Every finding on record at Layhill Nursing and Rehabilitation Center

Based on record reviews and interviews, it was determined that the facility failed to implement a physician's order to treat a resident's non-pressure-related skin issues. This was evident in one (Complaint #2743075) of five complaints investigated during the complaint survey. The findings:A review of Complaint #2743075 noted an allegation that a physician's order was placed for Resident #103 to have a prescription lotion applied to the resident's lower extremities, but the order was not carried out. A review of Resident #103's medical record on 7/9/26 at 9:31 AM included a wound provider's notes dated 1/5/26, stating that Resident #103 had lower legs lymphedema [ a condition where extra fluid gets trapped in the body, making a part of the body like an arm or a leg look puffy or feel heavy] wounds. The treatment recommendations were to: 1. Cleanse with soap and water, pat dry. 2. Apply Ammonium lactate 12% to the base of the wound. 3. Secure with leave open to air.4. Change BID (Twice per day). Continued review of Resident #103's order summary as of 1/14/26 showed a physician's order initiated on 1/8/26 for Ammonium Lactate External Lotion 12% (Lactic Acid) Apply to LOWER LEGS topically two times a day for lymphedema. Cleanse with soap and water, pat dry, then apply lotion to lower legs. Further review of Resident #103's treatment administration record (TAR) for January 2026 revealed the following:On 1/8/26 at 5:00 PM, 1/9/26 at 9:00 AM, and 1/12/26 at 9:00 AM and 5:00 PM, staff documented in the TAR that the treatment was completed.On 1/9/26 at 5:00 PM, 1/10/26, 1/11/26, and 1/13/26, staff recorded that the facility was waiting for pharmacy to deliver the lotion, so Resident #103's treatment was not administered on those dates. During an interview with the director of nursing (DON) on 7/10/26 at 2:31 PM, she reported that the facility did not receive Resident #103's lotion from the facility's pharmacy as expected. As a result, the treatment was not completed from 1/8/26 to 1/13/26. She did not expect her staff to document that Resident #103's treatment was completed on 1/8/26 at 5:00 pm, 1/9/26 at 9:00 AM, and 1/12/26 at 9:00 AM and 5:00 PM. The DON explained that she had called the pharmacy and was awaiting a callback to explain why Resident #103's Ammonium Lactate lotion, ordered by the Resident's physician on 1/8/26, had not been delivered to the facility. A follow-up interview with the DON on 7/13/26 at 9:31 AM indicated that the facility's pharmacy believed Resident #103's Ammonium Lactate was in the facility's house stock of lotions for treatment and therefore did not deliver it. However, the facility expected the pharmacy to deliver the lotion because the facility did not have it. The DON explained that the miscommunication was addressed across the board after the surveyor's intervention. The DON added that she also provided her staff with education on her expectations regarding new orders for residents and on documentation of treatment.

Based on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided according to professional standards of practice that included non-pharmacological interventions (NPI) attempted/provided to a resident prior to administering as needed (PRN) pain medication and reordering routine pain medication in a timely manner. This was evident for 1 (Resident #101) of 12 residents reviewed during the survey.The findings include:Resident#101 was admitted into the facility in late 2025 with diagnoses that included but was not limited to chronic pain. Complaint 3063662 indicated pain management concerns with the resident's care.A review of Resident #101's medical record was conducted on 7/10/26 at 10:28 AM. The review revealed medical orders for pain management that included Buprenorphine (a long-acting narcotic pain medication with instructions to administer routinely 2 times a day), Oxycodone (a short acting narcotic pain medication with instructions to administer every 4 hours PRN pain), and NPI's (with instructions to administer and document the specific number/s corresponding to the different interventions. 1. Propped and reposition resident for comfort. 2.Music/Television of interest as appropriate. 3.Basic/Simple message. 4.Distraction/Diversional activities 5. Reduce Stimulation: Dim light/Reduce noise 6. Bed rest if sitting up for extended period 7. Reminiscence/Guided imaginary)Resident #101's administration record for June 2026 was reviewed on 7/10/26 at 11:09 AM. The review revealed that the Buprenorphine was not administered for 3 consecutive doses (6/22 at 9AM, 6/22 at 9PM, and 6/23 at 9AM) and that the Oxycodone was administered 26 times with no documentation to indicate what NPI was administered/attempted prior to the administration. The Progress notes for Resident #101 were also reviewed on 7/10/26 at 11:55 AM. The review confirmed that the Buprenorphine was not administered on the dates listed above due to the medication not being available and staff were still waiting for the pharmacy to deliver. Furthermore, there was no documentation found to indicate that the nursing staff had provided or attempted any NPI's prior to administering the PRN Oxycodone.A review of the facility's pain management policy and procedures was conducted on 7/13/26 at 9:40 AM. Item #4 in the procedures read, Non-pharmacological interventions attempted prior to medication administration will be documented in the medical record with administration of PRN medication.The Director of Nursing (DON) was interviewed on 7/13/26 at 9:47 AM. During the interview, the concern was discussed that the nursing staff had failed to reorder Resident #101's routine narcotic pain medication in a timely manner and that no documentation was found to indicate that NPI's were administered/attempted prior to administering the PRN narcotic pain medication. The DON indicated that she would review the resident's medical record and report back to the surveyor.On 7/13/26 at 1:06 PM, the DON confirmed and acknowledged the concerns listed above.

Based on observations, record review, and interviews, it was determined that the facility failed to ensure food and equipment was prepared in a manner that maintains professional standards of food service safety and sanitation. This was found to be evident for 2 (Cook #1 and Dietary Aide #2) out of 4 kitchen staff and 1 commercial dishwasher observed during the recertification and complaint survey. This practice had the potential to affect all Residents who consumed food prepared by the facility's kitchen. The findings include: A beard net is a lightweight, disposable, and breathable mesh covering-typically made from nylon or polypropylene-designed for food service workers to cover facial hair and prevent hair from falling into food. It ensures compliance with FDA Food Code standards to prevent contamination, featuring an elastic band for a secure, universal fit.During observations conducted 02/09/2026 at 8:28 AM of the initial tour in the facility's kitchen, the Surveyor observed [NAME] #1 and Dietary Aide #2 without wearing a beard net. Wet nesting is the unsafe practice of stacking, nesting, or storing dishes, pots, and pans while they are still wet, which prevents proper air circulation. This creates a dark, moist, low-air environment that fosters rapid bacterial growth and mold, creating a significant health violation in foodservice settings. FDA guidelines mandate that all wares should be air dried. Using towels to dry dishes is never permitted. During the continued initial tour, the Surveyor and [NAME] observed wet nesting in between the silver metal pans that were stacked on the metal rack inside the kitchen and plastic cups stacked on a tray by the steam table.Commercial dishwashers generally reach between 150 degrees Fahrenheit (F) and 180 degrees (F) to sanitize, depending on the type. High-temp machines require a final rinse of 180 degrees (F) for heat sanitation, while low-temp machines operate at lower temperatures, typically at least 120 degrees (F) relying on chemicals instead.During a follow up tour of the kitchen conducted on 02/12/2026 at 11:00 AM, the Surveyor observed Dietary Aide #2 run the commercial dishwasher located in the dish room. The Surveyor observed the wash and rinse cycle and discovered that the rinse temperature was 160 degrees Fahrenheit. The Surveyor asked the Dietary Aide to run the dishwasher again; the rinse cycle temperature again read 160 degrees Fahrenheit. The Surveyor asked the District Dietary Manager to run the commercial dishwasher. The dishwasher was ran 2 times with the same results for the rinse cycle temperature of 160 degrees Fahrenheit. The District Dietary Manager reported that the dishwasher was a high temperature dishwasher which required a rinse cycle 180 degrees (F). The District Dietary Manager reported that he would contact the facility's dishwasher repair vendor Ecolab immediately for repair. A review of the dishwasher temperature log from February 1, 2026 through February 12, 2026, showed the temperatures for wash and rinse were documented at 180 degrees (F). During an interview conducted on 02/12/2026 at 12:00 PM, the District Dietary Manager reported that Ecolab was scheduled to come to the facility today (02/12/2026). The District Dietary Manager also reported that the commercial dishwasher was converted to chemical instead of high temp. On 02/12/2026 at 12:10 PM, the Surveyor observed the commercial dishwasher now running on a chemical cycle for wash and rinse. The wash and rinse temperatures were maintained at 140 degrees (F).

Based on interviews and record review it was determined that that facility failed to ensure Resident personal funds were fully accessible. This was found to be evident for 54 out of 54 Residents who have Resident Fund Accounts. The findings include: During an interview conducted on 02/09/2026 at 8:30 AM, Resident #11 reported that his/her money from the Resident Fund Account is not always available during the week and never available on the weekends or holidays. The Resident was unable to provide a time period or date when he/she could not access their personal funds. During an interview conducted on 02/12/2026 at 1:32 PM, the Business Office Manager (BOM) reported that Resident funds are available at the front desk from Monday - Friday from 7:45 AM to 6:00 PM or 7:00 PM when she leaves for the day. On weekends and holidays Resident funds are available at the front desk from the hours of 7:45 am to 5:00 pm. The BOM stated that during the week she maintained a balance of $200 a day at the front desk and on the weekends and holidays she gave the front desk $50.00 for the entire weekend or holiday. The BOM explained that she made sure that all Residents received their money on Fridays to ensure the Residents would not have a need to get money from the front desk on weekends and holidays. The BOM reported that those Residents who wanted funds on the weekends would receive $5-$10, however that was rare because she made sure all Residents received the money they would need on Fridays. During a review of the Resident Fund Management Service report conducted on 02/18/2026 at 10:02 AM it was discovered that there are 54 Residents who have a Resident Fund account. During an interview conducted on 02/18/2026 at approximately 10:30 AM, the Director of Nursing (DON) reported that the front desk receptionist hours are from 7:00 AM and 10:00 PM seven days a week including holidays. The DON reported that Residents can access their Resident funds during those hours. The Surveyor expressed concern that the front desk had a total of $50.00 for the entire weekend and holidays for 54 residents who had a Resident Fund Account. The Surveyor also expressed concern that if a Resident was not available to receive their money on Friday the Resident would receive limited funds on the weekends and/ or holidays.

Based on observations, interviews and record review, it was determined that the facility failed to ensure 1) Residents were free of physical restraints and 2) a physician order was obtained for the use of a physical restraint. This was found to be evident for 1) 4 (Resident #16, #27, #4, & #11) out of 4 Residents reviewed for restraints and 2) 47 (Resident #90, #142, ##107, #146, #86, #137, #129, #81, #145, #70, #75, #68, #144, #91, #109, #99, #10, #147, #66, #119, #12, #84, #133, #124, #92, #56, #9, #47, #52, #37, #55, #41, #39, #59, #128, #105, #113, #11, #49, #13, #98, #102, #62, #25, #53, #104, & #34) out of 47 Residents reviewed for physician orders for physical restraints during the recertification and complaint survey. The findings include: 1 )According to Centers of Medicare and Medicaid Services (CMS), positioning a bed directly against a wall prevents a resident from exiting is considered a physical restraint. Such actions limit freedom of movement and, unless clinically justified for a specific medical symptom and properly documented, are prohibited as they violate patient rights regarding autonomy and safety.During an initial tour of the second-floor nursing unit conducted on 02/08/2026 at 8:35 AM it was discovered that Resident #16, #27, #4, & #11 beds were positioned directly against the wall. A CMS-defined care plan is a structured, person-centered document that outlines a patient's specific health issues, goals, and the medical or supportive services needed to manage them. It serves as an actionable, often electronic, instruction manual for care teams, incorporating assessments, treatments, and coordination across providers.A review of Resident #16, #27, #4, & #11 care plans conducted on 02/08/2026 at 2:45 PM did not show a care plan that the Residents requested to have their bed placed against the wall. During an interview conducted on 02/11/2026 at approximately 8:30 AM, the Surveyor expressed concerned with the Director of Nursing (DON) that Residents #16, #27, #4, & #11 beds were positioned directly against the wall which was a physical restraint. The DON reported that she would conduct a facility sweep to ensure the Resident's beds were not positioned against the wall. Those Residents who had a bed positioned against the wall would be immediately removed from the wall. During an interview conducted on 02/12/2026 at 7:00 AM, the DON reported that staff conducted facility sweep and moved Residents beds 18 inches from the wall. The DON reported that as of 02/11/2026 all Resident beds had been moved from against the wall apart from the Residents who refused to have their beds moved. The DON provided the Surveyor with a list of Residents who refused to have their beds removed from the wall.A review of the list showed there were 47 Residents who were now care planned for their refusal to have their beds moved from against the wall. During a review of the Resident #90, #142, ##107, #146, #86, #137, #129, #81, #145, #70, #75, #68, #144, #91, #109, #99, #10, #147, #66, #119, #12, #84, #133, #124, #92, #56, #9, #47, #52, #37, #55, #41, #39, #59, #128, #105, #113, #11, #49, #13, #98, #102, #62, #25, #53, #104, & #34 medical records conducted on 02/11/2026 from 7:33 AM to 8:52 AM, it was discovered that the Residents did not have a physician's order for a physical restraint.

Based on observations and interviews it was determined that the facility failed to ensure Residents had a comfortable chair in their room. This was found to be evident for 5 (Resident #40, #41, #12, #108, & #11) out of 5 Resident rooms observed during the recertification and complaint survey. The findings include: During random observations conducted on 02/08/2026 from 9:23 AM to 1:37 PM, the Surveyor was unable to locate a chair in Resident #40, #41, #12, #108, & #11 rooms. During interviews conducted on 02/08/2026 from 9:23 AM to 1:37 PM Residents #40, #41, #12, #108, & #11 confirmed that they did not have a chair in their room. During an interview conducted on 02/18/2026 at approximately 8:00 AM, the Director of Nursing (DON) was given the room numbers of each resident that did not have a chair in their room. The DON reported that each resident should have a chair in their room.

Based on record reviews, interviews and observations, it was determined that the facility (1) failed to provide access to services outside the facility and (2) failed to ensure Residents were provided a dignified existence. This was found to be evident for 2 (Resident #22 and #41) out of 2 Residents observed for resident rights. The findings include: (1) A CT (computed tomography) scan is a quick, painless, non-invasive imaging procedure that uses rotating X-rays to create detailed, cross sectional slices of bones, blood vessels and soft. tissues. Usually lasting only 10 to 15 minutes, these scans are used to diagnose injuries, diseases, or guide treatment. During a review of medical records for Resident #22 on 2/12/2026 at 8:07 AM it was found that the Resident had an appointment with his/her neurosurgeon's office on 5/21/2025, following this appointment the provider ordered for a CT scan of the Resident's head to be completed with the results being sent to the neurologist. During additional review of medical records for Resident #22 a progress note date 5/22/2025 at 12:16 PM was revealed that stated to Order head CT without contrast. Results to be faxed to neurosurgeon. There was also an order dated 5/22/2025 which stated, Schedule CT of head without contrast to follow-up and Fax result to patient's Neurosurgeon. During continued review of medical records for Resident #22 it was discovered that there was no documentation of a CT scan being scheduled or completed for the Resident following this order from 5/22/2025. During an interview with Unit Manager #5 on 2/12/2026 at 3:43 PM she reported that the appointment should've been scheduled as ordered but it was not completed. She advised that the Unit clerk had attempted to make the appointment for the CT but was told their system was down when she called and was supposed to call back to schedule the CT appointment but did not. She advised the resident ended up going to the emergency room in July 2025 and had a CT while there, so she stated she would contact the neurosurgeon's office to ensure they received a copy of the results. During an interview with Unit Clerk #19 on 2/17/2026 at 1:32 PM she reported that she had made the initial phone call to schedule the CT for Resident #22 and was told their system was down. She advised she was supposed to call back to schedule the appointment and confirmed that a second call to schedule the appointment was never made. (2) During an observation conducted on 02/09/2026 at 8:02 AM, the Surveyor observed Licensed Practical Nurse (LPN) #16 knock on Resident #41's entry door and then entered the Resident's room. The LPN entered the Resident's room without gaining permission and without announcing who she was. During an interview conducted on 02/09/2026 at 8:04 AM, LPN #16 was asked what the expectation was when entering a Resident's room. The LPN replied you knock and then enter, when asked does she wait for permission to enter and does she announce herself, the LPN stated yes. The LPN stated that when she entered Resident #41's room today she was trying to see who was in the Resident's room. The Surveyor observed the LPN holding a clip board and blood pressure cuff when she entered the Residents room without permission and unannounced.

Based on observations and interviews, it was determined that the facility failed to provide a homelike environment. This was found to be evident for 4 (Residents #53, #22, #62 and #119) out of 27 resident rooms observed for homelike environment during the course of the survey.The findings include: (1) During an observation of the room for Resident #53 on 2/09/2026 at 11:04 AM a large white area where the paint had peeled or had been scraped off was discovered behind the Resident's bed. An additional observation was made of a small dresser used by Resident #53 which revealed the bottom drawer was lopsided, not closing completely and was missing a handle. During an interview with Resident #53 on 2/09/2026 at 11:05 AM he/she reported that he/she had been in the room for years and that the white area behind the bed had been there since coming to the room. Resident #53 advised the dresser had been supplied by the facility and had been missing the handle to the bottom drawer since being transferred into the room. During an interview with the Maintenance Director on 2/18/2026 at 11:26 AM he advised nursing staff notify him by word of mouth and they have an electronic reporting system to notify maintenance of any concerns. He also reported that he and his assistant would complete rounds on random rooms to identify areas needing to be repaired. He advised that he had been working to get rooms in the facility painted but was trying to get help. During an observation with the Maintenance Director on 2/18/2026 at 11:32 AM of the room for Resident #53 he agreed the wall needed to be painted and the dresser needed to be repaired. He reported that he was not notified of the wall, lopsided drawer or the missing handle to the drawer. He was able to fix the drawer so it would slide back in appropriately and advised he would get a new handle for the drawer. He added he would add the room to the list of rooms needing painted. (2) During an observation of inside the room for Residents #22 and #62 on 2/09/2026 at 12:51 PM it was discovered to have a large area above and to the right of the Residents doorway had been painted over with a white color that did not match the room's coloration. Additional observations of the wall near the doorway revealed several black streaks running along the lower wall and additional patches of white paint along with white paint drips were noted on the mid and upper wall. During an interview with the Maintenance Director on 2/18/2026 at 11:26 AM he advised nursing staff notify him by word of mouth and they have an electronic reporting system to notify maintenance of any concerns. He also reported that he and his assistant would complete rounds on random rooms to identify areas needing to be repaired. He advised that he had been working to get rooms in the facility painted but was trying to get help. During an observation with the Maintenance Director on 2/18/2026 at 11:30 AM of the room for Residents #22 and #62 he agreed the walls needed to be painted. He advised he would add the room to the list of rooms that needed to be painted. (3) During an observation conducted on 02/09/26 at 12:11 PM, the Surveyor observed Resident #119's bed against the wall. The wall had large areas of paint that had peeled. During an interview the Resident stated that the wall had been like that for some time. During a tour with the Maintenance Director conducted on 02/09/26 at 1:47 PM the Surveyor and the Maintenance Director observed Resident #119's wall that had peeling paint on the wall next to the resident's bed. During an interview conducted on 02/09/26 at 1:49 PM, the Maintenance Director reported that the Maintenance Assistant and himself conduct rounds on randomly selected rooms and if they identify areas for repair either the assistant or himself will make the repair to the area of concern. The Maintenance Director reported that he was unaware of the peeling paint in Resident #119's room and stated that he would repair the wall. The Maintenance Director further stated that the facility had a formal reporting system but because both him and his assistant are on the floor regularly, the staff and residents report maintenance concerns to them in person.

Based on record reviews and interviews it was determined that the facility failed to ensure the Resident/Resident Representative and Ombudsman received notification of a proposed transfer. This was found to be evident for 1 (Resident #27) out of 1 Resident reviewed for transfer during the recertification and complaint survey. The findings include: A review of complaint #2734130 submitted to the Office of Health Care Quality (OHCQ) was conducted on 02/11/26 at 6:00 AM. The complainant, who was Resident #27's Representative, reported that the facility failed to provide notification of a proposed transfer of Resident #27 to another Skilled Nursing Facility (SNF) for Long Term Care. During an interview on 02/11/26 at 6:45 AM the Business Office Manager (BOM) reported that Resident #27 was referred to another facility because the facility was bed locked and the facility needed to transfer residents out to open beds for rehab. She further stated that at the same time unaffiliated facilities reached out to Layhill inquiring if they had residents they could transfer to their facility due to their low census. The Surveyor questioned the BOM if that was that normal practice for random facilities to contact Layhill to obtain Residents when they experience low census. The BOM stated yes, it's called Quid Pro Quo.We work with each other. The Resident was identified as a Resident that could be transferred out because he/she was easy going and did not have behaviors. When asked if the Resident's Representative was notified she replied yes, however she was not the person who notified the Representatives. She reported that she thought maybe Social Services made the notifications. During an interview conducted on 02/12/26 at 12:05 PM the complainant reported that a family member was contacted by Kensington Rehab on 02/04/26 about Resident#27 being transferred to their facility. The complainant reported that he/she was the medical decision maker for the Resident and the facility was aware. The Representative reported that he/she was confused and upset that a family member was called instead. The complainant reported that after speaking with Kensington Rehab Admissions he/she immediately contacted the Business Office Manager (BOM) via email expressing his/her concern that the facility had attempted to transfer the Resident to another facility without first discussing the transfer and obtaining permission.During an interview conducted on 02/12/26 at 12:36 PM, the Social Service Director (SSD) reported that she received a list of residents to be referred out for transfers due to a bed lock. When asked what the facility's process was when transferring a resident to another Skilled Nursing Facility (SNF) the SSD reported that she sends the referrals out and then contacts the family. The SSD stated that she had not contacted Resident #27's Representative to discuss the transfer. When asked why she had not contacted the Representative the SSD reported that she was busy and that Kensington had reached out to the Representative quickly. During a review conducted on 02/12/26 at 12:55 PM, it was discovered that the SSD sent a referral for placement at [NAME] Grove on 01/27/26 and a referral on 2/04/26 for placement at Kensington Rehab. During an interview conducted 02/12/26 at 1:00 PM, the Director of Nursing (DON) reported that other facilities do not contact their facility to obtain Residents, and the facility absolutely does not engage in Quid Pro Quo of any sorts. The DON also reported that the facility's expectation is to contact and discuss a proposed transfer with the Resident or Resident Representative prior to sending out a referral. The Surveyor expressed concern that the Social Service Director (SSD) sent the first referral to transfer Resident #27 on 01/27/26 to [NAME] Grove. However, the first communication of the proposed transfer was made by the Representative to the facility on [DATE] after Kensington Rehab contacted a family member to discuss the transfer. During an interview conducted on 02/13/26 at 7:12 AM, the Ombudsman reported that she was not notified of the bed lock and residents referred out for transfer.

Based on interview and record review it was determined that the facility failed to ensure Resident care plans were developed. This was found to be evident for 2 (Resident #2 & #12) out of 27 Resident care plans reviewed during the recertification and complaint survey. The findings include: 1) During an interview conducted on 02/09/2026 at 2:36 PM, Resident #2 reported that he/she had experienced childhood trauma. The Resident stated that the trauma has messed my head up. A review of Resident #2's trauma screening conducted on 02/17/2026 at 12:59 PM showed that the resident screened positive for trauma. According to Centers for Medicare & Medicaid Services (CMS) guidelines, a care plan is a comprehensive, person-centered document that outlines a patient's medical, functional, and psychosocial needs, along with specific goals, treatments, and services. It serves as an actionable guide for managing chronic conditions and coordinating care across providers. A review of Resident 2's care plan conducted on 02/17/2026 at 1:03 PM did not show a care plan for trauma.During an interview conducted on 02/17/2026 at 1:57 PM, the Director of Nursing (DON) reported that the Social Service Director (SSD) should have triggered a care plan for trauma. The DON returned and confirmed that the Resident was not care planned for trauma. The DON stated that she would investigate it further and have the care plan updated to include trauma. 2) The Centers for Medicare & Medicaid Services (CMS) defines palliative care as patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. It involves addressing physical, intellectual, emotional, social, and spiritual needs throughout the continuum of a serious illness and can be provided alongside curative treatment.During a review of Resident #12's medical record conducted on 02/17/2026 at 9:26 AM, the Surveyor discovered an order for a Palliative care consultation on 11/26/25. During a review of Resident #12's care plan conducted on 02/17/2026 at 10:37 AM, it was discovered that the Resident did not have a care plan for Palliative Care. During an interview conducted on 02/17/2026 at 10:41 AM, the Director of Nursing (DON) confirmed that Resident #12 was on Palliative Care however did not have a care plan.

Based on record reviews, observations and interviews, it was determined the facility staff failed to revise care plans to meet the needs of the residents. This was evident for 2 (Residents # 15 and #13) of 2 residents reviewed for care plan revisions during the recertification survey.The findings include:A Care Plan is used in nursing facilities to summarize a resident's health conditions and care needs. It is used to ensure resident's needs are met and consistent care is provided to the resident based on those needs. 1. During a review of the care plan for Resident #15 on 2/11/2026 at 10:04 AM it was discovered that the Resident had a care plan with a focus that was added on 1/14/2024 and it stated the Resident wears a left hand splint and left elbow splint. The plan identified the goal as The resident will maintain their range of motion as much as possible throughout review period and the interventions included Periodic review by licensed nurse.During an observation of Resident #15 on 2/11/2026 at 12:07 PM it was noted that the resident was not wearing a splint on his/her left hand or elbow.During an observation with GNA #18 on 2/12/2026 at 9:20 AM she confirmed that Resident #15 was not wearing a splint and advised that he/she did not have a splint to wear.During additional record review on 2/12/2026 at 1:37 PM it was discovered that there was a previous order for Resident #15 which stated, Splint order - Patient to wear left hand splint and left elbow splint for 5 hours during the day. This order was discontinued on 6/11/2024.During an interview with Unit Manager #9 on 2/12/2026 at 2:38 PM she confirmed that Resident #15 did not have a splint that he/she should be wearing. She advised the resident had used splints in the past but did not use them any longer. She provided a list of Residents that required splints to be worn and Resident #15 was not on that list.During an interview with the Director of Nursing (DON) on 2/12/2026 at 2:48 PM she reported that the expectations are for the care plan to be updated quarterly or if something changes with the Resident's care. She advised that since Resident #15 was no longer using a splint as a part of his/her care, the care plan should have been updated to discontinue the plan for the left hand and elbow splint to be used. She advised anything in the care plan not matching orders should be removed.During a review of the facility's policy Care Planning on 2/18/2026 at 8:48 AM it was discovered that the Care plans will be updated on an ongoing basis as changes in the patient occur and reviewed quarterly with the quarterly assessment.2. During a review of the care plan for Resident #13 on 2/17/2026 at 9:13 AM it was discovered that the Resident had a care plan with a focus that was added on 4/15/2025 and it stated the the resident has a midline venous access site.During a review of the orders for Resident #13 on 2/17/2026 at 9:26 PM it was discovered that the resident had a midline and it was discontinued on 4/23/2025.During an interview with the Director of Nursing (DON) on 2/17/2026 at 1:12 PM she reported that the expectations are for the care plan to be updated quarterly or if something changes. She advised that since Resident #13 no longer had a midline the care plan should have been updated to discontinue the midline as a part of the resident's care.During a review of the facility's policy Care Planning on 2/18/2026 at 8:48 AM it was discovered that the Care plans will be updated on an ongoing basis as changes in the patient occur and reviewed quarterly with the quarterly assessment.

Based on record reviews and interviews it was determined that the facility failed to ensure nursing standards of practice were met. This finding was evident for 1 (Resident #9) of 1 resident reviewed for standards of practice during the recertification survey.The findings include:During an interview with Resident #9 on 2/09/2026 at 1:01 PM he/she reported having diarrhea every day for the last two weeks but advised he/she didn't feel the facility was doing anything about it. Clostridioides difficile (C. diff) is a bacterium causing severe, sometimes fatal, diarrhea and colon inflammation (colitis), often triggered by recent antibiotic use that disrupts normal gut flora. It frequently affects people in hospitals or nursing homes. Symptoms include watery diarrhea, fever, and abdominal pain. It is treated with specific antibiotics and, in recurring cases, fecal transplants. During a review of medical records for Resident #9 on 2/17/2026 at 1:14 PM it was discovered that an order for his/her stool to be tested for C. diff had been placed on 2/10/2026 at 3:47 PM and it was signed off as completed on the Treatment Administration Record on 2/11/2026 at 10:55 PM.During a continued review of medical records for Resident #9 it was revealed that there were no lab results for the order to test stool for C. diff.During a review of the Laboratory Orders and Results binder on 2/17/2026 at 1:48 PM it was discovered that the C. diff order was not signed off as being picked up by the lab but was labeled as no stool.During an interview with Licensed Practical Nurse (LPN) #8 on 2/17/2026 at 1:56 PM she confirmed that she had worked during the shift of 2/11/2026 and that Resident #9 did not have a bowel movement during her shift, so the specimen was not obtained. She advised that she had notified the oncoming shift that the specimen was still needed.An additional record review of the medical records for Resident #9 on 2/17/2026 at 1:59 PM it was discovered that there was daily documentation of the Resident having bowel movements after the order to test stool was placed. The bowel movements were documented as occurring on the night shift of 2/10/2026; the day, evening and night shifts of 2/11/2026; the day, evening and night shifts of 2/12/2026; the day evening and night shifts of 2/13/2026; the day, evening and night shifts of 2/14/2026; the day, evening and night shifts of 2/15/2026 and the day, evening and night shifts of 2/16/2026.During an observation of the Laboratory Orders and Results binder with the Assistant Director of Nursing (ADON) on 2/17/2026 at 2:17 PM she reported the lab technician wrote no stool on the stool order in the Draw Log when they came to pick up the specimens. She confirmed the lab did not pick up a specimen for that order.During an interview with the ADON on 2/17/2026 at 2:19 PM she reported that if no stool was obtained for the lab order it should not have been signed off as completed for Resident #9 and it should have been noted that the order was not done because the resident didn't have a bowel movement. She advised that the order for a stool sample is usually placed for a duration of one to two days and if the order for the specimen runs out due to the Resident not having a stool, we should communicate with the doctor so we can extend the order. She confirmed that this order should have been extended since the stool specimen was not obtained.During an additional medical record review 02/18/2026 7:40 AM it was discovered that a new order for Resident #9 to have stool tested for C. diff was placed on 2/17/2026 at 3:19 PM.

Based on record reviews and interview it was determined that the facility failed to ensure Pharmacy Medication Regimen Review (MRR) recommendations were reviewed in a timely manner. This was found to be evident for 1 (Resident #4) out of 5 Residents reviewed for unnecessary medications during the recertification and complaint survey. The findings include: A pharmacy Medication Regimen Review [MRR] is a comprehensive evaluation of all a patient's medications-prescription, OTC [over the counter], and herbal-conducted by a pharmacist to ensure safety, efficacy, and appropriateness. It identifies, prevents, and resolves issues like drug interactions, duplicate therapies, improper dosages, and noncomplianceOn 02/18/2026 at 8:33 AM a review of Resident #4's MRR showed that the physician had not reviewed the pharmacy recommendations within the 30 days per the facility's policy. On 09/20/2025 the pharmacy made a recommendation for a reduction in the dosage from 40 milligram (mg) to 20 mg for Pantoprazole. The physician reviewed, agreed and signed the recommendation on 11/15/2025. A review of the Medication Administration Record (MAR) showed that the dosage was decreased to 20 mg on 11/21/2025 although the pharmacy recommended the decrease in dosage on 09/20/2025. Further review of the Resident #4's MRR showed that on 11/23/2025 the pharmacy made a recommendation that stated Risk: Antidepressants with antiplatelet effects (e.g. Sertraline HCI Oral Tab 50 milligram) may enhance the anticoagulant effect of direct oral anticoagulants (e.g. Eliqius Oral Tablet 5 milligram). The physician reviewed the recommendation and selected the section that stated no change at this time as the benefit outweighs the risk. The physician signed the recommendation on 02/13/26 although the recommendation was made 11/23/2025. During an interview conducted on 02/18/2026 at 8:52 AM, the Director of Nursing (DON) stated that she saw that there was a delay in the physician review and response to the pharmacy recommendations. She further stated that she would speak to the providers on the timeliness of their pharmacy medication review recommendations.

Based on observation, interview and record review, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 3 out of 29 medications administered during the observation.The findings include:Dysphagia is a condition that involves difficulty swallowing food, liquids, or medications.On 02/11/2026 at 9:17 AM, this surveyor observed Licensed Practical Nurse (LPN) #15 begin medication administration to Resident #3.On 02/11/2026 at 9:20 AM, while reviewing Resident #3's medical record, LPN #15 stated that the resident has a diagnosis of dysphagia and reported that she routinely crushes medications for residents with this condition. The surveyor inquired whether there was a physician's order to crush medications for Resident #3. LPN #15 and the surveyor reviewed the resident's orders together, and LPN #15 confirmed that there was no order authorizing medications to be crushed.On 02/11/2026 at 9:35 AM, LPN #15 reported that, despite there being no physician's order to crush medications, she uses her nursing judgment to determine whether to crush medications for Resident #3 due to the resident's diagnosis of dysphagia.On 02/11/2026 at 9:36 AM, this surveyor observed LPN #15 crush the following medications: two tablets of Carbidopa 25 milligrams (mg) / Levodopa 100 mg, one 81 mg enteric-coated (EC) delayed-release Aspirin tablet, and one 50 mg Losartan potassium tablet. LPN #15 then mixed the crushed medications with applesauce for administration.On 02/11/2026 at 9:38 AM, LPN #15 entered Resident #3's room, introduced herself and her purpose, correctly identified the resident, explained the medications to be administered, and then administered the medications.On 02/11/2026 at 10:00 AM, this surveyor conducted an interview with LPN #15 and asked whether enteric-coated medications may be crushed. LPN #15 confirmed that enteric-coated medications should not be crushed. The surveyor then informed LPN #15 that she had just crushed an enteric-coated aspirin tablet. LPN #15 acknowledged this error and stated that it was a mistake.On 02/11/2026 at approximately 12:13 PM, a record review of the facility's Medications Not to Be Crushed list showed that both Aspirin (enteric-coated) and Carbidopa/Levodopa were included on this list.On 02/11/2026 at approximately 1:00 PM, a record review of the facility's General Guidelines for Medication Administration policy indicated that long-acting or enteric-coated dosage forms should not be crushed and that an alternative form of the medication should be sought. The policy also states that the pharmacist should be contacted to review all medications being considered for crushing, regardless of whether a physician's order is present, and that instructions for crushing medications should be included on the resident's orders and Medication Administration Record (MAR) so that all staff administering medications are aware.On 02/12/2026 at 9:35 AM, this surveyor conducted an interview with the Administrator and the Director of Nursing (DON). During the interview, the medication errors identified during the Medication Administration observation were discussed. It was explained that the facility's medication error rate was calculated at 10.34%. It was further explained that the errors were related to LPN #15 crushing medications that should not be crushed and doing so without a physician's order. It was also communicated that Aspirin (enteric-coated) and Carbidopa/Levodopa are listed on the facility's Medications Not to Be Crushed list, and that the facility's Medication Administration policy requires consultation with a pharmacist prior to crushing medications.

Based on medical record reviews and interviews it was determined that the facility failed to ensure medical records were complete and accurate. This was evident for 2 (Resident #22 and #9) of 2 residents reviewed for medical record documentation during the recertification survey.The findings include:1. PASRR stands for Pre-admission Screening and Resident Review. It is a federal mandate requiring that all applicants to Medicaid-certified nursing facilities be screened for serious mental illness (SMI), intellectual disabilities (ID), or developmental disabilities (DD) prior to admission. The process ensures proper placement, preventing inappropriate nursing home admissions and guaranteeing individuals receive necessary, specialized services in the most appropriate setting.During a review of Residents medical records on 02/09/2026 at 2:08 PM it was discovered that that Resident #22 was admitted on [DATE] and did not have a completed PASRR documented in his/her medical records.During an interview with the Social Work Director on 2/10/2026 at 11:10 AM she reported that Resident #22 should have a completed PASRR and it should be uploaded into his/her medical records. She found the PASRR had been completed on the Qualitrac website on 4/10/2025 and confirmed that it had not been uploaded into the medical records for Resident #22. She advised when Resident #22 was admitted she did not have access to the PASRR initially because the facility identification was not added for her to access the document, so it was not added to the Resident's chart upon his/her admission.During additional review of the medical records for Resident #22 on 2/10/2026 at 11:26 AM it was discovered that the PASSR was added to the Resident's chart on 2/10/2026 at 11:21 AM. During a review of the PASRR for Resident #22 it was confirmed that it was submitted and approved on 4/10/2025.During a review of the facility's Level I PASRR policy on 2/11/2026 at 1:32 PM it was revealed that, When the patient is admitted to the Center the Social Work and Discharge Planner will scan and upload the PASRR(s) into the patient's electronic medical record no later than five (5) days after the patient is admitted to the Center.2. Clostridioides difficile (C. diff) is a bacterium causing severe, sometimes fatal, diarrhea and colon inflammation (colitis), often triggered by recent antibiotic use that disrupts normal gut flora. It frequently affects people in hospitals or nursing homes. Symptoms include watery diarrhea, fever, and abdominal pain. It is treated with specific antibiotics and, in recurring cases, fecal transplants. During a review of medical records for Resident #9 on 2/17/2026 at 1:14 PM it was discovered that an order for his/her stool to be tested for C. diff had been placed on 2/10/2026 at 3:47 PM and it was signed off as completed on the Treatment Administration Record on 2/11/2026 at 10:55 PM.During a continued review of medical records for Resident #9 it was revealed that there were no lab results for the order that requested stool testing for C. diff.During a review of the Laboratory Orders and Results on 2/17/2026 at 1:48 PM it was discovered that the C. diff order was not signed off as being picked up by the lab but was labeled as no stool.During an interview with Licensed Practical Nurse (LPN) #8 on 2/17/2026 at 1:56 PM she confirmed that she had worked during the shift of 2/11/2026 and that Resident #9 did not have a bowel movement during her shift, so the specimen was not obtained. She advised that she had notified the oncoming shift that the specimen was still needed.During an interview with the Assistant Director of Nursing on 2/17/2026 at 2:19 PM she reported that if no stool was obtained for the lab order it should not have been signed off as completed for Resident #9 and it should have been noted that the order was not done because the resident didn't have a bowel movement.

Based on observation and interviews it was determined that the facility failed to ensure staff practiced infection control. This was found to be evident for 2 (Residents #13 and #22) out of 2 Residents observed for infection control during the recertification survey. The findings include:2. During an observation of the hallway for Resident #13 on 2/09/2026 at 10:18 AM Geriatric Nursing Assistant (GNA) #17 was seen exiting the room of Resident #13 and entered into the room of Resident #22. GNA #17 returned from the room of Resident #22 holding a plastic bottle. He took the bottle back into the room of Resident #13.During an interview with GNA #17 on 2/09/2026 at 10:19 AM he reported that GNA #18 was giving a bed bath to Resident #13 and was out of body wash. GNA #18 had asked him to get her more body wash. He reported he had taken the body wash from the room of Resident #22 and took it to GNA #18 to so she could continue with the bed bath for Resident #13.During an interview with GNA #18 on 2/09/26 at 11:01 AM she confirmed that she was giving Resident #13 a bed bath and had run out of body wash so she requested GNA #17 to get her more body wash. She advised that each resident gets their own body wash and that it was not common practice in the facility for staff to take supplies from another resident's room to use for a different resident. During an interview with the Director of Nursing (DON) on 2/10/2026 at 9:07 AM she advised that personal hygiene products should not be taken from a Resident's room and taken to another Resident's room. She reported that GNA #17 should have went to storage to get a new bottle of body wash for Resident #13. She reported taking supplies from one resident and to another resident is an infection control issue.

Based on observations and interviews it was determined that the facility failed to ensure a Resident's smoke detector was in working condition. This was found to be evident for 1 (Resident #44) out of 9 Resident smoke detectors observed during the recertification and complaint survey. The findings include: During a random observation conducted on 02/08/2026 at 10:28 AM, the Surveyor heard a chirping sound from the 2nd floor nurse's station. The Surveyor followed the sound to Resident #44's room and determined the chirping sound came from the ceiling smoke detector.During an interview conducted on 02/08/2026 at 10:30 AM, Resident #44 reported that the smoke detector had been chirping for an extended period. During the interview the Surveyor observed Licensed Practical Nurse (LPN) #20 with her medication at the entry door of Resident #44's room. During an interview conducted on 02/08/2026 at 10:33 AM, LPN #20 reported that although she was in front of Resident #44's room she did not hear the smoke detector chirping so therefore she had not reported it the maintenance. On 02/08/2026 at 10:35 AM the Surveyor reported that the smoke detector was chirping to the Director of Nursing (DON). The Surveyor observed the DON enter Resident #44's room. The DON returned and advised that the smoke detector's batteries needed to be replaced. The DON called the Maintenance Director, reported the issue, and requested batteries.

Based on record reviews and interviews it was determined that the facility failed to provide services that met professional standards of practice. This was found to be evident for 1 (Resident #5) out of 1 Resident reviewed for professional standards of practice during the complaint survey. This deficient practice was identified as past non-compliance. The findings include:Antirejection medications, also known as immunosuppressants, are drugs used to prevent the body's immune system from attacking and rejecting a transplanted organ. These medications are essential for ensuring the success of organ transplants and maintaining the health of the transplanted organ. A review of the Facility Reported Incidents (FRIs) #365430 and #365429 investigations was conducted on 10/06/25 at 9:54 AM. The investigation reported that following a discussion with Resident #5's Cardiologist on 4/23/25, it was determined that an error had occurred. It was identified that the therapeutic drug level of anti-rejection medications was low which indicated that the Resident had not taken the medications as prescribed. At the request of the cardiologist the resident was transferred to the hospital for a non-emergent evaluation and treatment. During a review of the Resident #5's medical records conducted on 10/06/25 at 10:07 AM, it was discovered that the Resident was transferred and admitted to a local hospital on [DATE]. A review of Resident #5's hospital discharge summary conducted on 10/06/25 at 10:19 AM revealed a discharge medication list. The discharge medication list dated 03/11/25 showed 2 anti-rejection medications: Sirolimus 0.5 mg (milligram) tablet every 24 hours, and Tacrolimus 2 (1) mg capsules every 24 hours. A review of Resident 5's Physician orders and Medication Administration Record (MAR) conducted on 10/06/25 at 10:33 AM for March and April 2025 did not show an order for Sirolimus 0.5 mg tablet every 24 hours and Tacrolimus 2 (1) mg capsules every 24 hours. The review confirmed that the Resident had not received the anti-rejection medications as listed on the discharge medication list on 03/11/25. A medication trough is the lowest concentration of a drug in the bloodstream, measured just before the next dose is administered. This measurement is part of a process called therapeutic drug monitoring and is essential for medications with a narrow therapeutic index, meaning the difference between an effective dose and a toxic dose is very small. To ensure effectiveness the trough level confirms that the drug concentration stays above the minimum effective level throughout the entire dosing interval. If the trough level is too low, the medication may not be working correctly.During an interview conducted on 10/06/25 at 10:49 AM, the Director of Nursing (DON) explained that the facility was made aware that Resident #5 had not been administered the anti-rejection medications by the Resident's Cardiologist during a routine appointment. The Cardiologist had requested labs to be drawn for the trough of Sirolimus and Tacrolimus a few days prior to the routine appointment. The lab results reported that the trough levels were low which prompted the Cardiologist to request the Resident's active medication list. There it was discovered that the Resident did not have an active order for the anti-rejection medications. When asked why the anti-rejection medications weren't ordered and administered for an organ transplant Resident, the DON stated that there were multiple system failures. She stated that the medications were overlooked during the admission process on 03/11/25 and overlooked again during the pharmacy medication regimen review the next day (03/12/25). When asked what the admission process was, the DON explained that a physician or nurse practitioner are required to review the resident's hospital discharge summary to identify the level of care the Resident required which included reviewing the discharge medication list prior to admission. She further explained that once the Resident was admitted the admitting nurse was required to review the hospital discharge summary and place an order for each medication listed on the medication discharge list unless directed differently from the admitting provider. However, everyone overlooked the anti- rejection medications. When asked why anyone didn't question why the Cardiologist requested troughs for medications that Resident #5 were not receiving, the DON responded unfortunately it was another missed opportunity. The DON advised that the facility had implemented new processes that would ensure this deficient practice would not occur again. On 10/06/25 at 1:45 PM a review of the facility's Ad-Hoc Qapi Action Plan /Qapi Meeting Report was conducted. The report dated 05/01/25 identified the following problems: failure to enter medication orders, breakdown in medication reconciliation, communication gaps, unclear role responsibility and training deficiency. The Report showed that the facility's resolution listed mandatory charge nurse training, enhanced admission protocols, supervisory follow up process, pharmacist review process and continuous process evaluation. A continued review of the report included in-service education, audits of the admission process, quizzes, and medication reconciliations audits that were completed on 05/05/25. Based on this review it was determined that the facility's past non-compliance period was from 03/11/25 through 05/05/25.

Based on record reviews and interviews, it was determined that the facility failed to ensure all medications were ordered as listed on the hospital discharge summary. This was evident for 1 (resident #5) out of 22 residents reviewed for physician services during the complaint survey. The findings include: Antirejection medications, also known as immunosuppressants, are drugs used to prevent the body's immune system from attacking and rejecting a transplanted organ. These medications are essential for ensuring the success of organ transplants and maintaining the health of the transplanted organ. A review of the Facility Reported Incidents (FRIs) #365430 and #365429 investigations was conducted on 10/06/25 at 9:54 AM. The investigation reported that following a discussion with Resident #5's Cardiologist on 4/23/25, it was determined that an error had occurred. It was identified that the therapeutic drug level of anti-rejection medications was low which indicated that the Resident had not taken the medications as prescribed. At the request of the cardiologist the resident was transferred to the hospital for a non-emergent evaluation and treatment. During a review of the Resident #5's medical records conducted on 10/06/25 at 10:07 AM, it was discovered that the Resident was transferred and admitted to a local hospital on [DATE]. A review of Resident #5's hospital discharge summary conducted on 10/06/25 at 10:19 AM revealed a discharge medication list. The discharge medication list dated 03/11/25 showed 2 anti-rejection medications: Sirolimus 0.5 mg (milligram) tablet every 24 hours, and Tacrolimus 2 (1) mg capsules every 24 hours. A review of Resident 5's Physician orders and Medication Administration Record (MAR) conducted on 10/06/25 at 10:33 AM for March and April 2025 did not show an order for Sirolimus 0.5 mg tablet every 24 hours and Tacrolimus 2 (1) mg capsules every 24 hours. The review confirmed that the Resident had not received the anti-rejection medications as listed on the discharge medication list on 03/11/25.During a telephone interview conducted on 10/07/25 at approximately 1:00 PM, Certified Registered Nurse Practitioner (CRNP) #16 explained that when a Resident was to be admitted to the facility she would review the hospital discharge summary to determine the resident's level of care which included reviewing the medication list. The CRNP #16 further explained that she does not change or stop any of the medications listed on the discharge medication list. When asked does she reconcile the Resident's admitting medications, the CRNP #16 responded yes. When asked how the medications were reconciled she stated she used the hospital discharge summary medication list. When asked did she reconcile the medications for Resident #5 the CRNP #16 stated she does not have access to the Medications Administration Record (MAR) only to the Electronic Health Record (EHR), but that she could review the medications listed in the EHR. When asked did she reconcile the medications for Resident #5, the CRNP replied no because the admitting nurse completes that task. This Surveyor reminded the CRNP that she earlier stated that she reconciles the medications, the CRNP replied it is the admitting nurse responsibility. When asked if the CRNP #16 notice that the heart transplant Resident was not on any anti-rejection medication she stated no I was focused on the Resident's heart failure medications. During an interview conducted on 10/07/25 at 1:47 PM, the Director of Nursing (DON) confirmed that the admitting nurse will place the order for each admitting medication however the provider is expected to reconcile the medication list.

Based on record reviews and interviews, it was determined that the facility failed to ensure that an accurate pharmacy medication regimen review was conducted. This was found to be evident for 1 (Resident #5) out of 1 Resident reviewed for pharmacy medication regimen review during the complaint survey. The findings include: During a review of the Resident #5's medical records conducted on 10/06/25 at 10:07 AM, it was discovered that the Resident was transferred and admitted to a local hospital on [DATE]. A further review of Resident #5's medical record showed that the Resident was re-admitted to the facility on [DATE] following the hospital admission on [DATE]. Antirejection medications, also known as immunosuppressants, are drugs used to prevent the body's immune system from attacking and rejecting a transplanted organ. These medications are essential for ensuring the success of organ transplants and maintaining the health of the transplanted organ. A review of the discharge summary conducted on 10/06/25 at 10:19 AM revealed a discharge medication list. The discharge medication list dated 03/11/25 showed 2 anti-rejection medications: Sirolimus 0.5 mg (milligram) tablet every 24 hours, and Tacrolimus 2 (1) mg capsules every 24 hours. A pharmacy medication regimen review is a comprehensive evaluation by a pharmacist to assess a patient's complete medication list for safety and effectiveness. It identifies potential problems like drug-drug interactions, incorrect dosages, unnecessary drugs, or side effects, aiming to promote positive outcomes and minimize risks. This process involves reviewing the patient's medical records and lab reports and often results in a written report to the physician with recommendations for action. A review of Resident #5's pharmacy New admission Medication Review (aMMR) was conducted on 10/06/25 at 10:30 AM. The aMMR failed to identify 2 anti-rejection medications: Sirolimus 0.5 mg (milligram) tablet every 24 hours, and Tacrolimus 2 (1) mg capsules every 24 hours that were listed on the hospital discharge medications list. During an interview conducted on 10/06/25 at 10:49 AM, the Director of Nursing (DON) explained that when a Resident is admitted , the pharmacy has a responsibility to review the hospital discharge medication list and reconcile the medications. The DON confirmed that the pharmacy completed Resident #5's admission medication review however they overlooked the 2 anti-rejection medications.

Based on medical record review and interview, it was determined that the facility failed to have an effective system in place to correctly identify the appropriate decision maker regarding health care decisions and that the resident/health care decision maker's wishes regarding CPR were clearly documented in the medical record to ensure CPR was performed if needed. This was evident for 4 out 51 Residents, (Resident #328, #30, # 97 #55), reviewed for advanced directives during a survey. The facility's failure to ensure that each resident had only one active MOLST, led to the determination that immediate jeopardy existed. The facility was notified of this determination on [DATE] at 6:25 PM. Surveyors accepted the facility's plan to remove the immediacy on [DATE] at 11:00PM. The plan was validated, and the immediate jeopardy was removed on [DATE] at 5:05 PM. The findings include: A Maryland MOLST, (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. The orders on a MOLST are commonly referred to as code status. 1) On [DATE] at 8:02 AM, a review of medical records revealed Resident # 328, was admitted to the facility for rehabilitation following a hospital stay. Further review revealed a MOLST( MOLST #1) order, dated [DATE]. A review of MOLST #1 revealed that Resident #328 was not to receive CPR ( Do not resuscitate) if the resident experienced cardiac arrest. Continued review revealed the physician obtained the information, not by speaking to the Resident but by communicating with the resident's representative or surrogate. On [DATE] at 1:45 PM, the Regional Social Worker (Staff # 17) provided an additional MOLST order, (MOLST #2) for Resident #328. Further review of MOLST #2 revealed the MOLST was dated [DATE] and was still active. Further review of the MOLST #2 revealed that Resident #328 was to receive CPR ( full code ) in the event the resident experienced cardiac arrest. Continued review revealed the physician obtained this information by speaking directly to the resident. Further review of Resident #328's medical record revealed the following orders for the resident's code status: On [DATE] at 10:28 PM order for full code On [DATE] at 5:74 PM order for Do Not Resuscitate (DNR) On [DATE] at 11:29 AM order for Full Code On 9//,d+[DATE] at 5:02 PM DNR/DNI active for one day On [DATE] at 5:47 PM order for DNR On [DATE] at 10:14 AM, a review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE] section C indicated that the resident did not have any cognitive decline as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On [DATE] at 10:15 AM, Resident # 328's medical records were reviewed and there was no documentation that the resident was incapable of making health care decisions. On [DATE] at 1:43 PM, Nurse Staff #18 was interviewed regarding what actions she would take if Resident #328 became unresponsive and was not breathing. During the interview, staff #18 reported she would call for help and request another nurse to verify the code status of resident #328. Staff # 18 reported that the resident's profile page documented full code (perform CPR). Staff # 18 then showed the surveyor a MOLST form on the computer screen. The MOLST form indicated the resident was a DNR. The nurse reported she would follow the MOLST and would not perform CPR. She reported that to further verify the code status of a resident she would refer to the MOLST Binder. Staff #18 reported that the MOLST binder contains all the resident's most current MOLST orders and is kept at the nurse's station. On [DATE] at 2:29 PM, the Director of Nursing (DON) was interviewed regarding Resident #328 having 2 active MOLSTs with orders that contradicted each other in the medical record. During the interview, she reported that MOLST #1 was completed at the hospital, and sent with the resident to the facility. Additionally, MOLST #2 was completed at the facility. The DON reported that staff should follow the most recent MOLST as indicated by the date on the MOLST. She reported, that a voided MOLST should have a line through it. The DON reported that MOLST #2 was the correct order because it was completed at the facility and therefore more recent than MOLST# 1 which was completed at the hospital. On [DATE] at 3:13 PM, an interview was conducted in Resident # 328 room with the resident and the resident's family, which included the resident's power of attorney (POA). During the interview, Resident #328 and Resident # 328's POA (Resident's daughter) clearly communicated that the resident did not want CPR if s/he suffered a cardiac arrest. On [DATE] at 3:17 PM, resident# 328's family member (not POA) reported that he was with Resident # 328 when the resident was admitted to the facility. He reported that he and the resident agreed to receive CPR if s/he suffered cardiac arrest. The next day he realized they made a mistake. He reported he had spoken to a nurse at the nurse's station and told her that Resident # 328's true wishes were to not have CPR performed if s/he suffered a cardiac arrest. He reported that the nurse told him that it was not a problem, and they had the paperwork from the Resident's primary physician indicating that the resident's code status was Do not resuscitate, DNR. On [DATE] at 2:56 PM, Social Services personnel (Staff #11) were interviewed. During the interview, she reported, that before a care plan meeting for Resident #328, she obtained Resident #328's code status under the profile section in the medical records. Staff #18 reported that she did not actually review the MOLST, and at the time, she did not discuss the code status of Resident #328 with the resident or the resident's family during the meeting. 2) On [DATE] at 10:05 AM, Resident #97 's MOLST order dated [DATE] was reviewed. The review revealed that the residents' wishes were communicated to the physician through the resident's surrogate, per the authority granted by the Health Care Decisions Act. Further review revealed that the resuscitation status chosen was No CPR, DNR option B. On [DATE] at 10:10 AM, a review of progress notes revealed a social services note, dated [DATE] at 12:39, A review of the note revealed that the Regional Social Worker (Staff #17) contacted resident #97's emergency contact representative to confirm the DNR status on file. On [DATE] at 10:15 AM, further review of electronic health records failed to reveal certifications of incapacity for Resident #97. The resident's BIMS score was ,d+[DATE] indicating the resident was cognitively intact. On [DATE] at 11:45 AM, During an interview with the medical director, he reported that he is familiar with resident # 97 and his opinion was that the resident has capacity. On [DATE] at 11:00 AM, the above concerns were discussed with the administrator. He reported that he would reeducate the staff involved and re-audit the residents. On [DATE] at 4:00 PM, a review of 8 percent of the facility residents failed to reveal any additional issues with residents' MOLST orders. On [DATE] at 4:48 PM, The administrator reported that the 2 outstanding concerns were corrected. On [DATE] at 4:50 PM. a review of Resident #97 medical record revealed a new MOLST dated [DATE]. A review of the MOLST revealed that the Medical Director communicated with Resident #97 regarding their wishes. Further review revealed that the residents' wishes were not the same as the resident's representative. The resident wished to receive resuscitative treatment (CPR) if s/he would suffer cardiac arrest. On [DATE] at 4:50 PM, a review of resident # 97's MOLST revealed that the MOLST certification for the basis of these orders, was the resident and the order was for CPR. On [DATE] at 4:51 PM, review of the Residents code status listed in the resident profile was a full code. 16218 3) On [DATE], a review of Resident #30's medical record revealed a Minimum Data Set assessment, with a reference date of [DATE], that revealed the resident has a BIMS (Brief Interview for Mental Status) of ,d+[DATE] indicating the resident had severe cognitive impairment. On [DATE] at approximately 5:00 PM, review of the electronic health record revealed 4 active current MOLST forms. Three of the MOLSTs, (dated [DATE], [DATE], and [DATE]) included orders for No CPR (DNR) and one (dated [DATE]) included orders to perform CPR (full code). Further review of the MOLST, dated [DATE] and signed by Physician #31, revealed in the section for Certification for the Basis of these Orders the physician had initialed the section [NAME] this line if the patient or authorized decision maker declines to discuss or is unable to make a decision about these treatments. This section of the MOLST also included the following: The patient's or authorized decision maker's participation in the preparation of the MOLST form is always voluntary. If the patient or authorized decision maker has not limited care, except as otherwise provided by law, CPR will be attempted and other treatments will be given. The [DATE] MOLST included an order to perform CPR (full code). Review of the progress note completed by Physician #31 for a visit conducted on [DATE] revealed an acknowledgement that the resident was previously a long term care resident at the facility prior to a recent hospitalization . The progress note also included: Code Status: I reviewed/completed the MOLST form with [name of Resident #30] on [DATE] and the patient is Full Code. Further review of this progress note revealed the resident was alert and oriented x1 and had AMS (altered mental status) -- baseline. Further review of the medical record revealed a Physician Certification Related to Medical Condition, Decision Making, and Treatment Limitations, dated and signed by Physician #31 on [DATE], which indicated the resident lacks adequate decision making capacity (including decisions about life-sustaining treatments). Further review of the medical record failed to reveal a second certification that the resident lacked decision making capacity, since the [DATE] certification indicating the resident had capacity. Review of the resident's Advance Directive included the identification of a Health Care Agent and an Alternative Health Care Agent. Both of these agent's contact information was found in the Contacts section of the resident Profile in the electronic health record. Further review of the medical record failed to reveal documentation to indicate that an attempt was made to consult the resident's healthcare agent prior to establishing the full code MOLST on [DATE]. An interview was conducted with Physician #31 on [DATE] at 2:31 PM. She reported she sees new admissions and follows the resident while at the facility short term, and confirmed she does not see the residents when they are in long term care. When asked about completing a MOLST when a resident is readmitted , the physician reported in this facility she has to fill out a brand new MOLST everytime the resident is admitted . She reported if the resident obviously has dementia and can't complete the form and no poa [health care agent] is available then the resident would have to be a full code by default. When asked if she looks to see if there is a valid MOLST she responded: if one is available to me. When asked about Resident #30, Physician #31 indicated she did not recall the resident. After surveyor reviewed the concerns related to Resident #30's MOLST, the physician reiterated that this facility requires a new MOLST be completed regardless of the old MOLST. During the [DATE] interview, when asked about the process of putting the order into the EHR system, the Physician #31 reported there is a binder that we put the signed MOLST into and then the nursing staff put the order into the EHR. Further review of the electronic health record for Resident #30 revealed an order, dated [DATE] for DNR. This order was signed by Physician #31 on [DATE]. The physician signed the DNR order two days after completing a MOLST which included orders for CPR (Full Code). Further review of the medical record revealed a Multidisciplinary Care Conference note for a meeting held on [DATE]. Review of this note revealed the resident and the Health Care Agent participated in the meeting. The following was found in the Social Work Summary section: .Resident is alert and oriented x 3. MOLST updated reviewed and on file; Code Status; full code In the last section of this note, labeled Resident/Family Care Level Review, revealed Do Not Resuscitate was checked. Further review of the EHR revealed an order, dated [DATE] for FULL CODE. This was signed by Physician # 33 on [DATE]. This was two weeks after Physician #31 completed the MOLST with orders for CPR (full code). On [DATE] at 10:54 PM, surveyor reviewed with the corporate Social Worker #17 the findings that the resident had DNR orders in place until [DATE] despite the MOLST on [DATE] indicating full code, also reviewed the discrepancy in the [DATE] care plan note which indicated the social worker discussed with family and resident that resident was a full code, but at the end of the note DNR was marked. Surveyor also reviewed the concern that there was only one certification of incapacity for the resident with a BIMS of 4. The SW #17 acknowledged the need to re-evaluate the resident's code status. On [DATE] at approximately 8:30 AM, review of the EHR revealed a note dated and signed by SSD #19 on [DATE] at 3:30 PM that stated: SW [social worker] followed up with [Health Care Agent] from the previous call on [DATE] regarding current code status and [Health Care Agent] requested code status be changed to DNR. Further review revealed a new MOLST, dated [DATE], which indicated that the orders were based on instructions in the patient's advance directive and included orders for No CPR. 37276 4) On [DATE] at 1:00 PM, a review Resident #55's electronic medical record (EMR) revealed the resident resided in the facility for long term care since 2020, and, following a brief hospitalization in [DATE], the resident was readmitted into the facility. Review of Resident #55's 5-day assessment with an assessment reference date (ARD) of [DATE] documented Resident #55's BIMS (brief interview for mental status) summary score was 15, indicating the resident was cognitively intact. Continued review of Resident #55's EMR revealed 3 active MOLST forms; none of the MOLST forms had been voided when a new MOLST had been completed. In the EMR, under the document tab, Resident #55 had 1) an active MOLST signed and dated [DATE] that documented Resident #55 elected, CPR (resuscitation) status, 2) an active MOLST form that was signed and dated [DATE] that documented Resident #55 elected No CPR, Option A-2, Do not intubate (DNI): Comprehensive efforts may include limited ventilatory support by CPAP or BiPAP, but do not intubate, and, 3) Resident #55 had an active MOLST signed and dated [DATE] that documented Resident #55's elected CPR (resuscitation) status was Attempt CPR. None of the scanned MOLST forms had been voided by the practitioner when a new MOLST had been created, indicating the resident's MOLSTs were active. A copy of Resident #55's MOLST forms was requested and provided on [DATE]. Further review of Resident #55's EMR, revealed, on [DATE], at 12:45 PM, in a medical progress note, the physician documented s/he was asked to evaluate advance care planning and MOLST with Resident #55, advance care planning was reviewed, the MOLST reviewed and completed. There was no other documentation in the progress note to indicate the discussion the physician had with Resident #55 which led to the resident's DNR order. In a medical progress note on [DATE] at 12:49 PM, the physician documented s/he was asked to evaluate advance care planning and MOLST with Resident #55, and advance care planning was reviewed, MOLST reviewed and completed. There was no other documentation in the progress note to indicate the discussion the physician and Resident #55 had which resulted in a change in the resident's wishes for life sustaining treatment, and a new MOLST. The presence of more than one active conflicting MOLST in Resident #55's medical record, put the staff at risk of failing to accurately confirm the resident's wishes regarding cardiopulmonary resuscitation (CPR) and implement medical treatment based on the resident's wishes. On [DATE] at 10:51 PM, Staff #20, Licensed Practical Nurse (LPN), Regional Director of Clinical Reimbursement was made aware of the finding that Resident #55 had more than one unvoided MOLST in his/her medical record and the concern with the resident having more than one conflicting MOLST. Staff #20 acknowledged the concerns at that time, and indicated the administration was aware of the concern with active, conflicting MOLSTS in resident records. Failures to identify residents that have the capacity (maintain the ability to make their healthcare decisions), failure to honor residents' wishes for life-sustaining treatments, and failure to maintain one accurate MOLST in a resident's medical record, put the resident at risk of not receiving the correct orders for life-sustaining treatments. Immediate action was needed to ensure that residents who wished life-sustaining treatment would receive that treatment if needed and were not just left to die and/or that residents who did not want life-sustaining treatments, did not endure those treatments unnecessarily. As a result of these findings, an Immediate Jeopardy situation was identified on [DATE] at 6:30 PM, and the facility was provided with the Immediate Jeopardy Template at that time. The facility's failure to ensure each resident had only one active MOLST, led to the determination that immediate jeopardy existed. The facility was notified of this determination on [DATE] at 6:25 PM. Surveyors accepted the facility's plan to remove the immediacy on [DATE] at 11:00PM. The plan was validated, and the immediate jeopardy was removed on [DATE] at 5:05 PM. The facility submitted a removal plan on [DATE] at 7:43 PM and again on [DATE] at 9:18 PM, which was not accepted. The facility submitted another plan to remove the immediacy on [DATE] at 9:52 PM, which again was not accepted. On [DATE] at 10:40 PM, the administrator provided an additional plan that was accepted by the survey team and OHCQ (The Office of Healthcare Quality) on [DATE] at 11:00 PM. The following corrective measures were established on [DATE] at 8:50 AM Social workers will complete a 100% audit of all alert and oriented residents and all non-alert and oriented resident's representative(s) via conversation to ensure they have an active and correct MOLST uploaded in their chart. All old MOLST forms will be voided and uploaded to ensure that the correct MOLST form is followed. ADON will educate weekend supervisors and ,d+[DATE] & ,d+[DATE] weekday supervisors on the process of uploading new residents ' MOLST into the electronic healthcare record upon admission. The Regional Director of Admissions will educate the admissions director and admissions coordinator on the process of uploading new residents' MOLST into PCC upon admission. The Regional Director of social services will educate social workers to discuss MOLST and code status with residents and/or representative(s) during care plans, that all residents are to have an active and completed and uploaded in their chart, that CPR/DNR status are found in the residents ' chart under the document section and titled active MOLST that any changed MOLST will be voided and reflected on the chart, and that the order for code status matches the MOLST. ADON will educate licensed nurses and physicians that all residents are to have an active and correct MOLST completed and uploaded in the chart, that CPR/DNR status ' are found in the residents; chart under the document section titled active MOLST, that any changed MOLST will be voided and reflected on the chart, and that the order for code status matches the active MOLST. On [DATE], the facility provided an audit list of the MOLST forms which was to include all the residents in the facility. An initial review of the audit list failed to reveal 2 current residents (Resident #84, #13). On [DATE] at 8:50 AM the Administrator was interviewed regarding the audit. During the interview, he confirmed that the audit was not acceptable, since it was incomplete. On [DATE] at 9:50 am - an updated MOLST Audit list was provided to the survey team from the NHA. On [DATE] at 10:10 AM, the NHA was interviewed to ask about any additional evidence to be provided, and he said this was the current evidence, and confirmed the previous evidence of education to staff regarding MOLST documentation. On [DATE] at 10:00 AM, the facility audits were completed as part of their correction plan and were reviewed. A random 10 percent of the facility's residents were reviewed for accurate MOLST forms.

Based on medical record review and staff interview, facility staff failed to provide privacy to a vulnerable resident (resident #26). This was evident for 1 of 8 residents reviewed during a complaint survey and resulted in psychosocial harm to resident #26. The findings include: On 6/12/24 at 7:50 am, the surveyor received a facility reported incident (FRI) (MD00189048) that is associated with complaint MD00189537 which alleged a male facility housekeeper entered a facility shower room while a resident was bathing on 2/12/23. The resident was being assisted by another facility staff member at the time of the incident. The FRI reported resident #26's family contacted the Administrator on 2/15/23 complaining that a male facility housekeeper #15 violated the resident's privacy when he/she entered a facility shower room without permission from the resident while the resident was bathing. Review of the facility investigation on 6/12/24 at 9:30am revealed a written statement by resident #26 on 2/15/23 stated that his/her privacy was violated in two incidents on 2/12/23. The first incident was in a facility shower room. The second incident was in the resident's room. Review of GNA #16's interview statement written on 2/15/23 revealed he/she was assisting resident #26 to bathe in a facility shower room at approximately 10:00 am on 2/12/23. Male facility housekeeper #15 entered the facility shower room without knocking on the door. GNA #16 told male facility housekeeper #15 to stop entering the shower room because he/she was assisting resident #26 to bathe. Male facility housekeeper #15 ignored GNA #16 and continued to enter the shower room. Male facility housekeeper #15 walked through the shower room to the attached bathroom. GNA #16 stated that resident #26 was upset that male facility housekeeper #15 entered the shower room without permission. GNA #16 and resident #26 immediately reported the shower room incident to RN weekend Supervisor #17. GNA #16's interview statement written on 2/15/23 also revealed a second privacy incident occurred on 2/12/23 at approximately 10:30am. Male facility housekeeper #15 knocked on resident #26's room door and entered the resident's room without the resident's permission. Resident #26 was being assisted by GNA#16 with personal care when male facility housekeeper #15 knocked and entered the resident's room. When resident #26 saw male facility housekeeper #15, he/she started to cry and became fearful that male facility housekeeper #15 entered his/her personal space without permission twice on 2/12/23. GNA #16 and resident #26 reported the second privacy incident to RN weekend Supervisor #17 immediately after the second incident. Review of RN weekend Supervisor #17's witness statement on 6/12/24 at 9:30 am revealed the statement was written on 6/15/23. The statement confirmed that GNA #16 and resident #26 reported both privacy incidents between resident #26 and male facility housekeeper #15 on 2/12/23. RN weekend Supervisor #17 admitted in his/her statement that he/she did not make a facility self-report that day because he/she felt that the incidents did not require an immediate self-report. Further review of the facility investigation on 9/12/24 at 9:30am revealed that the Administrator filed the facility self-report of the two privacy incidents between resident #26 and male facility housekeeper on 2/15/23 at 12:00 pm. The facility also provided resident #26 with a psychiatric assessment on 2/15/23 at 10:00 am. The psychiatric assessment record revealed that resident #26 felt violated by male facility housekeeper #15 when he/she violated the resident's privacy twice on 2/12/23. Resident #26 also stated that he/she felt the privacy incidents on 2/12/23 triggered his/her anxiety. Interview with resident #26 on 6/12/24 at 9:00 am revealed the resident was still traumatized by the events on 2/12/23. Resident #26 stated during the interview, I still have nightmares about that man that walked in on me in the shower and in my room. The resident also stated that facility supervisors failed to contact the Administrator when the resident reported the events on 2/12/23. The resident's family informed the Administrator of the events on 2/12/23 during a telephone call. Surveyor interview with Health Services Corporation District Manager #19 on 6/12/24 at 12:30 pm revealed that male facility housekeeper #15 was suspended from work duties on 2/15/23 and terminated from the facility on 2/20/23. Health Services Corporation District Manager #19 also was unable to confirm that male facility housekeeper #15 had any abuse training before or after the privacy incidents on 2/12/23. Surveyor interview with former administrator #24 on 6/13/24 at 10:35 am revealed that RN weekend Supervisor # 17 failed to inform administration of the privacy incidents on 2/12/23. Former administrator #24 also confirmed that he/she became aware of the privacy incidents on 2/12/23 by resident #26's family who called to complain about the privacy incidents on 2/15/23. On 6/13/24 at 12:30pm, the surveyor reviewed concerns with the Director of Nursing (DON) regarding staff supervisors' failure to report the privacy incidents on 2/12/23 to administration. The DON stated that he/she understood.

Based on record review and staff interview it was determined that the facility failed to ensure that residents were free from abuse. This was evident for 2 (#3 and #29) of 27 residents reviewed for abuse. These identified concerns rose to the level of harm for both identified residents. The findings include: Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1. Review of the facility reported incident regarding an alleged abuse on 6/11/24 at 7:39 AM revealed Resident #3 made an allegation on 4/5/24 at approximately 2:00 AM that a GNA, staff #7, was assisting Resident #3 with perineal care. Resident #3 was attempting to assist and adjust the brief and pull it up, however, the GNA, staff #7 asked [Resident] to leave the brief alone and let her, the GNA, fix it. However, Resident #3, wanted to assist, as is in their care plan. According to Resident #3 ' s care plan, reviewed on 6/11/24 at 8:23 AM, staff was to allow the resident to make decisions about care and treatment and provide a sense of control and encourage as much participation as possible during care activities. Resident #3 was also noted with a diagnosis including hemiplegia/hemiparesis and lack of coordination. In addition, a BIMS score was most recently completed on 3/24/24 with a score of 15. According to a statement from LPN #6, the nurse on duty that night, available in the investigation packet, he stated that Resident #3 reported to him that GNA staff #7 refused to allow him/her to assist in care and then the GNA hit his/her left hand. The resident admitted to hitting the GNA staff back in the hand and chest and the GNA then grabbed Resident #3 ' s left hand and twisted it causing pain. LPN #6 was notified of the incident after the GNA left Resident #3 ' s room and reported an ' interaction ' between her and the resident, all according to the facility investigation report. Staff LPN #6 then proceeded to check on Resident #3 who corroborated the incident. LPN #6 notified GNA, staff #7 not to interact with Resident #3 anymore, however, he did not report the incident to the supervisor on duty and the GNA continued to work the remainder of their shift interacting with other residents. A statement from the supervisor that was on duty the night of the allegation, documented as acquired on 4/12/24, revealed that he had no idea about the incident until he came back the next night and was notified that GNA staff #7 was not at work because she was suspended. Facility policy and procedure on abuse, reviewed on 6/12/24 from 10/17/2023, revealed that according to #3 all employees are responsible for immediately reporting to the Administrator or in their absence the DON, or their immediate supervisor, any and all suspected or witnessed incidents or patient abuse, neglect .and/or mistreatment .against a patient and #4 Failure by an employee to report any suspected or witnessed incident of mistreatment . against a patient will result in corrective action. According to the facility report that was reviewed on 6/11/24, GNA #7 continued to work her entire 11 PM-7 AM shift from 4/4/24 into 4/5/24. Further, according to the investigative report, Resident #3 notified the charge nurse on 4/5/24 at 9:00 AM about the incident that occurred on the night shift of 4/4/24 into 4/5/24. This prompted notification to the facility DON and a physical assessment of Resident #3 that determined s/he would need further treatment including an x-ray and Tylenol that was ordered 3 times a day for 5 days. Surveyor interviewed Resident #3 on 6/12/24 at 7:20 AM. Resident #3 at first was hesitant to talk about the incident but then was reassured after this surveyor stated the reason for being here was to ensure that the facility had investigated the incident appropriately and to see if s/he feels safe. Resident #3 stated during this interview that at the time of the incident s/he didn ' t feel safe, the employees ' attitude was ' wrong, she twisted [residents] thumb, and it was swollen and hurt. ' A continued review of the facility investigation revealed that according to the list of statements in the packet, the facility interviewed staff present starting on the day shift of 4/5/24, but not all the staff that worked on the 11 PM-7AM shift from 4/4/24 into 4/5/24. Additionally, the facility failed to acquire interviews of potential witnesses from the night of the incident. The statements in the investigation packet also failed to document who was completing the interviews of the staff that worked and the dates of the interviews completed were noted and documented as occurring 7 days after the incident. Surveyor interviewed the DON on 6/11/24 at 10:10 AM regarding the facility investigation and she stated that the dates on the interviews were just when the previous Administrator had typed up the interviews, and that he was the one that had completed them. However, there was no name, signature, or time on the interviews as to who had completed them besides the signatures of the respondents. A review on 6/12/24 of the employee file for GNA staff #7 revealed that she was hired in 2019, however, her new hire GNA skills checklist that was included in the investigation packet was never completed. This was reviewed with the DON on 6/12/24. There was no evidence of follow up education or training information provided to the survey team. 2. A medical record review for Resident #29 on 6/11/24 at 11:34 AM revealed Review of the physician ' s history and physical notes revealed that the resident was alert and oriented to person and place. A situation background, assessment, and recommendation (SBAR - a form for staff to use when notifying the doctor regarding a resident ' s condition) was completed on 12/5/22 to notify the physician the resident had a fall that day and indicated there were no injuries noted. Staff documented that the physician gave the order to continue to monitor. A radiology report dated 12/5/22 revealed the resident had an x-ray of the pelvis due to a fall and pain. The admission MDS with ARD of 12/6/22 revealed the resident had moderate cognitive (ability to think and process information) impairment and staff were able to understand what the resident said and the resident understood what staff said. On 12/7/22 the resident was seen by a geriatric psychiatric service and reported to the clinician that someone had pushed him/her down in the hallway on their buttocks. On 6/11/24 at 10:38 AM a review of the facility ' s investigation file for the facility reported incident #MD00186435 revealed a self-report form that documented on 12/5/22 at 2:25 PM the resident reported that Housekeeper #20 had pushed him/her which resulted in a fall. The facility failed to obtain a statement from the resident and to whom the resident reported the incident. On 6/13/24 at 8:00 AM a review of the facility ' s Housekeeping and Laundry Service Agreement that went into effect on 7/20/18, revealed that the Scope of Work was that the contracted company would provide housekeeping and laundry management, supervision, labor, and materials as the determine necessary. There was no mention that the contracted staff were to provide redirection and/or direct care for the residents. An interview conducted by the previous Administrator #24 on 12/7/22 with Housekeeper #20 revealed the information was confined to 3 questions: 1) where was the resident standing when you approached them, 2) How did the resident fall, and 3) Did you ask the resident not to enter the housekeeping closet? The information collected was that Resident #29 was standing outside the housekeeping closet on the 2nd floor Maplewood nursing unit. The resident was trying to enter the closet and Housekeeper #20 placed his hands on the resident ' s arm to redirect them from entering the housekeeping closet and the resident fell . The nurse did come to assist the resident off the floor. The housekeeper reported he told the resident they were not allowed to come into the housekeeping closet and again stated that he put his hands on the resident ' s arm to redirect them out. A review of the staff statements and interviews revealed that three staff had been potential witnesses of the incident Unit Clerk (UC) #26, Registered Nurse (RN) #22, and RN #21, however, none of them witnessed the interaction between the Housekeeper #20 and Resident #29. When they heard a noise, they looked over and saw the resident on the floor. Some stated the resident was lying and some stated sitting on the floor, however, the facility failed to reconcile these differences in their investigation. The surveyor could not reconcile the differences because staff were not available for an interview and/or were unable to recall the details. RN #22 wrote in his statement that he when he saw Resident #29 lying on the floor, he went to them to assess and assist them off the floor. He did not write that the resident said anything to him at the time but stated that he asked Housekeeper #20 if he had pushed the resident to which the housekeeper replied he had pushed the resident because they were attempting to come into the housekeeping closet. The surveyor was unable to interview RN #20 because the facility had no contact information available, therefore it was uncertain if he was the staff member that Resident #29 had reported they were pushed by the housekeeper as stated on the self-report form. A review of the Disciplinary Action Form dated 12/9/23 for Housekeeper #20 revealed that facility staff determined that the housekeeper had placed his hands on the resident to redirect them from the housekeeping closet and as a result the resident fell , however, the housekeeper failed to assist or seek assistance for the resident once they fell and instead went back to his duties. Further review of the documents revealed that due to Housekeeper #20 physically and intentionally touching the resident which resulted in a fall as well as the lack of insight and judgment when Housekeeper #20 stated that he did not get help or choose to notify a nurse but rather focused on his duties he was terminated. This document was signed by the housekeeper ' s supervisor, a witness, and the previous Administrator #24. The surveyor attempted to interview the housekeeper but was unable to reach him because the phone number on his application was no longer his phone number. An interview with Unit Clerk (UC) #26 on 6/14/24 at 9:12 AM, via a telephone call, revealed she recalled sitting at the nurses ' station on the day of the incident (12/5/22) which faced the housekeeping closet where the incident had occurred. She recalled RN #22 was sitting next to her but did not recall where RN #21 was located. She reported that she did not recall any other details of the incident. She reported she had written a statement that day regarding the incident, however, this was not provided to the surveyor. RN #21 was interviewed on 6/11/24 at 11:34 AM, he reported that he had not witnessed the interaction between Housekeeper #20 and Resident #29. He heard a noise and turned around to see the resident sitting in the middle of the hallway outside the housekeeping closet. He did not recall seeing the housekeeper. An interview conducted over the phone with the previous Administrator #24 on 6/13/24 at 10:12 AM revealed that he did not think it was appropriate for housekeeping staff to touch the resident to redirect them. He confirmed that Housekeeper #20 was terminated for the reasons as stated on the disciplinary form. When asked if the actions of the employee were willful without intention to harm the resident was considered abuse and if it was abusive for the housekeeper to go about his duties without assisting the resident after they fell , he stated that he could see where it could be perceived that it was abuse. According to the definition of abuse it is the willful act of an employee that causes harm or pain. The willful act of the housekeeper placing his hands on the resident resulted in a fall with pain that meets the definition of abuse. The concerns were reviewed with the current Administrator and Director of Nursing on 6/13/24 at 12:34 PM. This deficient practice resulted in harm to Resident #29 since the resident suffered pain as a result of the fall. Cross Reference F609 and 610

Based on the review of the facility ' s investigative documents, medical records, and interviews with, residents and facility staff, it was determined that the facility failed to keep a vulnerable resident (Resident #1) free from abuse by the resident ' s roommate (Resident #3). Resident #3 had a known history of physical aggression towards his/ her previous roommate (Resident #4). The failure of the facility to keep a resident safe and free from abuse resulted in physical harm to Resident #1, who was transferred to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evident for 1 out of 3 residents reviewed for abuse during the investigation of MD 154 and MD 682 The findings include: The Minimum Data Set (MDS) is part of a federally mandated process for clinical assessment of all residents in Nursing homes. This process provides a comprehensive assessment of each resident ' s functional capabilities and helps nursing homes identify health problems On 1/10/2022 at 1:00 PM the review of Resident #1 ' s medical record revealed the resident was admitted to the facility in December 2019 for long-term care with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical records revealed that on 12/6/21 the resident had a Brief Interview Mental Status (BIMS) assessment with a score of 12, which indicates the resident's cognition is moderately impaired. A review of Resident #1 ' s November 2021 MDS assessment revealed that the resident was non-ambulatory and required extensive assistance for activities of daily living which includes: bathing, dressing, toileting, transferring and feeding. On 1/10/2022 at 12:45 PM a review of Resident #3 ' s medical record revealed the resident was admitted to the facility in June 2020 for rehabilitation with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical records revealed Resident #3 had a BIMS score of 14, which indicated the resident was cognitively intact. The records also revealed that the resident was ambulatory and able to move around the facility without difficulty. On 1/10/2022 at 1:45 PM during an interview with the Director of Nursing (DON), the surveyor requested a list of all resident to resident altercations documented in the past six months. On 1/11/2022 at 10:30 AM a review of the list of resident to resident altercations provided by the facility revealed that Resident #3 was involved in two altercations between October 2021 and January 2022. The details surrounding the incidents are listed below: 1. On 1/11/2022 at 10:45 AM a review of a Licensed Practical Nurse (LPN) #3 ' s statements revealed that on 10/30/2021 Resident #3 told LPN #3 that his/her roommate (Resident #4) was ripping up paper and putting the shredded paper on his/her own bedside table. LPN #3 informed Resident #3 that it is Resident #4 ' s side of the room and asked Resident #3 to please leave Resident #4 alone. LPN #3 further stated that Resident #3 followed LPN #3 into the room shared by both residents and the residents began to argue. Resident #3 spit on Resident #4, then Resident #4 hit Resident #3. LPN #3 separated the residents and moved them to separate rooms. 2. On 1/10/22 at 12:30 PM, a review of the facility ' s investigation documentation related to the second incident involving Resident #3 occurred on 1/6/2022. LPN #3 statement revealed that while doing rounds a Geriatric Nursing Assistant (GNA) #30 walked into the room shared by Residents #1 and Resident #3. GNA #30 found Resident #1 in bed with blood on his/her head, hands and arms. GNA #30 immediately called for assistance for Resident #1. The resident was transferred to the emergency room for evaluation. Further review of the investigation statement revealed that while staff attended to Resident #1 ' s injury, Resident #3 was observed pacing in the hallway. When interviewed by staff, Resident #3 revealed that Resident #1 was making noise and he/she asked the resident to stop, but the resident continued to mumble. Resident #3 admitted to attacking Resident #1 with a metal grab bar and causing injury to Resident #1 ' s head, arms and hands. On 1/11/2022 at 12:30 PM a review of Resident #1 ' s hospital discharge records confirmed that Resident #1 was evaluated on 1/6/2022 for an assault resulting in small lacerations and contusions to the resident ' s forehead and arms (Laceration: an injury that results in break in the skin; Contusion: broken blood or damaged blood vessels). The emergency room discharge report also revealed that Resident #1 received a [CONDITION(S)] [MEDICATION(S)] [MEDICATION(S)], a vaccine combination to prevent an infection, and the resident ' s wounds were cleaned and bandaged. The resident was discharged back to the facility on [DATE]. On 1/11/2022 a review of Resident #3 ' s medical records revealed a care plan, dated 1/6/2022, with interventions to address Resident #3 ' s behavior; however, there was no evidence that Resident #3 ' s had a care plan with goals and interventions to address the resident ' s aggressive behavior after the incident on 10/30/2021, when Resident #3 spat in Resident #4 ' s face following an argument. Further review of the record revealed the facility issued a behavioral contract to Resident #3 regarding aggressive behavior four days after the altercation on 1/10/22, the day the surveyors initiated an investigation into the altercation with Resident #1. On 1/11/2022 at 11:30 AM in an interview with the DON, the surveyor requested a copy of the care plan addressing Resident #3 ' s aggressive behavior after the 10/ 1 altercation (between Resident #3 and Resident #4). The DON replied that a care plan was not initiated after that resident to resident altercation due to the altercation being deemed as an unusual occurrence. On 1/11/22 at 2:15 PM Resident #1 was interviewed regarding the altercation with Resident #3. Resident #1 ' s speech was slurred, and the resident was unable to discuss the incident that had occurred on 1/06/2022. On 1/11/2022 at 2:30 PM Resident #3 was interviewed. The resident revealed that he/she remembered the incident, the resident stated that he/she was sorry and that he/she had snapped on the day of the incident. On 1/12/22 at 2:45 PM LPN #3 was interviewed, she revealed that she is the nurse that has taken care of Resident #3 for both incidents. During the interview she revealed that Resident #3 has a temper at times. She further revealed that the resident appeared remorseful a day after the attack on Resident #1, then added that Resident #3 knew (was aware) of what he/she was doing when he/she attacked Resident #1. During an interview with the corporate DON at exit on 1/18/22 at 2:30 PM the surveyor discussed the concerns of the resident to resident altercations and lack of intervention in place to address Resident #3 ' s behavior. The corporate DON revealed that she felt a care plan was not needed because the resident only had one (1) unusual occurrence in October 2021.

Based on surveyor review of clinical records and staff interviews, it was determined that the facility's staff failed to clarify medication orders related to a diuretic and failed to notify the physician of elevated lab results for 1 of 3 residents reviewed during the complaint survey (Resident #2). The facility's failure to provide needed care and services in accordance with professional standards of practice resulted in acute kidney failure, septic shock and eventual death of Resident #2. This finding was identified during the investigation of complaints# MD 281 and MD 795. The findings include: 1. On 03-11-21 at 10:41 AM, a review of Resident #2's clinical record revealed the resident had a gastrostomy tube (G-Tube) for feeding and nutrition. A G-tube is a tube inserted through the belly that brings nutrition directly to the stomach. According to the clinical record, Resident #2 also received fluids and food by mouth. Resident #2's clinical record revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A diuretic is a medication that promotes diuresis, the increased production of urine. Further review of Resident #2's record revealed that on 02-04-21 at 2:10 PM, nursing staff documented that the resident had a one-time episode of a large volume of vomit. On 02-04-21 the primary physician ordered a chest x-ray to find out whether the resident aspirated after the vomiting episode. The x-ray results indicated that Resident #2 had fluid around the lungs. Resident #2's primary physician ordered 40 mg of [MEDICATION(S)] to be given to the resident twice a day for three (3) days. According to the order, after the three (3) days Resident #2 would receive 40 mg of [MEDICATION(S)] once a day. However, the physician did not discontinue Resident #8's original order for 20 mg of [MEDICATION(S)] once a day. On 03-12-21 at 1:10 PM, a review of Resident #2's Medication Administration Record (MAR) revealed that from 02-05-21 to 02-08-21, the resident received the original dosage of [MEDICATION(S)], 20 mg, once a day; and the newly ordered dosage of [MEDICATION(S)] (40 mg, twice per day). This equals 100 mg of [MEDICATION(S)] each day. A continued review of Resident #2' MAR revealed that on 02-08-21, after the three (3) days outlined in the new order, staff reduced the frequency of the resident's order for 40 of [MEDICATION(S)] from twice a day to once a day. However, staff continued to administer the original order of [MEDICATION(S)] (20 mg once a day). The resident received 60 mg of [MEDICATION(S)] each day between 02-08-21 and 2-10-21. On 02-21-21, staff found Resident #2 unresponsive in the facility, the resident was transferred to the hospital. On 03-12-21 a review of the facility's Quality Assurance Performance Improvement (QAPI) materials related to Resident #1 revealed the QAPI team did not identify that Resident #2 received an extra 20 mg of [MEDICATION(S)] between 02-05-21 through 02-10-21 in their findings. On 03-12-21 at 11:50 AM an additional interview with the physician revealed that she increased the [MEDICATION(S)] from 20 mg to 40 mg when Resident #2's chest x-ray on 02-04-2021 indicated mild Congestive heart failure (CHF) and an infiltrate. The physician stated that she intended to discontinue the 20 mg [MEDICATION(S)] and not have both 20 mg and 40 mg given at the same time. 03-12-21 at 12:30 PM, in an interview with the charge nurse (Staff #1), the surveyor asked the employee about Resident #2's [MEDICATION(S)] order. Staff #1 stated the doctors usually write their own orders in the clinical record. Occasionally, if a nurse gets a verbal order, then the nurse writes the order. Staff #1 verbally confirmed that she gave Resident #2 both the 40 mg and 20 mg of [MEDICATION(S)] the days she worked. Staff #1 further stated, the physician did not discontinue the 20 mg [MEDICATION(S)] order. The charge nurse didn't ask the physician if the 20 mg [MEDICATION(S)] should be discontinued or not. 2. On 03-11-21 at 2:10 PM, surveyor review of Resident #2's laboratory results revealed the following: Blood Urea [MEDICATION(S)] (BUN) and Creatinine: 02-01-21 BUN 22mg/dl, Creatinine 0.96 02-05-21 BUN 20mg/dl, Creatinine 0.94 02-06-21 BUN 34mg/dl, Creatinine 1.39 02-08-21 BUN 73mg/dl, Creatinine 3.03 According to American Health Associates Laboratory Inc. the acceptable range for BUN is between 7-25 mg/dl and the acceptable creatinine range is 0.60-1.30 mg/dl. A high BUN level outside the laboratory BUN is between 7-25mg/dl and the acceptable recommended range means the kidneys are not working well or at full strength. Creatinine level outside the recommended range signifies impaired kidney function or kidney disease. However, there was no documented evidence that the primary physician was notified of these abnormal lab results. In addition, there was no evidence of any medical interventions for Resident #2 from 02/08/21 to 02/10/21 when the resident's BUN was 73 mg/dl and the creatinine was 3.03 mg/dl before being transferred to the hospital on 02/10/21. On 03-11-21 at 3:26 PM, surveyor interview with Resident #2's primary physician revealed that the facility nursing staff did not notify her of the resident's abnormal lab results for 02-06-21, and that she did not find the lab results in the resident's clinical record. As a result, she ordered the same labs again. However, when the repeated lab results were received on 02/08/21, the facility staff did not notify the physician of those results either. According to Resident #2's primary physician, she found out about the resident's abnormal lab results (from 02-08-21) on 02-10-21, after the resident had been sent to the hospital. The primary physician stated, I would have at least ordered IV fluids if I had been notified. On 03-12-21 at 4:10 PM, A review of Resident #2's hospital record revealed the emergency department physician documented on 02/10/21 at 4:02 PM, [Resident #2] appeared to be extremely dehydrated and unresponsive to verbal and tactile stimuli. Further review of the hospital's physician assessment on 02/10/21 at 4:02 PM revealed, Patient was found to be hypotensive [low blood pressure] and poorly responsive likely due to acute kidney injury secondary to severe volume contraction resulting from poor intake or diuretic therapy. On 03-12-2021 at 9:05 AM, an interview with the Dietitian revealed on 02-05-2021, the speech therapist reported that, [Resident #2] wasn't getting enough by PO [oral] intake alone. So, I increased the fluid and feeding amount. When the surveyor asked the dietician whether he monitors residents' lab results he stated, I usually check resident labs, but I don't recall checking the labs for this particular resident. The increase in fluids had nothing to do with the resident's lab results. 03-12-21 at 12:30 PM, interview with Staff #1, who was the charge nurse assigned to the resident on 02-08-21, revealed, I usually call in abnormal lab results to the physician. However, on 02-08-21, the lab results did not come on the 7-3 shift so I gave report to the incoming nurse that I was expecting labs and so she will need to follow up. The incoming nurse was an agency nurse so when I came the next day, I checked on the lab and it indicated in the record as reviewed. On 03-12-21 at 4:10 PM, surveyor interview with the Administrator and the assistant Director of Nursing revealed that Resident #2's physician brought the concern about nursing staff not providing the physician with timely lab results to their attention on 02-10-21. The Administrator stated that an emergency Quality Assurance Performance Improvement (QAPI) meeting was done on 02-22-21 to address the problem. The Administrator further stated a four-point action plan was initiated and all facility nursing staff were educated. On 03-12-21 a review of the in-service record revealed education for staff was initiated on 02-22-21; however education had not been completed with all nursing staff as of 03-12-21.

Based on surveyor review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to promptly notify the ordering physician of abnormal laboratory results for 1 of 3 residents reviewed during a complaint survey (Resident #2). The facility's failure to communicate laboratory resultes contributed to acute kidney failure, septic shock and eventual death of Resident #2. This finding was identified during an investigation of complaint # MD 281 and MD 795. The findings include: On 03-11-21 at 2:10 PM, surveyor review of Resident #2's laboratory results revealed the following: Blood Urea Nitrogen (BUN) and Creatinine: 02-01-21 BUN 22mg/dl, Creatinine 0.96 02-05-21 BUN 20mg/dl, Creatinine 0.94 02-06-21 BUN 34mg/dl, Creatinine 1.39 02-08-21 BUN 73mg/dl, Creatinine 3.03 According to American Health Associates Laboratory Inc. the acceptable range for BUN is between 7-25 mg/dl and the acceptable creatinine range is 0.60-1.30 mg/dl. A high BUN level outside the laboratory BUN is between 7-25mg/dl and the acceptable recommended range means the kidneys are not working well or at full strength. Creatinine level outside the recommended range signifies impaired kidney function or kidney disease. However, there was no documented evidence that the primary physician was notified of these abnormal lab results. In addition, there was no evidence of any medical interventions for Resident #2 from 02/08/21 to 02/10/21 when the resident's BUN was 73 mg/dl and the creatinine was 3.03 mg/dl before being transferred to the hospital on 02/10/21. On 03-11-21 at 3:26 PM, surveyor interview with Resident #2's primary physician revealed that the facility nursing staff did not notify her of the resident's abnormal lab results for 02-06-21, and that she did not find the lab results in the resident's clinical record. As a result, she ordered the same labs again. However, when the repeated lab results were received on 02/08/21, the facility staff did not notify the physician of those results either. According to Resident #2's primary physician, she found out about the resident's abnormal lab results (from 02-08-21) on 02-10-21, after the resident had been sent to the hospital. The primary physician stated, I would have at least ordered IV fluids if I had been notified. On 03-12-21 at 4:10 PM, A review of Resident #2's hospital record revealed the emergency department physician documented on 02/10/21 at 4:02 PM, [Resident #2] appeared to be extremely dehydrated and unresponsive to verbal and tactile stimuli. Further review of the hospital's physician assessment on 02/10/21 at 4:02 PM revealed, Patient was found to be hypotensive [low blood pressure] and poorly responsive likely due to acute kidney injury secondary to severe volume contraction resulting from poor intake or diuretic therapy. On 03-12-2021 at 9:05 AM, an interview with the Dietitian revealed on 02-05-2021, the speech therapist reported that, [Resident #2] wasn't getting enough by PO [oral] intake alone. So, I increased the fluid and feeding amount. When the surveyor asked the dietician whether he monitors residents' lab results he stated, I usually check resident labs, but I don't recall checking the labs for this particular resident. The increase in fluids had nothing to do with the resident's lab results. 03-12-21 at 12:30 PM, interview with Staff #1, who was the charge nurse assigned to the resident on 02-08-21, revealed, I usually call in abnormal lab results to the physician. However, on 02-08-21, the lab results did not come on the 7-3 shift so I gave report to the incoming nurse that I was expecting labs and so she will need to follow up. The incoming nurse was an agency nurse so when I came the next day, I checked on the lab and it indicated in the record as reviewed. On 03-12-21 at 4:10 PM, surveyor interview with the Administrator and the assistant Director of Nursing revealed that Resident #2's physician brought the concern about nursing staff not providing the physician with timely lab results to their attention on 02-10-21. The Administrator stated that an emergency Quality Assurance Performance Improvement (QAPI) meeting was done on 02-22-21 to address the problem. The Administrator further stated a four-point action plan was initiated and all facility nursing staff were educated. On 03-12-21 a review of the in-service record revealed education for staff was initiated on 02-22-21; however education had not been completed with all nursing staff as of 03-12-21.

Based on surveyor review of administrative and clinical records, resident and facility staff interview, and review of policies and procedures, it was determined that facility staff failed to protect a vulnerable resident from abuse related to wandering behavior and failed to prevent the resident from being subjected to further abuse upon direct observation of abusive conduct (Resident #4). The Centers for Medicare and Medicaid Services (CMS) defines sexual abuse as non-consensual sexual contact of any type with a resident. The finding of sexual abuse was evident during investigation of facility reported incident #MD 737. The findings include: On 12-30-2019, surveyor review of administrative records revealed that on 12-01-2019, GNA #1 entered Resident #1's room and observed Resident #4 lying on Resident #1's bed. Resident #1's hand was observed inside the crotch of Resident #4's pants. Further review of administrative records also revealed a statement obtained from Resident #1 on 12-01-19 in which the resident admitted to touching the private parts of Resident #4 who had wandered into his/her room and sat on the bed. On 12-30-2019, surveyor review of the clinical record for Resident #4 revealed the resident has a [DIAGNOSES REDACTED]. Further review of the clinical record revealed a care plan initiated on 08-06-2018 which identified Resident #4 as a wanderer, disoriented to place, with impaired safety awareness. The care plan intervention for wandering initiated on 08-06-2018 instructed staff to identify pattern of wandering: is it purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. The care plan did not indicate specific protective measures the facility's staff would take to prevent Resident #4 from wandering into other residents' rooms, and did not identify the intervention to be implemented once facility staff had identified what type of wandering was prevalent for Resident #4. On 12-30-2019, review of the hospital record revealed that a forensic work-up was completed on Resident #4 in the emergency roiagnom on [DATE], and the forensic team determined that Resident #4 required no further treatment. The emergency department note also stated that Resident #4's responsible party did not want the resident returned to the facility. On 12-30-2019 a review of Resident #1 clinical record revealed the resident does not have a [DIAGNOSES REDACTED]. Resident #1' s physician assessed the resident as being alert, oriented and coherent on 12-02-2019. On 12-30-2019 at 12:20 PM, an interview with GNA #1 revealed that upon entering Resident #1's room she observed Resident #4 on Resident #1's bed with Resident #1. GNA #1 stated she immediately instructed Resident #1 to stop, however she stated Resident #01's hand remained inside Resident #4's pants. GNA#1 stated she asked Resident #1 to stop, a couple of times, stating Resident #1 did not stop, but did slow the hand movement inside Resident #4 ' s pants. GNA #1 stated she went out to get the nurse to help because Resident #1 did not stop as she directed. Surveyor asked GNA #1 where Resident #1's hand were when she left the room to get help. GNA #1 responded, It was still down inside the pants. GNA #1 then stated she went to the nurse's station where the charge nurse was documenting to report the sexually inappropriate behavior, and both went back into Resident #1's room. Upon re-entering the room with the charge nurse, GNA 1 stated Resident #1's hands were no longer in Resident #4's pants, and Resident #1 was trying to get Resident #4 to get up off the bed. GNA further stated that Resident #4 has a history of wandering into other residents' room. On 12-30-2019 at 1:40 PM, surveyor interview of Resident #1 revealed the resident acknowledged sexual contact with Resident #4, and stated I meant no harm, I haven't done it anymore. On 01-03-2020 at 2:45 PM, surveyor interview with the responsible party confirmed that he/she informed the hospital staff that the resident was not to be returned to the facility, but that he/she requested placement in another facility.

Based on surveyor observations, review of clinical records, the facility's policy and procedure and Quality Assurance and Performance Improvement (QAPI) minutes, and interview of residents, facility staff and family, it was determined that the facility staff failed to provide a safe and secured environment to residents #1, #2 and #3. In addition, the facility staff failed to safely transfer resident #4 in and out of bed. The findings include: 1. Based on surveyor observations, review of clinical records, the facility's policy and procedure and QAPI minutes, and interview of residents, family and facility staff, it was determined that the facility staff failed to implement adequate safety interventions to address the needs of residents assessed as an elopement risk. After the elopement of resident #1, the facility failed to develop and implement a quality assurance plan to maintain a safe environment for residents who are at risk for elopement. This finding was evident for 3 of 3 residents, who were identified as at risk for elopement. (resident #1, #2 and #3). On 06-7-18 at 4 PM, an immediate jeopardy to residents' health and safety was determined by the State Office of Health Care Quality. On 06-07-18 at 7:30 PM, the immediacy was removed after the security system was checked to ensure that all the wanderguard signaling devices were in working condition. In addition, a daily monitoring system was implemented. On 06-08-18 at 8:30 PM, the immediate jeopardy was abated following the facility's implementation of corrective actions to ensure the health and safety of all residents that were at risk for elopement. This finding is related to the facility reported incident MD 939. The findings include: a. On 06-07-18, review of the clinical record and the facility's investigation report revealed that resident #1 was found on a busy street across from the facility, on 05-20-18 about midnight, by a pedestrian. The pedestrian then called staff #1 to pick up the resident. The resident returned to the facility on the same night and was under one on one supervision until 05-23-18. On 06-07-18 at 6:30 PM, interview of staff #1 revealed that he/she overheard an alarm go off on 05-20-18 around 12 MN, but did not know what the alarm meant. Then, staff #1 received the call from the pedestrian about resident #1. Interview of staff #2 on 06-08-18 at 7:10 AM revealed that he/she did not hear the alarm go off at 12 AM on 05-20-18 when providing care in a resident's room. On 06-07-18, review of the facility's QAPI committee meeting minutes dated, 05-22-18, revealed that the root cause of resident #1's elopement on 05-20-18 was due to the alarm sound of the wanderguard system not being loud enough to alert the facility staff. Therefore, the facility's action plan was to install a magnet lock at the main entrance door, to upgrade the enunciator at the 1st floor nursing station and install a strobe light at the 1st floor nursing station for visual identification as means to prevent elopemeent. This action plan would be completed on 05-23-18. The wanderguard is an alarm system that is used in wandering or elopement management. The system usually involves some type of antenna system connected to a controller and a door contact switch. Residents who are at risk for elopement wear a wrist or ankle transmitter, and when the transmitter comes in contact close to the door that is protected by this type of system, the antenna signals out the transmitter of the resident. On 05-23-18, the director of nursing reported to the QAPI committee that a magnetic lock was installed at the main entrance door on 05-23-18 to provide a 15 second delay to residents who walked through the main entrance door with a wanderguard signaling device. In addition, a strobe light was installed at the 1st floor nursing station with an upgraded enunciator on 05-23-18. On 06-07-18 at 2 PM, surveyor observation revealed that two wanderguard sensors were located at the facility's main door entrance, as well as at the 1st floor service hallway. During the demonstration of the wanderguard system, in the presence of the facility's Maintenance Director on 06-07-18 at 2 PM, the strobe light did not light up at the 1st floor nursing station when the service hallway's wanderguard alarm sound was activated. Interview of the Maintenance Director on 06-07-18 at 2 PM revealed that he/she assumed the strobe light was functional after it was installed on 05-23-18 by a contractor. However, there was no monitoring system developed and completed after 05-23-18 to ensure that the strobe light and upgraded enunciator worked simultaneously when the wanderguard system alarm was activated. b. On 06-07-18 at 11:40 AM and 12:45 PM, surveyor observation and interview of resident #1 and a family member revealed there was no wanderguard signaling device found on the resident's extremities. Even though resident #1 had some cognitive impairment, the resident was oriented and able to answer simple questions. The resident and the family member stated that no wanderguard signaling device was in place after the resident returned to the facility from an emergency room visit. However, the resident could not recall when he/she returned to the facility. On 06-07-18, review of resident #1's clinical record revealed tht two physicians documented in the Fall of (YEAR) that the resident did not have adequate decision making capacity due to a stroke. In addition, the resident had a history of [REDACTED]. On 05-17-18 at 8 PM, resident #1 was found in the facility's parking lot. Staff #5 completed an elopement risk assessment the same evening and determined that the resident was at risk of elopement. Therefore, a wanderguard signaling device was placed on the resident, beginning 05-17-18. Interview of staff #5, on 06-07-18 at 6:50 PM, revealed that the wanderguard signaling device was placed on resident #1's right ankle on the evening of 05-17-18. Further review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed that the facility staff checked off every shift that the resident's wanderguard signaling device was in place. On 06-07-18 at 2:45 PM, the surveyor reported to the interim Director of Nursing (DON) about the observations, on 06-07-18 at 11:40 AM and 12:45 PM, that the resident did not have a wanderguard device in place. The interim DON explained that this was because the resident removed the wanderguard signaling devices himself/herself. However, there was no supportive documentation provided. On 06-07-18 at 3:30 PM, there was a wanderguard signaling device noted on resident #1's left ankle. On 06-07-18 at 3:30 PM, interview of staff #3 revealed that he/she placed a new wanderguard signaling device this afternoon on the resident's left ankle. Staff #3 could not locate the old one that was reportedly removed by the resident on 06-07-18 as stated by the interim DON. On 06-08-18 at 8 PM, interview of resident #1 and his/her parents revealed the resident's wanderguard signaling device was removed by an Emergency Medical Technician (EMT) on 05-27-18 before transferring the resident to the hospital. After the resident returned to the facility on [DATE] from the hospital, the resident did not have the wanderguard signaling device on until 06-07-18 following surveyor intervention. c. On 06-07-18, review of resident #1's care plan related to elopement, which was developed on 05-18-18, revealed that all facility staff should monitor the security bracelet per protocol. On 06-07-18, review of the facility's security bracelet protocol and the manufacturer instructions for a wanderguard signal device revealed that testing should be done daily to ensure the functional status of an individual's wanderguard signaling device. However, there was no evidence that the facility staff conducted testing daily to ensure the status of resident #1's wanderguard as stated on the care plan. On 06-07-18 at 3 PM, interview of the interim DON revealed there were a total of 3 residents (resident #1, #2 and #3), who had the signaling device due to elopement risk. On 06-07-18 at 3:40 PM, interview of staff #3, staff #4 and the Long Term Care (LTC) unit manager revealed they did not test the status of the wanderguard signaling device for residents #1, #2 and #3 routinely. On 06-07-18 at 7 PM, the Maintenance Director conducted testing on the wanderguard signaling devices of resident #1, #2 and #3. He stated resident #3's wanderguard signaling device was malfunctioning and replaced. Interview of resident #3 on 06-08-18 at 8 PM revealed the wanderguard signaling device was noted on the right wrist. The resident stated no one checked his/her device except 06-07-18 evening. On 06-07-18 at 7:30 PM, interview of the facility's administrator revealed no additional information. 2. Based on surveyor review of the closed record and the facility's investigation report, and interview of the facility staff, it was determined that the facility staff failed to transfer resident #4 properly. As a result of the improper transfer, bruising and fracture was noted on the resident's left arm. This finding was identified during an investigation of a facility reported incident, MD 110, which is valid and considered as a harm deficiency. On 06-08-18, review of the closed record revealed some bruising was noted on resident #4's left upper arm in the evening on 05-26-18. Since the resident was non-verbal and required total assistance with activities of daily living (ADL), the cause of bruising was unknown. Therefore, an investigation was initiated. Further review of the care plan revealed resident #4 required total assistance of 2 persons for transfer using a total lift. According to the facility's policy and procedure, a total lift is referred to a mechanical lift, which requires 2 person assistance. However, review of the facility's investigation report dated 05-31-18 revealed an evening staff transferred resident #4 alone with a fork lift in the evening on 05-24-18. In the morning on 05-25-18, bruising was noted on the resident's left arm. After morning care on 05-25-18, resident #4 was carried out of bed by a day nursing assistant, which was inconsistent with the resident's care plan of transfer. See F 600. In the late evening on 05-26-18, the attending physician was notified about the bruising on resident #4's left arm. An x-ray was ordered to rule out the cause of the swelling. On 05-27-18 at 11:37 PM, the x-ray result showed that resident #4 had a [MEDICAL CONDITION] arm. On 05-28-18 at 3 AM, the resident was sent to a hospital for further evaluation. On 06-08-18 at 4 PM, interview of the former DON revealed a fork lift referred to the total mechanical lift. Based on review of the incident investigation, the evening staff, who worked on 05-24-18, and the morning staff, who worked on 05-25-18, failed to transfer resident #4 properly as stated on the care plan. Therefore, the former DON provided in-service training of proper transfer to the nursing staff starting on 05-29-18. On 06-08-18 at 8:50 PM, interview of the administrator revealed no additional information.

Based on surveyor review of the clinical record and facility staff interview it was determined that facility staff failed to prevent head injuries related to multiple falls for resident #165. This finding was related to complaint #MD 383 and is valid. The findings include: On 10-30-15 surveyor review of the clinical record for resident #165 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed that resident #165 had 11 falls from 08-21-15 through 10-03-15. Of the 11 falls, the following five falls resulted in head injuries: On 09-01-15 resident #165 fell in the room and sustained a 8cm x 8cm hematoma on the back of her head. A hematoma is a collection of blood outside the blood vessels caused by injury to the blood vessels. On 09-11-15 resident #165 fell at the nurses station and complained of a headache. Nursing assessment revealed a big bump on the back of her head. On 09-13-15 resident #165 fell in the room and sustained a subdural hematoma. A subdural hematoma is blood that collects between the layers of tissue that surround the brain caused by severe head injury. On 09-23-15 resident #165 fell in the room and sustained a 0.5cm skin tear and swelling to the back of her head. On 10-03-15 resident #165 fell in the room, was unresponsive for 15-20 seconds, and had bleeding from the head. Review of the resident fall and investigation reports revealed that after falls on 09-13-15, 09-23-15, and 10-03-15, the documented corrective action to be implemented was for resident #165 to have one on one supervision or private duty. However there was no evidence that this intervention was ever implemented. In addition, surveyor review of the clinical meeting report notes written on 09-23-15 revealed can not use floor mat due to balance or alarms due to quick impulsive behavior and no other interventions available for (care plan). Further review of the clinical record revealed a hospital discharge summary written on 09-24-15 that documented a plan for recurrent falls in patient that stated the case was discussed with the director of admissions at the facility and included that the patient needs: falls prevention, all the safety measures to be reinstated, bed alarm, and close monitoring from nursing staff. However, there was no evidence that a bed alarm was ever implemented, plan for closer monitoring or further discussion regarding the use of a bed alarm after 09-23-15. Surveyor review of the care plan for falls for resident #165 revealed that despite falls on 09-19-15, 09-22-15, 09-23-15, 09-28-15, 10-02-15 and 10-03-15, the only revision to the fall care plan was to assist the resident getting in and out of bed on 09-29-15. However, this intervention had already been determined as ineffective in preventing falls due to the resident's impulsivity. In addition, despite 5 of the falls resulting with injuries to the back of the head and documentation that falls were expected due to poor impulse control, there was no evidence of safety measures implemented to prevent head injuries, i.e. soft helmet. On 10-30-15 surveyor interview with the director of nursing revealed that staff discussed the falls and interventions for resident #165 throughout the resident's stay at the facility. Facility staff felt that one on one supervision and a bed alarm would be ineffective due to the resident's impulsivity and moving too quick.

Based on surveyor review of the clinical records, review of the complainant information, and staff interviews, it was determined that the facility staff failed to document, assess, monitor, and provide timely treatment for [REDACTED].#1. This finding was identified in the investigation of complaint MD 659 that was substantiated and determined to cause harm to the resident. The findings include: On 6-14-12, review of the complainant information revealed that a family member observed a soiled bandage on the resident's right ankle. The wound was described as painful, bruised and bleeding, during a visit on Sunday, May 6, 2012. According to the complaint, the family member questioned the nursing staff about the ankle wound and all staff replied that they were not aware of the wound. There was no further response or follow up to the family member by the facility staff. On 6-14-12, review of the clinical records revealed that resident #1 was admitted to the facility on [DATE] for rehabilitation services following a hospitalization for scheduled spine surgery related to cervical [DIAGNOSES REDACTED], with complications of a pneumothorax (collapsed lung) and [MEDICAL CONDITION] ([MEDICAL CONDITION] or blood clot) in the right upper arm. The resident's medical history includes dementia, [MEDICAL CONDITION], hypertension, and diabetes mellitus with [MEDICAL CONDITION] and [MEDICAL CONDITION]. She was admitted to the facility with a sacral pressure ulcer and has been dependent with all activities of daily living and functional tasks. Review of a skin condition report dated 5-6-12, revealed that this resident was noted with an open area on her right outer ankle, measuring 2.1 cm in length, 1.6 cm in width, and 0.1 cm in depth, with slough and serosanguinous drainage. Based on the skin condition report and related incident report, the wound was caused by trauma when, as stated by the resident, she hit her right ankle on the wheelchair. However, there was no incident / accident report or any other documentation as to when this trauma injury occurred. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 6-14-12 and 6-18-12 at approximately 5:00 PM revealed it was thought that the injury incident may have occurred between 5-2-12 to 5-4-12. Therefore, record review revealed no evidence of an assessment, notification to the physician, or treatment for [REDACTED]. ankle. Further review of the clinical records revealed no documentation or evidence of medical intervention regarding the trauma injury and open wound until sixteen days later on 5-21-12, after the family member had visited on 5-6-12 and spoke to the nursing staff about the bandaged wound on the resident's right ankle. On 5-21-12, the resident was seen by the specialist physician who was providing wound care management for the sacral pressure ulcer on a weekly basis at the facility. Review of this physician's exam report revealed the initial evaluation of the right ankle wound, which was the next documented assessment of the wound since initiation of the skin condition report on 5-6-12. Based on the wound physician's initial evaluation, the wound surface area was noted to encompass 9.0 cm with the open wound measuring 3.6 cm in length and 2.5 cm in width. The depth was not measurable due to 100% "thick adherent devitalized necrotic tissue." A "surgical excisional debridement of the muscle" was performed by the wound physician on 5-21-12 and treatment orders were given, which were the first treatment orders initiated for the right ankle wound as evidenced to date in the clinical record. Continued review of the clinical records revealed that following the surgical debridement performed by the wound physician on 5-21-12 a new pain medication, [MEDICATION NAME] 50 mg, was started on 5-23-12, to be given one hour before the daily wound care and dressing change. Prior to this new medication order, the resident's pain regimen included routine Tylenol 650 mg given three times a day at 10:00 AM, 4:00 PM, and 10:00 PM, without specificity to wound care. The wound physician's recent follow up evaluation on 6-11-12 stated that the resident's right ankle wound was "Overall improved - however, there is residual necrotic tissue within the wound which will likely worsen and increases the risk of wound infection. Surgical excisional debridement is indicated." In addition, the wound physician's physical exam noted the resident had associated pain during this visit, with the resident verbalizing a pain score of 5 out of 10. Based on this pain assessment, the wound physician addressed a new plan to give pain medication 30 minutes prior to the wound rounds examination. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 6-14-12 and 6-18-12 at approximately 5:00 PM revealed no additional evidence or disagreement with the investigative findings.