Every finding on record at Manokin Nursing and Rehab

Based on a review of complaint 2965994, observations during a dining experience, and interviews with facility staff, it was determined that staff failed to sit while feeding residents and failed to serve meals to all seated residents at the same time to provide a dignified dining experience. This was evident on 1 (Chase) of 2 nursing units observed during the dining experience of the complaint survey.The findings include:On 6/29/26 at 11:00 AM a review of complaint 2965994 was conducted regarding alleged concerns over resident care in the facility.On 6/29/26 at 12:38 PM observation on the dementia unit (Chase) noted residents eating lunch at the table adjacent to the nurse's station. Observation was made of Geriatric Nursing Assistant (GNA) #16 standing to feed Resident #9 and Resident #10. Licensed Practical Nurse (LPN) #7 was standing to feed Resident #11 and Unit Manager #8 was standing to feed Resident #12.On 6/30/26 from 8:27 AM to 8:46 AM a second observation of the dining experience during breakfast was made on the dementia unit.Observation was made of Resident #15 eating breakfast at the table while Resident #7 and Resident #16 watched until their breakfast came on the next food cart. Resident #10 ate at a separate table while Resident #17 waited for his/her breakfast tray. Resident #10 also had a fly flying around his/her head and the food while he/she was eating. It was also noted that while residents were eating, there were excessive crumbs, spills, pieces of food, and trash on the floor under their tables, by their feet, and adjacent to their tables. Six residents were sitting at a round table in front of the nurse's station for breakfast. Resident #18 had a breakfast tray and was eating. Resident #9 was fed breakfast by a staff member. Resident #19, #20, and #21 received their breakfast trays when Resident #18 and Resident #9 were done eating. Resident #22 sat there while all other residents at the table ate their breakfast. Resident #22 did not get his/her breakfast tray until 8:46 AM. GNA #11 was asked why Resident #22 did not get his/her breakfast tray until everyone else was done eating. GNA #11 stated, because [he/she] has to be fed.GNA #11 was asked why there was a delay in all of the residents getting their meal trays at the same time. GNA #11 stated that the kitchen does not send all the trays up at the same time because they have some residents that require feeding. GNA #11 was asked about the spills, crumbs, and trash on the floor in the dining area. GNA #11 stated that housekeeping leaves at 4 PM.On 6/30/26 at 10:05 AM the surveyor discussed the condition of the Chase dining area with the Nursing Home Administrator (NHA) and showed him pictures of the area. The NHA stated that someone should have cleaned up after dinner last night. The NHA was also informed of the dignity issues.On 6/30/26 at 10:51 AM an interview was conducted with the Director of Nursing (DON). The surveyor showed the DON the pictures of the Chase unit. The DON stated there was a mop, bucket, and a broom in the utility closet on that unit and someone should have cleaned up. The DON stated she agreed about the dignity issue with standing to feed the residents and the residents sitting at the tables and getting their food at the same time. The DON stated they would talk to the kitchen about when the food was delivered.

Based on review of complaints, observations, and interviews, it was determined that the facility failed to 1) provide maintenance services necessary to keep resident rooms and equipment sanitary and orderly and 2) ensure a resident's room was a safe, comfortable and homelike environment. This issue was observed on 3 of 5 nursing units reviewed for maintenance services and 1 of 4 resident rooms reviewed for safe, comfortable and homelike environment during a complaint survey. The findings include: 1) On 6/29/26 at 12:20 PM the following environmental observations were made during a tour of the facility: Ceiling Tiles in Disrepair: [NAME] water stains of various sizes were observed on ceiling tiles in rooms 106, 307, and room [ROOM NUMBER]. Plastic plumbing pipes were on the floor and in resident basins in rooms 107, 111, and room [ROOM NUMBER]. Toilet paper rollers were missing from toilet paper holders in rooms 303, 111, and room [ROOM NUMBER]. Bathroom exhaust fans were hanging down from the ceiling in rooms [ROOM NUMBERS]. Drywall was missing on the corner approximately 3 inches with the gray corner beading exposed by the bathroom door in room [ROOM NUMBER]. The drywall was also missing in the bathroom approximately 6 inches by 3 inches in room [ROOM NUMBER]. Resident #13's left wheelchair armrest was missing the front 3 inches of foam padding and the vinyl on the left armrest was cracked throughout. The door to the bathroom in room [ROOM NUMBER] had (2) 1-inch holes. The light bulb was burned out at the sink in room [ROOM NUMBER]. The nightstand drawer in room [ROOM NUMBER] was missing the third drawer. In the Chase (dementia unit) observations were made of the floor in the TV room where a majority of the dining tables were located. There were spills on the floor, crumbs, pieces of paper towels, plastic cups, and pieces of food. In the alcove was trash on the floor including a plastic cup, napkins, and newspaper ads from circulars. On 6/29/26 at 12:55 PM a tour was conducted Infection Control Preventionist (IP) #5 and she confirmed the maintenance concerns in the resident rooms. IP #5 stated that she informed the maintenance director, and he informed her to put the concerns in the TELS system. The TELS system is an electronic system to report maintenance concerns. On 6/29/26 at 1:47 PM an interview was conducted with Director of Maintenance (DOM) #9. DOM #9 stated that he had 1 assistant that has been at the facility for the past 2 months. Previously the DOM was by himself for a short time. DOM #9 stated that staff were supposed to put any maintenance issues or repairs in TELS. DOM #9 stated, we have a hard time getting them to do that. I tell them that no matter what the size of the issue is to put it in TELS. I do room audits once a week. Regarding the brown ceiling stains, DOM #9 stated there were certain spots on the roof that get a lot of water and there has been a lot of rain. DOM #9 stated, I have been playing catch up today changing ceiling tiles because of the rain we had this weekend. On [NAME] the air conditioning unit was leaking, and I shop vacuumed that out. DOM #9 stated, once a week they will take the wheelchairs out of the unit and we will clean them and they are supposed to report the issues like wheelchair armrests. On 6/30/26 at 8:46 AM Geriatric Nursing Assistant (GNA) #11 was shown the trash and crumbs on the floor in the Chase unit. GNA #11 stated that housekeeping leaves at 4 PM. On 6/30/26 at 10:05 AM the surveyor discussed the condition of the Chase dining area with the Nursing Home Administrator (NHA) and showed him pictures of the area. The NHA stated that someone should have cleaned up after dinner last night. The NHA was also informed of the other maintenance issues. On 6/30/26 at 10:51 AM an interview was conducted with the Director of Nursing (DON). The surveyor showed the DON the pictures of the Chase unit. The DON stated there was a mop, bucket, and a broom in the utility closet on that unit and someone should have cleaned up. 2) The facility staff failed to ensure a resident's room was a safe, comfortable and homelike environment. Review of Resident #6's medical record on 6/29/26 revealed the Resident was admitted to the facility in February 2026 with a diagnosis to include Dementia. Dementia is an umbrella term for a decline in memory, thinking or reasoning skills that is severe enough to impair a person's ability to perform everyday activities. Observation of Resident #6's room on 6/29/26 at 12:00 PM revealed the Resident was not in his/her room and there was no sheet on the Resident's bed. Observation of Resident #6's room on 6/29/26 at 1:00 PM revealed the Resident was in his/her bed and the bed still did not have a sheet on it. At that time the Surveyor observed Ant and Roach spray can on the Resident's bedside table. The Surveyor went with the Unit Manager (UM) #8 on 6/29/26 at 1:29 PM to Resident #6's room. At that time UM #6 confirmed the Ant and Roach spray at the Resident's bedside and stated it was brought in by the Resident's family and she would remove it immediately. UM #6 also stated the facility staff had cleaned the Resident's bed earlier that day, hadn't had a chance to put a sheet on it and the Resident had placed him/herself in the bed without the staff knowing. The observations for Resident #6's room were shared with the Administrator on 6/30/26 at 10:14 AM.

Based on review of complaint 2965994, observation, and staff interview, it was determined the facility failed to follow infection control practices and guidelines to prevent the development and transmission of disease. This was evident for 3 of 5 nursing units observed during the complaint survey.The findings include: On 6/29/26 at 11:00 AM a review of complaint 2965994 alleged that a visitor to the facility observed dirty meal trays, a dirty towel on the floor with a brown liquid on it and a puddle of dried brown liquid on the floor, a stained pillow, and dried food all over the floor that appeared to have been there for some time. The worker was concerned with the cleanliness of the rooms in the facility. On 6/29/26 at 12:20 PM a tour of the facility was conducted with the Infection Preventionist (IP) #5. The following infection control concerns were observed:room [ROOM NUMBER]: bathroom: There was 1 gray and 1 pink basin lying on the floor under the sink. The basins were not labeled and were not in plastic. There also was an elbow piece of plumbing pipe sitting in the pink basin.room [ROOM NUMBER]: In the bathroom there was a fly sitting on the toilet rim. There was no toilet paper roller, and the toilet paper was sitting on the back of the toilet. There was a gray bedpan on the floor by the toilet that was not labeled or in plastic. There was 1 gray basin on the floor with a scrunched up brown soiled washcloth inside the basin. There was 1 gray basin sitting on top of the plastic drawers under the sink. The basins were not labeled or in plastic.room [ROOM NUMBER]: There was no toilet paper roller, and the toilet paper was sitting on the back of the toilet. There was a gray basin sitting on the back of the toilet that was not in plastic or labeled.room [ROOM NUMBER]: There was a white basin that appeared to go with a bedside commode sitting on the floor under the sink along with a white toilet urine collection hat. Neither item was labeled or wrapped in plastic.room [ROOM NUMBER]: There was a white urine collection hat on the floor by the door that was upside down. There was 1 gray fracture pan and 1 pink basin sitting on the floor under the sink along with 2 gray basins sitting inside of each other. There were 2 gray basins sitting in each other on the back of the toilet. None of the items were labeled or in plastic.room [ROOM NUMBER]: There was 1 gray basin sitting on the floor sitting inside a pink basin. They were not labeled or in plastic.room [ROOM NUMBER]: There was no toilet paper roller in the toilet paper holder. The toilet paper was sitting on top of the hand rail.In the rooms identified in the 100 hallway and the 300 hallway, the bathrooms were shared between 2 rooms of residents.room [ROOM NUMBER]: In a room that housed 4 residents there was a gray basin sitting on the floor under the sink with no label and not in plastic.On 6/30/26 at 8:27 AM observations were made of the floor in the TV room of the Chase Unit (dementia) where a majority of the dining tables were located. There were numerous spills on the floor, crumbs, pieces of paper towels, plastic cups, and pieces of food on the floor. In the alcove was trash on the floor including a plastic cup, napkins, and newspaper ads from circulars.On 6/29/26 at 12:55 PM an interview was conducted with IP #5. IP #5 was asked what the policy was for storage of urinals, basins, fracture pans, and toilet collection hats. IP #5 stated, for residents they should be dated with the patient's room number or last name. The basins, fracture pans, and toilet collection hats should be put in a bag to store them. IP #5 confirmed the surveyor's findings while on a tour with the surveyor and stated she would have to look for the policy. On 6/29/26 at 1:45 PM IP #5 came back to the surveyor and stated that they did not have a policy. IP #5 stated that Regional #19 said that they were cited previously for this back in December 2025 and they did not have a policy then and they still did not have a policy.On 6/30/26 at 10:05 AM the Nursing Home Administrator (NHA) was informed of the findings. He was shown the pictures of the Chase Unit, and he agreed with the surveyor's findings.On 6/30/26 at 10:51 AM the Director of Nursing (DON) was informed of the findings.

Based on review of complaint 2965994, observations, interviews, and documentation review, it was determined that the facility failed to maintain an effective pest control program, evidenced by numerous flies throughout the facility. This was evident on 2 of 2 days observed during a complaint survey.The findings include: On 6/29/26 at 9:35 AM a review of complaint 2965994 alleged concerns regarding the facility's environment.On 6/29/26 at 9:48 AM a tour of the facility was conducted. Observation was made on the dementia unit (Chase) of a fly on the baby doll's head that Resident #14 was holding. There was a fly in the back dining area of the unit and in the 500 hallway.On the 100 hallway in room [ROOM NUMBER] there was a fly buzzing around in the resident's room and a fly sitting on the toilet seat in the resident's bathroom.On 6/29/26 at 12:55 PM a tour was conducted with Infection Preventionist (IP) #5. IP #5 confirmed the facility had a fly problem as there were several flies observed on the tour and in resident bathrooms.On 6/29/26 at 1:08 PM flies were observed around resident food in the A/B day room where residents were eating lunch.There were flies in the conference room where the surveyors were located.On 6/30/26 at 8:45 AM Resident #10 had a fly flying around his/her head and food while eating breakfast in the dementia unit.On 6/30/26 at 8:52 AM an interview was conducted with Director of Maintenance (DOM) #9 who stated that the pest control company comes to the facility every 2 weeks. DOM #9 stated they were here last week, but he was unsure of what they had been treating. DOM #9 stated they have pest control books at the nurse's station and the staff would put concerns in the book. DOM #9 stated he had noticed they were having a fly problem, and he noticed it was bad yesterday. DOM #9 stated that the supervisor from the pest control company would come out to the facility. He stated that the pest control company was backed up and would be out after the holidays. DOM #9 stated that when the pest control company was here last week he asked about the flies and they said they would ask the supervisor about adding on a treatment.The pest control logs and pest control invoices were reviewed with DOM #9. Review of the pest control logs documented flies at the nurse's station and in multiple resident rooms on the Chase unit on 3/17/26 and 3/19/26. Another pest control log documented on 5/18/26 there were flies throughout the whole building.Review of the 6/25/26 pest control invoice documented that the service technician checked in with the facility staff on duty and looked at log books and reports and there were no concerns. Review of the invoice dated 5/28/26 documented, verbal report of fly activity throughout the building. DOM #9 confirmed the findings.On 6/30/26 at 10:05 AM the fly concerns were discussed with the Nursing Home Administrator (NHA). The NHA stated he was aware of the issue and that he called the pest control company to talk to a supervisor.

Based on review of facility reported incident 3044296, documentation review, and interviews, it was determined the facility failed to report an alleged abuse immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #3) of 2 residents reviewed for 2 facility reported incidents during a complaint survey. The findings include:On 6/29/26 at 11:00 AM a review of facility reported incident 3044296 was conducted and revealed Resident #3 alleged that Certified Medicine Aide (CMA) #17 refused to give Resident #3 his/her breakfast tray until Resident #3 took his/her medication. On 6/15/26 at 2:30 PM Resident #3 was interviewed by the Nursing Home Administrator (NHA) and the Unit Manager (UM). According to the facility report, Resident #3 stated that the incident happened the previous Saturday or Sunday. Review of a written statement from Physical Therapy Assistant (PTA) #14 documented that he went to see Resident #3 on 6/14/26 at 2:00 PM and the resident informed him that CMA #17 withheld the resident's lunch because the resident would not take his/her medicine and today, 6/15/26 at 12:30 PM the resident told him that the same thing happened at breakfast. Review of an email dated 6/17/26 from Geriatric Nursing Assistant (GNA) #18 documented that the resident told her that he/she reported it on 6/4/26 to the nurse at the desk. Review of Licensed Practical Nurse (LPN) #15's statement documented that the pulmonary nurse practitioner (NP) reported to her that Resident #3 made accusations that staff had twisted the resident's arm and legs and that everyone was aware. LPN #15 documented that she went to interview the resident and the resident stated that he/she reported it on 6/11/26 to the nurse. On 6/30/26 at 3:27 PM an interview was conducted with PTA #14 who stated that Resident #3 had reported to him that he/she did not have breakfast because CMA #17 told the resident if he/she did not take the medications that he/she would not receive breakfast. He said the resident stated that it happened 2 times. PTA #14 stated he saw the resident on 6/14/26 at 2:00 PM and that is when Resident #3 told him that his/her breakfast was withheld that day and when he went back to see the resident on 6/15/26 at 12:30 PM the resident told him the same thing happened again. PTA #14 was asked if he reported it to anyone on 6/14/26 and he said, I did not tell my supervisor on 6/14/26, so I forgot to tell my supervisor until the next time [he/she] said the same thing again. I told my director and that was it. We received education after that but if you forget you forget. The surveyor read the statement back to PTA #14 with another surveyor in the room and he confirmed the statement. PTA #14 stated, [his/her] leg was not turned, it was just that [his/her] breakfast was withheld. On 6/30/26 at 3:40 PM an interview was conducted with Resident #3. Resident #3 stated that he/she was not going to take a silly pill so she (CMA #17) put her hands under my blanket and wrenched my knee cap. It was the first time. I went to report her. That night she told everyone to withhold my food. I called the police and told them that she was holding my food back. It happened more than 1 day with [name of CMA #17]. I told someone at the desk and they wrote it down. I asked them to report it to the director. The surveyor asked Resident #3 if his/her food was withheld more than 1 day and he/she replied, yes.On 7/1/26 at 8:24 AM the Director of Rehabilitation (DOR) #13 was interviewed and stated that she did have a conversation with PTA #14 about reporting immediately to the nurse. The DOR stated, for us we should report it to the nurse. I don't work on Sundays. You tell the closest nurse in management. He did say he forgot after it happened the first time.On 7/1/26 at 8:40 AM the NHA was informed of the surveyor's findings of facility staff not reporting timely. The NHA stated he found out from rehab, and he was putting a plan in place.

Based on medical record review and interview, it was determined the facility staff failed to administer medications timely. This was evident for 1 (Resident #6) of 4 residents reviewed during a complaint survey. The findings include:Review of Complaint 2988557 was conducted on 6/29/26 regarding the timeliness of administration of medications for Resident #6.Review of Resident #6's medical record on 6/29/26 revealed the Resident was admitted to the facility in February 2026 with a diagnosis to include Dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.Review of Resident #6's physician medication orders revealed the Resident was ordered on 2/27/26 Pantoprazole Sodium 40 mg give in the morning for GERD (Gastroesophageal Reflux Disease) and Synthroid 75 mcq one time of day for thyroid. Review of Mayo Clinic guidelines on administration of Pantoprazole and Synthroid revealed they are recommended to be given at least 30 minutes before a meal.Review of Resident #6's June 2026 Medication Administration Audit Report on 6/30/26 with the Director of Nursing revealed the Resident was scheduled to receive Pantoprazole and Synthroid daily at 6 AM. Further review revealed the Resident did not receive those medications timely on the following dates:6/2/26 Administered at 9:48 AM6/3/26 Administered at 8:26 AM6/11/26 Administered at 12:37 PM6/20/26 Administered at 8:21 AM6/24/26 Administered at 8:10 AM6/27/26 Administered at 10:52 AM6/28/26 Administered at 9:19 AMInterview with the Director of Nursing on 6/30/26 at 2:30 PM confirmed the facility staff failed to administer Pantoprazole and Synthroid to Resident #6 timely in June 2026.

Based on medical record review and staff interview it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers as ordered for a resident. This was evident for 1 (Resident #4) of 3 residents reviewed during a complaint survey. The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed).Review of a Complaint 3017918 was conducted on 6/29/26 regarding the care of Resident #4.Review of Resident #4's medical record on 6/29/26 revealed the Resident was admitted to the facility in February 2026 with a diagnosis to include muscle wasting and atrophy. Muscle wasting is the wasting or thinning of your muscle mass, often from aging or inactivity. 1) The facility staff failed to provide treatment as ordered to prevent pressure ulcersReview of Resident #4's physician orders revealed on 3/31/26 the Resident was ordered skin prep two times a day for boggy heels. A boggy heel is typically caused by excess fluid and can be an early indicator of a developing heel pressure injury. Review of Resident #4's April and May Treatment Administration Records revealed the facility staff failed to administer the skin prep on the following dates at 10:00 PM: 4/8, 4/19, 4/22, 4/24, 5/4, 5/7 and 5/14/2026.Interview with the Regional Nurse on 6/30/26 at 1:46 PM confirmed the facility staff failed to administer skin prep to Resident #4's heels as ordered.2) The facility staff failed to provide treatment as ordered for a pressure ulcer.Further review of Resident #4's medical record revealed the Resident was assessed by the Wound NP (Nurse Practitioner) on 5/22/26 for an unstageable pressure ulcer. At that time the Wound NP ordered the facility staff to administer the following treatment twice daily: cleanse with wound cleanser/normal saline. Medical grade honey. Skin prep surrounding tissue or periwound. Bordered dressing. The Resident was assessed by the Wound NP on 5/29/26. At that time the Wound NP ordered the facility staff to administer the following treatment twice daily: cleanse with wound cleanser/normal saline. Medical grade honey. Zinc oxide paste to periwound. Bordered dressing.Review of Resident #4's May 2026 Treatment Administration Record revealed the facility failed to change the sacrum wound treatment orders until 5/30/26 and at that time was only doing once a day instead of twice a day as ordered. During interview with the Regional Nurse on 6/30/26 at 1:46 PM confirmed the facility staff failed to administer the Wound NP's 5/22/26 sacral pressure treatment orders until 5/30/26 and failed to administer the treatments twice daily.

Based on medical record review and interview, it was determined the facility staff failed to assess and monitor a resident's nutritional needs and intervene in a timely manner. This was evident for 1 (Resident #4) of 4 residents reviewed for nutrition during a complaint survey. The findings include:Review of a Complaint 3017918 was conducted on 6/29/26 regarding the care of Resident #4.Review of Resident #4's medical record on 6/29/26 revealed the Resident was admitted to the facility in February 2026 with a diagnosis to include muscle wasting and atrophy. Muscle wasting is the wasting or thinning of your muscle mass, often from aging or inactivity. Further review of Resident #4's medical record revealed the facility staff documented Resident #4's weight on admission 2/18/26 was 164 pounds, 3/6/26 173.4 pounds and 4/9/26 178.6 poundsFurther review of Resident #4's weights revealed the facility staff documented the Resident's next weight on 5/20/26 and it was 156.6 pounds.On 5/22/26 the Resident was seen by the Dietitian who documented: Resident has fair to good PO (by mouth) intake, he/she is triggering for significant weight loss, reweight requested, will assess change after re-weight is obtained.Further review of Resident's medical record revealed the Resident was not reweighed until 6/2/26, 13 days later, with a documented weight of 153 pounds. The Resident was not seen by the Dietitian after the documented re-weight on 6/2/26 and transferred out of the facility on 6/9/26.Interview with the Dietitian on 6/30/26 at 11:43 AM, the Dietitian stated weights should be weekly on admission times 4 then monthly and no further interventions were put in place for the Resident after the 5/20/26 documented weight loss.Review of the facility's Weight Monitoring policy implemented on 2/15/24 revealed it stated: A weight monitoring schedule will be developed upon admission for all residents: Newly admitted residents-monitor weekly for 4 weeks. All others-monitor weight monthly.Interview with the Regional Nurse on 6/30/26 at 1:15 PM confirmed Resident #4 was not weighed weekly on admission times 4 and no additional nutritional interventions were put in place after the documented 5/20/26 weight loss.

Based on a review of facility reported incident 3044296, complaints 3044605, 3017702, 2980425, medical record review, and interviews, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 3 (Residents #3, #5, #7) of 8 residents reviewed for 9 intakes reviewed on a complaint survey. The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 6/29/26 at 11:00 AM a review of complaint 3044605 and facility reported incident 3044296 were conducted regarding an abuse complaint from Resident #3. Review of complaint 3044605 alleged that Resident #3 stated on 6/8/26 Certified Medicine Aide (CMA) #17 physically assaulted Resident #3. Resident #3 refused to take his/her medication and Resident #3 threw an inhaler at CMA #17 and then CMA #17 grabbed Resident #3's wrist and twisted it. Resident #3 stated that on 6/11/26 he/she again refused to take his/her medication and CMA #17 grabbed and twisted the resident's leg while in bed and again in the evening of that same day Resident #3 refused to take medication, so his/her dinner/food was withheld because he/she had not taken his/her medication. Resident #3 claimed there were injuries, however there were no obvious signs of injuries to the right wrist, but there was a large bruise on the back of the resident's hand by the thumb. However, the resident claimed that bruise resulted from him/her accidentally getting his/her hand caught between the bed frame and the wheelchair. Review of facility reported incident #3044296 documented that the social worker was notified by the ombudsman on 6/15/26 at 11:15 AM that there was a complaint that came in about Resident #3 regarding abuse. Review of both the complaint and the facility reported incident documented that police were notified and came to interview the resident. There was no documentation found in the medical record that the police ever came to interview Resident #3 and there was no documentation found in the medical record about the allegations that the resident made. Review of Resident #3's medical record revealed a 6/7/26 change in condition note that documented the nurse noted a small spot of bleeding on top of Resident #3's right hand discoloration that per the resident occurred in the dining room on Wednesday. Review of a 6/9/26 alert note documented a new skin condition: a large bruise to the right top of the hand, which the resident stated he/she hit on the footboard. Review of a 6/12/26 physician's note documented that the resident was found on the floor and questioned whether he/she fell out of bed, but he/she was found sitting on the floor at the bedside. The resident did not have any injuries but was noted several days ago to have an injury to the right hand that the resident blamed on the wheelchair apparatus. It was simply a bruise on the anterior surface of the resident's right hand, and it was healing well. No further documentation was found regarding any allegations of meals being withheld or accusations of abuse. On 6/30/26 at 9:17 AM Nurse Practitioner (NP) #10 was interviewed and stated that Resident #3 would tell her about people that have predeceased the resident and that the resident was waiting for them to come see him/her. NP #10 stated that Resident #3 cannot make difficult decisions and had mild cognitive impairment. NP #10 stated, I am not aware of any assault and I saw [him/her] the next day and [he/she] did not report any of this to me. NP #10 stated that Resident #3 will occasionally mention delusions about the opposite sex. NP #10 stated that she would put in for a psych (psychiatry) evaluation. NP #10 reviewed Resident #3's medical record with the surveyor and questioned why there was no documentation in the medical record about Adult Protective Services (APS) coming out and the Sheriff. NP #10 stated that if she had known the Sheriff had come out that she would have gone right in to see the resident. Further review of the medical record failed to produce a psych note. There was a typed note in the documentation with facility reported incident #3044296 that was not dated and not signed and was assumed to be from psych. On 7/1/26 at 8:40 AM the Nursing Home Administrator (NHA) stated he was aware that there was no documentation in the medical record about the police coming to the facility to see Resident #3. The NHA stated the undated and unsigned note was from psych and the psych note was not put in the medical record timely. 2) A review of Complaint 3017702 was conducted on 6/30/26 regarding Resident #5's fall on 5/17/26. Review of Resident #5's medical record on 6/30/26 revealed the Resident was admitted to the facility in 2024 with a diagnosis to include Dementia. Dementia is an umbrella term for a decline in memory, thinking or reasoning skills that is severe enough to impair a person's ability to perform everyday activities. Further review of Resident #5's medical record revealed the Resident had an unwitnessed fall on 5/17/26. Review of a nurse's note on 5/17/26 at 4:30 AM stated: Patient found on floor at bedside. Head to toe assessment performed. 2 cm laceration to right brow. Provider notified who recommended first aide and fall protocol. During interview with the Regional Nurse on 6/29/26 at 4:08 PM, the Regional Nurse stated for an unwitnessed fall the facility staff would be expected to perform neuro checks on the Resident. A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. Further review of Resident #5's medical record revealed no neuro checks in the medical record. On 6/30/26 at 10:49 AM the Director of Nursing (DON) presented the Surveyor the neuro checks for Resident #5 for 5/17/26. At that time the DON stated the neuro checks were not in the Resident's medical record but in a file in her office to be uploaded into the medical record. The DON added she has not had time yet to upload them. 3) Review of Resident #7's medical record on 6/29/26 revealed the Resident was admitted to the facility on [DATE]. Review of the Resident's hospital discharge summary revealed it stated the Resident's cognition and memory are impaired. Observation of Resident #7 on 6/29/26 at 12:45 PM revealed the Resident is on the locked Dementia unit. Further review of Resident #7's medical record revealed the facility assessed the Resident on 5/12/26 to have a BIMS (Brief Interview for Mental Status) of 5 of 15, indicating severe cognitive impairment. Further review of Resident #7's medical record revealed the facility staff assessed the Resident's elopement risk on 6/4 and 6/29/26 and scored the Resident a 0 indicating the Resident is not an elopement risk. Interview with the Administrator on 6/30/26 at 7:48 AM, the Administrator was asked why the Resident was on the locked Dementia unit. The Administrator stated the Resident was trying to leave the facility and can be very confused. During interview with the Regional Nurse on 6/30/26 at 4:18 PM, she confirmed the 6/4 and 6/29/26 Elopement Risk Evaluations were inaccurate assessments and Resident #7 is an elopement risk.

Based on interview, record review, document review, and facility policy review, the facility failed to protect a resident's right to be free from physical and verbal abuse by staff for 1 (Resident #3) of 10 sampled residents reviewed for abuse. It was determined the non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, at a scope and severity of J.The IJ began on 02/05/2026 when the Administrator verbally and physically abused Resident #3.The survey team notified the Administrator and Director of Nursing of the IJ and provided the IJ template on 03/24/2026 at 2:17 PM. Beginning 02/12/2026 until 02/24/2026, the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past non-compliance was cited with a compliance date of 2/24/2026.Findings included:A facility policy titled, Abuse, Neglect and Exploitation, revised 03/25/2025, indicated, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The policy specified, Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment and Verbal Abuse mean the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.An admission Record revealed the facility admitted Resident #3 on 12/06/2024. According to the admission Record, the resident had a medical history that included diagnoses of dementia, post-traumatic stress disorder, and generalized anxiety disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2025, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Per the MDS, Resident #3 used tobacco and did not exhibit any physical or verbal behaviors directed toward others during the assessment period. The Facility Reported Incident [FRI] Initial Report Form submitted by the Chief Nursing Officer (CNO) on 02/12/2026, revealed on 02/05/2026 a verbal exchange occurred during a resident smoke break that involved the Administrator and Resident #3. Per the FRI Initial Report Form, initial reports and observations indicated an interaction escalated and Resident #3 engaged in physical contact with the Administrator; however, subsequently Resident #3's resident representative (RR) reported an allegation that the Administrator might have made physical contact with Resident #3 prior to the resident's physical response. The FRI Initial Report Form indicated this information was not known at the time of the initial observation, was received after the event, and the matter remained under investigation.During an interview on 03/17/2026 at 11:32 AM, Resident #3 stated on the day of the incident (02/05/2026), there was a resident smoke break and usually only four residents were allowed out at the smoke break at one time, but the Administrator made a mistake and let all the residents out who wanted to smoke at the same time. Resident #3 stated they were smoking and minding their own business when all of a sudden the Administrator started to call them racial slurs. Resident #3 stated they never got along with the Administrator because she always tried to start something with them. Resident #3 stated they were trying to get back in the building but the Administrator kept hitting them, so they choked the Administrator to get her out of their way. Resident #3 stated they did not want to hurt the Administrator, they just wanted her out of their way. According to Resident #3, there were multiple residents and staff that witnessed the incident.Contained within the facility's investigation file was Certified Nursing Assistant (CNA) #1's handwritten Witness Statement Form completed 02/05/2026, which indicated 'I [CNA #1] witnessed admin [Administrator] standing in front the door stopped [Resident #3] from coming in the building at which they asked for the code to open the door at which another aide open the door and administration [Administrator] pushed the door back closed and said no which amplified the situation and [Resident #3] had become aggressive after she [Administrator] kept pushing on [Resident #3].During an interview on 03/18/2026 at 2:07 PM, CNA #1 stated she was sitting at the nursing station when she heard an activity staff person yell for help. CNA #1 stated as she approached the door, she saw the Administrator standing in front of the door screaming no to Resident #3. CNA #1 stated she saw Resident #3 trying to get around the Administrator but the Administrator kept blocking the door and was not letting Resident #3 come in. CNA #1 stated she witnessed the Administrator push Resident #3 in their chest two times in an attempt to move the resident from the door, all while screaming no at the resident. CNA #1 stated then all of a sudden she saw Resident #3 grab the Administrator's neck and pressed her against the door. CNA #1 stated the activity aide (AA) was present and separated Resident #3 and the Administrator.During an interview on 03/23/2026 at 12:18 PM, AA #31 stated on 02/05/2026 as she walked by she saw Resident #3 and the Administrator both shoving each other. AA #31 stated she did not hear what was being said, but when she approached the door to put the code in so that the door would open, the Administrator screamed no and repeatedly stated do not open the door. AA #31 stated the next thing she saw was Resident #3 choking the Administrator. AA #31 stated she screamed for help and more staff came to help.Contained within the facility's investigation file was Resident #9's handwritten Witness Statement Form completed 02/09/2026, which indicated On Thursday [02/05/2026] at the smoke break, I [Resident #9] saw the administrator [Administrator] push [Resident #3] after [Resident #3] tried to come back in facility with cigarette [half] one. She [Administrator] pushed [Resident #3] back again then used the N word [a racial slur].After the N word was used [Resident #3] grabbed her [Administrator] by the throat.During an interview on 03/17/2026 at 2:00 PM, Resident #9 stated they witnessed the incident between Resident #3 and the Administrator. Resident #9 stated Resident #3 wanted to come in facility and the Administrator blocked Resident #3 from going in the facility because the resident had a cigarette. According to Resident #9, the Administrator wanted Resident #3's cigarette and would not let the resident in the facility. Resident #9 stated Resident #3 kept trying to get in and then after a few blocks, the Administrator pushed Resident #3 in their chest and the resident rocked back. Resident #9 stated Resident #3 tried to enter the code on the key pad again in an attempt to enter the facility. Resident #9 stated it was at that time, the Administrator called Resident #3 a racial slur and that set Resident #3 off and the resident choked the Administrator. Resident #9 stated Resident #3 did not put their hands on the Administrator until after the Administrator called Resident #3 a racial slur. A quarterly MDS, with an ARD of 01/06/2026, revealed Resident #9 had a BIMS score of 15, which indicated the resident had intact cognition. Contained within the facility's investigation file was Resident #10's handwritten Witness Statement Form undated which indicated The administrator stopped [Resident #3] from going in the door to come back in. The administrator [Administrator] pushed [Resident #3] away from the door because [Resident #3] was bringing [his/her] cigarette back in. When the administrator pushed [Resident #3] she also used the N word when she put her hands on [Resident #3] & used the N word is when she was choked by [Resident #3].During an interview on 03/17/2026 at 2:13 PM, Resident #10 stated Resident #3 was trying to come in the facility from a smoke break. According to Resident #10, the Administrator stated Resident #3 had a cigarette in their hand, but the resident did not Resident #10 stated the Administrator shoved Resident #3 in chest real hard maybe three times and Resident #3 kind of fell against the door, but did not fall down. Resident #10 stated Resident #3 kept trying to put the code in on the key pad to open the door. Per Resident #10, the Administrator called Resident #3 a racial slur and Resident #3 got mad. A quarterly MDS, with an ARD of 11/05/2025, revealed Resident #10 had a BIMS score of 15, which indicated the resident had intact cognition. Contained within the facility's investigation file was Resident #11's handwritten Witness Statement Form completed 02/09/2026, which indicated [Resident #3] had half a cigarette [Resident #3] was trying to punch the code in to go inside. I yelled 2x [two times] & said [Resident #3] always keeps [his/her] own cigarette & lighter. She [Administrator] broke her own rule by taking every one out at one time instead of groups as she has stated before. The administrator pushed [Resident #3] 2x then used the N word. [Resident #3] then after that choked her.Contained within the facility's investigation file was Resident #16's Witness Statement Form completed by Social Services Director (SSD) #29 on 02/12/2026, which indicated [Administrator] gave [Resident #3] two cigarettes and [Resident #3] smoke one and then tried to come back in building. [Administrator] told [Resident #3] [he/she] couldn't go back in the building with the cigarette and to put it back in the drawer. [Resident #3] tried to put numbers in to open the door. [Administrator] blocked the door with her body and then threw her hand to block the key code. At that time voices became escalated and [Resident #3] and [Administrator] started verbally arguing with each other. Resident stated that they were all trying to tell [Administrator] that [Resident #3] always has a cigarette but she wasn't paying attention. [Resident #16] stated that someone tried to get [Administrator] inside but she refused and shut the door stating no. [Resident #3] told her [he/she] does this all the time and tried to get in again. Resident reports that [he/she] did see administrator shove [Resident #3] and [the resident's] hands at her neck, but was trying to get away and could not recall the order of those events.During an interview on 03/17/2026 at 3:28 PM, Resident #16 stated Resident #3 was trying to get inside the facility, but they had a lit cigarette and the Administrator stood in front of the resident with her hand out asking for the cigarette. Resident #16 stated Resident #3 would not give the cigarette to the Administrator and the Administrator blocked the key pad so that Resident #3 could not press the code to enter the facility. Per Resident #16, Resident #3 got pissed and kept trying to enter the facility. Resident #16 stated both Resident #3 and the Administrator started to push each other, but the Administrator pushed Resident #3 in their chest with both of her hands really hard. Resident #16 stated both Resident #3 and the Administrator were screaming at each other and the next thing they knew, Resident #3 started to choke the Administrator. An admission MDS, with an ARD of 01/14/2026, revealed Resident #16 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment.A review of the facility plan of correction revealed the facility initiated corrective actions on 02/12/2026 to remove the immediate jeopardy and correct the failed practices as follows:The Administrator was suspended pending investigation of the abuse allegation on 02/12/2026.On 02/12/2026, a quality assurance (QA) meeting was held with the Assistant Administrator, Maintenance Director, Infection Preventionist, Social Services Director (SSD), Director of Nursing (DON), Assistant Dietary Director, Admissions Director, Minimum Data Set Coordinator, Central Supply Coordinator/Transportation Clerk, unit managers, Activity Director, Scheduling Coordinator, Business Office Manager, and Human Resource Director. The QA team reviewed the case findings for Resident #3. The QA committee developed, reviewed, and approved a corrective action plan, to include auditing progress notes, grievances, behaviors, and risk management.On 02/12/2026 - 02/24/2026, 148 employees were provided an in-service by the Chief Nursing Officer (CNO). The in-service education included but was not limited to abuse policy, smoking policy, and resident rights.On 02/12/2026, a performance improvement plan (PIP) audit worksheet was implemented for any residents admitted to the facility, to ensure they were able to exercise their right to smoke without potential for abuse and accurate investigation of abuse allegations. The PIP audit worksheet was to be completed by DON, CNO, Regional Director of Operations (RDO), or designee daily for seven days, with results of the PIP audit worksheet to be reported to the QA committee for determination of the need for ongoing formal monitoring.On 02/16/2026, the facility conducted interviews with residents who were members of Resident #3's smoking group. These interviews were conducted to determine if the resident was abused, had witnessed abuse, or informed a staff member of abuse.On 02/16/2026, the facility conducted observations of residents who were members of Resident #3's smoking group. These observations were made to determine how the residents were being treated by staff, other residents, or anyone else visiting the facility.On 02/19/2026, the RDO and corporate Human Resource Manager provided in-service education to the Administrator, including de-escalation techniques, smoking policy, abuse prevention, and residents' rights.The facility's alleged date of compliance was 02/19/2026 however, all staff education was not completed until 2/24/26.The survey team reviewed the facility's corrective action plan, in-service education records, monitoring tools, the facility's investigation file, and interviewed residents and staff which revealed the facility implemented corrective actions from 02/12/2026 to 02/24/2026.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure an allegation of resident abuse was reported to the state survey agency (SSA) within two hours for an allegation involving 1 (Resident #3) of 10 sampled residents reviewed for abuse. Findings included:A facility policy titled, Abuse, Neglect and Exploitation, revised 03/25/2025, indicated, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further revealed, VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia, for example], law enforcement when applicable) within specified timeframes; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. An admission Record revealed the facility admitted Resident #3 on 12/06/2024. According to the admission Record, the resident had a medical history that included diagnoses of dementia, post-traumatic stress disorder, and generalized anxiety disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2025, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Per the MDS, Resident #3 used tobacco and did not exhibit any physical or verbal behaviors directed toward others during the assessment period. A Physical Aggression Initiated incident report, completed by Licensed Practical Nurse (LPN) #12 on 02/05/2025, revealed a Nursing Description of the incident that indicated Resident #3 was physically aggressive toward a staff member (Administrator). The section of the report for the Resident Description of the incident indicated Resident #3 stated that they were outside smoking and once done, they threw their cigarette down in the snow, at which time the staff member (Administrator) instructed them to pick it up. The report indicated that Resident #3 reported that they declined to pick up the cigarette, and the staff member began pushing them. Per the report, the resident reported that they also had an unlit cigarette with them, and the Administrator asked that the resident hand it over, and the resident again refused and informed the Administrator they had always kept their cigarettes in their possession. The resident alleged the Administrator then started pushing them again while saying the resident was not listening, so Resident #3 choked the Administrator. The incident report included statements from two staff members, Certified Nursing Assistant (CNA) #1 and CNA #33. CNA #33's attached statement indicated that around 4:15 PM, she responded to a request for help, and upon her arrival, Resident #3 was trying to get into the building, but the Administrator was blocking the door, and the Administrator and Resident #3 were shoving each other back and forth. Per the statement, CNA #33 opened the door to let Resident #3 or the Administrator inside in an attempt to deescalate the situation, but the Administrator slammed the door back closed with her body and hollered, No, which triggered the resident further. Per CNA #33's statement, the Administrator shoved the resident back again, and the resident then choked the Administrator. CNA #1's statement indicated she witnessed the Administrator standing in front of the door blocking Resident #3 from reentering the building, and another CNA (CNA #33) opened the door, but the Administrator pushed the door back closed and said no, which amplified the situation. CNA #1's statement further indicated Resident #3 became aggressive after she [Administrator] kept pushing on [the resident].A Facility Reported Incident [FRI] Initial Report Form, dated 02/12/2026, revealed the Chief Nursing Officer (CNO) submitted an initial report for the 02/05/2026 incident involving Resident #3 and the Administrator to the SSA on 02/12/2026 at 3:50 PM. During an interview on 03/18/2026 at 8:16 AM, LPN #12 stated staff were to report any witnessed or alleged resident abuse immediately, within two hours. She stated she was the nurse working on 02/05/2026 when the incident occurred between Resident #3 and the Administrator. She further stated that CNA #33 reported to her that following a smoke break, the Administrator provoked Resident #3. LPN #12 stated that she also interviewed Resident #3, who reported the Administrator yelled at them and pushed them. Per LPN #12, she notified Resident #3's family, the local police, the Director of Nursing (DON), and the Medical Director (MD). During an interview on 3/25/2026 at 10:27 AM, the Regional Director of Admissions (RDOA) stated that any abuse should be reported immediately. The RDOA then reviewed CNA #1's statement from 02/05/2026 and confirmed the information did represent an allegation of abuse and should have been reported immediately. The RDOA stated he did not know why the initial report was not submitted on 02/05/2026. During an interview on 03/27/2026, the Regional Administrator stated that the facility should submit initial reports of abuse within two hours of receiving an allegation.A review of the facility's plan of correction revealed the facility initiated corrective actions on 02/12/2026 as follows:On 02/12/2026, a quality assurance (QA) meeting was held with the Assistant Administrator, Maintenance Director, Infection Preventionist, Social Services Director (SSD), Director of Nursing (DON), Assistant Dietary Director, Admissions Director, Minimum Data Set Coordinator, Central Supply Coordinator/Transportation Clerk, unit managers, Activity Director, Scheduling Coordinator, Business Office Manager, and Human Resource Director. The QA team reviewed the case findings for Resident #3. The QA committee developed, reviewed, and approved a corrective action plan, to include auditing progress notes, grievances, behaviors, risk management, timely reporting of abuse, and collection of witness statements.On 02/12/2026 - 02/24/2026, 148 employees were provided an in-service by the Chief Nursing Officer (CNO). The education included but was not limited to the facility's abuse policy. The education included information about mandatory reporters and the facility's responsibility to ensure timely internal reporting as well as external reporting to the SSA for all allegations of abuse.The survey team reviewed the facility's corrective action plan, in-service education records, monitoring tools, the facility's investigation file, and interviewed residents and staff which revealed the facility implemented corrective actions from 02/12/2026 to 02/24/2026.

Based on the review of facility reported incident # 2602973, medical records, facility documentation, interview with facility staff, and observation, it was determined that the facility failed to 1) protect a cognitively impaired resident (Resident #50) from physical abuse by a resident (Resident #21) with a known history of verbal and physical aggression towards staff and residents. This was evident for 1 (Resident #50) of 4 residents reviewed for abuse during the annual survey. 2) In a separate occurrence, not Immediate Jeopardy, the facility also failed to prevent resident to resident physical abuse. This was evident for 1 of 3 (Resident #93) reviewed for behaviors during the annual survey. The Maryland Office of Health Care Quality (OHCQ) determined that the facility's failure to protect a cognitively impaired resident from physical abuse from another resident met the Federal definition of Immediate Jeopardy, and the facility was notified of Immediate Jeopardy at 2:50 PM on 9/25/2025. The facility developed a plan sufficient enough to remove immediacy which was reviewed and accepted by OHCQ after 4 attempts at 7:38pm on 9/25/2025 while surveyors remained onsite. The plan was verified on 9/26/25 and Immediate Jeopardy was abated on 9/26/25 at 3:12 pm. The findings include: 1) On 09/22/2025 at 11:12 AM a phone interview with the complainant for Resident #50 was conducted, and he/she stated that Resident #50 was attacked by another resident and that is how an injury was obtained. On 09/23/2025 at 11:23 AM in Review of Resident's #21's medical record revealed: On 02/03/2025 at 10:41 PM a Nurse Practitioner progress note stated Resident #21 was previously a resident at another Nursing Home Facility and was Emergency Petitioned (a form filed with the court that is for situations where a resident shows symptoms of a mental disorder and presents a danger to their life or safety or the safety of others, and cannot or will not voluntarily seek treatment.) to the hospital on 1/23/25 for homicidal ideations. He/she verbalized that he/she was going to kill everyone and noted it was because they pluck my last nerve. On 02/15/2025 a Physician Progress note, stated Resident #21 was sent to the emergency room from another facility secondary to making threats to kill other residents. On 4/23/2025 a Psychiatric Eval and Consultation report for Resident #21 stated, Increased behaviors including physical contact is reported. On 5/28/2025 at 5:40 PM a progress note indicated that Resident #21, expressed vulgar language towards other residents and staff for unknown reasons. On 6/2/25 at 2:04 PM a progress note revealed that Resident #21, upon assessment, verbal aggression with derogatory slander was heard from resident while punching his fists in own hands repeatedly, related to another resident coming into his/her room without permission. On the date of service of 6/6/2025 a Psychiatric evaluation and consultation for Resident #21 stated, low mood and low energy remain present, sleep disturbance. On 06/06/2025 at 9:17 PM a Nurse Practitioner Progress note stated, Resident #21 has been noted to be yelling out. He/she has been using derogatory slander. He/she has been punching his fists into the air and into his own hands repeatedly. He/she has been upset about other residents coming into his/her room without permission. Aggression does occur frequently. Under Assessment in Plan: Continue to monitor closely. On 6/17/2025 at 07:02 AM, a progress noted stated, Resident #21 was heard yelling at the roommate. Resident #21 continues yelling out. Staff attempting to redirect without success. Further review of Resident #21's medical record revealed that there was no plan of care in place from the time of admission on [DATE] until 08/16/2025 for Resident #21's history of homicidal ideations, abusive behaviors, or aggression towards residents or staff. (A care plan is a document that summarizes health conditions, specific care needs, and current treatments. It should outline what needs to be done to manage the person & Resident #21's care needs.) On 09/23/2025 at approximately 11:30 AM in review of Resident's #50's medical record revealed the following: On 08/16/2025 at 6:50 PM a Change in Condition Evaluation revealed Resident #21 was heard yelling, when writer got to Resident #21's room, Resident #50 was on the floor in a puddle of blood on side with laceration above right eye. Resident #21 was yelling, I told him/her out of my bed and punching his/her fist in his/her hand in rage, separated from aggressor, Resident #50 was sent out by 911. On 08/16/2025 at 7:58 PM a Progress note, Resident heard yelling while this writer at nurses' station, med aide went into room came out yelling he had thrown resident in the floor. When this writer got to the room resident yelling I told her get him/her out of my bed so he/she got him/her out him/her self, in a wheelchair was punching his fist stating and I will do it again. The Nurse Practitioner (NP) was notified and came to see the resident to review medications. On 08/16/2025 at 8:42 PM an Emergency Provider Note indicated that Resident #50 presented to the emergency room after a fall, was pulled out of bed by another resident that resulted in a fall to the ground with a laceration. Right eyebrow laceration was 2.5 CM (centimeters) in length and required 3 sutures. On 08/16/2025 at 10:42 PM, an Emergency Department (ED) provider notes that stated Resident #50 included a history of severe dementia. Per Emergency Medical Services (EMS) Resident #50 walked into another resident's room into another resident's bed and was pulled out and fell to the ground and hit their head, was noted to have a laceration. The resident required 3 sutures to the right eyebrow. Further review of Resident #21's medical records revealed a care plan initiated on 8/16/25, with a focus of physically aggressive behavior: the resident is physically aggressive to other residents related to a post physical altercation of pulling another resident out of his/her bed. with interventions of 1) Administer medications as ordered. Monitor/document for side effects and effectiveness. 2) Medication review by MD. 3) Psych consult related to physical aggression. However, the care plan was only placed after the physical aggression occurrence involving injury of Resident #50 and did not include non-pharmacological interventions (methods that use non-medicinal approaches to manage distress, agitation, or inappropriate behaviors, focusing on environmental, social, and personal adjustments rather than medications) and/or de-escalation techniques for Resident #21's continued aggressive behavior. On 08/17/2025 at 1:26 AM, a Progress note for Resident # 50 indicated, came back from hospital with 3 sutures placed to forehead bruising noted to the right side of face and eye.On 09/23/2025 at approximately 11:40 AM review of Facility Reported Incident #2602973 on 08/16/2025, revealed the following: Resident #50 had a laceration above the right eye. The allegation of resident-to-resident abuse was verified by witness statements collected from staff present at time of the altercation. Resident #21 pulled Resident #50 out of Resident #21's bed without waiting for staff to assist and redirect Resident #21 prior to physical abuse towards Resident #50. Resident #50 was transferred to the hospital. Continued review of Facility Reported Incident #2602973 revealed the following witness statement: A handwritten statement by Staff # 18 revealed that Resident #21 went to the medication cart and told Staff #18 someone was in his/her bed. Staff #18 told Resident #21, she would get Resident #50 out of the bed, at this point Resident #21 was near Resident #50 and stated, there and yanked Resident #50 out of the bed by the shirt and pants.On 9/23/25 at 2:52 PM during a phone interview, Staff #18 confirmed the investigation statement, adding she was putting away medications when Resident #21 demanded Resident #50 be removed from his bed. Resident #21 then forcefully yanked Resident #50 from the bed, stating, I told you to get him/her out of my bed or I was going to. Staff #18 noted, In the last 6 months Resident's #21's anger has become worse. Further review of the facility reported incident revealed that there no evidence that staff on the unit where Resident #21 was located received education related to Resident #21's aggressive behaviors. On 9/23/2025, at approximately 11:45 AM, continued review of Resident #21's medical record revealed the following: On 08/17/2025 at 1:24 PM a Physician Progress note stated that in review of Resident #21's record, the response of Resident #21, was provoked and pushing Resident #50 out of his/her bed to the floor causing injury was excessive as he/she has been prone to aggressive behavior in the past. On 8/17/25 a Psychiatric report, revealed Resident #21, has exhibited episodes of aggression and agitation towards staff and peers. Resident #21 has been verbally abusive towards both staff and his peers. Plan: Melatonin 3 mg by mouth at bedtime.On 8/23/25 at 6:30 PM a progress note revealed, verbal aggression towards staff, generally aggressive demeanor, successfully verbally redirected and back in his room.On 9/07/25 at 12:26 PM a progress note revealed Resident #21, used profanity and derogatory language toward staff and other residents for no apparent reason.On 9/09/25 at 10:34 AM a progress note stated that. Resident #21 proceeded to use profanity and derogatory remarks upon assessment insulting staff stating, with that black a** baby inside of you b***h, to our pregnant staff member offering assistance. Further review of Resident's #21's medical record revealed a Care plan dated 9/09/25 with a focus of the resident has a behavior problem related to verbal aggression toward residents and staff. With one Intervention to assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. However, the care plan did not include additional non-pharmacological interventions or de-escalation techniques for Resident #21's continued aggressive behavior. Additionally, there was no evidence that staff had received training in behavior management. Such training would focus on assisting residents in developing more appropriate coping or interaction methods, and/or expressing their feelings suitably.On 9/10/25 at 7:24 AM a nurse's note stated, Resident #21 is sitting in the dining room threatening the staff and other residents. The resident is stating that he will beat everyone's ass one on one. Nursing staff was unable to redirect Resident #21. On 9/10/25 at 7:57 AM a nurses note stated, Resident #21 was attempting to self-transfer from a wheelchair to a regular chair, the resident started screaming I will do what I want to do bitch and if you stop me, I will have every cop and news station in this place. Resident attempted to be redirected with no success at this time. On 9/10/25 at 8:56 AM a nurse note stated, Resident #21 was educated again on the importance of asking for assistance, the resident then became irate and tried to flip to a table over in the dining room. The Resident threatened staff stating he was going to kill all of us. On 9/10/25 at 12:26 PM: a progress noted stated, Resident #21 attempted to stand up again without assistance. When the resident was asked to sit back down, the resident proceeded to say I will slit everyone's throat in here. On 09/10/2025 at 12:35 PM a nurse progress note stated, Responsible Party (RP) called and {was}notified a clinical social worker {was} sending {resident #21} out for a mental eval due to the resident having the intent and means to hurt someone.On 9/10/25 at 2:52 PM a Nurse Practitioner Note stated, seen today for an acute visit. Resident with extreme behaviors, including racial slurs, using profanity and vulgar language. The resident verbalized to several staff members that he was going to slit their throats as well as making gestures to insinuate strangling them around their neck. Resident #21 was unable to be calmed or redirected and could not care plan for safety. With a Plan of the resident sent to the emergency room for evaluation.On 9/11/25 at 2:54 PM a progress note that indicated Resident #21 was readmitted to the facility. On 9/11/2025 late entry at 2:55 PM a Nurse Practitioner Progress Noted revealed, Resident #21 was sent out to hospital due to extreme behaviors and threats. Resident #21 was Emergency Petitioned (EP) to the hospital but no new orders were given. Resident #21 continues to yell out racial slurs. On 9/15/25 at 12:35 PM a progress note stated, Resident #21 was making threats, using profanity and being vulgar toward staff while collecting trays. Resident #21's verbal abuse continued, yelling while standing and making threats then plopping back down into the chair unsafely. The resident states, come closer so I can beat your ass.On 9/17/2025 Psych Note stated: Resident # 21 seen at the request of the facility, due to increased aggression. Resident #21 has been verbally and physically abusive towards staff and residents. The plan is to start Risperdal (an atypical antipsychotic medication used to treat certain mental health conditions) for aggression, titrate melatonin up. Continue to provide nonpharmacological interventions, monitor and document any increase or worsening behaviors, changes in mental status, and encourage participation in activities as tolerated.On 9/17/25 at 12:31 PM a progress note revealed, Resident #21 was trying to have another resident push him down the hall, and the resident was educated. After being educated, Resident #21 became very belligerent calling nursing staff ni**ers, and b***es and stating was going to kill everyone in this place. resident was attempted to be redirected with no success. On 9/17/25 at 2:34 PM a progress note revealed, Resident #21 continues to threaten staff stating, I will kill you all with a machine gun. Resident #21 then tried to flip the table in the day room. The resident was asked to calm down. Resident #21 then stated shouting I will f***ing hit every single one of you. On 09/18/2025 at 9:56 AM a progress note revealed, Resident #21 cursing and saying racial slurs at staff, unable to redirect, care continues. On 9/18/25 at 10:17 AM a progress note revealed, Resident #21 continues to curse and yell racial names at staff, care continues. On 9/19/25 at 3:02 PM a progress note revealed, Resident #21 continues with baseline behaviors of cursing and yelling at staff. On 9/20/25 at 2:45PM a nurse's progress note revealed, Resident #21 had an episode of cursing at staff this afternoon. On 9/22/25 at 11:30 AM a progress note revealed, Resident #21 is verbally aggressive using loud profanity and vulgar language towards staff in the middle of lunch time, standing up and plopping back down in a chair using punching motions punching his fits into his other hand repeatedly. On 9/22/25 at 1:58 PM a progress note revealed, Resident #21 was screaming and yelling obscenities and making accusatory remarks.On 9/23/25 at 2:30 PM in an interview with Staff #3, stated R #21 is frequently aggressive, requiring intervention. GNA #3 also mentioned witnessing the end of an occurrence with R#50 where R #21 threatened to kill the resident if he/she was to enter his room again. From 9/23/2025 to 9/24/2025 the surveyor interviewed 7 staff on the unit where Resident #21 is located regarding training that included abuse, behavior management, and homicidal/suicidal interventions they stated:-Geriatric Nursing Assistant (GNA) Staff #3, stated she has been employed at the facility for 5 years, she has not received any training since being hired.-Geriatric Nursing Assistant/Certified Medication Tech (GNA/CMA) Staff #18 did not have training, does not remember as it has been so long since having any training.-Licensed Practical Nurse (LPN), Staff #26 stated that she had not received any training since being hired and was hired in May of 2025.-Activities Assistant (AA) Staff #28 stated she has not received any training in the last couple years.-Registered Nurse (RN) Supervisor, Staff #19 stated she has not received any training.-Geriatric Nursing Assistant (GNA), Staff #29 stated she has not received any training through this facility.-Certified Medication Tech (CMA) Staff #27 stated she has not received any specific training. Staff #27 stated that a form may be required for signature, simply stating the obligation to report abuse to a supervisor immediately. On 09/24/2025 at 2:20 PM, during an interview with the Director of Nursing (DON), stated that a resident specific care plan must be developed and updated to address any behavioral changes observed in residents. This plan should include resident-specific interventions and non-pharmacological interventions. On 9/25/25 at 9:31AM, in an interview with the Medical Director, he stated Resident # 21 poses a significant risk of harming other residents if triggers are not identified, as he has the means (fists) and a history of striking others. Staff require de-escalation training for behavior management. Our Psych Services are inadequate, and facilities suffer from the lack of Psych services across the Eastern Shore. These identified concerns were brought to the attention of the facility's Medical Director, Nursing Home Administrator(NHA), and the Director of Nursing(DON) on 09/25/2025 and an Immediate Jeopardy was called on 09/25/2025 at 2:50 PM related to failure to protect a cognitively impaired resident (R#50) from resident to resident abuse from a resident (Resident #21) with a known history of verbal and physical aggression towards staff and residents.The facility developed a plan sufficient enough to remove immediacy which was reviewed and accepted after 4 attempts at 7:38pm on 9/25/2025 while surveyors remained onsite. The facility's abatement plan was accepted by the OHCQ at 3:12 PM on 09/26/2025.The plan included:The following actions were taken to prevent Resident #21 from perpetrating additional abusive behaviors. (Alleged Completion Date: 9/25/25)Six Residents with care plan focuses of verbal or physical aggression were identified and 100% care plans were updated with person-centered non-pharmacological interventions and resident specific triggers and behavioral monitoring orders as applicable.Resident #21 has been on alert charting for aggressive behaviors since 9/18/25.Resident #21 received psych consultation, medication adjustment, and follow-up.Resident #21 was evaluated by psych provider on 9/17/25 and was started on anti-psychotic/hypnotic medication.Resident #21 has therapy scheduled with licensed mental health professionals.Behavior charting upgraded to 1:1 supervision 24:7 on 9/25/25 at 1609 until IDT assessment reviews and confirms a reduction in his behaviors during weekly risk meetings.Resident #21 has been moved from secured locked unit room [ROOM NUMBER]A to private room [ROOM NUMBER]B on 9/25/25 around 1530.IDT reviewed and revised care plans to identify patterns in resident's behaviors of profanity, racial slurs, punching his own fist, yelling, derogatory remarks, and threats on 9/25/25 at 1700. Facility implemented non-pharmacological interventions such as resident preferred food choices such as candy, tv imagery, providing personal space and the freedom to exhibit independence in his personal care on 9/25/25 at 1700. Care plan revisions and interventions communicated to front line staff caring for resident to include providing the Kardex on 9/25/25 at 1745 with new non-pharm interventions.Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 9/25/25)Abuse policies were reviewed/updated to include all sources of abuse, including residents to residents on 9/25/25 by the Chief Nursing Officer.The abuse investigation procedure and documentation process were reviewed and revised on 9/25/25 by the Chief Nursing Officer.Staff Development Coordinator educated, and knowledge checked with a quiz all current working Nurse Aides and Licensed Nurses on de-escalation techniques including abuse policies and procedures on 9/25/25 (19/97 nursing staff=19.6%). Nursing staff will be educated on abuse and de-escalation before clocking in on their next shift according to their working schedules in When to Work. PRN staff will be called in for education and quizzing and if unable to come to the facility they will be educated via phone and quizzed by nurse management. 100% of nursing staff will be educated by 09/25/2025. Ongoing behavior documentation will be monitored by the Director of Nursing and Nurse Management daily during clinical morning meetings, and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by nurse management.Social Service Director to start discharge planning immediately for Resident #21 on 9/25/25, Resident accepted to another facility with transfer on 9/26/25.The Survey team confirmed the facility followed their abatement plan and the Immediate Jeopardy was abated on 09/26/2025 at 3:12 PM 2) On 09/22/2025 at 12:31 PM an observation of Resident #93 in his/her room lying on bed, no staff were present.On 09/24/2025 at 9:45 AM a review of Resident #93's medical record revealed the following progress notes:On 7/15/2025 at 3:54 PM a Progress Note revealed, Resident #93, keeps hitting female residents.On 7/25/2025 at 11:03 AM a progress note revealed, Resident #93, was sitting at table in dining room, asking another resident for his/her money, who declined to have his/her money, Resident #93 began hitting the resident in the neck, both residents separated.On 8/29/2025 at 4:51 PM a Nurse Practitioner Note stated of note, another resident was sitting in the dining room eating dinner. The resident was singing while sitting there, and Resident #93 told the other resident to shut up. The other resident did not stop singing, so Resident #93 slapped the other resident in the face with an open hand. No injuries were noted to either party.On 9/10/2025 at 2:26 PM a progress note stated, Resident #93 was observed hitting another resident in the dayroom. Resident #93 was observed to have another resident by the shirt smacking the other residents back with an open hand. Resident #93 stated that the other resident had his book. Residents were separated and assessed for any injuries. Further review of Resident #93's medical record revealed a care plan created on 07/25/2025 with a Focus of the resident has a behavior problem related to physical aggression towards other residents and staff. with an intervention initiated on 07/25/2025 that indicated, Resident will have 1:1 supervision. However, there was no evidence that the resident was under 1:1 supervision, nor was the plan of care revised to include new interventions aimed at preventing physical aggression toward other residents.On 09/24/2025 at 1:14 PM, in an interview, Staff #33 stated there were no current residents on a 1:1 Supervision on the unit where Resident #93 resided. Staff #33 clarified that a 1:1 supervision requires a completed form and presented Surveyor a form, titled Safety check log Employee #33 stated the form would be kept either in the resident's paper chart or electronic medical record. Staff #33 stated that this level of supervision mandates a staff member to remain with the resident, only being relieved by another staff member for breaks. During the interview, Resident #93 approached the nurses' station without being accompanied by any staff.On 09/24/2025 at 2:20 PM, in an interview the Director of Nursing (DON) stated, the 1:1 supervision staff would be with the resident and the process involves GNA/staff documentation of observations on a paper form, uploaded to the electronic medical record. Staff are informed via a form at the nurses' station and during shift changes, as it's a care plan intervention. Care plans are revised for behavioral changes or resolved if not applicable. A 1:1 intervention continues until the behavior no longer exists and then should be resolved from the plan of care. The Surveyor inquired about Resident #93's 1:1 documentation; the DON stated there was none and verified that the behavior care indicated an intervention for 1:1 supervision. At this time concerns were shared with the DON.

Based on interviews with facility staff and review of pertinent documentation, it was determined that the facility failed to employ a qualified social worker on a full time basis in a facility licensed with more than 120 beds. The facility is licensed for 135 beds. This deficient practice was found to be evident during the facility's recertification/complaint survey and has the potential to affect all residents. The findings include:On 9/23/25 at 9:41 AM in an interview with Social Worker Designee (SWD #6) she stated she was not licensed or certified. During the interview she stated she had worked at the facility for 1 year, been in the Social Services position for 5 months, and that prior to this position she was a certified medicine aide.On 9/23/25 at 12:35 PM the surveyor requested SWD #6's degree and credentials qualifying her for the Social Worker position; however, by the exit of the survey team on this day, no documents were provided. On 9/23/25 at 5:25 PM review of SWD #6's employee file revealed an application for the Social Work Designee position. In the Record of Education section under college it revealed, Health as the course of study and that it was a certificate program. On 9/24/25 at 9:43 AM in an interview with the Director of Nursing she verified and confirmed that the facility does not have the qualifying degree/credentials to provide for SWD #6.The concern that there was not a qualified social worker on staff was reviewed with the Director of Nursing throughout the survey and again during exit on 9/25/2025.

Based on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received mandatory communication training. This was evident for 5 (GNA #3, GNA #18, GNA #22, LPN #33, RN #19) out of 5 direct care staff employees reviewed during the Extended Survey investigation portion of the facility's recertification survey. This deficient practice had the potential to impact all residents.The findings include:On 9/23/25 at 5:19 PM in an interview with the Human Resources Director (HRD #20), when asked about the training and education provided to facility staff, she stated the facility did not use an online learning platform like Relias. She stated that all new hires (clinical and non-clinical) completed tasks online for their onboarding and showed the surveyor a printed copy from a binder in her office. When asked for clarification of what it meant to complete a task, she stated the staff read the tasks and then signed off when they finished showing they read through all of them. She verified and confirmed there was no evaluation criteria, written or otherwise, of staff after reading the tasks. Additionally, she stated they completed a 4 hour orientation with her onsite at the facility where they reviewed the onboarding tasks. When asked to share a time estimate for each task, she stated, They [staff] probably just click through them which is why I review them at the orientation. She stated that there were some additional training and in-services provided, but that nursing would have those sign in sheets. On 9/24/24 at 9:35 AM HRD #20 provided the survey team with a copy of the required onboarding tasks, titled Mandatory Staff Education and had written on the first sheet, Onboarding tasks that are completed prior to hire. [5 hours estimated]. In an interview with HRD #20 she verified and confirmed that the 5 hour estimated time was for completion of all the onboarding tasks. Review of the tasks revealed the following topics:- Resident Rights- Abuse/Abuse Prevention/Abuse Reporting- HIPPA (Health Insurance Portability and Accountability Act)- Fire Safety- Infection Control- Bloodborne Pathogens- OSHA (Occupational Safety and Health Act ) Right to Know - Read the Chemical Label- Incident Accident Prevention- Writing a Statement- Aggressive Behaviors- Employee Violence- Body Mechanics- Customer Service- Using the Telephone- Advanced Directives- Dementia Care Tips- Facts about Sexual Harassment- Elopement- Pain Assessment and Management- PoemThe review failed to reveal Communication as an onboarding task for employees in the facility.On 9/24/25 at 9:38 AM Geriatric Nursing Assistant (GNA #3's) employee file was reviewed. The review revealed she was hired on 1/19/24; however, failed to reveal evidence of communication training. On 9/24/2025 at 9:48AM GNA #18's employee file was reviewed. The review revealed she was hired on 11/7/05; however, failed to reveal evidence of communication training. On 9/24/2025 at 10:17 AM GNA #22's employee file was reviewed. The review revealed she was hired on 11/19/24; however, failed to reveal evidence of communication training. On 9/24/2025 at 10:27 AM Licensed Practical Nurse (LPN #33's) employee file was reviewed. The review revealed she was hired on 9/26/24; however, failed to reveal evidence of communication training. On 9/24/2025 at 12:17 PM Registered Nurse (RN #19's) employee file was reviewed. The review revealed she was hired on 12/24/24; however, failed to reveal evidence of communication training. Staff Educator (SE #23) was interviewed on 9/24/24 at 8:36 AM. The surveyor requested evidence of communication, QAPI, dementia, cognitive impairment/mental illness, and infection control training from 10/1/23 through present. On 9/24/25 at 10:21 AM in an interview with SE #23, HRD #20 and the Director of Nursing (DON), when asked what training she was involved with, HRD #20 stated she only handled the onboarding and 4 hour orientation for all staff. The DON and SE #23 confirmed that HRD #20 only handled the onboarding and 4 hour orientation. The remainder of the interview was conducted with SE #23 and the DON. During the interview when asked what the various methods were used to provide training, in-services, and education to staff, the DON stated outside of the onboarding and orientation, there was a 12 month calendar published by the CNO (Chief Nursing Officer, CNO #1) that ran from January to December. SE #23 and the DON verified and confirmed there was no online learning platform used by the facility to provide education/training to staff.When asked if there was any mandatory training all staff received, SE #23 stated for clinical staff, yes, and it was outlined on the 12 month calendar. When asked if there were any mandatory trainings that nonclinical staff received, SE #23 stated, Not that I provide. You can ask [DON's name]. The DON stated, The head of the departments would do the trainings if they had any. I am clinical so I would refer you to the department heads. When asked about Rehab (physical therapy, occupational therapy and speech therapy) participation in facility trainings, the DON and SE #23 stated that the Rehab staff do not participate in the 12 month calendar education. When asked about the process in place to track staff participation in the required trainings, SE #23 and the DON said, Sign in sheets. Additionally, SE #23 stated, I have not looked or seen them [sign in sheets], but I can get with [Assistant Director of Nursing's (ADON's) name] to find them because she was the facility's previous Staff Educator. SE #23 stated she had only been at the facility as the Staff Educator for about a month.The Activities Director was interviewed on 9/24/25 at 10:48 AM. During the interview she stated there was no mandatory training she provided for her staff. During the interview she stated, I know that HR does some, but no, I do not.The Director of Housekeeping/Laundry was interviewed on 9/24/25 at 12:50 PM. During the interview she stated there was no mandatory training that she provided for her staff. The Director of Rehab was interviewed on 9/24/25 at 1:19 PM. During the interview she stated there was no mandatory training that she provided for her staff. On 9/24/25 at 10:42 AM in an interview with the ADON when asked about evidence of staff trainings she stated, I was the Staff Educator, but only for like 2 weeks and [Licensed Practical Nurse (LPN #33)] was it for like a year. On 9/24/25 at 10:45 AM in an interview with LPN #33 when asked if she was the facility's previous Staff Educator, she stated she had never been the Staff Educator for the facility. During the interview she stated, I believe here that always fell with the ADON. On 9/24/25 at 10:51 AM in an interview with CNO #1 she stated, She [SE #23] was wrong, all staff do attend some of those trainings (and provided the Monthly Education Calendar 2025). [SE #23's name] checked off which trainings were [for] non-clinical [staff also]. When asked for evidence of staff participation in training, education, and in-services, CNO #1 provided the surveyor with 3 binders and 2 manilla folders. When asked for the duration of each training on the 12 month calendar, CNO #1 flipped to one of the pages in the binder, pointed to the line that read length, and stated that the times were listed on the attendance sheets. On 9/24/25 at 10:59 AM review of the Monthly Education Calendar (2025) revealed education on Effective Communication was scheduled for April and October. On 9/24/25 at 11:04 AM review of the 3 binders and 2 manilla folders of staff education, training, and in-services failed to reveal an attendance sheet or any further evidence of an Effective Communication training. On 9/24/25 at 2:06 PM in an interview with Activities Aide (AA #28), when asked if s/he had received any training in 2023, 2024, or 2025 s/he stated no. S/he stated when s/he was hired, s/he had completed some online training but verified and confirmed that s/he had not received any training in 2023, 2024 or 2025. Registered Nurse (RN #39) was interviewed on 9/25/25 at 8:54 AM. During the interview, when asked if s/he had communication training upon hire or since s/he had been employed the facility s/he stated, no. GNA #27 was interviewed on 9/25/25 at 9:05 AM. During the interview, when asked if s/he had communication training upon hire or since s/he had been employed the facility s/he stated, no. On 9/24/25 at 4:13 PM in an interview with SE #23 a dual observation of the 3 binders and 2 manilla folders was conducted. When asked if there was any further evidence of staff participation in educations, in services, or trainings, she stated, No, not to my knowledge and I asked the lady before me, and she did not have anything either. Another request was made to SE #23 to verify if there was any evidence of any communication training for employees and the duration for each training on the 12 month calendar. She said she would check. On 9/24/25 at 4:44 PM in an interview with the DON when asked if there was any further documentation/evidence of staff participation in education, in services, or trainings, she stated, No, there is no further documentation to provide for staff training. The surveyor shared this was a concern and the DON confirmed understanding. On 9/25/25 at 9:29 AM in an interview with SE #23 she stated, [Nursing Home Administrator's name] and [CNO #1's] said we had a survey in 2023, and we do not have any evidence of the training you requested from 2024 or 2025. The surveyor shared this was a concern and SE #23 acknowledged understanding.

Based on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to provide mandatory Quality Assessment and Performance Improvement training to staff. This was evident for 7 (GNA #3, GNA #18, GNA #22, LPN #33, RN #19, DA #41, HA #42) out of 7 employees reviewed during the Extended Survey investigation portion of the facility's recertification survey. This deficient practice had the potential to impact all residents.The findings include:Quality Assurance and Performance Improvement (QAPI) helps long-term care facilities improve the quality of life and care for residents by using a structured, data-driven process to identify issues, address the root causes of problems, and implement solutions. It involves ongoing monitoring, teamwork from all staff levels, and continuous review and revision of plans to ensure a safe, resident-focused environment, and adherence to regulations. As a facility's QAPI program involves input and collaboration from all staff, the term staff includes all new and existing facility staff (with direct and indirect care functions); individuals providing services under a contractual arrangement; and volunteers per the State Operations Manual.On 9/23/25 at 5:19 PM in an interview with the Human Resources Director (HRD #20), when asked about the training and education provided to facility staff, she stated the facility does not use an online learning platform like Relias. She stated that all new hires (clinical and non-clinical) completed tasks online for their onboarding and showed the surveyor a printed copy from a binder in her office. When asked for clarification of what it meant to complete a task, she stated the staff read the tasks and then signed off when they finished showing they read through all of them. She verified and confirmed there was no evaluation criteria, written or otherwise, of staff after reading the tasks. Additionally, she stated they completed a 4 hour orientation with her onsite at the facility where they reviewed the onboarding tasks. When asked to share a time estimate for each task, she stated, They [staff] probably just click through them which is why I review them at the orientation. She stated that there were some additional training and in-services provided, but that nursing would have those sign in sheets. On 9/24/24 at 9:35 AM HRD #20 provided the survey team with a copy of the required onboarding tasks, titled Mandatory Staff Education and had written on the first sheet, Onboarding tasks that are completed prior to hire. [5 hours estimated]. In an interview with HRD #20 she verified and confirmed that the 5 hour estimated time was for completion of all the onboarding tasks. Review of the tasks revealed the following topics:- Resident Rights- Abuse/Abuse Prevention/Abuse Reporting- HIPPA (Health Insurance Portability and Accountability Act)- Fire Safety- Infection Control- Bloodborne Pathogens- OSHA (Occupational Safety and Health Act ) Right to Know - Read the Chemical Label- Incident Accident Prevention- Writing a Statement- Aggressive Behaviors- Employee Violence- Body Mechanics- Customer Service- Using the Telephone- Advanced Directives- Dementia Care Tips- Facts about Sexual Harassment- Elopement- Pain Assessment and Management- PoemThe review failed to reveal QAPI as an onboarding task for employees in the facility.On 9/24/25 at 9:38 AM Geriatric Nursing Assistant (GNA #3's) employee file was reviewed. The review revealed she was hired on 1/19/24; however, failed to reveal evidence of QAPI training. On 9/24/2025 at 9:48AM GNA #18's employee file was reviewed. The review revealed she was hired on 11/7/05; however, failed to reveal evidence of QAPI training. On 9/24/2025 at 10:17 AM GNA #22's employee file was reviewed. The review revealed she was hired on 11/19/24; however, failed to reveal evidence of QAPI training. On 9/24/2025 at 10:27 AM Licensed Practical Nurse (LPN #33's) employee file was reviewed. The review revealed she was hired on 9/26/24; however, failed to reveal evidence of QAPI training. On 9/24/2025 at 12:17 PM Registered Nurse (RN #19's) employee file was reviewed. The review revealed she was hired on 12/24/24; however, failed to reveal evidence of QAPI training. On 9/24/2025 at 1:31PM Dietary Aide (DA #41's) employee file was reviewed. The review revealed he was hired on 6/5/25; however, failed to reveal evidence of QAPI training. On 9/24/2025 at 1:42PM Housekeeping Aide (HA #42's) employee file was reviewed. The review revealed he was hired on 10/28/24; however, failed to reveal evidence of QAPI training. On 9/24/24 at 8:36 AM in an interview with Staff Educator (SE #23), the surveyor requested of evidence of QAPI, communication, dementia, cognitive impairment/mental illness, and infection control training from 10/1/23 through present. On 9/24/25 at 10:21 AM in an interview with SE #23, HRD #20 and the Director of Nursing (DON), when asked what training she was involved with, HRD #20 stated she only handled the onboarding and 4 hour orientation for all staff. The DON and SE #23 confirmed that HRD #20 only handled the onboarding and 4 hour orientation. The remainder of the interview was conducted with SE #23 and the DON. During the interview when asked what the various methods were used to provide training, in-services, and education to staff the DON stated outside of the onboarding and orientation, there was a 12 month calendar published by the CNO (Chief Nursing Officer, CNO #1) that ran from January to December. SE #23 and the DON verified and confirmed there was no online learning platform used by the facility to provide education/training to staff.When asked if there was any mandatory training all staff received, SE #23 stated for clinical staff, yes, and it was outlined on the 12 month calendar. When asked if there were any mandatory trainings that nonclinical staff received, SE #23 stated, Not that I provide. You can ask [DON's name]. The DON stated, The head of the departments would do the trainings if they had any. I am clinical, so I would refer you to the department heads. When asked about Rehab (physical therapy, occupational therapy and speech therapy) participation in facility trainings, the DON and SE #23 stated that the Rehab staff do not participate in the 12 month calendar education. When asked about the process in place to track staff participation in the required trainings, SE #23 and the DON said, Sign in sheets. Additionally, SE #23 stated, I have not looked or seen them [sign in sheets], but I can get with [Assistant Director of Nursing's (ADON's) name] to find them because she was the facility's previous Staff Educator. SE #23 stated she had only been at the facility as the Staff Educator for about a month.The Activities Director was interviewed on 9/24/25 at 10:48 AM. During the interview she stated there was no mandatory training she provided for her staff. During the interview she stated, I know that HR does some, but no, I do not.The Director of Housekeeping/Laundry was interviewed on 9/24/25 at 12:50 PM. During the interview she stated there was no mandatory training that she provided for her staff. The Director of Rehab was interviewed on 9/24/25 at 1:19 PM. During the interview she stated there was no mandatory training that she provided for her staff. On 9/24/25 at 10:42 AM in an interview with the ADON when asked about evidence of staff trainings she stated, I was the Staff Educator, but only for like 2 weeks and [Licensed Practical Nurse (LPN #33)] was it for like a year. On 9/24/25 at 10:45 AM in an interview with LPN #33 when asked if she was the facility's previous Staff Educator, she stated she had never been the Staff Educator for the facility. During the interview she stated, I believe here that always fell with the ADON. On 9/24/25 at 10:51 AM in an interview with CNO #1 she stated, She [SE #23] was wrong, all staff do attend some of those trainings (and provided the Monthly Education Calendar 2025). [SE #23's name] checked off which trainings were [for] non-clinical [staff also]. When asked for evidence of staff participation in training, education, and in-services, CNO #1 provided the surveyor with 3 binders and 2 manilla folders. On 9/24/25 at 10:59 AM review of the Monthly Education Calendar (2025) revealed education on QAPI was scheduled for January and July. On 9/24/25 at 11:04 AM review of the 3 binders and 2 manilla folders of staff education, training, and in-services failed to reveal an attendance sheet or any further evidence of QAPI training. On 9/24/25 at 2:06 PM in an interview with Activities Aide (AA #28), when asked if s/he had received any training in 2023, 2024, or 2025 s/he stated no. S/he stated when s/he was hired, s/he had completed some online training but verified and confirmed that s/he had not received any training in 2023, 2024 or 2025. GNA #27 was interviewed on 9/25/25 at 9:05 AM. During the interview, when asked if s/he had QAPI training upon hire or since s/he had been employed the facility s/he stated, No, I do not know what that is. On 9/24/25 at 4:13 PM in an interview with SE #23 a dual observation of the 3 binders and 2 manilla folders was conducted. When asked if there was any further evidence of staff participation in educations, in services, or trainings, she stated, No, not to my knowledge and I asked the lady before me, and she did not have anything either. Another request was made to SE #23 to verify if there was any evidence of any QAPI training for employees. She said she would check. On 9/24/25 at 4:44 PM in an interview with the DON when asked if there was any further documentation/evidence of staff participation in education, in services, or trainings, she stated, No, there is no further documentation to provide for staff training. The surveyor shared this was a concern and the DON confirmed understanding. On 9/25/25 at 8:37 AM in an interview with SE #23 when asked if there was evidence of QAPI training provided to the staff in 2024 or 2025 she stated, If it is not on the [attendance] sheets, I was not here then so I cannot confirm that. On 9/25/25 at 9:29 AM in an interview with SE #23 she stated, [Nursing Home Administrator's name] and [CNO #1's] said we had a survey in 2023, and we do not have any evidence of the training you requested from 2024 or 2025. The surveyor shared this was a concern and SE #23 acknowledged understanding.

Based on observation, interview, and record review, it was determined that facility staff failed to treat residents with dignity. This was evident for 2 (#214, #97) of 27 residents that resided on the memory care unit and for 13 residents on the memory care unit that were in the dining/activity area on 1 of 3 days observed during a revisit survey. The findings include:On 12/1/25 from 1:30 PM to 2:20 PM observation was made on the Chase memory care unit of 13 residents sitting in the dining/activity area of the unit. There were no activities at the time. There was no music on, the television screen was on with a still photo of channels and there was no sound. One resident was crying, and one resident was complaining. None of the residents had any type of activity such as books, coloring books, music, videos, or any type of interaction with the staff on the unit. The residents were sitting and staring at each other. There were 5 nursing staff members standing and sitting around the nurse's station. Resident #213 said to the surveyor, they won't turn the tv on and that bothers me.After the surveyor left the common area observation was made on 12/1/25 from approximately 2:00 PM to 2:04 PM of Staff #10 (Activity Assistant) sitting in a chair at the bedside of Resident #214, who resided on the memory care unit. The surveyor walked in the resident's room and stood in front of Staff #10. Staff #10 was sleeping in the chair with activity material on her lap. The surveyor looked at Resident #214, who was lying in bed. Resident #214 shrugged his/her shoulders and stared at the surveyor. The surveyor then walked to the other side of the room which was around a wall where another bed was located and then opened the bathroom door and looked into the bathroom. The surveyor shut the door and stood at the entrance doorway and then walked back to Staff #10. The surveyor stood in front of Staff #10 and made a noise. Staff #10 opened her eyes, and the surveyor informed Staff #10 that she was sleeping. Staff #10 confirmed and stated that she had a bad headache. Review of Resident #214's care plan documented, resident is dependent on staff for activities, meeting emotional, intellectual, physical, and social needs. The care plan was revised on 11/17/25 with the intervention added, The resident needs 1:1 bedside/in-room visits and activities if unable to attend out of room events. On 12/2/25 at 8:26 AM observation was made on the Chase unit of Staff #32 (GNA) standing to feed Resident #97 breakfast in the resident's room while the resident was lying in bed. Staff #32 did not hear the surveyor walk in the room as she was talking on a cell phone in another language while standing to feed Resident #97. The surveyor walked up to Staff #32 and asked her what she was doing, and she said she was talking to her sister because she needed money. At that time Staff #33 walked into the room and the surveyor informed her what was going on. LPN #33 stated that it was a dignity issue and then walked out of the room. On 12/2/25 at 9:15 AM the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were informed of the observations. The NHA stated that the behavior of the staff was unacceptable.On 12/2/25 at 9:45 AM an interview was conducted with the Director of Activities. She stated that they had planned activities on the memory care unit (Chase). She was informed of the observations and of the observation of Staff #10 in the resident's room. She stated that Staff #10 normally did not work on that unit.

Based on observation and staff interviews, it was determined that the facility failed to maintain a homelike environment for the residents, this was evident for 2 of 3 units observed during the recertification/complaint survey.The findings include,On 9/22/2025 at 9:39 AM during the initial tour of the facility, observations were made of the following rooms/bathrooms:RM 200: The bedroom door was scraped up all the way to the handle and needed replacement covers.room [ROOM NUMBER]B: the wall trim at the head of the bed was missing from bed A to bed B. Also observed behind the head of the bed on the B-side were lots of paint scrapings on the wall.room [ROOM NUMBER]: The bathroom door had holes about 6 x 5 inches long; there were paint scraps on the wall opposite the toilet measuring about 12 x 5 inches. The wood on the bathroom door was scraped off towards the bottom section in two areas measuring about 3 x 2 and 7x 5 inches long.room [ROOM NUMBER]A: The wall paint by the bed was peeled off about 10 x 9 inches, and the vent in the bathroom ceiling was hanging loose, about to fall off.room [ROOM NUMBER]: The bathroom ceiling had holes measuring about 2 x 4 inches and another brown circular stains on four different areas about 4 x 5 inches long.room [ROOM NUMBER]-The bathroom ceiling had two big brown circular stains, one measuring about 10 x10 inches and the other 4 x 3.5 inches. The soap dispenser was broken, and the cover was missing.Rom 504 B-2: The nightstand had worn out edges all around it.room [ROOM NUMBER]A-A: The wheelchair arm rest was torn and the resident sitting on it was picking on the foam and string.room [ROOM NUMBER]B-2: The nightstand had worn out edges.On 9/24/2025 at 1:01 PM in an Interview with Staff #17, the regional maintenance director who has oversight over the building, he stated that the prior maintenance director was terminated at the end of August and it's just the maintenance assistant doing all the work. He was asked if maintenance do rounds on the floors, and he said that they have tasks in the TELs System that are supposed to be completed weekly, monthly, quarterly and semiannually which they check off once done. He was asked how issues that need fixing are brought to their attention and he said that anyone with Point Click Clear (PCC)access can create a report that comes directly to their cell phones and computers through their TELs system and that Issues are fixed based on their urgency.He was asked about their wheelchair maintenance process, and he said that the Physical therapists are responsible for putting in orders for their repairs. As for residents on wheelchairs who do not go for therapy, he stated that maintenance has a monthly inspection for all wheelchairs. On 9/24/2025 at 1:38 PM the nursing home administrator, the regional maintenance director and the surveyor did a walk through and the surveyor pointed out the above concerns. The regional maintenance director said he will get started on some of the repairs right away.

Based on medical record reviews and interviews, it was determined that the facility staff failed to provide appropriate care to residents when they had abnormally elevated blood pressure (BP). This was evident in 1 (Resident #6) out of the 45 residents reviewed for their care during this recertification/complaint survey.The findings include:On 9/22/25 at 2:38 PM, the review of Resident #6's medical record revealed that the resident had transferred to the hospital on 8/13/25 due to elevated blood pressure; the systolic blood pressure went over 200 mm Hg.Further review of Resident #6's vital signs from 8/14/25 to 9/23/25 revealed that the resident had elevated blood pressure, with systolic BP measured over 190 mm Hg, 14 times during the period. The highest record was 215/88 mm Hg on 9/12/25. However, there was no documentation to support that Resident #6's medical conditions were notified to the physician or that specific care was provided to the resident related to managing the symptoms.During an interview with Staff #13 (Licensed Practical Nurse) on 9/23/25 at 11:35 AM, she stated that if a resident's blood pressure is abnormally elevated, it should be notified to the provider, rechecked, and medication gotten per the provider's order (if still high). Staff #13 said, All communication should be documented in the system; also, a change in condition form is required to be completed.In an interview with the Director of Nursing (DON) on 9/24/25 at 11:48 AM, she reviewed Resident #6's blood pressure and stated that the resident had a history of high blood pressure and had been taking several hypertension medications. Also, she explained that Resident #6 was followed up with a cardiologist. The surveyor requested documentation to support how the resident's elevated blood pressures were cared for by the facility staff.On 9/24/25 at 12:00 PM, the surveyor reviewed Resident #6's most recent cardiologist follow-up note. The note showed that the last visit was on 7/31/25 for a regular follow-up and no new orders at that time. Also, the most recent facility's attending physician's note was on 7/07/25 without new orders.In an interview with the Medical Director on 9/25/25 at 9:39 AM, he confirmed that even though a resident was followed up by a specialist (such as a cardiologist), their current changed condition should be notified and assessed by the attending physician. The surveyor asked to review Resident #6's blood pressures. The Medical Director stated that those elevated blood pressures should be notified to the physician, and interventions recommended.During an interview with the Director of Nursing (DON) on 9/25/25 around 10 AM, the surveyor shared the above concerns, and she validated them.

Based on review of employee files and interviews with facility staff, it was determined that the facility failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was found to be evident for 2 (GNA #3, GNA #18 ) out of 2 GNA employee files reviewed during the Sufficient and Competent Nurse Staffing facility task for the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. On 9/24/25 at 9:38 AM GNA #3's employee file was reviewed. The review revealed she was hired on 1/19/24; however, failed to reveal a performance review was conducted in 2025. On 9/24/2025 at 9:48AM GNA #18's employee file was reviewed. The review revealed she was hired on 11/7/05; however, failed to reveal a performance review was conducted in 2023 or 2024. On 9/24/25 at 1:44 PM an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) when asked if performance reviews were conducted for GNAs, the DON stated yes. During the interview when asked how frequently they were conducted, the DON stated, Let me verify. The ADON stated, I think it is 12 months. When asked who conducted the performance reviews, the DON stated the ADON or DON. When asked where they were stored, the DON stated, HR has them in their employee files. The surveyor shared that there were no performance reviews for GNA #18 from 2023 or 2024 and there was no performance review for GNA #3 in 2025 observed in their employee files. On 9/24/25 at 1:56 PM in an interview with GNA #3 when asked how long s/he has worked at the facility s/he stated on and off for years. During the interview when asked if s/he has had a performance review she stated, No, never.On 9/24/2025 at 2:25 PM the surveyor requested the performance reviews for GNA #3 and GNA #18. On 9/24/25 at 2:32 PM in an interview with the DON and ADON, the DON stated if the Director of Human Resources did not have the performance reviews in their employee files, then they did not have them. The surveyor shared this was a concern and the DON acknowledged understanding.

Based on a review of records and interview with facility staff, it was determined that the facility failed to 1) ensure that drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication, and 2) complete controlled medication counts with two nurses. This was evident for four (Resident #44, #79, #96, #35) out of the six residents reviewed for administration of narcotic medication during this recertification/complaint survey.The findings include:A Controlled Medication Utilization Record (count sheet) is a form used to record controlled medication dispense. It documents the details for each use of any controlled substance amount removed from its original container, including the date, time, the dose given, the signature of the nurse administering the medication, the amount remaining, the amount wasted, and the signature of the individual who checked.A shift count sheet in a nursing home is a form used at the end of a nursing shift to document the inventory of controlled substances, particularly narcotics, ensuring accuracy and accountability. 1) On 9/22/25 at 3:10 PM, the surveyor reviewed randomly selected residents' Medication Administration Records (MARs) and count sheets. The review revealed the following discrepancies:a. Resident #44 was prescribed Morphine Sulfate 100mg/5ml (liquid) 0.25 ml by mouth every 4 hours as needed for breakthrough pain. The MAR showed that he/she received the medication four times between August 2025 and September 2025. However, the count sheet documented fifteen administrations during that period, meaning eleven administrations were not reconciled.b. Resident #79 was prescribed Alprazolam 0.5 mg tablet orally every 8 hours as needed for anxiety for 14 days, starting 8/05/25. The MAR showed that the resident received this medication on 8/11/25, 8/14/25, and 8/18/25. However, the count sheet documented that Resident #79 took the medication thirteen times from 8/01/25 to 8/29/25. This included ten additional administrations not documented in the MAR. Furthermore, the MAR showed no active order for the medication from 8/01/25 to 8/04/25 and 8/20/25 to 8/29/25.c. Resident #96 was prescribed pain medication with Oxycodone 10 mg by mouth every 4 hours as needed. The MAR showed that he/she received the medication on 9/19/25 at 3 PM. However, the count sheet documented that the medication was removed on 9/19/25 at 6 AM, which does not match the administration time. d. Resident #35 was prescribed Zolpidem 5 mg by mouth every 24 hours as needed for insomnia. The count sheet documented that the resident received the medication every night from 9/16/25 to 9/22/25. However, the MAR lacked documentation for 9/16/25 and 9/18/25.During an interview with the Director of Nursing (DON) on 9/24/25 at 1:57 PM, she explained that nurses should document controlled medication use on both the MAR and the count sheet. The surveyor reviewed medical records for Resident #44, #79, #96, and #35 with the DON. She confirmed that the documentation was not reconciled between the MAR and the count sheet.2) During an investigation of the narcotic box and count sheets for each unit on 9/22/25 at 3:10 PM, it was revealed that the facility nurses failed to complete shift count sheets with two nurses. The sheet has columns for date, time of day, a Yes or No section for EDK (Emergency Drug Kit) box sealed, a Yes or No section for count correct, the on-duty nurse's signature, and the off-duty nurse's signature.a. The review of shift count pages for the 100s unit on 9/22/25 at 3:34 PM revealed incomplete nurse signatures on the following shifts: 9/11/25 Day shift (missing off-duty signature). 9/15/25 Evening shift (missing on-duty signature). 9/15/25 Night shift (missing off-duty nurse's signature). Furthermore, the form had incomplete answers for the questions regarding the EDK box sealed and count correct for 34 out of 49 columns from 8/29/25 to 9/22/25.b. The review of shift count pages for the Dementia unit on 9/22/25 at 3:52 PM revealed: * Missing on-duty nurse's signatures on 9/18/25 and 9/20/25. The next line of the 9/22/25 day shift documentation had an off-duty nurse's signature without other information.During an interview with Staff #13 (Licensed Practical Nurse) on 9/22/25 at 3:10 PM, she stated that two nurses, one going on duty and one going off duty, were required to count narcotic medications and document them with a signature.In an interview with Staff #32 (Licensed Practical Nurse) on 9/22/25 at 3:28 PM, she stated that signing the shift count meant they had responsibility for those medications. She added that answering each question was not required.In an interview with the Director of Nursing (DON) and the Infection Preventionist (IP) on 9/24/25 at 1:57 PM, they confirmed that the shift count sheet should be completed with both on- and off-duty nurses, and all questions need to be answered. The surveyor shared the shift count sheets from the two units with the DON. She verified that the documentation was not completed in full.

Based on observation and interview with facility staff, it was determined that the facility failed to remove expired food items and label opened stored food items and in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility kitchen. The findings include: Surveyors conducted an initial brief tour of the kitchen on [DATE] with and identified: - Three unopened 6-lb cans of marinara sauce without an expiration date - Five bags of unopened hot dog buns with an expiration date on [DATE] - 50 Resident food trays were rusty around the trim and cracked - 10 Blue domed plate covers, and plate holders, were cracked and missing pieces The surveyor conducted a second tour of the kitchen including the dry storage area on [DATE] at 9:27 AM with cook, Staff #6. During the tour, we observed: - One sealed 52 ounce (oz) can of Red and Green Pepper strips without an expiration date - Elbow macaroni stored in an opened transparent plastic container without an opened date - Egg noodles stored in an opened transparent plastic container without an opened date - Tri colored rotini stored in a transparent plastic container without an opened date - Spaghetti stored in a transparent plastic container without an opened date - One 52 oz can of dry navy beans without an expiration date - Raisins stored in unsealed transparent bag inside an open brown box with an open date of [DATE] - One opened box with white shredded coconut with expiration date ,d+[DATE] - One small bag of mini marshmallows with an expiration date of [DATE] - Two 52 oz unopened cans of split peas with uncured ham uncured bacon; one with an expiration date of [DATE] and one can with an expiration date of [DATE] - Three 52 oz cans of Cream of Mushroom with an expiration date of [DATE] - One 52 oz can of beans with uncured bacon with an expiration date of [DATE] - One opened metallic colored bag of vanilla pudding filling mix with out and expiration date - One opened 20 oz container of Welch's grape jelly, the label advises to: refrigerate after opening - One 5-pound (lb.) bag of fudge brownie mix without an expiration date - Two 5-lb. bags of buttermilk pancake mix with an expiration date of [DATE] - Two 5-lb. bags of yellow cake mix unopened without an expiration date - One 28 oz brown bag labelled cream soup base without an expiration date - Four 5-lb. boxes of buttermilk biscuit mix with an expiration date of [DATE] - One gallon of thousand island dressing with an expiration date of [DATE] - One opened gallon plastic container labelled LA Choy Sweet & Sour Sauce, open date of [DATE] and label advises to refrigerate after opening - One rusty and dented 6-lb. can pf aged cheddar cheese sauce. During a tour of the dishwashing area of the kitchen that took place on [DATE] at 9:55 AM, with the Maintenance Director, the surveyor found a broken eyewash station filled with paper trash and missing a white plastic drainpipe from under the eyewash station. The surveyor and Maintenance Director also identified a faucet with a red hose attached, leaking onto the floor near the entrance of the dishwasher room. The Maintenance Director advised the surveyor that a plumber was contracted to fix the drainpipe and leaking faucet. A second tour of the dishwashing area of the kitchen took place on [DATE] at 6:55AM with the Certified Dietary Manager (CDM). The surveyor and CDM observed the eyewash station with crumbled paper trash in it. The CDM indicated to the surveyor that he scheduled a mandatory all dietary staff meeting which includes use and maintenance of the eye wash station equipment.

Based on clinical and administrative record reviews, and interviews, the facility failed to protect residents' right to be free from physical abuse by other residents. The facility's failure to implement adequate interventions for a resident (#79) to prevent recurring resident-to-resident abuse placed residents at risk for serious harm. This finding was evident for 3 of 9 residents (#62, #22, and #6) reviewed for abuse. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 6:08 PM on 8/7/23. On 8/7/23 8:42 PM The facility submitted an abatement plan to remove the immediacy while surveyors were onsite. The abatement plan was accepted by the OHCQ at 8:48 PM on 8/7/23. The findings include: On 08/02/2023 at 7:50 AM the surveyor reviewed the facility's investigation file regarding the incident between Resident #79 and Resident #22 that occurred on 05/27/2023 and the incident that occurred on 6/21/23 between Resident #79 and Resident #62. Review on 08/02/2023 at 8 AM of the facility reports revealed that Resident #79 was identified as the aggressor for 3 of the 20 Facility Reported Incidents reviewed during the annual survey. Additional review of Resident #79's medical record revealed diagnoses including adjustment disorder with mixed anxiety and depressed mood and delusional disorders. Further review of Resident #79's medical record revealed that the resident did not have a care plan for abusive behaviors or aggression towards residents. A care plan is a document that summarizes a person's health conditions, specific care needs and current treatments. It should outline what needs to be done to manage the person's care needs. Review of Resident #79's medical record on 08/02/2023 showed that on 02/17/2023, the psychiatrist recommended Resident #79 to start taking a medication for anxiety. Review of the physician orders for Resident #79 revealed that the anti-anxiety medication was not acknowledged or ordered by the physician. Review of resident #79's Medication Administration Record on 08/07/2023 at 9:30 AM revealed that for the months of February 2023 through August 2023 there were no orders for anti anxiety medication that the psychiatrist recommended. On 08/02/2023 review of the Facility Report for Resident #62 revealed that on 04/19/2023, Staff #26 witnessed Resident #79 hit Resident #62 on the back of his/her head with an open hand multiple times. Review of the medical record for Resident #79 revealed a note written by Staff #4 on 4/19/2023 at 3:25 PM that documented Resident # 79 was moved from a room on a secured unit into another room on a general nursing unit. Further review of the Facility Report Incident revealed that on 05/27/2023 Resident #22 reported to facility staff that, while Resident #79 was exiting their room, Resident #79 used his/her hand to hit him/her on the top of the head while Resident #22 was in a wheelchair. During record review on 8/7/2023 7:30 AM Resident #79's psychiatric evaluation dated 05/31/2023 revealed that Resident #22 stated I am afraid of her (Resident #79), {Resident #79} told me to shut up all the time. Resident #22 was moved to another room for safety. Surveyor interview on 8/7/2023 9:10 AM with Staff #17, the resident's room was changed because staff realized that Resident #79 was offended by wandering residents on the locked unit. Review of the follow up psychiatry visit notes dated 06/02/2023 for Resident #79, revealed that the psychiatrist recommended that the resident start an anti depressant used to treat depression and generalized anxiety disorder for anxiety and aggressive behavior. Further review of the physician orders revealed that the medication was not acknowledged or ordered by the physician. Review of resident #79's Medication Administration Record on 08/07/2023 9:30 AM revealed that for the months of June 2023 through August 2023 there were no orders for the anti depressant recommended by the pharmacist. On 08/02/2023 review of the Facility Report for Resident #6 revealed that on 06/21/2023, Resident #79 hit Resident #6 on his/her head with a remote control. On 08/02/2023 at 1:30 PM the interim Administrator was interviewed and stated she could not provide surveyors with the facility's investigation files for the incident on 5/27/2023 regarding Resident #79 as the aggressor towards Resident #22 and for the incident on 06/21/2023 regarding Resident #79 as the aggressor towards Resident #6. The interim Administrator went on to say that she was sure the investigations were conducted but she searched for them and could not find the documentation of the investigations. During an interview on 08/07/2023 at 9 AM, surveyors asked Licensed Practical Nurse (LPN), Staff #18, if she had knowledge of the medication recommendations from the psychiatrist, to which she answered, Yes. I told the psychiatrist that Resident #79 refuses medications. Staff #18 went on to say she also discussed Resident #79's refusal of medications with the covering Nurse Practitioner. That is why the recommended medications were not ordered. Surveyors requested documentation of Resident #79's refusal of medications. Staff #18 stated, I usually document resident refusals in the progress notes or the medication administration record, but somehow, I missed this one. Sorry. On 08/07/2023 at 9:20 AM Staff #18 provided surveyors with Resident #79's psychiatric notes dated 7/27/2023 which stated Resident #79 has been refusing to take medications. There was no documented evidence that the resident was refusing to take medications nor was there a plan to implement alternate interventions if the resident refused medications. During a phone interview on 08/07/2023 at 7:06 PM, the Psychiatrist confirmed that he recommended the antidepressant medication after one of the incidents that had occurred and the antianxiety medication after another incident had occurred. He also stated that he was told by Staff #18 that the resident refuses medications which is why he documented that in the 07/27/2023 note. The psychiatrist stated that he was in contact with facility staff on 08/07/2023 and gave the recommendation to move Resident #79 to a room, without a roommate, and to place Resident #79 on 1:1 (one resident to one staff person) observation for 24 hours a day until reevaluated. An interview held on 08/7/2023 9:25 AM with the Social Worker Assistant, Staff #4, with Staff #17 present, revealed that Resident #79 makes his/her needs known to nursing staff. Staff #4 went on to say that Resident #79 displays aggression when surrounded by wandering residents and when being questioned about anything. During an interview on 08/07/2023 at 5:50 PM with the Interim Nursing Home Administrator (NHA), surveyors made concerns known that the facility failed to ensure effective systems to prevent resident-to-resident abuse that occurred and that reached three different residents (#62, #22 and #6) and further, left residents at continued risk for serious harm. Review of the facility reported incident which occurred on 4/19/2023, the facility verified the allegations of abuse and implemented a room change for Resident #79. The facility also verified the allegation of abuse that occurred on 5/27/2023 and 06/21/2023. However, after the room change on 4/19/2023, there were no other preventative measures put in place to prevent further resident to resident abuse. These identified concerns were brought to the attention of the facility interim NHA on 08/07/2023 and an immediate jeopardy was called on 8/7/23 6:08 PM related to preventing abuse of residents. On 08/07/2023 8:42 PM The facility submitted an abatement plan to remove the immediacy while surveyors were onsite. The abatement plan was accepted by the OHCQ at 8:48 PM on 08/07/2023. The plan included: - An audit of all residents in the facility that have exhibited behaviors (date of alleged compliance 08/07/2023) their care plans updated accordingly with appropriate interventions to reduce the risk of resident to resident abuse (date of alleged compliance 08/08/2023) - Referrals to the psychiatrist for recommendations with (date of alleged compliance 08/08/2023) . - Mandatory training was conducted for all staff in all departments on resident behaviors, interventions, and implementation of new interventions when incidents occur including resident to resident abuse (date of alleged compliance 08/09/2023). - Also, included in the plan was all recommendations from the psychiatrist would be reviewed during the clinical meeting to ensure that recommendations are followed up with the medical provider for implementation by alleged date of compliance 08/08/2023. Tour of the facility on 08/09/2023 7:05 AM and of Resident #79 ' s room revealed that only one resident was assigned to the room (Resident #79) and the 1:1 sitter was present outside of the door. The Surveyor approached certified nursing assistant (CNA), Staff #45, positioned by the entrance of Resident #79 ' s room door, she stated she received a report from the 11 PM to 7 AM staff that the resident was awake throughout the night and had recently laid in the bed without any incident. Staff stated if there were any incidents, she would make sure the resident isn ' t harmed or harms others then report to the Unit Manager. On 08/09/2023 at 9:45 AM the Surveyor received a list from the interim NHA, which included the sign-in list of all staff who received the training on resident to resident abuse and a list of all facility staff. Review of the documents revealed several staff signatures were missing from the sign-in sheet therefore the facility was not in compliance with their 8/8/23 date of completion for all staff education. An interview was held with the interim NHA on 08/09/2023 at 11:45 AM and the interim NHA confirmed that the missing signatures were for the staff that were current employees but not scheduled to work, therefore they would be contacted by phone and if no contact could be made, they would not be scheduled to work unless the training was completed. On 08/11/2023 at 9 AM the interim NHA submitted a list of all scheduled staff which the surveyor verified signatures were present on the training titled, Resident to Resident Behaviors/Documentation of Behavior/Interventions sign-in sheet dated 08/11/2023. The team confirmed the facility implemented their abatement plan and the Immediate Jeopardy was abated on August 11, 2023.

Based on clinical record review and staff interviews, it was determined that the facility staff failed to ensure adequate supervision while positioning a resident in bed during the provision of care. This deficient practice resulted in harm for Resident #212. This was evident for 1 (#212) of 14 residents reviewed for accidents. The findings include: On 08/08/2023, a record review was conducted which revealed that Resident #212 had diagnoses which included, but were not limited to, left femur fracture, stroke and hemiplegia affecting his/her left non-dominant side. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body. The MDS (Minimum Data Set) is a screening tool that is utilized to ensure each resident's individual needs are identified. A review of the MDS assessment, with an assessment reference date of 01/17/2023, identified that to turn from side to side and position body when in bed, the resident was totally dependent on staff for the activity and required 2 staff persons to physically assist. According to facility notes dated 03/10/2023 at 12:27 PM, Resident #212 fell from bed during activities of daily living (ADL) care. Rolled to the floor, hit head on the way down. As a result, he/she sustained an injury to the right ear. A facility incident report was obtained. The report described how Staff #29, a Geriatric Nursing Assistant (GNA) and the only witness to the fall, had been providing care without the assistance of another staff member. Per the incident report, the resident was holding onto quarter rail and pulled self over too far in bed causing [his/her] weight to shift. The GNA could not reach across the bed quickly enough to prevent the fall. On 8/8/23 at 1:50 PM, an interview was conducted with Staff #41, a GNA. When asked how a GNA would know how much assistance a resident requires, Staff #41's answer included using the Kardex that can be found in the resident's electronic chart. According to the facility's training materials, the Kardex is a quick summary of individual resident needs tells you all you need to know about the resident, how to care for them, and any items that they require. Before providing care to Resident #212, Staff #29 would have been able to quickly find information pertaining to the resident's bed mobility in the Kardex. After the fall, Resident #212 was sent to the Emergency Department (ED) for an evaluation. ED notes revealed that the resident suffered a laceration of the right ear that required 10 sutures.

Based on observation, review of medical records, facility investigative file, and staff and resident interviews it was determined the facility failed to ensure a resident was free from physical abuse. This was evident for 1 (resident #2) out of 1 resident reviewed for abuse. As a result, this deficient practice was identified as a Harm. The findings include: On 01/09/2023 at approximately 9:45 AM a review of the facility investigative report submitted to the Maryland Office of Health Care Quality (OHCQ) revealed a physical altercation occurred on 12/29/2022 between an alleged perpetrator who was a maintenance assistant and a resident (resident #2). The employee (alleged perpetrator) was interviewed and relieved of his/her duty until the conclusion of the investigation. Resident #2 was interviewed and alleged s/he had tried to open the door to his/her room to ask for a spoon to eat. The employee was on the other side of the door and pulled on it to keep the door closed. The resident stated that the employee then cursed at him/her, poked them in the eye, and choked them. During an interview conducted on 01/09/2023 at approximately 10:00 AM, the Occupational Therapist Assistant (OTA) # 12 stated she had provided therapy for the resident ' s roommate (resident #12) on the day of the altercation and had witnessed the events. She stated resident #2 opened his/her door to ask for a spoon and heard the maintenance assistant #14 yell at the resident to close the entry door while pulling the door closed. The resident reopened his/her entry door, the maintenance assistant entered the room, and began to argue with the resident. The OTA further stated she asked the maintenance assistant multiple times to stop, however he continued to argue. The OTA stated she heard a thud sound, turned around and saw the maintenance assistant grab the front of the resident ' s shirt at which time she left the room to get help. According to the Centers of Medicare and Medicaid Services (CMS) the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. In most cases, participants in the assessment process are licensed health care professionals employed by the nursing home. MDS information is transmitted electronically by resident nursing homes to the national MDS database at CMS. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively now. It is a required screening tool used in nursing homes to assess cognition. The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. On 01/09/2023 at approximately 10:00 AM a record review was conducted for resident #2 ' s MDS quarterly assessment dated [DATE]. The assessment revealed the resident scored a 15 for his/her cognitive pattern. During an interview conducted on 01/09/2023 at approximately 12:20 PM, resident #2 stated that s/he opened the entry door to his/her room to ask for a spoon at which time the maintenance assistant #14 yelled to close the door and then he/she pulled the door closed. The resident stated; s/he reopened the door, the maintenance assistant came inside his /her room and they both began to argue. The resident stated the maintenance assistant choked the resident ' s neck and then poked him/her in the left eye which caused the eye to bleed. The resident further stated that s/he was still very upset and confused that the maintenance assistant had attacked him/her since they had been friends in the community. The resident also stated he/she refused to go to the emergency roiagnom on the day of the incident and had not received a medical assessment of the left eye since the incident occurred on 12/29/2022. However, s/he continued to experience pain and a scratchy feeling in the left eye. On 01/09/2023 at approximately 12:40 PM the resident ' s roommate #12 with a BIMS of 14 stated in an interview that s/he saw that the maintenance assistant #14 choked the resident but did not see what happened to the resident ' s eye. However, s/he saw resident #2 ' s head go backwards, resident #2 grabbed his/her eye and yelled my eye during the altercation. On 01/09/2023 at approximately 1:00 PM a review of the resident #2 ' s nurse ' s note dated 12/29/2022 stated writer was notified of injury to eye due to an altercation that occurred. The resident was assessed, and the resident had no complaints at the time of pain although the resident had visible bleeding to left eye, in the corner. The writer discussed in depth the risk vs the benefits of going vs not going for evaluation to ER. The writer spent 35 minutes educating the resident. The resident refused to go to the ER. The resident stated he understood the severity of the eye if there is any internal trauma. The resident stated he will be ok. The writer educated the resident to notify clinical staff right away with any changes to vision or eye pain. resident aware to notify staff of any change in condition or if resident starts to feel bad. The resident agreed. The resident stated, ma'am I know you are just doing your job and I appreciate you. but I had dialysis today and just don't feel like going and sitting all night in the hospital. The writer notified the staff nurse on the unit of the resident not going to ER for evaluation. Also, the staff nurse is aware that the resident will report any change in his/her conditions. Review of resident #2 ' s medical record on 01/09/2023 at approximately 1:15 PM did not show that physician #17 was notified of the resident's injury. During an interview conducted on 01/09/2023 at approximately 1:30 PM the [NAME] President (VP) of Clinical for the facility stated maintenance assistant # 14 was terminated on the day (12/29/22022) of incident due to his/her insubordination during the facility ' s interview of the allegation of abuse. Maintenance assistant #14 remained very upset and refused to calm down, the interview escalated, the maintenance assistant was terminated, and escorted out of the building. The VP of Clinical further stated that after the conclusion of the investigation the facility unsubstantiated the allegation of abuse. During a phone interview conducted on 01/09/2023 at 2:33 PM the physician #17 stated he did not recall that the facility notified him of resident #2 ' s injury to his/her left eye and as such he had not performed an assessment specific to the injury to the resident ' s eye. However, he had seen the resident for another medical concern and had noted no concerns for the resident ' s eyes. During an interview conducted on 01/09/2023 at approximately 2:50 PM the Assistant Director of Nursing (ADON) showed the surveyor a text message on her cell phone that was sent to physician #17 on 12/29/2022 that stated, We had an employee to resident altercation today, reported to the state. The text message did not say who the resident was or that the resident was injured. On 01/09/2023 a change of condition was documented; an ophthalmology consult was ordered; the resident was treated for pain for the left eye and an order for Artificial Tears eye drops for irritation for the left eye was initiated.

Based on facility investigation review, review of the medical record, and staff interviews, it was determined that the facility staff failed to honor a resident's (#1) written directions not to have cardiopulmonary resuscitation administered and to allow death to occur naturally. This was evident for 1 of 11 residents reviewed during a complaint survey. This incident resulted in actual harm to the resident. Review of the facility's plan of correction, implemented immediately after the facility gained knowledge of the incident, resulted in the citation being cited as past noncompliance. The findings include: On [DATE] and [DATE], the surveyor reviewed the facility investigation regarding not honoring a resident's wishes and physician's end of life orders reported to the Office of Healthcare Quality by the facility. The intake number was MD 601. Review of Resident #1's medical record on [DATE] and [DATE] revealed the Resident was admitted to the facility on [DATE]. On [DATE] the Resident completed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form, along with their physician. Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's directions about medical treatments. The completed MOLST form dated [DATE] indicated Resident #1 selected: No Cardio-Pulmonary Resuscitation (CPR) Option A-2, Do Not Intubate (DNI). DNI (Do Not Intubate) is the insertion of a tube into the lungs for breathing. The no CPR/DNI is a medical order written by the physician to prevent a person from undergoing CPR/DNI if their heart were to stop or they were to stop breathing. The no CPR/DNI request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect the end of life directive. Review of GNA #1's written statement on [DATE] revealed Resident #1 rang his/her bell and stated he/she wanted his/her oxygen mask off because it wasn't working. GNA #1 stated she then called for Nurse #1 and Nurse #1 arrived immediately to Resident #1's bedside. GNA #1 then described Nurse #1 and GNA #1 were both at the bedside checking on the Resident's oxygen when the Resident became unresponsive. GNA #1 stated she then called for help and began CPR per Nurse #1's direction. GNA #1 further stated Nurse #2 and Nurse #3 then arrived at Resident #1's bedside. GNA #1 stated Nurse #1 and Nurse #3 reviewed Resident #1's MOLST together and when EMS staff arrived the facility staff was advised to continue CPR. Review of Nurse #1's written statement on [DATE] revealed she entered Resident #1's room at approximately 3:20 AM and the Resident stated to fix this thing pointing to the oxygen. Nurse #1 stated she and GNA #1 were working on the Resident's oxygen when he/she became nonresponsive and had no pulse. Per Nurse #1's statement, she and GNA #1 called for help and began CPR. Nurse #2 then arrived at the bedside to assist with CPR. Nurse #1 stated Nurse #3 advised her of Resident #1's form and said he/she was a no code (DNR) and DNI. Nurse #1 does not include in her statement that she advised EMS staff of DNR/DNI orders. Nurse #1 does state the hospital was advised of the Resident's impending arrival and all forms were faxed to the hospital. Review of Nurse #2's written statement on [DATE] revealed when she arrived to the Resident's room Nurse #1 and GNA #1 were performing CPR and she took over for Nurse #1 and assisted GNA #1 with performing CPR. Nurse #2 stated she then left the room to call the doctor and family and returned to the Resident's room to assist with CPR. Nurse #2 stated Nurse #3 then returned to the room with Resident #1's MOLST and questioned if Resident #1 was a no CPR. Nurse #2 stated immediately after that EMS staff arrived and instructed the staff to continue CPR. Review of Nurse #3's written statement on [DATE] revealed when Nurse #3 arrived to the Resident's room Nurse #1, Nurse #2 and GNA #1 were performing CPR. Nurse #3 stated she asked the Resident's code status and if 911 had been called. Nurse #3 stated Nurse #1 and Nurse #2 told her the Resident was a full code and 911 had not been called. Nurse #3 stated when she went to call 911, she reviewed the MOLST and saw the Resident was a DNR/DNI and ended the call with 911. Nurse #3 stated she then went to the Resident's room and informed Nurse #1 and Nurse #2 the Resident was a DNI. Nurse #3 stated Nurse #1 reviewed the Resident's MOLST with her and stated the Resident is a full code and for Nurse #3 to call 911. Nurse #3 stated she thought Nurse #1 and Nurse #2 must know the Resident better since they were his/her nurses for a while and followed Nurse #1's instructions to call 911. Then Nurse #3 stated she copied the Resident's paperwork for transfer and when she returned to the room the EMS staff were instructing the facility staff what to do. Review of the EMS report dated [DATE] revealed when the EMS arrived for report of [MEDICAL CONDITION], CPR was already in progress. EMS stated they were given a verbal history of Resident #1 that did not include the Resident's DNR status. EMS stated they advised the facility staff to continue CPR and EMS placed Resident #1 on a cardiac monitor, administered [MEDICATION NAME] and began mechanical ventilations. [MEDICATION NAME] is the primary drug administered during cardiopulmonary resuscitation (CPR) to reverse [MEDICAL CONDITION]. On transfer to the stretcher, the Resident's heart rate decreased to 30 beats per minute. EMS placed Resident #1 on a temporary pacemaker. EMS then intubated the Resident with an advanced airway. Per the EMS report, the Resident then had no pulse, EMS staff gave 2 more doses of [MEDICATION NAME]. EMS also continued to administer CPR and transported the Resident to the hospital. Review of the emergency room report dated [DATE] revealed the emergency room was notified of the DNR/DNI status of the Resident while he/she was in route to hospital. Upon arrival the emergency room staff supported the Resident airway status by a ventilator but did not administer any further CPR. The emergency room physician contacted the Resident's family who stated they were aware of the Resident's DNR status but felt for now to keep him on the ventilator for support but to not perform further CPR. The Resident was then admitted to the Intensive Care Unit and ultimately passed away on [DATE]. The facility responded with immediately suspending Nurse #1 on [DATE], terminating Nurse #1 on [DATE] and reporting the event to OHCQ (Office of Healthcare Quality). The facility staff reported Nurse #1 to the Maryland Board of Nursing on [DATE]. The facility also began training on the MOLST on [DATE] and completed training on [DATE] for all facility nurses. Review of the training included, where to find a MOLST and how to read a MOLST. Staff were reminded that the MOLST is the first thing that is to be given to the EMS provider. Staff were given posttests that were checked to ensure competency. On [DATE] the facility audited all residents' MOLSTs for accuracy to physician orders. No irregularities were found per interview with the Regional Nurse on [DATE] at 3:00 PM. Interview with the Regional Nurse on [DATE] at 3:00 PM revealed the facility completed another MOLST training of all facility nurses in February 2017, and have additional trainings on MOLST scheduled for May and [DATE]. The interview also revealed all deaths and hospital transfers are immediately called to the Director of Nursing. The Director of Nursing completes an analysis of all deaths and hospital transfers and reports findings to the Medical Director and Administrator for their review. The results of the analysis are then reported to Quality Assurance Performance Improvement Committee for further review. Interview with the Regional Nurse on [DATE] at 3:00 PM confirmed the facility staff failed to honor Resident #1's wishes and the physician's written end of life orders for Resident #1.