Every finding on record at Montgomery Village Care Center

Based on record review and interviews, it was determined that the facility failed to ensure that residents' Electronic Health Records (EHR) accurately reflected their cognitive status. This was evident for 2 out of (Resident #11 and #93) out of 7 residents reviewed for advanced directives during the recertification survey. The findings include: On 06/01/2026 at 12:18 PM, the surveyor performed a record review. Resident #11's EHR stated that the resident was his/her responsible party. Resident #11 had a medical diagnosis of dementia, a Brief Interview for Mental Status (BIMS) score of 1, and a physicians' certification of incapacity to make an informed decision. Resident #11's discharge summary note from 05/19/26 stated that he/she is alert, oriented, verbalized understanding of all discharge instructions provided and will sign all necessary discharge paperwork prior to discharge. On 06/01/2026 at 12:35 PM, the surveyor performed a record review. Resident #93's EHR stated that the resident was his/her responsible party. Resident #93 had a medical diagnosis of dementia, a Brief Interview for Mental Status (BIMS) score of 1, and a physicians' certification of incapacity to make an informed decision. On 06/02/2026 at 12:40 PM, the Social Services Director stated that residents with incapacity certifications do not have the ability to make decisions independently. On 06/02/2026 at 12:55 PM, the Director of Nursing acknowledged the concern.

Based on record review and staff interviews, it was determined the facility failed to ensure consent for psychotropic medications was obtained and maintained in accordance with resident decision-making capacity. This deficient practice was evident for 4 (Resident #4, Resident #5, Resident #3, Resident#8) of 5 residents reviewed for psychotropic medication consent during the annual survey.The findings include:Psychotropic medication is any drug that affects brain activities associated with mental processes and behavior.1.) On 06/03/2025 at 7:45 AM, a review of Resident #4's medical record revealed that on 11/30/2022, and 12/05/2022, two physicians certified the resident lacked decision-making capacity due to dementia and delirium. Further review of the record showed the facility identified the resident's family member as the substitute decision maker. However, the records failed to show documented evidence that the resident's family accepted or agreed to serve in the role of a surrogate decision maker. Records also showed that on 07/23/2025, the resident's family member consented to the use of psychotropic medications.2.) On 06/03/2026 at 7:45 AM, a review of Resident #5' psychotropic medication consent form, revealed the resident was prescribed two psychotropic medications in August 2025 for dementia. Further review of the consent form failed to show documented evidence of the name or signature of the individual providing consent for the medications.On 06/03/2026 at 8:26 AM, during an interview, the surveyor and Assistant Director of Nursing (ADON) #25 reviewed Resident#5's psychotropic medication consent form. The ADON #25 acknowledged the name and signature of the resident's surrogate were not documented on the form. When asked whether a progress note or other documentation supported that consent was obtained from the surrogate, the ADON #25 stated she did not document a progress note and had no additional documentation to support that consent was obtained3.) On 06/03/2026 at 10:28 AM, a review of Resident #3's psychotropic medication consent form dated 09/12/2024, showed consent was obtained for Olanzapine. Further review of the medical record revealed the resident was prescribed Clozapine with a start date 09/13/2024 for Schizophrenia. The records failed to show documented evidence of consent for Clozapine.During an interview regarding Resident #3's psychotropic medication consent form, the Divisional Director of Quality Assurance #4 stated she reviewed the form with the nurse who completed it. The Divisional Director of Quality Assurance #4 stated the nurse reported the incorrect medication was documented on the consent form. The Divisional Director of Quality Assurance #4 further stated the facility did not have documented evidence of the resident's consent for Clozapine.4.) On 06/03/2026 a review of Resident #8's medical records revealed the resident consented to psychotropic medication on 04/02/26. Further review of psychiatry progress note dated 03/11/2026, 12/17/2025, and 10/01/2025, described the resident as thought blocking, severely confused, and having illogical responses.On 06/03/2026 at 2:00 PM, the surveyor discussed concerns with the Divisional Director of Quality Assurance #4 regarding Resident #8's documented mental status and ability to provide informed consent for psychotropic medications. The surveyor also discussed concerns identified for Resident #3, Resident #4, and Resident #5 related to psychotropic medication consent form. The Divisional Director of Quality Assurance #4 acknowledged the concerns and stated the facility was developing a plan to address the issue and identify other potentially affected residents

Based on record review, and staff interviews, it was determined that the facility failed to properly identify, verify, and document a legally authorized resident representative to exercise the rights of a resident who lacks capacity. This deficient practice was evident for 2 (Resident #8 and Resident #71) of 2 residents reviewed for rights exercised by representative during the annual survey. The findings include: The BIMS score, short for Brief Interview for Mental Status, comes from a quick test that looks at how well you think, learn and remember. Scores range from 0 to 15. Lower scores can point to difficulties with memory or thinking (cognitive) skills. BIMS score: 13 to 15: Normal thinking and memory (no or very little impairment) 8 to 12: Moderate problems with thinking and memory 0 to 7: Severe problems with thinking and memory 1.) On 06/02/2026 at 11:56 AM, a review of Resident #8's medical records revealed the resident was admitted to the facility on [DATE]. At the time of admission, the residents BIMS score was 14. The following BIMS assessment completed on 09/22/2025 revealed a score of 11. The resident was reassessed on 12/23/2025, with a BIMS score of 7, and again on 03/25/2026, with a BIMS score of 3. Further review of the medical records revealed psychiatry progress note dated 10/01/2025, 12/17/2025, and 03/11/2026, which described the resident as severely confused, thought blocking, and having illogical responses. The records failed to show evidence that the facility made attempts to establish a surrogate decision maker after records indicated a clear cognitive decline. During an interview on 06/02/2026 at 1:17 PM, the Director of Social Services #5 and the Regional Director of Social Work #10 stated that residents identified with two or more consecutive low BIMS scores would warrant a psychological evaluation to rule out any underlying conditions. They further explained that following the evaluation, staff would contact the physician to obtain a physician certification for lack of mental capacity. The surveyor informed both staff members (#5, #10) of Resident #8's consecutive low BIMS and psychiatry progress notes documenting cognitive impairments. Neither staff members (#5, #10) could provide an explanation as to why attempts had not been made to establish a surrogate decision maker. 2.) On 06/01/2026 at 12:05 PM, a review of Resident #71's medical records revealed the resident was identified as their own responsible party at the time of readmission to the facility on [DATE]. Further review of the records indicated a BIMS assessment was completed on 12/31/2025 and revealed a score of 14. The resident was reassessed on 03/31/2026 with a BIMS score of 2, and again on 04/17/2026 with a BIMS score of 1. The records failed to show documented evidence that the facility made attempts to establish a surrogate decision maker for the resident. On 06/02/2026 at 9:46 AM, the surveyor informed the Director of Social Services #5 of the concerns identified for Resident #8 and Resident #71. The surveyor asked if the facility had surrogate decision maker documents for the residents. The Director of Social Services #5 stated she would review the residents' medical records and follow up with the surveyor. The Director of Social Services #5 was not about to provide the requested information. On 06/03/2026 at 2:00 PM, the surveyor discussed the identified concerns for Resident #8, and Resident #71 with the Divisional Director of Quality Assurance who acknowledged the concern.

Based on observation, staff interviews, and record review, it was determined that the facility failed to follow professional standards of practice when administering intermittent intravenous (IV) antibiotic infusions. This was evident for 1 (Resident #53) out of 1 resident observed for IV therapy. The findings include: On 6/1/2026 at 9:49 AM, the surveyor observed Resident #53's IV tubing. The IV tubing was not dated or labeled. On 6/3/2026 at 12:28 PM, the surveyor again observed Resident #53's IV tubing. The IV tubing was not dated or labeled. In addition, the end of the IV tubing was not capped and was connected to the lower port. On 6/3/2026 at 12:31 PM, the surveyor interviewed RN #6 regarding IV tubing practices. Registered Nurse, RN #6 stated that IV tubing should be changed every day and that the end of the IV tubing should be capped when not in use. On 6/3/2026 at 12:41 PM, the surveyor conducted an additional review of Resident #53's medical record. The record revealed an order for an IV antibiotic to be administered every 12 hours. However, there was no physician's order or documented direction for IV tubing changes. On 6/3/2026 at 1:19 PM, the [NAME] President of Clinical Services (VPCS) acknowledged the concern and provided a new order for IV tubing changes every 72 hours. The VPCS stated that staff education regarding IV tubing practices was in progress.

Based on record review and staff interviews, it was determined that facility staff failed to properly manage care choices for residents in the absence of an advance directive. This deficient practice was evident for 2 (Resident #16 and Resident #4) of 7 residents reviewed for Advance Directives during the annual survey. The findings include: 1.) On 06/02/2026 at 8:24 AM, a review of Resident #16's medical records revealed the resident was admitted to the facility in February 2025 with multiple medical diagnoses including dementia. At the time of admission, the resident was screened for Advance Directive (AD). Records revealed that an AD form was reviewed with the resident, and a copy was provided; however, the resident declined to formulate an AD. Further review of the medical records revealed that on 04/05/2025, two physicians certified that the resident lacked the capacity to make healthcare decisions due to dementia. The records failed to show documented evidence that the facility made attempts to establish a legal surrogate decision maker. 2.) On 06/02/2025 at 8:45 AM, a review of Resident #4's medical record revealed, the resident was initially admitted to the facility in September 2022 and readmitted to the facility June 2025. At the time of admission on [DATE], the resident was screened for an AD. Records revealed that an AD form was reviewed with the resident, and a copy was provided; however, the resident declined to formulate an AD. Further review of the records indicated on 11/30/2022, and 12/05/2022, two physicians certified the resident lacked decision-making capacity due to dementia and delirium. The records failed to show documented evidence that the facility made attempts to establish a legal surrogate decision maker. On 06/02/2026 at 9:46 AM, the surveyor informed the Director of Social Services #5 of the concerns identified for Resident #16 and Resident #4. The surveyor asked if the facility had a surrogate decision maker document for the residents. The Director of Social Services #5 stated she would review the residents' medical records and follow up with the surveyor. The Director of Social Services #5 was not able to provide the requested information. On 06/03/2026 at 2:00 PM, the surveyor discussed the identified concerns for Resident #16 and Resident #4 with the Divisional Director of Quality Assurance who acknowledged the concerns.

Based on observation and interviews with facility staff, it was determined that the facility failed to ensure that the environment of resident's care area was kept safe and sanitary. This was evidenced by the paper towel dispenser missing the front cover, which exposed paper towels in the bathroom. This was evident for 2 (Resident #9 and Resident #14) of 160 residents observed during the annual survey. The findings include: On 06/01/2026 at 11:10 AM, during the initial observation of room [ROOM NUMBER] for Resident #9 and #14's bathroom, the front cover of the paper towel dispenser was missing, exposing brown paper towels. The dispenser was located next to the mirror on the wall between the toilet and the sink. On 06/01/2026 at 1:25 PM, the Director of Nursing (DON) was informed that the paper towel dispenser was missing the front cover in Resident's #9 and #14's bathroom and that this was a concern. The DON verbalized understanding. On 06/02/2026 at 9:15 AM, during the second observation of the bathroom for Resident #9 and #14, the paper towel dispenser was observed with the front cover still missing, exposing brown paper towels. On 06/02/2026 at 10:53 AM, the Nursing Home Administrator (NHA) was interviewed and was asked how staff inform Maintenance when something is broken. NHA stated staff should put what was broken in Tels, their electronic system to communicate with Maintenance. On 06/02/2026 at 1:50 PM, the Director of Housekeeping, Staff #23, was interviewed and asked if they were aware that the paper towel dispenser in room [ROOM NUMBER]'s bathroom was missing the front cover. Staff #23 stated, yes, I am, but just because the cover is missing the paper towel dispenser still works, staff just needs to push the blue button, and the paper towels will come out. Staff #23 stated that when the cover is defective, the automatic sensor to remove the paper towels without touching the device does not work, therefore the cover must be removed, and staff must push the blue button to get the paper towels out of the machine. Staff #23 also stated, I have put an order in to replace 5 or 6 paper towel dispensers in the facility. Staff #23 was then asked to provide a copy of the request to fix the paper towel dispenser from Tels. On 06/04/2026 at 10:33 AM, the Tels report was received, showing that the request to repair the paper towel dispenser in room [ROOM NUMBER] was put in Tels on 6/1/2026, which was the first day of the survey when the surveyor observed the missing cover to the paper towel dispenser in room [ROOM NUMBER] and notified the facility.

Based on review of resident medical records and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for a resident receiving hemodialysis. This was evident in 1 (Resident #15) of 8 residents reviewed for MDS accuracy during the recertification survey. The findings include: In the long-term care (LTC) setting, MDS stands for Minimum Data Set. It is a federally mandated, standardized clinical assessment tool used in Medicare and Medicaid-certified nursing homes to evaluate every resident's functional, cognitive, and health status. On 6/2/2026 at 12:24 PM, the surveyor interviewed Staff #24 regarding Resident #15's MDS 5 Day assessment dated [DATE]. Staff #24 stated that s/he did not code hemodialysis in Section O of the MDS assessment because there was no documentation in the progress notes indicating the resident had attended hemodialysis. Staff #24 stated there was no other way to determine this information. On 6/3/2026 at 7:30 AM, the surveyor reviewed the dialysis communication book and found a dialysis communication sheet covering the look-back period of the MDS assessment. On 6/3/2026 at 8:30 AM, the surveyor interviewed [NAME] President of Clinical Services (VPCS), who stated that the facility does not consider the dialysis communication book part of the medical record but agreed that dialysis documentation should be part of the medical record. On 6/3/2026 at 8:39 AM, the surveyor conducted an additional review of Resident #15's medical record. The review revealed physician orders on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) related to dialysis. Therefore, documentation was available in the medical record indicating that Resident #15 received dialysis during the MDS look-back period of 5/1/2026 - 5/3/2026. On 06/03/2026 at 9:50 AM, the VPCS acknowledged that the Minimum Data Set (MDS) was not coded accurately and the documentation showed Resident #15 received hemodialysis on 5/1/2026.

Based on interviews and record review, it was determined that facility staff failed to ensure residents responsible party were provided care plan meeting invitations and failed to conduct quarterly care plan meetings within the required timeframe. This deficient practice was evident for 2 (Resident #2 and Resident #5) of 3 residents reviewed for care plans during the annual survey. The findings include: 1.) On 06/01/2026 at 12:33 PM, during an interview, Resident #2, stated they were unsure how often care plan meetings were conducted. The resident further stated they were not certain whether care plan meetings occurred at least every three months. A review of Resident #2's medical records on 06/02/2026 at 9:07 AM revealed the resident's family member was identified as the legal guardian. Further review of the records indicated that care plan meeting invitations were provided to the resident rather than the resident's guardian. The records also revealed a care plan meeting was scheduled in October 2024, and the following care plan meeting was scheduled in March 2026 which exceeded the required quarterly timeframe. 2.) A review of Resident #5's medical records on 06/02/2026 at 9:07 AM, revealed the resident's spouse as the surrogate decision maker. Further review of the records indicated that a care pan meeting invitation was provided to the resident rather than the resident's designated surrogate decision maker. The records also revealed a care plan meeting was scheduled in April 2025, with the following care plan meeting conducted in February 2026, which exceeded the required quarterly timeframe. On 06/02/2026 at 9:11 AM, during an interview, the Director of Social Services #5 explained that care plan meetings were conducted upon admission, quarterly, with a change in the resident condition, or upon request by the resident or the resident's responsible party. She further explained that for residents lacking mental capacity, care plan meeting invitations were sent to the resident's responsible party. She stated that care plan meeting invitations were generally sent by mail or email one to two weeks prior to the scheduled care plan meeting. The surveyor informed the Director of Social Services #5 of missing care plan invitations for Resident #2 and Resident #5, and the lack of quarterly care plan meetings. The surveyor requested documented evidence of quarterly care plan invitations and care plan conference notes for both residents for the previous 12 months. The Director of Social Services #5 followed up with the surveyor and could not provide the requested documentation. On 06/03/2026 at 2:00 PM, the surveyor discussed the identified concerns for Resident #2 and Resident #5 with the Divisional Director of Quality Assurance who acknowledged the concerns.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure the environment was maintained in a manner that minimized the potential spread of infection as evidenced by 1) oxygen tubing was on the floor, 2) foley catheter bag was on the floor, and 3) the laundry area. This was evident for 2 (Resident #1, #17) of 160 residents and the laundry area observed during the annual survey. The findings include: 1.) On 06/01/2026 at 8:57 AM, Resident #1's oxygen tubing was observed wrapped around the oxygen concentrator with the nasal cannula, the part of the tubing that goes in Resident #1's nose, was observed on the floor. On 06/01/2026 at 8:59 AM, Staff #8, Registered Nurse (RN) was shown Resident #1's oxygen tubing was on the floor. Staff #8 verbalized that the oxygen tubing being on the floor was an issue and put on gloves, discarded the tubing and went to get new oxygen tubing for Resident #1. 2.) On 06/01/2026 at 8:14 AM, Resident #17's foley catheter was observed on the floor. On 6/01/2026 at 9:10 AM, Resident #17's foley catheter was again observed on the floor. On 06/01/2026 at 9:20 AM, Staff #9, Licensed Practical Nurse (LPN) was interviewed and asked if Resident #17's foley catheter should be on the floor, Staff #9, LPN replied no, verbalized understanding that this was an issue and put on gloves and adjusted the foley catheter, so that the foley bag was no longer touching the floor. 3.) On 6/4/2026 at 11:43 AM, the surveyor observed that there was no door or physical barrier between the designated clean and soiled areas in the laundry room. The two areas were open to one another, increasing the risk of cross-contamination. On 6/4/2026 at 11:53 AM, the surveyor interviewed the Administrator. The Administrator stated that the laundry room never had a door separating the sections and that they would look into it. During a follow-up interview on 6/5/2026 at 7:15 AM, the Administrator stated that they were still working on the door between the clean and soiled laundry areas and acknowledged that the lack of a door was a potential infection control concern.

Based on observations and staff interviews, it was determined that the facility failed to ensure that call bells were kept within reach for residents to utilize. This was found to be evident for 8 (Residents #3, #23, #45, #49, #53, #73, #99, and #105) of 44 residents observed on the 4th floor of the facility during the recertification survey. The findings include: During observations of the 4th floor of the facility during the morning on 4/3/2025, the surveyor observed call bells on the floor and not within reach of Residents #3, #23, #49, #53, #73, #99, and #105. Further observations by surveyor on 4/4/2025 revealed the call bell on the floor for Resident #45 and call bells on the floor and not accessible for Residents #3, #49, and #73. On 4/7/2025 at 3:30 PM, Geriatric Nursing Assistant (GNA) #15 was interviewed by the surveyor and stated that it is the facility's expectation that call bells are within reach of residents and that facility staff will check when entering and exiting resident rooms that call bells are accessible. The Director of Nursing (DON) was interviewed on 4/8/2025 at 12:19 PM. The DON was made aware with concerns about inaccessible call bells for residents on the 4th floor of the facility and stated she would go upstairs and investigate. The DON stated that the facility does have a call bell audit process that is headed by the facility educator. On 4/8/2024, the facility call bell policy was reviewed which stated that staff will ensure the call light is within reach of resident and secured, as needed, and the call system will be accessible to residents while in their bed or sleeping accommodations within the resident's room.

Based on observation and interviews, it was determined that facility nursing staff failed to follow professional standards of nursing practice when administering medications to residents.This was evident for 1 (Resident # 393) of 39 residents during a random observation on the annual survey. The findings include: Based on complaint MD00214790, allegedly Resident # 396 on two different occassions, medications were found on his/her bed. It was noted to have 5 medications found on the first occassion and 1 medication on the second occurence. On 4/09/2025 at 11:19 AM, two Surveyors entered Resident #393's room to conduct an interview. The surveyors observed a medication cup on top of the overbed table for Resident #393. There were 5 pills inside the medicine cup, unlabeled. Resident #393 stated that it was left by Staff # 24 around 2 minutes ago before the surveyors came in. The Surveyor asked if he/she knew what those pills were. He/She was able to identify a few but not all. While surveyors were interviewing the resident, Staff # 24, registered nurse (RN), came to the room and asked Resident # 393 if he/she could administer the Lidocaine patch. Surveyors did not intervene with the resident's care. Staff # 24 was observed holding the Lidocaine patch (unpackaged) with her bare hand, no date, no label. Resident # 393 responded that he/she can have it at a later time. The Staff # 24 also reminded Resident # 393 to take the pills that were on the overbed table. The surveyors observed that Resident #393 took all the medications in the cup immediately. On 4/9/2025 at 12:30 PM, the findings were discussed with Staff # 5 (Vice President for Clinical Services).

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to implement an effective discharge process that adequately prepared Resident # 394 for transition to post-discharge care. This was evidenced by the failure to: 1) develop a discharge care plan for Resident # 394, 2) coordinate the referral to an outside provider for the transition of care, 3) order the recommended medical equipment and 4) provide complete and adequate discharge instructions for Resident # 394. This was evident for 1 (Resident #394) of 39 residents reviewed during the annual survey. The findings include: On 4/14/2025 at 10:10 AM, the Surveyor reviewed a complaint, MD00206515, submitted to the Office of Health Care Quality. The facility allegedly failed to adequately coordinate the discharge of Resident #394 from the facility. A record review was conducted for Resident # 394. He/She was admitted to this facility on 5/3/2024 from the hospital due to multiple fractures post fall and was discharged on 6/7/2024 to home after he/she was notified on 6/7/2024 that he/she had to go since his/her payer discontinued his/her coverage in the facility. Upon further record review, the resident had a care conference held on 5/6/2024 categorized as introductory care conference noted for the discharge plan, home with Mother No other care conference was found. Upon review of the Minimum Data Set (MDS) dated [DATE] Section GG - Resident # 394 required maximal to moderate assistance with toilet transfers, sit to stand, sit to lying, lower body dressing, toileting hygiene and bathing. Limited range of motion, on bilateral lower extremities. He/She was not able to control the bladder, with intermittent self-catheterization and not able to control bowel movements. Further record review revealed that on 6/7/2024 at 3:42 PM, an email was sent to Staff # 34 (Social Worker) by the insurance representative notifying the end of coverage was on 6/6/2024. It was noted that the discharge packet My Transition was incomplete, unlocked, and no home medication listed. It was initiated on 6/7/2024 at 5:42 PM. Review of the physician's discharge summary and instruction written on 6/7/2024 at 8:43 PM stated: He/She remained non-weight-bearing on the right lower extremity per orthopedic surgeon. He/She participated in Physical Therapy (PT)/Occupational Therapy (OT) as he/she was able. He/She had follow-up with urology, where urodynamic testing was not yet completed. Patient was discharged with wheelchair for movement due to end of payer benefit. Continue PT/OT Instructions: Non weight bearing to Right Lower Extremity; Urinary catheterization every 6 hours; Follow up with Orthopedic surgery on 6/19/2024; Follow up with Urology when ambulating; Neurology consult; Continue medications; Diabetic Diet. On 4/15/2025 at 8:42 AM, Staff # 34 (Director of Social Services) was interviewed. She confirmed that she was in charge of the discharge planning, setting up for any referral to a home health agency. She also added that discharge planning starts on admission. Discharge paperwork includes medication list, Advance Directives, contact information for vendors and home health agencies. Staff # 34 provided a copy of Resident #394's discharge paperwork titled My transition.

Based on review of interviews and record review, it was determined that the facility staff failed to provide a resident with a completed discharge summary upon discharge. This was found to be evident for 1 of 39 residents (Resident #335) that were reviewed during the recertification survey. The findings include: On 4/14/2025 at 8:42 AM, the Director of Social Services for the facility was interviewed by surveyors. The Director stated that social services is responsible for arranging home health referrals and discharge paperwork will have contact information for any post facility agencies continuing care in the community. He/She also stated that residents and family members are made aware of any home health agencies that have been sent referrals by the facility. Resident #335's medical record was reviewed on 4/15/2025 at 8:25 AM. Record review revealed that the resident was admitted to the facility on [DATE] for short term rehabilitation after an acute care stay at a hospital due to a fall with fracture. The resident requested to leave the facility and was discharged on 3/8/2025. A social services note was reviewed with an effective date of 3/7/2025 at 9:34 AM and a created date of 3/9/2025 at 7:53 AM that stated that home health services were arranged through a local agency. On 4/15/2025 at 12:30 PM, the surveyor spoke with complainant about the resident's discharge from the facility. The complainant stated that the resident requested to leave the facility earlier and was informed that the facility would arrange home health services upon discharge. The complainant stated that the resident was discharged on 3/8/2025, was given discharge paperwork, and was picked up by their spouse. The complainant stated that the discharge paperwork the resident received was incomplete, missing pages (pages 11-13), and did not have contact information for the home health agency. The complainant tried contacting social services at the facility without success and stated it wasn't until two weeks later she was emailed a complete discharge summary on 3/21/2025 that had all sections filled out and included contact information for home health. The complainant also stated that when they were able to contact the home health agency, the agency stated that they were told that the resident was discharged on 3/11/2025. On 4/22/2025, the complainant sent a copy of the initial discharge paperwork to this writer. Review of the initial discharge paperwork dated 3/8/2025 revealed multiple sections that were not filled out, pages 11-13 were missing, and there was no contact information for any home health agency.

Based on observation, review of resident medical records and interviews with residents and facility staff, it was determined that the facility failed to ensure that the resident received care to promote the highest practicable wellbeing as evidenced by failure to monitor the resident's mood state after an assessment was completed. This was evident for 1 of 39 residents (Resident # 124) that were reviewed during the survey. The findings include: The PHQ-2 to 9 (Patient Health Questionnaire-9), is a brief assessment tool used to screen for and diagnose depression in adults. It is a validated interview that screens for symptoms of depression. It provides a standardized severity score and a rating for evidence of a depressive disorder. The Total Severity Score is a summary of the frequency scores on the PHQ2 to 9 that indicates the extent of potential depression symptoms. This score provides a standard score which can be communicated to the resident's physician, other clinicians and mental health specialists for appropriate follow up. The Total Severity Score can be interpreted as follows: 1-4 - minimal depression 5-9 - mild depression 10-14 - moderate depression 15-19 - moderately severe depression 20-27 - severe depression The Minimum Data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. On 04/04/2025 at 08:30 AM during an interview, Resident # 124 was observed to be tearful when he/she was sharing what happened to him/her prior to her hospitalization. Resident # 124 stated, I became tearful whenever I recalled what happened to me. Crying made me feel better. The surveyor asked if he/she was seen by psychiatry and he/she responded no, I have not been seen by psychiatry. On 04/10/25 at 11:16 AM a record review was conducted. The resident was admitted on [DATE] to the facility for sub-acute rehabilitation following a hospitalization due to sustaining a left foot fracture at home. Upon review of the Minimum Data Set (MDS) Assessment reference date (ARD) of 3/11/2025, Section D - PHQ 2 to 9 assessment revealed a score of 15/27. This score indicates moderately to severe depression. There was no record found that he/she was seen by the psychiatry/psychology provider. There was a behavior monitoring order initiated on 3/8/2025 however no mood state monitoring was found. On 4/10/2025 at 12:11 PM, an interview with the Director of Nursing (DON) was conducted. The surveyor asked: What was your protocol for the referral to the psychology/psychiatry provider? The DON stated, we have a referral binder for psychiatry, for any new admission, if there were psychotropic medications, any psychiatric diagnosis with or without psychiatric medications, or any behavior found from the hospital discharge summary, we refer them to psychiatry. For our long-term care residents, if any behavior has been identified, we also refer them too. In addition, based on the PHQ-9 assessment (Patient Health Questionnaire-9), we have to refer them to psychiatry. We also have our risk meetings, and any resident who was at risk for falls with psychotropic medication, we refer them to psychiatry. The DON added that sometimes, the resident is being seen by the psychologist, not the psychiatrist. The surveyor shared that Resident # 124 scored 15/27 from the PHQ2 to 9 assessment. The surveyor asked: Was he/ she seen by psych to be screened? The DON responded I have to look. The surveyor also mentioned that during an interview with Resident #124, the resident was observed to be tearful while he/she was telling how she sustained his/her condition, hospitalized and in the facility. On 04/10/25 at 01:23 PM, the DON provided documentation from the psychology group through an email dated 4/10/2025 at 1:05 PM. The DON explained that Resident # 124 refused to be seen on 3/25/2025 due to payer issues. DON confirmed that it was only found that the resident refused to be seen after the surveyor asked about Resident #124 she immediately contacted the psychology provider. There was no documentation found in the resident's medical record about the refusal of psychiatry/psychology services On 04/11/25 at 12:07 PM, an interview with Staff #34, Director for Social Services, was conducted. The surveyor asked who was in charge for the referral to psychiatry/psychology. Staff # 34 mentioned that she was responsible for the referral. Staff # 34 also explained that they use a referral binder and through the binder, they included the reason for the referral. In addition, the psychology group sees all the residents from admission and also for any new referral. Staff # 34 added that after the provider sees the resident, the documentation will be in the electronic medical record and also in the referral binder. The surveyor shared that Resident # 124 had a PHQ-9 of 15, the Care Area Assessment triggered for mood state and during the initial interview he/she was noted to be tearful. The surveyor asked if she was aware that Resident # 124 refused to be seen by the psychology group. Staff #34 stated that she was aware of the refusal, she added that the resident has the right to refuse treatment. A follow up question was asked if he/she was aware of the reason for the refusal. Staff #34 responded, I have to look. The surveyor asked how they were monitoring his/her mood state. Staff #34 responded through the care plan. On 04/11/2025 at 12:35 PM a record review was conducted. The last care conference happened on 3/11/2025, no note about the resident's mood state or referral to psychology was found. The care plan was reviewed, no update nor revisions were found. The Physician's order was reviewed, there was a behavior monitoring order, but there was no mood state monitoring order found.

Based on observations, record reviews, and staff interviews, it was determined that the facility failed to develop an effective method to determine when the oxygen tubing needed replacing. This was found to be evident for 7(Residents #45 # 71, #73, #83, #96, # 107,# 437) of 7 residents reviewed for respiratory care during the annual survey. The findings include: Oxygen therapy is the medical administration of supplementary oxygen to individuals experiencing low blood oxygen levels or conditions that require increased oxygen delivery to the body. It involves providing extra oxygen to the lungs through various methods to improve oxygen saturation in the blood and to support vital functions. 1) An oxygen concentrator is a medical device that uses the air in the atmosphere, filters it, and delivers to the patient air that is 90%-95% oxygen. On 4/3/2025 at 12:30 PM, Resident #83 was observed with an oxygen concentrator with humidity. It was observed that there were no labels indicating the date and time when either the oxygen tubing or the humidifier water filter bottle was present. On 4/3/2025 at 2:15 PM, during record review, a physician's order for the oxygen was found but not for care and maintenance of the oxygen tubing or humidifier filter. Review of the oxygen administration guidelines stated that the tubing should be changed every seven days. A follow up observation visit with the resident on 4/7/2025 at 9:30 AM found that the oxygen tubing had been updated with the date of 3/30/2025. 2) On 4/3/2025 at 9:54 AM, Resident #45 was observed to be on humidified oxygen through nasal cannula (NC), no date was observed on the oxygen tubing. At 11:27 AM, Resident #73 was also observed to be on humidified oxygen through NC with no date on oxygen tubing. Resident #71 was interviewed on 4/4/2025 at 9:20 AM. The resident stated that their oxygen tubing usually does not have a date on it, and that the facility staff placed a date on their tubing the day before. The date on the oxygen tubing for Resident #71 was noted as marked 3/24/25. On 4/4/2025 at 12:40 PM, record review of Residents #45, #71, and #73 did not reveal any orders in their charts for oxygen tubing exchanges. Further record review of the facility's oxygen administration policy stated change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. During an interview on 4/7/2025 at 11:45 AM, the Director of Nursing (DON) was made aware of the surveyor's concerns with oxygen tubing exchange orders and date labeling. The DON stated that the night shift supervisor changes and labels oxygen tubing weekly. However, no physician's order for this procedure was documented. Record review on 4/8/2025 at 10:37 AM revealed that Residents #45, #71, and #73 had updated orders for weekly oxygen tubing exchanges in their medical charts. 3) On 4/3/2025 at 10:00 AM, Residents #96, #107, and # 437 were each observed lying in their beds with oxygen with humidity in use. No labels indicating the date and time were present on any of the oxygen tubings. On 4/3/2025 at 11:00 AM, the record reviews didn't reveal the physician orders for weekly oxygen tubing changes. Review of the oxygen administration guidelines stated that tubing should be changed every seven days. During the interview on 4/7/2025, at 11:45 AM, the Director of Nursing (DON) stated that the night shift supervisor changes and labels oxygen tubing weekly. However, no physician order for this procedure was documented.

Based on observations, family and staff interviews, and record reviews, it was determined that the facility failed to provide supervision for a resident with significant weight loss. This was found to be evident for 1 (Resident # 66) out of 1 resident reviewed for weight loss. The findings include: According to the Centers of Medicare and Medicaid (CMS) a significant weight loss is defined as: 5% in one month; 7.5% in 3 months; or 10% in 6 months. On 04/03/25 at 12:13 PM, Resident #66 was observed sitting in a wheel chair near the nurses station desk and appeared frail. Resident # 66 was unresponsive to interview attempts. During interview on 04/03/25 at 12:52 PM, Resident # 66's family member reported that her mother had dementia, a very poor appetite, and was losing weight. Record reviewed on 4/3/2025 at 1:00 PM, showed that on 03/10/2025, the resident weighed 107.8 lbs. On 04/02/2025, the resident weighed 102.0 pounds which is a -5.38 % loss in 23 days. A record review on 4/3/2025 at 11:00 AM, revealed that Resident # 66's weight loss was identified and documented by the Dietician. Interventions were made including assisting Resident #66 with meal set up, encouraging by Mouth (po) intake, and supplementing mighty shakes to increase caloric intake. No mention was found documented by any medical provider. When questioned about Resident #66's weight loss and lack of physician monitoring on 4/3/2025 at 1:05 PM, the Director of Nursing (DON) acknowledged the concern and stated that she would consult with Physician # 29. During a phone interview on 4/4/2025 at 9:00 AM, Physician # 29 stated he was aware of the weight loss, and acknowledged that he had not addressed it in his documentation.

Based on observation of the medication carts on unit 1 and unit 3 and interviews with facility staff it was determined that the facility failed to ensure that medications were stored appropriately, and that wasted medication was disposed of properly. This was evident with 3 out of 4 medication carts reviewed during the medication storage facility task. The findings include: On Monday, April 7, 2025, at 11:25 AM-While performing the Medication Storage facility task, the surveyor discovered 21 loose pills in the back of the 2nd drawer of medication cart 2 and 2 loose pills and an unmarked pharmacy type medication bottle with approximately 20 quarter tablets in the drawer on medication cart 1on unit 1. While interviewing the Nurse Manager on unit 1, the Unit Manager stated that it can be a problem of the blister packs and that he would educate the nurses on checking for and disposing of any lost pills. While conducting the Medication Storage facility task on unit 3 at 1:30 PM on Monday, April 7, 2025, the surveyor discovered 2 loose pills in the back of the 2nd drawer of medication cart 1 Unit 3. The Nurse Manager was made aware.

Based on medical record review and staff interview, it was determined the facility staff failed to maintain an accurate wound treatment order for a pressure ulcer. This was evident for 1 (Resident #56) of 39 residents reviewed during this annual 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 resident records. The sacrum is primarily considered part of the back, specifically the lower back. It is located at the base of the spine and forms the back wall of the pelvis. A Stage 4 pressure ulcer, also known as a bedsore, is the most severe stage, characterized by full-thickness skin loss with exposed bone, muscle, tendon, or ligament. On 04/07/25 at 11:24 AM, a record review was conducted for Resident # 56. He/She was admitted to this facility on 2/21/2025 with a chronic pressure ulcer on the lower back, sacral area. The wound treatment order for the pressure ulcer on his/her sacrum was initiated on 2/21/2025 and was written as Sacral wound. Clean with Dakins solution, pack with Dakins soaked gauze and cover with foam dressing every day for sacral wound. Resident # 56 was seen by the wound provider on 2/25/2025. Upon review of the wound note dated 2/25/2025, Resident # 56 had a Stage 4 Sacral Pressure Ulcer measured length: 9cms (centimeters) X width: 2cms X depth: 2.5cms. Treatment order was daily dressing, cleanse the wound with wound cleanser, apply iodoform strip, zinc oxide paste to peri wound and cover with bordered foam. On 3/25/2025, Resident # 56 was followed up by the wound provider who wrote a new wound treatment order for the sacral wound pressure ulcer. The order was written as Sacral Wound, cleanse with wound cleanser, apply Calcium Alginate with Silver, apply [NAME] and skin prep to peri wound and cover with bordered foam, daily dressing. Further review on 4/1/2025 revealed a new treatment order was written by the wound provider as Cleanse wound with wound cleanser, apply Calcium Alginate with Silver, [NAME] to peri wound, cover with bordered foam daily. The Medication Administration Record (MAR) was reviewed from February 2025 to April 2025 and revealed that the sacral wound treatment order initiated on 2/21/2025 remained to be an active order until April 7, 2025. Staff were signing off for both active wound treatments for the sacral pressure ulcer.

Based on observation and interviews, the facility failed to provide safe, functioning equipment in the shower room. This was found to be evident for 1 out of 6 shower chairs observed in the 2nd floor shower room. The findings include: On 04/07/25 at 10:40 AM, the surveyor observed a broken shower chair in a shower stall in the second-floor shower room. The chair's seat was wet with large puddles, had a large crack, and one leg was pushed through the seat, creating a jagged edge. On 04/07/25 at 10:50 AM, interviews with GNA#6 and GNA #7 confirmed that the broken chair was wet and appeared to have been recently used. GNA #6 stated, we typically call maintenance to remove broken equipment. On 04/07/25 at 11:17 AM, the Director of Nursing (DON) acknowledged the concern about the broken chair being used and stated maintenance would be called to remove it. The chair was subsequently removed from the second-floor shower room.

Based on surveyor review of clinical records and staff interviews, it was determined that the facility staff failed to implement a resident's wishes as stated in an advance directive, and failed to verify the authority of a medical decision maker on a Maryland Medical Orders for Life-Sustaining (MOLST) form. This finding was evident for 1 of 3 residents reviewed for advance directive care area (Resident #72). The findings include: A MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. On 01-25-2021, a review of Resident #72's clinical record revealed the resident had an advance medical directive which stated that the resident required to be certified incompetent for making informed medical decisions before Resident #72's named health care agent shall be granted authority to make health care decisions on the resident's behalf. Further review of Resident #72's clinical record revealed no evidence that a physician had certified the resident as incompetent for making medical decisions. A review of the MOLST revealed it was completed and signed by their attending physician on 06-14-2019 as a result of discussion with the resident's health care agent, as named in the resident's advance directive. On 01-27-2021 at 5:00 PM, an interview with Resident #72's attending physician revealed she neither read resident #72's advance directive nor completed incapacity certification of the resident as of 01-27-2021. She revealed she filled Resident #72s MOLST on 06-14-2019 after discussion with the resident's health care agent. On 01-28-2021 at 2:00 PM, an interview with facility Administrator revealed no additional information.

Based on surveyor observation, clinical record review, and facility staff interview, it was determined that facility staff failed to prevent the development of a stage 3 pressure ulcer, and to promote the healing of that pressure ulcer. This finding was evident for 1 of 30 residents selected in the stage 2 reviews. (#33) The findings include: On 05-10-17, surveyor review of the clinical record for resident #33's 03-18-17 nursing admission assessment indicated that resident #33 did not have any pressure sores on admission to the facility. A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A Stage 3 pressure sore indicates a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough tissue (dead tissue that is yellow, tan, gray, green or brown) may be present, but does not obscure the depth of tissue loss. In addition, the Braden Scale Assessment for pressure ulcer risk completed on 03-18-17 indicated that resident #33 was low risk for development of a pressure sore. The Braden Scale is an assessment that uses a scoring system to evaluate a resident's risk for developing a pressure sore. The score ranges from 6-23. The lower the score, the higher the risk. The level of risk indicates the interventions that should be used. At risk preventative interventions for residents, even at low risk, include turn and reposition the resident on a regular schedule, and manage moisture, nutrition, friction, and shear. Surveyor review of the admission comprehensive assessment for the period of time covering 03-18-17 to 03-25-17 revealed that resident #33 required extensive assistance from two people for bed mobility and toileting. Surveyor review of the physician's orders [REDACTED].#33's potential for skin breakdown were to be completed weekly. However, this assessment was not done on 03-25-17 as ordered. Based on the admission comprehensive assessment information, a Braden Scale assessment completed on 03-25-17 would have resulted in a lower score (higher risk) indicating further interventions to prevent the development of a pressure sore. In addition, further review of the physician's orders [REDACTED].#33's potential for skin breakdown were to be completed on 04-01-17 and 04-08-17, however, these assessments were not done. On 04-15-17, the Braden Scale assessment was done as ordered. However, based on the comprehensive assessment information for the dates of 04-08-17 through 04-14-17, the Braden Scale assessment completed on 04-15-17 would be incorrect, and would have resulted in a lower score (higher risk) than documented, indicating further interventions to prevent the development of a pressure sore. Surveyor review of the care plan for resident #33 revealed a care plan for At risk for alteration in skin integrity related to history of falls written on 03-18-17. This care plan did not adequately address pressure reduction interventions to maintain skin integrity, nor was this care plan individualized to the specific needs of resident #33. (Refer to F279) Further review of the clinical record revealed an occupational therapy note, written on 03-26-17, that stated resident #33 was complaining of pressure on bottom-small wound. However, there was no evidence of an assessment or new interventions on 03-26-17. Surveyor review of nursing documentation revealed that, on 03-27-17, a change in condition note reflected that resident #33 had an open area 1 x .5 (cm) on sacral area (the sacrum is the large wedge shaped vertebra at the bottom of the spine). However, the area is described under the heading Skin issues-Location and Description as Redness in sacral area. Review of the physician orders [REDACTED]. In addition, an order was written on 03-27-17 to turn and reposition resident #33 every two hours, and as needed. Turning and repositioning at least every two hours is a standard intervention to relieve pressure and prevent pressure sores. However, there was no evidence this intervention was implemented until after resident #3 had developed a stage 3 pressure sore. On 05-10-17, surveyor review of the care plan for resident #33 revealed a care plan for Actual skin breakdown related to open area on sacrum and peri wound maceration (breaking down of skin due to moisture)/[DIAGNOSES REDACTED] (redness), moisture associated redness to right groin written on 03-27-17. This care plan was not individualized to the specific needs of resident #33. (Refer to F279) Further review of the clinical record revealed that resident #33 was seen by the wound care physician on 03-28-17. The wound care physician documented the sacral area as a Stage 3 pressure sore measuring 1.1cm x 0.6cm x not measurable with 50% thick adherent devitalized necrotic tissue 50% granulation tissue (new connective tissue). The recommendations were to continue antibiotic ointment and foam dressing once daily, keep pressure off wound, and apply a low air loss mattress to the bed. Surveyor review of resident #33's weights revealed that, on 03-30-17, resident #33 had lost 13 pounds since admission. (Refer to F325) However, there was no evidence that facility staff recognized, evaluated, reported to the practitioner, or addressed this nutritional concern that can impact the development, treatment, and healing of a pressure sore. Surveyor review of the physician's orders [REDACTED].#33's potential for skin breakdown were to be completed on 04-01-17 and 04-08-17, however, these assessments were not done. On 04-15-17, the Braden Scale assessment was done as ordered. However, based on the comprehensive assessment information for the dates of 04-08-17 through 04-14-17, the Braden Scale assessment completed on 04-15-17 was incorrect, and would have resulted in a lower score (higher risk) than documented, indicating further interventions to prevent the development of a pressure sore. Review of the occupational therapy notes revealed a note, written on 04-15-17, that stated resident #33 refused to be transferred to the wheelchair due to buttock pain after sitting in the wheelchair for 6 hours on 04-14-17. Repositioning at least every two hours is a standard intervention to relieve pressure to prevent pressure sores. Further review of the clinical record revealed that, on 04-18-17, resident #33's pressure sore measured 0.8cm x 0.4cm x 0.3cm with 90% necrotic tissue. In addition, the resident lost another 6 pounds since 03-30-17 (19 pounds since admission). However, again, there was no evidence that facility staff recognized, evaluated, reported to the practitioner, or addressed this nutritional concern that can impact the development, treatment, and healing of a pressure sore. On 04-25-17, resident #33's pressure sore measured 0.9cm x 0.8cm x 0.3cm with 60% necrotic tissue. The wound care physician note for 04-25-17 revealed recommendations to have resident #33 return to bed between meals. However, there was no documented evidence that this recommendation was followed. On 05-01-17, the dietician completed a nutritional assessment with updated estimated nutritional needs that revealed increased calorie and protein needs. Further review of the wound care physician notes revealed that, on 05-02-17, the physician recommended to limit resident #33 to sitting 60 minutes up to three times per day. However, there was no documented evidence that this recommendation was followed. Surveyor review of the occupational therapy notes, written on 04-28-17, revealed that resident #33 was revaluated for wound management to sacral wound as wound is {greater than} 30 days duration in an effort to assist with wound healing to assist with expedited discharge home as patient to return home after sacral wound heals. In addition, an occupational therapy note written on 05-02-17 stated resident #33 was provided with a wheelchair cushion with increased pressure relief for sacral coccyx wound. This was 5 weeks after resident #33 developed a Stage 3 pressure sore. On 05-11-17 at 1:45PM, surveyor interview with the Director of Nursing revealed that the wheelchair cushion had been changed on 05-02-17 by the occupational therapy department. On 05-11-17 at 2:45PM, surveyor interview with the director of rehab (therapy) revealed that the occupational therapy department had provided a gel cushion for the wheelchair of resident #33 prior to providing the J2 cushion on 05-02-17. In addition, the director stated that all resident's are provided cushions for their wheelchairs on admission, but did not know if the gel cushion had been the cushion on the chair since admission. There was no documented evidence of any wheelchair cushion being used on the resident's chair until 05-02-17. On 05-11-17 at 3:30PM, follow up interview with the Director of Nursing revealed no additional information.

Based on surveyor review of the medical records and the facility documents, it was determined that the facility staff failed to safely transport resident #3 and failed to safely transfer resident # 1 which resulted in leg fractures. These findings were identified during the investigation of facility reported incidents MD 142 and MD 142 respectively and are valid and considered to have caused harm. The findings include: 1). On 9-20-12, record review revealed that resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was fully alert and oriented and used a wheelchair for mobility but was able to walk with a walker. Review of the facility documentation revealed that on 8-20-12 at approximately 11 AM, GNA (geriatric nursing assistant) #1 was pushing resident #3 in a shower chair back to her room from the shower room. GNA #1 had told the resident to hold her feet up so she could push her. As GNA #1 approached the nursing station, the resident was unable to hold her legs up and the right foot was caught under the wheel of the shower chair. The resident screamed which alerted LPN #2 at the nursing station. LPN #2 advised GNA #1 to pull the shower chair backwards so that the resident's feet would not get caught again. LPN #2 was not assigned as this resident's nurse and she said that she advised LPN #3, her assigned nurse, of what happened to the resident in the hallway. Review of the resident's written statement revealed that GNA #1 observed the resident's right foot which appeared to be bruised and she reported to LPN #3. In her statement, the resident said that LPN #3 met with her and she informed LPN #3 that she had hurt her foot and was in pain. Record review revealed that the resident was on routine pain medication which was administered. Record review revealed no evidence of an incident report documenting exactly what happened, a complete assessment of the resident's foot, or notification of the physician about the incident and an onset of new pain in the resident's foot at the time of the incident. The evening LPN received a report about the incident, assessed the resident, and notified the physician. The Nurse Practitioner (NP) was in the facility, assessed the resident, and ordered an x-ray. The x-ray revealed a non-displaced fracture of the right distal fibula and the weight bearing diaphysis of the tibia. These are the two bones of the lower leg with the fractures near the ankle. The x-rays did not reveal osteoporosis. On 8-21-12, the resident was transferred to the hospital for treatment of [REDACTED]. On 9-20-12 at 8:30 AM, an interview with the Administrator revealed that the resident had told GNA #1 to hurry as she was returning her to her room because she needed to use the bathroom. The facility conducted a thorough investigation and took appropriate and necessary action to protect other vulnerable residents. 2). On 9-20-12, surveyor review of the medical records and the facility documents, and interviews with the staff revealed that resident #1 was admitted to the facility in June 2012 as a transfer from another long term care facility. The [DIAGNOSES REDACTED]. The resident was fully alert and oriented and unable to stand or walk. Record review revealed a nursing care plan for impaired ability to perform activities of daily living which included transferring from the bed to the chair and back. The facility determined that the resident required the assistance of 2 staff for all transfers. Using this information, the facility completed a care card. The care card was an individualized plan of care used by the GNAs so they would be informed to provide the necessary and safe care to the residents. The care card included but was not limited to the following areas of assessment: mental status, bathing, dressing, eating, mobility, transfers, toileting, skin prevention, and safety and fall prevention. However, on the morning of 9-8-12 at approximately 11:30 AM, only one GNA (GNA #5) transferred the resident to the shower chair to transport her to the shower. Review of the resident's written statement revealed that when GNA #5 told her she was going to pick her up and put her into the shower chair, the resident informed GNA #5 that she would need the assistance of another staff. She stated that GNA #5 continued to pick her up and her left leg "got stuck within the leg of the shower chair". The resident said she heard a "pop" and screamed out in pain. GNA #5 then picked her up and placed her back in the bed. The resident's daughter came into the facility shortly after the incident and reported it to a nurse. She stated that after her daughter reported the pain to the nurse, "they did give me something for pain". A change in condition form was completed after the report of the pain. The physician was notified at 1 PM and ordered an x-ray of the left knee. The nurse documented that GNA #5 reported that the resident's left foot "went inside the shower chair". The nurse assessed the resident and observed no abnormal findings. The knee was immobilized while awaiting the x-ray. Review of the Director Of Nursing's (DON) written statement revealed that the evening supervisor called her at approximately 6 PM on 9-8-12 and reported that 2 GNAs - #5 and #6 -were transferring the resident to the shower chair and that her left let got caught in the bottom rail of the shower chair. The x-ray had shown a fractured distal femur (the long bone in the thigh with the fracture near the knee) and the physician ordered the resident to be sent to the emergency room . Further review of the DON's statement revealed that on 9-10-12, the resident's daughter called her to say that the resident said that only one GNA attempted to transfer the resident. Review of GNA #5's 9-8-12 statement (who the resident identified as the GNA who transferred her) revealed that she asked GNA #6 to assist her in transferring the resident to the shower chair. She stated that the resident did not say anything during the transfer but after she was in the shower chair, she complained about her leg. She stated that she asked GNA #6 to move the shower chair, she saw the leg caught under the chair, and asked GNA #6 to move the chair so she could get the leg out. She said that she reported this to the nurse immediately. Review of GNA #6's statement revealed much the same information. On 9-10-12 at 2:15 PM, an interview with the Administrator revealed that after they reviewed the resident's statement that only one GNA transferred the resident, they went back to re-interview GNAs #5 and #6. The Administrator and the DON continued their investigation and GNA #5 recanted her written statement on 9-11-12 and stated that she transferred the resident by herself. When the resident complained of pain, she called to GNA #6 in the hallway to come assist her. GNA #6 had initially documented that she assisted with the transfer to the shower chair but recanted her statement also after the GNA #5 changed her statement. The Administrator also re-interviewed LPN #4 who wrote the statement that GNA #5 and #6 had transferred the resident. LPN #4 stated that she had helped the GNAs write their statements based on what they were reporting to her. The Administrator further stated that LPN #4 and GNAs 5 and #6 were good employees who had no previous disciplinary actions in their files. Additionally, they had received training in abuse and neglect in January 2012. The facility conducted a thorough investigation and took the appropriate and necessary actions to protect the other residents.