NHA) was made aware of call bell concerns on 10/2/2025 at 2:06 PM. The NHA stated their expectation is that residents should be able to access call bell and be placed next to them if the resident is in bed.

Based on observations and interviews, it was determined that the facility failed to 1) treat a resident with dignity by exposing the resident to a public area and 2) ensure that resident rights were maintained by knocking prior to entering a resident's room. This was found to be evident for 1 (Resident #35) of 1 residents reviewed for dignity and 2 out of several observations of Resident #1 and #6's room and during the annual survey. The findings include: 1) On 10/01/2025 at 9:14 AM, during the initial tour of the facility, while walking past Resident #35's room, the surveyor observed the resident fully exposed to staff, residents, and visitors in the hallway. Resident #35 was undressed, the privacy curtain had not been pulled, and the room door was wide open. On 10/01/2025 at 9:16 AM, during an interview with Registered Nurse (RN) Staff #20, she stated that Resident #35 had a history of exhibiting behaviors such as removing their clothing. She further stated that the expectation was for the privacy curtain to be pulled and the door to be closed in order to prevent the resident from being exposed. On 10/14/2025 at 10:28 AM, the Administrator and the Director of Nursing were made aware of the concern. 2) On 10/01/2025 at 9:52 AM, during an observation of Resident #6, Geriatric Nursing Assistant (Staff #19) walked into Resident #1 and #6's room, but failed to knock on the door prior to entering the room. On 10/01/2025 at 9:53 AM, an interview with Staff #19 revealed that the expectation was for staff to knock prior to entering resident rooms. When asked why she did not knock prior to entering the room she indicated she did not know why she did not knock. On 10/01/2025 at 12:17 PM, during an observation outside of Resident #1's room, Activities Leader (Staff #13) walked into Resident #1 and #6's room, but failed to knock on the door prior to entering the room. On 10/01/2024 at 12:19 PM, an interview with Staff #13 revealed that the expectation was for staff to knock prior to entering resident rooms. When asked why she did not knock prior to entering the room she indicated she forgot. On 10/02/2024 at 11:23 AM, the surveyor reviewed the concerns with the Administrator. She indicated that the expectation was that staff should knock on every resident's door prior to entering.

Based on interviews and record review the facility failed to provide quarterly statements to the resident's representative. This was evident for 1 (Resident #8) of 3 residents reviewed for personal funds during the annual survey. The findings include:On 10/02/2025 at 8:52 AM, during an interview with Resident #8's representative, they stated that they had never received a quarterly resident funds statement. On 10/02/2025 at 9:36 AM, a review of the resident's medical records revealed that the resident had a diagnosis of dementia and severe cognitive impairment as evidenced by a BIMS (Brief Interview of Mental Status) of 5 out of 10. Further review of an admissions record face sheet revealed the resident had a resident representative. On 10/09/2025 at 10:20 AM, during an interview with Business Office Manager (BOM) (Staff #8), she stated that if a resident was not their own representative then a copy of the quarterly funds statement would be mailed to the representative. She confirmed that Resident #8 was not their own representative and that they had never mailed out a quarterly statement to the resident's designated representative. On 10/09/2025 at 10:42 AM, a review of Resident #8's quarterly resident fund statement from 07/01/2025 through 9/30/2025, revealed signatures by the Administrator and the BOM. However, there was no evidence provided that the statement had been reviewed by the resident or sent to the responsible party.On 10/14/2025 at 11:00 AM, the Administrator was made aware of the concern, she confirmed that the resident's representative had never received a copy of the quarterly financial statement.

Based on observations and staff interview, it was determined that the facility failed to ensure Resident #23 was free from physical restraints. This was evident for 1 (Resident #23) of 1 residents reviewed for physical restraints during the annual survey. The findings include:On 10/01/2025 at 9:05 AM, during the initial tour of the facility, the surveyor observed a Geri chair placed beside Resident #23's bed, restricting the resident from getting out of bed. On 10/01/2025 at 9:06 AM, during an interview with Registered Nurse (RN) Staff #20, she confirmed that the chair should not have been there and acknowledged it as a restraint concern. Following the interview and surveyor intervention, she immediately removed the chair from the side of Resident #23's bed.

Based on medical record review and interviews, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of a resident enrollment in hospice. This was found to be evident for 1 (Resident #70) out of 1 resident reviewed for hospice services during the survey. The findings include:The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A Significant Change in Status MDS is required when a resident enrolls in a hospice program.On 10/7/2025 at 10:25 AM, Resident #70's medical record was reviewed which revealed that the resident was admitted to hospice services at the facility on 6/9/2025 and passed away on 8/23/2025. Chart review of MDS assessments showed a quarterly assessment with assessment referral date (ARD) of 5/26/2025 was completed for Resident #70. The next MDS assessment for Resident #70 was a Death in facility MDS on 8/23/2025. No significant change assessment was revealed between the two previous MDS assessments.An interview was held on 10/7/2025 at 11:15 AM with the Nursing Home Administrator (NHA), who stated that the facility's full time MDS coordinator was currently out on extended leave and that regional MDS staff were covering for the facility.MDS Regional Coordinator was interviewed on 10/8/2025 at 11:38 AM who confirmed that Resident #70 did not have a significant change MDS assessment after enrollment in hospice services. MDS Regional Coordinator stated that their expectation is that residents going into hospice services should have a significant change MDS within 14 days of enrollment of services.On 10/9/2025 at 2:40 PM, surveyor reviewed the concern regarding the failure to complete the significant change MDS assessment within 14 days of hospice enrollment with the NHA.

Based on record review and interview, it was determined that the facility failed to ensure a baseline care plan was developed and implemented for a resident who was unable to move or feel anything below their neck (including arms and legs). This was evident for 1 (Resident #1) out of 7 residents investigated for care planning. The findings include: The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety. Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that are most likely to occur right after admission. On 10/03/2025 at 11:15 AM, review of the Resident #1's 48 hour care plan failed to reveal that it included a plan of care for the resident who was unable to move or feel anything below their neck (including their arms and legs). On 10/07/2025 at 11:58 AM, an interview with the Regional Director of Clinicals revealed that the expectation was that the resident's plan of care for the condition should have been included in the 48 hour care plan. On 10/10/2025 at 7:50 AM, a record review of the resident's hospital Discharge summary dated [DATE] indicated that resident had the condition upon admission to the facility. On 10/14/2025 at 9:33 AM, the concern was brought up to the Director of Nursing and Administrator and it was revealed that the expectation was that the plan of care should have been included in the residents 48 hour care plan.

Based on interview, record review, and observations, it was determined that the facility staff failed to maintain professional standards of practice related to signing off resident care orders. This was evident for 2 out of 2 days observed for Resident #1's arm splint. The findings include: 1) On 10/02/2025 at 11:28 AM, an interview with Resident #1 revealed that staff was supposed to put arm splints on her/him everyday but that they do not. On 10/03/2025 at 11:15 AM, review of Resident #1's medical record revealed an active order for the resident to wear bilateral elbow and hand splints during the daytime 5-7 hours everyday as tolerated. On 10/07/2025 at 9:04 AM, an observation in the resident's room revealed that the resident had no splints placed on his/her hands, the splints were next to the resident's bedside. On 10/07/2025 at 11:19 AM, record review revealed that the order for the splints was signed off as complete. On 10/07/2025 at 11:21 AM, an observation in the resident's room revealed that the resident had no splints placed on his/her hands, and the splints were next to the resident's bedside. On 10/07/2025 at 1:05 PM, an observation in the resident's room revealed that the resident had no splints placed on his/her hands, and the splints were next to the resident's bedside. 2) On 10/08/2025 at 7:40 AM an observation in the resident's room revealed that the resident had no splints placed on his/her hands, the splints were next to the resident's bedside. On 10/08/2025 at 10:19 AM, an observation in the resident's room revealed that the resident had no splints placed on his/her hands, and the splints were next to the resident's bedside. On 10/08/2025 at 10:29 AM, record review revealed that the order for the splints was signed off as complete. On 10/08/2025 at 12:04 PM, an observation in the resident's room revealed that the resident had no splints placed on his/her hands, and the splints were next to the resident's bedside. On 10/08/2025 at 1:26 PM, an observation in the resident's room revealed that the resident had no splints placed on his/her hands, and the splints were next to the resident's bedside. On 10/08/2025 at 10:21 AM, an interview with Licensed Practical Nurse (Staff #3) revealed that the expectation was that staff only sign off orders as complete if it was done, and if a resident refused an order they could document it as refused. On 10/09/2025 at 12:07 AM, the concern was reviewed with the Regional Director of Clinical Services and Administrator and it was revealed that the expectation was that staff should not sign off on orders as completed unless they were done.

Based on observations, medical record review, and interview, it was determined that the facility failed to ensure that residents with orders for orthopedic devices were wearing them as prescribed and device administration was being appropriately documented. This was found to be evident in 1 (Resident #3) of 2 residents reviewed for limited range of motion during the annual survey.The findings include:On 10/1/2025 at 10:30 AM, Resident #3 was observed lying in bed in their room. Contractures were observed to resident's left arm and hand; no brace or splint was noted to be worn by the resident.On 10/6/2025 at 1:45 PM, Resident #3 was observed lying in bed in their room, no brace or splint was observed in place on Resident #3's left arm or hand.On 10/08/2025 at 9:27 AM, Resident #3's medical record was reviewed. It was reviewed that Resident #3 had an order initiated on 10/23/2024 that stated, Device: Apply left elbow and hand carrot splint up to 4-6 hrs. a day as tolerated. Remove for skin inspection and ADL care. Every day shift for contracture management.On 10/08/2025 at 10:05 AM, Resident #3 was observed lying in bed in their room, no brace or splint was observed in place on resident. When questioned, Resident #3 stated no to wearing an orthopedic device in the last few months.On 10/10/2025 at 10:15 AM, Resident #3's treatment administration record (TAR) for October 2025 was reviewed which showed documentation that Resident #3 had brace and splint administered by facility staff on October 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10, 2025. Resident #3's TAR also showed that it was documented under behavior monitoring and interventions that the resident was not exhibiting behaviors, and there was no documentation of Resident #3 refusing to wear their elbow and carrot splint.On 10/10/2025 at 10:35 AM, Resident #3 was observed lying in bed in their room, no elbow and hand carrot splint was observed being worn by the resident. Resident #3 shook their head no to the surveyor when questioned if they had the elbow and carrot splint applied to their left arm and hand today at any time.On 10/10/2025 at 10:50 AM, Registered Nurse (RN) #7 was interviewed and confirmed that Resident #3's TAR showed documentation that the elbow and carrot splint was applied. RN #7 toured Resident #3's room with surveyor and confirmed that Resident #3 was not wearing the ordered elbow and carrot splint. RN #7 was able to locate the resident's elbow and carrot splint in the resident's top drawer in their room. RN #7 stated that Resident #3 has a history of refusing administration of the splint, and the resident had not worn the splint in about a year. RN #7 was unable to show surveyor any documentation of Resident #3 refusing to wear the splint in their medical chart on days it was documented as administered in October 2025.On 10/10/2025 at 11:39 AM, surveyor concern was addressed with the Regional Clinical Director. The Regional Clinical Director stated that elbow and carrot splint should not be documented as administered if resident did not wear the device, and that the facility's expectation is that staff document under behavioral monitoring all instances of refusing care.

Based on interview and record review, it was determined that the facility failed to ensure that the facility staff implemented interventions consistent with a resident's plan of care to avoid a fall. This was evident for 1 (Resident #1) out of 4 residents reviewed for accidents. The findings include: A care plan is a written guide that outlines a person's medical and personal care needs, goals, and the specific actions required to meet them. Care plans help ensure that all members of the healthcare team provide consistent, safe, and effective care tailored to the individuals needs. On 10/02/2025 at 10:40 AM, an interview with Resident #1 revealed that he/she recently fell out of bed while a staff member was providing incontinence care. He/she confirmed only one staff member was with him/her when they fell out of bed. On 10/02/2025 at 11:00 AM, record review revealed a progress note dated 09/21/2025 at 10:13 PM which indicated that the resident fell on [DATE] at 3:15 PM. The fall documentation indicated Geriatric Nursing Assistant (Staff #18) was with the resident during the fall and failed to reveal a second staff member was present. On 10/03/2025 at 8:08 AM, review of Resident #1's care plan revealed a focus of activities of daily living self care performance, with the following intervention: 2 or more helpers is required for toileting hygiene, initiated on 2/6/25. On 10/10/2025 at 9:33 AM, the surveyor reviewed the concern with the Administrator and Regional Director of Clinical Services. They indicated that there should have been two staff members with the resident providing care.

Based on observations, medical record review, and staff interviews, it was determined that the facility failed to provide necessary respiratory care services by failing to maintain an ambu bag at bedside per physician order. The was found to be evident in 1 (Resident #9) of 1 resident reviewed for respiratory care during the annual survey.The findings include:An ambu bag, also known as a manual resuscitator or bag-valve-mask, is a portable, handheld device used to provide positive pressure ventilation to a patient who is not breathing or not breathing adequately. A trach, short for tracheostomy, is a surgical procedure that creates an opening in the front of the neck (trachea) and inserts a tube to provide an airway. On 10/1/2025 at 10:24 AM, Resident #9's room was observed. Resident #9 had an oxygen concentrator at beside, with attached sterile saline bottle for humidification with oxygen tubing and trach mask. Surveyor observed Resident #9 with a tracheostomy tube. No ambu bag was observed to be in Resident #9's room.Resident 9's medical record was reviewed on 10/8/2025 at 8:49 AM which showed a physician order initiated on 1/30/2024 for Trach: Ambu Bag at bedside every shift.No ambu bag was observed in Resident 9's room during observation on 10/8/2025 at 10:17 AM.On 10/8/2025 at 10:17 AM Registered Nurse (RN) #7 observed Resident 9's room with surveyor. RN #7 was unable to locate an ambu bag in the room, stating that there was an ambu bag on the crash cart which was located outside Resident 9's room and down the hall. RN #9 stated that their expectation is that if the order states ambu bag at bedside, there should be one in the room.Surveyor concern about lack of ambu bag at bedside was addressed with the Nursing Home Administrator on 10/9/2025 at 2:40 PM.

Based on observation, record review, and interviews, it was determined that the facility failed to obtain informed consent and document alternatives attempted prior to initiation of bedrails. This was evident for 1 (Resident #1) out of 1 resident reviewed for bedrails for an annual survey. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. The facility should obtain a signed consent form before the use of bedrails. On 10/02/2025 at 10:21 AM, an observation of Resident #1 in bed revealed two 1/4 bed rails up on either side of the top end of the bed. On 10/02/2025 at 10:21 AM, an interview with Resident #1 revealed that the staff had rolled the resident toward the bed rail, it gave out during incontinence care, and in result fell out of bed. Further interview with the resident revealed that he/she has a condition where he/she is unable to move or feel anything below their neck. On 10/02/2025 at 11:00 AM, review of document titled, incident note dated 9/21/2025 indicated that the bed rail gave way when the resident fell out of bed on 9/21/2025. On 10/09/2025 at 11:44 AM, an interview with the Administrator and Regional Director of Clinical Services revealed that bedrails were implemented when a resident was able to grab the bedrail and unable to roll on their own. They also indicated that other alternatives were attempted prior to bedrails being used, and that therapy does the assessment. In the same interview it was also revealed that they did not obtain consent because as a facility they don't view them as bedrails. On 10/10/2025 at 1:35 PM, an interview with the Therapy Manager (Staff #15) revealed that therapy did not recommend bedrails for Resident #1 and would not recommend bedrails for a resident with the condition Resident #1 had. On 10/14/2025 at 9:33 AM, the concern was reviewed with the Administrator and Director of Nursing and they indicated that they understood.

Based on observations and interviews, it was determined that the facility failed to ensure infection control practices were maintained during medication administration. This was evident for 1 (Resident #27) out of 4 residents observed for medication administration. The findings include: On 10/09/2025 at 8:40 AM, during medication administration, the surveyor observed Licensed Practical Nurse (Staff #12) into Resident #27's room, and prepared to administer eye drops. At the same time, Staff #12 walked out of the room with the eye drop bottle but failed to perform hand hygiene upon leaving the residents room On 10/09/2025 at 8:41 AM, the surveyor observed Staff #12 walk back into Resident #27's room with one glove on, and failed to perform hand hygiene upon entering the resident's room. Staff #12 then put a second glove on in the resident's room, still without performing hand hygiene since entering the room. At the same time Staff #12 administered eye drops into both of Resident #27's eyes. On 10/09/2025 at 12:07 PM, the concern was reviewed with the Administrator and Regional Director of Clinical Services and they indicated that the expectation was that staff members must perform hand hygiene when entering and exiting a resident's room.

Based on observations and interviews, it was determined that the facility failed to ensure a safe and comfortable environment for residents and staff. This was evident during multiple observations during the annual survey. The findings include: 1) On 10/01/2025 at 8:48 AM, an observation of room [ROOM NUMBER] revealed a wall foot board that was detached from the wall completely and was leaning diagonally against the wall, in the bathroom there was a rubber lining below the shower that was detached from the floor and in the pathway of the bathroom. Further observation of room [ROOM NUMBER] revealed the right side blinds on the window were bent or cracked on several of the panels. Looking into the bathroom, there was a corner protector on the left which was detached from the wall on the bottom. 2) On 10/01/2025 at 12:24 PM, an observation of room [ROOM NUMBER] revealed that the bathroom door panel on the outside part of the door was split from the main part of the door at the bottom by the hinges. Inside the bathroom, there was a missing square tile behind the toilet, exposing the inside of the wall. The toilet was running for several minutes as the surveyor stood there. Further observation of room [ROOM NUMBER] revealed the light bulbs from the light fixture above bed B were exposed, one side of the blinds on the window was completely detached from the window laying on the window seal, and the other side there were several panels on the blind that were bent. The privacy curtain between bed A and B was off of the ceiling tracks in multiple sections. Further observation of room [ROOM NUMBER] revealed the furnace had missing and loose top square pieces which exposed the internal parts of the furnace. The night stand in between both beds failed to have a top drawer which exposed the inside of the night stand. The 4 drawer dresser in the room between the two closets had a broken handle on the third drawer down; the dresser had several scratches and chips of its paint across the entire piece. On 10/01/2025 at 12:32 PM, an interview with Geriatric Nurse Assistant (Staff #16) revealed that the staff were able to report a maintenance issue via text message, or they can request the maintenance director themself. On 10/09/2025 at 10:30 AM, an interview with Licensed Practical Nurse (Staff #3) revealed that staff were able to submit a maintenance concern in person to the maintenance director directly by calling him or asking him in person. Staff #3 further indicated another way to submit a maintenance concern was by an online request. On 10/10/2025 at 9:58 AM, an interview with the Maintenance Director (Staff #9) revealed that there was an online system, TELS, where a maintenance concern could be reported by staff, and he would address them as he received them. He further indicated the expectation was for staff to report maintenance concerns as they identified them. On 10/10/2025 at 10:10 AM, the surveyor walked with the Maintenance Director (Staff #9) around the facility and reviewed the identified concerns above. He made note of each of the concerns and indicated he would address them. 3) On 10/10/2025 at 10:56 AM, an observation of the laundry room revealed that the 3 section sink on the left upon entry was filled with various items including soiled rags, a plastic container, a plastic spray bottle, a small trash can with trash, soiled rubber gloves, and a metal wire. The sink itself was covered in rust and white particles. At the same time, an interview with the Director of Housekeeping (Staff #21) revealed that the sink was not in use. Further observation of the laundry room revealed a circular drain under the hand washing sink to the right upon entry into the room, which failed to have a drain cover, exposing the inside part of the drain. Further observation of the laundry room revealed the wall corner cover on the right side of the hand washing sink, which failed to be intact, revealing the bottom half of the corner and metal piece of the wall on the bottom which was curling outward. Further observation of the laundry room revealed the folding table in the center of the room which was rusted in several places including where approximately three staff aprons were on and the legs of the table. The folding table was also covered in dust on the bottom where the staff aprons were. An interview with the Director of Housekeeping (Staff #22), who was present during the observation, revealed that the bottom of the folding table which was covered in dust was cleaned once a week. On 10/14/2025 at 9:33 AM, the concerns noted above were reviewed with the Director of Nursing and the Administrator and they indicated that they understood.

Based on review of a facility reported incident with investigation, medical record review, and interviews, it was determined the facility staff failed to protect a cognitively impaired resident from physical abuse from facility staff. This was evident for 2 (#6, and #11) of 3 residents reviewed for abuse during a complaint survey. This resulted in actual harm to resident #6. The findings include: 1. A review on 7/30/25 at 9 AM, investigation revealed that on 9/7/24 Resident #6 alleged that GNA #10, physically abused them by slapping open hands on the face. The GNA was suspended, and a full investigation was launched. Further review of the facility investigation revealed that another Resident #8, was a witness to the incident. On 7/30/25 at 9 AM, a review of Resident # 6's written statement dated 9/7/24, revealed that the resident stated that someone hit me in the face, they ambushed me and punched me in the face. On 9/7/24 the Resident was assessed by his/her physician and received psychiatric services after the incident. The Nursing progress note assessment on 9/7/24 in the electronic medical record (EMAR) right after the incident revealed a red area noted around the resident's cheeks. The nursing note in the EMAR on 9/9/24 noted bruising to the left side of Resident #6's face with a quarter sized blood-filled blister on their ear. The facility terminated the GNA, staff member #10, and reported the GNA to the Maryland Board of Nursing for abuse. In an interview with Resident #8 on 7/30/25 at 10:30 AM, the resident stated that s/he did remember the incident where the GNA, staff member #10, was physically slapping resident #6 in the face, hard, and multiple times. Resident #8 also stated that the State Attorney contacted them about being a witness to physical abuse. On 9/15/24 at 12 PM the case was discussed with the Director of Nursing (DON) and the Administrator. The surveyor reviewed the full incident report. The Administrator and Director of nursing completed a full house abuse training that was completed on 9/11/24. The administrator and DON interviewed all staff and residents on the unit. The Administrator reported GNA #10 to the Board of Nursing. The incident was reviewed and monitored in QUAPI. The surveyor determined the facility plan of correction date, for the allegation of staff-to-resident abuse, to be 09/11/24. This citation has been cited as substantiated past noncompliance. 2. On 7/29/25 at 1:16 PM an investigation of resident # 11 was conducted. Resident # 11 has a Bims of 9/15 which indicates she/he is moderately impaired. (A Bims score is a brief mental interview used by long term care facilities to evaluate cognitive function of a resident.) Resident # 11 claimed she was hit in the face by GNA # 10 during morning care on 9/7/25. GNA # 10 was suspended pending investigation. Resident # 11 was assessed for injury and had redness on the left side of cheek and left ear. Police were called and responded. An officer spoke with resident # 11 and stated she/he was hit by staff member # 10 She/he stated that Staff # 10 hit her/him with an open hand in the face while she /he was in their room for her/his morning care. When asked by the officer if she/he was assaulted, the resident responded yes. Resident # 11 also stated, Staff # 10 squeezed her and said this type of assault happens every now and then and it had not been reported to staff members. In an interview with Resident #8 on 7/29/25 at 1:30 PM, the resident stated that s/he did remember the incident. Resident #8 stated as s/he was propelling s/his wheelchair in the hallway, he/she saw GNA #10 through a crack in the door , physically slapping resident # 11 in the face hard, and multiple times. Resident # 11was interviewed on 9/7/24 by facility social worker staff #11 and denied being hit by any staff members. On 9/9/2024 resident # 11 reported to a Psychology consultant post incident on 9/7/2024 that he/she was slapped in the face. On 9/7/2024, The former Executive Director received a call from ADON informing him that resident # 11 stated she/he was hit by her assigned GNA. The facility terminated Staff # 10's employment and reported them to the Board of nursing. Several attempts were made to inform GNA # 10, not return back to work. A meeting was held on 7/29/25 at approx. 2pm with the administrator and Director of Nursing regarding this incident.

Based on the interview with facility staff, it was determined that the facility failed to have a full time (Full-time means working 35 or more hours a week) clinically qualified Food Service Director. This was evident for 1 of 1 Food service Director reviewed for required credentialing. The findings include: On 02/28/24 at 01:07 PM, during an interview with Registered Dietician (RD) Staff #13, it was revealed that she/he worked 16 hrs a week and did not get involved with the kitchen, but monitored monthly food tasting and temperatures only. On 02/29/24 at 12:01 PM, the Dietary Director (staff #17) was interviewed and reported that he/she worked for five years in healthcare-related areas, and had a certificate for Baltimore food service manager valid until Sep 2026. They were enrolled in a self-paced Certified Dietary Manager (CDM) program. They had initiated the first module and anticipating to complete it in 8-12 months. Staff #17 reported he has oversight from a corporate CDM. Surveyor Requested copies of any credentials he currently has; as well as credentials from the corporate CDM. State regulations require in a nursing home with more than 50 beds, overall supervisory responsibilities for the food service department and food production shall be assigned to a full-time qualified dietetic service supervisor. The state regulations define a dietetic service supervisor as a person who: a) Is a graduate of a dietetic technician program approved by the American Dietetic Association; (b) Is a graduate of a dietetic technician program approved by the American Dietetic Association; (c) Is a certified dietary manager who has successfully completed the required course and maintains certification as required by the certifying board for the Dietary Managers Association; (d) Is a graduate of a State-approved course that provided 90 or more hours of classroom instruction in food service supervision and has experience as a supervisor in a health care institution with consultation from a dietitian; or (e) Has training and experience in food service supervision and management in a military service equivalent in content to SB(15)(b) and (d) of this regulation. [ See COMAR S0790-10.07.02.21B] On 02/29/24 at 02:08 PM, surveyor reviewed with staff # 17 the Code Of Maryland Regulations (COMAR) and the definition of dietary supervisor(see above). Staff #17 revealed that s/he does not have any of these qualifications. On 03/04/24 at 03:30 PM, surveyor reviewed with the Director of Nursing (DON) the concern regarding the failure to ensure the facility has a qualified dietary manager. As of the time of the survey exit 03/05/2024 at 5:30 PM, no documentation was provided regarding the credentials of the corporate individual who Staff #17 had reported was a CDM providing oversight.

Based on observation and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents at the facility. The findings include: On 02/22/24 at 12:52 PM, surveyor observed food serving trays with chipped and cracked edges. On 02/22/24 at 01:20 PM, surveyor reviewed chipped and cracked trays that were observed in use with the Food service Director (staff#17). On 02/29/24 at 12:08 PM, an observation of the trayline revealed several food trays with chips and cracks. At least 6 out of 10 trays observed in a food transportation cart revealed significant chips and cracks. On 02/29/24 at 02:08 PM, surveyor reviewed the concern with staff #17, that many of the serving trays had chips and cracks. Staff #17 confirmed that new trays would be ordered to replace the chipped and cracked trays. On 03/04/24 at 03:30 PM, surveyor reviewed with the Director of Nursing (DON) the concern regarding the failure to maintain food trays in good condition.

Based on observation and interviews, it was determined that the facility failed to ensure that all laundry was processed and handled in a manner that prevents cross contamination and the spread of infections by failing to keep the door closed that separated the clean from the soiled area of the laundry room. This was evident for 1 of 1 laundry rooms and had the potential to affect all residents. The findings include: On 3/5/24 at 3:38 PM, while accompanied by the Nursing Home Administrator (NHA), a tour of the facility's laundry area revealed the laundry area consisted of a soiled laundry room, a clean laundry room and a room holding clean clothing , which the NHA indicated held clothes and linens belonging to residents which had not been labeled with a resident's name. Both the clean laundry room and the clean clothing room were accessed from the soiled laundry room. At that time, 2 surveyors observed that the door between the soiled and clean laundry room remained open while a laundry aid was processing clean laundry and, the entrance to the clothing room was open, with no barrier between the soiled linen room and the clean clothing room. Upon entering the opened door into the clean laundry room, an observation was made of washing machines and dryers that were next to each other, without a physical barrier separating soiled (washer) and clean (dryer) laundry. In front of the washers and dryers, there was a was a large counter height table which had folded stacks of clean linens on the top of the table, and in a corner of the laundry room, there were clean clothes hanging on a garment rack. At that time, during an interview, the laundry aide, Staff #26 confirmed she had been processing clean laundry, and the folded linens on the table were clean. Staff #26 also indicated that the clothes on the garment rack in the corner of the laundry room were overflow of residents' clean clothes. When asked to explain the laundry process, Staff #26 stated that prior to bringing soiled laundry into the laundry room, she would remove the clean linens from the table and remove them from the laundry room, however, the overflow of residents' clean clothes and linens remained in the room when the soiled laundry was brought in and remained in the room when the soiled laundry was sorted. Staff #26 stated that once the soiled laundry was brought out of the soiled laundry room into the clean laundry room, the laundry would be sorted before being placed in the washers. The above concerns were discussed with the NHA on 3/5/24 at 3:45 PM and the NHA acknowledged the surveyor's concerns at that time.

Based on interview, observation and record review, it was determined that the facility failed to provide reasonable accommodations to maintain residents' independence by failing to provide adequate bed side lighting that was accessible to residents with decreased mobility. This was evident for 14 rooms out of 16 rooms, observed during a survey. The findings include: On 2/21/24 at 10:30 AM, during an Interview, Resident #269 reported that s/he had recently been admitted to the facility. Resident #269 reported that s/he liked to read, however, s/he was unable to get out of bed without assistance and was unable to turn on or off their overhead bed light from their bed. On 2/21/24 at 10:31 AM, an observation in Resident #269's room revealed a light switch on the wall behind the resident bed, which was out of reach of the resident. On 2/23/24 at 10:18 AM, an interview with Occupational Therapist Staff #7 reported that the resident was unable to get out of bed safely without assistance. On 2/21/24 at 7:08 AM, an observation was made in Resident #37s room. Observation revealed the resident in bed with the call bell out of reach of Resident # 37. On 2/21/24 at 7:10 AM, the surveyor alerted Assistant Director of Nursing (ADON), regarding the call bell being out of reach of Resident #37. ADON reported the issue had already been taken care of. On 2/21/24 at 7:24 AM, during an interview, Resident # 37 reported s/he had been recently admitted to the facility. S/he reported that s/he enjoyed coloring, and s/he showed the surveyor several pictures s/he was currently coloring. In addition. Resident #37 stated she was unable to turn on her overhead light while in bed. On 2/21/24 at 7:24 AM, an observation in Resident #37's room revealed a light switch for the overhead bed lighting on the wall that was behind the bed, out of reach of the resident. The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems 02/23/24 12:08 PM, a review of Minimum Data Set (MDS) dated [DATE], section F0800, staff assessment of daily activity preferences, 1/27/23, revealed that the Resident #37 liked reading books, newspapers, or magazines. Continued review of MDS under mobility, revealed s/he was dependent on staff to transfer from a bed to a chair/wheelchair. On 1/28/24 at 2:00PM, the Maintenance Director Staff # 19 and surveyor began a tour of the residents' rooms on the first floor. The following room observations and brief interviews were as follows: During a room tour with Maintenance Director Staff #19 on 1/28/24 at 2:01PM, an observation of Resident #17 in their room revealed a private room with the light switch, for overhead bed lighting, that was on the wall behind the head of bed, out of reach for the resident. Continued observation revealed the resident was awake and sitting up in bed. On 1/28/24 at 2:02 PM, during an interview, Resident # 17 reported that s/he was able to turn on and off their over the bed light. First, s/he used the remote bed control and reclined the bed to a flat position, then they scoot up toward the head of the bed. Next, s/he reached their right arm above their head and used a back scratcher to turn the light on. S/he repeated this procedure to turn the light off. Resident reported that if the light switch was on the left side of the bed, they would be unable to operate the light switch due to pain in their left shoulder. On 3/4/24, a review of the physical therapy discharge notes,dated 2/8/24, revealed that the resident required minimal assistance for transfers. Minimal Assistance. The patient can perform 75% of the mobility task while the caregiver assists with 25%. During the continued room tour with the Maintenance Director Staff #19, an observation was made in Resident # 10's room. Observation revealed that a light switch, for the over the bed light, was on the wall behind the bed, out of reach of the resident. Continued observation revealed a grabber sitting on top of a dresser on the opposite wall from the light switch. 0n 1/28/24 at 2:02 PM, Resident #10 was interviewed. During the interview s/he reported that s/he could only turn on and off the light switch with the help of her/his grabber device. S/he continued that s/he did not currently have her/his grabber. In a subsequent interview with Resident #10 on 3/01/24 at 9:29 AM, s/he reported that s/he sometimes liked to do activities at night, and they had made a request to their family, to bring them a head lamp for light. On 3/01 /24 at 9:30 AM, an observation of Resident #10 room revealed a grabber lying on the dresser on the wall opposite the over the bed light and out of reach of Resident #270 On 3/4/23 review of Residents #10's MDS SECTION C, dated 2/27/24, revealed the resident had a BIMS of 15, indicating the resident did not have a cognitive decline. Continued review of medical records revealed the following under the section, Transfer -self performance, (How resident moves between surfaces, including to or from: bed, chair, wheelchair, standing position. Between the dates of 2/1/24 and 2/27/24, residents' self performance ability was documented 79 times during this period. On 9 occasions their ability was documented as total dependance, (full staff performance). On one occasion, extensive assistance was documented, and on one occasion independent (no help or staff oversight at any time) was documented. On 2/28/24 at 2:05PM, a continued room tour revealed the following: RM 114- over head light switch on the wall, not within reach from the resident's bed. RM 113 - over head light switch on the wall, not within reach from the resident's bed. RM 111 -over head light switch on the wall, not within reach from the resident's bed. RM 110 -over head light switch on the wall, not within reach from the resident's bed. Rm 119 -over head light switch on the wall, not within reach from the resident's bed. On 2/28/24 at 2:10 PM, a brief interview with Maintenance Director Staff #19 revealed that rooms 1 through 12 on the ground floor, rooms 110 through 122 on the first floor, and rooms 210 through 222 on the second floor all have over the bed lighting that must be turned on by a switch on the wall. On 2/28/24 at 2:11 PM, continued room tour with Maintenance Director Staff #19 revealed the following: RM 105 - pull cord was available to use for overbed lighting, no issue. RM 106 - pull cord was available to use for overbed lighting, no issue. RM 107- Bed A had a pull cord that the resident could reach, however the light did not turn on. room [ROOM NUMBER] -The light cord is short and at the foot of the bed. On 3/01/24 at 5:48 PM, the concerns regarding the lack of access to adequate overhead bed lighting for residents, the inability to transfer out of bed without assistance, were discussed with the administrator. The administrator reported that when a resident needed assistance, they should use the call bell and staff would assist them.

Based on medical record review and staff interviews, it was determined that the facility failed to notify the resident/resident's representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#27, #15 and #33) of 4 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 2/27/24 at 11:00 AM, a review of Resident #27's electronic health record (EHR) revealed that Resident #27 was transferred to an acute care facility on 2/2/24. In a SBAR Summary for Providers note, on 2/2/24 at 12:24 PM, the nurse documented that Resident #27 had a change in condition, the primary care provider was notified, and recommended Resident #27 be sent to the hospital. Further review of the resident's EHR, and hard paper medical record failed to reveal any documentation that Resident #27 and/or the resident's representative (RR) was notified in writing of the resident's transfer along with the reason for the transfer. On 3/1/24 at 11:52, during an interview, Staff #15, Social Services Director (SSD), stated that s/he notified the Ombudsman of resident transfers and discharges monthly, however, the SSD was not responsible for notifying the resident's representative in writing of the transfer. On 3/5/24 at 12:22 PM, during an interview, when asked if residents were provided with a written transfer notice upon transfer to the hospital, Staff #20 indicated s/he was unsure if a resident would be given a transfer notice when transferred to the hospital. The above concerns were discussed with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) on 3/5/24 at 1:30 PM and the DON and ADON indicated they understood the concerns at that time. 48259 2) Review of Resident #15's medical record on 2/21/24 at 12:15 PM, revealed a change in condition evaluation form dated 1/27/24, that recorded the resident had shortness of breath while performing tasks. The attending provider was notified and ordered to send the resident to the emergency room for evaluation. Further review of the medical record failed to reveal that the resident and/or the resident representative was notified in writing of the transfer/discharge of the resident along with the reason for the transfer. Continued review of Resident #15's medical record on 2/21/24 at 12:50 PM, revealed an e-interact transfer form dated 1/27/24. The transfer form included a section labeled SNF to ED or Outpatient Clinic Transfer checklist, followed by a list of statements to be checked if completed and sent with the resident to the hospital. The checked statements were: lab results, MOLST and face sheet. The statement Notice of Transfer was not checked, indicating written notification was not sent with the resident upon transfer to the hospital. On 2/22/24 at 1:41 PM, during an interview with staff #21, a Licensed practical nurse (LPN), she was asked about the process for transferring a resident to an acute care facility. Staff # 21 reported that she only notified the Resident's representative of a hospital transfer via phone and not in writing. A subsequent interview with staff #3, an LPN on 2/23/24 at 11:59 AM, showed that she gave a packet that included face sheet, MOLST (medical orders for life-sustaining Treatments), medication list and any recent laboratory results to the Emergency Medical Staff at the time of transfer of a resident to the hospital. On 2/23/24 at 1:36 PM, an interview was conducted with the Director of Nursing. During the interview, she stated that per Resident #15's e-interact Transfer form completed on 1/27/24, a written notification along with the reason for transfer was neither given to the resident nor the Resident's Representative upon transfer to the hospital. She also reported that the staff only notified Residents' Representatives of an acute facility transfer via phone calls. 48470 3) Resident #33 had been residing in the facility since 2019. On 2/21/24 at 3:09 PM, Resident #33's medical record was reviewed and revealed that s/he was sent out to the emergency room in January of 2024. On 2/28/24 at 1:40 PM, Resident #33's transfer form with a reference date of 1/21/24, completed by Licensed Practical Nurse (LPN Staff #21) was reviewed and revealed section E, item number 5 as emergency department or outpatient transfer checklist. The items listed in this checklist were as follows: a) X-Ray b) Medication list c) Lab results d) Care plan goals e) MOLST f) Facesheet g) Other info h) Bed Hold i) Notice of Transfer with an instruction to print these documents in this order and include with the transfer from to send with the patient to the hospital. A check mark in a boxed area before each item indicated which document was printed and sent with the resident. Staff #21 did not put a check mark next to item (i) for Notice of Transfer. On 3/1/24 at 11:52 AM, the Social Service Director (SSD Staff #15) was interviewed about her process when a resident is transferred or discharged to the hospital. Staff #15 reported that she would send the notification to the Ombudsman and indicated that sending the notification to the family member or RP was the nurse's responsibility. On 3/01/24 at 12:09 PM, Registered Nurse (RN Staff #10) working on the 2nd floor was interviewed about her process when a resident needed to be sent out to the hospital. Staff #10 reported that, after having the Physician or Nurse practitioner evaluate the resident and getting an order to send the resident to the hospital, she would print the necessary documentation for transfer and call 911. Staff #10 stated each document that she would print and then call the family and/or resident representative (RP) to inform them of the resident's situation and which hospital the resident would be transferred to. If the incident were to happen after hours, then she would call the on-call provider and repeat the same process. The surveyor asked Staff #10, is there anything else you would do or provide the resident and family or RP with? Staff #10 answered No, and added, if the resident is not coming back immediately, then she would update the family on the treatment and development of the resident in the hospital. On 3/01/24 at 1:46 PM, a nurse working on the 1st floor (RN Staff #22) was also interviewed about her process when a resident had an order to be sent out to the hospital. Staff #22 indicated that the process would be individualized for each resident but also failed to note that she would provide a written notice of transfer to the resident and/or RP. When Staff #22 was asked if there was anything else she would provide the resident or RP with, she reported that she would also inform the family of any personal belongings that went with the resident. On 3/01/24 at 5:44 PM, the surveyor discussed the concern with the Director of Nursing (DON) about the notice requirements before transfers, where there was no evidence of the written notice of transfers being provided to the resident and/or RP in a practicable time. The DON confirmed that this was the responsibility of the nurse and indicated that a transfer form is used by the nurses and that it had a portion where the nurse would mark all the required documents that were printed and sent with the resident. The surveyor reviewed with the DON the transfer form for Resident #33, with a reference date of 1/21/24, and revealed the portion the DON was referring to was section E and confirmed the surveyor finding that the notice of transfer was not marked as printed and sent with the resident when s/he was transferred to the hospital or provided to the RP in a practicable time.

Based on facility investigation documentation and medical records, observations and interviews, it was determined that the facility failed to have an effective system in place to prevent residents with cognitive impairment, who had a guardian designated as the appointed decision maker, from leaving the facility without appropriate supervision. Additionally, the facility failed to notify the resident's guardian of their desire to sign out against medical advice (AMA) resulted in the resident, who was deemed unsafe to be discharged , signing out AMA. This action placed this resident and other residents in the facility at risk for serious harm. This deficient practice was evident for 1 of 4 residents reviewed for elopement during a complaint survey (Resident #5). The facility took immediate action after the elopement. After validation from the surveyor that the plan had been implemented, a determination of past non-compliance was made as of 7/19/21. An extended survey was also conducted. The findings include: According to the Centers for Medicare and Medicaid Services (CMS), an Elopement occurs when a resident without decision-making capacity leaves the premises or a safe area without authorization. A resident who leaves a safe area without supervision is at increased risk for harm including potential heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Any resident at risk should have interventions in their comprehensive plan of care to maintain resident safety. AMA, Against Medical Advice is when a patient (resident) leaves before their treating physician recommends discharge. A Court Appointed Guardian protects vulnerable individuals. When a person is unable to take care of their personal or financial needs because of age, disease, or disability, the court may appoint a guardian. The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. BIMS stands for Brief Interview for Mental Status. It is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. A series of standardized questions in the BIMS are scored and when added result in a total score between 0-15. The numeric value falls into one of three cognitive categories: Intact which is 13 to 15 points, Moderate which is 8 to 12 points or Severe cognitive impairment which is 0 to 7 points. After comprehensive assessment the facility care planned Resident #5 for impaired cognitive function r/t [CONDITION(S)] history and [CONDITION(S)]. 1) Resident #5, who was deemed cognitively impaired during this admission, was under the care of a guardian, and was deemed by the physician as unsafe for discharge to the community but was nonetheless allowed to sign out of the facility against medical advice and leave the facility. Resident #5 could not be located for 2 days once he/she left the building. A review of Resident #5's medical record on 7/27/21 at 12:23 PM revealed that the resident was admitted to the facility in July 2021 with a complex medical history that included a diagnosis of cognitive impairment and [CONDITION(S)]. Resident #5 was prescribed an anti-[CONDITION(S)] medication two times daily in the nursing home. On 7/27/21, a review of Resident #5's hospital summary, dated 6/26/21, documented that the resident, on 6/25/21 presented to the Emergency Department (ED) after leaving another facility AMA. Resident #5 was noted as intoxicated at that time and had suffered a fall. Resident #5 was admitted to this facility from the hospital. On 7/27/21, a review of Resident #5's medical record revealed a hand-written physician's order, signed on 7/1/21, documenting, admitted resident to long term care. Patient is unsafe to be discharged to the community. On 7/27/21, a review of Resident #5's admission Minimum Data Set (MDS) assessment, with an assessment reference date of 7/7/21, coded that Resident #5 had severe cognitive impairment with a BIMS score of 6. Further review of the medical record revealed that Resident #5 also had a court appointed guardian. On 7/27/21, a review of the Discharge for Resident #5 revealed that he/she left the faciity on [DATE]at 8:10 AM after signing the form titled Release from Responsibility for Discharge Against Medical Advice (AMA) which indicated that he/she was discharging against the advice of the attending physician and the center administration. Staff #14 (RN) was the supervisor on duty at the time of the discharge. On 7/27/21, a written statement, dated 7/17/21, from Staff #14 was reviewed which documented that he was at the ground floor around 7:30 AM when he saw Resident #5 walking out of the elevator with a walker and belongings. The statement documented that the resident was alert and oriented x 3 and that Resident #5 said angrily, I am leaving this place as he/she walked towards the exit door. Staff #14 documented that all efforts to make Resident #5 change his/her mind about leaving did not work. Staff #14 documented, I told one of the nurses to watch [him/her] while I sent a secure message to the doctor on call via [name of system] and placed a call to DON (Director of Nursing). I checked [his/her] chart, got [his/her] responsibility status, prepared an AMA form, explained and gave [him/her] the form to sign before [he/she] left around 9 AM. On 7/30/21 at 1:29 PM, a phone call was made to Staff #14 and a voice mail message was left. As of exit date of 8/3/21, Staff #14 did not return the surveyor's call. On 7/27/21, a written statement from Staff #37 (LPN) dated 7/17/21 was reviewed which documented that Staff #37 arrived to assigned shift at 6:45 AM. Upon receiving report from the off going nurse, Staff #37 learned that Resident #5 was downstairs wanting to leave AMA. Resident #5 kept saying he/she had the right to sign out AMA and Staff #15 said that Resident #5 had every right to sign out AMA if he/she wanted to go, he/she could go. Staff #37 documented that she told Staff #15 and the supervisor present, Staff #14, that if she let Resident #5 leave, she needed to call APS (adult protective services) or the police because Resident #5 could not make decisions for him/herself because he/she had a court appointed person assigned to him/her. Staff #37 documented that she tried to convince Resident #5 to stay, but Resident #5 stated that the other nurses said that he/she could leave. Staff #37 documented that she knew that Resident #5 should not have left. Staff #37 was also unavailable for interview. In interview on 7/28/21 at 10:39 AM, the Nursing Home Administrator (NHA) stated that Resident #5 was a ward of the state and had a guardian. The NHA stated, having a conversation with [Resident #5], he/she presents as being alert and oriented and staff thought he could leave AMA as any other alert and oriented person could do. The NHA stated, being a ward of the state, [he/she] should not have been able to sign [him/herself] out. Within 20 minutes of [him/her] leaving, it was realized that[he/she] should not have been allowed to sign out. The staff tried to contact the emergency contacts on the face sheet. I was able to get a hold of the guardian within the hour. They said they would not have consented to let [him/her] leave the facility. The NHA stated that she notified all department heads to immediately come into the facility and a search was initiated. The police were called. The NHA stated that she went to the community that the resident frequented and was informed by members of the community of a liquor store that Resident #5 frequently visited. The NHA provided the liquor store with the facility's information. Two days after the elopement, on 7/19/21 the store called the NHA to inform the NHA that Resident #5 was there. The NHA then notified police and the NHA met the police at the liquor store and Resident #5 was taken to an area hospital. Resident #5 did not return to the facility. The NHA stated she informed the police of the medications that Resident #5 was receiving at the facility. With Resident #5's history of leaving another facility in an unsafe manner and AMA, and despite physician documentation that discharge to the community would be unsafe, the facility nonetheless allowed Resident #5, who was cognitively impaired, to leave both (1) AMA and (2) without obtaining consent from the guardian. On 7/30/21 at 10:30 AM, a review of the facility's corrective action that was implemented immediately on 7/17/21 was reviewed. 1) The DON initiated and completed a head count of all residents in the facility per the census sheet. 2) Elopement assessments were completed for all residents in the building on 7/17/21 and the elopement book was updated. 3) An initial self-report was submitted to the regulatory agency, The Office of Health Care Quality (OHCQ). The Medical Director and Guardian were notified. 4) An investigation of the event was initiated. 5) Maintenance checked all doors/windows to ensure they were secure. 6) Staff statements of the incident were obtained. 7) A Root Cause analysis of the incident was performed 8) Immediate In-Service education was provided to all department heads and all licensed staff. The topic was Elopement Incident of Resident #5. The facility in-serviced the differences between resident decision makers. If a resident has a legal decision maker, then they are not able to make the decision for themselves regardless of the resident presenting as alert and oriented. Information about decision maker was located in the resident's chart and PCC (electronic health system). The staff were educated on the elopement policy, guardianship, and protocols for managing elopement situations. The DON and ED (Executive Director) should be notified if the resident is desiring to leave the facility. 9) An emergency AdHoc QAPI (Quality Assurance and Performance Improvement) meeting was held on 7/17/21 conducted by the NHA and all the department heads, including the medical director. The discussion centered around Resident #5 signing self out AMA. Resident #5 had a state appointed guardian. A search of the building, grounds and surrounding community was unsuccessful. Police and guardian were called and informed. Staff continued with search of local bus line. 10) Social Work audited all face sheets to ensure that residents with a guardian, POA/HCA were clearly identified with the phone numbers and names listed. A list of residents with a guardian was placed in the elopement book at the front desk to ensure that these residents do no attempt to sign themselves out. 11) NHA and/or DON to contact RDCO/RDO if a resident with a guardian attempts to leave the facility. 12) A monthly audit of guardianship residents and a list sent to nurse managers and to the front desk. 13) New Staff to be educated on the P&P (policy & procedure) for elopement prevention as it relates to guardianship protected residents. P&P for missing resident/elopement/resident wander search. 14) Audit elopement risk assessments for all guardianship residents monthly and initiate/update care plans as appropriate. 15) Elopement drills (all shifts) every 6 months. 16) Audit weekly x 4 weeks, then monthly x 3 months. The items to be audited were elopement care plans, guardianship residents and care plans, elopement risk assessments. On 7/30/21 at 10:30 AM the surveyor reviewed all medical records of the current residents in the building to ensure that elopement/wandering evaluations were done as stated by administration on 7/17/21. All in-service sign-in sheets were reviewed and compared to the list of employees that were currently employed in the facility as of 7/30/21. The surveyor confirmed that all education of licensed staff was completed in-person and via telephone by 7/19/21. A review of the elopement binder that was kept at the receptionist desk was reviewed on 7/30/21. A tour of the facility with the maintenance director was conducted to view all points of entry and exit to confirm door codes and alarms. A review was conducted of the audits that have been conducted since 7/17/21. A review of the list of residents with guardians was conducted. Interviews of licensed staff was conducted to ensure that any licensed staff responsible for residents knew the protocol for allowing a resident to sign out AMA. After review of all interventions and processes that were put in place by the facility and 100 % compliance in educating staff was achieved, a determination of past non-compliance for allowing a resident to sign out AMA was confirmed as of 7/19/21.

Based on interviews and medical record reviews, the facility staff failed to ensure that an effective infection control program was in place, when staff failed to follow an effective process to isolate and adequately address a communicable outbreak of scabies for nearly three months. This was evident for 5/5 residents reviewed during a complaint survey but placed all staff and residents at risk. The findings include: On 7/28/15 complaint investigations were done at the facility for complaints of Scabies. There are a number of residents and staff who contacted scabies, some that had complaints as early as April and May. Review of the medical records revealed that on 7/6/15 the dermatologist scraped and diagnosed four residents; Resident #5, Resident #11, Resident #13, and Resident # 14 with Scabies. Resident #12 ' s records were reviewed during this survey as well. Samples are below: During review of Resident #11 ' s medical record it was documented on 4/9/15 that the Resident was noted to have a red rash to bilateral arms, chest and back with itching. On 5/16/15 the Resident was treated with a [MEDICATION NAME] Dose Pack (a steroid used to treat conditions that affect the skin) for a skin rash. On 5/25/15 the rash was still present on Resident #11. On 5/27/15 it was documented that the Resident continued to have a rash to the body, and a dermatology consult was pending. On 6/9/15 the resident was still itching. On 6/29/15 the Resident had a room change. It was on 7/6/15 that the resident had the dermatologist consult and was confirmed to have Scabies. During review of Resident # 5's medical records, it was documented that on 5/16/15 the Resident complained of itching and was treated with 25 mg of [MEDICATION NAME] every 6 hours as necessary. On 6/3/15 the Resident was treated with [MEDICATION NAME] (a topical cream used for itching) for a rash. On 6/4/15 the Resident was started on a [MEDICATION NAME] Dose Pack for an upper body rash. The Resident continued to itch on 6/8/15, with an ongoing rash. A Dermatologist consult was ordered on [DATE], and on 7/6/15 the dermatologist confirmed that the Resident had Scabies. An order was written for [MEDICATION NAME] (an antiparasitic drug) on 7/6/15 and the Resident did not receive the medication until 7/9/15. On 7/11/15 Resident #5 was doing what was described as intense scratching, and was given [MEDICATION NAME] for increased rash and blisters over the body. After the Resident was sent to the hospital and returned, the family transferred the resident out to another facility. Resident #13 had an abdominal rash on 6/4/15. On 6/22/15 the rash was treated with [MEDICATION NAME]. On 6/24/15 it was documented that the resident was to see the dermatologist. On 7/1/15 the Resident's daughter became concerned about the rash to the abdomen, because the Resident was still receiving [MEDICATION NAME]. On 7/7/15 the resident was scratching over the entire body when the treatment was given. Records reveal that Resident # 14 had a rash to the back and sides of the breast on 6/6/15, and complained of itching on 6/7/15. This resident was diagnosed on [DATE]. On 5/14/15 Resident #12 was stated to have contact dermatitis and was treated with [MEDICATION NAME]. A change in condition was documented for this resident on 5/14/15 for anterior abdominal contact dermatitis. On 6/15/15 per medical record the rash on Resident #12 ' s chest, stomach, arms and legs had increased. On 6/17/15 the rash was treated with [MEDICATION NAME]. The resident received an order for [REDACTED]. An Interview with Staff #16 from infection control on 7/28/15 at 1:00 PM revealed that a Line Listing (standard of practice) was not kept on residents with rashes during this surveillance period. This type of listing allows the facility to be alerted to a potential infectious outbreak.

Based on medical record review and interviews with the Administrator, Director of Nursing, Medical Director and Contracted Pharmacy it was determined that the facility failed to assess, educate, and administer for at least 8 residents the Influenza immunization. The facility failed to assess, educate, and administer for at least 20 residents the Pneumococcal immunization. The facility made an informed decision not to offer Influenza or Pneumococcal immunizations after October 10, 2011 to residents. Due to the facility's failure to assess, educate and administer the Influenza and Pneumococcal immunizations to resident's that requested to be immunized an Immediate Jeopardy situation was declared at 11:30 AM on May 2, 2012. The facility had left the residents vulnerable to developing influenza and pneumonia. A plan of correction was submitted by the facility which included educating the nursing staff on assessing resident's immunization history. The facility obtained the Pneumococcal immunizations. Consents were obtained from the residents as well as physician orders [REDACTED]. The Immediate Jeopardy was abated at 3:00 PM on May 2, 2012. The findings included: The Director of Nursing on May 1, 2012 at 1:00 PM stated no Influenza vaccinations or Pneumococcal vaccinations had been administered to residents since October 10, 2011 even if the resident and/or responsible party requested the vaccines and the vaccine was ordered by a physician. The Administrator and Medical Director confirmed this finding on May 2, 2012. The Director of Nursing stated she was unable to obtain more Influenza vaccines from the Contracted Pharmacy after October 10, 2011 and did not pursue other sources. The lack of Influenza vaccines in the facility was reported to the Quality Assurance (QA) committee on January 11, 2012 and February 8, 2012. The QA committee did not follow through investigating where to obtain more Influenza vaccines but reported ordering the 2012 Influenza vaccines. Per the QA committee minutes 97% of the facilities staff received Influenza vaccines but after October 10, 2011 new hires were not offered the vaccination. The facility did not order Pneumococcal vaccines for residents after October 10, 2011. The facility did not state a reason for not ordering or administering Pneumococcal vaccines. The Contracted Pharmacy stated on May 2, 2012 at 10:15 AM that the Pneumococcal vaccine is always available. The lack of Pneumococcal vaccines was not recorded as discussed in the QA committee meeting minutes. On May 3, 2012 at 8:00 AM the Administrator admitted a total system failure at the facility concerning administration of Influenza and Pneumococcal immunizations. The facility houses debilitated residents who have multiple chronic diseases. Influenza and Pneumonia are serious but preventable infections that can lead to death in this vulnerable population.