Every finding on record at Marley Neck Rehabilitation and Wellness Center

Based on review of an email and interviews it was determined that the facility staff failed to report an allegation of verbal abuse to the state agency. This deficient practice was evidenced in 1 (#4) of 2 allegations of abuse reviewed during the complaint survey.The findings include:On 03/11/26 at 4:01pm during an interview with Resident #4 the surveyor asked about the incident when the Geriatric Nursing Assistant's (GNA) were talking about them as if they were not present. The resident verbalized they sent an email to Administrator #1 and Director of Nursing (DON) #2 about the incident.On 03/12/26 at 11:14 am during an interview with Administrator #1 she verbalized Resident #4 emailed them about their concern, but she was out sick and DON #2 was at a hearing. Administrator #1 provided the surveyor a copy of the email. Resident #4 sent an email to Administrator #1 and DON #2 on 12/09/25 at 12:57 am reporting while GNA #16 and GNA #17 were providing care the night before, they were making comments about the resident. Administrator #1 verbalized they missed the email and did not address Resident #4's concerns.On 03/12/26 at 12:14 pm during an interview with DON#1, she verbalized Resident #4 usually sent an email or would call them to be changed. They were not aware the resident had an issue with the GNA's; they missed the email as she just came back from vacation and they report allegations of abuse immediately to the state within 2 hours. They also report allegations of abuse to the Ombudsman.

Based on review of email and interviews it was determined that the facility staff failed to investigate an allegation of verbal abuse. This deficient practice was evidenced in 1 (#4) of 2 allegations of abuse reviewed during the complaint survey.The findings include:On 03/11/26 at 4:01pm during an interview with Resident #4 the surveyor asked about the incident when the Geriatric Nursing Assistant's (GNA) who were talking about them as if they were not present. The resident verbalized an email was sent to Administrator #1 and Director of Nursing (DON) #2 about the incident.On 03/12/26 at 11:14 am during an interview with Administrator #1 she verbalized Resident #4 emailed them about their concern, but she was out sick and DON #2 was at a hearing. Administrator #1 provided the surveyor a copy of the email. Resident #4 sent an email to Administrator #1 and DON #2 on 12/09/25 at 12:57AM reporting while GNA #16 and GNA #17 were providing care the night before, they were making comments about the resident. Administrator #1 verbalized they missed the email and did not address Resident #4's concerns.On 03/12/26 at 12:14 pm during an interview with DON#1, she verbalized Resident #4 usually sent an email or call them to be changed. They were not aware the resident had an issue with the GNA's; they missed the email.

Based on medical record review and interviews it was determined that the facility staff failed to document a resident's pain score after administering pain medication and failed to administer oxygen therapy and report to the provider a resident's oxygen saturation decreased to 86%-87%. This deficient practice was evidenced in 1 (#3) of 5 resident records reviewed during the complaint survey.The findings are:1. On 03/10/26 at 9:06 am a review of Resident #3 medication administration record (MAR) the resident was prescribed Methadone 10 mg PO (by mouth) BID (twice a day) for pain and Oxycodone 10 mg q (every) 8 hours PRN (as needed) for pain. On 02/06 @7:33 am Licensed Practical Nurse # documented they administered Oxycodone 10 mg PO to the resident. Resident #3 pain score was documented as 6. When the surveyor checked the electronic health record (EHR) there was no documentation to verify the pain medication was effective.On 03/10/26 at 11:14 am during an interview with Licensed Practical Nurse (LPN) #18 the surveyor asked when pain medication is administered to a resident does the nurse assess if the medication is effective. LPN #18 verbalized when they administer pain medication they assess the pain level prior to administration of the medication. They ask the resident if the medication was effective and document the follow up (F/U) pain score in PC. The F/U is done 30 minutes to 1 hour after the medication had been administered. On 03/10/26 at 11:16 am during an interview with Director of Nursing (DON) #2 she verbalized routine and PRN pain medication pain score should be documented. Prior to the administration of PRN medication, nurses should attempt non-pharmalogical techniques first. The F/U pain score is documented in PCC15-30 minutes after the medication is given. If the medication is not effective they have to call the provider and ask for another option. On 03/10/26 at 1:33 pm a review of the EHR revealed LPN #20 documented Resident #3 F/U pain score although LPN #19 administered the medication and was working on the unit. LPN #20 worked the night before. During an interview with DON #2 the surveyor asked why LPN #20 documented for LPN #19 when LPN was working. DON #2 was unable to answer the surveyor's question. The surveyor was unable to reach LPN #19 for an interview. 2. On 03/10/26 at 3:20 pm the surveyor reviewed Resident #3 change in condition and the CRISP report which revealed while the resident was in distress their oxygen saturation was 86%-87% but Resident #3 was not administered oxygen; DON #2 was made aware of the surveyor's findings. On 03/17/26 at 9:46 am during an interview with DON #2 she verbalized if there is a significant change in the residents' condition Monday -Friday, the inhouse Nurse Practitioner (NP) would assess the resident. During off hours they will notify the on-call provider; the provider would give recommendations. Even though the nurse reached out to the provider they didn't realize Resident #3 oxygen saturation decreased. DON #2 verbalized administering oxygen is a nursing judgment; the nurse dropped the ball.

Based on observation and interviews it was determined that the facility staff provided a resident with a wheelchair without assessing if the wheelchair was safe for use. This deficient practice was evidenced in 2 (#4 & #8) of 2 residents reviewed for having necessary equipment.The findings include: 1. On 03/11/26 at 5:20 pm a review of a Concern Form dated 02/06/26 revealed Resident #4 requested footrests for their wheelchair. There was a note indicating Rehab Director #12 had difficulty finding footrests for Resident #4's wheelchair because of the size of the wheelchair.On 03/12/26 at 12:01pm during an interview with Rehab Director #12 the surveyor asked did they ensure the resident had leg rests on their wheelchair. Rehab Director #12 verbalized they are having difficulty finding the legs rests that fit the resident's wheelchair. The prongs were wider than the standards rest; they don't stay in place. They tried modifications to keep the pieces together. Rehab Director #12 advised Resident #4 legs were propped up on chairs when their legs got tired while receiving therapy, however there was no documentation to verify they were trying to get the footrests for the wheelchair. They were just looking on Google to see if they could find them and did not reach out to a supply company.2. On 03/17/26 at 9:28 am while speaking with Resident #8 they verbalized their wheelchair did not lock and the arm rest would not lock. The resident verbalized feeling unsafe when they transferred from the wheelchair to the commode.On 03/17/26 at 11:23 am during an interview with Rehab Director #12 the surveyor asked if equipment is assessed for safety prior to giving the equipment to residents. Rehab Director #12 verbalized usually a wheelchair that has come to their department was from another resident. They turn them over quickly. Resident #8's arm rest that releases needed to be spun for the arm rest to work properly. The wheelchair was not assessed to be safe, it looked like the break was bent and they bent it back this morning.

Based on observations and interviews it was determined that the facility staff failed to ensure the dome food covers were dry before covering residents' plated food. This deficient practice was evidenced in 2 of 7 observations of the kitchen staff plating residents' food during the complaint survey.The findings are:On 03/10/26 at 8:18am during the modified kitchen tour the surveyor observed the kitchen staff preparing the residents' food. The surveyor observed Dietary Aide #5 place dome food covers with standing water over Resident #6 and Resident #7's plates. The surveyor requested Dietary Aide #5 to lift the dome food covers from the residents' trays and observed liquid in Resident #6's pureed food and liquid on Resident #7's bacon and on the plate. The surveyor observed wet dome shaped food lids stacked on top of each other near the tray line. Certified Dietary Manager #4 removed the plates from the tray line.On 03/17/26 at 10:02 am during an interview with Dietary Aide #5, they verbalized they thought the lids were already dry because they were cleaned the night before. They were not aware the lids needed to be dry before using as the kitchen staff just started using the racks.

Based on observations and staff interview it was determined that the facility failed to maintain essential equipment in proper operating conditions. This was evident for 2 of 4 pieces of equipment assessed in the kitchen during the complaint survey.The findings include:All essential kitchen equipment must be maintained in safe operating condition in accordance with the manufacturer's specifications and remain accessible throughout kitchen operations.On 03/11/26 at 11:43 am the surveyor observed the kitchen staff preparing lunch trays. The last cart left the kitchen at 12:25 pm. The kitchen staff continued to prepare lunch trays that were unable to be placed in the cart due to the lack of space. The kitchen staff prepared a test tray for the surveyor.On 03/11/26 at 1:00 pm the surveyor tested temperatures of the food for a regular try. The temperatures wereHam 118.8 degrees FSweet potatoes 121.3 degrees FCollard greens 120.9 degrees [NAME] 03/17/26 at 10:51 am during an interview with Certified Dietary Manager #4 the surveyor voiced concerns about the temperatures of the food on the test try. CDM #4 verbalized they totally agreed that none of the temperatures were the proper temperature. An electrician was at the facility to repair the plate warmer and the pellet warmer. The plate warmer worked properly for about an hour. The pellet warmer was reading 135 degrees Fahrenheit initially, but when the staff pull it out for use, it would cool too fast.

Based on observations and interviews it was determined that the facility staff failed to maintain a safe and sanitary environment for residents and staff. This deficient practice was evident based on observations in the kitchen during the complaint survey. The findings include:On 03/11/26 at 11:56 am while in the kitchen the surveyor observed different colored particles on the base of the food lid rack, copious black dust on the exhaust fan, and the front of the PTAC heat/air conditioner unit was detached from the unit. On 03/12/26 at 12:46 pm during an interview with Maintenance Director #13 the surveyor asked if there was a preventative maintenance schedule and the surveyor reported the maintenance issues observed in the kitchen. Maintenance Director #13 verbalized they have an app called TELS that the employees use to submit maintenance concerns. Sometimes it's word of mouth and the staff will tell them about issues. They have a monthly and a weekly schedule that's a part of TELS. Usually, the kitchen comes up every month. They inspect the dishwasher water temps, sometimes the kitchen staff would tell them if something is not working. Maintenance Director #13 stated when the kitchen was inspected on Monday, he did not notice the surveyor's concerns with the face of the P-Tech which was the AC/Heater that was falling. Everything in the kitchen goes out through that exhaust. He stated, the exhaust fan was usually cleaned about once a month. The kitchen staff was cleaning the tray table at one time, but maintenance will start cleaning it now. Usually, they would take the rack outside and power wash it.On 03/17/26 at 10:51 am during an interview with certified Dietary Manager #4 the surveyor asked when there are maintenance issues in the kitchen how they were reported. CDM #4 verbalized the staff are supposed to put maintenance issues in TELS, there is a computer in the office for the dietary staff to use. CDM #4 indicated they saw the issues but was focused on something else.

Based on incident report, record review, and interviews with staff and residents, it was determined that the facility failed to change the brief of Resident #5 and #6. This was evident for 2 out of 6 residents reviewed during the complaint survey.Findings Include:1) On 8/16/25, a family member of Resident #5 sent in complaint stating the resident was left on several occasions with stool and urine in his/her diaper. On the GNA (Geriatric Nursing Assistant) documentation sheet for the month of March and April 2025, the documentation shows that resident was not changed on 3/28/25 day and night shift and on 3/31/25 night shift. The Director of Nursing (DON) was made aware on 10/15/25 and she stated she would look into this.2) On 10/15/25 at 9:45 AM an interview was held with Resident #6 who is alert and oriented with a BIMS score of 14/15, indicating he/she is cognitively intact and can make his/her needs known. Resident #6 stated he/she normally does not have a problem with getting changed, however last eve he/she stated they put the call bell on at 7:30PM and a GNA (Geriatric Nursing Assistant) came in to answer the call bell. He/she stated they needed to be changed and the GNA stated she would be right back. However, she never came back and call light was on until 11:30 PM. The DON was made aware and went in to speak with Resident #6. The DON stated she would look into the matter and educate staff if needed.

Based on interview and medical chart review, it was determined that the facility failed to place CPAP on resident every night. This was evident for 1 (Resident #6) out of 1 resident reviewed for CPAP usage during the complaint survey.The findings include:On 10/15/25 at 10:45 AM, the surveyor went to room [ROOM NUMBER]-2 to interview Resident # 6 about the care he/she is receiving. The resident has been at this facility since 10/6/25 and has a history of COPD and respiratory failure. Resident #6 is alert and oriented and can make all needs known. The resident was ordered a CPAP machine for sleep Apnea. A CPAP machine (continuous positive airway pressure) machine is one of the most common treatments for sleep apnea. It keeps your airways open while you sleep so you can receive the oxygen you need. CPAP machines can significantly improve sleep quality and reduce your risk for a number of health issues, including heart disease and stroke.Resident #6 stated that he/she wears the CPAP machine when he/she can. I asked the resident what that means and the resident stated I can not put the machine on by myself and need assistance but when I call for assistance sometimes the nurse will come and other times no one answers my call bell. The DON (Director of Nursing) was made aware on 10/15/25 at 10 AM. The DON stated she will look into this.

Based on observations, interviews and record reviews it was determined that the facility failed to store food 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's kitchen. The findings include: During the initial tour of the main kitchen on 6/16/25 at 08:00 AM with the Certified Dietary Manager (CDM), the following items were found open, unlabeled, and undated. 1. Frozen Omelets were found in a clear plastic bag on a shelf in the freezer. The bag was open and not labeled or dated. 2. An opened container of Tajín seasoning was found on a shelf in the kitchen area. It was not labeled or dated. During an interview with the Certified Dietary Manager (CDM) on 6/16/25 at 9:00 AM, he stated that the items found unlabeled should have been dated after opening. On 6/16/25 at 9:05 AM, the CDM was made aware of the findings and acknowledged the concerns. An observation with the CDM and District Manager was conducted on 6/20/25 at 7:05 AM of a food cart for breakfast service in A Wing. This Surveyor, the CDM, and District Manager observed the staff began to pass the breakfast tray at 7:10 AM and completed the service at 7:18 AM. Following the last tray served the CDM, then began to take the temperature of the food on the test tray. The following food temperatures were recorded: Orange Juice - 49 degrees Fahrenheit Milk - 49 degrees Fahrenheit Oatmeal - 163.9 degrees Fahrenheit Sausage Patty - 139 degrees Fahrenheit Eggs Florentine Bake - 140 degrees Fahrenheit On 6/20/25 at 7:25 AM, the surveyor informed both the CDM and the District Manager of concerns regarding the temperatures of milk and orange juice. Both acknowledged the findings. On 6/20/25 at 7:28 AM, an observation was conducted in the A-Wing nutrition storage room with the Certified Dietary Manager (CDM). The following was noted: A sandwich in a Ziplock bag labeled with resident #243's name was observed in the refrigerator without a date. On 6/20/25 at 7:35AM, the surveyor inquired about the expectations for resident food storage. The CDM stated that items should be labeled with the residents' name and the date of placement. He further confirmed that, according to facility policy, food may be stored in the refrigerator for up to five days. The surveyor informed the CDM of the concern, and he acknowledged the finding. Review of facility Food Safe Handling for Food from Visitor Policy statement on 6/20/25 at 8:19AM revealed that label foods with the resident name and the current date. On 6/20/25 at 8:46 AM, the Surveyor made the CDM and the Administrator aware of the above concern and both acknowledged receipt. On 6/24/25 at 7:20 AM, an observation on B-Wing Breakfast Service with Administrator and CDM recorded the following food temperatures: Fried eggs: 136°F Hot Ham: 126°F Apple juice: 50.5°F These findings were confirmed on-site with both the Administrator and the Certified Dietary Manager (CDM). The surveyor informed them of the concerns regarding food safety and temperature compliance. Both individuals acknowledged receipt of the information. On 6/24/25 at 8:30 AM, the Policy Review of Health Services Group, Inc Policy for Food Storage: Cold Foods/Beverages and Hot Foods explicitly required that: Cold beverages and cold foods must be maintained at 41 degrees Fahrenheit or below to ensure proper temperature control and prevent bacterial growth. Hot foods must be held at 135 degrees Fahrenheit or above to maintain food safety and prevent the growth of harmful microorganisms.

Based on interview, review of facility-reported incident investigation and record review, it was determined that the facility failed to thoroughly investigate an incident. This was evident for 1 (Resident #59) of 3 residents reviewed for abuse during the recertification survey. The findings include: A Hoyer lift, also known as a patient lift, is a mechanical device used to safely lift and transfer individuals who are unable to move themselves, often due to mobility limitations. On 6/16/25 at 11:11 AM, in an interview with Resident #59, he/she stated that a Geriatric Nurse Assistant (GNA) was rough when he/she was transferred from wheelchair to bed. He/she added that he/she was supposed to be transferred via Hoyer lift, however, the GNA picked him/her up from my wheelchair and transferred him/her manually to the bed. On 6/27/2025 at 8:09 AM, a review of facility-reported incident MD00211974 revealed that on 11/19/24 at 6:00 PM, Resident #59 was transferred by GNA #10 from the wheelchair to the bed without using a lift. The allegation was confirmed with a statement provided by Resident #53. Further review of the facility's investigation revealed that the facility obtained statements from the staff and witnesses, however, the facility indicated, there were no interviews with other residents. The facility's findings also stated, failure to honor the resident's request for Hoyer lift was substantiated. On 6/27/25 at 10:35 AM, a review of Resident #59's medical records indicated a BIMS score of 13 of 15, cognitively intact (Brief Interview for Mental Status, BIMS, is a screening tool used to assess basic cognitive function in patients in long-term care facilities.) On 6/27/25 at 12:45 PM, in interview with the NHA, she stated that once the facility received a report of an incident from a resident/ family or staff, the facility immediately started the investigation. She added that the facility obtained statements from the victim, perpetrator, witnesses, staff and added that she expected that other residents who were under the care of the alleged perpetrator would be interviewed by the facility.

Based on record review and interview, it was determined that the facility failed to accurately code the resident's discharge status on the Discharge MDS assessment. This was evident for 1 (Resident #88) of 3 residents reviewed for hospitalization during the recertification survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, discharge assessments include the completion of a select number of MDS items in order to track residents when they enter or leave a facility. A Discharge Assessment-Return Not Anticipated (DCRNA) must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days while a Discharge On 6/20/25 at 7:20 AM, a review of Resident #88's medical records indicated a discharge date of 3/25/2025 at 11:50 AM to an Assisted Living Facility (ALF). This was supported by a Nurses note, a Discharge summary visit notes by Nurse Practitioner (NP #9), a Social Services note and a Physician's order dated 3/25/2025 which indicated, Discharge to ALF. However, a review of Section A of the MDS Discharge Return Not Anticipated (DCRNA) assessment with an Assessment Reference Date (ARD) of 3/25/2025 revealed that the discharge status was incorrectly coded as Discharge Status- Short- term General hospital (acute hospital). On 6/20/25 at 9:08 AM, during an interview with the Social Worker (SW), she described that changes to the residents' discharge status were communicated to the Interdisciplinary Team (IDT) through a weekly meeting. She also verified that Resident #88 was discharged to an ALF in Severna Park. On 6/20/25 at 9:17 AM, in an interview with the Minimum Data Set (MDS) coordinator, she confirmed that Resident #88 was discharged to an ALF and acknowledged that the discharge assessment should have been coded as discharged to community/AL. On 6/20/25 at 12:58 PM, the Director of Nursing (DON) was notified of the concern.

Based on medical record reviews and facility staff interviews, it was determined that the facility failed to initiate care plans based on medication use. This was evident for 2 (Residents #4, #32) out of 36 residents reviewed for care plan implementation during a recertification survey process. The findings include: A care plan details the daily support an individual requires to maintain quality of life, including personal care, medication, meals, social interaction, and mobility assistance. It ensures coordinated care across caregivers and service providers. On 6/18/25 at 6:35 AM, a review of Resident #32's medical record revealed a physician order dated 3/21/25 for busPIRone HCl 5 mg oral tablet. The order directs staff to administer 1 tablet by mouth every 8 hours for treatment of anxiety. On 6/18/25 at 12:49 PM, further review of the medical record revealed that the facility failed to initiate a care plan related to antianxiety medication to reflect the plan of care for Resident #32. During an interview with the Director of Nursing (DON) on 6/18/25 at 1:49 PM regarding Care Plan Initiation Process, the DON stated that a care plan is initiated upon admission and is updated as needed. She explained that the MDS Coordinators, in collaboration with the interdisciplinary team, are responsible for updating the care plan when there is a change in the resident's condition. When asked who is responsible for initiating the care plan, the DON responded, Any of the nurses, especially the admission nurse, managers, and MDS Coordinators. She further noted that medication updates are handled by both the nursing staff and MDS Coordinators. The surveyor informed the DON on 6/18/25 at 1:55 PM of concerns related to Resident #32, whose care plan had not been initiated for antianxiety medication. The DON acknowledged the concern and stated, I will look into it, noting that the resident is frequently admitted and discharged from the facility. On 6/20/25 at 8:33 AM, the DON confirmed that no care plan had been initiated for the resident #32's antianxiety medication. The DON stated, I went ahead and initiated one. The surveyor brought the concern to her attention, and she acknowledged the oversight. On 6/20/25 at 12:10 PM,a review of the medical record revealed that the care plan addressing the Resident #32 's antianxiety medications was initiated on 6/18/25, following surveyor's intervention. On 6/20/25 at 12:36 PM, a review of Resident #4's medical record review revealed the physician orders for Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT on 3/21/25. On 6/20/25 at 1:27 PM, the surveyor informed the DON that Resident #4 is currently receiving anticoagulant therapy; however, there is no care plan in place addressing this intervention. The DON confirmed that a care plan for anticoagulant therapy had not been initiated and acknowledged the concern. On 6/20/25 at 1:52 PM, further review of the medical record revealed that a care plan addressing Resident #4's anticoagulant medication was initiated on 6/20/25, following the surveyor's intervention.

Based on record reviews and facility staff interviews it was determined that the facility failed to ensure a Resident was provided scheduled showers. This was found to be evident for 1 (Resident #77) out of 1 Resident reviewed for Activities of Daily Living (ADL) during the re-certification survey. The findings include: According to the National Institute of Health (NIH) Activities of Daily Living (ADL) are basic routine tasks that most healthy individuals can perform without assistance. These activities include personal care tasks such as eating, dressing, bathing, toileting, managing continence, and transferring (moving from 1 position to another). The ability to perform activities of daily living is an essential measure of an individual's functional status. The inability to perform basic activities of daily living may lead to unsafe conditions and a poor quality of life. The healthcare team should be aware of the importance of assessing activities of daily living in patients to help identify those who require assistance, whether for temporary rehabilitation or long-term care planning. On 6/30/25 at 6:06 AM a review of the complaint MD00218418 revealed a concern that Resident #77 did not receive routine showers. A review of Resident #77's ADL's Documentation Survey Reports V2 was conducted on 6/30/25 at 6:39 AM. The report showed that the Resident's scheduled shower days were Tuesdays and Fridays on the day shift. Further review of the reports showed that the Resident had 13 opportunities since admission to receive a shower: 5/16/25,05/20/25, 05/23/25, 05/27/25, 05/30/25, 06/03/25, 06/06/25, 06/10/25, 06/13/25, 06/17/25, 06/20/25, 06/24/25, and 06/27/25. However, the Resident received 7 showers duing this period: 5/16/25,05/20/25, 05/23/25, 05/27/25, 05/30/25, 06/20/25, and 06/24/25. During an interview conducted on 6/30/25 at 8:40 AM, Geriatric Nursing Assistant (GNA)#7 stated that she had provided care routinely for Resident #77 and stated that the Resident had been compliant with all care and had not refused showers when offered. The GNA further stated that she was unaware of a reason why the Resident had not received his/her showers as scheduled. During an interview conducted on 6/30/25 at 9:16 AM, this Surveyor discussed the concern that Resident #77 had not received showers as scheduled. The Nursing Home Administrator (NHA) stated she understood the concern and would speak with the Director of Nursing.

Based on interview, observation and record review, it was determined that the facility failed to apply a preventative brace ordered for a resident. This was found to be evident for 1 (Resident #1) out of 1 resident reviewed for quality of care. The findings include: Foot drop is an inability to lift the front part of the foot and toes. This can be caused by nerve injuries, muscle disorders, brain or spinal cord disorders (such as stroke). If foot drop persists, the muscles that point the foot downward can become tight and lead to a contracture. A foot drop brace, is designed to support the ankle and foot. The brace extends from the calf, wraps around the ankle, and extends under the foot, often inside the shoe. It provides support and can help lift the foot, preventing it from dropping and allowing for a more normal gait. An Ankle-Foot Orthosis (AFO) is a brace worn on the lower leg to support the ankle and foot. It is commonly used to treat foot drop by holding the foot in a proper position to prevent dragging and improve walking safety. On 6/16/25 at 2:36 PM, during an interview with Resident #1, he/she expressed a concern that he/she was supposed to have a foot brace on his/her left foot. He/she reported that the last time the foot brace had been worn was about a month prior. The resident explained that the brace was used to help with his/her foot drop. On 6/16/25 at approximately 2:40 PM, an observation in Resident #1's room showed that he/she was not wearing his/her brace. On 6/25/25 at approximately 8:30 AM, this surveyor conducted an interview with the Rehab Director. During the interview, the surveyor inquired about the status of Resident #1 and his/her left foot brace. The Rehab Director explained that the Resident had been using the brace to help maintain proper foot alignment and prevent contracture; however, use of the brace had resulted in a wound. He stated that the anticipated plan involved consulting with the wound care nurse and obtaining his/her approval before proceeding with a new brace. When asked about the current plan for the Resident and the brace, he further explained that once the wound healed, the team would move forward with reintroducing the brace. When asked what type of wound it was, he responded that he believed it was an ankle wound. On 6/25/25 at 9:11 AM, a record review of Resident #1 ' s Task Treatment Administration Record (TAR) for June 2025 showed that he/she had an order for: Hard Brace to LT [left] Lower Leg on while at bedtime & off in morning - check skin with application & removal every day and evening shift every day and evening shift for CONTRACTURE PREVENTION Record review also showed that a new order had been placed on 06/24/2025: Hold off Hard Brace to LT [left] Lower Leg on while at bedtime & off in morning - check skin with application & removal every day and evening shift every day and evening shift for CONTRACTURE PREVENTION due to impaired skin integrity. On 6/25/25 at 9:30 AM, a record review of Resident #1 showed a care plan for the following: MR. [NAME] has an ADL [activities of daily living] Self Care Performance Deficit r/t [related to] Limited ROM [range of motion]/Mobility, Weakness, Hemiplegia, with an intervention of AFO [ankle foot orthoses] to left lower leg during bedtime hours. On 6/25/25 at 9:43 AM, a record review of Resident #1's records showed that there was no documentation indicating that he/she had a wound on his/her left ankle. There was no documentation of a change in condition, and no mention of the ankle wound was found in the wound care orders. On 6/25/25 at 10:08 AM, this surveyor conducted an interview along with an observation of Resident #1 in his/her room. He/she did not have a foot brace on at that time. It was observed that a brace was sitting in the corner of the room, and on the side of the brace it stated, Foot Drop Protection. A picture was taken of the brace at that time. On 6/25/25 at 10:15 AM, this surveyor conducted an interview with Licensed Practical Nurse (LPN) #5. During the interview, she was asked if she was aware whether the resident had a wound. She responded that she was aware of a sacral wound but was not aware of any other wounds. She reported that she did not know of any other wounds. At that time, this surveyor requested that LPN #5 go to Resident #1 ' s room. This surveyor then asked LPN #5 to check the resident ' s ankles for wounds. Together, the resident ' s ankles were observed, and no wounds were identified. His/her skin was clear, with no open areas noted. On 6/25/25 at 10:20 AM, during an interview, this surveyor asked Licensed Practical Nurse (LPN) #5 if she was aware of any orders for Resident #1 to utilize a foot brace. She explained that he/she was supposed to use compression stockings but was not aware of any braces or similar equipment ordered for the feet. At that time, the foot drop brace was still visible in the corner of the room. On 6/25/25 at 10:42 AM, an interview was conducted with the Administrator. This surveyor made the Administrator aware of the concern that Resident #1 had an order to wear a foot drop brace for contracture prevention, and that LPN #5 was not aware of this order. Based on observation and interview, it appeared that he/she had not worn the brace in some time. The Administrator confirmed understanding.

Based on interview and record review, it was determined that the facility failed to 1. provide a Resident with safe transfer from chair to bed and 2. ensure a Resident was free from an accident. This was found to be evident for 2 (Residents #59 and #146) out of 3 Residents reviewed for accidents during the re-certification survey. The findings include: 1. On 6/30/25 at 8:06 AM a review of the Facility Reported Incident (FRI) MD00178278 revealed a report of a fall to the Office of Health Care Quality (OHCQ). The report advised that Resident #146 complained that during incontinent care the Resident fell off the bed. During review of the investigation file conducted on 6/30/25 at 8:17 AM, this surveyor reviewed the statement from Geriatric Nursing Assistant (GNA)#8. In the statement the GNA reported that around 5 am on 5/18/22, while changing Resident #146, the Resident rolled toward me but was sliding off the bed. I quickly grabbed him/her upper body that was leaning toward the floor and guided the Resident to the floor. I was unable to get the Resident back on to the bed alone. I then covered him/her up and called the nurse for assistance. According to the Centers of Medicare and Medicaid Services (CMS) a 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. Bed mobility indicates how a resident moves to and from a lying position, turns side to side, and positions body while in bed or alternate sleep furniture On 6/30/25 at 8:32 AM a review of Resident #146's MDS quarterly assessment dated [DATE] was conducted. The Care Area Assessment (CAA) for Functionality showed that the resident required extensive assistance with a 2-person assist for bed mobility. During an interview conducted on 6/30/25 at 8:42 AM, GNA # 7 stated that she refers to the nurse assigned to the resident to understand the level of care a resident needed which included how many people are needed to provide care and transfer the resident. During an interview conducted on 6/30/25 at 11:00 AM, the Director of Nursing (DON) stated it is the expectation of the facility that if the Resident's bed mobility is a 2 person assist than there should be 2 staff assisting the Resident when turning on their side. This surveyor explained the concern for their being one staff member when Resident#146 rolled to one side and fell off the bed. The DON stated that she would review the investigation file and return to discuss. On 6/30/25 at 11:50 AM, the DON returned and stated that after reviewing Resident #146's medical record it was determined that GNA #8 did not follow protocol. The Resident required a 2 person assist for bed mobility therefore the GNA should have gotten a second staff member to assist in the care of the Resident. 2. A Hoyer lift , also known as a patient lift, is a mechanical device used to safely lift and transfer individuals who are unable to move themselves, often due to mobility limitations. On 6/16/25 at 11:11 AM, in an interview with Resident #59, he/she stated that a Geriatric Nurse Assistant (GNA) was rough when he/she was transferred from wheelchair to bed. He/she added that he/she was supposed to be transferred via Hoyer lift, however, the GNA picked him/her up from my wheelchair and transferred him/her manually. On 6/27/2025 at 8:09 AM, a review of facility-reported incident MD00211974 revealed that on 11/19/24 at 6:00 PM, Resident #59 was transferred by GNA #10 from the wheelchair to the bed without using a lift. The allegation was confirmed with a statement provided by Resident #53. The reported indicated that the Nursing Home Administrator (NHA) interviewed GNA#10, and he/she admitted to seeing the green Hoyer pad in the wheelchair prior to transferring Resident #59 to the bed. He/she admitted not checking the care plan on how the resident should be transferred. Further review of the facility's investigation revealed this findings: failure to honor the resident's request for Hoyer lift was substantiated. On 6/27/25 at 10:35 AM, a review of Resident #59's medical records indicated a BIMS score of 13 of 15, cognitively intact (Brief Interview for Mental Status, BIMS, is a screening tool used to assess basic cognitive function in patients in long-term care facilities.) The care plan initiated on 6/2/24 had an intervention of Mechanical lift required with transfers. On 6/27/25 at 11:57 AM, in an interview with GNA#11, he/she confirmed that the nursing staff are expected to utilize 2- 3 staff when transferring the residents using a Hoyer lift. On 6/27/25 at 12:45 PM, the Nursing Home Administrator was notified of the concern.

Based on record review and interview, it was determined that the facility failed to implement nonpharmacological interventions of pain and ensure that pain medication was given consistent with the professional standards of practice. This was evident for 1 (Resident #59) of 3 residents reviewed for pain management during the recertification survey. The findings include: The medical abbreviation PRN stands for pro re nata, a Latin phrase that translates to as needed or as the situation arises. Nonpharmacological interventions are treatments that manage pain without the use of medication. These interventions may include but are not limited to massage, music therapy, aromatherapy, applying mild heat or cold packs and repositioning. Oxycodone is a strong painkiller from a group of medicines called opiates, or narcotics used to treat moderate to severe pain. Pain parameters are the specific aspects of pain that are evaluated during an interview to understand a person's pain experience. On 6/18/25 at 7:18 AM, a review of Resident #59's active Physician's orders revealed the following: 1. Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 6 hours as needed for pain. 2. Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for Pain. 3. Pain level Q (every) shift (1-3 mild) (4-7 moderate) (8-10 severe) pain of 1-3 with no prn: contact practitioner, >= 4 with no prn or prn non-effective or new onset pain: contact practitioner. Document nonpharmacological pain intervention prior to PRN pain medication administration every shift for Assessment. 4. Non-pharmacological interventions: 1. Repositioning 2. Distraction 3.Activity involvement 4. As needed for Assessment. Further review of the medical record revealed a Care plan intervention which indicated Administer non-pharmacological interventions (repositioning, diversion activities, snacks and fluids, ice / heat, music therapy, relaxation techniques, imagery. On 6/18/25 at 1:18 PM, in an interview with Registered Nurse/Unit Manager (RN/UM #3) and Licensed Practical Nurse (LPN #1) with regards to the facility's pain management process, they described that when a resident complained of pain, the nurses were expected to assess the resident and ask for their pain level. They added that the facility used a pain scale from 0-10. They stated that prior to giving the PRN pain medication, they would verify the orders in the medical record and checked the options based on the residents' pain level. They revealed that the facility used Tylenol for mild pain and gave stronger pain medication for severe pain. They confirmed that the nurses utilized pain parameters set in the PRN order before administering pain medication, however, if the resident had 2 PRN pain medications without pain parameters in the order, they would use their nursing judgment to determine which pain medication was the best for the resident. They added that generally, the Physician would specify if the medication was for mild, moderate or severe pain. However, after verifying the PRN pain medications of Resident #59 with RN/UM #3, he/she agreed that medications had no pain parameters. RN/UM #3 attempted to show the surveyor where the nonpharmacological interventions were documented in the medical record, however, after he/she verified the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) she confirmed that there was no evidence that the interventions were documented. He/she stated she would inform the Director of Nursing (DON) of the issue. On 6/18/25 at 1:42 PM, in an interview with the DON, she stated that in pain management, the facility utilized nonpharmacological interventions for pain and if the interventions were not effective, the nurses were expected to administer the medication based on the resident's pain level. The DON added that the pain parameters should be part of the PRN pain medication orders. The surveyor reviewed the June MAR of Resident #59 with the DON which showed that PRN Oxycodone and Tylenol did not have any pain parameters in the orders. The surveyor also informed the DON that the Oxycodone was administered on 6/9/25 for a pain level of 2 and Tylenol was administered on 6/2/25 and 6/11/25 for a pain level of 4. The surveyor also showed the June TAR with the DON, which indicated that the nonpharmacological interventions were not documented by the nurses as ordered. The DON stated that she would look for any documentation to verify the concern. On 6/18/25 at 1:55 PM, a review of the facility's Pain Management policy approved on 3/28/25, indicated the following: 1. The use of the appropriate Pain Management Scale for the resident's ability to express pain. 2. History of pain and treatment for the resident- To include non-pharmacological and pharmacological treatment and whatever or not each treatment has been effective. On 6/20/25 at 8:34 AM, the DON confirmed that the nonpharmacological interventions for pain were not implemented, she stated that she notified the staff development and an in-service/education for the nurses will be conducted. The DON added that she discussed the PRN pain parameters concern with the attending Physicians, and they all agreed to include them in the PRN pain med orders.

Based on observation, interview and record review, it was determined that the facility failed to ensure that the medication error rate was not 5% or greater. This was evident for 2 (Resident #74 and #82) out of 6 residents observed for medication administration. 2 errors were discovered out of 38 opportunities. The findings include: According to the Centers for Medicare and Medicaid (CMS) the Medication error rate is determined by calculating the percentage of medication errors observed during a medication administration observation. The numerator in the ratio is the total number of errors that the survey team observes, both significant and non-significant. The denominator consists of the total number of observations or opportunities for errors and includes all the doses the survey team observed being administered plus the doses ordered but not administered. The equation for calculating a medication error rate is as follows: Medication Error Rate = Number of Errors Observed divided by the Opportunities for Errors (doses given plus doses ordered but not given) X 100. On 06/18/25 at 8:26 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 administered the following medication order in error to Resident #74: Med Pass Product (2 [NAME]) one time a day for nutritional supplement. Give 6 oz. The surveyor observed LPN #1 pour the Med Pass Product into a plastic cup. When asked how the quantity of medication was supposed to be measured, LPN #1 stated that she did not know. She explained that the plastic cup held approximately 240 milliliters (mL) but was unsure of the exact method for measuring the amount of Med Pass Product. LPN #1 proceeded to administer the full cup to Resident #74. This is a medication error, as 240 mL equals approximately 8 ounces-exceeding the prescribed dose of 6 ounces. On 06/18/25 at 9:29 AM, it was observed that LPN #1 also administered the incorrect dose of medication to Resident #82: Spiriva Respimat Inhalation Aerosol Solution 2.5mcg/act (Tiotropium Bromide Monohydrate). 2 puff inhale orally in the morning for COPD educate the resident to rinse mouth after use. The surveyor observed LPN #1 administer only one puff inhalation of the medication to Resident #82, instead of the prescribed two puffs. On 06/18/25 at approximately 9:40 AM, an interview was conducted with LPN #1. The medication errors were discussed, and she confirmed her understanding. She further explained that, in the future, she could measure the Med Pass Product using the plastic medication cups, which have ounce measurements marked on the side. LPN #1 also apologized for not administering two inhalations of Spiriva to Resident #82 as ordered. On 06/18/25 at 12:46 PM, a record review of the Medication Administration Record (MAR) for Resident #74 confirmed that the medication order for Med Pass Product was for 6 ounces. Additionally, the MAR for Resident #82 confirmed that the medication order for Spiriva required two puff inhalations, not one.

Based on observation and interview, it was determined that the facility failed to ensure that the staff followed infection control protocols. This was found to be evident during the review of (1) medication administration and (2) laundry services, it has the ability to affect all residents. The findings include: 1) On 6/18/25 at 9:09 AM, this surveyor observed Licensed Practical Nurse (LPN) #1 administering medications to residents. At that time, it was observed that LPN #1 did not perform hand hygiene before entering the room to administer medication to Resident #82 and Resident #60. On 6/18/25 at 9:43 AM, this surveyor also observed that LPN #1 did not wipe down the blood pressure cuff or the pulse oximeter probe between use on Resident #82 and Resident #60. On 6/18/25 at 9:59 AM, this surveyor conducted an interview with LPN #1 to discuss concerns regarding infection control practices during medication administration. It was explained that the surveyor observed a failure to perform hand hygiene before entering residents' rooms, as well as a failure to disinfect the blood pressure cuff and pulse oximeter before using them on another resident. LPN #1 acknowledged the concerns and confirmed understanding that these practices pose infection control risks. 2) On 6/23/25 at approximately 12:50 PM, prior to the initial tour, this surveyor conducted a brief walkthrough of the laundry area. It was observed that clothing, which appeared to belong to residents, was hanging on a rack located in a hallway. The hallway was dirty, placing the clothing at risk for contamination. On 6/23/25 at 12:59 PM, this surveyor began a brief tour of the laundry room. At that time, it was observed that the Account Manager was covering the clothing in the hallway with blankets. On 6/23/25 at 01:00 PM, this surveyor conducted an interview with the Account Manager and inquired about the clothing and its ownership. The Account Manager explained that the clothing was intended for residents as donations, in case some arrived without any personal clothing. On 6/23/25 at 01:03 PM, this surveyor completed an interview and observation with the Account Manager regarding the blankets placed over the clothing. It was explained to the Account Manager that earlier, at approximately 12:50 PM, the clothing had not been covered at all. The surveyor further explained the concern that, even with blankets placed on top, the clothing remained at risk for contamination because it was not fully covered. Multiple areas of the clothing remained exposed and visible. Pictures were taken at that time of the clothing hanging on the racks with the blankets placed on top. This was identified as an infection control concern, as the hallway where the clothing was stored-based on the laundry area tour-was not clean and posed a contamination risk to the clothing intended for resident donations. The Account Manager reported understanding of the concern and stated that the issue would be addressed immediately.

Based on interview, observation and record review, it was determined the facility failed to ensure that the resident's bathroom call system was functioning properly. This evident for 1 of multiple rooms observed during the recertification survey. The findings include: On 6/24/25 at 1:02 PM, in an interview with Resident #47, he/she stated that she fell in the bathroom on 6/23/25. He/she added that he/she attempted to pull the bathroom call cord to alert the staff, however, he/she was unsuccessful. He/she described the the cord got stuck and was not functioning, so he/she started yelling and maneuvered themselves towards the switch and slid the on/off switch for the call bell to activate. During an observation, the surveyor noted that the bathroom call cord was attached to a switch on the wall; the cord was hanging approximately 2 inches from the floor and the switch was 40 inches from the floor. Also, the surveyor attempted to pull the cord to activate the switch and confirmed that the pull cord was not functioning. The surveyor had to slide the on/off switch for the bathroom call light to activate the light. On 6/24/25 at 1:21 PM, the surveyor requested Licensed Practical Nurse (LPN #4) to test the call device of Resident #47's bathroom. The nurse demonstrated to the surveyor that for the bathroom light to function, the resident would pull the cord to activate the call light, however, when he/she pulled the cord, it did not work, he/she had to slide the switch to activate the light. The surveyor requested the LPN #4 to test the bathroom call cords of rooms #40 and #41, and as soon as he/she pulled the cords, it activated the call light. On 6/24/25 at 1:30 PM, the surveyor informed the Nursing Home Administrator (NHA) about the concern and asked her to accompany the surveyor to Resident #47's bathroom to test the call device. She pulled the cord and confirmed that it was not working and stated that she would put up a maintenance request and conduct an audit of all the bathroom call devices. On 6/26/25 at 8:09 AM, the surveyor conducted a follow up observation of the call device in the of Resident #47, the pull cord was still not working. The observation was witnessed by another surveyor. On 6/25/25 at 10:27 AM, the surveyor received a copy of the Bathroom Call Light Audits from the Business Office Manager (BOM). A review of the audit which was completed by the Interdisciplinary Team (IDT) on 6/25/25 revealed the following: room [ROOM NUMBER]- 1- no battery (replaced), room [ROOM NUMBER]-1 no battery (replaced) , room [ROOM NUMBER]-2 no battery (replaced). On 6/25/25 at 11:16 AM, the surveyor notified the NHA and the Maintenance Director that the bathroom call device of Resident #47 was still not functioning. They confirmed that the device has been fixed.