Every finding on record at Montcare at Bethesda

Based on observations and interviews, the facility failed to ensure a homelike environment was provided for all residents. This was evident to be true for 9 out of 44 resident rooms observed during an annual recertification survey. The findings include: During observational rounds and interview with staff #22 on 02/18/2026 at 7:45 AM the following observations were made: room [ROOM NUMBER]-bathroom sink hot water facet dial was broken off and missing with water running continuously.room [ROOM NUMBER]-bathroom wallpaper was torn, no towel rack, lightbulbs in light fixture were not working, and bathroom cove base was noted to be missing and or not in good repair.room [ROOM NUMBER]-bathroom had a brown color, resembling rust, substance found around the base of the toilet seal as well as on the back of the toilet seat. The bathroom floor was found to have several areas of a brown substance smeared throughout.room [ROOM NUMBER]-bathroom wallpaper was torn, and cove base was separating from wall and not in good repair. Doors of bathroom and room were found to have deep marring and scratches.room [ROOM NUMBER]-bathroom wallpaper was discolored and in poor repair. The bathroom floor was found to have several areas of a brown substance smeared throughout as well as the toilet and sink. Staff #22 agreed with these observations and stated, I will let them know about this. On 02/18/2026 at 08:15 AM the surveyor conducted observation rounds on the second-floor clinical unit that included rooms 204A through room [ROOM NUMBER]A. The following observations were made: room [ROOM NUMBER] A, B: the bathroom wallpaper was torn, there was no towel rack present, the residents' dresser had multiple scratches and peeled wood present, the visitor had broken wood spindles/rungs and was leaning against the wall.room [ROOM NUMBER] A, B: there were residents' clothing and shoes lying on the floor. There was a broken wooden wardrobe door and there was an absent wardrobe on the right side that had been broken off with rough edges present.room [ROOM NUMBER] A, B: the wallpaper below the window appeared water damaged and was buckling.room [ROOM NUMBER] A, B: the bathroom wallpaper had patches of spackling present, some wall paper was peeling that was located across from the bathroom. On 02/25/2026 at approximately 10:20 AM the surveyor completed walking rounds with the maintenance director and discussed the identified areas of concerns. The maintenance director stated that the identified areas of concern would be addressed in a timely manner. On 02/25/2026 during the exit conference the maintenance repair issues were reviewed with the Director of Nursing, administrator and the regional operations staff present.

Based on record review and staff interviews, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who know the resident and his/her needs, and failed to ensure that each resident's care plan meeting was done quarterly. This was evident for 4 (Resident #29, #9, #32, and #59) out of 36 residents reviewed for comprehensive care plan revision.The findings include:The Interdisciplinary team (IDT) must, at a minimum, consist of the resident's attending physician, a registered nurse, and a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, and, to the extent possible, the resident and resident representative, if applicable.1) On 2/18/2026 at 11:51 AM, the surveyor conducted an interview with Resident #29 and asked if s/he participated in their care plan meetings. Resident #29 stated that s/he has not had any care plan meetings.On 2/24/2026 at 11:07 AM, a review of medical records revealed that Resident #29's last care plan meeting was 12/27/24.On 2/24/2026 at 11:25 AM, an interview with the social worker, Staff #16, was conducted in reference to care plan meetings. Staff #16 was asked how often care plan meetings were conducted with residents. Staff #16 answered that care plan meetings were conducted with the residents and their representatives within the first 14 days of admission, quarterly (every 3 months), when there is a significant change with the resident, or annually. Staff #16 was asked who was involved in the care plan meetings for each resident. Staff #16 responded that social work, nursing, rehab, activities, and the resident and/or the resident representative usually attend the meetings. Staff #16 was asked if she was aware that a GNA and the doctors should be involved in the care plan meetings. Staff #16 answered no.Staff #16 was then asked when the last time Resident #29 had a care plan meeting. Staff #16 reviewed the resident's records on her laptop and stated that the last care plan meeting for Resident #29 was 12/27/24. When Staff #16 was asked why the facility had not conducted a care plan meeting for Resident #29 in over a year, she responded that she was not sure.2) On 2/19/2026 at 8:43 AM, the surveyor conducted an interview with Resident #9. When asked if they attend care plan meetings Resident #9 stated that s/he had not attended a care plan meeting in a while.On 2/24/2026 at 11:30 AM, an interview with the social worker, Staff #16, was conducted. Staff #16 was asked when the last care plan meeting was done with Resident #9. Staff #16 reviewed the resident's records on her laptop and answered on 1/16/26. Staff #16 was asked when the care planning meeting was done before that. Staff #16 reviewed the resident's records on her laptop and responded on 10/10/25. Staff #16 was asked to open the document and tell the surveyor why there was an error next to the document. Staff #16 opened the document and said that the error indicated that the document was not complete and signed off. Staff #16 was then asked who the social worker working on the document was. Staff #16 stated that the social worker was no longer working at the facility and that the document could not be completed. Staff #16 was then asked if this document was to be considered a completed care plan meeting; she responded no.3) On 2/19/2026, a record review was conducted for Resident #32. During this review, it was revealed that the last care plan meeting was 1/9/2026, and the care plan meeting before that was 5/16/25.On 2/24/2026 at 11:30 AM, an interview with the social worker, Staff #16, was conducted. Staff #16 was asked when the last care plan meeting was done with Resident #32. Staff #16 reviewed the resident's records on her laptop and answered on 1/9/26. Staff #16 was then asked when the care planning meeting was done before that. Staff #16 reviewed the resident's records on her laptop and responded on 5/16/25. Staff #16 was then asked why the care plan meetings were not completed quarterly. Staff #16 was unable to answer.4) On 2/22/26, a record review was conducted for Resident #59. During this review, it was revealed that the last care plan meeting was 1/9/2026, but when the meeting notes were opened, the document was blank. The care plan meeting done before that was on 10/10/2025 and 3/28/25.On 2/24/2026 at 11:30 AM, an interview with the social worker, Staff #16, was conducted. Staff #16 was asked when the last care plan meeting was done with Resident #59. Staff #16 reviewed the resident's records on her laptop and answered on 1/9/26. Staff #16 was then asked to open the document. When she opened the care plan meeting notes, she noted that it was blank. Staff #16 was then asked who the social worker was who was working with the resident at that time. Staff #16 stated that the social worker was no longer working at the facility and that the document could not be completed. Staff #16 was then asked when the care planning meeting was done before that. Staff #16 reviewed the resident's records on her laptop and responded on 10/10/25. The surveyor then asked for the date before that. Staff #16 reviewed the resident's records on her laptop and responded on 3/28/25. Staff #16 was then asked why the care plan meetings were not completed quarterly. Staff #16 was unable to answer.

Based on record review and staff interviews, it was determined that the facility failed to ensure that each resident formulated an advance directive. This was evident for 2 (Resident #29, Resident #59) residents out of 36 residents reviewed for advance directives.The findings include:1) On 2/19/2026 at 9:03 AM, Review of medical records reveals that the surveyor was unable to find the advance directives for Resident #29. However, it was noted that Resident #29 has a living will.An interview with the social worker (Staff #16) was conducted on 2/19/26 at 1:37 pm, and asked if she knew where the copy of the living will was in the resident's records. Staff #16 stated that she thought that there was a copy in the records, but she was unable to locate it in the chart. She then stated that she would have to get in touch with Resident #29's daughter to get a copy.On 2/24/2026 at 9:21 AM, Review of medical records stated that Resident #29 has a living will and that his/her daughter is the Power Of Attorney. Staff #16 tried to contact the daughter to obtain a copy of the living will. Staff #16 was unable to provide a copy of the living will during the survey.2) On 2/24/2026 at 11:18 AM, a review of medical records revealed that the surveyor was unable to find documentation of advance directives for Resident #59. On 2/24/26 at 9:25 am, the surveyor interviewed Staff #16, the Social Worker, and asked if Resident #59 had advance directives. Staff #16 confirmed that Resident #59 did not have an advance directive completed during his admission evaluation.

Based on observation and interviews it was determined the facility failed to maintain patient care equipment in working operating conditions. This was evident for 1 resident #83 out of 5 residents reviewed for patient care equipment. The findings include:During observational rounds and interview on 02/18/2026 at 7:45 AM with Staff #22, Resident #83's bed was observed having a pressure reducing mattress and pump that was not on and not working. Staff #22 confirmed this observation and was unable to get the air mattress pump to work and stated, It is not working and I will have someone come and look at it. Review of Resident #83's medical record on 02/18/2026 at 11:30 AM revealed an order dated 10/28/2025 for Resident #83 to have a pressure reducing mattress every shift.During observational rounds and interview on 02/19/2026 at 9:15 AM with the Director of Nursing, Staff #3, Resident #83's bed was still observed having a pressure reducing mattress and pump that was not on and not working. Staff #3 stated, I will get Maintenance to look at it. During an interview on 02/20/2026 at approximately 1:00 PM, Staff #14 stated; We do not have residents' air mattresses and pumps as part of the facility preventive maintenance program.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure that residents' records were accurate and complete. This was evident for 2 (Resident #9 and #59) residents out of 36 residents reviewed during this annual Medicare/Medicaid recertification survey.The findings include:1) On 2/24/2026 at 11:30 AM, an interview with the social worker, Staff #16, was conducted. Staff #16 was asked when the last care plan meeting was done with Resident #9. Staff #16 reviewed the resident's records on her laptop and answered on 1/16/26. Staff #16 was asked when the care planning meeting was done before that. Staff #16 reviewed the resident's records on her laptop and responded on 10/10/25. Staff #16 was asked to open the document and tell the surveyor why there was an error next to the document. Staff #16 opened the document and said that the error indicated that the document was not complete and signed off. Staff #16 was then asked who the social worker working on the document was. Staff #16 stated that the social worker was no longer working at the facility and that the document could not be completed. Staff #16 was then asked if this document was to be considered a completed care plan meeting; she responded no. 2) On 2/24/2026 at 11:30 AM, an interview with the social worker, Staff #16, was conducted. Staff #16 was asked when the last care plan meeting was done with Resident #59. Staff #16 reviewed the resident's records on her laptop and answered on 1/9/26. Staff #16 was then asked to open the document. When she opened the care plan meeting notes, she noted that it was blank. Staff #16 was then asked who the social worker was who was working with the resident at that time. Staff #16 stated that the social worker was no longer working at the facility and that the document could not be completed.

Based on observation, record review, and staff interviews, it was determined that the facility failed to provide the resident with a diet that meets his/her nutritional needs. This was evident for 1 resident (Resident # 116) out of 8 residents reviewed during the annual recertification survey.The findings include: On 02/21/2026 at 7:47 AM, the surveyor observed Resident #116's breakfast tray. Resident #116's breakfast tray was observed to have scrambled eggs, toasted white bread, oatmeal, a banana, a 4-ounce carton of cranberry juice, and a carton of reduced fat milk. On 02/21/2026 at 7:48 AM, the surveyor conducted a record review. The record review revealed that Resident #116's breakfast meal ticket, dated 02/21/2026, indicates that Resident #116 has a standing order for 4 ounces of cranberry juice and a half cup of fresh apples. When the surveyor compared Resident #116's breakfast meal ticket to the breakfast tray, it revealed that Resident #116 did not receive a half cup of fresh apples. On 02/21/2026 at 7:50 AM, the surveyor conducted a staff interview. During the staff interview, the Payroll and Scheduler, Staff #10, who was passing out resident breakfast trays, verified that Resident #116's breakfast tray had scrambled eggs, toasted white bread, oatmeal, a banana, a 4-ounce carton of cranberry juice, and a carton of reduced fat milk, and did not have a half cup of fresh apples. On 02/21/2026 at 8:09 AM, the surveyor conducted a staff interview. During the staff interview, the Food Service Director, Staff #7, confirmed that Resident #116's breakfast tray did not have a half cup of fresh apples, and that Resident #116's breakfast tray should have contained a half cup of fresh apples.

Based on medical record reviews and interviews it was determined that the facility failed to ensure medical records were accurate. This was evident for 1 (Resident #9) of 12 residents reviewed for accurate medical record documentation during the complaint survey. The findings include:A mediport is a small, implantable device with a catheter, surgically placed under the skin to provide long-term, reliable venous access for medications, blood transfusions, and blood draws.During a medical record review on 10/08/25 at 10:07 AM it was discovered Resident #9 had a mediport in place and had an order starting on 5/04/25 to Flush implanted port monthly every day shift every 1 month starting on the 4th for 28 days. It was revealed the order had been signed off as completed daily from 5/04/25 -5/31/25, 6/04/25 - 6/31/25, 7/01/25, 7/04/25 -7/07/25 on the Treatment Administration Record (TAR).Additional record review revealed that Resident #9 had his/her mediport removed on 6/13/25. The order to flush the mediport monthly continued to be signed off as completed every day from 6/14 -6/30, on 7/01, and on 7/04 - 7/07.Further record review revealed the order to flush the mediport monthly was discontinued for Resident #9 on 7/08/25 due to port removed.During an interview with the Director of Nursing on 10/10/25 at 12:10 PM he advised that the order should not be signed off unless it was completed and the order should have only been signed off as completed on the date it was due, the 4th of the month. He confirmed the order to flush the mediport should not have been signed off as completed on the dates after the mediport was removed.

Based on medical record review and interviews it was determined that the facility failed to provide appropriate wound care. This was evident for 1 (Resident #8) of 1 residents evaluated for pressure ulcer care during the complaint survey.The findings include:A pressure ulcer, also known as a bed sore or decubitus ulcer, is a localized area of skin damage that develops when prolonged pressure or shear forces disrupt blood flow to the tissues resulting in damage to the underlying tissue. Pressure ulcers are staged based on their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). During a medical record review on 10/07/25 at 1:17 PM it was revealed that Resident #8 had a Stage #3 pressure ulcer to the sacral area. A Skin and Wound progress note from 8/20/25 written at 6:56 PM reported the sacral wound was improving without complications and the wound care provider added a wound treatment recommendation for Collagen to undermine area to base of the wound to be completed three times a week. During additional medical record review it was discovered that the recommendation added by the wound care provider was not added to the treatment orders for Resident #8. During continued medical record review of a Skin and Wound progress note from 8/27/25 written at 7:41 PM it was revealed the wound care provider documented, Sacral pressure wound worsening on this exam, order was updated to Dakins fluffed gauze twice a day and will reevaluate next week. The Wound Assessment report from 8/27/25 listed the following wound treatment recommendations made by the wound care provider:1. Cleanse with 0.125% Dakins solution2. Apply Dakins moistened fluffed gauze, Zinc Oxide Paste to periwound to base of the wound3. Secure with transparent film. 4. Change Twice per Day During additional medical record review it was revealed that the recommendations added by the wound care provider on 8/27/25 were not initiated for Resident #8. The orders added to the Treatment Administration Record (TAR) for Resident #8 on 8/29/25 at 8:37 AM stated, Sacral wound - Cleanse with Normal Saline Solution, pat dry, apply Dakins fluffed gauze, zinc oxide paste to peri wound and cover with transparent film daily as needed and one time a day every Monday, Wednesday, Friday for wound healingDuring further review of Wound Care Progress notes from 9/03/25 written at 11:03 AM it was discovered that the Wound Care Provider evaluated Resident #8 and determined the sacral wound had worsened, it was now a Stage 4 Pressure Ulcer. The Wound Care Progress notes further added, will recommend transfer to hospital and a nursing progress note written on 9/03/25 at 11: 23 AM reported the responsible party requested resident to be transferred to the emergency room for further management of non-healing sacral ulcer.During an interview with the Director of Nursing on 10/09/2025 at 12:38 PM he advised he would expect the wound care provider's recommendations to be followed. He confirmed the wound care provider recommendations for Resident #8 and the order added by the facility to the Resident's TAR were different. He agreed Dakins Cleanse should have been used in place of the Normal Saline Solution as recommended by the Wound Care Provider and the treatment should have been ordered to be completed two times a day, not once a day on Monday, Wednesday and Friday as ordered by the facility.During additional review of the Treatment Administration Record (TAR) on 10/09/25 at 1:38 PM it was discovered that there was no documentation of wound care being completed from 8/28/25 - 8/31/25 and there was wound care documented as being completed once on 9/01/25 and 9/03/25.During an interview with the 1st floor Unit Manager on 10/10/25 at 10:20 AM he agreed the recommendations made by the Wound Care Provider should have been entered into the TAR for Resident #8. He confirmed the orders in the TAR were different from the Wound Care Provider's recommendations. He was not sure why the facility orders were different from the wound care provider recommendations. He was made aware of no wound care documentation on 8/28/25 - 8/31/25 and was not sure why wound care was not completed.

Based on review of facility-reported incident and a complaint, record review and interview, it was determined that the facility failed to obtain a physician's order prior to performing a straight catheterization. This was evident for 1 (Resident #4) of 14 residents reviewed during the complaint survey. The findings include:A straight catheterization is a procedure where a thin, hollow tube is inserted into the bladder through the urethra to drain urine and then removed after the bladder is empty.On 10/6/25 at 11:24 AM, a review of the facility-reported incident #292100 dated 11/3/24, at 8:27 PM, revealed an incident involving Resident #4 and the alleged Licensed Practical Nurse (LPN #3) and Registered Nurse (RN #4). Both nurses were suspended pending investigation. Also, a complaint #292101 regarding the same issue was reported by Resident #4 on 11/4/25 at 3:34 PM.On 10/7/25 at 8:26 AM, a review of progress notes written on 11/2/24 at 10:40 PM indicated that the Director of Nursing (DON) received a call from Resident #4, who stated that on 11/1/24 around 3:00 AM, 2 nurses collected a urine sample against his/her will.On 10/7/25 at 9:00 AM, a review of the physician orders showed an order written on 10/31/2024 which stated: Check Complete Blood Count (CBC), Complete Metabolic Panel and Urinalysis with Culture and Sensitivity (UA C & S) to rule out infection, one time only until 11/1/2024. However, there was no evidence that a straight catheterization was written.On 10/7/25 at 9:18 AM, a review of Resident #4's medical record revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated intact cognitive function. On 10/7/25 at 10:44 AM, in an interview with Resident #4, he/she confirmed that the incident occurred around 3:00 AM. Resident #4 stated that 2 nurses asked if he/she could walk to the bathroom for a urine sample, to which the resident replied no. However, the nurses proceeded to insert a catheter without obtaining consent or explaining the procedure. The resident added that he/she contacted the local police department, feeling violated.On 10/8/25 at 12:48 PM, during an interview with LPN #2, he/she stated that the nurses were expected to inform and explain the procedure before obtaining a urine specimen from an alert resident. LPN #2 added that if nurses were to obtain urine via straight catheterization, both resident consent and a physician's order would be necessary.On 10/9/25 at 8:44 AM, a review of the facility's Catheterization policy (implemented on 5/15/23 and revised on 2/3/25) indicated the following guidelines: Urinary catheters shall be inserted by licensed nurses under the orders of the attending physician. For straight or intermittent catheterizations, obtain a physician's order for frequency of catheterization.On 10/9/25 at 11:00 AM, the DON confirmed that a straight catheterization order was not obtained because the procedure was completed based on the nurse's judgement. The DON was notified of this concern.On 10/9/25 at 12:38 PM, the [NAME] president of Clinical Services was notified and acknowledged this concern.

Based on record review and interview, it was determined that the facility failed to update the comprehensive care plan. This was found to be evident for 1 (Resident #11) out of 12 residents reviewed for care plans.The findings include:According to the Centers for Medicare & Medicaid Services (CMS), a comprehensive care plan is a detailed, individualized plan developed for each resident that addresses the resident's medical, nursing, psychosocial, and functional needs. The care plan specifies interventions, services, and treatments required to meet the resident's needs and achieve the desired outcomes, and it must be reviewed and updated regularly to reflect any changes in the resident's condition or care requirements.On 10/08/2025 at 8:57 AM, this surveyor conducted a record review of Resident #11's progress notes. A Skin and Wound Note documented, Patient has new wounds to [Resident #11's] bilateral buttocks abscess.On 10/08/2025 at 10:14 AM, a review of the documentation for Resident #11's Wound assessment dated [DATE] showed that Resident #11 had developed a new wound, identified as an abscess of the bilateral buttocks.On 10/09/2025 at 10:39 AM, a record review of Resident #11's Care Plan, including its revision history, showed that the resident's care plan had not been updated to include a care plan for the resident's new wound.On 10/08/2025 at 2:02 PM, this surveyor conducted an interview with Nurse Practitioner (NP) #5. During the interview, NP #5 confirmed that the resident had developed an abscess on 08/04/2025 during a wound care assessment.On 10/09/2025 at 1:19 PM, this surveyor conducted an interview with the Director of Nursing (DON). The surveyor explained the concern that the comprehensive care plan had not been updated after the resident developed a new wound. The DON reviewed Resident #11's chart and confirmed that the care plan had not been updated when the wound developed on 08/04/2025.The DON explained that around this time (08/04/2025), the facility employed a wound treatment nurse who was responsible for updating care plans. He stated that the care plans were not being updated as required and confirmed that the employee was subsequently terminated. When asked what an appropriate care plan entry for a new wound would include, the DON stated it would indicate potential/actual impairment to skin integrity r/t [related to] [insert specific wound description here]. The surveyor communicated that this concern would be brought to the Office of Health Care Quality for review.

Based on observations and staff interviews, it was determined that the kitchen failed to store food items to maintain the integrity of the specific item. This was evident during multiple observations of the kitchen on a recertification survey. The findings include: On 10/28/24 at 9:32 AM surveyors conducted an initial tour of the kitchen. During the tour, surveyors identified 2 items within the food prep refrigerator that were improperly stored: - A bottle of Red Cooking Wine marked with an open date showing 8/15/24 and a dispose date of 9/15/24 - An opened 48 oz glass container of Concord Grape Jelly without any open date and dispose date. On 10/28/24 at 9:40 AM, Surveyors reviewed these items with Cook, Staff #1, who confirmed that both items were to be removed from the refrigerator and disposed of. During a tour of the dry storage room on 10/31/24 at 8:25 AM, observations with the Kitchen Manager, Staff #19, revealed: - Two, unopened, 35 oz bags of Crispy Rice Cereal with a use-by-date of 10/2/24 - Five, unopened, 16 oz unopened boxes of Confectioners [NAME] Sugar with a use-by-date of 2/1/22 At the end of the observation, Surveyors observed Staff #19 remove the identified items from the shelf and dispose of them.

Based on record review and interview it was determined that the facility failed to 1) notify the Ombudsman of a Resident's (Resident #23) transfer to an acute care facility and 2) notify the Resident (Resident #47) /Resident representative of transfer to an acute care facility in writing. This was found to be evident for 2 (Resident #23 & #47) out of 3 residents reviewed for transfers during the annual survey. The findings include: 1) During a review of Resident #23's medical record conducted on 11/01/2024 at 10:03 AM it was revealed that the resident was transferred to a Hospital emergency roiagnom on [DATE]. A review of the Ombudsman notification of transfers was conducted on 11/04/24 at approximately 9:00 AM. The notification for April 2024 and May 2024 did not show that the Ombudsman was notified of Resident #23's transfer on 04/28/2024. During an interview with the Director of Nursing (DON) conducted on 11/01/2024, this surveyor advised the Ombudsman notification did not show that Resident #23 was transferred on 04/28/2024. The DON stated that the facility's expectation is to notify the Ombudsman of all Resident Transfers. 48393 2) On 11/04/24 at 10:13 AM, a review of Resident #47's clinical record revealed that Resident #47 was transferred to the hospital for further evaluation of his/her medical needs on the following dates: 4/12/2024, 4/25/2024 and 5/5/2024. Further review of Resident #47's clinical record revealed no documentation that the resident/resident representative was notified in writing of the hospital transfers. On 11/06/24 at 7:20 AM, an interview conducted with the Divisional Director of Quality Assurance revealed that it is the expectation of nursing staff to notify the resident/resident representative of hospital transfers verbally and send a written copy of the hospital transfer/discharge form along with the resident when they transfer out. The Divisional Director of Quality Assurance further stated that copies of the resident's written hospital transfer/discharge form and bed hold policy are kept in a separate binder. On 11/06/24 at 8:15 AM, the surveyor requested and reviewed the separate binder which showed no evidence that the facility staff had provided written notice of transfer at the time of transfer or as soon as was practicable for resident #47's hospital transfers on 4/12/2024, 4/25/2024 and 5/5/2024. At the time of exit conference, the facility did not provide any evidence that a written notice of transfer was given to Resident #47 and the resident's representative.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#47) out of 3 residents reviewed for hospitalization s during the annual survey. The findings include: On 11/04/24 at 10:13 AM, a review of Resident #47's clinical record revealed that Resident #47 was transferred to the hospital for further evaluation of his/her medical needs on the following dates: 4/12/24 and 5/5/24. Further review of Resident #47's clinical record revealed no documentation that the resident / resident representative was notified of the bed hold policy in writing. On 11/04/24 at 10:55 AM, an interview conducted with the Business Office Manager revealed that she was not able to locate any evidence that a written copy of the bed hold policy was given to the resident/resident representative for hospital transfers on 4/12/24 and 5/5/24. At the time of exit conference, the facility did not provide any evidence that a written copy of the bed hold policy was given to Resident #47 and the resident's representative for hospital transfers on 4/12/24 and 5/5/24.

Based on observations and staff interviews it was determined that the facility failed to 1) maintain a safe and effective system for securing medication and 2) store medications properly. This was found to be evident for 1 out of 3 medication carts observed during the re-certification survey. The findings include: 1) During an interview conducted on 10/31/24 at 1:12 pm, Resident #85 gave this surveyor a set of keys on a lanyard that he/she stated were found on the hallway floor of the 1st floor nursing unit on the evening of 10/30/24. The Resident further stated that the keys belonged to the medication cart. An interview was conducted on 10/31/24 at 1:15 PM with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). During the interview this surveyor gave the keys to the medication cart to the NHA. This surveyor advised both the NHA and DON that a resident was in possession of the keys and asked if they were aware that a set of keys to the medication cart had been missing or lost. The DON stated they were not aware but would immediately investigate and inform the surveyor of the results. During observation of the 1st floor medication cart conducted on 10/31/2024 at 1:19 PM, this Surveyor and Licensed Practical Nurse (LPN) #16 reviewed all the narcotics and confirmed the narcotic counts were accurate and matched the narcotic log. During an interview conducted on 11/01/24 8:07 AM, the DON stated that he identified the nurse as Registered Nurse (RN) #15, the RN was disciplined and educated on ensuring the medication cart is secured and notifying administrations if keys are lost. The DON stated that the RN used a spare set of keys to access the medications in the medication cart to administer medications after the keys were lost and that all Residents received their medications as ordered. The DON further stated that both him and the VP of Clinical Services reconciled the medication cart and did not find any medications including narcotic discrepancies. 50504 2) On 11/1/24 at 6.45AM, a medication storage observation was conducted on the medication carts on the Embassy Unit with Staff Nurse # 14 present. The surveyor observed a Humalog Kwik Pen100 unit/ml insulin pen for Resident #224 and a Glargine Solostar 100unit/ml pen for Resident #20 were in a basket stored in the 3rd drawer of the medication cart. Both Insulin pens were unopened with a pharmacy label which stated refrigerate until opened. During an interview conducted on 11/01/24 at 7:10 AM both the Director of Nursing (DON) and Staff Nurse #14 acknowledged the surveyor's findings.

Based on record review and interview, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments within 14 days of completion. This was evident for 1 (Resident #74) of 2 residents reviewed for resident assessments during the annual survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. Nursing homes are required to submit the Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source to Centers for Medicare and Medicaid Services (CMS') Internet Quality Improvement and Evaluation System (iQIES). Skilled nursing facilities (SNFs) are required to transmit additional MDS assessments for all Medicare beneficiaries in a Part A stay reimbursable under the SNF Prospective Payment System (PPS). Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. On 11/1/24 at 7:28 AM, a record review of the MDS assessment was conducted for Resident #74 with a discharge date on 5/9/2024. The MDS assessment Discharge Return Not Anticipated (DCRNA) with an Assessment Reference Date (ARD) of 5/9/24 was completed on 5/15/24, however, the assessment was not transmitted to CMS' iQIES for over 120 days. On 11/1/24 at 8:19 AM, during an interview with the MDS Coordinator, she stated that the timeline for completing and submitting MDS assessments was 14 days. She added that all assessments were required to be transmitted regardless of the payor source such as Entry, Admission and Discharge assessments, except the 5 day assessment for insurance or private pay residents. She also stated that she transmitted the MDS assessments weekly or twice a week to CMS. The surveyor showed the MDS Coordinator the DCRNA assessment of Resident #74 with an ARD of 5/9/24. She verified that the DCRNA assessment was not submitted and confirmed that it was an error, and she stated that she would immediately fix it. On 11/01/24 at 8:55 AM, the [NAME] President of Clinical Services was notified that the DCRNA assessment for Resident #74 was completed on 5/15/24 but never transmitted to CMS.

Based on record review and interview, it was determined that the facility failed to 1) develop and implement non-pharmacological interventions of pain and 2) ensure that pain medication was given consistent with the professional standards of practice. This was evident for 2 (Resident #92 and #1) out of 2 residents reviewed for pain management during the annual survey. The findings include: The medical abbreviation PRN stands for pro re nata, a Latin phrase that translates to as needed or as the situation arises. Non-pharmacological interventions are treatments that manage pain without the use of medication. These interventions may include but are not limited to massage, music therapy, aromatherapy, applying mild heat or cold packs and repositioning. Oxycodone and Tramadol are strong painkillers from a group of medicines called opiates, or narcotics used to treat moderate to severe pain. Pain parameters are the specific aspects of pain that are evaluated during an interview to understand a person's pain experience. 1) On 11/01/24 at 8:41 AM, a record review of Resident #92 revealed that Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 2 tablet by mouth every 6 hours as needed for pain was administered 18 times for the month of October. On 11/01/24 at 9:20 AM, a record review of Resident #1 revealed that Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for Moderate Pain was administered twice for the month of October and Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 50 mg by mouth every 6 hours as needed for Severe Pain was administered 8 times for the month of October. On 11/01/24 at 10:30 AM, further review of Resident #92 and #1's medical records revealed no evidence that non-pharmacological interventions of pain were provided and documented in the Medication Administration Record (MAR), Treatment Administration Record (TAR), in progress notes nor in the resident's care plan. A review of the Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 9/11/24 for Resident #92 revealed, section J Received non-medication intervention for pain? Indicated No and MDS with ARD of 10/29/24 for Resident #1 also answered No, which confirmed that no non-pharmacological interventions were provided. On 11/01/24 at 10:58 AM, the surveyor attempted to interview Licensed Practical Nurse (LPN #16) about the process of initiating non- pharmacological interventions of pain. He/she stated he was not sure and asked to verify with the Unit Manager (UM). UM #10 stated that the facility documented the interventions in the resident's medical record under pain care plan, such as music, range of motion exercises and repositioning. He/she added that the nurses sometimes added in their progress notes. On 11/01/24 at 11:30 AM, in an interview with UM #17, he/she stated that the non-pharmacological interventions of pain were not specified anywhere, it could be documented in the nurses' progress notes. On 11/01/24 at 11:45 AM, during an interview with the Assistant Director of Nursing (ADON), she was asked about the facility's process of providing non- pharmacological interventions prior to administering pain medication. She stated that she was not sure and would come back. On 11/01/24 at 11:59 AM, the DON returned and stated that the nursing interventions were documented in the progress notes, she confirmed that it was not incorporated in care plans nor in nursing orders. 2a.) On 11/01/24 at 8:41 AM, a record review indicated that Resident #92 was on the following PRN pain medication: Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 2 tablet by mouth every 6 hours as needed for pain, mod Further review of the nursing progress note, and the Medication Administration Record (MAR) revealed that the facility staff failed to follow the pain parameters indicated in the physician order: On 10/21/2024 at 22:00, oxyCODONE HCl Oral Tablet 5 MG Give 2 tablet by mouth every 6 hours as needed for pain, mod was administered, however the MAR indicated that Resident #92 had a pain level of 3 prior to pain medication. 2b.) On 11/04/24 at 8:55 AM, a review of the active physician orders of Resident #1 revealed the following PRN pain medications: Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for Moderate Pain Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 50 mg by mouth every 6 hours as needed for Severe Pain Further review of the nursing progress notes, and the Medication Administration Records (MAR) revealed that the facility staff failed to follow the pain parameters indicated in the physician orders: On 10/18/2024 at 00:05, Tylenol Extra Strength Oral Tablet 500 MG Give 2 tablet by mouth every 8 hours as needed for Moderate Pain (4 - 7) was administered, however the MAR indicated pain level of 0 prior to medication administration. On 10/3/2024 at 21:59, TraMADol HCl Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for severe pain (8 - 10) was administered, however, nurse's note indicated resident required Tramadol for pain of 5 in her right leg. On 10/3/2024 at 14:18, TraMADol HCl Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for severe pain (8 - 10) was administered, however the MAR indicated a pain rating of 5. On 10/18/2024 at 17:34, TraMADol HCl Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for severe pain (8 - 10) was administered with a pain level of 7 in the MAR. On 11/04/24 at 10:42 AM, in an interview with Registered Nurse (RN #15), he/she stated that when entering PRN pain medication orders in the medical record, the nurses were expected to enter the medications as ordered with pain parameters of 1-4 for mild pain and 5-10 for moderate to severe pain. He/she added that the nurses documented in the MAR under PRN medication and indicated the pain level prior to giving the pain medication, after an hour the nurses went back and asked the resident if the medication was effective and recorded the pain level. On 11/04/24 at 11:06 AM, in an interview with UM #10, he/she revealed that for PRN pain medications, the MAR had a section which indicated pain level prior to giving the medication, 1-3 for mild pain, 4-7 for moderate pain and 8-10 for severe pain. He/she added that the documentation was automatically pulled in the electronic charting once the nurse entered the pain level, and the nurses would come back after an hour to document the effectiveness of the pain medication. On 11/06/24 at 7:53 AM, during an interview with the ADON, she stated that a pain scale automatically populated when nurses entered the order in the medical record. She described that the facility had a standard pain scale that nurses followed, a 0-10 pain scale for cognitive residents and non-verbal signs for non-cognitive residents. She also added that if the doctor did not specify the pain parameter in the order, the pharmacy would send an email to the facility to correct the order. She gave the following examples of pain parameters used for PRN pain medications: Tylenol for pain level of 1-3, Tramadol for pain level of 4-7 and Oxycodone for pain level of 8-10. The ADON was made aware that the PRN pain parameters in the physician orders were not followed by the nurses before the PRN pain medications were administered to Residents #92 and #1.

Based on observations and interviews it was determined that the facility failed to provide the respiratory care and services that are in accordance with professional standards. This was evident for 1 (Resident #456) out of 1 resident reviewed for respiratory services. The findings include: On 10/28/2024 at 12:33 PM, the surveyor observed Resident #456's oxygen tubing and nasal cannula disconnected and laying on the floor. The Resident's son reported that water had backed up in the tubing from the oxygen concentrator. The surveyor checked the tubing and observed moving water droplets in the tubing that came from the concentrator to the Resident 's nasal cannula. It was also observed that the humidifier bottle and the tubing were not dated with the date they were connected to the oxygen concentrator. On 10/28/2024 at 12:45PM The Licensed Practical Nurse (LPN) #18 was interviewed and asked if she had seen the tubing on the floor and the water in the tubing. LPN #18 said that she had not been aware of the problem, that she had briefly checked on the resident but had not yet done her morning assessment. On 10/28/2024 at 12:50 PM The surveyor spoke to the Assistant Director of Nursing (ADON) and made her aware of the water in the tubing, and that the water bottle and tubing were not dated. ADON observed the water in the tubing and the undated water bottle and tubing and stated that she felt the water in the tubing was condensation from the oxygen concentrator being near the room heater. The ADON moved the concentrator away from the heater and changed the tubing. On 10/29/2024 at 9:45 AM the surveyor observed the Resident #456 holding the nasal cannula. The Resident stated that the oxygen had not been used all night because there was water in the tubing, and it had been dripping into my nose. The surveyor observed water still backing up in the tubing and dripping from the nasal cannula. During an interview conducted on 10/29/2024 at 10:00 AM, the surveyor spoke with the ADON and made her aware. She came into the room and stated that the problem had to be the oxygen concentrator and that it would be replaced. On 10/29/2024 at 12:30 PM the surveyor observed that the oxygen concentrator had been changed and there was no water in the tubing and the humidifier bottle and tubing were correctly dated with the date it had been connected to the oxygen concentrator. On 11/06/24 at 10:36 AM The surveyor observed that the date on the tubing on the oxygen concentrator was 10/29/2024. The surveyor interviewed LPN #18 and asked what the policy was regarding changing tubing on the oxygen concentrator. She stated it was supposed to be changed every 5 days.

Based on observations, record review and interviews, it was determined that the facility failed to provide appropriate treatment and services to a resident receiving tube feedings. This was evident for 1 (Resident #72) of 1 Resident reviewed for tube feedings. The findings include: A gastrostomy tube, also known as a G-tube or feeding tube, is a tube that is inserted through the abdomen and into the stomach to provide nutrition, fluids, and medicine. A G-tube should be checked for placement before feeding, flushing or administering a medication to ensure it is not clogged or displaced outside the stomach. On 10/30/24 at 08:44 AM during medication pass, the surveyor observed Staff #9 flush Resident #72's G-tube with 30ml of water. Staff #9 did not check for G-tube placement before administering the flush. The surveyor inquired about the facility's policy for checking the placement of G-tubes. Staff#9 stated I should have checked for placement by aspirating the contents of the stomach before I give anything. I will do so now. A review of the facility policy for Verifying Placement of Feeding tube which was revised on 5/8/24 stated. Before beginning a feeding, flushing the tube, or administering a medication via feeding tube, proper placement and functioning will be verified. On 10/30/24 at 11:31 AM the Assistant Director of Nursing (ADON) was made aware of the surveyor's concerns. ADON stated that the G-tube should have been checked for placement before the flush was administered and she would do an inservice with the nurses on G-tube placement checks.

Based on record reviews and interviews it was determined that the facility failed to ensure a care plan was revised. This was found to be evident for 2 (Resident #50 & #92) out of 5 Residents reviewed for care plan revisions. The findings include: Psychotropic medications are used to treat mental health disorders. There are five main types of psychotropic medications, and each type has its own specific uses, benefits, and side effects. The five main types are anti-anxiety agents, antidepressants, antipsychotics, mood stabilizers, and stimulants. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Anticoagulant therapy is the use of anticoagulants, or blood thinners, to prevent or treat blood clots. Heparin injection is an anticoagulant. It is used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels. 1) A review of Resident #50's Medication Administration Record (MAR) conducted on 11/01/2024 at 07:22 AM revealed that the Resident received the following psychotropic medication: busPIRone HCl 7.5 mg and Seroquel 25 mg. On 11/01/24 at 07:31 AM a review of Resident #50's Care Plan did not reveal a care plan for the psychotropic medications. During an interview conducted on 11/01/2024 at 9:00 AM, the Divisional Director of Quality Assurance stated that it's the facility's expectation that psychotropic medications are Care Planned with a focus, goal and interventions. 50502 2) On 11/01/24 at 8:41 AM, a record review of Resident #92's medications indicated that he/she was on Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML (Heparin Sodium (Porcine)Inject 5000 unit subcutaneously every 8 hours for Deep Vein Thrombosis prophylaxis. On 11/04/24 at 10:34 AM, further review of Resident #92's medical record revealed no evidence that a care plan was developed and implemented to monitor bruising and bleeding related to anticoagulant therapy. On 11/04/24 at 10:53 AM, during an interview with Licensed Practical Nurse (LPN #16), he/she stated that the monitoring and the care plan for blood thinners should be in the electronic system. He/she added that the Unit Managers initiated the care plan in the medical record. The surveyor asked LPN #16 to show an example of a care plan that addressed blood thinners, he/she replied that he/she had no idea where to find it. On 11/04/24 at 11:06 AM, an interview with Unit Manager (UM #10) revealed that the UMs created the residents' care plan on admission. The surveyor asked UM #10 to locate the care plan of Resident #92 related to anticoagulant therapy. He/she confirmed that there was no care plan developed to address potential for bleeding and bruising for Resident #92. He/she then initiated a care plan even though Resident #92 had been discharged from the facility. He/she stated that he/she just wanted to find out if the problem and interventions would show in Resident #92's care plan. On 11/06/24 at 7:53 AM, during an interview with the Assistant Director of Nursing (ADON), she revealed that it was expected that if a resident had an order of blood thinner, a care plan should be initiated in the resident's medical record. She added that the UMs were responsible for developing the care plans. ADON was made aware that Resident #92 had no Anticoagulant care plan.

Based on interviews and surveyor observations, it was determined that the facility failed to reasonably accommodate the needs and preferences of a resident by not ensuring a call bell was kept within a resident's reach and by not providing the appropriate type of call bell device needed for resident use. This finding was evident for 2 of 3 random observations (Resident #75) during the annual survey. The findings include: The Minimum Data Set (MDS) is an assessment used by staff to assist in planning care for the resident. On 10/29/24 at 9:30 AM, a surveyor interview with Resident #75 revealed that he/she was not able to use his/her call bell and would make his/her needs known by requesting his/her roommate to activate their call bell for assistance. The surveyors then requested Resident #75 to activate the call bell. Surveyors observed the resident laying on his/her back, the call bell device resting on the resident's chest area but tucked under the blanket. The resident's right hand was not near the call device. Resident #75 was not able to reach or activate the call bell. Review of Resident # 75's medical record revealed a current diagnosis of left side paralysis and severe limited use of his/her right arm. Review of the Minimum Data Set (MDS) for Resident #75's most recent admission revealed that the resident's needs were coded as dependent for all care. On 10/29/24 at 9:45 AM, an interview with the resident's roommate revealed that he/she uses their call bell multiple times daily, to alert nursing staff of Resident #75's needs. During a follow up tour of the unit on 10/30/24 at 12:02 PM, surveyors observed Resident #75 lying in bed and the call bell resting on the headboard of the bed, out of the resident's reach. On 10/30/24 at 12:10 PM, surveyors located Resident #75's licensed practical nurse (LPN), Staff #9, and requested that she assist with determining the location of Resident #75's call bell device. Staff #9 located the device, then removed the call device from the resident's headboard and placed it on the resident's chest area, near his/her right hand. The surveyor asked Staff #9 if Resident was able to activate the call bell device to alert nursing staff when he/she needed assistance and Staff #9 stated that most of the time it was the roommate, Resident #78, that would alert staff when Resident #75 needed assistance. Staff #9 requested Resident #75 to press the button on the end device to activate the call device. After several minutes, the resident was not able to press the button with his/her right hand. Staff #9 told the surveyors that nursing staff conduct frequent rounding on Resident #75, however it was not identified by nursing staff that Resident #75 was not able to adequately use his/her call bell device. Staff #9 also stated that a ticket would be put into the maintenance department, requesting to replace the device with the appropriate soft touch call bell device that would allow the resident to press the call bell on his/her own. On 10/30/24 at 12:33 PM surveyors interviewed the Director of Nursing, DON, who revealed that the call bell device will be replaced with a soft touch device immediately. Surveyors toured Resident #75's room again on 10/31/24 at 11:00 AM and observed a soft touch call bell device located under the resident's right hand. Resident #75 stated that he/she was able to use the call bell device without any challenges. During an interview held with the Maintenance Director on 10/31/24 at 12:45 PM he confirmed that Resident #75's call bell device was replaced with a soft touch pad call device.