Every finding on record at Montcare at Potomac

Based on observation, interview and record review, it was determined that the facility failed to provide necessary personal hygiene to dependent residents. This was evident for 2 (Residents #111 and #91) of 5 residents reviewed for Activities of Daily Living (ADLs) during the recertification survey.The findings include: ADL is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. 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. On 02/05/2026 at 1:24 PM, Resident #111 was observed with long fingernails. A medical record review showed a (Brief Interview for Mental Status) BIMS score of 15.0 which indicated intact cognition and a Quarterly MDS with an Assessment Reference Date (ARD) of 11/07/25 indicating no impairment in range of motion, but a functional status of Dependent for personal hygiene. (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.)On 02/05/2026 at 1:32 PM, Resident #91 expressed frustration regarding untrimmed fingernails, noting that staff had been notified multiple times. The resident's fingernails were observed extending approximately half an inch beyond fingertips. A medical record review showed a BIMS score of 15.0 (intact cognition) and a Quarterly MDS (ARD 11/25/25) which indicated impairment in upper and lower extremities, with a functional status of Dependent for personal hygiene.On 2/06/2026 at 8:32 AM, a follow-up visit confirmed that both residents still had overgrown fingernails.On 2/06/2026 at 8:40 AM, during an interview with Geriatric Nurse Assistant (GNA #1), he/she stated that staff were expected to provide ADL care, including nail trimming, and must notify the assigned nurse if a resident refuses.On 2/06/2026 at 8:51 AM, the Registered Nurse/Unit Manager (RN/UM #4) was notified of the findings, and the Director of Nursing (DON) was informed at 9:27 AM and acknowledged the concerns.

Based on record reviews and interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded, including coding related to wander/elopement risk status. This was evident for 2 (Residents #108 and #154) out of 5 residents reviewed for accidents during the recertification survey.The findings include: 1.Resident #108 diagnoses included Vascular Dementia and Depression. A review of Resident #108's clinical record on 2/13/26 at 8:00 AM revealed the quarterly Minimum Data Set (MDS) assessments with Assessment Reference Data (ARD) of 09/30/25 and 12/30/25 were inaccurately coded. Section N0415 (medication is taking) the resident was coded as not receiving an antipsychotic medication in the last 7 days. Further review of Resident#108's clinical record revealed a physician order dated 03/19/25 to administer Aripiprazole (Abilify) daily at bedtime. A review of the resident's Medication Administration Record revealed that Resident #108 had been receiving Aripiprazole (Abilify) daily at bedtime since 03/19/25. The MDS Coordinator #2 was interviewed on 02/13/26 at 8:42 AM and she reviewed the clinical records and confirmed that Aripiprazole (Abilify) was classified as an antipsychotic medication and the MDSs were inaccurately coded. After the surveyor's intervention the MDSs were corrected on 02/13/26. On 02/13/26 at 11:25 AM the Director of Nursing was notified of the findings. Based on record review and interview, it was determined that the facility failed to accurately code the resident's wander/elopement alarm status on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #154) of 5 residents reviewed for accidents during the recertification survey. 2. Minimum Data Set (MDS) is a federally mandated comprehensive clinical 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. Wander guard or alert bracelet is a wandering management system that monitors residents using a wearable bracelet. The system relies on three components: bracelets that residents wear, sensors that monitor doors, and a technology platform that sends real-time safety alerts. When a resident with a bracelet approaches a monitored door, the system alerts. On 2/05/2026 at 1:54 PM, Resident #154 was observed pacing in the hallways. Registered Nurse Unit Manager (RN/UM #4) confirmed that Resident #154 was at risk for elopement and was wearing an alert bracelet. On 2/10/2026 at 12:47 PM, a review of Resident #154's medical records revealed the following: BIMS (Brief Interview for Mental Status) score of 4.0 which indicated severe cognitive impairment. Section G (Elopement) of the Quarterly Risk Evaluation dated 2/25/25, confirmed that Resident #154 was at risk for elopement. Physician's order: Alert bracelet- check function of alert bracelet on right lower extremity every shift, expires 7/2027, # FOBO66 every shift for Check function of alert bracelet on right lower extremity On 2/10/2026 at 3:42 PM, a review of care plan indicated Resident #154 is an elopement risk/wanderer as evidenced by history of attempts to leave facility unattended, impaired safety awareness. Resident wanders aimlessly, Significantly intrudes on the privacy or activities of others. Has a history of removing wander alert bracelet, continue to check daily. However, a review of the Annual MDS assessment with an Assessment Reference Data (ARD) of 10/14/25 revealed that Section P0200 (Alarms), item E (Wander/elopement alarm) was inaccurately coded as 0- Not used. On 2/11/2026 at 9:46 AM, MDS Coordinators #2 and #3 verified the error, and stated that the item should have been coded as 2- Used daily. They stated that the MDS assessment will be modified accordingly. On 2/11/2026 at 10:09 AM, the Director of Nursing (DON) was informed of the concern. On 2/13/2026 at 12:57 PM, MDS Coordinator #2 confirmed that the Annual MDS assessment have been modified to reflect the correct coding.

Based on observation, record review, and interview, it was determined that the facility failed to develop and implement comprehensive care plan regarding the use of a nebulizer. This was evident for 1 (Residents #1) of 41 residents reviewed for care planning during the recertification survey.The findings include: 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. The care plan consists of focus, goal and interventions. A nebulizer is a medical device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs through a mouthpiece or face mask.On 2/5/2026 at 1:55 PM, during the initial tour of the facility, a nebulizer machine with unlabeled tubing was observed on Resident #1's nightstand.On 2/11/2026 at12:43 PM, a review of the active physician orders confirmed the following: NEBULIZER - Change nebulizer mask and nebulizer tubing weekly every night shift every Monday, Saturday. NEBULIZER - Change nebulizer mask and nebulizer tubing weekly every night shift every Saturday. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally via nebulizer every 6 hours as needed for Shortness of breath/Emphysema.On 2/11/2026 at 1:09 PM, a review of care plan revealed no evidence that a care plan has been initiated to address the use of a nebulizer treatment.On 2/13/2026 at 10:22 AM, the Director of Nursing (DON) confirmed that the care plans were generated upon admission and updated by the Unit Manager or Minimum Data Set (MDS) Coordinator. She acknowledged the findings and concerns identified during this survey.

Based on observation, clinical record reviews and interviews, it was determined that the facility failed to review and revise care plans to meet the specific needs of the residents. This was evident of 3 (Residents #4, #111 and #91) out of 41 residents reviewed for care plan timing and revision during the recertification survey. The findings include: 1. On 02/11/26 at 11:32 AM, a review of Resident #4's clinical record revealed that the resident was prescribed Triamterene-HCTZ 37.5-25 mg 1capsule by mouth once a day for Hypertension on 10/17/24. The resident was administered the medication from 10/17/24 until 12/24/24 when it was discontinued. Further review revealed an active Care Plan for Resident #4 with focus Resident is on diuretic therapy (HCTZ) r/t hypertension. Goal Resident will be free of any discomfort or Adverse side effects of diuretic therapy through the review date. Revised on 12/16/24 with Target date 03/21/26. The care plan had not been revised to reflect the medication was discontinued on 12/24/24. In an interview on 02/12/2026 at 10:03 AM the Unit Manager Staff #7 stated that when a medication was discontinued the care plan pertaining to that medication was also discontinued. Unit Manager Staff #7 reviewed the clinical record and confirmed that HCTZ was discontinued on 12/24/24 but the care plan remained active. I will resolve the care plan. The surveyor noted that Unit Manager Staff #7 resolved the care plan on 02/12/26 after the surveyor's intervention. On 02/12/2026 at 11:53 AM the Surveyor informed the Director of Nursing of the concerns and findings. 2. 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. The care plan consists of focus, goal and interventions. According to CMS (Centers for Medicare and Medicaid Services), in long-term care facilities, care plans should be reviewed and updated at least every 90 days, or more frequently if a resident's condition changes significantly. ADL is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. 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. On 02/05/2026 at 1:24 PM, Resident #111 was observed with long fingernails. A review of the Quarterly MDS with an Assessment Reference Date (ARD) of 11/07/25 indicated no impairment in range of motion, but a functional status of Dependent for personal hygiene. (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) On 02/05/2026 at 1:32 PM, Resident #91 expressed frustration regarding untrimmed fingernails, noting that staff had been notified multiple times. The resident's fingernails were observed extending approximately half an inch beyond fingertips. A review of the Quarterly MDS (ARD 11/25/25) indicated impairment in upper and lower extremities, with a functional status of Dependent for personal hygiene. On 2/06/2026 at 8:51 AM, the Registered Nurse/Unit Manager (RN/UM #4) was notified of the findings and stated that one of the residents had behaviors which were indicated in the care plan. On 2/12/2026 at 9:08 AM, a review of the following care plans for both residents revealed that revisions were only initiated after surveyor intervention: Resident #111's care plan indicated resistive to care related to Anxiety and Dementia. Revised on 2/6/26 to include The resident may resist care such as bathing, dressing, hygiene, nail care, turning and positioning. Encourage the resident to accept daily ADL care such as bathing, dressing, grooming, hygiene, nail care and repositioning. Resident #91's care plan indicated has an ADL Self Care Performance Deficit related to physical limitation due to left sided weakness/comorbidity and is at risk for skin alterations. Revised on 2/6/26 to include May need encouragement to accept ADL care such as grooming, hygiene, dressing, nail care. If patient refuses ADL care such as bathing, grooming, hygiene, nail care report to assigned nurse to provide encouragement and education. Due to patient's preference, will attempt to have licensed staff provide nail care and as needed. 2/13/2026 at 10:22 AM, the Director of Nursing (DON) confirmed that care plans were generated upon admission and updated by the Unit Manager or MDS Coordinator. She acknowledged the specific findings and concerns identified during this survey.

Based on observations, record reviews and interviews, it was determined that the facility failed to provide residents with necessary respiratory care services consistent with professional standards. This was evident for 3 (Resident #28, #4 and #1) out of 4 residents reviewed for respiratory care during the recertification survey.The findings include:1.On 02/06/26 at 8:53 AM the surveyor observed Resident #28 in bed receiving oxygen via nasal canula at 2 liters per minute. The oxygen tubing and humidifier bottle were not labeled to indicate when they were changed. On 02/06/26 at 10:45 AM a review of Resident #28's clinical record revealed physician orders as follows: Oxygen at 2L per minute continuously Q Shift - Start Date 12/19/25 Oxygen tubing - change and date tubing, respiratory bag and humidified water (if applicable) weekly, every night shift every Sat. Please date tubing, date the respiratory bag for storage and date the humidified water bottle if applicable Start Date: 08/30/25 On 2/06/26 at 12:43 PM in an interview LPN #9 stated that oxygen tubing and humidifier bottles were changed weekly on the night shift and labeled. She accompanied the surveyor to Resident #28's room and confirmed that the oxygen tubing and humidifier bottle were not labeled to indicate the date they were changed. The staff member stated I do not know when they were changed On 02/06/26 at 12:53 PM Unit Manager Staff #7 also accompanied the surveyor to the resident's room and confirmed that the oxygen tubing and humidifier bottle were unlabeled. 2. Resident #4 was observed lying in bed on 02/06/26 at 7:45 AM with oxygen in use at 2 liters per minute via nasal cannula. The resident's Humidifier bottle was dated 02/01/26 and the nasal cannula was undated. The facility's Oxygen Administration Policy dated 03/20/24 and revised on 02/14/25 stated on Page 2 (5c) as follows: Nurse responsibilities: Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty, weekly, or as recommended by the manufacturer. On 02/06/26 at 12:48 PM a review Resident #4's clinical record revealed a physician order for Oxygen as follows: O2 at 2 Liters via nasal cannula as needed for Pulse Ox < 92% as needed for sats <92%. Order Date: 01/02/26 The clinical record failed to reveal an order to change the oxygen tubing and the humidifier bottle. On 02/06/2026 at 12:53 PM in an interview, Unit Manager Staff #7 stated that it was the practice of the facility to have oxygen tubing and humidifier bottles changed weekly and documented in the residents' Treatment Administration Record (TAR). Unit Manager Staff #7 checked the clinical record and confirmed there was no order to change Resident #4's oxygen tubing, I will put in the order now. On 02/06/2026 at 1:41 PM the Director of Nursing was notified of findings and stated that Resident # 4's clinical records had been updated to include the order. 3. A nebulizer is a medical device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs through a mouthpiece or face mask. On 2/5/2026 at 1:55 PM, during the initial tour of the facility, unlabeled nebulizer machine tubing and suction catheter were observed on Resident #1's nightstand. On 2/06/2026 at 8:50 AM, during an interview with Registered Nurse/ Unit Manager (RN/UM #4), he/she stated that respiratory equipment must be dated and changed according to facility protocol. On 2/6/26 at 9:27 AM, a review of Nebulizer policy (reviewed 1.1.25 and revised 2.2.25) indicated: Care of equipment: Item #8 Change nebulizer tubing weekly. On 2/11/2026 at12:43 PM, a review of the active physician orders confirmed the following: NEBULIZER - Change nebulizer mask and nebulizer tubing weekly every night shift every Monday, Saturday. NEBULIZER - Change nebulizer mask and nebulizer tubing weekly every night shift every Saturday. Suction as needed for excessive secretion every 1 hours as needed for excessive secretion On 2/13/2026 at 10:22 AM, the Director of Nursing (DON) was notified of the findings and acknowledged the concerns.

Based on observation, record review and interviews, it was determined that the facility failed to ensure a resident received medication according to the physician's orders. This was evident for 1 (Resident #31) of 6 residents reviewed for unnecessary medications.The findings include:On 02/09/2026 at 8:15 AM Resident #31 was observed sitting in a wheelchair at nurse's station with a bandage over the left eye and bluish discoloration with swelling on the face. The resident said I fell.A review of the resident's clinical record on 02/15/2026 at 6:40 PM revealed that Resident #31 fell on [DATE] then again on 02/08/26 and was transferred to the Emergency Room.Further review of the clinical record revealed that the facility requested a pharmacy review of Resident #31's medications due to the resident's falls. On 02/09/26, the Pharmacy Consultant provided the facility with several recommendations. One recommendation was to decrease the dosage of the resident's medication, Gabapentin. A review of the resident's Medication Administration Record revealed that the resident had been receiving Gabapentin 100mg twice a day from 01/11/26.On 02/11/26 the attending physician reviewed the pharmacy recommendations and wrote an order as follows Decrease Gabapentin to 100 mg Q D. The facility failed to act on physician's order and continued to give the resident Gabapentin 100mg twice a day.During an interview on 02/17/26 at 10:54 AM the Unit Manger #7 reviewed the resident's clinical record and confirmed that the resident was receiving Gabapentin twice a day and that the physician's order was not implemented. The Unit Manager stated that she would address the issue immediately.The Director of Nursing (DON) was notified on 02/17/2026 at 11:15 AM of the surveyor's concerns and stated that she would look into the matter. Later at 11:40 AM the DON stated that she had no comment. On 02/17/2026 at 11:45 AM the surveyor was given copies of documents to show that the physician was notified and Resident #31's medication, Gabapentin, was decreased to 100mg once a day.

Number of residents sampled: Number of residents cited: Based on observation, interviews, and review of facility policy, the facility failed to ensure opened insulin pens were labeled with the date opened as required by policy. This was evident in 1 of 5 medication carts observed during the annual survey. The findings include: On 2/11/26 at 10:42 AM, during a random observation of a medication cart on the Medbridge Unit (1st floor), the surveyor observed two opened insulin pens for Resident #48 stored in the top drawer without an opened date documented on either pen.In an interview on 2/11/26 at 10:45 AM, RN Unit Manager #6 confirmed that both insulin pens were opened and did not contain an opened date label.In an interview on 2/11/26 at 10:51 AM, the Director of Nursing stated that once insulin pens are opened, they are expected to be labeled with the opened date.In a follow-up interview on 2/11/26 at 11:23 AM, RN Unit Manager #6 stated that the facility discarded the opened insulin pens and reordered new pens for Resident #48 because staff could not determine when the pens were opened as the opened date was not documented.On 2/11/26 at 11:57 AM, review of the facility's policy titled Insulin Pen, revised 1/31/24, revealed that insulin pens must be labeled with the resident name and the date opened. The policy further revealed that if the label is missing, the pen will not be used and a new pen must be ordered. The policy also states that insulin pens should be discarded after 28 days or according to the manufacturer's instructions.The findings were discussed with the Director of Nursing.

Based on observation and interviews, it was determined that the facility failed to ensure appropriate infection prevention and control practices were followed. This was evident for 1 of 1 observation in the laundry room.The findings include:On 02/09/2026 at 8:20 AM during rounds in the laundry room, the surveyor observed Staff #12 removing clean linen from a dryer and placing them in a bin. In the process of removing the linen, a cream-colored blanket fell on the floor. Staff #12 picked up the blanket and placed it in the bin containing clean linen. After the surveyor voiced concern Staff #12 said I am sorry, I should not do that. At 8:35 AM, Supervisor Staff #13 arrived in the laundry room and the surveyor in an interview informed the supervisor of the findings. Supervisor Staff #13 communicated with Staff #12 who confirmed the findings in the presence of the surveyor. Supervisor Staff #13 stated that she would address the issue as Staff #12 was educated on infection control practices and should not have put the blanket in the bin with other clean linen.On 02/10/2026 at 7:04 AM the Administrator was notified of the findings in the laundry room.

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 (#136, #70) of 4 residents reviewed for hospitalization during a recertification/complaint survey. The findings include: 1) During an initial screen of Resident #136 on 9/18/2024 at 9:18 AM, the resident stated that s/he was sent out to the hospital on 7/31/2024 for shortness of breath. On 9/24/2024 at 12:15 PM a review of nurses' progress notes and change in condition documentation dated 8/1/2024 at 22:15 (10:15 PM) revealed Resident #136 was sent to the ER (emergency room ) via 911 on 8/1/2024 for further evaluation and treatment of shortness of breath, weakness, and hypotension (low blood pressure). On 9/24/2024 at 12:50 PM, surveyor requested and received from the VP of Clinical Services (Staff #23), copies of the change in condition form dated 8/1/2024. She stated that she could not locate any written notification of the reason for transfer to the hospital on 8/1/2024. However, she added that the reason for transfer to the hospital was noted in the change in condition form that was given to the surveyor. On 9/25/2024 at 9:20 AM an interview was conducted with Licensed Practical Nurse (LPN #10). Regarding written notification of reason for transfer to the hospital, LPN #10 stated that the reason for transfer was documented in the transfer form that was included in the paperwork (transfer packet) sent with the resident to the hospital. She stated that the residents were notified verbally of the reason for transfer to the hospital. LPN #10 added that family members/RP were notified of reason for transfer verbally in person if they were present in the building, and if they were not present, they were notified over the phone. She confirmed that she has not given in writing the reason for transfer to the hospital to any resident and/or their RP. On 9/30/2024 at 11:35 AM, in an interview with the Director of Nursing (DON), surveyor shared concerns regarding written notification of resident and/or their RP of reason for transfer/discharge to the hospital. She did not provide any documentation that Resident #136 and/or their RP was notified in writing the reason for transfer to the hospital on 8/1/2024. 37296 2) Review of the medical record for Resident #70 revealed the resident was transferred to an acute care facility on 8/19/2024. There was no documentation found in the medical record that the resident, and or the resident's responsible party was given written notice why the resident was transferred to the hospital in a language and manner that they understand. On 9/20/24 at 11:27 AM the Administrator was made aware there was no documentation found in the medical why the resident was transferred to the hospital in a language and manner that they understand and confirmed the findings. The Administrator provided the surveyor a plan of correction to include the reason for transfer to an acute care facility.

Based on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (#70). This was evident for 1 of 54 residents selected for review during the recertification/complaint survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. On 9/23/24 at 10:30A, the surveyor reviewed Resident #70's medical record. The review revealed that Resident was discharged to acute care on 8/19/24 and readmitted to the facility on [DATE]. Resident #70's physician's orders on 4/20/2024 Cleanse stage 4 sacrum pressure injury with NSS, pat dry apply calcium alginate with silver and cover with foam every day. Further review of Resident #70's Electronic Medical Record and Treatment Administration Record did not reveal wound care management on 8/1, 8/7, 8/12, 8/13 and 8/18/2024. The Treatment Administration Record for the month of September did not reveal wound care management on 9/2, 9/3, 9/8, 9/10, 9/12, 9/18, and 9/20/2024. On 9/23/24 at 11 AM, the Director of Nursing confirmed the findings.

Based on observation and interview it was determined facility staff failed to 1) safely store a resident's medication (Resident #42), and 2) dispose of expired medications and dressing supplies. This was evident on 2 of 3 nursing units observed during a recertification/complaint survey. The findings include: 1) On 9/25/24 at 9:45 AM, during Medication Administration observation on the 2nd floor Unit for Resident #134 by Registered Nurse (RN # 8), surveyor observed a labeled plastic bag with a pill in it on the floor by the trash can close to the resident's bedside table. Surveyor showed RN #8 the plastic bag containing the pill, and she (RN #8) immediately picked it up. Upon exiting the room, surveyor requested to see what was in the plastic bag. RN #8 stated she threw it in the trash can in the resident's room. Surveyor asked RN #8 to go retrieve the bag. RN #8 went into the room and brought the plastic bag that she had picked from the floor and identified it as Atenolol 50 mg tab belonging to Resident #134's roommate (Resident #42). Surveyor verified that it was an unopened tab of Atenolol 50 mg (expiration date [DATE]) labeled for Resident #42. On 9/25/2024 at 9:50 AM, surveyor shared her observation with the 2nd floor Unit Manager (UM # 12), who took the medication and stated he was going to follow up. On 9/25/2024 at 12:31 PM, Surveyor reviewed with the Director of Nursing (DON) findings during med administration observation: Regarding the Atenolol found on the floor in the residents' room, DON stated that they took a picture of the plastic bag with the med in it and sent to their pharmacy (Geri Script) for verification. DON stated that the pharmacy did not recognize the plastic bag labeled with the Atenolol and stated that it was not from them. She added that the pharmacy did not send single dose /individual packet of any medication to the facility, they send blister packs that contain multiple doses. However, DON stated that Resident #42 was not currently on Atenolol and she (DON) was going to follow up with the resident's daughter to find out if they brought him/her any medications. On 9/26/2024 at 8:23 AM, the Divisional Director of Quality Assurance (Staff #11) provided the surveyor with documentation from their pharmacy that the Atenolol 50 mg tablet was not supplied by them. She stated that the medication might have been in the resident's personal belongings because s/he came from the hospital. However, when asked how the medication ended up on the floor by the roommate's section of the room, Staff #11 stated that she did not know. 2) On 9/27/2024 at 11:40 AM, 1st Hallway medication cart (cart #22) was reviewed for medication storage and labeling in the presence of Registered Nurse, RN #19: Surveyor found in the bottom drawer of the med cart one bottle of Pro-Stat 15 g of Protein (floor stock) that expired on 7/26/2024. RN #19 verified and confirmed the finding and immediately removed the bottle from the cart. On 9/27/2024 at 11:52 AM, observation was made of the treatment cart on the 1st floor unit in the presence of RN #15: The following expired and unsterile dressing supplies were found: a) One (1) sealed/unopened bottle of Iodoform Packing Strip (1 inch) that expired on 6/4/2024. RN #15 verified the expiration date and confirmed that it was expired. She immediately removed it from the cart. b) One (1) pack of Xeroform Petrolatum dressing 5x9 inch cut opened and the remaining dressing inside exposed. RN #15 confirmed that the dressing in the opened pack was no longer sterile and should not be in the treatment cart and immediately removed it. On 9/30/2024 at 11:31 AM, the medication storage carts observations were reviewed with the Director of Nursing (DON). DON stated she was going to follow up.

Based on record review and interview it was determined the facility failed to ensure a resident (Resident #81) received a recommended specialist follow up appointment after a hospitalization . This was evident for 1 out of 4 residents reviewed for hospitalization during the facility's recertification/complaint survey. The findings include: On 9/24/24 at 12:49PM the surveyor conducted a review of the medical record for Resident #81 which revealed the resident was discharged after hospitalization on [DATE] and during their hospitalization the resident was seen by urology for a cystoscopy with right ureteral (tube that carries urine from the kidneys to the bladder) stent placement (small plastic tube inserted into the ureter to keep the urine pathway open). Review of the resident's hospital discharge summary revealed they needed to have a follow up outpatient appointment with urology after their hospital discharge, and further stated the ureteral stent was temporary and that the urologist office was to be called for scheduling of the outpatient ureteroscopy with laser lithotripsy. Further review of subsequent hospitalization documentation for the resident revealed they had been hospitalized again on 1/18/24 with discharge diagnoses which included a complicated urinary tract infection. The hospital discharge summary dated 2/6/24 revealed the following information: Urinary tract infection with gross hematuria, right ureteral stent extensively coiled upon itself within central collecting system and proximal ureter on CT (computed tomography: scan of the body), presented with uti suspected secondary to right ureteral stent causing gross hematuria and uti. Stent placed in July 2023; patient seemed to never follow up with urology. Documentation on the discharge summary documented the resident underwent a cystourethroscopy with laser (urologic procedure) on 1/23/24 and a right retained ureteral stent and right nephrolithiasis (solid material or stones formed in the urinary tract) was removed at that time. On 9/24/24 at 12:49PM the surveyor requested documentation of all urology consults/appointments for the resident from July of 2023 through 1/18/24 from the Director of Nursing (DON). Review of the medical record by the surveyor on 9/24/24 at 12:53PM of the Attending Physician #4's progress note dated 7/23/23 revealed the following information was documented: Obstructive uropathy: Notes: Patient status post cystoscopy with stent placement, patient was noted to have mild hematuria post stent, patient will need to follow up with urology, overall patient appears to be doing well and denies any dysuria or urinary frequency. No further documentation regarding scheduling or follow up with the urology specialist could be found by the surveyor in the medical record between the date of the first hospitalization and subsequent hospitalization . The surveyor additionally noted that the resident had documented urinary symptoms and treatments that further occurred at times leading up to the 1/18/24 hospitalization . On 9/25/24 at 9:50AM the surveyor conducted an interview with Unit Manager #21 who observed the appointment calendar at that time and was unable to see any appointment having been scheduled for the urology follow up in question. During the interview, Unit Manager #21 asked for Unit Secretary #24 to check if any appointments had been made for the resident for the urology follow up appointment. On 9/25/24 at 10:00AM the surveyor conducted an interview with the Assistant Director of Nursing #22 who reported to the surveyor that they could not recall if the resident had the appointment or not. On 9/25/24 at 10:07AM the surveyor conducted an interview with the DON who confirmed there was no consult in the medical orders for the resident to see the urology specialist. On 9/25/24 at 12:10PM the surveyor conducted an interview with Attending Physician #4 who reported to the surveyor several reasons as to why the appointment had not occurred, however, it was confirmed with Physician #4 that there was no documentation that could be found in the medical record that further discussed the recommended follow up urology appointment after their written progress note on 7/23/23. On 9/26/24 at 11:41AM Unit Manager #21 confirmed with the surveyor that Unit Secretary #24 was unable to find any documentation regarding the facility having made any attempts to schedule the follow up urology appointment. At this time, the surveyor shared their concern with Unit Manager #21 and they acknowledged and confirmed understanding of the concern.

Based on medical record review and interview, it was determined the facility staff failed to follow physician orders by administering as needed (PRN) pain medication outside the prescribed parameters. By failing to follow the prescribed parameters for the medication administration, the resident was given an unnecessary medication. This was identified for 1 (#203) of 5 residents reviewed for unnecessary medications during a recertification/complaint survey. The findings include: On 9/23/2024 at 11:54 AM, review of Resident #203's medical record revealed the resident was admitted to the facility in September 2024 with medical diagnosis that included but not limited to other specified disorders of muscle, infection and inflammatory reaction due to cardiac valve, pneumonia, type 2 diabetes mellitus, presence of cardiac pacemaker, and spondylosis lumbar region (osteoarthritis of the spine). On 9/23/2024 at 12:04 PM, review of physician orders revealed an active order with a start date of 9/3/2024 for Tramadol HCL tablet 25 mg, give 25 mg by mouth every 4 hours as needed for Moderate Pain. Further review of the orders revealed active orders for: Pain Score every shift on a scale of 0-10, 0 = no pain 1-3 = mild pain 4-6 = moderate pain 7-10 = severe pain every shift for Pain dated 9/3/2024. On 9/23/2024 at 12:29 PM, review of Resident #203's Medication Administration Record (MAR) for September 2024 was completed. Staff documentation revealed PRN Tramadol HCL 25 mg was given outside ordered parameters for Moderate pain level (4-6) on the following dates: On 9/6/2024 - for pain score 0 at 0620 (6:20 AM) and On 9/23/2024 - for pain score 2 at 1153 (11:53 AM). On 9/23/2024 at 12:32 PM, Surveyor reviewed Resident #203's September 2024 MAR with the Director of Nursing (DON). She verified and confirmed that the 25 mg Tramadol was given inappropriately on the days/times when the resident's pain score was below 4 (ordered parameters not followed). DON stated that sometimes the residents may request a particular pain med, and the nurses would give it without paying attention to the orders. However, she indicated that she was going to review the nurses' notes and follow up with surveyor for explanation why the Tramadol was administered for pain score of 0 and 2 respectively. On 9/25/2024 at 7:52 AM, in a follow up interview with the DON, she stated that she identified the nurses who administered the above Tramadol without following the ordered parameters and have started providing one-on-one education to them. DON further stated that they were working on harmonizing the pain scale throughout the facility and educating staff on following ordered parameters during PRN med administration.

Based on observation, interview, and record review it was determined the facility failed to ensure the call bell device was within reach of a resident (Resident #28). This was evident for 1 out of 34 facility residents observed by the surveyor during initial tours during the facility's recertification survey. The findings include: On 9/19/24 at 9:52AM the surveyor observed Resident #28 laying in their bed, repeatedly gesturing and pointing to their head. When the surveyor attempted interview of the resident and inquired as to if they had a call bell device to ask for staff assistance, the resident was observed looking around their bed for the call bell device. At this time, the surveyor observed the call bell cord was plugged into the wall and was laying draped over top of the resident's wheelchair with the call device located behind a pillow situated on the wheelchair parked next to the resident's bed, not within reach of the resident. Upon further observation, the surveyor noted this was a tap style type of call bell device. On 9/19/24 at 9:52AM the surveyor requested for a dual observation with Unit Manager #21, who accompanied the surveyor to the room of Resident #28 and observed and acknowledged the surveyor's concern. The surveyor observed Unit Manager #21 retrieve the call bell from the resident's wheelchair and secure it within reach of the resident. The resident was observed to have the ability to utilize/press the call bell. Upon interview of Unit Manager #21, they confirmed the call bell was not within reach of the resident, and confirmed their expectation was for residents to have their call bell within reach. On 9/25/24 at 10:44AM upon review of the medical record, the surveyor observed the following intervention was listed on the careplan of Resident #28: Reinforce need to call for assistance.

Based on review of facility reported incident investigation and interview, it was determined the facility staff failed to report a possible misappropriation of resident property within 24 hours of the incident to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #48) of 12 residents reviewed for abuse during a recertification/complaint survey. The findings include: On 9/20/2024 at 11:27 AM, review of the investigation report of Facility Reported Incident (FRI), MD00180957, revealed Resident #48's medication (28 tablets of Ativan 0.5 mg) that was supposedly delivered to the facility on [DATE] on the 3-11 PM shift was not found even though staff found the controlled substance log that was to accompany the medication on their desk. On 9/20/2024 at 11:56 PM, surveyor requested from the Director of Nursing (DON) the email/fax receipt of the initial and final (5-day) report of the FRI to the State Survey Agency (OHCQ). On 9/20/2024 at 12:56 PM, surveyor received from DON the email receipt for the initial and final self-report to OHCQ. A review of the initial self-report revealed it was sent to OHCQ on 3/18/2022 at 6:48 PM. Thus, failing to meet the 24 hours reporting requirements for any allegation of misappropriation of resident property. On 9/23/2024 at 12:38 PM in a follow up interview with DON, Surveyor reviewed the above FRI with her. DON was informed of surveyor's concerns regarding the actual date of the above incident (3/13/2022) and the date/time the initial report was sent to OHCQ (3/18/2022 at 6:48 PM). DON confirmed that the initial report did not meet the 24 hours reporting requirements for any allegation of misappropriation of resident property. However, she stated that the delay in reporting the above incident to the State Survey Agency was because they were waiting for pharmacy to review the medications delivered to the facility on that day (3/13/2022), and felt it was not necessary to do a self-report.

Based on a medical record review and staff interview, it was determined that the facility failed to ensure that the physician documented a resident's discharge in the medical record. This was identified for one (Resident # 152) of three residents reviewed for discharge during the recertification/complaint survey. The finding includes: On 9/23/24 at 10:51 AM, the surveyor reviewed Resident #152's medical record for system-selected closed record review. The review revealed that a progress note written by a Licensed Practical Nurse (LPN #10) on 8/23/24 documented that Resident #152 was discharged home. Also, the facility had a form named My Transition Home, which was reported by LPN #10 about Resident #152's discharge. However, there was no documentation from the physician regarding Resident #152's discharge. During an interview with the facility attending physician (Staff #4) on 9/24/24 at 10:07 AM, Staff #4 stated that they should document residents' discharge in the electronic medical records system within 30 days of discharge. On 9/30/24 at 8:10 AM, the surveyor reviewed Resident #152's medical records again to verify whether the resident had discharge documentation from the physician within 30-day window. There was no record from the physician. In an interview with the Director of Nursing (DON) on 9/30/24 at 11:30 AM, the surveyor shared concerns regarding residents' discharge records from a physician. She validated the concern.

Based on medical record review, policy review, and staff interview, it was determined that the facility failed to monitor and evaluate residents' weight gain and notify the physician. This was evidenced by 1 (Resident #145) out of 3 residents reviewed for nutrition during the recertification/complaint survey. The findings include: A review of Resident #145's medical record on 9/25/24 at 09:48 AM revealed that the resident was receiving tube feedings upon admission. Resident #145's body weight was documented as 80 pounds on 8/25/24 and 93.4 pounds on 9/13/24, which was a 16% weight gain within 19 days. Further review of a progress note written by Staff # 25 (Dietitian-former) dated 9/13/24 at 2:33 PM revealed that 80 lbs (pound) is the recorded weight upon admission on 8/25/24 and is awaiting further weights to determine loss, gain or stability since admission. She also wrote that the resident was awaiting weekly weights 4X (times four). On 9/25/24 at 11:10AM, an interview was conducted with the Registered Nurse (RN #8) about the process of obtaining weight and communicating the results. She stated that the Geriatric Nursing Assistants (GNAs) and nurses obtained residents' body weights. RN #8 explained that the weight was done by mechanical lift or scale, which would be documented monthly or weekly (if there was a specific order). When the GNA obtained weights, they were given to the nurse, who documented them in the electronic medical record (EMR). If there was a gain/loss of weight, the physician and dietitian were notified, and information was documented in the EMR. On 9/25/24 at 11:32 AM, a review of the weight monitoring policy under the compliance guidelines stated that weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. under the documentation section of the policy, it states that the physician should be informed of a significant change in weight and may order nutritional interventions. On 9/25/2024 at 12:31 PM, an interview with the Director of Nursing (DON) confirmed that resident #145's weight was 80 pounds upon admission, and the next weight was 93.4 pounds on 9/13/24. The DON further explained that parameters were in place to notify the physician if there was a weight gain or loss of 3-5 pounds. On 9/25/24 at 1:10 PM, an interview with Staff #9 (Dietitian) stated that a resident's weight gain was a concern for the dietitian. She said the facility would review the weight formula with the physician when it was reported. The residents' conditions would also be reviewed, and interventions would be implemented. In addition, if a resident was underweight upon admission and weight gain was expected, it was still required to document their weight changes. On 9/25/24 at 1:15 PM, upon further review of the Resident #145's medical record, there was no weight tracking found, and no documentation of communication between nursing, dietician, provider and resident's family member concerning the resident's weight gain. On 9/30/24 at 11:30 AM, the surveyor shared the concern with the DON, and the DON validated the concern.

Based on medical record review and staff interview, it was determined that the facility failed to provide education regarding the benefits and potential side effects of the influenza and pneumococcal vaccine. This was evidenced for 1 (Resident #29) of 5 residents reviewed for Influenza and Pneumococcal Immunizations records during the recertification/complaint survey. The findings include: Pneumococcal vaccine helps prevent pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for ages [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people [AGE] years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications. Influenza (Flu) vaccines can prevent influenza. (Centers for Disease Control and Prevention- vaccines and preventable disease) On 9/26/24 at 11:49 AM, the surveyor reviewed the medical records of 5 randomly selected residents for immunization. The review revealed that Resident #29 had been residing at the facility since March 2020. Further review of Resident #29's record revealed that the resident refused influenza vaccine in 2020. There was no documentation for the influenza vaccine in 2021. The documentation for the influenza vaccine in 2022 showed that the resident refused it. However, there was no evidence to support the resident receiving education on the vaccine's risks and/or benefits. There was no documentation for the influenza vaccine in 2023. During an interview with the Infection Control Preventionist (Staff # 22) on 09/30/24 at 10:25 AM, she stated that the facility provided influenza education yearly to all residents, which should be documented in the Electronic Medical Record. On 9/26/24 at 12:30 PM, the surveyor reviewed Resident #29's pneumococcal immunization record. The documentation for the pneumococcal vaccine for 2020 revealed that the resident refused. There was another documentation in March 2024 stating that Resident #29 refused the vaccine. However, there was no evidence to support the resident receiving education about the vaccine's risks and/or benefits. During an interview with Staff #22 on 9/30/24 at 10:25 AM, she stated that the facility offered the pneumococcal vaccine and educated residents who had refused it quarterly and yearly about its risks and/or benefits. On 9/30/24 at 11:30 AM, the surveyor shared the concern with the Director of Nursing (DON) regarding providing residents education about immunization risks and/or benefits. The DON validated the concern.

Based on observations, record reviews, and resident and staff interviews, it was determined that the facility failed to evaluate and manage residents' pain consistently. This was evident for one resident (# 97) of four residents who were reviewed for pain during the recertification/complaint survey. The findings include: Resident #97 was at the facility receiving short-term rehab. A record review conducted on 09/20/24 at 8:30 am revealed that resident #97 had a BIMS score of 0/15 on admitted d 08/26/24, indicating severe cognitive impairment. BIMS stands for Brief Interview for Mental Status, a standardized assessment tool to evaluate a patient's cognitive function. One of Resident #97's diagnoses was Chronic pain syndrome. During an interview with the family member of Resident #97 on 9/20/24 at 09:13 AM, she/he stated that the resident has been in pain frequently despite getting pain medication. During an interview with the Geriatric Nursing Assistant (GNA), staff # 27, on 09/30/24 at 09:47 AM, revealed that resident #97 was in pain when staff moved her/him during care and always grimaced with pain. During an interview with the Licensed Practical Nurse (LPN), staff # 26 on 09/30/24 at 9:53 am, she/he stated that she/he reviews the pain medication parameters prior to administering pain medication as needed. On 09/24/24 at 10:19 AM, a record review revealed that resident # 97's pain was not managed consistently. Resident #97 had an order written on 08/26/24 to document his/her pain score, stating Pain Score every shift on a scale of 0-10 0 = no pain 1-3 = mild pain 4-6 = moderate pain 7-10 = severe pain every shift for Pain. Medication orders (as needed) did not have parameters to correspond with pain scores: Acetaminophen Oral Solution (Acetaminophen) Give 20.3 ml via PEG-Tube every 4 hours as needed for Pain Morphine Sulfate Oral Solution 20 MG/5ML, Give 2.5 ml via PEG-Tube every 4 hours as needed for Pain. oxyCODONE HCl Oral Tablet 5 MG, Give 5 mg via G-Tube every 4 hours as needed for Abdominal pain. Further review of Resident #97's Medication Administration Record (MAR) revealed that the resident received: On 09/23/24 at 8:47 AM Acetaminophen 20.3 ml via PEG tube for Pain Level 2, On 09/10/24 at 4:49 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 5, On 09/14/24 at PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 6, On 09/15/24 at 1:48 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 6, On 09/19/24 at 5:45 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 5, On 09/22/24 at 5 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 3, On 09/24/24 at 5:25 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 3, On 09/26/24 at 5 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 6, On 09/29/24 at 4:34 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 4. The surveyor reviewed and validated pain score information and medication parameters with the Director of Nursing (DON) on 09/30/24 at 11 am. DON stated that she/he would communicate with the physician to make the necessary changes.

Based on the review of the facility administrative records and interview it was determined the facility failed to have a mechanism in place that provided notification to residents of the facility ' s Covid-19 status. This was found to be evident for all residents. Findings include: A review of the facility administrative records on 01/19/2022 at 11:07 am, the Surveyor was unable to identify a record of notification to all residents for the facility ' s Covid-19 status. During an interview conducted on 01/19/2022 at 11:25 am the Administrator confirmed the facility did not have a mechanism in place to notify all residents of the facility ' s Covid-19 Status. The Administrator further stated s/he would include the facility ' s Covid-19 status in the daily newsletter the Daily Chronicle immediately.