Every finding on record at Maplewood Park Place

Based on review of medical records and interview with facility staff, it was determined that the facility failed to ensure the assessment accurately reflected the resident's status. This was evident for 1 (Resident #18) out of 1 residents reviewed for resident assessments. The findings include:The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's functional, medical, psychosocial and cognitive status. It is administered to all residents at admission, quarterly, annually, and whenever a significant change in an individual's condition occurs. It is the foundation for creating an individualized care plan and ensures the appropriate care and services are provided to each resident. MDS assessments must be accurate to ensure each resident receives the personalized and resident specific care they need.On 5/6/26 at 11:30 AM review of Resident #18's medical record revealed he/she was most recently admitted to the Skilled Nursing side of the facility on 12/25/25 and discharged on 12/29/25. However, further review revealed an admission MDS assessment was completed on 12/31/25. On 5/6/26 at 12:28 PM in an interview with the MDS Coordinator, when asked if Resident #18 was still an active resident on the census for the Skilled Nursing side, he stated, No. When asked when he/she was discharged from the Skilled Nursing side, he looked on his laptop and stated, 12/29/25. During the interview, he stated, Hold on, let me confirm another way just to be sure. Yup, 12/29/25. When asked if the resident was readmitted to the Skilled Nursing side after being discharged on 12/29/25, he stated no. When asked why there was a 12/31/25 MDS admission assessment completed after the resident was discharged , he stated, I was looking through the progress notes and census, and I do not see it. And I am trying to check because I do not see a reason why. That was bad, where did that come from? The surveyor shared this was a concern and the MDS Coordinator acknowledged understanding of the concern.

Based on observation it was determined that the facility failed to dispose of wasted controlled substance in an appropriate manner. This was evident for 1 out of 1 controlled substance medications observed during medication administration. Controlled substances are drugs or chemicals whose manufacture, possession, and use are strictly regulated by government law due to their potential for abuse, addiction, and physical or mental harm. Regulated by the Drug Enforcement Agency under the Controlled Substances Act, these substances are classified into five schedules based on their medical utility and dependency risks.The Drug Buster(R) is a specialized medication disposal system designed to deactivate and destroy non-hazardous pharmaceuticals, such as unused or expired pills, liquids, and patches. It uses activated charcoal to neutralize active ingredients, turning them into a safe slurry within 15 minutes, allowing for eco-friendly disposal in regular trash. On [DATE] at 8:30 AM during the observation for medication administration, RN #23 was preparing the AM medications for Resident #24. One of Resident #24's medications was a 50mg Lyrica capsule, which is a a schedule controlled drug. When preparing it RN #23 placed the Lyrica capsule in a medication cup and then accidently knocked that medication cup over and the Lyrica capsule on the floor in front of the medication cart. RN #23 picked the Lyrica capsule up from the floor and disposed of it in the regular trash bin attached to the medication cart. RN #23 then noted the wasted Lyrica on the narcotics count sheet. On [DATE] at 10:15 AM the Nursing Supervisor provided a copy of the facility's Narcotics policy including how wasted narcotics were to be disposed of. This policy stated that wasted narcotics was to be disposed of in the facility Drug Buster witnessed by 2 nurses. On [DATE] at 1:55 PM, RN#23 came to conference room that the surveyors were meeting in and made them aware that the Nursing Supervisor had re-educated RN #23 on the appropriate way of disposing of a controlled substance and had, with the Nursing Supervisor witnessing, retrieved it from the trash bin and disposed of it in the Drug Buster.

Based on observations, and staff interviews, it was determined that the kitchen failed to store food items so as to maintain the integrity of the specific item and ensure that canned and dry goods were used in a timely manner. On 05/04/2026 at 9:37 AM, during the brief initial tour none of the dry, canned, frozen or refrigerated food were dated. A bin that had bread crumbs and a bin with sugar were both open with the lids slid open. In the freezer there was a box that contained loaves of bread that had been opened and the inner plastic liner was open and the remaining loaves were exposed. On 05/05/2026 at 10:15 AM after a second observation tour it was noted that the dry goods and canned goods still did not have the date they were delivered marked on them. The dietary manager stated they would see that the deficiencies were corrected.

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to maintain medical records that were complete and accurately documented. This was evident for 4 (Resident #24, #25 #13, #10) out of 14 residents reviewed during the facility's recertification survey.The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. The medical record must reflect the resident's condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. All entries to the record should be complete, accurately documented, readily accessible, and systematically organized.A face sheet in healthcare is a one-page summary document, often the first page of a patient's medical record, that provides a quick overview of essential patient information. It acts as a concise snapshot for healthcare providers to review demographics, insurance, key medical conditions, and emergency contacts instantly. Since the face sheet consolidates the most crucial administrative and clinical facts, it is constantly referenced during hospital admissions, emergency treatments, and daily clinic check-ins. 1) On 5/4/26 at 9:54 AM review of Resident #24's medical record failed to reveal any diagnoses. On the Med Diag (Medical Diagnosis) section of the medical record it had, No Medical Diagnosis found. Further review failed to reveal any diagnoses listed on the face sheet for Resident #24.On 5/4/26 at 11:02 AM review of Resident #25's medical record failed to reveal any diagnoses documented. On the Med Diag (Medical Diagnosis) section of the medical record it had, No Medical Diagnosis found. Further review failed to reveal any diagnoses listed on the face sheet for Resident #25.On 5/5/26 at 10:12 AM in an interview with the Director of Nursing (DON) a dual observation was conducted on the surveyor's laptop of Resident #24 and Resident #25's medical records. At that time, the surveyor shared the concern that Resident #24 and Resident #25 had no diagnoses documented in their medical record, neither on the medical diagnosis section of their medical record or their face sheet. The DON acknowledged understanding of the concern. When asked the expectation of when diagnoses should be entered into the medical record, the DON stated, Some get entered upon admission. Then the doctor comes in and we consolidate and add whatever else. The doctor may add additional diagnoses, but there should be at least some diagnoses entered by the nurse upon admission. When asked whose responsibility it was to enter diagnoses into the medical record, she stated the admitting nurse. The surveyor again shared the concern that for Resident #24 and Resident #25 no diagnoses were listed under the Medical Diagnosis section of the medical record and/or on the Face Sheet for the residents. The DON verbalized understanding of the concern. On 5/5/26 at 1:45 PM review of the facility's admission of Residents Policy revealed, Purpose: To ensure that all residents are admitted to Maplewood Park Place Skilled Nursing Facility (SNF) are appropriate for the level of care provided, that admissions are conducted safely and efficiently, and that resident's rights, needs, and care requirements are identified and addressed upon admission. Further review revealed, Documentation: All admission related documentation shall be completed accurately and maintained in the EMR (electronic medical record).2) The Health Care Decisions Act, which became effective 10/1/1993, applies in all healthcare settings. In Maryland a patient is presumed to have capacity until two physicians, one of whom shall have examined the patient within 2 hours before making the certification, shall certify in writing that the patient is incapable of making an informed decision. The certification shall be based on a personal examination of the patient after which the physician attests that a patient lacks the mental ability to understand or make informed decisions about their healthcare or personal affairs, often triggering legal processes like guardianship or activating advanced directives for treatment, ensuring someone else can legally act on their behalf. Brief Interview of Mental Status (BIMS) is a standardized test used to assess a resident's cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. In long term care, a responsible party (RP) is an individual (often a family member or legal representative) who handles a resident's affairs. While it legally means acting as an authorized decision-maker for care, nursing facilities may also define it as a financial guarantor to secure payment.On 5/4/26 at 10:01 AM review of Resident #13's medical record revealed a BIMS assessment dated [DATE] that documented a BIMS of 2. Further review of his/her face sheet revealed he/she was listed as the Responsible Party. On 5/4/26 at 10:09 AM review of Resident #10's medical record revealed a 3/7/26 Minimum Data Set Assessment that documented a BIMS of 9. Further review revealed a diagnosis of Alzheimer's Disease. Continued review revealed Resident #10 was listed as his/her own RP on his/her face sheet.On 5/4/26 at 1:30 PM review of the certifications of incapacity provided by the Director of Nursing (DON) revealed that Resident #13 had 2 certifications of incapacity dated from August 2021 and that Resident #10 had 2 certifications of incapacity from March 2026; however, both residents were documented as their own RP. On 5/5/26 at 10:10 AM in an interview with the DON and Nursing Home Administrator (NHA) when asked where in the medical record it documented who a resident's RP was, the DON stated on their face sheet. Additionally, she stated that the Social Worker puts that information on the face sheet upon admission or if a new admission comes on a Friday or the weekend the nurse does it. When asked what a BIMS score of 0-7 indicated she stated, severe cognitive impairment. When asked if a resident with a BIMS of 2, 3, 5 or 9 could be their own RP and be able to make sound decisions in their medical care, she stated, I would say no and looked to the NHA who shook her head no. On 5/5/26 at 10:17 AM the surveyor shared the concern with the DON and NHA that these residents were listed as their own RPs; however, they had 2 certifications of incapacity and/or BIMS scores indicating cognitive impairment. The NHA stated that for Resident #13 his/her son was their RP and for Resident #10 his/her daughter was their RP; however, the surveyor showed the NHA and DON that their face sheets had themselves documented as their own RP. The DON and NHA acknowledged understanding of the concern.

Based on record review, observation, and staff interviews, it was determined that facility staff failed to develop and implement a comprehensive person-centered care plan for the resident. This was evident for 1(Resident # 5) of 10 residents reviewed for care plans during an annual survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident, which provides the facility information necessary to develop a care plan, provides the appropriate care and services to the resident, and modifies the care plan based on the resident's status. The CAA (Care Area Assessment) process provides a framework for guiding the review of triggered areas and clarification of a resident's functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. The assessment of the causes and contributing factors gives the interdisciplinary team (IDT) additional information to help them develop a comprehensive plan of care. When implemented properly, the CAA process should help staff. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals. It will address the resident's medical, physical, mental, and psychosocial needs. On 3/6/2025 at 11:12 AM, an initial medical record review was conducted. It was noted that Resident # 5 had a fall on 2/5/2025 with no injury. On 3/7/2025 at 7:19 AM, an electronic medical record review was done. Resident # 5 was admitted to the facility on [DATE] after a fall incident with injury. He/she was hospitalized on [DATE] due to a displaced left hip fracture and underwent surgery. Additional diagnoses were Cognitive Impairment, Osteoporosis, Urinary Tract Infection, and Atrial Fibrillation with respiratory failure. Upon further review, the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed in Section GG that he/she was required to have moderate to extensive assistance for activities of daily living such as bed mobility, transfers, toileting, dressing, and bathing. Section J of the assessment confirmed a history of a fall with fracture within the last 6 months before admission. The Care Area Assessment (CAA) was triggered for falls. The care plan for Resident # 5, who was at risk of falls, was reviewed and initiated on 5/23/2024. The interventions stated: 1. Anticipate and meet the residents' needs daily. 2. Call light within reach and remind and encourage the residents to use it to request assistance if it is needed. 3. Educate the Resident about safety and use of any devices or to request assistance as needed. Further review of the care plan revealed a care plan for an actual fall that was initiated on 8/29/2024. It was stated that Resident # 5 had an actual fall on 6/21/2024 and 2/5/2025, both with no injuries. The interventions were: Assess/report and monitor resident x72 hours /document any changes or injuries. Report to the physician any signs and symptoms of pain, bruises, change in mental status, and any new onset: confusion, sleepiness, inability to maintain posture, agitation. Physical Therapy consult for strength and mobility post fall and as needed. On 3/7/2025 at 11:57 AM, Resident # 5 was observed to have bilateral fall mats with the bed in the lowest position. No documentation was found in the resident's medical record for the fall mat and bed in the lowest position. On 03/07/25 at 12:14 PM, an interview with the Director of Nursing (DON) conducted. The surveyor shared the findings that Resident # 5 had the bilateral fall mats with the bed in the lowest position; however, it was not found in the medical record. The DON confirmed that the fall mats and the bed in the lowest position were already in place before the resident's most recent fall that happened on 2/5/2025. The DON reviewed the electronic medical record with the surveyor, and she confirmed the findings.

Based on observation, record review, and interviews with facility staff, it was determined that the facility failed to ensure that the resident received treatment and care to promote the highest practicable well-being as evidenced by failure to follow the physician order, monitor and document the outcome for effectiveness. This was evident for 1 (Resident # 4) of 14 residents reviewed during this annual survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident, which provides the facility information necessary to develop a care plan, provide the appropriate care and services to the resident, and modify the care plan based on the resident's status. On 03/06/25 at 11:35 AM, Resident # 4 was observed to have a palm protector on bilateral hands. On 03/06/25 at 08:31 PM, an electronic medical record review was conducted. Resident # 4 had a physician order initiated on 3/5/2025 that was written as: Palm protector on bilateral hands for skin protection on day shift for 8 hours. Remove every 2 hours and monitor the skin. On further review, the Treatment Administration Record (TAR) revealed that staff were signing off for the treatment with the time of administration of 7:00 AM - 3:00 PM. No further documentation was found for the skin check monitoring. On 3/7/2025 at 1:54 PM, Staff # 3 Registered Nurse (RN) was interviewed. The surveyor asked why Resident # 4 had the palm protector for the bilateral hands. Staff # 3 responded that it was a trial recommendation from the Rehab Department because his/her bilateral hands were stiff and his/her fingers were pressing on the palm. We applied them for 8 hours, removed them, and checked the skin every 2 hours. The surveyor asked if any documentation or notes were written about the palm protector and skin checks, and she stated none. On 3/9/2025 at 10:04 AM, a record review revealed the MDS (Minimum Data Set) Annual assessment dated [DATE], Section GG0115 Functional Limitation in Range of Motion was coded for limitation in range of motion for both upper and lower extremities. Upon further review, a care plan for the limited range of motion was initiated on 3/6/2025. The interventions were: 1. Apply Palm Protector on bilateral hands for skin protection to both palms; 2. Observe me and report to the nurse any change in my range of motion; 3. Observe me for any complaint of pain or altered comfort during care and mobility. On 3/10/2025 at 10:01 AM, The Director of Nursing ( DON) was interviewed. The surveyor asked what the purpose of the palm protector was. The DON responded to prevent skin breakdown. It was a nursing recommendation. Resident # 4 was on a rehabilitation caseload for wheelchair positioning only. A follow-up question was asked: How do you monitor the palm protector and skin check? The DON stated the staff monitored the palm protector when it was applied and when removed. The Physician order for the palm protector was discontinued on 3/10/2025 because there was no need to take it out every 2 hours. A new order was created on 3/10/2025 for the palm protector. The new order stated: Palm Protector on bilateral hands for skin protection every shift, remove for hygiene, and monitor skin. The surveyor shared with the Director of Nursing the concern from the previous order for the palm protector and that there was no documentation for the skin monitoring. DON stated that was the reason why the order was revised.

Based on the medication administration observation, review of the facility's policy and procedure for medication administration, and interview with facility staff, it was determined that licensed facility staff failed to ensure a medication error rate of less than 5 percent during the medication pass observation. This finding was evident for 3 out of 46 opportunities, which resulted in a medication error rate of 6.52%. The findings include: On 03/07/25 at 09:31 AM, the surveyor observed Staff # 3, a Registered Nurse (RN), administer medications to Resident #8. He/She received Triamterene - Hydrochlorothiazide (antihypertensive) 37.5-25 mg 1 tablet by mouth. The physician's order stated: Maxide 25 Triamterene - Hydrochlorothiazide) 35.5-25 mg tablet; give 0.5 tablet by mouth once a day for hypertension. Hold for Systolic Blood Pressure of less than 110. The surveyor did not observe Staff # 3 taking the resident's Blood Pressure before administering the medication. Staff # 3 documented the BP reading after the medication was given. The surveyor asked who was taking the blood pressure reading, and Staff # 3 responded that the Geriatric Nursing Aide (GNA) was taking it. On 03/07/25 at 09:35 AM, Staff # 3 prepared the medications for Resident # 6. Staff # 3 administered Amlodipine (antihypertensive), 5 mg 1 tablet by mouth, and Losartan (antihypertensive), 100 mg 1 tablet by mouth. Both medications had the physician's instruction to Hold for Systolic Blood Pressure of less than 110. The blood pressure was not taken before the administration of the two medications. After all the medications were given, Staff # 3 went to the medication cart and documented the blood pressure reading of Resident # 8. The Surveyor asked who took his/her blood pressure. Staff # 3 stated that the Geriatric Nursing Aide (GNA) took it. On 3/7/2025 at 9:47 AM, Staff # 5, a Registered Nurse (RN), went to Resident # 5 to administer his/her medications. Staff # 5 gave him/her half tablet of Metoprolol (antihypertensive) 25 mg tablet. The physician's order was as follows: Metoprolol tartrate 25 mg tablet, give 0.5 tablet orally every 12 hours. Hold for Heart Rate less than 60. After all the medications were given, the surveyor did not observe Staff #5 checking the heart rate before the medication was given. Staff # 5 documented the information in the electronic medical record and included the heart rate reading. The surveyor asked who was taking the heart rate for Resident # 5, and he responded that it was the Geriatric Nursing Aide.

Based on surveyor review of clinical records and staff interviews, it was determined that the facility staff failed to provide adequate supervision and failed to implement intervention to prevent accidents. This finding was evident for 1 of 4 residents reviewed for falls/accidents during the survey (#5) and resulted in actual harm. The findings include: On 07-30-19, review of the clinical records revealed that resident #5 had a history of [REDACTED]. Resident #5 had [DIAGNOSES REDACTED]. On 02-13-19, resident #5 had a baseline assessment which documented she/he can walk up to 200 feet using a walker with minimal assistance. Additionally, on 02-13-19, after the rehab evaluation, the physical therapist documented that resident #5 needed contact guard at all times while walking with the walker. (Contact guard requires a staff member to hold on to a gait belt placed around the resident's waist while resident #5 walks). On 04-03-19, resident #5 was seen by the nurse practitioner who documented resident #5 needs stand by assist and supervision when walking. (The resident had sustained another fall on 03-08-19). However, review of the clinical record and staff interview revealed that facility staff were not consistently providing stand by assist or contact guard while resident #5 walked as recommended by both physical therapy and the nurse practitioner. Surveyor review of the care plan for resident #5 revealed care plan interventions related to monitoring the resident's safety while dining and providing contact guard assist while the resident was ambulating. On 10-17-16, interdisciplinary staff initiated an intervention staff in the dining room to provide verbal reminders to wait for assistance when he/she is attempting to stand or ambulate by himself/herself. Additionally, staff were to provide frequent monitoring of the resident while awake in his/her room and dining room. On 03-15-19 staff initiated an intervention to provide contact guard assist to the resident while ambulating. However, there was no evidence that the facility staff implemented these interventions when the resident left the dining room unattended on 04-17-19 immediately prior to the fall. Further review of the clinical record revealed a nursing assessment, dated 04-17-19, in which the nurse (LPN staff #10) documented that resident #5 was walking in the hallway using a walker after dinner. The assessment further documents that the resident sustained [REDACTED]. The nurse also noted a nosebleed at the time of the fall. An X-ray was ordered by attending physician on 04-17-19 which revealed fractures of the right patella (kneecap) and the left humerus (upper arm). During the review of resident #5's fall, which was documented in the clinical record, surveyor also requested to review the incident report. The facility staff refused to allow surveyor to have access to the incident report. Instead, the Assistant Director of Nursing (ADON) provided the surveyor with an incident investigation sheet dated 07-31-19 which documented that on 04-17-19, a team member saw resident #5 walking independently and called out her/his name and she/he lost her/his balance and fell . The incident investigation form further documented when resident #5 was approached while she/he was turning around she/he fell . There was no evidence in the incident investigation that contact guard was provided to the resident at the time of the fall. On 08-01-19 at 11:02 AM, interview with Director of Rehabilitation (DOR) revealed that resident #5 had not been an independent walker since beginning a functional maintenance program in (MONTH) (YEAR). On 08-01-19 at 11:20 AM, interview with GNA staff #2 revealed that staff were aware that resident #5 was never an independent walker. Resident #5 always needed at least one person/staff to supervise while walking with a walker. GNA staff #2 also stated resident #5 did not need contact guard at all times while walking with the walker. On 08-01-19 at 11:40 AM, interview with GNA staff #4 revealed that resident #5 always needed assist and supervision while walking with the walker. GNA staff #4 stated her awareness that resident #5 had to have a gait belt and staff stand by when walking with a walker (contact guard). On 08-02-19 at 08:55 AM, interview with GNA staff #5 revealed that prior to the fall on 04-17-19, if staff on the unit observed resident #5 had begun walking independently, they would go and walk behind her/him. GNA staff #5 stated that resident #5 did not always have a gait belt or contact guard while ambulating with walker. GNA staff #5 further stated resident #5 was able to walk on her/his own sometimes. On 08-02-19 at 10:42 AM, a telephonic interview with LPN staff #10 revealed that resident #5 was an independent walker and used a walker. LPN staff #10 also stated that resident #5 did not like staff touching her/him while walking, so staff walked beside or behind her/him to guide her/him verbally. On 04-17-19, 3-11 shift, LPN staff #10 was assigned to resident #5, did not witness the fall, but was notified of the fall and assessed the resident immediately after the fall occurred. On 08-02-19 at 11:02 AM, a telephone interview with GNA staff #7 revealed that she knew resident #5 very well. GNA staff #7 stated when resident #5 walked with walker, staff were required to be present. However, GNA staff #7 stated that resident #5 walked independently every now and then. When resident #5 got agitated or weak, staff would provide contact guard on one side to prevent the resident from falling but at other times, staff would walk behind her/him with no contact guard. On 08-02-19 at 09:29 AM, interview with GNA staff #8 revealed that, prior to the fall on 04-17-19, resident #5 was able to walk with a walker but someone had to be with her/him with a gait belt (contact guard). GNA staff #8 also said she always used the gait belt (contact guard) to assist resident #5. On 08-02-19 12:35 PM, facility staff were unable to provide the name of the staff member who witnessed resident #5 walking independently on 04-17-19 and witnessed the fall (as documented in the incident investigation). However, on 08-02-19 at 04:20 PM, (after the conclusion of the survey and survey exit conference) the facility administrator met surveyors in the parking lot of the facility and stated she/he had literally just found out (on 08-02-19) who witnessed resident #5's fall on 04-17-19. The facility administrator then provided the investigating surveyor contact information of the witness. On 08-05-19 at 2:40 PM, a telephone interview with Dining Services staff #9 revealed that she saw resident #5 walking every day after dinner prior to the fall on 04-17-19. She/he further stated that resident #5 walked alone with a walker and staff would be walking beside or behind the resident. She agreed that staff who walked resident #5 did not provide contact guard every day. On 04-17-19, Dining Service staff # 9 said she/he was working in the assisted living dining room when she/he saw resident #5 walking alone in the hallway without any staff walking beside or behind him/her. As staff #9 left to check on resident #5, she observed that resident #5 was already on floor lying flat on her/his back. Dining Service Staff #9 stated that two nursing staff came to assist resident #5 at that point and she/he returned to the dining room. On 08-06-19 at 11:00 AM, a second telephone interview was held with the Director of Rehab (DOR) for clarification. The DOR stated that, since (MONTH) (YEAR), when resident #5 was being seen for functional maintenance, therapy had recommended that resident #5 receive stand by assist with contact guard at all times while walking with the walker for safety due to high fall risk, and with each subsequent fall, the recommendation for contact guard while walking remain unchanged. The Director of Rehab stated this requirement was discussed in weekly interdepartmental meetings. On 08-06-19 at 02:15 PM, a telephone interview with GNA staff #3 revealed that, prior to the fall on 04-17-19, someone would be with resident #5 while walking with a walker. On 08-07-19 at 11:10 AM, a telephonic interview with GNA staff #11 revealed that she/he was working in a resident room in the assisted living area when she/he heard resident #5's name being called out. Simultaneously, she/he heard a resident fall outside in the hallway. She/he immediately went out into the hallway and witnessed resident #5 lying on floor calling for help. GNA staff #11 informed resident #5 that she/he was going for help and advised resident #5 to remain still. GNA staff #11 then went to the skilled unit and informed RN staff #6 and GNA staff #3 that resident #5 was on the assisted living unit having fallen in the hallway. The facility staff failed to consistently provide adequate supervision and contact guard to resident #5 when walking which resulted in a fall with multiple fractures.

Based on surveyor review of the clinical record and staff interview, it was determined that the facility staff failed to revise the plan of care to reflect the type of assistance needed for walking in a timely manner.This finding was evident for 1 of 4 residents reviewed for falls during the survey (#5). The findings include: On 08-01-19, review of the clinical record for resident #5 revealed that, on 04-17-19, the resident sustained [REDACTED]. Further review of the clinical record revealed that resident #5 had sustained a total of 6 falls in a 12- month period. On 02-13-19, resident #5 was evaluated by physical therapy who determined that the resident needed contact guard at all times while walking with the assistive device (walker). A contact guard requires facility staff to use a gait belt placed around the resident's waist for staff to hold while the resident walks. On 03-08-19, resident #5 sustained a fall with no injury, however, there was no evidence that facility staff revised the care plan to add or update the intervention recommended by physical therapy at the time of the fall. On 03-15-19, facility staff revised the care plan and initiated the intervention to provide contact guard assist to the care plan (one month after the physical therapy determined the need for resident #5 to have contact guard while walking).

Based on surveyor observation and staff interviews, it was determined that the facility staff failed to store, prepare, and serve food under sanitary conditions. This finding was evident for the facility's kitchen during the surveyor's initial tour. The findings include: On 07-02-18 at 08:20 AM, surveyor tour of the kitchen revealed the following: A. Two bins filled with dirty aprons left standing in front of the ice maker machine. B. Further observation in the walk-in refrigerator revealed: 1. A half-filled pan of cooked shrimp in the walk-in refrigerator was not covered or dated. 2. An opened package of frank beef hot dogs was not covered or dated. 3. A half package of Prosciutto beef was opened and not covered/wrapped and not dated. 4. A half package of salami beef was not wrapped and dated. 5. A half package of blue cheese was opened and not dated On 02-26-18 at 8:30 AM, surveyor interview with the Dietary Manager revealed no further information.

Based on surveyor review of the closed clinical record and interview with facility staff, it was determined that the facility failed to provide notification in writing to the resident/resident's representative of resident #15's transfer to the hospital. This finding was evident for 1 of 1 residents selected for the hospitalization review. The findings include: On 07-05-18, surveyor review of the closed record for resident #15 revealed that, on 06-14-18, the attending physician documented an assessment for a change in condition regarding resident #15. Further review revealed that the attending physician wrote orders for the resident to be transferred 911 to the hospital, and this was verbally discussed with both resident #15 as well as the resident's family prior to the transfer. However, record review revealed no evidence that the information regarding resident #15's hospital transfer and the reason for the transfer was provided in writing to either the resident and/or the resident's representative. On 07-05-18 at 3:30PM, surveyor interview with the facility's administrator and the Director of Nursing revealed no additional information.

Based on surveyor observation, staff, resident and family interview, and review of administrative records, it was determined that the facility staff failed to adequately address the screening and reporting components of abuse prevention. This finding was evident in 2 of 7 residents selected in the stage 2 review (#38, # 21) . The findings include: 1a. On [DATE] at 9:20 AM, surveyor observation revealed resident #38 lying in bed attended by two private duty aides (PDA) hired by the spouse of the resident. On [DATE] at 12:30 PM, surveyor observed PDA's assisting resident #38 to transfer into chair in the dining room during the lunch dining observation. Resident #38 has significant cognitive impairment. Further interview with the Director of Nursing revealed no information regarding abuse prevention screening of these private duty aides that were observed in resident rooms during the survey. On [DATE] at 11:00 AM, interview with the facility administrator revealed private duty aide/companion protocol. This protocol states the facility strongly recommends that residents hire private duty assistance through a facility approved agency, and that agency is required to provide: criminal background screening, TB testing, workers' compensation insurance, liability insurance/medical benefits, reference checks, completed I-9 form (authorization to work in the USA), CPR certificate, and CNA (certified nursing assistant) license. The protocol also states the resident/owner will be required to provide copies of all of the above if he/she has employed any independent aide. (not thru an agency). The facility's private duty aide guidelines and expectations directs before you can begin working with residents, you or your employer (resident/ power of attorney) must provide the following documentation to management: Proper photo identification on your first visit and at all times while on premises, negative TB test result/screening, worker's compensation, current CNA or GNA (geriatric nursing assistant) license, liability insurance, current criminal history check, completed I-9 form (authorization to work in USA), current CPR certification and reference checks. A random review of 2 residents with private duty aides revealed that the PDAs did not have the required documentation as specified in the facility protocol and guidelines. The facility failed to ensure the proper screening of private duty employees assisting in the provision of care to the residents. 2. Based on surveyor review of the clinical record, resident interview, and staff interview, it was determined that the facility failed to report to the State authority two allegations of abuse involving resident #21. a. On [DATE], an email was sent to the Director of Social Work from a family member of resident #21. The email informed the Director of Social Work that resident #21 alleged that a staff member gets in his/her face in an inappropriate way, and the staff member is rough when changing his/her incontinence brief. The resident informed the family member that he/she was scared of the staff member. b. On [DATE], the Director of Social Work retrieved the email and notified the Director of Nursing of the family member's concern. The Director of Social Work informed the family member that, as a result of resident #21's serious concern, the staff member was being removed from providing care to the resident, effective immediately. The Director of Social Work also initiated a facility Grievance Report on this date as a result of the allegation. He/she also interviewed the resident, and documented on the grievance that the resident stated that the staff member had been rough and rude for a long time. c. Additionally, on [DATE], the Director of Nursing completed a Grievance Worksheet regarding the allegation but failed to submit the required report to the appropriate authorities. The Grievance Worksheet identified pertinent findings regarding resident #21's concerns, and stated that the staff member had been removed from caring for the resident. d. On [DATE], review of the clinical record for resident #21 revealed a psychiatrist's progress note dated [DATE] which stated during visit the resident Claims a staff member was rough with her/him while putting her/him in a chair and now her/his sides hurt. On [DATE] at 2:00 PM, interviews with the Director of Nursing and the Director of Social Services revealed that the facility did not report this second allegation, but rather completed its' investigation and determined that resident #21 complained of discomfort during a mechanical lift transfer into a wheelchair that was performed by two nursing assistants.

Based on surveyor observation and staff interview during the initial kitchen tour, it was determined that the facility staff failed to ensure proper preparation of food under sanitary conditions. This finding includes: On 07-05-2017 at 12:15 PM, during the initial tour of the kitchen, surveyor observation revealed a cook handling a hamburger bun with ungloved hands while simultaneously spreading mayonaise on the bun. The cook proceeded to place the bun in a to-go container with ungloved hands while adding lettuce and tomato slices to the other bun side inside the container. Upon surveyor intervention, the food was discarded, the cook washed their hands with soap and water, put on gloves and continued further with preparation tasks. A follow up interview about 12:25 PM on 07-05-17 with the culinary and dietary manager provided no additional informational.

Based on surveyor observation, review of the clinical record and staff and resident interview, it was determined that the facility staff failed to adequately address decreased range of motion which was causing physical discomfort. This finding was evident in 1 of 7 residents selected in the stage 2 reviews. (#5). The findings include: On 07-05-17 at 9:50 AM, surveyor observation revealed resident #5 with noticeable limited range of motion in his/her right upper extremity. When asked if he/she could raise the arm over his/her head, resident #5 attempted to lift the right arm, however they were only able to lift it to chest height before responding it hurts. Review of the clinical record for resident #5 revealed a physician's progress note, dated 02-13-17, which documented doing alright, some pain right shoulder if lifts arm. Further review of the clinical record revealed a plan of care with an intervention initiated on 06-15-16 that stated OT (occupational therapy) does not recommend any upper body range of motion (ROM) exercises to address limited ROM of shoulders as ADL (activities of daily living) routines provide enough ROM. However, there was no reevaluation of the intervention after the physician documented the resident's complaint of pain when attempting to lift the right arm on 02-13-17. While there was a revision of the goal in resident #5's care plan to improve the current level of function in ADL's, dated 05-22-17, there was no revision of interventions related to the impact of pain associated with the limited range of motion that was identified on 02-13-17. The intervention remained the same as when initiated on 06-15-16. The attending physician also documented in the 02-13-17 physician progress notes [REDACTED]. There was no evidence in the clinical record that a trial cortisone injection was ever administered. On 07-06-17 at 1:15 PM, interview with the Director of Nursing revealed no additional information. On 07-07-17 at 9:30 AM, interview with the attending physician of resident #5 revealed that the resident had refused and changed his/her mind before agreeing, and that the resident had a history of [REDACTED]. A review of the clinical record with the attending physician revealed no mention of shoulder problems in the admission history and physical dated 01-11-16. Additionally, resident #5 has certification of incapacity to make medical decisions, dated 01-14-16 and 02-02-16. There was no evidence in the clinical record that the responsible party was contacted regarding the cortisone injections or treatment. There was no documented evidence that the physician discussed the proposed treatment plan for the right shoulder impingement with the durable medical power of attorney.

Based on surveyor observation, review of the clinical record and interview of the resident and facility staff, it was determined the facility staff failed to revise and update a care plan regarding the use of contracture boots to bilateral (both) ankles. This finding was evident in 1 of 19 residents selected in the stage 2 review. (#20) The findings include: On 06-20-16 at 9:30 AM during tour, observation of resident #20 revealed he/she was sitting in a wheelchair eating breakfast with both feet unsupported by a footrest. The toes were pointing down with no support. Further observation at 12:00 PM revealed no support to resident #20's feet. Interview of facility nurse #1 at 1:00 PM on 06-20-16 revealed resident #20 had foot drop with no splint. Foot drop is a general term for difficulty lifting the front part of the foot. If you have foot drop, the front of the foot may drag on the ground when walking. A contracture deformity is the result of a stiffness or [MEDICATION NAME] in the muscles, joints, tendons, ligaments, or skin that restricts normal movement. It develops when normally pliable connective tissues become less flexible. This means range of motion will be limited. The main symptom is reduced ability to move an area of the body. On 06-21-16, review of the clinical record revealed an order for [REDACTED]. The contracture boot is a splint like device placed above and below the ankle to allow the foot to remain in a flexed position. On 06-21-16, review of resident #20's Treatment Administration Record (TAR) for June 2016 revealed the resident refused to have the contracture boots applied on the day shift for both 06-20-16 and 06-21-16. Further observation on 06-21-16 at 3:00 PM revealed the boots were visible on resident #20's bureau but not on the resident. At this time, resident #20 revealed the staff do put them on sometimes, but sometimes he/she refuses as they are not always comfortable. Review of the care plans for resident #20 revealed no specific care plan for the contractures of the feet however, the care plan for ADL (Activities of Daily Living) included under focus has ADL self-care performance deficit related to impaired mobility and balance and contractures to bilateral ankles. The goal was for resident #20 to maintain current level of function through the review date. The interventions included: elevate lower extremities at all times to decrease [MEDICAL CONDITION]; put boots on per doctors orders for contractures. Other interventions included interventions concerning the morning routine, bathing/showering, bed mobility, dressing , eating and transfers. On 06-22-16 at 10:00 AM, interview with GNA (Geriatric nursing assistant) #2 who was caring for the resident revealed resident #20 frequently refuses to wear the boots. On 06-22-16 at 11:00 AM, interview with nurse #1 revealed the resident frequently refuses to allow staff to put the boots in place. The staff do educate resident #20 that by wearing the boots, the ability to flex the feet will not deteriorate. However, the resident frequently refuses. At 2:00 PM, interview with therapist #3 revealed resident #20 has had the boots to wear for a year and frequently refuses to wear them. In addition, footrests are to be used when resident #20 is seated upright in the wheelchair, but again the resident refuses to allow them to be placed on the wheelchair frequently. Interview of 3 facility staff revealed that resident #20 frequently refused to allow the boots to be placed on the feet to prevent the foot drop from worsening. This information concerning resident #20's refusals and being uncooperative with care has not been addressed in the care plan. No revisions have been noted in the care plan referring to the use of the contracture boots. On 06-22-16 at 11:30 AM, interview with the Director of Nursing (DON) revealed no additional information.

Based on surveyor observation, review of the clinical record and facility staff interview, it was determined that the facility staff failed to meet professional standards of nursing practice. This finding was evident in 1 of 19 residents selected in stage 2 reviews (#28). The findings include: On 06-22-16 at 09:30 AM, surveyor review of the clinical record revealed resident #28 was admitted to the skilled care unit with multiple [DIAGNOSES REDACTED]. Additional record review revealed multiple medications including but not limited to Vitamin B12 1000 mg 1 tablet by mouth one time a day for vitamin deficiency (Crushed). On 06-22-16 at 07:20 AM, during medication administration observation, surveyor observed LPN (licensed practical nurse) #1 administer Vitamin B12 tablet to resident #28 as a whole tablet. However, review of resident #28 clinical record for reconciliation revealed crush as part of the physician order [REDACTED].>On 06-22-16 at 07:30 AM, surveyor interview with LPN#1 revealed that resident #28 takes all medications by mouth in whole table form. Additional interview with resident #28 on 06-22-16 at 07:40 AM revealed that resident #28 prefers to take all medications in whole tablet form. Based on the nursing administration of the medication and resident stated preference, clarification needed to be sought regarding the order to crush the medication. On 06-22-16 at 08:20 AM, surveyor interview with the Director of Nursing (DON) revealed that the order was confusing. The DON stated that the facility staff should have clarified the order with the physician. As a standard of practice as defined in the Maryland nurse practice act 10.07.09.03 a licensed nurse is required to obtain physician clarification on orders that are unclear in a timely manner. Following surveyor intervention on 06-22-16, the DON clarified the Vitamin B12 order with the physician.

Based on surveyor review of the clinical records and interview of the facility staff, it was determined the facility staff failed to follow the physician's orders [REDACTED]. This finding was evident in 2 of 19 residents selected in the stage 2 review. (#40, #20) The findings include: 1. On 06-21-16, review of the closed clinical record revealed resident #40 was in the facility for rehabilitation. On admission, 05-19-16, an order was written for the resident to have a bedtime snack and document the percentage consumed. However, no evidence of the percentage consumed was documented as ordered for May 20, 21, 22, and 23, 2016. In addition, on June 3, a weight loss was noted and a new order was written for Ensure Clear, a nutritional supplement, to be given at 10:00 AM with the percentage consumed recorded. There is no evidence of the percentage being documented on June 3 and 4, 2016. On 06-22-16 at 11:00 AM, interview with the Director of Nursing (DON) revealed no additional information. 2. On 06-21-16, review of the clinical record revealed resident #20 was a diabetic who had a sliding scale fingerstick blood sugar level checked prior to each meal. The order dated 05-31-16 revealed that, if the fingerstick blood sugar was greater than 350 mg/dl, the physician should be called. Further review of the Medication Administration Record [REDACTED]. There is no evidence the physician was contacted. On June 17 at 7:30 AM, resident #20's fingerstick blood sugar was 360mg/dl. There is no evidence the physician was contacted as ordered. On 06-21-16 at 3:00 PM, interview with the DON revealed no additional information.

Based on surveyor review of the clinical records, observation of dining and interview of facility staff, it was determined that the facility staff failed to meet the standard of nursing practice, in new order transcription and documentation, after a nutritional supplement was offered. This finding was evident in 2 of 21 residents selected in stage 2 review (#50 and #45). The findings include: 1. On 06-10-15, review of the clinical record revealed that resident #50 was under diabetic management. A nurse practitioner gave a new order for insulin administration on 04-17-15 and instructed the nursing staff to contact her or the attending physician if resident #50's blood sugar was above 350 mg/dL. However, review of the May 2015 Medication Administration Record [REDACTED]. Further review of the June 2015 MAR indicated [REDACTED]. On 06-10-15 at 12 noon, interview of the director of nursing revealed no additional information. As a standard of nursing practice, a licensed nurse is required to transcribe a physician order [REDACTED]. 2. On 06-08-15, review of the clinical record revealed an order was written on 02-05-15 to give a cold nutritional supplement at lunch for resident #45 to increase her calories intake and record her consumption. On 06-08-15 at 11 AM, interview of staff #2 and review of the June 2015 MAR indicated [REDACTED]. Staff #2 stated the nutritional supplement was provided by the food service department at lunch. On 06-08-15 at 1 PM, observation of resident #45 revealed that she was eating lunch in the dining room, but no nutritional supplement was seen on the table. On 06-08-15 at 1:05 PM, interview of staff #1 revealed she provides the nutritional supplement to resident #45 daily after she completes her entree. On 06-09-15 at 3:40 PM, interview of the director of nursing revealed no additional information. As a standard of nursing practice, a licensed nurse is required to ensure an individual receives a nutritional supplement as ordered. In addition, a licensed nurse is required to document intake after the nutritional supplement is offered in order to track caloric intake with the weight.

Based on surveyor review of the medical records and interviews with staff, it was determined that the facility staff failed to comprehensively assess weight loss. This finding was evident in 2 of 16 resident selected for the stage 2 reviews. (#42 and #26) The findings include: 1. Based on surveyor review of the closed clinical record and staff interview, it was determined that the facility staff failed to assess a weight loss for over 30 days for resident #42. On 06-10-14, review of the closed clinical record revealed resident #42 was admitted to the facility for rehabilitation services on 01-16-14 following hospitalization for a [MEDICAL CONDITION] with surgical repair. Review of the weight record revealed the resident's weight at admission (01-16-14) was 139.4 pounds. The next weight measurement taken on 01-22-14 was 136.4 pounds. The following day on 01-23-14, the registered dietitian (RD) completed an initial nutrition/dietary assessment and noted the resident's weight at 136.4 pounds. Based upon this weight, the RD calculated the resident's dietary needs. The RD documented the resident "needs to be assisted and cued to consume > 75% meals... Her dementia may prevent her from consuming adequate calories/protein necessary for healing. Monitor po (by mouth) intake, weights and labs closely." Continued review of the weight record revealed: 01-29-14 134.4 pounds 01-30-14 135.6 pounds 02-05-14 133.0 pounds. Based on record review, on 02-05-14 the RD noted the resident's "Weight is 133#, stable. She requires cueing and encouragement and min(imal) assistance to eat. Eating approx(imately) 50-75% Regular diet." There was no evidence that the RD addressed the pattern of weight decline and the weight loss of 6 pounds since admission at this time. Continued review of the weight record revealed: 02-12-14: 132.2 pounds, with a calculated warning stating "-5.0% change over 30 days (-5.2%, -7.2 lbs)." There was no evidence that the RD assessed the weight loss of 7 pounds less than 30 days after admission. Interview with the RD on 06-11-14 at 1:30 PM revealed she based the initial nutrition/dietary assessment on the 5 day MDS (Minimum Data Set - a required assessment of the resident's status) weight of 136.4 pounds, which did not correctly reflect the resident's weight at admission of 139.4 pounds. Therefore, the warning of 5% change over 30 days was disregarded by the RD. Continued review of the weight record revealed: 02-19-14 133.4 pounds 03-05-14 131.4 pounds 03-12-14 131.2 pounds. On 03-12-14 the resident was discharged from the skilled nursing unit. The RD note on the same date stated "Resident's weight was 131.4#, which was in keeping with UBW (usual body weight) here." Based on record review and interview with the RD, there was more than 1 month between the RD's review dates on 02-05-14 and 03-12-14, when there was no evidence of an assessment of the resident's progressive and significant weight loss prior to discharge. 2. Based on resident record review and staff interview, it was determined that the facility staff failed to conduct a comprehensive assessment for resident #26's weight loss in a timely manner. On 6-10-14 surveyor review of the medical record revealed that resident #26 was admitted on [DATE] for therapy after surgery for [REDACTED]. 3-25-14: 137lbs 3-26-14: 136lbs 3-27-14: 130lbs 4-2-14: 128.4lbs Review of the medical record revealed the 7 lb weight loss in 3 days on 3-27-14 was not verified for accuracy. There was no nursing note indicating physician notification or family notification. Further review of the record revealed the initial nutritional assessment was not conducted timely. The dietitian visited and assessed the resident on 4-3-14, a week after the resident had significant weight loss. Interview of the dietitian on 6-11-14 at 2:30 PM revealed no further information.

Based on surveyor review of the medical record and interviews with staff, it was determined that the facility staff failed to accurately update a care plan for transferring a resident and failed to ensure a timely and comprehensive revision of care plans. This finding was evident in 2 of 16 residents selected in the stage 2 reviews. (#24 and #26) The findings include: 1. On 06-11-14, surveyor review of the medical record and interviews with staff revealed that the facility staff failed to update a care plan related to transfers from the bed to the wheelchair for resident #24. Record review revealed that resident #24 was admitted to the facility in January 2014 with [DIAGNOSES REDACTED]. The resident was wheelchair bound on admission and had a history of [REDACTED]. The resident received therapy services and was discharged from physical therapy on 03-11-14. At that time, the physical therapist documented that the resident required minimum assistance from staff to transfer from the wheelchair to standing using a Spryte lift (a mechanical device to assist rising from a seated position). Review of the occupational therapist (OT) discharge summary dated 03-11-14 revealed that the resident required moderate to maximum assist for transfers "depending on the day". The OT also documented that staff were to use the Spryte lift for increased safety, body mechanics and joint protection. Review of the ADL (activities of daily living) care plan revealed the section for transfers stated "the resident requires extensive assistance of 2 person assist to move between surfaces" and "the resident uses wheelchair and staff to assist to maximize independence with transferring". This plan was developed on the initial admission to the facility. The therapy staff educated the GNAs (geriatric nursing assistants) on the Spryte lift use. The ADON (assistant director of nursing) stated that staff were using the lift. However, no evidence was identified on either the nursing or the GNA's care plan that the Spryte was to be used for transfers. 2. Based on resident record review and staff interview, it was determined that the facility staff failed to ensure a timely and comprehensive revision of care plans for resident #26. On 6-11-14, surveyor review of the medical record revealed resident #26 was admitted for therapy after hip surgery due to a fracture. The resident was alert and oriented. a. Review of the MDS (minimum data set) dated 4-22-14 revealed the resident continued to need 2 persons to assist her in transfer. There was no additional note related to the assessment of the resident's transfer status for lack of improvement in transfer need. The resident continued receiving skilled therapy 5 times a week including transfer and ambulation. Review of the therapy notes revealed the resident had made steady progress in transfer and ambulation. The resident was able to transfer and use a walker for ambulation with limited assistance in April. The resident was able to be discharged to home on 5-30-14. Review of the nursing assistant documentation for the month of April revealed the resident only needed 1 person for transfer except one time on 4-1-14. Review of the nursing notes in April revealed there were notes indicating the resident needed 1 person for transfer and other daily activities. However, on 4-21-14, one nursing note documented that the resident "continues with two person assist with transfers, one person assist with ADL's (activity of daily living)". This was contradictory to the nursing assistant's documentation in transfer need of 1 person assist and other nursing notes in transfer need of 1 person assist. Interview of the MDS coordinator on 6-11 at 11AM revealed no further information. b. Review of the care plan for activities of daily living revealed the care plan was initiated on 3-26-14 and the resident needed 2 persons for transfer. There was no revision of the care plan when the resident had a change. Interview with the assistant director of nursing on 6-11 at 11:15AM revealed no further information.