Every finding on record at Levindale Hebrew Ger CTR & HSP

Based on interview and record review it was determined that the facility failed to ensure allegations of abuse were timely reported. This was evident for 1(#211) out of 1 Resident reviewed for timely reporting of abuse allegations during the facility's recertification survey. The findings include: On 3/11/26 at 10:33AM the surveyor conducted a review of documented correspondence dated 11/17/25 at 3:12AM in which the following information (1-6) was included in communication from Resident #211 to Chief Administrative Officer (CAO) #37:1.) I will not be going to (Director of Nursing), The last time I did, s/he came into my room and yelled at me, While I am here, this hospital room is my home, I would never stand for someone yelling at me in my home, I will not stand for it here, I did not yell at (Director of Nursing) first.2.) The Administrator's conduct felt disrespectful to them.3.) Allegations which included the following information: S/he (Geriatric Nursing Assistant # 38) proceeded to yell at me. 4.) The following request for the facility to self report: I would like you to self report. 5.) An additional request for reporting: Please report (GNA #38) to the Board of Nursing.6.) Another request for the facility to self-report: Please self-report to CMS and do not retaliate.Further review by the surveyor on 3/11/26 at 10:33AM of documented correspondence dated 11/17/25 at 10:33PM from the facility's CAO #37 to Resident #211 revealed the following information was communicated in response to Resident #211's communication sent to them on 11/17/25 at 3:12AM: (Resident #211) Thank you for your e-mail and voicemail today, I apologize for what you have described below, I have included our culinary leaders for one of your primary concerns noted below, I will follow up with the leaders on the tech (GNA #38) you noted below and appropriate action will be taken, Sincerely, (CAO #37).On 3/11/26 at 10:45AM the surveyor conducted an interview of the facility's Administrator and requested for them to provide all self-reports made including to all agencies, and provide all investigation that occurred regarding Resident #211 at which time the Administrator reported to the surveyor that the facility had no knowledge of Resident #211's concern for abuse until a surveyor informed them on 2/5/26 which resulted in a self-report made at that time once aware.On 3/11/26 at 10:54AM the surveyor conducted an interview of the facility's Administrator who confirmed that the only reports made regarding Resident #211 was one initial report made to the Office of Health Care Quality (OHCQ) on 2/5/26 and one follow up report made to OHCQ on 2/12/26.On 3/11/26 at 12:05PM the surveyor conducted an interview of CAO #37 who informed the surveyor that Resident #211's care concerns were handled through the normal processes and when his/her concerns came in, they were investigated and unsubstantiated. When the surveyor inquired as to the initial timeframe that Resident #211's care concerns were brought to them by the Resident, CAO #37 reported that documentation was maintained by the facility Administrator, Patient Experience Leader #39 and Staff #40, and that everything goes through the patient experience department. CAO #37 reported to the surveyor that Resident #211 was discharged at the end of November 2025 and that they had received emails regarding care concerns prior to his/her departure and confirmed that they provided responses to the Resident by email and that there were multiple correspondence in which they dealt directly with Resident #211. The surveyor requested for all concern forms and all responses provided by the facility to be provided to this surveyor.On 3/11/26 at 12:46PM the surveyor conducted an interview of the facility's Administrator in the presence of the survey team at which time the facility Administrator stated they had no knowledge of the allegations of abuse until surveyor notification in February of 2026. The Administrator stated to the survey team during the interview that the timeframe for reporting of an allegation of abuse was within two hours of the allegation being made. During the interview, the Administrator confirmed with this surveyor that all facility staff are responsible for timely reporting even if the allegation information does not reach them timely. The facility Administrator identified themself during the interview as the facility's abuse coordinator and stated: (Resident #211) did not want a grievance filed. This surveyor then inquired to the facility Administrator as to if the facility was reporting allegations of abuse received by facility staff in situations where Residents choose not to file a grievance. At this time, the Administrator confirmed that allegations of abuse would still need to be reported. At this time, the surveyor shared their concerns for abuse not being timely reported regarding the allegation of abuse made regarding GNA #38, and shared the concern that the allegation of abuse regarding the facility's DON had not been reported or investigated. The Administrator inquired to this surveyor as to what the abuse concern was regarding the DON at which time the surveyor referred them to review the correspondence documentation from Resident #211 dated 11/17/25 and CAO #37's correspondence documentation in response to the Resident on 11/17/25 which they had not provided to this surveyor. On 3/11/26 at 1:12PM the Administrator provided this surveyor with self-report email documentation dated as sent 3/11/26 at 1:10PM to OHCQ and reported that they were now beginning investigation of the allegation regarding the DON.Concerns were again reviewed during the facility's exit conference on 3/13/26 with the facility's Director of Nursing and Administrator. Reference to F610.

Based on review of Facility Reported Incident (FRI) #329725 and #329731, resident medical records, and other pertinent documentation, interviews with staff, and observations, it was determined that the facility failed to prevent a cognitively impaired resident with known exit seeking/elopement behaviors from exiting the facility on two occasions. This was evident for 1 (Resident #7) out of 16 residents reviewed for wandering/elopement during the complaint survey. This failure resulted in an Immediate Jeopardy for Resident #7.The facility implemented effective and thorough corrective measures following this incident. The facility's plan and actions were verified during this survey, therefore this deficiency will be cited as past noncompliance. The date of correction was 6/17/2025. The findings include: On 11/13/2025 at 10:00AM, a review of Resident #7's electronic medical record revealed that the resident had a diagnoses of but not limited to dementia with agitation, anxiety, and behavioral disturbance, schizoaffective disorder, bipolar type, drug induced parkinsonism, and epilepsy. The resident was admitted to a secured nursing unit of the Long Term Care facility on 1/22/2025 for cognitive impairment and worsening psychosis. The resident was independent with ambulation. A review of an admission Wandering Risk Assessment completed 1/22/2025 revealed a score of 0, indicating the resident was not a wandering risk. However, a review of a nursing progress note dated 1/23/2025 at 7:04PM stated the resident was busy seeking exit and wanted to go to floor 2 and go home. According to the admission Minimum Data Set (MDS) assessment completed 1/28/2025, the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment.Further review revealed a care plan with a focus, [Resident #7] is at risk for elopement/wandering related to cognitive impairment initiated on 1/24/2025 with interventions to Monitor [Resident] for tailgating when visitors are on the unit, Provide direct staff supervision when attending out of facility activities, Reassess elopement risk quarterly, and Use verbal and if necessary physical cues for redirection to persuade exit-seeking behaviors. Review of Facility Reported Incident #329725 and the facility's investigative file on 11/13/2025 at 10:25AM, revealed that on 3/6/2025 at 3:04PM, after participating in a group activity in the Town Center on the first floor, Resident #7 exited the facility through the [NAME] doors to the right of the main entrance while activity staff were escorting other residents to their units. The resident was discovered missing at about 3:15PM. Facility staff conducted an initial search for the resident in the Town Center, on the resident's Household unit, and all Household units. Unit Manager (UM) #10 for the Household units and the Director of Nursing (DON) were informed and called a code grey at about 3:20PM. Staff searched the entire facility, including the outside of the facility and surrounding areas. Campus Security and Maryland Transit Administration (MTA) were notified. The resident representative was notified at 4:11PM. The police were called and given a description of the resident. Based on a statement made by the Chief Administrative Officer #11, on 3/6/2025, after reviewing security film, Resident #7 exited the building via the double doors to the left of the main entrance. At 3:16PM the resident boarded an MTA bus. Later that evening, around 8:00PM, the facility was notified that Resident #7 had just arrived at the hospital via ambulance. The resident was later admitted to the hospital for observation and evaluation. The resident sustained no injuries. The resident was readmitted to the facility on [DATE].A review of Resident #7's electronic medical record on 11/14/2025 at 12:20PM, revealed a Behavior Note dated 5/2/2025 which stated at approximately 9am [Resident #7] followed a staff through the locked door and went down the elevator towards the front door, [the resident] was brought back to [his/her] room. During a review of FRI #329731 and the facility's investigative file on 11/13/2025 at 10:50AM, it was revealed that on 6/17/2025 at approximately 3:55PM, Resident #7 eloped again. An elopement alert, code grey, was initiated over the loudspeaker at about 4:15PM and full sweep of the facility and surrounding areas were searched. Campus security was immediately notified. At about 4:30PM, the police and transit authority were notified and the resident's representative. During a review of Resident #7's electronic medical record conducted on 11/13/2025 at 11:00AM, the Surveyor discovered a clinic note dated 6/17/2025, written by the UM #10, which stated that at around 3:10PM, the nurse called UM #10 to inform her that Resident #7 wants to go out for a walk, and she needed help to get the resident out. At around 3:44PM, the nurse called UM #10 to inform her that Resident #7 was nowhere to be found. UM #10 called an elopement alert, code grey when she arrived on the unit. The nursing team searched all the rooms on Household (HH) 5, and the stairways. Other staff searched the entire interior and exterior of the building. The nurse called 911 and the resident representative to notify them of the situation. The resident could not be located. At around 6:14PM, the police officer who remained at the facility, notified the facility that the resident had been located downtown. Upon UM #10's arrival to pick up the resident, the resident informed the Unit manager of unit 5 that they wanted to go to their house downtown and wanted to go home. The resident returned to the facility with UM #10 and was returned to Household 5, a secured unit. The resident was assessed and had sustained no injuries and had no complaints of distress. During observation rounds on 11/13/2025 at 11:30AM, the Surveyor observed HH 5. The staff had to use their badges for entry into the unit and exit. There were multiple signs on the doors which stated High Elopement Risk in bold red letters. A sign to inform visitors and staff to DO NOT open door when residents are standing near or at them. Please wait for a safe time to enter. Thank you for ensuring the doors close safely behind you upon your exit. Another sign in capital red letters and highlighted in yellow which states, Attention all staff and visitors. You must stop and wait for the door to completely close before walking away. Another sign with SAFETY that states High Elopement Risk; Prevent unsafe departures; Ensure door fully closes before walking away. A wander guard electronic system with exit sensors was observed at the doorway. During a continued tour of the facility 11/13/2025 at 11:40AM, the Surveyor noted that there was a wander guard system with exit sensors located on the doors at the main entrance and on the double doors to each side of the main entrance doors. The doors to the right of the main entrance, labeled [NAME] doors, have an Exit sign and allows someone to exit the facility but not enter the facility (unless it is [NAME] days). The doors to the left of the main entrance, have an Exit sign and allows someone to exit the facility but not enter the facility. During an interview conducted with the Director of Maintenance (DOM) on 11/13/2025 at 12:10PM, the Surveyor was informed that the WanderGuard electronic monitoring system was a new system for the facility. It was installed and fully functioning throughout the facility by the end of September 2025. There were exit sensor alarms and keypads at all the doors which enter and exit each unit of the facility. There are exit sensor alarms at the main entrance sliding doors and the double doors to the left and the right of the main entrance doors. The maintenance department was responsible for checking the function of the exit sensor alarm system and that was tested daily. The DOM informed the Surveyor that they were aware of Resident #7's elopement on 6/17/2025. In response to Resident #7's elopement, the maintenance department staff tested the doors on HH 5 to ensure it was magnetized and closed properly, they tested the time the doors closed and tested the hardware of the door. The doors of HH 5 were functioning properly. On 11/14/2025 10:45AM, the Surveyor reviewed a wander/elopement risk list provided by the facility. The Surveyor identified the location of the 16 residents listed. During a tour of the facility, a Surveyor observed Hall 1, Hall 2, HH 1 and HH 2 on the first floor, HH 3 and HH 4 on the second floor, and the secured units HH 5 and HH 6 on the third floor to ensure the wander guard system exit sensors and keypad were at each entry and exit to the units. The Surveyors observed High Elopement Risks signs on the inside and outside the doors at HH 3, HH 4, HH 5, and HH 6. A Surveyor confirmed the placement of a wander guard electronic bracelet for the residents listed on Hall 1 and Hall 2. On 11/14/2025 at 11:30AM, during an interview and observation conducted with Licensed Practical Nurse (LPN) #8 working on HH 5 and HH 6, the Surveyors confirmed the placement of the wander guard electronic bracelet for each resident on the wander/elopement risk list who resided on those units. During the tour of HH 5 and HH 6, LPN #8 made sure the unit doors closed behind her before proceeding to the next unit. The stairways doors, on both units, do not have wander guard system exit sensors in place. LPN #8 informed the Surveyors that those doors can only be accessed by facility staff via keypad and badge. LPN #8 demonstrated how the wander guard electronic monitoring system works. The Surveyors observed a resident approach the unit door on HH 5, the resident's electronic bracelet activated exit sensors and the keypad started to alarm and display the bracelet's tag # assigned to that resident. A staff member approached the unit door on HH 5 with another resident, with an electronic bracelet on, who was in a wheelchair. As the staff member opened the doors with her badge, the resident's electronic bracelet activated the exit sensor and a loud alarm sounded. LPN #8 deactivated the alarm using the keypad. During an interview conducted with the Director of Nursing and the Nursing Home Administrator (NHA) on 11/14/2025 at 1:30PM, the Surveyor was informed that Resident #7 was ambulatory and very active at the time the resident eloped on 3/6/2025. As a result of the Resident #7's elopement, staff completed a head count of all residents, the facility implemented larger, more bold signs on the doors for staff and visitors, elopement education was initiated for all staff, elopement drills were initiated, Wandering Risk Assessment reinitiated for all residents in the facility, and effective immediately, all activities were held on HH 5 and HH 6 for the residents who reside on those units, and 7am and 7pm unit huddle meetings were held to inform staff of the elopement and to provide increased supervision for wandering/exit seeking residents. Upon readmission, Resident #7 returned to the secured unit on HH 5 and the resident was 1:1 with rounding observation sitter, and redirection activities. During a continued interview, the NHA reported that on 6/17/2025 Resident #7 was able to elope because a staff member did not ensure the doors were fully closed behind them when they exited the unit. Per security film, the resident waited until the staff member exited HH 5 doors, went to the door, held it open with their foot, and waited until the staff member entered HH 6. The resident then slipped out the door quickly and proceeded to the elevators. Once on the 1st floor, the resident exited the facility through the double doors to the left of the main entrance doors. The resident caught an MTA bus downtown, where the resident was found by police. Resident #7 returned to the secure unit in HH 5. The facility staff implemented 1:1 sitter for a week and then 1:1 rounding observation sitter for supervision, 7am and 7pm huddle meetings to inform staff of the elopement and increased supervision of the residents at risk for wandering/exit seeking. The staff member was educated to wait for the all unit doors to fully close behind them before walking away, staff continue to receive education on elopement risk resident and identifying exit seeking behaviors. After Resident #7's second elopement in June 2025, the facility decided to implement an alternative method of preventing elopement through acquiring the WanderGuard electronic monitoring system. On 9/15/2025, the facility started a rolling activation of the WanderGuard electronic monitoring system. Resident #7's unit, HH 5 was the first unit to be activated and wander/exit seeking residents received a wander guard electronic bracelet that communicates with exit sensors at the unit doors to alert staff if a resident at risk attempts to leave the secured area. By 9/29/2025, the entire facility was completed. During installation, a representative from the company educated staff on how the WanderGuard electronic system works. All facility residents were reassessed with the Wandering Risk Assessment to confirm who needed a wander guard electronic bracelet. HH 5 and HH 6 are secured units, and the majority of the wandering/exiting seeking residents reside on those units. There have been no other elopements from the facility. After surveyor review, interview, and observation and based on the above actions taken by the facility and verified by the surveyor on-site, it was determined that the facility had corrected the deficient practice by 6/17/2025, prior to the start of the survey.

Based on observation, record review, and interview with staff, it was determined that the facility failed to : 1.) ensure residents had physician orders for placement of a WanderGuard device (sensor bracelet) and facility staff were checking the WanderGuards for function. This was evident for 3 (Resident #17, #18, and #19) out of 16 residents reviewed for wandering/elopement; 2.) ensure adequate supervision and monitoring for a resident with documented wandering behaviors and an identified high wander risk, and ensure significant changes in vital signs were recognized, reported, and acted upon. This was evident for 1 (Resident #5) of 2 residents reviewed; 3.) ensure the resident received timely necessary care in response to a resident's change of condition (Resident #4); 4.) ensure necessary incontinence care was provided as well as timely response to resident calls for assistance, and ensure interventions on the care plan for diet were appropriately reflected in the medical diet orders (Resident #8 and #9). This was evident for 2 out of 3 Residents reviewed for quality of care. The findings include: 1a. Wandering is random or repetitive locomotion; this movement may be goal directed (e.g., the person appears to be searching for something such as an exit) or may be non-goal directed or aimless and can significantly increases the risk of injury to the individual. Elopement is when a person leaves the premises or a safe area without the facility's knowledge and supervision. On 11/13/2025 at 1:15PM, the Surveyor reviewed the Identifying Risk for Patient Wandering and Use of the WanderGuard System policy with an effective date of 11/13/2025. According to the policy, the facility should obtain a physician's order for the implementation of a WanderGuard device (sensor bracelet) for a resident. On 11/14/2025 at 10:30AM, during a review of the Wander/Elopement Risk List and review of the electronic medical record, the Surveyor discovered that Resident #17, #18, and #19 did not have physician's orders for a WanderGuard device. On 11/14/2025 at 11:30AM, during an interview and observation tour conducted with Licensed Practical Nurse (LPN) #8, the Surveyor confirmed the placement of WanderGuard devices on Residents' #17, #18, and #19. During an interview conducted with the Administrator on 11/14/2025 at 1:40PM, the Surveyor expressed the concern that Resident #17, #18, and #19 had a sensor bracelet on and failed to have documentation of a physician's order for them. The Surveyor was informed that any resident with a WanderGuard device, should have a physician's order for placement. The Administrator was asked to provide documentation of a physician's order for placement of a WanderGuard device on Resident #17,#18, and #19. On 11/17/2025 at 10:45AM, the Administrator confirmed that Resident #17, #18, and #19 did not have a physician's order for a WanderGuard device and provided documentation of new physician's orders placed on 11/14/2025 for the Residents #17, #18, and #19. 1b. On 11/13/2025 at 11:25AM, the Surveyor conducted an interview with Licensed Practical Nurse (LPN) #22 who was working on a secured unit, household (HH) 5. During the interview, the Surveyor was informed that residents wearing a WanderGuard device (sensor bracelet) are reported to the on coming nurse during shift report. Nurses are to check the WanderGuard device for placement and document in the resident's electronic medical record each shift. Nurses do not check the resident's WanderGuard device for function. During an interview conducted with the Director of Maintenance (DOM) #7 on 11/13/2025 at 12:10PM, the Surveyor was informed that the WanderGuard electronic monitoring system was a new system for the facility. It was installed and fully functioning throughout the facility by the end of September 2025. The maintenance department was responsible for checking the function of the exit sensor alarm system and that is tested daily. Maintenance staff do not test the resident's individual sensor bracelets for functioning. On 11/13/2025 at 1:00PM, a review of Testing You WanderGuard BLUE System Correctly: Important Information guide revealed that WanderGuard device bracelets should be tested daily and more frequently for residents who are known to tamper with their bracelets. The results should be documented in the resident's electronic medical record. On 11/13/2025 at 1:40PM, an interview with the Director of Nursing (DON) revealed that the WanderGuard system was new to the facility. All staff are still learning the new system. At this time, the nurses are checking the residents to ensure the WanderGuard device placement on the resident and that is documented in the electronic medical record. The nurses are not testing the residents' devices to make sure they are functioning. On 11/14/2025 at 1:30PM, during an interview with the Administrator and the DON, the Surveyor expressed the concern that the facility does not conduct routine testing of the resident's individual bracelets to ensure they are functioning and that the nurses are just checking for placement. The Surveyor was informed that the facility was currently working on the concern. On 11/17/2025 at 2:28PM, the Administrator reported that the maintenance department will be checking the function of the residents' individual WanderGuard device daily and documenting the results in a maintenance log. 2a. On 11/14/25 at 11:12 AM, review of the electronic medical record identified a Wander Risk Score of 13 dated 6/27/25, indicating the Resident #5 was at high risk for wandering. At 1:07pm, during review of Resident #5's care plan, it was revealed that the care plan was initiated on 4/3/25 and revised 5/1/25. It was documented that the resident is resistive to care and exhibits wandering related to adjustment to nursing home. During an interview on 11/14/25 at 1:14 PM, the DON and NHA confirmed that Resident #5 was not included on the facility's wander list, and that a quarterly assessment for wander risk for Resident #5 was past the date required to complete an updated assessment. On 11/17/25 at 8:29 AM, record review showed the wander assessment had been completed on 11/14/25, after the surveyor identified the missing quarterly assessment.The failure to reassess the resident for wandering risk and to provide increased supervision placed the resident at risk for unsafe wandering or potential elopement. 2b. On 11/17/25 at 10:25 AM, review of the electronic medical record revealed Resident #5's temperature was recorded as 35.7 degrees C (96.26 Fahrenheit) by Staff #27 with no documented significant change in condition assessment, recheck, or provider notification. A review of the electronic medical record further showed that on 11/9/25, two separate GNAs recorded a temperature of 33.6 degrees C (92.48 Fahrenheit), first at 8:44 AM by Staff #20 and again at 10:21 AM by Staff #27. No documentation of licensed nurse notification, follow-up, recheck, or provider notification was found for either reading. On 11/17/25 at 10:50 AM, interviews were conducted with the Director of Nursing (DON) and the nursing home administrator (NHA). When asked what the accepted temperature range was, both the DON and NHA were unsure. The DON confirmed that 35.7 degrees C (96.26 Fahrenheit) was outside the acceptable range. When asked what staff were expected to do when vital signs fell outside of the acceptable range, the DON stated the expectation was that the GNA would notify the nurse, who should then notify the provider. The DON stated that the procedure was for GNA's to report abnormal vital signs to the licensed nurse, who would then contact the provider. At this time the surveyor requested the facility's written policy and clarification of how the GNA determined what was reportable to the nurse, where parameters could be located for reference, and written policy used by the facility. As of 1:49 PM the same day, no documentation of any recheck of Resident #5's vitals or further follow-up had been received. On 11/18/25 at 12:44 PM, review of the facility policy provided by the DON titled Reporting Changes in Condition stated, The GNA is responsible for notifying the licensed nurse, the licensed nurse is responsible for notifying the nursing supervisor, the physician and responsible party for any significant change in condition and documenting this notification on the Change in Condition form. The policy did not contain specifics about what should be reported regarding actual vital signs. During a subsequent interview with the DON, when asked how the GNAs know of the acceptable vital sign parameters and which findings should be reported, she stated, The GNA's should just know. The surveyor again shared the concern regarding the low temperatures documented on 11/9/25 by two different GNAs (both at 33.6 degrees C) and the lack of documentation showing that the nurse assigned to the resident had reviewed or acted upon these findings. 3. On 11/13/25 at 9:15AM the surveyor conducted a review of complaint #329723 which alleged that Resident #4 had to be evaluated elsewhere for them to get properly cared for relating to a change of condition of the Resident that occurred in January of 2025. Review of the medical record of Resident #4 by the surveyor on 11/13/25 at 9:29AM revealed that on 1/15/25 the Resident was assessed by Certified Registered Nurse Practitioner (CRNP) #12 in response to abnormal lab results documented as suggestive of a bacterial infection during which time Resident #4 was documented as not feeling well, reported pain, blood pressure issues and decreased appetite to CRNP #12 and a chest x-ray was ordered. Review of the chest x-ray results dated as reported on 1/15/25 at 11:01PM revealed the following documentation: Impression: 1.) Multifocal patchy nodular opacity/infiltrates Review of the medical order by the surveyor on 11/13/25 at 9:29AM revealed the Levofloxacin antibiotic was entered on 1/16/25 by CRNP #12 and would not begin until 1/17/25 at 10:00AM, and was ordered to be given every 2 days for Pneumonia for 5 days. Review of the SBAR communication form utilized by nursing staff to notify the primary care clinician on 1/17/25 at 8:40AM revealed the following provider recommendation in response to the nurse's report of change in condition of Resident #4: Give STAT (immediate, with no delay) dose Levaquin 750mg/UTI, call 911 transport to ER r/o (rule out) sepsis. Review of the January 2025 medication administration record revealed there were no antibiotics administered to Resident #4 prior to their transfer to the hospital on 1/17/25. On 11/13/25 at 10:20AM the surveyor conducted an interview with CRNP #12 who reported to the surveyor that they reviewed Resident #4's x-ray result on 1/16/25 which revealed pneumonia and that day they ordered the Levaquin antibiotic; when the surveyor inquired to CRNP #12 as to if they ordered antibiotics for administration right away, or for them to begin the next day, they stated: No we don't wait, we order and schedule for right away. CRNP #12 stated to the surveyor during the interview that: My order (antibiotic) was put in on 1/16, I reviewed the x-ray result on the 1/16, but it seems like they didn't give it (antibiotic) but I don't know why the nurse didn't give it. On 11/13/25 at 10:55AM the surveyor shared the concern with the facility Administrator and Director of Nursing (DON). On 11/13/25 at 11:13AM the surveyor conducted an interview with the DON who reported to the surveyor that the Resident's antibiotic had not been given because they were sent to the hospital at 9:15AM. The surveyor noted that the SBAR communication form was documented at 8:40AM for the STAT (immediately, with no delay) dose to be given to the Resident. When the surveyor inquired to the DON as to if the Levaquin antibiotic medication was on hand and would have been able to be immediately pulled and given to the resident, they replied: Yes. On 11/13/25 at 11:19AM the surveyor conducted an interview of Licensed Practical Nurse (LPN) #13 who was assigned to Resident #4's care on 1/16/25, who reported the following information to surveyors regarding the antibiotic order dated 1/16/25 but not having a begin date until 1/17/25: Honestly it didn't click, I just confirmed the order, It was to start on 1/17 at 10:00AM. During the interview, LPN #13 and the DON presented the surveyor with a copy of the January 2025 medication administration record and LPN #13 pointed to the documentation for the Levaquin antibiotic and stated: The antibiotic was given. At this time, the surveyor reviewed the documentation which did not indicate the medication had been given, the administration for the antibiotic that morning had been coded with a #6. When the surveyor inquired to the DON as to what a #6 code on the medication administration record meant, they stated: Code 6 means it was not given. At this time, both the DON and LPN #13 confirmed the antibiotic was not given and both the DON and LPN #13 acknowledged and confirmed understanding of the surveyor's concern. On 11/13/25 at 11:28AM the surveyor conducted another interview of CRNP #12 who stated the following information to surveyors: I expected the nurse to give the antibiotic on the evening of 1/16/25. Review of the medical record of Resident 14 on 11/13/25 at 11:42AM revealed the following transfer to hospital summary note dated 1/17/25 at 9:19AM: This morning during my rounds the aide noticed (Resident #4) was shaking and coughing, I then went to assess (Resident #4), his/her vitals were 92/66, HR (heart rate) 114, respirations was 22, O2 was 87, then (Resident #4) was given 02 at 3liters 02 went to 93, FS was 163, (CRNP #12) was notified and said to send (Resident #4) out 911, family was also notified, 911 arrived and patient was transferred to (Hospital). Further review of the medical record revealed a clinic note documented by Geriatric Nursing Assistant #14 on 1/17/25 at 4:38PM: (Resident #4) was transfer to (hospital) for change in mental status, fever, and shaking. On 11/18/25 at 2:23PM the surveyor shared the concern with the facility Administrator and DON. 4a. On 11/13/25 at approximately 7:45AM the surveyor conducted a review of complaint #2591161 which included allegations regarding incontinence care issues of Residents #8 and #9, concerns for the timeliness of care being provided by facility staff, and concern for resident diet plans being followed. On 11/13/25 at 12:00PM the facility's Director of Nursing (DON) confirmed with surveyors during an interview that their expectation of timely incontinence care meant providing the care within ten to fifteen minutes of the request having been made. During an interview conducted by the surveyor on 11/13/25 at 12:00PM the surveyor inquired to both the Administrator and Director of Nursing as to if they had received any concerns brought to their attention regarding staff being disrespectful, unhelpful, and/or unprofessional since August 2025, to which the Administrator responded: We have a customer service excellence team, I can get them for you. At this time, the surveyor further inquired to the Administrator, that aside from the customer service team, had they or the DON received any concerns from resident family members regarding staff being disrespectful, unhelpful, and/or unprofessional since August 2025, to which they then responded: Unofficially, yeah, I've received concerns. Not concerns of being disrespectful. During the interview the DON reported the following information: I have been told residents wait too long for assistance, if I have the employee's name, I investigate the employee, I pulled the call lights history and one was 7 minutes, one was 27 minutes, I addressed that staff member. During the interview the Administrator reported the following information to surveyors: Our main concern we hear is there is not enough staff, I'm sure other places are having that issue also. During the interview the DON stated to surveyors: We've had customer service issues that were addressed with staff. On 11/13/25 at 12:34PM the surveyor requested call bell timeliness reports from the facility's Administrator for four resident rooms on Hall 2 of the facility. On 11/13/25 at 1:04PM during an interview conducted by the surveyor, the DON reported that regarding care concerns for Residents #8 and #9 no formal grievance had been filed, however, complaints and issues brought to them were addressed, some were valid, some were not. After several repeated requests for the call bell timeliness reports from the facility's Administrator and DON, on 11/17/25 the surveyor was provided with two of the four requested room's call bell timeliness reports. Review of the call bell reports for the two rooms provided, revealed that on approximately 32 occasions of call bell requests for assistance, the report documented the response time to be greater than fifteen minutes. Review of Resident #9's care plan revealed the following goal was present to address incontinence which documented as initiated on 6/17/25, revised on 8/11/25, with a target date of 2/1/26: (Resident #9) Will be clean, dry and odor free every day for the next two weeks. On 11/17/25 at 11:00AM the surveyor conducted an interview with Resident #8 and Resident #9. Resident #8 stated the following information regarding timeliness of call bell response with regard to incontinence care: Sometimes it's a long time we have to wait, sometimes 45 minutes to 1 hour. On 11/17/25 at 11:59AM the surveyor conducted an interview with the Manager of Wound Care Treatment Team, Registered Nurse who was also performing the role of Interim Unit Manager (IUM) #5 for Hall 2. IUM #5 reported to the surveyor during the interview that Resident #8 and #9's family member had shared their concern regarding incontinence care with them and when the surveyor inquired as to if the concern shared with them was investigated, they stated to the survey team: No. When the surveyor inquired as to what actions were taken in response to the family member's concern, IUM #5 stated: I just made sure they cleaned her up and told them (the staff) not to leave him/her soiled. When the surveyor inquired to IUM #5 as to if Resident #9 had been left soiled, they reported they did not know if the resident had been left soiled. The surveyor conducted an observation of Residents #8 and #9 on 11/18/25 at 8:13AM at which time Resident #8 reported to the surveyor that they needed staff to provide incontinence care. On 11/18/25 at 8:15AM the surveyor conducted an interview of Registered Nurse (RN) #15 assigned to the care of Residents #8 and #9 who stated the following information to the surveyor regarding incontinence care provided to the residents: Prior to shift change residents are rounded on by the overnight geriatric nursing assistants (GNA's) and staff before shift change to ensure they are clean and dry. At this time the surveyor informed RN #15 of the resident's request for incontinence care and observed RN #15 go into Resident #9's room and stated to the resident: I'll go find the GNA to help you to get changed. When the surveyor inquired to RN #15 as to if they had some other task going on at this time, RN #15 stated: It's shift change, I'll go get the GNA assigned to him/her. At this time, the surveyor asked for RN #15 to show this surveyor the medical record documentation of the last time that Resident #9 had been provided with incontinence care, at which time RN #15 reported that the surveyor would have to ask IUM #5 to observe the documentation. On 11/18/25 at 8:16AM the surveyor observed RN #15 inform GNA #16 and GNA #17 that Resident #9 needed incontinence care. At this time the surveyor conducted an interview of GNA #16 and GNA #17 who confirmed with the surveyor that if they are unable to document directly after each incontinence care performed, the documentation happens at a different time other than when the incontinence care was given. At this time, both GNA #16 and #17 confirmed the facility's expectation was for them to document each time incontinence care is provided. On 11/18/25 at 8:24AM the surveyor conducted an observation of the incontinence care status of both Resident #8 and Resident #9. At this time, Resident #9 was observed to be wearing a heavily saturated wet yellow incontinence brief. Both GNA #16 and #17 confirmed they were familiar with providing care to Resident #9 and GNA #16 reported they hadn't been changed like they were supposed to be overnight, and reported that they would be letting IUM #5 know about it because the Resident should've been changed. IUM #5 was then observed entering the room and confirmed with the surveyor that they had observed Resident #9's very wet brief. IUM #5 informed the surveyor that they would be contacting GNA #18 who was the overnight GNA assigned to the Resident and a disciplinary action would be given to them. On 11/18/25 at 8:30AM the surveyor requested for IUM #5 to show this surveyor documentation of the last time Resident #9 was provided with incontinence care. This surveyor observed IUM #5 open the electronic health record (pcc), and IUM #5 asked this surveyor what the Resident's name was. This surveyor provided Resident #9's name and IUM #5 was unable to figure out how to see if incontinence care was provided or not, and stated they were Interim Unit Manager since October 2025 and had worked for the facility for approximately 5.5 years. IUM stated to this surveyor I am not familiar with PCC, I'm calling the DON. I'm still learning. This surveyor observed IUM #5 call the DON to ask how to check when the last time a Resident was changed in the computer system. IUM #5 ended the call and stated the DON was coming to show them how. IUM #5 stated to the surveyor: Residents should be rounded on for incontinence every 2 hours and are supposed to be changed. On 11/18/25 at 8:34AM the surveyor observed the incontinence status of Resident #8 who was observed to have a mildly saturated incontinence product in place. On 11/18/25 at 8:35AM the DON showed this surveyor the incontinence care documentation which revealed that point of care documentation was not occurring, facility staff documentation for incontinence care consisted of a once per shift sign off documentation that incontinence care was performed for the shift. Documentation of how many times and when the Residents were changed throughout the shift was not observed to be present. The DON was observed teaching IUM #5 how to observe incontinence care documentation in the medical record. The DON reviewed the incontinence care documentation of Resident #9 and reported to the surveyor regarding the facility staff's care of the resident: This is not acceptable. On 11/18.25 at 8:40AM the DON informed the survey team that staff are only expected to document every shift. The surveyor inquired to the DON as to if all incontinence care that is provided during the shift was not expected to be documented; to which the DON replied: I am unsure, I have to check on this. On 11/18/25 at 11:32AM the surveyor conducted an interview of GNA #20 who reported to the surveyor that From my GNA training, you document at point of care, care is provided and care is then documented after. On 11/18/25 at approximately 11:35AM the surveyor conducted an interview with Licensed Practical Nurse #19 who stated to the surveyor: Residents do have to wait sometimes, because of staffing when people call out. On 11/15/25 at 11:58AM the surveyor conducted an interview with the DON and inquired as to where specifically, incontinence care was to be documented in the medical record. During the interview, the DON reported to the survey team that the expectation was: Staff are supposed to be rounding every two hours to make sure the person is clean and dry, the staff know that. On 11/18/25 at 12:30PM the surveyor conducted an interview with the DON and inquired as to how the rounding every two hours was documented; at which time the DON responded to the survey team: I don't know, I have to find out. 4b. On 11/17/25 at 12:26PM the surveyor conducted an interview of Director of Food and Nutrition #21 who stated the following information: The PCC (point click care electronic health record system) medical order directs and produces the meal ticket for the kitchen. Surveyors confirmed during the interview that the selected diet is what directs the type of diet that populates onto the meal ticket, the information entered in the directions section of the order does not populate on the meal ticket. On 11/17/25 at 2:42PM the surveyor reviewed the medical record which revealed the following information: Resident #9's care plan documented a focus on decreased nutrient needs for carbohydrate/concentrated sweets and sodium relating to their diabetic diagnoses with a history of intermittent hyperglycemia and hypertension with an intervention of providing a therapeutic diet initiated on 6/6/25 with the supporting diet order of a controlled carbohydrate and heart healthy diet Diet order history of Resident #9 having received only a heart healthy diet from 6/7-7/17/25 with directions written in the order for low sodium, diabetic heart healthy and low fat, and a regular diet from 7/18-7/20/25. On 11/18/25 at 2:23PM the surveyor shared concerns with the facility Administrator and DON.

Based on observations, review of resident medical records, and interviews, it was determined that the facility failed to ensure that residents' rights to a dignified existence were preserved. This was evident for 3 (Resident #1, #12, and #10) out of 22 residents observed during the complaint survey.The findings include: 1. During observation rounds and interview on 11/13/2025 at 10:45 AM Resident #1 was found in his/her room sitting in a wheelchair wearing a soiled, brown in color substance smeared on the front and outside of, incontinent brief and a white in color t-shirt. Resident's #1 room door was completely open allowing other residents, staff and public visitors to view the resident. Resident #1 pointed to his lower extremities and then pointed to his pants located over by the closet indicating that he/she wanted to be dressed. Resident #1 stated Yes that he/she wanted to be dressed. During observation rounds on 11/14/2025 at 9:55 AM Resident #1 was found in his room, lying in bed, being fed breakfast by staff #4 who was observed standing over resident while talking on his/her cell phone. During an interview on 11/14/2025 at 11:20 AM the Director of Nursing staff #2 and staff #5 were made aware of the concerns found by surveyor with Resident #1 and staff #4. Staff #2 and #5 stated that, it is the expectation that staff are to feed residents sitting down next to residents to provide respect and dignity and not be on their cell phones. Staff #5 also stated that, residents should be dressed and incontinence care provided. 2. A foley drainage bag, or urinary drainage bag, is a medical device used to collect urine from a catheterized resident. The drainage bag is usually worn on the leg or attached to a bed. On 11/13/25 at 7:49 AM, Resident #12 was observed lying in bed with a Foley drainage bag partially filled with yellow liquid. The bag had no privacy cover and was hung on the side of the bed facing the open door, making the drainage bag visible from the hallway. The resident door was open and anyone walking by could see the bag. A second observation on 11/18/25 at 12:13 PM again showed Resident #12 in bed with the Foley drainage bag uncovered, containing yellow liquid, and positioned on the bed frame facing the open doorway, with the bag clearly visible from the hallway. 3. On 11/13/25 at 8:03 AM, Resident #10 was observed in bed with a Foley drainage bag that was partially filled with yellow liquid and not covered. The bag was hung on the side of the bed facing the open door, making it visible from the hallway. On 11/17/25 at 2:12 PM, the surveyor observed that Resident #10's catheter bag containing yellow liquid was again uncovered and visible from the hallway. At 2:17 PM, Staff #9, who stated they were covering the resident at that time, was alerted to the dignity concern and acknowledged the uncovered Foley bag. The administrator was made aware of the resident dignity concerns during an interview on 11/18/25 at 2:30pm.

Based on observation, interview and record review it was determined the facility failed: 1.) to identify all surrogate decision makers and follow professional standards for surrogate decision making, 2.) to ensure all social work actions taken were documented as part of the resident's medical record, and 3.) to ensure supervision of the work of the Social Work Designee. This was evident for 1 out of 2 Residents (Resident #) reviewed for advanced directives complaint survey.The findings include: On 11/13/25 at approximately 7:45AM the surveyor conducted a review of complaint #2591161 which included allegations expressing concerns regarding the initial facility Social Worker assigned to care of Residents #8 and #9 and allegations expressing concern regarding medical decision making which occurred for Resident #8. On 11/13/25 at 12:00PM the surveyor requested from the Director of Nursing (DON) and facility Administrator to provide the name of the Social Worker which was assigned to Hall 2 Residents. The DON stated the following in response to the surveyor's request: (Staff #23) is the Manager of Social Work, the facility has multiple social work staff for different areas of long-term care. On 11/13/25 at 12:41PM the surveyor conducted an interview with SWM #23 who stated to the surveyor: Hall 2 is (Staff #24) who is the only Social Worker assigned to that unit, s/he is a Social Work Designee. During the interview SWM #23 confirmed with the survey team that there were no Social Work Consultants and no one else that oversees social work. SWM #23 reported that Social Work Designee (SWD) #24 had been on Hall 2 for years. At this time the surveyor inquired to SWM #23 if they had any concerns with social work staff not returning the calls of resident family members; to which they responded: Occasionally, I can't remember if it was any Social Worker in particular. During the interview, SWM #23 confirmed that advanced directives of residents were obtained on admission. On 11/13/25 at 1:04PM the surveyor conducted an interview of SWD #24 and observed their name badge which displayed their job title Social Work Designee. When the surveyor inquired about Residents #8 and #9, SWD #24 responded: Currently I don't have [Residents #8 and #9] my manager [SWM #23] is covering and because of differences my manager [SWM #23] is covering them. During the interview, SWD #24 reported having knowledge of Resident #8 and #9 having lived previously on Hall 1 and that prior to hospitalization they had lived with their son. SWD #24 reported knowledge of the resident's daughter wanting them to stay long term care and having provided communication to them regarding having a brother. SWD #24 reported that Resident #9 was at first the decision maker for Resident #8 upon incapacity being determined, and the daughter became the primary decision maker for Resident #8 because the daughter told them Resident #9 was in the hospital and unable to talk. The surveyor further inquired as to if they made an attempt to contact Resident #9 at the hospital, to which SWD #24 replied: I spoke to someone at the hospital, s/he was unable to talk or I would have spoken to him/her. SWD #24 reported that at the time of Resident #8's admission, they did not know about the resident's son being involved, because my process is, if there's multiple children, to contact both children. The surveyor asked for SWD #24 to provide documentation of an attempt made to contact Resident #8's spouse upon determination of any level of incapacity. SWD #24 responded to the surveyor: No I don't think I wrote a note but I am not sure. The surveyor noted that review of the medical record by the surveyor on 11/17/25 at 8:20AM revealed: 1.) Paperwork from Resident #8's hospital admission which included a care management initial assessment with contact phone numbers listed for both of the Resident's adult children and summary of the prior living environment which included the Resident's son's involvement, 2.) Resident #8 was admitted to the facility beginning on 4/4/25 and a decision making capacity and treatment limitations form with two medical care provider certifications was dated as completed on 4/8/25 in which Resident #8 was determined to be incapable of decision making for medical care and for financial decisions, There was no medical record documentation that could be found showing that the facility made any attempts to contact Resident #8's son in addition to their daughter, in accordance with surrogacy decision making hierarchy. Review of the medical record revealed that from 4/8/25 until Resident #9's admission on [DATE], the daughter was the only adult child involved by the facility for medical decision making for Resident #8. Review of a social services note with an effective date of 4/16/25 documented a care plan meeting was held by SWD #24 with Resident #8 and their daughter which noted a discussion regarding discharge planning in which Resident #8 having a son was again mentioned with SWD #24 documenting again in the medical record as having reached out for decision making and discussion of discharge plan to the Resident's daughter, There was no medical record documentation that could be found showing that prior to 7/29/25, any attempts were made by the facility's social work department to contact the Resident's son. Review of the medical record by the surveyor revealed a Social Services- Social Worker e-signed note by SWD #24 dated 7/29/25 which documented the following information: SW (Social Worker) explained to son that previously sister was surrogate decision maker due to an error, Son and daughter verbally acknowledged and understood. On 11/17/25 at 8:30AM the surveyor conducted an interview of the facility's Director of Nursing (DON) and SWM #23 and inquired to them as to if they expected for the social work staff to make documented attempts to determine if a resident who is incapacitated has family in order to correctly determine surrogacy. The DON responded to the surveyor's question with: Let's call (SWD #24) first. The surveyor then further inquired to the DON and SWM #23 that aside from calling SWD #24, what their expectations were, at which time the DON stated: Yes, that is the expectation, and SWM #23 stated Yes. At this time SWM #23 made a phone call to SWD #24 who confirmed that not having talked with the son was the error in which was described in their 7/29/25 note. At this time the surveyor shared the concern with SWM #23, SWD #24, and the DON who each acknowledged and confirmed understanding of the concern and error and acknowledged that Social Work Designees should have adequate supervision for the steps they are taking when providing social work support to facility Residents. On 11/17/25 at 10:10AM the surveyor conducted an interview with Manager of Patient Experience #26 who confirmed with surveyors that they had received concerns from Resident #8's son and The daughter was who we had actually been speaking to for any of the concerns, The son he actually called us about when Resident #9 went out to the hospital, we didn't know who he was- so we couldn't give him any information, then we contacted the daughter and she informed us he was her brother and could get information, we called the daughter first because she was listed as the person we should be speaking with. On 11/18/25 at 2:23PM the surveyor shared concerns with the facility Administrator and DON. On 11/20/25 at 10:15AM the surveyor conducted an interview with Ombudsman #25 who reported that previously, SWD #24 had informed them that s/he was the social worker.

Based on record review and interview, it was determined that the facility failed to ensure an allegation of abuse was reported immediately, but not later than two hours, to the State Survey Agency. This deficient practice was evident for 1 of 5 facility reported incidents reviewed.The findings include: On 11/14/25 at 11:27 AM, a review of the facility's incident report documentation revealed that staff were notified of an allegation of abuse on 8/15/25 at 8:40 AM. The administrator was notified at 9:54 AM the same morning. The initial report to the Office of Health Care Quality (OHCQ) was documented as being made on 8/15/25 at approx. 12 PM, more than two hours after staff were first made aware of the allegation. During an interview with the Director of Nursing (DON) on 11/14/25 at 12:50 PM, she was made aware that the allegation had not been reported within the required two-hour time frame and she stated that she would check the submission record and follow up. At 1:05 PM, the DON returned and confirmed that the report had been submitted late.

Based on review of a Facility Reported Incident (FRI), record review, and interview with staff, it was determined that the facility failed to maintain documentation of a thorough investigation. This was evident for 1(#329731) out of 5 FRI's reviewed during the complaint survey. The findings include:During a review of FRI #329731 and the facility's investigative file on 11/13/2025 at 10:50AM, the Surveyor discovered that on 6/17/2025 at approximately 3:55PM, Resident #7 eloped. An elopement alert, code grey, was initiated over the loudspeaker at about 4:15PM and full sweep of the facility and surrounding areas were searched. Campus security was immediately notified. At about 4:30PM, the police and transit authority were notified. Resident representative notified. The resident returned to the facility at approximately 6:25PM.A review of the Facility Reported Incidents Follow-Up Investigation Report revealed the facility verified the elopement in the conclusion by stating [Resident #7] did leave the facility but was found shortly after. The facility failed to include the circumstance leading up to the resident's elopement, how the facility determined how the resident exited the facility, and how, when, and where the resident was found. Corrective actions were limited to patient was placed on a1:1 sitter.An additional review of the investigative file revealed a Nurses Note dated 6/17/2025 at 6:48PM with the nurse's depiction of the incident stating that the resident was located by police at 6:15PM and escorted back to the facility. A Behavioral note written by Unit Manager (UM) #10 dated 6/17/2025 at 8:33PM with the nurse's depiction of the incident and their involvement in the search for the resident. There was one staff statement, which was unsigned and did not identify the staff member's title. There were no other staff statements or evidence of interviews conducted with staff. There was no evidence of an interview with the resident or any other resident who resided on the unit with Resident #7.During a review of Resident #7's electronic medical record conducted on 11/13/2025 at 11:00AM, the failed to reveal documentation of how the resident was able to exit the unit and the facility.On 11/14/2025 at 11:48AM, during an interview with the Director of Nursing (DON) and the Administrator, the Surveyor expressed the concern that the investigative failed to identify any evidence as to how the facility determined the circumstances of the resident having eloped and how the resident exited the unit and the building. The Surveyor also expressed the concern that the corrective measures implemented, as stated in the follow up report only included a 1:1 sitter. The DON informed the Surveyor that they reviewed camera footage and were able to determine that Resident #7 was able to elope because a staff member did not ensure the doors were fully closed behind them when they exited the unit. Per film, the resident waited until the staff member exited HH 5 doors, went to the door, held it open with their foot, and waited until the staff member entered HH 6. The resident then slipped out the door quickly and proceeded to the elevators. Once on the 1st floor, the resident exited the facility through the double doors to the left of the main entrance doors. The resident caught an MTA bus downtown, where the resident was found by police. Resident #7 returned to the secure unit in HH 5. The facility staff implemented 1:1 sitter for a week and then 1:1 rounding observation sitter for supervision, 7am and 7pm huddle meetings to inform staff of the elopement and increased supervision of the residents at risk for wandering/exit seeking. The staff member was educated to wait for the all unit doors to fully close behind them before walking away, staff continue to receive education on elopement risk resident and identifying exit seeking behaviors. The Surveyor reiterated the concern that this information was not included in the investigative file or in the resident's electronic medical record.

Based on record review and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan for a resident who has eloped. This was evident for 1 (Resident #7) out of 16 residents reviewed for wandering/elopement during the complaint survey. The findings include:A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the Interdisciplinary team after the completion of a comprehensive Minimum Data Set assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.Elopement is when a person leaves the premises or a safe area without the facility's knowledge and supervision.On 11/13/2025 at 10:25AM, during a review of Facility Reported Incident #329725 and the facility's investigative file on, the Surveyor discovered that on 3/6/2025 at 3:04PM Resident #7 eloped.A review of Resident #7's electronic medical record on 11/14/2025 at 12:20PM, revealed a Behavior Note dated 5/2/2025 which stated at approximately 9am [Resident #7] followed a staff thru the locked door and went down the elevator towards the front door, [the resident] was brought back to [his/her] room and assessed a WNL, [the resident]was asked not to sit by the door.On 11/13/2025 at 10:50AM, during a review of FRI #329731 and the facility's investigative file the Surveyor discovered that on 6/17/2025 at approximately 3:55PM, Resident #7 eloped again. On 11/14/2025 at 2:30PM, during a review of Resident #7's electronic medical record the Surveyor discovered that the resident had been transferred to the specialty hospital on 8/5/2025 and was readmitted to the facility on [DATE]. On 10/30/2025, the facility initiated a care plan with a focus, Resident is at risk for elopement related to Dx of Unspecified dementia with other behavioral disturbance, a goal, [Resident] will not successfully elope from the facility and will have whereabouts monitored on an ongoing basis through the next review date, and Interventions: Wander guard to the left ankle Monitor each shift every shift for Elopement risk (initiated on 10/31/2025), and Monitor [Resident] for tailgating when visitors are on the unit. A review of the care plan failed to identify and reflect that the resident had actual elopements from the facility on 3/6/2025 and 6/17/2025, and an elopement off the secured unit on 5/2/2025, and failed to include resident specific interventions based on identified triggers, enhanced monitoring including behaviors, redirectional activities, wander risk assessments, and the increased need for supervision such as 1:1 rounding supervision as ordered.On 11/17/2025 at 2:28PM during an interview with the DON and the Administrator, the Surveyor was informed that safety measures were put into place when the resident returned from the specialty hospital 10/29/2025. The resident was admitted to the secured nursing unit, a wander guard bracelet was placed on the resident, and the resident was supervised by staff including a 1:1 non-clinical observation sitter at all times.

Based on record review and interviews, it was determined that the facility failed to revise the care plan to meet the needs of a resident identified as a high wander risk. This is evident for 1 (Resident #5) of 16 residents reviewed for wander/elopement risk.The findings include: On 11/14/25 at 11:12 AM, a review of the electronic medical record showed that Resident #5 had a Wander Risk Score of 13, with scores above 11 indicating high risk, based on an assessment dated [DATE]. Resident #5's care plan, initiated 4/3/25 and revised on 5/1/25, identified the resident as resistive to care and exhibits wandering related to adjustment to nursing home. Despite this high-risk score and documented wandering behaviors, the care plan was not revised to include interventions addressing increased risk and the need for increased supervision. During an interview on 11/14/25 at 1:14 PM, the DON and NHA confirmed that Resident #5 was not included on the wander list and that the required quarterly assessment had not been completed since 6/27/25. The concerns with the lack of care plan interventions appropriate to the resident's high Wander Risk score and the lack of revision to the care plan after the assessment on 6/27/25 were brought forward at this time. On 11/17/25 at 8:29 AM, the overdue wander risk assessment was found to have been completed on 11/14/25, after surveyor identification. Resident #5 now had a Wander Risk Score of 17, indicating a higher risk than on the previous assessment.

Based on observation and interview it was determined the facility failed to ensure safe storage of medications. This was evident during the surveyor's initial tour of the facility for 1 medication cart on 1 out of 10 nursing units during the facility's complaint survey. The findings include: During the survey team's initial tour of the facility on 11/13/25 at 7:49AM a medication cart was observed with the metal button protruding outward which indicated the cart was unlocked, and was unattended in the resident hallway. Upon further surveyor observation, all drawers of the cart, containing various medications, was able to be opened by the surveyor. Surveyors attempted to find facility staff to inform of the concern. Upon informing staff at the nurse's station, Registered Nurse (RN) #3 responded to the surveyor's concern. At this time surveyors conducted an interview and shared concerns with RN #3 who confirmed they were responsible for the medication cart. On 11/13/25 at 7:55AM the concern was shared by surveyors with the facility's Director of Nursing who acknowledged understanding of the concern. On 11/18/25 at 2:23PM the concern was shared with the facility Administrator.

Based on record review and interview with staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices related to residents wander risk status and required assessments. This was evident for 2 (Resident #5 and Resident #7) out of 16 residents reviewed for wandering/elopement during the complaint survey.The findings include: 1. On 11/14/25 at 11:12 AM, review of the electronic medical record for Resident #5 documented a high wander risk score of 13 from an assessment completed 6/27/25; however, the resident was not included on the facility's wander list, and there was no quarterly assessment documented after 6/27/25. Review of Resident #5's care plan, documented on 4/3/25 and revised 5/1/25, noted wandering behaviors related to adjustment to the nursing home. The incomplete and inaccurate documentation failed to represent the resident's current risk status and need for monitoring. At 1:14 PM, the Director of Nursing and the administrator acknowledged that the quarterly wander assessment had been missed and that the resident's risk status was not reflected on the wander list. On 11/17/25 at 8:29 AM, further review confirmed the wander assessment was completed on 11/14/25, after surveyor intervention. 2. On 11/13/2025 at 10:00AM, during a review of Resident #7's electronic medical record, the Surveyor discovered a nursing progress note dated 1/23/2025 at 7:04PM which stated the resident was busy seeking exit and wanted to go to floor 2 and go home. On 11/13/2025 at 10:25AM, during a review of Facility Reported Incident #329725 and the facility's investigative file on, the Surveyor discovered that on 3/6/2025 at 3:04PM Resident #7 eloped. A review of Resident #7's Wandering Risk assessment dated [DATE] revealed an incomplete assessment with a score of 0. A review of Resident #7's readmission Wandering Risk assessment dated [DATE] revealed an incomplete assessment with a score of 0. Scores 0-8 indicate a low risk to wander. According to the Wandering Risk Assessment instructions, the assessment should be completed on admission and readmission, with a change of condition, and annually on all residents. On 11/13/2025 at 1:15PM, the Surveyor reviewed the Identifying Risk for Patient Wandering and Use of the WanderGuard System policy with an effective date of 11/13/2025. According to the policy, residents will be screened upon admission, whenever there is a change regarding wandering, and quarterly. The facility failed to complete an updated Wandering Risk Assessment that recognized Resident #7's exit seeking behaviors on 1/23/2025 and failed to complete an accurate Wandering Risk Assessment on 4/11/2025 that recognized the resident's elopement on 3/6/2025. During an interview with the Administrator and the Director of Nursing (DON) on 11/14/2025 at 1:30PM, the Surveyor was informed that all resident will be screened for wandering risk upon admission, quarterly, and as needed. The Surveyor expressed the concern with the accuracy and timeliness of the Wandering Risk Assessments.

Based on facility staff interviews and closed record reviews it was determined that the facility failed to report alleged violations of abuse as required. This was found to be evident in 5 (Resident #11, #217, #195 & #39 & #147) out of 13 Residents reviewed for reporting of alleged violations. The findings include: 1a) On 11/4/2024 at 9:45 AM the surveyor reviewed the facility investigation file for the facility reported incident (FRI) #MD00200402 for Resident #11. Review of the facility investigation file revealed that Resident #11 sustained a fracture of the right hip, and the facility Director of Nursing (DON) reported the fracture as an injury of unknown origin on the initial report form that was submitted to the Office of Healthcare Quality (OHCQ) on 12/8/2023 at 14:30 PM (2:30 PM). Further review of the facility investigation file (FRI) and Resident #11's closed medical record on 11/4/2024 at 11:00 AM revealed that Resident #11 reported that he/she had a fall. A fall risk assessment tool, neurological assessments and change in condition progress note was documented by nursing staff for Resident #11 on 12/8/2023. In an interview with the Nursing Home Administrator (NHA) on 11/4/2024 at 11:30 AM, the surveyor conveyed to the NHA that the Office of Healthcare Quality (OHCQ) did not receive a final investigation/follow-up report form for this 12/8/2023 facility reported incident (FRI) from the facility. The NHA acknowledged the surveyor and was unable to provide the surveyor with a final/investigation follow-up report for this 12/8/2023 facility reported incident (FRI). The only report that the OHCQ received from the facility was the initial report form on 12/8/2023 at 14:30 PM, and the only report that the Nursing Home Administrator was able to provide was the initial report form for this 12/8/2023 facility reported incident (FRI). 1b) On 11/15/2024 at 9:01 AM the surveyor reviewed complaint #MD00171165 that was received on 8/27/2021 at 15:55 PM (3:55 PM at the Office of Healthcare Quality (OHCQ) and Resident #217's closed medical record. Review of the medical record revealed that Registered Nurse (RN) #36 documented in the progress notes of Resident #217 at 7:43 AM on 8/27/2021 that Geriatric Nursing Assistant (GNA) stated by informed daughter on phone that Resident #217 was strangled by staff. Additionally, in the progress notes for Resident #217, there was a skin/wound note dated 8/27/2021 at 13:36 PM (1:36 PM), skin evaluation completed by treatment team, skin intact with no open areas, no rash, no lesions, bruise noted to right hand. In an interview with the Nursing Home Administrator (NHA) on 11/18/2024 at 8:00 AM, the surveyor conveyed to the NHA the progress note that was documented in Resident #217's medical record by RN #36 regarding an allegation of abuse. The surveyor asked the NHA for any concern or compliant forms for Resident #217. In a follow-up interview at 10:22 AM, the NHA stated that he did not have any concern or complaint forms for Resident #217 and he further stated that he would review his files to see if he had any facility reported incidents (FRI) for Resident #217. Follow-up interview with the Nursing Home Administrator (NHA) at 11:52 AM on 11/18/2024, the NHA stated that he was not able to locate any facility reported incidents (FRI) for Resident #217, and that he was not notified of any allegation of abuse for Resident #217. Additionally, the NHA stated that he was not aware of the progress note and the allegation of abuse that was documented in Resident #217's closed medical record. The surveyor reviewed the employee personnel file for Registered Nurse (RN) #36 on 11/19/2024 at 9:15 AM. Review of the employee personnel file revealed that RN #36 received abuse training and abuse education which included reporting of allegations of abuse to facility management. RN #36 was no longer employed by the facility. No additional information was provided by the Nursing Home Administrator (NHA). 50385 1c) On 11/15/24 at 10:55 AM, Facility Reported Incident #MD00185819 was reviewed. The report stated that Resident #195 alleged abuse from a GNA. The allegation was that the GNA pulled the resident on to the floor on 11/17/2022 at 8:30 AM. The resident's representative reported this incident to staff 11/17/2022 at 9:30 AM. On 11/15/24 at 11:15 AM, The facility's report of the alleged abuse was reviewed. The documentation provided indicated that the initial and final report was sent to the Office of Health Care Quality on 11/18/2022 at 9:30 AM. On 11/15/24 at 11:20 AM, an interview was conducted with the Administrator. The Administrator confirmed that the initial and final report were sent together on 11/18/2022 at 9:30 AM. 45733 1d) Record review, on 11/14/24 at 2:20 PM, of the facility's self-report investigation file MD: 00206273, revealed that the medical record Nurse Staff #37 documented that Resident #39 had a change in condition of left knee pain and swelling on 6/2/24 at 5:58 PM. Further review found that the facility initial self-report to OHCQ was sent on 6/3/24 at 5:06 AM which was 9 hours later. The facility staff failed to report the allegation of abuse immediately but not later than 2 hours after the event. During the interview, on 11/14/24 at 3PM, the Director of Nursing (DON) was made aware of the concern related to the late reporting on 6/3/24 at 5:06 AM. The DON indicated that she did not handle this incident but understood that it was a concern that the initial report to OHCQ was outside of the 2 hours timeline. 1e) Record review, on 11/4/24 at 9:30 AM, of the facility's self-report investigation file MD: 00196122, revealed that Geriatric Nursing Assistant (GNA) Staff #38's interview statement that she reported to shift nurse, on 8/27/23 at 8:20 PM, of the Resident #147's multiple bruises to the right eye, right hand and bilateral lower extremities. This reasonable suspicion of abuse should have been reported immediately to OHCQ but not later than 2 hours from the time that the event was reported. However, the facility's initial report to OHCQ was not sent until 8/28/23 at 12:16 AM, almost 16 hours later. During interview, on 11/4/24 at 12:01 PM, the DON confirmed that the facility initial self-report was sent on 8/28/23 at 12:16 AM. The DON was informed that it was a concern.

Based on facility staff interview and medical record review, it was determined that the facility failed to accurately document Resident assessments on the Minimum Data Set (MDS) assessment as evidenced by inaccurate coding for Residents. This was found to be evident for 4 (Resident #191, #11, #164 and #40) out of 73 Residents reviewed on the survey. The findings include: The Minimum Data Set (MDS) is a health status screening and assessment tool used for all Residents of long-term care nursing facilities. The MDS is part of the federally mandated process for clinical assessment of all Residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each Resident's functional capabilities and helps nursing home staff identify health problems 1a) The surveyor conducted a record review of the closed medical record for Resident #191 on 11/1/2024 at 9:10 AM. The review revealed documentation in the progress notes that Resident #191 was transferred to the hospital on 7/29/2024 at 19:15 PM. Further review of the medical record on 11/1/2024 revealed that Resident #191 had a 7/30/2024 Discharge - Return Not Anticipated Minimum Data Set (MDS) assessment completed by the facility staff. The surveyor interviewed the Director of Clinical Reimbursement #21 on 11/18/2024 at 10:00 AM. The surveyor conveyed to the Director #21 that Resident #191 was discharged to the hospital on 7/29/2024 as documented in the progress notes, but the MDS assessment was coded as Resident #191 discharged to the hospital on 7/30/2024. Director #21 stated that she would review Resident #191's Discharge MDS and hospital records and follow up with the surveyor. At 12:32 PM on 11/18/2024 a follow-up interview was conducted with the Director of Clinical Reimbursement #21. Director #21 stated that Resident #191 did transfer and was admitted to the hospital on 7/29/2024, and that she completed a modification to the 7/30/2024 Discharge MDS. Director #21 provided the surveyor with the modified Discharge MDS coded with the accurate discharge date of [DATE]. 1b) An indwelling catheter is a thin, hollow tube that is inserted into the bladder to drain urine. It is also known as a Foley catheter. An ostomy is an opening (stoma) from an area inside the body to the outside of the body. The surveyor conducted a record review of the closed medical record for Resident #11 on 11/1/2024 at 11:31 AM. Review of the 12/21/2023 Significant Change MDS assessment revealed that Resident #11 had an indwelling catheter and did not have an ostomy. Further review of the 12/21/2023 MDS revealed that Resident #11 for urinary continence was coded as always incontinent and for bowel continence was coded as Not rated. On 11/18/2024 at 10:00 AM the surveyor interviewed the Director of Clinical Reimbursement #21. The surveyor conveyed to the Director #21 that Resident #11 had indwelling catheter coded as Yes but urinary continence coded as always incontinent, and ostomy coded as a No, but bowel continence coded as Not rated on the 12/21/2023 Significant Change MDS assessment. Director #21 acknowledged the inaccurate coded MDS assessment and stated to the surveyor that she would correct and complete a modification to the 12/21/2023 Significant Change MDS for Resident #11. At 12:32 PM on 11/18/2024 a follow-up interview was conducted with the Director of Clinical Reimbursement #21. Director # 21 stated that she completed a modification to the 12/21/2023 Significant Change MDS and provided the surveyor with a copy of the modified MDS assessment for Resident #11 coded with the accurate assessments for catheter, ostomy, and urinary and bowel continence. 45733 1c) During the interview, on 10/29/24 at 1:12 PM, Resident #164 stated that an accident knocked his/her front teeth out almost [AGE] years ago. Visibly this resident's front upper and lower teeth were missing and the resident had no dentures. Further record review revealed that on 2/12/ 2024 at 3:49 PM the MDS coordinator Staff #40 coded section L0200D in the MDS, No for obvious or likely cavity or broken natural teeth. During the interview, on 11/06/24 at 3:14 PM, the Director of Nursing reviewed the MDS record as above for miscoding and she was made aware of the concern that the initial MDS's full assessment did not code that and noted the upper and lower front natural teeth were missing. 44440 1d) On 10/29/24 at 12:05 PM, the surveyor observed that Resident #40 had no splints on and had bilateral (both) contracted hands. On 11/13/24 at 9:45 AM, the surveyor conducted an interview with the Rehab Manager Occupational Therapist (OT) Staff #22. During the interview Staff #22 stated that Resident #40 would benefit from hand splints and the rehab department utilizes the Minimum Data Set assessment to determine which residents should be screened for splint application. The surveyor noted that on Resident #40's quarterly MDS assessment dated [DATE] the upper extremity impairment was coded for yes for both sides. On the significant change assessment dated [DATE] and the quarterly MDS assessment dated [DATE] the upper extremity impairments were coded to indicate that Resident #40 had no upper extremity impairments. On 11/13/24 at 11:19 AM, the surveyor conducted a phone interview with the Clinical Director of Reimbursement Staff #21. During the interview Staff #21 confirmed that the MDS assessments dated 6/28/24 and 9/28/24 were inaccurately coded for Resident #40's upper-extremity abilities. Cross reference F688

Based on review of the facility's investigation file, review of medical records and interviews, it was determined that the facility failed to honor and respect a resident's wishes for Activities of Daily Living (ADL) cares. This was found evident in 1 (Resident #77) of 3 residents reviewed for Resident rights. The findings include: On 10/29/24 at 9:03 AM, the surveyor interviewed Resident #77. During the interview Resident #77 was able to answer questions by nodding, mouthing answers and using electronic devices to communicate. During the interview Resident #77 confirmed that a Geriatric Nursing Assistant (GNA) held him/her down and continued to perform cares that he/she had expressed he/she did not want or need to be performed. Resident #77 further communicated that he/she had not seen that GNA since the incident. On 11/13/24 at 1:12 PM, the surveyor reviewed Resident #77's medical record. The review revealed that Resident #77 was assessed as cognitively intact on 8/21/24 with a Brief Interview for Mental Status (BIMS) score of 15. Resident #77's Decision Making Capacity and Treatment Limitation form dated 11/18/23 documented yes to all three competency ability questions, deeming Resident #77 capable of making his/her own medical decisions. On 11/13/24 at 1:38 PM, the surveyor reviewed the facility's investigation file into the alleged abuse of Resident #77 by GNA #33. The surveyor reviewed the statement written by GNA #33. GNA #33 stated that on the day of the alleged incident she was told by other staff that Resident #77 was resistant to cares and that he/she should be checked even if the resident refused. She further wrote when she went into Resident #77 room and told him/her that she was there to check for him/her for incontinence, Resident #77 communicated that he/she did not want to be checked or changed. GNA #33 instructed Resident #77 that the other GNAs and nurses told her she needed to check for incontinence. GNA #33 next stated that Resident #77 held his/her cover so tight to his/her neck she was not able to pull the covers back. After this GNA #33 decided to pull the covers up from the foot of the bed and hold Resident #77's arm across him/her. On 11/14/24 at 7:09 AM, the surveyor interviewed the Director of Nursing (DON). The DON confirmed that GNA #33 was suspended and was placed on the do not return list to the facility. The DON agreed that the GNA should have respected Resident #77 request to not have the ADL cares performed and honor his/her rights to refuse.

Based on record review, and interviews it was determined that the facility failed to notify the Resident's health care Responsible Party (RP) of a change to the Resident's plan of care and the facility failed to provide a Resident's Representative/guardian the right to be involved in the care planning process. This was found evident in 2 (Resident #51 and #40) of 3 Residents reviewed for resident rights. The findings include: 1. On 10/30/24 at 12:59 PM, the surveyor reviewed Resident #51's paper medical record. The review revealed that on 3/3/21 Resident # 51 was deemed not to have the capacity for decision making capacity for medical treatments. On further review it was noted that Resident #51's daughter was the Responsible Party (RP) for Resident #51. On 11/7/24 at 1:36 PM, the surveyor reviewed Resident #51's electronic medical record. The review revealed a change of condition evaluation written on 8/20/24. The evaluation noted a new skin tear on Resident #51. At the end of the report the section titled, Resident Representative Notification had a statement; Name of the family/resident representative notified. The respective answer was documentation as self. On 11/7/24 at 12:09 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated that the RP should have been notified of the new skin condition and she would look for documentation to support the RP was notified. On 11/7/24 at 1:33 PM, the surveyor conducted a follow-up interview with the DON and at this time the DON confirmed she could not provide documentation that the RP was notified. 2. On 10/30/24 at 1:07 PM, the surveyor reviewed Resident #40's paper medical record. The review revealed documentation dated 1/21/19 that established Resident #40 had co-guardians. On 11/1/24 at 1:32 PM, the surveyor reviewed Resident #40's electronic medical record. The review revealed that on 2/14/24 and 10/30/24 Social Worker Staff #30 documented a care plan meeting was held and the family was in attendance for Resident #40. However, a care plan meeting note written by Staff #30 dated 7/17/24 stated Staff #30 left a detailed voice message for Resident #40's son pertaining to Resident #40's care plan. On 11/6/24 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON stated that Resident #40 did not have his/her care plan in June of 2024 due to being hospitalized . The surveyor asked if the family was invited or in attendance for the July 2024 care plan meeting that was held. The DON stated she would look into the concern and follow up. On 11/6/24 at 11:58 AM, the surveyor conducted a follow-up interview with the DON. The DON confirmed that there was no documentation that the family was invited or in attendance of the care plan meeting that was held in July of 2024.

Based on record review and interview, it was determined that the facility failed to maintain a proper resident's Advance Directives in the Resident's medical record and/or offer to formulate one. This was found to be evident for 2 (Residents #32 and #49) out of 7 residents reviewed for the Advance Directives during the annual survey. The findings include: An Advance Directive is a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness. An Advance Directive may also give a person (such as a spouse, relative, or friend) the authority to make medical decisions. 1a) Record review, on 10/31/24 at 1:03 PM, revealed that Resident 32's Medical Orders for Life-Sustaining Treatment (MOLST) certification stated that his/her Advance directives was selected on 8/5/24 by Nurse Practitioner Staff #42. However, no Advance Directives document was found. During the interview, on 10/31/24 at 2:17 PM, the Director of Social Service Staff #6 stated that Advance Directives information was built into the facility's internal face sheet section under the legal contact person. She stated there was no need to maintain proper Advance Directives records. Staff #6 was informed that she failed to comply with and implement the MOLST certification/order to obtain a proper Advance Directive to direct Resident #32's life-sustaining treatments. During an interview, on 11/1/24 at 11:09 AM, the Director of Nursing (DoN) reviewed the above-mentioned deficiency concerns. The DoN agreed that a copy of the Advance Directives should be on file either in the floor chart or in the electronic record. After the surveyor's intervention, the DoN later presented a copy of the Advance Directives that she had obtained from the hospital's record. 44440 1b) On 10/30/24 at 12:55 PM, the surveyor reviewed Resident #49's paper medical record. The review revealed that Resident #49 was deemed to have capacity to make medical decisions for him/herself. On 11/8/24 at 7:27 AM, the surveyor reviewed Resident #49's electronic medical record. The review revealed a psychosocial assessment was completed on 5/14/20 and noted that Resident #49 did not have advanced directives. A box was checked that stated, resident/family had been informed of surrogate decision making regulations. On further review a progress note was written by Social Worker Assistant Staff #30 on 9/11/24 stated that Resident #49 requested information about advanced directives be sent to his/her mother. On 11/12/24 at 9:19 AM, the surveyor interviewed the Director of Social Service Staff # 6 and the Director of Nursing (DON). The surveyor asked how the facility determines if the Resident has advanced directives. Staff #6 stated during the psychosocial history assessment advanced directives are addressed. The surveyor asked if Resident #49 was offered to make advanced directives on 5/14/20 when his/her psychosocial assessment was completed it was noted that Resident #49 did not have any advanced directives. Staff #6 stated because there is no area on the psychosocial history assessment to indicate if advanced directives were offered to be formulated, she is unclear if Resident #49 was offered the opportunity to create one on 5/14/20 when it was identified that Resident #49 did not have one.

Based on record review and interviews it was determined that the facility failed to inform the Resident's primary care physician of the need to alter treatment. This was found evident of 1 (Resident #51) of 2 residents reviewed for change of condition. The findings include: On 11/7/24 at 11:04 AM, the surveyor reviewed Resident #51's medical record. The review revealed that Resident #51 was admitted to the facility in early 2021. On admission Resident #51 had a percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube that is inserted through the skin and into the stomach to provide direct access to the stomach). The PEG tube was used to provide tube feeding for Resident #51. On further review the surveyor noted Resident #51 had vomited on 10/1/24, 10/10/24, 10/11/24, (an X-ray was ordered) 10/13/24 (tube feed held),10/17/24 (tube feed held for 2 hours),10/18/24 (tube feed held for 2 hours) with notation provided notified, 10/19/24 2 (tube feed held for 2 hours), 10/21/24, 10/23/24 (tube fee on hold), 10/27/24,10/31/24 (tube feed held for 2 hours) and on 11/2/24. The surveyor reviewed the orders. 10/18/24 and 10/24/24 were the only two days where orders were written to hold or restart the tube feeding. The surveyor reviewed the Tasks documentation for bowel regimen notation. The review revealed Resident #51 had no bowel movement documented from 10/16/24-10/21/24 and none from 11/1/24-11/6/24. Review of the facility policy titled: Bowel Assessment and Management revealed that if a resident does not have a bowel movement within 48 hours an order should be obtained from a physician to initiate a bowel protocol or other alternative bowel management treatment. On 11/8/24 at 6:30 AM, the surveyor reviewed a progress note written by Physician #20. The note was written after a follow-up visit on 11/7/24. Staff #20 documented that Resident #51 was noted to have been given Zofran (a medication given to help with nausea) and also vomited on 11/6/24. The note further stated that Resident #51 is likely constipated due to his/her bowel movement was last recorded on 10/31/24. A new bowel regimen was ordered. On 11/14/24 at 9:42 AM, the surveyor interviewed Staff #20 along with the Director of Nursing (DON). During the interview Staff #20 stated that Resident #51 has had chronic vomiting. She further stated that sometimes his/her coughing could lead to vomiting and that the vomiting is not always gastrointestinal related. The surveyor asked Staff #20 if she was aware of the number of episodes of vomiting, the number of times tube feeding that were held and the two times Resident #51 went 6 days without a bowel movement in the last two months. Staff #20 stated she discovered the 6 days without a bowel movement on her visit on 11/7/24 but was not informed of the days in October. She further stated she was not notified of all of the vomiting episodes or the number of times the tube feeds were put on hold. She further stated she would have liked to have been notified of these episodes.

Based on record review and staff interviews, it was determined that the facility failed to protect the residents' private space from unauthorized photographs and recordings. This was evident for 1 (Household 5) out of 10 units. The findings include: On 11/12/24 at 11:53 AM, a review of complaint #MD00194059 was conducted. The complaint stated that Staff #19 recorded themselves in a common care area and posted it on the social media platform Tiktok. On 11/13/2024 at 9:58 AM, Staff #19's employee file was reviewed. The employee file revealed that Staff #19 was terminated for Gross Misconduct. The specific incident causing termination was that the employee was caught recording a video of themselves in a clinical area and posted it on social media. In Staff #19's statement, they stated that she admitted to recording video in the care area while on break. Staff #19 stated that no residents were recorded. On 11/13/2024 at 10:30 AM, an interview with the Director of Nursing (DON) was conducted. When asked if Staff #19 was educated on resident rights and Health Insurance Portability and Accountability Act HIPAA (a federal law that protects the security and confidentiality of personal health information), the DON stated that they were educated on orientation. The DON provided this surveyor with proof of the education provided to Staff #19. On 11/13/24 at 1:26 PM, an interview was conducted with the Administrator (Staff #1). Staff #1 stated that the incident was reported to administration anonymously and was reported to have happened on Household 5. Staff #1 stated that no specific resident was involved but Staff #19 did record a video on Household #5 and posted it on social media.

Based on observation, review of the facility's investigation report, record review, and interviews, it was determined that the facility failed to protect a resident from physical and verbal abuse. This was found evident of 2 (Resident #201 & #53) of 7 Residents reviewed for abuse. The findings include: 1a) On 11/15/25 at 8:53 AM, the surveyor reviewed Resident #201's medical record. The review revealed that Resident #201 was readmitted to the facility related to multiple falls. Further review revealed a progress note written by Physician #34 on 11/30/24 that reported Resident #201 was very confused at baseline and due to impaired gait and high fall risk a 1:1 (one resident to one staff person care services) sitter was ordered. The surveyor reviewed a summary for provider note written by Registered Nurse (RN)# 35 dated 12/26/23. RN #35 described in the note that she heard the 1:1 sitter shouting out from Resident #201's room. When she entered the room Resident #201 was lying in the bed with his legs hanging out of bed. She further reported she did not know what happened in the room before she entered. On 11/15/24 at 9:10 AM, the surveyor reviewed the facility's investigation file into the alleged abuse reported by Resident #201 from Certified Nursing Assistant (CNA)#32. The file contained a statement from Resident #201 and alleged CNA #32 provided rough care, hit him/her with a flashlight, and kept yelling at him/her. The surveyor reviewed the statement from Resident #201's roommate Resident #46. Resident #46 witnessed CNA #32 be rough with Resident #201 and reported CNA #32 was grabbing him/her by the wrists, ankles and feet. Resident #46 also stated CNA #32 was slamming Resident #201 into the wheelchair and when Resident #201 stated ouch your hurting me CNA #32 did not stop. There was, however, no corroboration that Resident #201 was hit by CNA #32 with a flashlight. On 11/18/24 at 9:13 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON stated the CNA#32 was suspended and later terminated related to the incident. She further stated that it was determined that CNA#32 had poor customer service. The DON agreed that CNA #32 was verbally abusive to Resident #201 and should not have been yelling at the resident. On 11/18/24 at 9:13 AM, the surveyor interviewed Resident #46, Resident #201's roommate at the time of the incident. During the interview Resident #46 confirmed his/her statement that rough care was witnessed, and that CNA #32 was rough with Resident #201. He/she stated that he/she remembered the day of the incident because he/she had been woken up in the early hours of the morning from CNA #32 yelling at Resident #201. Resident #46 further stated he/she felt scared in that moment due to the yelling. 50385 1b) On 10/29/24 at 9:45 AM, an observation of Resident #53 was made. The resident was observed lying in bed and was noted to have a hearing impairment. Upon further review of the resident's record, the resident was noted to have a Brief Interview for Mental Status (BIMS) score of 6. The Brief Interview for Mental Status (BIMS) is a structured evaluation aimed at evaluating aspects of cognition in elderly patients. BIMS score: Interpretation, 0 - 7: Severe cognitive impact, 8 - 12: Moderate impairment, 13 - 15: Intact cognitive response. On 11/4/24 at 9:10 AM, a review of Facility Reported Incident #MD00203620 was conducted. The report stated that on 3/14/24 at 6:00 PM, Resident #224 pushed Resident #53 causing them to fall. On 11/4/24 at 10:29 AM, a review of the facility's investigation was conducted. The facility conducted an interview with Resident #224 and the resident confirmed they pushed the linen cart knocking Resident #53 to the floor because Resident #53 was trying to wander into Resident #224's room. Resident #224 stated in the interview that they told staff to keep the wandering residents out of his room or he would hurt them. On 11/4/24 at 11:23 AM, a review of Resident #53 care plans was conducted. A care plan for wandering was created after the incident on 3/14/24. On 11/4/24 at 11:45 AM, a review of Resident #224's care plans. The care plan initiated on 7/12/23 stated [Resident #224] has a behavior problem (conflict with other residents & staff, potential for physical and/or verbal aggression) r/t threats made to harm a neighboring resident on unit. The intervention for this care plan is documented as the resident's triggers for verbal aggression are invasion of privacy by residents wandering into [his/her] room. The resident's behavior is de-escalated by removing other residents from [his/her] room and minimizing wandering into [his/her] room through increased supervision.

Based on review of the facility's investigation report, record review, and interviews, it was determined that the facility failed to protect a resident from being physically restrained by an employee. This was found evident on 1 (Resident #77) of 7 Residents reviewed for abuse. The findings include: On 10/29/24 at 9:03 AM, the surveyor interviewed Resident #77. During the interview Resident #77 was able to answer questions by nodding, mouthing answers and using electronic devices to communicate. During the interview Resident #77 confirmed that a Geriatric Nursing Assistant (GNA) held him/her down and continued to perform cares that he/she expressed he/she did not want or need to be performed. Resident #77 further communicated that he/she had not seen that GNA since the incident. On 11/13/24 at 1:12 PM, the surveyor reviewed Resident #77's medical record. The review revealed that Resident #77 was assessed as cognitively intact on 8/21/24 with a Brief Interview for Mental Status (BIMS) score of 15. On 11/13/24 at 1:38 PM, the surveyor reviewed the facility's investigation file in the alleged abuse of Resident #77 by GNA #33. The surveyor reviewed the statement written by GNA #33. GNA #33 stated that on the day of the alleged incident she was told by other staff that Resident #77 was resistant to cares and that he/she should be checked even if the resident refuses. She further stated when she went into Resident #77's room and told him/her that she was there to check for incontinence Resident #77 communicated he/she did not want to be checked or changed. GNA #33 instructed Resident #77 that the other GNAs and nurses told her she needed to check for incontinence. GNA #33 next stated that Resident #77 held his/her cover so tight to his/her neck she was not able to pull the covers back so she pulled the covers up from the foot of the bed and held Resident #77's arm across him/her. On 11/14/24 at 7:09 AM, the surveyor interviewed the Director of Nursing (DON). The DON confirmed that GNA #33 was suspended and was placed on the do not return list to the facility. The DON agreed that Resident #77 should not have been held down by GNA #33.

Based on medical record review and interview with facility staff, it was determined that the facility failed to have an effective system in place to ensure that the hand-off communication regarding resident needs were clearly and effectively communicated between staff and from shift to shift. This was evident regarding the review of falls for 1 of 11 residents (#5). The findings include: Review of the facility investigation regarding Resident #5 regarding an incident occurring on 1/30/18 resulting in bilateral ankle fractures, revealed the resident was transferred from his/her wheelchair to the bed improperly according to the resident's care plan. The facility root cause analysis of the incident occurring on 1/30/18 revealed that the resident sustained [REDACTED]. Review at 11:16 AM on 6/15/18 of the residents Minimum Data Set (MDS-provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems and needs) for 11/24/17 and 2/8/18, completed prior to and after the incident documented the resident as requiring 2 'person' for transfers. Additionally, according to the MDS, the resident was noted as mobile via a wheelchair with the assistance of one person. According to the resident's care plan initiated on 12/1/17, regarding adaptive equipment use, wheelchair and Hoyer lift for transfer was listed. In addition, the residents brief interview for mental status (BIMS) was assessed on those dates as an 11, showing mild cognitive impairment. Surveyor attempted to interview resident on 6/15/18 at 2:28 PM, however, was unable to get a clear answer and explanation of the incident that occurred on 1/30/18. Further review of the facility investigation revealed that on the 11-7 AM shift on 1/30/18 Resident #5 was transferred from his/her wheelchair to the bed by one staff identified as an agency geriatric nursing assistance (GNA), using a stand pivot transfer, in which the resident was made to stand from the wheelchair, weight bearing on both legs and pivoted to the bed with the assistance of one staff. The following evening on 1/31/18 on the 11-7 AM shift the GNA caring for Resident #5 stated the resident had complaints of pain in his/her legs and foot. The resident stated that s/he had a history of [REDACTED]. The resident was treated again for pain on the morning shift 7-3 AM for pain reported of 9/10. It was not until the afternoon at 3:00 PM that staff noted the resident's right ankle was swollen and the nurse was informed and x-rays were ordered. Resident #5 was sent to the emergency roiagnom on the afternoon of 2/1/18 after x-ray results completed on 2/1/18 showed 'probable fracture, additional imaging suggested.' Resident #5 returned to the facility on the morning of 2/2/18 with [DIAGNOSES REDACTED].) and left nondisplaced [MEDICATION NAME] fracture (the bone cracks either part or all of the way through, but does move and maintains its proper alignment). The Resident returned to the facility with bilateral splints with casts to be placed later by orthopedics. The facility completed an investigation on 2/22/18 of the incident and through the investigation was unable to determine who reported to the agency GNA that the resident could be transferred via weight bearing stand and pivot. The agency GNA stated she was told in report she could transfer the resident by herself, however, the out-going GNA and Nurse on duty deny the report. All findings were reviewed throughout the survey with the DON and Administrator again on 6/18/18 at 11:40 AM.