Every finding on record at Montcare at Wheaton

Number of residents sampled: Number of residents cited: Based on observations and interview it as determined that the facility staff failed to store and label medications in accordance to professional principles as evidenced of loose medications on the medication cart. This deficient practice was evidenced in 1 of 1 medication cart inspected during the recertification survey.The findings include:On 01/09/26 at 10:53 am when the surveyor inspected the medication cart assigned to Licensed Practical Nurse (LPN) #26 the surveyor observed nine loose medications in the top drawer, four loose medications in the second drawer, and three loose medications in the third drawer. There was a stock bottle of Acetaminophen 500 mg tabs with an expiration date of 03/25; there were about 26 pills left in the 1,000-count container. In addition, the surveyor observed a pocketknife and a leaking container of orange juice in the bottom drawer. The loose medications, pocketknife, and container of orange juice were given to LPN #26.On 01/09/26 at 11:10 am during an interview with LPN #26 they verbalized sometimes the medications are too tight in the drawers and the medications fall out of the blister packs. When that happens, they put medications in the bottom drawer.

Number of residents sampled: Number of residents cited: Based on observations and interviews it was determined that the facility staff failed to return medications to the pharmacy when residents were discharged or when the physician ordered a dose change, and the pharmacy failed to specify how much fluid to add to a powdered medication. This deficient practice was evidenced in 4 (#2, #100, #101, #103) residents who were discharged and 1 (#59) resident whose medication dose was adjusted and 2 (#24, #35) residents whose medication order was incomplete. The deficient practice was discovered during the recertification survey. The findings include:On 01/08/26 at 9:05 am the surveyor observed Licensed Practical Nurse #26 prepare Resident #35 medications. The surveyor read an order dated 02/12/25 Miralax Oral Powder 17 Gram/Scoop Give 1 scoop by mouth one time a day for bowel regimen; hold for loose stool. The order did not provide instructions about how much liquid to add to the powder to be dissolved. After LPN #26 poured the powder into the cup, the surveyor asked how much liquid he/she would add to dissolve the powder. LPN #26 was uncertain, and the surveyor instructed LPN #26 to read the manufacturer's instructions. Resident #24 Miralax order did not provide instructions about how much liquid should be used to dissolve the powder.On 01/08/26 at 9:51 am while in the medication storage room located on Medbridge, the surveyor observed a large red bag of medications and personal care products in the cabinet. The medication belonged to Resident #103 who was discharged on 05/25/25. At 9:58 am the surveyor asked Registered Nurse unit Manager #11 why the bag of medications was in the cabinet. RN Unit Manager #11 verbalized that the resident was discharged , and the nurse should have given the medications back. Normally the family would call to get the medications. On 01/09/26 at 10:53 am when the surveyor inspected the medication cart assigned to Licensed Practical Nurse (LPN) #26 the surveyor observed six blister packs of medications prescribed for Resident #100 who was discharged on 11/09/25, one blister pack of medication prescribed for Resident #101 who was discharged on 11/06/25, one blister pack of medication prescribed for Resident #2 who was transferred to the hospital on [DATE]. The surveyor asked LPN #26 why medications of discharged residents on the medication cart were. LPN #26 verbalized they typically pack the medications, and the pharmacy picks up the medication. Sometimes they don't have bags available to return the medications to the pharmacy. LPN #26 verbalized they forgot to notify pharmacy there were medications that needed to be returned.On 01/08/26 at 2:05 pm during an interview with the Divisional Director of Quality Insurance the surveyor reported the Miralax order did include the amount of fluid required to prepare the medication. The Divisional Director of Quality Assurance verbalized the order should have indicated how much liquid should have been added to the powder. The surveyor asked when a resident is discharged what happens to the residents' medications. He/she they are returned to the pharmacy or if they came from home the medications are given to the family.

Based on surveyor record review and facility staff interviews it was determined that the facility failed to update and revise a Resident's care plan. This finding was found to be evident for 1 (Resident #18) out of 9 Residents reviewed for revision of Resident's care plans.The findings include:A Care Plan is a written document that outlines a person's care needs and how they will be met. It's a key tool for health and social care professionals to ensure a Resident receives the right level of care. Care plans are usually created after care needs assessment and risk assessment, involving the person receiving care and their family. Care plans are used to guide health and social care professionals in delivering care and standardize evidence-based care. Care plans should be regularly reviewed to monitor their effectiveness. Care plans are updated and revised periodically and as care needs and conditions change with Residents.A Minimum Data Set (MDS) assessment is a comprehensive, federally mandated clinical evaluation for Residents in Medicare/Medicaid-certified nursing homes in the United States. The purpose is to provide a standardized, uniform assessment of Resident health status, identify problems, strengths, and preferences, and inform care planning and payment. MDS assessments are completed by trained nursing home staff upon admission, quarterly, annually, and whenever a Resident's condition significantly changes. Functional capabilities, cognitive status, health conditions, treatment, therapies, psychosocial well-being and discharge planning are assessed in the MDS process.The surveyor conducted a record review of Resident #18's medical record on 1/6/2026 at 1:45 PM. Review of the medical record revealed that Resident #18 had a care plan for an anticoagulant (blood thinner) medication that was initiated on 6/25/2020 and a revision on 4/12/2024 with a target date of 9/28/2025. Further review of Resident #18's medical record revealed that there was no active, current physician order for an anticoagulant medication.Continued record review of Resident #18's medical record on 1/6/2026, specifically the MDS assessments dated 2/23/2024, 2/23/2025 and 11/23/2025 revealed that these MDS assessments did not indicate that Resident #18 was taking an anticoagulant medication. In an interview with the Divisional Director of Quality Assurance/Assessment (QAA) on 1/7/2026 at 8:50 AM the surveyor conveyed that Resident #18 had an active, current care plan for an anticoagulant medication since June of 2020, but Resident was not taking an anticoagulant medication currently, did not have a physician order for an anticoagulant medication and the anticoagulant medication was not coded on the MDS assessments. The surveyor asked what the expectation was for updating and revising Resident care plans and the Divisional QAA Director stated that care plans should be updated and revised by the Unit Manager and clinical team as needed to reflect the status and condition of the Resident. The Divisional QAA Director acknowledged the surveyor and confirmed that the anticoagulant medication should not have been on Resident's care plan as an active problem, as Resident #18 was not taking an anticoagulant medication.Additionally, the surveyor conveyed to the Divisional QAA Director that Resident #18's current care plan had duplicate care plan problems for neurological status related to a CVA (stroke).No additional information was provided by the facility at the time of exit.

Number of residents sampled: Number of residents cited: Based on an observation and interview it was determined that the facility staff failed to ensure a medication was stored according to professional nursing standards as evidenced by a unlabeled blister pack of medication on the medication cart. This deficient practice was evidenced in 1 of 1 medication cart inspected during the recertification survey.The findings include:On 01/09/26 at 10:53 am when the surveyor inspected the medication cart assigned to Licensed Practical Nurse (LPN) #26 the surveyor observed a blister pack of medication that did not have a label with a resident's name or the name of the medication. The blister pack of medication was in the third drawer in the right corner. The surveyor asked LPN #26 why the medication was not labeled. LPN #26 verbalized they didn't realize the unlabeled medication was on the cart.On 01/09/26 at 11:24 am the surveyor reported there was an unlabeled blister pack of medication on the medication cart. Registered Nurse Unit Manager #2 verbalized the night shift and staff who pass medications are responsible for checking the medications on the cart.

Number of residents sampled: Number of residents cited: Based on observation, interviews and record review it was determined that facility staff failed to provide a homelike environment by having another resident's clothes in the room and having unnecessary equipment in the room hindering the resident's independence. This was evident for 1 Resident (#9) of 24 residents observed during the recertification survey. The findings include: On 01/5/2025 at 10:58 AM a wheelchair was observed with a box of clothes on the seat. Additionally, a box labeled with Resident #104's name was found on top of Resident #9's wardrobe. When questioned, Resident #9 stated, No, I do not use this wheelchair, I can walk now, but this wheelchair is preventing me from walking around my bed by the window. Regarding the box on the wardrobe, Resident #9 explained that it has been there since I was admitted in this room and I don't want that box in my room. 01/05/2026 at 11:08 AM Staff #3, Geriatric Nursing Assistant (GNA) was interviewed and asked if they could retrieve and open the box on top of Resident #9's wardrobe. Staff #3, GNA was asked if the name of the outside of the box was resident #9's name and they replied no it is not that is Resident #104's name on the box. Staff #3, GNA was then asked to open the box, and clothes and shoes were seen inside. On 01/05/2026 at 11:18 AM, Staff #2, a Registered Nurse (RN), was interviewed concerning the procedure for removing a previous resident's belongings before a new resident moves in. Staff #2, RN stated that the procedure involves calling housekeeping to take the items to the laundry downstairs. Staff #2, RN confirmed that a room should be cleaned and the previous resident's belongings removed before a new resident is admitted . Staff #2, RN verbalized understanding that this was a concern. On 01/07/2026 at 9:00 AM, a record review revealed that Resident #9 was admitted to their room on 06/10/2025. This record review supports Resident #9's assertion that the box on their wardrobe had been present since the date of their admission.

Based on surveyor observations and facility staff interviews it was determined that the facility failed to have a call light device accessible for Residents to call for staff assistance. This was found to be evident in 4 (Resident #18, 62, 92 and 37) out of 32 Residents reviewed for Resident call system accessibility.The findings include: On tour of the nursing units on 1/4/2026 at 9:30 AM the surveyor observed Resident #62 in a wheelchair in his/her room. Resident #62 was alert and oriented, in no distress and able to propel wheelchair in his/her room. The call light device was observed lying on the floor between the wheelchair and bed. The call light device was not easily accessible for Resident #62 to call for staff assistance. At 10:51 AM on 1/4/2026 the surveyor observed Resident #18 in bed, in no distress with the call light hanging from the overbed light. Resident #18 was unable to reach the call light device. Resident #18's nurse, employee #18, was notified and observed the call light device hanging on the overbed light not accessible to Resident. Staff nurse, employee #18 stated sorry and placed the call light device within Resident #18's reach. The surveyor asked staff nurse #18 what the expectation was for Resident accessibility of call light devices, and he/she stated that the call light devices should be in reach for Residents to call for staff assistance. On 1/6/2026 at 11:15 AM the surveyor observed the call light device string/cord in Resident #92's bathroom. The call light device string/cord was short in length and was not easily accessible for Resident to call for staff assistance. Resident #92 was alert and oriented, in no distress, sitting in his/her wheelchair and able to propel wheelchair in his/her room. In an interview with the Maintenance Director at 1:15 PM on 1/9/2026, he was notified and observed the call light device string/cord in Resident #92's bathroom. The Maintenance Director stated that he would follow up by replacing the call light device with a longer string/cord for Resident #92's bathroom. No additional information was provided by the facility at the time of survey exit. On 01/05/2026 at 10:40 AM the surveyor conducted observations of various resident rooms. During interview with Resident # 37, the surveyor asked the resident if he/she had a call bell to use when assistance was needed. The resident replied, I don't know. The surveyor observed the call bell device under the resident's bed. At 10:41 PM the surveyor located registered nurse, Staff #6, who confirmed that she was assigned to care for Resident #37. Staff #6 entered Resident #37's room with the surveyor and was asked to help locate the resident's call bell. The surveyor observed Staff #6 locate the resident's call bell wedged under the frame of the resident's bed. Staff #6 then sought help from another staff member to lift the bed enough to untangle and dislodge the call bell device from under the resident's bed. Staff #6 then placed the call bell device within the resident's reach.

Based on surveyor record review and facility staff interviews it was determined that the facility failed to maintain an accurate and complete medical record for a Resident. This finding was found to be evident in 1 (Resident #6) out of 9 Residents reviewed for Resident Record identifiable information.The findings include:Medication/Treatment Administration Record (MAR/TAR) is a crucial legal document in healthcare tracking every medication and treatment given to a Resident, detailing the drug, dose, time, route and the caregiver who administered it, serving to prevent errors, ensure compliance, and provide clear communication about Resident care. MARs/TARs are paper based or electronic (eMARS/eTARs) and are essential for safe medication/treatment management in long term care. The purpose of the MARs/TARs is Resident safety, continuity of care, legal documentation and accountability.Care Plan is a written document that outlines a person's care needs and how they will be met. It's a key tool for health and social care professionals to ensure a Resident receives the right level of care. Care plans are usually created after care needs assessment and risk assessment, involving the person receiving care and their family. Care plans are used to guide health and social care professionals in delivering care and standardize evidence-based care.The surveyor conducted a record review of Resident #6's medical record on 1/8/2026 at 8:50 AM. Review of the medical record revealed that Resident #6 had an active, current physician order as of 1/31/2025 for monitoring of anticoagulant medication (blood thinner). The physician order stated: anticoagulant medication - monitor for discolored urine, black tarry stools, sudden severe headache, nausea/vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, nose bleeds and document every shift. Further review of the physician orders revealed that Resident #6 was not currently taking an anticoagulant medication. Also, review of Resident #6's Treatment Administration Record (TAR) revealed that nursing staff was documenting the monitoring of an anticoagulant medication. Additionally, there was a current care plan problem for an anticoagulant medication in the electronic medical record for Resident #6. In an interview with the Divisional Director of Quality Assurance/Assessment (QAA) at 9:40 AM on 1/8/2026 the surveyor conveyed that there was an active, current physician order for monitoring side effects related to the use of an anticoagulant medication for Resident #6 and that Resident was not taking an anticoagulant medication. In addition, the Divisional QAA Director was notified that there was a current care plan problem for anticoagulant medication for Resident #6. The Divisional QAA Director acknowledged the surveyor and stated that maybe there needs to be education conducted regarding what medications were anticoagulants.Follow-up review of Resident #6's medical record on 1/9/2026 at 11:55 AM revealed that the Resident no longer had an active, current physician order for monitoring side effects of an anticoagulant medication. The monitoring order for anticoagulant medication for Resident #6 was discontinued by the physician/facility staff.No additional information was provided by the facility at the time of survey exit.

Based on surveyor record review and facility staff interviews it was determined that the facility failed to develop and implement a comprehensive care plan for a Resident. This finding was found to be evident for 1 (Resident #6) out of 9 Residents reviewed for development and implementation of a comprehensive care plan. The findings include:A Care Plan is a written document that outlines a person's care needs and how they will be met. It's a key tool for health and social care professionals to ensure a Resident receives the right level of care. Care plans are usually created after care needs assessment and risk assessment, involving the person receiving care and their family. Care plans are used to guide health and social care professionals in delivering care and standardize evidence-based care.A Minimum Data Set (MDS) assessment is a comprehensive, federally mandated clinical evaluation for Residents in Medicare/Medicaid-certified nursing homes in the United States. The purpose is to provide a standardized, uniform assessment of Resident health status, identify problems, strengths, and preferences, and inform care planning and payment. MDS assessments are completed by trained nursing home staff upon admission, quarterly, annually, and whenever a Resident's condition significantly changes. Functional capabilities, cognitive status, health conditions, treatment, therapies, psychosocial well-being and discharge planning are assessed in the MDS process.The surveyor conducted a record review of Resident #6's medical record on 1/8/2026 at 8:50 AM. Review of the medical record revealed that Resident #6 had a care plan for anticoagulant therapy, date initiated 4/26/2024, revision on 10/31/2024 and a target date of 3/16/2026. Review of Resident #6's physician orders did not reveal that Resident was ordered an anticoagulant medication (blood thinner), and Section N of the MDS assessments for 2025 (12/14/2025, 9/13/2025, 6/13/2025 and 3/13/2025) were not coded that Resident was taking an anticoagulant medication. Further review of the medical record revealed that Resident #6 had a physician order as of 4/25/2024 for Clopidogrel 75 mg one time a day which was an antiplatelet medication (prevent blood clots). Additionally, the antiplatelet medication was coded on the MDS assessments for 2025; however, there was not an active, current care plan for an antiplatelet medication for Resident #6. In an interview with the Divisional Director of Quality Assurance and Assessment (QAA) at 9:33 AM on 1/8/2025 the surveyor conveyed that Resident #6 had an active care plan for anticoagulant therapy, but Resident was not currently taking an anticoagulant medication. Additionally, the surveyor conveyed that there was no physician order for an anticoagulant medication and the MDS assessments for 2025 did not indicate that Resident #6 was taking an anticoagulant medication. The surveyor further conveyed that Resident #6 had a physician order for an antiplatelet medication, Clopidogrel 75 mg one time a day, but did not have a care plan for the antiplatelet medication. The Divisional QAA Director acknowledged the surveyor and stated that maybe there needs to be some education on types of medications.No additional information was provided by the facility at the time of survey exit.

Based on surveyor record review and facility staff interviews it was determined that the facility failed to accurately code a Resident's Minimum Data Set (MDS) assessment. This finding was found to be evident in 1 (Resident #82) out of 9 Residents reviewed for accuracy of assessments during the recertification survey.The findings include:Minimum Data Set (MDS) assessment is a comprehensive, federally mandated clinical evaluation for Residents in Medicare/Medicaid-certified nursing homes in the United States. The purpose is to provide a standardized, uniform assessment of Resident health status, identify problems, strengths, and preferences, and inform care planning and payment. MDS assessments are completed by trained nursing home staff upon admission, quarterly, annually, and whenever a Resident's condition significantly changes. Functional capabilities, cognitive status, health conditions, treatment, therapies, psychosocial well-being and discharge planning are assessed in the MDS process.Medication Administration Record (MAR) is a crucial document in healthcare that tracks every medication given to a Resident, detailing the drug name, dose, route, time, and who administered the medication to ensure Resident safety, prevent errors, and provide clear communication among providers.The surveyor conducted a record review of Resident #82's medical record on 1/8/2026 at 10:20 AM. Review of the medical record revealed that Resident #82 had an active, current physician order for an anticoagulant medication (blood thinner), Eliquis 5 mg two times a day since 6/5/2024. Further review of the medical record revealed that Resident #82 had a Quarterly MDS assessment dated [DATE] which did not indicate that Resident was taking an anticoagulant medication, as the anticoagulant medication was not coded under Section N of this MDS assessment. Additionally, the surveyor reviewed Resident #82's Medication Administration Record (MAR) for November 2025. The November 2025 MAR revealed that Resident #82 was administered Eliquis 5 mg two times a day for the entire month of November 2025.In an interview with the Divisional Director of Quality Assurance/Assessment (QAA) on 1/8/2026 at 11:10 AM, the surveyor conveyed that Resident #82 had an active, current physician order for Eliquis 5 mg two times a day, and that the Quarterly MDS dated [DATE] was not coded that Resident was taking an anticoagulant medication. The Divisional QAA Director stated that she would review with the Regional MDS Coordinator as the facility MDS Coordinator was new to the position. In a follow-up interview with the Divisional QAA Director at 11:21 AM, she stated that she reviewed the Quarterly MDS and notified the Regional MDS Coordinator. The Divisional QAA Director further stated that the facility was completing a modification/correction to the Quarterly MDS assessment dated [DATE] for Resident #82 regarding the anticoagulant medication.Follow-up review of Resident #82's medical record confirmed that the facility completed a modification/correction to the Quarterly MDS assessment dated [DATE] on 1/8/2026 at 11:32 AM. The Quarterly MDS assessment dated [DATE] under Section N was now coded that Resident #82 was taking an anticoagulant medication.No further information was provided by the facility at the time of exit.

Based on interviews with facility staff and review of facility administration records, it was determined that the facility failed to ensure that nursing staff had an active nursing license. This was evident for 1 (Staff #13) of 1 health care professional reviewed during the recertification survey. The findings include:On [DATE] 7:35 AM the surveyors conducted an interview with the Nursing Home Administrator (NHA). The NHA stated that the previous Director of Nursing, (Staff #24), was termed in [DATE] and a new DON (Staff #13) was hired in [DATE]. The NHA verbally confirmed that he submitted the notification of DON change to the Office of Health Care Quality at the time of the new DON's hire.On [DATE] at 10 AM the surveyor reviewed a document titled, Nursing Home Director of Nursing- Change of Information which showed: Staff #13 was listed as the new employee, a District of Columbia Registered Nurse number, and hired as DON with a start date of [DATE].On [DATE] at 11 AM the surveyor interviewed the Director of Human Resources, Staff #20. The surveyor asked Staff #20 if Staff #13 held an active nursing license that qualified him for employment at the time of hire. Staff #20 stated that Staff #13 was hired on [DATE], with his Tennessee Registered Nurse's license.On [DATE] at 11:30 AM, surveyor review of the employee file for Staff #13 revealed no evidence of a current license to practice nursing in Maryland. Verification of Staff #13's qualifications through Nursys.com, a national license verification website, revealed Staff #13's Tennessee Registered Nurse license had expired on [DATE].On [DATE] at 12:30 PM, surveyor interview with the NHA provided no additional information.

Based on surveyor observation and facility staff interviews it was determined that the facility failed to dispose garbage and refuse properly. This finding was found to be evident during the tour of the kitchen and outside dumpster area during the recertification survey.The findings include:On 1/4/2026 at 9:00 AM the surveyor toured the outside dumpster area with 2 dietary staff members (employees #22 and 23) in attendance. Observation of the dumpster area revealed that the dumpster door was opened and adjacent to the dumpster were 2 bags of trash on the ground. The dietary staff closed the dumpster door and stated that the trash bags were from the housekeeping staff. In an interview at 9:10 AM on 1/4/2026 in the facility lobby with a Licensed Nursing Home Administrator (LNHA) employee #21, the surveyor conveyed that the observation of the dumpster area revealed that the dumpster door was opened and that there were 2 bags of trash on the ground adjacent to the dumpster. Employee #21 acknowledged the surveyor and expressed that he would follow up.In a follow up observation of the dumpster area on 1/4/2026 at 11:30 AM the surveyor observed that the dumpster door was closed and that there were no trash bags on the ground. No additional information was provided by the facility at the time of exit.

Number of residents sampled: Number of residents cited: Based on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure that physicians/ nurse practitioners document resident treatments accurately. This was evident for 1 Resident (#3) of 5 residents reviewed for unnecessary medications during the recertification survey. The findings include: On 01/08/2026 at 10:48 AM, a review of Resident #3's psychiatry notes, dated 01/05/2026 and written by Staff #27, PMHNP, indicated that the resident was to continue Zoloft 200 mg by mouth daily for depression, with no changes indicated today. This dosage was noted to be inconsistent with previous psychiatric notes dating back to 01/14/2025, which documented the dosage as Zoloft 100 mg daily for depression. On 01/08/2026 at 12:24 PM Staff #2, Registered Nurse (RN) was interviewed regarding the process for provider recommendations. They stated that providers typically enter their own orders directly into Point Click Care (PCC) to prevent missed orders. On 01/08/2026 at 3:11 PM the Medication Administration Record (MAR) was reviewed and confirmed the current prescribed dose for Resident #3 was Zoloft 100 mg by mouth daily, with a start date of 7/23/2022 On 01/09/2026 at 09:315AM Staff # 11, interim Director of Nursing (DON), was interviewed and presented with the discrepancy between the 01/05/2026 note's recommendation for Zoloft 200 mg and the MAR Zoloft 100 mg. the DON expressed concern and stated they would clarify the intended Zoloft dosage with the provider. On 01/09/2026 at 12:16 PM, Staff #11, DON, provided documentation showing that Staff #27, PMHNP, had entered a correction note for Zoloft 100 mg po daily.

Based on surveyor observations and facility staff interviews, it was determined the facility failed to 1) ensure that the environment of resident care was maintained in a manner that minimized the potential spread of infection and 2) use appropriate infection control practice during urinary catheter maintenance. This was evident for 4 ( Resident's #37, #1, #2 and #68) out of 24 residents observed during the recertification survey. 1)On 01/05/2026 at 10:40 AM the surveyor conducted observations of resident care areas. Upon entrance into Resident #37's room, it was observed that there were two bags of trash on the bathroom floor. During interview with Registered Nurse, Staff #6, the surveyor showed the bags of trash to Staff #6, who acknowledged that the trash was improperly stored and confirmed that the bags will be disposed appropriately. 2) On 1/4/2026 at 10:30 AM during the initial observation, foley catheter bags for Residents #1, #2, and #68 were observed resting on the floor inside a privacy bag. On 1/4/2026 at 10:54 AM Staff #1, Licensed Practical Nurse (LPN) was shown the bag placement. Staff #1, LPN confirmed the bags should not be on the floor and promptly took corrective action by donning gloves and hanging the foley catheters on the residents' bed hooks.

Based on surveyor observations and facility staff interviews it was determined that the facility failed to maintain a safe, functional, sanitary and comfortable environment for Residents and staff providing assistance to Residents. This finding was found to be evident in 1 shared Resident bathroom (room [ROOM NUMBER]) and in the nursing unit nourishment room.The findings include:The surveyor conducted a tour of the facility on 1/4/2026 at 9:30 AM. The surveyor observed the shared bathroom in Resident room [ROOM NUMBER] and observed that the bathroom did not have a trash receptacle. Further observation of the nursing unit on 1/4/2026, specifically the Medbridge nourishment room, revealed that the plastic ice scoop was found in the portable ice chest that was 1/2 full of ice instead of in a separate holder.At 11:43 AM on 1/4/2026 both Unit Managers were notified and observed the ice scoop in the ice chest with ice and stated that the ice scoop should not be in the ice chest and corrected this.Additionally, the surveyor observed on 1/4/2026 that there was a large hole in the wall in the nourishment room where the door handle hit the wall when the door was opened by the staff. TELS is a building management platform designed for Senior Living with Integrated Asset Management, Life Safety, and Maintenance Solutions. The TELS Platform connects the facility data (work orders, assets, compliance, and capital planning) all in one place. It plans, tracks and manages facility maintenance from one centralized platform. It creates work orders, schedules preventative maintenance and manages assets with full visibility to optimize facility operations.At 11:46 AM on 1/4/2026 the Unit Manager and the Licensed Nursing Home Administrator (LNHA) were notified and observed the hole in the wall in the nourishment room. The LNHA stated that they did not know about this and that it is in TELS now for maintenance repair.On 1/9/2026 at 1:15 PM in an interview with the Maintenance Director the surveyor conveyed that the shared bathroom for Resident room [ROOM NUMBER] did not have a trash receptacle and that there was a hole in the wall in the nourishment room. The Maintenance Director stated that he would notify housekeeping about the trashcan and that he had already repaired the hole in the wall in the nourishment room. At 1:30 PM the surveyor observed that the hole in the wall in the nourishment room had been repaired.No additional information was provided by the facility at the time of survey exit.

Based on surveyor observations and facility staff interviews it was determined that the facility failed to maintain a safe/clean/comfortable/homelike environment for Residents. This finding was found to be evident in the following Resident rooms (room [ROOM NUMBER], 210, 214, 215 and 216) and the facility internet cafe.The findings include:On tour of the facility on 1/4/2026 at 9:30 AM the surveyor observed the facility environment was not in good repair. Resident room [ROOM NUMBER] - baseboard loose and pulling away from wall in bathroom; room [ROOM NUMBER] - wall marred/chipped behind head of bed; room [ROOM NUMBER] - marred/chipped bathroom door and wall above baseboard in bathroom; room [ROOM NUMBER] - marred/chipped bathroom door; and Resident room [ROOM NUMBER] - marred/chipped wall and door. Additionally, the piano bench in the facility internet cafe was severely marred with chipped and splinted wood with sharp edges. In an interview with the Maintenance Director at 1:15 PM on 1/9/2026 the surveyor conveyed the areas in the facility environment (Resident rooms and internet cafe) that were not in good repair. The Maintenance Director and the surveyor observed several of these areas in the facility that were not in good repair. The Maintenance Director acknowledged the surveyor and stated that he would follow up on the repairs.No additional information was provided by the facility at the time of exit.

Based on observations and interviews with facility staff, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: 1) During an initial tour on 6/17/24 at 8:52 AM of the facility's walk-in refrigerator with staff #32, corporate food services manager, the following observations were made: - an opened thickened lemon-flavored water with an open date of 6/10/24 and a use-by date of 6/17/24. Staff #32 stated that once opened, the thickened water must be used in 5 days. Staff #32 then said, I will discard it. - an opened cranberry cocktail juice from concentrate with an expiration date of 9/12/23; staff #32 stated, I will discard it. - an opened thickened apple juice from concentrate, dated 5/24. Staff #32 stated that it was delivered on 5/24. However, it did not indicate an open date or use-by date. Staff #32 stated it should have an open date and use-by date. - opened thickened pomegranate flavored water with no open date and use-by date. - opened thick and easy milk dated 2/7. Staff #32 indicated 2/7 was the delivery but should also have an open and use-by date. - sliced American cheese in a zip-lock bag dated 6/8/24 and a use-by date 6/30/24. Staff #32 stated it should say use by 6/29/24 because we keep it for 21 days from the open date. - sliced ham labelled 6/8/24, and use by 6/30/24. Staff #32 stated, The use-by date should have been 6/22/24. - opened gold medal heavy duty (1 gallon) mayonnaise and not dated; staff #32 stated, It has no open or use by date. - sweet pickle relish (1gal) labeled opened 5/1 and had no use-by date. Staff #32 stated that it should have been thrown away on 6/1. - Half-cut fresh tomato and lettuce in saran wrap had no use-by date. Staff #32 stated, It's not fresh. Every fresh produce should be dated from the date we received it, and we have two weeks from that date to use it. I will discard them. - Cabbage in a box with no use-by date; staff #32 stated it should have been dated with a use-by date. 2) On 6/24/24 at 9:22 AM, the surveyor observed the short-stay unit snack/refreshment refrigerator. The observation revealed pineapple slices in a plastic container not labeled with an open date or use-by date. Staff #22, a registered nurse, was present and stated, It's for a resident; it should have been labeled and dated. 3) An observation on 6/24/24 at 9:51 AM of the long-term care Unit snack/refreshment refrigerator with staff #13, a unit manager showed the following: -opened Thickened pomegranate berry flavored water with an open date of 5/29/24. Staff #13 stated he does not know how long it should be kept once opened. -cake in a gift bag with no use-by date. Staff #13 stated, It's from a family, but it has no date. Before staff take it and put it in the fridge, they should date it. -opened pineapple slices in a container with no date opened. Staff #13 stated, It's for a resident; it should have been labeled and dated. In an interview on 6/24/24 at 9:41 AM, staff #14, the unit manager for the skilled unit, stated that foods to be kept in the snack/refreshment refrigerators had to be labeled, dated, and discarded after three days. In a subsequent interview on 7/1/24 at 1:05 PM, staff #39, the General manager for food services, stated that they labeled the food items when they were to expire upon receiving them. Staff #39 added that the kitchen refrigerators were checked daily to see what items were due to be discarded.

Based on medical record review and resident and staff interview, it was determined that the facility failed to provide the resident or resident representative with a summary of their baseline care plan and a summary of their medications on admission. This was evident for 1 (#64) of 5 residents reviewed for unnecessary medications. The findings include: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is given to the resident and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. 1.1) On 6/20/24 at 12:30 PM, a review of Resident #64's medical record revealed that Resident #64 was admitted to the facility towards the end of April 2024, Review of Resident #64's admission assessment with an assessment reference date (ARD) of 4/28/24 revealed documentation that Resident #64 was able to make him/herself understood and was able to understand others, and the resident was moderately cognitively impaired. Review of an Admission/Readmission Evaluation form, with an effective date of 4/24/24 at 9:59 PM, revealed nurse documentation that Resident #64 had been evaluated and a base line care plan had been developed. On 4/24/24 at 4:42 PM, in a care plan progress note, the nurse documented that when asked, Resident #64 indicated it was okay for the nurse to review the baseline care plans the resident, and the nurse reviewed the baseline care plans, and medications with the resident. There was no documentation to indicate that a copy of their baseline care plan, along with a summary of their medications was offered and/or provided to Resident #64 at that time. Continued review of Resident #64's medical record failed to reveal documentation to indicate that the facility offered or provided the resident and/or the resident representative with a copy of their baseline care plan along with a summary of their medications. 1.2) Further review of the medical record revealed Resident #64 was transferred to the hospital in the beginning of May 2024 and readmitted to the facility in mid to late May 2024. Review of an Admission/Readmission Evaluation form, with an effective date of 5/21/24 at 6:18 PM, revealed nurse documentation that a readmission evaluation of Resident #64 was completed and a baseline care plan for the resident had been developed. There was no documentation in the form to indicate that Resident #64 had been provided a copy of their baseline care plan. On 5/23/24 at 4:31 PM, in a care plan progress note, the nurse documented that on that date, baseline care plans were reviewed with Resident #64. No documentation was found in the progress note to indicate that Resident #64 had been provided a copy of the baseline care plan. Continued review of Resident #64's medical record failed to reveal documentation to indicate that the facility offered or provided the resident and/or the resident representative with a copy of their baseline care plan along with a summary of their medications. The Director of Nurses was made aware of the concerns on 6/21/24 at 11:02 AM and offered no further comments at that time.

Based on medical record review and staff interview, it was determined that the facility staff failed to develop and implement comprehensive, resident centered care plans. This was evident for 1 (#22) of 1 residents reviewed for rehab and restorative and 1 (#64) of 5 residents reviewed for unnecessary medication. 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. 1) During an interview with Resident #22 on 6/17/24 at 3:01 PM, s/he reported that s/he was not doing any kind of therapy and was told that it was not doing him/her any good. Functional mobility is a person's ability to move around independently and safely in their environment to participate in daily activities. This includes movements like standing, bending, walking, climbing, sitting down, and scooting around in bed. Functional mobility can take place at home, work, and in the community, and can contribute to a person's quality of life. On 6/20/24 at 12:22 PM, Resident #22's care plan was reviewed and revealed a functional mobility care plan that indicated a goal to improve as evidenced by blank. Blank was an area where the facility staff was supposed to indicate the evidence of the resident's improvement in functional mobility. Further review of this care plan history indicated that it was initiated as part of the baseline care plan and has had a revision 7 times. All 7 revisions failed to indicate evidence for improvement in the functional mobility goal. On 6/25/24 at 11:07 AM, the Physical Therapist (PT) was interviewed about his involvement in care planning. The PT reported that either he or the Director of Rehab (DOR) participate in care plan meetings but do not update the resident's care plan. The PT also indicated that he thinks it was the social workers who updated the care plan. Later that day at 2:03 PM, the DOR confirmed in an interview the PT's statement that they do not update the care plan and that it was the social services department who updated them. On 6/26/24 at 8:56 AM, the Social Services Director was interviewed, and she denied responsibility of updating the resident's care plan regarding functional mobility stating, I don't update the care plan for that, I wouldn't have any idea about their mobility. The Director of Nursing (DON) was then interviewed on 6/26/24 at 9:59 AM. Resident #22's functional mobility care plan was reviewed with the DON, and she stated, it looks like it came from a template. The DON confirmed that the care plan was not resident-specific. On the same day at 10:17 AM, the DON, together with Nursing Home Administrator, (NHA) discussed the care plan concern with the surveyor. Resident #22's care plan was again reviewed with both staff and confirmed that it did not reflect the resident specific information to convey appropriate treatment and services to maintain, restore or improve abilities with functional mobility. Also, the care plan has had several revisions but the only thing that changed were the revision dates. Both the DOR and the NHA acknowledged the concern. 37276 2) On 6/20/24 at 12:30 PM, a review of Resident #64's medical record revealed that Resident #64 was initially admitted to the facility in April 2024, then, following an acute hospitalization , Resident #64 was readmitted to the facility in mid to late May 2024 with diagnoses which included depression. Review of Resident #64's June 2024 MAR revealed an active 5/22/24 order for Mirtazapine (Remeron) (antidepressant) tablet by mouth at bedtime for an anti-depression that was documented as given every day as ordered from 6/1/24 - 6/19/24. Review of Resident #64's care plans revealed, a care plan, [Resident #64] may have the potential of feeling down/depressed or potential for depression, with the goal, Resident will be given opportunity to ventilate feelings within next 90 days, that had the interventions, 1) Encourage family involvement and visits when able, and 2) Psychology services as needed. The care plan was not comprehensive, with a resident centered, measurable goal and interventions to address the resident's depression and Resident #64's use of the psychotropic medication Mirtazapine, including monitoring the resident's response or lack of response to the medication for the targeted behaviors for which the psychotropic medication had been prescribed, and monitoring for adverse consequences and side effects of the medication. The above care plan concerns were discussed with the Director of Nurses (DON) on 6/21/24 at 11:02 AM. The DON acknowledged the concern and offered no comments at that time

Based on medical record review, pertinent documenatation and staff interviews, it was determined that the facility failed to complete a thorough investigation of an allegation of abuse potential abuse. This was evident for #4 (#137, #104, #107, #108) of 12 residents reviewed for abuse. The findings include Review of Resident #137's medical record on 6/22/24 revealed that the resident had a brief admission to the facility in January 2022. 1) Review of MD00182200, a facility self report of an abuse allegation, revealed that the resident's family had submitted a concern form alleging rough handling by staff while at the facility. Review of the final report by the facility, received by the State Survey Agency on 2/2/22, revealed the alleged events took place on 1/23/22 - 1/24/22 but failed to include a specific shift or name a specific staff member involved. The final report included: Interviews with staff assigned to [him/her] revealed the patient was neither physically or verbally abused . Further review of the facility investigation documentation revealed staffing sheets for evening and night shift of 1/23/22 and day and night shift for 1/24/22 (no sheet was found for 1/24 evening shift). Review of the staffing sheets revealed the resident was cared for by at least 3 different nurses and 3 different geriatric nursing assistants (GNA) on those two days. Further review of the documentation provided by the facility revealed a total of four witness statements: one by a nurse (Staff #12) and three by residents. No documentation was found to indicate that interviews were conducted with any of the other multiple staff that worked with the resident on 1/23 and 1/24/22. Further review of the documentation failed to reveal the concern form that the family had submitted to the facility. It is unclear from the facility report as to when the allegation was initially made to the facility. On 6/21/24 at 2:43 PM, the Nursing Home Administrator (NHA) reported there was no additional documentation regarding this facility report. Surveyor reviewed the concern that, based on the documentation provided, there was a concern form but it was not included, the NHA indicated he would look for the concern form. Surveyor also reviewed that the report indicated that interviews were conducted with staff assigned to the resident but only one staff interview was found despite staffing sheets indicating several different staff were assigned to care for the resident. As of time of survey exit on 7/11/24 at 3:30 PM, no additional documentation was provided regarding these concerns. 50573 2) Review of Resident #104's medical record on 6/28/24 revealed that the resident resided at the facility for a month, needed partial to maximal assistance with Activities of Daily Living (ADLs), was alert and sometimes oriented, and able to verbally communicate. Review of MD00169154, a facility self report of an abuse allegation, revealed that, on 7/5/21 Resident #104 reported that a staff member slapped his/her wrist during morning ADLs and that the facility initiated an investigation. Further review of facility documentation for MD00169154 revealed a final report from 7/6/21 summarizing the incident and concluding that, based on their investigation, they were unable to substantiate the allegation of abuse. This final report indicated the alleged staff was GNA Staff #30. Further record review on 6/28/24 of the facility documentation provided for the investigation revealed that Resident #104 reported to Geriatric Nursing Assistant (GNA, Staff #26) on 7/5/21 at around 7:00 AM that she/he did not like how the night GNA took care of her/him, furthermore, that he was rough. Further review of documentation on 6/28/24 failed to reveal staffing schedules for the shift in which the alleged abuse occurred or how the alleged staff member was identified. On 06/28/24 at 12:48 PM, an interview with the Nursing Home Administrator (NHA, Staff #1) revealed that, when the surveyor asked about abuse allegations and what was the status of alleged employee during the investigation, he indicated that they were suspended. On 6/28/24 at 01:30 PM, an interview with the NHA revealed that there was no further documentation. On 6/28/24 at 02:40 PM, the surveyor reviewed the concern with the NHA that the documentation provided for MD00169154 failed to include staffing assignments and requested to see the schedules from the night shift on 7/4/21 and 7/5/21. Review of interviews with residents revealed that they were asked about GNA (Staff #25) by name, not GNA (Staff #30). Review of the 7/4/21 staffing sheets revealed GNA (Staff #25) was working with the resident on the 7/4/21 night shift. No documentation was found to indicate Staff #30 was working the 7/4/21 night shift. Further review of the staffing sheets revealed GNA (Staff #25) again worked the night shift on 7/5/24. On 07/03/24 at 11:10 AM, the surveyor reviewed the concern with the NHA that GNA (Staff #25) was the one that was working night shift 7/4/21 and then came back to work for night shift 7/5/21. 3) Review of Resident #107's medical record on 7/1/24 revealed that the resident resided at the facility for a month, needed partial to maximal assistance with Activities of Daily Living (ADLs), was alert and somewhat oriented, and able to verbally communicate. Review of MD00196992, a facility self report of a neglect allegation, revealed that, on 9/14/23, Resident #107's family member reported that, on 8/5/23, it took 45 to 60 minutes for someone to come in and change Resident #107 after the family member had asked and that the facility initiated an investigation. Review of the final report indicated that staff interviews were conducted. On 7/03/24, review of MD00196992's investigative documentation revealed that Licensed Practical Nurse (LPN) and Geriatric Nursing Assistant (GNA) who were assigned to the resident on 8/5/23 were identified and a document titled Coaching/Counseling Form signed by both staff members of alleged neglect (LPN, Staff #12 and GNA, Staff #26) indicating that they agreed to answer call lights in a timely manner. However, no documentation of interviews with either of the staff were found. Final review of MD00196992 revealed that the facility was unable to substantiate the alleged neglect. On 07/03/24 at 03:25 PM, the surveyor reviewed the concern with the NHA (Staff #1) that there was no documentation provided to indicate that an interview was conducted with the staff to determine what had occurred that day. 4) Review of Resident #108's medical record on 06/26/24 at 09:53 AM revealed that the resident resided at the facility for over a year, needed partial to maximal assistance with Activities of Daily Living (ADLs), was alert and oriented, and able to verbally communicate. Review of MD00163688, a facility self report of an abuse allegation, revealed that, on 2/12/21, Resident #108 reported that she/he was punched in the leg by a night shift nurse aid and that the facility initiated an investigation. Further review of MD00163688 revealed that the alleged staff perpetrator was identified, but the documentation provided failed to reveal the name of the staff member or any interviews with the alleged staff member and that there is no documentation of the residents that were interviewed or what they had reported. Final review of the documentation provided by the facility on MD00163688 revealed the facility concluded there was no evidence to substantiate the allegation of the abuse incident. On 06/28/24, an interview with the Nursing Home Administrator (NHA #1) revealed that there was no further documentation pertaining to MD00163688. On 06/28/24 at 02:40 PM, the surveyor reviewed the concern with NHA #1 that the facility documentation provided for the incident failed to show documentation identifying the staff of alleged abuse and there was no documentation of any interviews.

Based on interviews and medical record review, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#24) of 4 residents reviewed for position and mobility, 1 (#37) of 3 residents reviewed for vision/hearing, 1 (#84) of 4 residents reviewed for hospitalization , and 2 (#35, #67) of 4 residents reviewed for pressure injuries. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. MDS assessments must be accurate to ensure that each Resident receives the care they need. 1) In an interview on 6/17/24 at 12:25 PM, Resident #24 was asked about having any limitation in his/her range of motion (ROM). The resident responded that he/she could not lift his/her right leg. A medical record review on 6/28/24 at 1:14 PM contained a physical therapy evaluation and plan of treatment dated 12/9/23, that recorded that Resident #24 had a limited range of motion in the left and right legs. Continued review, on 6/28/24 at 2:40 PM, found three MDS assessments for Resident #24 dated 12/20/23, 3/20/24, and 5/3/24. The MDS assessments had recorded that Resident #24 could not walk, required assistance from staff with transferring from one surface to another, and had no limitation in range of motion in section GG0115. In an interview on 6/28/24 at 2:47 PM, staff #9, an MDS coordinator, stated that her process for assessing a resident's limited ROM was through observation and review of documentation by physical therapy, occupational therapy, and nurses. Staff #9 continued to say that she would record the limitations on a resident's MDS assessment if the impaired ROM affected the resident's movement or ability to move. In a subsequent interview on 7/1/24 at 9:46 AM, staff #36, a physical therapist, said a resident's impaired ROM to his/her legs would affect the resident's ability to transfer or walk. However, Resident #24's MDS assessments for 12/20/23, 3/20/24, and 5/3/24 failed to capture his/her limitation in range of motion to the legs. 2) In an interview on 6/17/24 at 2:46 PM, Resident #37's representative reported that Resident #37 had poor vision and hearing. A record review on 6/24/24 at 1:58 PM found an admission MDS assessment, dated 7/1/20, that recorded Resident #37 had moderately impaired vision in section B and blindness to the right eye in section I. Continued review contained an attending provider's note, dated 11/17/2022, which documented that Resident #37 had right eye blindness. A subsequent record review, on 6/24/24 at 3:58 PM, contained a nutritional assessment, dated 12/4/23, which recorded that Resident #37 was edentulous (edentulous is having no natural teeth or tooth fragments in the mouth). Further review found an MDS assessment, dated 2/23/24, which recorded in section L-Oral/Dental status that Resident #37 was not edentulous and in section B that Resident #37 had adequate vision. However, the MDS assessment failed to capture Resident #37's edentulous and impaired vision status. In an interview on 6/26/24 at 8:38 AM, staff #9, an MDS coordinator, reported that she documented sections B and L of Resident #37's MDS assessment, dated 2/23/24 in error. 16218 3) On 6/20/24, review of Resident #84's medical record revealed a Minimum Data Set discharge assessment, with an assessment reference date of 3/25/24, that included documentation that the resident was discharged to a short term general hospital. Further review of the medical record failed to reveal documentation to support that the resident was discharged to a hospital. Review of the medical record revealed a My Transition Home document, dated 3/25/24, which included in Section D Social Services, which was signed by Director of Social Service (Staff #17), the reason for the discharge was the completion of therapy and discharge goals met. The transfer setting was listed as Home/Community (eg.private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements). The area for discharge address was noted to be blank. The section titled My Discharge Goals included that the goal was discharge to ALF. An ALF is an assisted living facility which is a less intense level of care than a skilled nursing facility. Review of a 3/25/24 11:59 AM nursing note revealed .Resident schedule to be discharge to ALF today Review of a 3/25/24 at 4:24 PM nursing note revealed: Resident has an order to be transferred to ALF - [name of a skilled nursing facility]. Transportation arrived and Resident left in stable condition. Review of a 3/25/24 at 4:46 PM social service note, written by Staff #17, revealed: Resident was discharged to another SNF [skilled nursing facility] ([name of the other facility]) on 3/25/24 .Resident was set up with home health services with [name of a home health agency] . Further review of the My Transition Home document, which was signed by the resident's responsible party, failed to reveal documentation to indicate the resident was being discharged to a skilled nursing facility or a hospital. Review of a 3/26/24 at 12:27 PM nursing note, written by the unit nurse manager (Staff #14) revealed: Post discharge and transition home call was made spoke with resident's one of [his/her] daughter, how was how was the first day of discharge home, daughter stated thank you for every thing. On 6/20/24 at 2:59 PM, the MDS nurse (Staff #9) reported she reads the notes to determine where a resident is discharged to. After surveyor reviewed the concern that the discharge MDS indicated the resident went to a hospital, the MDS nurse reported that must have been an error, let me check, I'll do a correction now. On 6/20/24 at 4:26 PM, surveyor reviewed the concern with [NAME] President of Clinical Operations (Staff #20) that based on record review, surveyor cannot determine where the resident went after discharge. Staff #20 indicated she would investigate. On 6/21/24 during a 10:00 AM interview, the Nursing Home Administrator (NHA) reported that he spoke with the family this morning and confirmed the resident was currently at [name of the SNF referenced in SS note]. He confirmed this SNF is not an ALF. On 6/21/24 at 12:15 PM, review of the modified MDS revealed documentation that the resident went to a home/community setting, not a SNF. This assessment was locked but had not yet been submitted. When asked about this discharge assessment, the MDS nurse reported there was some confusion due to documentation that indicated the resident went to an ALF, but that social work reports the resident went to a nursing home. MDS nurse indicated she will change the assessment again. On 6/21/24, surveyor confirmed with the state licensing office that, according to the receiving SNF MDS submission, the resident was admitted to a SNF on 3/25/24. 45139 4) On 6/20/24, review of records revealed that Resident #35 had been a long-term resident of the facility for several years. On 6/25/24 at 11:20 PM, an observation was made of a wound care treatment for resident # 35. The observation revealed that Resident #35 had contractures in both legs. On 6/26/24, review of Resident #35's physical therapy discharge documentation, dated 1/13/2020, was reviewed. Review failed to reveal that Resident #35 had any contractures of his/her right or left legs. On 6/28/24 at 12:12 PM, The hospice visit notes, written by Nurse Practitioner Staff #47, dated 3/20/2021, were reviewed. Review revealed that the resident had a significant contracture of the right knee. On 6/26/24 at 7:55 PM, the MDS for Resident # 35, with the following assessment reference dates, were reviewed for section G0400, Functional Limitations in Range of Motion. The noted dates were: 4/18/21, 10/17/21, 1/17/22, 6/29/22, and 8/13/22. The review failed to reveal that the significant contracture was coded. 06/28/24 at 3:11 PM, MDS Coordinator Staff #9, was interviewed to determine what data sources had been used to document the information in section G0400, Functional Limitations in Range of Motion. The MDS coordinator reported she reviews the following: Residents chart, any physical examinations, nurses' notes, and the GNA documentation. The MDS coordination agreed that 40 percent contracture of the knee was significant and confirmed that it was an error in coding. 50573 5) Review of Resident #67's medical record revealed the resident had resided at the facility since January 2024 to present, used a wheelchair independently, needed partial to maximal assistance with ADLs,was alert and oriented, and able to verbally communicate. Further record review of the initial assessment note, completed on 1/24/24 at 08:49 PM, revealed that Resident #67's skin was intact upon admission. Record review revealed that, on 2/2/2024 at 11:29 PM, a change of condition progress note was completed indicating that during a shift assessment, there was a wound noted on Resident #67's left buttocks and that the wound doctor (Staff #40) was notified. Record review revealed that on 4/19/24 at 01:40 PM, Unit Nurse Manager (Staff #14) completed a nursing progress note which indicated, right lateral heel eschar was noted . Eschar is dead tissue that sheds or falls off from the skin and is commonly seen with pressure ulcer wounds. Further record review revealed that, on 4/19/24 at 02:20 PM, an eINTERACT SBAR Summary for Providers progress note was completed, which indicated that Resident #67 had an open area on the left ischium and left heel. The ischium is part of the pelvis bone that forms the lower and back part of the hip bone. Record review revealed on 4/26/24, a wound note by Medical Doctor (Staff #40) that indicated they were managing Resident #67's wound on the left ischium. Further record review revealed an MDS, with an assessment reference date of 4/28/24, which indicated that Resident #67 had one pressure wound and that the wound was present upon admission. On 06/24/24 at 02:17 PM, an interview with MDS coordinator (Staff #9) revealed that she used the nursing assessments and notes from the wound doctor to complete the skin section of MDS assessments. The surveyor explained that, according to the 4/28/24 MDS for Resident #67, he/she had 1 wound and it was marked as being present upon admission. Staff #9 explained she would look into it and get back to the surveyor to confirm. On 06/24/24 at 02:47 PM, an interview with Staff #9 confirmed that Resident #67 developed the wound at the facility and the coding of it being present upon admission was an error. Surveyor requested clarification from Staff #9 regarding the number of pressure wounds that were present at the time of the 4/28/24 admission. On 6/24/24 at 3:40 PM, Staff #9 confirmed Resident #67 had two additional wounds that were not captured on the 4/28/24 MDS assessment. On 06/27/24 at 02:01 PM, the surveyor expressed the concern to the Director of Nursing that an MDS assessment failed to correctly reflect a resident's status.

Based on surveyor review of clinical and administrative records and interviews with facility staff, it was determined that the facility staff failed to verify the accuracy of the physician's orders [REDACTED]. This deficient practice placed the resident at risk for serious medication side effects. This finding was evident for 1 of 5 residents selected for review during the complaint survey and was related to complaint MD 697 (Resident #1). These failures resulted in an immediate jeopardy (IJ) being identified on 03-04-2020 at 11:13 AM related to the facility's failure to administer medications according to physicians' orders (Resident #1). On 03-04-2020 at 1:35 PM, the facility staff submitted an IJ removal plan, which was accepted. The IJ was removed on 03-04-2020 at 4:33 PM after confirmation that the plan had been fully executed. After removal of the immediacy, the deficient practice remained at a scope and severity of D. The findings include: On 03-02-2020, surveyor review of Resident #1's clinical record revealed on 02-20-2020, Resident #1 went to a neurology appointment and returned to the facility with a new physician's orders [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] is a medication used to treat [MEDICAL CONDITION]. [MEDICAL CONDITION] is a progressive nervous system disorder that affects movement. A review of the physician's order [REDACTED].#1 transcribed the order for [MEDICATION NAME]-[MEDICATION NAME] four (4) times a day, but did not discontinue the previous order for [MEDICATION NAME]-[MEDICATION NAME] three (3) times a day. According to Resident #1 ' s Medication Administration Record [REDACTED]. Further review of Resident #1 ' s MAR indicated [REDACTED]. On 02-22-2020 at 2:00 PM, Resident #1 was noted to have altered mental status and low blood pressure. The attending physician was contacted and ordered to transfer the resident to the hospital. On 02-22-2020 at 6:21 PM, Nurse #3 documented that the nursing supervisor discovered there were duplicate orders of [MEDICATION NAME]-[MEDICATION NAME] since 02-20-2020 resulting in the resident receiving multiple additional doses of [MEDICATION NAME]-[MEDICATION NAME] for two days. In addition, the resident's blood pressure was low (85/56), resulting in the physician ordering to transfer the resident to the emergency room for evaluation. On 03-03-2020, surveyor review of the Resident #1's hospital records written on 02-22-2020 revealed the resident was transferred to the emergency room from the facility for altered mental status as a result of [MEDICATION NAME]-[MEDICATION NAME] intoxication. On 03-02-2020 at 11:24 AM, interview with Nurse #1 revealed she received the new order on 02-20-2020 to increase the [MEDICATION NAME]-[MEDICATION NAME] to four (4) times a day but forgot to discontinue the previous order for three (3) times a day in Resident #1 ' s electronic record. Nurse #1 stated Nurse #3 told her about the duplicate order on 2-20-2020 and she asked Nurse #3 to discontinue the previous order. On 03-02-2020 at 11:50 AM, interview with Nurse #3 revealed she worked on 02-20-2020 during the 3:00 PM -11:00 PM shift and realized there was a duplicate order for [MEDICATION NAME]-[MEDICATION NAME]. Nurse #3 confirmed Nurse #1 asked her to discontinue Resident #1 ' s previous order for [MEDICATION NAME]-[MEDICATION NAME] three (3) times a day. Nurse #3 stated she acknowledged the request and promised to do it, but forgot later during the shift. Nurse #3 further stated she documented that she gave the resident the 02-20-2020 6:00 PM dose of [MEDICATION NAME]-[MEDICATION NAME], but in actuality did not give the dose of medication to the resident at 6:00 PM. On 03-03-2020 at 9:45 AM, surveyor interview with Nurse #2 revealed she was assigned to Resident #1 on 02-21-2020 and 02-22-2020. Nurse #2 stated she documented that she administered three (3) extra doses of [MEDICATION NAME]-[MEDICATION NAME] to Resident #1 on 02-21-2020 and two (2) extra doses of [MEDICATION NAME]-[MEDICATION NAME] to the resident on 02-22-2020. On 02-22-2020 at 2:00 PM Resident #1's family noticed the resident was lethargic and requested Resident #1 be transferred to the hospital. On 03-03-2020 at 11:30 AM, interview with the Director of Nursing (DON) revealed the 11:00 PM - 7:00 AM licensed nurses are supposed to check all new electronically transcribed physician orders [REDACTED]. The DON confirmed that this was not done by the nurse who worked the night of 02-20-2020, resulting in duplicate orders for Resident #1 ' s [MEDICATION NAME]-[MEDICATION NAME] medication. In addition, the DON stated she was on leave for multiple weeks and the 11:00 PM-7:00 AM nurses failed to check new electronically transcribed physician orders [REDACTED]. On 03-02-2020 at 12:05 PM, interview with the Assistant Director of Nursing and Administrator revealed the facility administration discovered the medication error on Monday 02-24-2020. The three nurses involved in the incident were provided education regarding transcribing physician orders [REDACTED]. On 03-04-2020 at 11:13 AM, an immediate jeopardy (IJ) was determined due to the facility ' s failure to administer medications according to physicians ' orders (Resident #1). On 03-04-2020 at 01:35 PM, the facility staff submitted the IJ removal plan which included the following: -On 02-22-2020, Nurse #2 informed Resident #1 ' s attending physician of the additional [MEDICATION NAME]-[MEDICATION NAME] doses administered to Resident #1 on 02-21-2020 and 02-22-2020. Resident #1 was transferred to the hospital for evaluation. -On 02-24-2020, the Assistant Director of Nursing identified six (6) residents who went out to a doctor ' s follow up appointment in the month of February 2020 and reviewed recommendations from the appointments to validate that all recommendations were transcribed accurately. -On 02-25-2020, Resident #1 returned to the facility and all orders for [MEDICATION NAME]-[MEDICATION NAME] were discontinued per the attending physician. -100% of active licensed nurses were in-serviced by 03-02-2020 to ensure that current interventions are reviewed prior to initiating new interventions to include accurate transcription, all new physician appointment recommendations are reviewed by the supervisor on duty and new physicians ' orders are placed in the 24 hour report binder, and night shift licensed nurses will audit all new physicians ' orders and make the audit available for morning clinical meeting. -On 03-03-2020, the Director of Nursing reviewed Resident #1's physician orders [REDACTED]. -On 03-03-2020, the Director of Nursing initiated reviews of all residents ' physicians ' orders to validate that they were transcribed accurately. -Finally, the removal plan stated that the Director of Nursing will perform random audits of new physician orders [REDACTED]. Results of these audits will be reported to the facility ' s Quality Assurance and Performance Improvement Committee (QAPI) for appropriate action to be taken. On 03-04-2020 at 04:33 PM, the administrator and DON were notified that the surveyors had verified that the removal plan had been fully implemented as of 03-04-2020 at 04:00 PM, and the immediacy was removed.

Based on surveyor review of the clinical records and interview of the facility staff, it was determined the facility staff failed to ensure a resident without a pressure sore did not develop pressure sores. This finding was identified during the investigation of complaint MD 850 and is considered valid. This finding was identified in 1 out of 4 residents selected for review during a complaint survey. The findings include: Resident #1 was admitted to the facility 02-08-16 for rehabilitation after a hospitalization for acute onset of left hip pain which was diagnosed as advanced [MEDICAL CONDITION] arthritis. In addition to other diagnoses, the resident also has diabetes. On 04-27-16 at 2 PM, interview of the complainant revealed that, upon resident #1's admission, they asked the facility staff if resident #1's footboard could be removed because the resident was over 6 feet tall and the feet were rubbing against the footboard. On admission, review of the nursing admission assessment, physician's history, and physical dated 02-09-16, revealed that the resident had no open wounds or skin alterations. In addition, resident #1's height was noted to be 6 ft 2 in. A Braden Risk Assessment was completed to evaluate the possibility of resident #1 developing a pressure sore. The results revealed that the resident was at risk of developing a pressure sore with a score of 15. A care plan was initiated on admission revealing that the resident was at risk for alteration in skin integrity related to impaired mobility, and diabetes. The interventions included to encourage the resident to reposition as needed; observe skin condition with ADL (activity of daily living) care daily, and report abnormalities; use assistive device as needed, pressure redistributing device on bed (air loss mattress,(sic)); provide preventative skin care routinely and PRN(as needed). The facility did not provide any provisions to accommodate and make the resident comfortable, such as a longer bed or removing the footboard. There is no evidence of an assessment or care plan to address this concern. The admission MDS, dated [DATE], revealed under functional status, that the resident required extensive assistance with 1 person physical assist for both bed mobility and transfers. The Minimum Data Set (MDS) is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and health problems to assist nursing home staff with the provision of appropriate care. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. On 02-14-16, a nursing note revealed resident noted with scattered excoriated buttocks, red with no drainage, site measures 3 x 3 (cm), treatment order obtained to apply z-guard, a skin protectant q (every) shift and brief change . The resident had an indwelling catheter. An indwelling catheter is a tube placed into the bladder to allow urine to flow out of the body into a bag. On 02-17-16, resident #1 was seen by the facility's wound nurse who noted Right buttock with stage II pressure wound, appears to be an open blister 4 x 4 cm, pink/red base, no drainage Left heel 6 x 8 cm stage II pressure blister, fluid filled, pt on low air loss mattress ordered marathon (liquid skin protectant) to L heel q 3 days, float heels, hydrogel to R buttock with dressing qd (daily) A Stage II pressure sore is a partial thickness / loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. It may also present as an intact or open/ruptured blister. On 02-17-16, a skin note revealed 1. right buttock wound stage II pink/red with no drainage no depth, no odor, site measures 4 x 4, will start to apply hydrogel daily and PRN (as needed), 2. left heel soft blister, no drainage, no depth, area soft related to fluid, site measures 6 x 8, will continue with Marathon (skin protectant) q 3 days and float heels while in bed and in w/c (wheelchair), wound rounds today with the team. Preventative measures put into place at this time included the treatments as ordered and to float the heels, which were documented as being performed in February. The care plan also included: encourage and assist as needed to turn and reposition, use assistive devices as needed (which were not documented in February as being performed). There was no evidence that the length of the bed was addressed. A nutritional assessment completed on 02-15-16 revealed no evidence of any skin issues. There was no evidence that the dietician was notified of the new open areas. The next assessments for these open areas were to be done on 02-24-16, every 7 days. However, on 02-24-16, resident #1 had an appointment with an orthopedist and was not in the facility at the time that the dressing was to be changed and assessed. There was no evidence that the assessment was ever completed or care provided. Review of the medical record revealed that the resident went to the hospital on 02-28-16 after a fall, and a low blood sugar. The hospital records revealed the following: The hospital ER admission history and physical on 02-28-16 revealed evidence of the buttock decubitus ulcer, and and an ostomy consult (wound consult) was ordered. The hospital discharge summary, dated 03-01-16, under hospital course revealed an ostomy consult was done concerning the buttock pressure ulcer. Included was: per notes left plantar fore-foot with an intact SDTI (suspected deep tissue injury) this area was protected with skin prep, allowed to dry and the footboard was removed as well as the heel was floated off the bed- resident #1 also had a left heel intact blood filled blister that is also a SDTI - resident #1 was admitted with this ulcer and skin prep applied and allowed to dry. Resident #1 also had the right buttock ulcer re-evaluated as well- cleansed with normal saline, pat dry, applied santyl, a [MEDICATION NAME] agent, and cover with a dampened 4x4 applied to cover. There was no evidence of any measurements for these wounds in the hospital. On 03-02-16, the nursing admission assessment, revealed under the skin section, evidence of no existing pressure ulcers, but then identified a wound on the right buttock measuring 4.5 x 7 cm, and the left heel soft tissue filled with fluid and purple measuring 6 cm x 8cm. The left plantar foot area was also identified as a blister measuring 6 x 6 cm and purple. Treatments were ordered; skin prep for the left heel and plantar area. The buttock wound had an order for [REDACTED]. On 03-09-16, resident #1 was seen on wound rounds by the wound nurse. The following was identified: 1. the pressure ulcer to the right buttock, now unstageable and measures 14 x 6 cm with 50% open, purple suspected DTI, with 25% slough and 25% granulation and small sudsy drainage, an increase in size from 4.5 x 7 2.adjacent to the skin wound is a sacral area 3 x 1cm SDTI, open purple 50%, 50% granulation, a new opening 3. left heel with SDTI with purple blister no drainage 8 x 10 cm., an increase in size from 6 x 8 cm 4. left plantar SDTI with purple blister,9 x 8 cm, no drainage, an increase from 6 x 6 cm 5. right plantar foot now with stage II pressure ulcer 3.5 x 5.5 cm with intact fluid blister, a new opening. Patient is over 6 feet and has feet on footboards. The recommendation was to extend the footboard to remove the feet from being in constant contact with the footboard. On 04-28-16 at 2 PM, interview with the ADON revealed that the footboard was extended after the wound nurse's visit, either on 03-09-16 or 03-10-16. He could not recall hearing the resident's family member asking for the footboards to be removed prior to that day. The staff were floating the heels and encouraging repositioning. Resident #1 was 6 ft 2 in and the bed was not long enough to allow for the resident to be comfortable especially when the head of the bed was in a raised position. In summary, Resident #1 was admitted in February 2016 to the facility requiring extensive assistance for bed mobility and at risk for developing pressure ulcers. The resident subsequently developed pressure ulcers on the right buttock and left heel. During and before that time, there was no documented evidence that he/she received regular assistance with turning and positioning while in bed during the month of February 2016. Furthermore, the resident was later sent to the hospital and returned with an additional blister on the left foot plantar area, which the hospital felt was caused by the footboard on the hospital bed, which was removed. Eight days after the readmission, a new area occurred on the right plantar area. Despite the development of 2 pressure ulcers on the resident's left foot, the initial concern about the footboard from the complainant, and the concern about the footboard raised in the hospital discharge summary, there was no evidence that the facility evaluated the bed/footboard to prevent development or progression of pressure areas from the time of admission until March 9, 2016.