Every finding on record at Mountain City Rehab Center

Based on record review and interview it was determined that the facility failed to provide the required information to the resident and their representatives at the time of discharge to the hospital; and failed to ensure required documents were sent with the resident to the hospital at the time of transfer. This was found to be evident for two (Resident #6 and #9) out of three residents reviewed for hospitalization.The findings include: 1) Review of Resident #6's medical record revealed the resident was a long-term care resident who has resided at the facility for more than a year. On 2/23/26 the resident was transferred from the facility to the hospital, where the resident was admitted . Review of the progress notes for 2/23/26, including the eInteract Transfer Form, failed to reveal documentation to indicate the resident's care plan goals or current orders were sent to the hospital with the resident. On 3/5/26 further review of the medical record failed to reveal documentation to indicate a bed hold policy or written notice of transfer was provided to the resident or their responsible representative. On 3/5/26 at 2:43 PM surveyor requested the bed hold and notice of transfer information from the Medical Records Director #6 who indicated she would forward the request to the Social Service Director (SSD) #8. On 3/05/26 at 2:51 PM SSD #8 presented with the bed hold and notice of transfer documents, both dated 2/23/26. The SSD #8 reported these written notices had not yet been sent to the resident's family and indicated they were on her desk to be sent.Review of the transfer notice document dated 2/23/26, which was signed by the previous Nursing Home Administrator (NHA) #10, failed to reveal a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. 2) Review of Resident #9's medical record revealed the resident was a long-term care resident who has resided at the facility for more than 6 months. On 2/24/26 the resident was transferred from the facility to the hospital, where the resident was admitted . Review of the progress notes for 2/24/26, including the eInteract Transfer Form, failed to reveal documentation to indicate the resident's care plan goals or orders were sent to the hospital with the resident. Further review of the medical record failed to reveal documentation to indicate the bed hold or notice of transfer was provided to the resident or the resident's representative. On 3/04/26 at 4:10 PM Nurse #9 reported that when a resident is transferred out to the hospital the process includes making sure the resident and family are aware of the transfer, print out the orders, the care plan, the advance directive, the MOLST (Maryland Orders for Life Sustaining Treatment), bed hold policy and capacity paperwork. When asked for documentation to support that these items are printed out and sent with the resident, Nurse #9 reported there is the e-Interact transfer note and then a separate nurse's note. She went on to report that there are examples of this note in binders for nurses to reference. Surveyor reviewed the concern that no documentation was found to indicate care plan goals and orders were sent to the hospital with the resident. Surveyor also reviewed the concern that no documentation was found regarding the bed hold policy or notice of transfer for the 2/24/26 hospitalization.On 3/4/26 at 5:04 PM Nurse #9 confirmed no documentation to support that the care plan goals or orders were sent with the resident, stating that she thought it was included in the e-Interact form. Also at this time, 3/4/26 at 5:04 PM, Nurse #9 and the new Director of Nursing (DON) #7 presented with a letter that was being used for the notice of transfer. This notice failed to include several of the components required by this regulation. Nurse #9 reported they had a different version of this notice, but the previous NHA had them change it to this version.On 3/06/26 at 5:05 PM surveyor reviewed with the Nursing Home Administrator the concern regarding failure to ensure required information was sent to the hospital at the time or transfer and failure to ensure the notice of transfer and bed hold information was provided to the resident and responsible representative.On 3/06/26 at 5:29 PM the SSD #8 provided Bed Hold and notice of transfer, both dated 2/24/26, but reported that she sent this to the family yesterday or the day before. Review of the transfer notice document, dated 2/24/26, which was signed by the previous NHA #10, failed to reveal a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman.

Based on medical record review and interview it was determined that the facility failed to ensure staff completed physical assessment of resident after they returned from dialysis treatment. This was found to be evident for one (Resident #5) out of one resident reviewed for dialysis.The findings include:The intent of this requirement is that the facility assures that each resident receives care and services for the provision of dialysis consistent with professional standards of practice including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.Review of Resident #5's medical record revealed the resident was admitted to the facility more than 6 months ago, has a diagnosis of end stage renal disease (ESRD) and receives dialysis at a facility offsite three times a week. The resident has an order, in effect since July 2025, for dialysis Monday, Wednesday and Fridays at 11:40 AM. ESRD occurs when the kidneys are no longer functioning well enough to meet the body's needs. Treatment includes dialysis or kidney transplant. Dialysis is a treatment that filters and purifies the blood using a machine. This helps keep your fluids and electrolytes in balance when the kidneys can't do their job.On 3/5/26 review of the dialysis communication book for Resident #5, found at the nursing station, revealed Dialysis Communication Forms for January through March 4, 2026. These forms had an area at the top for nursing home staff to complete prior to sending the resident out to the dialysis center, and an area at the bottom for the staff at the dialysis center to complete. The section for the dialysis center to complete included, but was not limited to, documentation of vital signs pre and post dialysis, as well as the status of the access site, the resident's mental status , lung sounds and the presence of edema and pain. On 3/5/26 at 3:30 PM review of the Dialysis Communication Form dated 3/4/26 failed to reveal documentation from the dialysis center of the resident's status post (after) dialysis treatment. Interview at that time with Nurse #9 reported that the dialysis center fills out the bottom portion of the form and if they fail to complete that portion the nurse is supposed to call to obtain the information. Nurse #9 also reported that there is a pre and post dialysis UDA (User Defined Assessment) that facility staff are to complete on the days a resident attends dialysis. After reviewing the electronic health record, Nurse #9 confirmed that there were no follow up notes for Resident #5 for 3/4/26.On 3/5/26 at 3:42 PM surveyor reviewed the concern with the Corporate Nurse #14 the concern regarding the nursing staff's failure to follow up with dialysis after the 3/4/26 communication form failed to include documentation of the resident's status post dialysis.On 3/6/26 further review of the medical record failed to reveal documentation to indicate nursing staff completed a post dialysis assessment of the resident on 2/2; 2/6; 2/16; 2/18; 2/20 or 2/27/26. On 3/6/26 at 10:56 AM the Corporate Nurse #14 confirmed that the expectation is that nursing staff complete an assessment after returning from dialysis. Surveyor then reviewed the concern that no post dialysis UDA, or documentation of a blood pressure in the vital signs section, was found in the medical record to indicate facility nursing staff completed an assessment when the resident returned from dialysis on 2/2; 2/6; 2/16; 2/18; 2/20 or 2/27/26. On 3/6/26 at 11:24 AM Corporate Nurse #14 provided documentation to indicate facility staff followed up with the dialysis center for post dialysis information for 3/4/26. Review of the updated Dialysis Communication Form for 3/4/26 revealed a faxed date of 3/6/26 at 9:51 AM. The Corporate Nurse #14 also provided copies of the Dialysis Communication Forms for 2/2; 2/6; 2/16; 2/18; 2/20 and 2/27/26, however these forms do not include documentation to indicate an assessment was completed by facility staff after return from the dialysis center.On 3/6/26 at 1:33 PM Corporate Nurse #14 provided documentation of blood pressures in the electronic health record for the resident from 1/21/26 through 3/6/26. Review of this documentation revealed: -On 2/2/26 no blood pressure was found.-On 2/6/26 one blood pressure was recorded for 2/6/26 at 11:33 AM. -On 2/16/26 no blood pressure was found. -On 2/18/26 one blood pressure was recorded at 11:20 AM and corresponded to the blood pressure recorded by facility staff on the Dialysis Communication Form prior to being sent to dialysis center. -On 2/27/26 no blood pressure was found.On 3/6/26 at 1:33 PM the Corporate Nurse #14 confirmed that there was no additional documentation regarding assessments for facility staff post return from dialysis for the dates previously reviewed.On 3/06/26 at 5:04 PM surveyor reviewed with the Nursing Home Administrator the concern regarding the failure to ensure a resident assessment was completed after the resident returned from dialysis.

Based on observations and interviews, it was determined that the facility failed to treat residents with respect and dignity, as evidenced by failing to knock and request permission before entering residents' rooms. This was evident for 2 (Resident #79, #72) of 2 residents reviewed for dignity. The findings include:1) On 3/3/26 at 6:25 AM, Staff #2, a Geriatric Nursing Assistant (GNA), was observed by the surveyor walking into Resident #79's room without knocking on the resident's door before entering. When Staff #2 exited the room, the surveyor inquired about the resident's indwelling urinary catheter. Staff #2 returned to the resident's room with the surveyor a short time later, without knocking or announcing her intent, and showed the surveyor Resident #79's indwelling urinary catheter bag. On 3/6/26 at approximately 4:15 PM, the facility's Nursing Home Administrator and Director of Nursing were made aware of the concern. 2) On 3/4/26 at 9:01 AM, during an observation of the unit, it was noted that Resident #72 activated his/her call light for assistance. Staff #20, a GNA, entered Resident #72's room in response to the call light and asked the resident what s/he needed. However, the observation did not show that Staff #20 knocked on the resident's door or asked for permission before entering. In an interview on 3/4/26 at approximately 9:10 AM, staff #20 indicated that she usually knocked before entering residents' rooms; however, she confirmed that she had not done so and waited for permission before entering Resident #72's room during an earlier observation. During an interview on 3/6/26 at 4:53 PM, staff #7, the new director of nursing in training, stated that her expectation of staff was that they knock and introduce themselves whenever they entered residents' rooms.

Based on observation, record review, and interview, it was determined that the facility failed to ensure necessary equipment for pressure ulcer prevention was properly functioning and monitored. This was evident for 1 (Resident #8) of 1 residents reviewed for pressure ulcers. The findings include: On 03/03/26 at 7:37 AM , Resident #8 was observed while eating breakfast. The resident's bed was equipped with a pressure-reducing low air loss (LAL) mattress. The control unit setting was observed at 180 soft. Indicative for 180 pounds. On 03/03/26 at 8:27 AM, Resident #8's clinical record revealed that Staff #4, a Registered Nurse (RN), documented in the treatment administration record that the LAL mattress settings were correct for the shift on 03/03/26 at 6:30 AM. Further review of Resident #8's care plan revealed a focus for: Resident #8 having a self-care deficit related to displaced fracture of left femur, being at risk for skin impairment related to dementia, history of falls, and advanced age. The interventions documented included: Low air loss mattress: LAL mattress to bed. Check functionality and weight settings every shift. Initiated 11/27/25. On 03/03/26 at 9:06 AM , Resident #8's clinical record revealed a physician order that included:Low air loss mattress: LAL mattress to bed. Check functionality and weight settings every shift.Review of Resident #8's clinical record revealed the following most recent documented weights (in pounds):02/03/26: 106.8 (wheelchair)02/09/26: 108.4 (wheelchair)03/03/26: 110.4 (wheelchair)On 03/05/26 10:02 AM - Resident #8 was observed self-propelling in their wheelchair in the day room. The LAL mattress on the resident's bed remained set at 180 soft, consistent with the setting previously observed on 03/03/26.On 03/05/26 10:12 AM - A joint observation of the LAL mattress control unit was conducted by the surveyor and Staff #3, a Licensed Practical Nurse (LPN), on the Haven unit. The control unit setting remained 180 soft. Staff #3 was asked whether the facility had a user manual to guide staff in determining the correct LAL mattress settings. Staff #3 stated that maintenance maintains the user manual.On 03/05/26 at 10:22 AM, a review of Resident #8's clinical record revealed that Staff #3 documented on 03/05/26 at 6:30 AM that the LAL mattress settings were correct for the shift.03/05/26 11:10 AM - The facility provided the surveyor with the manufacturer's user manual for the LAL mattress. The manual instructs staff to determine the resident's weight and set the control knob to the corresponding weight setting on the control unit.At the time of the observations on 03/03/26 and 03/05/26, Resident #8's most recent documented weight was 110.4 pounds (03/03/26). The LAL mattress remained set at 180 soft, which did not correspond to the resident's documented weight.Despite this discrepancy, Staff #3 on 03/03/26 and Staff #4 on 03/05/26 documented that Resident #8's LAL mattress settings were correct when observed by the surveyor.On 03/06/26 at approximately 4:15 PM, the facility's Nursing Home Administrator and Director of Nursing were made aware of the concern.

Based on observations, record review, and interviews, it was determined that the facility failed to provide reasonable accommodations to maintain residents' independence by failing to ensure access to remote bed controls that worked to adjust their bed settings independently. This was evident in 1 of 2 room observations.The findings include:On 3/3/26 at 8:59 AM, Resident #12 was observed lying in bed with the head of the bed elevated about 30-45 degrees and legs straight. The resident reported being stuck in that position and unable to change it because the bed remote was not functioning. The resident complained of neck and back pain due to being in that position. Resident #12 added that the staff was aware but had not taken any action to fix the remote.In a separate observation on 3/4/26 at 8:52 AM, Resident #12 was lying flat on his/her back in bed, with feet elevated higher than the head. The resident tried to lift his/her head using the remote bed control but reported that it was not working.A review of Resident #12's medical record showed that s/he was alert, oriented, and able to communicate needs. However, s/he was non-ambulatory and needed staff assistance to move.During an interview on 3/4/26 at 8:54 AM, staff #17, a nursing assistant, reported that Resident #12's remote bed control had not been working properly for some time and that staff had to use manual control at the foot of the bed. Staff #17 confirmed that Resident #12 was unable to change their position in bed due to the remote's malfunction.An interview conducted on 3/4/26 at 9:03 AM with staff #18, a maintenance assistant, indicated that Resident #12 could not operate his/her remote bed control to change positions in bed because the nursing staff had locked it. However, during an interview on 3/5/26 at 8:47 AM with staff #19, a nursing assistant, it was revealed that Resident #12's remote bed control had locked itself due to a malfunction. Staff #19 attempted to use the resident's control during the interview, but was unable to because it did not work.During an interview on 3/5/26 at 9:44 AM, the Interim Nursing Home Administrator (NHA) was in Resident #12's room with the surveyor. The NHA was observed attempting to operate the resident's bed remote control. It initially worked, but then stopped. The NHA said she would find out what was going on with it.In a follow-up interview on 3/5/26 at 10:04 AM, the NHA informed the surveyor that they had replaced Resident #12's remote bed control following the surveyor's intervention and stated that staff would continue to monitor it to ensure it remained functional.

Based on observations and interviews, it was determined that the facility failed to ensure a clean, comfortable, and home-like environment for residents. This was evident in 1 of 2 rooms identified with environmental concerns during the survey.The findings include:An observation on 3/3/26 at 6:54 AM noted a strong urine odor in Resident #72's room. A follow-up observation on 3/4/26 at 9:01 AM showed that Resident #72's room still had a strong urine smell. The bathroom also had a noticeable urine odor, a sticky floor, and dark brown residue. Additionally, upon entering the bathroom, two floor tiles to the right were stained brown. The toilet bowl was heavily stained with bowel movements.During an interview on 3/4/26 at 9:26 AM, staff #21, a registered nurse, reported that the strong urine smell in Resident #72's room and bathroom had been present most of the time.In an interview on 3/5/26 at 12:07 PM, the interim nursing home administrator (NHA) was present at Resident #72's room with the surveyor. The NHA confirmed that the resident's bathroom and room had a strong urine smell; the bathroom floor had dark brown, sticky residue; and two tiles on the right side of the entrance floor had brown stains. The NHA reported that she was already aware of the concerns. During an interview on 3/5/26 at 12:17 PM with staff #22, the housekeeping manager confirmed the concerns and stated that his department's goal was to strip and deep-clean two residents' rooms weekly; however, that goal had not yet been met. He also mentioned that Resident #72's room was next on their list for deep cleaning and stripping.

Based on record review and staff interview, it was determined that the facility failed to monitor and prevent the misappropriation of resident property. This was evident for 1 (Resident #76) of 4 residents reviewed for abuse during the recertification survey.The findings include:A review of the medical record on 3/3/26 at 10:42 AM showed that Resident #76 had been at the facility since 2023. Continued review included an attending provider's order dated 2/3/25 for Resident #76 to receive oxycodone 5 mg tablets four times daily for chronic back pain. A review of facility-reported incident #2657499 involving Resident #76 found that on 10/27/25, staff #24, a licensed practical nurse, received 30 tablets of oxycodone 5mg from the pharmacy for Resident #76. Further review showed that on 10/31/25, staff #25, a registered nurse, discovered that all 30 tablets of oxycodone and the administration record sheet for Resident #76 were missing. The review also included the packing slip for the 30 5mg oxycodone pills from the pharmacy for Resident #76, which showed it was signed on 10/27/25 at 9:16 PM by staff #24, confirming that the medications were delivered and received.A review of Resident #76's medication administration record for November 2025 showed that Resident #76 did not receive his/her scheduled 5 mg oxycodone for chronic back pain on 11/1/25 at 12:00 AM, 11/1/25 at 6:00 AM, 11/2/25 at 12:00 AM, and 11/2/25 at 6:00 AM.Further review of Resident #76's medication administration progress notes for November 2025 showed that Resident #76 did not receive his/her pain medication on 11/1/25 at 12:00 AM, 11/1/25 at 6:00 AM, and 11/2/25 at 12:00 AM due to medication unavailability.During an interview on 3/6/26 at 1:27 PM, the acting director of nursing (DON) reported that her investigation revealed that staff #24 signed for the 30 pills of oxycodone 5mg for Resident #76 from the pharmacy on 10/27/25. However, staff #24 continued to deny opening the plastic bag containing the drugs. The facility was unable to locate Resident #76's pain medications that were delivered and received by staff #24 on 10/27/25. The acting DON indicated that the pharmacy delivered a new supply on 11/2/25, and the facility implemented a new process for receiving controlled medications from the pharmacy.

Based on medical record review and interview it was determined that the facility failed to ensure the completion of a death in facility tracking record for a resident who expired. This was found to be evident for one (Resident #44) out of one resident reviewed for the Resident Assessment task.The findings include: Review of Resident #44's medical record revealed a Significant Change Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], was signed off as completed by Nurse #11 on [DATE]. On [DATE] further review of the medical record failed to reveal documentation to indicate another MDS assessment was completed following the [DATE] assessment. This was more than four months (which constitutes a quarter of a year) without the transmission of MDS assessment documentation.Upon entering the resident's electronic health record a notice was observed in RED which stated Death ARD: [DATE] 49 days overdue.Review of the nursing progress notes confirmed that on [DATE] the resident had expired at 2:15 AM.On [DATE] at 3:57 PM a phone interview with Nurse #11 revealed she works remotely but is responsible for ensuring the completion of the MDS assessments. In regard to tracking, Nurse #11 reported she runs a missing assessment report but confirmed Resident #44 had not come up on the report yet. Nurse #11 reported: I missed it in regard to the failure to complete the death in facility tracking assessment.

Based on interviews and record reviews, it was determined that the facility failed to ensure that a resident participated in the care planning process and that interdisciplinary team (IDT) care conference meetings were conducted following completion of MDS assessments. This was evident in one (Resident#12) of three residents reviewed for care planning during the survey.The findings include:The Minimum Data Set (MDS) is a federally mandated tool that nursing home staff use to collect information about each Resident's strengths and needs. This information is then used to make care planning decisions for the Resident. The nursing home shall hold the care planning conference with an interdisciplinary team (IDT), including the attending physician, a registered nurse, a nursing aide, a dietary services representative, the Resident, and the Resident's representative (as practicable), no later than 7 calendar days after completing the MDS assessment. However, the conference may be scheduled earlier if agreed upon by the Resident, a family member, or the Resident's representative.During an interview on 3/3/26 at 8:55 AM, Resident #12 was asked whether s/he had participated in the latest care plan meeting and responded that s/he was not aware of any such meeting because s/he had not been invited. A review of Resident #12's record showed that s/he was alert, oriented, and able to verbalize needs. Continued review of Resident #12's care plan indicated that the Resident was bedfast (confined to bed due to illness) and required staff assistance with most of his/her self-care needs, including moving from one place to another.Further review included an MDS assessment dated [DATE], completed on 1/12/26, for Resident #12. Another MDS assessment dated [DATE] was completed on 2/5/26. Following the MDS completion date of 1/12/26, an IDT care plan meeting was held on 1/13/26 for Resident #12. However, the review did not show that Resident #12 attended his/her own meeting or that s/he declined to attend. A continued review of the medical record did not find documentation showing that an interdisciplinary care plan meeting also took place after Resident #12's MDS dated [DATE].During an interview on 3/4/26 at 4:13 PM, staff #8, the Social Services Director (SSD), reported that IDT care plan meetings were scheduled for Residents according to their MDS schedules, so a meeting was scheduled for Resident #12 on 1/13/26 following the 1/12/26 MDS assessment. The SSD reported that before the meeting dates, staff mailed notification letters to the residents' representatives and also handed copies to the Residents themselves. The interview also showed that, on the day of the meeting, direct care staff were informed to help facilitate residents' preparation. However, she was off work on 1/13/26. The SSD reported that, per the care conference record for 1/13/26, Resident #12 was not in attendance, and there was no documentation indicating that s/he declined to attend. In a follow-up interview on 3/4/26 at 4:56 PM, the SSD reported that no care plan meeting was scheduled after the completion of Resident #12's MDS dated [DATE].

Based on medical record review and interview it was determined that the facility failed to ensure a resident's medication was obtained in a timely manner and that it was administered as ordered. This was found to be evident for one (Resident #5) out of one resident reviewed for dialysis.The findings include: Review of Resident #5's medical record revealed the resident was admitted to the facility more than 6 months ago, has a diagnosis of end stage renal disease (ESRD) and receives dialysis at a facility offsite three times a week. ESRD occurs when the kidneys are no longer functioning well enough to meet the body's needs. Treatment includes dialysis or kidney transplant. Dialysis is a treatment that filters and purifies the blood using a machine. This helps keep your fluids and electrolytes in balance when the kidneys can't do their job. Further review of the medical record revealed an order, with a start date of 7/20/25, for Renvela Oral Tablet 800 mg give 1600mg by mouth with meals for ESRD (end stage renal disease).Renvela, also known as Sevelamer Carbonate, is a medication used to control high blood phosphate levels in patients receiving dialysis.Review of a 1/3/25 memo from the pharmacy to the facility regarding phosphate binders (such as Sevelamer Carbonate) for patients with ESRD receiving dialysis revealed that, due to billing changes, it is the responsibility of the dialysis center to provide a full supply of medication to the patient for routine administration. Review of the resident's Medication Administration Record for January 2026 revealed documentation to indicate the Renvela 1600 mg was administered to the resident as ordered three times a day. No documentation was found to indicate any doses were missed in January 2026.On 3/5/26 at 3:30 PM review of the dialysis communication book for Resident #5, found at the nursing station, revealed Dialysis Communication Forms for January through March 4, 2026. Review of the communication form for 1/9/26 revealed the following notation in the portion of the form completed by nursing home staff: *Pharmacare is to send (his/her) Renvela to you!On 3/5/26 at 4:20 PM Nurse #13 confirmed that she had written the Pharmacare is to send.Renvela to you on the 1/9/26 communication form and that she had actually written the note on the evening of 1/8/26. Nurse #13 reported that there were a few days that the resident was without a supply of the Renvela, so she borrowed some from another resident's supply. She went on to report that she kept track of what was borrowed and then replaced it. Nurse #13 confirmed that the three doses of Renvela that she had documented as administered on 1/8/26 was borrowed from another resident. During the 3/5/26 interview, Nurse #13 had the resident's current supply of Sevelamer Carbonate 800 mg tablets with her. The label on the bottle was 1/12/26, indicating it was not available from the pharmacy prior to 1/12/26. Surveyor and Nurse #13 agreed there were at least 20 tablets left in the supply. The bottle indicated it initially contained 240 tablets. Nurse #13 confirmed that each dose of 1600 mg would require the administration of two tablets.Two tablets per dose, three doses per day would mean the resident should receive 6 tablets per day. That would mean 240 tablets would equal a 40-day supply. If the resident began receiving the supply on 1/12/26 the supply should have run out 40 days later, around 2/21/26.On 3/6/26 at 4:30 PM surveyor informed Corporate Nurse #14 that at least 20 pills were remaining from the 40-day supply, which, if started on 1/12/26, should have run out in February. Also reviewed the concern regarding Nurse #13's report of borrowing the medication from another resident and that other staff had documented administration between 1/9/26 - 1/12/26. Corporate Nurse #14 indicated she would investigate to see if there was another supply.Review of the 1/12/26 Dialysis Communication Form revealed the following handwritten notation: Pharmacare to send Renvela to dialysis. [S/he] is now out. If you have it please send it back c [with] [him/her].Review of the 1/16/26 Dialysis Communication Form revealed the following handwritten notation: Need [his/her] Renvela from pharmacare.Review of the February MAR revealed staff documented the Renvela as ordered three times a day except for three doses. The 2/11/26 and 2/20/26 doses due at 11:00 AM were documented with a 9 indicating it was not given and to see nursing notes; no documentation was found for the dose due at 5:00 PM on 2/17/26 as evidenced by a blank space.Review of the March 2026 MAR revealed documentation that the medication was administered as ordered from 3/1 through 3/5/26.On 3/06/26 at 8:06 AM Corporate Nurse #14 reported that the amount of medication left in the supply does not account for all the doses that staff have documented as given. She reported it was documented as not given on two occasions in February which only accounts for 4 pills. Nurse #14 did not have the actual count of the pills that were left over.On 3/06/26 at 9:15 AM surveyor and Corporate Nurse #14 counted Resident #5's supply of Sevelamer Carbonate 800 mg tablets that was dated 1/12/26. A total of 63 tablets remained. Nurse #14 informed surveyor that Nurse #13 reported she had borrowed the medication from Resident #94 who has been discharged . She also confirmed that no other current resident has a supply of Sevelamer Carbonate 800 mg tablets.Review of Resident #94's medical record revealed this resident was discharged on 1/28/26 and has not returned to the facility.On 3/6/26 further review of the medical record revealed that on 3/6/26 at 11:25 AM a new order was put in placed for Renvela Oral Tablet 800 mg Give 2 tablets by mouth with meals for ESRD **2 tabs to equal 1600mg **.On 3/6/26 at 5:04 PM surveyor reviewed with the Nursing Home Administrator the concerns regarding the failure to ensure Resident #5's Renvela medication was obtained in a timely manner; failure to ensure the medication was administered as ordered and the failure to ensure professional standards as evidenced by staff borrowing medication from another resident.

Based on observations, record review, and interviews, it was determined that the facility failed to maintain respiratory care equipment for residents who required continuous oxygen via nasal cannula. This was evident in 1 (Resident #72) of 3 residents reviewed for respiratory care.The findings include:Humidified water is used with oxygen concentrators to provide comfortable humidity and moisture to continuous-flow oxygen therapy, preventing upper airway dryness.During an initial interview with Resident #72 on 3/3/26 at 6:54 AM, it was observed that Resident #72 was receiving 2 liters (L) of continuous oxygen via nasal cannula. The tubing or nasal cannula was neither initialed nor dated. Further observation revealed an empty humidifier canister attached to Resident #72's oxygen concentrator, dated 2/11/26.A follow-up observation on 3/3/26 at 10:40 AM showed that Resident #72 continued to receive continuous oxygen while the humidifying water canister attached to the oxygen remained empty. A review of the facility's 'Oxygen Administration policy was completed. The review included a statement: Be sure there is water in the humidifying jar and that the water level is high enough that water bubbles as oxygen flows through. A review of Resident #72's order summary as of March 3, 2026, showed an attending provider's order dated 6/28/25 indicating that Resident #72 was to receive oxygen at every shift, and that his/her oxygen tubing and humidifying bottle should be changed, dated, and initialed weekly on Wednesdays. However, an earlier observation of Resident #72's humidifier canister revealed that the last change was on 2/11/26, and the oxygen tubing was neither initialed nor dated. There was no humidifying water in the canister.During an interview on 3/3/26 at 10:45 AM, staff #23, a licensed practical nurse, was present in Resident #72's room with the surveyor. Staff #23 reported that Resident #72's humidifying water canister was overdue for a change. She stated she would replace it immediately and fill it with water. On 3/3/26 at 11:06 AM, staff #23 reported to the surveyor that Resident #72's oxygen tubing and canister had been replaced and dated after the surveyor's intervention. She also said that she filled the canister with humidifying water. During an interview with staff #7, the new director of nursing in training, on 3/6/26 at 4:57 PM, she mentioned that she expected the nurses to change the resident's canister, tubing, and humidifying water weekly before signing the task as completed.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure medications were labeled and discarded when expired. This was evident in 2 of 3 medication carts observed during medication storage and labeling inspection. The findings include:A total of 3 medication carts were inspected on 3/3/26 from 10:39 AM to 11:36 AM. 2 of the 3 medication carts had concerns identified and they were: The medication cart labeled as 100 hall 100-111 assigned to staff nurse (Nurse #5) was inspected on 3/3/26 at 10:39 AM. The inspection revealed a) an bottle of Geri-Kot (laxative) that was opened on 11/8/25 with an expiration date of 1/2026, b) Spiriva-Respimat (inhaler) for Resident #9 had no indication or label from when it was opened with instructions to discard 3 months after inserting the cartridge, and c) Breo-Ellipta (inhaler) for Resident #71 had no indication or label from when it was opened with instructions to discard 6 weeks after opening. On 3/3/26 at 10:57 AM, Nurse #5 indicated that she would discard and replace the expired laxative.Nurse #5 then stated, it's probably time to replace it. Referring to Resident #9's inhaler and indicated that a new one was also in the medication cart. However, she confirmed that the inhaler was administered earlier that day to the resident.Nurse #5 also reported that she would review Resident #71's medical record to figure out when the inhaler was opened or reorder the medication if she could not identify the open date. 2. The medication cart labeled as 300 hall 300-315 assigned to staff nurse (Nurse #4) was inspected on 3/3/26 at 11:12 AM. The inspection revealed Resident #74's Anoro-Ellipta (inhaler) that was opened on 1/12/25 with instructions to discard after 6 weeks from opening.On 3/3/26 at 11:28 AM, Nurse #4 stated, I don't think s/he's (Resident #74) on this anymore. However, after a review of the resident's administration record, she confirmed that it was administered earlier that day and indicated that she would discard the inhaler.The interim Director of Nursing (DON) was interviewed on 3/3/26 at 11:54 AM. During the interview, the concern of finding expired and unlabeled medications was discussed. The DON reported that the consultant pharmacist inspects medication carts monthly for cleanliness and ensures all medications are labeled and expired medications discarded. However, the pharmacist does not inspect all medication carts as it was done at random. The DON acknowledged the concern.

Based on interviews and record reviews, it was determined that the facility failed to offer and administer covid-19 immunization to residents. This was evident for 2 (Resident #11 and #59) of 5 residents reviewed for immunizations. The findings include:The Facility's Infection Preventionist (IP) nurse (Staff #12) was interviewed regarding immunizations on 3/6/26 at 10:27 AM. During the interview, Staff #12 explained her process and documentation. She indicated that resident immunization records are kept in the electronic health record and hard copies for consents and declination forms are kept in a binder in her office. Staff #12 then reported that she would provide the binder to the surveyor for review. While waiting for Staff #12, a review of resident electronic health records for immunizations was conducted on 3/6/26 at 10:38 AM. The review revealed the following concerns:Resident #11 had no documentation to indicate Covid-19 immunization was administered or declined in 2025.Resident #59 had no documentation to indicate Covid-19 immunization was administered or declined in 2025. The findings listed above were discussed with Staff #12 when she returned with the immunization binders on 3/6/26 at 10:56 AM. The Binders were reviewed with Staff #12 and revealed on 9/17/24, Resident #11's responsible party had given verbal consent via phone for the resident to receive 2024-2025 Covid-19 immunization. However, the bottom part of the consent had spaces with lines that was meant for documenting the administration (date, site, lot numbers, etc.) of the vaccine. This part of the document was left blank and there was no other documentation found to indicate that Resident #11 received the vaccine. On 3/6/26 at 11:09 AM, further review of the binders with Staff #12 failed to reveal any documentation that Resident #59 had received or declined the vaccine. Staff #12 reported that she recalls talking to the resident's responsible party (RP) and declining the vaccine. However, there was no declination form found or any documentation to indicate that the resident and/or resident's RP received information to decline the vaccine. The Nursing Home Administrator (NHA) was interviewed on 3/6/26 at 5:02 PM. During the interview, the concern that the facility failed to offer and provide information on Covid-19 vaccine to 2 residents was discussed. The NHA verbalized understanding and acknowledged the concern.

Based on facility policy review, record review, facility document review, interview, and observation, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, which affected 4 (Resident #8, #7, #12, and #18) of 9 residents reviewed for accidents or falls during the complaint survey. Specifically, Resident #8 was improperly transferred by one staff when they required two staff to safely transfer causing actual harm. The Findings include: A facility policy titled, Assessing Falls and Their Causes, revised 03/2018, revealed, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The policy revealed, Preparation included, 1. Review the resident's care plan to assess any special needs of the resident. The policy revealed, Identifying Causes of a Fall or Fall Risk specified, 2. Evaluate chains of events or circumstances preceding a recent fall, including: a. Time of day of the fall; b. Time of the last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching, or transferring from one position to another; e. Whether the resident was among other persons or alone; f. Whether the resident was trying to get to the toilet; g. Whether any environmental risk factors were involved (e.g. [exempli gratia; for example], slippery floor, poor lighting, furniture or objects in the way); and/or h. Whether there is a pattern of falls for this resident. 1. An admission Record revealed the facility originally admitted Resident #8 on 12/11/2024 and readmitted the resident on 03/01/2025. According to the admission Record, the resident had a medical history that included diagnoses of generalized muscle weakness, difficulty walking, fatigue, and congestive heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2025, revealed the Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance to transfer from a chair to a bed. Resident #8's Care Plan Report included focus area dated 12/13/2024, that indicated Resident #8 had an activities of daily living (ADLs) deficit related to confusion and forgetfulness and was alert and oriented to person only. Interventions directed staff to provide two staff to assist the resident with transfers (initiated 12/13/2024). Resident #8's Kardex [a guide for direct caregivers outlining each resident's care needs] Report as of 3/31/2025, documented Resident #8 assistance from two people for transfers. A Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Initial Report Form revealed that the facility reported to the state survey agency that Resident #8 had a laceration to left lower leg outer aspect that the facility reported as an injury of unknown source. The report indicated that the Director of Nursing (DON), who was the Assistant Director of Nursing (ADON) at the time, became aware of the injury on 04/01/2025 at 9:45 AM. The report indicated that the DON submitted the report to the state survey agency on 04/01/2025 at 12:45 PM. Per the report, all beds in the facility were inspected by maintenance staff to ensure there were no sharp edges and indicated that any issues that were identified were fixed immediately by maintenance staff. A Maryland Department of Health Office of Health Care Quality Facility Reported Incident Follow-Up Investigation Report, submitted to the state survey agency on 04/07/2025, revealed Geriatric Nursing Assistant (GNA) #19 was transferring Resident #8 when the resident stated that their leg hurt. The report indicated that there was probable cause that the laceration occurred from the resident's leg hitting against an uncapped edge of their bed frame when the resident was being transferred to bed. Per the report, the resident required 15 sutures to the laceration. The report indicated the GNA #19 was suspended, pending investigation. Resident #8's New Skin Concern record, dated 04/01/2025 at 12:00 AM, indicated that Licensed Practical Nurse (LPN) #20 was called to Resident #8's room by GNA #19 related to the resident's left leg bleeding. The record indicated Resident #8 was in bed, alert, with an open gash on the left leg. The record indicated the nurse applied pressure, cleansed the wound, and applied a dressing. The record indicated Resident #8 was unable to give a description of what had happened, and a nurse was asked to call 911. Resident #8's hospital Patient Visit Information, dated 04/01/2025, indicated that the resident had a laceration on their left lower leg, with a component of skin avulsion. Per the record, This means that the skin was torn off. As such, the edges are not perfectly sewn together. A Witness Statement, dated 04/01/2025 and signed by GNA #19, revealed that on 04/01/2025 at 12:00 AM, GNA #19 transferred Resident #8 to bed. The statement revealed that after the GNA got the resident in bed, the resident stated, Ouch, my leg hurts. The statement indicated that when GNA #19 looked, she saw the cut and blood and also saw blood and skin in the bedframe. Per the statement, she reported it to the nurses. A Witness Statement, dated 04/01/2025 and signed by LPN #1 revealed that a GNA assigned to Resident #8 reported that the resident complained of pain after being transferred from their wheelchair to their bed. The statement indicated that LPN #1 noted blood and skin tissue inside of an un-capped bed frame [sic] edge. During an interview on 10/12/2025 at 4:24 PM, GNA #7 stated that she and another orientee found Resident #8 with a tube feeding pole that had fallen over the resident's shoulder. GNA #7 stated that a nurse did a complete head-to-toe assessment on the resident at that time, and they did not see any blood or a cut on the resident. GNA #7 stated that she recommended to GNA # 19 that the resident should be put to bed, and shortly after that she heard GNA #19 yelling that Resident #8 caught their leg during when being transferred, and the resident was bleeding. GNA #7 stated she told GNA #19 to get the nurse. GNA #7 stated the GNAs knew how to transfer a resident by checking the Kardex. During an interview on 10/11/2025 at 8:15 PM, GNA #8 stated that she was an orientee with GNA #7 on the night Resident #8 hurt their leg. She stated that before that happened, she noticed the resident had wheeled away from their tube feeding pole and it fell across the back of the wheelchair and the resident's shoulders. She stated that they straightened the resident and the pole and notified the nurse. She stated they did not transfer the resident but notified the resident's GNA (GNA #19) that the resident was moving around. She stated that there was no bleeding or a cut noted on the resident when she saw them. She stated GNAs followed the care plan in the Kardex to know how to transfer a resident. During an interview on 10/12/2025 at 4:49 PM, LPN #20 stated that she was called to Resident #8's room by two GNAs when the resident's pole for the tube feeding fell on the resident's shoulder. LPN #20 stated that she looked the resident over from head to toe, and there were no marks and no bleeding. LPN #20 stated that the two GNAs asked the resident's GNA (GNA #19) to move the resident to bed. LPN #20 stated GNA #19 notified her and informed her that Resident #8's leg was bleeding, and she had the charge nurse accompany her to the resident's room. LPN #20 stated she and the charge nurse noted blood on the resident's bed frame, and no blood on the resident's wheelchair. LPN #20 stated the GNAs should know how to transfer a resident by using the Kardex. During an interview on 10/15/2025 at 2:03 PM, the Director of Nursing (DON) stated that the GNA should have gotten assistance to transfer the resident. The DON stated that Resident #8 required two people to assist with transfers, and stated that they fired the GNA because she did not follow the care plan. 2. An admission Record indicated the facility admitted Resident #7 on 04/09/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety; polyosteoarthritis (arthritis affecting multiple joints simultaneously); other specified disorders of bone density and structure; and generalized muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/01/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #7 had inattention and disorganized thinking. The MDS indicated Resident #7 had no functional limitations in movement of the upper extremities but had bilateral limitations in range of motion of the lower extremities. The MDS indicated Resident #7 was dependent on staff for rolling left and right while lying in bed, moving from sitting to lying, and for tub/shower transfers. The MDS indicated Resident #7 required substantial/maximal assistance with moving from lying to sitting on the side of the bed, moving from sitting to a standing position, for chair-to-bed and bed-to-chair transfers, and for toilet transfers. The MDS indicated Resident #7 was able to walk 10 feet with partial/moderate assistance from staff. Per the MDS, Resident #7's fall history revealed the resident had fallen in within the month prior to admission or re-entry, experienced a fall in the previous two to six months prior to admission/entry or reentry, and had a fracture related to a fall in the six months prior to admission or re-entry. Resident #7's Care Plan Report included a focus area, initiated 04/10/2024, that revealed Resident #7 was at risk for falls related to a history of falls, poor balance, and an unsteady gait. Interventions included instructions for staff to do the following: - Ensure the call bell/light was within reach, encourage the resident to use the call light, and respond promptly to the resident's requests for help (initiated 04/10/2024); - Provide increased visual cue in room (initiated 09/12/2024); and - Frequently re-orient the resident and reinforce the need to call for assistance (initiated 04/10/2024). Resident #7's Care Plan Report included a focus area initiated 09/19/2024, that indicated the resident had an alteration in their musculoskeletal status. Interventions initiated 09/19/2024 directed staff to ensure the call light was within the resident's reach and respond promptly to requests for assistance (this was a repeated intervention that was already initiated 04/10/2024), and to educate the resident/family/caregivers on safety measures to reduce the risk of falls. Resident #7's Care Plan Report included a focus area initiated 04/10/2024, that indicated the resident had a fall on 02/06/2025 that resulted in a skin tear to the left hand, and a fall on 02/18/2025 from their bed that resulted in a skin tear to the left elbow. Interventions directed staff to do the following: - Assess the resident after each fall and ensure safety, ensure eating was done in staff sight, and keep the call light in reach (initiated 04/10/2024); - Monitor the resident more closely when out of bed at night (initiated 04/27/2024); - Offer more frequent checks to minimize falls (initiated 05/24/2024); - Provide visual cue in the resident's room to remind the resident to ask for assistance when getting out of bed (initiated 07/08/2024); - Place the resident at a table when a snack is given (initiated 10/16/2024): - Attempt to monitor the resident's whereabouts and redirect for safety as needed (initiated 04/02/2025); - Educate the resident of the importance of transfer assistance and the dangers of transferring independently (initiated 04/28/2024); and - Keep the resident in sight when the resident was antsy [anxious]/wanting to assist/clean (initiated 05/21/2025). Resident #7's Kardex (an electronic form used by the geriatric nursing assistants [GNAs] to direct resident care), dated 10/09/2025, revealed, Fall Prevention, which included the following directions to staff: Ensure the resident's call light was within reach, encourage the resident to use it for assistance as needed and respond promptly to all requests for assistance, educate the resident on the importance of transfer assistance and the danger of transferring independently, frequently re-orient and repetitively reinforce the need to call for assistance, keep the call bell in the resident's reach (this was already previously mentioned), offer more frequent checks to minimize falls, monitor the resident more closely when out of bed at night, and provide verbal cues for safety. The Kardex revealed the Resident Care section included staff directions to ensure call light was in reach and respond promptly to all requests for assistance and ensure the resident had a table in front of them for snacks. A facility incident report dated 02/22/2025 at 12:00 AM, revealed Resident #7 was found on the floor in front of their wheelchair in their room. The report indicated Resident #7 had been reaching for a tissue, slid to the floor, did not hit their head, and had no injury. The report revealed sections for Predisposing Environmental Factors, Predisposing Physiological Factors, and Predisposing Situation Factors. The report revealed that each of those sections were blank. Resident #7's Progress Notes revealed a note, dated 02/24/2025 at 1:40 PM, that indicated the Interdisciplinary Team (IDT) met two days after Resident #7's fall to discuss the fall. The note indicated that Resident #7's care plan was updated to keep personal items, tissues, and water on their overbed table within reach. Resident #7's Care Plan Report revealed an intervention initiated 02/24/2025, that directed staff to ensure the resident's personal items were in reach on their overbed table (initiated 02/24/2025). A facility incident report, dated 03/02/2025 at 2:22 PM, indicated Resident #7 was found in their room on the floor, sitting in front of their wheelchair. Resident #7's Progress Notes revealed a note, dated 03/02/2025 at 2:22 PM, that indicated Resident #7 was assessed after the fall, assisted to their wheelchair by staff, and the care provider and the resident's power of attorney were notified of the fall. Resident #7's Progress Notes revealed a note, dated 03/03/2025 at 2:36 PM, that indicated the IDT met concerning the resident's fall and added a new intervention to place the resident at the nurses' station between meals and activities for supervision and safety. Resident #7's Care Plan Report revealed an intervention initiated 03/02/2025, that directed staff to provide supervision for the resident at the nurses' station between meals and activities (initiated 03/02/2025). The record revealed no investigation or witness statements included to determine how long the resident had been in the room alone or what the resident had been doing prior to the fall. A facility incident report, dated 03/10/2025 at 6:45 PM, indicated Resident #7 was found in their room lying on the left side in front of their wheelchair, an old skin tear was reopened on their left forearm, and a new skin tear was found on their left knee. The report indicated Resident #7 was assessed, the resident's left knee and left forearm were cleansed, a dressing was applied, and a family member and care provider were notified of the fall. Resident #7's Progress Notes revealed a note, dated 03/11/2025 at 11:36 AM, that indicated the IDT met concerning the resident's fall and added the intervention of a perimeter mattress to the bed (although the resident was found in front of their wheelchair). Resident #7's Care Plan Report revealed an intervention initiated 03/10/2025, that directed staff to ensure a perimeter mattress was used on the resident's bed (initiated 03/10/2025). The record revealed no evidence of an investigation to determine the cause of the fall and no witness statements that indicated where the resident had been prior to being found on the floor in front of the wheelchair or when care was last received. A facility incident report, dated 04/20/2025 at 8:00 PM, indicated Resident #7 was eating a snack while sitting in the wheelchair, dropped the snack, and fell out of the wheelchair while bending over to pick up the snack. The report indicated Resident #7 was assessed, was at their baseline with no pain, and a family member and care provider were notified. Resident #7's Progress Notes revealed a note, dated 04/21/2025 at 2:48 PM, that indicated the IDT met concerning the resident's fall and added a new intervention to ensure the resident had a stand in front of them at snack time. Resident #7's Care Plan Report revealed an intervention initiated 04/20/2025, that indicated that re-education was provided to staff to keep a table in front of the resident during snacks. The record revealed a Post Fall Huddle (PFH [meeting of staff members after a resident fall]) Fall Scene Investigation Form that revealed no information about when the resident had last received care. The record also revealed staff statements related to the fall. A facility incident report, dated 06/13/2025 at 4:45 PM, indicated that Resident #7 was found on the bathroom floor in the dining room, sitting with their back against the wall near the sink. The report indicated that Resident #7 stated that they took themself to the bathroom and fell when transferring back to their wheelchair and the wheelchair kept moving away. The incident report revealed the resident was assessed, assisted with toileting, assisted to their wheelchair, and taken to the nurses' station. A Post Fall Huddle (PFH) Fall Scene Investigation Form, dated 06/13/2025 at 4:45 PM, revealed Resident #7 had transferred independently in the dining room bathroom, the resident was last seen at 3:45 PM, and Current Interventions in place at the time of the fall was listed as unknown. Resident #7's Progress Notes revealed a note, dated 06/16/2025 at 5:16 PM, that indicated the IDT met concerning the resident's fall and added a new intervention to ensure staff brought Resident #7 out of the dining room after activities (the intervention did not address stopping the wheelchair from rolling backwards should Resident #7 attempt self-transfer again). Resident #7's Care Plan Report revealed an intervention initiated 06/13/2025, that directed staff to remove the resident from the dining room when activities were over. The record revealed no witness statements that revealed why the resident was in the dining room bathroom alone or when the resident had last received care or by whom. A facility incident report dated 07/22/2025 at 5:00 PM, indicated Resident #7 had an unwitnessed fall in the dining room while waiting for dinner to be served. The report indicated that the resident was assessed, skin tears were observed on the resident's right lower arm and left knee, the tears were cleansed and ointment and dressings were applied to the tears, the resident was taken to the nurses' station to sit with staff, and the resident stated that they knew they could not walk, but wanted to try. Resident #7's Progress Notes revealed a note, dated 07/23/2025 at 2:02 PM, that indicated the IDT met concerning the resident's fall and added a new intervention for a psychiatric medication evaluation related to increased anxiety and fidgeting. Resident #7's Care Plan Report revealed an intervention initiated 07/22/2025, that directed staff to provide a medical evaluation related to increased anxiety/fidgeting. The record revealed no staff statements as part of the investigation. A facility incident report, dated 08/02/2025 at 7:45 PM, indicated Resident #7 was sitting in their wheelchair at the nurses' station; the resident leaned forward, and the resident fell out of the wheelchair onto the right side of their face. The report indicated Resident #7 sustained an abrasion to their right knee and a hematoma to the top of their scalp. The report indicated that Resident #7 was assessed and sent to the emergency department. The report revealed sections for Predisposing Environmental Factors, Predisposing Physiological Factors, and Predisposing Situation Factors. The report revealed that each of those sections were blank. Resident #7's ED [Emergency Department] Provider Documentation record, dated 08/02/2025, revealed, Findings: There is osteopenia or osteoporosis. There appears to be smoothly-marginated deformity at the distal clavicle, possibly related to fracture, age uncertain. An acute fracture is not totally excluded. The appearance could also be related to suboptimal positioning. Pending clinical correlation, a dedicated complete examination of the shoulder and clavicle should be considered. Otherwise, no fracture or dislocation is demonstrated. Impression: 1. Limited exam 2. Query fracture deformity at the distal clavicle, age uncertain. The record indicated that a sling was placed for a possible distal clavicle fracture. Resident #7's Progress Notes revealed a note, dated 08/04/2025 at 1:50 PM, that indicated the IDT met concerning the resident's fall and added a new intervention for an antibiotic for a urinary tract infection (UTI) as ordered. Resident #7's Care Plan Report included a focus area initiated on 08/04/2025, that indicated the resident had a right clavicle (collarbone) fracture. Interventions initiated 08/04/2025 directed staff to ensure the resident's call light was in reach and respond promptly to requests for assistance (this was a repeated intervention that was originally initiated on 04/10/2024), educate resident/family/caregivers on safety measures to reduce the risk of falls (this was a repeated intervention that was originally initiated on 09/19/2024), and provide antibiotic treatment of a urinary tract infection UTI as ordered. During an interview on 10/15/2025 at 1:20 PM, the Medical Director (MD) stated Resident #7's clavicle fracture was treated as acute but was most likely an old fracture or other anomaly according to the radiology report. During an interview on 10/10/2025 at 8:30 PM, LPN #9 stated she witnessed Resident #7's fall. LPN #9 stated she was in the 400 Hall and looked toward the nurses' station and saw Resident #7 lean forward and land on their face. LPN #9 stated Resident #7 had a bruise on their forehead. LPN #9 stated that sometimes, a nurse could watch the people who were sitting in front of the nurses' station, but if a nurse was charting, then they were trying to do two things at once. LPN #9 stated that nobody was assigned to watch the residents at the nurses' station, and it was everyone's job. LPN #9 stated if a resident was a high fall risk, she took the resident with her or kept them closer to her if she had to go down the hall. LPN #9 stated she did not take Resident #7 with her that shift because the resident was talking with other residents. LPN #9 stated Resident #7 always tried to climb out of their chair, and no interventions were really effective. During a concurrent observation and interview on 10/09/2025 at 10:12 AM, Resident #7 was observed sitting in their wheelchair in their room. GNA #25, who was initially in the room, stepped out of the room and left the resident alone. When Resident #7 was asked what it meant to remember to call for assistance, the resident stated, It means to pray. When GNA #25 returned, she gave Resident #7 their call light and gave the resident instructions to press the bell. Resident #7 held the call light up to their face and stated that no one was answering. Resident #7 was unable to find the place on the call light to push for assistance. On 10/09/2025 at 10:15 AM, Resident #7 was observed alone in their room, sitting in their wheelchair, trying to remove their brief with their gown pulled up above their waist, and trying to get up several times. At 10:19 AM GNA #25 returned to Resident #7's room and admitted she was not supposed to leave the resident alone when the resident was sitting in their wheelchair because the resident would undress and try to get up. GNA #25 stated she had gone to get clean linen and then answered another resident's call light. GNA #25 stated she could have asked another staff member to get the linen for her and to answer the other call light. GNA #25 was interviewed on 10/09/2025 at 3:07 PM. GNA #25 stated she should not have left Resident #7 alone in their room while in the wheelchair and the next time she planned to change the resident's linens, she would take the linen with her, activate the call light for someone to bring the needed items, or place Resident #7 in the hallway where the resident was observed. GNA #11 was interviewed on 10/09/2025 at 2:38 PM. GNA #11 stated Resident #7 was unable to remember instructions, unable to use a call light, confused, and thought they were at their home. During an interview on 10/09/2025 at 6:51 PM, GNA #11 stated that they were supposed to watch Resident #7 at all times because the resident could not stand but would try to. GNA #11 stated that if she had to take care of another resident, she took Resident #7 to the nurses' station to be watched. GNA #11 stated there was not always someone at the nurses' station as, at times, those staff members had to leave to take care of residents. During an interview on 10/11/2025 at 8:15 PM, GNA #8 stated that if Resident #7 saw something on the floor, the resident would bend down to pick it up. GNA #8 stated that it was usually an effective intervention to place residents near the nurses' station. GNA #8 stated that if the aides were busy, nurses had the aides bring residents who were high fall risks behind the nurses' station to be next to the nurses while the nurses charted at the desk. GNA #8 stated that during medication administration, when nurses had to go to the floor, at times residents were left alone in front of the nurses' station and no staff were assigned to be with them. Licensed Practical Nurse (LPN) #17 was interviewed on 10/09/2025 at 10:29 AM. LPN #17 stated that she was the primary day shift nurse for Resident #7. LPN #17 stated that when a resident fell, the assigned nurse was expected to complete all the paperwork, and it was important to complete all sections of the incident report to capture all the details of the fall. LPN #17 stated the assigned nurse was expected to get statements from all staff that were working with the resident at the time of the fall and to gather information about when the resident was last seen and provided care. LPN #17 stated that the assigned nurse at the time of the resident's fall was also responsible for organizing and initiating the Post Fall Huddle (PFH) Fall Scene Investigation Form and that it was important to know what interventions were in place for the resident at the time of the fall and to determine what caused the fall. LPN #17 reviewed the documentation for Resident #7's fall on 02/22/2025 and stated she had no reason to give as to why she did not fully complete the incident report. LPN #17 stated the incident report painted a picture of the fall, and from her documentation, she had not painted a very pretty picture. LPN #17 stated the time at the top of the report was to identify the time the fall had occurred, but she had not worked at midnight, so the form was inaccurate. The LPN described Resident #7 as fidgety and stated that the resident should not be left in a room alone and had no explanation as to why the resident had been alone in the room. LPN #24 was interviewed on 10/09/2025 at 11:55 AM. LPN #24 stated that it was important to complete an incident report to document any injuries in case an injury was found later; it would be already documented in the prior assessment. LPN #24 stated the assigned nurse was responsible for documentation about when the resident was most recently seen, what they were doing prior to the fall, and to gather witness statements. LPN #24 stated a picture was drawn on the Post Fall Huddle (PFH) Fall Scene Investigation Form and a written description of how the resident was found, including which side the resident was on, if there was environmental issues contributing to the fall, if the resident was continent or incontinent, and what kind of shoes the resident had on at the time of the fall. LPN #24 stated witness statements were obtained from assigned staff and the person that found the resident. LPN #24 stated that the assigned nurse was also responsible for the Post Fall Huddle (PFH) Fall Scene Investigation Form. LPN #24 stated she was familiar with Resident #7. LPN #24 stated Resident #7 was a high fall risk, and the resident was not to be left in their room alone when up in their wheelchair, that directive had been communicated to all staff, and she had passed the information to all GNAs on her shift. LPN #24 stated she was sure that GNA #25 was aware not to leave Resident #7 alone in their room when up in the wheelchair since GNA #25 provided care to Resident #7 daily. LPN #24 stated that the visual cues in Resident #7's room (initiated as an intervention on 07/08/2024 and 09/12/2024) were of no benefit to the resident since the resident was independent and thought they could still stand. LPN #24 stated Resident #7 was unable to comprehend the visual cues, and she had discussed the lack of comprehension with other staff. LPN #24 stated that using education or reminders for Resident #7 (initiated as an intervention on 09/19/2024) was not an effective intervention since the resident had impaired memory. LPN #24 stated Resident #7's roommate tried to take care of Resident #7, which aggravated the resident and would make Resident #7 try to get up and away from the roommate. LPN #24 stated she had communicated that concern to the Assistant Director of Nursing (ADON), the former Director of Nursing (DON), and the current DON. The LPN stated that even after telling the administrative nurses, no one had mentioned changing the resident's room to decrease the aggravation. During an interview on 10/10/2025 at 11:18 AM, LPN #10 stated the nurses' station was not always staffed, and if the nurses had to administer mediations, they asked the GNAs to keep eyes on the residents. LPN #10 stated Resident #7 should never be left alone in their wheelchair because they would attempt to walk. Registered Nurse (RN) #26 was interviewed on 10/08/2025 at 3:05 PM. RN #26 stated that it was important to fully complete an incident report so leadership would know what caused the fall, and so they could choose interventions to prevent further falls. RN #27 was interviewed on 10/10/2025 at 2:06 PM and stated that in addition to a physical assessment after a fall, she was expected to ask the resident what happened to make them fall. RN #27 stated that if the res

Based on facility policy review, record review, facility document review, and interview, the facility failed to report allegations of abuse, including injury of unknown origin, to the state survey agency within the required timeframe, which affected 6 (Residents #14, #15, #4, #7, #19, and #10) of 12 residents reviewed for abuse or resident-to-resident altercations.Findings included: A facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised 11/06/2024, revealed, Reporting included, I. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies, which included, A. The State licensing/certification agency responsible for surveying/licensing the facility. The policy continued, II. An alleged violation is considered by, but not limited to neglect, exploitation, mistreatment, physical abuse, sexual abuse, mental abuse, injuries of an unknown source and misappropriation of resident property, involuntary seclusion or meet the definition of the below descriptions will be reported immediately but not later than, including, A. Two (2) hours (of knowledge of the allegation or injury noted) if the alleged violation resulted in, which included, 1. Serious bodily injury, 2. Harm/injury sustained from an unknown origin, 3. Allegation of abuse, and 4. Resident to resident altercations. 1. An admission Record revealed the facility admitted Resident #9 on 01/31/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, major depressive disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/2025, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #9 exhibited no physical or verbal behaviors during the assessment look-back period. Resident #9's Care Plan Report included a focus area revised 07/31/2024, that indicated the resident had inappropriate behaviors at times that included sitting on the floor and packing their clothing and sitting at the nurse station, stating that their family was coming to pick up the resident. Interventions directed staff to refer the resident to behavioral health services as indicated (initiated 10/31/2023). An admission Record revealed the facility admitted Resident #15 on 08/02/2019. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. A quarterly MDS, with an ARD of 07/01/2025, revealed Resident #15 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident exhibited no physical or verbal behaviors during the assessment look-back period. Resident #15's Care Plan Report included a focus area initiated 04/28/2024, that indicated the resident had a behavioral problem that involved wandering into other residents' rooms, related to dementia. Interventions directed staff to intervene as necessary to protect the rights and safety of others (initiated 04/28/2024 and revised 10/21/2024). Resident #9's Progress Notes revealed a physician progress note, dated 9/18/2025 at 2:18 PM, that indicated the resident was examined after it was reported that the resident had attempted to dump another resident out of [his/her] wheelchair. Per the note, Resident #9 would not make eye contact or answer any questions but would only say that they wanted to go home. Resident #15's Progress Notes revealed a physician progress note, dated 9/18/2025 at 1:58 PM, that indicated the resident was examined after another resident had attempted to dump [Resident #15] from the wheelchair [the resident] was sitting in. During an interview on 10/11/2025 at approximately 9:00 AM, the Director of Nursing (DON) stated that resident-to-resident altercations were reportable to the state survey agency. Per the DON, the incident between Resident #9 and Resident #15 was discussed but since Resident #9 had not touched Resident #15, they were told that incident was also not reportable. During an interview on 10/11/2025 at 9:22 AM, the Administrator (ADM) stated that resident-to-resident altercations fell under abuse, which was reportable. The ADM stated she was never informed of an altercation between Resident #9 and Resident #15. The ADM stated her expectation was that a resident-to-resident altercation be reported to the SSA. 2. An admission Record revealed the facility admitted Resident #4 on 12/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) and aphasia (an inability to understand or produce speech) following cerebral infarction (a stroke), gastrostomy tube, chronic obstructive pulmonary disease (COPD), paroxysmal atrial fibrillation, atherosclerotic heart disease, and congestive heart failure. A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident did not exhibit any behavioral symptoms during the assessment timeframe. Per the MDS, the resident required maximal assistance from staff for activities of daily living (ADLs), including personal and oral hygiene, toileting, bathing, dressing, and putting on footwear. The MDS indicated the resident did not have any falls since admission, and the resident did not have a fracture related to a fall in the previous six months. Resident #4's Care Plan Report included a focus area initiated 12/13/2024, that indicated the resident had a self-care deficit related to cerebral infarction. Interventions dated 12/13/2024 directed staff to provide Resident #4 with assistance from two staff for walking and transfers, assist with repositioning, fall precautions, and indicated the resident utilized a wheelchair. A Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Initial Report Form, dated 12/17/2024, revealed the facility reported an incident of physical and mental/verbal abuse involving Resident #4, perpetrated by Licensed Practical Nurse (LPN) #3. The document indicated that the incident occurred at 1:02 AM on 12/17/2024. Per the document, two geriatric nursing assistants (GNAs), GNA #2 and GNA #4, witnessed LPN #3 being rude and rough with Resident #4 when assessing the resident for injuries after a fall. The report indicated that the GNAs reported the alleged abuse to LPN #6, who reported it to the current Director of Nursing (DON), who was the Assistant Director of Nursing (ADON) at that time, who then reported it to the former DON (in the position at the time of the alleged incident). The initial report indicated that it was submitted to the state survey agency on 12/27/25024 at 12:30 PM. An email to the former DON, dated 12/17/2024 at 2:09 PM, revealed confirmation that the state survey agency received the initial report. During an interview on 10/13/2025 at 11:24 AM, the former DON stated the facility tried to follow a two-hour timeline to report an allegation of abuse to the state survey agency. She stated they were required to contact their corporate office when there was an allegation of abuse to walk through the steps to complete the report. She stated that if the report was sent in later than the two-hour timeframe, then it was because the corporate office did not respond to the facility timely. During an interview on 10/13/2025 at 2:55 PM, the Administrator stated that for an abuse allegation, the initial report should be sent to the SSA within two hours, and the final report within five working days. During an interview on 10/15/2025 at 11:17 AM, the Regional Director of Operations (RDO) stated they collaborated with the facility when there was a reportable event and assisted the facility as needed. The RDO stated that the allegation should have been reported initially within two hours as per the regulation. 3. An admission Record indicated the facility admitted Resident #7 on 04/09/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety; polyosteoarthritis; other specified disorders of bone density and structure; and generalized muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/01/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #7 had inattention and disorganized thinking. The MDS indicated Resident #7 had no functional limitations in movement of the upper extremities. According to the MDS, the resident was dependent on staff for bed mobility, moving from a sitting to lying position, and tub/shower transfers. Per the MDS, the resident required substantial/maximal assistance with lying to sitting on the side of the bed, moving from a sitting to a standing position, chair/bed-to-chair transfers, and toilet transfers. The MDS indicated the resident was able to walk 10 feet with partial/moderate assistance. The MDS also revealed that Resident #7's fall history on admission/entry or reentry included a fall in the previous month, a fall in the previous two to six months, and had a fracture related to a fall in the previous six months. Resident #7's Care Plan Report included a focus area initiated 09/19/2024, that indicated the resident had an alteration in their musculoskeletal status related to positive ulnar [the ulna bone is in lower arm and runs from the elbow to the wrist on the little finger side of the arm] variance. Interventions directed staff to make sure the call light was within the resident's reach, respond promptly to requests for assistance, and to educate the resident/family/caregivers on safety measures to reduce the risk of falls (initiated 09/19/2024). Resident #7's Physical Therapy Treatment Encounter Note(s), dated 03/27/2025, indicated that the Assistant Director of Nursing (ADON) checked Resident #7's left distal wrist, and the resident was transported to the first-floor nurses' station for the provider to evaluate the resident's left hand and wrist. Acute visit summary Progress Notes dated 03/27/2025 revealed a physician's assistant (PA) examined Resident #7 because therapy staff noticed the resident's left wrist was swollen and seemed tender. The note indicated Resident #7 fell frequently and due to dementia and indicated that pain and injury were hard to assess. The note also indicated that on assessment, Resident #7 had edema to the left wrist, the wrist was tender, and the resident pulled away from the PA when the distal radius and ulna were palpated. The note indicated that Resident #7 had a history of cellulitis and an old fracture in the same area. Per the note, an X-ray was ordered to determine whether Resident #7 had a fracture or bony abnormalities. Resident #7's Progress Notes revealed a note, dated 03/28/2025 at 12:49 PM, that indicated a mobile X-ray company completed the ordered X-rays. Resident #7's Progress Notes revealed a note, dated 03/28/2025 at 10:54 PM, that revealed the results of the X-rays were returned to the facility, indicating the resident had an acute fracture of the distal ulna. A Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Initial Report Form indicated that the facility reported an injury of unknown source related to Resident #7's acute distal fracture of the distal ulna. The document indicated that the X-ray results were received on 03/28/20254 at 10:45 PM and was reported to the former Director of Nursing (DON). The document was completed by the former DON and indicated that it was submitted to the state survey agency on 03/29/2025 at 11:00 AM. An email to the former DON, dated 03/29/2025 at 12:32 PM, revealed confirmation of the initial report regarding Resident #7's injury of unknown origin, which was approximately 14 hours after the facility received the X-ray report that indicated the resident had an ulna fracture. During a telephone interview on 10/15/2025 at 11:11 AM, the former DON stated that she always followed the two-hour timeline for reporting to the state survey agency. She stated that before submitting a report to the state survey agency, she notified corporate staff and someone from the corporate office walked her through the steps of the report. The Regional Director of Operations (RDO) was interviewed on 10/15/2025 at 11:33 AM. The RDO stated that for any issue that required a report to the state survey agency, the facility was also expected to contact him as soon as possible. The RDO stated that the corporate office staff collaborated with the facility staff to make sure the resident involved was kept as safe as possible. The RDO stated the corporate office was there to lend guidance, but the facility was able to send reports to the state survey agency when they chose. The RDO stated that the reporting timeframe for an injury of unknown origin was two hours. The RDO reviewed the report sent to the state agency for Resident #7 on 03/29/2025 and revealed that the report had been submitted late. The facility's current DON was interviewed on 10/15/2025 at 11:05 AM. The DON stated that the timeframe for reporting an injury of unknown origin was two hours; therefore, the 03/29/2025 report was submitted late. The DON stated that the X-ray of Resident #7's wrist indicated an acute fracture, which meant the fracture was new and had not started healing. The Administrator (ADM) was interviewed on 10/15/2025 at 10:51 AM. The ADM stated injuries of unknown origin should be reported to the state survey agency within two hours. The ADM reviewed the initial report related to Resident #7's fracture and stated that if the staff were aware of the fracture on 03/28/2025 and the former DON did not report the injury to the state survey agency until 03/29/2025, then the report was submitted late. The ADM stated that she had just started at the facility in March 2025, and the former DON had not shared with her when the report was submitted to the state survey agency. 4. An admission Record revealed the facility admitted Resident #19 on 11/06/2019. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and the membrane that cover it) affecting the left non-dominant side, recurrent major depressive disorder, difficulty in walking, alcohol-induced disorder, and other abnormalities of gait and mobility. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2025, revealed Resident #19 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated that the resident did not exhibit any physical or verbal behavioral symptoms directed at others. An admission Record revealed the facility admitted Resident #3 on 10/16/2024. According to the admission Record, the resident had a medical history that included diagnoses of early onset Alzheimer's disease, brief psychotic disorder, severe dementia with other behavioral disturbance, depression, generalized muscle weakness, difficulty in walking, and fatigue. An admission MDS, with an ARD of 10/24/2024, revealed Resident #3 had a BIMS of 4, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #3 exhibited physical and verbal behavioral symptoms directed toward others on one to three days during the seven-day look-back period. Per the MDS, the behavioral symptoms did not put others at significant risk for injury. The MDS also revealed that Resident #3 exhibited wandering behaviors on four to six days during the seven-day look-back period. According to the MDS, the wandering behavior did not intrude on the privacy or activities of others. Resident #3's Care Plan Report revealed a focus area initiated 10/18/2024, that indicated the resident had a cognitive decline related to dementia. The Care Plan Report also revealed a focus area initiated 10/18/2024, that indicated the resident was at risk for wandering or pacing. The resident's Care Plan Report also revealed a focus area initiated 11/22/2024, that indicated the resident was often aggressive and agitated with staff. Interventions directed staff to be alert of safety concerns to prevent injury to the resident or others (initiated 12/09/2024). Resident #3's Progress Notes revealed a note, dated 12/13/2024 at 4:10 AM, that revealed that at 7:30 PM, Licensed Practical Nurse (LPN) #37 was notified that Resident #3 was in Resident #19's room, and it appeared that Resident #3 was trying to choke Resident #19. The note indicated that Resident #3 was also observed pushing Resident #19's tray table against Resident #19's leg. Per the note, there were no injuries or bruises to Resident #19's neck or legs. The note revealed staff assisted Resident #3 to the hallway, gave the resident snacks, and administered medications until Resident #3 appeared to be ready to go to bed. The Progress Notes did not indicate whether the Director of Nursing (DON) or the Administrator (ADM) were notified. The resident's record revealed no documented evidence that the facility reported the incident to the state survey agency. During an interview on 10/09/2025 at 2:52 PM, LPN #37 stated that a geriatric nursing assistant (GNA) reported that Resident #3 attempted to choke Resident #19. LPN #37 stated she did not witness the incident; she only documented what the GNA reported. LPN #37 stated they assessed Resident #19, who had no injuries. LPN #37 stated she reported the alleged resident-to-resident abuse to the former DON (in the position at the time of the alleged incident) and to the nurses on the following shift. During an interview on 10/09/2025 at 6:31 PM, the former DON stated she vaguely remembered the allegation involving resident-to-resident abuse between Resident #3 and Resident #19. The former DON stated that she would have notified the ADM of the abuse allegation. She stated that she was unable to recall whether the abuse allegation was reported to the state survey agency. During an interview on 10/13/2025 at 12:21 PM, the facility's current DON stated the alleged resident-to-resident abuse between Resident #3 and Resident #19 should have been reported to the Assistant Director of Nursing (ADON) or the DON (whoever was on-call), the ADM, corporate staff, and to the state survey agency within two hours of the incident. The DON stated the allegation should have been reported timely so they could capture what truly happened, for the safety of the residents. During an interview on 10/15/2025 at 6:22 PM, the ADM stated abuse allegations should be reported within two hours. 5. An admission Record revealed the facility admitted Resident #10 on 12/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of displaced intertrochanteric fracture of right femur and subsequent encounter for closed fracture with routine healing (onset date 6/02/2025); repeated falls; unspecified dementia, generalized muscle weakness, difficulty in walking, fatigue, and ataxic gait. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. An admission Record revealed the facility admitted Resident #1 on 12/27/2023 and readmitted the resident on 03/04/2024. According to the admission Record, the resident had a medical history that included diagnoses of Wernick's encephalopathy, uncomplicated alcohol use, vitamin B12 deficiency anemia, unspecified dementia, generalized muscle weakness, difficulty in walking, unspecified hallucinations, and fatigue. A quarterly MDS, with an ARD of 06/11/2025, revealed Resident #1 had a BIMS of 0, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #1 displayed no physical or verbal behavioral symptoms during the assessment look-back period. Resident #1's Care Plan Report revealed a focus area initiated 02/28/2025, that indicated the resident had the potential to be aggressive and agitated. According to the Care Plan Report, prior to 05/28/2025, there were two incidents when Resident #1 hit another resident. Interventions directed staff to be alert to prevent injury to the resident or others and to remove potentially harmful items from Resident #1's access (initiated 02/28/2025). Resident #10's Progress Notes revealed a note, dated 05/28/2025 at 11:14 PM, that indicated Resident #10 was standing in the hallway talking to their roommate (Resident #1), telling Resident #1 that they had been roommates for quite a while. Per the Progress Notes, Resident #1 was upset because they were not able to sleep with another resident, who Resident #1 thought was their spouse. The note revealed that Resident #1 became aggressive and tried to hit Resident #10. The note indicated that Resident #10 stepped backwards to get away from Resident #1 and fell on to their back. The note revealed Resident #1 complained of pain to the lower back, right hip, right knee, and right upper leg. The note also revealed that Resident #1 was unable to bear weight on their right leg and had pain with standing or moving. A Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Initial Report Form indicated the facility reported the incident between Resident #1 and Resident #10 to the state survey agency. The form indicated that Resident #1 tried to hit Resident #10, who then stepped backwards to get away, and fell. The form indicated that the date and time the facility became aware of the incident was on 05/28/2025 at 9:40 PM. The form indicated the date and time the Administrator (ADM) was notified was on 05/29/2025 at 9:00 AM. The form indicated that it was completed by the former Director of Nursing (DON) (in the position at the time of the incident) and submitted the form on 05/29/2025 at 11:45 AM. An email to the former DON, dated 05/29/2025 at 1:21 PM, revealed confirmation that the state survey agency received the initial report. During a telephone interview on 10/09/2025 at 2:32 PM, Geriatric Nursing Assistant (GNA) #13 revealed Resident #1 believed that another resident (Resident #30) was their spouse and was walking towards that resident's room. GNA #13 stated that she closed Resident #30's door and Resident #1 got aggressive and combative towards the GNA. GNA #13 stated that Resident #10 then walked out of their room and tried to coach Resident #1 back to their shared room. She stated that Resident #1 turned, grabbed a trash can lid, and headed towards Resident #10. GNA #13 stated she grabbed the trash can lid from Resident #1; however, by that time, Resident #10 jumped back to get away from Resident #1 and fell backward. GNA #13 stated that Registered Nurse (RN) #32 and GNA #40 came and assisted in separating and taking care of Resident #1 and Resident #10. During an interview on 10/13/2025 at 12:21 PM, the facility's current DON stated the alleged resident-to-resident abuse should have been reported within two hours of the incident to the Assistant Director of Nursing (ADON) or the DON (whoever was on-call), the ADM, the corporate staff, and to the state survey agency. The DON stated the allegation should have been reported timely so they could capture what truly happened, for the safety of the residents. During an interview on 10/15/2025 at 6:22 PM, the ADM stated abuse allegations should be reported within two hours. 6. An admission Record revealed the facility admitted Resident #13 on 12/22/2023. According to the admission Record, the resident had a medical history that included a diagnosis of cerebral infarction (a stroke). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2025, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #13 exhibited physical and verbal behaviors directed toward others, and other behavioral symptoms not directed toward others one to three days during the seven-day assessment look-back period. Resident #13's Care Plan Report included a focus area, revised 12/28/2023, that indicated the resident had a behavior problem related to exit seeking and sitting on the floor. Interventions initiated 12/27/2023 directed staff to monitor behavior episodes and attempt to determine the underlying cause. An admission Record revealed the facility admitted Resident #14 on 06/17/2025. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. A quarterly MDS, with an ARD of 09/24/2025, revealed Resident #14 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #14 exhibited no physical or verbal behaviors directed toward others during the seven-day assessment look-back period. Resident #14's Care Plan Report included a focus area, initiated 07/02/2025, that indicated the resident had inappropriate behaviors related to poor insight and judgement, related to dementia. Interventions initiated 07/02/2025 directed staff to set limits and make the resident aware that behavior was inappropriate at the time the behavior occurred. Resident #14's Progress Notes revealed a note, dated 9/15/2025 at 2:30 AM, that revealed Resident #14 was brought to the nursing desk in their wheelchair by Resident #13, and indicated that Resident #14 was upset and crying. The note indicated Resident #13 had Resident #14 by their shirt collar, and the nurse had to get additional staff assistance to separate the residents. Resident #14's record revealed no evidence of a resident-to-resident abuse incident involving Resident #13 and Resident #14 being reported to the state survey agency. During an interview on 11/06/2025 at 3:09 PM, the facility's current DON stated that she was in the 100 Hall when she got a call from Registered Nurse (RN) #32, who was on the secured unit, and she stated she needed help. She stated that she and Licensed Practical Nurse (LPN) #9 went to the secured unit and when they arrived, Resident #13 was standing behind Resident #14 and had ahold of Resident #14's shirt collar. She stated that it did not take long to redirect Resident #13 and separate the residents. She stated that she notified the former DON (in the position at the time of the incident), who said she was going to call corporate staff to discuss the resident-to-resident altercation. She stated that the former DON called her back and told her that it did not need to be reported and to tell RN #32 to document it as a behavior. She stated that she believed the incident should have been investigated and reported to the state survey agency and to the police. During an interview on 11/07/2025 at 8:51 AM, RN #32 stated that she was sitting at the desk charting and looked up and saw Resident #13 pushing Resident #14 down the hallway in their (Resident #14's) wheelchair, and Resident #14 was crying. She stated Resident #13 had a hold of Resident #14's shirt collar, pulling it, saying to get the resident out of their room and to call the police. She stated she had to call for help to get them separated, and she kept Resident #13 at the desk in a recliner. She stated that the former DON was called, and she called corporate staff, then called back and said the Regional Director of Operations (RDO) said it was not an altercation. She stated she told the current DON that she did not feel comfortable with that decision and was going to document what she saw. RN #32 stated that the altercation was resident-to-resident abuse. During an interview on 11/07/2025 at 9:50 AM, the Regional Nurse Consultant (RNC) stated she was not called about the incident involving Resident #13 and Resident #14. She stated the facility was supposed to call her and the RDO to discuss the incident, and she did not get a call, and the RDO told her that he did not get a call either. During an interview on 11/07/2025 at 2:23 PM, the RDO stated that he was not notified of the incident between Resident #13 and Resident #14, and that was one of the reasons the former DON's employment was terminated. During an interview on 10/11/2025 at 9:22 AM, the Administrator (ADM) stated that resident-to-resident altercations fell under abuse, which was reportable. Regarding the incident between Resident #13 and Resident #14, the ADM stated that the former DON told her that one resident was trying to help another resident be pushed in their wheelchair, but the resident in the wheelchair did not want to be pushed. The ADM stated that they were informed that the alleged perpetrator never touched the victim, and that staff discouraged the alleged perpetrator who walked away with no concerns. The ADM stated that as described, that incident was not reportable, but if she had all the facts, then she would have reported the incident. During an interview on 11/07/2025 at 8:28 AM, the ADM stated that she was not in the facility when the incident occurred between Resident #13 and Resident #14 but heard about it in the morning meeting. She stated that she was told that one resident was pushing the other resident in their wheelchair and that resident did not want to be pushed, so they were separated. She stated she was not aware of the resident being grabbed by the collar. She stated that if she had known the details, she would have investigated and reported it at that time.

Based on facility policy review, record review, facility document review, and interview, the facility failed to conduct a thorough investigation or maintain evidence of a thorough investigation. The facility also failed to protect residents from potential further abuse by allowing an alleged abuser to remain in the building. The deficiencies affected 6 (Residents #14, #15, #16, #4, #7, and #19) of 12 residents reviewed for abuse or resident-to-resident altercations during the complaint survey.Findings included: A facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised 11/06/2024, revealed, Reporting included, I. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies, which included, A. The State licensing/certification agency responsible for surveying/licensing the facility. The policy revealed, Abuse Investigating and Reporting, included, II. Supporting documents relative to alleged incident will be obtained, and III. The employee accused of alleged abuse will be immediately suspended and removed from the primacies [sic]. 1. An admission Record revealed the facility admitted Resident #9 on 01/31/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, major depressive disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/2025, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #9 exhibited no physical or verbal behaviors during the assessment look-back period. Resident #9's Care Plan Report included a focus area revised 07/31/2024, that indicated the resident had inappropriate behaviors at times that included sitting on the floor and packing their clothing and sitting at the nurse station, stating that their family was coming to pick up the resident. Interventions directed staff to refer the resident to behavioral health services as indicated (initiated 10/31/2023). An admission Record revealed the facility admitted Resident #15 on 08/02/2019. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. A quarterly MDS, with an ARD of 07/01/2025, revealed Resident #15 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident exhibited no physical or verbal behaviors during the assessment look-back period. Resident #15's Care Plan Report included a focus area initiated 04/28/2024, that indicated the resident had a behavioral problem that involved wandering into other residents' rooms, related to dementia. Interventions directed staff to intervene as necessary to protect the rights and safety of others (initiated 04/28/2024 and revised 10/21/2024). Resident #9's Progress Notes revealed a physician progress note, dated 9/18/2025 at 2:18 PM, that indicated the resident was examined after it was reported that the resident had attempted to dump another resident out of [his/her] wheelchair. Per the note, Resident #9 would not make eye contact or answer any questions but would only say that they wanted to go home. Resident #15's Progress Notes revealed a physician progress note, dated 9/18/2025 at 1:58 PM, that indicated the resident was examined after another resident had attempted to dump [Resident #15] from the wheelchair [the resident] was sitting in. Three documents titled, Witness Statement, each dated 09/14/2025, were provided by the facility related to the alleged incident between Resident #13 and Resident #14. During an interview on 10/09/2025 at 9:00 AM, the facility's current Director of Nursing (DON) stated she was unable to locate any additional evidence of an investigation regarding the alleged incidents between Residents #9 and Resident #15. During an interview on 10/13/2025 at approximately 9:00 AM, the DON stated that the alleged incident between Resident #9 and Resident #15 was not investigated due to the former DON telling her that it was not reportable. The DON stated that not investigating the alleged incident did not meet expectations. She stated that after an allegation of resident-to-resident abuse, she would expect an investigation to be completed. During an interview on 10/11/2025 at 9:22 AM, the Administrator (ADM) stated that resident-to-resident altercations fell under abuse, which were reportable. The ADM stated she was never informed of an altercation between Resident #9 and Resident #15. 2. An admission Record revealed the facility admitted Resident #16 on 09/27/2024. According to the admission Record, the resident had a medical history that included diagnoses of Hodgkin lymphoma, adult failure to thrive, chronic kidney disease, and hypertension. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required supervision or touching assistance from staff for chair/bed-to-chair transfers, toilet transfers, and to ambulate 10 feet and 50 feet with turns. Resident #16's Care Plan Report included a focus area revised 01/16/2025, that indicated the resident had falls related to weakness. Interventions initiated 09/30/2024 directed staff to maintain a call light within reach when the resident was in their room and to reinforce the use of their call light. A document titled, Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Initial Report Form, dated 12/05/2024, revealed the facility reported an injury of unknown source. The report indicated that Resident #16 had left rib fractures of their seventh and eighth ribs. Per the report, the allegation details indicated that an X-ray was completed in the emergency room that showed acute rib fractures of the seventh and eighth ribs. The document further indicated that Resident #16 had sustained a fall in the facility on 11/10/2024 and had complaints of pain to their left rib/breast area with an X-ray completed that was negative for fracture. The document indicated that a second X-ray was completed on 11/14/2024 and was also negative for any fracture. A document titled, Maryland Department of Health Office of Health Care Quality Facility Reported Incident Follow-Up Investigation Report Form, submitted on 12/11/2024 at 5:30 PM, revealed the Medical Director concluded the X-ray results from 11/10/2024 and 11/14/2024 did not clearly show the area of the fractured seventh and eighth ribs and that there was probable cause that the rib fractures occurred from the resident's fall on 11/10/2024. The facility's investigation revealed no evidence of resident interviews, staff interviews, body audits of non-verbal residents, or any other evidence the facility conducted an investigation to ensure nothing had occurred between 11/10/2024 and 12/05/2024, when the fractures were identified. During an interview on 10/14/2025 at 2:34 PM, the Medical Director (MD) stated that he was able to determine the fractures from 12/05/2024 were from the fall on 11/10/2024 due to the fact Resident #16 had no other falls in that time period. He stated that rib fractures were notoriously hard to catch. The MD stated that realistically, the two sets of X-rays the facility obtained could have missed the fractures. He stated that when he found out Resident #16 was in the hospital with pneumonia and they had completed X-rays, he reviewed the films independently and there were signs of healing. He stated he could immediately tell they were subacute not acute, which meant they had signs of healing. The MD stated that he determined it was from the fall because of several factors, which included there being no suspicion of abuse and no resident-to-resident altercation. During an interview on 10/13/2025 at 11:24 AM, the former Director of Nursing (DON) (in the position at the time of the alleged incident) stated that Resident #16 was sent to the hospital and they discovered rib fractures. The former DON stated that she reported it to the state survey agency because the hospital reported it to her. The former DON stated that Resident #16 had a fall at the facility, and the facility obtained X-rays twice, but neither one indicated any fractures. She stated that she did not suspect abuse, but thought the fractures were a result of the fall. She stated that if she had suspected abuse, she would have conducted interviews and body audits of residents. During an interview on 10/14/2025 at 11:22 AM, the facility's current DON stated that she could not speak to the former DON's investigation, but that her expectation was to obtain statements from all staff that worked with Resident #16 and obtain statements from the resident if they had intact cognition, to determine if the resident was afraid or if anyone had been rough with the resident. She stated that she would review the previous 48 to 72 hours to see if anything had happened within the time frame the incident occurred. Per the DON, as for Resident #16, if they found the fractures on 12/05/2024, then she would review the timeframe prior to that. The DON reviewed the facility's investigation file and stated it was not a complete investigation. During an interview on 10/15/2025 at 11:22 AM, the Administrator (ADM) stated that her expectation for the investigation of the self-reported incident related to Resident #16 was to report an unknown injury and start an investigation. She stated the facility should have assessed the alleged victim, assessed other residents, collected statements from staff that worked the shift during and the shift prior, even a few other days, to see if someone noticed anything. She stated that there should have been more interviews and assessments in the investigation for it to be complete and to rule out abuse. 3. An admission Record revealed the facility admitted Resident #4 on 12/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) and aphasia (an inability to understand or produce speech) following cerebral infarction (a stroke), gastrostomy tube, chronic obstructive pulmonary disease (COPD), paroxysmal atrial fibrillation, atherosclerotic heart disease, and congestive heart failure. A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident did not exhibit any behavioral symptoms during the assessment timeframe. Per the MDS, the resident required maximal assistance from staff for activities of daily living (ADLs), including personal and oral hygiene, toileting, bathing, dressing, and putting on footwear. The MDS indicated the resident did not have any falls since admission, and the resident did not have a fracture related to a fall in the previous six months. Resident #4's Care Plan Report included a focus area initiated 12/13/2024, that indicated the resident had a self-care deficit related to cerebral infarction. Interventions dated 12/13/2024 directed staff to provide Resident #4 with assistance from two staff for walking and transfers, assist with repositioning, fall precautions, and indicated the resident utilized a wheelchair. A Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Initial Report Form, dated 12/17/2024, revealed the facility reported an incident of physical and mental/verbal abuse involving Resident #4, perpetrated by Licensed Practical Nurse (LPN) #3. The document indicated that the incident occurred at 1:02 AM on 12/17/2024. Per the document, two geriatric nursing assistants (GNAs), GNA #2 and GNA #4, witnessed LPN #3 being rude and rough with Resident #4 when assessing the resident for injuries after a fall. The report indicated that the GNAs reported the alleged abuse to LPN #6, who reported it to the facility's current Director of Nursing (DON), who was the Assistant Director of Nursing (ADON) at that time, who then reported it to the former DON (in the position at the time of the alleged incident). The report indicated that Resident #4 did not have serious bodily harm or injuries as a result of the alleged abuse. A Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Follow-Up Investigation Report Form, dated 12/23/2024, indicated, 3. Conclusion revealed, After the investigation of the incident the allegation has been verified. The report indicated that multiple staff members reported witnessing LPN #3 being rough, rude, and mean to Resident #4. The report indicated that staff seen and heard LPN #3 yelling and pulling on Resident #4's arm. A typed statement included in the facility's investigation documents, dated 12/17/2024, from the DON, who was the ADON at the time of the incident, indicated that she received a call at 1:02 AM on 12/17/2024 from LPN #6 that Resident #4 had fallen. The statement indicated that while on the call, LPN #6 further informed the DON that GNA #2 and GNA #4 reported they observed LPN #3 being rude and rough during the resident's fall assessment. Per the statement, GNA #2 indicated that LPN #3 was pulling on the resident's arm and yelling at the resident to stop. Per the statement, GNA #4 indicated that when LPN #3 pulled a blood pressure cuff off the resident's arm, the nurse was rough and caused the cuff to break. The statement revealed the DON requested statements from staff and requested LPN #6 to observe for further concerns. There was no evidence that the DON provided instruction for LPN #3 to be suspended or removed from the premises. Resident #4's Neurological Evaluation Flow Sheet, dated 12/17/2024, revealed LPN #3's initials were on evaluations for 12:15 AM, 12:30 AM, 12:45 AM, 1:00 AM, 1:30 AM, and 2:00 AM. A document titled, Shifts Report, revealed LPN #3 clocked in to work on 12/16/2024 at 6:30 PM and clocked out on 12/17/2024 at 3:30 AM. During an interview on 10/09/2025 at 8:00 PM, LPN #6 stated that as soon as the GNAs notified her of the allegation of abuse, she immediately notified the DON because the DON was on call at that time. During an interview on 10/08/2025 at 4:47 PM, LPN #3 stated she continued to assess Resident #4 after the resident's fall. She stated she continued neurological evaluations of the resident until the DON arrived at the facility. She stated that she completed several neurological checks on Resident #4 after their fall. Per LPN #3, after the DON arrived, she (LPN #3) was told to finish her documentation work. She stated that she provided a written statement and then clocked out. During an interview on 10/13/2025 at 11:24 AM, the former DON (in the position at the time of the alleged incident) stated for staff-to-resident abuse, the alleged abuser should be sent off the premises immediately, and she thought LPN #3 was sent home immediately. She stated she could not remember who informed her of the abuse allegation or what transpired after allegation was reported. During an interview on 10/13/2025 at 1:21 PM, the facility's current DON (who was the ADON at the time of the alleged incident) stated that she arrived at the building at 2:15 AM and took the keys from LPN #3. The DON stated that LPN #3 did not clock out of work until 3:30 AM, and acknowledged Resident #4 was exposed to LPN #3 during neurological assessments until 2:00 AM. The DON stated she should have instructed LPN #6 to take LPN #3's keys and ask her to clock out. She stated that they determined that abuse did occur. During an interview on 10/13/2025 at 2:55 PM, the Administrator stated that for an abuse allegation, the alleged perpetrator should clock out and be sent home immediately. 4. An admission Record indicated the facility admitted Resident #7 on 04/09/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety; polyosteoarthritis; other specified disorders of bone density and structure; and generalized muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/01/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #7 exhibited inattention and disorganized thinking. The MDS indicated Resident #7 had no functional limitations in movement of the upper extremities. According to the MDS, the resident was dependent on staff for bed mobility, moving from a sitting to lying position, and tub/shower transfers. Per the MDS, the resident required substantial/maximal assistance with lying to sitting on the side of the bed, moving from a sitting to a standing position, chair/bed-to-chair transfers, and toilet transfers. The MDS indicated the resident was able to walk 10 feet with partial/moderate assistance. The MDS also revealed that Resident #7's fall history on admission/entry or reentry included a fall in the previous month, a fall in the previous two to six months, and had a fracture related to a fall in the previous six months. Resident #7's Care Plan Report included a focus area initiated 09/19/2024, that indicated the resident had an alteration in their musculoskeletal status related to positive ulnar [the ulna bone is in lower arm and runs from the elbow to the wrist on the little finger side of the arm] variance. Interventions directed staff to make sure the call light was within the resident's reach, respond promptly to requests for assistance, and to educate the resident/family/caregivers on safety measures to reduce the risk of falls (initiated 09/19/2024). Resident #7's Care Plan Report also revealed a focus area initiated 04/10/2024, that indicated the resident had sustained falls with no injury, minor injury, or serious injury, related to poor balance and unsteady gait. Interventions directed staff to provide a perimeter mattress to the bed (initiated 03/10/2025). A Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Initial Report Form, dated 03/29/2025 at 12:32 PM, indicated that the facility reported an injury of unknown source related to Resident #7 having an acute distal fracture of the distal ulna. The report revealed that X-ray results received on 03/28/2025 revealed the injury. A Maryland Department of Health Office of Health Care Quality Facility Reported Incident Follow-Up Investigation Report Form, submitted to the state survey agency on 04/02/2025, indicated that Resident #7 was in therapy on 03/27/2025 and was noted that the resident rubbed their left wrist. Per the report, when the resident's wrist was assessed, the wrist was noted to be red, tender, and swollen. The report revealed that the resident's provider also assessed the wrist and noted that when the resident's distal radius and ulna were palpated, the resident pulled away. Per the report, an X-ray was ordered, which revealed the resident had an acute fracture in the left distal ulna. The facility report revealed the facility staff interviewed therapy staff who observed concerns with the resident's wrist on 03/27/2025 and the nurse practitioner who assessed the resident. The report indicated that neither abuse nor neglect was verified. According to the report, Resident #7 had fallen on 03/10/2025 and was observed lying on their left side. The report revealed at the time of the fall that the resident had no complaints of pain. Per the report, on 03/18/2025, the resident was treated for cellulitis due to redness and swelling in the same area. The report indicated that Resident #7 had no complaints of pain until 03/27/2025. The report indicated that the Medical Director (MD), who was also the resident's primary physician, found the probable cause of the fracture occurred during the fall on 03/10/2025. The facility's investigation documents revealed no evidence of interviews with staff who provided care to the resident preceding the identification of Resident #7's injury. During a telephone interview on 10/15/2025 at 9:18 AM, the MD stated that Resident #7's 03/28/2025 fracture was acute, and there was no way to connect Resident #7's 03/27/2025 fracture to the fall the resident sustained on 03/10/2025 (in contrast with the Facility Reported Incident Follow-Up Investigation Report Form). The PCP stated he did not think the origin of the ulna fracture was determined. During a telephone interview on 10/14/2025 at 10:20 AM, the Physician's Assistant (PA) stated that she was unable to give any insight into why Resident #7's 03/27/2025 left wrist fracture had been associated with the resident's 03/10/2025 fall. The PA stated that when the orthopedist read the X-ray, he was not even sure the ulna fracture was new. The PA stated that she had no insight into why Resident #7 had no complaints of pain or no deformity had been noticed prior to 03/27/2025. The Director of Nursing (DON) (who was the Assistant Director of Nursing [ADON] at the time of the alleged incident) was interviewed on 10/13/2025 at 10:15 AM. The DON stated that on 03/27/2025, Certified Occupational Therapy Assistant (COTA) #21 reported to her that Resident #7 was complaining of arm pain and the resident's arm looked different. The DON stated she assessed Resident #7's arm and found the arm to be painful, and a deformity was present in the lower forearm-wrist area of the resident's left arm. The DON stated the provider was in the building at the time, and the provider also assessed the resident and ordered an X-ray. The DON stated she was unsure how the conclusion was formed that the 03/10/2025 fall was responsible for the 03/27/2025 fracture. The DON stated she knew that therapy staff had treated Resident #7 prior to 03/27/2025 and had not reported that Resident #7 had problems with their arm. The DON stated the former DON (in the position at the time of the alleged incident) had been responsible for the investigation for Resident #7's fractured arm. COTA #21 was interviewed on 10/10/2025 at 2:55 PM. COTA #21 stated Resident #7 had been in the gym for therapy when their arm was noted to be painful. She stated that at the time of the discovery, the resident was working with physical therapy staff. COTA #21 stated that the last day she had treated Resident #7 was on 03/25/2025, and at that time, Resident #7 had no complaints of pain and no bruising, swelling, or decreased movement in the left wrist. The facility's current DON was interviewed on 10/15/2025 at 11:05 AM. The DON stated that the X-ray for Resident #7 revealed an acute fracture of the resident's wrist. The DON stated that the X-ray indicated that it was an acute fracture, meaning a new fracture and a fracture that was not in any stage of healing. The DON stated that the staff that had worked with Resident #7 in the shifts preceding the identification of the fracture should have been interviewed to complete a thorough investigation. The Regional Director of Operations (RDO) was interviewed on 10/15/2025 at 11:33 AM. The RDO stated that since Resident #7's wrist fracture had been identified as an acute fracture, the best practice for the facility would have been to interview staff that worked with the resident in the shifts preceding the identification of the fracture The Administrator (ADM) was interviewed on 10/14/2025 at 8:32 AM. The ADM stated that she had not been in the facility when the fracture to Resident #7's wrist was diagnosed. The ADM stated that the investigation of injury of unknown origin should have included interviewing staff that had worked with the resident in the days prior to the diagnosis of acute fracture to try to determine when Resident #7's pain started and the deformity appeared. 5. An admission Record revealed the facility admitted Resident #19 on 11/06/2019. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and the membrane that cover it) affecting the left non-dominant side, recurrent major depressive disorder, difficulty in walking, alcohol-induced disorder, and other abnormalities of gait and mobility. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2025, revealed Resident #19 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated that the resident did not exhibit any physical or verbal behavioral symptoms directed at others. An admission Record revealed the facility admitted Resident #3 on 10/16/2024. According to the admission Record, the resident had a medical history that included diagnoses of early onset Alzheimer's disease, brief psychotic disorder, severe dementia with other behavioral disturbance, depression, generalized muscle weakness, difficulty in walking, and fatigue. An admission MDS, with an ARD of 10/24/2024, revealed Resident #3 had a BIMS of 4, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #3 exhibited physical and verbal behavioral symptoms directed toward others on one to three days during the seven-day look-back period. Per the MDS, the behavioral symptoms did not put others at significant risk for injury. The MDS also revealed that Resident #3 exhibited wandering behaviors on four to six days during the seven-day look-back period. According to the MDS, the wandering behavior did not intrude on the privacy or activities of others. Resident #3's Care Plan Report revealed a focus area initiated 10/18/2024, that indicated the resident had a cognitive decline related to dementia. The Care Plan Report also revealed a focus area initiated 10/18/2024, that indicated the resident was at risk for wandering or pacing. The resident's Care Plan Report also revealed a focus area initiated 11/22/2024, that indicated the resident was often aggressive and agitated with staff. Interventions directed staff to be alert of safety concerns to prevent injury to the resident or others (initiated 12/09/2024). Resident #3's Progress Notes revealed a note, dated 12/13/2024 at 4:10 AM, that revealed that at 7:30 PM, Licensed Practical Nurse (LPN) #37 was notified that Resident #3 was in Resident #19's room, and it appeared that Resident #3 was trying to choke Resident #19. The note indicated that Resident #3 was also observed pushing Resident #19's tray table against Resident #19's leg. Per the note, there were no injuries or bruises to Resident #19's neck or legs. The note revealed staff assisted Resident #3 to the hallway, gave the resident snacks, and administered medications until Resident #3 appeared to be ready to go to bed. The note indicated Resident #3 was assisted to bed by two staff members, and the resident slept during the night. Resident #19's Progress Notes revealed a Social Services note, dated 12/17/2024 at 10:44 AM, that indicated that Resident #19 was interviewed and stated that another pushed a table towards them and when Resident #19 told the other resident that they were in the wrong room, the other resident stated, Are you trying to be tough? The note indicated that Resident #19 stated that the resident came near them (Resident #19) but did not touch them. The facility-provided investigation documents related to the incident involving Resident #3 and Resident #19 revealed Residents #3's and Resident #19's respective admission Records, Resident #3's 12/13/2024 progress note, Resident #19's 12/17/2024 Social Services note, and a Witness Statement Form. The Witness Statement Form indicated that Resident #19 was interviewed by the former Director of Nursing (DON), who was in the position at the time of the alleged incident, regarding the incident of Resident #3 entering Resident #19's room. The facility's investigation documents revealed no evidence of statements from direct care staff, no evidence of the Administrator (ADM) being notified, no evidence that the incident was reported to the state survey agency, a description of the incident, an assessment of the residents, immediate interventions placed following the incident, or factors that predisposed to the incident. During an interview on 10/06/2025 at 4:12 PM, Resident #19 stated that they recalled the incident with Resident #3. Per Resident #19, they were lying on the bed when Resident #3 entered Resident #19's room and stated, Are you trying to start trouble? Be quiet. Resident #19 stated that Resident #3 tried to push Resident #19's tray table towards them (Resident #19). Resident #19 stated that was when Resident #19 pressed the call light, and staff came immediately and redirected Resident #3 out of the room. Resident #19 stated Resident #3 did not touch or attempt to choke them (Resident #19). During an interview on 10/09/2025 at 2:52 PM, LPN #37 stated that a geriatric nursing assistant (GNA) reported that Resident #3 attempted to choke Resident #19. LPN #37 stated she did not witness the incident; she only documented what the GNA reported. LPN #37 stated they assessed Resident #19, who had no injuries. LPN #37 stated she reported the alleged resident-to-resident abuse to the former DON and to the nurses on the following shift. During a telephone interview on 10/13/2025 at 3:42 PM, GNA #5 stated she reported the alleged attempt of Resident #3 to choke Resident #19 to a nurse. GNA #5 stated she went to Resident #19's room when she heard screaming from the resident. She stated that while at the doorway, she saw Resident #3 standing close to the head of Resident #19's bed and close to Resident #19's tray table. GNA #5 stated she saw Resident #3's hands raised, but she did not see Resident #3's hands directly close to or on Resident #19's neck. During an interview on 10/09/2025 at 6:31 PM, the former DON stated she vaguely remembered the allegation involving resident-to-resident abuse between Resident #3 and Resident #19. The former DON stated that she would have notified the ADM of the abuse allegation. She stated that she was unable to recall whether the abuse allegation was reported to the state survey agency. During an interview on 10/13/2025 at 12:21 PM, the facility's current DON stated that the alleged resident-to-resident abuse between Resident #3 and Resident #19 should have been thoroughly investigated to ensure resident safety. The DON stated that there should have been written statements from staff, and Resident #3 and Resident #19 should have been monitored. The DON stated that the investigation would have included identificati

Based on facility document review and interview, the facility failed to ensure their Quality Assurance Performance Improvement (QAPI) program effectively implemented a plan to address quality deficiencies identified related to falls. This deficient practice affected 3 (Residents #7, 12, and #18) of 9 sampled residents reviewed for accidents during the complaint survey.Findings included:The facility's QAPI meeting documentation from June 2025 to September 2025 indicated that falls were reviewed each of the months. The documents revealed that in May, the facility documented that there were 25 falls with 22 residents and that two of the residents accounted for five of the falls. A review of the facility's documents revealed no evidence of corrective actions being developed to address the concern nor evidence of a good faith effort to address the concerns.During an interview on 10/15/2025 at 3:54 PM, Registered Nurse (RN) #26 stated that she had never been to a QAPI meeting and had never been asked to contribute to a performance improvement project (PIP). She stated that there were papers that listed falls by shift at the nurses' station, but no one had asked for her opinion or suggestions on how to decrease falls.During an interview on 10/15/2025 at 4:00 PM, Licensed Practical Nurse (LPN) #38 stated that she had never been asked to participate in QAPI. She stated that she had been asked for suggestions to decrease falls on the secured unit for specific residents, but not in development of a PIP with goals and outcomes.During an interview on 10/15/2025 at 11:14 AM, the Director of Nursing (DON) stated that falls had been identified as a concern and were being discussed in QAPI meetings. She stated that there was a weekly fall meeting with administrative staff and the interdisciplinary team (IDT) and discussion in morning meetings where the facility staff reviewed risk incident reports. She stated that for an identified concern, she expected a written action plan that showed the identified problem and ways the facility was trying to fix it, with tools like audits, metrics to meet, and ways to determine if interventions were effective. She stated that if one was drafted somewhere, she was not involved in the follow up or action items.The Administrator (ADM) was interviewed on 10/11/2025 at 9:50 AM. The ADM stated that she noticed falls were high about six months prior, when she first started at the facility. She stated that one intervention discussed included frequent and constant rounds, but she ran into push back from the former DON (in the position at the time of the discussion of frequent and constant rounds). She stated that the standard was two hours, but she expected more. She stated that the corrective action plan for falls was verbally relayed to staff, but there was no written plan. She stated her main focus related to falls was to reduce the number of falls and then when the numbers of falls started declining, the plan was to assess other parts of the fall policy to see if there were other issues. She stated staff did daily angel rounds, which were documented where department managers were to discuss what they had found, including any fall risks identified.During a follow up interview on 10/15/2025 at approximately 12:00 PM, the ADM stated that her expectation for an identified concern with falls for QAPI was for there to be a plan. She stated that they needed to talk about the concern and put interventions in place. In regard to whether there should be a written plan with steps to follow and tools to measure effectiveness, the ADM stated that she expected the fall protocol to be followed and to change things that did not work. The ADM stated that if the falls continued to happen, then they would try a new intervention. In regard to how staff tracked interventions the facility had tried, she stated they discussed the concern in morning meetings and made corrections on an individual basis. She stated that they were implementing angel rounds and increased monitoring facility wide.

Based on facility policy review, record review, facility document review, and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse by a staff member for 1 (Resident #4) of 4 residents sampled for abuse during the complaint survey. Findings included:A facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised 11/06/2024, revealed, An owner, licensee, administrator, licensed nurse, employee, or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat, or harmfully neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment neglect, or misappropriation shall immediately report to the Nursing Home Administrator.An admission Record revealed the facility admitted Resident #4 on 12/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) and aphasia (an inability to understand or produce speech) following cerebral infarction (a stroke), gastrostomy tube, chronic obstructive pulmonary disease (COPD), paroxysmal atrial fibrillation, atherosclerotic heart disease, and congestive heart failure.A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident did not exhibit any behavioral symptoms during the assessment timeframe. Per the MDS, the resident required maximal assistance from staff for activities of daily living (ADLs), including personal and oral hygiene, toileting, bathing, dressing, and putting on footwear. The MDS indicated the resident did not have any falls since admission, and the resident did not have a fracture related to a fall in the previous six months. Resident #4's Care Plan Report included a focus area initiated 12/13/2024, that indicated the resident had a self-care deficit related to cerebral infarction. Interventions dated 12/13/2024 directed staff to provide Resident #4 with assistance from two staff for walking and transfers, assist with repositioning, fall precautions, and indicated the resident utilized a wheelchair. A Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Initial Report Form, dated 12/17/2024, revealed the facility reported an incident of physical and mental/verbal abuse involving Resident #4, perpetrated by LPN #3. The document indicated that the incident occurred at 1:02 AM on 12/17/2024. Per the document, two geriatric nursing assistants (GNAs), GNA #2 and GNA #4, witnessed LPN #3 being rude and rough with Resident #4 when assessing the resident for injuries after a fall. The report indicated that the GNAs reported the alleged abuse to LPN #6, who reported it to the Director of Nursing (DON), who was the Assistant Director of Nursing (ADON) at that time, who then reported it to the former DON (in the position at the time of the alleged incident). The report indicated that Resident #4 did not have serious bodily harm or injuries as a result of the alleged abuse.A Maryland Department of Health Office of Health Care Quality Facility Reported Incidents Follow-Up Investigation Report Form, dated 12/23/2024, indicated, 3. Conclusion revealed, After the investigation of the incident the allegation has been verified. The report indicated that multiple staff members reported witnessing LPN #3 being rough, rude, and mean to Resident #4. The report indicated that staff seen and heard LPN #3 yelling and pulling on Resident #4's arm.A written statement signed by LPN #6, dated 12/17/2024, indicated that GNA #2 and GNA #4 reported to her that LPN #3 was rude and rough with Resident #4 during a fall assessment. Per the statement, GNA #2 witnessed LPN #3 pull hard on the resident's arm and yell at the resident to stop. The statement indicated that the resident was not able to move, but LPN #3 kept pulling on the resident really hard on their arm. The statement indicated that GNA #4 reported that LPN #3 pulled a blood pressure cuff off the resident very rough and caused the cuff to break.A written statement signed by GNA #4, dated 12/17/2024, indicated that she, along with LPN #3, GNA #2, and GNA #5, assisted Resident #4 following the resident's fall out of bed. The statement indicated that she witnessed LPN #3 be mean to Resident #4 and yelled at the resident to stop moving. Per the statement, LPN #3 pulled the resident's arm really hard and yelled at the resident. The statement indicated that LPN also spoke to the resident rudely when the resident was on the floor.An undated written statement signed by GNA #2 indicated that on 12/16/2024, LPN #3 was rude and disrespectful to Resident #4. The statement indicated that the resident had fallen out of bed when she was asked to help GNA #5, GNA #4, and LPN #3 pick the resident up. The statement indicated that she witnessed LPN #3 yell at the resident to stop moving so much and witnessed her pushing, pulling, and jerking [Resident #4] around.A written statement signed by GNA #5, dated 12/17/2024, indicated that she witnessed LPN #3 being rough with Resident #4 after the resident fell out of bed. The statement indicated that LPN #3 yelled at the resident to stop moving. Per the statement, LPN #3 told her that she was so mad that she ripped a blood pressure cuff off the resident and broke it because the resident would not stop moving. The statement indicated that LPN #3 also had a rude attitude towards the resident.During an interview on 10/08/2025 at 1:41 PM, GNA #2 stated LPN #3 pulled on and jerked Resident #4's arms while struggling to remove the resident's t-shirt and obtain the resident's blood pressure. She stated she reported it to LPN #6 because she thought it was abuse. During an interview on 10/08/2025 at 5:30 PM, GNA #4 stated that when she entered Resident #4's room to help GNA #2 and GNA #5 transfer Resident #4 back to bed after the resident's fall, she observed Resident #4 covered in vomit on the floor. GNA #4 stated that they assisted the resident back to bed, and the resident sat on the edge of the bed. GNA #4 stated that LPN #3 was behind the resident on the bed and stuck her knee against the resident's back while pulling up and she had one of the resident's arms behind them pulling on it also. GNA #4 stated that the other two GNAs and she discussed LPN #3's behavior and believed it to be abuse and reported it to the other nurse on duty. During an interview on 10/20/2025 at 6:15 PM, GNA #5 stated that they found resident #4 on the floor while checking on residents at around midnight and assisted with getting the resident back to bed after the fall. GNA #5 stated that LPN #3 handled Resident #4 roughly by pulling, grabbing, and yelling at the resident in an attempt to have the resident lie still so that the LPN could obtain a blood pressure reading. GNA #5 stated that the three GNAs discussed the incident and agreed it was abuse and then reported it to LPN #6.During an interview on 10/09/2025 at 8:00 PM, LPN #6 stated that as soon as the GNAs reported the alleged abuse, she called her supervisor (the current DON, who was the ADON at the time of the incident) immediately. During an interview on 10/13/2025 at 1:21 PM, DON stated that they determined that abuse did occur.During interview on 10/13/2025 at 2:55 PM, the Administrator (ADM) stated that she was not familiar with the incident involving Resident #4 because she was not the Administrator yet at the time of the incident.

Based on facility policy review, record review, and interview, the facility failed to ensure staff communicated all pertinent information to a physician, which affected 1 (Resident #4) of 4 residents reviewed for abuse. Findings included:A facility policy titled, Change in a Resident's Condition or Status, dated 02/2021, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. [exempli gratia; for example], changes in level of care, billing/payments, resident rights, etc. [et cetera; and so forth]. The policy revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an), which included, a. accident or incident involving the resident, d. significant change in the resident's physical/emotional/mental condition, and g. need to transfer the resident to a hospital center. The policy also indicated, 3. Prior to notifying the physician or healthcare provider, the nurse will make detained observation and gather relevant and pertinent information for the provider, including (for example) information prompted by the interact SBAR [Situation, Background, Assessment, Recommendation] Communication Form.A facility policy titled, Acute Condition Changes-Clinical Protocol, dated 03/2018, indicated, 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. The policy continued, a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. The policy also indicated, 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). The policy revealed, 9. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The policy continued, a. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.An admission Record revealed the facility admitted Resident #4 on [DATE] and discharged the resident on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) and aphasia (a communication disorder) following cerebral infarction (a stroke), gastrostomy tube, chronic obstructive pulmonary disease (COPD), paroxysmal atrial fibrillation (occasional irregular heartbeat), atherosclerotic heart disease, and congestive heart failure (CHF).A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident did exhibit behavioral symptoms and required maximal assistance from staff for activities of daily living (ADLs), including personal and oral hygiene, toileting, bathing, dressing, and putting on footwear. The MDS revealed that no falls were recorded for the resident since admission, and the resident did not have a fracture related to a fall in the previous six months.Resident #4's Care Plan Report included a focus area initiated [DATE], that indicated the resident had an altered cardiovascular status related to hypertension, atrial fibrillation, cardiovascular disease, and indicated that the resident had a pacemaker. Interventions initiated [DATE] directed staff to monitor, document, and report as necessary any signs or symptoms of cardiovascular disease including chest pain, nausea and vomiting, shortness of breath, changes in capillary refill, and color/warmth of the resident's extremities.Resident #4's SBAR Change in Condition, dated [DATE] at 2:54 AM and locked at 3:01 AM, revealed that Resident #4 had a fall from bed at 12:15 AM and NP #29 was called at 12:40 AM. The record indicated that NP #29 had not returned the call at that time. Per the record, the nurse completed a change in condition assessment, completed a neurological check, and assessed the resident for any changes. The record revealed the Respiratory Evaluation and Abdominal/GI [Gastrointestinal] Evaluation were marked as Not clinically applicable to the change in condition being reported.Resident #4's Progress Notes revealed a note, dated [DATE] at 4:43 AM and electronically signed by the Director of Nursing (DON), who was the Assistant Director of Nursing (ADON) at the time of the incident, that indicated that she and Licensed Practical Nurse (LPN) #17 assessed the resident. The note indicated the resident appeared slightly gray in color, their pulse varied between 122-131 beats per minute, the resident had a history of atrial fibrillation, and the resident was a mouth breather and oxygen saturation rates were 86% - 91% on room air. The note indicated that the resident had a history of COPD, CHF, and had a recent stroke, and that NP #29 was notified by LPN #17 of the elevated pulse and oxygen saturation levels. The note indicated that NP #29 ordered laboratory values to be obtained that day. The note revealed it did not indicate that the NP was notified of Resident #4's recent fall or that the resident vomited twice around the time of the fall, including once after the fall.Resident #4's Progress Notes revealed a note, dated [DATE] at 10:04 AM, that indicated that the resident was found unresponsive, was gray in color, and was breathing heavily. The note indicated that Certified Registered Nurse Practitioner (CRNP) #36 was notified, who was in the facility's parking lot at that time and said she would be in to see the resident. Per the note, the resident expired at 8:50 AM.During an interview on [DATE] at 12:51 PM, the facility's DON stated that on [DATE], she came in to relieve LPN #3 at 2:15 AM and she went in to do the neurological check for Resident #4 at 3:00 AM. She stated that the resident's pulse was 122. She stated that LPN #17 contacted the provider and told her about the pulse, but she was not sure if the fall was mentioned. She stated she could have reminded the provider about the fall and should have thought about a brain bleed because the resident was on an anticoagulant medication.During an interview on [DATE] at 11:23 AM, the DON stated that when she came in on [DATE], the previous nurse (LPN #3) told her that the resident had vomit on them. She stated that the nurse did not say that the resident had vomited after the fall. She stated she was not aware the resident had vomited twice. She stated that to her, vomiting twice was significant and would have needed to be followed up on. She stated that she felt that the nurse did not give her a complete and accurate report. She stated she was told that the provider was aware that Resident #4 had fallen. She stated she did not have time to review LPN #3's nurse notes before providing care to the residents.During an interview on [DATE] at 3:09 PM, the DON stated that she was told in report that Resident #4 had vomited. She stated that the information should have been included on the SBAR and communicated to the physician. She stated that if a resident was taking an anticoagulant medication, it should be included on the SBAR and communicated to the physician. She stated that neurological checks were done to see if there was a change in the resident's mental state and to determine if there was a brain bleed or stroke. She stated that they would monitor grip changes, pupil changes, and changes to the resident's vital signs. She stated neurological checks included checking the resident's orientation, pupils, confusion, vital signs, grips, and range of motion (ROM). She stated that if the resident had a change in their pupils, increased confusion, speech change, change in their ROM or grips, or a change in their vital signs, it would indicate a positive neurological check for a head injury, and the physician should be notified of the changes. She stated LPN #17 contacted NP #29 and was told to give the metoprolol (a blood pressure medication) and complete laboratory tests in the morning. She stated the anticoagulant medication was not mentioned, and they did not have an order to hold it. She stated that she was told in report that the fall was reported to the NP. She stated that when they called the NP with the change in vital signs, they should have reminded the NP of the fall that the resident was on an anticoagulant.During an interview on [DATE] at 10:07 AM, LPN #17 stated she was not assigned to Resident #4 but was assisting the facility's current DON with Resident #4 after the resident's fall on [DATE]. She stated she contacted NP #29 and notified her that the resident's heart rate was elevated, and that the resident was not acting right, so NP #29 gave her permission to give the resident's anticoagulant and blood pressure medication early and ordered laboratory tests to be completed that day. She stated that at the time, she had assumed the NP already knew about the fall, and she did not mention it to the NP.During an interview on [DATE] at 1:30 PM, the LPN #17 stated that she did call NP #29, but she did not report the fall because the previous nurse documented that she had notified the physician.During an interview on [DATE] at 9:36 AM, NP #29 stated that the nurse who notified her regarding Resident #4 did not mention the fall but stated that she would have ordered the same things. She stated that she did not recall talking about the anticoagulant medication when she told the nurse to give the medications, but it should have been held. She stated that if she had been notified of the fall, she would have held the anticoagulant medication and ordered laboratory tests and would have asked more questions but still would not have sent the resident to the hospital. She stated that everything but the resident's pulse was normal, and even if she had been told about the fall, she would have made the same decision and stood by the decision to keep the resident at the nursing home and ordered laboratory tests.During an interview on [DATE] at 1:38 PM, CRNP #36 stated that she was notified of Resident #4's change of condition when she was in the parking lot of the facility, about to enter. She stated that when she got into the facility, she was notified that the resident had already passed away, and she did not assess the resident. She stated the ambulance would not have made it there any faster than when she arrived. She stated that if she had been made aware of the resident's fall, she would have ordered the anticoagulant medication to be held. She stated that if all the details of the resident's condition were not communicated with the provider, then they would not have been able to make an informed decision.During an interview on [DATE] at 1:58 PM, the Medical Director, who was also Resident #4's primary care physician, stated that if a resident vomited and then fell, he would not be concerned, but if the vomiting came after the fall, he would expect that to be reported to the provider. He stated that when there was a change in the vital signs, he would expect the provider to be notified. He stated that when the nurses called about Resident #4's change in vital signs, they should have given a complete report on the resident's status.During an interview on [DATE] at 8:28 AM, the Administrator stated that documentation should be as accurate as possible and include all critical elements to be able to tell the story of the situation. She stated neurological checks were done to assess brain activity and to assess for complications. She stated she would expect the physician to be notified of any change.

Based on interview, record review, and facility policy review, the facility failed to implement their policies regarding investigating, documenting, and reporting an incident of resident-to-resident abuse, for one (Resident #14) of 12 residents reviewed for abuse or resident-to-resident altercations during the complaint survey.Findings included:A facility policy titled, Resident-to-Resident Altercations, revised 09/2022, indicated Policy Statement - All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. The policy also indicated, 4. If two residents are involved in an altercation, staff: a. separate the residents, and institute measures to calm the situation; b. identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; and c. notify each resident's representative and attending physician of the incident. The policy continued, i. complete a Risk Management form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; and j. report incidents, findings, and corrective measures to appropriate agencies as outlined in Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation.A facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, dated 11/06/2024, indicated, Reporting - I. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: A. The State licensing/certification agency responsible for surveying/licensing the facility. The policy also indicated, Abuse Investigating and Reporting - I. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the incident will be reported immediately to one of the following: Administrator, DON [Director of Nursing], or Charge Nurse. II. Supporting documents relative to alleged incident will be obtained. The policy continued, V. The Administrator or his/her designee, will provide the appropriate agencies or individuals listed above with written report of the findings of the investigation withing five (5) working/business days of the initial self-report.An admission Record revealed the facility admitted Resident #13 on 12/22/2023. According to the admission Record, the resident had a medical history that included a diagnosis of cerebral infarction (a stroke).A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2025, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #13 exhibited physical and verbal behaviors directed toward others and other behavioral symptoms not directed toward others one to three days during the seven day assessment look-back period.Resident #13's Care Plan Report included a focus area, revised 12/28/2023, that indicated the resident had a behavior problem related to exit seeking and sitting on the floor. Interventions directed staff to monitor behavior episodes and attempt to determine the underlying cause, initiated 12/27/2023.An admission Record revealed the facility admitted Resident #14 on 06/17/2025. According to the admission Record, the resident had a medical history that included a diagnosis of dementia.A quarterly MDS, with an ARD of 09/24/2025, revealed Resident #14 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #14 exhibited no physical or verbal behaviors directed toward others during the seven day assessment look-back period.Resident #14's Care Plan Report included a focus area, initiated 07/02/2025, that indicated the resident had inappropriate behaviors related to poor insight and judgement, related to dementia. Interventions directed staff to set limits and make the resident aware that behavior was inappropriate at the time the behavior occurred, initiated 07/02/2025.A Witness Statement by Licensed Practical Nurse (LPN) #9, dated 09/14/2025, indicated that at 11:35 PM Resident #13 was grabbing Resident #14 by the shirt collar, and Registered Nurse (RN) #32 was in between the residents attempting to get the residents away from one another. A Witness Statement by Geriatric Nursing Assistant (GNA) #44, dated 09/14/2025, indicated that at 11:35 PM, she walked over to the secure unit and saw a nurse positioned between two residents to keep them separated. The statement indicated GNA #44 helped another resident away from the situation. A Witness Statement by the Director of Nursing (DON), dated 09/14/2025, indicated that at 11:35 PM there was Resident to Resident incident. The statement indicated Resident #13 was standing behind Resident #14, and Resident #13 was holding and pulling on Resident #14's shirt collar. The statement indicated staff redirected Resident #13 away from Resident #14. A nurse's Progress Note[s], dated 09/15/2025 at 2:18 AM, revealed that on 09/14/2025 at 11:35 PM Resident #13 pushed their roommate, Resident #14, in a wheelchair to the nurse's desk. The note indicated Resident #13 had Resident #14 by the shirt collar and was saying get her out of here. The note indicated the nurse called for additional staff members to assist with separating the residents. The note indicated Resident #13 kept yelling for the police. A nurse's Progress Note[s], dated 9/15/2025 at 2:30 AM, revealed that Resident #14 was brought to the nursing desk in their wheelchair by Resident #13, and Resident #14 was upset and crying. The note indicated Resident #13 held Resident #14 by the shirt collar, and the nurse had to get additional staff assistance to separate the residents. During an interview on 11/06/2025 at 3:09 PM, the DON stated she was on the 100 Hall when she received a call from Registered Nurse (RN) #32, on the secure unit, requesting assistance. The DON stated when she and Licensed Practical Nurse (LPN ) #9 arrived on the secure unit, Resident #13 was standing behind Resident #14, and Resident #13 was holding Resident #14's shirt collar. The DON stated the residents were separated, she assessed Resident #14, staff began writing witness statements, and she notified the Former DON, who was the DON at that time. The DON stated the Former DON called her back and told her the incident did not need to be reported and to have RN #32 document the incident as a behavior. The DON stated there was not an incident report done at that time, but there should have been. The DON stated she believed this resident-to-resident incident should have been investigated and reported to the state and the police. The DON stated she was not aware of an assessment being completed to determine that the residents could remain in the same room.During an interview on 11/07/2025 at 8:28 AM, the Administrator (ADM) stated she was not in the facility when the incident occurred but heard about it in the morning meeting. The ADM stated she was told that one resident was pushing the other resident, that the resident did not want to be pushed, so the residents were separated. The ADM stated she was not aware of the resident being grabbed by the collar, and if she had known the details she would have investigated and reported it at that time. The ADM stated she was not aware that the residents were roommates and were still in the same room together. The ADM stated the residents should have been separated and then assessed to determine if a room change was necessary. The ADM agreed that the facility did not follow their policy since risk management was not done, and the incident was not investigated or reported. During an interview on 11/07/2025 at 8:51 AM, RN #32 stated she was at the desk charting, saw Resident #13 pushing Resident #14 down the hallway, and Resident #14 was crying. RN #32 stated Resident #13 held and pulled on Resident #14's shirt collar. RN #32 revealed Resident #13 was saying to get the resident out of their room and call the police. RN #32 stated she had to call for help to separate the residents, and she kept Resident #13 at the desk in a recliner. RN #32 stated that normally they would separate the residents, but they were full that night, and she did not think Resident #14 would have gone to their room because they wanted to be by people. RN #32 stated the Former DON was called, and the Former DON called the corporate office. RN #32 stated the Former DON called back after talking with the Regional Director of Operations (RDO). RN #32 revealed the Former DON indicated that the RDO stated the incident was not an altercation. RN #32 stated she told the DON that she did not feel comfortable with that decision and documented what she saw. RN #32 stated the altercation was resident-to-resident abuse, and that was why they got the witness statements and notified the Former DON. During an interview on 11/07/2025 at 11:23 AM, the DON reviewed the facility's policy about resident-to-resident altercations and agreed that they did not follow their policy in regard to updating the care plan, completing a risk management form at the time of the incident, investigating the incident, and reporting it.

Based on review of facility reported incident investigation documents and medical records, interviews and observations it was determined that the facility failed to provide adequate supervision to prevent a vulnerable resident from exiting the facility unattended by staff. This was found to be evident for 1 (Resident #234) out of 3 residents reviewed in relation to facility self reports of elopement during the survey. The findings include: Review of Resident #234's medical record revealed the resident was admitted to the facility in December 2021 with multiple psychiatric diagnosis which included paranoid schizophrenia. In November 2022 the resident was receiving multiple psychoactive medications including an antipsychotic, an antidepressant and antianxiety medications. The resident had a court ordered guardian of person since 2016. On 10/8/22 the resident was deemed by two facility providers unable to make health care decisions. Review of a nursing progress note dated 8/27/22 revealed: No behaviors noted other than resident has all of [his/her] stuff packed to go home. Review of the 9/30/22 Minimum Data Set assessment revealed the resident required supervision or touching assistance for walking and did not use a wheelchair. The resident had wandering behavior on 1-3 days during the assessment period. Review of a 11/2/22 nursing progress note, written by Nurse #4, revealed: Resident able to walk around in [his/her] room and out in the hallway with steady gait. Review of the medical record revealed a progress note written by the then Activity Director (Staff #30) on 11/7/2022 at 4:45 PM that revealed: [Resident] sitting in lobby beside Dining Room with [his/her] belongings packed in plastic bags. Observation of the lobby area near the dining room, on 11/15/24 at 9:45 AM, revealed it is next to glass exit doors leading to a road. These doors were noted to be locked at the time of the observation. This lobby is on the second floor of the facility, where all of the resident rooms are located. Interview with the Director of Nursing on 11/15/24 at approximately 9:00 AM revealed these doors were utilized for transporting residents in stretchers in and out of the building up until July 2024. The main facility lobby is located on the first floor. During an interview on 11/15/24 at 10:18 AM surveyor and nurse #4 reviewed the 11/7/22 activity note. After review of the note surveyor asked : If this had been reported to you would you have completed an elopement assessment? The nurse responded yes, and went on to report that she would try to get to the bottom of the situation. Review of progress note written by the then social worker (Staff #32) on 11/8/22 at 4:04 PM revealed: Resident stated that [he/she] felt that [s/he] should be admitted to an in-patient psych facility. Resident began to state [his/her] diagnosis. [Resident] also began to make delusional statements, as well. Review of the progress note written by social worker (Staff #32) on 11/10/22 revealed: [Resident] once again stated that [he/she] would like to be placed in an in-patient psych facility. [Resident] stated that s/he felt like she was having a breakdown. Review of the nursing progress note, dated 11/30/22 at 8:00 PM revealed: [Resident] attempted elopement and was on the first floor of the parking garage; returned without incident accompanied by [Nurse #4] and [Nurse #7] back to room. Review of the initial self report (MD00186275) submitted by facility staff revealed that on 11/30/22 at approximately 8:00 PM the resident went to the first floor of the building in an attempt at elopement stating I just want to go home. Staff returned the resident to the second floor and placed the resident on 15 minute checks. Resident was placed on 15 minute checks, and was moved to the locked unit to ensure safety. The resident's guardian, attending physician, social worker , and psychiatry were notified for follow up. Further review of the medical record failed to reveal documentation of an elopement assessment prior to 11/30/22. Review of the care plans revealed a plan addressing behavioral issues was initiated in July 2022 for behaviors that included, but was not limited to: frequently packs up belongings. Further review of the care plans failed to reveal interventions to address a potential for elopement prior to 12/1/22. During an interview on 11/15/24 at 10:18 AM nurse (Staff #4) confirmed that sometimes the resident would pack up his/her bags. Nurse #4 reported the resident had significant psychiatric history with delusions but was not considered an elopement risk and indicated it was a surprise when the resident eloped. Observations made throughout the survey revealed a main entrance at the front of the building that leads into the main lobby on the first floor. From this lobby there is a door that leads to the parking garage and an elevator to the resident care area on the second floor. Observations on the second floor revealed codes were required to gain access to the elevators or the stairs that led to the first floor. On 11/14/24 at 2:21 PM observation of the door from the main lobby to the parking garage revealed it is unlocked; and was able to be opened without any impediment. The garage is a small parking lot which leads to an access drive to the front entrance of the facility. It is a short walk to the road that the facility is located on. There is a steep hill down to the main road just outside the garage. On 11/15/24 review of the witness statements revealed the resident was found in the parking garage by two GNAs (Staff 5 and 6) who were on their break. The Resident was attempting to gain access to a truck at the time s/he was found. One GNA remained with the resident while the other went to get assistance. On 11/15/24 at 10:18 AM Nurse #4 reviewed her written statement and confirmed the contents. Review of the statement revealed Nurse #4 was alerted to the situation by one of the GNAs and assisted the resident back inside the facility. When found in the garage the resident was noted to be dressed in a hospital gown, pants, shoes and a jacket and was holding a bag with a few pieces of clothing in it. Nurse #4 confirmed that the resident was found in the parking garage attempting to gain access to a vehicle. On 11/15/24 at 9:52 AM the facility presented to the survey team a plan of correction that was implemented on 11/30/22 with a final date of compliance of 12/6/22. This plan was verified on site on 11/18/24. The plan included : -Initial Performance Improvement Project on Elopements through QAPI [Quality Assurance Performance Improvement]. -Provided education to visitors to seek assistance if any resident attempts to accompany them into the elevator or out the door, posted signs as a reminder to visitors and staff. -Systemic Change to elevator code. -Reviewed and revised elopement risk policy. -Educated staff on policy as well as tips to prevent elopement. -Completed updated elopement risk assessments on all current residents. -Scheduled monthly Elopement Drills for three months. On 11/19/24 at 10:40 AM surveyor informed the DON and Nursing Home Administrator that, after consultation with the office, a determination of IJ Past Non-Compliance was made.

Based on medical record review, observation and interview it was determined that the facility failed to provide care to prevent the development of pressure ulcers. This was found to be evident for one(Resident #34) out of four residents reviewed for pressure ulcers during the survey. This deficient practice resulted in actual harm to Resident #34. The findings include 1.) On 11/13/24 review of Resident #34's medical record revealed the resident has resided at the facility for several years and whose diagnosis include but are not limited to, dementia, osteoporosis, high blood pressure, and hypothyroidism. The resident had two pressure ulcers, one on each foot, with orders for daily dressing changes. Further review of the medical record revealed these ulcers were originally identified on 8/12/24. Further review of the medical record revealed an order, in effect from 5/18/24 until it was discontinued 8/12/24, to apply small sized border foam dressings as skin prevention on right inner ankle, left lateral pedal (side of foot) area, and right lateral pedal areas daily and as needed. During an interview on 11/20/24, the wound NP #27 revealed she had seen the resident on 5/17/24 during a wound sweep, had identified blanchable red areas and had recommended preventative dressings. The NP reported she attempts to see all residents during a skin sweep conducted quarterly. On 11/19/24 review of the 6/21/24 Minimum Data Set assessment revealed the resident had functional limitations in range of motion with impairment of both sides of the lower extremities (legs) and the resident was dependent on staff for bed mobility and transfers. This assessment also identified the resident as being at risk for pressure ulcers but currently did not have any pressure ulcers. Review of the resident's care plans revealed a plan, initiated 11/9/22, for potential impairment to skin integrity related to advanced age, incontinence and limited mobility. The interventions included, but were not limited to, Medline mattress with pump to reduce pressure, initiated 6/26/24; and Turn and Position every 2 hours, initiated 10/5/23. Further review of the medical record revealed an order, in effect from 8/31/22 until it was discontinued on 6/26/24 for a pressure reducing mattress. Review of the Treatment Administration Records (TAR) revealed staff were documenting the presence of the pressure reducing mattress every shift. On 11/25/24 at 4:00 PM the corporate nurse confirmed the pressure reducing mattress is the regular standard mattress, with no pump. On 11/26/24 at 8:23 AM the corporate nurse reported previously all the mattresses had the pump and then the facility started switching out to regular mattresses. She went on to report she thought they only have a couple of the Medline mattresses left in the building. Further review of the medical record revealed an order for the Medline mattress with pump was in place from September of 2022 until it was discontinued in August 2024. No orders were found for staff to monitor the functionality of the Medline mattress with pump. No documentation was found on the Treatment Administration Record to indicate what mattress was being used from 6/26/24 until a new mattress order was written on 8/12/24 for Continuous Air Flow Mattress with pump. During the 11/20/24 interview, the wound NP confirmed that the Medline mattress with pump is a low air loss mattress. She went on to report that if the resident was already on this mattress she would not have recommended a low air loss mattress, instead she would have documented to continue on the current mattress. On 11/25/24 at 12:31 PM the Director of Nursing was unable to validate what mattress the resident had on 8/11/24; and indicated it was probably a regular mattress and that is why they ordered the new mattress. The resident had a room change on 7/26/24. The resident ' s new room was located on a different nursing unit. Further review of the medical records, including the Treatment Administration Records (TAR) and the Geriatric Nursing Assistant (GNA) documentation for the 30 days prior to 8/12/24 failed to reveal documentation to indicate the resident was being turned and re-positioned every two hours as indicated in the care plan. On 8/5/24 the resident was seen by a primary care nurse practitioner. The note from this visit includes: Resident is being evaluated today for a Regulatory 30 day visit. Interval history has been reviewed. There were no interval visits or returns to the acute care setting. Resident's weight is up 2 lbs over the past month, favorable. Further review of the medical record revealed the nursing staff was completing Weekly Skin Checks. Review of these assessments completed in July and on 8/6/24 revealed the resident's skin was intact with no pre-existing conditions or newly identified conditions. Review of the 8/11/24 Weekly Skin Check, completed by Nurse (Staff #40), revealed documentation that the resident had a pre-existing and a newly identified area, and the Body Diagram section revealed documentation of a skin tear to the knee from a fall. No documentation was found on the 8/11/24 Weekly Skin Check, or elsewhere in the medical record, of the presence of a pressure ulcer prior to 8/12/24. Further review of the medical record revealed a wound nurse practitioner note (Staff #27), dated 8/12/24, which documented that this was a new consult to assess skin breakdown to bilateral (both) feet and ankles. The note documented 4 pressure injuries: -Left lateral malleolus (ankle), unstageable 1 cm x 0.8 cm x 0.2cm 80 % slough -left lateral (outer side) foot; DTI(deep tissue injury); 0.5 x 0.5 x 0.2 cm; 80 % eschar -left lateral foot distal (closer to toes); DTI; 0.5 cm x 1 cm x 0.0 90% eschar -right medial (bottom) foot DTI; 1 cm x 1 cm x 0 cm; 80 eschar Review of policy documentation provided by facility staff during the survey revealed the following definitions: -Slough: Non-viable yellow, tan, gray, green or brown tissue; usually moist; can be soft, stringy and mucinous in texture. -Eschar: Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color; and may appear scab-like. -Unstageable Pressure Ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. -Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation reveals a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia (connective tissue), muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). On 11/20/24 at 8:53 AM an interview was conducted with the wound NP #27. The NP confirmed the 8/12/24 visit was a new consult but she was unable to say who reported it, other than nursing staff. The NP indicated there was a wound referral book on the unit. Review of the Wound Reporting Log, located on the nursing unit in a binder, revealed a notation on 8/11 for Resident #34 by nurse #40. In the column for Wound Type, staff documented Pressure?. In the column for Site, staff documented: L. malleolus (ankle), L. lateral foot and R. med foot. In the column for Current Treatment, staff documented BF (Border Foam). During the 11/20/24 interview, when asked if she thought the resident's wounds were unavoidable, the wound NP reported: If unavoidable I would put that in the note. When asked if she thought these wounds could have developed in a week, she said yes, when asked if they could have developed in a day, she said no. Further review of the 8/12/24 wound NP note failed to reveal documentation that the newly identified wounds were unavoidable. Further review of the medical record revealed the resident was being followed by the wound NP for assessment of pressure ulcers and recommendations for dressings since 8/12/24. A new order for Continuous Air Flow Mattress with Pump was put in place on 8/12/24 and nursing staff have been documenting on the TAR twice daily that they are checking for proper inflation, monitoring for any air leaks and monitoring the cleanliness of the air mattress. Additionally, nursing staff have been documenting on the TAR twice daily, since 8/26/24 of turning and positioning every 2 hours and as needed. A review of the GNA documentation revealed that a prompt was added, on 8/26/24, to document: turn, ambulate, move resident at least every two hours. During the 11/20/24 interview, the wound NP reported the resident had 4 wounds and is currently down to two areas, one stage 3 and one unstageable. Further review of the medical record and observation on 11/21/24 confirmed that two of the pressure ulcers had healed. On 11/25/24 at 10:55 AM surveyor reviewed with the Director of Nursing the concerns that the there was an order for an air mattress since 2022 but no documentation to support that this mattress was being monitored, or was even on the bed, in the weeks prior to the identification of the pressure ulcers; no documentation found to indicate the resident was being turned and repositioned, as indicated in the care plan, in the weeks prior to the identification of four pressure ulcers; and the nursing staff's failure to identify the pressure ulcers on the weekly skin assessments.

Based on facility documentation, medical record review and staff interview, it was determined that the facility failed to ensure safe transitions of care when transport staff were allowed to place residents in their room beds with no assistance or oversight from the facility staff who would have been aware of the plans, and the individualized needs of the residents. Allowing this unsafe process in the facility resulted in harm to Resident #230. In addition, the facility failed to assess a resident for safe smoking. This was evident for 1 (#230) of 4 accidents reviewed and 1 (#22) of 1 residents that smoked at the facility. The findings include: 1) Review of Facility Incident Report MD 754 revealed that Resident #230, who had a [DIAGNOSES REDACTED]. Resident #230 stopped breathing at the facility after the fall and was not resuscitated, as the resident was designated as a no code (No CPR). Review of Resident #230's (MONTH) (YEAR) physician's orders [REDACTED]. Review of the potential for falls/injury r/t confusion, agitation with wandering, recurrent falls care plan had the approaches frequent checks on resident to ensure safety, safety devices as ordered: bed/chair alarm, Posey mat to floor, noodles to bed, Hi-low bed, self-releasing lap belt to w/c and use falling star sign on door to alert staff to increased risk per protocol. Review of the medical record revealed that, earlier in the day on [DATE] at 9:50 AM, Resident #230 experienced a fall from his/her wheelchair and sustained an abrasion and hematoma that was noted in the middle of the forehead. The resident was transferred to the local acute care emergency room for evaluation, because of the morning incident. Review of the local acute care emergency room documentation, dated [DATE], revealed a CT scan of the head, C-Spine without contrast with the impression of no skull fractures or [MEDICAL CONDITION] and prominent spondylosis, no definite fractures. Additional documentation of medical decision making at the emergency room documented sent by the nursing home after a fall from the wheelchair. Patient was sent because the nursing home felt that he/she was not calling out and as combative as usual. CT scan shows no acute process. Patient stable while present in the emergency department. Documentation continued patient calling out and trying to climb out of bed, while present in the emergency department, which sounds consistent with nursing home reported patient's baseline behavior. At this time, patient has no acute decompensating pathology warranting admission. The medical decision making ended with patient discharged stable. Review of the ambulance transport report, dated [DATE], documented that the resident was transported from the emergency room to the facility between 17:03 and 17:25. The summary of events documented that, during transport, the patient had no change in condition and vitals remained stable. According to the facility report, the resident was returned to the facility via the ambulance company at approximately 1740 (5:40 PM) on [DATE], per Staff #14, a registered nurse. It was documented that Staff #14 reported that the ambulance staff returned the resident directly to his/her room, placing him/her in the bed, and then approached Staff #14 at the nurse's station for a signature, which indicated the resident had returned. Continued review of facility documentation revealed that Staff #16, a geriatric nursing assistant entered Resident #230's room at 1745 (5:45 PM) and found the resident lying on the floor beside the bed and called for Staff #14. Staff #14 noted the resident lying on the floor on his/her right side, with an area of blood approximately 2.5 inches in diameter on the floor as well as blood noted around the nose. The resident was returned to the bed. At that time, Staff #14 noted the resident's respirations to be shallow and noted that the resident breathed a few breaths and then stopped breathing. Resident #230 was designated as a no code (No CPR). At that time, Staff #14 (a nursing supervisor) notified administration and the attending physician of the resident's death. On [DATE] at 2:14 PM, an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). Both explained to the surveyor that the ambulance staff entered the unit at the opposite end of the nursing station and placed the resident in the bed, which was left in the highest position, and then proceeded to go to the nurse's station to give the receiving nurse the paperwork. Both stated that the 2 geriatric nursing assistants that were assigned to the unit were in the dining room feeding residents at the time. The surveyor asked if the facility had a policy related to receiving residents back to the facility and the NHA stated prior to this incident we never required that staff must be in the room, however we never had an issue before. On [DATE] at 3:16 PM, Staff #14 was interviewed and stated it wasn't my normal unit. There were 2 gentlemen that came to blows and I had 1 resident kicking on the door and 1 man trying to get him to stop. The ambulance came in from the 400 hallway and the first I knew he/she was back was when Staff #16 was coming up the hall saying he/she was on the floor. I went down there and he/she had blood on the floor and I called the supervisor. The bed was in high position, it should have been in low position. In the past, the ambulance people would take residents to their room first and then come and get my signature. Staff #16 was coming up the hall to check on the 2 guys because it was dinner time and she saw him/her on the floor. I did not see the ambulance people come on the unit because I was dealing with the 2 men. The surveyor asked if Staff #14 received report that the resident was coming back to the facility and Staff #14 stated I personally didn't receive the report, but someone in the facility did, I just don't know who it was. On [DATE] at 4:30 PM, an interview was conducted with Staff #16. Staff #16 stated when Resident #230 came back from the hospital, we were back in the dining room feeding and no one told us he/she was back from the hospital. In the Haven unit, we start feeding at 5:00 PM and we had a lot of feeds and it took us longer to feed. It was probably 6:15 around that time. I don't remember the exact time. He/She was moving his/her mouth but nothing was coming out. He/she was laying on his/her side and blood was around his/her head. I yelled for the nurse and she came back and said to stay with him/her and she called for the supervisor. Once we got him/her up on the bed, the nurse told us to clean the blood off his/her head, so we could see where the blood was coming from. The surveyor asked who moved the resident and Staff #16 stated me and Staff #19 moved him/her back to the bed. I got underneath his/her upper body and she got under his/her legs and butt. We put the bed down. His/her bed was left up in the air in high position. Staff #14 told us to pick him/her up. We were concerned about picking him/her up and we both said that someone should come and check him/her. Staff #16 continued prior to this incident there were times the ambulance people would leave residents in the room and then find someone. For some reason, they had a bad habit of leaving people in the room. The surveyor asked if Staff #14 had been down to check on the resident. Staff #16 stated Staff #14 had signed the paper but couldn't get out from behind the desk. The surveyor stated, so some time passed after the nurse signed the paperwork before she could get to check on the resident and the answer was yes. She made a comment that she couldn't get down to the room because of the other residents beating on everything and freaking out. The paper that the nurse signed was a patient care report from the ambulance company which documented what happened with the resident while in the care of the ambulance crew. Staff #14 signed as the receiving agent where it was written, The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services, or assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered. The signature was Staff #14's and it was signed on [DATE] at 17:32. Staff #16 stated the resident was confused as he/she was on the Haven unit (a secured dementia unit). He/she was a falls risk. We would have an alarm on him/her so every time he/she would sit up we could get to him/her. Continued review of facility documentation revealed at 1900 (7:00 PM) the forensic nurse came to the facility, took pictures of the resident and the room, placed a toe tag on the resident and notified the transport team regarding the need to transport to the medical examiner's office. The surveyor requested to see the medical examiner's report which was not in the file that was initially given to the surveyor. The medical examiner's report Post Mortem Examination documented on [DATE] under evidence of injury that palpation of the upper cervical spine, the C1/C2 vertebrae were widely separated/dislocated with associated hemorrhage. The pathologic [DIAGNOSES REDACTED]. Abrasions and contusion of neck, nose and forehead and B. C1/C2 vertebra separation/dislocation with hemorrhage. The medical examiner documented that the opinion was Resident #230 died of neck injury. Reportedly, the decedent had a history of [REDACTED]. The manner of death is Accident. Review of the comprehensive report from the ambulance company revealed that the ambulance departed from the hospital at 17:03, arrived at the facility at 17:25 and was in-service at 17:38. Staff #14 signed the paperwork which stated the resident was received by the facility on [DATE] at 17:32 (5:32 PM). Staff #16 signed a statement as follows: I found the resident laying on the floor with his/her head close to the wall. This occurred about 5:40 PM. I was unaware that the resident had come back from the hospital when I found him/her. His/her bed was left in the air by the paramedics. I called for the nurse to come help me. At the time, he/she was still breathing. Staff #17 signed a statement which stated, I heard Staff #16 yell he/she's on the floor and I ran from the dining room to help. When I entered the room, the resident was on the floor between the bed and the wall with an area of blood under his/her head about 8 inches in diameter. Staff #14 and I picked him/her up into bed and called for the nursing supervisor. I ran for the oxygen tank as the resident appeared to be gasping for breath. The nurse checked for a heartbeat but found none and pronounced him/her. Staff #14 signed a statement as follows at approximately 1740 the ambulance crew member from {name} came to the nurse's station desk and reported to me that they had returned resident to his/her room. At approximately 1743, I started down the hallway toward the resident's room and Staff #16 called out who put this patient in bed, he/she is on the floor. I ran to the room. The resident was lying on the floor on his/her right side between the bed and the wall of his/her room. I observed a 2.5-inch diameter area of blood on the floor and some blood around the resident's nose. I assessed the resident and observed shallow breathing, but no further injuries were observed. The nursing supervisor was summoned. Staff #17 and I returned the resident to his/her bed. The resident's lips were cyanotic. The resident breathed several more times and then breathing ceased at 1747. The ambulance paperwork documented that Staff #14 signed paperwork at 1732. Staff #16 documented that she found the resident at approximately 1740. Staff #14 documented that she headed down the hallway towards the resident's room at 1743. On [DATE] at 12:25 PM, an interview was conducted with Staff #5. Staff #5 normally worked on the unit. Staff #5 stated that typically the ambulance company would come up past the nursing station, however, the local ambulance company would come in through the 400 hallway and they would go to the resident's room first and then bring paperwork, but I would go down there right away. Staff #16 reported that there was a known history of transport staff taking residents directly to their rooms without notifying staff to ensure a safe hand-off of care. Staff #5, the dementia unit nurse corroborated that she also knew that transport staff sometimes did not check in to provide a necessary hand-off of residents before taking them directly to their room(s). Although staff were aware of this unsafe practice, when interviewed, the DON and NHA were not. The NHA gave the surveyor a copy of the agreement between the ambulance company and facility which was signed by both parties in (MONTH) 2009. Based on a review of the contract, it did not contain information or a policy which detailed the transfer of care process. On [DATE], without any appropriate hand-off communications, transport staff placed Resident #230 into bed in a manner not consistent with the resident's care plan or the resident's needs. The resident's bed was not in the lowest position in accordance with the resident's care plan. After transport staff placed Resident #230 in bed, the resident was left alone and while left alone, fell from the bed suffering a broken neck and death. The failure to ensure a safe and effective hand-off process when residents returned with transport staff resulted in harm and death to Resident #230. 2) An interview was conducted with Resident #22 on [DATE] at 10:47 AM in which the resident revealed that he/she goes outside to smoke without supervision. The resident also revealed that he/she did not wear a smoking apron. Resident #22 also revealed I had a fall about 2 weeks ago while outside. I banged my head on the blacktop, but I was ok. On [DATE] at 11:14 AM, the DON advised the surveyor that it was a smoke free campus but an exception was given to Resident #22. The surveyor requested the smoking policy and the DON advised there was not a smoking policy for the one resident that smoked. When asked if the resident was assessed for safe smoking, the DON stated, we don't do a safety assessment. The DON stated the resident was deemed capable. Review of Resident #22's medical record documented the resident was deemed capable on [DATE], however, the annual MDS with an assessment reference date (ARD) of [DATE], documented the resident had a BIMS (Brief Interview of Mental Status) score of 7 which indicated the resident had some cognitive impairment and Section I, diagnosis, had documented [MEDICAL CONDITION]. The quarterly MDS with an ARD of [DATE], Section I, documented dementia. Continued review of the medical record failed to reveal evidence that the resident was assessed for safe smoking. Review of Resident #22's care plan revealed a care plan cognitive loss/dementia that was last reviewed on [DATE] at 9:59 AM which stated, moderately impaired in decision making. There was also a care plan Resident has verbal behavioral symptoms directed toward others r/t history of [MEDICAL CONDITION] with poor impulse control, agitation, verbally threatening and especially rude to his roommate-yelling at his roommate; making rude comments to other residents. A third care plan stated resident will safely smoke during the next 92 days which stated explain facility's smoking policy to resident. Remind as needed. There was no smoking policy per the DON, therefore this could not have been done. Discussed concerns with the DON.

Based on review of the medical record, facility documents and staff interview, it was determined that the facility staff failed to honor the resident's right to refuse treatment for 1 out of 29 admission records reviewed. An Immediate Jeopardy was called. The findings include: Resident #55 was a [AGE] year old male admitted from an acute care hospital with diagnosis' not limited to [MEDICAL CONDITIONS] infarction ([MEDICAL CONDITION]), and acute [MEDICAL CONDITION]. Review of the medical record reveals a Physician's Certification for Decision Making Capacity stating to the doctor by the resident "Do not attempt cardiopulmonary resuscitation (CPR)". The resident wanted to be a DNR (Do Not Resuscitate). The resident was alert and oriented to person, place and thing. The MOLST form (Maryland Medical Orders for Life-Sustaining Treatment) stated "No CPR, Option B Palliative and support care: Prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate (put a breathing tube in). Allow death to occur naturally". Review of the concurrent review by the nurse on [DATE] reveals the following: "temp 87, low blood pressure ,[DATE], slurred speech, blue lips. This AM when Geriatric Nursing Assistant (GNA) was giving bath, resident's lips were blue, oxygen saturation was 86 to 90 % on room air, slurred speech, lungs clear. Sitting at nurses station at present time. Asked about resident going to hospital and resident declined due to the cost of the ride. Notified physician reason: condition and orders to send resident to emergency room (ER) for evaluation and possible admission. (Private) ambulance was called at 10:45 AM and stated would be 1 hour. Attempted to call son without success. Resident aware." The next entry stated "son notified, ambulance picked up at 12:45 PM and gave report to staff member in emergency room ". Last entry stated "(staff) for the ER phoned to let writer know that the resident went into respiratory (stopped breathing) en route to the ER and expired (passed away)". On [DATE] at 10:20 AM a call was placed to Nurse #4, the nurse who handled the incident. She stated "I sent him out by ambulance and I know he died en route to the hospital. He did not want to go and I told him I had to make him go." When asked why she didn't call 911 due to the slurred speech and the blood pressure of ,[DATE] Nurse #4 stated "Nurse #2 came over and started the paperwork and she called the ambulance. I do not know why 911 was not called. He kept begging me not to take him to the hospital and we had a GNA (Geriatric Nursing Assistant) there talking to him while he was in a wheelchair and he kept telling her that he did not want to go either". When asked if his lips were still blue Nurse #4 stated "they started to turn regular color." The question was then asked did you give him oxygen and the response was "oxygen was offered and he didn't want it. Offered the nasal cannula and he refused it". When asked if he had trouble breathing the response was "his natural breathing was trouble breathing. When the ambulance got here and they put him on the gurney he kept saying don't take me and I said you have to go". Interviewed GNA #1 on [DATE] at 2:06 PM about the incident and asked if the resident was confused or alert and oriented. She stated "he was alert and oriented and had no confusion". GNA #1 stated "I was on the floor that day and he started getting real excited, just getting a little bit anxious, he thougt he could walk and stuff and then we asked him if he would go to the hospital and he said no. When we rolled him to wash him he started having trouble breathing and he said he didn't want to go to the hospital, that this was his home and he did not want to go. They called the ambulance for him and we waited and waited. I can't remember if they put oxygen on him or not. We put the bed up. He was not at the nurses station, he was in his room. He was in bed. During the time they waited I cannot remember if his condition got worse. He kept saying he didn't want to go and even when the ambulance got here he said I don't really want to go. We said to him go ahead and go get checked out. We helped load him on the ambulance because he was a tall guy. He was coughing when we loaded him on the ambulance and that was the first time today he coughed, you know how when you cough and it sounds like you are choking. They just wheeled him out and he wasn't really talking then". GNA #1 stated "In my opinion he did not want to go to the hospital. He did not care for hospitals". When asked if he was concerned about the cost of the ambulance ride GNA #1 said "no because he used to tell us he would take us to his house and write out a check for any amount." The facility staff failed to honor the resident's wishes to not be transported to the hospital. The resident was transported and passed away in the ambulance while en route. The failure to honor the resident's wishes resulted in the determination that an immediate jeopardy existed and the facility was notified of the same on [DATE] at 4:11 PM. An acceptable plan of correction was provided and the immediate jeopardy was abated as of [DATE] at 6:37 PM.