Every finding on record at Lorien Health Systems Mt Airy

Based on record reviews and interviews it was determined that facility failed to ensure employee annual performance evaluations were conducted. This was found to be evident for 5 Geriatric Nursing Assistants (GNA) (GNA #6, GNA #7, GNA #8, GNA #9 & GNA #10) out of 5 employee files reviewed during the recertification and complaint survey. The findings include:An employee performance evaluation is a structured, periodic process where an organization assesses an employee's job performance, skills, and work habits against pre-established expectations. Also called a performance review or appraisal, it is used to guide compensation, promotions, and professional development.During a review of employee files conducted on 07/29/2026 at 1:01 PM the Surveyor was unable to locate annual performance evaluations for GNA #6, GNA #7, GNA #8, GNA #9, & GNA #10.During an interview conducted on 07/29/2026 at 6:51 AM the Surveyor advised the Assistant Nursing Home Administrator (NHA) and Director of Nursing (DON) that she was unable to locate the annual performance evaluations in any of the employee files. During an interview conducted on 07/29/2026 at 8:31 AM, the Surveyor requested the annual performance evaluations again from the NHA and DON.During an interview conducted on 07/29/2026 at 12:14 PM, the Surveyor requested the annual performance evaluations for a 3rd time. The DON reported that the facility had not completed annual performance evaluations since Covid. During an interview conducted on 07/29/2026 at 12:45 PM the HR Director (HRD) reported that she had been with the facility for 4.5 months. In her role she discovered that the annual performance evaluations were overdue and planned to send a list to all department managers for the employees that had an overdue annual performance evaluation. She also reported that she identified the issue and notified the facility last weekThe HRD returned on 07/29/2026 at 1:31 PM and reported that it appeared that some employees received an annual performance evaluation in 2024.

Based upon record review and staff interview, the facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) program implemented and monitored Performance Improvement Projects (PIPs) including the development of measurable actions and tracking of outcomes to determine whether identified areas of concern improved. This was found to be evident in 8 of the 9 monthly reports reviewed during the recertification and complaint survey. The findings include:QAPI is a data-driven, proactive approach used in healthcare settings to maintain and continuously improve the quality, safety, and outcomes of care. A Performance Improvement Project (PIP) is a focused, structured project to actively improve a specific process. In a record review on 07/31/2026 at 08:30 AM, the QAPI binder included monthly slides of areas for concern. Documents provided to the surveyor by Staff #12, labeled Summary of Reports included concerns related to falls, hospital transfers, wounds, weights, and infection rates. Review of the data revealed the following: January 2026: 15 falls, 9 hospital transfers, 4 new facility acquired skin impairments, 3 unplanned weight changes, 41 residents on anti-infectives. February 2026: 4 falls, 8 hospital transfers, 20 new facility acquired skin impairments, 5 unplanned weight changes, 29 residents on anti-infectives. March 2026: 15 falls, 18 hospital transfers, 21 new facility acquired skin impairments, 9 unplanned weight changes, 33 residents on anti-infectives. April 2026: 7 falls, 4 hospital transfers, 13 new facility acquired skin impairments, 7 unplanned weight changes, 20 residents on anti-infectives. May 2026: 12 falls, 17 hospital transfers, 25 new facility acquired skin impairments, 7 unplanned weight changes, 27 residents on anti-infectives. June 2026: 8 falls, 11 hospital transfers, 18 new facility acquired skin impairments, 3 unplanned weight changes, 31 residents on anti-infectives. Although the facility had collected data demonstrating recurring and fluctuating areas of concern, the QAPI binder did not include evidence of analysis of the data for trends, identification of specific area requiring performance improvement, measurable goals, interventions to reduce the identified concerns, responsible persons, target dates or follow-up data demonstrating whether implemented interventions resulted in improvement. In an interview on 07/31/2026 at 9:00 AM, Staff #12 stated that they were unfamiliar with what tools should be utilized to track this information.

Based on record review and staff interview, it was determined that the facility failed to ensure notification was provided to the resident's responsible party. This was found to be evident for 1 (Residents #6) of 5 residents reviewed for transfer/discharge requirements during the recertification and complaint survey. The findings include: A bed hold is an agreement or policy that saves a specific room or bed for a patient while they are temporarily away from a care facility. It is most commonly used in nursing homes, skilled nursing facilities, and residential treatment centers when a resident has to go to a hospital or take a short leave 1.) In a record review on 07/28/2026 at 3:00 PM, the Surveyor was provided copies of the bed-hold policy that had been phoned to Residents #6. The form contained sections which defined the bed-hold rights that were applicable to residents who were private pay, Medicare or Medicaid recipients. The facility failed to complete the form for Resident #6 with the resident-specific information and failed to document if the form was phoned to Resident #6 or delivered in writing. In an interview on 07/29/2026 at 8:26 AM, with the Director of Admissions, Staff #11, it was confirmed that the current practice is to call residents responsible parties when the residents are discharged to the hospital and verbally notify them of the bed-hold policy. She then follows -up with an email, providing the information in writing. Documentation of the phone call or email that she sent to Resident #6 regarding the bed-hold policy was requested. Staff #11 admitted that she failed to send Resident #6 an email with the policy and remembers calling the resident, who is their own responsible party, but did not document the call. Staff #11 indicated the residents are also educated on the bed-hold policy, including bed prices on admission. Staff #11 agreed that those prices given on admission may not reflect the current bed prices. Staff #11 indicated that if the residents are choosing to privately pay for the bed while in the hospital, she will give them a verbal notification for the price of the bed but is unable to produce any written documentation of giving that verbal bed price to Resident #6. A review of the bed hold policy was conducted on 07/29/26 at 9:33 AM. The policy stated that the facility will provide clear written notice to residents and/or their representatives regarding bed hold rights, condition of return, and any associated financial obligations.

Based on medical record review and interviews it was determined the facility failed to ensure the accuracy of minimum data set assessment (MDS). This was evident for 1 resident (Resident #3) out of 14 residents reviewed for MDS accuracy during the recertification and complaint survey. The findings include:The MDS (minimum data set) is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.Diabetes Mellitus type II is a chronic metabolic condition characterized by high blood sugar levels caused by insulin resistance and relative insulin deficiency. It is the most common form of diabetes, where the body's cells do not respond properly to insulin, meaning glucose cannot enter cells efficiently to be used for energy On 07/28/2026 at 8:32 AM, a review of Resident #3 medical records revealed a medical diagnosis of Diabetes Mellitus type II (DM type II) with active medication orders for the resident to be administered NovoLog and Lantus insulin daily. On 07/28/2026 at 8:54 AM, a review of Resident #3 MDS assessment completed on 05/08/2026 confirmed the active diagnosis of DM type II with documentation that the resident received injections for 7 days over the 7-day look back period. The medication assessment portion of the MDS was coded as no for receiving hypoglycemic medication. Further review of Resident #3 MDS assessments showed the resident was coded as not taking insulin on the MDS assessment completed on 03/24/2026. A review of Resident #3 Medication administration record (MAR) for May 2026 and March 2026 confirmed Resident #3 was administered NovoLog and Lantus insulin daily. On 07/29/2026 at 2:34 PM, an interview with MDS Registered Nurse (RN) #23 confirmed Resident #3 was inaccurately documented as not taking hypoglycemic medication under section N medications for the MDS assessments completed on 3/24/26 and 5/8/26. The MDS RN #23 pulled Resident #3's MAR for March 2026 and confirmed the resident was administered insulin for the entire month of March. The MDS RN #23 stated her process for documenting medications is to pull the MAR and cross reference with the MDS assessment. She stated she will take notes and double check her work when finished completing the assessment. The MDS RN #23 agreed it was a concern that the medication was not accurately documented. On 07/31/2026 at 8:20 AM, an interview with the Director of Nursing #2 (DON) and MDS RN #23 confirmed that the MDS assessments for Resident #3 had been corrected to accurately code the resident's received medications.

Based on observation, interview and record review, it was determined that the facility failed to ensure medications were administered and stored in accordance with professional standards of practice and physician orders. This was found to be evident for 1 (Resident #6) of 5 residents reviewed for professional standards of practice during the recertification and complaint survey.The findings include:In an observation on 07/27/2026 at 10:53 AM, a tube of clobetasol ointment (a steroid ointment available only with a physician's prescription, used to treat various inflammatory skin conditions) was noted on Resident #6's bedside table. During an interview, Resident #6 stated staff permitted him/her to keep the medication in his/her room and use it when needed.In a record review on 07/30/2026 at 10:20 AM, the medical record failed to identify a physician's order authorizing the resident to keep clobetasol ointment at the bedside or to self-administer the medication. During an interview, staff #25 acknowledged there was no physician order permitting bedside storage of the medication and stated a physician's order would be requested that day.In a follow-up observation on 07/30/2026 at 12:46 PM, additional medications were noted on Resident #6's bedside table, a ProAir inhaler (a brand-name inhaler containing albuterol sulfate, which is only available with a physicians order, used to relax the muscles around the airways making breathing easier.), Arnicare gel (an over-the-counter medication used to temporarily relieve muscle pain, stiffness, swelling and bruising) and the previously observed clobetasol ointment.In a record review on 07/30/2026 at 1:30 PM, orders for the ProAir inhaler were located, however, the orders failed to indicate Resident #6 was authorized to keep the inhaler at the bedside or self-administer the medication. The record failed to show an order for the Arnicare gel in the previous 7 months.In an interview and observation with the Director of Nursing (DON) on 07/30/2026 at 2:10 PM, the DON observed medications in Resident #6's room and agreed the medications should not have been accessible at the bedside without appropriate authorization.

Based on observations, interviews, and record reviews it was determined that the facility failed to ensure medications were properly stored and labeled. This was evident for 1 of 10 medications observed in resident rooms and 1 of 2 medication carts observed during the recertification and complaint survey. The findings include: 1.) On [DATE] at 9:50 AM, Resident #22 was observed to have iosource and saline solution hanging on an IV pole next to their bed with no label. On [DATE] at 9:51 AM, an interview with RN #4 revealed it's the facility's process when hanging any fluids to label the bag with the resident's name, date, time, and rate. On [DATE] at 9:52 AM, an Interview with Unit Manager# 19 confirmed it is the facility's process when hanging fluids to label bag with date, resident's name, room number, and time. This surveyor showed Unit Manager #19 Resident #22's unlabeled fluids hanging in the resident's room. Unit Manager #19 confirmed that both bags of fluids were not labeled with any of the required information per facility process. 2.) During an observation of the Medication Cart for rooms on the Prospect Unit with Licensed Practical Nurse (LPN) #15 on [DATE] at 2:15 PM it was revealed to contain a Novolog FlexPen (insulin pen) for Resident #1 that had the date of 6/24 handwritten on the medication label. An Insulin Lispro KwikPen for Resident #63 was found to have been opened and had no date opened or expiration date labeled on the KwikPen. During an interview with LPN #15 on [DATE] at 2:19 PM she reported that the date of 6/24 written on the Novolog FlexPen for Resident #1 was the date the FlexPen was opened. She reported that the Novolog FlexPen was good for 28 days after opening and confirmed that the date of 6/24 was over 28 days. She confirmed that the Novolog FlexPen should have been removed from the cart. LPN #15 also reported the insulin pens should be dated after being opened and confirmed the the Insulin Lispro Kwik Pen for Resident #63 should have been dated when it was opened. During an interview with Director of Nursing (DON) #2 on [DATE] at 2:57 PM she reported that the insulin pens should be dated when opened and would be good for 28 days. She confirmed that the Novolog FlexPen for Resident #1 should have been removed from the medication cart after 28 days and that the Insulin Lispro Kwik Pen for Resident #63 should have been dated after being opened. During a review of the facility's Insulin Storage policy on [DATE] at 8:05 AM it stated that Opened insulin vials and pens shall be labeled with the date opened. Open vials shall be discarded according to the manufacturer's recommendations or expiration date, whichever comes first. The policy added, Insulin that is expired, frozen, exposed to excessive heat, discolored, or otherwise compromised shall be discarded and reported according to facility policy. During an observation of the [NAME] Unit Medication Storage Room on [DATE] at 6:16 AM it was revealed to have a posting on the wall titled Labeling of Flexpen. The posting stated Flexpens are required to be labeled the same as vials of insulin: date opened with initials of staff and Novolog must be discarded after 28 days.

Based on observations, interviews and record review it was determined that the facility failed to prepare food that ensures sanitary and safe food service operations. This was evident in 2 out of 2 observations done for kitchen and dining services during the recertification and complaint survey. The findings include:1. During an observation of the kitchen during lunch preparation on 7/29/2026 at 12:19 PM Director Dining Services #18 was observed holding a box of pasta noodles, he reached inside the box with his bare hand, grabbed some noodles and placed the noodles in a cup. He added water to the cup and placed the cup into the microwave before placing it on the tray for Resident #69. During an interview with the Director of Dining Services #18 on 7/29/2026 at 12:22 PM he reported that staff members should be using gloves when touching food and that using bare hands to touch food is not a standard procedure in the facility's kitchen.During an observation of the kitchen on 7/29/2026 at 12:23 PM the Director of Dining Services was observed returning the box of noodles back on the shelf where it was stored.2. During an observation of the kitchen during lunch preparation on 7/29/2026 at 12:32 PM Dietary Aide #20 was observed removing a plate cover from the clean rack, a separate plate cover fell to the floor. Dietary Aide #20 then picked the plate cover off the floor and returned the plate cover to the clean rack.During an interview with the Director of Dining Services on 7/29/2026 at 12:42 PM he reported that the plate cover and other dishes should be put with the dirty dishes when they fall onto the floor and not back on the clean rack.

Based on record reviews and interviews it was determined that the facility failed to ensure the hospice designated staff member was knowledgeable of the hospice requirements. This was found to be evident for 1 (Resident #16) out of 1 Resident reviewed for hospice services during the recertification and complaint survey.The findings include:Hospice is specialized comfort care for people with a terminal illness who have a life expectancy of six months or less. It shifts the focus from curing an illness to maximizing the patient's quality of life, dignity, and pain management. A certification of terminal illness (CTI) is a formal medical document. It states that a patient has a life expectancy of six months or less if their illness runs its normal course. This form is required to start and keep Medicare or Medicaid hospice benefits.In a record review on 7/30/2026 at 1:25 PM, the medical record failed to provide a current certification of terminal illness (CTI) for Resident #16. The most recent certification available in the medical record covered 5/18/2026 through 7/16/2026. In an interview on 7/30/2026 at 1:30 PM, Staff #24 stated that Staff #21 was responsible for obtaining the updated hospice certification. In an interview on 7/30/2026 at 1:40 PM, Staff #21 stated that she had never seen the hospice certification form before and would contact hospice to obtain the current copy. Both Staff #21 and Staff #24 stated they were unfamiliar with the CTI and what documentation was required to be maintained in the resident's medical record. In an interview with the Director of Nursing (DON) on 7/30/2026 at 2:05 PM, the DON was unable to locate the current CTI in the medical record. While the record was being reviewed by the DON, Staff #21 arrived with a current CTI which covered the certification period 7/17/2026 through 9/14/2026. The new CTI was signed on 7/30/2026 by a physician with notation that indicated the attending physician's signature could not be obtained, therefore the form was signed by a covering physician.

Based upon record review and staff interview, the facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program maintained and implemented a comprehensive, data- driven program. This was found to be evident in 8 of the 9 monthly reports reviewed during the recertification and complaint survey. The findings include:QAPI is a data-driven, proactive approach used in healthcare settings to maintain and continuously improve the quality, safety, and outcomes of care. A Performance Improvement Project (PIP) is a focused, structured project to actively improve a specific process. Risk management is the ongoing process of identifying, evaluating and reducing clinical and operational hazards.In a record review on 07/31/2026 at 08:30 AM, the QAPI binder failed to include evidence of identified areas for improvement that included, but was not limited to, the systemic areas of noncompliance identified by the survey team. In an interview with staff #12 on 07/31/2026 at 09:00 AM the Quality Assurance (QA) and staff development representative admitted that while they hold monthly QAPI meetings, they do not identify PIPs each month and indicated their focus has been on medication errors during the 9 monthly reports this surveyor reviewed. Staff #12 stated that each department would identify an area for improvement and work on those areas independently, reporting their progress during QAPI meetings but acknowledged that these are not formal PIPs but are more like risk management plans.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#9, #1, #4, #3) of 12 residents reviewed during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 5/5/26 at 9:03 AM a review of Resident #9's medical record was conducted and revealed Resident #9 had current diagnoses of thrombocytopenia and history of malignant neoplasm of other sites of lip, oral cavity, and pharynx.Review of a 12/19/25 physician's note documented, thrombocytopenia, unspecified*: Critically low platelet count at 30 trending down from 116 on 12/14/25. The physician recommended a hospital transfer to rule out internal bleeding. Additionally, the physician documented, nystatin 100,000 unit/mL suspension, give 5 ml by mouth four times a day for carcinoma of buccal mucosa for 1 week swish for 4-5 min and spit.Review of Resident #9's MDS assessments with assessment reference dates (ARD) of 12/19/25 and 1/8/26, Section I Active Diagnoses, failed to capture the cancer and thrombocytopenia.On 5/6/26 at 2:18 PM MDS Coordinator #11 was interviewed and reviewed the MDS assessments with the surveyor. MDS Coordinator #11 confirmed the errors.On 5/7/26 at 9:16 AM the DON confirmed the errors.2) On 5/5/26 at 10:14 AM a review of Resident #1's medical record was conducted and revealed Resident #1 had a history of neuropathy and was prescribed Gabapentin (anti-convulsant) 300 mg. 2 times a day for neuropathy.Review of Resident #1's July 2025 and August 2025 Medication Administration Records (MAR) documented that Resident #1 was receiving Gabapentin 300 mg. every morning and every evening.Review of Resident #1's MDS Assessments with ARDs of 7/16/25 and 8/26/25, Section N0415, high risk drugs, failed to capture Gabapentin as an anticonvulsant.On 5/6/26 at 2:16 PM MDS Coordinator #11 was interviewed and reviewed the MDS assessments with the surveyor. MDS Coordinator #11 confirmed the errors.On 5/7/26 at 9:16 AM the DON confirmed the errors.3) On 5/5/26 at 1:24 PM a review of Resident #4's medical record was conducted and revealed Resident #4 had a history of multiple sclerosis, major depressive disorder, other specified mental disorders, and intervertebral disc degeneration, lumbar region with discogenic back pain.Review of Resident #4's October 2025 Medication Administration Record (MAR) documented that Resident #4 received Diazepam 2 mg.(anti-anxiety) twice per day and Gabapentin (anti-convulsant) 300 mg. every 8 hours.Review of Resident #4's MDS assessment with an ARD of 10/9/25, Section N0415 High Risk Medications failed to capture the anti-anxiety and anti-convulsant medications.Review of Resident #4's January 2026 MAR and April 2026 MAR documented that Resident #4 continued to receive the Diazepam 2 mg. twice per day and the Gabapentin 300 mg. every 8 hours.Review of the MDS assessment with an ARD of 1/9/26 and 4/10/26, Section N0415 High Risk Medications, failed to capture the anti-anxiety and anti-convulsant medications. Additionally, on both of the MDS assessments, antidepressant was coded as being administered. However, review of the January 2026 and April 2026 MARs failed to have documented that antidepressant medications were administered.On 5/6/26 at 2:20 PM MDS Coordinator #11 was interviewed and stated that she did not realize she should have coded Diazepam as an anti-anxiety medication.On 5/7/26 at 9:16 AM the DON confirmed the errors.4) On 5/6/26 at 7:45 AM a review of Resident #3's medical record was conducted and revealed Resident #3 had a history that included cerebral infarction, unspecified convulsions, epilepsy, cervicalgia, connective tissue and disc stenosis of intervertebral foramina of cervical region, and obstructive sleep apnea.Review of Resident #3's November and December 2025 MARs documented that Resident #3 received Divalproex Sodium (anticonvulsant) 125 mg. every morning, Divalproex Sodium 250 mg. every evening, and Gabapentin (anticonvulsant) 400 mg. 3 times a day.Review of Resident #3's November 2025 Treatment Administration Record (TAR) documented that Resident #3 used non-invasive mechanical ventilator, BiPAP, every evening.Review of Resident #3's MDS assessment with an ARD of 11/7/25, Section N0415 High Risk Medications, failed to capture the administration of anticonvulsant medication. Review of Section O, Special Treatments, Procedures, and Programs, O0110G2, BiPAP, failed to capture the use of BiPAP every evening for obstructive sleep apnea.Review of Resident #3's MDS assessment with an ARD of 12/21/25, Section N0415 High Risk Medications, failed to capture the administration of anticonvulsant medication.On 5/6/26 at 2:12 PM, MDS Coordinator #11reviewed the MDS assessments with the surveyor and confirmed the errors.On 5/7/26 at 9:16 AM the DON confirmed the errors.

Based on medical record review and interview, the facility staff failed to follow wound care provider's orders for a resident. This was evident for 1 (Resident #8) of 3 residents reviewed for wound care during a complaint survey.The findings include:Review of Resident #8's medical record on 5/5/26 revealed the Resident was admitted to the facility in 2025 with a diagnosis to include peripheral vascular disease (PVD). PVD is a slow and progressive circulation disorder characterized by narrowing, blockage or spasms in blood vessels, commonly affecting the legs.Further review of Resident #8's medical record revealed on 2/22/26 the facility staff assessed the Resident to have a wound to the second right toe and began treatment.The Resident was seen and assessed by the Wound Care NP (Nurse Practitioner) on 2/24/26 who ordered treatment of the wound.On 3/3/26 the Resident was seen and assessed by the Wound Care NP. At that time the Wound Care NP changed the treatment orders for the Resident's second right toe. The Wound Care NP ordered: a) Cleanse wound with wound cleanser b) Apply Skin Prep at peri wound area and c) Secure dressing daily. Review of Resident #8's March 2026 Medication and Treatment Administration Records revealed the facility staff failed to administer treatment to the Resident's right second toe wound from 3/3/26 through 3/7/26, 5 days.Interview with the Director of Nursing on 5/6/26 at 9:15 AM confirmed the facility staff failed to provide wound treatment for Resident #8 from 3/3/26 through 3/7/26 for the Resident's right second toe wound.

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #65) of 37 residents reviewed during a recertification / complaint survey.The findings include:A closed record review of Resident #65's medical records for death conducted on [DATE] at 10:47 AM, revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. On [DATE] at 11:41 AM, review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for [DATE] revealed staff documentation that assessments were done and treatments were provided during the evening and night shifts on [DATE] for Resident #65:- Medications scheduled to be given in the evening and at bedtime for [DATE] had staff documenting NI.[NI=Clinical Finding WNL(within normal limit) - No intervention required] as indicated under Chart codes/Follow up codes.- Night shift staff documented 0 under Assess Resident daily for change of status/Assess for Delirium daily.- Night shift staff checked that resident was assessed for Bleeding/Bruising Precautions. - Night shift staff checked that resident's Oxygen: Every shift O2 @ 2 L/Min continuous via N/C for hypoxia.Maintain O2 above 93% . was monitored.- Night shift staff documented that they performed pain assessment and resident's pain score/level was 0 (No pain).Aspiration Precautions, Barrier cream to buttocks and peri area every shift after soap/water was checked including Elevate/float heels while in bed, Fall precautions, Pressure relieving device, and Turn and Repositioning every 2 hours.Resident #65 was pronounced dead at 12:30 PM on [DATE] and body released to funeral home at 16:47 (4:47 PM) on [DATE]. Hence, Resident #65 was no longer in the facility when evening and night shift staff documented they completed the above mentioned tasks.On [DATE] at 11:52 AM, a review of nurses' progress notes revealed a change in condition documentation dated [DATE] at 12:10:. Resident was sitting in dining/activity room following BINGO activity and awaiting lunch to arrive when s/he became short of breath.EMTs arrived at approx. 12:23, at which time resident was assessed and about a minute following their arrival resident ceased breathing. Resident assessed for pulse and signs of life which were confirmed to be absent. Resident with no respirations, no heart sounds, and was pronounced deceased by EMTs at 12:30pm.On [DATE] at 12:50 PM in an interview with the Director of Nursing (DON), surveyor reviewed Resident #65's MAR and TAR for [DATE]. DON verified that evening and night shift staff documented on [DATE] that ordered treatments/ assessments/monitoring were performed. She confirmed that the staff documentation was inaccurate as Resident #65 had expired and was no longer in the facility at the time of their documentation. DON stated that she was very disappointed and was going to talk to the specific nurses who documented on [DATE] after Resident #65 was deceased . DON further stated that she was going to provide staff education.

Based on medical record review and interview, it was determined the facility failed to provide documentation that Advance Directives (AD) was reviewed with and/or information/education regarding advance directives provided to residents and/or their responsible representatives (RP). This was evident for 2 (#4 and #11) of 37 residents reviewed during a recertification/complaint survey. The findings include:1) On [DATE] at 2:35 PM, a review of the Resident’s #11’s medical record revealed that there was no documentation to support that the advance directives were obtained as required. On [DATE] at 11:37 AM A review of the resident records revealed that a Social Work admission Assessment was completed on [DATE]; section “F” of the assessment revealed that Resident #11 had a MOLST form in the chart. However, there was no evidence to support that the AD was obtained, or that documentation was provided to the resident and or the representative. On [DATE] at approximately 11:49 AM, in an interview with the Director of Nursing (DON), she was asked for Resident #11’s AD, and she stated that they would investigate further. On [DATE] at 12:40 PM, the surveyor followed up on the AD documentation request and it was revealed that a Power of Attorney (POA) document was obtained from the resident’s representative after the surveyor’s inquiry. However, there was still no documentation to support that the advance directive information was provided to the residents or their representative(s) as required. The DON verbally confirmed and acknowledged that the AD documentation was not available. On [DATE] at 3:12 PM, in an interview with the social work director, she reported that she spoke with the family about the advance directives and they stated that they will have to look to see if they have the resident’s AD in their possession. 2) On [DATE] at 2:03 PM a review of Resident #4's medical records revealed a Maryland Order for Life Sustaining Treatment (MOLST) dated [DATE] which indicated “No CPR, Option B, Palliative and Supportive Care” selected. There was no Advance Directives (AD) found in the resident's records. However, further review of the medical records failed to reveal documentation of advance directives or that a discussion about advance directives had occurred with the resident and/or their RP. On [DATE] at 2:19 PM a review of social services progress notes did not reveal any documentation on Advance Directives. On [DATE] at 3:02 PM, in an interview with the Director of Nursing (DON), she stated she could not find any Advance Directives in Resident #4's chart. However, DON stated that she followed up with the Social Worker (SW #3) who confirmed there was no AD in the resident’s chart. DON further stated that SW #3 was currently calling Resident #4's family. On [DATE] at 3:04 PM, surveyor reviewed the concern regarding the lack of documentation about advance directives in the medical record with the Director of Social Services (Staff #3), in the presence of the DON, Staff #3 confirmed that she did not address Advance Directives with Resident #4 and/or their RP. DON stated that they were doing an audit to make sure all the residents had AD and/or documentation that AD was reviewed and education provided to the residents and their RPs. [DATE] 12:22 PM Review of the facility's Advance Directives/Advance Care Planning policy statement and Procedure noted that 1. Prior to, or upon admission, the admission staff and/or Medical Provider will ask resident's and/or their family members about the existence of any advance directives including the Maryland MOLST form. 2. Should the resident indicate that he or she has issued advance directives about his or her care and treatment, the facility will require that copies of such directives be included in the medical record . The facility staff failed to provide evidence that this was done for Resident #4.

Based on record review and interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan. This is evident for 1 (Resident #11) of 24 resident care plans reviewed during the survey process.The findings Included:A voiding trial is the removal of a urinary catheter allowing the bladder to fill with urine naturally, and monitoring voiding to see if the bladder has returned to normal so that the urinary catheter can be removed permanently.On 08/04/2025 at 2:21 PM, in a resident representative interview, they expressed concern for the Resident #11's recurrent Urinary Tract Infection (UTI).On 08/11/2025 at 1:11 PM, in an interview with RN #10, she reported that Resident #11 had a history of recurrent UTI. The resident was admitted to the facility without a urinary catheter; however, after the resident's admission, the resident began to have difficulty with urination, as a result a urinary catheter was ordered and inserted as ordered. RN #10 reported that they have attempted voiding trials since the resident's admission, but the resident failed them, as a result the resident still had a urinary catheter. She reports that Resident#11's goal is to be discharge home.A review of Resident #11 charts revealed that medication order for Flomax Capsule 0.4 MG, one capsule by mouth at bedtime for urinary retention. On 7/14/2025 urinary catheter was ordered for urinary retention. On 7/28/2025 a urology consults for Urinary retention and chronic UTI's was ordered.On 08/11/2025 at 1:57 PM, a review of Resident #11's care plan revealed that there was no documented evidence to support that the facility developed a person-centered care plan to address urinary retention and urinary catheter usage.On 8/11/2025 at approximately 3:00 PM, in an interview with the unit manager (Staff #5), she explained that care plans are usually done frequently, whenever there is a change in condition, quarterly or a decline in resident status. She was asked if Resident #11's care plan should be updated to reflect the interventions that were implemented such as the voiding trials, and she stated that she will update the care plan with the dates of the voiding trials.8/11/2025 at approximately 3:30 PM, the Director Of Nursing (DON) was notified that the surveyor had concerns that the urinary catheter was initiated in the facility on 7/14/2025 for urinary retention; however, there was no documented evidence to suggest that Resident #11's care plan was developed to address the care needs of urinary retention and urinary catheter care. She acknowledged that it was not developed until 8/11/2025.

Based on record review and interviews, it was determined that the facility failed to revise the care plan by the interdisciplinary team after each assessment. This was true for 1 (Resident #21) of 3 resident records reviewed for hospitalization during the recertification/complaint survey.The findings include:A care plan is a tool used to summarize the resident's healthcare needs, treatments, and care goals. This tool is to be developed within 7 days after completion of the comprehensive assessment (MDS) and prepared by an interdisciplinary team.The Minimum Data Set (MDS) is a standardized comprehensive assessment tool that measures health status in nursing home residents.Mechanical ventilator is a machine that promotes or supports the movement of air in and out of the lungs. The machine takes over the work of breathing when a person is unable to breathe on their own.Tracheostomy is a surgical hole or stoma which consists of making an incision on the front of the neck to open a direct airway to the trachea. A tracheostomy allows air to pass into the windpipe to help with breathing.On 08/05/2025 at 12:03 PM, in an interview with Resident #21, the resident stated that he/she was sent to the hospital in mid-July 2025 for respiratory distress.On 08/12/2025 at 4:08 PM, a review of the resident's emergency room treatment record indicates that the resident was dependent on a mechanical ventilator via a tracheostomy and resident was sent to the hospital after being found unresponsive and without a pulse in the facility, mid-July, the resident was subsequently resuscitated and sent to the hospital.On 08/13/2025 at 8:45 AM, a review of Resident #21's MDS revealed that an assessment was completed on 7/21/2025 post hospitalization. However, there was no documented evidence to support that the facility reviewed and revised the care plan for continuous mechanical ventilation related to respiratory insufficiency after each MDS assessment.On 8/13/2025 at approximately 11:15 AM, the Director of Nursing was notified that Resident #21's respiratory care plan was not reviewed and revised after the last assessment following the mid-July 2025 hospitalization. She verbally acknowledged the care plan should be reviewed as required.

Based on a complaint, medical record review, and interview, it was determined the facility failed to ensure staff followed physician orders as evidenced by failure to ensure residents receive medications as ordered by the physician. This was evident for 1 (Resident #69) of 37 residents reviewed during a recertification/complaint survey. The findings include:On 8/8/2025 at 11:26 AM, review of a complaint #365844 revealed that Resident #69's medicines were not given as prescribed.On 8/11/2025 at 8:11 AM, a review of Resident #69's Medication Administration Audit Report from 4/3/2025 through 4/9/2025 for actual times meds were given revealed the resident's meds were not given as scheduled on the following dates/time:- On 4/3/2025: Med [Tizanidine HCL 4 mg tab ordered for 23:00 (11:00 PM) was given on the next day (4/4/2025) at 06:40 (6:40 AM)] - more than 7 hours past the scheduled time.- On 4/3/2025: Meds scheduled for 20:00 (8:00 PM) were given on the next day (4/4/2025) at 06:40 (6:40 AM).- On 4/4/2025: Pain med scheduled for 20:00 (8:00 PM) was given at 23:44 (11:44PM); more than 3 hours late.- On 4/6/2025: Meds scheduled for 07:00 (7:00 AM) were given at 14:55 (2:55 PM), 15:05 (3:05 PM), and 15:35 (3:35 PM) respectively.- On 4/9/2025: Meds scheduled for 07:00 (7:00 AM) were given at 12:46 PM.On 8/11/2025 at 10:16 AM a review of the facility's policy and procedure for Administration of Drugs revealed the following It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Under procedure: 7). Medications must be administered within one (1) hour before or after their prescribed time. (Note: before meals = one hour before meals, after meals=two hours after the end of meals). and 9). Unless otherwise specified by the resident's attending physician, routine medications should be administered as scheduled.On 8/11/2025 at 9:19 AM an interview was conducted with the Unit Manager (UM #12) for Prospect Unit, in the presence of the Director of Nursing (DON): Regarding medication administration times, UM #12 stated that meds that have a specific time scheduled to be given were expected to be given either an hour before or an hour after the scheduled time. For example, a med scheduled for 7:00 AM could be given as early as 6:00 AM and/or as late as 8:00 AM.Surveyor reviewed Resident 69's medication administration times for 4/3/2025 through 4/9/2025 with UM #12 and the DON. They both verified and confirmed that there was a delay in Resident #69's med administration on the aforementioned dates. DON stated that they were working with the nursing staff to address issues regarding delays in medication administration to residents.

Based on Observation, record reviews and staff interviews, it was determined that the facility failed to label and date humidifier bottles and oxygen tubing with change dates per physician's orders. This was evident for 2 (#33 and #47) of 4 residents reviewed for Respiratory care during the recertification/complaint survey.The findings include:During the initial rounds on 8/4/25 at 10:16 AM and on 8/5/25 at 8: 56 AM, Resident #33 was observed to be on supplemental oxygen (O2) delivered through a nasal cannula (a device that delivers O2 through the nose) and attached to a humidifier bottle on the O2 concentrator at the bedside in the resident's room. The humidifier bottle and the O2 tubing were not dated to indicate when they were last changed. A review of the physician's order on 8/5/25 at 9:10AM revealed an order that reads Check SPO2 Q shift - Administer OXYGEN TO MAINTAIN SPO2 >92% DOCUMENT LITERS PER MINUTE (LPM) VIA NASAL CANNULA APPLICABLE FOR HYPOXIA . A second order reads: OXYGEN EQUIPMENT: 11-7 Shift Weekly O2/NEB Equipment CHANGE O2 TUBING NASAL CANNULA AND HUMIDIFER BOTTLE WEEKLY IF IN USE - LABEL TUBING WITH DATE CHANGED. The order was dated 12/12/24 every night shift every Sun EVERY 7 DAY.On 8/5/25 at 8:30 AM the surveyor went to resident #47's room and observed another O2 concentrator with humidifier bottle attached, at the bedside. An oxygen tubing was connected to the humidifier and was lying on the floor. Both the oxygen (O2) tubing and the humidifier bottle were not dated to indicate when it was last changed. A review of the physician's order for Resident #47 revealed an order dated 6/16/25. The order read, Oxygen 2 LPM via nasal cannula PRN to keep pulse ox above 92% .On 8/5/25 at 9:38 AM, Staff #6, a Licensed Practical Nurse (LPN) was shown the two rooms with the O2 tubing and humidifier bottles not labelled. She acknowledged that they were not and stated that they should have been labelled even if the orders were as needed. She explained that night shift was responsible for labelling the O2 tubing. On 8/5/25 at 9:53 AM The Director of Nursing (DON) was made aware of the concern. She stated that it was unacceptable and will check it out.

Based on record review and interviews, it was determined that the facility failed to assess the effectiveness of pain medication consistent with professional standards of practice. This was evident for 1 (Resident #2) of 5 resident records reviewed for unnecessary medications during the recertification/complaint survey.The findings included:On 08/08/2025 at 12:52 PM, a review of Resident #2's record revealed that the resident had an order for traMADol HCl Tablet 50 MG Give 0.5 tablet by mouth every 6 hours as needed for PAIN. A review of the resident's Medication Administration Record (MAR) revealed that on 6/23/2025 at 05:59 AM the resident received tramadol for a pain level of 7 out of 10 (severe pain); however, it was documented that the medication was not effective. A review of the Treatment Administration Record (TAR) and MAR for medication reassessment and interventions showed that there was no documented evidence that additional interventions were implemented.On 08/11/2025 at 1:15 PM, in an interview RN #10, she was asked about the expectation for the medication administration of as needed (PRN) medication. She explained that PRN pain medications was administered based on a pain scale. A resident reporting a pain score of 4 would be offered a Tylenol first, if available based on the physician order. If the pain score was higher she would offer the narcotics based on the physician order. Reassessment would be done within the hour after administering medication. She was asked if there were any non- pharmalogical interventions that were used to aid with pain. She stated that sometimes an ice pack may be offered as an alternate intervention. When asked if she documented this anywhere in the resident records, she stated that not really unless there was a physician's order for ice pack, in that case it would be found on the TAR. Otherwise, the intervention would be discussed during shift report with the other nurse.08/11/2025 2:40 PM, in an interview with RN #10 and the Director Of Nursing (DON), the surveyor notified them that there was no documentation to support that the above-mentioned pain medication ineffectiveness was addressed. A review of the progress notes revealed that the pain medication was given on 6/23/2025 at 05:59 AM, but additional interventions were not offered to Resident #2's until approximately 10am on 6/23/2025.The professional standard of practice for pain medication reassessment for effectiveness is 1-hour after medication administration.The DON acknowledged that based on the available documentation the pain medication reassessment was completed late.

Based on observation and interview it was determined facility staff failed to remove expired supplies from a medication cart. This was evident for 1 of 3 medication carts reviewed for medication storage and labeling during a recertification survey.The findings include:An IV start kit typically includes essential supplies for inserting an intravenous (IV) line. They usually contain a tourniquet (used to make veins more visible and accessible for needle insertion), antiseptic wipes (used to disinfect the insertion site, minimizing the risk of infection), IV catheter (the device that is inserted into the vein to provide access for fluids or medications), a transparent dressing, gauze, tape, and sterile gloves. They may also include other items like saline syringes, IV tubing, and needles. The specific contents can vary by manufacturer and kit type.Expiration dates are primarily related to maintaining the sterility of the kit's components. Using expired items can pose infection risks.On [DATE] at 8:50 AM, Medication cart #1 on the Prospect Unit was reviewed for Medication Storage and Labeling in the presence of Registered Nurse (RN #7). Surveyor found an IV Start kit with expiration date of [DATE] in the bottom drawer of the med cart.RN #7 confirmed the IV start kit was expired and stated it should not have been in the med cart. He immediately removed the expired IV start kit and stated he was going to discard it. On [DATE] at 1:21 PM, In an interview with the Director of Nursing (DON), surveyor shared concerns regarding findings of expired IV start kit during Medication Storage and Labeling review. DON stated she was aware of the surveyor's finding and added that the expired IV start kit was immediately removed from the med cart. She further stated that the Nurses and Unit Managers were responsible for checking the med carts for expired items.On [DATE] at 1:22 PM a review of the facility's policy and Procedure for Storage of medications revealed the following: It is the policy of this facility that drugs and biologicals shall be stored in a safe, secure, and orderly manner. Under Procedure: .3) No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this facility. All such drugs are destroyed

Based on review of facility documentation and interview, it was determined the facility staff failed to have a social service director and a medical director participate monthly in the facility's Quality Assessment Performance Improvement (QAPI) committee meetings.The findings include:Review of the monthly QAPI sign-in sheet for August 2024, the medical director signature block indicated Leave of Absence (LOA) and March 2025 and June 2025, the social service director signature block indicated Leave of Absence (LOA).During an interview on 08/13/2025 at 11:41 AM with the Director of Nursing (DON), and staff # 4, the DON stated that there is no designated person for the Medical director, and the facility had one social services worker, who is the director. Staff #4 stated that he/she would discuss the information from the QAPI meeting during the risk management meeting with the members who were absent from the QAPI committee meeting.On 08/13/2025 at 11:48 AM staff #4 stated that he/she acted as the designee for the Social Services Director and the facility had a covering medical director. When asked if staff #4 has training in social services, he/she stated no. and the sign in roster did not have a signature for the covering medical director.On 8/13/2025 at 12:03 PM the DON and Staff #4 were made aware of the concern for not having a qualified designee for the medical director and social services director in attendance for the months of their absence from the QAPI committee meetings.