Every finding on record at Northampton Manor Nursing and Rehabilitation Cente

Based on record review and interviews, it was determined that the facility failed to provide evidence of coordination of care with hospice services. This was evident for 1 (Resident #19) of 3 residents reviewed for hospice/end-of-life care.The findings include:On 1/29/26 at 5:19 PM, the surveyor conducted a record review of Resident #19 and discovered that the resident was admitted to hospice services on 12/1/2025. Further review revealed that the care plan had been updated to include hospice services and stated: Approach Start Date: 12/01/2025. If using hospice services, the facility will coordinate care approaches, schedules, and tasks with the chosen provider. Created: 12/01/2025. The record also included new physician orders; however, the surveyor was unable to locate hospice communication notes.On 1/30/26 at 12:11 PM, the surveyor interviewed Licensed Practical Nurse (LPN #24) and asked him to explain how communication between hospice services and the facility occurs. He stated, There isn't a communication book. We just receive orders which are dropped off in boxes in the charting room for us to give to the physicians. He reported that the orders are scanned and showed the surveyor an orange binder that contained some of the most recent orders. He further stated, We used to get a file about the residents, which is where the notes for the resident were kept. He explained that since the facility stopped using the mailboxes, staff are now handed new orders or they are left in a bin, and staff are rarely given a report. He stated that communication sometimes occurs verbally.On 1/30/26 at 12:22 PM, the surveyor interviewed the Director of Nursing (DON) regarding the process for hospice communication. She stated that each hospice resident has a purple plastic folder that includes the care plan, standard orders, contact information, and communication documents. The surveyor asked the DON to provide this folder for Resident #19. The DON led the surveyor to the charting room and noted that Resident #19 did not have a communication folder. The surveyor informed the DON that LPN #24 had stated the folder was no longer accessible to staff. The DON confirmed this finding and stated she would add a folder for Resident #19.

Based on medical record review and interview it was determined that the facility failed to ensure urinary catheter bags were emptied as ordered. This was found to be evident for one (Resident #4) out of two residents reviewed for indwelling catheter usage.The findings include: Review of Resident #4's medical record revealed the resident has an indwelling foley catheter and a history of urinary tract infections. The resident was treated with antibiotics for a urinary tract infection in December 2025. A indwelling foley catheter consists of a flexible tube that is inserted into the bladder via the urethra, and is anchored in the bladder via a small inflated balloon. The tubing allows for continuous drainage of the bladder into a catheter bag. The resident has an order, in place since 10/31/25, to empty foley catheter bag every shift and document the output. Review of the Treatment Administration Record (TAR) revealed an area for nurses to document regarding this order, including a space to document the amount of urinary output. On 1/30/26 at 12:56 PM interview with Nurse #18 revealed that the majority of the time it is the nursing assistants who empty the catheter bag and confirmed this should occur every shift unless the resident refuses. Nurse #18 went on to report that the nursing assistants also document output in their charting, which the nurse has access to, or they can just tell the nurse. Nurse #18 reported she also goes into the resident's room to make sure they emptied the foley (catheter bag). The nurse confirmed she documents resident refusals. On 1/30/26 review of the nurse TAR and the nursing assistant documentation failed to reveal documentation to indicate the resident's urinary catheter bag was emptied as ordered on the 11/21/25 day shift, the 12/20/25 day shift or the 1/9/26 evening or night shift. No documentation was found to indicate the resident had refused to have the urinary catheter bag emptied during these shifts. Review of the TAR revealed Nurse #34 had documented on 1/10/26 at 1:29 AM (this is during the 1/9 night shift), this RN [registered nurse] was not scheduled during time of this task. On 1/30/26 at 1:22 PM surveyor asked Nurse #35 about the note written by Nurse #34 which stated 'this RN was not scheduled during the time of this task. Nurse #35 reported she thought it may have to do with overlapping time schedules, but was not sure and indicated she would go check. On 1/30/26 at 3:15 PM surveyor reviewed the concern with the Director of Nursing and the Nursing Home Administrator regarding the failure to ensure catheter bag was emptied as ordered. No additional information was provided in regard to these concerns prior to survey exit on 1/30/26 at 4:00 PM.

Based on observations, record review, and staff interviews it was determined that the facility failed to provide oxygen therapy per the physician's order. This was evident for 1 (Resident #7) out 1 resident reviewed for oxygen therapy during the survey.The findings include:Oxygen therapy is an intervention of delivering oxygen through a device such as a nasal cannula (small tubes that rest in your nostrils) or a mask. Oxygen therapy is prescribed by a doctor and tailored to each person's needs.On 1/22/26 at 10:26 AM this surveyor observed Resident #7 was receiving oxygen (O2) at 5 liter/minute via nasal cannula.On 1/30/26 at 9:48 AM a record review of Resident #7 Care Plan revealed the resident is at risk for respiratory distress/shortness of breath due to diagnosis of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and obstructive sleep apnea (OSA). One of the interventions was to administer O2 as ordered. On 1/30/26 at 10:31 AM a record review of physician orders revealed: O2 at 2 liters per minute via nasal cannula. On 1/30/26 at 11:35 AM this surveyor observed Resident #7 with O2 at 5L/minute via nasal cannula.On 1/30/26 at 12:41 PM Licensed Practical Nurse (LPN #19) acknowledged that the physician order for oxygen was O2 2L. On 1/30/26 at 12:45 PM LPN #15 confirmed that Resident #7's oxygen was set at 5 liters. LPN #15 reduced the O2 2 liter/minute. The Director of Nursing was made aware of the concern.

Based on observation, interview and record review it was determined that the facility failed to ensure side rails were only used when the resident assessment indicated a need for them and a physician order was in place for their use. This was found to be evident for one (Resident #60) out of three residents reviewed for accidents. The findings include: Review of Resident #60's medical record revealed a diagnosis of dementia and a January 2026 Brief Interview for Mental Status score of 3 out of 15, indicating severe cognitive impairment.On 1/29/26 at 11:31 AM resident was observed sitting on side of their bed, quarter side rails were noted to be in the up position on both sides of the bed.Even when bed rails are properly designed to reduce the risk of entrapement or falls, are compatible with the bed and mattress, and are used appropriately, they can present a hazard to certain individuals, particularly to people with physical limitations or altered mental status, such as dementia or delirium.Review of the facility policy for side rails, titled Enablers with a revision date of 5/5/2023, revealed in the Procedures section: Obtain physician's orders when appropriate; for instance, if a mechanical device is needed. Include medical diagnosis and/or behavior, time frame for use of enabler, and release times, if device is used.On 1/29/26 review of the medical record failed to reveal a current order for the use of side rails. Further review of the medical record revealed a progress note, dated 7/31/25 which stated: Resident no longer requires 1/4 side rails, moving in bed and transferring to w/c [wheelchair] with out device assist, cga [care giver assist]. Order d/c'd [discontinued]. POC [plan of care] updated. Review of the physician orders revealed a corresponding order for two 1/4 side rail to aid with independence in turning, re-positioning, transfers and bed mobility was in place from 5/30/24 until it was discontinued on 7/31/25.On 1/29/26 at 11:49 AM nurse #33 confirmed that the quarter side rails are in the up position on the resident's bed. Surveyor reviewed the concern that the 7/31/25 progress note indicated the resident no longer needed the side rails and that the order was discontinued.On 1/29/26 at 2:17 PM the Maintenance Director #15 reported that when bed side rails are discontinued they use to remove them but then they would be told to put them back on, so now they strap them down.On 1/29/26 at 3:03 PM maintenance worker #6 confirmed that he strapped down the bed side rails for Resident #60 today. On 1/30/26 at 3:15 PM surveyor reviewed the concern with the Director of Nursing and the Nursing Home Administrator regarding the failure to ensure side rails were only used when an assessment indicated their need and ordered by a physician.

Based on record review and interviews, it was determined that the facility failed to ensure staff received education based on findings from their annual performance evaluations. This was evident for 2 (Staff #25 and #26) of 3 Geriatric Nursing Assistants (GNAs) reviewed during the staffing task.The findings include:On 1/28/26 at approximately 10:00 AM, the surveyor reviewed the annual performance evaluations for three GNAs (#25, #26, and #27). The evaluations revealed that both GNA #25 and GNA #26 received a score of 1, defined as Performance Below Standard. Comments included Relias 0% and Needs to do Relias. Relias is the program used by the facility to provide staff education.On 1/28/26 at 1:07 PM, the surveyor interviewed the Nursing Home Administrator (NHA) and expressed concerns regarding gaps in staff education, noting that review of the performance evaluations identified incomplete required training. The NHA acknowledged that there is an issue with staff completing required courses. She stated that she began looking into the matter following the surveyor's request for records and was aware it would be a concern. She reported that she spoke with Human Resources (HR), and they planned to address the issues. She stated that the Assistant Director of Nursing (ADON) is responsible for clinical staff education and that both the Director of Nursing (DON) and ADON are responsible for completing performance evaluations.On 1/28/26 at 2:09 PM, the surveyor conducted a follow-up interview with the NHA, DON, ADON, and HR (Staff #28). The ADON confirmed that she, in conjunction with the facility infection prevention expert, assists with conducting clinical staff education. HR (staff #28) confirmed responsibility for onboarding. However, none of the four staff members were able to identify who was responsible for ensuring nursing assistants receive education related to deficiencies identified in their performance evaluations. The NHA confirmed, and the DON agreed, that there is a systemic gap in ensuring that education addresses weaknesses identified in employee evaluations.

Based on record review and interviews, it was determined that the facility failed to assess a resident for behavioral health needs following a change in behavior. This was evident for 1 (Resident #121) of 4 residents reviewed for accidents during the survey.The findings included: On 1/29/26 at 2:15 PM, review of intake #2714236 revealed that Resident #121 was transported to the hospital for a behavioral emergency on 1/11/26.On 1/29/26 at 2:20 PM, review of progress notes added as a late entry on 1/12/26 and dated 1/9/2026 revealed that Social Services visited Resident #121 based on concerns expressed by a staff member to check on the resident's welfare. Further review of the Social Services note revealed that the resident was calm, pleasant, and redirectable. Continued review failed to reveal that a suicide ideation assessment interview was completed with Resident #121.On 1/29/26 at 2:25 PM, continued review of a progress note dated 1/11/2026 revealed that Resident #121 was found lying on the floor with a plastic bag over their head. Continued review revealed that the resident was assessed and transported to the hospital. The police, physician and family were notified.On 1/29/2026 at 3:39 PM, Social Worker (Staff #23) was interviewed. During the interview, the social worker reported visiting Resident #121 on 1/9/26, due to staff concerns regarding the resident's behavior. The social worker further reported that a suicide ideation assessment was not completed because the social worker was not aware that the resident had voiced a desire to die previously to a Nursing Aide. The social worker reported reviewing the resident's medical record and did not find documentation indicating that the resident voiced a desire to die. Social Worker Staff #23 reported that a brief suicide ideation assessment would have been conducted if the social worker had been aware that the resident voiced a desire to die.On 1/29/2026 at 3:00 PM, review of progress notes revealed a nurse's note which referred to the date 1/8/2026. Further review revealed that the note was added as a late entry on 1/13/2026 and was not available to the social worker on 1/9/2026, prior to the Social Workers interview/visit with Resident #121. Review of the late-entry note revealed that the nurse was notified by a nursing assistant reporting that Resident #121 did tell the nursing assistant that the resident wanted to die.On 1/29/26 at 3:55 PM, the Social Services Director provided the facility's Social Services policies and procedures regarding suicide precaution management. Review of the policy revealed that the facility was required to complete a brief suicide ideation assessment for current residents who voiced or indicated suicidal ideation in any manner.On 1/30/26 at 9:59 AM, the Clinical Services Director (CSD, Staff #20) was interviewed. During the interview, the concern was discussed that the social worker did not have all pertinent information regarding Resident #121 prior to interviewing the resident on 1/9/26. The CSD confirmed that the pertinent information was not documented or available to the social worker at the time of the interview and that a brief suicide ideation assessment was not completed.

Based observation and interview it was determined that the facility failed to ensure staff reported environmental concerns to maintenance. This was found to be evident for one out of seven rooms reviewed for potential environmental concerns.The findings include: On 1/22/26 at 2:17 PM while interviewing Resident #5 in the resident's room, the Surveyor heard what sounded like a lawn [NAME] or a chain saw. The resident reported the noise was coming from the window. The Surveyor then observed an approximately 18 inch area of tape on the window and noted the sound was present when the wind blew. The resident indicated the window had been like that for more than several months.On 1/28/26 at 1:56 PM when asked how he monitors items in need of repair, the Maintenance Director (#15) reported they have the TELS system. The Surveyor requested any work orders for Resident #5's window.TELS is a computer-based system used to track building maintenance. Staff that have access to TELS can put in maintenance requests/notifications.On 1/28/26 at 2:19 PM the Maintenance Director reported that there is no open work order for Resident #5's room. The Surveyor then informed the Maintenance Director of the observation of the tape and the sound coming from Resident #5's window. The Surveyor and Maintenance Director then went to the Resident #5's room and observed the tape on the window. The Maintenance Director reported that it was not our [maintenance's] tape and indicated that he would write up a repair order and get the issue taken care of.On 1/30/26 at 1:44 PM an interview with Environmental Services Director (ESD #36) revealed the environmental services staff, including the director, do not have access to the TELS system. If concerns are identified the ESD reported that staff jot concerns down on scrap paper and then let Maintenance Worker (#6) or Maintenance Director #15 know, or they tell me and I'll pass it on. The ESD indicated he tells them verbally or via email. On 1/30/26 at 3:15 PM during an interview with the Nursing Home Administrator (NHA) when asked how housekeeping (environmental services) staff should report concerns to maintenance the NHA responded: through TELS. The NHA then acknowledged that housekeeping staff currently do not have access to TELS. The Surveyor reviewed the concern regarding staff's failure to report environmental concern to maintenance.Cross reference to F 700.

Based on interviews and record reviews, it was determined that the facility failed to ensure the resident's comprehensive care plan accurately reflected the resident's discharge wishes. This deficient practice was identified for 1 (Resident #75) of 2 residents reviewed for discharge planning.The findings include:A comprehensive care plan is a personalized document that organizes a person's medical treatment, daily support needs, and their exit strategy from long-term care, known as discharge planning.On 1/22/26 at 10:24 AM, the surveyor interviewed Resident #75, who stated they were in a pickle because they wanted to return to the community to work; however, their car was broken and all of their belongings were currently in the facility. When asked whether there was an active plan in place to assist with transitioning from long-term care to the community, the resident stated they were not aware of any such plan.On 1/28/26 at 3:30 PM, the surveyor reviewed Resident #75's discharge care plan dated 12/22/25 and completed by the Social Worker (SW #23), which stated, [Resident's name] has indicated they wish to remain in LTC [long-term care].Additional record review revealed the following social services documentation:On 12/22/25, SW #23 documented, Care plan remains appropriate. Resident wishes to remain in LTC and is interested in the Maryland Medicaid community waiver. Referral has been sent for a lower-level setting.On 12/22/25, SW #23 also documented, in part, Social Services completed the quarterly assessment. The resident's cognition remains intact. The resident expressed motivation to obtain independent housing and demonstrated insight into the need to prioritize his/her health.On 11/26/25, a social services progress note indicated Resident #75 would like assistance finding a shelter or other resources in [area removed for privacy].On 1/29/26 at 3:28 PM, the surveyor interviewed SW #23, who confirmed familiarity with Resident #75 and stated the resident is a complex case with multiple barriers to discharge. She confirmed the resident does wish to discharge to the community at some point. When asked whether the care plan should reflect this goal, she stated it should include the resident's desire to discharge and goals to support that outcome. SW #23 acknowledged the current care plan was not appropriate for Resident #75 and stated, I need to document better. She further stated that while the resident had indicated the facility was the safest place at this time, the resident had repeatedly expressed a desire to work toward discharge.On 1/30/26 at 10:13 AM, the surveyor interviewed the Clinical Services Director, who confirmed that Resident #75's care plan did not reflect the resident's stated wish to discharge to the community and stated the facility was working to update the discharge plan.

Based on medical record review and interview it was determined that the facility failed to ensure residents were free from significant medication errors. This was found to be evident for one (Resident #4) out of six residents reviewed for unnecessary medications.The findings include: 1)On 1/23/26 review of Resident #4 medical record revealed a diagnosis of diabetes and orders for both long acting and fast acting insulin. The order for the fast-acting insulin, with a start date of 10/31/25, revealed a Humalog KwikPen Insulin (insulin lispro) with a strength of 100 units per ml and the amount to be given was per carb intake. The order also included the following Special Instructions: method for calculating insulin coverage. Blood glucose -100=X Round X to the nearest 10th. Give 1 unit of insulin for each 10mg/dL. Resident will continue to calculate with each dose. (example BS is 294. 294-100= 194. Resident to get 19 units of insulin). This insulin was to be administered before meals and at bedtime.According to these special instructions, any blood glucose level above 110 would require an administration of insulin.Blood glucose is often referred to as blood sugar.Review of the Medication Administration Record (MAR) for January 2026 revealed nursing staff were obtaining and documenting the blood sugar levels (measured in mg/dl) and then the amount of insulin lispro administered.Review of this MAR on 1/26/26 at approximately 9:30 AM revealed multiple wrong dose orders. Examples of these errors included:On 1/1/26 at 11:30 AM the resident's blood glucose level was 304mg/dl and 25 units were administered. According to the order, 20 units were due.On 1/6/26 at 6:30 AM the resident's blood glucose level was 158mg/dl and 0 units were administered. According to the order, 6 units were due.On 1/6/26 at 11:30 AM the resident's blood glucose level was 298mg/dl and 10 units were administered. According to the order, 20 units were due.On 1/8/26 at 6:30 AM the resident's blood glucose level was recorded as low and 9 units were administered.On 1/9/26 at 6:30 AM the resident's blood glucose level was 152mg/dl and 15 units were administered. According to the order, 5 units were due.Further review of the January MAR for 1/1/26 through 1/22/26 revealed more than 30 wrong dose errors out of the 88 times the blood sugar level was due to be checked. Additionally, three shifts failed to include documentation to indicate a blood glucose level was checked, or that the resident had refused to have the level checked. Further review revealed that on 1/21/26 the bedtime blood glucose level was documented as 190 mg/dl and 0 units were administered. The nurse documented at 9:16 PM: Not administered; WNL [within normal limits]. The order did not include instructions to hold the insulin if the blood glucose level was below a certain level. No documentation was found to indicate nursing staff contacted the ordering provider for clarification regarding this order, or that the insulin was being held.On 1/23/26 at 9:51 AM surveyor reviewed the insulin lispro order with the Director of Nursing (DON) who reported this was the order the resident had when admitted and that the resident did not want it changed. Surveyor reviewed the concern with the DON that multiple medication errors are evident based on the documented blood glucose levels and the doses administered by staff. The DON indicated she would follow up regarding this concern.Further review of the Medication Administration Record for November and December 2025 revealed multiple similar dosage errors as those found in the January 2026 MAR.On 1/23/26 at approximately 3:30 PM the Clinical Services Director (CSD #20) provided documentation of a Medication/Treatment Error Investigation Report that revealed that sometimes the resident would tell staff to administer an extra 5 units of insulin. Further review of the medical record failed to reveal an order to provide an extra 5 units of insulin upon resident request.Further review of the Medication/Treatment Error Investigation Report revealed, in the section to document steps taken to prevent reoccurrences, that the orders for insulin had been changed to the house sliding scale in addition to 5 units with meals.Further review of the medical record on 1/28/26 revealed that on 1/23/26 at 12:27 PM an order was written to administer an extra 5 units of insulin lispro with meals. The previous insulin lispro order was discontinued on 1/23/26 and a new order was put in at 2:50 PM.The new order was for Humalog KwikPen Insulin (insulin lispro) insulin pen with a strength of 100 units per ml and the amount to be given was Per Sliding Scale. The scale included the following: If Blood Sugar is 0 to 179, give 0 units.If Blood Sugar is 180 to 219, give 4 units.If Blood Sugar is 220 to 259, give 6 units.If Blood Sugar is 260 - 299, give 8 units.If Blood Sugar is 300 to 339, give 10 units.If Blood Sugar is 340 to 400, give 12 units.If Blood Sugar is greater than 400 give 12 units; if blood sugar is greater than 400, call MD.2) Further review of Resident #4's medical record revealed the resident was receiving trazodone (an antidepressant medication) for depression. An order was in effect from 12/19/25 until 1/4/26 for two trazodone 100 mg tablets to be given at bedtime. The resident was seen by the primary care nurse practitioner (NP #32) on 1/2/26. Review of the corresponding progress note revealed the resident was reporting increased depression related to a chronic condition as well as inadequate sleep at night. The Plan section of the progress note revealed: Trazodone increased to 300 mg.Review of the orders revealed that on 1/4/26 NP #32 entered an order for trazodone 100 mg, amount: 3 tabs. But the Special Instructions section of the orders stated: Give 2 tabs = 200mg.On 1/28/26 at 1:45 PM the Assistant Director of Nursing (ADON #16) was interviewed about the resident's trazodone order. After reviewing the trazodone order, the ADON indicated she would have to look at the handwritten order and the nursing note since she was unable to determine what the dose was suppose to be. ADON stated: I will have to go look into that because it is wrong.On 1/28/26 at approximately 2:05 PM the ADON presented with new orders, dated 1/28/26 at 1:56 PM, for the trazodone 100 mg, amount: 3 tabs; Special Instructions: Give 3 tabs = 300 mg. ADON went on to report that the NP had put the order in [to the electronic health record] herself and the special instructions was not removed. She also reported that Nurse #33 was following up with the pharmacy to see how much was being sent.On 1/28/26 at 2:15 PM surveyor and Nurse #33 observed the daily packaging of medication for Resident #4 which indicated two tablets of trazodone were being sent rather than three.Review of a 1/5/26 care plan note, written by Nurse #33, revealed: Order received from NP to decrease Trazodone from 200 mg QHS [at bedtime] to Trazodone 100 mg po QHS. Resident and POA [power of attorney] updated with plan of care. On 1/30/26 at approximately 3:51PM Surveyor asked Nurse #33 if there was documentation to support this care plan update that there was a decrease ordered, rather than the increase. On 1/30/26 at 4:00 PM Nurse #33 confirmed that this note was written in error.Further review of the medical record revealed the pharmacist had completed monthly medication regimen reviews on 11/12/25; 12/15/25; and 1/22/26. The progress note associated with each of these reviews indicated that there were no irregularities in the resident's medication regimen. All three of these reviews were completed by Pharmacist #31. Cross reference to F 756On 1/29/26 at 10:24 AM surveyor reviewed the concern with the Clinical Services Director regarding the significant medication errors and the failure of the pharmacist to identify these errors as irregularities.

Based on observation, record review, and interview, it was determined that the facility failed to ensure that medications were secured and stored at the required temperature and that the narcotics were stored in permanently affixed compartments. This deficiency was evident for 1 out of 3 narcotic boxes observed, 1 out of 3 medication refrigerators observed, and 1 medication cart observed during a random observation.1.On 1/27/26 at 2:27 PM, an observation was made of the medication room on the [NAME] Creek unit with Staff #4. Review of the medication refrigerator revealed a narcotic box with a lock on the front side. Further observation showed that the box was not affixed to the refrigerator.On 1/27/26 at 2:29 PM, during a brief interview, Staff #4 reported that the narcotic box could be removed from the refrigerator.On 1/27/26 at 3:54 PM, the Director of Nursing (DON), was interviewed and stated that the expectation was for all narcotic boxes in the medication refrigerators have to be locked and be permanently affixed to the refrigerators.On 1/27/26 at 4:05 PM, an additional observation was made in the medication room with the DON and with Staff #6 (maintenance staff). the DON confirmed that the narcotic box was not permanently affixed and could be removed. The DON reported that maintenance would correct the issue.On 1/27/26 at 4:07 PM, the DON confirmed that it was the expectation for the narcotic box to be attached to the refrigerator and stated that the issue would be corrected.2. On 1/27/26 at 2:38 PM, an observation was made of the Potomac 2-unit medication room. Staff #5 accompanied the surveyor into the medication room and checked the temperature of the refrigerator. Both the surveyor and Staff #5 observed the temperature reading at 50 degrees Fahrenheit.On 1/27/26 at 2:40 PM, Staff #5 reported that maintenance would be notified.On 1/27/26 at 2:40 PM, Staff #5 provided the temperature logs for December and January 2026.On 1/27/26 at 2:45 PM, review of the December Potomac 2 refrigerator temperature log revealed spaces for the staff to record temperatures in the AM and PM of each day. The log included the instruction, Refrigerator acceptable range 36 F-46 F. Record exact temperature twice daily.Further review of the December log showed missing temperature documentation for the following dates: 12/19/26, 12/20/26, 12/21/26, 12/22/26, 12/23/26, 12/24/26, 12/25/26, 12/26/26, 12/27/26, 12/29/26, 12/30/26, and 12/31/26.Continued review of the January 2026 temperature log showed missing entries for the PM of 1/11/26, the PM of 1/12/26 and of 1/15/26, along with both AM and PM of 1/13/26.On 1/27/26 at 2:53 PM, the maintenance staff confirmed that the temperature reading of 50 F by using two thermometers. The maintenance staff reported that the temperature dial of the refrigerator had been set to medium and stated that it would be adjusted.On 1/27/26 at 4:35 PM, the above findings were discussed with the Assistant Director of Nursing (Staff #16). During the interview, Staff #16 confirmed that the expectation was for the medication refrigerator temperature to be documented in the AM and PM every day. Staff #16 acknowledged that the missing documentation was a concern and stated that corrective action would be taken.3.On 1/29/26 at 12:05 PM, an observation was made of the Potomac 2-unit medication cart near the nursing station. During the observation, a resident of the facility, Resident #20, was seen with their hand resting on the edge of the cart. Continued observation showed that Staff #18 was on the opposite side of the nursing station and did not have a direct line of sight to the front of the cart, where the cart drawers could be opened.On 1/29/26 at 12:07 PM, Staff #18 asked Resident #20 to move to a different medication cart to receive medications.On 1/30/26, observation of the unlocked medication cart from 12:05 PM to 12:09 PM, when the DON walked by the cart. The surveyor inquired about the cart, and the DON confirmed that it was not locked. The DON immediately locked the cart and stated that all medication carts should remain locked when unattended.

Based on record review and interviews, it was determined that the facility failed to ensure concerns identified through the Quality Assurance and Performance Improvement (QAPI) process were addressed through the development of a Performance Improvement Project (PIP). This was evident for 1 of 1 QAPI plans reviewed during the QAA/QAPI task.The findings include:In long-term care, the Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) programs are systems designed to monitor care, identify concerns, and implement corrective actions to protect resident health and safety. QAA focuses on identifying and correcting areas of noncompliance, while QAPI uses ongoing data analysis and proactive improvement efforts to prevent problems and improve outcomes. Performance Improvement Projects (PIPs) are structured, team-based initiatives within QAPI used to investigate identified concerns, determine root causes, and implement measurable system improvements.On 1/27/26 at 1:23 PM, the surveyor interviewed the Director of Nursing (DON) and asked her to explain the facility's QAPI program. She stated the facility meets monthly to discuss concerns identified by the QAA committee and confirmed the process is data driven. She informed the surveyor that one of the current concerns discussed in QAPI included annual staff training.On 1/28/26 at approximately 10:00 AM, the surveyor reviewed performance evaluations for GNAs #25, #26, and #27. The evaluations revealed that both GNA #25 and GNA #26 received a score of 1, defined as Performance Below Standard. Comments included Relias 0% and Needs to do Relias (Relias is the program used by the facility to provide staff education). Review of training records revealed multiple instances of incomplete annual trainings (See CMS 2567-F940).On 1/28/26 at 1:07 PM, the surveyor interviewed the NHA and expressed concerns regarding gaps in employee education and that performance evaluations indicated staff had failed to complete assigned courses. She acknowledged that there is an issue with staff completing required courses.On 1/28/26 at 2:09 PM, the surveyor interviewed the NHA, DON, Assistant Director of Nursing (ADON), and Human Resources (HR, Staff #28). None of the four staff members were able to identify who was responsible for ensuring all facility staff completed required annual training. The NHA confirmed, and the DON agreed, that there is a systemic gap in ensuring staff complete annual education.On 1/30/26 at 2:22 PM, the surveyor interviewed the NHA and DON to discuss the facility's QAPI program. During that meeting, the surveyor asked if the quality assurance committee was aware of concerns related to staff not completing annual training. The DON stated they were aware and it was something they had discussed. She stated that they Have been pulling people off the floor to take education when the census drops; however, when asked whether an improvement plan was in place, she confirmed the facility had not developed a Performance Improvement Project (PIP) to analyze the causes or implement solutions to address the lagging education. The DON and the NHA acknowledged that it would be expected for a formal PIP to be initiated when an issue is identified by the quality assurance committee.

Based on observation and interview it was determined that the facility failed to ensure staff appropriately wore source control (face masks) during a period of increased influenza in the community. This was found to be evident during 6 random observations made on day one of the survey.The findings include: On 1/22/26 at 8:25 AM the survey team entered the facility. Night nurse supervisor #37 reported that due to the high flu rate in the county face masks were currently required. On 12/31/25, the Maryland Department of Health (MDH) issued recommendations in response to increased rates of respiratory virus-associated hospitalizations. MDH advised that healthcare facilities implement facility-wide source control measures in patient care areas and other patient-facing settings. These measures include requiring all individuals-including clinical staff, non-clinical staff, and visitors-to wear masks in patient-facing areas.On 1/22/26 at 10:17 AM the surveyor observed Geriatric Nursing Assistant (GNA #39) coming out of room [ROOM NUMBER] with his mask below his nose. GNA #39 confirmed the mask was below his nose and reported: it was a little bit suffocating.On 1/22/26 at 11:20 AM the surveyor observed GNA #14 in the hallway of the Potomac 2 unit with her mask not worn appropriately to cover both mouth and nose; the GNA was observed adjusting the mask as she entered a resident's room.On 1/22/26 at 11:30 AM GNA #14 was observed in the Potomac 2 hallway with her mask not covering her nose or mouth. Resident #87 and Resident #90 were noted in the hallway at the time of this observation.On 1/22/26 at 11:38 AM GNA #14 was observed in the hallway near the nursing station without a mask on. GNA #14 was then observed entering the elevator without wearing a mask and Resident #57 was also observed entering the elevator at this same time.On 1/22/26 at 12:00 noon GNA #14 was observed providing care to Resident #63 in the resident's room. The GNA's mask was not covering her nose or mouth at the time of the observation. The GNA then came out of the room, acknowledged that the mask should be worn over the mouth and nose, and stated: it was 80 degrees in there, I had to pull it down. GNA #14 then adjusted the mask to be worn correctly.On 1/22/26 at 12:28 PM the environmental service staff #38 was observed on the Potomac 2 unit waiting for the elevator, their mask was below their nose and mouth. ESS # 38 adjusted the mask when approached by the surveyor and reported he was aware of how the mask is suppose to be worn.On 1/28/26 at 11:38 AM the surveyor interviewed the Infection Preventionist Nurse (IP #40). The IP #40 nurse acknowledged that she was aware of the Maryland Department of Health notice about masks. She reported that the current expectation for staff in regard to masks is that anyone on the floor should be masking just to reduce transmission. She confirmed that the masks should be worn in patient care areas including the hallways. The Surveyor then reviewed the concern regarding multiple observations made the week before of staff failing to wear the face masks correctly.

Based on record review and interviews, it was determined that the facility failed to ensure employees completed required annual training. This was evident for 4 (Staff #10, #11, #16, and #29) of 5 staff reviewed for the sufficient and competent staffing task.The findings include:On 1/27/26, the surveyor requested that the Nursing Home Administrator (NHA) provide education records for Staff #10, #11, #16, #29, and #30, as well as annual performance evaluations for three Geriatric Nursing Assistants (GNAs #25, #26, and #27).On 1/28/26 at approximately 10:00 AM, the surveyor reviewed the annual performance evaluations for GNAs #25, #26, and #27. The evaluations revealed that both GNA #25 and GNA #26 received a score of 1, defined as Performance Below Standard. Comments included Relias 0% and Needs to do Relias (Relias is the program used by the facility to provide staff education).Further review of training records for Staff #10, #11, #16, #29, and #30 revealed the following:-Compliance and Ethics Training (F946) was not completed by Staff #10, #11, or #16-Dementia Training (F949) was not completed by Staff #16 or #29Additionally, review of Relias annual education records showed that several assigned courses due had not been completed, as follows:- Staff #10 - Standards of Conduct, Injury and Supervision, HIPAA Level 1, Communicating Effectively, and Managing Elopement (all due 12/31/25)-Staff #11 - Compliance Level 2 training (due 11/30/25) and Managing Elopement (due 12/31/25); completed 2 of 42 courses in 2024-Staff #16 - completed 0 of 44 courses assigned in 2024 and 0 of 2 courses assigned in 2025-Staff #29 - Standards of Conduct (assigned 12/31/24, completed 9/26/25) and 32 incomplete courses for 2025-Staff #30 - completed assigned courses during the onboarding processOn 1/28/26 at 1:07 PM, the surveyor interviewed the NHA and expressed concerns regarding gaps in education for employees and that review of performance evaluations revealed that it was a known issue that staff had failed to take assigned courses. She acknowledged that there is an issue with staff completing required courses. She stated that she started looking into it following the surveyor request for the records and was aware that it would be a concern. She stated that she spoke with Human Resources and that they were going to address the issues.On 1/28/26 at 2:09 PM, the surveyor conducted an interview with the NHA, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Human Resources (HR, Staff #28). The ADON confirmed that she, in conjunction with the facility infection preventionist, assists with conducting clinical staff education. HR confirmed responsibility for onboarding. However, none of the four staff members were able to identify who was responsible for ensuring all facility staff completed required annual training. The NHA confirmed, and the DON agreed, that there is a systemic gap in ensuring staff complete annual education and both agreed that they would work on it.On 1/28/26 at 3:53 PM, HR Staff #28 previously stated she believed additional training records might be available; however, after review, she confirmed that she was unable to locate any documentation and could not provide evidence that staff completed compliance and ethics, dementia, or any other required annual trainings in the Relias program.On 1/30/26 at 2:22 PM, the surveyor conducted an interview with the NHA and DON to discuss QAPI (Quality Assurance Performance Improvement). During that meeting, the surveyor asked if the quality assurance committee was aware of concern over staff not completing annual training. The DON stated that they were aware and it was something that they had talked about. She stated that they Have been pulling people off the floor to take education when the census drops but confirmed that they had not developed a Performance Improvement Project (PIP) that dug into the issues behind why or created solutions to address the lagging education. The DON and the NHA acknowledged that it would be expected that a formal PIP would be created when the facility identifies an issue within the quality assurance committee.

Based on medical record review and staff interview, it was determined that the facility failed to provide evidence that the resident or the resident's representative was notified in writing of the facility's bed hold and transfer policies at the time of hospital transfer. This deficient practice was identified for 2 residents (Residents #1 and #90) of 4 residents reviewed for hospitalization during the survey.The findings include:1. On 1/23/26 at 1:36 PM a record review of Resident #1's electronic health record revealed Resident #1 was hospitalized on [DATE]. Further review revealed that Resident #1's Power of Attorney (POA) was notified via telephone of transfer as well as the bed hold policy. On 1/28/26 at 11:57 AM, in an interview, Business Office Manager (Staff #17) acknowledged that the hospital transfer policy states that a bed hold notice should be provided in writing to the resident/ resident representative within 24 hours. She could not provide evidence that a written bed hold notice was provided to the resident/resident representative. On 1/28/26 at 12:19 PM, in an interview, Licensed Practical Nurse (LPN # 9) could not provide evidence that written notice was given to the resident/resident representative at time of transfer. On 1/28/26 at 1:39 PM in an interview, the Director of Nursing confirmed that written notice of the bed hold was not provided to the resident/ resident representative. 2. On 1/30/26 at 11:08 AM, the surveyor conducted a record review of Resident #90's medical chart and identified that the resident was transferred to the hospital on [DATE]. The surveyor was unable to locate evidence in the medical record to support that the resident or the resident's representative had been provided with written notification of the facility's bed hold and transfer notices. The surveyor requested that the facility provide evidence of compliance. On 1/30/26 at 11:47 AM, the Clinical Services Director (CSD) stated that the facility was unable to provide evidence that Resident #90 or the resident's representative had been given the bed hold and transfer notices. She stated she believed the business office mailed the original documents but did not scan them into the resident's medical record. On 1/30/26 at 11:51 AM, the surveyor interviewed the Business Office Coordinator (Staff #21), who confirmed she had been asked to mail Resident #90's bed hold and transfer documents but was not instructed to retain a copy of the originals. The Business Office Manager (BOM) overheard the conversation, acknowledged the facility was unable to provide evidence that the bed hold and transfer notices were provided, and stated that, going forward, the documents would be scanned into the medical record and sent via certified mail.

Based on medical record review and interview it was determined that the facility failed to ensure the pharmacist's monthly medication regimen review identified significant medication errors. This was found to be evident for one (Resident #4) out of six resident's reviewed for unnecessary medications.The findings include: 1) On 1/23/26 review of Resident #4 medical record revealed a diagnosis of diabetes and orders for both long acting and fast acting insulin. The order for the fast acting insulin, with a start date of 10/31/25, included: Humalog KwikPen Insulin (insulin lispro) pen with a strength of 100 units per ml and the amount to be given was per carb intake. The order also included the following Special Instructions: method for calculating insulin coverage. Blood glucose -100=X Round X to the nearest 10th. Give 1 unit of insulin for each 10mg/dL. Resident will continue to calculate with each dose. (example BS is 294. 294-100= 194. Resident to get 19 units of insulin). This insulin was to be administered before meals and at bedtime.Blood glucose is also referred to as blood sugar.Review of the Medication Administration Record (MAR) for January 2026 revealed nursing staff were obtaining and documenting the blood sugar levels (measured in mg/dl) and then the amount of insulin lispro administered. Review of this MAR on 1/23/26 at approximately 9:30 AM revealed multiple wrong dose errors.Examples of these errors included:On 1/1/26 at 11:30 AM the resident's blood glucose level was 304mg/dl and 25 units were administered. According to the order, 20 units were due.On 1/6/26 at 6:30 AM the resident's blood glucose level was 158mg/dl and 0 units were administered. According to the order, 6 units were due.On 1/6/26 at 11:30 AM the resident's blood glucose level was 298mg/dl and 10 units were administered. According to the order, 20 units were due.On 1/8/26 at 6:30 AM the resident's blood glucose level was recorded as low and 9 units were administered.On 1/9/26 at 6:30 AM the resident's blood glucose level was 152mg/dl and 15 units were administered. According to the order, 5 units were due.Further review of the January MAR for 1/1/26 through 1/22/26 revealed more than 30 wrong dose errors out of the 88 times the blood sugar level was due to be checked.Further review of the Medication Administration Record for November and December 2025 revealed multiple similar dosage errors as those found in the January 2026 MAR.Review of the facility's Pharmacy Services Policies and Procedures 1.2 Medication Regimen Review (revision date of 4/17/2024) revealed A written report (either paper or electronic) of all irregularities and recommendations resulting from the medication regimen review are provided to a facility designee for the Attending Physician, Director of Nursing and Medical Director. Examples of a medication 'irregularity' include, but are not limited to, a medication that: .H. Presents as a medication error or the risk for such errors.On 1/28/26 further review of the medical record revealed the pharmacist had completed monthly medication regimen reviews on 11/12/25; 12/15/25; and 1/22/26. The progress note associated with each of these reviews indicated that there were no irregularities in the resident's medication regimen. All three of these reviews were completed by Pharmacist #31.On 1/28/26 at 12:33 PM a phone interview was conducted with Pharmacist #31. The pharmacist confirmed that she looks at Medication Administration Records as part of her monthly medication review. Surveyor reviewed the 10/31/25 order for Humalog KwikPen Insulin (insulin lispro) which inlcuded: Special Instructions: method for calculating insulin coverage. Blood glucose -100=X Round X to the nearest 10th. Give 1 unit of insulin for each 10mg/dL. Resident will continue to calculate with each dose. After this review, and accessing the resident's medical record, the pharmacist stated: I've never seen that before, missed that, if I saw that order I would of said something. Surveyor then reviewed the concern with the pharmacist that multiple medication errors have been identified in regard to this insulin order.2) Further review of Resident #4's medical record revealed the resident was receiving trazodone (an antidepressant medication) for depression. An order was in effect from 12/19/25 until 1/4/26 for two trazodone 100 mg tablets to be given at bedtime. Further review of the medical record revealed a primary care provider note, dated 1/2/26, that indicated the dose was to be increased to 300 mg based on the resident's report of increased depression. On 1/28/26 review of the Medication Administration Record for January 2026 revealed the trazodone order was for three 100 mg tabs but the Special Instructions stated: Give 2 tabs = 200 mg.On 1/28/26 at 1:45 PM the Assistant Director of Nursing (ADON #16) was interviewed about the resident's trazodone order. After reviewing the trazodone order, the ADON indicated she would have to look at the handwritten order and the nursing note since she was unable to determine what the dose was suppose to be. ADON stated: I will have to go look into that because it is wrong. On 1/28/26 at approximately 2:05 PM the ADON presented with new orders, dated 1/28/26 at 1:56 PM, for the trazodone 100 mg, amount: 3 tabs; Special Instructions: Give 3 tabs = 300 mg. On 1/28/26 at 2:15 PM surveyor and Nurse #33 observed the daily packaging of medication for Resident #4 which indicated two tablets of trazodone were being sent rather than three.On 1/29/26 at 10:24 AM surveyor reviewed the concern with the Clinical Services Director regarding the significant medication errors and the failure of the pharmacist to identify these errors as irregularities.Cross reference to F 760

Based on record review and interview, it was determined that the facility failed to ensure that residents with an elopement risk had the appropriate interventions in place to prevent an elopement. This was evident for 1 (#109) of 10 residents reviewed for elopement. Evidence was provided by the facility that an action plan was developed, and corrective measures were implemented on 4/30/24, immediately after the incident, to remove the immediacy of the noncompliance and correct the deficient practice. On 8/20/24, a determination of immediate jeopardy was made regarding the deficient practice with the potential for past non-compliance. The Director of Nursing and Corporate Clinical Director Nurse #2 were informed at 5:45 PM. Review of all facility corrective actions implemented prior to the survey start date, revealed that the facility had met minimum standards for plans of correction and the concern was therefore deemed past noncompliance. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so A medical record review for Resident #109 on 8/20/24 at 11:26 AM revealed a hospital discharge summary that documented the resident was living at home and found to have lewd and erratic behavior, so the family took the resident to the hospital. The resident was found to have a UTI and worsening dementia. The resident was admitted to the facility in 2/2024. A review of the resident ' s admission MDS with an assessment reference date of 3/6/24, documented the resident had a BIMS of 11/15 (moderate cognitive impairment) and was independent for indoor ambulation with a walker. On 2/29/24, an elopement assessment was opened by Licensed Practical Nurse (LPN) #7 and the assessment indicated the resident was an elopement risk (Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so) and a wander guard device (a device that is placed on the resident which causes an alarm to sound when they get too close to a door that is armed) was recommended. However, the assessment was not closed until 4/24/24 by the Director of Nursing (DON) and it was unclear which sections were completed by the LPN versus the DON. Review of the physician's orders revealed that the wander guard was not ordered until 5/1/24. Review of the care plan revealed that no care plan had been initiated for the elopement risk. There was no evidence in the medical record that the wander guard device was placed on the resident at the time of the assessment on 2/29/24. Further review of the medical record revealed the attending physician's history and physical visit notes, dated 3/6/24, the physician documented the resident was alert and oriented to themselves only. He also noted the resident was upset about being at the facility and wanted to be discharged another indication this resident was an elopement risk. Facility staff failed to implement the wander guard device following this physician's visit. During a review of the facility's investigation file for the facility reported incident #MD00205031 on 8/20/24 at 12:15 PM, it was revealed that Resident #109 had eloped from the facility on 4/24/24. According to Receptionist #8 's statement, the resident told her they were going to meet their daughter. The receptionist advised the resident to wait inside because it was windy out and she thought the resident was a FYI (an abbreviation that indicated the resident should not go outside alone). The receptionist further documented that, at 3:45 PM, she was checking in another resident and their son who had returned from an appointment (taking their temperatures). She wrote that when she turned back around, she did not see the resident and went outside and did not see the resident. She called upstairs to check if the resident went back upstairs and once confirmed the resident had not, a code for elopement was called. Review of a statement written by the Business Office Manager (BOM) revealed that, in response to the code, she was searching for the resident to the right of the building. She located the resident walking with their walker towards a housing development adjacent to the facility and brought the resident back to the facility at 3:52 PM. Review of a statement from the DON revealed she had interviewed LPN #7 on 4/25/24 and he reported that he had assessed Resident #109 and found the resident to be at risk for elopement. However, he could not locate a wander guard to put on the resident. He reported he had forgotten to pass the information to the oncoming nurse. Further review of the investigation file revealed the facility's corrective actions. The facility had determined the root cause of the elopement was due to LPN #7's failure to follow through with implementation of interventions following an elopement assessment. The facility took the following steps to correct the deficient practice: the resident was reassessed for elopement, a care plan was developed, and a wander guard placed on the resident; LPN #7 received 1:1 education regarding the need to immediately implement the wander guard when indicated; the current residents ' elopement assessments were reviewed for accuracy; the wander guard list and elopement notebook (containing a picture of each resident at risk for elopement) were reviewed and updated; all nurses were educated on how to complete the elopement assessment accurately; and implemented that all residents were assessed for elopement upon admission, with quarterly and annual reviews, and with any change in condition. On 8/20/24 at 1:08 PM, a review of 8 new admissions to the facility in the last 30 days revealed there were no concerns regarding their elopement assessments. An interview with LPN #7 on 8/20/24 at 1:20 PM revealed that he had completed the elopement assessment for Resident #109 on 2/29/24, confirmed the resident was an elopement risk and needed a wander guard. He stated that the admission was on evening shift however, he was unable to find a wander guard, so he did not put one on the resident. He could not remember if he passed the information to the oncoming nurse at the end of his shift. The DON was interviewed on 8/20/24 at 4:14 PM regarding the elopement and the corrective actions taken by the facility. She reported that, during an interview with LPN #7, she determined that the nurse had completed the assessment accurately, however, was unable to find a wander guard and failed to report that to the oncoming nurse. She reported that the wander guards had been kept in the supply closets for security reasons. After the incident, they were placed in the Unit Manager's office on each unit and there were two bracelets available for each unit. She confirmed that all the nurses have access to the Unit Manager's office after hours. She reported another step that they added was to have the unit managers review each new admission's elopement assessment to ensure accuracy and to double check that the interventions were implemented immediately. A second check was completed by the clinical team during their morning meeting following the new admission. A corrective action plan was developed and started on 4/24/24: Staff interviews were conducted to determine the details of the elopement and root cause analysis. An inventory of available wander guards was completed. Wander guards were ordered and available if an indication for use was identified. Licensed nursing staff will be re-educated on completion of Elopement Risk Assessment at the time of admission, readmissions, with change in condition, and periodically as indicated. If the Elopement Risk assessment indicates proceed interventions need to be implemented immediately to ensure resident safety. Staff will be re-educated regarding residents at risk for elopement and the method for identifying these residents to include the wander guard book kept at the front desk, elopement policy and drills, and code silver protocols. An audit of elopement risk evaluations was conducted to identify active residents who wander and those with existing wander guard devices in place. The elopement book [at the front desk] was updated to reflect residents at risk and residents with wander guard devices. New admissions, re-admissions, and residents with changes in condition will be reviewed in clinical morning meeting Monday - Friday to review elopement risk assessments for completion, accuracy, and immediate implementation of interventions as indicated. Quarterly assessments will be reviewed as part of the MDS/Care plan process. The Director of Nursing and/or designee will randomly audit a minimum of 5 elopement risk assessments weekly for 4 weeks, monthly for 2 months to validate accuracy. Any concerns identified will be addressed at the time of discovery. Elopement drills to be conducted 1 per quarter as per facility policy. An ad hoc Quality Assurance Performance and Improvement (QAPI) committee meeting was held on 4/25/24. The Medical Director was notified on 4/25/24. This process will be reviewed for QAPI for 3 months. From 8/21/24 - 8/28/24, the facility's action plan and implementation of interventions were reviewed. Review of 8 residents newly admitted to the facility in the previous 30 days were reviewed, interviews with multiple staff, review of facility documentation including education, policies and procedures on elopement and elopement drills, as well as observation of the main lobby doors and the wander guard system, and staff practices confirmed that the above interventions were implemented by the facility. It was determined that the date of compliance was 4/30/24.

Based on records review and interviews, it was determined that the facility failed to 1) have an effective system in place to ensure that all allegations of abuse are reported to the state agency, 2) to ensure that reports are sent within the mandated timeframe, and 3) to report the results of the investigation no later than 5 working days after the incident. This was evident in 6 (Resident #19, #9, #6, #25, #67, and #92) of 21 residents reviewed for abuse. The findings include: 1) On 8/26/24 at 2:50 PM, a review of facility reported incident MD00200510 revealed that, on the morning of 12/12/23, Resident #25 reported to a staff member that a GNA (geriatric nursing assistant) had made a movement like s/he was going to hit the resident. On the self-report form, the facility documented the date of the incident was 12/11 to 12/12/23 and reported by the resident on 12/12/23. The facility's initial self-report indicated the allegation of abuse was reported to the state agency on 12/12/23 at 12:40 PM and the final report was reported to the state agency on 12/19/23 at 1:50 PM. During an interview on 8/28/24 at 3:54 PM, the Director of Nursing (DON) stated she thiought that she was made aware of the allegation of abuse the morning of 12/12/23, around 9:00 AM, that she could not recall the exact time, but it was before the morning meeting. The time the facility reported the allegation to the state office was past the 2-hour required timeframe. In addition, the facility failed to report the results of the investigation no later than 5 working days after the incident. The concerns with the late reporting of an allegation of abuse were discussed with the DON at that time, and the DON verbalized understanding. 48168 2). On 8/26/24 at 9:00 AM, a review of complaint #MD00208610 revealed an allegation that staff yelled at and hit Resident #67. On 8/26/24 at 12:10 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. When asked if there were any FRIs for Resident #67, the ADON said she did not have any. On 8/26/24 at 4:21 PM in an interview with Unit Manager (Staff #5), she said she was aware of an allegation of abuse for Resident #67. She thought it happened on a weekend. Staff #5 further explained that she informed the Director of Nursing (DON) of the allegation and thought the DON did an investigation. When asked what the process was for reporting alleged abuse, Staff #5 said that the DON was immediately notified, anytime 24/7, even if it was the weekend, and that the ADON and DON alternated taking call on the weekends. When asked if she remembered the date of the alleged incident, she said she could not remember. When asked if she has record of it, she said she did not. She further explained that sometimes she helped investigate allegations, but she did not investigate this incident. On 8/27/24 at 1:44 PM an interview with the DON was conducted. The DON stated she learned of the allegation of abuse for Resident #67 from the unit manager, who had a phone message left on her unit manager phone on a weekend. The DON said she asked the resident, who said the incident did not happen, and since the resident denied the occurrence, the facility did not do an investigation or make a report. The DON confirmed that this did not meet the regulatory requirements to report and investigate all allegations of abuse. 3). On 8/28/24 at 1:16 PM, a review of the FRI #MD00191798 revealed an allegation that Resident #92 was abused by another resident (Resident #77) on 4/18/23. A review of the facility's investigation file revealed an Initial Self-Report report to the Office of Health Care Quality (OHCQ) dated 4/26/23 at 5:30 PM with a corresponding email confirmation. The facility's investigation file also contained a typed witness statement, dated 4/18/23, by Licensed Practical Nurse (LPN #37) who witnessed the incident. On 8/28/24 at 2:54 PM an interview with the DON was conducted to review the FRI #MD00191798 report, the facility's investigation file, and the timing of the facility's self-report. The DON confirmed that, since the incident occurred on 4/18/23 but was not reported to OHCQ until 4/26/23, the facility was not compliant with reporting regulations. 48470 4) Resident #19 had been residing in the facility since 2015. In an interview with the resident on 8/15/24 at 3:50 PM, the resident reported that a Geriatric Nursing Assistant (GNA) who still worked for the facility was calling him/her numerous names, including being referred to as the devil. The resident indicated that this happened about 5-6 months ago, and that it had been reported to the Director of Nursing (DON). The DON was interviewed on 8/26/24 at 1:12 PM. The DON confirmed Resident #19's report and indicated that, when the incident happened, 2 GNA's were with the resident and both staff reported that the allegation was not true. Since 2 staff members confirmed with her that the allegation did not happen, she did not do a facility report. On 8/27/24 at 8:09 AM, the Corporate Clinical Nurse (Staff #2) reported to the surveyor that she would be interviewing the resident, and that the facility had started a formal investigation of the allegation. 5a) On 8/20/24 at 1:43 PM, Resident #9 reported an allegation of abuse against a male GNA that had happened about 3 weeks ago. The resident indicated that s/he had reported it to the Unit Manager (Staff #30), the DON, and the scheduler. Then the resident stated, But then they scheduled him again this Saturday night and I went off! Resident #9 further reported that the nurse on duty calmed him/her down and helped facilitate in assigning a different staff member to put him/her back to bed. On 8/20/24 at 2:28 PM, the DON was interviewed about the resident's allegation and she confirmed that it was brought to her attention. The DON was asked if she reported and investigated the allegation and she replied, No I did not, because it's usually he said s/he said, and I don't have any report against that staff from other residents. In a subsequent interview with the DON on 8/21/24 at 12:49 PM, the concern was discussed that the resident's allegation was not reported to the state agency. The DON indicated that the resident was always reporting things and did not like agency staff. The resident was known for making stuff up and was care planned for it as well. The DON acknowledged the concern and reported that she would report all allegations from now on. 5b) On 8/20/24 at 4:45 PM, the surveyor received a complaint intake information submitted by Resident #9 related to MD00208809. The resident reported 2 nurses who refused to administer his/her medications on 8/11/24 and 8/14/24. In an interview with the DON and the Assistant DON on 8/26/24 at 11:01 AM, both staff confirmed that Resident #9 had brought to their attention an issue about a nurse who refused to administer his/her medications. The DON reported that the resident had left a message on her cell phone to report the 8/14/24 incident, but not the 8/11/24 incident. Both staff indicated that they immediately investigated the concern on 8/14/24. However, there was no evidence of the investigation conducted by the DON and the ADON. Subsequently on the same day at approximately 4:00 PM, the DON reported that she would start a facility reported incident regarding the deprivation of services by the nurses to Resident #9. 6) Resident #6 was admitted into the facility in late 2023. A facility reported incident (FRI) investigation packet related to MD00207289, regarding abuse, was reviewed on 8/23/24 at 10:52 AM. The review revealed that the allegation was reported to the wound nurse (Staff #58) by the resident on 7/1/24 at approximately 9:00 AM. Further review of the investigation packet revealed the FRI initial report form that stated the form was submitted on 7/2/24 at 7:00 PM. The confirmation email that the initial report was submitted was dated 7/2/24 at 7:37 PM. The DON was interviewed on 8/23/24 at 12:09 PM and the concern was discussed that the initial report for an allegation of abuse was sent approximately 34 hours after the facility was made aware. The DON acknowledged the concern and offered no explanation. A review of the facility's abuse, neglect, exploitation or mistreatment policies and procedures was conducted on 8/26/24 at 2:19 PM. The review revealed a section titled Reporting/Response and item number 1 stated, All alleged violations concerning abuse, neglect, or misappropriation of property are reported immediately to Abuse coordinator, NHA, other officials in accordance with the state law including state survey and certification agency. On 8/29/24 at 11:00 AM, the findings were reviewed with the DON, ADON, and the Corporate Clinical Nurse (Staff #2) and the concern was discussed that allegations of abuse must be reported to the state agency and that reports must be submitted within the mandated timeframe. All staff verbalized understanding and acknowledged the concern.

Based on records review and interviews, it was determined that the facility failed to implement their abuse policies and procedures by 1) failing to report all allegations of abuse to the state agency and the facility's abuse coordinator and 2) failing to conduct a thorough investigation of all allegations of abuse. This was evident for 1 of 1 policies and procedures reviewed for abuse, neglect, exploitation, or mistreatment and has the potential to affect all residents of the facility. The findings include: A review of the facility's abuse, neglect, exploitation or mistreatment policies and procedures was conducted on 8/26/24 at 2:19 PM. The policies and procedure indicated in the bottom of the document that it had a complete revision on 11/1/2017. In the section under Policy, item number 2. indicated that if the events that cause the allegation involve abuse, the facility shall report immediately, but no later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including state survey agency) in accordance with the state law. Item number 3. stated, The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident. And item number 5. stated The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator) During the survey process, the surveyor had identified 3 occurrences through interviews and records review where residents had reported allegations of abuse to staff, but the facility's leadership failed to report the incident to the state agency and failed to conduct a thorough investigation of the allegation. The 3 occurrences were: 1) On 8/15/24 at 3:50 PM, while in an interview with Resident #19, s/he reported a Geriatric Nursing Assistant (GNA) who allegedly called him/her numerous names. The allegation was reported to the Director of Nursing (DON) and the GNA was taken off the floor and was not allowed to care for Resident #19 anymore. The DON was interviewed on 8/26/24 at 1:12 PM. The DON confirmed Resident #19's report and indicated that when the incident happened, 2 GNA's were with the resident and both staff reported that the allegation was not true. Since 2 staff members confirmed with her that the allegation did not happen, she did not do a facility report. 2) On 8/20/24 at 1:43 PM, Resident #9 reported an allegation of abuse against a male GNA that had happened about 3 weeks ago. The resident indicated that s/he had reported it to the Unit Manager (Staff #30), the DON, and the scheduler. Then the resident stated, But then they scheduled him again this Saturday night and I went off! Resident #9 further reported that the nurse on duty calmed him/her down and helped facilitate in assigning a different staff member to put him/her back to bed. On 8/20/24 at 2:28 PM, the DON was interviewed about the resident's allegation and she confirmed that it was brought to her attention. The DON was asked if she reported and investigated the allegation and she replied, No I did not, because it's usually he said s/he said, and I don't have any report against that staff from other residents. A subsequent interview with the DON on 8/21/24 at 12:49 PM, the concern was discussed that the resident's allegation was not reported to the state agency. The DON indicated that the resident was always reporting things and did not like agency staff. The resident was known for making stuff up and was care planned for it as well. The DON acknowledged the concern and reported that she would report all allegations from now on. 3) On 8/20/24 at 4:45 PM, the surveyor received a complaint intake information submitted by Resident #9 related to MD00208809. The resident reported 2 nurses who refused to administer his/her medications on 8/11/24 and 8/14/24. In an interview with the DON and the Assistant DON on 8/26/24 at 11:01 AM, both staff confirmed that Resident #9 had brought to their attention an issue about a nurse who refused to administer his/her medications. The DON reported that the resident had left a message on her cell phone to report the 8/14/24 incident but not the 8/11/24 incident. Both staff indicated that they immediately investigated the concern on 8/14/24. However, there was no evidence of the investigation conducted by the DON and the ADON. Subsequently on the same day at approximately 4 PM, the DON reported that she will start a facility reported incident regarding the deprivation of services by the nurses to Resident #9. In an interview with the Nursing Home Administrator (NHA) on 8/27/24 at 9:55 AM, he reported that he was the facility's abuse coordinator. The DON sends reports on behalf of the facility. The NHA reported the facility's process when an abuse allegation is made and indicated that all allegations are reported to him prior to investigations and him reporting the event to regional staff. In a subsequent interview with the NHA on the same day at 3:07 PM, the 3 allegations identified above was discussed. The NHA reported that he does not recall the incident with Resident #19, he was not aware initially about Resident #9's allegation against the GNA who was assigned to him/her on 8/17/24 and confirmed that refusing to administer medications was a type of abuse and a reportable offense. The NHA acknowledged the concern that the DON had not reported and thoroughly investigated all the allegations being brought to her attention. On 8/29/24 at 11 PM, the concern was discussed with the DON, ADON, and the Corporate Clinical Nurse (Staff #2) that the facility failed to implement its policies and procedures for the prevention of abuse as evidenced by allegations made by residents were not reported to the facility's abuse coordinator, not reported to the state agency, and no thorough investigations were conducted on several occasions. All 3 staff acknowledged the concern. Cross reference F609, F610

Based on record review and staff interview, it was determined that facility staff failed to conduct a thorough investigation of abuse and maintain evidence of the investigation. This was evident for 7 (#424 #19, #9, #41, #92 #322, #67 ) of 21 residents reviewed for abuse and for 3 facility reported incidents reviewed for abuse (FRIs) (#MD00194834, and #MD00207292, and #MD00191798), of 34 FRIs investigated during the recertification survey. The findings include: 1). On 8/27/24 at 12:03 PM a review of the Office of Health Care Quality (OHCQ) report #MD00194834 revealed an allegation that staff mistreated Resident #322 on 7/27/23 when they ripped the remote control from the resident's hand. On 8/27/24 at 12:10 PM, the facility's investigation file was obtained and reviewed. Although the file contained a suspension notice for a Geriatric Nursing Assistant (GNA #38), the file lacked 1) any staff witness statements, 2) evidence that Resident #322 had a physical assessment done after the incident, and 3) assignment sheets of staff on duty at the time of the incident. 4) demographic and clinical information regarding the resident and the resident's care needs at the time, 5) any evidence of education provided to staff after the alleged incident. The file also contained a skin assessment for Resident #322, dated 7/29/24. On 8/27/24 at 1:31 PM, an interview with the Director of Nursing (DON) was conducted to review the facility's investigation file. The DON confirmed that there were no staff statements, no resident information or assessment, no evidence of education or follow up other than the suspension notice, and that the clinical documentation, dated 7/29/24, could not have been part of the investigation because it occurred more than one year later. On 8/27/24 at 3:19 PM, an interview with the Nursing Home Administrator (NHA) was conducted and he was informed of the incomplete investigation. He said he had only worked at the facility for 10 months, and that he understood the investigation was not thorough. 2). On 8/26/24 at 3:18 PM, a review of the FRI #MD00207292 revealed an allegation that, on 6/30/24, a male Geriatric Nursing Assistant (GNA #11) grabbed Resident #41's leg and left a mark on it. On 8/26/24 at 3:20 PM, a review of the facility's investigation file revealed that, although the alleged perpetrator wrote a statement on his suspension notice, there were no other staff statements in the file. A typed statement by the Assistant Director of Nursing (ADON) indicated that she conducted resident and staff interviews, but did not indicate who was interviewed, nor was there a list of staff on duty at the time. And although the ADON wrote a statement that she spoke with the Resident #41, who indicated being safe, there was no statement from Resident #41 about the actual incident. The file also lacked the 5-day final report to OHCQ and lacked any evidence of education provided to staff about abuse prevention and reporting. On 8/27/24 at 1:20 PM, the DON was interviewed about the facility's investigation of the alleged abuse of Resident #41. When asked about the lack of pertinent information in the investigation file, the DON stated she might have some additional information in her computer, but she did not have time to make sure it was complete before giving it to the survey team, and she also confirmed that the investigation should have included names of staff and residents who were interviewed. The DON confirmed that the investigation file was incomplete. On 8/27/24 at 3:19 PM, an interview with the NHA was conducted regarding the incomplete investigation and he validated that this was a deficiency. 3). On 8/28/24 at 1:16 pm a review of the FRI #MD00191798 revealed that Resident #92 made an allegation of abuse against Resident #77 on 4/18/23. On 8/28/24 at 2:00 PM a review of the facility's investigation file revealed a staff witness statement by Licensed Practical Nurse (LPN #37) which described an incident that occurred on 4/18/23 around 7 PM. The typed statement was dated 4/18/23 and contained an illegible signature, and indicated it was an interview of LPN #37. The file lacked 1) any clinical or identifying information for either resident involved, 2) no other staff or resident witness statements, 3) no roster of residents on the unit, and 4) no list of staff on duty at the time. The file also contained the 5-day Final Report which included a statement that Resident #92 wanted to press charges against Resident #77, but there was no police report case number or officer name listed in the file. On 8/28/24 at 2:54 PM an interview with the DON was conducted regarding the facility's investigation of the allegation that Resident #92 was abused by Resident #77. When asked, the DON said the typed interview statement of LPN #37 was written by the facility Social Worker (SW #39) who no longer worked at the facility, although her name was not legible on the document. The DON also confirmed that the facility's investigation file lacked other staff or resident witness statements, lacked a roster of resident census or staff duty assignment, lacked documentation of follow up of resident's aggressive behavior, lacked evidence of education provided to the staff after incident, and lacked evidence of a police report filed per Resident #92's request. The DON validated that the investigation was incomplete. 48470 4) Resident #19 had been residing in the facility since 2015. In an interview with the resident on 8/15/24 at 3:50 PM, the resident reported that a Geriatric Nursing Assistant (GNA) who still works for the facility was calling him/her numerous names including being referred to as the devil. The resident indicated that this happened about 5-6 months ago and that it had been reported to the Director of Nursing (DON). The DON was interviewed on 8/26/24 at 1:12 PM. The DON confirmed Resident #19's report and indicated that when the incident happened, 2 GNA's were with the resident and both staff reported that the allegation was not true. Since 2 staff members confirmed with her that the allegation did not happen, she did not do a facility report. On 8/26/24 at 1:29 PM, a review of Resident #19's medical records failed to reveal evidence that the allegation was investigated and unsubstantiated. No record was found to indicate that the resident and/or other residents were interviewed, and staff were interviewed. A review of the facility's abuse, neglect, exploitation or mistreatment policies and procedures was conducted on 8/26/24 at 2:19 PM. The review revealed a section titled Guidelines for Investigation and stated in item G Interview individuals having first-hand knowledge of the incident and write summaries of the interviews. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff and interviewer will record all witness accounts in a document, written, dated and signed by the interviewer. On 8/27/24 at 8:09 AM, the Corporate Clinical Nurse (Staff #2) reported to the surveyor that she would be interviewing the resident, and that the facility had started a formal investigation of the allegation. On 8/29/24 at 11:00 AM, the concern was discussed with the DON, Assistant DON, and the Corporate Clinical Nurse (Staff #2) that an allegation of abuse was not thoroughly investigated. All staff acknowledged the concern. 5) Resident #9 had been residing in the facility since 2017. The resident's medical records indicated that s/he was cognitively intact with a BIMS of 15. BIMS : stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. During the survey process, the surveyor had identified allegation of abuse that involved Resident #9. These allegations were: a) On 8/20/24 at 1:43 PM, Resident #9 reported an allegation of abuse against a male GNA that had happened about 3 weeks ago. The resident indicated that s/he had reported it to the Unit Manager (Staff # 30), the DON, and the scheduler. Then the resident stated, But then they scheduled him again this Saturday night and I went off! Resident #9 further reported that the nurse on duty calmed him/her down and helped facilitate in assigning a different staff member to put him/her back to bed. On 8/20/24 at 2:28 PM, the DON was interviewed about the resident's allegation and she confirmed that it was brought to her attention. The DON was asked if she reported and investigated the allegation and she replied, No I did not, because it's usually he said s/he said, and I don't have any report against that staff from other residents. In a subsequent interview with the DON on 8/21/24 at 12:49 PM, she reported that she reviewed the GNA's schedule to see which residents were assigned to the staff. None of the other residents had any complaints or concern with the staff and that Resident #9 was always reporting things and did not like agency staff. The resident was known for making stuff up and was care planned for it as well. b) On 8/20/24 at 4:45 PM, the surveyor received a complaint intake information submitted by Resident #9 related to MD00208809. The resident reported 2 nurses who refused to administer his/her medications on 8/11/24 and 8/14/24. In an interview with the DON and the ADON on 8/26/24 at 11:01 AM, both staff confirmed that Resident # 9 had brought to their attention about a nurse who refused to administer his/her medications. The DON reported that the resident had left a message on her cell phone to report the 8/14/24 incident but not the 8/11/24 incident. Both staff indicated that they immediately investigated the concern on 8/14/24. However, there was no evidence of the investigation conducted by the DON and the ADON. Subsequently on the same day at approximately 4:00 PM, the DON reported that she will start a facility reported incident regarding the deprivation of services by the nurses to Resident #9. On 8/29/24 at 11:00 AM, the allegations made by Resident #9 was discussed with the DON, ADON, and the Corporate Clinical Nurse (Staff #2) and the concern was discussed that there was no evidence that the allegations were investigated. All staff verbalized understanding and acknowledged the concern. 40927 6) On 8/22/24 at 8:53 AM, a review of the facility's investigation file for the facility reported incident #MD00182597 revealed a self-report form that documented a staff member had witnessed Resident #424 being abused on 4/20/22 at 2:30 PM by another staff member. Further review of the investigation file revealed that facility staff failed to maintain evidence that they had interviewed and/or assessed other residents who had been in the care of GNA #53 to ensure no one else had been abused. They facility failed to interview other staff who may have had knowledge of the incident, or the care provided to other residents by GNA #53. The facility also failed to maintain a completed investigation and evidence as to when it was sent to the state agency. On 8/28/24 at 9:54 AM, the concerns were reviewed with the Director of Nursing and the Assistant Director of Nursing. Neither of them were in their current positions at the time of the incident. The Administrator, at the time of the incident, was no longer there. The DON was unable to find the original investigation file and had printed what they could find in the computer to recreate the file. Cross Reference F600

Based on record review and interview, it was determined that the facility failed to ensure that all Geriatric Nursing Assistants (GNAs) had annual performance evaluations. This was evident for 3 GNAs (GNA #11, GNA #13, and GNA #14) of 3 GNAs reviewed during the Sufficient and Competent staffing task portion of the recertification survey. This had the potential to impact all residents. The findings include: On 8/20/24 at 10:00 AM, the annual performance evaluations were requested for GNA #11, GNA #13, and GNA #14 for 2019 through 2023. On 8/20/24 at 1:00 PM, the requested files were received and reviewed and revealed that each file lacked evidence of a performance evaluation in 2022, and GNA #13's file also lacked evidence of performance evaluations in 2020, 2021, and 2023. On 8/23/24 at 9:27 AM, an interview with the Director of Nursing (DON) and the Director of Human Resources (Staff #24) was conducted. They both confirmed the lack of evidence that GNA #11, GNA #13, and GNA #14 had performance evaluations in 2022, and that there was no evidence that GNA #13 had performance evaluations in 2020, 2021, or 2023. They confirmed that this was a deficiency.

Based on record review, facility staff and family interviews and other pertinent documentation, it was determined that the facility staff failed to adequately monitor Resident #1's blood glucose, after Resident #1 experienced a significant hypoglycemic episode. This was evident for 1 (#1) of 4 residents reviewed during this complaint investigation for care issues. The findings include: [MEDICATION NAME] is an oral medication of the sulfonylurea drug classification that is used to control high blood sugar in people with diabetes. According to the Food and Drug Administration (FDA) label for [MEDICATION NAME], all sulfonylurea drugs can produce severe [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (kidney disease) or hepatic insufficiency (liver disease) can cause elevated blood levels of [MEDICATION NAME] and can increase the risk of serious hypoglycemic reactions. The metabolism and excretion of [MEDICATION NAME] may be slowed in patients with impaired renal and/or hepatic function. If [DIAGNOSES REDACTED] should occur in such patients, it may be prolonged and appropriate management should be instituted. [DIAGNOSES REDACTED] is more likely to occur in the elderly and when more than one glucose-lowering drug is used. Overdosage of sulfonylureas, including ([MEDICATION NAME]), can produce [DIAGNOSES REDACTED]. Mild hypoglycemic symptoms without loss of consciousness or neurologic findings should be treated aggressively with oral glucose and adjustments in drug dosage and/or meal patterns. Close monitoring should continue until the physician is assured that the patient is out of danger. Severe hypoglycemic reactions with coma, [MEDICAL CONDITION], or other neurological impairment require that patients should be closely monitored for a minimum of 24 to 48 hours since [DIAGNOSES REDACTED] may recur after apparent clinical recovery. (https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/ 3s021lbl.pdf) According to the FDA label for insulin detemir, insulin detemir is a long acting insulin that works by lowering levels of glucose (sugar) in the blood. It has a relatively constant 24-hour duration of action. The prolonged effect of subcutaneous (insulin detemir) may delay recovery from [DIAGNOSES REDACTED]. Careful glucose monitoring and dose adjustments of insulin, including . (insulin detemir) ., may be necessary in patients with renal impairment. After apparent clinical recovery from [DIAGNOSES REDACTED], continued observation and additional carbohydrate intake may be necessary to avoid recurrence of [DIAGNOSES REDACTED]. (https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/ 6s037lbl.pdf) Review of the medical record on 1/31/19 at 10:00 AM revealed that Resident #1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. At the time of admission, the physician ordered: [MEDICATION NAME] 10 milligrams by mouth every day at 10:00 AM. Insulin detemir 45units subcutaneous (under the skin) two times a day for Diabetes. Monitor Blood Sugar via Accu Chek four times a day -before meals and at bedtime. (cover with sliding scale insulin if needed 0-179 no coverage). Review of the MAR (Medication Administration Record) on 1/31/19 at 9:00 AM, revealed that Resident #1's BS (Blood Sugar) was obtained at 6:30 AM on 10/4/18, results documented as 127mg/dl. At 10:00 AM the resident was administered for the first time during this admission [MEDICATION NAME] 10 milligrams by mouth and [MEDICATION NAME] 45 units subcutaneous as ordered by the physician. The resident BS was again taken at 11:30 AM which resulted in a BS of 145mg/dl. According to the Intake and Output documentation the resident consumed 76-100% of his/her lunch on 10/4/18. Review of the medical record on 1/31/19 at 10:00 AM revealed a Nurse's note from RN #9 dated 10/4/18 at 8:18 PM, which revealed the resident's BS at 5:30 PM was 31mg/dl. The nurse documented the resident was sitting in bed, staring into space not responding verbally. According to the documentation at 5:34 PM, [MEDICATION NAME] (a medication used to treat severe low blood sugar) times one was given. The resident's BS was rechecked a few minutes later and was 58mg/dl. At 5:36 PM the NP (Nurse Practitioner) Staff #7 was made aware. The NP (Staff #7) discontinued the [MEDICATION NAME] and current insulin detemir order. The resident was ordered [MEDICATION NAME] 45units every morning and a snack at bedtime. At 5:40 PM the resident's BS was rechecked and the results were 40mg/dl. The NP was notified and a second dose of [MEDICATION NAME] was administered. According to the nurse's note the resident did not respond to verbal or tactile stimuli after the administration of the second dose of [MEDICATION NAME]. At 5:44 PM, Staff #9 rechecked the resident's BS and documented 49mg/dl. According to the medical record the resident was alert, moving his/her head, blinking and responsive. Further review of the nurse's note revealed the resident had apple sauce and drank juice. Dinner was fed to resident. S/he consumed 25% of dinner according to the documentation. According to the documentation at 5:52 PM on 10/4/18, the resident's BS was 52mg/dl, and at 6:07 PM, the resident's BS was 67mg/dl. Review of the medical record revealed a nurses' note, dated 10/04/18 at 8:32 PM, at which time the nurse (#9) revealed the following: at 6:36 PM, the resident's BS was 103mg/dl. Report given to the oncoming nurse. Review of the medical record revealed that the resident's BS was taken at 8:00 PM on 10/4/18 and the results were documented by Nurse #6, an LPN, as 121mg/dl. No further BS were done on 10/4/18 after 8 PM. During interview with the Director of Nursing on 1/31/19 at 12:30 PM, the surveyor asked why the resident's BS were not monitored closely after the resident had a significant hypoglycemic episode requiring several interventions. The DON stated, the facility did all they could for this resident. During interview with the Resident's physician on 1/31/19 at 2:00 PM, s/he stated, the resident's medications were reviewed; the medications prior to hospitalization , admission and during the hospital stay. S/he stated s/he was aware of the [MEDICATION NAME] being ordered. The medication was discontinued the next day due to a low blood sugar. The resident was only given one dose. Further review of the medical record on 2/1/19 at 9am revealed that, on 10/5/18 at approximately 12:00 AM and 4:00 AM, Nurse #1 was in resident #1's room administering (IV) Intravenous medications that were ordered for this resident. However, Nurse #1 failed to obtain a BS on either occasion. Nurse #1 documented on a 10/5/18 SBAR Communication Form that s/he entered the resident's room at approximately 5:00 AM to take down the resident IV medication, and check VS and BS. The resident's BS at that time was 31mg/dl. The resident's skin was warm and dry to the touch. The resident was unresponsive, glucogel given, no change. The NP was notified gave order to administer D10W times 200mls (milliliters). Resident #1 BS was rechecked 73mg/dl, D10W increased. Resident BS rechecked 99mg/dl. The NP was notified. New orders received to discontinue the am [MEDICATION NAME] and Sliding Scale Insulin, continue accu-checks ac (before meals) and hs (hour of sleep) without SSI coverage. D10W decreased, BS rechecked 77. The NP was notified gave new orders for D50W times 1 STAT (now)IV bolus; if resident still unresponsive after bolus transfer the resident to (the hospital). According to the documentation the D50W was administered at approximately 6:25 AM. The resident's BS was rechecked. Results were 189mg/dl. 911 was called at 7:08 AM, EMTs arrived at 7:20 AM. The resident was transported to (the hospital) at 7:25 AM. Review of Resident #1's hospital medical record revealed that she/he was admitted to the hospital on [DATE] for altered mental status and [DIAGNOSES REDACTED]. The resident was discharged from the hospital later that month in a persistent comatose and vegetative state since (his/her) admission. A statement from Resident #1's family member received on 1/26/19 revealed the following: On Thursday, (MONTH) 4, (YEAR), (resident #1) was alert and talking, and in a good mood. S/he had a physical therapy and an occupational therapy evaluation. They were able to get him/her into a wheelchair. S/he was given medications by mouth before lunch. This is when s/he was given [MEDICATION NAME]. S/he was previously taken off this medication by the doctor in (MONTH) because it made him/her blood sugar levels go crazy). S/he was also given [MEDICATION NAME], a long-acting insulin. That afternoon, s/he was put back into bed, as s/he was getting tired, and slept most of the afternoon. At around 4:30pm, his/her blood sugar was checked (as is normal before dinner), the blood sugar was 31 mg/dL, which is dangerously low. At this point, s/he was sleeping and did not wake while the blood sugar was being taken. S/he was given glucose at this time and it took about 10 minutes before s/he woke up. After about 30 minutes, s/he was talking and acting normal. S/he ate dinner and got ready for bed at around 8:00 pm. During interview with Nurse #1 on 2/1/19 at 2:00 PM, she stated that she had been in Resident #1's room at 12:00 AM, 3:00 AM and 4:00 AM (the resident was receiving IV antibiotic therapy). The resident was verbally responsive at 3:00 AM. Nurse #1 reported that, at 5:00 AM, she checked the resident's BS and it was 31mg/dl. Several interventions were done, and the resident BS's increased to 189mg/dl prior to transfer. Nurse #1 was asked by this surveyor why the resident's BS was not monitored after 8:00 PM on 10/4/18 and she stated, the resident BS was 121mg/dl at 8pm, which was within normal range. When asked why s/he sent the resident out 911 on 10/5/18, if the BS had reached 189mg/dl, Nurse #1 responded that Resident #1 was not communicating well. After additional information was obtained from the hospital on (MONTH) 5, 2019 this surveyor revisited the facility on 4/5/19 to interview the Medical Director, however s/he was out of town. Nurse Practitioner (NP- staff #7) was interviewed on 4/5/19, because he/she was taking care of Resident #1. The NP stated that the resident had previously been at the facility and at that time his/her BS were high. S/he stated, Nurse #1 made him/her aware of the resident's condition and s/he made several changes to the resident's medications. When asked by the surveyor why a BS was not ordered to monitor the resident closely, the NP stated it was not clinically indicated.

Based on interview of the resident, the resident's attorney, facility staff, and ambulance transportation staff, it was determined that the facility staff of Northampton Manor failed to honor the rights of the resident by transferring her to another nursing home after she rescinded her decision to transfer, and wanted to remain at Northampton Manor.The findings include: Resident # 1 is non-ambulatory, dependant on staff for care and has a tracheotomy that requires round the clock nursing care. The resident is also her own responsible party. On [DATE] resident #1 filed the following complaint with the Office of Health Care Quality (OHCQ). " Received a call from (name of resident) stating that she was placed on a stretcher and transported to (name of nursing home) without her permission. She states she told the facility that she did not want to leave, but they put some of her belongings in the ambulance and sent her anyway. " Surveyor onsite review of the above complaint [DATE] revealed the following information. Surveyor interview with the facility social worker on [DATE] at 1pm in the Director of Nursing's office revealed that, on [DATE], after multiple referrals to facilities within the State, another nursing facility agreed to accept the resident for transfer. The social service worker met with the resident for approximately 2 hours and the resident agreed to the transfer. It was at this point the facility staff made arrangements to transfer the resident by ambulance to the other nursing home. At approximately 3pm on [DATE], the resident began to make multiple phone calls to her attorney stating that she no longer desired to be transferred from the facility. Surveyor spoke with the resident ' s attorney on [DATE] at 10 am who revealed that the resident indeed decided not to be transferred from Northampton Manor. Several voice mails the resident left for her attorney were also played for the surveyor (with the resident ' s permission) indicating that the resident declined to leave the facility. On [DATE], ambulance company staff arrived at Northampton Manor at approximately 5pm. The Patient Care Report documented by the transfer crew states the following; " Arrived at Northampton Manor. Met with social worker and manager at front entrance. They informed us the patient was extremely un-cooperative and stated patient would " put up a fight " and did not want to leave. Furthermore staff stated there is a court order stating the patient had to be moved from Northampton Manor by the 30th of March. My partner and I entered the patient's room, gave our names, and told the patient we would be transporting her to (name of nursing home). Patient screamed " I'm not going anywhere, you can't take me. " The manager of the nursing home again explained to the resident that she had to leave today and all legal documents were in order for her transfer. " The legal document noted by the manager was a mediation agreement (not a court order) between the nursing home and the resident regarding a Notice of Proposed Involuntary Discharge that had been issued to the resident on (date of notice). This agreement expired on [DATE]. Surveyor interview on [DATE] at 2pm at the ambulance company corporate office with the 2 ambulance staff who transferred the resident revealed that the Patient Care Report filed on [DATE] 5 pm was accurate to the events that occurred. Surveyor interview with the resident on [DATE] 10:29 am revealed, " I didn't want to go. I wanted to stay. The social worker and ADON (assistant director of nursing) put me on the gurney and told me I had to go, taking me against my will. I told the driver (of the ambulance) to drive me to the nearest police station. I was taken against my will. " The resident on [DATE] called OHCQ, her attorney and 911 a total of approximately 14 calls. All calls indicated that, the resident was very upset about her transfer to another nursing home, and did not want to leave Northampton Manor. The facility failed to recognize the resident's right to refuse the transfer and her choice to stay at the facility.