Every finding on record at Maryland Baptist Aged Home

Based on reviews of a facility reported incident (FRI), the facility investigation and clinical record, and staff interview, it was determined that the facility failed to provide adequate supervision to a resident to prevent elopement through a facility door. This was evident in 1 (#1) of 1 residents reviewed for Accident Hazards/Supervision during a complaint survey. The findings include:A review of facility reported incident 3108439 on 7/24/26 revealed that on 07/16/26 at 3:15 pm the Office of Health Care Quality received an allegation that Resident #1 walked out of the facility through the back entrance door. The door was identified as not functioning properly, which allowed Resident #1 to pass through the door to the back steps without it alarming. The facility staff identified Resident #1 as missing and immediately conducted a search and found Resident #1 at the bottom of the steps of the back door. Resident #1 was redirected back into the facility. Brief Interview for Mental Status (BIMS): A screen used to assist with identifying a resident's current cognition. The BIMS score ranges from 00 to 15. A score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 00-07 indicates severe cognitive impact. A review of Resident #1's Electronic Medical Record on 7/24/26 at 10 AM revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment conducted on 06/04/26 with a score of 00. A BIMS score of 00 indicates severe cognitive impairment. A head to toe assessment was completed by director of nurses (DON) on 07/15/26 that indicated no visible signs of injury were noted. During an interview with Charge Nurse #1 on 07/24/26 at 9:20 am, Charge Nurse #1 stated, Resident #1 has a history of dementia with exit seeking behavior. Resident #1 exited through the back door on 07/15/26 after being toileted by the nursing staff. The back door did not alarm because the door had not completely closed.During an interview with the facility Maintenance Director on 07/24/26 at 11:25 am, the maintenance director revealed the following:-Neither the Maintenance Supervisor nor the facility staff checked the back door routinely and did not document when the door was last checked for proper functioning.-The Maintenance Director stated that following the incident the facility contacted a local vendor who came to the facility and fixed the door alarm and adjusted the door so the door would not stick in the open position after being opened. An observation of the back door at this time revealed the back door was functioning properly. Since then, a full audit of all windows and doors was conducted to maintain the safety of all residents and interviews with staff were completed. Resident #1 was placed on 1:1 observation. An elopement action plan was initiated, and continued safety checks were conducted.

Based on record review and staff interviews, it was determined that the facility failed to develop and implement a water management plan to identify and reduce the risk of waterborne pathogens. This was evidenced by the facility not having a documented water management plan.The findings include:On 6/17/26 at 8:27 AM, the surveyor conducted a record review of the facility's infection control plans, policies, and procedures. During the record review, the surveyor could not locate the facility's water management plan.On 6/17/26 at 11:22 AM, the surveyor interviewed the Infection Preventionist (IP) #7. During the interview, the surveyor asked the IP #7 for a copy of the facility's water management plan. The IP #7 indicated that she would provide a copy of the facility's water management plan.On 6/17/26 at 11:42 AM, the surveyor interviewed the Nursing Home Administrator (NHA) #1. During the interview, the surveyor asked the NHA #1 for a copy of the facility's water management plan. The NHA #1 indicated that she would provide a copy of the facility's water management plan.On 6/17/26 at 2:52 PM, the surveyor interviewed the NHA #1. During the interview, the surveyor asked the NHA #1 if she had a copy of the facility's water management plan. The NHA #1 indicated that she was working on obtaining a copy of the facility's water management plan.On 6/17/26 at 3:20 PM, during the exit conference, the surveyor interviewed the NHA #1. During the interview, the surveyor asked the NHA #1 if she was able to obtain a copy of the facility's water management plan. The NHA #1 indicated that she was unable to obtain a copy of the facility's water management plan.

Based on record review and interview it was determined that the facility failed to provide the local ombudsman's office with copies of the notifications of resident transfers/discharges. This was evident for 4 (#6, #27, #5, #13) of 4 Residents reviewed for hospitalization during the facility's recertification survey.The findings include: 1. On 6/16/2026 at 9:30 AM, a record review was performed by the surveyor on Resident #6, who was last hospitalized on [DATE]. During the review, it was noted that the surveyor was unable to locate the Bed Hold or Hospital Transfer forms. Later that day at 12:54 PM, the Social Worker (SW) #3 was asked if she had given Resident #6 a Bed Hold form at the time of their transfer to the hospital. The SW#3 stated yes and continued to explain that upon admission, the residents are given a Bed Hold form to sign, which is copied multiple times and placed in the hard chart. Then it is given to the resident at the time of the transfer to the hospital. She continued to explain that all residents who want to return are not denied returning to the facility. The SW#3 was then asked if a Hospital Transfer form was completed for the resident when they were transferred out to the hospital. The SW#3 said yes and that she would get a copy for the surveyor. The SW#3 returned approximately 5 minutes later with a copy of the form. The SW#3 was asked how the facility reports transfers and hospitalizations to the Ombudsman. The SW#3 stated that they would notify the ombudsman verbally when she's in the facility of any residents who are out at that time. She continued to state that the facility does not send any notifications to the Ombudsman on a regular basis of residents transferred out to the hospital. SW#3 then stated that she will communicate with the Ombudsman about how they would like to receive notification of any transfers and hospitalizations of residents. 2. On 6/16/2026 at 9:30 AM, a record review was performed by the surveyor on Resident #27, who was last hospitalized on [DATE]. During the review, it was noted that the surveyor was unable to locate the Bed Hold or Hospital Transfer forms. Later that day at 12:54 PM, the Social Worker (SW#3) was asked if she had given Resident #27 a Bed Hold form at the time of their transfer to the hospital. The SW#3 stated yes and continued to explain that upon admission, the residents are given a Bed Hold form to sign, which is copied multiple times and placed in the hard chart. Then it is given to the resident at the time of the transfer to the hospital. She continued to explain that all residents who want to return are not denied returning to the facility. The SW#3 was then asked if a Hospital Transfer form was completed for the resident when they were transferred out to the hospital. The SW#3 said yes and that she would get a copy for the surveyor. The SW#3 returned approximately 5 minutes later with a copy of the form. The SW#3 was asked how the facility reports transfers and hospitalizations to the Ombudsman. The SW#3 stated that they would notify the ombudsman verbally when she's in the facility of any residents who are out at that time. She continued to state that the facility does not send any notifications to the Ombudsman on a regular basis of residents transferred out to the hospital. SW#3 then stated that she will communicate with the Ombudsman about how they would like to receive notification of any transfers and hospitalizations of residents. 3. On 6/17/26 at 10:49 AM, Resident #5's medical record was reviewed. The medical record review revealed that Resident #5 was hospitalized on [DATE]. On 6/17/26 at 11:17 AM, Resident #5's medical record was reviewed. During the medical record review, the surveyor could not locate documentation indicating that the facility notified the local ombudsman's office about Resident #5 being transferred to the hospital on 4/13/26. On 6/17/26 at 11:39 AM, the surveyor interviewed the Social Worker (SW) #3. During the interview, the surveyor asked the SW #3 if the facility notified the local ombudsman's office about Resident #5 being transferred to the hospital on 4/13/26. The SW #3 indicated that the facility did not notify the local ombudsman's office about Resident #5 being transferred to the hospital on 4/13/26. The SW #3 also indicated that the facility will start notifying the local ombudsman's office when Residents are transferred to the hospital. 4. On 6/17/26 at 10:35 AM, Resident #13's medical record was reviewed. The medical record review revealed that Resident #13 was hospitalized on [DATE]. On 6/17/26 at 10:43 AM, Resident #13's medical record was reviewed. During the medical record review, the surveyor could not locate documentation indicating that the facility notified the local ombudsman's office about Resident #13 being transferred to the hospital on 5/25/26. On 6/17/26 at 11:39 AM, the surveyor interviewed the Social Worker (SW) #3. During the interview, the surveyor asked the SW #3 if the facility notified the local ombudsman's office about Resident #13 being transferred to the hospital on 5/25/26. The SW #3 indicated that the facility did not notify the local ombudsman's office about Resident #13 being transferred to the hospital on 5/25/26. The SW #3 also indicated that the facility will start notifying the local ombudsman's office when Residents are transferred to the hospital.

Based on record review and staff interviews, it was determined that the facility failed to ensure that continuing competence for nurse aides was completed at least 12 hours per year. This was evident for 2 of 4 nurse aides (GNAs #6 and #12) who were reviewed during this annual survey for competencies. A minimum of 12 hours of nurse aide training per year is required under S483.95(g)(1). The training must be sufficient to ensure the continuing competence of the nurse aides, which may require more than 12 hours of training per year to meet identified staff or resident needs. Include dementia management training and resident abuse prevention training. Or nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.The findings include:On June 17, 2026, at 2:58 PM, during the record review of staff competencies: GNAs and LPNs. The surveyor was unable to find the annual evaluations or any up-to-date competencies completed in their charts. The following staff members were reviewed: GNA #6, LPN #8, GNA #12, GNA #13, and GNA #14.1.GNA#6 completed their last annual competency for abuse training on 12/8/2025, dementia training on 11/20/24, and was missing competencies for Resident Rights and Infection Control training. Annual evaluation was completed on 4/21/2026.2.LPN #8 completed their last set of annual competencies and annual evaluation in 2021. There were no current evaluations or competencies found,3.GNA#12 had her annual evaluation completed on 4/8/2026 and her last set of annual competencies on 12/11/2024. The GNA#12 is missing current competencies for Resident Rights, Infection Control, Dementia, and Abuse Training,4.GNA #13 had all of their competencies on 12/24/2025 and was not due to have an annual evaluation until December 2026.5.GNA #14 had all of their competencies on 11/21/2025 and was not due to have an annual evaluation until November 2026.On June 17, 2026, at 2:30 PM, the surveyor interviewed the DON#2 and NHA#1 regarding the competencies and evaluations. When asked whether there was any additional training documentation for the GNAs and LPNs missing from their charts, the NHA#1 stated that all training was already in the charts and that there was nothing more to add. When asked why the GNAs were not up to date on the competencies, the DON#2 stated that she has been working on getting additional help to complete the annual evaluations.

Based on observation, interview, and record review it was determined the facility failed to ensure rooms afforded Residents with 80 measured square feet in shared rooms. This was evident for 2 (#101, #102) out of 4 Resident rooms reviewed for square footage during the facility's recertification survey.The findings include:Upon surveyor initial tour of the facility on 6/15/26 at 6:43AM it was observed that several rooms in which more than one Resident lived in appeared to be less than the required 80 square feet.On 6/15/26 at 7:52AM during the surveyor's entrance conference with the facility Administrator, it was confirmed that the facility had previously applied for waivers due to the size of rooms #101 and #102 being below the required minimum of 80 square feet. Review of the provided documentation revealed the facility Administrator did not have an approved waiver to provide.On 6/17/26 at 11:14AM the surveyor shared the concern and conducted dual observation, rounding, and measurement of several rooms including #101 and #102 with Maintenance Staff #8 at which time it was determined that rooms #101 and #102 were below the required minimum of 80 square feet per Resident in these shared rooms. Maintenance Staff #8 acknowledged and confirmed the surveyor's concern.On 6/17/26 at 11:49AM the surveyor reviewed all concerns with the facility Administrator, Director of Nursing, and Social Worker #3 who acknowledged the concerns.On 6/17/26 at 3:15PM all concerns were reviewed with the facility's Administrator and staff during the facility's exit conference.

Based on record review and interview it was determined the facility failed to ensure the arbitration agreement included language to ensure Residents are made aware of the right to rescind the agreement, time frame, and ensure Residents are made aware that signing of the arbitration agreement was not a condition of admission to the facility or a requirement for continuation of care at the facility. This was evident for 1 out of 1 arbitration agreement utilized by the facility during the surveyor's review of the arbitration task during the facility's recertification survey. The findings include:On 6/16/26 at 12:19PM the surveyor conducted an interview of Social Worker (SW) #3 who confirmed with the surveyor that the facility offered arbitration agreements to facility Residents. During the interview this surveyor requested for SW #3 to provide a copy of the arbitration agreement utilized by the facility.On 6/17/26 at 9:06AM the surveyor conducted a review of the facility's provided binding arbitration agreement at which time it was observed that the agreement did not include language regarding the Resident right to rescind the agreement and the time frame for rescinding, and did not include language to ensure Residents are made aware that the signing of the agreements was not a condition of admission to the facility and was not a requirement for continuation of care at the facility. At this time, the surveyor offered for SW #3 to show where in the agreement the language was located, at which time it could not be found and the surveyor shared the concern with SW #3 who acknowledged and confirmed understanding of the concern.On 6/17/26 at 11:49AM the surveyor reviewed all concerns with the facility Administrator, Director of Nursing, and SW #3 who acknowledged the concerns.On 6/17/26 at 1:24PM SW #3 provided an amended arbitration agreement to the survey team.On 6/17/26 at 3:15PM all concerns were reviewed with the facility's Administrator and staff during the facility's exit conference.

Based on record review, observation, and interview it was determined the facility failed to employ sufficient qualified dietary staff with the required certification(s) to ensure overall daily supervisory responsibilities for the facility's kitchen. This was evident for 1 (#11) out of 1 food service manager qualifications reviewed during the facility's recertification survey.The findings include:During the surveyor's initial tour of the facility's kitchen on 6/15/26 at 7:17AM the surveyor conducted an interview with Food Service Manager (FSM) #11 who confirmed with the surveyor that they were the kitchen manager and in charge of running the daily operations of the facility's kitchen. At this time the surveyor observed FSM #11's name tag which read Food Service Manager.On 6/16/26 at 7:25AM the surveyor conducted an interview of the facility's Administrator who reported that the facility has a Consultant Certified Dietary Manager on a consultant basis approximately two days per week. The Administrator confirmed with the surveyor that FSM #11 was the facility's Dietary Manager, however, they did not possess professional certification such as Certified Dietary Manager or Food Service Manager and stated CDM's are hard to find. At this time, the surveyor shared the concern with the facility Administrator and offered additional opportunity for the facility to provide further documentation of professional certification/education for the Food Service Manager. Surveyor review of FSM #11's provided documentation on 6/17/26 revealed they did not hold professional certification for food service management. Review of the facility's key personnel list provided by the facility Administrator in response to the requested entrance conference documentation, revealed that FSM #11 was listed as the Food Service Manager and there was no other person listed as in charge of the facility's kitchen.On 6/17/26 at 11:49AM the surveyor reviewed all concerns with the facility Administrator, Director of Nursing, and Social Worker #3 who acknowledged the concerns. On 6/17/26 at 3:15PM all concerns were reviewed with the facility's Administrator and staff during the facility's exit conference.

Based on observation and interview it was determined the facility failed to ensure furniture and fixtures were maintained. This was evident for 1 (#25) out of 6 residents' rooms observed by the surveyor during the surveyor's initial tour of the facility during the recertification survey.The findings include:On 6/15/26 at 7:22AM the surveyor observed the room of Resident #25 at which time the surface of their nightstand was observed to be in severely worn condition and their wardrobe was observed with scrape marks present on the surface. One drop ceiling tile holding an air vent above the middle bed was observed by the surveyor to have a bowed appearance.On 6/17/26 at 11:29AM the surveyor conducted an interview and dual observation of the concerns with Maintenance Staff #9 who observed and acknowledged and confirmed understanding of the surveyor's concerns. Maintenance Staff #9 reported during the interview that they had been looking into a replacement part for the vent and tile.On 6/17/26 at 11:49AM the surveyor reviewed all concerns with the facility Administrator, Director of Nursing, and Social Worker #3 who acknowledged the concerns. On 6/17/26 at 11:56AM the surveyor shared concerns and conducted an interview with the facility's Director of Maintenance #10 who reported during the interview that staff had started repairing worn furniture and had started on a different hallway of the facility and had not yet gotten to the room of Resident #25.On 6/17/26 at 3:15PM all concerns were reviewed with the facility's Administrator and staff during the facility's exit conference.

Based on interview and record review it was determined the facility failed to issue advanced beneficiary notices to Residents of the facility. This was evident for 2 (#2, #7) out of 2 Residents during the surveyor's review of the beneficiary task during the facility's recertification survey.The findings include:On 6/15/26 at 9:40AM the surveyor requested from the Administrator; the list of residents who were discharged in the last six months from a Medicare covered Part A stay with benefit days remaining. On 6/15/26 at 7:25AM the surveyor was provided with a list of two Residents (#2, #7) who were discharged in the last six months from a Medicare Part A stay with benefit days remaining. Review by the surveyor of the facility provided documentation forms for Residents #2 and #7 on 6/16/26 at 1:45PM revealed that the facility indicated they had provided both a notice of Medicare non-coverage and Advance Beneficiary Notice of non-coverage to each Resident, however, only provided copies of the notice of Medicare non-coverage forms issued. No documentation of Advance Beneficiary Notice of non- coverage was provided to the surveyor. Review of the facility census revealed both Resident #2 and #7 continued to remain in the facility. On 6/16/26 at 1:45PM the surveyor requested to Social Worker (SW) #3 for them to provide copies of the Advance Beneficiary Notices of non-coverage for Residents #2 and #7.On 6/17/26 at 8:23AM SW #3 informed the survey team that the Advance Beneficiary Notices of non-coverage were not provided to Residents #2 and #7. At this time, the surveyor shared the concern and SW #3 acknowledged and confirmed understanding of the concern. On 6/17/26 at 11:49AM the surveyor reviewed all concerns with the facility Administrator, Director of Nursing, and SW #3 who acknowledged the concerns. On 6/17/26 at 3:15PM all concerns were reviewed with the facility's Administrator and staff during the facility's exit conference.

Based on observation and interview it was determined the facility failed to ensure handled scoopers were stored in accordance with professional standards for food service safety. This was evident for 1 out of 1 kitchens reviewed for food procurement, store/prepare/serve - sanitary during the initial tour of the facility's kitchen during the facility's recertification survey. The findings include: On 6/15/26 at 7:13AM the surveyor observed a container of flour in which the handled scooper was resting within the flour. Further observation by the surveyor revealed a second container which held sugar in which the handled scooper was resting within the sugar.On 6/15/26 at 7:14AM the surveyor observed the ice cooler's handled scooper in the kitchen sitting on a table with the scooper sitting on top of the handle of an ice cream scooper.On 6/15/26 at 7:17AM the surveyor shared and observed the concerns with Food Service Manager #11 who observed and acknowledged understanding of the concerns.On 6/15/26 at 7:19AM the surveyor observed an ice scooper located in a bag with frayed fabric material which was attached to an ice cooler located on a rolling cart within the Resident hallway. On 6/15/26 at 7:52AM the surveyor shared concerns with the facility's Administrator during the entrance conference.On 6/17/26 at 11:49AM the surveyor reviewed all concerns with the facility Administrator, Director of Nursing, and Social Worker #3 who acknowledged the concerns.On 6/17/26 at 3:15PM all concerns were reviewed with the facility's Administrator and staff during the facility's exit conference.

Based on observations, interviews, and record review, it was determined that the facility failed to: 1) maintain proper labeling, dating, and expiration practices for food items, and 2) did not consistently meet the manufacturer-recommended range of Quaternary Ammonium Compounds (QACs) for dish sanitization. This was found to be evident during the initial kitchen visit of the annual recertification survey. The findings include: 1) During a Kitchen tour on 5/28/25 at 8:17 AM, Staff #8 was unable to identify the correct expiration date on a box of hot sauce, noting conflicting and possibly expired dates. Cereal dispensers (Raisin Bran, [NAME] Krispies, Frosted Flakes) were all labeled 2/14/25. Staff #8 was unsure if this was the date the cereal was put in the dispenser or the expiration date. Expired spices were found Poultry Seasoning (exp. 9/27/2019) and Allspice (exp. 8/10/2023). On 5/28/25 at 8:35 AM, Staff #7 and Staff #8 could not consistently identify or date items in the Unit 2 freezer due to lack of labeling. Conflicting dates were given for chicken and ground beef, and Staff #7 acknowledged the need for proper labeling of frozen goods received. An unlabeled container of potato salad in Unit 1 refrigerator was shown to Staff #8 and was discarded by Staff #8 due to uncertainty about its expiration. On 5/28/25 at 8:53 AM, two unlabeled zip lock bags of spreadable butter were found in the Unit 4 freezer without an expiration date. Staff #7 acknowledged the need to label all received food items with a received date and an expiration date going forward. Quaternary ammonium compounds (QACs) are a large class of chemicals used as antimicrobials for cleaning and disinfecting food processing equipment, food contact surfaces and utensils. Bartavation is the brand of QAC that the facility used. According to Bartovation Quaternary Ammonium (QAC, Multi-Quat) Sanitizer Test Paper strips, the target range for effective sanitization of dishes is 200-400 ppm (parts per million). 2) On 5/29/25 at 10:04 AM, Staff #9 and Staff #8 were shown the May 2025 temperature/sanitizer log. Staff #9 was unsure of the correct QAC concentration range. The May 2025 temperature/sanitizer log showed readings of 100, which Staff #9 and Staff #8 did not recognize as being outside of the proper range. Staff #7 was informed that 100 ppm was too low and needed to be between 200-400 ppm for proper sanitization. Staff #7 verbalized understanding of the correct range.

Based on observations and staff interview it was determined that the facility staff failed to: 1) ensure a call device was installed in shower areas and 2) a cord used to turn on/off a call light was attached to the call system in the toilet stalls. This was evident for 2 of the 2 environmental observations during the annual survey. The findings include: On 5/28/25 at 10 AM the surveyor conducted a tour of the facility and observed the bathroom on the long hall without a call device in the shower area, and no string attached to the call device in the toilet stall. The shared bathroom on the short hall was without a call device in the shower area and two of the 3 toilet stalls were without strings attached to the call device. On 5/29/25 at 11:01 AM a subsequent tour of the facility with the Nursing Home Administrator (NHA) and Maintenance Director revealed the bathroom on the long hall without a call device in the shower area, and no string attached to the call device in the toilet stall. The shared bathroom on the short hall was without a call device in the shower area and two of the 3 toilet stalls were without strings attached to the call device. The Maintenance Director confirmed that the call device strings would be installed right away and installation of the call devices for the showers will be done as soon as approval to purchase is received from the NHA.

Based on record review and interviews it was determined that the facility's governing body and/or executive leadership failed to ensure the Quality Assurance Performance Improvement (QAPI) program identified & prioritized problems that reflected the organizational process, functions, and services provided to residents based on performance indicator data, resident and staff input, and other information. This deficient practice was discovered during the recertification survey. The findings include: On [DATE] at 10:26 AM after reviewing the Quality Assurance Performance Improvement plan the surveyor interviewed the Director of Nursing (DON). The surveyor informed DON that the QAPI plan was ineffective because it lacked a systematic approach that identified problems, tracked, investigated, and analyzed data. When the surveyor asked the DON, was there oversight of the QAPI processes by a governing body and the DON verbalized, No. On [DATE] at 10:45 AM the Administrator verbalized Chief Financial Officer #14 provided oversight of the QAPI process. When the surveyor asked has CFO #14 attended any of the QAPI meetings and provided input to determine if the QAPI process was effective. The surveyor's question was not answered. On [DATE] at 12:23 PM during a telephone interview with CFO #14 the surveyor asked do they provide oversight of the QAPI process. CFO #14 verbalized the Administrator, and the Director of Nursing keeps them abreast with what was going on with the QAPI process and they try to attend some of the morning calls. The surveyor asked what was discussed during the most recent QAPI meeting. CFO #14 verbalized they discussed a couple of resident passings, and they always discuss staffing; he/she is part of the governing body. They just went to the facility to see how the survey was going, but did not review the QAPI book. The surveyor asked CFO #14 were they aware some of the nursing staff were not certified in cardiopulmonary resuscitation (CPR) as a provider, which was identified by the QAPI committee. CFO #14 verbalized, No.

Based on record review and interviews it was determined that the facility assessment did not accurately reflect the services provided by the facility. This deficient practice was discovered during the recertification survey. The findings include: On 05/30/25 at 4:30 PM the surveyor reviewed the facility assessment provided by the Director of Nursing. A review of the assessment revealed it was documented the facility had an average of 10 resident admissions during the weekday. The assessment failed to include they have the capacity to admit residents who had infectious diseases such as COVID-19, MRSA, and/or Clostridium Difficile. The portion of the assessment regarding caring for residents with conditions not listed was incomplete. The assessment indicated that the facility is equipped to care for residents with a tracheostomy, although there are no current residents within the facility. Showers were not listed for assistance provided for activities of daily living. On 06/02/25 at 11:21 AM during an interview with the Director of Nursing and Administrator the surveyor reported the concerns about the inaccuracy of the Facility Assessment. The Director of Nursing verbalized it's been a while since they had a skills lab for the nurses. There are no competencies to verify the staff have been trained to care for residents with a tracheostomy or gastrostomy tube. The Administrator verbalized the area of the assessment that indicated the facility had an average of 10 admissions during the week was an error.

Based on staff interviews and record review it was determined that the facility failed to have an Registered Nurse (RN) on duty 24 hours a day for 7 consecutive days. The findings include: The PBJ Staffing Data Report listed that on Saturday, 10/05/2024, Saturday, 11/02/2024, Sunday, 12/01/2024, Saturday, 12/07/2024, Saturday, 12/14 /2024, Saturday, 12/21/2024, and Wednesday, 12/25/2024 there weren't any RNs on duty for the full 24 hours. The facility provided 2 weekends of scheduling (5/24-5/25/2025) and (5/31-6/1/2025) and consistently on Saturdays and Sundays there weren't any RNs on duty for the entire day. During an interview with the Administrator on 05/29/25 at 10:22 AM , she was asked about the dates targeted in the PBJ report. She stated that there was not an RN on duty on those dates. The Administrator stated that the facility was unable to find RN staff for weekends and holidays either from staff or agency. For the 2 week staffing schedule that was provided, there weren't any RNs working on the weekends (weekends of 5/24-5/25 and 5/31-6/1).

Based on medical record review and interviews, it was determined that the facility staff failed to provide a copy of the Notice of Medicare Non-Coverage to a resident's representative prior to being discharged from the facility. The deficient practice was evidenced in 1 (#4) of 1 resident record reviewed for NOMNC compliance during the recertification survey. The findings include: On 05/29/25 at 1:36 PM the surveyor received the list of residents who were discharged from the facility within the past 6 months. Three residents transitioned, five residents remained in the facility, and one resident went to an assisted living facility (ALF). On 05/29/25 at 2:32 PM during an interview with Social Worker #4 and the Administrator, the surveyor asked, Did Resident #4's responsible party (RP) receive a Notice of Medicare Non-Coverage prior to the resident's discharge? The surveyor received a copy of Resident #4 Notice of Medicare Non-Coverage dated 05/16/25. The resident representative's signature was not on the form; a note was typed on the form indicating that Resident #4's responsible party (RP) was notified via telephone on 05/16/25. The resident was discharged on 05/23/25. The Masters of Social Work (MSW) staff provided an envelope addressed to the RP. Social Worker #4 was unable to verify when the letter was mailed or if the RP received the letter. Social Worker #4 verbalized the facility had not received a signed copy from the RP.

Based on medical record review and interviews it was determined that the facility staff failed to notify a resident's representative in writing of the reason why the resident was transferred to the hospital and failed to provide a copy of the bed-hold policy to the resident representative. This deficient practice was evidenced in 1 (#17) of 2 resident records reviewed for transfer/discharge practices during the recertification survey. The findings include: On 05/28/25 at 2:01 PM a review of Resident #17 electronic medical record (EMR) revealed the resident was hospitalized in February and April 2025. The surveyor was unable to find documentation in the EMR indicating why the resident was hospitalized . On 05/29/25 at 9:15 AM the surveyor along with the Director of Nursing (DON) reviewed Resident #17's paper medical record located at the nurse's station. The transfer summaries dated 2/26/25 and 04/27/25 indicated the resident's family/responsible party was notified by telephone of the hospitalizations. There was no documentation to verify that Resident #17's responsible party was notified in writing of the hospital transfers. On 05/29/25 at 1:22 PM during an interview with Social Worker #4 the surveyor asked did they send a copy of the Bed-Hold Policy to Resident #17's responsible party when the resident was hospitalized on [DATE] and 04/27/25. Social Worker #4 verbalized the facility only provides a copy of the Bed-Hold Policy upon admission.

Based on resident record review and staff interview it was determined that the facility failed to complete a Minimum Data Set (MDS) assessment within 14 days of a significant change of the resident's physical or mental condition. This was evident for 1 (Resident #20) of 1 resident reviewed for Hospice during an annual survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A significant change means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both. On 5/29/25 at 12:16 PM a record review revealed that Resident #20 was admitted to hospice services on 5/9/25. However, the MDS significant change assessment was started on 5/19/25 and remained incomplete as of 5/30/25. On 5/30/25 at 12:37 PM a phone interview was conducted with the MDS Coordinator, and he confirmed that the resident was admitted to hospice on 5/9/2025. The MDS Coordinator also acknowledged that the significant change assessment for Resident # 20 was still in process as of 5/30/25. The Coordinator agreed that a MDS assessment should be updated within 14 days of a significant change, and the electronic records were not updated in a timely manner. The Nursing Home Administrator, Director of Nursing, Social Worker, Chief Financial Officer and other pertinent staff were made aware of these findings during the exit conference on 6/2/25. Cross Reference F640

Based on review of the medical record and interview with facility staff, it was determined the facility failed to ensure that the resident receiving psychotropic medications were necessary and justified when staff failed to complete behavioral and mood monitoring documentation for the conditions that the psychotropic medications were prescribed for. This was evident for 1 (Resident # 6) of 4 residents reviewed for unnecessary psychotropic medications. The findings include: Psychotropic medications, also known as psychiatric or psychoactive medications, are drugs that affect the mind, emotions and behavior. They are primarily used to treat mental health disorders, and can be divided into several categories, including antidepressants, antipsychotics, antianxiety, and hypnotics. On 05/29/25 at 08:36 AM, a record review was conducted. Resident # 6 was admitted to the facility on [DATE]. He/She had the diagnosis of Paranoid Schizophrenia; Major depressive disorder; anxiety disorder unspecified; Dementia with behavioral disturbance. Upon further review, he/she was taking psychotropic medications such as, Quetipine fumarate 200 mg tablet 1 tablet by mouth twice a day together with Quetipine fumarate 50 mg tablet 1 tablet by mouth twice a day to equal 250 mg tablet. There was no indication for the Quetipine in the Physician order. Additionally, he/she was taking Valproic acid 250 mg/5 ml solution given 10 ml by mouth twice daily for Schizophrenia. He/She was also given Trazodone 50 mg tablet 1 tablet by mouth at bedtime for Insomnia and Lorazepam 1 mg tablet 1 tablet by mouth twice daily for anxiety. Further review of the medical record was done; it was found that there was no behavior and mood monitoring documentation in his/her record. Additionally, the care plan for Resident # 6 was reviewed, Resident # 6 had a history of exhibiting behavioral outburst such as persistent yelling and screaming at others. He/She has the potential to be verbally aggressive. One of the interventions was to monitor behavior every shift, document the behavior and attempted intervention. On 05/29/25 at 09:58 AM, an interview with the Director of Nursing (DON) was conducted. This surveyor asked if they were doing the behavior monitoring for any resident who was taking psychotropic medications? The DON responded yes, we do it on paper. It was in front of the medication administration binder on top of the medication cart. The DON instructed staff # 10 (Registered Nurse) to pull it from the binder. Staff # 10 were not able to find the behavior monitoring flowsheet and instead provided the Treatment Administration Record for the month of May 2025. This surveyor asked Staff # 10 if they had the behavior monitoring record and she had no response. In addition, the DON was asked for medication regimen review process, the DON stated that the pharmacy consultant comes once a month to conduct the medication review and upon completion of the review, a report will be provided to her. On 06/02/25 at 10:26 AM, a record review was done for the medication regimen review. It was found that on March 26, 2025, Staff # 15 (Pharmacy Consultant) reported as follows: Resident # 6 has received Trazodone 50 mg at bedtime since 12/22/2023 for Insomnia. A recommendation to attempt a gradual dose reduction (GDR) of Trazodone 25 mg at bedtime. The psychiatry provider visited Resident # 6 on 3/26/2025 and 4/30/2025 respectively and there was no documentation that this recommendation was addressed. On 6/2/2025 at 11:45 AM, The findings were shared to the DON. No comment was noted.

Based on medical record review and interviews it was determined that the facility staff failed to provide residents with showers and get residents out of bed. This deficient practice was evidenced in 2 (#1 & #22) of 2 residents assessed for choices during the recertification survey. The findings include: On 05/28/25 at 9:28 AM during observation rounds the surveyor asked Resident #22 how often he/she gets out of bed (OOB). Resident #22 verbalized they don't get OOB although they would like to. The surveyor observed a Gerry chair in the shared bedroom. Resident #22 verbalized the chair was used for their roommate. On 05/29/25 at 1:27 PM a review of Resident #1 and Resident #22 electronic health records (EMR) to verify if the residents had a shower; there was no documentation to verify whether the residents had a shower. A review of the shower list revealed Resident #1 was scheduled to have a complete bed bath (CBB) on Monday and Friday during the 3 PM - 11 PM shift. Resident #22 was scheduled to have a CBB on Monday and Friday during 11 PM - 7 AM shift. On 05/29/25 at 2:06 PM the surveyor asked Geriatric Nursing Assistant (GNA) #17 to show the surveyor in the electronic medical record (EMR) PointClickCare (PCC) documentation to verify Resident #22 had a shower. There was no place in the EMR for GNA #17 to document whether the resident had a shower. The surveyor asked GNA #17 if there is another place to document that a resident had a shower. GNA #17 verbalized, no. On 05/29/25 at 2:11 PM the surveyor made the Director of Nursing (DON) aware that Resident #22 had not had a shower since being admitted to the facility in October 2023 and there was no documentation to verify that Resident #1 or Resident #22 had a shower. Also, the surveyor observed both residents were in bed the past two days. The surveyor and DON went to Resident #22's room and the resident verified they had not had a shower since being admitted and they do not get OOB.