Every finding on record at Laurelwood Healthcare Center

Based on record review and interview, it was determined the facility failed to ensure residents' personal hygiene needs were adequately met. This was evident for 3 (Resident #4, #1, and #5) of 3 residents reviewed for hygiene during the complaint survey.The findings include:Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, toileting, and mobility.1) On 08/24/2026 at approximately 10:00 AM, a review of intake #3095576 raised a concern of residents not receiving bathing/showers. On 08/24/2026 at approximately 10:15 AM, a review of Resident #4's care plan (initiated 06/03/2021, revised 08/08/2026) for ADL Self-Care Performance Deficit (assistance needed with cognitive and functional deficits) included an intervention for shower/bathe self: dependent-helper does all effort or 2+ helpers assist (initiated 11/13/2025).On 08/24/2026 at 11:12 AM, a review of Resident #4's Section GG Shower/Bathe Self and Skin Observation task revealed that over a 30-day period, the resident received only 2 bed baths and 2 showers, with no further documentation explaining entries for not applicable or refusal. The recorded entries were:-07/28/26: Bed bath-07/31/26: Not applicable-08/04/26: Shower-08/07/26: Refused-08/11/26: Not applicable-08/14/26: Not applicable-08/18/26: Shower-08/21/26: Bed bath2) On 08/24/2026 at 11:43 AM, a review of Resident #1's ADL care plan revealed an ADL Self- Care Performance Deficit (initiated 10/18/2024, revised 10/20/2024) with an intervention for independent showering/bathing (initiated 10/10/2025).On 08/24/2026 at 11:35 AM, a review of Resident #1's Section GG Shower/Bathe Self and Skin Observation task revealed that over a 30-day period, the resident received only 1 bed bath and 2 showers, with no further documentation explaining entries for not applicable/not available or refusal. The recorded entries were:-07/27/2026: Shower-07/30/2026: refused-08/03/2026: Not applicable-08/06/2026: Not available-08/10/2026: Bed bath-08/13/2027: refused-08/17/2026: refused-08/20/2026: Shower3)On 8/24/2026 at 12:07 PM, a review of Resident #5's ADL care plan revealed a self-care performance entry (initiated 11/13/2025, revised 1/2/2026); however, the care plan lacked an intervention for bathing/showering.On 08/24/2026 at 12:01 PM, a review of Resident #5's Section GG Shower/Bathe Self and Skin Observation task revealed that over a 30-day period, the resident received only 1 bed bath and 2 showers, with no further documentation explaining entries for not attempted or refusal. The recorded entries were:-07/29/2026: refused-08/01/2026: refused-08/05/2026: not attempted-08/08/2026: Bed bath-08/12/2026: refused-08/15/2026: refused-08/19/2026: shower-08/22/2026: showerOn 08/25/2026 at 8:56 AM, during an interview, Geriatric Nursing Assistant (GNA) Staff #12 stated that shower processes are maintained in a shower book and posted on the board. Staff must document completed tasks in the electronic medical record. If a resident refuses a shower, staff notify the nurse, who speaks with the resident and documents the refusal. The shower is reoffered later that day and documented.On 08/25/2026 at 9:11 AM, during an interview, the Director of Nursing (DON) stated that shower/bathing schedules are created upon resident admission. Geriatric Nursing Assistants (GNAs) are aware of the schedule for showers via the shower book and assigned tasks in the electronic records. Refusals of bathing/showers would be recorded by the GNA and reported to the charge nurse, who would speak with the resident, provide further intervention, and add a nursing note. Entries for not attempted, not applicable, or not available require supporting documentation. This concern was shared with the DON.

Based on facility documents, resident records, and interviews, it was determined that the facility failed to provide wandering interventions for dementia residents who were identified as a risk for elopement. This was evident for 3 (Resident #4, #7, and #8) of 3 residents reviewed for wandering/elopement during the complaint survey. The findings include: 1)On 08/25/2026 at approximately 9:35 AM, a review of intake #3173123 revealed that on 08/21/2026 at approximately 6:20 AM, nursing reported Resident #4 missing and the break room back door alarm sounding. Staff searched the facility, rooms, and perimeter. Neighbors found Resident #4 and escorted them back. Upon return, Resident #4 was assessed with no injuries, pain, or range of motion issues noted.On 08/25/2026 at 1:00 PM, a review of the facility investigation packet included handwritten statements from Geriatric Nursing Assistant (GNA) Staff #14 and Registered Nurse (RN) Staff #18, indicating that Resident #4 wandered the halls all night.On 08/24/2026 at 9:51 AM, in review, Resident #4's care plans revealed an elopement risk care plan (initiated 10/25/2024) and a dementia-related behavioral problem care plan (initiated 08/26/2024, revised 01/10/2026). Behaviors included wandering/exit seeking. Non-pharmacological interventions included diversional activity, talking to the resident, a calm approach, redirection, and offering a snack. However, further review of Resident #4's August behavior monitoring showed no recorded wandering/elopement or an attempted intervention during the night shift of 08/21/2026. 2)On 08/26/2026 at 9:00 AM, a review of Resident #7 shows an elopement risk due to exit-seeking behavior (Initiated: 06/30/2021, Revised: 07/27/2024). Care plans and orders for behavioral monitoring addressed dementia with behaviors (Initiated: 01/04/2022, Revised: 09/29/2024; and Initiated: 08/26/2024, Revised: 06/18/2026). A monitored behavior included wandering.On 08/26/2026 at 9:18 AM, a review of Resident #7's progress notes from the dates of 08/06/2026 to 08/25/2026 showed behaviors documented 17 times. However, Resident #7's August behavior monitoring documentation contained only 2 entries (08/20/2026 and 08/24/2026), leaving 15 instances missing documentation of the behavior, interventions used, or intervention effectiveness.3)On 08/26/2026 at 9:56 AM, a review of Resident #8's care plan revealed an elopement risk (initiated 09/01/2022) and behavioral issues related to psychosis, anxiety, and TBI (initiated 03/22/2026, revised 05/17/2026), noting behavioral monitoring in orders. Additionally, a psychiatric note from 08/18/2026 documented dementia with behavioral disturbance. On 08/26/2026 at 9:35 AM, a review of Resident #8's progress notes from 08/02/2026 through 08/25/2026 showed behaviors documented 32 times. However, further review of Resident #8's August 2026 behavior monitoring logs contained only 1 entry (08/05/2026), leaving 31 instances missing documentation of the behavior, interventions used, or intervention effectiveness.On 08/26/2026 at 10:55 AM, during an interview, the Director of Nursing (DON) explained the behavior monitoring process, which involves a physician order in the electronic medical record with a template list of behaviors. If a nurse selects yes for a behavior, they are expected to document the specific behavior, the intervention used, and its effectiveness. The DON acknowledged staff statements and missing documentation regarding Resident #4's wandering on 08/21/2026. Additionally, the DON confirmed that for Residents #7 and #8, the monitored behavior for August 2026 was wandering, and any yes entry should have included documentation of the corresponding intervention and effectiveness.

Based on observation, interview, and facility document review, it was determined the facility failed to provide a clean, comfortable, and homelike environment by not maintaining an adequate supply of linens. This was evident in a review of linens during the complaint survey.The findings include: A facility's PAR level (Periodic Automatic Replenishment) is the minimum number of complete linen sets required on hand to prevent supply shortages during daily resident care.On 08/24/2026 at approximately 10:00 AM, a review of intake #3095576 raised a concern of the facility not having adequate linens. On 8/24/2026 at 9:15 AM, during an observation of Unit B linen supplies accompanied by Geriatric Nursing Assistant (GNA) Staff #5, it was shown that hallway cart #1 and the clean storage unit contained only gowns, with no bed linen, towels, or washcloths. A second linen cart, observed and accompanied by GNA Staff #7, contained only gowns, 10 washcloths, and 2 blankets.On 08/24/26 at 2:44 PM, during an interview with Registered Nurse (RN), Staff #9 indicated the facility is low on linens. On 8/24/2026 at 2:50 PM, during an interview/observation, accompanied by the Housekeeping manager and a laundry aide, Staff #10 revealed a shortage of towels, washcloths, and bed linens in the main storage for linens. Staff #10 was observed stocking two units with only three towels for the evening and night shifts. Staff #10 stated, I have a total of 3 towels to place on 2 units; this is to fill the whole building for this evening and night shifts. The Housekeeping manager stated that new linens are ordered monthly, but only one of four cases ordered this month was received. Although a PAR level exists and backup stock is required, no more supplies can be ordered until September due to August budget limits.On 8/24/2026 during an observation at 3:01 PM, accompanied by Staff #10 on Unit 1, it showed 15 towels on cart #2 (out of 2 carts) and 14 towels in the linen closet. On Unit 2, cart #1 had 7 towels and minimal washcloths. Staff #10 noted an ongoing linen shortage.On 08/25/2026 at 8:56 AM, during an interview, Geriatric Nursing Assistant (GNA) Staff #12 reported a facility shortage of towels, washcloths, and bed linens.On 8/25/2026 at approximately 1:30 PM, a review of facility linen PARs showed that for each shift (7-3, 3-11, and 11-7), Closets A and B in Units A and B must maintain 50 flat sheets, 50 fitted sheets, 100 towels, and 200 washcloths per unit.On 08/25/2026 at 9:11 AM, during an interview, the Director of Nursing (DON) acknowledged linens have to be requested from housekeeping. At this time the concern was shared.

Based on record review and interview, it was determined that the facility failed to assess, address and implement for a resident with verbalized history of trauma. This was evident for 1 (Resident #2) out of 3 residents reviewed for trauma informed care. The findings include:Facility's Trauma-Informed and Culturally Competent Care policy defined 'Trauma-Informed care' as an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices toa covid retraumatization.'Trigger' is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening.Resident Screening- 1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. 4. Utilize initial screening to identify the need for further assessment and care. Resident Assessment- 1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. 2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments.Resident Care Planning- 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident.On 8/25/26 at 1PM while investigating FRI (Facility Reported Incident) #3069781 and Complaint #3069781, the Surveyor reviewed Resident #2's electronic medical record (EMR), which revealed Resident #2 was admitted to the facility on [DATE] from another long-term care nursing facility with diagnoses, including but limited to, stroke with left-sided weakness, diabetes and vascular dementia.Further review of Resident #2's EMR revealed that on 9/8/25 at 3:18 PM, SW (Social worker) #25 performed a PTSD (Post-Traumatic Stress Disorder) Screening, which involved reading this statement Sometimes people experience unexpected or especially frightening, horrific, and otherwise traumatic life events that cause overwhelming levels of stress and undesired change. For example: a serious accident or fire, combat/military exposure, childhood abuse or neglect, abuse and/or assault during adulthood (i.e. physical, sexual, psychological, verbal, financial), natural or 'man-made' disasters, witnessing actual or threatened death or injury of another person, sudden or catastrophic medical incidents (including self and/or others), and even occupational traumas and, then asking a series of questions. The following answers were documented by SW#25 as Resident #2's responses to the assessment questions: 1. Have you ever experienced any events (listed above) or any additional events in which you consider to have been traumatic? Resident #2 was documented as responding yes, 1a.Type of exposure Resident #2's response was a). Directly experienced 1b. Describe endorsed traumatic event Resident #2's documented response as a child experienced abuse. Resident #2's EMR revealed additional PTSD screening on 11/22/25 at 6:12 PM performed by LPN (licensed practical nurse) #9 and on 12/6/25 at 4:09 PM by RN (registered nurse) #26 with almost the exact same responses from Resident #2. A follow up PTSD screening by SW #27, who happened to be the only male to ever assess Resident #2 for PTSD, on 12/10/25 at 4:57 PM resulted in Resident #2 answering question 1. Have you ever experienced any events (listed above) or any additional events in which you consider to have been traumatic? with a response of no. Ongoing review of Resident #2's EMR revealed a PTSD Screening dated 5/17/26 at 4:26 PM performed by LPN #9 in which Resident #2 reverted back to stating he/she experienced abuse as a child. It should be noted that this PTSD screening was performed after Resident #2 was in a resident-to resident altercation.A review of the Nursing admission Evaluations that occurred each time Resident #2 was readmitted to the facility revealed on five separate occasions (10/11/25 at 11:09 PM, 11/19/25 at 10:24 PM, 4/19/26 at 4:08 PM, 4/29/26 at 00:16 AM and 6/16/26 at 3:54 PM), RN #18 and RN #28 documented Resident #2 as having denied any trauma history. It should be noted that the 11/19/25 Nursing admission Evaluation with Resident #2 denying any trauma history was three days before the 11/22/25 PTSD Screening which documented Resident #2 answering positively to the trauma screening question.A review of Resident # 2's care plans show no evidence of interventions to address Resident #2's history of trauma until 7/7/26, which was 10 months after the facility documented Resident #2's history of trauma.During an interview on 8/25/26 at 3:31 PM, DON (Director of Nursing) #2 stated that the facility was aware of [Resident #2]'s abusive past prior to the recent care plan meeting (on 7/7/26). DON#2 stated, [family member] is very forthcoming about [Resident #2]'s past and feels that it does affect his/her behaviors. DON#2 confirmed that Resident #2 's traumatic past was not addressed in his/her care plan or in staffing assignments prior to the 7/7/26 meeting with [family member] despite multiple assessments noting the traumatic past. DON#2 stated that the facility needs to educated the staff about assessing and then reporting resident's trauma history so that all staff can be conscious of that resident's history and triggers.

Based on record review and interview, it was determined that the facility failed to refer Resident #2 for a PASARR level II screen when Resident #2 was diagnosed with bipolar disorder and started on new psych medication. The findings include:Facility's PASARR- Pre-admission Screening and Resident Review policy stated,.PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care.Federal law mandates that Medicaid-certified nursing facilities (NF) may not admit an applicant with serious mental illness (MI), developmental delay (DD), or a related condition, unless the individual is properly screened, thoroughly evaluated, found to be appropriate for NF placement, and will receive all specialized services necessary to meet the individual's unique MI needs.Procedure: 4. Resident Review (RR) is completed when a current resident meets specific criteria in Residents with an SMI (significant mental illness) or ID/RC (intellectual disability/related conditions) who experience a significant change in physical or mental condition, and residents who appear to have a previously unidentified SMI or ID/RC, are required to receive a Resident Review (Essentially a post-admission Level II evaluation and determination).On 8/25/26 at 1PM while investigating FRI (Facility Reported Incident) #3069781 and Complaint #3069601, the Surveyor reviewed Resident #2's electronic medical record (EMR), which revealed Resident #2 was admitted to the facility on [DATE] from another long-term care nursing facility with guardianship of person assigned to a family member by the courts on 3/27/25. The review revealed the guardianship paperwork was scanned into Resident #2's EMR on 6/25/25.Further review of Resident #2's EMR revealed a PASARR that was completed on 10/15/24 at 3:31 PM when Resident #2 was being transferred from [acute care hospital] to [another long-term care/ rehab nursing facility]. The only diagnoses on this 2024 PASARR form for Resident #2 were diabetes and cerebral vascular accident (stroke). There was no evidence that when Resident #2 transferred from the other nursing facility to this facility on 6/5/25, a new PASARR was obtained.During an interview on 8/25/26 at 1:46 PM, RN (registered nurse) #19, who is the facility's MDS (Minimum Data Set- a federally mandated comprehensive, standardized, clinical assessment of all residents in Medicare/Medicaid nursing homes that evaluates functional capabilities and health needs) Coordinator, confirmed that Resident #2's PASARR was from the previous facility and makes no mention of his/her diagnosis of bipolar disorder. I don't know when [Resident #2] was diagnosed with bipolar disorder. He/she needs a new PASARR.I will resubmit the PASARR to reflect the bipolar diagnosis and the medications that are prescribed for it.Extensive review of Resident #2's EMR on 8/25/26 at 2:30 PM revealed no documentation from the previous facility or hospital records prior to 2025 documenting a diagnosis of bipolar disorder. The review revealed that Resident #2 was initiated on lamotrigine (a mood stabilizer for people with bipolar disorder) 50 mg (milligrams) one time a day for bipolar disorder on 9/17/25 by Nurse Practitioner (NP) #24. A review of Resident #2's guardianship paperwork did not contain any documentation of Resident #2 having any psychiatric history. During the review of Resident #2's MDS (Minimum Data Set) assessments on 8/25/26 at 2:45 PM, the Surveyor discovered that the first documentation of bipolar disorder (MDS Section I5900) occurred on a quarterly MDS assessment dated [DATE] despite two previous MDS assessments on 6/15/25 (admission) and 9/11/25 (quarterly). Neither of these prior assessments captured Resident #2 as carrying the diagnosis of bipolar disorder (MDS Section I5900). In October 2025, when the facility coded for the first time that Resident# 2 had been diagnosed with bipolar disorder, a significant mental health illness, a new PASARR should have been initiated.A follow up interview on 8/25/26 at 2:52 PM, RN# 19 reported that a new PASARR application for Resident #2 that contained the psych (psychiatric) diagnosis of bipolar disorder had been filed on behalf of Resident #2. RN #19 stated, [Resident #2] is currently not on any psych (psychiatric) medications right now. They just did a GDR (Gradual Drug Reduction) on 8/17/26 and discontinued his/her Seroquel (an atypical anti-psychotic).

Based on observations and interviews, it was determined that the facility failed to provide individual closet space that keeps a resident's clothing separate from their roommates. This was found to be evident in all double occupancy rooms in the facility.The findings include:On 1/29/2026 at 10:20 AM, License Practical Nurse (LPN) #7 was interviewed regarding resident furniture in rooms. LPN #7 stated that in double occupancy rooms, residents share one large dresser that has 5 drawers, each resident gets their own side table with 2 drawers, and both residents share one closet.On 01/29/2026 at 10:53 AM, observations of double occupancy rooms 120, 128, 215, 221, 225, 228, and 229 revealed that there was no physical separation of items in the room closet shared by residents. On 01/29/2026 at 10:59 AM, an interview was conducted with Resident #16 in room [ROOM NUMBER]. Resident #16 stated that they shared the closet space with their roommate. No partition was noted inside the closet to separate roommates' belongings. Resident #16 stated they would not mind having a process in place to separate roommate belongings in the closet.On 01/29/2026 at 11:05 AM, concern about the lack of private closet space for residents was addressed with the Nursing Home Administrator.

Based on observation and staff interviews, it was determined that the facility failed to ensure a safe, homelike environment as evidenced by multiple sliding closet doors being broken and not being able to close properly. This was found to be evident in rooms 120, 128, 215, 221, 225, 228, and 229.The findings include:On 1/29/2026 at 10:53 AM, a tour of the facility revealed sliding closet doors were used in resident rooms. In rooms 120, 128, 215, 221, 225, 228, and 229, the closet doors were observed to no longer be attached to the top tracks that would allow the doors to open and close properly. Multiple closet doors in these rooms were observed to be prop up against the inside walls of the closets.On 01/29/2026 at 11:05 AM, the rooms were toured with the Maintenance Director (MD) and the Nursing Home Administrator (NHA). The MD stated the facility often must repair closet doors because they currently do not have bottom tracks and often get hit by equipment like wheelchairs that knock them off the top tracks. Surveyor concern with closet doors was addressed with the NHA at this time.

Based on medical record review and facility staff interview, the facility staff failed to protect and value a resident's right to religious freedom (residents #18, 40, 43, 81, 83, and 91). This was evident for 6 out of residents reviewed for resident rights during a recertification survey.The findings include: Review of complaint # 2676017 on 1/19/26 at 10:30am revealed a complaint from a eucharistic minister stating that he/she was unable to provide communion to Catholic residents because the facility has failed to provide the eucharistic minister with an accurate list of Catholic residents for approximately 2 years. Interview with eucharistic minister # 25 on 1/20/25 at 10:17am revealed eucharistic minister attempted to obtain an accurate list of Catholic residents since October 2025. Eucharistic minister #25 normally sends an email to the Administrator and the Activity Director approximately 4 days before he/she will visit the facility. Since March 2025, eucharistic minister #25 alleged that he/she has not recieved an accurate list of Catholic residents so he/she has been unable to provide communion to these residents. Eurcharistic minister #25 also alleged that he/she contacted the Administrator about the unability to receive an accuate list of Catholic residents from the facility. The Administrator was alleged to have stated that he/she saw the email but he/she did not believe that the list of Catholic residents was unimportant at the time of review. On 1/20/26 at 10:45am, the surveyor interview Activity Director #2 regarding the list of Catholic residents. Activity Director #2 provided the surveyor with a copy of the list. Review of the list of Catholic residents on 1/20/26 at 11:30am revealed the list was inaccurate. Comparing the list of Catholic residents with the most recent annual activity preference forms revealed residents #18, 40, 43, 81, 83, and 91 did not indicate that they were Catholic. All of the most recent activity preference forms were signed and reviewed by Activity Director #2. Interview with Activity Director #2 on 1/21/26 at 10:30am revealed that all residents receive an assessment of their activity preferences when admitted , when there are any changes to activity preferences, at re-admission and annually. The surveyor asked when the list of Catholic residents is updated. Activity Director #2 stated that the list of Catholic residents is updated based on any changes to the activity preference form. The Surveyor pointed out that he/she found inaccurate information on the list of Catholic residents. Activity Director #2 stated that his/her assistants normally update the list of Catholic residents as necessary. The surveyor provided copies of the most recent annual activity preference form for resident's #18, 40, 43, 81, 83, and 91. Activity Director #2 reviewed the forms and admitted that the list of Catholic residents was inaccurate. During an interview with the Director of Nursing and the Administrator on 1/21/26 at 11:15am, the surveyor informed the DON and the Administrator that the list of Catholic residents was inaccurate based on the most recent activity preference form. The Administrator stated that the list of Catholic residents would be updated. On 1/21/26 at 12:30pm, Activity Director #2 provided the surveyor with a new list of Catholic residents.

Based on record review and interviews, it was determined that the facility failed to ensure that a resident was free from a significant medication error. This was evident for 1 (#343957) of 7 complaints reviewed during an annual survey.The findings include:On 01/22/2026 at 11:06 AM, review of anonymous complaint #343957 revealed that Resident #27 was sent to the hospital following the administration of an incorrect methadone dose.Methadone is a medication used to treat addiction to controlled, strong pain medications. Taking too much or not as ordered can result in overdose which can cause life-threatening symptoms such as slow or irregular breathing, extreme sleepiness, and confusion.On 01/23/2026 at 8:44 AM, an interview with the Director of Nursing confirm the incident did occur to Resident #27. She indicated that the resident was ordered two separate dose amounts for the morning and evening administration (a larger dose in the morning), and that the resident received the morning dose in the evening. She further indicated it was an agency Licensed Vocational Nurse (LVN) who made the error. At the same time, the Director of Nursing indicated she put a new process in place immediately following the incident which required two nurses to sign off on the administration of the medication to ensure that the dose would be administered as ordered, and to prevent the incident from happening in the future. The surveyor requested further information regarding the incident investigation. On 01/23/2026 at 11:55 AM, the surveyor received the incident investigation which revealed the resident was ordered 123mg of Methadone HCI Oral Concentrate in the morning and 45mg of Methadone HCI Oral Concentrate in the evening. Further review of the investigation revealed LVN, Staff #26 administered 123mg of Methadone HCI Oral Concentrate to Resident #27 in the evening instead of the ordered 45mg. The medication error was identified during the resident's methadone medication count at approximately 11pm during shift change on 12/29/2024 due to an incorrect amount of methadone left. At the same time, further review of the investigation revealed that the resident was noted to be breathing slow. The provider was notified of the incident and ordered Narcan (a life saving medication which can reverse taking too much of strong controlled drugs/medications) which was administered. Shortly after, the resident was noted to be breathing at a more normal rate. The resident was sent to the hospital for further evaluation.On 01/23/2026 at 12:11 PM, the surveyor reviewed the concern regarding the significant medication error regarding the incorrect methadone dose administered to Resident #27 and she indicated that she understood and agreed it was a concern.

Based on record review and interviews, it was determined that the facility failed to ensure that a resident was free from a significant medication error. This was evident for 1 (#343957) of 7 complaints reviewed during an annual survey. The findings include:Based on record review and interview, it was determined that the facility failed to ensure a resident was offered activities throughout each month based on the comprehensive care plan and activity interest. This was evident for 1 (#2586001) of 7 complaints reviewed during an annual survey.The findings include:On 01/23/2026 at 10:34 AM, review of anonymous complaint #2586001 revealed that Resident #32 felt bored at the facility.On 01/23/2026 at 10:37 AM, review of Resident 32's medical record revealed they were admitted to the facility on [DATE].At the same time, further review of Resident #32's medical record revealed a document titled, Activity Preferences Interview, dated 7/12/2025 which indicated that the resident was interested in several activities such as those involving animals, group activities, sports, religion, cards, bingo, games, audio books, reading, writing, music, TV, movies, outdoors, talking, parties, and more. On 01/23/2026 at 10:42 AM, review of Resident #32's comprehensive care plan revealed an activity focus that indicated the resident was dependent on staff for activities and engagement (initiated on 7/15/2025) with interventions such as encourage attendance (initiated 7/15/2025), invite resident to scheduled activities (initiated 7/15/2025), and provide activity materials of interest such as books, puzzles, and magazines (initiated 7/15/2025).On 01/28/2026 at 8:57 AM, an interview with the Activities Director (Staff #2) revealed that the expectation was that residents were offered to attend all scheduled activities, and if they refuse, it would be documented on the activity log. She further indicated the facility will try and provide residents' several activities based on their interests. The surveyor revealed the concern from complaint #2586001 that Resident #32 was noted to feel bored at the facility.The surveyor requested Resident #32's activity log from July 2025 - January 2026.On On 01/28/2026 at 10:35 AM, the Activities Director (Staff #2) provided the activity logs requested. She indicated that she was going to educate the activities staff on the expectation of documenting when activities were offered, if the resident attended the activity, and if the resident refused. She indicated she was aware that Resident 32's activity log indicated the resident had not been offered nor attended many activities throughout the months requested.On 01/28/2026 at 10:37 AM, review of Resident #32's activity log form July 2025 - January 2026 revealed:In July 2025, the resident was offered an activity 10 out of 31 days.In August 2025, the resident was offered an activity 7 out of 31 days.In September 2025, the resident was offered an activity 7 out of 30 days.In November 2025, the resident was offered an activity 9 out of 30 days.In December 2025, the resident was offered an activity 8 out of 31 days.In January 2026, the resident was offered an activity 5 out of 28 days (reviewed on 1/28/26).On 01/28/2026 at 11:46 AM, the surveyor reviewed the concern with the Director of Nursing and she indicated she understood.

Based on observations and staff interview, it was determined that the facility failed to ensure staffing information was complete and was not missing information. This was evident for 2 out of 2 units observed during the recertification survey. The findings include: On 1/29/2026 at 9:01 AM, an observation of the nurse staffing boards in both units was made. Staffing boards on both units had the accurate date, Facility Name, and Census. There were no actual hours worked for either Nurses or Nursing Assistant on either of the boards.On 1/29/2026 at 9:14 AM, an interview with the Director of Nursing (DON) was conducted. This surveyor made the DON aware of the nurse staff postings not having the hours worked for nursing staff. The DON stated that they will address the boards and was not aware of the requirement.

Based on observation, review of the facility investigation, record review, and interview. It was determined that the facility failed to provide a safe environment to prevent a fall with injury causing actual harm (Resident #102 ), and failed to provide supervision to prevent an elopement (Resident #18 and #106). This was evident in 3 of 3 residents reviewed for accidents during a recertification/complaint survey. The findings include: 1) On 7/31/24 at 8:38 AM a review of complaint MD00204146, that was received by the State Survey Agency (SA), alleged that Resident #102 was unable to walk or move out of bed. The complaint alleged that staff were changing Resident #102 and apparently dropped Resident #102 resulting in a broken hip. On 7/31/24 at 8:38 AM a review of Resident #102's medical record was conducted and revealed Resident #102 was admitted to the facility in August 2022 with diagnoses that included heart disease, chronic obstructive pulmonary disease (COPD), and chronic pain. The medical record further revealed that Resident #102 was admitted to hospice care in March 2023 due to heart disease. The MDS (Minimum Data Set) 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. Review of Resident #102's 3/25/24 return anticipated MDS, section GG, Functional Abilities and Goals, documented A: roll left and right: the ability to roll from lying on back to left and right side, and return to lying on back on the bed as a (1) which was Dependent - helper does all of the effort. Resident does none of the effort to complete the activity; or the assistance of 2 or more helpers is required for the resident to complete the activity. The resident was also coded a (1) Dependent for personal hygiene, upper and lower body dressing and toileting hygiene. 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. Review of Resident #102's activities of daily living care plan (ADL), that was created on 2/28/23 documented, Resident requires Mod (moderate) to Max (maximum) assistance with bed mobility. Review of a physician's progress note dated 3/25/24 revealed the physician saw Resident #102 for an acute visit. The physician documented, seen today for left leg and hip pain. Patient was seen at the bedside; said [he/she] fell yesterday while being turned in bed. Patient was in severe pain at 8/10, was unable to move [his/her] left hip and leg and did not want provider to move them either. Tramadol was given to patient for [his/her] pain; continue to monitor pain. Stat Xray to be ordered to rule out fracture. Review of the results of the x-ray that was taken on 3/25/24 documented, Acute intertrochanteric femoral fracture with mild displacement with varus angulation. Review of the nursing progress notes dated 3/25/24 at 8:00 PM documented, hospice here to see resident - agrees with plans to transfer to hospital for further evaluation of left hip fracture - resident would like to transfer to hospital to discuss [his/her] options as [he/she] is experiencing pain to [his/her] left hip. Review of the ED (Emergency Department) physician record dated 3/25/24 at 20:29 (8:29 PM) documented, fell out of bed yesterday at [his/her] skilled nursing facility when [he/she] was being repositioned. Has left hip and upper femur pain. Apparently had an x-ray done which showed a left hip fracture. [He/She] is bedbound and does not ambulate. The physician ' s assessment and plan documented, Fall out of bed with left hip pain. Will do x-ray of left femur and hip to look for any fracture. Start pain control with Percocet. [He/She] will require admission to get [his/her] pain under control. On 7/31/24 at 10:15 AM an interview was conducted with Registered Nurse (RN) #4 who was the unit manager. RN #4 stated he had been the unit manager for 1 year. When asked about Resident #102's fall, RN #4 stated he could not remember how Resident #102 had the fall. RN #4 stated that Resident #102 was totally dependent on staff. When asked further about Resident #102, RN #4 stated that he remember that an agency aide (Staff #24) took care of the resident the night the resident fell . RN #4 stated he could not remember anything else. On 7/31/24 at 11:36 AM an interview was conducted with the Director of Nursing (DON). The DON was asked about Resident #102's fall. The DON stated the resident complained of hip pain and that he/she had fallen. When asked about the fall, the DON stated an agency aide assisted one of the facility ' s geriatric nursing assistants (GNA) with the resident. The DON stated, the resident was found on the floor wrapped in blankets. When asked when the fall happened, the DON stated that the resident would have fallen on 3/21/24, however the nurse was not aware of the fall, therefore it was not documented. The DON stated the agency GNA #24 was responsible for the resident that night and that GNA #25 helped agency GNA #24 pick the resident up off the floor and put the resident back to bed. The DON confirmed that the nurse and nursing administration were not aware of the fall until 3/25/24. After nursing administration became aware of the fall, the agency was notified that GNA #24 was to be a DNR (Do Not Return) to the facility. On 7/31/24 at 12:15 PM a review was conducted of the fall investigation given to the surveyor by the DON. The investigation consisted of a word document that stated, Resident presented with pain to hip to nursing staff, nursing staff reports resident had fallen 3 days prior. The document stated pain evaluation and x-rays were done, family was notified, resident discharged to ER (emergency room ) and then to another facility from the ER. In the investigation there were only 3 witness statements, from RN #19 and GNA #25. There was a document that stated, multiple attempts made, and agency called several times. Would not locate GNA. Also included was a copy of the 3/25/24 nursing schedule. The DON was asked if there was any other information related to the fall and the response was, that ' s all I have. On 7/31/24 at 12:40 PM RN #19 was interviewed. RN #19 stated that she was the nurse assigned to Resident #102 on 3/21/24. RN #19 stated that she was not aware of the fall on 3/21/24. RN #19 stated that she did not know how the resident fell . RN #19 stated, one of the mornings the unit manager came to me and asked me if he/she had a fall, and I said I didn ' t know he/she had a fall. RN #19 stated Resident #102 was not able to get out of bed by him/herself. RN #19 stated that Resident #102 did have pain in the leg. RN #19 stated that she worked and was assigned to the resident on 3/25/24 and that the doctor saw the resident and wanted an x-ray. It was confirmed that the resident had a fracture. RN #19 stated, If I had known about the fall on 3/21/24 I would have called the doctor immediately. On 7/31/24 at 12:54 PM an interview was conducted with GNA #25. GNA #25 stated that Resident #102 was total care and that sometimes the resident could turn on her own but most of the time was a 2 person assist. GNA #25 stated that she only worked one half of a shift on 3/21/24 and came in at 7:00 PM. GNA #25 stated that she went on break around 9:00 PM and last rounds were between 9:30 PM and 10:00 PM. GNA #25 stated, I did not have a group because I came in late. There was no one in the hall. I went into the nurse ' s station to put my stuff down. GNA #24 came around to the station and she peaked around the corner and asked if I could help get (Resident #102) off the floor. RN #19 was up at the other end of hall. The resident was laying on his/her back on the floor beside the bed. I asked GNA #24 what happened, and she said she was changing Resident #102 and [he/she fell ]. I helped get [him/her] up and back in the bed. GNA #24 told GNA #25 that she told RN #19 that the resident fell . Once Resident #102 was back in bed I left the room. The DON said I should have made sure it had been reported to the nurse before I helped get [him/her] up. I should not have assumed anything regarding the situation. I should have got the OK from the nurse. On 8/1/24 at 10:24 AM an interview was conducted with the facility's Corporate Nurse (Staff #36) who confirmed that the fall was not reported for 4 days, and that facility wide education was not done after the incident and that the incident was not reported to the Office of Health Care Quality (OHCQ). Staff #36 confirmed that the fall's investigation was incomplete. On 8/1/24 at 10:52 AM an interview was conducted with GNA #24 (agency GNA). She was asked about the evening of 3/21/24. GNA #24 stated, ' when they called me, I was baffled about the situation because I had no recollection of the incident. GNA #24 denied that anyone had a fall and that she did not help anyone pick up a resident from the floor. GNA #24 repeated several times to the surveyor that she could not recall that evening. Review of Resident #102's March 2024 Medication Administration Record (MAR) documented the medication Tramadol 50 mg. was ordered on 11/2/23 prn (when necessary) every 6 hours as needed for pain. Tramadol is an opioid that is used to relieve moderate to severe pain. Prior to 3/21/24, the Tramadol was only administered 1 time in March 2024, which was on 3/11/24. From 3/21/24 to 3/25/24, the Tramadol was administered daily for pain levels of 8 out of 10. On 3/21/24 Tramadol 50 mg. was administered at 11:04 PM. On 3/22/24 Tramadol 50 mg. was administered at 3:12 PM. On 3/23/24 the Tramadol was administered twice, at 1:45 PM and 8:00 PM for left leg pain. Also, a dose of Tylenol (Acetaminophen) 650 mg. was administered on 3/23/24 at 10:14 PM after it was documented that the pain level was a 6 after the administration of the Tramadol. On 3/24/24 Tramadol was administered at 12:33 PM. There was also a prn order for Morphine (ordered on 3/23/23 when the resident was admitted to Hospice) that was given on 3/24/24 at 4:35 PM for a pain level of 6 (which was 4 hours after the Tramadol was administered). On 3/25/24 at 10:13 AM Tramadol was administered. Further review of the medical record revealed no additional documentation of any investigations as to why the resident was in pain every day from 3/21/24 to 3/25/24. On the March MAR there were places for day, evening, and night shift to document monitor for pain every shift that had nurse ' s initials and check marks, however there was no description of the pain and no other documentation as to why or what was done. On 8/1/24 at 1:17 PM an interview was conducted with the DON related to pain assessments. The DON stated that when Resident #102 already had an order for pain medication and the pain medication was administered a couple of days in a row, he would assume it was from the arthritis and not expect a total pain assessment in the assessments section of the medical record. The DON stated he would expect the number of severity, which was documented on the MAR. The DON stated, We weren't aware of the fall so therefore did not associate the pain with that. On 8/5/24 at 2:12 PM an interview was conducted with RN #37. RN #37 was asked about the care she provided to Resident #102 on 3/23/24 and 3/24/24 and the pain the resident was experiencing. RN #37 stated she did not really remember the resident and that she had just started at the facility a month prior. RN #37 was asked if the resident had a prn for pain medication but had not received any medication until all of a sudden received it 5 days in a row, would that trigger her to see what is going on with the resident. RN #37 said yes. When asked when she would fill out a pain assessment, RN #37 said, if it was new and acute or if it was a quarterly pain assessment required by the facility, I would fill it out. RN #37 was asked if the facility had asked her if the resident had a fall. RN #37 stated that no one had told or asked her about a fall. RN #37 stated, if the resident had a fall and was in pain then the resident should have been sent to the hospital. 50502 2) On 7/22/24 at 9:50 AM, Resident # 18 was observed in bed with eyes closed. One fall mat was noted on the right side of the bed. The resident did not respond when surveyors greeted him/ her. On 7/23/24 at 10:14 AM, surveyors reviewed Facility Self-Reported incident MD 00188036. The review revealed Resident #18 had an elopement incident on 1/20/23 around 5:45 PM. Two family members coming into the building to visit another resident found Resident #18 outside in the facility's parking lot. The resident allegedly exited the building without the knowledge of the facility staff. The facility staff assisted the resident back to the building and assessed for any injuries. On 7/23/24 at 10:42 AM, a review of the staff statement regarding Resident #18's elopement incident indicated that Resident #18 was initially seen at the nurse's station around 5:25 PM. Also, a statement from the family members stated that they found Resident #18 outside the south end of the building, wearing a hospital gown and carrying a bag. On 7/23/24 at 11:03 AM, a review of Resident #18's medical record revealed as A BIMS score was 5 of 15: Brief Interview for Mental Status (BIMS) is a screening tool used to assess basic cognitive function in patients in long-term care facilities. A score of 0-7 indicates that a patient has severe cognitive abilities. The resident was found going inside the Physician's room on 1/18/13 and to another resident's room on 3/18/23 by accident. But Resident #18 had no other wandering, exit seeking and/or elopement incidents. On 7/24/24 at 10:18 AM, in an interview with the Director of Nursing (DON), he stated that the facility staff assumed that Resident #18 did not use the front door to go out but used the kitchen exit door. He stated that the facility had no video footage verifying the resident's exit. The DON confirmed that they presumed the resident followed a kitchen staff to go out and indicated that the door leading to the dumpster was the only door not secured before the elopement incident. He also verified that the kitchen staff didn't lock the kitchen door and that the kitchen staff only locked the door when they were finished with the shift when the elopement occurred. The DON stated that Resident #18 had no wandering issues in the past and had no exit-seeking behavior. The DON added that the wanderguard was ordered after the incident, and discontinued on 8/14/23 because the resident can no longer ambulate and bear weight. On 7/25/24 at 11:02 AM, in an interview with Staff #10 (Cook), he stated that the staff could access the main door to the kitchen and usually went inside the kitchen to get ice. He added that before the incident, the kitchen staff would push the door to go out towards the dumpster and use a keypad with a code to enter back to the kitchen. He stated that the kitchen exit door lock was replaced after the incident and that a key was now used instead of a keypad. Staff #10 showed the surveyors how to exit using the kitchen door towards the dumpster. He unlocked the door using a key that was kept inside a drawer. On 07/25/24 at 1:08 PM, in an interview with Staff #12 (Maintenance director), he revealed that before the incident, the kitchen staff used a numerical lock/ keypad system located outside the kitchen back door. The staff had to push the door to go outside and use the keypad to go inside. He/she added that the keypad was removed and changed right away after the incident. On 8/08/24 at 09:35 AM, during an interview with the DON and Administrator, the surveyor shared concerns that the facility failed to prevent the elopement incident by ensuring that all exit doors were locked, especially the back kitchen door. 34484 3) Review of Resident #106's medical record on 7/29/24 revealed the Resident was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease. Alzheimer's disease is a progressive disease that destroys memory and other important mental functions. The MDS (Minimum Data Set) 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. Further review of Resident #106's medical record revealed the facility staff assessed the Resident's behaviors in Quarterly MDS on 1/26/21 and 5/13/21. The facility staff coded the Resident as a 0 for Behavior not exhibited in Section E Behavior E0900 Wandering: Presence and Frequency. Review of an anonymous concern in June 2021 that Resident #106 was found outside the building by the facility staff, the Surveyor asked on 7/29/24 for the investigation of the incident. Review of the facility investigation revealed it was reported to the Office of Health Care Quality that Resident #106 was found in the facility's adjacent parking lot on 6/5/21 by facility staff and escorted back to the building unharmed. During interview with Staff #38 on 7/30/24 at 2:34 PM, Staff #38 stated on 6/5/21 she was leaving the facility when she saw Resident #106 in the adjacent parking lot to the facility. At that time she escorted the Resident back to the facility and notified the nurse. Staff #38 was asked how she believed the Resident was able to get out, she stated the front door is always locked so I believe the Resident followed visitors out and the Receptionist didn't notice the Resident leave with the visitors. Staff #38 stated she has worked at the facility full time for 7 years and stated this is the only time I am aware the Resident had eloped from the facility. Interview with the Director of Nursing on 8/1/24 at 9:58 AM confirmed the facility staff failed to provide supervision for Resident #106 to prevent an elopement on 6/5/21.

Based on the surveyor's observation and staff interviews, it was determined that the facility failed to maintain the guidelines and the facility's policy for storing food brought in by family or visitors and distinguishing it from the facility's food. This was evidenced by observations of residents' food storage brought in by family and visitors and has the potential to affect all residents. The findings include: On 07/24/24 at 11 AM, an interview with the unit Manager (Staff # 23) revealed that the refrigerator located in the nourishment room next to the Nurses' station is used for the purpose of saving any supplements, sandwiches for residents, and any food brought by the residents' family or visitors. He/She also stated that the food is always labeled and will be removed after three days. On 07/24/24 at 11:12 AM, the surveyor observed food in the refrigerator at unit A in a paper bag with the resident's name on it but no date. Surveyor also observed an unlabeled container with a smoothie-like drink and an unlabeled open water bottle. The unit manager (Staff # 23) was not able to verify if it was the resident's food or not. On 07/25/24 at 04:43 PM, an Interview with RN staff # 5 stated that he/she was unsure how long the residents' food could be saved in the refrigerator. On 07/25/24 at 04:50 PM, the surveyor observed food in the refrigerator in the nourishment room of unit B. Noted that the refrigerator was full of food packs like pepperoni slices, cheese sticks, etc,. The balanced beef stew pack was labeled with the resident's name but no date when it was placed in the refrigerator. On 07/25/24 at 5:10 PM reviewed with NHA regarding unlabeled food in both refrigerators.

Based on the surveyor's observation and interview with staff, it was determined that the facility failed to ensure that it had qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. This was evidenced by the lack of qualified staff and has the potential to affect all residents. The findings include: Full-time means working 35 or more hours a week. Part-time employees typically work fewer hours in a day or during a work week than full-time employees. The U.S. Department of Labor, Bureau of Statistics uses a definition of 34 or fewer hours a week as part-time work. On 07/22/24 at 09:32 AM, an Interview with the Culinary Director (Staff #11) revealed that he/she has been working for the past two years as the Culinary Director and does not have a Certificate in Dietary Management (CDM). He/she enrolled in the CDM course and can provide the registration. Staff #11 also stated that the Registered Dietician (RD) supervises the kitchen and works at the facility four days a week, adding, My understanding is that as long as the Dietician is in the building, we are okay to meet the requirement. On 07/24/24 at 10:40 AM, an Interview with a Registered Dietician (Staff # 17) revealed that he/she had worked at the facility for two years and didn't have a Certified Dietary Manager. While at the Facility, RD assists with tray line temperatures, checks residents' food preferences, and attends risk meetings, but does not attend care plan meetings. The surveyor reviewed with both the RD and the Culinary Director that the Culinary Director's lack of a CDM certificate does not meet the facility's requirement of having qualified staff to carry out food and nutrition services.

Based on the surveyor's observation and Interviews with staff, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for food safety requirements. This was identified during multiple observations of the kitchen food service operations during the recertification/complaint survey and has the potential to affect all residents. Findings include: The surveyor's kitchen initial observation on 07/22/24 at 09:32 AM revealed ice plaques on plastic freezer curtain strips in the freezer room. Icicles were noted on the black cord connecting the freezer and freezer door. Icicles noted behind condenser connection. Several icy spots were noted on the floor of the freezer room (they appear like black ice, making them hard to notice), and some icy spots were noted on the ceiling of the Freezer room. On 07/22/24 at 09:35 AM, a pile of untilted dessert bowls was noted on the countertop near the dishwashing area. Above the untitled dessert bowls, a non-functional wall-mounted insect light trap was noted. Black dust particles were noted in the top bowl. On 07/24/24, at 10:15 AM, the surveyor observed a pile of dessert bowls on the countertop near the dishwashing area. An Interview with dietary staff # 53 on 07/22/24 at 9:45 AM revealed that the bowls will be used for the dessert tray line. An interview with the Culinary Director (Staff #11) on 07/22/24 at 10 AM revealed that the freezer temperatures are checked once a week, and he/she walks through to inspect the freezer. He/she creates a ticket for environmental service to check if any issues are identified. On 07/24/24 at 10:22 AM, an Interview with the district manager (Staff # 52) revealed that the environmental services staff checks the freezers as part of preventive maintenance schedules and also addresses any issues that are identified by the staff. On 07/24/24 at 10:45 AM, the surveyor reviewed with the Culinary Director and the District Manager that the icicle formation and icy spots identified in the freezer room do not meet the food safety requirements. The surveyor also reviewed the collection of black dust particles in untitled dessert bowls under a wall-mounted insect light trap and next to the dishwashing area, with potential contamination via splash, dust, etc.

Based on medical record review, observation and interview, the facility staff failed to provide residents a dignified existence (Resident #20, #50, #121, #594, #595, #596, #597, #598 and #599). This was evident for 9 of 42 residents reviewed during a recertification/complaint survey. The findings include: Review of a complaint from Resident #121's responsible party (RP) revealed the RP stated the Resident was forced to share a bathroom with a member of the opposite sex. Review of Resident #121's medical record on 8/2/24 revealed the Resident was admitted to the facility on [DATE] and was in room [ROOM NUMBER]. Observation on 8/5/24 at 8:00 AM revealed room [ROOM NUMBER] has a shared bathroom with room [ROOM NUMBER]. Further observation of room [ROOM NUMBER] and 121's shared bathroom revealed there are no locks on the interior bathroom doors leading from the bathroom to rooms [ROOM NUMBERS] to provide privacy from residents of the opposite sex. Observation on 8/5/24 at 8:00 AM of all the resident rooms and shared bathrooms on A wing and review of the facility's Midnight Census Report for 10/3/22 revealed in addition to Resident #122 the following residents had to share a bathroom with members of the opposite sex with no mechanism to lock the bathroom door: Resident #20, #50, #594, #595, #596, #597, #598 and #599. Further review of the facility's Midnight Census Report for 10/3/22 revealed the facility had 3 rooms without residents assigned on A wing. Interview with the Infection Preventionist on 8/5/24 at 8:10 AM confirmed it is not the facility's practice to have residents of the opposite sex share a bathroom that can not be locked.

Based on observation and interview it was determined the facility failed to ensure a homelike environment. This was evident throughout the facility during the surveyor's environmental tour. The findings include: On 7/30/24 at 9:02AM the surveyor observed room [ROOM NUMBER] and observed an area of unpainted spackling felt to be soft and movable on the wall approximately 4.5ft long by 1.5ft tall adjacent to the resident's window. The resident's television was observed to only have one working tv channel with a fuzzy appearance to the screen. The dresser furniture was observed to have a broken drawer handle on the top drawer which was dangling. Upon observation of the shared bathroom, the surveyor noted the following: one ceiling tile containing a plastic air vent with a bowed appearance and 0.5in separation present, approximately a 1ft long by 3in tall brown stain on the ceiling tile containing the light fixture, one missing ceramic wall tile below the toilet paper dispenser with exposed wall board, one broken ceramic wall tile in which the toilet paper dispenser was affixed to, various chipped paint and scraping present on the wooden trim molding and bathroom door, a 4in x 4in circular area of cracked, unpainted spackling on the wall across from the toilet. On 7/30/24 at 9:13AM the surveyor conducted an interview with Resident #73 who conveyed to the surveyor that seeing the room in disrepair made them feel put down. On 7/30/24 at 9:14AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: one ceiling tile above the window with 2 brown stains present, and a 5in section of window blind was missing. On 07/30/24 at 9:16AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: a 2ft long x 3in tall area of unpainted spackling behind the window bed, another area of unpainted wall spackling 6in long x 1ft tall adjacent to the window with cracked areas and peeling paint, a cracked open area in the drywall approximately 0.5in long x 4in tall adjacent to the left side of the window, one ceiling tile above the window with 3 brown stains present, black scrape marks present on an interior bathroom door, and worn off paint on the toilet seat. On 7/30/24 at 9:22AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: a 5in section of window blind was missing, a 5in section of blind was broken backwards, a broken wooden window sill with approximately a 1.5ft long diagonal appearance, a bathroom ceiling light fixture with no cover and observable wiring and bulb, chipping paint on the wooden trim molding surrounding the bathroom flooring, On 7/30/24 at 9:29AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: approximately a 2ft long section of missing bathroom trim molding, and the nightstand furniture for the bedroom closest to the entry door to the room was observed to have the stain worn off in several areas. On 7/30/24 at 9:35AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: a strong, foul odor present in the bathroom, 3 out of 6 bathroom ceiling tiles with brown staining present, a cracked wooden window sill, no door stopping mechanism present on the room's entry door, and a cracked, damaged area on the bathroom door approximately 5in long x by 4in tall where the door handle from the entry room door made contact with the bathroom door, unpainted trim molding in the bathroom, sitting, non draining water was observed in the sink inside the room, dark areas of wood were exposed on the trim molding below the sink with worn off paint, cracked and peeling paint was observed behind the bed area and in various areas throughout the room. On 7/30/24 at 9:43AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: a two foot long piece of wooden wall molding missing with splintery edges behind the bed area on the molding that remained, a 2in long x 3in tall area of missing paint with exposed wall board to the left of the door bed, an in room sink with sitting, undrained, pink water with no drain plug/stopper present, the door handle to the bathroom was loose upon entry, no cylinder type part was present to hold the toilet paper roll on the holder, and a cracked area was present in the bathroom door where the room entry door handle was able to make contact with the bathroom door. On 7/30/24 at 9:56AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: a 1ft long x 2in tall cracked area of spackling with exposed mesh pieces on the bathroom door where the room entry door handle was able to make contact with the bathroom door, mismatched pieces of cut flooring were in disarray with a portion which was unattached and surrounding the commode with several of the mismatched pieces supporting the base of the commode, bathroom trim molding paint was observed to be worn and chipped with exposed wood surface, and the wall corner situated in between the in-room sink and the bathroom was observed to be dented with chipped paint and gray markings present. On 7/30/24 at 9:58AM the surveyor conducted an interview and shared concerns with Director of Maintenance #12 who acknowledged understanding of the concerns and reported that room [ROOM NUMBER] and room [ROOM NUMBER] shared plumbing. Director of Maintenance #12 reported the following information to the surveyor: It backs up and I have to snake it, it's on my list. On 7/30/24 at 10:02AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: there was no door stopper present for the entry door to the room, a spackled cracked area on the bathroom door was present in the area where the entry room door handle was able to make contact with the bathroom door, one bathroom ceiling tile was missing with observable exposed insulation present and cobwebs, caulking around the base of the commode was observed to be in disarray with brown debris present, and black debris was observed in the air duct above the entry door to the room. At this time, the surveyor conducted an interview with the Environmental Services Director #47 who confirmed with the surveyor that the bathroom was currently being utilized and was shared with the adjoining room, #217. On 7/30/24 at 10:08AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: areas of wall paint were unfinished in between the resident beds, and a resident's personal clothing was observed in a bag on the floor without closet space necessary to accommodate hanging them. On 7/30/24 at 10:14AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: approximately a 3ft long x 1ft tall area on the wall below the bathroom sink with exposed wall board and peeling paint with black debris present, and orange colored staining on the bathroom sink drain with no drain plug/stopper present. On 7/30/24 at 10:23AM the surveyor observed the light fixture behind the resident's bed in room [ROOM NUMBER], with a cord that was not in reach of the resident. At this time, the resident reported they could not reach the cord for the light and needed it to be extended. The surveyor shared and observed this concern on 7/30/24 at 10:32AM with Corporate Nurse #36 who acknowledged the concern and confirmed with the resident that this issue would be fixed. Upon observation of the bathroom, the surveyor noted areas of unpainted spackle on the wall adjacent to the commode. On 7/30/24 at 10:32AM the surveyor observed room [ROOM NUMBER] with various areas of brown staining on the ceiling tiles and peeling paint present on the wall behind the bed along the wall molding, a missing section of wooden wall molding and a broken area of wooden wall molding with exposed edges. On 7/30/24 at 10:37AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: unpainted areas of wall spackling, one ceiling light fixture cover in the bathroom with tape present across it, and one paper towel dispenser with a crooked appearance which was movable, loosely attached to the bathroom wall by one screw which was protruding. On 7/30/24 at 10:42AM the surveyor observed room [ROOM NUMBER] and noted two out of two electrical sockets with no plate cover present, each with an additional plug attached to it providing 6 additional outlets to each. On 7/30/24 at 10:44AM the surveyor observed room [ROOM NUMBER] and noted the following areas of concern: an area of missing trim molding with exposed cracked drywall and unpainted spackle, peeling and chipped wall and trim molding paint, and an area with no mirror present on the wall below the light fixture above the in-room sink, with areas on the wall which appeared to have held a mirror previously. On 7/30/24 at 10:48AM the surveyor observed room [ROOM NUMBER] with damaged areas present to the wall area between the dresser and the closet, and unpainted areas of paint on the walls including the bathroom. On 7/30/24 at 10:53AM the surveyor observed room [ROOM NUMBER] with unpainted areas and missing molding trim along the wall behind the resident bed. On 7/30/24 at 10:58AM the surveyor observed room [ROOM NUMBER] with one ceiling tile in bathroom which had a bowed appearance with approximately a 0.5in opening present. On 7/30/24 at 11:01AM the surveyor observed the facility's courtyard which was observable from several resident rooms and community areas. The courtyard was observed by multiple surveyors to have an unkempt appearance with overgrown weeds in the middle of a fenced section, and with dark stained broken concrete areas and rocky debris, several planter pots were observed to be present with no plants. On 7/30/24 at 11:03AM the surveyor conducted an interview with District Manager #52 who reported to the surveyor that the courtyard can be used by residents, and they had observed residents and others utilizing the courtyard. On 7/30/24 at 11:05AM the surveyor observed room [ROOM NUMBER] and noted the following concerns: one missing ceiling light cover in the bathroom with one of two bulbs observed to be lit with the bulbs and wiring exposed, unpainted spackling on the wall across from the commode, and missing areas of caulk around the base of one side of the commode along the floor. On 7/30/24 at 11:10AM the surveyor observed room [ROOM NUMBER] with a loose vent cover and ceiling tile in the bathroom. On 7/30/24 at 11:12AM the surveyor observed room [ROOM NUMBER] with one electrical socket with no cover plate with a second plug attached which provided six additional sockets. On 7/30/24 at 11:14AM the surveyor observed room [ROOM NUMBER] with a loose light fixture present on the wall above the resident who was in bed nearest to the entry door to the room. On 7/30/24 at 11:25AM the surveyor observed the housekeeping room with seven damaged wall tiles. On 7/30/24 at 1:23PM the surveyor conducted interviews with multiple resident council members who reported residents of the facility utilize the courtyard. On 8/5/24 at 2:59PM the facility Director of Maintenance #12 participated in an interview and dual observation of the surveyor's concerns and acknowledged and confirmed understanding of the concerns. During an interview on 8/8/24 at 9:10AM the surveyor's concerns were shared with the facility's Administrator, who acknowledged understanding of the concerns.

Based on review of complaints, medical record review, policy review, and interview, it was determined the facility staff 1) failed to notify the physician in a timely manner when a resident had a fall and weight loss and, 2) failed to notify the responsible party when there was a significant change in weight and a change in residents condition. This was evident for 1 (#102) of 8 residents reviewed for accidents and 3 (#247, #125, #133) of 3 residents reviewed for nutrition and significant change in condition The findings include: 1) On 7/31/24 at 8:38 AM a review of complaint MD00204146, that was received by the State Survey Agency (SA), alleged that Resident #102 was unable to walk or move out of bed. The complaint alleged that staff were changing Resident #102 and apparently dropped Resident #102 resulting in a broken hip. On 7/31/24 at 8:38 AM a review of Resident #102's medical record was conducted and revealed a physician's progress note dated 3/25/24 which revealed the physician saw Resident #102 for an acute visit. The physician documented, seen today for left leg and hip pain. Patient was seen at the bedside; said [he/she] fell yesterday while being turned in bed. Patient was in severe pain at 8/10, was unable to move [his/her] left hip and leg and did not want provider to move them either. Tramadol was given to patient for [his/her] pain; continue to monitor pain. Stat Xray to be ordered to rule out fracture. Review of the fall's investigation revealed the resident had a fall on 3/21/24. There was no documentation that the fall was reported to the physician or responsible party until 4 days later on 3/25/24. Review of the Notification of Change in Condition policy that was given to the surveyor by Staff #30 documented, The center must inform the resident, consult with the resident's physician and/or notify the residents' representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification including but not limited to 1. A. Accidents resulting in injury, b. potential to require physician intervention. On 7/31/24 at 11:36 AM an interview was conducted with the Director of Nursing (DON) who stated the resident was found on the floor wrapped in blankets on 3/21/24. The DON stated that Geriatric Nursing Assistant (GNA) #25 asked GNA #24 if she reported it to the nurse, and she stated she did. The DON stated the nurse on duty, RN #19 stated she was not aware of the fall and was not informed by the GNA. The DON confirmed the fall was not reported to administration, the physician, and the responsible party until they became aware of it 4 days later on 3/25/24. 2) On 7/30/24 at12:30 PM review of complaint MD00186837 revealed a concern that Resident #247 entered the facility at a much higher weight and that the facility failed to monitor the resident's nutritional needs. On 7/30/24 at 12:30 PM Resident #247's medical record was reviewed and revealed the resident was admitted to the facility in November 2022 for rehabilitation following hospitalization . Review of the weight section of Resident #247's medical record revealed on 11/6/22 Resident #247's weight was documented at 137.0 lbs. On 11/7/22 the recorded weight was 137 lbs. On 11/14/22 the weight was documented as 128.4 lbs. and on 11/21/22 the weight was documented as 132.4 lbs. Review of the admission dietary assessment dated [DATE] documented, Most recent wt.128.4# (11/14/22) show wt. loss 8.6# compared to wt. 137# on 11/6/22 and 11/7/22. Weight on 11/6 and 11/7 questionable. Resident on weekly wts. x 4 weeks to monitor wt. trend. Review of the physician's progress note of 11/20/22 documented, Weight loss. Currently being monitored closely. Multiple contributing factors including cognitive impairment as well as poor appetite and dysphagia. Continue multidisciplinary approach along with dietitian team. Review of the Notification of Change in Condition policy that was given to the surveyor by Staff #30 documented, The center must inform the resident, consult with the resident's physician and/or notify the residents' representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification including but not limited to 3. Circumstances that require a need to alter treatment which may include a. new treatment b. discontinuation of current treatment, adverse consequences, acute condition, exacerbation of a chronic condition. Notifications: When a change in condition is noted, the nursing staff will contact the resident representative. There was no documentation that Resident #247's responsible party was notified of the weight loss. On 7/31/24 at 10:13 AM the issue was discussed with the Director of Nursing (DON). The DON stated they have had issues with the weights and that they were aware. 3) On 7/31/24 at 11:03 AM a review of complaint MD00185198 revealed a concern that Resident #125, who was on a feeding tube (gastrostomy) was extremely malnourished. A G-tube (gastrostomy) is a small, soft tube that surgically is inserted through the abdomen and into the stomach to provide direct access for feeding, hydration, or medicine. Review of the weight section of the electronic medical record documented on 10/25/22 there were (2) weights; (1) was 82.28 lbs. and (1) was 82.6 lbs. On 11/7/22 the weight was 68.8 lbs. and on 11/10/22 the weight was 69.0 lbs. Review of the admission nutritional assessment on 11/8/24 documented, weight trend since admission show weight loss of -16.7%/-13.8# compared to 82.6# on 10/25/22. The dietician documented, Requests reweigh; BMI classification underweight; Most current wt. show sig wt. loss. Change in wt. discussed with nursing and reweigh requested. Will adjust enteral nutrition using current wt. 68.8# to provide 41 kcal/day and 1.7 gm pro. Review of a 11/9/22 skilled note documented, weight loss of > 10 lbs. On 8/1/24 at 9:17 AM an interview was conducted with the RD about Resident #125's weight. When asked about physician notification the RD stated that the weights were discussed in risk meetings which are held once a week on Wednesdays but not documented in the medical record. The RD was asked what happened if a weight was noticed out of parameters on a Thursday and the risk meeting was not held until the following Wednesday. The RD stated that she would talk to the nurses but not the physician and the physician would not be made aware until the following Wednesday, therefore if the nurses don't notify the physician, then there is a delay. Review of the Notification of Change in Condition policy that was given to the surveyor by Staff #30 documented, The center must inform the resident, consult with the resident's physician and/or notify the residents' representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification including but not limited to 3. Circumstances that require a need to alter treatment which may include a. new treatment b. discontinuation of current treatment, adverse consequences, acute condition, exacerbation of a chronic condition. Notifications: The attending practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition. When a change in condition is noted, the nursing staff will contact the resident representative. Further review of the medical record failed to have documentation that the physician and responsible party were made aware of the documented weight loss. On 8/1/24 at 10:05 AM discussed the weights and process issues with the DON who confirmed the findings. On 8/6/24 at 2:15 PM the Nursing Home Administrator was informed of the process issues with weights and nutrition. 44441 4) On 8/1/24 at 11:00 AM a review of a complaint incident MD00183575, stated that Resident #133 had a change in medical condition, was seen by a physician and that new treatments and medications were ordered for this resident. However, the family was not notified of this change in condition, or of the new treatments. Review of the nurses note dated 5/26/22 on 8/1/24 at 12:41 AM confirmed that resident had a change in condition and that new treatments and medications were ordered. The note however, did not state that the family members or their representatives were notified. In an Interview with the Director of Nursing (DON) on 8/1/24 at 12:54PM, he was asked the expectation for family notification when a change in condition occurs. The DON stated that for any change in condition, the family should be notified, that they don't have to be the residents Power of Attorney (POA), just the Emergency contact person. On 8/1/24 at 1:08 PM The DON was made aware that Resident #133's family members were not notified when resident had a change in condition and that this was a concern.

Based on record review, interview with staff and facility reported incidents, it was determined the facility failed to ensure that allegations of abuse, neglect, exploitation, injuries of unknown origin, an elopement and unwitnessed fall were reported to the state agency within required timeframe. This was evident for 3 (Resident #101, #27, #129) of 26 residents reviewed for the facility's self-reported incidents and 1 (#102) of 8 residents reviewed for accidents. The findings include: 1) On 7/24/24 at 2:46 PM, a review of facility-reported incident MD00179979 revealed that on 6/23/22 Resident #101 alleged that the resident did not receive care timely when he/she had respiratory issue. Further review of Resident #101's statement for the incident on 7/24/24 at 3:00 PM revealed that the resident pushed the call bell several times for help because his/her oxygen bottle was empty and he/she did not get any oxygen through his/her nasal cannula on 6/23/22 around 5:45 AM. Resident #101 also reported that a nursing staff member approached him/her around 6:23 AM. The review of Registered Nurse (RN #27)'s statement on 7/24/24 at 3:05 PM showed that she heard someone yell help around 6:30 AM on 6/23/22 from [Resident #101's room], checked the room, and provided care for the resident. However, the review of the facility-reported incident form for this incident on 7/25/24 at 9:10 AM revealed that the initial report was submitted to OHCQ (Office of Health Care Quality) on 6/27/22 and the follow-up report was submitted on 7/02/22. On 7/25/24 at 10:10 AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA said, Any abuse, neglect, and injury of unknown origin should be reported immediately or, in some cases, within 2 hours. The surveyor asked the report timing for the above incident. The NHA said, I don't know how it was reported a few days later. The surveyor shared concerns regarding self-incident reporting time, and the NHA validated it. 44441 2) On 7/24/24 at 11:30 AM, review of a facility report MD00193085 had that on 9/1/22, Resident #27 was in his room, opened his window and walked to the gas station in front of the facility to buy a cigarette. Resident was found by one of the staff members and assisted back to the facility. A complete head to toe assessment was completed. No injuries were noted, local law enforcement was notified. Resident was moved to a different room with the window facing a courtyard. Other appropriate interventions were initiated to prevent future elopement. Further review of the investigative report on 7/26/24 at 11:08 AM did not however show that the initial and final report was sent timely to the office of healthcare quality . The report was not in the investigative folder. The facility was asked to provide the missing document. On 7/29/24 at 1:25PM the Director of Nursing (DON) was asked again about the missing documents and he stated that his computer was down at some point and was sent out for repair, but when it was returned, all the documents stored within were wiped out. That he sent the computer back for the documents to be retrieved and still waiting to hear back from them. He was told that there was no proof that the incident was reported timely and that this was a concern. 31145 3) On 7/30/24 at 8:47 AM a review of facility reported incident MD00187669 revealed on 1/11/23, Resident #129 alleged that Staff #34 spoke to the resident, in a nasty manner and mean manner and screamed at the resident. Review of the facility's investigation failed to produce documentation as to when the initial report and 5-day report were sent into OHCQ. On 7/30/24 at 9:10 AM the Director of Nursing (DON) was interviewed and stated that he was having issues with self-reports. The DON stated, we saved them on my computer and my computer shot off and the files were wiped off. That is the issue I had. I do not have any documentation of when it was sent. On 8/6/24 at 2:15 PM the Nursing Home Administrator was informed. 4) On 7/31/24 at 8:38 AM a review of complaint MD00204146 revealed an allegation that staff were changing Resident #102 and during that process dropped the resident onto the floor which resulted in a fractured hip. Review of the facility's investigation into the fall revealed that the fall was unwitnessed. The facility failed to report the unwitnessed fall with hip fracture to OHCQ. On 8/1/24 at 11:10 AM the complaint was discussed with the Corporate Nurse #36 who confirmed that the incident was not reported to OHCQ.

Based on interviews, record reviews and a review of facility-reported incident investigations, it was determined that the facility failed to thoroughly investigate allegations of abuse, neglect, injury of unknown origin, unusual occurrence, elopements, and falls. This was evident for 9 (Resident #18, #101, #109, #112, #20, #27, #129 and #102) of 26 residents reviewed for facility self-reported incidents and 1 (#102) of 8 residents reviewed for accidents during a recertification/complaint survey. The findings include: 1)A portion of reviewing the facility reported incident MD00188036 on 7/22/24 at 12:04 PM revealed that Resident #18 exited the facility building without staff knowledge and was found outside of the building by other residents' family member on 1/20/23 around 5:45 PM. Further review of the facility's investigation revealed that the facility's investigation documentation contained that Resident #18 had a wander guard applied after the incident, care plan revised, psychology followed-up, and staff education provided. However, there was no documentation to explain how Resident #18 was eloped from the building. During an interview with the Director of Nursing (DON) on 7/24/24 at 10:18 AM, the DON stated that the facility did not have video footage to prove how Resident #18 exited through the kitchen door and followed the kitchen staff to get out. He said the kitchen door was the only one that was not secured then. However, the facility's investigation documentation did not include how they concluded Resident #18's exit. On 7/24/24 at 3:33 PM, the surveyor interviewed with the DON. The DON was informed that the self-reported incident MD00186359 was not thoroughly investigated to explain how it occurred. He validated it. 2) On 7/24/24 at 1:00 PM, a review of facility-reported incident MD00182626 revealed that on 4/26/22 Resident #101 alleged that the resident was neglected by a nurse evident by not received care when she/he had a respiratory distress. Further review of the facility's investigation for Resident #101's neglect incident on 7/24/24 at 1:20 PM revealed that the facility staff conducted staff interviews seventy of other residents and filled out 'resident interview & resident observation' forms. However, these forms did not include the date and information of who documented them. Also, no statement was obtained from Resident #101. During an interview with the Director of Nursing (DON) on 7/24/24 at 2:30 PM, the DON stated that if a resident had an issue and the facility reported a self-reported incident, the facility should interview the resident, staff, and other residents with a documenting date. The surveyor shared concerns about Resident #101's neglect incident, which was not investigated with the resident's interview and other residents' statements. The DON validated the above concern. 3) On 7/24/24 at 2:46 PM, a review of facility-reported incident MD00179979 revealed that on 6/23/22 Resident #101 alleged that the resident did not receive care timely when his/her had respiratory issue. Further review of the facility's investigation of this incident on 7/24/24 at 2:50 PM revealed that the facility staff conducted interviews with Resident #101 and four nursing staff who cared for this resident, and other residents interviewed. The residents' interview form had sections of 'resident interview' and 'resident observation.' The facility staff filled out the form with each resident's name. However, none of these forms had a date, who conducted the interview, and/or observation. During an interview with the Director of Nursing (DON) on 7/24/24 at 3:24 PM, the surveyor asked about the other residents' interview regarding Resident #101's neglect incident that occurred on 6/23/22. The DON stated that the facility should interview other residents regarding this. The surveyor reviewed with the DON other residents' interview/observation forms, which did not contain the date and who performed. The DON said that it should be documented dates and interviewees. On 7/25/24 at 10:10 AM, the surveyor shared the above concerns with the nursing home administrator in an interview, and she validated them. 4) A review of the facility self-reported incident MD00180959 on 7/26/24 at 10:01 AM revealed that Resident #109 reported that a lady came into his/her room and put something into his/her rectum. On 7/26/24 at 9:45 AM, the surveyor interviewed the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON explained that Resident #109 kept reporting a rape since he/she was in the hospital. Resident #109's family member confirmed that the resident had been reporting a rape for a long time. However, there was no incident at the hospital or the facility. The surveyor requested facility self reported incident documentation for Resident #109's case. The NHA said, We were not able to find the file for this case. I wish I had a files for you. But I don't have. The NHA stated that any reportable incidents should be investigated by the Director of Nursing and/or Nursing Home Administrator, and they are supposed to keep the files. 5) On 7/25/24 at 1:20 PM, a review of facility-reported incident MD00186359 revealed that on 11/28/22 Resident #112 reported that a Geriatric Nursing Assistant hit his/her hand. Further review of the facility's investigation on 7/25/24 at 1:30 PM revealed that the facility submitted an initial self-reported incident on 11/28/22. However, there was no follow-up report. Also, 56 other residents' interview/observation forms were found without a written date and information about who conducted the interviews or observations. In an interview with the Director of Nursing (DON) on 7/25/24 at 3:28 PM, the DON stated that the facility should have documentation of follow up report of each self reported incident. The surveyor shared concerns regarding the leak of the investigation about Resident #112's abuse incident. The DON validated this. 48168 6) On 7/23/24 at 2:41 PM a review of the Office of Health Care Quality's (OHCQ) report of FRI #MD00207558 described an incident that occurred on 7/11/24 when Resident #20 was found to be excessively sleepy and was subsequently treated with Narcan. On 7/23/24 at 2:43 PM a review of the facility's investigation records of the incident revealed a copy of the initial report to OHCQ which indicated a date but lacked the time the report was made. The file also contained medical records that documented the nurse's assessment of the resident's condition and collaboration with the on-call physician, a list of Resident #20's medications, a list of other residents who had orders for narcotic medications, a handwritten notice that listed a police case number and officer name from Elkton PD. There was also an education sheet with the topic Use of Narcan; Hospice (when to call) with an attached attendance form, but both were undated. No staff or resident interviews or statements were included in the file and no explanation for the incident was documented in the file. Although a copy of the initial report to OHCQ was present, the final 5-day report to OHCQ was not present in the investigation file. On 7/29/24 at 1:30 PM an interview with the Director of Nursing (DON) was conducted. When asked about the incident, he explained that Resident #20 was under hospice care for a terminal condition and had been very lethargic. He also explained that the nurse who worked with the resident on 7/11/24 called the on-call physician to report the resident's lethargy/excessive sleepiness, and was given an order to administer Narcan to reverse the effects of the narcotic medication. However, the nurse did not consult with any hospice staff regarding the resident's condition. The DON further explained that during the facility investigation, the primary physician was interviewed who said he did not agree that the resident should have received Narcan since the resident's lethargy was not due to the narcotics, but was due to a decline in condition. The DON confirmed that the facility's investigation file did not contain any written statement from the primary physician, or explanation of the facility's conclusion regarding their investigation. He also confirmed that the documentation of education provided to staff lacked the date that the education was provided, and he could not validate when the education occurred. On 8/08/24 at 9:10 AM an interview with the Nursing Home Administrator (NHA) was conducted and she acknowledged and validated that the facility's investigation of incident # MD00207558 was incomplete. 44441 7) On 7/24/24 at 11:30 AM, review of a facility reports MD00193085 had that on 9/1/22, Resident #27 was in his room, opened his window and walked to the gas station in front of the facility to buy a cigarette. Resident was found by one of the staff members and assisted back to the facility. A complete head to toe assessment was completed. No injuries were noted, local law enforcement was notified. Resident was moved to a different room with a window facing a courtyard. Other appropriate interventions were initiated to prevent future elopement. Further review of the investigative file documents was done on 7/26/24 at 11:08AM. Some of the documents could not be found such as, copies of the initial and final reports, copies of the one-on-one supervision provided to the resident and the post elopement staff education sign in sheets. The facility was asked to provide the missing documents. On 7/29/24 at 1:25PM the Director of Nursing (DON) was asked again about the missing documents. He stated that his computer was down at some point, he sent it out for repairs but when it came back, all the documents stored within was wiped out. The DON said he sent it back to be retrieved and is still waiting to find out if that was possible. He was made aware that this was a concern as the facility was unable to provide proof that a thorough investigation was conducted. 31145 8) On 7/30/24 at 8:47 AM a review of facility reported incident MD00187669 revealed on 1/11/23, Resident #129 alleged that Staff #34 spoke to the resident, in a nasty manner and mean manner and screamed at the resident. Review of the facility's investigative packet that was given to the surveyor on 7/30/24 revealed (6) employee statements, (1) resident statement, care plans and the Medication Administration Record (MAR) for Resident #129. There were no other resident interviews on the unit and there was no training in the file. On 7/30/24 at 9:10 AM the Director of Nursing (DON) was interviewed and stated there was no other documentation regarding the incident. The DON was informed that there was no documentation as to the date of the incident, no resident interviews, and no documentation of suspension of the employee or staff education. On 8/6/24 at 2:15 PM the Nursing Home Administrator was informed. 9) On 7/31/24 at 8:38 AM a review of complaint MD00204146 revealed an allegation that staff were changing Resident #102 and during that process dropped the resident onto the floor which resulted in a fractured hip. Review of the facility's investigation into the fall revealed that the fall was unwitnessed. On 7/31/24 at 12:15 PM a review was conducted of the fall investigation given to the surveyor by the DON. The investigation consisted of a word document that stated, Resident presented with pain to hip to nursing staff, nursing staff reports resident had fallen 3 days prior. The document stated pain evaluation and x-rays were done, family was notified, resident discharged to ER (emergency room ) and then to another facility from the ER. In the investigation there were only 3 witness statements, from RN #19 and GNA #25. There was a document that stated, multiple attempts made, and agency called several times. Would not locate GNA. Also included was a copy of the 3/25/24 nursing schedule. The DON was asked if there was any other information related to the fall and the response was, that's all I have. On 8/1/24 at 11:10 AM the complaint was discussed with the Corporate Nurse #36 who confirmed that the incident was not thoroughly investigated. 34484 10) Review of Resident #120's medical record on 8/2/24 revealed Resident #120 was admitted to the facility on [DATE] following a hospitalization and on 1/6/23 at 10:00 PM the Resident was found on the floor. At that time the facility staff were asked if there was any investigation into Resident #120's unwitnessed fall to the ground. Interview with the Infection Preventionist on 8/2/24 at 8:55 AM confirmed the facility had no staff interviews or investigation of Resident #120's fall on 1/6/23.

Based on medical record review, observation, and interview, it was determined the facility failed to ensure that facility staff utilized effective infection control practices to prevent the spread of COVID-19. This was evidenced by: 1. Failing to isolate residents after possible exposure to COVID-19. This was evident for 4 out of 4 residents reviewed. (Residents #3, #9, #10, #12); 2. Failing to maintain a new admission resident on 14-day observation for COVID-19 in a private room. This was evident for 1 out of 4 residents reviewed. (Resident #4); and 3. Failing to cohort staff for COVID-19 positive residents. This was evident for 4 out of 4 residents reviewed. (Residents #1, #2, #3, #11). These practices increased risk of harm and possible death to all residents, staff, and visitors during a declared health emergency. As a result of these findings, an immediate jeopardy was declared on 11/24/20 at 2:25 PM. The facility submitted a plan of removal at 7:58 PM and it was accepted by the State Agency at 8:10 PM. The findings include: 1. Failure to isolate residents after exposure to a COVID-19 positive resident. On 4/30/2020 the Centers for Disease Control and Prevention (CDC) published guidance entitled Responding to Coronavirus (COVID-19 in Nursing Homes. This guidance provided that for a resident with new-onset suspected or confirmed COVID-19, roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. On 7/21/20 the Maryland Department of Health (MDH) issued updated guidance entitled Preparing for and Responding to COVID-19 in Nursing Homes and Assisted Living Facilities. MDH indicated to place (potentially exposed to COVID-19) in a private room with a private bathroom, if possible. If the (resident) had a roommate, the roommate should also be kept in a separate room without a roommate. Review of the line listing of COVID -19 positive residents on 11/20/20 revealed 3 positive residents (Residents #1, #2 and #3). Further review of the line listing revealed all 3 residents were asymptomatic. Review of Resident #1 and #2's medical records revealed the Residents were cohorted on 11/14/20 to the COVID-19 positive unit after both residents received a COVID-19 positive laboratory result from a test conducted on 11/11/20. During interview with the Assistant Director of Nursing (ADON) on 11/20/20 at 1:30 PM, she stated the facility staff were notified of the lab results on 11/13/20 at 10:42 PM and the facility staff immediately cohorted Resident #1 and #2 in the same room. Prior to the cohorting of Resident #1 and #2, Resident #1 was roommates with Resident #12 and Resident #2 was roommates with Resident #3. a. On 11/14/20 Resident #12 who had been exposed to Resident #1 was moved into room [ROOM NUMBER]A with Resident #10 (who was confirmed negative for COVID-19 on 11/13/20), instead of placing Resident #12 in a private room for a 14 day observation for COVID-19. During interview with the ADON on 11/24/20 at 10:15 AM, the ADON stated the Director of Nursing (DON) made the decision on moving Resident #12 in the same room as Resident #10. b. On 11/14/20 Resident #3 who had been exposed to Resident #2 was moved into room [ROOM NUMBER]A with Resident #9 (presumed negative for COVID-19), instead of placing Resident #3 in a private room for a 14-day observation for COVID-19. Review of Resident #9's medical record revealed the Resident was admitted to the facility on [DATE] and had completed his/her 14-day observation period and was located on the COVID-19 negative unit. Review of Resident #3's medical record revealed the Resident was tested on [DATE] and received a COVID-19 positive result on 11/19/20. Resident #3 was moved to the COVID positive unit on 11/19/20. During interview with the ADON on 11/24/20 at 10:15 AM, the ADON stated the DON made the decision on moving Resident #3 in the same room as Resident #9 on 11/14/20. Review of the facility's census provided by the Administrator revealed the facility had 4 empty rooms on 11/14/20. c. On 7/21/20 the Maryland Department of Health (MDH) issued updated guidance entitled Preparing for and Responding to COVID-19 in Nursing Homes and Assisted Living Facilities. MDH provided do not move a resident to the COVID-19 unit unless they test positive. Review of Resident #9's medical record revealed on 11/19/20 Resident #9 was moved to the COVID-19 positive unit without a COVID-19 positive laboratory result. Resident #9 was placed again in a room with Resident #3 who is COVID-19 positive. As of 11/24/20 Resident #9 remains on the COVID-19 positive unit. Review of the facility's census provided by the Administrator revealed the facility had 9 empty rooms on 11/19/20. During interview with the Administrator on 11/23/20 at 9:23 AM, the surveyor requested and interview with the DON. The Administrator stated the DON was unavailable for interview due to being on leave and was last in the building on 11/17/20. During interview with the ADON on 11/23/20 at 10:40 AM, the ADON stated Resident #9 was moved to the COVID-19 positive unit because he/she refused to be tested and was already exposed for to Resident #3 for approximately one week. The ADON also stated at that time the Physician #1 was notified on 11/19/20 of Resident #3's positive COVID 19 laboratory test and Resident #9's refusal to be tested for COVID-19. The ADON then stated Physician #1 directed the facility staff to move Resident #3 and #9 to the positive COVID unit. Further review of Resident #9's medical record revealed the following nurses' notes: -On 11/23/20 at 6:31 PM Resident with nonproductive cough. -On 11/23/20 at 10:43 PM Patient noted with elevated temperature 100.1. -On 11/24/20 at 2:08 PM Resident verbalized having difficulty breathing overnight and wanted to know if he/she could have [MEDICATION NAME] as he/she used to get it in the hospital. [MEDICATION NAME] is a [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways and increases air flow to the lungs. During interview with Physician #1 on 11/24/20 at 12:25 PM, Physician #1 stated she instructed the facility staff to move both Resident #3 and Resident #9 to the same room on the COVID positive unit because she considered Resident #3 and Resident #9 the same household. Physician #1 then stated Resident #9 was considered already exposed to Resident #3 and since he/she was refusing to be tested for COVID-19 it was best to keep them together on the COVID-19 unit. During interview with the Medical Director on 11/24/20 at 12:40 PM, the Medical Director stated Resident #9 has difficult behaviors, refuses to wear a mask in his/her room and refuses to be tested for COVID-19. The Medical Director stated he considered Resident #9 positive for COVID-19 and even if the Resident tested negative for COVID-19, the Resident is treated as a high-risk exposure and therefore it is best to keep Resident #3 and Resident #9 together. 2. Failure to maintain a newly admitted resident on 14-day observation for COVID-19 in a private room. According to guidance from the CDC reviewed by surveyors on 6/18/20 entitled Coronavirus Disease 2019 (COVID-19): Nursing Homes & Long-Term Care Facilities and located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, the CDC advises to Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown: Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (health care providers) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Review of new admissions and readmissions since 11/1/20 revealed Resident #4 was admitted to the facility on [DATE] to room [ROOM NUMBER]A, a private room. Further review of the medical record revealed on 11/4/20, one day after admission, Resident #4 was moved to room [ROOM NUMBER]B with Resident #5. Review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE], therefore Resident #5 was not currently on 14-day observation for COVID-19. Review of the facility's census provided by the Administrator revealed the facility had 4 empty rooms on 11/4/20. Interview with the ADON on 11/23/20 at 10:40 AM confirmed the facility staff failed to maintain Resident #4 in a private room for 14-day observation for COVID-19 in a private room. 3. Failure to cohort staff for COVID-19 positive residents. On 4/2/2020 the Centers for Medicare and Medicaid Services released the following under COVID-19 Long-Term Care Facility Guidance: 5. To avoid transmission within long-term care facilities, facilities should use separate staffing teams for COVID-19-positive residents to the best of their ability, and work with State and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status. On 4/5/2020, the Maryland Secretary of Health issued a Directive and Order Regarding Nursing Home Matters Pursuant to Executive Order No. 20-04-05-01 I The order stated: Staff Assignments: Nursing homes shall immediately implement, to the best of their ability, the following personnel practices: - Establish a cohort of staff who are assigned to care for known or suspected COVID-19 residents. Guidance from the Centers for Disease Control (CDC) with a revision date of 4/30/2020 and titled Responding to Coronavirus COVID-19 in Nursing Homes indicated the following under the subheading Resident Cohorting: -Assign dedicated HCP to work only on the COVID-19 care unit. During tour of the facility's observation and COVID-19 positive units on 11/20/20 at 8:45 AM, LPN #1 was the only nurse seen on both the observation and COVID-19 positive units. During interview of LPN #1 at the time, she confirmed she was assigned both observation and COVID-19 positive residents. During interview with the Administrator on 11/20/20 at 10:30 AM the Administrator stated the facility did not have any staffing shortages. The surveyor reviewed the staffing sheets from 11/14/20 until 11/23/20 day shift with the Administrator and ADON on 11/23/20 at 10:05 AM. At that time the ADON confirmed the following dates and shifts when the facility had staff providing care for both COVID-19 positive residents and observation residents: a. 11/14/20 day, evening, and night shift; b. 11/15/20 day, evening, and night shift; c. 11/16/20 day and night shift; d. 11/17/20 day, evening, and night shift; e. 11/18/20 day and night shift; f. 11/19/20 day, evening, and night shift; g. 11/20/20 day, evening, and night shift; h. 11/21/20 night shift; i. 11/22/20 night shift. During a conference call on 11/23/20 at 11:45 AM with the Administrator, ADON and Local Health Department Employee (LHD #1), the surveyor advised LHD #1 the facility was not cohorting staff on the COVID-19 positive unit. LHD #1 told the facility that they should be cohorting staff on the COVID-19 positive unit. The Administrator told LHD #1 the facility was having difficulty getting staff. LHD #1 asked the Administrator if she would like assistance from LHD in attempting to get staff for the facility. The Administrator stated, yes. LHD #1 told the Administrator she would request staff for the facility with MD (Maryland) Responds. As a result of these findings, a state of immediate jeopardy was declared on 11/24/20 at 2:25 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a plan at 7:58 PM and it was accepted by the state agency at 8:10 PM. The provisions of the plan to remove the immediacy had a completion date of 11/30/20 and included the following: For Part 1: 1. Resident #9 is now in a private room on COVID-19 positive unit due to refusal to move. Resident #10 and #12 moved to PUI unit. All residents tested for COVID-19. 2. Regional Director of Clinical Operations educated Administrator and DON on proper cohorting of COVID-19 positive, PUI, observations residents and importance of moving residents immediately. 3. All facility staff including medical director and other physicians educated on proper cohorting of COVID-19 positive residents, PUI observation and importance of moving residents immediately based on positivity of lab results and/or exposure. 4. DON to audit daily COVID-19 test results for residents. Administrator to audit COVID-19 units daily. Audits to QAPI (Quality Assurance Performance Improvement) to assure all residents test results have been reviewed and COVID-19 positive residents are moved and cohorted appropriately. Audits to QAPI for review to determine need for further audits and/or action plans. For Part 2: 1. Resident #4 has been discharged . Resident #5 has tested negative for COVID-19 and shows no signs and symptoms. 2. Audit of admissions to facility for last 14 days completed to ensure that these residents are in the PUI unit and in single rooms for the complete 14-day of their observation period. All new admissions moving forward will be placed in the PUI unit in single rooms for the duration of the 14-day observation period. 3. Regional Director of Clinical Operations educated Administrator and DON/ADON on proper room assignments for new admissions to the PUI for the appropriate length of time. All facility staff including medical director and other physicians educated on proper room assignments for new admissions to the PUI for the appropriate length of time. 4. DON will daily audit admissions to assure new admissions are placed on the PUI unit for appropriate 14-day time frame. Audits to QAPI for review to determine need for further audits and/or action plans. Part 3: 1. Staffing assignments have been changed to have separate staff assigned to the PUI and COVID-19 positive units. 2. Staffing assignments have been reviewed to reflect the need to have separate staff assigned to the PUI and COVID-19 positive units. 3. Regional Director of Clinical Operations educated Administrator, DON, and Staffing Coordinator on need to have separate staff assigned to PUI and COVID-19 positive units. All facility staff educated by Administrator and Regional Director of Clinical Operations on proper staff assignments to the PUI and COVID-19 units. 4. DON will audit daily schedules to ensure that the PUI and COVID-19 positive units are assigned by different staff. Audits to QAPI to determine the need for further audits and/or action plans. The Immediate Jeopardy was removed on 11/30/2020 at 2:35 PM after on-site confirmation of the completion of the facility's plan of removal.