Every finding on record at Mount Airy Nursing and Rehab Center

Based on complaint, reviews of clinical records and interviews with staff, it was determined that the facility staff failed to immediately report an allegation of suspected resident abuse to the State Survey agency. This was evident for 1 (Resident #1) of 4 residents reviewed during a complaint survey. The findings include: On 08/03/26, the Office of Health Care Quality received a complaint (3131253) with allegations of staff to resident physical abuse and concerns related to the quality of care being provided to residents in the facility. In an interview with staff member #4 on 08/10/26 at 11:23 am, staff member #4 stated that on 07/30/26 at approximately 11:45 am, S/he was preparing to provide therapy to Resident #1. Upon entering Resident #1's room, Resident #1 was observed sitting close to the edge of the bed. Staff member #4 asked for assistance from GNA#1 to reposition Resident #1 in bed before starting the therapy session. After initially repositioning Resident #1 in bed with the draw sheet, staff member #4 stated Resident #1 was still not seated safely in the middle of his/her bed. Staff member #4 described that s/he and GNA#1 were unable to lift and slide Resident #1 to the center of the bed due to his/her weight. Staff member #4 stated this is when s/he witnessed GNA#1, without warning, place his/her right hand against the right side of Resident #1's head/face and pushed with enough force that Resident #1 screamed Ow!. Staff member #4 stated that Resident #1 proceeded to shift his/her body slightly to the left towards the middle of the bed. Staff member #4 then indicated GNA#1 then stated, It hurt, but it works, followed by, They are feeding him/her too much. S/he is getting fat. Staff member #4 stated that after providing therapy to Resident #1, s/he immediately informed the nursing unit manager (LPN#1) about what s/he had witnessed when repositioning Resident #1 with GNA#1. In a telephone interview with the nursing unit manager (LPN#1) that over see's care for Resident #1 on 08/10/26 at 11:42 am, LPN#1 stated that s/he was home today due to a recent illness. LPN#1 stated that s/he did not recall being informed of an allegation of suspected staff to resident physical abuse by Staff member #4 on 07/30/26. LPN#1 stated that s/he may have written it down but was unable to check his/her office since s/he was at home. In an interview with the facility Administrator and Director of Nurses (DON) on 08/10/26 at 11:45 am, the facility administrator and DON were made aware of the allegation of staff to resident physical abuse as alleged in complaint 3131253 that allegedly occurred on 07/31/26. In an interview with Resident #1 on 08/10/26 at 2:58 pm, Resident #1 was unable to recall any details about the alleged incident during care on 07/30/26. In a telephone interview with GNA #1 on 08/10/26 at 3:37 pm, GNA#1 stated that s/he did recall assisting Staff member #4 with repositioning Resident #1 in bed on 07/30/26. GNA#1 denied touching Resident #1's face during the repositioning. Later that day on 07/30/26, GNA#1 stated that s/he was approached by LPN#1 (the nursing unit manager) and was asked if something had happened during care with Resident #1 earlier in the day. GNA#1 stated s/he told LPN#1 nothing had happened. GNA#1 then stated that LPN#1 stated that Staff member #4 is a snitch and will report staff members behind their backs and that s/he (GNA#1) needs to be careful.

Based on complaint, reviews of administrative files and all pertinent documents, and staff interview, it was determined that the facility failed to initiate an investigation of alleged staff to resident physical abuse and to ensure that the accused staff member was removed from patient care following an allegation of abuse. This was found to be evident for 1 (Resident #1) out of 4 residents reviewed during a complaint survey. The findings include: On 08/03/26, the Office of Health Care Quality received a complaint (3131253) with allegations of staff to resident physical abuse and concerns related to the quality of care being provided to residents in the facility. In an interview with staff member #4 on 08/10/26 at 11:23 am, staff member #4 stated that on 07/30/26 at approximately 11:45 am, S/he was preparing to work with Resident #1. Upon entering Resident #1's room Resident #1 was obswerved sitting close to the edge of the bed. Staff member #4 asked for assistance from GNA#1 to reposition Resident #1 in bed. After initially repositioning Resident #1 in bed with the draw sheet, staff member #4 stated Resident #1 was still not seated safely in bed. Staff member #4 described that the 2 staff members were unable to lift and slide Resident #1 to the center of the bed due to his/her weight. Staff member #4 stated this is when S/he witnessed GNA#1, without warning place his/her right hand against the right side of Resident #1's head/face and pushed with enough force that Resident #1 Ow!. Staff member #4 stated that Resident #1 proceeded to shift his/her body slightly to the left. GNA#1 then stated, It hurt, but it works, followed by, They are feeding him/her too much. S/He is getting fat. Staff member #4 stated that after caring for Resident #1, S/he immediately informed the nursing unit manager that over sees the unit Resident #1 resides on. Staff member #4 stated that s/he also witnessed GNA#1 working and providing care to residents on 07/31/26 during the day shift. In an interview with the facility Administrator and Director of Nurses (DON) on 08/10/26 at 11:45 am, the facility administrator and DON were made aware of the allegation of staff to resident physical abuse to Resident #1, as alleged in complaint 3131253, that allegedly occurred on 07/30/26. The facility administrator acknowledged that this was the first time hearing about the allegation of staff to resident physical abuse to Resident #1 on 07/30/26. A review of the facility staffing records on 08/10/26 confirmed that GNA#1 worked the day shifts on 07/30/26 and 07/31/26.

Based on complaint, staff interviews and observation, it was determined that the facility staff failed to ensure residents had access to call bells when in bed. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey. The findings include: On 08/10/26 11:23 AM, the Office of Health Care Quality received a telephone complaint with concerns about resident abuse and safety concerns related to the lack of quality of care that is being provided to residents in the facility. In an interview with staff member #4 on 08/10/26 at 11:23 am, staff member #4 alleged observing GNA#2 place Resident #3's call bell into the bottom drawer of the bedside table on 07/30/26. A review of Resident #3's clinical record on 08/10/26 revealed that Resident #3 was admitted to the facility on [DATE] with diagnoses that include but not limited to: Blindness in both eyes, Parkinson's disease, chronic obstructive pulmonary disease, seizures and dementia. Resident #3 was determined to be incapable of comprehending any medical procedures by his physician on 05/15/2020. The facility staff determined that Resident #3 requires assistance from the nursing staff for all of his care needs. A BIMS (Brief Interview for Mental Status) score is a 0-15-point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. On 05/22/26, the facility staff conducted a BIMS evaluation on Resident #3 and determined a score of 9/15 which indicates Resident #3 suffers from moderate cognitive impairment.During an observation of Resident #3 in bed on 08/10/26 at 3:22 pm, the nurse surveyor observed Resident #3's call bell again located in the bottom drawer of his bedside table. These findings were brought to the attention of the facility Administrator, Director of Nurses, and the Corporate Consultant at the exit conference on 08/10/26 at 3:50 PM.

Based on record reviews and interviews, it was determined that the facility failed to ensure that residents remained free from sexual, physical, and verbal abuse, as well as intimidation by facility staff. This was evident for 3 (Residents #4, #1, and #5) of 4 residents reviewed for allegations of abuse related to facility reported incidents (FRIs #2987931, #2789533, and #3012852).The findings include:1). On 5/21/26 at 1:40 PM, the surveyor conducted a review of the facility-reported incident (FRI #2987931), which indicated that on 4/17/26, Resident #4 reported to Nurse #21 that another resident, Resident #6, had touched [them] in [their] private areas. On 5/21/26 at approximately 2:00 PM, the surveyor reviewed Resident #6's medical records, which revealed a documented pattern of sexually inappropriate, aggressive, and disruptive behaviors toward residents and staff. On 1/8/26, behavioral documentation indicated Resident #6 threatened another resident in the hallway and required staff intervention and redirection. On 1/9/26, Care Plan documentation revealed Resident #6 reportedly told another resident to shut up while in the hallway. Staff redirected the resident and referred them for psychiatric consultation due to ongoing behaviors. On 1/24/26, nursing documentation revealed Resident #6 engaged in a verbal altercation with their roommate that required staff intervention and separation of the residents for safety. On 2/10/26, Care Plan, Social Services, and psychiatric documentation revealed staff and witnesses observed Resident #6 inappropriately touching another resident in the hallway. Witness statements indicated Resident #6 had their hand inside the resident's shirt and removed it when approached by staff. Resident #6 denied the allegation and stated they were patting [them] on the shoulder. Psychiatric follow-up documentation revealed the resident was evaluated for report of inappropriately touching another resident. The psychiatric provider educated Resident #6 that non-consensual sexual contact is considered abuse and documented plans to continue monitoring the resident for inappropriate behaviors. Resident #6 was subsequently placed on 1:1 supervision due to the incident. On 2/11/26 at approximately 11:30 AM, nursing documentation revealed Resident #6 again attempted to touch another resident seated in the hallway. Staff redirected the resident and instructed them that touching another resident without consent was inappropriate. On 2/12/26, nursing documentation confirmed Resident #6 remained on 1:1 supervision due to recent inappropriate touching behaviors. On 3/4/26, documentation revealed Resident #6 was transferred to the emergency room for psychological evaluation related to aggressive behavior, inability to manage behaviors within the facility, and threats toward other residents. On 3/5/26, post-hospital documentation revealed Resident #6 exhibited aggressive behaviors toward their roommate, used foul language, and attempted to strike the roommate with their walker. Documentation indicated staff redirected the resident multiple times without success prior to hospital transfer. On 3/10/26, behavioral monitoring documentation revealed Resident #6 remained on 1:1 supervision due to ongoing behavioral issues. On 3/18/26, nursing staff documented that while administering medications, Resident #6 attempted to touch the staff member's leg. Staff moved away quickly and instructed the resident that the behavior was not tolerated. On 4/17/26, Care Plan documentation revealed Doctor #24 discontinued Resident #6's 1:1 supervision, documenting the resident has not had any recent behaviors, despite ongoing documented sexually inappropriate and aggressive behaviors. Subsequent documentation revealed ongoing inappropriate behaviors after the discontinuation of the supervision intervention. On 4/17/26, Social Services documentation revealed Resident #6 stated, I did not touch anyone inappropriately, I only touched [their] knee, in response to allegations that Resident #4 had been touched in the private area. On 4/23/26, behavioral documentation noted additional verbal altercations with other residents. On 5/12/26, interdisciplinary documentation revealed Resident #6 remained under review due to physical behaviors toward another resident and a documented history of aggressive behaviors and being inappropriate with [sex removed] residents. Documentation further revealed the resident was routinely followed by psychiatric services with no improvement in behaviors. The interdisciplinary team discussed transfer to an all-[sex removed] facility due to the resident's ongoing inappropriate behaviors toward [sex removed] residents. Documentation further revealed multiple transfer attempts to alternative facilities had been unsuccessful. Review of the FRI follow-up investigation submitted to the Office of Health Care Quality (OHCQ) on 4/23/26 indicated the facility determined the allegation of sexual abuse to be inconclusive despite Resident #6's documented history of sexually inappropriate behaviors toward other residents and staff. On 5/21/26 at 3:26 PM, the surveyor interviewed Geriatric Nursing Assistant (GNA #6), who stated she was aware of Resident #6's sexually inappropriate behaviors toward residents and staff and confirmed there had been prior allegations involving inappropriate sexual behaviors toward other residents before the incident involving Resident #4. GNA #6 stated she was surprised the 1:1 supervision had been discontinued because Resident #6 had ongoing behavioral issues involving other residents. On 5/21/26 at 3:45 PM, the surveyor interviewed Resident #4, who stated a [sex removed] had touched their private parts. Resident #4 stated Resident #6 was sitting on the seat of their walker, reached over, and touched their private parts. Resident #4 further stated they had heard Resident #6 had previously done this to another resident. On 5/22/26 at 11:44 AM, the surveyor interviewed the Nursing Home Administrator (NHA), who stated the facility was aware prior to admission that Resident #6 had a history of sexually inappropriate behaviors toward staff. The NHA stated the facility's previous President requested admission of Resident #6 due to low census concerns despite awareness of the resident's behavioral history. The NHA further stated the referral had been facilitated through the President's daughter, who worked as a Social Worker. When asked whether a background review or behavioral screening had been conducted prior to admission to assess potential safety risks to other residents, the NHA stated she was unsure and could not provide documentation indicating such a review had been completed under the prior ownership. The NHA stated the facility had experienced ongoing difficulties managing Resident #6's behaviors since admission and confirmed the resident had been placed on and removed from 1:1 supervision multiple times. The NHA further acknowledged the facility was aware of at least two incidents involving inappropriate touching of other residents, including an incident in which Resident #6 placed their hand down another resident's shirt and groped their breast. The NHA also confirmed Resident #6 had demonstrated aggressive behaviors toward other residents, including physically striking another resident. When asked about discontinuation of the 1:1 supervision, the NHA stated Doctor #22 believed Resident #6 was doing better despite ongoing documented behaviors. The NHA further stated that 1:1 supervision was expensive. The NHA acknowledged the allegation involving Resident #4 occurred the day after the 1:1 supervision was discontinued. The NHA expressed understanding that Resident #6 posed a risk to other residents when not under 1:1 supervision and acknowledged it was likely Resident #4 had been sexually touched by Resident #6. 2). On 5/21/26 at 4:45 PM, the surveyor reviewed Resident #1's Facility Reported Incident (FRI #2789533). The investigation documented that on 2/26/26, Geriatric Nursing Assistant (GNA #18) reported concerns to a supervisor after overhearing a conversation between another GNA (#7) and Licensed Practical Nurse (LPN #19). According to the report, GNA #7 allegedly stated that while she was in training, she was taught to hit Resident #1 and witnessed another aide hit the resident. Further review of the investigation file revealed the following written statement from GNA #18: I am writing to report an incident that was brought to my attention. While I was at the nurse's station with GNA #7 and Nurse #19, I overheard GNA #7 say that one of the aides who trained her in building A hit the resident. In her words, [sex removed]said the aide 'banged [sex removed], yeah she hit [sex removed].' I asked why someone would do that and after that GNA #7 continued speaking with Nurse #19 while I stepped away to tend to another resident. Statements obtained from GNA #7, and LPN #19 denied that the incident occurred. In her written statement, GNA #7 identified the staff member who trained her as GNA #20. Further review of the FRI investigation file revealed a statement dated 2/13/26, prior to the reported allegation, from GNA #20 in which she documented that Resident #1 punched her in the side of the face. There was no additional statement obtained from GNA #20 on or after 2/26/26 related to the abuse allegation. Additionally, there was no evidence that additional staff statements were obtained or that the allegation was comprehensively investigated as abuse. Additionally the FRI investigation failed to show evidence that the facility protected Resident #1 by suspending the staff alleged to be involved in the abuse allegation (GNA #7 and GNA #20) pending the investigation. The Follow-up Investigation Report submitted to the Office of Health Care Quality (OHCQ) on 3/4/26 by the facility Director of Nursing (DON) documented the following: Steps taken to investigate the allegation: Authorities notified, head-to-toe assessment (including pain assessment) conducted, Resident #1 referred to psychiatric services, staff interviewed, and emotional support provided. Summary of interview with witnesses: None Summary of interview with alleged perpetrator(s): None Summary of interview(s) with staff responsible for oversight and supervision of this location: Incident not witnessed Summary of interview(s) with staff responsible for oversight and supervision of alleged perpetrator: None Conclusion: Incident unsubstantiated On 5/22/26 at approximately 10:00 AM, the surveyor reviewed the facility policy and procedure titled Maryland Abuse, Neglect, & Misappropriation (Policy #NS 1300-03). The policy stated, An employee who is alleged or accused of being a party to abuse, neglect, or misappropriation, will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. If multiple employees are involved the employees will not be permitted to be alone in the facility at any time until the investigation is complete. The policy further stated, After completing the statement(s) the employee(s) will be asked to vacate the facility until further investigation of the incident is completed. On 5/22/26 at 10:59 AM, the surveyor conducted an interview with the DON and the Nursing Home Administrator (NHA) regarding the facility's process for handling allegations of abuse. The DON stated that if an allegation involves a staff member, the staff member would be suspended during the investigation and terminated if the allegation is substantiated. She further stated that the facility would obtain statements from staff and assess or interview the resident depending on the residents' cognition level. The surveyor asked whether statements would only be obtained from the staff directly involved in the allegation. The DON stated that statements would be obtained from all staff who provided care to the resident and staff would be asked whether they were aware of any reports or had witnessed abusive behaviors. The surveyor then asked, If you had an allegation that a GNA was being abusive toward residents, what would you do as a plan of action to determine if there is validity? The DON responded, The main issue is abuse. The staff members involved in the allegation would be abuse. Due to the unclear response, the surveyor asked specifically about Resident #1 and the allegation that a GNA had been instructed to abuse the resident. The DON stated that GNA #18, who reported the allegation, heard GNA #7 say that she herself hit Resident #1 as instructed by her preceptor, GNA #20. The DON reiterated that the facility would obtain statements from staff and assess or interview the resident depending on the resident's Brief Interview for Mental Status (BIMS), a tool used to assess cognitive status. The surveyor then asked why the staff involved were not suspended and why additional investigative measures were not conducted related to the reported allegation. The DON paused for an extended period and did not initially respond. When prompted again by the surveyor, the DON stated that she asked GNA #7 and LPN #19 about the allegation and, because both denied it, she determined that the allegation was not true. The surveyor then asked how determinations regarding validity of abuse allegations are made. The NHA stated that she reviews investigations with the DON. The surveyor expressed concerns that Resident #1 was not protected from potential abuse, that the allegation was not thoroughly investigated, and that the facility failed to follow its own policy and procedure regarding allegations of abuse and the removal of accused staff from resident care pending completion of the investigation. Both the NHA and DON acknowledged the surveyor's concerns and stated they understood the findings. 3). Resident #5 had diagnoses including, but not limited to, congestive heart failure, type 2 diabetes mellitus, chronic kidney disease, generalized anxiety disorder, moderate intellectual disability, and peripheral vascular disease. The facility identified Resident #5 as having a Brief Interview for Mental Status score of 11. On 5/21/26 at 11:15 AM, a review of the facility-reported incident (FRI #3012852) documentation revealed that on 5/11/26, during the 11:00 PM to 7:00 AM shift, Resident #5 reported that Staff #7, a Geriatric Nursing Assistant (GNA), stated they would break their fingers if Resident #5 did not take medication. On 5/21/26 at 11:20 AM, the review of the facility's investigation summary revealed that Resident #5 reported to the Nursing Home Administrator (NHA) that the night shift nurse had brought medications into the room, but Resident #5 was tired and wanted to take them later. Resident #5 reported that Staff #7 told the resident that if they did not take the medications, Staff #7 would break my fingers. The facility documented that Resident #5 was offered emotional support and referred to psychiatric services. The facility further documented that Staff #7 was suspended during the investigation and later terminated. On 5/21/26 at 11:25 AM, the review of facility staff statements obtained during the facility's investigation revealed that multiple staff members described Staff #7's conduct as loud, rude, disrespectful, aggressive, and inappropriate toward residents and staff. Staff #8, Licensed Practical Nurse (LPN), stated Staff #7 can be loud and rude with staff and residents and was disrespectful to both residents and staff. Staff #9, a GNA, stated Staff #7 needed to be more patient with residents and learn to talk to them nicely. Staff #10, an LPN, stated Staff #7 tends to be loud with residents and staff. Staff #11, a GNA, stated Staff #7 was very aggressive when she talks to the residents and that Staff #11 was not comfortable working with Staff #7. Staff #11 also reported overhearing Staff #7 state to the nurse, I told you, that's how you handle them, after an incident involving Resident #5's medication refusal. On 5/21/26 at 2:53 PM, during an interview with Resident #5 in the Building A Day Room, with no other residents or staff present, Resident #5 confirmed the incident occurred. Resident #5 stated they did not want to take the medications while the nurse was administering them. Resident #5 stated that Staff #7 entered the room and said, I'll break your fingers. Resident #5 stated that it was when they took the medication cup from the nurse. On 5/21/26 at 2:55 PM, during the same interview, Resident #5 stated Staff #7 had spoken to them in this manner many times before. Resident #5 provided examples of previous statements by Staff #7, including that Staff #7 told Resident #5 they would contact a psych facility and have me thrown out of here if I don't do what she tells me. Resident #5 further stated that Staff #7 did not strike them but rather grabbed the resident's hand used to take the medication cup. Resident #5 stated Staff #7 made a fist and drew it towards my face. On 5/21/26 at 3:01 PM, Resident #5 continued the interview and stated they had provided a statement to the unit manager and facility social worker. Resident #5 stated they felt safe at the facility overall; however, Resident #5 stated they did not feel safe when cared for by Staff #7 and described feeling scared. Resident #5's description of the incident was consistent with the facility's incident report and investigation documentation. On 5/22/26, at 9:30 AM, a review of the facility's follow-up investigation report revealed that the facility substantiated the allegation based on statements obtained during the investigation process. The facility documented that staff who worked with Staff #7 during the 72 hours prior to the incident reported Staff #7 was loud and disrespectful toward residents and staff. During the review of the facility's follow-up investigation, it was revealed that Staff #7 was terminated from employment at the facility. The facility's corrective action plan identified ongoing abuse reporting education as oversight of implementation of corrective action. On 5/22/26 at 10:59 AM, during an interview with the Director of Nursing (DON), the DON that the facility substantiated that Staff #7 had been disrespectful, rude, and inappropriately interacted with residents and staff. The DON stated the substantiation was corroborated by staff statements regarding Staff #7's conduct toward residents and other staff. When asked whether the finding was considered abuse under facility policy, the DON stated yes. The facility failed to ensure Resident #5 remained free from verbal, mental, and physical intimidation by Staff #7 when Staff #7 threatened to break Resident #5's fingers, grabbed Resident #5's hand, made a fist, and moved the fist toward Resident #5's face during a medication refusal. This failure resulted in Resident #5 reporting fear of Staff #7 and stating they did not feel safe when cared for by Staff #7. Cross-reference F610

Based on record reviews and interviews, it was determined that the facility failed to complete the required follow-through after a substantiated allegation of abuse involving a credentialed Geriatric Nursing Assistant and failed to thoroughly investigate allegations of physical and sexual abuse. This was evident for 3 of 4 residents (Resident #5, Resident #1, and Resident #4) reviewed for allegations of abuse related to facility reported incidents (FRI #2789533, #2987931, and #3012852).The findings include: 1). Resident #5 was admitted to the facility with diagnoses including, but not limited to, congestive heart failure, type 2 diabetes mellitus, chronic kidney disease, generalized anxiety disorder, moderate intellectual disability, and peripheral vascular disease. The facility's reported incident summary (FRI #3012852) identified Resident #5 as having a Brief Interview for Mental Status score of 11. On 5/21/26 at 11:20 AM, a review of the facility-reported incident (#3012852) revealed that on 05/11/2026, during the 11:00 PM to 7:00 AM shift, Resident #5 reported that Staff #7, a Geriatric Nursing Assistant (GNA), told Resident #5 they would break their fingers if Resident #5 did not take their medication. The facility documented that the Nursing Home Administrator (NHA), Director of Nursing (DON), Unit Manager, responsible party, and police were notified; Staff #7 was suspended during the investigation; staff statements were obtained; Resident #5 was seen by the psychiatric provider; and Staff #7 was terminated. On 5/21/26 at 2:53 PM, during an interview with Resident #5 in the Building A day room, Resident #5 stated they did not want to take their medications while the nurse was administering them. Resident #5 stated that Staff #7 entered the room and stated, I'll break your fingers, and Resident #5 explained that this was when they took the cup of medication from the nurse. Resident #5 further stated Staff #7 had spoken to them in that manner many times before. Resident #5 also stated Staff #7 previously threatened to contact a psych facility and have Resident #5 thrown out of here. Resident #5 stated Staff #7 did not strike them during the 05/11/2026 incident, but grabbed the hand Resident #5 used to take the medication cup, made a fist, and drew it towards my face. On 5/21/26 at 3:01 PM, Resident #5 stated they had provided a statement to the Unit Manager and to the facility's Social Worker. Resident #5 stated they felt safe at the facility, but did not feel safe when cared for by Staff #7 and described feeling scared. Resident #5's recall of the event was consistent with the facility's incident report. On 5/22/26 at 9:30 AM, a review of the facility's follow-up investigation report revealed that the facility substantiated the allegation based on statements obtained during the investigation. The facility documented that Staff #7 was terminated following a suspension during the investigation, and that statements obtained from staff who worked with Staff #7 during the 72 hours prior to the incident revealed that Staff #7 was loud and disrespectful toward residents and staff. The facility's corrective action plan identified ongoing abuse reporting education as oversight of implementation of corrective action. Review of staff statements contained in the facility's investigation file revealed the following: Staff #8, a Licensed Practical Nurse, documented that Staff #7 can be loud and rude with staff and residents, does not like being told when something is incorrect or wrong, and is disrespectful to both residents and staff. Staff #9, a GNA, documented that Staff #7 needs to be more patient with residents and learn to talk to them nicely. Staff #10, an LPN, documented that Staff #7 tends to be loud with residents and staff. Staff #11 documented that Staff #7 was very aggressive when she talks to the residents, and that Staff #11 was not comfortable working with her. Staff #11 also documented overhearing Staff #7 state to the nurse, I told you, that's how you handle them, after later learning Resident #5 had refused medication. On 5/22/26 at 10:59 AM, during an interview, the DON stated that when an allegation is reported directly by a resident, the facility obtains a statement from the resident, obtains a statement from the staff member who received the report, and interviews the staff member alleged to be involved. The Director of Nursing stated the facility's expectation is for staff to report findings immediately to the NHA and/or DON. The DON stated a GNA may report to the charge nurse, who then reports to the NHA and/or DON. The DON stated the facility understood the Office of Health Care Quality (OHCQ) reporting timeline to be a 2-hour initial report and a 5-day final report. During the same interview, the DON stated that the substantiated finding was that Staff #7 was disrespectful, rude, and inappropriately interacted with residents and staff. The DON stated the substantiation was corroborated by staff statements regarding Staff #7's conduct toward residents and other staff, and confirmed the substantiated finding was considered abuse under the facility's policy. On 5/22/26 at 11:05 AM, during an interview, when asked whether CNA/GNA registry reporting had been initiated, the DON did not respond. The NHA intervened, stating it had not been reported because it's so fresh, and that they had not had an opportunity to report the incident to the nurse aide registry. 8 days had elapsed since the date of Staff #7's termination from the facility and the surveyor's investigation of the incident. When asked why it was not reported, the DON stated that she was unaware of the Maryland Nurse Aide Registry and the process for reporting allegations of abuse involving credentialed persons. On 5/22/26 at 11:05 AM, during the same interview, the NHA confirmed the failure to report the substantiated abuse finding to the nurse aide registry was a systemic/operational oversight and failure. The facility leadership stated that legal/corporate had not been consulted, and confirmed there had been no consideration of mandatory reporting obligations. The NHA and DON confirmed OHCQ had been informed that the allegation was substantiated; however, the substantiated finding had not been reported to the Maryland Nurse Aide Registry. Specifically, the facility substantiated an allegation that Staff #7, a GNA, who threatened Resident #5 during medication administration, terminated Staff #7 following the investigation, and reported the substantiated allegation to OHCQ however, the facility failed to initiate reporting to the Maryland Nurse Aide Registry, failed to consider mandatory reporting obligations related to a credentialed nursing assistant, and failed to ensure facility leadership knew the process for reporting substantiated abuse findings involving a GNA. This failure created the potential for Staff #7 to continue working with vulnerable residents in other settings without the substantiated abuse finding being reported to the appropriate registry for review. 2). On 5/21/26 at 4:45 PM, the surveyor reviewed Resident #1's facility reported incident (FRI #2789533). The investigation documented that Geriatric Nursing Assistant (GNA #18) reported concerns to a supervisor after overhearing a conversation between another GNA (#7) and Nurse #19. According to the report, GNA #7 allegedly stated that while she was in training, she was taught to hit Resident #1 and witnessed another aide hit the resident. Further review of the investigation file revealed the following written statement from GNA #18: I am writing to report an incident that was brought to my attention. While I was at the nurses station with GNA #7 and Nurse #19, I overheard GNA #7 say that one of the aides who trained her in A building hit the resident. In her words, she said the aide 'banged her, yeah she hit her.' I asked why would someone do that and after that GNA #7 continued speaking with Nurse #19 while I stepped away to tend to another resident. Statements obtained from GNA #7 and Nurse #19 denied that the incident occurred. In her written statement, GNA #7 identified the staff member who trained her as GNA #20. Further review of the facility investigation failed to show evidence that additional staff interviews were conducted, including an interview with GNA #20, the staff member identified as having trained GNA #7 and allegedly hit Resident #1. Additionally, several resident assessment forms were included in the investigation packet; however, six of the assessments were left completely blank and signed by Nurse #21. On 5/22/26 at 10:59 AM, the surveyor interviewed the Director of Nursing (DON) and Nursing Home Administrator (NHA) regarding the facility's investigation process for allegations of abuse. The DON stated that investigations typically begin with staff interviews, resident interviews, and resident assessments. When asked whether she reviews all information collected before determining the investigative outcome, the DON stated that she does. When asked what information a blank assessment provides, the DON stated that it doesn't provide any information. The DON confirmed that Nurse #21 left several assessment forms blank and stated that she must have missed it during review of the investigation. The surveyor then asked specifically why additional staff interviews were not conducted for FRI #2789533. The DON hesitated and shook her head before responding. The surveyor expressed concern that resident assessments were incomplete and that additional staff were not interviewed to determine the validity of the allegation. The DON stated that she asked GNA #7 and Nurse #19 whether they discussed the alleged abuse, and because both denied that it occurred, she determined the allegation to be unsubstantiated without conducting further investigation. 3). On 5/21/26 at 1:40 PM, the surveyor conducted a review of the facility-reported incident (FRI #2987931), which indicated that on 4/17/26, Resident #4 reported to Nurse #21 that another resident, Resident #6, had touched her in her private areas. Further review of the FRI revealed that, as part of the investigation, other residents were interviewed and assessed to determine whether there had been any witnesses or whether other residents had similar experiences. Review of the investigation documentation revealed that nine resident assessment forms completed by the Director of Nursing (DON) on 4/18/26 had been left blank. One assessment form completed by Nurse #21 had also been left blank. On 5/22/26 at 10:59 AM, the surveyor interviewed the DON and Nursing Home Administrator (NHA) regarding the facility's investigation process for allegations of abuse. The DON stated that investigations typically begin with staff interviews, resident interviews, and resident assessments. When asked whether she reviews all information collected before determining the investigative outcome, the DON stated that she does. When asked what information a blank assessment provides, the DON stated that it doesn't provide any information. The DON confirmed that she and Nurse #21 left several assessment forms blank and stated that she must have missed it during review of the investigation. The DON acknowledged that by failing to complete the assessments, important evidence may have been missed during the investigation. The NHA stated that she should have identified the incomplete assessments as well, as she and the DON review investigative findings together before determining the outcome of the investigation. Cross-reference F600

Based on record reviews and interviews, it was determined that the facility failed to include adverse event monitoring of alleged physical and sexual abuse in the facility's Quality Assurance and Performance Improvement (QAPI) activities. This was evident for 2 of 2 facility reported incidents (FRI #2670676 and #2686939) involving injuries of unknown origin and 4 of 4 facility reported incidents (FRI #2707002, #2787931, #2987931, and #3012852) involving allegations of abuse.The findings include:Definitions:Abuse is the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish.Sexual abuse is non-consensual sexual contact of any type.An injury of unknown origin is an injury that was not observed by another person, cannot be explained by the resident, and is suspicious because of the extent of the injury or the location of the injury.A QAPI (Quality Assurance and Performance Improvement) committee is a group within a healthcare facility responsible for continuously evaluating and improving resident care, safety, and operational performance through data-driven analysis and performance improvement activities.According to the facility policy and procedure (Policy #NS 1300-03), Maryland Abuse, Neglect, and Misappropriation, all investigations involving abuse, neglect, and misappropriation will be reviewed by the QAPI committee.On 5/21/26, throughout the first day of the change of ownership and facility reported incident (FRI) investigation survey, the surveyors reviewed six FRIs alleging the following:-FRI #2670676 - Injury of unknown origin-FRI #2686939 - Injury of unknown origin-FRI #2707002 - Alleged employee-to-resident abuse-FRI #2787931 - Alleged employee-to-resident abuse-FRI #2987931 - Alleged resident-to-resident sexual abuse-FRI #3012852 - Alleged employee-to-resident abuseOn 5/22/26 at 2:37 PM, the surveyor conducted an interview with the Nursing Home Administrator regarding how the QAPI committee determines areas requiring performance improvement activities and monitoring. The Nursing Home Administrator stated that resident safety is prioritized when determining areas of focus. When asked whether any of the alleged abuse incidents or injuries of unknown origin had been reviewed or tracked through the facility's QAPI process, she stated that they had not.Cross-reference F600, F609, & F610

Based on record review and interviews, it was determined that the facility failed to ensure timely reporting of an injury of unknown origin in accordance with facility policy and federal requirements. This was evident for 1 of 2 residents (Resident #1) reviewed for a facility reported incident (FRI #2670676) related to an injury of unknown origin.The findings include:According to the facility policy titled Maryland Abuse, Neglect, and Misappropriation (Policy #NS-1300-03), an injury of unknown origin is defined as an injury that was not observed by another person, could not be explained by the resident, and is suspicious due to the location and extent of the injury. Subpart IV, Identification of Incidents and Allegations, stated, The accurate and timely identification of any event which would place our residents at risk is a primary concern of the facility. The policy further stated that injuries of unknown origin are to be identified and reported to the supervisor, and that the supervisor or designee will immediately notify the Director of Nursing (DON) and Executive Director/Nursing Home Administrator (NHA) of the incident or allegation.On 5/21/26 at approximately 1:00 PM, the surveyor reviewed the facility's internal investigation related to FRI #2670676 and noted the following:On 11/17/25, Geriatric Nursing Assistant (GNA #12) documented in a written statement that on 11/16/25 they observed a new bruise to Resident #1's eye. GNA #12 stated that another GNA verified the injury and that the nurse supervisor was notified.On 11/17/25, GNA #14 documented in a written statement that on the evening of 11/16/25 they observed bruising to Resident #1's left eyelid and reported it to the supervisor.On 11/17/25, GNA #15 documented that during the night shift on 11/16/25 they observed redness on and around Resident #1's left eye.On 11/17/25, Registered Nurse (RN #16) documented in a written statement, Nothing was reported to me regarding left eye discoloration.On 11/17/25, RN #17 documented that at approximately 6:00 AM she entered Resident #1's room to administer medications and observed bluish discoloration to the resident's left upper eyelid. RN #17 stated that the Manager on Call was notified.On 11/17/25, the Unit Manager (RN #13) documented in a written statement that he did not receive any calls from staff over the weekend regarding bruising or discoloration to Resident #1's left upper eyelid.Federal regulations require that injuries of unknown origin are reported immediately, but not later than 24 hours after discovery, when the events do not involve abuse and do not result in serious bodily injury.Review of the initial report submitted to the Office of Health Care Quality (OHCQ) revealed that the facility documented the injury of unknown origin as having been discovered on 11/17/25 at 7:03 AM. However, RN #17 documented discovery of the injury at approximately 6:00 AM on 11/17/25, and multiple staff members reported observing and reporting the injury sometime on 11/16/25.Although staff members stated they reported the injury to the supervisor in accordance with facility policy, the Unit Manager stated he was not informed of the injury until the morning of 11/17/25. There was no documentation identifying when management was initially notified after staff first observed the injury on 11/16/25.On 5/22/26 at 1:12 PM, the surveyor interviewed the Nursing Home Administrator (NHA) regarding concerns that staff identified the injury on 11/16/25, but facility management was not made aware until the morning of 11/17/25. The NHA stated that staff are expected to immediately report incidents to the Unit Manager, even when the Unit Manager is not physically present in the facility, and that the Unit Manager is then responsible for notifying the DON or NHA. The NHA confirmed that staff failed to follow facility protocol related to reporting the injury of unknown origin.

Based on complaint, interviews with facility staff, and reviews of all pertinent administrative records, it was determined that the facility failed to provide Resident #1's representative with a copy of the Resident's #1 medical record in a timely manner. This was evident for 1 of 3 residents reviewed during a complaint survey.The findings include:Review of complaint #2624577 on 10/28/2025 revealed an allegation the facility did not honor Resident #1's representative's request to obtain a copy of Resident #1 medical record on 04/08/2025 and 09/18/2025.Resident #1 was admitted to the facility on [DATE] with diagnosis that are not limited to a cerebrovascular accident, Parkinsonism, and vascular dementia. Resident #1 was deemed incompetent by 2 physicians at the previous long term care facility on October 30, 2024. A review of Resident #1's admission face sheet, dated 12/02/2024, listed Resident #1's daughter as emergency contact #1 and the healthcare surrogate for Resident #1.On 09/23/2025 the Office of Health Care Quality received a complaint regarding Resident #1 alleging that an authorization form for the release of Resident #1's medical records was submitted to the facility twice during Resident #1's residency at the facility. Resident #1's representative was informed that the medical record request would need to be referred to the facility's legal team. In an interview with the facility administrator on 10/28/2025 at 1:50 PM, the facility administrator advised the nurse surveyor that the 2 written requests for Resident #1's medical record were sent to the corporate staff and they said they would not release Resident #1's medical records to Resident #1's responsible party.

Based on interview and record review it was determined that the facility failed to provide activities for residents. This was evident for five residents (R #44, #45, #47, #50, #53) of seven residents reviewed for Activities during the recertification survey.The findings include:The findings include:On 8/25/2025 at 1:17 PM an interview was conducted with the Activities Director (Staff #20) and the Nursing Home Administrator (NHA). Staff #20 said the activities program at the facility offered mental stimulation, creative expression and physical activity, and that these were provided in both group and individual settings, depending on the residents' needs and preferences. She further described that for residents who don't like group activities or for residents who have dementia the activity staff would try different activities to see what each resident enjoyed the most. She gave examples of music, talking, and tactile activities. When asked how activity participation was tracked, Staff #20 said she kept an activities binder, and she left to retrieve it.On 8/26/25 at 11:00 AM a review of the facility's activities tracking binder revealed blank pages for 5 residents (R #44, #45, #47, #50, #53). On each individual resident's page, the heading indicated the resident's name and that the resident should have weekly one to one activity. There were no activities logged on any of the pages and no documentation of any refusal or unavailability.On 8/26/2025 at 1:57 PM another interview with Staff #20 and the NHA was conducted to review the activities documentation. When Staff #20 was shown the blank forms for the Residents #44, #45, #47, #50, #53, she responded that the activities staff had been inconsistent with their documentation but she confirmed that there was no evidence that any activities were provided to those residents.

Based on observation, interview, and record review, it was determined that the facility failed to 1) Ensure medications and treatment supplies were secured and stored properly for 4 of 6 medication/treatment carts observed, 2) Discard medications per manufacturer's instructions when opened beyond the recommended timeframe, and 3) Ensure staff consistently followed facility policy and practice for securing medication/treatment carts during the annual recertification survey.The findings include: 1) On [DATE] at 12:03 PM , during an observation of the nursing unit during meal time and tray distribution, it was observed that a treatment cart was unlocked and unattended in front of the nurses' station adjacent to resident room [ROOM NUMBER] in the A building. The surveyor stood nearby, observing for approximately 6 minutes. The drawers opened, revealing supplies that were visible and accessible, including shears, over-the-counter topical medications, and adhesives. Staff Nurse #15 approached when they realized the cart was accessible to the surveyor. At 12:09 PM, Staff Nurse #15 on the unit approached the surveyor who was at the treatment cart. They confirmed it was unlocked, retrieved what was needed from the cart, and walked away. Later, at 12:19 PM, still in the A building during lunchtime and meal tray distribution, an observation of the medication cart near room [ROOM NUMBER] revealed it to be unlocked and unattended. Resident #62 was out of their room, walking in the hallway near the cart. The cart was observed for approximately four minutes with the surveyor opening drawers, exposing resident medication blister packages, until it was noticed by Staff Nurse #15, who quickly came and stated, Sorry! On [DATE] at 12:30 PM, the unit manager, Staff Nurse #16, for A building, was notified of the observation. At 4:09 PM, on the same day, during an Observation of B building, it was observed that one of the two treatment carts for the unit near the nursing station was unlocked and accessible. Resident #46 was nearby in the hallway. Staff Nurse #17 promptly intervened and locked the cart with the surveyor's presence. On [DATE] at 4:20 PM, the Director of Nursing was made aware of observations of unlocked carts at this time. Cross-reference and refer also to CMS F689. 2) On [DATE] at 10:38 AM, an inspection of the medication cart in building “A” assigned to Licensed Practical Nurse (LPN #6) was conducted. During the inspection, an inhaler (Fluticasone Propionate and Salmeterol inhalation powder 250mcg/50 mcg) for Resident #29 was observed to have an open date of [DATE]. Further review of the inhaler packaging revealed instructions to discard the inhaler 1 month after opening. A review of Resident #29's electronic Medication Administration Record (eMAR) for [DATE] was conducted on [DATE] at 10:52 AM. The review revealed that the inhaler was scheduled for 2 times daily (AM and PM) with the AM dose marked as already administered for [DATE] by LPN #6. Resident #29's inhaler was reviewed with LPN #6 and he confirmed the open date and indicated that it should have been discarded already based on the manufacturer's instructions. He also reported that he had already called the pharmacy around 10 AM and that the inhaler would most likely be delivered later today. The eMAR of Resident #29 was being reviewed with LPN #6 and he reported that he did not administer the AM dose when he found out that the medication was already expired. During this time at 11:03 AM, the Director of Nursing (DON) walked in the nursing unit. The DON was asked to look at the resident's eMAR and she confirmed that LPN #6 documented that he administered the AM dose. The DON was asked what her expectation was from staff when a medication has instruction to discard after 1 month. The DON indicated that the facility's practice was to discard medications after 30 days and reported that in the case of Resident #29's inhaler with an open date of [DATE], it should have been discarded on [DATE]. 3) On [DATE] at 3:19 PM, an observation was made in the hallway of Building A. A treatment cart was seen in front of the nursing station. The cart was unlocked, and its doors could be easily opened. No nursing staff were observed nearby. At 3:20 PM on [DATE], Nurse Staff #9 approached the surveyor and the cart. During a brief interview, Staff #9 stated he had just come on shift and had not yet used the treatment cart. He immediately locked the cart. At 3:22 PM on [DATE], Nurse Staff #9 and the surveyor observed the cart's contents. The cart contained, but was not limited to, scissors in the top drawer and a bottle of Dakin's solution in the bottom drawer. Note: Dakin's solution is diluted bleach (sodium hypochlorite) used to clean wounds and prevent infection. At 4:01 PM on [DATE], the Administrator and Director of Nursing (DON) were informed of the unlocked and unattended treatment cart. Both confirmed that it is their expectation for medication and treatment carts to remain locked when unattended. They reported that staff re-education had begun. [DATE] 10:41 AM Administrators provided the facility policy titled “Policy #4.1 Storage of Medications.” Review of the policy revealed that medication and biologicals were to be stored safely, securely and properly following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Number of residents sampled: Number of residents cited: Based on record review, observation, and interview it was determined that the facility failed to accurately assess residents' dental status. This was evident for one resident (Resident #69) of one resident reviewed for dental care during the recertification survey.The findings include:A review of Resident #69's nursing admission assessment dated [DATE] stated no oral concerns in section 3B Oral Status. In the same section there were questions to indicate if the resident had no teeth, or had broken or missing teeth, but none of those questions were answered.On 8/20/2025 at 11:25 AM Resident #69 was observed and interviewed in their room. The resident was seated in a wheelchair next to their bed, and was able to respond to questions but they had a soft voice and were difficult to understand. No teeth were observed in the resident's mouth, and when asked, the resident said they had no teeth. They said they had dentures, but they did not know where the dentures were. When asked if they were able to eat the food provided, they did not give a specific answer.On 8/27/2025 at 10:25 AM a joint observation and interview of Resident #69 was conducted with the Director of Nursing (DON) at the resident's bedside. The DON looked in the resident's mouth and determined that the resident did not have any teeth. She also said that the nursing documentation should have described that. On 8/27/2025 at 11:17 AM an interview was conducted with the Nursing Home Administrator (NHA) to review the finding that Resident #69's dental assessment was inaccurate, and she acknowledged the deficiency. No further evidence was provided by the end of the survey.

Based on observations, record reviews and interviews, it was determined that the facility failed to ensure medication errors were below 5% during the medication administration observation. This was evident for 2 of 29 medications administered during the observation.The findings include: The medication administration task started on 8/28/25 at 8:04 AM. A total of 29 opportunities for errors were observed between 2 Licensed Practical Nurses (LPN #18 and #19). During the observation, the following concerns were identified:1) On 8/28/25 at 8:16 AM, LPN #18 was observed during her medication administration to Resident #51. Included in the medications that she administered was Geri-Kot (Sennosides 8.6 mg) to the resident.A review of Resident #51's medical orders was conducted on 8/28/25 at 10:07 AM. The review revealed the order was for Senna-S (Sennosides-Docusate Sodium 8.6-50 mg). LPN #18 was interviewed on 8/28/25 at 11:21 AM. During the interview, Resident #51's medical record was reviewed, and she confirmed the order was for Senna-S but administered Geri-Kot instead, which did not have the 50 mg of docusate sodium in the active ingredient. An inspection of her medication cart was also conducted and revealed that Senna-plus (Sennosides-Docusate Sodium 8.6-50 mg) was available. LPN #18 verbalized that she should have administered Senna-plus instead of Geri-Kot.2) On 8/28/25 at 9:12 AM, LPN #19 was observed during her medication administration to Resident #44. Included in the medications that she administered was Geri-Kot (Sennosides 8.6 mg) to the resident.A review of Resident #44's medical records was conducted on 8/28/25 at 10:42 AM. The review revealed the order was for Senna-S (Sennosides-Docusate Sodium 8.6-50 mg).LPN #19 was interviewed on 8/28/25 at 11:32 AM. During the interview, Resident #44's medical record was reviewed, and she confirmed the order was for Senna-S but administered Geri-Kot instead, which did not have the 50 mg of docusate sodium in the active ingredient. An inspection of her medication cart was also conducted and revealed that Senna-plus (Sennosides-Docusate Sodium 8.6-50 mg) was available. LPN #19 verbalized that she should have administered Senna-plus instead of Geri-Kot.The Director of Nursing (DON) was interviewed on 8/28/25 at 11:44 PM. During the interview, the concern was discussed with the DON that both LPN #18 and #19 administered Geri-Kot instead of the available Senna-Plus on their medication carts. These 2 medication administrations were counted as errors out of the 29 total opportunities observed during the medication administration task. The medication error rate was computed as 7%. The DON verbalized understanding and acknowledged the concern.

Based on observation and relevant document review, it was determined that the facility kitchen failed to provide residents with the meals as indicated on their meal tickets. This was evident for 3 residents (Resident #5, #65, and #33) out of 3 observed during a dinner dining observation.The findings include:On 8/19/25 at 10:16 AM during an interview Resident #6, a long-term resident of the facility, they reported the meal portions were small and sometimes the food served was not enough to eat. On 8/27/25 at 5:40 PM, a dinner observation was conducted in the A building dining room. Observation of Resident #5's meal ticket revealed a buttered dinner roll was to be included. However, the served dinner tray did not contain a dinner roll. This was confirmed by GNA Staff #10. After surveyor intervention, Staff #10 requested a buttered dinner roll from the kitchen staff.On 8/27/25 at 5:41 PM, observation of Resident #65's meal ticket revealed a buttered dinner roll was to be included. However, the served dinner tray did not contain a dinner roll. This was confirmed by GNA Staff #11. After surveyor intervention, Staff #11 requested a buttered dinner roll from the kitchen staff.On 8/27/25 at 5:42 PM, observation of Resident #33's meal ticket revealed yogurt was to be included. However, the dinner tray served did not contain yogurt. This was confirmed by GNA Staff #10. After surveyor intervention, Staff #10 requested yogurt from the kitchen staff.On 8/27/25 at 5:47 PM, the above observations were discussed with the Regional Dietary Manager (Staff #12). He stated that he and the Facility Dietary Manager were ensuring the remaining meal trays were complete.

Based on observation, interview, and record review it was determined that the facility failed to use proper infection control strategies. This was evident for 1) one of two laundry rooms observed, and 2) while providing feeding assistance to a resident(s). The findings include: 1). A review of the facility's laundry policy and procedure revealed a statement that read, in part, “employees should don appropriate PPE (e.g. tear resistant reusable gloves, gown/apron, and/or face shield/goggles) prior to collecting, transporting, or sorting soiled linens.” On 8/25/25 at 8:35 AM during an observation of the soiled laundry room in A building, laundry aide (Staff #4) was observed in front of the washing machine with the door open. She was not wearing any PPE. When interviewed, she said her normal process was to wear gown and gloves and she pointed in the room to where they were stored but said she was busy and so did not put them on. She said she knew that she was supposed to do so. She also said she had worked at the facility for 38 years. On 8/25/25 at 8:40 AM an interview was conducted with the district manager for Health Care Services group, (Staff #5) who in a nearby office. She was informed of the observation that Staff #4 was observed without PPE when she loaded dirty laundry into the washer, and Staff #5 acknowledged the deficient practice and said she would in-service the laundry staff on the proper use of PPE. On 8/29/25 the deficient practice was reviewed with the Director of Nursing and the Nursing Home Administrator, and they provided no further evidence. 2). On 08/23/25 at 12:00 PM, a dining observation was conducted in Building A. Geriatric Nursing Assistant (GNA) Staff #13 was sitting between Resident #14 & Resident #48. Further observation revealed that GNA #13 was observed assisting Resident #14 and Resident #48 with eating. Staff #13 was feeding both residents simultaneously and did not perform hand hygiene in between assisting each of the two residents. On 08/23/25 at 12:10 PM the Director of Nursing (DON) entered the dining room and observed Staff #13 feeding both residents without practicing proper hand hygiene. The DON did not provide a comment at the time of the observation. On 08/25/2025 at 10:10 AM, during an interview, the Administrator acknowledged concerns regarding infection control. She confirmed the issue had been addressed with GNA Staff #13. Stating that education on appropriate feeding practices and hand hygiene, when assisting multiple residents, had been provided.

Based on observations and interviews, it was determined that the facility failed to ensure call systems devices were within reach and available to the residents. This was evident for one (Resident # 60,) in a random observation during a survey.The findings include: On 8/19/25 at 10:39 AM an observation was made in Resident # 60s room. The observation revealed that the resident's call system device was hooked over the wall light behind the resident's bed, approximately 5 feet off the floor. The call light was beyond the resident's reach and not accessible to the resident.On 8/19/25 at 1:52 PM a second observation was made in Resident # 60s room. The observation revealed the call light in the same place as observed at 10:39 AM. Which was out of reach for the residents and not accessible to them.On 8/19/25 at 1: 53 PM the above observation was confirmed by the infection control nurse (Staff #8). Staff #8 removed the call light from above the wall light and placed the call system on the bed within reach of resident #60.On 8/21/25 at 2:55 PM the surveyor shared this information with the DON (Director of Nursing). She confirmed that the call light should be checked during 2-hour resident rounds to ensure that it is in reach of the resident.

Based on reviews of the resident's medical record and administrative records, and resident and staff interviews, it was determined that the facility staff failed to ensure a mechanical lift sling was properly positioned under a totally dependent Resident (#11) before initiating the transfer. This failure led to Resident (#11) sliding through the front of the lift sling onto the floor. This failure led to Resident (#11) being sent to the emergency room and being diagnosed with a fractured pelvis. This resulted in harm to Resident #11. This was evident for 1 (Resident #11) of 2 residents reviewed for accidents during an annual Long Term Care Survey Process. After the incident, the facility developed initiated, and completed a plan of correction to prevent further injuries to residents during care. Therefore, this deficiency will be cited as past non-compliance. The date of correction was 03/02/2023 The findings include: During the initial phase of the Long Term Care Survey Process (LTCSP), Resident #11 was identified and selected for review related to having had a fall with a major injury. A review of Resident #11's medical record on 04/21/23 revealed Resident #11 had a history of multiple sclerosis, stroke with lasting paralysis, slurred speech, and anxiety. A review of Resident #11's Activity of Daily Living (ADL) care plan revealed that Resident #11 requires 2 staff members' assistance when providing care and requires dependent assistance with bed mobility. A review of Resident #11's 12/10/22 Fall Risk Observation Tool, indicated Resident #11 was non-ambulatory, and required a total mechanical lift for all transfers. A review of the facility's Mechanical Lifts and Transfer policy on 04/21/23 revealed that the use of mechanical lifts requires a competent and skilled user and requires the use of two employees to perform the lift safely, for both the resident and the employees. In an interview with GNA #42 (Staff #42) on 04/25/23 at 1:39 PM, the GNA stated that S/he has been a GNA for [AGE] years and has worked in the facility full-time since 2007. GNA #42 stated that S/he and GNA #27 (Staff #27) were in the process of transferring Resident #11 back to bed on 02/25/23 at approximately 6:30 PM. GNA #42 stated that Resident #11 had been placed in his/her Geri chair on the prior shift and that Resident #11's mechanical lift sling was already beneath Resident #11. GNA #42 stated that S/he noticed Resident #11's mechanical sling was not sitting properly beneath Resident #11 before the chair-to-bed transfer was performed. GNA #42 stated that the bottom of the sling rose up beneath Resident #11, towards his/her head, and was not positioned down behind Resident #11's knees. GNA #42 stated that S/he and GNA #27 did try adjusting Resident #11's sling at this time. GNA #42 stated that after Resident #11 fell , it was hard to figure out what had happened. GNA #42 stated, We were using the one sling that fits everyone. One size fits all types of residents. GNA #42 stated, I did what I could and tried to minimize Resident #11's fall. Resident #11 fell approximately 2 - 2.5 feet onto the floor. GNA (#42) stated that the mechanical lift sling did not become disconnected from the mechanical lift during the transfer. GNA (#42) also stated that Resident #11's fall from the mechanical lift was determined to be an accident. A review of GNA (#42) education record on 04/26/23 revealed that GNA (#42) received training on Mechanical Lift Application and Use on 02/27/2023 and 03/15/2023 after Resident #11's fall. A review of GNA (#27) education record on 04/26/23 revealed that GNA (#27) had a hire date of 01/22/2013. GNA (#27) received training on Mechanical Lift Application and Use on 02/27/2023 and 03/02/2023 after Resident #11's fall. The facility administrator and Director provided the survey team with a plan of correction regarding Resident #11's fall with a major injury on 04/22/2023. The plan of correction revealed the following: a) all nursing staff were provided with education on how to transfer a resident using a mechanical lift. This was completed by 03/01/23. b) all residents were screened and sized by the Director of Nurses for the use of a properly sized Hoyer sling. This was completed by 02/25/23. c) the facility initiated a quality assessment and performance improvement plan on 02/26/23. d) the facility conducted a thorough investigation and reported the incident to the State Survey Agency. e) Resident #11 was assessed by his/her physician on 02/28/23. f) Resident #11's plan of care was updated. The survey team determined that the facility corrected the incident. The date of the plan of correction was determined to be 03/02/23.

Based on resident and staff interviews it was determined that the facility did not ensure that residents received mail on the weekend. This has the potential to affect all residents. The findings include. On 4/24/23 at 10:15 AM, an interview was conducted with a select sample of resident council members for the B-building and the activities director. The resident council members were asked if mail is delivered on Saturdays. The B-building resident council president responded No. The activities director (staff #7) was asked who gives out the mail on Saturdays, she responded that she did not know. An interview was conducted with the NHA administrator on 4/26/23 at 9 AM. She was asked who distributes mail to the residents. She indicated that the activity staff give out the mail and are responsible for distributing it on weekends. She was informed that the activity staff did not know who distributes the mail on weekends. On 5/2/23 at 11:43 AM activities staff (#34) was asked who gives out the mail to residents and she responded that she did not know.

Based on review of facility records and interview with staff it was determined the facility failed to establish and implement a grievance policy to ensure resolution of all grievances and evidence demonstrating that the result of all grievances were maintained for no less than 3 years. This was evident during review of 1 (#MD00186812) of 8 complaints reviewed during the survey and had the potential to affect all residents in the facility. The findings include: Complaint #MD00186812 was reviewed on 5/1/23 at 1:02 PM. The complaint included concerns related to residents entering another resident's personal space and taking snacks and drinks in November or December 2022. The Nursing Home Administrator (NHA) was asked to provide the grievance logs for November and December 2022. On 5/1/23 at 1:34 PM the NHA reported that there were no grievance logs for that time frame and explained that the Social Worker would have been responsible for investigating grievances however, the facility did not have a Social Worker at that time. On 5/2/23 at 9:15 AM the NHA was asked to provide the facility's grievance logs from January 2022 to present. She indicated that she became the grievance official in January 2023 and could only provide the logs since she took over. She indicated that the logs for 2022 could not be found and that the former owners of the facility took all of the documents when the facility was sold. She provided grievance logs dated 2/9/23 to 4/9/23. The facility failed to maintain grievance logs prior to that time.

Based on observation and interview, the facility failed to post the required Names, addresses, and telephone numbers for all pertinent State agencies and advocacy groups, such as the State Survey Agency. This was identified in one of the two facility buildings affecting up to 32 residents at the time of the survey. The findings include. Observation of the entire A-building conducted on 4/21/23 did not reveal any required postings related to contact agencies for Abuse and Nursing Home complaints. At 11:33 AM on 4/21/23, the nursing home administrator was asked where the required posting are, listing the Office of Health Care Quality and the local Office on Aging. She asked the medical records person staff # 4 and they both confirmed that there were not any of the required postings of the contact agencies in the A-building. An empty bulletin board by the nursing station was identified as where the required posting should have been found. Observations of the B-building at 11:50 AM (4/21/23) found the required posting of the agencies to contact for Abuse and nursing home complaints.

Based on record review and staff interviews it was determined that the facility failed to have a system in place for notifying residents and their representatives in writing of their remaining Medicare benefit days. This was evident for 1 of (#39) of 3 residents reviewed for beneficiary notice. The findings include: On 4/26/23 at 9:14 AM, a review of Resident #39's Beneficiary Protection Notification revealed that the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted and that notifications were made by phone to the residents' representatives. The Business office manager Staff #33 was asked on 4/26/23 at 10:44 AM about the process for Beneficiary Notification. She explained that Notifications were made by phone calls to resident's representatives and that three staff members (Social Services Designee #32, Minimum Data Set Coordinator #10, and Social Worker #8) were responsible for providing the notifications. The Social Worker SW staff #8 was asked on 4/26/23 at 11:15 AM to explain how Resident #39's representatives were notified. She indicated that it was done by phone call. She was asked if the notices were mailed afterward, and she stated that beneficiary notices are mailed to the resident's representatives only if they were unable to reach them by phone. She was asked if there was a system to ensure that resident's families received written notifications and she stated that there was none. On 4/28/23 at 8:42 AM the administrator was made aware that written notifications were not sent to the resident's representatives.

Based on observation, medical record review and interview it was determined that the facility failed to maintain a safe and effective infection prevention and control program by failing to 1. ensure isolation was maintained for residents admitted from the hospital prior to the determination of their COVID status, 2. ensure isolation from outside visitors during a declared pandemic when staff assisted a resident to going outside of the building to visit family in direct conflict with facility policy and State mandate, 3. ensure a COVID positive resident was isolated away from COVID negative residents, and 4. have a process in place to provide surveillance of symptoms of communicable diseases, identify an outbreak, and promptly report the outbreak to the local health department. These interrelated infection prevention and control concerns were evident for two out of two newly admitted residents (Resident #2 and #9), one out of eight residents (Resident #10) who were COVID negative, and three of three residents initially identified with respiratory issues (#24, #20, and #7) On 5/21/2020 a determination of immediate jeopardy was made regarding these failures and the Administrator was informed at 8:19 AM and an IJ summary tool was then provided to the facility. The facility submitted the first draft of their plan to remove the immediacy at 10:36 AM and it was not accepted. The facility submitted 3 additional drafts that were not accepted. The fifth draft was submitted at 6:16 PM and it was accepted by the state agency at 6:58 PM. After removal of the immediacy, the deficient practice remained at potential for more than minimal harm and at a scope and severity of E. The findings include: On 4/5/2020 the Maryland Secretary of Health issued a Directive and Order Regarding Nursing Home Matters Pursuant to Executive Order No. 20-04-05-01 I Language in the order included: Staff Assignments: Nursing homes shall immediately implement, to the best of their ability, the following personnel practices: -Establish a cohort of staff who are assigned to care for known or suspected COVID-19 residents. -Designate a room, unit, or floor of the nursing home as a separate observation area where newly admitted and readmitted residents are kept for 14 days on contact and droplet precautions while being observed every shift for signs and symptoms of COVID-19. -Designate a room, unit, or floor of the nursing home to care for residents with known or suspected COVID-19 In the State Operations Manual, Appendix PP updated 11/22/2017, the Centers for Medicare/Medicaid Services (CMS) defines cohorting as the practice of grouping residents infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible residents (cohorting residents). CMS notes also that during outbreaks, healthcare staff may be assigned to a specific cohort of residents to further limit opportunities for transmission. On 5/12/2020 at 1:30 PM surveyors arrived at the facility to initiate the COVID-19 focused survey. The facility consists of two separate buildings (Building A and Building B) with 13 resident rooms in each building. Each room may be shared by up to four residents. The rooms are located on a long single hallway with the nursing station at about the halfway point. The main entrance for each building is located in a lobby at the halfway point of the building. Staff and visitors enter the resident care area thru a short hallway from the lobby, which runs directly past the entrance to the nursing station. Upon entering the main hall there are four resident rooms a dining area to the left of the nursing station and nine resident rooms to the right. Staff bathrooms are located in the left half of the building just beyond the midpoint, in a small hallway that leads to the laundry and the back exit of the building. There is a common area sunroom located at the end of the hall to the right in building A and to the left in the building B. On 5/12/2020 upon arriving at the facility staff informed surveyors that building A held the unit in which residents who were COVID positive (positive building) and building B housed only residents who were currently COVID negative (negative building). At the start of the survey 3 residents were identified as currently COVID positive. 1a. Review of Resident #2's medical record revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. On 5/7/2020 the resident was admitted to a room in the negative B building and was the only resident assigned to the room at the time of admission. The resident's room was at the far end of the right half of the building. Review of the 5/7/2020 Social Service note revealed Resident #2 had been noted in the hospital with hallucinations and delusions, and to have been aggressive, abusive, intrusive, exit seeking, and entering other's rooms. The resident had negative COVID tests on 4/16/2020 and 4/28/2020. A repeat COVID test was conducted on 5/6/2020 and test results were pending when admitted to the facility. Review of the nursing note written by the admitting nurse on 5/8/2020 at 12:02 AM revealed the resident was independent with ambulation, paces frequently up and down and wanders to other residents' rooms. Review of the night nurse (Licensed Practical Nurse- LPN #4) note, written at 4:14 AM on 5/8/2020 revealed the resident was Wandering in/out of rooms. Has been sitting in chair at nurse's station dozing on/off. On 5/12/2020 between 1:50 PM and 3:00 PM surveyors made observations in the negative building. At least five residents were observed in the hallway of the negative building; two of which were seated in the hallway, two walking independently and one ambulating independently in a wheelchair. Four of these five residents were not wearing masks. On 5/13/2020 at approximately 3:30 PM the Infection Control Nurse (a registered nurse-RN #3) reported that in regard to new admissions, the facility probably wouldn't take (accept the resident) if test (COVID-19) was 7 days out. He also reported that they may have a defined number of days but surveyors would need to ask the Acting Director of Nursing (ADON) for clarification, indicating that the ADON was involved with the new admissions and their placement in the facility. On 5/14/2020 at 12:15 PM interview with the ADON revealed that she oversees infection control with the Administrator and that they consult one another prior to making room placement decisions. In regard to COVID status for new admissions, the ADON reported they make sure the resident has had a negative test and another test within 24 hours prior to admission. She confirmed that they would accept prior to knowing the results of the most recent COVID test. She reported that the resident would be admitted to one of two isolation rooms, (numbers provided) and that both were located on the positive unit. The ADON stated the residents are isolated and in the room by themselves but that they can come out of the room with a mask on. Although the facility had a trained Infection Control Nurse, room placement decisions were made by the ADON or Administrator without consultation with the Infection Control Nurse and there was no evidence provided to indicate that the ADON or the Administrator had completed a State approved course in infection control. The ADON further reported that usually with a new admission the staff realize the resident would be a one on one (for supervision). When asked about allowing residents to come out of their rooms with a mask on, the ADON reported that the one on one staffing helps to make sure the residents keep masks on. On 5/14/2020 at approximately 12:30 PM the ADON reported that Resident #2 had a one on one for the first 12 hours. Later in the interview the ADON confirmed that there was no actual physician order [REDACTED]. On 5/15/2020 at 2:45 PM interview with nurse (LPN #4 ) revealed that on 5/7/2020 she had been informed Resident #2 was a new admission and that the resident was pretty much up all night, wandered up and down the hallway all evening. She reported the resident was down in (his room), in the dining room, back where the bathrooms were and that they stopped the resident before going into another resident's room. The nurse also stated that they had the resident sitting across from the nursing station so they could monitor the resident. Observation and review of facility floor plan revealed the resident's room on the day of admission was located across the hall and at the opposite end of the unit from the dining room. The bathroom referenced by the nurse was located in a hallway about midway down the unit. LPN #4 verbalized several interventions they attempted to keep the resident in his/her assigned room but that the resident would get right back up and go back out; tried drinks, tv, nothing seemed to work. She reported, all of us were watching (him/her) but failed to identify an assigned staff person to provide one on one supervision to the resident. The nurse also reported that they were unable to get the resident to wear a mask. When asked if she needed a one on one would she of had enough staff, the nurse replied that she thought so. Interview on 5/15/2020 at approximately 3:00 PM revealed that the assigned geriatric nursing assistant (GNA) #5, denied she cared for the resident although according to the assignment sheet she was the assigned GNA to care for Resident #2 on the evening of admission as well as the night shift. At the start of the interview the GNA reported that the resident was not on her assignment. She later stated that the nurse mostly cared for the resident on the evening shift since the resident was a new admission. For the night shift, the GNA reported they shared the hall (unit), the resident was tired and sleepy and that the nurse took care of the resident mostly. Review of the staffing sheets for the negative unit for the night of 5/7/2020 revealed one of the 3 GNA positions were listed as available. Review of the assignment sheet for 5/7/2020 revealed one nurse and two GNAs were working in the COVID negative building. One nurse and two GNAs were also working in the COVID positive building on the night of 5/7/2020. On 5/19/2020 at 10:23 AM interview with the Human Resources Manager #8, who is currently completing the schedules, reported that historically the staffing goal for night shift for one building would be one nurse and three GNAs. She reported the census for 5/7/2020 for the negative building was 46 residents and for the positive building was 18 or 19 residents. She confirmed that there, was an open slot that we were unable to fill for the 5/7/2020 night shift for the negative building. She went on to report that they could work with two GNAs and one nurse, although they wanted three GNAs. One nurse and two GNAs for 46 residents represents a slightly higher than 1:15 ratio of staff to residents within the negative building on the night of 5/7/2020. Review of the Resident #2's medical record and interviews with the night nurse as well as the GNA assigned to the resident's room at the time of admission and the following night shift failed to reveal any indication that one on one supervision was being provided to the resident. Thus, the newly admitted resident #2 with unknown COVID status did not have one-to-one staffing and was allowed in the hallways of the negative building with no mask. 1b. On 5/8/2020 the facility was informed that the 5/6/2020 COVID test for Resident #2 was positive. The resident was immediately moved to the COVID positive section of the positive building. Review of Resident #2's primary care physician note, dated 5/8/2020, revealed the following: .wanders all over going into the rooms of others. (S/he) is a management problem The note also revealed the resident had recent agitation and confusion. Review of Resident #2's progress notes revealed the following: -5/8/2020 at 10:19 PM: .Resident stable and alert to self, ambulate independently on unit but requires constant redirecting . -5/9/2020 at 10:39 PM: Alert and responsive, s/p (status [REDACTED]. -5/10/2020 at 10:38 AM: .Resident ambulates independently, but can not identify (his/her) room, (s/he) has to be redirected to (his/her) room On 5/20/2020 review of Resident #10's medical record revealed the resident had a [DIAGNOSES REDACTED]. Review of the progress notes revealed the following written by nurse (Licensed Practical Nurse-LPN #10) on 5/10/2020 at 10:36 PM: Alert and verbally responsive, out of bed to a chair in the hallway listening, singing and playing music as usual, mood/affect appropriate . Review of Resident #2's medical record revealed nurse (LPN #10) wrote the following on 5/10/2020 at 10:32 PM: Alert and responsive, continue to pace and wander frequently as usual, currently sitting down in chair and dozing off, hard to follow directions . On 5/12/2020 at approximately 3:30 PM surveyors entered the positive A building, staff reported that the area on the right half of the hall was the COVID positive section and to the left was the negative area. The hall was open with no physical barrier between the negative and positive sections of the hall. The fire doors were noted to be open during the observation period which lasted approximately half an hour. Two residents were observed sitting in the hallway on the positive side of the unit. Neither resident was observed to be wearing a mask. On 5/12/2020 at 3:45 PM the charge nurse (LPN #7) and the care plan nurse (LPN #6) reported that the three residents that were COVID positive were Resident #2, #6 and #22. Although there were also negative residents in the same unit, observation revealed the door to Resident #2's room was open and the door for the room assigned to Resident #6 and #22 was also open at this time. The geriatric nursing assistant (GNA) #5 revealed during the 5/15/2020 interview that she normally worked in the positive building. She confirmed that she was aware of Resident #2's COVID positive status and reported that the resident walks around on his/her side of the hallway. Review of several resident's medical records (Residents #3, 2 and 9) revealed that on 5/15/2020 a letter, written by the Administrator, was mailed out to responsible parties with an explanation of new guidance per the Centers for Disease Control (CDC) and updated information of the facility status. On 5/22/2020 review of this letter, dated 5/14/2020 included the following: As stated above, we only have one resident who continues to test positive for COVID-19 at this time. Because our status has drastically changed in the past few weeks little by little, we will be changing our cohorting plan again in the very near future. We began preliminary discussions regarding changing our plan at the beginning of this week as we prepared to do another round of testing to transition residents from positive to negative status. At this time, though some slight changes may occur, we plan to make the 'dining room side of A building for positive cases only. If/when we have no positive cases in house we may utilize that side of the hallway as our observation unit for new admissions. In the meantime, we will use a set of rooms on the 'sunroom side' of the hallway for observation and the remainder of the rooms on that side of the hallway will be designated for residents who have transitioned from positive to negative status. All residents currently in the rooms on the 'dining room side' of the hallway will be moving to another room. The location of the room will be determined based upon whether they transitioned from positive to negative status or never contracted COVID-19. B building will remain a 'negative' building and will only house those residents who are considered negative status. As we pass this letter out to residents, my staff and I will be having discussions regarding how these changes will affect our residents individually and for residents with representative we will, per normal protocol, contact you to discuss room changes prior to completing them. On 5/19/2020 at 11:00 AM the ADON confirmed names of the 8 residents in the facility who had never tested positive and were currently remaining in the facility. Resident #10 was one of the 8 who had never tested positive for COVID. Review of the 5/19/2020 list of room assignments revealed 5 out of these 8 residents were currently resident in the 'positive' building. Further review of the resident room assignments that had been provided on 5/12/2020, as well as additional room change information provided during the survey, revealed that Resident #10 had been moved to a room directly next door to Resident #2 on 5/10/2020 and had remained next door as of 5/12/2020. Review of the 5/19/2020 list of room assignments revealed that Resident #10 and #2 were now separated by one room. On 5/20/2020 at 1:08 PM interview with the Administrator revealed that Resident #10's room had been changed on 5/10/2020 due to a violation of protocol. She went on to report a GNA had taken the resident outside of the building to visit with family. This visit was in conflict with the 3/13/2020 CMS memo (QSO-20-14-NH) updating the Guidance for Infection Control and Prevention of COVID 19 which included the following: For ALL facilities nationwide: Facilities should restrict visitation of all visitors and non-essential health care personnel, except for certain [MEDICATION NAME] care situations, such as an end-of-life situation. On 5/20/2020, the Administrator reported the decision to move the Resident #10 on 5/10/2020 had been made by the infection control nurse, since he was the supervisor at the time, and they felt the resident needed to be in a room alone, rather than put back in with roommates who had always been negative. On 5/20/2020 review of care plans established for Resident #2 on 5/8/2020 revealed a care plan addressing a risk for elopement that included the following intervention added on 5/11/2020: distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book or music. Although COVID-19 positive, further review of the care plans for Resident #2, failed to reveal any documentation regarding the resident's COVID status or current interventions regarding the resident's wandering behavior as it related to potentially exposing other residents. On 5/27/2020 Resident #10 who was COVID negative, was observed wearing a mask and sitting in the hallway of the positive building near the entrance to the sunroom. 2. Review of Resident #9's medical record revealed the resident was admitted after an extended hospitalization . The resident's [DIAGNOSES REDACTED]. The resident was admitted to a room in the negative building. Resident #9 was not confined to a room for 10 - 14 days after admission. On 5/14/2020 at 3:00 PM the Acting Director of Nursing (ADON) reported that Resident #9 had been admitted as a known negative and that they had completed an additional test at the facility which was also negative. The ADON then provided the documentation of the two negative tests from the hospital, dated 4/22/2020 and 4/27/2020 and the one obtained by the facility. It was noted that the facility obtained the sample on the day of admission and results were obtained the next day, 5/9/2020. According to guidance from the Centers for Disease Control (CDC): -Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. -Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown: Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19 Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Review of a nursing progress note written on 5/8/2020 at 11:50 PM revealed the resident was independent with ambulation. Review of a 5/9/2020 nursing note written at 8:10 AM revealed the resident was standing at the exit doors and that staff were instructed by the nurse to monitor the resident for elopement risk. A note on 5/9/2020 at 2:30 PM revealed: Resident noted this am banging on doors, windows at nurses station . On 5/12/2020 between 1:50 PM - 2:30 PM Resident #9 was observed ambulating in the negative building without a mask and at one point was observed kicking the front door located in the lobby. Further review of the progress notes revealed the resident was in the hallways interacting with staff and residents frequently. On 5/13/2020 the physician did order one on one supervision for unsafe behaviors. This order was discontinued on 5/15/2020. On 5/14/2020 at 12:46 PM the Administrator reported they had consulted with the local health department in regard to the room assignment for the new admissions, due to their current observation rooms being located on their COVID positive unit. The two new residents (#2 and #9) to be admitted had no history of being COVID positive and had recent COVID negative tests. The Administrator reported the local health department instructed them if the resident was thought to be negative they were to put them in a room with other residents who had transitioned from positive to negative. The Administrator further reported that Resident #2 was put in a room without any roommates and that Resident #9 was placed in a room with residents that had transitioned from positive to negative. Both residents were placed in the COVID negative building. The Administrator confirmed the facility does not have an observation unit at this time. Review of an email sent by the ADON to staff on the day of admission, 5/8/2020, revealed Resident #9 was able to ambulate, had been pre-occupied with 'going home' and required supervision with all activities of daily living. On 5/26/2020 further review of the care plans, failed to reveal any interventions provided to encourage the resident to stay in the assigned room, or wear a mask if leaving the room prior to the completion of a 14 day observation period. Further review of resident census data revealed that on the day of admission for both Resident #2 and #9 there were residents who had never been COVID positive residing in both the positive and negative buildings. Resident #2 and #9 were new admissions requiring a 14-day period of isolation. Resident #9 was allowed to ambulate throughout the negative building prior to the completion of a 14-day observation period. Resident #2 was allowed to ambulate in the hallways and dining room of the negative building prior to the identification of the COVID positive status potentially exposing COVID negative residents. Resident #10 was taken outside in violation of the State Order to keep negative residents isolated away from potential sources of COVID-19, this resulted in the always COVID negative resident being placed on the COVID positive unit and potentially being exposed by Resident #2 who was allowed to wander the unit. As a result of these findings, an immediate jeopardy was declared on 5/27/2020 at 8:19 AM and an IJ summary tool was then provided to the facility. The facility submitted the first draft of their plan to remove the immediacy at 10:36 AM and it was not accepted. The facility submitted 3 additional drafts that were not accepted. The fifth draft was submitted at 6:16 PM and it was accepted by the state agency at 6:58 PM. The provisions of the plan to remove the immediacy included the following: -All 8 of the always negative residents have been moved to the negative building. -Resident #2 has been moved into one of the four rooms located on the left hand side of the positive building. After Resident #2 transitions from positive to negative the resident will be moved and these four rooms will become the observation area for new admissions. - Fire doors to remain closed and plastic sheeting was put in place between the back hallway and the first of the 4 observation rooms to separate the facility front and back entrances where staff donning and doffing and screening procedures occur from resident areas. -A room on the right hand side will be utilized for observation and total isolation as needed prior to Resident #2 moving out of the observation area. -A one on one will be implemented if a COVID positive, or resident under investigation, is non-compliant with remaining in designated area/room. -If the new admission is determined to be positive status any additional new admissions will be halted (unless they are determined positive, in which case they can cohorted with the other positive residents) until such time as the resident has transitioned from positive to negative status. -A COVID Committee has been formed that will meet daily to discuss pending admissions, residents transitioning from positive to negative, proposed room changes based on transition of status, identification of new persons under investigation and interventions in place for residents with isolation challenges to ensure person-centered interventions which allow for compliance with infection control protocol. -The COVID Committee consist of the Administrator, the Medical Director, the Acting Director of Nursing, the infection control/QA nurse and the care plan nurse. -The daily COVID Committee meeting shall be documented and submitted to the QA committee monthly for ongoing review. The facility submitted an acceptable removal plan on 5/21/2020 at 6:16 PM. The plan was reviewed and accepted on 5/21/2020 at 6:58 PM. The Immediate Jeopardy was removed on 5/28/2020 at 9:04 AM after validation of the implementation of the plan by the surveyor who was onsite at the facility. 3. A review of the facility's COVID-19 Line Listing revealed that on 3/17/2020, facility staff identified a cluster of residents in one building, housed at one end of the hallway that had either a fever and/or respiratory illness within a 2 day period. On 3/17/2020, Resident #24 and #20 were identified and on 3/19/2020, Resident #7 was identified and sent to the hospital. However, the facility failed to recognize this cluster as an outbreak and report this to the local health department until 3/23/2020. A review of the facility's Infection Prevention and Control Program (IPCP), that was undated, under Procedure #5 - An additional line list may be instituted for cases such as GI (Gastrointestinal), URI (Upper Respiratory Infection), etc. outbreaks. Suspicions of outbreaks will be communicated to local health department by facility's Infection Preventionist (IP) or Director of Nursing (DON). iii. Occurrence of 3 or more cases of the same infection over a specific length of time. During an interview with the Infection Control Preventionist (ICP) on 5/13/2020 at 3:07 PM, he revealed that the Director of Nursing (DON) was responsible for notifying the local health department when there was suspected outbreak. An interview with the previous staff member who was the DON in March 2020 (Staff 14) on 5/15/2020 at 7:51 AM, revealed that she covered the ICP position when the ICP was not available. She reported that there were residents with respiratory illness prior to the outbreak that were being treated as other illness, however she was not sure of the resident names. She reported that she started a line listing on 3/23/2020 and reported the outbreak to the local health department that day. During a subsequent interview with the ICP on 5/23/2020 at 9:08 AM, he revealed that he had identified Resident #23 with respiratory illness on 3/21/2020 and was aware that Resident #7 and Resident #20 had been diagnosed with [REDACTED]. He reported that he did not call the local health department because he thought the DON had done that earlier in the week and when he spoke with the DON on 3/21/2020, he failed to clarify that with her. Further, he was unable to provide a rationale as to why he did not contact the local health department with the additional cases identified on 3/21/2020. A discussion with the ICP regarding the Centers for Medicare and Medicaid Services (CMS) Memo 20-14-NH (dated 3/14/2020), revealed that he did not follow the recommendation to report any increase in respiratory illness regardless of the etiology (cause) to the local health department immediately. The ICP confirmed that he was not reviewing the COVID-19 guidelines and recommendations that were being sent out, but rather was being updated by the Administrator as she reviewed them. The Administrator was made aware of these findings via a teleconference call on 5/21/2020 at 12:03 PM.

Based on observation, record review, and staff interview, it was determined that the facility failed to have processes in place to provide supervision and oversight of environmental hazards for residents at risk for elopement. This was evident for 2 (#6 and #5) of 2 residents reviewed for elopement. As a result of these findings, a state of immediate jeopardy was declared on 1/24/20 at 5:09 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 1/24/20 around 6:31 PM and the State Agency was unable to accept this plan. After several requested revisions the facility submitted a plan on 1/24/20 at 11:36 PM and the removal plan was accepted at 11:41 PM. The immediate jeopardy was removed on 1/28/20 at 9:20 AM. The findings include: 1) A medical record review for Resident #6 on1/22/20 at 2:30 pm, revealed that the resident was admitted on [DATE]. A review of the current physicians' orders revealed that the resident had the following diagnoses: dementia, depressive disorder, hypertensive [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], mild cognitive impairment, unspecified mood disorder, suicidal ideation, and impulsiveness. Review of the assessments revealed an Elopement Risk Observation, dated 12/12/19, that concluded Resident #6 was at risk for elopement. Further review of the record revealed a Wandering and Elopement Risk care plan that was initiated on 12/12/19, with the following interventions: resident to have a door alarm bracelet (wander guard device), make sure staff were aware of elopement risk, and distract resident from wandering with structured activities, food, conversation, and television. The facility had 2 buildings that housed residents. In building A there were 5 doors that exited the building and all were unlocked 24 hours a day and 7 days a week. The door in the lobby was handicap accessible with a handicap button at waist height on the wall. In building B there were 4 doors and they were unlocked 24 hours a day and 7 days a week. The door on the right side of the building that led to a patio was handicap accessible with a handicap button on the wall at chest height. Anyone could freely go in and out of the doors except those resident who had a wander guard device. This device would engage a maglock if they were within 5 feet of the door and an alarm would sound. However, the door had to be closed for the maglock to engage. On 1/22/20 at 11:00 AM, review of the facility reported incident investigation report revealed that, on 1/12/2020 at 11:40 AM, Resident #6 was standing in the doorway of his/her room when another resident (who may independently go outside) exited the building through a side patio door in building B and Resident #6 followed them out while the door was open and the wander guard system was disengaged. At 11:41 AM, RN #4 was walking down the hallway and noticed the resident looking into the building from the patio. The Resident #6 was assessed and brought back into the building. The facility's single intervention was to move the resident's room further from the door. An observation of Resident #6 on 1/22/20, revealed resident was wearing a wander guard bracelet. During the time the surveyor was in building B between 12:27 PM and 1:19 PM, Resident #6 was observed going in and out of his/her room and wandering in the hallway. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 1/22/20 at 1:45 PM, revealed that the facility was aware that the doors with the handicap accessibility had an approximated 10 second delay in which the wander guard was disengaged and a resident with a functioning wander guard may exit without an alarm sounding. NHA reported that the facility had considered the risk versus benefit and determined that there was a greater likelihood of injury to handicapped, independent residents who frequently used the doors verses the likelihood of injury to a resident who may elope. Building A and B had similar layouts. In the front and center of the building is a door with a lobby area that leads to the nurses' station. Two hallways extend to the right and left of the nurses' station and the resident rooms were in these hallways. In Building B, where Resident #6 was housed, the door at the end of the right hallway was an exit to the patio. There were two hallways that extended to the back of the building and one hallway had an exit door. On 1/23/20 at 11:08 AM, a subsequent interview with the NHA, Assistant Nursing Home Administrator (ANHA), and DON, revealed that, at the time of Resident #6's admission, they were aware of the 10 second delay at the patio door in building B at the time the resident was admitted (with a known elopement risk) 2 doors down from this patio door. Subsequently, after the elopement on 1/17/19, the resident was placed further down the hallway towards the nurses' station. 2) A medical record review for Resident #5 on 1/23/20, revealed that the resident was admitted to the facility on [DATE]. Review of assessments revealed an Elopement Observation Risk, dated 6/30/19, that documented Resident #5 had been an elopement risk since admission. Review of the resident's care plan for elopement/wandering, initiated on 9/12/19, had a goal that the resident] would not exit the building during the next review period with date of review of 12/11/19. The interventions dated 9/12/19 were to redirect [resident] when wandering, mobility devices/equipment wander guard, and prompt activity attendance daily to keep resident the occupied. Review of a facility report on 1/23/20 at 10:00 AM, revealed that, on 1/17/2020 at 1:58 PM, Resident #5 was sitting beside the patio side door when a housekeeper entered building B through the patio doors. The resident exited through the open door before it could close, and the wander guard would reengage. At that time, the Activities Director was leaving building A and saw resident #5 at the patio gate. The Activities Director was unable to get the resident to go back in, so she called for help and at 2:04 PM, Resident was brought back into the building. The facility's single intervention was to change their internal policy/educate housekeeping staff to use a different door. Review of an additional self-report regarding Resident #5 on 1/23/20 at 10:00 AM, revealed the resident had a history elopement from the facility's front door while wearing a functioning wander guard. The resident was found in a parking lot to the left of the building 6 minutes after exiting. An interview with the Activities Director on 1/24/2020 at approximately 12:45 PM, revealed that on 1/17/20 Resident #5 was outside of the patio gate starting up the sidewalk towards building A when she saw the resident. On 1/22/20 at 12:50 PM, an observation of Resident #5 revealed the resident had a wander guard attached to the bottom of the wheelchair. During the observation, Resident #5 stated, I am going to get out of here today. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 1/22/20 at 1:45 PM, revealed that they were aware of the delay with the handicap accessible doors that were located near Resident #5's room. NHA reported these doors are used by independent residents to go out to the patio freely and failed to implement interventions to prevent future occurrences. A subsequent interview on 1/24/20 at 9:55 AM, with NHA, ANHA, and DON confirmed that all exit doors were unlocked all the time and if a resident with a wander guard device came within 5 feet of the any of the doors, then a maglock would engage until the resident moved away or a code was entered. They confirmed that if a resident with a wander guard would come to the door and it was open then the wander guard system was disengaged and that resident could leave the building with no alarm. The doors were checked weekly by maintenance staff. Concerns were reviewed with them at this time. As a result of these findings, a state of immediate jeopardy was declared on 1/24/20 at 5:09 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 1/24/20 around 6:31 PM and the State Agency was unable to accept this plan. After several requested revisions, the facility submitted a plan on 1/24/20 at 11:36 PM, and the removal plan was accepted at 11:41 PM. The removal plan included the following: a. All residents have the potential to be affected by the identified deficient practice. In order to immediately address the deficiency identified the facility has placed wander guard sensors at each facility egress to accomplish engaging all egress maglocks on an ongoing basis with immediate effect. The current contracted entity as of 1/24/2020, has silenced the alarm system on the keypads of each egress as of 7:45pm on 1/24/2020 to ensure a comfortable environment for the residents. b. A contracted company being able to come to the facility on Monday 1/27/2020 at 6am, will become the contracted entity at that time and will utilize the maglock system in place to change the system configuration and cause the system to engage all egress maglocks on a 24 hour continuous basis, the individual sensors will then be removed from each egress. Keypads are installed currently on the interior and exterior of each egress and will allow all staff to enter and exit the building per fire safety code. After completion of work, individual resident wander guards will be removed. c. Engaging the maglock system immediately, as well as changing the system configuration on a permanent basis on 1/27/2020 at 6am, will allow the facility to provide additional safety precautions to ensure resident safety. d. To ensure ongoing compliance, while wander guard sensors are placed for immediate affect at points of egress the facility will monitor all egress doors every 15 minutes to ensure functionality and the maglocks ongoing engagement. An assigned staff member will be assigned solely for this task with the charge nurse and another assigned GNA as backup (these assignments will be documented on the shift assignment sheet so all staff are aware). The every 15 minute checks will consist of physically going to each egress (5 in building A and 4 in building B) and physically pushing on the door to ensure the maglock is secured as well as checking the keypad for red light which will confirm locking in place. The assigned staff member will also immediately inform Administrator (NHA), Assistant Administrator (ANHA), and or Director of Nursing (DON) if any door is found to not be functioning properly. Any door not functioning properly shall be supervised by the assigned staff member at all times until the function of the door is restored. In the event that assigned staff member is supervising a malfunctioned door the charge nurse and backup Certified Medicine Aide (CMA)/Geriatric Nursing Assistant (GNA) will assist in continuing to monitor the remaining egress. Documentation of this process will be on every 15-minute timed checklist. e. To ensure ongoing compliance following the system configuration on 1/27/2020 at 6am, the facility will check door functionality q shift and will also immediately inform Administration if any door is found to not be functioning properly. Any door not functioning properly shall be manned by a staff member at all times until the function of the door is restored. f. Immediate corrective action of implanting the maglock on all egress was completed by 2:45 pm on 1/24/2020 and was communicated to all staff present at the facility at that time verbally, as well as to all staff in writing via facility memo, internal e-mail, and scheduling software. g. Education to all staff including PRN (as needed) staff will be conducted at each change of shift in person by supervisory team and/or by telephone education with 2 supervisors present to reach those staff members do not schedule to work until future dates. This is to ensure compliance in educating the entire staff on new process by Sunday 1/26/2020 at midnight. In person education will be documented by the staff signing off at the time the education is given. Phone education will be documented by two supervisory staff members sign off. h. Education will comprise of several aspects; introduction of a completely new process for safety of residents to include 24 hour locking system on all doors in both A & B Building, protection of the keypad code from any person other than staff, identifying low, medium and high elopement risk residents, how to answer pager system when doorbell is engaged as well as the assignment of doors per GNA section, and how to assist residents, visitors, and volunteers in and out of the buildings in a safe manner. See attached detailed educational process for all staff. i. This education will also address to all staff members the process to which those residents who are able to exit the buildings and how to assist them in doing so as well as those who need supervision in exiting the building. This process will include a visual marker (high visibility on resident name plate) of residents and on the resident's care sheet which will identify residents with confusion and exit seeking behaviors (medium to high risk per elopement risk observation). As of 11 pm all residents will have had an elopement risk assessment completed within the last 30 days. j. In addition, a notification is posted on all egress to visitors, vendors and volunteers addressing the need for them to see the charge nurse prior to exiting the building with any resident. k. The keypad code will change at regular bi-weekly intervals and be communicated to all staff at the time the change is made. The keypad code is not to be given to any visitors, residents, or volunteers. If you see a visitor, resident, or volunteer entering the keypad code, you must immediately notify Administration (Administrator; Assistant Administrator; DON) so that the keypad code can be changed and communicated to all staff immediately. l. Auditing of educational process will include weekly mock drill conducted by DON and/or designee which will include testing of answering of doorbell, proper identification of resident elopement status prior to exiting the building, exiting/entering an appropriate resident (low risk) from the building to include confirming closure of door and locking system. This auditing process will occur weekly x4, bi-weekly x2, and monthly x2. Nursing Supervisory and/or designee to do spot check of staff's knowledge of new process daily x7, weekly x4, bi-weekly x2, and monthly x2. m. From a Quality Assurance perspective, the facility will ensure education of all staff members to the above processes immediately, upon hire and at least annually, as a part of the emergency disaster in-service. Every shift, egress maglock functionality sign offs will be assigned to charge nurses to complete and will be reviewed daily during Interdisciplinary Team Clinical Meeting so that prompt review, investigation and correction can occur. Findings discovered during daily Interdisciplinary Team Clinical Review of q shift door function, audits for mock drill, and audits for spot check of staff knowledge will be referred to the Quality Assurance committee by the Administrator or designee monthly on an ongoing basis to indicate compliance or identified noncompliance as a part of the facility Quality Assurance committee responsibility to review all ongoing compliance measures. Any identified noncompliance will be reviewed by the Quality Assurance committee to review the plan on correction as written, formulate a new plan of correction, and determine additional steps to be taken to assure ongoing compliance. A copy of the education plan was provide by the facility and reviewed by the survey team. The immediate jeopardy was removed on 1/28/20 at 9:20 AM.