Every finding on record at Lorien NSG & Rehab CTR Belair

Based on observation and interview it was determined the facility failed to ensure food temperatures were taken and recorded prior to the serving of food, ensure foods were not left open to air within the walk in refrigerator and freezer, ensure the labeling of foods and follow professional standards for food service safety. This was evident during the surveyor's initial tour of the facility's kitchen and has the potential to impact all residents who eat food from the kitchen. The findings include: 1. On 01/05/2026 at 7:45 AM the surveyor conducted an initial tour of the facility's kitchen. On 01/05/2026 at 7:49 AM the surveyor observed Dietary Aide (DA) #10 assisting with the plating of food on the serving line taking a drink from a personal beverage container which they placed back onto the shelf on the food serving line equipment. Dietary Aide #10 was observed continuing to assist with the plating of food and the surveyor shared the concern with them. After the sharing of the concern by the surveyor, no action was observed to be taken in response to the personal beverage on the food serving line equipment. A bottle of drinking water was additionally observed by the surveyor sitting on the shelf of the food serving line. On 01/05/2026 at 7:49 AM the surveyor conducted an interview of DA #10 and inquired as to if they had received training in regards to personal items on the food serving line at which time DA #10 stated: Okay. On 01/05/2026 at 7:50 AM the surveyor conducted an interview of Dietary [NAME] (DC) #11 who confirmed that they were the person in charge of the kitchen at the time as the facility's Certified Dietary Manager was not there and the surveyor shared the concern with them at which time they stated regarding DA #10: S/he's new, I'll remove it now. When the surveyor inquired to DC #11 if the facility provides training to all kitchen staff regarding personal items on the serving line, they stated: Yes. DC #11 was then observed removing the personal beverage cup from the food serving line. 2. On 01/05/2026 at 7:56 AM the surveyor observed the facility's walk in refrigerator at which time various foods were observed on a mobile metal food cart open to air with no covering present: beans, two trays of a red gelatin type food, riblet portions, and chicken patties. On 01/05/2026 at 7:58 AM the surveyor requested and performed a dual observation of concerns and conducted an interview with DC #11 who observed and acknowledged the concerns and stated: I knew s/he was getting behind so I threw it in there real quick, I know, I need to put my cover on it, I put it in there real quick. After surveyor intervention on 01/05/2026 at 7:59 AM, the surveyor observed DC #11 obtain a cover and cover the cart of food. 3. On 01/05/2026 at 8:05 AM the surveyor observed the facility's walk in freezer at which time the following foods were observed left open to air and unlabeled: pepperoni, cornbread, two open bags of a circular round breaded type food, and an angel food type cake with a slice missing from it with no labeling or date present. Additionally a container of ice cream was observed with ice cream present on the top of the outside of the container's lid. 4. On 01/05/2026 at 8:07 AM the surveyor conducted an interview and inquired to DC #11 as to where the hot food temperatures were recorded/located. DC #11 was observed removing the temperature binder from a rack and showed the surveyor previous dates of temperature logs, and informed this surveyor that the temperatures were not done this morning and there was no sheet completed for today in the book. DC #11 reported: We are responsible for the temperatures, but the dietary aide is a newer employee, but we are both responsible for taking temperatures and recording on the log. After surveyor intervention at this time, food temperatures were taken by DC #11. This surveyor shared the concern with DC #11 that temperatures of food had not been taken prior to food being served to Residents, and DC #11 acknowledged and confirmed understanding of the concern. On 01/05/2026 at 12:16 PM the survey team was approached unsolicited by Dietary Manager (DM) #12 who provided various kitchen logs including temperature logs to the surveyor which had not been requested. At this time the surveyor inquired to DM #12 as to why the documentation was being provided at which time DM #12 stated to the surveyor: Food temperatures were taken, but not recorded, so here they are. At this time, the surveyor shared the concern with them and informed them that after surveyor intervention, food temperatures were then taken. On 01/05/2026 at 12:30 PM all concerns were shared with the facility's Administrator and Director Of Nursing who acknowledged the concerns. On 01/07/2026 at 8:55 AM the surveyor conducted an interview of Certified Dietary Manager (CDM) #6 and shared the concerns at which time they responded: Okay, thanks for letting me know. On 01/09/2026 at 9:05 AM the surveyor rounded the kitchen and conducted an interview with CDM #6 who reported that upon hearing the surveyor's concerns from their staff, they had observed and removed the opened and unlabeled items from the cold food storage. CDM #6 acknowledged and confirmed understanding of the surveyor's concerns.

Based on record review and interviews with staff, it was determined that the facility failed to ensure a system was in place to notify the local Ombudsman of the facility's initiated transfers to the hospital. This was evident for 1 (Resident #113) out of 3 closed records reviewed during the annual survey. The findings include:Transfer and discharge: Includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same facility. Specifically, transfer refers to the movement of a resident from a bed in one facility to a bed in another facility when the resident expects to return to the original facility. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another facility or other location in the community, when return to the original facility is not expected.On [DATE] at 11:41AM, during a review of Resident #113's electronic medical record, the Surveyor discovered that the resident was admitted to the hospital on [DATE].On [DATE] at 1:00PM a review of the Discharge List for the facility recorded between [DATE]-[DATE] that Resident #113 was not included on the list for his/her transfer to the hospital on [DATE]. Further review of the discharge lists from October and [DATE], failed to reveal any resident transfers to the hospital and included residents who had been discharged home, to another facility, to a funeral home, or who had expired.On [DATE] at 2:07PM, the Surveyor conducted an interview with the Nursing Home Administrator (NHA) in the presence of the Director of Nursing (DON). The Surveyor was informed that Corporate Office Staff #14 was responsible for sending the residents transfer/discharge notification to the local Ombudsman weekly via email. The Surveyor expressed the concern that Resident #113's transfer to the hospital on [DATE] was not included in the Discharge Lists for the facility for the month of [DATE] and that lists only contained residents who had been discharged home, to another facility, to a funeral home, or who have expired. The NHA acknowledged the Surveyor's findings and stated that the facility had not been sending resident transfer to the hospital notification to the local Ombudsman; however, would like to confirm with Corporate Office Staff #14.On [DATE] at 8:37AM, the NHA provided the Surveyor with a list of the transfers to the hospital for the month of [DATE]. Resident #113 was on the list for transfer on [DATE]. The Surveyor compared the list of residents who were transferred to the hospital in [DATE] to the discharge lists sent to the local Ombudsman for [DATE]. The discharge list failed to include the residents who were transferred to the hospital. The NHA confirmed that Corporate Office Staff #14 does not send resident transfer notification to local Ombudsman; however, sends resident discharges out of the facility. The NHA stated that Corporate Office Staff #14 will begin to send resident transfer notifications, along with the resident discharge notifications to the local Ombudsman weekly via email.

Based on observations, medical record reviews, and interviews with facility staff, it was determined that the facility failed to follow professional standards of practice by not administering physician-ordered medications at their scheduled times, and failed to ensure the timely administration of medications. This was found to be evident for 2 (Resident # 103 and Resident # 107) of 6 residents observed during medication administration observation, and for 1 (Resident #11) out of 2 Residents reviewed for pain during the survey. Findings include: 1.) Type 2 Diabetes Mellitus is a chronic condition where the body either does not produce enough insulin or doesn't use insulin effectively causing blood sugar levels to rise. A medication administration observation was conducted on 1/8/26 at 10:05 AM for Resident #103. Staff # 9, a registered nurse (RN) reviewed the computer screen as he poured medications for Resident # 103. The computer revealed a highlighted pink screen displaying the resident medication information for Aspirin Enteric Coated (EC) 81 mg tablet scheduled time of 8:00AM and medication information for Metformin 1000mg tablet displaying a scheduled time of 7:30AM. Staff # 9 administered Resident # 103's medications at 10:05 AM. Review of the physician orders for Resident #103 on 1/8/26 revealed the following: Metformin 1000mg give 1 tablet by mouth two times a day for Type 2 Diabetes before breakfast/dinner. Scheduled for 7:30AM. Metformin is an oral diabetic medication that is used to help control high blood sugar levels. Aspirin Enteric Coated (EC) 81 mg give 1 tablet by mouth 1 time a day for Cerebrovascular Accident (CVA). Scheduled for 8:00AM. Aspirin is used for preventative therapy against cardiovascular events such as heart attacks and strokes. Staff # 9 administered Resident # 103's medications outside of the scheduled physician ordered times. 2.) A medication administration observation was conducted on 1/8/26 at 10:05 AM for Resident #107. Staff # 9 reviewed the computer screen as he poured medications for Resident #107. The computer revealed a highlighted pink screen displaying the resident medication information for Baclofen 10 mg tablet scheduled time of 8:00AM and medication information for Lyrica 75mg capsule displaying a scheduled time of 8:00AM. Another nurse, Staff #8 entered Resident #107's room at this time as Staff # 9 was preparing the medications for Resident #107 and informed Staff # 9 that she would administer the resident the scheduled Lyrica 75mg capsule. At this time Staff # 8 administered Lyrica to Resident # 107 at 10:15AM. Staff # 8 stated to the surveyor and Staff # 9 that she was administering narcotics to the residents on the unit hall. Review of the physician orders for Resident #107's revealed the following: Baclofen 10 mg give 1 tablet by mouth three times a day for muscle spasm. Scheduled for 8:00AM Lyrica 75 mg give 1 capsule by mouth three times a day for moderate to severe pain. Scheduled for 8:00AM. Staff # 8 and Staff # 9 administered Resident # 107's medications outside of the scheduled physician order times. An interview was conducted with Staff # 9 at 10:30AM and he was asked why he administered the medications that were highlighted pink on the computer screen outside of the scheduled time range. He stated that the medications were administered late because he had to administer more than 10 other residents their medications prior and that he also had to obtain vital signs on the residents as well. Staff # 8 who was present in the hallway was interviewed at this time and she stated that she was there to assist. An interview was conducted with the DON on 1/8/26 at 2:20PM and she was made aware of the concerns identified during the medication administration observation and was asked what the expectation is for administering scheduled medications. The DON stated that during medication administration, if a pink screen displays or highlights on the computer screen, this is to alert the staff that the medication is late. She went on to say that when the pink screen is displayed, the staff are not to give the medication and are to notify the physician. The DON further stated that nurses are to notify the physician when medications are late and obtain a new order to administer the medication. She stated that education will be provided for the staff. All concerns were discussed with the Administration team at the exit conference on 1/9/26. 3.) On 01/06/2026 at 9:46 AM the surveyor conducted an observation of Resident #11 who was heard from the hallway stating: Help, I'm in pain. On 01/06/2026 at 9:48 AM the surveyor shared the concern with Licensed Practical Nurse #18 who stated: Okay. On 01/06/2026 at 9:51 AM the surveyor conducted an interview of Front Desk Staff #19 who confirmed Resident #11 was appropriately able to express needs. On 01/09/2026 at 9:29 AM the surveyor conducted an interview of Resident #11 who described experiencing delay relating to medication administration. On 01/09/2026 at 11:13 AM the surveyor requested the facility's Director of Nursing and Administrator to provide documentation which included medication administration audit reports for Resident #11. On 01/09/2026 at 12:00 PM the surveyor reviewed the facility provided medication administration audit reports for Resident #11 which revealed the following medications were not administered timely: 1. Gabapentin capsule 100mg Give 1 capsule by mouth three times daily scheduled for 1/7/26 at 8:00AM was documented by Certified Medication Assistant (CMA) #5 as administered on 1/7/26 at 10:59AM. 2. Losartan Potassium Tablet 50 MG Give 1 tablet by mouth in the morning scheduled for 1/8/26 at 7:00AM was documented by Registered Nurse #9 as administered on 1/8/26 at 8:37AM 3. Amlodipine Besylate Tablet 5MG Give 1 tablet by mouth in the morning scheduled for 1/8/26 at 7:00AM was documented by Registered Nurse #9 as administered on 1/8/26 at 8:38AM 4. Aspirin Tablet 325 MG Give 1 tablet by mouth in the morning scheduled for 1/8/26 at 7:00AM was documented by Registered Nurse #9 as administered on 1/8/26 at 8:38AM 5. Buproprion HCI Extended Release Tablet 12 hour 150MG Give 1 tablet by mouth every morning and at bedtime scheduled for 1/5/26 at 7:00AM was documented by CMA #5 as administered on 1/5/26 at 8:42AM 6. Aspirin Tablet 325 MG Give 1 tablet by mouth in the morning scheduled for 1/5/26 at 7:00AM was documented by CMA #5 as administered on 1/5/26 at 8:42AM 7. Amlodipine Besylate Tablet 5MG Give 1 tablet by mouth in the morning scheduled for 1/5/26 at 7:00AM was documented by CMA #5 as administered on 1/5/26 at 8:42AM 8. Losartan Potassium Tablet 50 MG Give 1 tablet by mouth in the morning scheduled for 1/5/26 at 7:00AM was documented by CMA #5 as administered on 1/5/26 at 8:42AM 9. Losartan Potassium Tablet 50 MG Give 1 tablet by mouth in the morning scheduled for 1/6/26 at 7:00AM was documented by CMA #5 as administered on 1/6/26 at 8:45AM 10. Amlodipine Besylate Tablet 5MG Give 1 tablet by mouth in the morning scheduled for 1/6/26 at 7:00AM was documented by CMA #5 as administered on 1/6/26 at 8:45AM 11. Buproprion HCI Extended Release Tablet 12 hour 150MG Give 1 tablet by mouth every morning and at bedtime scheduled for 1/6/26 at 7:00AM was documented by CMA #5 as administered on 1/6/26 at 8:45AM 12. Aspirin Tablet 325 MG Give 1 tablet by mouth in the morning scheduled for 1/6/26 at 7:00AM was documented by CMA #5 as administered on 1/6/26 at 8:45AM 13. Gabapentin Capsule 100 MG Give 1 capsule by mouth three times a day scheduled for 8:00PM was documented as not having been administered until 9:27PM on 12/6/25. On 01/09/2026 at 12:25 PM the surveyor conducted an interview of CMA #5 who confirmed with the survey team that medication administration is documented at the time of the medication being administered. On 01/09/2026 at 12:46 PM the surveyor conducted an interview of Unit Manager, Licensed Practical Nurse (UM, LPN) #15 who reported to the survey team that some medications were liberalized with the administration time, however, they confirmed that medications including Gabapentin or medications given every 8 or 12 hours was not liberalized with the medication administration time. UM, LPN #15 further informed surveyors during the interview that if a resident refuses a medication the expectation is for them to document the refusal and if the resident refuses more than three times, they let the physician know, but if they refuse one time, they do not usually let the physician know. On 01/09/2026 at 12:51 PM the surveyor conducted an interview with the facility's Director Of Nursing (DON) and inquired as to if Gabapentin medication was liberalized with the medication administration time. The DON stated to the survey team, No it cant be liberalized. The DON reported to the survey team that the late administration of Gabapentin was wrong and the expectation was for staff to document the refusal in the medical record and notify the physician. When the surveyor requested for the DON to provide the facility's policy for liberalized medication administration, they stated to the survey team that there was no policy for liberalized medication administration.

Based on observation, medical record review and interviews with facility staff it was determined the facility failed to prevent a medication error rate from exceeding above five percent, by administering medications outside of the scheduled time range resulting in a medication error rate of 14.81 percent. This was found to be evident for 2 (Resident # 103 and Resident # 107) of 6 residents observed during medication administration observation during the survey.Findings include,Type 2 Diabetes Mellitus is a chronic condition where the body either does not produce enough insulin or doesn't use insulin effectively causing blood sugar levels to rise. 1. A medication administration observation was conducted on 1/8/26 at 10:05 AM for Resident #103. Staff # 9, a registered nurse (RN) reviewed the computer screen as he poured medications for Resident # 03. The computer revealed a highlighted pink screen displaying the resident medication information for Aspirin Enteric Coated (EC) 81 mg tablet scheduled time of 8:00AM and medication information for Metformin 1000mg tablet displaying a scheduled time of 7:30AM. Staff # 9 administered Resident #103's medications at 10:05 AM. Review of the physician orders for Resident # 103 on 1/8/26 revealed the following:Metformin 1000mg give 1 tablet by mouth two times a day for Type 2 Diabetes before breakfast /dinner. Scheduled for 7:30AM. Metformin is an oral diabetic medication that is used to help control high blood sugar levels. Aspirin Enteric Coated (EC) 81 mg give 1 tablet by mouth 1 time a day for Cerebrovascular Accident (CVA). Scheduled for 8:00AM. Aspirin is used for preventative therapy against cardiovascular events such as heart attacks and strokes.Staff # 9 administered Resident # 103 medications outside of the scheduled physician ordered times. 2. A medication administration observation was conducted on 1/8/26 at 10:05 AM for Resident #107. Staff # 9 reviewed the computer screen as he poured medications for resident # 107. The computer revealed a highlighted pink screen displaying the resident medication information for Baclofen 10 mg tablet scheduled time of 8:00AM and medication information for Lyrica 75mg capsule displaying a scheduled time of 8:00AM. Another nurse, staff # 8 entered Resident #107's room at this time as staff # 9 was preparing the medications for Resident #107 and informed staff # 9 that she would administer the resident the scheduled Lyrica 75mg capsule. At this time staff # 8 administered Lyrica to Resident #107 at 10:15AM. Staff # 8 stated to the surveyor and staff # 9 that she was administering narcotics to the residents on the unit hall. Review of the physician orders for Resident #107 revealed the following:Baclofen 10 mg give 1 tablet by mouth three times a day for muscle spasm. Scheduled for 8:00AMLyrica 75 mg give 1 capsule by mouth three times a day for moderate to severe pain. Scheduled for 8:00AM.Staff # 8 and Staff # 9 administered Resident # 107's medications outside of the scheduled physician order times.An interview was conducted with staff # 9 at 10:30AM and he was asked why he administered the medications that were highlighted pink on the computer screen outside of the scheduled time range. He stated that the medications were administered late because he had to administer more than 10 other residents their medications prior and that he also had to obtain vital signs on the residents as well. Staff # 8 who was present in the hallway were interviewed at this time and she stated that she was there to assist.An interview was conducted with the DON on 1/8/26 at 2:20PM and she was made aware of the concerns identified during the medication administration observation and was asked what the expectation is for administering scheduled medications. The DON stated that during medication administration, if a pink screen displays or highlights on the computer screen, this is to alert the staff that the medication is late. She went on to say that when the pink screen is displayed, the staff are not to give the medication and are to notify the physician. The DON further stated that nurses are to notify the physician when medications are late and obtain a new order to administer the medication. She stated that education would be provided for the staff. All concerns were discussed with the Administration team at the exit conference on 1/9/26.

Based on interviews with the resident family, review of the medical record and interviews with facility staff it was determined that the facility failed to ensure that dental services were provided for a resident. This was found to be evident for 1 (Resident # 50) of 41 residents reviewed during the survey.The findings include: An interview was conducted with Resident # 50's family member on 1/5/26 at 2:22PM and the family member expressed a concern regarding the resident not being seen by the in-house dental services. The family stated that s/he had made this request at multiple care plan conferences and did not understand why it had not happened. When asked by the surveyor, the last time the resident was seen by the in-house Dentist, the family was unable to answer this. The family went on to say that the resident had bad breath as a result. The family further stated that they brought in mouth wash for the staff to use to rinse the resident mouth and that there was an approximate quarter amount remaining in the bottle. The surveyor observed a quarter of the amount of mouth wash remaining in the bottle during a follow-up observation on 1/8/26.Review of the resident medical record on 1/56/26 at 2:00PM revealed the following notes:Social Work (SW) Care Plan meeting held Thursday 2/27/25 at 11:30AM. SW to email Nursing on this. SW to also look into a dental appointment.SW Care Plan meeting held Monday 11/24/25 at 10:30AM. Oral care needs to be followed up. Spouse mentioned some concerns. SW to forward to Nursing.Resident needs a Dental appointment. Health Drive?An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 1/8/26 at 9:20AM and they were asked to provide documentation of the facility's dental policy. The DON stated that the facility does not have a policy. She went on to say that the outside dental service company that the facility uses comes into the building to provide dental care to the residents. The DON stated that the resident and/or the resident family must submit a request for services and then the services will be provided. At this time the surveyor explained the care conference review findings and that a request was made by the family on 2/27/25 and again on 11/24/25 and if an appointment was made for the resident to be seen. She stated that she would have the Director of Social Work (DSW) speak to the survey team. An interview was conducted with the DSW on 1/8/26 at 9:40AM and she was asked to explain the facility's expectation and process for scheduling the residents for dental appointments when the request is made by family during care conference meetings. The DSW stated that consultations are usually handled by nursing, however, it was a team approach. During another meeting with the NHA and the DON on the same date at 1:00PM the DON explained to the survey team that nursing and social work are responsible for following up on recommendations and/or requests made and that the team dropped the ball, therefore the resident was not seen. The DON confirmed that there were multiple opportunities to get the resident seen and the facility failed to do so. All concerns were discussed with the Administration team at the exit conference on 1/9/26.

Based on record review and interviews with staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices. This was evident for 3 (Resident #114, Resident #42, and Resident #84) out of 41 residents reviewed during the annual survey. The findings include: 1. Hospice care means a comprehensive set of services identified and coordinated by an interdisciplinary group (IDG) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care. This approach focuses on end-of-life comfort, dignity, and quality of life. On [DATE] at 11:00 AM, a review of Resident #114's electronic medical record revealed a discharge summary physician's note written on [DATE], which stated [he/she] was enrolled in hospice, rapidly declined, and expired on [DATE] at [1:56 PM]. The note also stated, After discussion with family, [he/she] transitioned to hospice care. Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice. This approach focuses on providing relief from the symptoms and stress of illness. Further review of Resident #114's electronic medical record failed to reveal a physician's order for hospice care, a plan of care, orders from the hospice agency, documentation of visitation and care provided by hospice staff, and a Minimum Data Set (MDS) assessment for significant change for the enrollment into hospice care. An additional review revealed orders for Hospice consult with [hospice company] provider and follow-up care as recommended-Unit Manager will speak with family first dated [DATE], Resident comfort care measures/palliative dated [DATE], No weight, no vital signs, comfort care measures dated [DATE], and No CPR, option B, Palliative and Supportive revision dated [DATE]. On [DATE] at 12:35 PM, during an interview conducted with Unit Manager #15, the Surveyor was informed that they believed Resident #114 was not in hospice care prior to his/her death and was provided comfort/palliative care as the family requested. UM #15 stated that they would review the resident's medical record to confirm. On [DATE] at 1:00 PM, during an interview with the Director of Nursing (DON) in the presence of the Nursing Home Administrator (NHA), the Surveyor expressed the concern that there was documentation in a physician's discharge summary for Resident #114 which stated the resident was enrolled in hospice care prior to his/her death on [DATE]; however, a review of Resident #114's electronic medical record failed to reveal a physician's order for hospice care, a plan of care and orders from the hospice agency, documentation of visitation and care provided by hospice staff, and an Minimum Data Set (MDS) assessment for significant change for the enrollment into hospice care. The DON stated they would look into the Surveyor's concern. On [DATE] at 2:15 PM, during an interview conducted with the DON in the presence of the NHA, the Surveyor was informed that the resident was not enrolled in hospice care as stated in the physician's discharge summary note dated [DATE]. The resident was receiving palliative care at the time of his/her death. The DON provided the Surveyor with a Patient Orders document sent to the Nurse Practitioner (NP) on [DATE] at 8:05 AM, which stated that the Family remains wanting resident to be comfort care/palliative in this building with [doctor] and [nurse practitioner] assistance. Family does not request hospice care at this time, only comfort care/palliative care. The NP acknowledged the orders on [DATE] at 8:47 AM, the orders were marked as processed on [DATE] at 8:48 AM, and signed by UM #15. After reviewing the document in the presence of the DON and the NHA, the Surveyor expressed concern for and confirmed inaccurate documentation in Resident #114's medical record. 2. Antibiotics are antimicrobial substances that fight bacterial infections by either killing or inhibiting bacterial growth. Antibiotics do not work against viruses. On [DATE] at 1:00 PM, a review of Resident #42's electronic medical record revealed a physician's order for Rocephin Solution reconstituted 1GM. Use 1 gram Intravenously in the morning for viral infection for 5 days x 5 days to start on [DATE] at 7:00 AM, created by UM #15. On [DATE] at 2:35 PM, during an interview with the DON in the presence of the NHA, the Surveyor expressed the concern that Rocephin was ordered for Resident #42, and the indication for use was for viral infection. The Surveyor and the DON acknowledged that Rocephin is an antibiotic and does not treat viral infections. The DON stated that they would clarify the order with UM #15 and the NP. On [DATE] at 4:00 PM, during an interview with the DON in the presence of the NHA, the Surveyor was informed that the NP confirmed the order for Rocephin was necessary for the resident and stated that Resident #42 presented with respiratory distress upon their examination, and pneumonia was suspected. Rocephin is an antibiotic frequently used to treat pneumonia. A review of the NP's note dated [DATE] revealed that Respiratory distress was noted on today's assessment. Will treat empirically for concern for pneumonia pending [chest x-ray] results. The indication of use transcribed within the order was inaccurate. 3. On [DATE] at 1:00 PM, a review of Resident #42's electronic medical record revealed a physician's order for Rocephin Solution reconstituted 1GM. Use 1 gram Intravenously in the morning for viral infection for 5 days x 5 days to start on [DATE] at 7:00 AM, created by UM #15. Further review revealed a nursing narrative note written by Registered Nurse (RN) #20 on [DATE] at 10:36 AM, which stated, First dose of IV Rocephin 1GM in 250ml of 0.9% set up to run for 30 mins. IV Rocephin set up at 10:28 AM. On [DATE] at 2:35 PM, during an interview with the DON in the presence of the NHA, the Surveyor expressed the concern that Rocephin Solution reconstituted 1GM IV was ordered for Resident #42 to start on [DATE] at 7:00 AM, and according to a nursing narrative note written by RN #20, the medication was given this morning at 10:28 AM. Further review of the resident's electronic medical record failed to reveal an order for the Rocephin to start today. The DON stated they would look into the Surveyor's concern. On [DATE] at 2:45 PM, during an interview conducted with Infection Control Registered Nurse (ICRN) #16, the Surveyor was informed that Resident #42 was experiencing respiratory distress that had worsened since [DATE]. The NP stated that they wanted to treat the resident with Rocephin. The resident was given the medication this morning. The Surveyor and ICRN #16 reviewed the order and confirmed that the order start date was [DATE]. ICRN stated that the NP wanted the medication given today because of the resident's condition. On [DATE] at 3:00 PM, during an interview conducted with RN #20 in the presence of ICRN #16, the Surveyor was informed that they received a verbal order from the NP to give the Rocephin STAT (immediately) and that UM #15 transcribed the verbal order onto a Physician's Order Form. The Surveyor reviewed the Physician's Order Form, and an order received [DATE] at 8:50 AM, which stated Rocephin IV GM daily x5 days. STAT. Transcribed by UM #15 and signed by the NP. The Surveyor, RN #20, and ICRN #16 confirmed that the Rocephin was to be given [DATE] STAT. On [DATE] at 3:55 PM, during an interview with the UM #15 and the DON in the presence of the NHA, the Surveyor expressed the concern of accurate transcription of verbal orders from the physicians that are then entered into the resident's electronic medical record. According to Resident #42's physician orders in the electronic medical record, Rocephin was due to start [DATE] at 7:00 AM; however, a review of the hand documented Physicians Order Form revealed a verbal order dated [DATE] at 8:50 AM for the medication to be given STAT. RN #20 gave the medication at 10:28 AM based on the verbal order. UM #15 stated that RN #20 informed them that they transcribed the order incorrectly. The medication was to be taken today. UM #15 stated that since the medication had already been given, they adjusted the duration of the medication from x 5 days to x 4 days for the [DATE] order. 4. On [DATE] at 12:52 PM, the surveyor reviewed the medical record of Resident #84, which revealed inconsistency was present in the Resident's skin assessment documentation. On [DATE] at 2:19 PM the surveyor conducted an interview of the facility's Director of Nursing and inquired to them and shared the concern as to why Physician #13's medical progress note for Resident #84 dated [DATE] documented the following information: Skin- Diabetic wound of the left second toe, wound on right heel, when their skin assessment by Wound Care Certified Registered Nurse Practitioner #17 on [DATE] indicated that the Resident was to be discharged from wound care with healed wounds with recommended interventions to prevent new wounds from developing. After the surveyor's intervention, the Director of Nursing reported to the survey team on [DATE] at 3:25 PM that Physician #13 amended his/her note because the resident did not have the heel or toe issue at that time, and provided the surveyor with one amended note, which was observed. At this time, the surveyor shared their concern and requested copies of all physician progress notes requiring amendment, and the Director of Nursing acknowledged and confirmed understanding of the concern. After the surveyor's intervention, further review of Resident #84's medical record by the surveyor on [DATE] at 3:45 PM revealed that Physician #13 amended progress notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] to correct inaccurate wound documentation. Review of the medical record further revealed the following documentation present in Physician #13's addendum to their [DATE] medical progress note for Resident #84 dated as created on [DATE] at 3:04 PM: Review of wound care and patient examination revealed that diabetic foot wound had resolved, Right heel wound has also resolved, and This was incorrectly entered into note.

Based on observation and interview it was determined the facility failed to ensure appropriate infection control measures was maintained for a resident's foley catheter bag. This was evident for 1 (#84) out of 1 Resident reviewed for urinary catheters during the facility's recertification survey. The findings include: During the surveyor's initial tour of the facility on 01/05/2026 at 8:52 AM the surveyor observed Resident #84's foley catheter bag laying directly on the floor's surface. On 01/05/2026 at 8:53 AM the surveyor conducted a dual observation and shared the concern with Unit Manager, Licensed Practical Nurse (UM, LPN) #15 who observed, acknowledged, and confirmed understanding of the concern. After surveyor intervention, UM, LPN #15 was observed by the surveyor picking Resident #84's foley catheter bag off of the floor's surface and hanging it up off of the floor. Review by the surveyor of the facility's provided urinary catheter care policy on 01/07/2026 at approximately 11:33 AM revealed the following information was present: The drainage bag and tubing should never be allowed to touch the floor. On 01/07/2026 at 2:04 PM the surveyor conducted an interview and shared concerns with the facility's Director of Nursing who acknowledged and confirmed understanding of the concerns and confirmed with the surveyor that the foley catheter bag should be stored off of the floor to prevent infection.

Based on review of a facility reported incident, medical record review, and interview, it was determined that the facility failed to provide needed activities of daily living (ADL) for a resident totally dependent for care (Resident #10). This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include:Review of facility reported incident 336885 on 11/14/25 for Resident #10 revealed the facility substantiated Staff #13 failed to provide care for the Resident on 5/23/25 from 3-11 PM.Review of Resident #10's medical record revealed the Resident was admitted to the facility in 2017 with a diagnosis to include Multiple Sclerosis.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.Review of the Resident #10's quarterly MDS assessment on 5/2/25 revealed the facility staff assessed the Resident in Section GG Functional Abilities to be dependent on staff for self-care. At that time the Resident was assessed in Section C to have a BIMS (Brief Interview for Mental Status) of 14 of 15, indicating he/she was cognitively intact.Review of facility investigation on 11/14/25 revealed on 5/23/25 at approximately 8:30 PM the Resident's nurse (Staff #14) stated she noted the Resident had a bowel movement and asked the Resident's GNA (geriatric nursing assistant) Staff #13 to change the Resident. In the investigation Staff #13 stated she went into the Resident's room at approximately 11 PM to empty the Resident's urinary catheter for urine and did not realize the Resident needed to be changed. Further review of the facility investigation revealed GNA #15 took over care for Resident #10 on 5/23/25 for 11 PM - 7 AM shift and stated when went into Resident #10's room and it smelled bad. GNA #15 stated Resident #10 stated the previous GNA never came in and changed him/her.Further review of Resident #10's medical record revealed the Resident was discharged from the facility in June 2025.Interview with the Administrator on 11/14/25 at 10:50 AM confirmed the facility staff failed to provide ADL care for Resident #10 on 5/23/25 3 PM- 11 PM shift.

Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #1). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey.The findings include:Review of Resident #1's medical record on 11/13/25 revealed the Resident was admitted to the facility on [DATE]. On admission the Resident was assessed to have no pressure ulcers.Further review of Resident #1's medical record revealed on 9/21/25 the Resident was assessed to have an open area on his/her left buttock, the provider was notified, treatment was started and a wound consult was ordered.On 9/25/25 the Resident was assessed by the Wound Nurse Practitioner to have a Stage III pressure ulcer to the left buttock and a DTI (deep tissue injury) to the right heel. Further review of the Wound Nurse Practitioner (WNP) notes revealed the WNP ordered for the Resident's right heel cleanse with wound cleanser, skin prep twice daily and offloading foam heel boots. The Resident was seen by WNP #2 on 10/2/25 who assessed the Resident's right heel DTI and ordered cleanse with wound cleanser, skin prep twice daily and offloading foam boots. The Resident was seen by WNP #1 on 10/9/25 who assessed the Resident's right heel DTI and ordered cleanse with wound cleanser, skin prep twice daily and offloading foam boots. WNP #1 also advised on obtaining an x-ray of both the left buttock and the sacrum to rule out osseous changes.Further review of Resident #1's medical record revealed the Resident was transferred to the hospital on [DATE]. Review of Resident #1's physician orders and Treatment Administration Records for September and October 2025 revealed the right heel DTI orders of cleanse with wound cleanser and skin prep twice daily were not ordered or administered from 9/25/25 through discharge on [DATE].Further review of Resident #1's medical record revealed the x-ray for the left buttock and sacrum was not completed prior to discharge on [DATE].Interview with the x-ray staff (Staff #12) on 11/17/25 at 11:12 AM, Staff #12 stated the x-ray for Resident #1 was not ordered until 10/12/25 at 7:15 PM.Interview with the Director of Nursing on 11/17/25 at 11:15 AM confirmed the facility staff failed to administer right heel treatments to Resident #1 from 9/25/25 until discharge on [DATE] and failed to obtain an x-ray per the Wound Nurse Practitioner's recommendations.

Based on observation, interview and record review it was determined that the facility staff failed to: 1) ensure cold holding temperatures were consistently taken, ensure cold holding temperatures are maintained within appropriate ranges, ensure ice cream freezers were free from ice build up, and ensure ice cream was covered, and 2) ensure the required sanitation levels of the facility's dishwashing machine at each mealtime were monitored. This was evident during the facility's recertification survey. The findings include: 1) On 5/28/24 at 9:01AM the surveyor conducted an initial tour of the facility's kitchen. On 5/28/24 at 9:05AM the surveyor observed the walk in refrigerator and the temperature documentation which revealed there were no documented temperature readings in the AM or PM for 5/1/24 and 5/2/24, no documented temperature readings for 5/9/24 in the AM, no documented temperature readings for 5/16/24 in the AM, and no documented temperature readings for 5/24/24 in the PM. Additionally, the surveyor observed the following temperatures documented above 41F for the walk-in refrigerator: 5/7/24 AM temperature of 42F 5/8/24 AM temperature of 42F 5/10/24 AM temperature of 43F 5/13/24 AM temperature of 45F 5/14/24 AM and PM temperature of 42F 5/15/24 AM temperature of 45F 5/25/24 AM temperature of 42F 5/28/24 AM temperature of 44F On 5/28/24 at 9:09AM the surveyor conducted an interview and shared their concerns with Staff #4, Food Service Director. At this time, the Food Service Director reported their awareness of missing temperatures and temperatures documented above 41F from a recent local health inspection. On 5/28/24 at 9:16AM the surveyor observed ice build up on top of a large ice cream tub with a damaged lid that was not securely covering the container, and approximately a one inch build up of ice was present around the perimeter of the freezer chest. On 5/28/24 at 9:23AM the surveyor observed a second freezer chest with a top sliding glass door, with several inches of ice build up around the perimeter present. On 5/28/24 at 9:26AM the surveyor observed the temperature log for the arctic air server refrigerator and noted that on 30 occasions during the month of May 2024, the temperature was documented as exceeding 41F. On 6/10/24 at 10:26AM the surveyor reviewed the local health inspecton report dated as performed on 5/23/24 documenting the facility was out of compliance for cold holding temperatures which was corrected on site. The surveyor noted that elevated temperatures and a missing temperature continued to occur after 5/23/24. On 5/29/24 at 2:25PM the surveyor shared additional kitchen concerns with the Administrator and Director of Nursing, who acknowledged understanding of the concerns. On 6/12/24 surveyor concerns were shared again during the exit conference. 15701 2) A follow-up kitchen inspection was conducted on 6/10/24 to observe the functioning of the dish washing machine and review dishwashing monitoring logs. One dietary staff member was operating the dishwashing machine. The water temperature gauges were observed to be above the minimal wash and rinse temperatures as per the dish machines manufactures guidelines. Review of the current Dishwashing/warewashing machine temperature log revealed missing documentation as the dishwasher temperatures were not checked at each mealtime. On 6/3/24 there were only recorded hot water temperatures for breakfast. On 6/4/24 there were only recorded temperatures for dinner. On 6/6/24 there were only temperatures recorded for breakfast. There were not any temperatures recorded on 6/7/24. On 6/8/24 there were only temperatures recorded for breakfast with a rinse temperature recorded at 113 degrees Fahrenheit which was below the minimal requirement of 180 degrees. There were not any temperatures recorded for all three meals on 6/9/24. Review of the previous dishwashing log with dates between 5/10/24 to 5/27/24. Review of the document revealed only one mealtime dishwasher temperatures were documented on 5/11/24 (L), 5/12/24 (L), 5/13/24 (B), 5/16/24 (D), 5/21/24 (D), 5/22/24 (D), 5/26/24 (L), 5/27/24 (L). The following dates did not have any documented dishwashing temperatures, 5/15/24, 5/20/24, and 5/25/24. An introduction to the director of food service (staff#4) occurred at 10:32 AM with review of the current dishwashing log with her acknowledgement of missing temperature documentation for certain dates and mealtimes. She was asked to make a copy of the current and previous temperature log. She took the dishwashing temperature log and questioned the dietary worker (staff#23) and filled in a couple of temperatures before making the requested copies. Upon receipt of the dishwasher logs, the concern that staff were not routinely monitoring the dishwashing water temperatures was addressed with the food service director.

Based on observation, medical record review, and staff interview, it was determined that the facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for 4 (# 70, #46, #54, #90) of 42 residents reviewed during a recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Minimum Data Set (MDS) is a standardized assessment tool that is used to evaluate the health status and functional capabilities of residents, and to help nursing home staff identify health issues. 1) On 6/3/2024 at 11:45 AM, a review of Resident #70's clinical records revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to adjustment disorder with mixed Anxiety and Depressed Mood, Unspecified Dementia, unspecified severity, without Behavioral disturbance, Psychotic Disturbance, Mood disturbance, and Anxiety. During a review of Resident #70's medical record conducted on 6/3/2024 at 12:16 PM, surveyor noted active physician orders for: Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth in the morning for Depression. On 6/3/2024 at 12:34 PM, review of the Medication Administration Record (MAR) for March, April, and May 2024 revealed staff documentation that Resident #70 was getting Sertraline HCl Tablet 25 mg 1 tablet by mouth in the morning for Depression, start date 3/21/2024. On 6/3/2024 at 2:30 PM, a review of Resident #70's care plan was completed: The Care plan did not address the diagnoses of depression and/or adjustment disorder with mixed anxiety and depressed mood. Furthermore, the plan of care did not mention that the resident was on a psychotropic (antidepressant) medication (sertraline 25 mg daily) as indicated in the physician's order and MAR. The facility staff failed to develop a comprehensive care plan for use of an antidepressant medication with measurable goals and nursing interventions/evaluations. On 6/4/2024 at 8:30 AM, surveyor reviewed Resident #70's active orders with Licensed Practical Nurse (LPN #14) who confirmed that the resident was receiving an antidepressant Sertraline HCl Oral Tablet 25 MG daily in the morning for depression. Regarding Care plans, LPN #14 stated that s/he has never updated/revised any resident's care plan. LPN #14 verified and confirmed that Resident #70's care plan did not address the use of antidepressant medication and/or depression. However, LPN #14 stated that she only referred to the care plan when she needed more information about a resident. The surveyor reviewed Resident #70's care plan with the Unit Manager (UM #1) during an interview on 6/4/2024 at 9:08 AM. UM #1 confirmed that there was no focus, goal, or interventions on the care plan for the use of antidepressant medication and/or indication for use of the medication. UM #1 stated s/he was going to revise the resident's care plan right away to address the use of antidepressant medication. On 6/5/2024 at 10:55 AM, in a follow up interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), surveyor reviewed the above findings with them. DON stated that the Unit Manager (UM #1) had informed them about the care plan not capturing Resident #70's diagnosis and use of antidepressant medication. 50502 2) On 05/29/24 at 09:08 AM, Resident #46 was observed having difficulty hearing the surveyor while being interviewed. He/she was also observed not wearing hearing aids on both ears. No hearing aids were seen within the resident's reach or elsewhere in the room. On 05/29/24 at 09:08 AM, Resident #46 stated that his/her hearing aids were in the room somewhere but that he/she was not sure where they were. He/she expressed that he/she likes wearing hearing aids because it helps him/her hear better. He/she added that he/she feels discouraged not hearing conversations and keeps on saying huh? He/she stated, I would like them to be accessible. He/she indicated that staff do not help him/her access the hearing aids and that he/she hasn't worn hearing aids for several weeks. On 05/30/24 at 01:01 PM, a record review of Resident #46's paper chart revealed a completed and signed belonging list dated 5/5/24, the resident's date of admission. The belonging list reflected that hearing aids 1 and 2 were present on admission. On 05/31/24 at 11:19 AM, the surveyor reviewed the hearing aid policy revised on 10/2022. The policy indicated the following: - Assess resident's knowledge of operating the hearing aid. - Assist resident to adjust control to desired level. Required if physically disabled. - Place the hearing aid in appropriate container when not in use, and store in a safe place. - Document in resident's clinical record, response to use of hearing aid, adjustment and include all pertinent observations. If resident refuses to have nursing staff lock up hearing aid at night, order must be obtained to keep it at bedside. On 05/31/24 at 11:19 AM, the surveyor reviewed the Minimum Data Set (MDS) with an assessment reference date of 5/10/24 for section B. The section was coded with ability to hear with the use of hearing aid or other hearing appliance. Also, the nursing admission assessment dated [DATE] reflected that Resident #46's hearing was not adequate and hearing aids were present on admission. On 05/31/24 at 12:17 PM, the surveyor interviewed the Minimum Data Set (MDS) nurse (Staff #11). He/she stated that Resident #46 has a hearing aid care plan dated 5/31/24 but incomplete, he/she added that there were no interventions yet. He/she further stated that even if Resident #46's assessment did not trigger the communication care area, he/she confirmed that care planning should have been completed. On 06/03/24 at 12:03 PM, the surveyor received the paper copy of the hard of hearing and hearing aid care plan from the DON. The care plan was initiated on 5/31/24, which was more than 14 days from the date of admission and after surveyors had begun their investigation. 48168 3) A nephrostomy tube is a thin, flexible catheter that drains urine from the kidney into a bag outside the body. On 5/29/24 at 9:36 AM a review of Resident #54's medical record revealed that the resident had been hospitalized in April 2024 for a urinary tract infection and kidney stones that obstructed the normal passage of urine. A nephrostomy tube was placed while the resident was at the hospital and was in place when the resident returned to the facility. On 5/31/24 at 12:54 PM a review of Resident #54's care plan revealed a problem for Risk for impairment to skin integrity related to surgical procedure (left flank nephrostomy tube) with the initiation date of 4/06/24. The associated goal for this problem was nephrostomy wound will have no complications through the review period. The following interventions were listed, all dated 4/06/24: -Check for incontinence every 2 hours and as needed. Use barrier cream with incontinence care to prevent skin breakdown. -Daily skin inspection. Notify the nurse of any changes to skin integrity. -Dietary consult for nutritional monitoring and evaluation of supplements for wound healing. -Enhanced Barrier Precautions-nephrostomy tube -Use caution with transfers The care plan lacked any care instructions for the nephrostomy wound site, care of the nephrostomy tube, or care of the urine collection bag. On 6/05/24 at 8:50 AM an interview with the Director of Nursing (DON) was conducted. Resident #54's care plan was reviewed with the DON, and she confirmed that the resident's care plan did not include care instructions for the resident's nephrostomy tube, site, and urine collection bag. 47200 4) On 5/28/24 upon surveyor's initial tour at approximately 10:20AM the surveyor observed Resident #90 in bed with a piece of paper posted on the wall behind their bed which indicated observation of left hip precautions and that the resident required a pink wedge pillow when in bed. At this time, no wedge pillow was observed to be in place for the resident. On 5/28/24 at 2:55PM the surveyor conducted a second observation of Resident #90 who was observed to be in bed with the wedge pillow in place. On 6/4/24 at 2:30PM the surveyor reviewed the medical orders for Resident #90 which revealed active medical orders for the following care beginning on 5/1/24: Anterior hip precautions- do not step backwards with surgical leg, no hip extension, do not allow surgical leg to externally rotate (turn outwards), do not cross your legs, use a pillow between legs when rolling to observe anterior hip precautions for left hip, kindly use the abduction pillow in bed at nighttime, every shift for post surgical precautions, Weight bearing as tolerated on left lower extremity with use of walker every shift, Apply ice pack to left hip for 20 min., may repeat TID (three times a day) indication for use; post surgical pain every 8 hours as needed for post surgical pain. On 6/4/24 at 3:35PM the surveyor reviewed the care plan for Resident #90 which revealed the care plan did not reflect interventions necessary to care for the resident who was admitted to the facility after their left hip fracture with surgical repair. On 6/5/24 at 9:20AM the surveyor conducted an interview with Licensed Practical Nurse (LPN) Unit Manager #1 and LPN Nursing Supervisor #40 who both confirmed with the surveyor that the care plan did not include anterior hip precautions and other post surgical care for the left hip fracture, but should be included. At this time, the surveyor shared their concern and requested a copy of the current care plan. On 6/5/24 the surveyor was provided with a copy of a care plan, that after surveyor intervention, had been revised to reflect post surgical care of the left hip dated 6/5/24. On 6/5/24 at 9:53AM the surveyor reviewed the post surgical and orthopedic discharge instructions which included the following post operative care instructions: postoperative sequential compression devices on both legs whenever on bed or chair more than 30 minutes, weight bearing as tolerated status, follow anterior hip precautions, use of the abduction pillow when in bed, avoid active hip abduction exercises for 6 weeks to protect the abductor repair, limit hip extension to neutral, avoid figure 4 position, limit external rotation to to 20 degrees, instructions for care of the surgical site, and ice the surgical site as frequently as possible for 20 minute periods, among other recommendations. Further review of the care plan revealed that after revisions were made on 6/5/24, the interventions still did not comprehensively reflect all of the resident's care interventions.

Based on observation, interview, and record review it was determined the facility failed to ensure Resident #68 had access to their call bell to call for staff assistance. This was evident for 1 out of 4 residents reviewed for environment. The findings include: During surveyor's initial tour of the facility on 5/28/24 at 10:28AM, Resident #68 was observed to be laying in bed with their call bell on the floor out of reach behind their bed. On 5/28/24 at 10:29AM the surveyor requested a dual observation with Licensed Practical Nurse (LPN) #35 who observed and upon interview, they confirmed the location of the call bell. The surveyor observed LPN #35 pick the call bell off of the floor and give it to Resident #68 and clipped the call bell cord to their bed. On 6/10/24 at 12:35PM the surveyor conducted review of the medical record for Resident #68 which revealed the following information included in the care plan interventions dated 3/5/24: keep call bell in reach and encourage me to use it for assistance and have commonly used articles within reach.

Based on observation, interview and record review it was determined the facility failed to 1) ensure a second certification of incapacity was obtained, 2) ensure that residents were provided information regarding advanced directives, and 3) obtain Advanced Directives from residents/resident's family. This was evident for 3 (Residents #54, #90, and #112) out of 7 residents reviewed for advanced directives during the recertification survey. The findings include: An advanced directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under the State law (whether statutory or as recognized by the State courts) relating to the provision of health care when the individual is incapacitated. 1) On [DATE] at 9:57AM the surveyor observed the Maryland Order for Life Sustaining Treatment (MOLST) form in the paper chart of Resident #90 and noted that under the certification section, it was marked as the resident or authorized decision maker having declined to discuss or unable to make a decision about treatments, and the form was signed by Physician #41 and dated [DATE]. On [DATE] at 9:59AM the surveyor observed the advanced directive document dated [DATE] for Resident #90 located in their paper chart stating the advanced directive was for in the event they became incapable of making an informed decision, and further detailed that the determination of incapacity would be made by the attending and a second physician or licensed clinical psychologist after a personal examination of them, and was to be certified in writing. On [DATE] at 9:59AM the surveyor additionally observed only one certification of incapacity in the resident's medical record dated [DATE]. Upon further surveyor observation of the resident's paper chart, a facility health care decision maker form was completed which documented that as of [DATE], the health care decision maker named in the resident's advanced directive was already in place. On [DATE] at 10:05AM the surveyor conducted an interview with Unit Manager #9 who observed documentation in the medical record with the surveyor and confirmed that upon the resident's admission to the facility, the following information was documented by Physician #41: (Resident #90) came with a MOLST done by him/her, I tried to dicuss MOLST with (Resident #90) but he/she had little understanding, (Resident #90) will be full code by default until decision maker clarified. On [DATE] at 10:07AM the surveyor further inquired to Unit Manager #9 regarding a decision maker being in place for the resident without a second certification of incapacity present. At this time, they communicated to the surveyor that it was their job to ensure two certifications of incapacity were completed and confirmed with the surveyor that only one certification of incapacity was present, and informed the surveyor they would need to call a supervisor regarding the inquiry. On [DATE] at 10:29AM the surveyor conducted an interview with the Director of Social Work #21 who reported to the surveyor that they typically consulted with relatives of the resident for decision making regarding the resident. At this time, they confirmed with the surveyor that a second certification of incapacity should be present in the medical record. On [DATE] at 12:07PM after surveyor intervention, the Director of Social Work #21 provided the surveyor with a copy of a second certification of incapacity completed on and dated [DATE] and informed the surveyor that although regular audits were performed, I missed the chart. 48168 2) On [DATE] at 9:48 AM a review of Resident #54's electronic medical record revealed no evidence that the resident had an advance directive or that one had been offered to the resident. On [DATE] at 10:19 AM a review of Resident #54's paper chart revealed a Maryland Order for Life Sustaining Treatment (MOLST) dated [DATE] which indicated No CPR, Option B and indicated that this decision was per the resident's advance directives. However, there was no advance directive document found in the paper chart. On [DATE] at 11:39 AM in an interview with the social services designee (Staff #10), she stated that advance directive information should be in each resident's paper chart and may also be scanned into the electronic record. She further stated that the facility process was to offer advance directive information to all new admissions and document any discussion with residents in the progress notes section of the electronic record. Additionally, all residents were seen every quarter for assessments, perhaps sooner if the resident had a change in condition. At each of these assessments a review of the advance directives should take place and the review should be documented in the resident's medical record. On [DATE] at 11:51 AM a follow up interview with Staff #10 was conducted. When asked if Resident #54 had made or been offered to make an advance directive, Staff #10 said she was not sure and would look for that documentation. On [DATE] at 3:38 PM the Nursing Home Administrator (NHA) provided the surveyor a copy of documentation written by Staff #10 and dated [DATE] at 15:02 that stated SWA has discussed formulating an advance directive with resident in the past. She has previously declined. SWA approached the resident today and now [the resident] is in agreement to formulate a directive. SWA to assist with directive today. Since the documentation was written the day of the surveyor interview, the surveyor asked to speak to Staff #10 again. On [DATE] at 3:51 PM an interview with Staff #10 and the Director of Social Work (SW#21) was conducted. A review of Resident #54's record was conducted again with both Staff #10 and SW #21, and they both confirmed that there was no previous documentation of any discussion with the resident regarding advance directives, the resident did not have any advance directive, and the resident had been at the facility for two years. They both confirmed that there was no evidence that the resident had previously been asked for or provided information about advance directives. 50458 3) A review of Resident #112's medical record on [DATE] at 12:39 PM revealed that the resident was admitted to the facility on [DATE]. There was no copy of his/her advance directive. Further review of Resident #112's Admission Assessment Notes, written by a social worker on [DATE], showed that the social worker documented that the resident had an Advanced Directive, ask [family member]. During an interview with a social worker (Staff #21) on [DATE] at 3:51 PM, Staff #21 stated that if a resident had an advance directive, she would ask who the facility could contact to bring a copy to file in the medical record. On [DATE] at approximately 9 AM, the surveyor requested that the Director of Nursing (DON) submit copies of documentation regarding Resident #112's advance directive. On [DATE] at 10:39 AM, the DON brought a copy of Resident #112's Advance Directive. She stated that the facility's social worker had contacted resident #112's family member to get a copy of the advance directive upon admission (about a month ago). The DON confirmed that the advance directive was submitted from Resident #112's family member on [DATE] after the surveyor asked about the social worker follow up.

Based on interview and record review it was determined the facility failed to ensure an allegation of neglect and an investigation of neglect were timely reported. This was evident for 1 (MD00205866) out of 6 facility reported incidents reviewed during the facility's recertification survey. The findings include: On 5/28/24 the surveyor began review of a facility reported incident (MD00205866). On 5/31/24 at approximately 10:27AM the surveyor conducted an interview with the facility Administrator who reported the following information regarding the facility's process for the reporting of allegations of abuse and neglect: Supervisors report to us and we act on and start investigation immediately, we talk to residents, we determine if it is something we need to report, determine if it is a care concern or a customer service issue, or something that looks like it could be abuse or neglect, and investigation along the lines of abuse is reported to OHCQ within 2 hours of us getting notified. On 5/31/24 at 12:41PM the surveyor observed the following documented in the facility's initial self report: On 5/9/24, the SW (Social Worker) made the DON/NHA (Nursing Home Administrator) aware that the resident was left lying flat in bed, uncovered and call bell was not within reach. Resident reported time was from around 8:30am to 1pm. Additionally, the surveyor noted the facility documented the allegation type was an investigation for neglect, the incident was alleged as occurring on 5/9/24, and was not initially reported to the Office of Healthcare Quality until 5/17/24 at 5:00PM, approximately eight days later, during which time, a second alleged incident of neglect of Resident #3 was documented as occurring beginning on 5/11/24. On 5/31/24 at 2:41PM the surveyor conducted an interview with the Director of Nursing (DON) and Administrator who confirmed the dates and times of submission of the reports, at which time, the surveyor shared their concerns. When the surveyor inquired as to why the allegation was not reported timely, the DON reported the incident didn't feel intentional. When the surveyor inquired to the Administrator, they reported the following: It was not as big of a gap of time as we were first told. It wasn't that long the resident was left, typical rounding should be every two hours, it was one hour beyond that, the resident didn't feel it was intentional. When the surveyor further inquired as to if intention had to be present in order to report the allegation, the Administrator replied: No, it's not that we think it has to be intentional, what does the policy say? It doesn't have to be intentional to report it. On 6/11/24 at 1:19PM the surveyor conducted an interview with Geriatric Nursing Assistant (GNA) #27, who was assigned to the care of the resident on 5/9/24. GNA #27 reported to the surveyor that when they entered the resident's room, s/he was on their side, and had been left from wound rounds and verbalized needing LPN #5 to do a dressing. GNA #27 further reported that on 5/9/24, Resident #3 stated the following to them in response to the incident: Wound rounds left me like this. At this time, GNA #27 confirmed with the surveyor that the resident was upset by the incident. GNA #27 confirmed they believed it had been several hours since the resident had been checked on last, and additionally reported, that after the incident, all parties involved were taken to the Director of Nursing's office where staff were asked if they understood the severity of the situation.

Based on complaint intake review, medical record review, and staff interview it was determined that the facility failed to document the transfer of a resident in the medical record including the reason for the transfer. This was evident for 1 (#166) of 3 residents reviewed for discharge. The Findings include: Resident #166's closed medical record was initially reviewed on 6/5/24, in relation to complaint intake MD00206001. Resident #166 was admitted to the facility on [DATE]. Per the census tab in the electronic health record (EHR) revealed the resident was discharged on [DATE]. There was not a discharge note to indicate the reason for the discharge, or information of how, or when the resident left the facility. Under the evaluations tab in the EHR was an in Progress discharge instructions document without indication as to who was provided the instructions. The Director of social services (staff #21) was interviewed on 6/5/24 at 1:30 PM. Upon identification of the resident in question she did a custom search of social work notes. She indicated that she could not remember the circumstance of the initiation for discharge, and she agreed that something should have been written. The social worker indicated that she may have some documentation in a soft file (personal file not in the medical record) and she would get back to the surveyor with any discovered information. On 6/6/24 at 10:16 AM the director of social services provided email documentation from March 2023 with indication the resident was issued a Notice of Medicare Non-Coverage (NOMNC) on 3/3/23 with indication of the discharge to occur on 3/6/23. The email documentation further indicated that resident #166 was granted an extra day with discharge set for 3/7/23. The social worker was informed of the concern that the medical record was absent and incomplete discharge documentation.

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#86) of 6 residents reviewed for hospitalization during a recertification survey. The findings include: In an initial interview with Resident # 86 on 5/28/2024 at 11:14 AM, the resident stated that s/he was sent to the hospital over a week ago for low blood level. When asked if s/he was notified in writing the reason for the transfer, Resident #86 state s/he was told verbally about the reason for the transfer but was not given anything in writing. On 5/30/2024 at 11:45 AM, a review of nurses' progress notes revealed the following documentation dated 4/30/2024 at 23:37 (11:37 PM): Note Text: Resident admitted to UCMC (Upper Chesapeake Medical Center) per [staff name] for symptomatic anemia and GI bleed. Change in condition documentation (SBAR) dated 4/30/2024 at 17:09 (5:09 PM) revealed Resident #86 was transferred to the hospital. However, there was no documentation and/or evidence in the record indicating that the facility staff notified the resident/resident's representative (RP) in writing of the reason for the transfer to the hospital. On 5/30/2024 at 12:05 PM, surveyor requested from the Nursing Home Administrator (NHA) to see written notification for the reason of transfer to the hospital given to Resident #86 and/or their RP and a copy of the bed hold policy given to the resident or their RP. On 5/31/2024 at 10:31 AM, in an interview with the Director of Nursing (DON) and NHA, DON confirmed that she could not find any documentation that Resident #86 and/or their RP was given any written notification of the reason for transfer to the hospital on 4/30/2024. However, DON stated that the reason for transfer was documented on the change in condition form (SBAR) including that family/RP was notified. On 6/4/2024 at 8:30 AM, an interview was completed with Licensed Practical Nurse (LPN #14) who has worked full time in the facility for over a year. Regarding transferring residents out to the hospital, LPN #14 stated that she has never given a resident/RP anything in writing regarding reason for transfer out. LPN #14 further stated that the reason was written in transfer sheet placed in packet sent to the hospital. LPN #14 added that the residents and/or their families were told verbally why the residents were transferred to the hospital. On 6/4/24 at 8:54 AM, an interview was completed with Unit Manager (UM #1). UM #1 confirmed that she has never given residents/their RPs in writing the reason for transfer to the hospital. She stated that the resident and/RP were told verbally the reason why the resident was transferred (in person if RP was in the facility and/or phone call if not in facility).

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 2 (#86, #104) of 6 residents reviewed for hospitalization during a recertification survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization . 1) In an initial interview with Resident # 86 on 5/28/2024 at 11:14 AM, the resident stated that s/he was sent to the hospital over a week ago for low blood level. When asked if s/he was notified in writing the reason for the transfer, Resident #86 stated s/he was told verbally about the reason for the transfer but was not given anything in writing. Resident #86 added that s/he knew they were holding their bed but did not know for how long. On 5/30/2024 at 11:45 AM, a review of nurses' progress notes revealed the following documentation dated 4/30/2024 at 23:37 (11:37 PM): Note Text: Resident admitted to UCMC (Upper Chesapeake Medical Center) per [staff name] for symptomatic anemia and GI bleed. Change in condition documentation (SBAR) dated 4/30/2024 at 17:09 (5:09 PM) revealed Resident #86 was transferred to the hospital and the resident's representative (RP) notified of the transfer. However, there was no written documentation that the resident/responsible party was notified in writing of the bed-hold policy. Bed hold was not checked off as provided. On 5/30/2024 at 12:05 PM, in an interview with the Director of Nursing (DON), she stated that bed hold notification was given by the transferring nurse when a resident was transferred out to the hospital. The surveyor requested bed hold and written transfer notification given to Resident #86 and/or their RP when the resident was transferred out on 4/30/2024 including the facility's bed hold policy. On 5/30/2024 at 12:50 PM, in a follow up interview with the DON, she gave the surveyor copies of the facility's bed hold policy. However, DON stated that they were still looking for the bed hold notification that was provided to Resident #86 when s/he was transferred to the hospital on 4/30/2024. On 5/31/2024 at 10:31 AM, in an interview with the DON and Nursing Home Administrator (NHA), DON confirmed that she could not find any documentation that Resident #86 and/or their RP was given a copy of the bed hold notification and/or any written notification of the reason for transfer to the hospital. However, DON stated that the reason for transfer was documented on the change in condition form (SBAR) including that family/RP was notified. DON added that bed hold notification was supposed to be included in the change in condition form, but facility staff failed to complete that part of the form. On 6/4/2024 at 8:30 AM, an interview was completed with Licensed Practical Nurse (LPN #14) who has worked full time in the facility for over a year. Regarding bed hold, LPN #14 confirmed that the facility's bed hold policy was included in the transfer packet when a resident was sent out to the hospital. However, LPN #14 stated that she has never given any written bed hold policy notification to a resident and/or their representative upon transfer to the hospital. She further stated, It's my understanding that residents' and their families are aware of the bed hold policy. On 6/4/24 at 8:54 AM, an interview was completed with Unit Manager (UM #1). Regarding bed hold notification, UM #1 stated that she has never given residents/their RPs a copy of the bed hold notification upon transfer to the hospital. UM #1 confirmed that the 3-day bed hold policy was given in the envelope to the hospital upon transfer but not to the resident and/or their RP. When asked to show a copy of the written bed hold policy provided for Resident #86 when they were sent out to the hospital on 4/30/2024, UM #1 was unable to do so. 49409 2) On 05/28/24 at 10:44 AM, an interview with resident #104 and the resident's family member/responsible party (R.P) revealed that the resident fell at the facility and was sent to the hospital on 05/08/2024. R.P. was present at the facility during the resident's transfer and confirmed that the facility did not offer a bed hold policy to the resident or R.P. On 5/29/2024 at 01:43 PM, the surveyor's record review revealed that the resident (#104) had been at the facility for the past two months for short-term rehabilitation. The resident was transferred to the hospital on 05/08/24 and was admitted . However, there was no evidence that the resident or resident's representative received a bed hold policy. Documentation from 05/08/24 at 8:50 PM, regarding the change in condition, by staff #42 revealed that Bed hold policy: Not given to resident or family. The package was given to EMTs. On 06/04/24 at 08:27 AM, an Interview with staff #43 revealed that the staff prepares the required documentation package, including the bed hold policy, and gives it to the paramedic (a person trained to give emergency medical care to people who are ill or injured outside the hospital) during resident emergency transfers. Staff #43 also confirmed that he/she does not communicate with residents or family, stating that maybe nursing supervisors communicate regarding the bed hold policy. On 06/04/24 at 01:13 PM, the surveyor reviewed the lack of communication with the resident or family member regarding the bed hold policy with the Director of Nursing (DON) and the Nursing home administrator (NHA). The surveyor's review also included resident #104 not receiving a bed hold policy from the facility at the time of transfer to the hospital. DON stated that the Director of admissions usually calls families, but was not able to provide documentation.

Based on observation, medical record review, and interview it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#70) of 42 residents reviewed during a recertification 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. On 6/3/2024 at 11:45 AM, a review of Resident #70's clinical records revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to adjustment disorder with mixed anxiety and depressed mood, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 6/3/2024 at 12:16 PM, review of physician orders revealed the following active orders originally written on 3/21/2024: Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth in the morning for Depression. On 6/3/2024 at 12:34 PM, review of the Medication Administration Record (MAR) for March, April, and May 2024 revealed the resident was getting Sertraline HCl Tablet 25 mg 1 tablet by mouth in the morning for Depression, start date 3/21/2024. On 6/3/2024 at 2:17 PM, review of Resident #70's quarterly MDS with an assessment reference date (ARD) of 4/20/2024 was completed. Section I (Active Diagnoses) did not capture adjustment disorder with mixed anxiety and depressed mood and/or Depression under psychiatric/mood disorder (subsection 15800). However, Section N (Medications) captured use of Antidepressant on both the quarterly MDS of 4/20/2024 and Discharge Return Anticipated MDS dated [DATE]. Review of progress notes revealed the following Nursing Narrative Note written on 3/21/2024 at 9:30 AM: Resident saw [Name] CRNP on 3-19-24 from Counterpoint Health Services, recommendation to start Sertraline 25mg po daily for depression, secondary to increase tearfulness and signs and symptoms of depression, Recommendation to start Sertraline 25mg po daily approved by [name of medical director]. On 6/3/2024 at 2:35 PM, a review of psychiatry note dated 3/19/2024 at 21:23 (9:23 PM) revealed the following documentation: under chief complaint/nature of presenting problem: Follow up assessment for depressed mood/grief Under Assessment/Plan/Orders/Recommendations: [Resident's name] presented as sad and tearful today. Add sertraline 25 mg po q day. Under diagnosis, assessment . adjustment disorder with mixed anxiety and depressed mood. On 6/4/2024 at 8:30 AM, surveyor reviewed Resident #70's active orders with Licensed Practical Nurse (LPN #14) who confirmed that the resident was receiving an antidepressant Sertraline HCl Oral Tablet 25 MG daily in the morning for depression. When asked if Resident #70 had depression, LPN #14 immediately navigated to the medical diagnosis tab in PCC (electronic record) and confirmed that depression was not indicated in the medical diagnoses tab. LPN #14 further stated that she could review Psych notes for their recommendations/indication regarding the antidepressant medication. On 6/4/2024 at 9:08 AM, an interview was completed with the Unit Manager (UM #1). Regarding Resident #70's active diagnoses, UM #1 verified that Depression was not included under the medical diagnosis tab in PCC, however, adjustment disorder with mixed anxiety and depressed mood was indicated. UM #1 stated she could look under psych notes for diagnosis of depression. UM #1 reviewed and noted that Psych notes dated 3/19/2024 had recommendations to start resident on the above antidepressant and diagnosis of adjustment disorder with mixed anxiety and depressed mood. UM #1 further reviewed notes dated 3/21/2024 that she had written regarding starting the resident on the above antidepressant. She also reviewed physician orders for Sertraline 25 mg with indication Depression, and reviewed MDS sections I and N for both the quarterly on 4/20/2024 and Discharge on 5/28/2024 with the surveyor. UM #1 verified and confirmed that the diagnoses of adjustment disorder with mixed anxiety and depressed mood and/or depression were not captured on both 4/20/2024 and 5/28/2024. UM #1 stated it's a learning process. On 6/4/2024 at 9:58 AM, in an interview with the MDS Coordinator (Staff #11), surveyor reviewed Section I of Resident #70's quarterly MDS with ARD of 4/20/2024 and MDS of 5/28/2024. Staff #11 verified and confirmed that Resident #70's MDS assessment was inaccurate. She stated that usually the MDS coordinator would code the diagnosis and the expectation was to go back 60 days to look for active diagnoses and make sure the diagnoses were still active in the 7 days ARD look back period. Staff #11 added it was an oversight on their part. On 6/5/2024 at 10:55 AM, in a follow up interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), surveyor reviewed Resident #70's Section I of the quarterly MDS with ARD of 4/20/2024 and Discharge MDS of 5/28/2024. DON stated she was not aware that the resident's diagnosis of depression and/or adjustment disorder with anxiety and depressed mood was not captured on the MDS.

Based on the resident and staff interviews and medical record review, it was determined that the facility failed to revise care plans after a resident sustained an injury after a fall. This was evident for one resident (Resident #95) out of 42 residents reviewed for care plan timing and revision. The findings include: Resident #65 has been at the facility for a month to get short-term rehab for a respiratory infection. On 05/29/24 at 11:07 AM, an Interview with a resident (#95) revealed that the resident sustained Fracture after a fall in the facility on 05/16/24. The resident was sent to the Hospital and returned to the facility on [DATE]. On 06/06/24 at 10:05 AM Record review revealed that the risk for falls care plan was Initiated on 05/02/2024 with the goal will have no falls through the review period. The resident sustained injury after a fall on 05/16/24, and after returning from the Hospital, the resident's care plan goals and interventions were not revised until 06/05/2024 to provide appropriate care after injury. On 06/04/24 at 08:27 AM, an Interview with Nursing Staff #43 revealed that she/he works mostly during night shifts. She/he gets the status of the residents at the beginning of the shift from outgoing staff and sometimes from progress notes. She/he will not initiate or update any care plans; she/he stated that supervisors may do the care plans. On 06/04/24 at 08:33 AM, an Interview with staff #47 revealed that she/he works the day shift, gets the report from outgoing staff, and reads the notes from medical records. She/he does not initiate or update care plans. On 06/04/24 at 01:13 PM Interview with the Director of Nursing (DON) & Nursing home administrator (NHA) reviewed the care plan-related issues for resident # 95. The DON stated that fall risk was assessed during the admission. If the resident is at risk for falls, appropriate interventions are implemented. If any additional changes occur, the team makes recommendations and documents. The team, including the medical Director, reviews falls weekly at a risk management meeting. IDT also trends the falls and comes up with interventions. The team also discusses fall management at QA meetings each Month. DON also stated that most of the management team is new. The DON also reviewed the Care plan process. Between unit managers, the Assistant Director of Nursing manager (ADON), the Nursing Supervisor, DON, and the Minimum Data set (MDS) coordinator, do care plan follow-ups and updates. ADON compiles and ensures that all the plans and recommendations are implemented and compiles data for the risk meeting.

Based on observation, interview and record review, it was determined that the facility failed to have a resident's hearing aids accessible to the resident. This was evident for 1( Resident #46) of 1 resident reviewed for management of their hearing aids. The findings include: Minimum Data Set (MDS) is a standardized assessment tool that is used to evaluate the health status and functional capabilities of residents, and to help nursing home staff identify health issues. On 05/29/24 at 09:08 AM, Resident #46 was observed having difficulty hearing the surveyor while being interviewed. He/she was also observed not wearing hearing aids on both ears. No hearing aids were seen within the resident's reach or elsewhere in the room. On 05/29/24 at 09:08 AM, Resident #46 stated that his/her hearing aids were in the room somewhere but that he/she was not sure where they were. He/she expressed that he/she likes wearing hearing aids because it helps him/her hear better. He/she added that he/she feels discouraged not hearing conversations and keeps on saying huh? He/she stated, I would like them to be accessible. He/she indicated that staff do not help him/her access the hearing aids and that he/she hasn't worn hearing aids for several weeks. On 05/30/24 at 08:36 AM, a review of Resident #46's record revealed that the resident was bed-bound and unable to get out of bed independently to obtain supplies in his/her room. On 05/30/24 at 12:05 PM, a record review of Resident #46's treatment administration record (TAR) did not reveal any information about Resident #46's hearing aids such as instructions and care of the hearing aids. The resident's physician notes were also reviewed at that time and revealed a physician's progress note dated 5/14/24 that documented the resident was hard of hearing (HOH). On 05/30/24 at 01:01 PM, a record review of Resident #46's paper chart revealed a completed and signed belonging list dated 5/5/24, the resident's date of admission. The belonging list reflected that hearing aids 1 and 2 were present on admission. On 05/31/24 at 08:49 AM, the surveyor interviewed Licensed Practical Nurse (LPN)#20 who was assigned to work with Resident #46 on that day. When asked if she was aware that Resident #46 was hard of hearing (HOH), she stated no, I'm not aware. She further stated that other residents who use hearing devices keep the devices in a container in their rooms. On 05/31/24 at 09:28 AM, Resident #46 was again observed not wearing hearing aids. Hearing aids were also not noted on the bedside table. Resident #46 required the surveyor to repeat several times, indicating that Resident #46 had trouble hearing. On 05/31/24 at 11:19 AM, the surveyor reviewed the hearing aid policy revised on 10/2022. The policy indicated the following: - Assess resident's knowledge of operating the hearing aid. - Assist resident to adjust control to desired level. Required if physically disabled. - Place the hearing aid in appropriate container when not in use, and store in a safe place. - Document in resident's clinical record, response to use of hearing aid, adjustment and include all pertinent observations. If resident refuses to have nursing staff lock up hearing aid at night, order must be obtained to keep it at bedside. On 05/31/24 at 11:19 AM, the surveyor reviewed the Minimum Data Set (MDS) with an assessment reference date of 5/10/24 for section B. The section was coded with ability to hear with the use of hearing aid or other hearing appliance. Also, the nursing admission assessment dated [DATE] reflected that Resident #46's hearing was not adequate and hearing aids were present on admission. On 05/31/24 at 11:19 AM, the surveyor interviewed the Director of Nursing (DON) and the Nursing Home Administrator. The DON stated Resident #46's hearing aids were found locked in the night stand. The surveyor expressed concerns that Resident #46 can't reach the night stand independently and that the resident has expressed frustration at not hearing well. The DON acknowledged the concern and stated that she will talk to the nursing staff.