Every finding on record at Maryland Masonic Homes Ltd

Based on review of complaint #2979118, resident records, and staff interviews, it was determined that the facility failed to adhere to professional standards of practice when ordering medications for newly admitted residents. This was found to be evident for 1 (#78) out of 1 resident reviewed for medications during the annual recertification survey.The findings include:On 06/25/2026 at 1:07 PM, the surveyor reviewed complaint #2979118. Complaint #2979118 indicated that when Resident #78 was admitted to the facility, he/she was denied medications for over seven hours.On 06/30/2026 at 7:20 AM, the surveyor conducted a resident record review. During the resident record review, progress note, dated 3/12/26, revealed that Resident #78 arrived at the facility on 03/12/2026 at 7:49 PM.On 06/30/2026 at 7:25 AM, the surveyor conducted a resident record review. During the resident record review, Resident #78's N Adv - Clinical admission form, dated 3/12/26, revealed that Resident #78's clinical admission was completed on 3/12/26 at 7:57 PM.On 06/30/2026 at 9:34 AM, the surveyor conducted a resident record review. The resident record review revealed that there is a Nurse's note Progress note, dated 03/13/2026 at 2:02 AM, which indicates that Resident #78 complained that during the 3 - 11 PM shift on 03/12/2026, Licensed Practical Nurse (LPN) #8 was unable to provide pain medication to Resident #78 when requested. The Nurse's Note progress note also indicates that Resident #78 also complained that, during the 3 - 11 PM on 03/12/2026, he/she was told by LPN #8 that the pain medication was unavailable and would be delivered on the next shift.On 06/30/2026 at 9:51 AM, the surveyor interviewed the Clinical Manager (CM) #9 for the Baltimore Unit. During the staff interview, the CM #9 mentioned that when a resident is admitted , the nurse should call pharmacy if they need a medication right away, and pharmacy will have the medication available within four hours.On 06/30/2026 at 11:02 AM, the surveyor interviewed LPN #6. During the staff interview, LPN #6 mentioned that Resident #78 complained about being in pain. LPN #6 also mentioned that Resident #78 complained about LPN #8 not providing him/her with Oxycodone HCl Oral Tablet 10 MG when he/she requested it during the 3 - 11 PM shift on 03/12/2026. LPN #6 mentioned that Resident #78 stated that LPN #8 mentioned that the Oxycodone HCl Oral Tablet 10 MG, PRN was not available and that pharmacy would deliver it on the 11 PM - 7 AM shift. LPN #6 mentioned that she called pharmacy to get Oxycodone HCl Oral Tablet 10 MG released so she could administer it to Resident #78. Also, LPN #6 mentioned that after contacting pharmacy, the Oxycodone HCl Oral Tablet 10 MG, PRN was available within 20 minutes and was administered to Resident #78 around 2:00 AM on 03/13/2026.On 06/30/2026 at 11:14 AM, the surveyor conducted a resident record review. The resident record review revealed that according to Resident #78's March 2026 Medication Administration Record, Resident #78 did not receive the following medications on 3/12/26:-Montelukast Sodium Oral Tablet 10 MG at bedtime for asthma, which was scheduled for 8:00 PM-Atorvastatin Calcium Tablet 40 MG at bedtime for hyperlipidemia, which was scheduled for 8:00 PM-GlycoLax Powder 17 grams for constipation, which was scheduled for 8:00 PM-Senna-S Oral Tablet 8.6-50 MG for bowel regimen, which was scheduled for 8:00 PM-Acetaminophen Extra Strength Tablet 500 MG for pain, which was scheduled for 10:00 PM-Gabapentin Capsule 100 MG for neuropathy pain, which was scheduled for 10:00 PM-Tizanidine HCl Tablet 2 MG for muscle relaxant, which was scheduled for 10:00 PMOn 06/30/2026 at 11:22 AM, the surveyor conducted a resident record review. The resident record review revealed that there is an Orders - Administration Note progress note written by LPN #8, dated 3/12/26 at 11:10 PM, which states that the facility is awaiting on pharmacy to deliver Atorvastatin Calcium Tablet 40 MG so it can be administered to Resident #78.On 06/30/2026 at 11:23 AM, the surveyor conducted a resident record review. The resident record review revealed that there is an Orders - Administration Note progress note written by LPN #8, dated 3/12/26 at 11:11 PM, which states that the facility is awaiting on pharmacy to deliver Senna-S Oral Tablet 8.6-50 MG so it can be administered to Resident #78.On 06/30/2026 at 11:24 AM, the surveyor conducted a resident record review. The resident record review revealed that there is an Orders - Administration Note progress note written by LPN #8, dated 3/12/26 at 11:11 PM, which states that the facility is awaiting on pharmacy to deliver Montelukast Sodium Oral Tablet 10 MG so it can be administered to Resident #78.On 06/30/2026 at 11:25 AM, the surveyor conducted a resident record review. The resident record review revealed that there is an Orders - Administration Note progress note written by LPN #8, dated 3/12/26 at 11:11 PM, which states that the facility is awaiting on pharmacy to deliver GlycoLax Powder 17 grams so it can be administered to Resident #78.On 06/30/2026 at 11:26 AM, the surveyor conducted a resident record review. The resident record review revealed that there is an Orders - Administration Note progress note written by LPN #8, dated 3/12/26 at 11:12 PM, which states that the facility is awaiting on pharmacy to deliver Tizanidine HCl Tablet 2 MG so it can be administered to Resident #78.On 06/30/2026 at 11:27 AM, the surveyor conducted a resident record review. The resident record review revealed that there is an Orders - Administration Note progress note written by LPN #8, dated 3/12/26 at 11:12 PM, which states that the facility is awaiting on pharmacy to deliver Gabapentin Capsule 100 MG so it can be administered to Resident #78.On 06/30/2026 at 11:28 AM, the surveyor conducted a resident record review. The resident record review revealed that there is an Orders - Administration Note progress note written by LPN #8, dated 3/12/26 at 11:12 PM, which states that the facility is awaiting on pharmacy to deliver Acetaminophen Extra Strength Tablet 500 MG so it can be administered to Resident #78.On 06/30/2026 at 11:29 AM, the surveyor conducted a resident record review. The resident record review revealed that there is an Orders - Administration Note progress note written by LPN #8, dated 3/13/26 at 11:12 PM, which states that the facility is awaiting on pharmacy to deliver Oxycodone HCl Oral Tablet 10 MG, PRN so it can be administered to Resident #78.On 06/30/2026 at 11:32 AM, the surveyor interviewed the Director of Nursing (DON) #2. During the facility staff interview, the DON #2 indicated that when Resident #78 was admitted to the facility, LPN #8 did not enter Resident #78's medication orders as STAT medication orders. The DON #2 mentioned that when a medication order is entered as a STAT medication order, the medication will be delivered to the facility within four hours. The surveyor asked the DON #2 what is the expectation of the nurse when entering medication orders for newly admitted residents. The DON #2 stated that the expectation is to enter the newly admitted resident's medication orders as STAT medication orders.On 06/30/2026 at 12:01 PM, the surveyor interviewed the Nurse Account Manager ([NAME]) #10. During the facility staff interview, the [NAME] #10 mentioned that if a medication order requires backup or immediate dosing and if the medication is available at the facility, the nurse will need to call pharmacy. Once the nurse calls pharmacy and they receive the order, pharmacy will send a code to nurse. Once the nurse has the code, the nurse will have immediate access to the medication in the Cubex.

3) On 5/27/25 at 10:38AM the surveyor observed Resident #20 from the hallway to be laying on their back in their bed which was in a flat position and also in the highest position, with a hoyer sling situated under them and their foley catheter bag laying on top of their right thigh. No staff was observed by the surveyor to be present within the resident's room or within the hallway. On 5/27/25 at 10:40AM the surveyor conducted an interview of Resident #20 who reported to the surveyor that their nursing assistant had left to get something and they had been laying there for five minutes. Resident #20 stated to the surveyor: It makes me feel helpless. On 5/27/25 at 10:47AM the surveyor observed Geriatric Nursing Assistant (GNA) #25 in the hallway and shared concerns with them. At this time the surveyor conducted an interview with GNA #25 who stated to the surveyor that No, s/he's not been here three seconds, I went to get the hoyer lift. At this time, in response to the sharing of the surveyor's concerns, GNA #25 was observed donning medical gloves and removing the resident's catheter bag from their lap and hung it below the level of the bladder, lowered the resident's bed height and while still wearing the medical gloves, exited the resident's room with the medical gloves on in the hallway, removed them, and threw them on top of the trash and dirty linen container and walked away leaving the medical gloves on top of the container. At this time the surveyor shared the concern with GNA #25 and inquired as to if they perform hand hygiene after removal of used medical gloves. After surveyor intervention, GNA #25 was observed to utilize hand sanitizer located in the hallway. On 5/27/25 at 10:48AM the surveyor shared concerns with Licensed Practical Nurse #6 and Unit Manager, Registered Nurse #11, who both acknowledged and confirmed understanding of the concerns. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and DON. 4) On 5/28/25 at approximately 9:45AM the surveyor conducted an interview with Maintenance Supervisor (MS) #26 at which time the surveyor requested for them to provide a copy of the facility's water management plan. On 5/28/25 at 10:22AM in response to the surveyor's request for a copy of the facility's water management plan, MS #26 provided water testing results to surveyors which revealed that on 8/9/24 the facility had received positive elevated test results for Legionella within several areas located within the facility. Review of maintenance records provided by the facility revealed steps taken to address the elevated results including installation of specialized shower heads, and a water treatment system. During an interview on 5/28/25 at 11:07AM of the facility Administrator, they reported to surveyors that they were not aware of the facility having a water management plan, but that they would check and see if they could locate one. During an interview on 5/28/25 at 12:30PM Registered Nurse, Infection Preventionist (RN, IP) #4 stated that the facility did not have a water management plan. On 5/28/25 at 3:27PM surveyors conducted an interview with the facility's Administrator, who in response to the surveyor's prior requests to provide the facility's water management plan, responded with the following information: I can't find it. After surveyor intervention, the Administrator informed and later provided surveyors with a copy of a contract for a water management company to perform the service of creating a water management plan for the facility which was dated 6/1/25. On 6/2/25 at 10:35AM surveyors conducted an interview with RN, IP #4 and the facility's Director of Nursing (DON), at which time an incomplete template for a facility water management plan was provided for surveyor review. Review of that template revealed the following areas which were left blank: compilation of the water management team, inventory of water system components with the identification of dead leg area locations (areas in which stagnant water is likely to harbor waterborne pathogens), incident response procedures, and monitoring procedures/grids. At this time surveyors shared concerns with RN, IP #4 and the DON who confirmed and acknowledged understanding of the concerns. On 6/2/25 at approximately 3:30PM the surveyor again reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing. Based on observation and interview and record review, it was determined the facility failed to ensure staff adherence to appropriate infection control measures consistent with accepted standards of practices during: 1) medication administration for 1 (Resident #26) out of 4 resident observations of medication administration; 2) equipment cleaning between resident use for 1 (Resident #63) out of 4 resident observations of medication administration; 3) staff performance of hand hygiene for 1 (Resident #20) out of 2 residents reviewed for accidents; and 4) the facility failed to ensure measures to minimize the risk of Legionella and other opportunistic pathogens in the building water system by having a documented water management program which has the potential to impact all residents. The findings include: 1) During observation rounds and staff interviews: On 5/28/25 at 1:40PM the surveyor observed Enhanced Barrier Precautions (EBP) signage was present and posted on the door to Resident #26's room that indicated a minimum mandatory standard: Everyone Must: Clean their hands, including before entering and when leaving the room. On 5/28/25 at 1:44PM surveyors observed Licensed Practical Nurse (LPN) #6 during medication administration at Baltimore hall #1, enter the room of Resident #26 without performing hand hygiene as indicated on the door signage. Surveyors observed LPN #6 sitting on the resident's bed to administer medications. LPN #6 placed the medication cup on the bedside table, the cup tipped over and one white round pill fell out of the cup; LPN #6 stated she would change out the medication, then exited the resident's room without performing hand hygiene. LPN #6 then went to the medication cart, obtained a clean pill from within the medication cart, re-entered the resident room without hand hygiene, sat on the bed again, and proceeded to give medications. The surveyor asked LPN #6 about the EBP sign and purpose; and LPN #6 stated that the EBP precautions were for Resident #26 who only has precautions for their foley catheter. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing. 2) On 5/29/25 at 9:20AM the surveyor observed Enhanced Barrier Precautions (EBP) signage was present and posted on the door to Resident #63's room that indicated a minimum mandatory standard: Everyone Must: Clean their hands, including before entering and when leaving the room. On 5/29/25 at 9:24AM the surveyor observed Registered Nurse (RN) #5 exit another resident room with a vital sign machine and then proceeded to Resident #63's room to complete vital signs; the machine was not cleaned between resident use and RN #5 did not clean hands upon entering or exiting Resident #63's room during vital signs. The surveyor then observed RN #5 during medication administration for Resident #63, and RN #5 failed to clean hands as indicated on the sign when entering Resident #63's room a second time. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing.

Based on observation, record review and interview it was determined that the facility failed to maintain proper storage with regards to reconciling expired medications and storing all drugs and biologicals in locked compartments. This was evident for 3 of 3 medication storage areas observed during the facility's recertification survey. The findings include: During observation rounds and staff interviews the following was found: On 5/28/25 at 1:57PM at the Baltimore hall #2 treatment cart to review the narcotic count log book with Licensed Practical Nurse (LPN) #6, the surveyor observed the Oxycodone tab 5mg medication pack for Resident #33 which had an expiration date of 4/30/25. The surveyor asked LPN #6 if the item was expired, and LPN #6 confirmed the expired date. On 6/2/25 at 10:40AM with Unit Manager #11 in the Baltimore hall medication supply room, two SURESITE IV slide safety intravenous catheter, size 2G ¾ syringes with expiration date of 8/31/24. The surveyor asked Unit Manager #11 if item was expired; and Unit Manager #11 confirmed the expired date. After surveyor intervention Unit Manager #11 discarded the expired item. On 6/2/25 at 10:42AM with Unit Manager #11 in the Baltimore hall medication supply room, one [NAME] STERILE IV START KIT was observed with an expiration date of 6/18/23. The surveyor asked staff #11 if the item was expired; at which time Unit Manager #11 confirmed the expired date. After surveyor intervention Unit Manager #11 discarded the expired item. On 6/2/25 at 11:10AM with Unit Manager #21 in the Harbor Hall medication supply room, one package of ArgiMent AT with Bimuno Prebiotic For Acute and Chronic Wounds - A Medical Food revealed an expiration date of 9/15/24. The surveyor asked Unit Manager #21 if the item was expired; Unit Manager #21 confirmed the expired date. After surveyor intervention, Unit Manager #21 discarded the expired item. On 6/2/25 at 11:15AM with Unit Manager #21 in the Harbor Hall medication supply room the narcotic lock box within the medication refrigerator was observed to be open and unlocked. The surveyor asked Unit Manager #21 if the narcotic box within the refrigerator was to remain locked; Unit Manager #21 confirmed the expectation for the narcotic box within the medication refrigerator to be always locked. During observation rounds and staff interview on 6/2/25 at 12:20PM with the Director of Nursing (DON) #2, within the Harbor Hall medication supply room, the surveyor informed the DON of the above findings as well as observed the medication storage refrigerator padlock was unlocked and the narcotic box within the refrigerator was unlocked. The DON stated the policy and procedure and expectation is for both to be always locked. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing.

Based on observation, interview, and record review it was determined the facility failed to: 1.) ensure the menu was followed, and 2.) meet resident choices based on his/her preferences. This was evident for: 1.) 7 out of 7 residents who had ordered bread sticks on their menu for the lunch meal occurring on 5/29/25 and 2.) 1 (Resident #5) out of 2 residents reviewed for food during the facility's recertification survey. The findings include: 1.) On 5/29/25 at 12:21PM the surveyor conducted a meal tray observation which revealed a menu ticket on a meal tray in which bread sticks were selected as an option, however they were not served on the meal tray. At this time, the surveyor requested a dual observation of the concern with Certified Dietary Manager (CDM) #28, who observed the meal tray, and acknowledged and confirmed understanding of the concern. On 5/29/25 at 12:27PM the surveyor observed CDM #28 approach the hot food cart and open it, and confirmed the bread sticks were not brought up from the kitchen to the unit. At this time, the surveyor conducted an interview with CDM #28 who stated the following to the surveyor: I am going to go get them from the kitchen and pass them out, I'm going to give that to them, there were seven resident orders for bread sticks. On 5/29/25 at 12:34PM the surveyor observed and confirmed with CDM #28 that the last resident meal tray for lunch service had been passed out and breadsticks listed on the menu had not been served. On 5/29/25 at 12:50PM the surveyor reviewed the concern with CDM #28. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing. 2.) During observation rounds, record review, and interview on 5/27/25 at 9:17AM the surveyor observed that Resident #5's dietary tray items did not reflect their dietary ticket on the tray. Per the dietary ticket, the items circled were: Beverage of choice, Milk of Choice, 8oz, Bacon, Danish, and Instructions: give 2 cereal at breakfast. The surveyor observed the breakfast meal tray to have the following: a hot beverage cup, and a tea bag and a half-eaten bagel on the plate. During interview on 5/29/25 at 3:25PM with Dietary Supervisor #8 the surveyor discussed the dietary ticket discrepancy with the food that was served to the resident on the breakfast tray. Dietary Supervisor #8 stated to the surveyor that the expectation is to follow the dietary ticket. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing.

Based on personnel record reviews and staff interviews, it was determined that the facility failed to have a system in place to ensure that Geriatric Nursing Assistants (GNA) received at least 12 hours of in-service training annually. This was evident for 3 (GNAs #16, 17, and 18) out of 3 GNA's reviewed during the facility's recertification survey. The findings include: On 5/30/25 at 3:30PM, a personnel record review revealed that GNA #16, 17, and 18 did not receive the required, annual, 12-hour, nurse aide, in-service training. On 5/30/25 at 3:35PM, Human Resources Director (HRD) #12 was interviewed. During the interview, HRD #12 was made aware that there was no documentation indicating that GNA's #16, 17, and 18 received the required, annual, 12-hour, nurse aide, in-service training. HRD #12 indicated that the Nursing and Health Services Educator, Infection Prevention Nurse (RN, IP) #4 manages documentation of the required, annual, 12-hour, nurse aide, in-service training. On 5/30/25 at 3:42PM, RN, IP #4 was interviewed. During the interview, the surveyor made RN, IP #4 aware that there is no documentation indicating that GNA's #16, 17, and 18 received the required, annual, 12-hour, nurse aide, in-service training. RN, IP #4 indicated that she did not have documentation indicating that GNA's #16, 17, and 18 were provided with an additional 12 hours of nurse aide in-service training. Also, RN, IP #4 stated that she was not aware that the regulation requires the facility to provide GNAs with an additional 12 hours of nurse aide in-service training. On 5/30/25 at 3:47PM, Director of Nursing #2 was made aware that the facility does not have documentation indicating that GNA's #16, 17, and 18 received the required, annual, 12-hour, nurse aide, in-service training. HRD #12 indicated that she was not aware that the regulation requires the facility to provide GNA's with an additional 12 hours of nurse aide in-service training.

Based on observations and interviews, it was determined that the facility failed to ensure maintenance of a homelike environment. This was evident for 3 (#30, #13, and #22) out of 18 resident's rooms observed during the surveyor's initial tour during the facility's recertification survey. The findings include: During observation rounds the following was found: On 5/27/25 at 8:09AM in the room of Resident #30, the surveyor observed damage to the wall area adjacent to the resident bed just outside of the bathroom. The wall appeared with scratches and peeling and flaking of paint. On 5/27/25 at 8:19AM in the bathroom of Resident #13, the surveyor observed paint damage, brown streaking to the surrounding wall, and crumbling wall fragments to the base of the toilet where it meets the wall. On 05/27/25 at 8:28AM in the room of Resident #22, the surveyor observed the wall to the head of the resident bed area with scratches and peeling and flaking paint. During staff interview on 5/28/25 10:10 AM the surveyor discussed with Maintenance Supervisor #26, the paint that is peeling, flaking, and with scratches within the resident areas. Maintenance Supervisor #26 stated they would submit work orders to start repairs to the resident room areas. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing.

Based on interview and record review it was determined the facility failed to ensure a resident was monitored for side effects of psychotropic medications. This was evident for 1 (Resident #50) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey. The findings include: On 5/28/25 at 8:46AM the surveyor reviewed the medical record of Resident #50 which revealed active medical orders for the following medications: trazodone (antidepressant/sedative), buspirone (anxiolytic), and zyprexa (atypical antipsychotic) with no side effect monitoring order observed to be in place. On 5/28/25 at 9:16AM the surveyor reviewed the medical record of Resident #50 which included the May 2025 medication and treatment administration records which revealed there was no medication side effect monitoring present for the trazodone, buspirone, or zyprexa medications. On 5/28/25 at 9:36AM the surveyor conducted an interview and shared their concern regarding Resident #50 with Unit Manager, Registered Nurse #11 who reported to the surveyor that during the admission process for residents, side effect monitoring orders are placed on the treatment administration record and also placed anytime there is a medication change, and so I'm not sure how that one was missed. On 5/28/25 at 9:55AM the surveyor conducted an interview with the Director of Nursing (DON) and inquired as to their expectation for medication side effect monitoring. The DON reported to the surveyor that there were two orders expected to be in place for psychotropic medication monitoring, one for behavior monitoring, and one for medication side effects monitoring which is used for monitoring of the specific target symptoms the resident could have, and they would be listed in the medical order and additionally reflect on the treatment administration record of the resident. At this time, the surveyor shared their concern with the DON who acknowledged and confirmed understanding of the concern and observed the concern within the medical record with the surveyor. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and DON.

Based on interview and record review it was determined the facility failed to ensure that an allegation of abuse was timely reported. This was evident for 1 (#MD00212201) out of 3 facility reported incidents reviewed during the facility's recertification survey. The findings include: On 5/29/25 at 8:47AM the surveyor requested and reviewed the facility's complete investigation file for facility reported incident #MD00212201. Review of the complete investigation file revealed the following information: 1.) a statement written by the Director of Social Services #7 dated 11/26/24 which documented allegations of abuse verbalized to them by Resident #269, 2.) an initial self report submitted by the facility on 11/26/24 which documented that facility staff became aware of the incident at 2:00PM with physical abuse as the type of allegation being reported, and 3.) an email confirmation of submission of the initial self report made to the Office of Health Care Quality on 11/26/24 at 4:10PM. Review of the complete investigation file and initial self report documentation revealed the self report to the Office of Health Care Quality was not made within the two hour timeframe. On 6/2/25 at 8:27AM the surveyor conducted an interview with the facility's Director of Nursing (DON) who confirmed that the facility's expectation is for staff to report an allegation of abuse within two hours to the Office of Health Care Quality. At this time the surveyor shared their concern with the DON, who acknowledged and confirmed understanding of the concern. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and DON.

Based on interview and record review it was determined the facility failed to ensure allegations of abuse were thoroughly investigated. This was evident for 1 (#MD00212201) out of 3 facility reported incidents reviewed during the facility's recertification survey. The findings include: On 5/29/25 at 8:47AM the surveyor requested and reviewed the facility's complete investigation file for facility reported incident #MD00212201. Review of the complete investigation file revealed a statement written by the Director of Social Services #7 dated 11/26/24 which documented allegations of abuse verbalized to them by Resident #269, which included both allegations of physical and verbal abuse. Review of the interviews conducted revealed that staff members were questioned regarding the allegation of physical abuse, however, there were no documented questions to staff regarding the allegations made of verbal abuse. Review of the complete investigative file revealed there was no documentation of an interview conducted or statement obtained from the alleged perpetrator, and no written statement obtained from the resident. On 6/2/25 at 10:55AM the surveyor conducted an interview with the facility's Director of Nursing (DON) and shared concerns that there was no written statement obtained from Resident #269, and no documentation of an interview or statement obtained from the alleged perpetrator, Geriatric Nursing Assistant (GNA) #23. At this time, the surveyor requested to the DON for the facility to provide all documentation regarding these concerns. On 6/2/25 at 12:08PM the DON informed the surveyor that there was no statement obtained from the resident, no statement obtained from the alleged perpetrator, and no interview of them conducted. The DON confirmed there was no documentation that could be provided to the surveyor to show the facility had made any attempt at either obtaining a statement or conducting an interview with GNA #23. At this time, the surveyor shared their concern with the DON who acknowledged and confirmed understanding of the concern. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and DON.

Based on review of medical records and interviews it was determined that the facility failed to review and revise a quarterly comprehensive care plan by all interdisciplinary team members. This was evident for 1 (Resident #21) out of 1 residents reviewed for care planning during the facility's recertification survey. The findings include: Review of Resident #21's medical record by the surveyor on 5/28/25 at 9:55AM revealed a progress note stating that a quarterly care plan meeting and review was completed for Resident #21 on 3/4/25 by the interdisciplinary team, but did not include the attending physician and a nurse aide with responsibility for the resident. During an interview on 5/28/25 at 2:07PM, Director of Social Services #7 confirmed and stated that the attending doctor and a nurse aide with responsibility for the resident did not review or revise Resident #21's 3/4/25 quarterly care plan. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing.

Based on observation, interview, and record review it was determined the facility failed to take measures to ensure a resident was free from accident hazards. This was evident for 1 (Resident #20) out of 2 residents reviewed for accidents during the facility's recertification survey. The findings include: On 5/27/25 at 10:38AM the surveyor observed Resident #20 from the hallway to be laying on their back in their bed which was in a flat position and also in the highest position, with a hoyer sling situated under them and their foley catheter bag laying on top of their right thigh. No staff was observed by the surveyor to be present within the resident's room or within the hallway. On 5/27/25 at 10:40AM the surveyor conducted an interview of Resident #20 who reported to the surveyor that their nursing assistant had left to get something and they had been laying there for five minutes. Resident #20 stated to the surveyor: It makes me feel helpless. On 5/27/25 at 10:42AM the surveyor requested a dual observation with the resident's assigned nurse. On 5/27/25 at 10:43AM the surveyor observed Activities Staff #24 enter the resident's room and inform them of the day's activities which were to occur, and then left the room while the resident remained in the same position. On 5/27/25 at 10:47AM the surveyor observed Geriatric Nursing Assistant (GNA) #25 in the hallway and shared the concerns with them. At this time the surveyor conducted an interview with GNA #25 who stated to the surveyor that No, s/he's not been here three seconds, I went to get the hoyer lift. At this time, in response to the sharing of the surveyor's concerns, GNA #25 was observed removing the resident's catheter bag from their lap and hung it below the level of the bladder and then lowered the resident's bed before leaving the room. On 5/27/25 at 10:48AM the surveyor shared concerns with Licensed Practical Nurse #6 and Unit Manager, Registered Nurse #11, who both acknowledged and confirmed understanding of the concerns. On 5/27/25 at 10:50AM the surveyor observed GNA #25 bringing the hoyer lift into the room to assist the resident. On 5/27/25 at 11:44AM the surveyor conducted an interview with the facility's Director of Nursing (DON) who stated that the facility's expectation is for GNA's to come into the room prepared with the hoyer lift to complete the transfer with the resident. The DON acknowledged the surveyor's concerns and informed the surveyor that in response to the surveyor's concerns, staff were provided safety education regarding bed height and a quality assurance plan was started for the issue. At this time the DON confirmed understanding of the surveyor's concerns. Review of Resident #20's care plan by the surveyor on 5/28/25 at 12:17PM revealed the following documentation: Dependent on staff for meeting emotional, intellectual, physical and social needs r/t physical limitations. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and DON.

Based on record review and interview it was determined that the facility failed to ensure proper reconciliation of expired controlled drug medications during medication administration and drug record keeping for the resident. This was evident for 1 (Resident #33) out of 6 residents reviewed for medication storage during the facility's recertification survey. The findings include: During observation rounds and resident record review on [DATE] at 1:57PM with Licensed Practical Nurse (LPN) #6, the surveyor reviewed the narcotic count log book and the narcotic medications on-hand within the lock box where they are stored. The surveyor observed Resident #33's Oxycodone TAB 5mg medication card and noted an expiration date located on the back of the card, which revealed the medication was expired as of [DATE]. The surveyor then reviewed the controlled drug receipt/record/disposition form within the narcotic count log book which revealed that Oxycodone 5mg Tab was given to the resident on [DATE] by Registered Nurse (RN) #27. During staff interview on [DATE] at 2:00PM the surveyor asked the LPN #6 if the record review reflected a narcotic medication card expired on [DATE] and an entry on the controlled drug receipt/record/disposition form reflected a medication entry made for [DATE]. LPN #6 confirmed that the expired medication was given to the resident. During staff interview on [DATE] at 2:57PM with Director of Nursing (DON) #2, they were informed of expired narcotic medication and administration to Resident #33. The surveyor asked the DON about the expectation of the narcotic count log with 2-person handoff at each change of shift, and the DON stated the expectation is to verify counts and expiration dates of the medication at the time of the 2-person count. Additionally, the DON stated the expiration date should have been checked during medication administration on [DATE]. Review of the medical record on [DATE] at 12:21 PM for Resident #33 revealed a physician's order for Oxycodone HCl Tablet 5MG Give 0.5 tablet by mouth every 6 hours as needed for pain administer for pain score >3 and per request by resident for Pain score >3, Start date [DATE] 1200. Further review of Resident #33's medical record revealed a medication administration record entry for Monday, [DATE]; Pain Level 5; given by RN #27, at 01:58. On [DATE] at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing.

Based on observation, record review, and interview it was determined that the facility failed to follow prescriber's orders and manufacturer's specifications regarding medication preparation during medication administration for the resident. This was evident for 1 (Resident #13) out of 4 residents observed for medication administration during the facility's recertification survey. The findings include: During observation rounds for medication administration on 5/28/25 at 8:56AM the surveyor observed Registered Nurse #5 prepare Resident #13's medications using a white eating utensil spoon not labeled with measurements to scoop 2 scoops out of a bulk Benefiber bottle, to mix in a measured cup prior to adding liquid. During surveyor review of Resident #13's medical record on 5/28/25 at 9:00AM the record revealed the following physician's medication order: Benefiber powder (Wheat Dextrin) Give 1 packet by mouth one time a day for diarrhea Dissolve contents in 8 ounces of liquid; Benefiber powder ADMINISTER 2 TEASPOONSFUL BY MOUTH ONE TIME A DAY FOR DIARRHEA DISSOLVE CONTENTS IN 8 OUNCES OF LIQUID. On 5/28/25 at 10:01AM the surveyor conducted an interview of Director of Nursing (DON) #2 who discussed the expectations for medication preparation and measuring devices. The surveyor asked DON #2 what measuring device should be used when measuring from a bulk bottled medication. DON #2 stated the expectation is for the staff to measure all medications with appropriate measurement labeled devices when applicable. During record review on 5/28/25 at 12:00PM the surveyor reviewed policy and procedures received which indicated the following: Medication Administration, Policy 5.3 GENERAL GUIDELINES FOR MEDICATION ADMINISTRATION, Procedure, 5. Preparing Medications for Administration: B) Liquid Medications, c. Pour correct amount directly into a graduated medication cup . On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing.

Based on observation and interview it was determined that the facility failed to ensure safe and separate storage of food brought in by family or visitors for residents. This was evident for 1 out of 2 Central Supply Room refrigerators observed during the recertification survey. The findings include: During observation rounds the following was found: On 6/2/25 at 11:00AM with Unit Manager (UM) #11 within the Central Supply room located on Baltimore Hall #2, the surveyor observed 3 of 6 containers of smoked salmon cream cheese spread, with an expiration date of 5/18/25. On 6/2/25 at 11:02AM with UM #11 within the central supply room located on Baltimore hall #2, the surveyor observed 2 of 2 white soup containers of liquid with visitor label dated [DATE]. On 6/2/25 at 11:04AM with UM #11 within the central supply room located on Baltimore hall #2, the surveyor observed 2 of 2 containers of cottage cheese with fruit, with the expiration date: 4/7/25. On 6/2/25 at 11:06AM with UM #11 within the central supply room located on Baltimore hall #2, the surveyor observed 1 of 1 container of Breakstone's cottage doubles with pineapple, with an expiration date of 3/18/25. During staff interview on 6/2/25 at 11:08AM with UM #11 the surveyor inquired as to if the items were resident items brought in by family and now expired, at which time UM #11 confirmed that they were resident items and that they were now expired. After surveyor intervention, UM #11 discarded the expired items. On 6/2/25 at approximately 3:30PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing.

Based on medical record review and interview it was determined that the facility failed to follow the standard of practice of verifying medication doses when ordering and administering medication. This was evident during the review of a facility reported incident where a resident was administered an inappropriate dose of morphine. This was evident for 1 of 3 Residents reviewed (#1) for deaths. This failure resulted in an Immediate Jeopardy for Resident #1. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey, therefore this deficiency will be cited as past noncompliance. The date of correction was [DATE]. The findings include: Review of the facility reported incident on [DATE] at 11:30 AM revealed concerns regarding the medication administered to Resident #1 was noted with a decline during his/her stay in the facility. Resident #1 was ordered Ativan for agitation on [DATE] secondary to increased oxygen requirement. At this time a hospice consult request was put in. On ,d+[DATE] at 11:31 AM, according to a nursing progress note, Resident #1 was noted with dyspnea and agonal breathing (shortness of breath and irregular, labored or gasping breaths). An E-medical (electronic communication) was sent to the on-call physician requesting for some type of narcotic pain killer to keep [resident] comfortable. Certified Registered Nurse Practitioner (CRNP) #7 responded at 3PM, 3 hours after the initial E-medical was sent, to continue the Ativan as she was waiting to hear back from the unit manager regarding hospice care. According to the facility investigation and statements, RN #5 stated that just after she received the E-medical for the Ativan, she then took a verbal order over the phone from CRNP #7 for Morphine 5mg to be given every 2 hours for pain and shortness of breath. RN #5 in a statement for the facility investigation stated that the verbal order was for 5 mg of Morphine for administration every 2 hours, which would be .25 ml dose from a 20 mg/ml concentration that was to be ordered. However, RN#5 wrote 2.5ml in the electronic order not .25ml (2.5 would be a 50 mg dose). She further stated that she had not administered the medication because it was not available but would have immediately noted that the order was wrong when she went to administer it, that 2.5ml was incorrect. Agency LPN #11 signed for the Morphine when delivered from the pharmacy on [DATE] and placed it in the narcotic box. The prescription sticker on the controlled drug receipt form stated Morphine concentration 20 mg/ml. Review of the nursing progress notes and according to the medication administration record (MAR), on [DATE] at 10:02 AM Resident #1 was noted with shortness of breath and was administered the Morphine as ordered on the MAR, a concentration of 10mg/5ml of Morphine, 2.5 ml. This dosage calculated out to 5mg, the expected dosage. However, according to the C-2 form requested by the physician, and the controlled drug receipt signed by LPN #11, the pharmacy delivered a concentration of 20 mg/ml vial of Morphine. According to the controlled drug receipt/record/disposition form, LPN #6 signed off at 10:02 AM and 9:23 PM she pulled and administered 2.5 ml of the 20 mg/ml concentration of Morphine which for Resident #1, calculated to a 50mg dose, 10 times the ordered dose. To administer 2.5 ml, LPN #6 would have needed to draw up and fill the pharmacy provided syringe 2.5 times as only a 1ml size syringe is delivered with that concentration of Morphine. This was confirmed during a tour and observation of the medication cart on [DATE]. At 1:40 AM on [DATE] Resident #1 was pronounced deceased . Interviews with 4 of 4 staff on 2 of 2 floors on [DATE] revealed that they still take verbal orders from physicians. Medication administration education was completed with the staff on [DATE] and [DATE] according to training documentation provided by the facility on [DATE]. At 12:57 PM on [DATE] the survey team reviewed the identified concerns with the Administrator, DON and ADON regarding the inappropriate medication administration. On [DATE] the facility presented to the survey team a plan of correction that was implemented on [DATE] with a final date of compliance of [DATE]. This plan was verified on site on [DATE]. Their plan included that all controlled substance orders requiring written authorization will be reviewed to ensure controlled substance written order forms and electronic orders in the electronic medical record are correct, education on medication administration to all licensed nursing staff, controlled substance order forms requiring written authorization order forms will be reviewed every shift, then reviewed daily then weekly x 3 months. There will also be daily checks of inventory records daily for 30 days and monthly for 3 months.

Based on facility document review and interview, it was determined that the facility administration failed to follow the guidelines for abuse investigation which included conducting complete and thorough investigations, identifying abuse and putting in appropriate interventions to prevent further occurrences of abuse. These failures placed all residents at risk for abuse. This was evident for 4 of 4 (#6, #7, #2 and #10) facility reported incidents reviewed completed by the previous facility Director of Nursing. The findings include: 1. Review on 10/17/24 at 11:55 AM of the FRI regarding Resident #6 an allegation of verbal abuse revealed that residents' family member reported to the (previous) facility DON, staff # 18, on 6/14/24 that staff were rude when delivering residents breakfast trays. The concern was further noted that staff would leave the breakfast trays in front of the resident and then would not assist the resident right away with eating. Record review at 12:30 PM on 10/17/24 revealed that Resident #6 was dependent on staff for meals and eating as noted in his/her care plan and in the daily nursing progress notes. On 6/20/24 a care plan meeting was held. That same family member, Resident #6's representative, asked the DON what the follow-up was to his reported concern about verbal abuse. According to the statement in the FRI, the DON did not feel the concern from the family member rose to the level of verbal abuse and no official investigation was initiated. It was not until 6/20/24 that an investigation into the care Resident #6 received on 6/14/24 was addressed, although the family reported concerns about breakfast delivery and staff to resident interactions. The concern that the previous DON failed to identify reported concern as a form of potential abuse and elevate them to an investigation and then further was not reported for another 6 days was reviewed with the current DON and NHA throughout the survey and again during exit on 10/21/24. cross reference F550, F609, F610 2. Review of a facility reported incident (FRI) regarding Resident #7 on 10/18/24 at 12:27 PM revealed a fall which was the 6th in a month and the second requiring hospitalization . This fall was documented as occurring in the common area, according to a statement from the on-duty nurse that day who did not observe the fall but documented seeing the resident afterwards on the floor. Resident #7 was sent to the hospital and diagnosed with a compression fracture of the thoracic vertebrae. Review of the facility 5-day follow-up investigation report form noted that there were no staff or resident interviews conducted. Additionally, section 3, the conclusion was noted as N/A under not verified and section 4 for corrective action taken was left blank. This was signed and submitted by staff #18, the previous DON. The concern that there was no conclusion or preventative measures presented was reviewed with the administrative team which included the DON, Administrator and ADON on 10/18/24 and again during exit on 10/21/24. Cross reference F610 3. Review on 10/16/14 at 10:45 AM of the FRI for Resident #2, revealed that on 8/10/24, Resident #2 reported to LPN #20 concerns related to possible abuse from GNA's that had provided him/her with activities of daily living. However, it was not until 8/14/24 that staff LPN #20 reported this concern to the (previous) DON #18. This concern was completed on a grievance form and the identified staff were educated on customer service training, not abuse or timely reporting of abuse. These collaborative concerns were reviewed with the current facility administration throughout the survey. Cross reference F609 4. Review of the FRI for Resident #10 on 10/18/24 at 10:37 AM revealed on 11/7/23 Resident #10 notified staff that s/he was not being treated well, that a GNA was being pushy and rushing him/her with care. This was immediately reported to the (previous) DON. The results of the concern form completed by the DON stated in actions: assignment change for employee, I reassured patient that GNA would be educated on customer service. On 11/9/23 another concern form was completed for Resident #10. The Social worker reported that the patient had continued concerns reflecting back from the previous Tuesday and Wednesday (7th and 8th), as previously reported, that the aide was rough and yelling at him/her. The documented facility follow-up from the previous DON was GNA re-educated on customer service and having a team member assist with repositioning, GNA educated and assignment on unit has been changed. A report was not sent to the Office of Health care Quality until 11/9/23 at 4:22PM by the facility DON. It was documented on the form that she notified the NHA that she was just notified at 2:30 PM on 11/9/23 by the social worker that Resident #10 had concerns about a GNA being pushy while providing care. The interventions included updating the resident care plan, education to the staff, interviews and changing the employes schedules. The facility report was submitted as mental/verbal abuse. According to the facility report there were 2 GNAs identified of concern. The documented facility follow-up from the previous DON was GNA re-educated on customer service and having a team member assist with repositioning, GNA educated and assignment on unit has been changed. A review of the schedules for 11/9/23-12/1/23 revealed only 10 of 26 days where Resident #10 was not in the presence of either identified employee that s/he had concerns and allegations of abuse against from 11/7-12/1/23 The initial allegation was made on 11/7/23. On 11/8/23, 11/9, 11/12, 11/20, 11/21, 11/23, 11/25 and 11/30 one of the 2 GNAs was assigned to Resident #10. On 11/11, 11/22, 11/26, 11/28 and 11/29 one of the 2 GNAs was caring for residents in adjacent rooms. There was no evidence that either GNA was suspended pending investigation, or that there was any preventative action put in place to prevent further occurrences of potential abuse to Resident #10. The concern that the DON was aware of the incident on 11/7/23 and dismissed it as a customer service issue was reviewed with the current facility DON on 10/18/24 at 12:10 PM. cross reference F609, F610

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to enhance a resident's dignity. This was evident during the review of a facility reported incident regarding activities of daily living care 2 of 30 (#6, R4). This failure placed residents at risk of their rights being violated and not upheld. The findings include: 1.) Review of the facility reported incident (FRI) on 10/17/24 at 11:55 AM regarding Resident #6 and an allegation of verbal abuse revealed that residents' family member reported to the (previous) facility Director of Nursing (DON) # 18 staff were rude when delivering residents breakfast trays. The concern was further clarified that staff would leave the breakfast trays in front of the resident and then would not assist the resident right away with eating. Record review at 12:30 PM on 10/17/24 revealed that Resident #6 was dependent on staff for meals and eating as noted in his/her care plan and in the daily nursing progress notes. Per the resident's care plan s/he was also noted to have poor intake and a 'poor feeder.' The DON was interviewed on 10/17/25 at approximately 12:50 PM. The expectation would be for staff to feed residents when the tray is delivered. The concern that family reported that staff were just leaving the breakfast meal tray in front of Resident #6 for an unknown amount of time prior to aiding the residents was reviewed with the current facility DON and Administrator. cross reference F609, F610, F835 2.) Review of the facility's policy titled, Resident [NAME] of Rights undated reads in part, .A. The facility shall provide care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, promote and respect the rights of the residents and in full recognition of the resident's individuality . Review of R4's undated Admission Record, located in the resident's electronic medical record (EMR) under the Resident Summary tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Surgical Aftercare following surgery on circular system, Hypertensive Heart and Chronic Kidney Disease and Pneumonia. Review of R4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/24 located in the resident's EMR under the MDS tab revealed the facility assessed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively alert. Review of facility Concern Form, receive date 07/18/24 revealed R4 reported s/he had a rough time during the shower. R4 stated the nursing aide asked him/her to stand and told him/her if s/he did not stand, she would let him/her fall. R4 also stated s/he was thrown against the wall and feet stepped on. Review of R4's typed statement dated 07/18/24 documented R4 stated, Certain staff should be fired, they threw me in the shower, pushed me against the wall and stepped on my feet. I begged them to stop, they said, they would let me fall. Interview with Geriatric Nursing Assistant (GNA) 17 on 10/17/24 at 2:44 PM, GNA 17 stated she gave R4 a shower and had assistance from GNA 18. GNA 17 stated R4 expressed they did not want a shower, but their family member requested the shower. GNA 17 stated R4 was screaming out and attempting to slide out of the shower chair once they were in the shower. GNA 17 stated s/he did not want to continue with the shower, but GNA 18 insisted since the family requested. Interview attempted with Geriatric Nursing Assistant (GNA) 18 on 10/22/24 at 11:31 AM via phone call and no answer. During an interview on 10/18/24 at 09:06 AM, Director of Nursing (DON) stated they expect resident's rights to be upheld. DON stated the GNA staff were trained to report to the nursed if a resident refuses care. DON stated the nurse is then supposed to follow up and try to get the resident to receive care. GNA stated that if the resident still does not want care following the nurse intervention, then staff are to document and try at a later time.

Based on review of facility documentation and interview with staff it was determine the facility staff failed to ensure that allegations involving abuse were reported to the Administrator of the facility and the State Agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident in 3 of 26 (#6, #2 and #10) facility reported incidents reviewed during a complaint survey. The findings include: 1. Review of the facility reported incident (FRI) regarding Resident #6 and an allegation of verbal abuse on 10/17/24 at 11:55 AM revealed that residents' family member reported to the (previous) facility Director of Nursing (DON) #18 on 6/14/24 that staff were rude when delivering residents breakfast trays. The concern was further noted that staff would also leave the breakfast trays in front of the resident and then would not assist the resident right away with eating. On 6/20/24 a care plan meeting was held. That same family member, Resident #6's representative, asked the DON what the follow-up was to his reported concern about verbal abuse. According to the statement in the FRI, the DON did not feel the concern from the family member rose to the level of verbal abuse and no official investigation was initiated. It was not until 6/20/24 that an investigation into the care Resident #6 received on 6/14/24 was addressed, although the family reported concerns about breakfast delivery and staff to resident interactions. The concern that the previous DON failed to identify reported concerns of potential abuse and elevate them to an investigation was reviewed with the current DON and Nursing Home Administrator (NHA) throughout the survey and again during exit on 10/21/24. 2. Review on 10/16/14 at 10:45 AM of the FRI for Resident #2, revealed that on 8/10/24, Resident #2 reported to LPN #20 concerns related to possible abuse from GNA's that had provided him/her with activities of daily living. However, it was not until 8/14/24 that LPN #20 reported this concern to the (previous) DON #18. This concern was completed on a grievance form and the staff were educated on customer service training, not abuse or timely reporting of abuse. These collaborative concerns were reviewed with the current facility administration throughout the survey. 3. Review of the FRI for Resident #10 on 10/18/24 at 10:37 AM revealed on 11/7/23 Resident #10 notified staff that s/he was not being treated well, that a GNA was being 'pushy' and rushing him/her with care. This was immediately reported to the (previous) DON. The results of the concern form completed by the DON stated in actions: 'assignment change for employee, I reassured patient that GNA would be educated on customer service;' On 11/9/23 another concern form was completed. The Social worker reported that the patient had continued concerns reflecting from the previous Tuesday and Wednesday (7th and 8th) as previously reported, that the aide was rough and yelling at him/her. The documented facility follow-up from the previous DON was 'GNA re-educated on customer service and having a team member assist with repositioning, GNA educated and assignment on unit has been changed.' A report was not sent to the Office of Health care Quality until 11/9/23 at 4:22PM by the facility DON. It was documented on the form that she notified the NHA that she was just notified at 2:30 PM on 11/9/23 by the Social worker that Resident #10 had concerns about a GNA being 'pushy' while providing care. The interventions included updating the resident care plan, education to the staff, interviews and changing the employes schedules. The facility report was submitted as mental/verbal abuse. According to the facility report there were 2 GNAs identified of concern. The concern that the DON was actually aware of the incident on 11/7/23 and dismissed it as a 'customer service' issue was reviewed with the current facility DON on 10/18/24 at 12:10 PM. cross reference F610, F835

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to thoroughly investigate allegations related to potential abuse and injuries of unknown origin. This was evident during the review of 5 of 30 (#4, #6, #7, #10, #25 ) incidents requiring facility reports and investigations. The findings include: 1. Review of the FRI regarding Resident #6 and allegation of verbal abuse on 10/17/24 at 11:55 AM revealed that residents' family member reported to the (previous) facility Director of Nursing (DON) # 18 on 6/14/24 that staff were rude when delivering residents breakfast trays. The concern was further noted that staff would leave the breakfast trays in front of the resident and then would not assist the resident right away with eating. Record review at 12:30 PM on 10/17/24 revealed that Resident #6 was dependent on staff for meals and eating as noted in his/her care plan and in the daily nursing progress notes. On 6/20/24 a care plan meeting was held. That same family member, Resident #6's representative, asked the DON what the follow-up was to his reported concern about verbal abuse. According to the statement in the FRI, the DON did not feel the concern from the family member rose to the level of verbal abuse and no official investigation was initiated. It was not until 6/20/24 that an investigation into the care Resident #6 received on 6/14/24 only was addressed, although the family reported concerns about breakfast delivery and staff to resident interactions. The concern that the previous DON failed to identify reported concerns of potential abuse and elevate them to an investigation was reviewed with the current DON and NHA throughout the survey and again during exit on 10/21/24. cross reference F550, F609, F835 2. Review of a facility reported incident (FRI) regarding Resident #7 on 10/18/24 at 12:27 PM revealed a fall which was the 6th in a month and the second requiring hospitalization . This fall was documented as occurring in the common area according to a statement from the on-duty nurse that day who did not observe the fall but documented seeing the resident afterwards on the floor. Resident #7 was sent to the hospital and diagnosed with a compression fracture of the thoracic vertebrae. Review of the facility 5-day follow-up investigation report form noted that there were no staff or resident interviews conducted. Additionally, section 3 ,the conclusion, was noted as 'N/A' under not verified and section 4 for corrective action taken was left blank and further was signed and submitted by staff #18, the previous DON. The concern that there was no conclusion or preventative measures presented was reviewed with the administrative team, that included the DON, Administrator and ADON on 10/18/24 and again during exit on 10/21/24. 3. Review of the FRI for Resident #10 on 10/18/24 at 10:37 AM revealed on 11/7/23 that Resident #10 notified staff that she was not being treated well, that a GNA was being 'pushy' and rushing [him/her] with care. This was immediately reported to the (previous) DON. The results of the concern form completed by the DON stated in actions: assignment change for employee, I reassured patient that GNA would be educated on customer service On 11/9/23 another concern form was completed. The Social worker reported that the resident had continued concerns reflecting from the previous Tuesday and Wednesday (7th and 8th) as previously reported, that the aide was rough and yelling at him/her. The documented facility follow-up from the previous DON was GNA re-educated on customer service and having a team member assist with repositioning, GNA educated and assignment on unit has been changed. A review of the schedules for 11/9/23-12/1/23 revealed only 10 of 26 days where Resident #10 was not in the presence of either identified employee that s/he had concerns and allegations of abuse against from 11/7-12/1/23 The initial allegation was made on 11/7/23. On 11/8/23, 11/9, 11/12, 11/20, 11/21, 11/23, 11/25 and 11/30 one of the 2 GNAs was assigned to Resident #10. On 11/11, 11/22, 11/26, 11/28 and 11/29 one of the 2 GNAs was caring for residents in adjacent rooms. There was no evidence that either GNA was suspended pending investigation, or that there was any preventative action put in place to prevent further occurrences of potential abuse to Resident #10. cross reference F609, F835 37296 4. Review of a facility reported incident MD00183392 on 10/18/24, revealed the facility reported to the Office of Health Care Quality (OHCQ) on 9/13/22, Resident #25 reported injury of unknown origin. On 10/18/24 at 10AM a review of the facility investigation report revealed the facility staff have no record of a completed investigation to include interviews from nursing staff other residents and all the staff on the unit. On 10/18/24 at 10:30 AM the Director of Nursing confirmed that the investigation failed to include interviews with other residents and staff.

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to appropriately review a medication order and administer medication according to professional standards. This was evident for 1 of 3 facility reported incidents reviewed regarding medication management (Resident #1). The findings include: Review of the facility reported incident for Resident #1 on [DATE] at 11:30 AM revealed that Resident #1 was administered 10 x the ordered dose of Morphine. Further review of the incident report revealed that the medication order was taken as a verbal order on [DATE] at approximately 3pm by RN #7. The order was intended for a concentration of 20mg/ml of morphine to administer a dose of .25ml every 2 hours as needed for a dose of 5mg of Morphine. However, RN #7 transcribed the order as 2.5ml. When the medication arrived, the controlled drug receipt/record disposition form showed that the concentration of the Morphine was 20mg/ml. According to the medication administration record (MAR) the order for the Morphine was put in as a concentration of 10mg/5ml, give 2.5ml by mouth every 2 hours as needed for shortness of breath, pain. This morphine order was signed off and given at 10:02 AM and 9:23 PM. The delivery of the Morphine came with a 1 ml syringe for administration. This was confirmed on tour [DATE]. Therefore, staff LPN #6 would need to draw up the Morphine liquid 2.5 times for administration. Although the order on the MAR that was signed off and the provided medication from the pharmacy did not match, the nurse on duty, LPN #6, still administered the medication without question. LPN #6 failed to verify that the delivered medication matched the ordered medication on the MAR, therefore a dose 10x the ordered dose was administered. In a statement in the facility report RN #7 stated that she did transcribe the verbal order incorrectly, however, if the medication had arrived when she was on duty she would have known that it was wrong when she went to administer it by the amount that had to be drawn up that she had never given 2.5 whole syringes of morphine before. Resident #1 subsequently passed away at 1:40 AM on [DATE]. An autopsy was completed and determined that Resident #1 died of Morphine Intoxication. Multiple interviews during the survey with the current facility DON revealed that education is ongoing regarding verbal orders related to narcotics verification. Additionally they review verbal orders in morning meeting with an action plan in place with the unit managers, ADON and DON which began on [DATE] and is currently ongoing. cross reference F760

Based on observation, interview, and review of medical records and other documentation on 9/2/16, it was determined that the facility failed to maintain a safe environment for Resident #97 and Resident #70, residents with documented and observed high-risk wandering behavior. This was evident for 2 of 2 residents reviewed for elopement. The facility's failures in this case led to the determination that immediate jeopardy existed and the facility was notified of this determination on September 2, 2016 at 2:58 PM. The facility submitted a plan of removal to the State Agency (Office of Health Care Quality) on September 2, 2016 at 7:35 PM. This plan was not accepted. A new plan was submitted at 7:58 PM. The plan was accepted and immediacy removed at 8:08 PM on September 2, 2016. After removal of the immediacy, the deficiency remained at a scope and severity of 'D.' The findings include: 1. A review of Resident #97's clinical record revealed that the resident had a wandering risk assessment completed on 3/10/16. The resident was scored as a 10 indicating the resident was a moderate risk for wandering. As a result, the resident's physician wrote an order on 3/10/16 for a wanderguard device (a device to alert staff that the resident is near or at a facility exit) to be placed on the resident's left ankle to alert staff when the resident attempts to leave the unit. The physician wrote the reason for the wanderguard device was wandering and poor safety awareness. Review of the clinical record also revealed that the resident was noted to be assessed as having a BIMS (brief interview for mental status) of 4 out of 15 as of 5/6/16. BIMS scores are categorized as follows: 13-15 indicate cognitively intact, 8-12 indicate moderate impairment and 0-7 indicates severe impairment. A review of the facility investigation revealed that on 7/10/16 Resident #70 and #97 were able to elope from the facility by taking the elevator to the basement level and leaving via the employee exit. Details of the investigation revealed that on July 10, 2016 at 7:48 PM, the residents' wanderguard alarms were sounding because both residents left the unit and got near the elevators. A visitor got onto the elevator and the residents followed. The visitor informed the Administrator, after the incident, that when they got on the elevator the residents did not know what floor they were going to. They asked to go to the next floor. The visitor pressed the button for the basement, and did not notify any of the facility staff at that moment. Both residents pressed the button to open the door to go outside once they reached the basement, and both went outside. The charge nurse went downstairs and escorted the residents back inside. According to the video camera footage the time from the start of the wanderguard alarm and both residents being brought back inside was less than 10 minutes. The respective responsible parties for both residents were made aware as well as the respective primary physicians. Resident #97 attempted to elope again on 8/6/16 at 8:15 PM but was stopped by staff at the basement exit. Details of the facility investigation revealed that a Geriatric Nursing Assistant (GNA) reported to the nurse that the resident was not on the unit. The nurse checked the monitoring screen in the nurse's station. The screen indicated that the resident was at the employee entrance. The nurse went down to the employee entrance and observed the resident at the employee entrance door. The nurse wrote that a Dietary staff member was preventing the resident from leaving the building. Resident #97 was returned to the unit by the nurse. He/She was combative and not wanting to return to the unit. Resident #97 stated there was a car waiting outside. The nurse practitioner, the RP, and the nursing supervisor were notified. The resident was observed to be without visible injury or complaint of pain or discomfort, and was transferred to bed with assist of staff. 2. A review of Resident #70 ' s clinical record revealed the resident had a wanderguard placed on 7/20/15. The resident was noted to be assessed as having a BIMS of 5 (severe impairment) as of 4/28/16. Review of the wandering risk assessment of Resident #70 completed on 7/26/16, sixteen days after the incident, revealed that he/she was scored as an 8 indicating the resident was a moderate risk for wandering. Resident #70's care plan for ambulating was reviewed on 8/9/16 by the Interdisciplinary Team (IDT) as a result of the elopement. There was no elopement assessment noted in the Resident's medical record prior to the one completed on 7/26/16. The Administrator was interviewed on 9/2/16 at 1:45 PM. The details of the second incident were discussed. When asked why the second elopement was not reported, she replied that she did not consider this incident to be an elopement because the resident never left the building. The Administrator, Director of Nursing, and Assistant Director of Nursing were interviewed on 9/2/16 at 2:14 PM. The Administrator stated that only staff could leave via the basement door because of a card reader that unlocked the door after staff swiped their badge. Two members of the survey team went to the basement with the Administrative staff on 9/2/16 at 2:25 PM to check the door. This surveyor was able to leave via the basement door despite not having an employee badge to swipe. The Plant Manager stated that a magnetic locking device was to be installed on the doors. This device would allow the doors to open only when a card was swiped or if the fire alarms went off. He stated the reason the device had not been installed yet, was the fire department had to approve it first then the installation company could be contacted to arrange a day for the installation. The fire department had since approved the device but the company that had been contracted to install the device was not scheduled to install it until later in the month. When asked how they were monitoring the area, they replied that security was monitoring it. Surveyors also requested a schedule of the guards and their specific times as evidence that the employee exit was under observation. The schedule was not provided. Interview with Administrator on 9/2/16 at 4:41 PM revealed that she thought the card reader had been installed a week after the initial incident on 7/10/16. However, the card reader had yet to be installed as of 9/2/16 at 5:00 PM. These related concerns were evident for 2 residents (Resident #97 and #70) out of the 19 residents who were identified as an elopement risk by the facility. Therefore, an Immediate Jeopardy for health and safety was called at 2:58 PM on 9/02/16. An initial plan to remove the immediacy was given to the survey team at 7:35 PM. This plan was not accepted by the survey team and the Office of Health Care Quality. At 7:58 PM another plan to remove the immediacy was given to the survey team and reviewed by the Office of Health Care Quality. The plan to remove the immediacy included, but was not limited to the following: placing a guard to be stationed at the basement door leading outside, installation of the card reader and magnetic lock. The plan was accepted by the Office of Health Care Quality at 8:08 PM.