Every finding on record at Northwest Healthcare Center

Based on review of facility reported incident #3013380, medical record review, and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#4, #17, #18) of 18 residents reviewed during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 6/16/26 at 12:38 PM a review of facility reported incident #3013380 was conducted along with Resident #4's medical record.Review of a 5/12/26 at 04:51 change in condition note documented that while assisting the resident in the bathroom, the resident became unsteady on his/her feet and fell. There was a small amount of bleeding observed from the nose and mouth.Review of a 5/12/26 at 12:43 alert note documented the physician and nurse practitioner were made aware of the fall and there was a new order to apply ice pack every shift for swelling.Review of a 5/12/26 at 23:59 progress note from the physician documented, nose swelling and mild erythema around lateral nostrils. The note also documented a mild bruise like area on top of the nose.Review of a 5/13/26 at 16:30 nurse's note documented, transferred to ER (emergency room) for fall on face with nose bleed and bruising around eyes, rule out head and facial trauma.Review of a 5/13/26 at 23:59 physician's progress note documented, some new bruising around the medial areas of eyes bilaterally.Review of Resident #4's Discharge Return Anticipated MDS with an assessment reference date (ARD) of 5/13/26: Section J, falls, J1900B, number of falls since admission/entry or reentry or prior assessment, documented 1 fall with no injury. This was incorrect as the resident had bruising after the fall.On 6/17/26 at 10:27 AM an interview was conducted with MDS Coordinator #16 who stated, it was not a major injury, and I will have to check with my regional to see if it should be coded.On 6/17/26 at 11:30 AM MDS Coordinator #16 confirmed the MDS error.2) On 6/17/26 at 9:00 AM a review of Resident #17's medical record was conducted.Review of a 5/14/26 at 14:58 alert charting observation note documented that the resident was noted with swelling on the forehead. During the investigation Resident #17 stated he/she fell down from his/her wheelchair 2 days ago in the downstairs bathroom. Resident #17 complained of a mild headache and the nurse practitioner ordered to send the resident out to the emergency room via 911 for a CT scan of the head.Review of a 5/15/26 at 20:53 nurse's note documented that Resident #17 was noted with a swelling/bump on the forehead due to a fall that happened 2 days prior per oral statement from the resident and staff (ADON) Assistant Director of Nursing.Review of Resident #17's quarterly MDS with an ARD of 5/29/26 documented no in Section J1800, any falls since admission/entry or reentry or prior assessment (which was 3/14/26). This was inaccurate as the resident was noted to have a fall according to the nursing notes. The status of the quarterly MDS was export ready which indicated that the MDS was completed and locked and waiting to be transmitted.On 6/17/26 at 11:30 AM an interview was conducted with the MDS Coordinator #16 who confirmed the MDS error.3) On 6/17/26 at 9:20 AM a review of Resident #18's medical record was conducted. Review of a 5/25/26 at 01:00 telehealth encounter note documented that Resident #18 had an unwitnessed fall and reported that he/she was in and out of consciousness with fluctuating blood pressures.Review of a 5/25/26 at 9:25 AM change in condition note documented that Resident #18 was found on the floor beside the wheelchair. It was documented that the resident complained of dizziness before falling.Review of Resident #18's 5/25/26 Discharge Return Anticipated MDS Assessment, Section J1800, any falls since admission/entry or reentry or prior assessment was coded no. The facility failed to capture the fall.On 6/17/26 at 11:30 AM an interview was conducted with the MDS Coordinator #16 who confirmed the MDS error.

Based on complaint, medical record review, and interview, it was determined that the facility failed to have a care plan meeting after an MDS assessment. This was evident for 1 (Resident #6) out of 18 residents reviewed during a complaint survey.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 is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 6/15/26 at 8:15 AM a review of complaint 2785504 along with Resident #6's medical record was conducted. Review of a 1/23/26 at 15:35 care conference note documented that a care plan meeting was held on 1/21/26. Further review of Resident #6's medical record revealed the last MDS assessment was on 4/23/26. There was no care plan meeting after the last MDS assessment. There have been no care plan meetings since 1/23/26. On 6/15/26 at 10:41 AM an interview was conducted with the Social Work Director #7 who stated that care plans are generally done quarterly after the MDS assessment, but new admissions are usually after the week they are admitted to the facility. Social Work Director #7 confirmed that Resident #6's care plan meeting that was supposed to happen after the 4/23/26 MDS assessment was missed.

Based on review of Medicare beneficiaries who were discharged from skilled therapy and nursing services and interviews with staff, it was determined that the facility staff failed to provide Medicare beneficiaries with a written Notice of Medicare Non-Coverage. This was evident for 1 (Resident #26) of 3 residents selected during the Beneficiary Protection Reviews.The findings include:The NOMNC, or Notice of Medicare Non-Coverage, is a mandatory form Medicare providers must give patients at least two days before covered skilled services (like home health or nursing facility care) end, informing them of the termination and their right to appeal, often by contacting a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for an expedited decision.On 01/21/2026 at 9:17 AM As part of the Beneficiary Notice Task, the surveyor requested Notice of Medicare Non-Coverage (NOMNC) notification that was provided to Resident #26 or the Resident representative. The facility provided a document that stated NOMNC therapy services were to end on 6/23/25, however, the document did not have any signatures from the resident or resident representative that indicated they received and understood that Medicare covered services were to end on 6/23/25.On 01/21/2026 at 9:45 AM An interview with Staff #1, facility Social Worker and Staff #13, Business Office Manager, was conducted. Staff #1 reported that NOMNC notifications are part of her responsibilities, however, she was not hired at the time of resident notification deadline. She further confirmed that residents are supposed to be notified 48 hours before their end of service date.Moreover, Staff #1 reported that the previous social worker was supposed to provide and review the NOMNC with Resident #26 by 6/21/2025. She later confirmed that there was no evidence that the resident or resident representative received the end of Medicare service notification.On 01/21/2026 at 10:45 AM The administrator was made aware of the concerns.

Based on observations, interviews and review of records, it was determined that the facility failed to provide a home-like environment for the residents. This was evident for 1 (room [ROOM NUMBER]) out of 3 rooms observed during the annual survey.The findings include:On 01/14/2026 at 8:34 AM An observation of room [ROOM NUMBER] on the Terrace Unit was conducted. The surveyor observed 1 wash hand basin (sink) that was shared by 4 residents. The sink was filled with water. There was a hole in the bathroom wall. On the ceiling of the bathroom, there was a cobweb with a spider.One of the sink faucet knobs was broken. On 01/14/2026 at 8:40 AM An interview with Staff #5 was conducted. They reported that the bathroom sink has not been draining for the past 2 days and that the facility was aware.On 01/14/2026 at 8:50 AM An interview with Staff #3 was conducted. They confirmed that the bathroom sink was not working and that there was a cobweb with a spider on the ceiling. On 01/14/2026 at 9:12 AM An interview with Staff #6 was conducted in room [ROOM NUMBER]. When asked if they were aware that the bathroom sink was not draining, the staff replied that they are aware because the nurses already put in a TELS ticket a few days ago. On 01/15/2026 at 9:00 AM A review of the TELS documents revealed tickets that were entered on 01/14/2026. A brief interview with the administrator was conducted. She stated that post surveyor's observations, she put in TELS tickets for identified concerns.On 01/20/2026 at 12:04 PM An interview with Staff #9, Maintenance Director, was conducted. He reported that there was a communication problem; the facility staff failed to put TELS tickets when items need repair in the facility. He acknowledged that there were no tickets placed in TELS to repair room [ROOM NUMBER]'s bathroom sink, tiles or the hole in the wall prior to Surveyor's observations. On 01/20/2026 at 1:00 PM The administrator and Director of Nursing (DON) were made aware of the concerns.

Based on record review and interviews, it was determined that the facility staff failed to obtain a signed admission agreement from an individual upon admission. This was evident for 1 (Resident #12) of 1 residents reviewed during the annual survey. The findings include: On 01/21/2026 at 09:58 AM, a review of Resident #12's medical records revealed that the resident was originally admitted [DATE] and had a BIMS of 15. Further review revealed that there was no record of an admission agreement signed by the resident. On 01/21/2026 at 10:52 AM, during an interview with the Admissions Director, staff #12, she stated that she was not able to provide proof that Resident #12 had ever had an admissions agreement signed. On 01/21/2026 at 11:58 AM, during a follow up interview with the Admissions Director, she stated that the resident should have had one completed within 48 hours of admission. After surveyor intervention, she obtained a signed admission agreement from the resident. On 01/21/2026 at 1:17 PM, a review of the facilities Resident admission policy revealed, under the Policy section it stated The resident will be required to: . 2. Sign our admission agreement and agree to abide by the facility policies and procedures. It also stated The prospective resident will be given a copy of the facilities description of services, payment options, resident's rights, and all other applicable policies and all questions regarding residency, services and rates for services will be answered prior or before completion of signing the admission agreement. Under the Procedure section, it stated, I. Admissions Director or Manager on Duty or designee meets with resident/resident representative to complete and sign all admission paperwork within 48 hours of resident's admission . J. Executive Director signs off on completed admission packet within 48 hours of resident's admission. On 01/22/2026 at 1:34 PM, during an interview with the administrator, she confirmed that there was no documentation proof that Resident #12 had ever been offered an admission agreement. At this time she was made aware of the concern.

Based on interviews, observations and review of records, it was determined that the facility failed to 1) provide dental services following a physician's referral and 2) provide routine dental services. This was evident for 3 (Resident #8, Resident #12 and Resident #47) of 5 residents reviewed for dental services during the annual survey. The findings include: 1.) On 01/14/2026 at 11:20 AM, during an interview with Resident #8, they stated that it had been a long time since they had seen a dentist. On 01/15/2026 at 12:48 PM, a review of Resident #8's medical record revealed an admission date of 8/4/2023. Further review failed to reveal any dental records for the resident since admission. On 01/15/2026 at 12:49 PM, review of the resident orders revealed an order placed on 9/27/2024 that stated Refer to Dentist--severe periodontal disease, per CT scan. On 01/16/2026 at 9:37 AM, review of physician progress notes on 9/27/2024 stated, K05.6: Periodontal disease Severe w/multiple small broken and eroded tooth roots in the maxilla with large surrounding periapical lucencies, per CT scan. Plan: Refer to dentist. Start chlorexidine rinse BID. On 01/16/2026 at 10:29 AM, the surveyor requested proof of dental records for Resident #8 from the facility. On 01/16/2026 at 12:28 PM, during an interview with the Administrator, she stated that they were not able to find dental visit records for the resident and were contacting HealthDrive for the resident's dental records. On 01/16/2026 at 1:04 PM, The facility provided the surveyor with 3 in-facility dental exams in the year 2025. The resident was seen for routine dental visits on 3/5/2025, 9/22/2025, and 10/15/2025. The provided dental records failed to show proof of follow up after an ordered dental referral for periodontal disease. On 01/20/2026 at 10:16 AM, during an interview with the administrator, she stated that Resident #8 had never been seen by a dentist until March of 2025. She further stated that the resident was not seen in regards to the consult that was placed by the physician on 9/27/2025. At this time the Administrator was made aware of the concern for routine dental exams and failure to follow up on a physician's consult request. 2.) On 01/14/2026 at 9:51 AM, during an interview with Resident #12, they stated that the dentist never showed up 3 or 4 months ago and that they had never seen a dentist. On 01/20/2026 at 9:05 AM, review of Resident #12's medical record revealed an initial admission date of 12/4/2023. On 01/20/2026 at 9:10 AM, review of the resident's orders revealed an order for dental consults as needed. On 01/20/2026 at 9:11 AM, review of Resident #12's care plan revealed a focus stating that they had oral/dental problems and a history of poor oral hygiene. On 01/20/2026 at 10:23 AM during an interview with the administrator, she stated that Resident #12 had never seen a dentist while being a resident at the facility. After surveyor intervention they were added to the list of residents to be seen for dental exams. At this time she was made aware of the concern for routine dental exams. 3.) On 01/14/2026 at 09:38 PM An interview with Resident #47 was conducted. They reported that they had broken teeth and had not received any dental services since they were admitted into the facility. The surveyor observed Resident #47 with missing teeth. On 01/14/2026 at 12:38 PM A review of Resident #47 medical records was conducted. The review indicated that the resident was admitted on [DATE]. Further review of the records failed to reveal any dental evaluation or routine dental services since admission. On 01/16/2026 at 11:28 AM An interview with Staff #4, Unit Manager- Terrace, was conducted. When asked if residents received dental assessment, she stated that the nursing staff conduct an initial assessment upon admission, however she was unsure how often residents were supposed to have routine dental services. The surveyor asked the Unit manager to provide the facility's dental policy. On 01/16/2026 at 1:37 PM A review of the facility dental policy was conducted. The policy stated that the facility would assist residents in obtaining routine dental services. Routine dental services was defined as annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental cleaning, dental radiographs, and smoothing of broken teeth. On 01/16/2026 at 1:43 PM An interview with the Director of Nursing (DON) was conducted. When asked if Resident #47 received an annual oral health assessment or routine dental services, she stated no. She also stated that the current Electronic Health Record (EHR) system did not have a nursing form for oral health assessment to be completed for the resident because of how the initial nursing evaluation was completed. On 01/16/2026 at 1:45 PM The DON and administrator were notified of the dental services concerns.

Based on observations and staff interviews it was determined that the facility failed to ensure food items were stored to maintain the integrity of the specific items. This was evident for the initial observation of the kitchen upon facility entry. This failure has the potential to affect a few residents. The findings include: On 01/13/2026 at 7:52 AM, an initial observation of the freezer revealed a bag of french fries and chicken tenders which were opened and unlabeled. At the same time, the Culinary Director (Staff #19) revealed that the expectation was that the items should have been labeled. On 01/21/2026 at 12:08 PM, the concern was reviewed with the Director of Nursing and she indicated that she understood.

Based on interviews and record reviews, it was determined that the facility failed to follow up on a physician order to obtain a radiology test and schedule a urology appointment. This was evident for 1 (Resident #47) out of 3 residents reviewed for use of outside resources during the annual survey.The findings include:On 01/13/2026 at 11:33 AM An interview with Resident # 47 was conducted. They reported that the facility failed to schedule their kidney function test for months and had failed to schedule an appointment with the urologist. Resident #47 further explained that they had a kidney function test that was ordered in January 2025, but it was not done until September 2025 and the results were needed by the urologist. On 01/20/2026 at 8:50 AM A review of Resident #47's medical records was conducted. The review revealed a recommendation note that was dated 2/25/25 with a recommendation to do nuclear medicine renal scan to look for renal function.Another consultation document dated 5/22/25 also recommended the facility to schedule a nuclear medicine scan for renal function.There was another follow up recommendation document dated 7/25/25 that also had a recommendation to schedule a nuclear medicine scan for renal function. In this document it also stated that resident must see a urologistThe review also revealed a nurses note dated 11/10/25 that stated Resident #47 needed to follow up with a urologist at Bayview.On 01/20/2026 at 9:55 AM An interview with Staff #2, facility appointment scheduler, was conducted. She reported nurses are supposed to fill out follow-up appointments form and submit to her, she then would call and schedule appointments for residents and organize transportation for the upcoming outside appointments. When asked if there were any forms that indicated Resident #47 had an appointment with urology, Staff #2 was unable to find any paperwork or evidence that an appointment was scheduled. Staff #2 was also unable to find evidence that an appointment was scheduled for the Nuclear Renal scan imaging for the months of February and May of 2025. On 01/20/2026 at 10:43 AM An interview with the Director of Nursing (DON) was conducted. She was asked if she was aware of the delay in obtaining Resident #47's radiology test and the lack of urology appointment set-up. DON replied that Resident #47 had in the past refused certain appointments. The surveyor asked DON to provide appointment refusal documentations.On 01/21/2026 at 10:29 AM The surveyor was provided 1 refusal for radiology testing that was dated 9/3/2025, however, the facility was unable to provide any documentation that the resident refused to go for a urology appointment.Further review of the documents provided by the facility indicated that Resident #47 was seen by an outside physician on 1/20/26 for a follow up appointment. The facility was provided with another recommendation that stated, resident need to be seen by a urologist; an appointment that has been requested for the past 2 years. On 01/22/2026 at 10:06 AM An interview with Staff #3 was conducted. She confirmed that Resident #47's appointment for urology was never scheduled. She also confirmed that there were no documented refusals for the appointment. On 01/22/2026 at 11:06 AM An interview with the administrator was conducted. When asked how soon should follow up appointments be scheduled, she replied within 72 hours. At this time, she was notified of the concerns of failing to schedule follow up appointments and assisting residents with obtaining outside resources.

Based on record reviews and interviews, it was determined that the facility failed to ensure all direct care staff received dementia management training, resident abuse prevention training, and 12 hours of training. This was evident for 2 (Staff #7 and #14) out of 5 staff reviewed for staff training. The findings include: On 01/21/2026 at 11:23 AM, review of Geriatric Nursing Assistant's (Staff #7 and #14) training failed to reveal that they completed dementia management training and resident abuse prevention training. On 01/23/2026 at 8:30 AM, review of Staff #7 and #14 training failed to reveal 12 hours of annual training. Staff #7 had 7.10 hours of training and Staff #14 had 11.15 hours of training. At the same time, during an interview with the Director of Nursing it was revealed that the expectation is that these training's should have been completed. The surveyor reviewed the concerns with the Director of Nursing and she indicated that she understood the concerns.

Based on observations, staff interviews, and policy review, the facility failed to ensure food was properly stored, prepared, distributed, and served in accordance with professional standards for food service safety as required for 83 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: During the initial observation with [NAME] (C)1 on [DATE] from 9:33 AM until 10:00 AM: -Infection Preventionist (IP) was noted to stand inside the kitchen food preparation area without a hair net on, speaking with the dietary staff. -C1, noted to have a ,d+[DATE]-inch length beard, was observed throughout the kitchen without the use of a beard net. -A large, opened container of applesauce was observed in the reach-in refrigerator. The container had [DATE] and [DATE] written on the outside. C1 said that the first written date was the open date, and the second date was the use by date. C1 discarded the container of applesauce. -A 46-ounce (oz.) thickened apple juice opened and undated was observed in the reach-in refrigerator. The carton documented, After opening, may be kept up to 7 days under refrigeration. C1 said that there should have been an open date recorded on the carton, and it would be discarded. -There was a 28 oz. box of cream of wheat on the food counter near the stove, opened and undated. -An additional reach-in refrigerator was observed with three 46 oz. cartons of thickened drink (two lemon water and one apple juice), all opened and undated. The cartons also documented, After opening, may be kept up to 7 days under refrigeration. C1 stated these cartons should also have been tossed in the trash. -Approximately 35 4 oz. cartons of strawberry shakes were observed in the reach-in refrigerator, thawed without thaw dates. The cartons documented, Use within 14 days after thawing. C1 said the shakes should have been dated with the thaw date. -An observation of the backsplash behind the dishwasher revealed a large area of black mildew speckled along the wall extending approximately three feet on both sides of the dishwasher unit. The chlorine test strips used by the dietary staff were labeled with an expiration date of [DATE]. C1 and Culinary Aide (CA) 1 had not been aware of the expired test strips and stated they would get them replaced. -An observation of the ice machine revealed the outer sides contained dirt buildup. Inside the machine was observed a small area of pinkish buildup along the inner rim of the door. -There were extensive areas of dark debris buildup along a broken corner of the wall near the stove. Corners of the kitchen floor were observed with dark debris buildup along edges of the tile floor, baseboards, and corners throughout the kitchen. -Geriatric Nursing Assistant (GNA) 2 was observed entering the kitchen with a snack cooler. GNA2 went to the ice machine and scooped out ice for the cooler. Her hair was not contained in a hair net. During an observation on [DATE] from 10:54 AM until 11:55 AM: -There was an opened and undated bag of frosted flake cereal on the food preparation table. -A window air conditioning unit was observed with a thick coat of dirt and debris coating the air vents. The air conditioning unit was observed blowing air onto metal bowls and colanders stored on a shelf directly in front of the window air conditioning unit. -During an interview on [DATE] at 11:55 AM, Healthcare Services Group District Manager (HSGDM) confirmed the air conditioning unit needed to be cleaned. He removed the metal bowls and colanders away from the blowing air. HSGDM stated that ensuring the floors and baseboard areas of the kitchen were the responsibility of the dietary staff, and confirmed the floors required cleaning. He confirmed that hair and beard nets were to be worn in the kitchen. He stated the backsplash area behind the dishwasher was being replaced. Review of a facility policy titled, Storage of Resident Food, dated [DATE], revealed, Unsafe foods: foods that have visible mold, mildew, foul odors .This may also include food that is expired, outdated or food that has been exposed to incorrect temperatures or other environmental contaminants .Safety for all residents is a priority for food handling .Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for ? 7 days .Foods will be stored in a closed container with sealable lids .Frozen foods must be stored and kept frozen.

Based on record review and interview it was determined the facility staff failed to provide written discharge/transfer notice to the resident and their representative. This was evident for 2 (#22 and #915) of 50 resident's reviewed during the survey. The findings include: 1) Review of Resident #22's medical record on 8/19/24 at 11:41 AM revealed a Social Services note dated 4/4/24 17:38 by the Social Services Director (SSD) indicating Resident #22 was sent to the hospital for evaluation after he/she was assaulted by another resident on 4/4/24. The note indicated the resident's guardian was notified by the Unit Manager of the incident. There was no evidence that the resident and their representative were provided with a written discharge notice. Licensed Practical Nurse (LPN3) who is the Unit Manager was interviewed on 8/19/24 at 2:29 PM. She was asked how the facility provides a written discharge notification to the resident and their representative when transferring to the hospital. She stated, we don't normally provide it in writing we call them, call their person of contact at that time. The Social Services Director (SSD) was interviewed on 8/20/24 at 9:25 AM. When asked if she provided a written notification of discharge to the resident and representative, she indicated she did not. This concern was reviewed with the Administrator and Mobile Director of Nursing (MDON) on 8/26/24 at 2:55 PM. 18819 2) On 08/19/24 reviews of Resident #915's closed medical record revealed the resident was admitted to the facility in January of 2023 and was discharged to another facility in January 2024. Further review of Resident #915's closed medical record revealed social worker documentation that on 11/02/23 at 3:50 PM, the Social Work Director spoke with Resident #915's responsible party and informed them that the facility is planning to transfer Resident #915 to another facility that has a dementia unit. Further review of the medical record failed to reveal documentation that a 30-day involuntary notice of transfer had been issued to the resident or the responsible representative. 08/20/24 at 3:11 PM, in an interview with the facility Social Work Director, the Social Work Director stated that the facility did not issue Resident #915 nor the resident's responsible party a 30-day notice of involuntary discharge. On 08/26/24 at 4 PM the surveyor reviewed this concern with the Administrator regarding failure to provide the transfer notice.

Based on record review and interview it was determined the facility staff failed to notify a resident representative of a resident-to-resident assault. This was evident for 1 (#20) of 50 residents reviewed. The findings include: Complaint #MD00173898 was reviewed on 8/20/24 at 3:45 PM. The complainant indicated Resident #20 informed him/her that on 11/3/21 he/she and a staff person were attacked by another resident however the facility never notified him/her of the incident. Review of Resident #20's medical record at that time failed to reveal documentation related to an incident involving resident #20. In an interview on 8/22/24 at 1:43 PM the complainant identified the staff person involved in the incident as the Activities Director (AD). The AD was interviewed on 8/22/24 at 3:23 PM and indicated she recalled the incident. When asked to describe the events she stated He/She struck us, I got in front, between the two residents, (Resident #912) was hitting (Resident #20) and kicking out at (Resident #20), I tried to stop him/her, and he/she kicked me in the stomach. I told the (former) Administrator, but he didn't think it was serious, so I called the regional, he immediately called the Administrator. When asked if facility staff notified Resident #20's responsible party she indicated that she did not know how staff followed up regarding Resident #20. This concern was reviewed with the Administrator and Mobile Director of Nursing (MDON) on 8/26/24 at 2:55 PM.

Based on medical record review, administrative record review, and staff interview, the facility failed to protect the resident's right to be free from verbal, mental, and physical abuse (R70, R48, R73 #914).These failures affected 4 of 61 residents reviewed for abuse. Findings include: 1. Review of the 5-Day Incident Report, provided by the facility, for R61 and R70 revealed, On 02/08/24, R70 was standing near the vending machine heard two other residents arguing tried to stop argument and one resident (R61) punched him/her in his/her nose R70 visibly upset after the incident, had complaint of bleeding from the nose and was transferred to the hospital for further investigation .Resident denied pain. Resident assessed by inhouse physician, followed by psychological services. No other injuries noted .Conclusion: The allegations were verified .Corrective actions taken: All three residents were separated and placed in a safe area. Police notified and responded to the situation. Skin assessment for all three residents done. Pain assessment done for all three residents. R70 was transferred to hospital and now returned to facility. Physician notified and assessed the residents. Nurse Practitioner assessed all three residents. Psych followed up with all three residents. Social Worker consulted with all three residents. Investigation of incident completed - witness statements and interviews completed. Resident's Representative aware of the incident. Behavior monitoring done for residents. Care plans updated. Inservice education held with staff for Behavioral health training. Education provided to all residents for reporting of such incidents to management staff. 1:1 monitoring completed for R61. Review of R70's undated Admission Record, located in R70's electronic medical record (EMR) under the Profile tab, showed a facility admitted [DATE] and a readmitted [DATE], with medical diagnoses that included anoxic brain damage, altered mental status, and undifferentiated schizophrenia. Review of R70's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/02/24, revealed the facility assessed R70 to have a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R70 was severely impaired. Review of Progress Notes, dated 02/08/24 and located in the EMR Progress Note tab, revealed, [R70] was standing near the vending machine heard two other residents arguing tried to stop argument and one resident [R61] punched him in his nose. Review of R61's undated Admission Record, located in R61's EMR under the Profile tab, revealed R61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include paranoid schizophrenia, malingerer. Review of the quarterly MDS with an ARD of 06/25/24, located under the EMR MDS tab, revealed a BIMS score of 12 out of 15 which indicated R61 was moderately impaired. Review of Progress Notes, dated 02/08/24 and located in the EMR Progress Note tab, revealed, [R61] had physical altercation with another resident [R70] no injuries noted . During an interview on 08/21/24 at 1:50 PM, the Administrator stated, Based on the facility investigation the incident between R70 and R61 did happen. Abuse situations with residents should not happen. 2. Review of the The 5-Day Incident Report, provided by the facility, for R29 and R48 revealed, On 05/03/24, R48 was in the hallway when R29 was displaying agitation, s/he was shoved by R29 and R48 shoved him/her back .R48 was taken to his/her room, the physician was notified, the family was notified, and the police were notified. Psychological services were called to review R29's medications. Staff are doing increased checks on R29 as s/he is refusing one on one observation .Preventative measures to prevent further incidents of similar nature, both residents had PTSD (Post Traumatic Stress Disorder) completed with no signs of trauma. No further interaction between residents. Medications were reviewed with no changes. Review of R48's undated Admission Record, located in R48's EMR under the Profile tab, revealed R48 was admitted to the facility on [DATE] with diagnoses that include schizophrenia, vascular dementia, disturbance, psychotic disturbance. Review of the quarterly MDS with an ARD of 05/05/24, located under the EMR MDS tab, revealed a BIMS score of 99 which indicated R48 was unable to complete the interview. Review of Progress Notes, dated 05/03/23 and located in the EMR Progress Note tab, revealed, .[R48] was in the hallway when another resident [R29] was displaying agitation, s/he was shoved by [R29] and [R48] shoved back. They were immediately separated, and a skin assessment was conducted to check for injuries, no injuries were noted . Review of R29's undated Admission Record, located in R29's EMR under the Profile tab, revealed R29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include schizophrenia, generalized anxiety. Review of the quarterly MDS with an ARD of 06/13/24, located under the EMR MDS tab, revealed a BIMS score of seven out of 15 which indicated R61 was severely impaired. Review of Progress Notes, dated 02/08/24 and located in the EMR Progress Note tab, revealed, .[R29] presented with increased agitation and fell while ambulating her walker . During an interview on 08/22/24 at 9:30 AM, the Administrator confirmed the incident between R48 and R29 did happen. Review of the facilities undated policy Maryland Abuse, Neglect & Misappropriation, revealed, .VI. Protection from Abuse: 2. When the alleged abuse involves a resident-to-resident altercation the residents will be separated by the staff and the appropriate physical assessments will be completed on each resident .VII. 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately .8. Facility staff members, upon hire, are in-serviced on how to and to whom they may report concerns, incidents and grievance with the fear of retribution . 42886 3.) Administrative record review of a facility investigation of alleged employee verbal abuse of a resident on 8/26/24 at 8:00 AM revealed a witness statement from Licensed Practical Nurse #5 (LPN #5) who witnessed the physical and verbal abuse of resident #914 on 1/18/23 at approximately 1:00 PM in the hallway outside of the resident's room. LPN #5 stated that he/she heard Geriatric Nurse Assistant #8 (GNA #8) tell the resident that he/she was being punished. LPN #5 then witnessed GNA #8 direct the resident's wheelchair to face the hallway wall with the wheelchair locked in place. LPN #5 asked GNA #8 while he/she positioned the resident at the wall. GNA #8 did not answer. LPN #5 then turned the resident's wheelchair around so the resident was able to face the hallway. Later in the afternoon, at approximately 2:00 PM, LPN #5 returned to the resident's previous location and noticed the resident's wheelchair was positioned again with the resident's face turned toward the wall. LPN #5 asked GNA #8 if he/she repositioned the resident's wheelchair. GNA #8 would not answer the LPN #5 and began to yell at the resident and LPN #5. LPN #5 then reported the incident to the Director of Nursing (DON). Continued review of administrative records on 8/26/24 at 8:20 PM revealed another witness statement from the facility investigation of alleged physical and verbal abuse of resident #914. This witness statement, dated 1/18/23, was from LPN #6 which corroborated LPN #5's witness statement. LPN #6's witness statement also added that GNA #8 was yelling at resident #914 for his/her shift on 1/18/23. Further review of administrative records on 8/26/4 at 8:30 AM revealed the witness statement from GNA #8 dated 1/18/23. GNA #8 stated that resident #914 asked to be turned toward the wall. GNA #8 also stated in his/her witness statement that he/she was unaware of the resident's diagnosis of altered mental status and if he/she was aware of the diagnosis prior to the incident, he/she would not have positioned the resident's wheelchair towards the hallway wall. Medical record review on 8/26/24 at 9:20 AM revealed resident #914 had instances of altered mental status and the resident's BIMS was 3/15 as of 12/8/22. Review of progress notes revealed that LPN #5 also placed a progress note in the resident's medical record which stated that GNA #8 told the resident, Get off, take your hands off the chair. You are facing the wall. That's your punishment. During an interview with the Executive Director on 8/26/24 at 1:30 PM, the Executive Director admitted that GNA #8 what physically and verbally abusive to resident #914 based on the statement of events listed in the facility investigation of the incident. The Executive Director also stated that GNA #8 was terminated from the facility on 1/18/23.

Based on record review and staff interview it was determined the facility staff failed to thoroughly investigate allegations of abuse. This was evident for 5 (R48, #901,#20, #14, and #913) of 75 residents reviewed during the survey. The findings include: 1) Review of a facility reported incident on 8/19/24 at 11:00 AM revealed Resident #901 was observed on 9/5/23 at 8:55 AM with a large cut above his/her right eye. The facility initiated an investigation. The facility investigation documentation revealed a Witness Statement from a Geriatric Nursing Assistant (GNA) who indicated she observed the injury upon entering the resident's room and notified the nurse. Another statement from the Nurse indicated she assessed the resident and followed facility precautions. 6 Witness statements asked, Did you see any resident fall or sustain a injury? all indicated no. 3 statements indicated they did not know anything about resident #901, and 1 statement indicated the staff member only worked with the residents they were assigned to. The facility's investigation did not demonstrate an attempt to rule out resident abuse or identify the circumstances as to how the resident's injury occurred. 2) Complaint #MD00173898 was reviewed on 8/20/24 at 3:45 PM. The complaint indicated Resident #20, and a staff person were attacked by another resident in the banking area on 11/3/21. The Unit Manager Licensed Practical Nurse (LPN3) was interviewed on 8/21/23 at 12:25 PM. She was unable to find documentation of an incident on or around 11/3/21. The Activities Director (AD) was interviewed on 8/22/24 at 3:23 PM. She confirmed that Resident #912 struck and kicked at Resident #20 and herself. She indicated that she reported the incident to the (former) Administrator, but he didn't think it was serious, so I called the regional, he immediately called the Administrator. The AD added that she wrote a statement and gave it to the (former) Administrator. There was no record that the report of resident-to-resident abuse was investigated by the facility. 3a.) A facility reported incident pertaining to Resident #14 was reviewed on 8/22/24 at 4:00 PM. A Change in Condition Evaluation dated 8/14/23 19:12 indicated that the resident had discoloration to the left lower eye. The facility investigative documents included statements from several staff which indicated that they either observed Resident #14 with or without a black eye or didn't observe him/her at all. The staff were not interviewed to determine when or how the injury occurred. There were no interviews with other residents. The facility's investigation was not thorough and failed to rule out resident abuse or identify the circumstances as to how the injury occurred. b.) Another facility reported incident pertaining to Resident #14 was reviewed on 8/23/24 at 4:30 PM. The report indicated the resident was noticed to have a bruise to his/her left eye at approximately 3:15 PM on 9/4/23. The facility investigative documentation revealed 4 staff statements. 3 indicated the staff members did not see the resident with an injury. The 4th statement by a Licensed Practical Nurse (LPN7) indicated the resident was observed in the hallway after lunch with no injury and that the resident propelled themselves to their room at approximately 2:50 PM. The statement then stated The nurse on the next shift observed the resident with a bruise to the left eyebrow. The resident indicated that (he/she) bumped his/her left eyebrow on the wall. There was no evidence that the facility thoroughly investigated to rule out abuse or identify the circumstances as to how the injury occurred including but not limited to interviews with Resident #14 and other residents, and a statement from the oncoming nurse who discovered the injury. c.) A third facility reported incident pertaining to Resident #14 was reviewed on 8/26/24 at 10:10 AM. The report indicated that on 6/15/23 at 6:40 AM Resident #910 reported being hit on the left side of his/her face with a walking cane by Resident #14. The investigative documentation consisted of 2 staff statements. The first indicated that the writer, a staff member, looked in the room and observed Resident #910 bleeding from his/her face and that Resident #910 reported Resident #14 hit him/her with a cane. The other statement by Registered Nurse (RN1) indicated Resident #910 had a skin tear to the lip below the left nostril, the provider was notified, and a message was left for the Resident Representative. The investigation documentation did not include interviews with Resident #14 or #910 nor other potential witnesses. The final report indicated the residents were separated and assessed and Incident has been substantiated after an in depth investigation. However, there was no evidence that the facility thoroughly investigated, or how they substantiated the allegation. 42886 4) Review of administrative records on 8/20/24 at 9:54 AM which revealed a facility reported incident (MD00196696) which alleged that a staff member was verbally and physically abusive to the resident. The facility investigated the allegations of abuse on 9/7/23. The facility investigation did not an investigation of the events, witness statements or other documents to show that the facility investigated the abuse allegation. During an interview with the Executive Director on 8/20/24 at 1:00 PM, the surveyor pointed out the lack of documentation showing the facility attempted to investigate resident #914's allegation of abuse. The Executive Director attempted to locate the investigative documentation but was unable to find the documents. 30347 Findings include: 5.) Review of the The 5-Day Incident Report, provided by the facility, for R29 and R48 revealed, On 05/03/24, R48 was in the hallway when R29 was displaying agitation, s/he was shoved by R29 and R48 shoved him/her back .R48 was taken to his/her room, the physician was notified, the family was notified, and the police were notified. Psychological services were called to review R29's medications. Staff are doing increased checks on R29 as s/he is refusing one on one observation .Preventative measures to prevent further incidents of similar nature, both residents had PTSD (Post Traumatic Stress Disorder) completed with no signs of trauma. No further interaction between residents. Medications were reviewed with no changes. Review of R48's undated Admission Record, located in R48's EMR under the Profile tab, revealed R48 was admitted to the facility on [DATE] with diagnoses that include schizophrenia, vascular dementia, disturbance, psychotic disturbance. Review of the quarterly MDS with an ARD of 05/05/24, located under the EMR MDS tab, revealed a BIMS score of 99 which indicated R48 was unable to complete the interview. Review of Progress Notes, dated 05/03/23 and located in the EMR Progress Note tab, revealed, .[R48] was in the hallway when another resident [R29] was displaying agitation, s/he was shoved by [R29] and [R48] shoved back. They were immediately separated, and a skin assessment was conducted to check for injuries, no injuries were noted . Review of R29's undated Admission Record, located in R29's EMR under the Profile tab, revealed R29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include schizophrenia, generalized anxiety. Review of the quarterly MDS with an ARD of 06/13/24, located under the EMR MDS tab, revealed a BIMS score of 7 out of 15 which indicated R61 was severely impaired. Review of Progress Notes, dated 02/08/24 and located in the EMR Progress Note tab, revealed, .[R29] presented with increased agitation and fell while ambulating his/her walker . During an interview on 08/22/24 at 9:30 AM, the Administrator stated, the incident between R48 and R29 did happen. I was not able to find any additional paperwork related to the incident investigation. The facility incident investigation failed to contain the initial report of the incident, any interviews of other residents in the facility who could be affected by the actions of R29. There were no notes regarding a Post Traumatic Stress Disorder evaluation of R29, or results of monitoring his/her for additional behaviors. Review of the facilities undated policy Maryland Abuse, Neglect & Misappropriation, revealed, .VI. Protection from Abuse: 2. When the alleged abuse involves a resident-to-resident altercation the residents will be separated by the staff and the appropriate physical assessments will be completed on each resident .VII. Reporting of Incidents and Facility Response: 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 [two] hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

Based on interview, record review, and policy review, the facility failed to ensure residents either had an advanced directive in place or failed to provide the residents and/or their representatives written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for two residents (Resident (R) 61 and R55) of nine reviewed for Advanced Directives. Findings include: Review of the facility's policy titled Advance Directive (Resident's Right to Choose, dated 03/27/24, revealed, Policy Explanation and Compliance Guidelines: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive. l. On admission, the facility will determine if the resident has executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive . 3. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment. The facility will provide the resident or resident representative with information on how to formulate an Advance Directive. The facility will offer to complete a new medical order for life-sustaining treatment based on the resident or resident representative's preference. 4. Upon admission, should the resident have an Advance Directive, copies will be made and placed on the hard chart medical record as well as communicated to the staff. 1. Review of R61's undated Admission Record, located in R61's EMR under the Profile tab, revealed R61 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R61's EMR revealed no documentation that R61 had an Advance Directive or that the facility provided written information to the resident, or the resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Review of R55's undated Admission Record, located in R55's EMR under the Profile tab revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R55's EMR revealed no documentation that R23 had an Advance Directive or that the facility provided written information to the resident, or the resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 08/21/24 at 4:30 PM the Social Services Director (SSD) stated, The residents do not have an advance directive and there is no documentation available for review regarding advance directives or that they were ever given written information. The SSD also confirmed there was no information of a signed Admission Package which would have also included information about the Advance Directive.

Based on record review and interview it was determined the facility staff failed to ensure residents were prepared and oriented to ensure safe and orderly transfer from the facility.This was evident for 1 (#22) of 50 resident's reviewed during the survey. The findings include: Review of Resident #22's medical record on 8/19/24 at 11:41 AM revealed a Social Services note dated 4/4/24 17:38 by the Social Services Director (SSD) indicating Resident #22 was sent to the hospital for evaluation after he/she was assaulted by another resident on 4/4/24. There was no evidence that the facility provided and documented sufficient preparation and orientation of Resident #22 to ensure his/her safe and orderly transfer from the facility. Licensed Practical Nurse (LPN3) who is the Unit Manager was interviewed on 8/19/24 at 2:29 PM. When asked where nurses were expected to document that they prepared and oriented the resident for transfer, she was unable to explain and failed to find documentation indicating Resident #22 was prepared and oriented to the situation prior to transfer to the hospital after the incident on 4/4/24. This concern was reviewed with the Administrator and Mobile Director of Nursing (MDON) on 8/26/24 at 2:55 PM.

Based on record review and interview, it was determined that the facility failed to provide a comprehensive care plan for a resident (resident #902) with a history of substance use disorder. This was found to be true for 1 of 50 residents reviewed during a annual survey. The findings include: Care Plan - This term refers to document which is the written plan of how a long-term care facility will provide care. This plan is based on resident health assessments, preferences and goals. Surveyor review of records on 8/22/24 at 8:15 AM revealed the resident #902 was admitted with records revealing a history of substance use disorder. Continued review of records on 8/22/24 at 8:30 AM revealed the resident's care plan failed to have interventions to prevent or assist with difficulties that can arise with a resident with a history of substance use disorder until the resident was in the facilities for over two weeks. During a surveyor interview with the Executive Director on 8/22/24 at 10:15 AM, the Executive Director admitted that the facility failed to fully develop a care plan that included interventions for substance use disorder.

Based on record review and interview with staff it was determined that the facility staff failed to review and revise resident care plans after each assessment or as resident care needs became apparent or changed over time. This was evident for 3 (#911, #51 and #14) of 50 residents reviewed during the survey. 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. 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 findings include: 1)Review of Resident #911's medical records on 8/19/24 at 1:30 PM revealed the facility administered Narcan, a medication that is used to reverse the effects of an opioid overdose, to the resident on 5/2/23. Review of the resident's care plan found no evidence of interventions for the prevention of substance use in the facility. During an interview with the Executive Director on 8/20/24 at 12:46 PM, the Executive Director admitted that the facility failed to place interventions for the prevention of substance use in the facility after the Narcan administration on 5/2/23. 31982 2)Resident #51's medical record was reviewed on 8/22/24 at 11:13 AM. The record revealed that the facility held a Care Plan meeting with the resident on 11/30/23 after his/her Quarterly MDS assessment dated [DATE]. Another Quarterly MDS assessment was dated 3/8/24 however, the next care plan meeting was not held until 6/4/24, 3 months after the MDS assessment and just prior to the next Quarterly MDS assessment dated [DATE]. The facility failed to ensure that the residents Plan of Care was reviewed and revised by the interdisciplinary team within 7 days after each assessment. The Administrator was asked to provide documentation for all care plan meetings held from 8/17/23 to 6/6/24. The documentation was provided however it did not include evident that a care plan meeting was held within 2 weeks after the Quarterly MDS assessment on 3/8/24 and 6/6/24. 3)A facility reported incident concerning a resident-to-resident assault was reviewed on 8/26/24. The report alleged Resident #14 struck Resident #910 with a walking cane on 6/15/23. The facility substantiated that the alleged assault took place. Resident #14's medical record revealed a Plan of Care initiated on 4/26/18 for behavior history. The resident's goal was (Resident #14) will have no episodes of behavioral problems through the next review date. The most recent revision of the plan of care was on 4/8/22. The Plan was not revised after Resident #14 assaulted another resident on 6/15/23. The surveyor requested the Administrator provide Resident #14's behavior care plan evaluations and revisions including after the alleged assault. He returned on 8/26/24 at 2:20 PM and revealed that the documentation could not be found and confirmed that it was not done. The Administrator was made aware that the plan of care was not evaluated and revised to reflect and address Resident #14's aggressive behavior toward others. These concerns were reviewed with the Administrator and Mobile Director of Nursing (MDON) on 8/26/24 at 2:55 PM.

Based on medical record review and interview with staff it was determined the facility staff failed to develop and implement an effective discharge planning process which addressed each resident's discharge goals and needs and involved the resident and the interdisciplinary team in development, implementation and ongoing evaluation. This was evident for 1 (#51) of 50 residents reviewed during the survey. Maryland's Medicaid waiver program, also known as the Home and Community-Based Services (HCBS) Waivers, provides vouchers to help Maryland residents pay for long-term care services. These services can help people live in their homes, with loved ones, in adult foster care, or in assisted living facilities instead of nursing homes. 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 findings include: Resident #51's medical record was reviewed on 8/22/24 at 11:13 AM. The record revealed the resident was admitted to the facility in 9/2022. A progress note dated 1/20/23 14:21 by the Social Services Director (SSD) indicated she contacted the Waiver program for Resident #51 to enroll in the program, the waiver rep referred the resident to Money Follows the People program. The note indicated the SSD would get a call back the following Friday 1/27/23. There was no further documentation in the record related to the call back. A Social Services Progress note dated 3/27/23 indicated that a waiver interview was held, the application was completed and sent back to the waiver coordinator. A care plan note dated 11/30/23 16:17 by the SSD indicated Resident #51 is on the waiver program wait list and was given an update on the status of his application. However, there was no documentation in the resident's record of what the updated status was. No other updates were found in the record related to Resident #51's application status. Review of Resident #51's comprehensive Care Plan revealed that the facility failed to develop and implement a plan of care related to discharge planning. No documentation was found in Resident #51's record to indicate the facility staff implemented an ongoing discharge planning process including the resident's goal(s), the actions staff were taking to facilitate the resident in reaching his/her goal(s), evaluation of the effectiveness of the interventions and updated to reflect the progress toward reaching the resident's goals. An interview was conducted with the SSD on 8/26/24 at 11:55 AM. She was made aware that the surveyor was unable to find a Plan of Care related to Resident #51's discharge planning. She stated We do a 48-hour care plan at admission, talk to them about discharge. We talk to them at quarterly care plan meetings. (48-hour care plans are completed within 48 hours of admission as an interim baseline plan for staff to follow until the Comprehensive Plan of Care is completed by the interdisciplinary treatment team.) The SSD added that she would add any changes in a note and indicated that she had 2 or 3 progress notes in Resident #51's medical record. When asked where she addressed residents ongoing discharge care planning needs, she replied, in the progress notes and I talk to them ongoing. She confirmed when asked, that she does not develop a Discharge Care Plan and stated no, we just document in the progress notes. This concern was reviewed with the Administrator and Mobile Director of Nursing (MDON) on 8/26/24 at 2:55 PM.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure an injury of unknown origin for 4 of 58 (R8, R35, #20 and #14) reviewed was reported to the state agency and in a timely manner. Specifically, the facility failed to ensure an initial incident report was submitted to the state survey agency within two hours as well as failed to submit the 5- day report following the investigation. This deficient practice had the potential to affect other residents at the facility that had unidentified pain, an injury of unknown origin, unwitnessed fall, or allegations of abuse. Findings include: 1. Review of R8's undated Admission Record, located under the Profile tab in the EMR, revealed R8 was admitted to the facility on [DATE] with diagnoses that included dementia with psychotic disturbance, encephalopathy, and convulsions. Review of R8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23, revealed a Brief Interview for Mental Status (BIMS) with a score of five out of 15, which indicated severe cognitive impairment. Review of R8's modified quarterly MDS with an ARD of 02/21/24, revealed a BIMS with a score of two out of 15, which indicated severe cognitive impairment Review of the Facility Reported Incidents Initial Report, provided by the facility, revealed that on 02/05/24 at 2:15 AM there was an allegation of injury of unknown origin that was identified for R8. The administrator was made aware on 02/05/24 at 10:00 AM. The incident documented that Staff reported resident had c/o (complaint of) pain in RT (right) sided pain in rib cage. Staff reported it to the physician. Resident assessed by Physician and chest x-ray and RT rib x-ray was ordered. Results of x-ray indicated Mildly deformed acute fractures lateral aspects right 9th, 8th and 7th rib. The facility documented that the incident occurred 02/05/24 at 2:00 AM. The report was documented as reported on 02/05/24 at 1:00 PM and submitted on 02/05/24 at 1:15 PM. During an interview on 08/22/24 at 4:18 PM, Administrator stated that he expected injury of unknown source concerns to be reported within two hours, regardless of the time of day or week. He said that by the time the facility submits the five-day summary he hoped to have the cause identified. He confirmed that this was a delay in reporting. 2.Review of R35's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R35 was admitted to the facility on [DATE]. Diagnoses included paraplegia, pressure ulcers, major depressive disorder, muscle weakness, psychoactive substance use, and neuromuscular dysfunction of the bladder. Review of R35's quarterly MDS with an ARD of 07/29/24 found in the EMR under the MDS tab revealed a BIMS, score of 15 out of 15 which indicated that R35 was cognitively intact. Review of R35's Progress Note dated 12/02/23 indicated The change in Condition's reported on this CIC (Change in Condition) Evaluation were: altered mental status. Review of R35's Progress Note dated 12/03/23 indicated Late Entry: R35 was noted hard to arouse with altered mental status. Review of the Initial Facility Investigation Report, dated 12/02/23 revealed on 12/02/23 at 9:20 PM, R35 was noted to be short of breath, unresponsive, and not able to be aroused. R35 received two doses of Naloxone HCI nasal liquid (a medication used to treat known or suspected opioid overdose) 8 mg (milligrams)/0.1 ML (milliliter) one spray in nostril as needed for opioid overdose and may repeat every two-three minutes until patient responds. R35 became more alert and was transported to the hospital on 12/02/23 at 10:12 PM. Review of the initial investigation report revealed a submission date of 12/02/23 at 11:35 PM to the state agency. Documentation of the facility's submission of the five-day final completed investigation for R35 on 12/02/23 was requested by the survey team on 08/21/24 at 6:00 PM. During an interview on 08/22/24 at 4:09 PM the Administrator stated that documentation that the completed investigation had been submitted to the state could not be found. Review of the facility's policy titled, Occurrence Reporting, dated 04/04/24, revealed, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. Occurrences or incidents will be investigated using the Risk protocol for tier reporting and investigation. Occurrences are entered, reported, tracked, and investigated using the electronic or online program with reference to specific types of incidents .The administrator is responsible for the oversight of timely reporting to Federal, State, and Local authorities as appropriate. 31982 Based on record review and interview it was determined the facility staff 1) failed to report an incident of resident-to-resident abuse to the state agency and 2) failed to report an injury of unknown origin timely. This was evident for 2 (#20 and #14) of 50 residents reviewed during the survey. The findings include: 1) Complaint #MD00173898 was reviewed on 8/20/24 at 3:45 PM. The complaint indicated Resident #20, and a staff person were attacked by another resident in the banking area on 11/3/21. Resident #20's medical record was reviewed at that time. No documentation was found in the record related to an incident involving Resident #20 on or around that date. Licensed Practical Nurse 3(LPN3) who is a Unit Manager, was interviewed on 8/21/23 at 12:25 PM. She was asked about an incident occurring on or about 11/3/21 in which Resident #20 and a staff member were assaulted by a resident in the banking area. She was unable to find documentation of the incident. In an interview on 8/22/24 at 1:43 PM the complainant identified the staff person who was involved in the incident, as the Activities Director (AD). The AD was interviewed on 8/22/24 at 3:23 PM. She indicated she recalled the incident. When asked to describe the incident she stated He/She struck us, I got in front, between the two residents, (Resident #912) was hitting (Resident #20) and kicking out at (Resident #20), I tried to stop him/her, and he/she kicked me in the stomach. I told the (former) Administrator, but he didn't think it was serious, so I called the regional, he immediately called the Administrator. The AD added that she wrote a statement and gave it to the (former) Administrator. At 12:00 PM on 8/22/24 LPN3 reported that after rechecking for a resident-to-resident abuse incident on 11/3/21 and the entire year, she was unable to find documentation of an incident. There was no evidence that a report of resident-to-resident abuse was sent to the state agency as required. 2) A facility reported incident pertaining to Resident #14 was reviewed on 8/22/24 at 4:00 PM. A Change in Condition evaluation dated 8/14/23 19:12 indicated that the resident had discoloration to the left lower eye. The facility failed to submit a report of an injury of unknown origin to the state agency until 8/18/23, 4 days after the injury was identified. These concerns were reviewed with the Administrator and Mobile Director of Nursing (MDON) on 8/26/24 at 2:55 PM.

Based on observation and interview with staff it was determined that the facility failed to: 1). consistently monitor and screen visitors and staff upon entry to the facility for signs and symptoms of COVID-19. This was evident for 13 of 13 staff and visitors reviewed; 2). quarantine residents timely when the residents were diagnosed with [REDACTED].#13 and #4); 3). ensure that staff utilized personal protective equipment and proper hand sanitizing practices in a manner that met minimum standards and minimized risk for infectious spread. This was evident for 5 of 27 sampled residents; 4.) ensure all staff were tested weekly for COVID-19. This was evident for 1 of 3 employees reviewed (Staff #22); and 5.) ensure staff that tested positive for COVID-19 did not continue to work in the facility. This was evident for 2 of 3 employees reviewed (Staff #10, #16). These failures have the potential to affect all residents, visitors and staff. As a result of the findings, on Friday, 11/20/20, at 3:45 PM an Immediate Jeopardy was called related to the facility's failure to follow accepted infection control procedures and monitor for compliance. The facility submitted an initial plan of action to the surveyors for review at 6:25 PM on 11/20/20. This initial plan was not accepted. Revised plans were submitted at 8:14 PM which were not accepted. The facility submitted a revised plan of action at 9:15 PM on 11/20/20, which was reviewed by the surveyors and the Office of Health Care Quality. The plan was accepted but the immediate jeopardy was not removed until 12/2/20 at 1:10 PM after the plan of correction was verified to have been implemented. After removal of the immediate jeopardy, the deficient practice remained with the potential for more than minimal harm at a scope and severity of an F. The findings include: On 3/5/20 the Governor of the State of Maryland declared that a state of emergency and catastrophic health emergency exists within the entire state of Maryland related to the spread of COVID-19. On 4/29/2020, the State of Maryland Health Secretary issued a Directive and Order Regarding Nursing Home Matters pursuant to Executive Order No. 20-04-05-01. This Order required that facilities licensed under Title 19, subtitles 3 and 14 of the Health-General Article and [MEDICAL CONDITION] (nursing homes) shall immediately ensure that they are in full compliance with all U.S. Centers for Disease Control and Prevention (CDC), U.S. Centers for Medicare & Medicaid Services (CMS) and the Maryland Department of Health (MDH) guidance related to COVID-19. 1a). On 11/20/2020 at 8:35 AM during entrance to the facility surveyors were asked to have their temperatures taken. Initial temperature results were 95 degrees for the first surveyor. Receptionist #6 was asked if that was an acceptable temperature to which she then stated that she wanted to try again. She then proceeded to change the batteries of the thermometer, stating that it could be the batteries and retook the surveyor's temperature for a result of 96.4 degrees. Surveyors, #1, #2, and #3 then all signed-in on the visitors screening log. Review at 1:00 PM on 11/20/2020 revealed an in-service completed on 9/16/2020 provided to the staff that the parameters for temperature monitoring was 96.6-99.7. If the readings were to fall below the parameters staff were to notify clinical staff. Additionally, the in-service stated to please monitor staff and visitors' signatures on sign-in sheets. If there is a temperature elevation notify clinical staff. A review of the in-service sign-in sheet revealed Receptionist #6's signature, acknowledging participation in the training. Upon signing into the visitor logbook, surveyors reviewed that the previous visitors that had signed in and noted that under initials of person taking temperature, the signature of person reviewing temperature, and symptom review, were blank or had missing entries. Receptionist #6, the current receptionist, was interviewed regarding when the surveyors entered on 11/20/2020 at 8:35 AM signing in on the visitor and staff logs and responsibility for reviewing the sign-in sheets. She stated that she would review them but had not yet during that current shift. The Director of Nursing DON #8 was interviewed at 8:40 AM on 11/20/2020 and asked who was responsible for following-up if someone signed in and marked yes to any of the questions regarding having positive symptoms including loss of taste, smell, cough, or had visited a facility with COVID active residents. He stated the receptionist, him, and/or the infection control nurse were responsible. Surveyor further asked, what happened if someone signed in and marked yes to any of the signs and symptoms and then proceeded to visit or carry on business throughout the facility and no one reviewed the symptoms. He had no answer. During this continued review/interviews regarding the sign in process, Staff #11, later identified as a facility staff member, was observed entering the building without a face mask or any other personal protective equipment (PPE). Before entrance into the facility, there is a foyer where space is provided to apply PPE before entering the facility. Surveyor continued to review the logs for the visitors and the staff concurrently with the DON #8 on 11/20/2020 at 8:50 AM. There were multiple days/evenings/nights that individuals signed in with no documented review of the sign-in symptoms where individuals documented y (yes) under any signs/symptoms of loss of taste and or smell, cough, body aches, shortness of breath, headaches, N/V (nausea/vomiting), diarrhea. Surveyor requested copies of all the sign-in sheets that were available at the front desk at that time. Further review of the sign-in sheets for staff revealed from 11/11/2020 to 11/20/2020: 7 employees documented yes under signs and symptoms. Only 3 were documented as reviewed and 4 were not reviewed. An additional employee signed in on 11/19/20 that did not complete the screening questions and no review was completed. Between 11/11/2020 and 11/20/2020, multiple days were not documented as reviewed. 1b). GNA #10 signed in on 11/10/2020 at 10:45 AM. She marked yes under having any signs and symptoms. A review of GNA #10's timecard reviewed on 11/18/2020 revealed that she worked on 11/10/2020, 11/13/2020, was noted to have called out on 11/15/2020, and tested positive for COVID-19 on 11/18/2020 after facility testing on 11/16/2020. A review of the visitor log revealed 3 visitors who signed in between 11/11/2020 and 11/19/2020 that signed in documenting having signs and symptoms that were not documented as reviewed by any facility staff. These findings were reviewed with the facility at 10:14 AM on 11/20/2020. 2a). On 4/5/2020, the Maryland Secretary of Health issued a Directive and Order Regarding Nursing Home Matters Pursuant to Executive Order No. 20-04-05-01 The order stated: Staff Assignments: Nursing homes shall immediately implement, to the best of their ability, the following personnel practices: - Establish a cohort of staff who are assigned to care for known or suspected COVID-19 residents. Designate a room, unit, or floor of the nursing home as a separate observation area where newly admitted and readmitted residents are kept for 14 days on contact and droplet precautions while being observed every shift for signs and symptoms of COVID-19. Designate a room, unit, or floor of the nursing home to care for residents with known or suspected COVID-19 During observation rounds on 11/20/20 at 8:50 AM, Resident #1 entered the front area from New Wing, which was the facility's positive COVID-19 unit. Resident #1 had on a surgical mask which was tucked under his/her chin. Resident #1 entered 2 double doors that had a sign that read yellow unit residents under observation. This surveyor asked the Administrator, who was standing in the lobby area, why Resident #1 was coming from a positive unit and entering an observation unit. He stated he was unsure. Review of Resident #1's medical record on 11/20/20 at 10:30 AM revealed the resident tested negative for COVID 19 on 11/8/20. 2b). On 11/9/2020 Resident #13 was diagnosed with [REDACTED]. According to test results, Resident #14 was not tested . Review of the residents' census records in the electronic health record (EHR) and nursing progress notes on 11/20/2020 revealed Resident #13 was not moved out of his/her room that was shared with Resident #14 until 11/14/2020. The DON #8, was interviewed, along with corporate staff on 11/23/2020 at 10:30 AM as to the delay in transfer of Resident #13 out of the room and away from Resident #14 as s/he tested positive with COVID-19 on 11/9/2020 and was not moved to another unit until 11/14/2020. He had no answer and stated, I don't know. The DON #8, was also asked why Resident #13 was tested at that time as there were no documented symptoms of COVID-19 and further why Resident #14, the roommate, was not tested . The DON stated that Resident #14 had a history of [REDACTED]. Surveyor stated that Resident #14 had a negative COVID-19 test on 11/6/2020 and agreed to be tested again on 11/9/2020. The facility did not retest Resident #14 at that time although s/he agreed to retest according to the nursing notes that were concurrently read to the DON and the corporate nurse during the interview. Additionally, the DON, had no answer as to why Resident #14 was not tested at that time. As of review on 11/23/2020, Resident #14 tested positive with COVID-19 after being tested on [DATE] when facility-wide testing was completed and was currently requiring oxygen for respiratory support and intravenous antibiotics. 2c). On 11/20/20 at 9 AM, GNA #1 was observed exiting the elevator pushing Resident #4 via wheelchair. GNA #1 was wearing only a mask. Resident #4 had no mask on, and her/his shoes were missing. GNA #1 pushed Resident #4 thru the double doors that had a sign that read yellow unit residents under observation. This surveyor asked the GNA why she was taking Resident #4 to the observation unit. The GNA stated the Resident #4 was being transferred from room [ROOM NUMBER] (Terrace Level) to 7 (Main Hall) because s/he tested positive yesterday (11/19/20) for COVID-19. In interview with the Administrator and DON on 11/20/20 at 9:15 AM, they stated the Main Hall unit was being used for COVID positive and observation residents; however plastic barriers were being used outside of the COVID positive resident room doors. Observation at this time revealed the plastic barriers had tears in them outside resident rooms designated as COVID positive and the room doors were open. A review of Resident #4's medical record on 11/20/20 at 9:30 AM, verified the Resident #4 tested positive for COVID 19 on 11/19/20 during the 7-3 pm shift. During observation of room [ROOM NUMBER] on Terrace Level on 11/20/20 at 9:45 AM it was noted that Resident #4 had two roommates (Resident #2 and Resident #3); both residents were cognitively impaired. It was later determined that Resident's #2 and Resident #3 were negative for COVID-19. Although staff was not made aware of this until testing was completed on 11/20/20, they were aware that Resident #4 was positive on 11/19/20 and continued to cohort all residents together in the same room. During an interview on 11/20/20 at 10:00 AM with Charge Nurse Staff #3, she stated that Resident #4 tested positive on 11/19/20 and she made the Administrator and the DON aware of the results. When asked why Resident #4 was not transferred to the COVID positive unit on 11/19/20, she also stated, I was waiting for directives from the DON and Administrator before I moved the resident. This surveyor then asked if any protective devices were put in place with the shared room while Resident #4 was waiting for transfer, Staff #3 replied No. In interview on 11/20/2020 at 2:58 PM with the DON, he was asked if he was aware that Resident #4 was positive for COVID-19 yesterday (11/19/2020) and he stated yes and was further asked why the resident was not moved. He stated, I don't know. On 11/20/20 at 10:30 AM during observation of the Main Hall where Resident #4 was transferred to room [ROOM NUMBER], no protective barriers were located in front of room [ROOM NUMBER]. Resident #4's door was open and s/he was observed lying in bed in a double room without a roommate and a mask. 3). On 5/8/2020 The Centers for Disease Control and Prevention released updated guidance on Hand Hygiene noting that hand hygiene should be performed in the following situations: before resident contact, even if PPE (personal protective equipment) is worn; after contact with the resident; after contact with blood, body fluids, or contaminated surfaces or equipment; before performing aseptic tasks; and after removing PPE. The facility failed to ensure that staff utilized personal protective equipment and proper hand sanitizing practices in a manner that met minimum standards and minimized risk for infectious spread. 3a). An observation tour of the Main Hall was conducted on 11/23/20 at 11:00 AM. While touring the back hallway, an observation was made of 6 PUI 's (Person Under Investigation for Covid-19 Virus) rooms and Personal Protective Equipment (PPE). There were no PPE bins in front of PUI Rooms #12, #14, #18, #22, #26 where residents resided, but a PPE bin was observed hanging on the wall in front of room [ROOM NUMBER], which was located at the end of the hall. The PPE bin was observed and contained no gowns, no masks, no gloves, and no eye coverings. 3b). On 11/23/20 at noon observation of the lunch service on the Main Hall unit (Person Under Investigation for Covid -19 Virus) was conducted. Surveyors noted GNA #10 in the hallway. The GNA wore a protective gown as she carried three disposable trays from the service cart and entered room [ROOM NUMBER]. The GNA was observed as she placed one plate on each bedside table and exited the room. The surveyor observed that although there was a hand sanitizer dispenser available in the hallway the GNA failed to use it. Also, GNA #10 did not attempt to remove her gown before she exited the room. The Dietary Manager approached to re-educate however, the GNA proceeded to pass him and continued to pass out trays. The surveyor approached the GNA and asked her why she wasn't changing her gloves and or using hand sanitizer between residents. GNA #10 replied that no one told her about changing gloves between residents. The GNA also stated she thought everyone on the unit was negative. She was not aware that Main Hall was an observation unit. Continued observation on 11/23/20 at 12:30 PM GNA #15 was observed entering Resident #18's room without wearing gloves. Resident #18 was noted to be a PUI. GNA #15 was asked to explain what was the appropriate PPE that was to be worn before entering a resident room noted to be a PUI. GNA #15 stated that a gown, mask, eyewear, and gloves are to be worn; however, there was no PPE on the unit. In interview with the DON after the observation, the DON stated that there was plenty of PPE in the facility and he didn't know why the PPE bin was empty. Another staff, GNA #16 left the unit to obtain PPE for the unit. The DON stated that the facility will get additional bins to place in front of each PUI room. The DON was asked who was responsible for ensuring that staff were following Infection Control guidelines and he stated the educator (Staff #19) was responsible for staff education as well as monitoring to ensure that the guidelines were followed. The DON stated that all staff were always to wear a mask and eyewear inside the facility and that the staff will be re-educated. 3c). Observation was made on 11/24/20 at 12:35 PM of GNA #15 exiting room [ROOM NUMBER] wearing a white Tyvek suit and gloves. There was a yellow sign on the door which indicated the resident was on the PUI unit for COVID 19. GNA #15 then went to the clean linen cart and removed a towel and washcloth from the cart and entered room [ROOM NUMBER] to assist the resident with care. GNA #15 did not put on a new gown or change gloves before going into the room. GNA #15 did not remove the white Tyvek suit gown after she came out of room [ROOM NUMBER] and did not sanitize her hands before going into room [ROOM NUMBER]. 4). Staff #19, identified as the prior infection control nurse and education nurse, was interviewed on 11/23/2020 at 10:58 AM. She was asked how staff were notified about upcoming facility testing. She stated that there was a notification text that goes out to all employees. She was next asked about the staff line listing and how the facility monitored staff coming in to get tested . She stated that those staff members that do not come in to get tested are supposed to be removed off of the schedule and get a 'star next to their name, however, she further stated that quite a few do not get removed. Review on 11/24/2020 of the staff listing of employees tested last on 11/16/2020, including the make-up testing days through 11/19/2020 revealed that Staff #22 was not marked as tested from 11/16 to 11/19/20. Review of Staff #22's timecard revealed that he worked in the facility on 11/17, 11/18, 11/19 and 11/21/20 without getting tested in the facility or notification to the facility of getting tested elsewhere. This was reviewed with Corporate Staff #20 on 1:10 PM on 11/24/2020. 5.) Review of Staff #10's timecard revealed that she worked on 11/10/2020, 11/13/2020. Staff #10 signed in on 11/10/2020 at 10:45 AM. She marked yes under having any signs and symptoms related to COVID. Staff #10 was noted to have called out on 11/15/2020 and tested positive for COVID-19 on 11/18/2020 after facility testing was completed on 11/16/2020. These findings were reviewed with the facility at 10:14 AM on 11/20/2020. 6.) The timecard and COVID-19 result for Staff #16 was reviewed on 11/23/2020. Staff #16 was tested on [DATE] for COVID-19. On 11/12/2020, positive results were reported back to the facility. According to the timecard for Staff #16, she took off on 11/12/2020 and worked on 11/13, 11/14 and 11/15/2020. This was reviewed and confirmed with Corporate Staff #20 on 11/23/2020 at 10:17 AM. The Director of Nursing (DON) was asked on 11/23/2020 at 2:02 PM who was responsible for reviewing the test results of employees. He stated the Administrator #7 who was active at that time was responsible when the infection control nurse went out on leave around 11/8/2020 and no longer was reviewing them. The DON further stated that he would be responsible from now on to review the employee test results. This was reviewed with Corporate Staff # 20 on 1:10 PM on 11/24/2020. Cross Reference F 885 and F 886 On Friday 11/20/20, at 3:45 PM an Immediate Jeopardy was called related to the facility's failure to follow accepted infection control procedures and monitor for compliance. The facility submitted an initial plan of action to the surveyors for review at 6:25 PM on 11/20/20. This initial plan was not accepted. Revised plans were submitted at 8:14 PM on 11/20/20, which was not accepted. The facility submitted a revised plan of action at 9:15 PM on 11/20/20, which was reviewed by the surveyors and the Office of Health Care Quality. The plan was accepted but the immediate jeopardy was not removed until Wednesday 12/2/20 at 1:10 PM after the plan of correction was implemented. A review of the facility plan of correction on 12/1/2020 at noon regarding the training of staff related to concerns identified in the immediate jeopardy initially revealed 56 of 89 staff identified in the staffing list that was provided to the survey team that were not trained and educated before the stated compliance date of 11/27/2020. The survey team repeatedly asked Staff #20, the corporate mobile director of nursing on 12/2/2020 if the survey team had the most updated employee list and the correct documentation of training before the review. Surveyors asked Staff #12 , the Regional Administrator for the timecards of all the staff on the list that were not documented as having been trained to determine if they worked after the 11/27/2020 facility plan of correction date (POC). Further review on 12/2/2020 of the employee timecards of staff on the staffing list not identified as being trained per the facility POC revealed a total of 12 staff that worked after the 11/27/2020 alleged compliance date from the POC submitted on 11/20/2020. The facility presented on 12/2/2020 an updated staffing list of the current active staff of all disciplines. Staff #20 also presented documentation of the staff that were educated according to their plan before 11/27/2020 that had been previously identified by the surveyors as not trained. On 12/2/2020 at 1:00 PM Staff #20 presented the survey team with documentation that all staff on the schedule had been educated and the plan moving forward for those staff that were not currently on the schedule which included sending certified letters to their address notifying them that they are unable to return to work until the education included in the plan of correction was completed with verbalized understanding. The Immediate Jeopardy Abatement Plan included: The facility Quality Assurance/ Performance Improvement (QAPI) Committee initially met on 11/20/20, regarding the Immediate Jeopardy and implemented an internal plan of correction. The following plan of correction was developed: Monitor for Covid-19 symptoms responses upon entering the facility. Staff #6 was immediately educated to report to the supervisor any Staff or Vendors who presented with signs and symptoms per the COVID-19 screening sheet. Staff # 6 was educated not to allow persons into the facility without a face shield, goggles, or mask past the foyer into the facility. Staff # 11 immediately removed PPE from the bag and DONNED. Staff # 11 educated to DON mask or eye shield /goggles before entering the facility. Educated all staff members to sign-in on the COVID-19 screening sheet upon entering the facility and assure. Educated all staff to DON mask and eye shield or goggles in the foyer area. Front desk clerk/designee will monitor the sign-in screening sheet with each entry of staff and vendors to identify those with symptoms of covid-19 and refer persons to supervisor for follow-up before facility entry House Supervisor working off shifts will monitor sign-in screening sheet with each entry of staff and vendors to identify those with symptoms of covid-19 before facility entry DON/Designee will monitor the COVID-19 sign-in screening sheet, and review sheet at the start of each shift, and periodically throughout the day. DON/Designee will be validated compliance daily with the COVID-19 screening sheet. Front desk clerk/Designee to assure staff and vendors DON PPE before allowing entrance to the facility. All staff educated on Screening Sheet modification to include supervisors being contacted for abnormality on screening sheet, and superior must be verified and review of employees, and vendors. All staff educated on the need to DON mask and eye shield when entering the foyer. Staff will not be allowed to return to work until in-service is completed. Northwest will be submitting reports and audits to QAPI for review monthly for 3 months. Cohorting of resident together: Resident # 4 room move completed. Residents #2 and 3 tested by POC and PCR with POC results negative and PCR results pending. Additional Covid-19 unit created. Repairs made to existing covid- 19 unit. All Residents tested by PCR and POC immediately. Residents testing positive by POC and PCR are isolated immediately upon receipt of results. RDO educated ED and DON on proper cohorting of covid-19 positive residents and the importance of moving residents immediately Facility staff educated on proper cohorting of covid-19 positive residents and the importance of moving residents immediately. Facility Staff educated regarding assuring walls are in proper repair and reporting to Administrative staff Administrator to assess covid-19 units daily for needed repair. Staff will not be allowed to work until the Inservice is completed. Director of Nursing to audit covid-19 test results for residents to identify positive covid-19 cases daily and with resident test completed due to new onset of symptoms. Administrator to audit covid-19 units daily Audits to be reviewed monthly at the Quality Assurance Performance Improvement Committee to assure all residents weekly test results have been reviewed and covid-19 positive residents are moved and cohorted appropriately. Results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for 3 months, the Committee will determine the need for further audits and/or action plans Have a secure unit to prevent the spread of COVID-19 from vulnerable adults and individuals. Additional Covid-19 unit created. Repairs made to existing Covid- 19 unit. Facility Staff educated regarding assuring walls are in proper repair and reporting to Administrative staff. Administrator to assess covid-19 units daily for needed repair Staff will not be allowed to work until the In-service is completed. Administrator to audit covid-19 units daily. Audits to be reviewed monthly at the Quality Assurance Performance Improvement Committee. Results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for 3 months, the Committee will determine the need for further audits and/or action plans.

Based on review of the facility investigation, medical records, interviews with facility staff and other pertinent documentation it was determined that the facility failed to: 1) notify the physician of the worsening condition of Resident #1's wound after maggots were discovered on 6/13/19, resulting in the resident being transferred to the hospital for further evaluation, 2) to document such worsening condition accurately and timely in the medical record, and 3) provide and implement a revised plan of care to meet the resident needs. This was true for 1 of 4 residents (Residents #1) reviewed as part of the complaint survey that ended 7/15/19. Based on the findings, on (MONTH) 11th, 2019 at 3:35 PM an Immediate Jeopardy was called related to the neglect of Resident (#1). After removal of the immediate jeopardy, the deficient practice remained for 3 days with the potential for more than minimal harm and a scope and severity of a D. The findings include: By way of history, Resident #1 was hospitalized in 9/2018 at (county name) and transferred to (hospital name) after being found on the driveway with ants and maggots on his/her face. Resident #1 was admitted to the nursing facility in (MONTH) (YEAR), with a [DIAGNOSES REDACTED]. According to the hospital discharge summary dated 9/28/18, the resident was transferred to the facility for management of his/her [DIAGNOSES REDACTED] and rehabilitation services due to resident's inability to care for his/herself in the community. Review of Resident #1's medical record on 7/3/19 at 11:30 AM, revealed the that on 9/28/18 Sodium Hypochlorite Solution was ordered to be applied to his/her body topically two times a day for melanoma skin rash; 7-3 PM and 3-11 PM shift until 1/4/19. A nursing note dated 9/29/18 at 6:42 AM documented: resident has melanomas all over the body, refused to receive treatment. Some bleeding occasionally. Review of Resident #1's treatment administration record for (MONTH) (YEAR) revealed all treatments signed off 7-3 PM and 3-11 PM shift as being administered for the entire month. Resident #1's (MONTH) (YEAR) record revealed the order for Sodium Hypochlorite Solution applied to the body topically two times a day for melanoma skin rash. For 11/15/18 (3-11 PM shift) and 11/16/18 (3-11 PM shift) staff documented 5 (treatment held). Review of the medical record on 7/11/19 at 8:10 AM revealed a nursing note dated 11/15/18 at 18:51 (6:51 PM) and 11/16/18 at 22:09 (10:09 PM), which revealed the Sodium Hypochlorite Solution was not available from the pharmacy. Review of Resident #1's medical record revealed a 12/11/18 order renewed for Sodium Hypochlorite Solution--apply to body topically two times a day for melanoma skin rash 7-3 PM and 3-11 PM shift. All treatments were signed off on 7-3 PM and 3-11 PM shift as being administered for the entire month of December. In addition, a nursing note dated 12/16/18 at 10:40 PM documented: facial Myeloma on left cheek appears larger than usual. A care plan note dated 1/2/2019 at 11:18 AM revealed the following: Resident #1 is resistive to care. Refusing to seek medical attention/intervention for the melanoma growing out the side of his/her face. The resident declined the oncologist to remove the growth on his/her face. Refused several attempts to send him/her to the emergency room for treatment of [REDACTED]. The Unit Manager and the Director of Nursing spoke with the resident about the melanoma growing bigger and the need to seek medical attention/intervention. The resident stated that it does not hurt s/he is just fine and s/he has been picking pieces of it slowly but surely; resident RP made aware. January 2019 physician orders [REDACTED]. According to the medical record, the treatment was administered on 1/1/19, 1/2/19, 1/3/19, and 1/4/2019 on 7-3 PM shift and 1/1/19, 1/2/19, 1/3/19 on 3-11 PM shift. On 1/4/19 the Sodium Hypochlorite Solution was discontinued. On 1/10/19 a new physician order [REDACTED]. Review of the medical record on 7/11/19 failed to reveal why treatment was discontinued. Further medical record review revealed that nursing staff continued to document concerning the resident's melanoma. The following documentation was noted the resident's record: -1/16/19 at 05:22 AM Nursing note - Resident scheduled for oncology appointment on 1/28/19. Resident denies pain. Melanomas growing rapidly; -1/28/19 at 2:37 PM Nursing note - resident was seen by oncology doctor. The resident refused treatment for [REDACTED]. The recommendation is for palliative care. Responsible Party (RP) and physician aware; -1/28/19 at 10:51 PM Nursing note- Follow-up treatment for [REDACTED]. The resident received the treatments from 1/11/19 thru 1/31/19 with no refusals documented. Review of a 2/28/19 at 6:48 PM wound care nursing note revealed wound care visited Resident #1 to assess the resident's left arm wound, however, the resident refused and requested the visit be rescheduled. Treatment records showed that Resident #1 refused the treatment with Dakin's Solution to the face bid (two times a day) for melanoma on 2/20/19 at 8 AM and on 2/4/19 at 4 PM, however, there were no progress notes related to refusal. A skin/wound nursing note dated 3/1/19 at 7:17 PM stated, Resident has a history of facial melanoma sites . Treated with Dakin's Solution twice per day . The resident has a history of refusing surgical interventions . No refusals were documented on the Treatment Administration Record (TAR) for (MONTH) 2019, for the resident's facial Dakin's solution. On 2/6/19, a new order was placed for wound treatment to Resident #1's left forearm with the instructions: Dakin's Solution to left forearm every day. Pat dry and apply secondary Oil [MEDICATION NAME] dressing, place dry dressing, wrap with Kling. Review of the resident's TAR for (MONTH) 2019, revealed that Code '9' was entered on 3/20/19 and 3/23/19. No progress notes could be found addressing either date. On 7/11/19 @ 8:36 AM- Interview with Staff #10 revealed that code 9 indicates there should be a nursing note to explain why the medication was not given. No refusals were documented on the TAR for (MONTH) 2019, for the resident's facial Dakin's Solution. The wound treatment ordered to the resident's forearm was administered on 4/1/19 and 4/2/19 and then was discontinued. A new order was begun on 4/3/19 with instructions: Dakin's solution to left arm, apply [MEDICATION NAME], crushed to wound bed, apply secondary Oil [MEDICATION NAME] dressing, place dry dressing, wrap with Kling. It was documented as administered for the remainder of the month except for 4/3/19 when a code 9 was entered. No related progress notes could be found to explain the code 9 on 4/3/19. Resident #1's medical record review indicated that from 5/1/19 - 6/30/19, Resident #1 was still ordered the Dakin's solution to left arm, apply [MEDICATION NAME], crushed to wound bed, apply secondary Oil [MEDICATION NAME] dressing, place dry dressing, wrap with Kling, and Dakin's Solution to the face bid (twice a day) for melanoma. There were no refusals documented for these treatments during this time period. Continued review of Resident #1's medical record revealed a nursing note written by the Director of Nurses (DON), dated 7/1/19 at 16:29 (4:29 PM): Resident's tumor on the left side of the face was assessed today. Area boggy and appeared infected .The resident's physician was notified, and the resident was sent to the hospital. Review of complaint MD 217 on Wednesday 7/3/19 at 6:30 AM, revealed that on 7/1/19 a Police Officer responded to an Emergency Medical Services call at this facility. Upon arrival, the Officer was advised by the medic that Resident #1 had a severe wound on the left side of his/her face and the wound was filled with full-grown maggots. The officer reported that the maggots were crawling around on the resident's face. Review of 911's (EMS) Emergency Medical Services summary on 7/3/19 at 7:00 AM, revealed the following: On 7/1/19 a call was received from (Northwest Nursing) Facility for a reported hemorrhage/laceration of a vulnerable adult. At 16:04 (4:04 PM) upon EMS arrival, Resident #1 was in his/her room, seated upright in bed with dried blood stained on his/her pajama top, neck and bilateral hands. The resident had what appeared to be bruising on the face and darkened areas underneath his/her eyes. The Resident had head wound/mass to the left side of his/her face with indentations and exposed tissue. The resident appeared to have sluggish, active bleeding from the mass on the left side of his/her head; resident appeared to be alert and oriented and was able to relay some pertinent information his/her name and birth date to EMS. Upon EMS asking the resident what happened regarding his/her head, the resident touched the wound and stated that s/he had it for months, it's always been there. During EMS further assessment to the resident head/face wound, small movements were noted within the wound. Upon further inspection, the resident had a maggot infestation that appeared to be embedded deep into the wound. The resident denied any pain or symptoms pertaining to his/her head/face. The resident has also had a bandage on the left forearm. The resident stated, the staff changes it sometimes. A supervisor was requested. The Director of Nursing, as well as a supervisor, entered the room, asking what the issue is? And when questioned about the resident's wound and maggot infestation, all the staff reported that they did not know of the problem nor how the maggots got into the wound. The resident's head wound was wrapped with gauze and cling while still in the facility by EMS. EMS contacted the (city name) Police Department to report possible abuse/neglect of a vulnerable adult. A Police Officer responded. The police escorted EMS to the hospital. Review of Resident #1's hospital medical record from (hospital name) on 7/3/19 at 8 AM, revealed a nursing noted dated 7/1/19 Resident #1 presented to the Emergency Department (ED) from the nursing home via EMS with bleeding from the facial wound. Past medical history included [DIAGNOSES REDACTED]dementia. The resident had a large lesion on left facial area, nose and left lower arm from [MEDICAL CONDITION]. The facial lesion was bleeding and infected with maggots. EMS reported the nursing home staff did not know what was going on with the resident. When asked for a supervisor s/he was reportedly abrupt with EMS and stated the resident does not allow staff to change his/her dressing. According to the ED documentation, the resident was cooperative and pleasantly confused in the ED and allowed staff to a place dressing on [MEDICAL CONDITION]. The resident was admitted with a fever of 38.5 (101.3). During an interview with the Hospital 4th floor Unit Manager on 7/3/19 at 9 AM, s/he stated that Resident #1, had allowed the hospital nursing staff to cleanse and dress his/her left facial area and left lower arm without refusal. During an interview with the hospital case manager on 7/3/19 at 9:15 AM, s/he stated that due to neglect issues the resident would not be returning to the previous nursing home. During an interview with Resident #1 on 7/3/19 at 9:30 AM at the hospital, when questioned about the wounds on his/her left side of the face and the left arm, the resident stated, I had it for months, it started to bleed so they sent me here. S/he stated that the wound on his/her left arm resulted from his/her fall on the driveway a year ago. The resident was observed by this surveyor, with a dressing to the left side of the face and arm during the interview. During an Interview with the DON on 7/3/19 at 1 PM, the DON stated that Resident #1 was transferred to the hospital on [DATE] after maggots were found, in the wound on the left side of Resident #1's face. During the interview, the DON admitted to seeing the maggots. When asked why he did not document them, he stated, the nurse should have documented the incident. The DON was then asked were maggots noted on the resident's face prior to 7/1/19. The DON stated, this is the first time, I heard of (the maggots). During an interview with the surveyor on 7/3/19 at 1:15 PM the Administrator, stated, the resident was sent to the hospital on [DATE] after the nurse saw maggots coming from the resident face. When asked had this occurred before, the administrator replied no. An interview with the surveyor on 7/9/19 at 3:30 PM revealed the wound nurse (Staff #20) revealed the Resident #1 was seen by the wound care team every three weeks for a left-arm lesion. The wound nurse stated, I knew nothing about the (maggots) until 7/2/19 when I returned from vacation. In an interview with the surveyor on Tuesday 7/9/19 at 3:40 pm, the Wound Care Doctor (Staff #21), stated, s/he was not notified of maggots being found on Resident #1's face. During an interview with the 3-11 nursing supervisor (Staff #10) on 7/9/19 at 4 PM, s/he stated that Resident #1 was on the lower level and s/he had not seen the resident. Staff #10 reported the first-time s/he heard of the maggot incident was when the police came to the facility on [DATE] in the evening. During an interview with the surveyor on 7/9/19 at 6 pm, the Terrace Charge Nurse (Staff #17) stated sometime in (MONTH) (was not able to remember whether it was the beginning/middle or end of June), I went to clean Resident #1's wound with Dakin's Solution as ordered by the physician on the left side of his/her face. During the treatment, I noticed maggots coming from the wound on his/her face. I took the resident into the bathroom and removed the maggots using a suture removal kit. I then reported the incident to the 3-11 PM supervisor (Staff #10). When asked why Resident #1's medical record failed to reveal any documentation that the resident was noted with maggots prior to 7/1/19, Staff #17 replied, the 3-11 PM supervisor (Staff #10) told me not to document the incident. When asked by the surveyor, if the physician was notified, Staff #17 replied no. Staff #17 stated that s/he did contact the Unit Manager (Staff #29) and made him/her aware of the incident. On 7/9/19 at 6:30 PM during a second interview with Staff #10, s/he amended his/her previous statement to include s/he was made aware of the maggots on 6/13/19 around 11 PM by Staff #17. S/he (Staff #10) stated, I told the nurse (Staff #17) to clean the area up. I also notified the wound nurse the next day. When asked by the surveyor if s/he documented this in the resident record or notified the physician, s/he replied no. This surveyor asked if s/he saw Resident #1's face that night after being informed of the maggot's and Staff #10 replied, yes, I saw the maggots. During an interview with the surveyor on 7/10/19 at 11:30 AM, the New Wing/Terrace Level Unit Manager (Staff #29) stated, that on 6/14/19, I was informed by the nurse (Staff #17) about maggots being on Resident #1's face. I then texted my DON about it. He called me and told me to go to the unit and see for myself if there were maggots on Resident #1's face. There weren't any maggots present at the time. I asked Staff #17 did (s/he)inform the supervisor when (s/he) saw them, (s/he) stated the supervisor told me not to document anything. I called the wound nurse to inform (him/her) of the maggots. (S/he) stated, (s/he) would contact the Wound Doctor. Meanwhile, all you can do is clean it with Dakin's Solution. I had informed my Administrator about the maggots, and he asked if the DON was made aware. I told him 'yes'; I was told by the DON. On 7/10/19 at 12 noon by phone, Resident #1's primary physician (Staff #22) was interviewed. S/he stated, the first time I was notified about this resident having maggots was by the DON on 7/1/19. On Wednesday 7/10/19 at 1 PM, the Regional Director of Operations (Staff #14), Regional Director (Staff #15), and the Director of Clinical Services (Staff #16) asked to meet with this surveyor. It was revealed at that time the facility had started an investigation after interviewing Staff (#17 and #29) on 7/9/19. Staff #14 stated the DON and the Administrator had prior knowledge that Resident #1 had facial maggots prior to 7/1/19 and there was no documentation and/or physician notification done. Staff #16 stated the DON and the Administrator were placed on suspension for neglect of Resident #1, pending the outcome of the investigation. A review of the DON and Administrator personal file on 7/10/19 at 1:30 pm, verified the suspensions. During an interview with Nurse #30 on 7/11/19 at 8:00 AM, s/he stated code 5 means the treatment was on hold and there should be a nursing note for that date and time. On 7/11/19 at 8:36 AM, during interview with Staff #10, she revealed code 9 indicated there should be a nursing note to explain why the medication was not given. On 7/11/19 at 9:28 AM, Resident #1's primary care physician was interviewed, s/he stated, the resident is seen by the Nurse Practitioner and s/he come to the facility on Tuesdays but does not see all his/her residents. When asked about the lapse in treatment from 1/4/19 -1/10/19, s/he stated the resident was refusing the treatments. On Thursday 7/11/19 at 1:45 PM, Resident #1's primary physician (Staff #22) was interviewed for the second time in the facility. S/he stated, the first time I was notified about this resident having maggots was by the DON on 7/1/19. It is not unusual for this to happen, due to the resident's refusal of treatments. The area was decaying, but no one ever notified me of Resident #1 having maggots to face area, prior to 7/1/19. When asked by the surveyor if s/he would have changed the plan of care for Resident #1. The physician replied, yes .the situation would have been considered critical then. I would have sent him/her out to the hospital. Review of Resident #1 TAR (Treatment Administration Record) on 7/11/19 at 2 PM, revealed that from 9/2018 thru 7/1/2019, Resident #1 was documented as refusing treatment to the left facial [DIAGNOSES REDACTED] wound his/her wound approximately 5 times. Review of the facility pest control log on 7/11/19 at 2:30 PM, revealed Resident #1's room was treated for [REDACTED]. On 7/11/19 The facility submitted an initial plan of action to the surveyors and the Office of Health Care Quality for review at 8:15 PM. This initial plan was not accepted and a revised plan was submitted at 8:32 PM on 7/11/19 which was not accepted. The facility submitted a another revised plan of action at 9:35 PM on 7/11/19 that was reviewed by the surveyors and the Office of Health Care Quality. The plan was accepted on, 7/11/19 but the Immediate Jeopardy was not removed until 7/15/19 at 3:13 PM, after the plan of correction was implemented. The Immediate Jeopardy Abatement Plan included: The resident was transferred to the hospital and admitted for wound evaluation and treatment on 7/1/19. The Director of Nursing and Nursing Home administrator were suspended pending investigation of neglect due to delay in reporting a change in condition initially identified 6/13/19 to the physician and due to the omission of documentation in the medical record. State reportable event was completed on 7/10/19. Upon further investigation, the decision was made to terminate the Director of Nursing due to gross misconduct and neglect. A report was made to the [NAME]land Board of Nursing on 07/11/19. The facility was notified on (MONTH) 10, 2019, by the hospital Social Worker, that the resident will not be returning to this facility. Identification of Others: Current residents will have a skin check completed, documented on a Shower Sheet audit and new orders/treatments as appropriate with Care plan updates. Completed 7/11/19. Current residents have the potential to be affected by neglect. The current residents deemed interview able are interviewed related to the possibility of abuse/neglect on 7/11/19 using the Resident interview and Observation tool (CMS- ). In addition, non-interview able residents will be observed using the Centers for Medicare and Medicaid services Family Interview and Observation tool (Form CMS- ). Identified issues will be immediately investigated and reported as necessary. Clinical meeting Interdisciplinary Team will review progress notes for the last 2 weeks for identifying a change in conditions, wound complications and notification of the MD for change in conditions, in accordance with regulation. They will also be monitoring for instances of potential abuse. Completion date 7/11/19. Education: Staff development coordinator will provide education to current staff on the definitions of abuse/neglect, investigation, and prevention of abuse/neglect. Those not able to be reached will be sent notice that they must complete the education related to abuse/neglect prior to the start of their next shift. New Hires will have their background checked for potential previous abuse complaints. Annually and upon hire, the staff is provided education on the abuse reporting, investigation and monitoring systems. The Staff will have a competency test completion to document understanding of training material. Full time and Part-time staff will have abuse/neglect education completed by (MONTH) 12, 2019. Nurses will be provided education by the Staff Development Nurse on the proper comprehensive documentation of skin areas requiring treatment and updating Care plan, Treatments as ordered. MD notification and the completion of the Concurrent Review will also be included in the education as to reporting Change in Condition of residents and completed by (MONTH) 12, 2019 Department Heads were trained by Regional Leadership on neglect, integrity and the requirement for proper reporting of neglect. This was reviewed during the Ad Hoc QAPI meeting on 7/10/19. System Change: Weekly Wound rounds completed by the Interim DON/Unit Managers (UM) will validate the presence of wounds identified. The documentation of the wounds will be completed on the Weekly Wound Log as well as validation of Care plan and Treatment interventions. Monthly during leadership rounds, three interview able residents per week will be interviewed for potential abuse and neglect. Additionally, 5 non-interview able residents per week will have completed the Centers for Medicare and Medicaid services Resident Interview and Observation tool (Form CMS- ). The 24-hour report will be reviewed by the Interim DON/UM daily for changes in condition, proper notification of the MD, RP, and documentation in the medical record. The Quality of Care log will be utilized to review for additional auditing by the Regional Director of Clinical Operations weekly x 4 weeks. Monitoring: An audit by the Registered Nurse (RN) Unit Managers weekly of 3 Residents with wounds to ensure assessments are timely and completed with new conditions, admissions or change in condition and include proper order for treatment and care planning of interventions. This audit will be completed 3x weekly then monthly x 3 by the RN Unit Managers. Weekdays the Social Service Director will review grievance log for potential allegations of abuse/neglect that may need investigation and follow up. This will be completed weekly x 3 then Monthly x 2. The Quality of Care log will be utilized to review for additional auditing by the Regional Director of Clinical Operations weekly x 4 weeks. Result of all audit trends will be reviewed through QAPI meeting monthly X 2 for trend and change in plan needed by the Administrator/Regional Director of Clinical Operations.

Based on medical record review and staff interview it was determined the facility failed to: 1) provide ongoing supervision to Resident #3 who was known to have smoked marijuana and cigarettes in his/her room and had an episode of suspected drug overdose requiring the administration of [MEDICATION NAME]; and 2) investigate these incidents to prevent future occurrences. This was evident for 1 of 3 residents reviewed for safety/supervision during this complaint survey. The facility's failure to provide adequate supervision for Resident #3 and promptly investigate the repeated incidents of illicit drug use, smoking violations and develop a definitive plan for safety and prevention of harm for current and future residents, posed an immediate threat to resident health and safety. Therefore, an immediate jeopardy situation was identified on (MONTH) 22, 2019 at 2:26 PM. The facility submitted an acceptable plan of action at 9:48 PM on (MONTH) 22, 2019 that was reviewed and accepted by the survey team and the Office of Health Care Quality. The immediate jeopardy was removed on (MONTH) 24, 2019 at 4:15 PM while the surveyor was on-site. After removal of the immediate jeopardy, the deficient practice remained for potential for more than minimal harm and at a scope and severity of D. The findings include: A Resident Smoking Policy with a review date of 4/1/16 noted smoking hours are posted by the facility and smoking materials are secured in a locked area when not in use by the resident. Medical record review on 5/17/19 revealed Resident #3 was admitted to the facility in (MONTH) 2019 for skilled nursing services with [DIAGNOSES REDACTED]. A Smoking Assessment completed on 2/8/19 revealed the resident was determined to be an independent smoker with supervision. The form noted that selecting the independent designation indicated the resident did not require supervision or other accommodations to maintain safety during smoking. The designation of an independent smoker that requires supervision is inconsistent with the facility's policy. A Behavior Note dated 2/9/19 at 10:18 PM reported that at approximately 9:50 PM the resident had a visitor, after which the writer smelled the strong odor of Marijuana smoke coming from the resident's room. The resident's door was locked on the inside and after several knocks on the door from security and other staff the resident unlocked the door to reveal even more pungent smell of Marijuana smoke coming from the room. The medical record contained a document entitled Guidelines for Resident Behavior that was signed by the resident on 2/11/19. The document contained information regarding rules relative to smoking, drug and alcohol use, and possession of weapons in the facility. It was noted that non-compliance with the rules could result in the initiation of a behavioral management plan, referral to local law enforcement or discharge from the facility. A care plan with initiation dates of 2/13/19 and 4/24/19 addressed the resident's desire to smoke and that the resident was assessed as an independent smoker. Interventions included monitoring the resident's safety during smoking and to complete a smoking assessment, quarterly, annually and with a change in condition. 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. A Behavior Note dated 2/17/19 reported the resident had visitors that day in her/his room. The writer, licensed practical nurse (LPN #1), noted a towel was placed at the bottom of the door, inside the resident's room, and the room smelled of marijuana. It was noted that the building manager and security were notified to witness the smell in the room. The writer documented that s/he would continue to monitor throughout shift for any other changes in behavior. There was no evidence of an investigation regarding how the resident obtained the smoking materials or if staff were able to determine if the smoking materials were brought in by visitors. A Care Plan note dated 3/4/19 at 4:58 PM reported the resident was noted to be smoking marijuana in the shower room on 3/3/19, was educated about the smoking policy and was asked to turn over any lighter, cigarettes, or marijuana s/he may have still had in her/his possession. It was noted that the resident denied smoking and having possession of a lighter, cigarettes, or marijuana. A Social Services note dated 3/4/19 reported the resident was re-educated on the facility Smoking Policy and the Guidelines for Resident Behavior that s/he signed on 2/11/19. The resident was informed that any continued non-compliance of the Smoking Policy could possibly lead to an involuntary discharge notice being given. A Nurses Note dated 3/11/19 at 11:23 PM reported the resident was in the shower room smoking. The resident denied smoking when asked by the nurse. The resident was educated on the danger of smoking inside the facility. A Behavioral Health Services note dated 3/13/19 noted the resident was evaluated for continued use of marijuana at the facility. It was noted the resident denied use of marijuana even though staff noted the smell of marijuana coming from the resident's room on multiple occasions. The Behavior Management Plan, noted by the Nurse Practitioner, was that staff would provide structured socialization, structured activities of daily living (ADL) care, and staff were to approach the resident respectfully and be clear about upcoming nursing care. This plan was compared to a plan for Resident #2 and found to be identical, therefore not individualized for Resident #3. Activities of Daily Living, ADLs refer to daily self-care activities such as bathing, grooming, eating and dressing. A Behavior Note dated 3/26/19 at 10:44 PM reported the resident was demanding staff to take her/him outside to smoke at 10:15 PM. S/he was educated and redirected on the time schedule for smoking, but stated s/he did not care because s/he needed to smoke to calm her/his nerves. The resident was reportedly yelling/screaming, cursing at staff and broke the hand rail close to the nurses' station. The resident threatened to wake all the patients up on every floor and smoke in her/his room and burn the building down. The Supervisor was made aware. A Skilled Documentation note dated 4/4/19 at 2:23 PM reported the resident had a visitor with whom s/he went outside in the courtyard and smoked Marijuana. It was noted that the resident was re-educated on the risks of her/his behavior but denied using/smoking marijuana. A physician's note dated 4/9/19 noted that per reports from nursing staff the resident had been meeting people online, bringing them into the facility and was caught smoking weed given to her/him by these individuals. On 4/10/19 the psychiatric Nurse Practitioner documented that the resident was encouraged to avoid using marijuana at the facility. The medical record contained care plans, with initiation dates of 4/24/19 that addressed a behavior problem related to smoking marijuana and cigarettes in the facility and/or allowing guests to smoke in her/his room, a history of marijuana abuse/substance abuse and soliciting staff for money to purchase marijuana. Interventions included but were not limited to assisting the resident to develop more appropriate ways of coping, encourage the resident to express his/her feelings appropriately, discuss behaviors, explain why behaviors are inappropriate, intervene as necessary to protect the rights and safety of others, and obtain a psychiatric consult as needed. Specific interventions to maintain the resident's safety including adjusting the level of supervision was not addressed. A Smoking assessment dated [DATE] indicated the resident was an independent smoker requiring supervision. The resident's care plan directed staff to reassess the resident with a change in condition. The resident had multiple episodes of smoking in non-designated areas before s/he was reassessed. A Behavior Note dated 5/5/19 at 11:32 PM reported the resident was smoking in her/his room and was educated on the risks of smoking in bed. A Behavior Note dated 5/7/19 at 10:54 PM noted the resident was smoking Marijuana along with another resident in her/his room. The resident told staff to go away when they knocked to enter the resident's room. It was noted that the resident was educated on the risks/danger of smoking in her/his room. A Behavioral Health services note dated 5/9/19 reported the resident's visiting privileges were taken away due to smoking in her/his room. The facility issued a notice to the resident, dated 5/9/19 that her/his visiting privileges were suspended for 1 week. A Care Plan note dated 5/10/19 at 12:23 PM reported that on 5/9/19, the resident was noted to be drowsy, incoherent and could hardly open her/his eyes and could not propel herself/himself in the wheelchair. The physician was notified and ordered the resident to be given [MEDICATION NAME] which was administered. It was noted that the [MEDICATION NAME] was effective. A Nurses Note dated 5/14/19 at 11:35 PM reported the Resident was in another resident's room and staff smelled cigarette smoke coming from the room. A Behavior Note dated 5/18/19 at 11:30 PM reported the resident was noted to be smoking in her/his room during rounds at the beginning of the shift. The writer reported the resident started spraying air freshener, but the room was still filled with cigarette smoke and s/he was re-educated on the risk of smoking in the room. During an interview with the surveyor on 5/17/19 at 3:45 PM the Director of Nursing (DON) was asked what actions were taken regarding Resident #3's repeated non-compliance with the smoking policy. The DON stated the Social Worker would usually talk to the resident about non-compliance and issue a 30- day notice if the problem persists. A Social Services note dated 5/21/19 (during the survey) at 6:09 PM noted the Social Worker met with the resident to discuss and re- educate him/her on the Guidelines for Resident Behavior- contract that was signed upon admission. The discussion was to re-educate on the facilities smoking policy. This writer did inform the resident of the no tolerance for smoking in the facility or having cigarettes and lighting material in possession or stored in resident rooms. This writer did discuss visitor guidelines including visitors' obligation to forward smoking material to the supervisor or front desk to be given to Activities staff for locked storage. The resident was told if s/he was found in violation of the smoking policy s/he would be given a 30-day discharge notice for continued violation of the facility's smoking policy and the Guidelines of Resident Behavior contract. In interview with the surveyor on 5/21/19 at 12:35 PM the Social Services Director stated s/he had been meeting with the resident's caseworker to discuss the behaviors. The Social Services Director stated s/he has a behavior contract with the resident and has reviewed that with the resident several times. The Social Worker was referencing the Guideline for Resident Behavior. During an interview with the surveyor on 5/21/19 at 3:45 PM the Administrator stated s/he did not issue a 30-day notice for continued violation of the smoking policy because s/he thought Resident #3's discharge was imminent and because the facility had not identified a safe discharge destination. During an interview with the surveyor on 5/21/19 at 4:05 PM the attending physician stated she gave an order for [REDACTED]. A Drug screen done on 5/9/19 was negative for opioids or other illicit drugs. The surveyor asked if staff knew how the resident may have obtained illicit substances and she replied that she did not know but there's a lot of trading going on out back (referring to the courtyard). The physician stated she was aware of the resident's marijuana use. Stated she did not discontinue the resident's [MEDICATION NAME] because the resident does not ask for it and would like to keep the order in case the resident experienced severe pain. The physician further stated she believed the resident was competent and was not interested in addressing substance use. During an interview with the Administrator on 5/22/19 at 11:15 AM the surveyor asked about the process for implementing a behavior management plan as outlined in the Guidelines for Resident Behavior and s/he stated the facility reached out to the resident's caseworker to ascertain what services or resources were available to the resident that could be utilized while the resident was in the facility. During this interview the surveyor discussed concerns that a behavior management plan had not been developed for the resident. The facility's failure to contact law enforcement regarding the presence of illicit substances in the facility, as outlined in the behavior contract, impose further visiting restrictions, and conduct investigations to ascertain how the resident was getting smoking materials and illicit substances was also discussed. As a result of these findings, an immediate jeopardy situation was identified on (MONTH) 22, 2019 at 2:26 PM. The facility submitted an initial plan of action to the surveyor and the Office of Health Care Quality for review at 5:08 PM. This initial plan was not accepted. Revised plans were submitted at 8:33 PM and 8:55 PM. PM which were not accepted. The facility submitted a revised plan of action at 9:48 PM that was reviewed by the survey team and the Office of Health Care Quality. The plan was accepted but the immediate jeopardy was not removed until 5/24/19 at 4:15 PM. The plan included: * Police were notified regarding resident's visitor bringing in drug paraphernalia on 5/22/19 * The Resident was placed on a 1:1 monitoring on 5/21/19; * The Resident's visitations will be supervised only, beginning 5/21/19; * The Resident was reassessed for smoking safety on 5/21/19; * The Resident's room was searched for smoking materials on 5/21/19; * The Resident was re-educated on the smoking policy on 5/21/19; * The Resident's room was checked for illicit drugs and smoking materials on 5/21/19; * The resident is to engage in smoking activities only under supervision. 5/21/19; * The resident's care plan was updated to reflect new interventions on 5/21/19 & 5/22/19; * An Ad Hoc QAPI meeting conducted to review updated Smoking Policy on 5/21/19; * Residents who smoke were re-educated that all smoking paraphernalia will be secured and locked up by staff. 5/21/19; * Smoking assessments were completed on residents at risk for smoking. 5/21/19 & 5/22/19; * Nursing staff will reassess residents smoking assessments. 5/22/19; * Smoking area was assessed for all safety equipment including ashtrays, aprons, fire extinguishers, etc. 5/21/19; and *Care plans updated to reflect most current assessment. 5/22/19. Education: * All residents who smoke were reeducated on the facilities smoking policy and process 5/21/19; * Staff education was provided to the staff to go over the smoking policy and process Started 5/21/19; * Front desk staff are being reeducated to ask all visitors and residents returning on LOA if they have any smoke paraphernalia. If they do, they need to get the items and give them to the nurse to secure; * The nurse will be reeducated on properly completing a smoking assessment and the nurse managers and social worker on updating the care plan; * Supervisors will be reeducated to conduct thorough investigations for residents smoking in the facility or in possession of illicit substances; Systems Change: * If a resident and or visitor is caught smoking in their room and or using illicit substances the supervisor, Executive Director (ED), Director of Nursing (DON) and Medical Director (MD) and law enforcement must be notified and a thorough investigation will be completed ED and or DON; * Social services will educate all new residents on the smoke policy; * Nursing supervisors will be educated to observe for smoking in the facility when they are completing rounds; * Patient's families and or responsible parties will be sent a letter informing them not to bring residents any smoking paraphernalia rather bring it to the facility staff; and * The Behavior contract is being reviewed. Monitoring: * Nursing supervisor and or Social worker will audit daily X 5 d, then weekly for 3 weeks and then monthly X 3 will search residents who are smokers for having smoking paraphernalia in their rooms or on their possession. Audits will be reviewed at QAPI. Once it has been determined that enhanced system interventions and monitoring have been made, the frequency of the auditing process will be determined. * Audits will be completed of investigations of residents smoking in their room or using illicit substances weekly for intervention, care plan and investigation purposes for the next 4 weeks and then monthly x 3. * Audits will be completed of smoking assessments for new admissions to ensure accuracy of the smoking accuracy and care planned for the next 4 weeks and then monthly x 3 * Education will be completed by the end of the day 5/23/2019. * Staff will be educated prior the onset of the shift. The surveyor conducted an extended survey on (MONTH) 23, 2019 and (MONTH) 24, 2019 that included a review of other residents that were identified as smokers to determine if assessments and care planning regarding safety needs were appropriate. The surveyor also reviewed in-service training, policies and procedures related to smoking and conducted additional staff interviews to determine their knowledge of the process for assessment and care planning for residents who smoke and the policies related to smoking.

Based on observation, staff interviews, and review of medical records and other pertinent documentation, it was determined that the facility failed to maintain a safe environment for a resident with documented high-risk elopement behavior. This was evident for 1 of 3 residents (#240) reviewed for elopement. The facility's failures in this case led to the determination that an immediate jeopardy situation existed, and the facility was notified of this determination on (MONTH) 1, (YEAR) at 6:37 PM. An acceptable plan of removal was received, and the immediacy removed on (MONTH) 2 at 12:00 AM. After removal of the immediacy, the deficiency remained for potential for more than minimal harm at a scope and severity of D for all remaining residents. The findings Include: On 3/1/18 review of the medical records revealed that Resident #240 was admitted to the facility in (MONTH) (YEAR) for long term care and with [DIAGNOSES REDACTED]. The [MEDICAL CONDITION] type of [MEDICAL CONDITION] disorder is characterized by the symptoms of two combined mental illnesses: [MEDICAL CONDITION], marked by hallucinations, delusions and disordered thinking; and [MEDICAL CONDITION] disorder, marked by mood changes that cycle from depression to mania. A review of Resident #240's clinical record revealed a care plan that was initiated on 1/6/16 which documented that the resident was an elopement risk and had a history of [REDACTED]. Interventions included: distract resident from wandering by offering pleasant diversions, structured activities; Identify pattern of wandering; Monitor location and document wandering behavior and attempted diversional interventions in behavioral log; and provide structured activities. There was no documentation of the level of supervision required in this initial care plan. The clinical record also revealed 2 physician certifications of incapacity to make informed decision dated 8/25/16. Review of the 6/21/17 Minimum Data Set (MDS) assessment also revealed that the resident was noted to be assessed as having a BIMS (brief interview for mental status) of 6 out of 15. BIMS scores are categorized as follows: 13-15 indicate cognitively intact, 8-12 indicate moderate impairment and 0-7 indicates severe impairment. On 3/1/18 review of the medical record revealed a nursing note completed on 8/29/17 which documented the resident climbed the fence using a ladder, and later was found on the street by staff and complaining of left leg pain. Further review of the medical records revealed that the physician was called and gave a verbal order for left leg and hip x-ray and to complete checks every 10-minute. Review of the paper chart revealed a hand-written order, dated 8/29/17 at 3:45 PM, to monitor the resident every 10 minutes for elopement. No order was found to discontinue these 10-minute checks. Further review of the paper chart and the electronic health record failed to reveal any documentation of these 10-minute checks. Further review of the electronic health record failed to reveal any documentation that the order for the 10-minute checks had been entered into the electronic health record system and thus the order was not found on the electronic treatment administration record. On the evening of 3/1/18, after reviewing that no documentation was found in the medical record that the 10-minute checks were implemented, the DON and corporate nurse presented the survey team with Safety check log sheets that they reported they found in the Director of Nursing's office. These Safety check log sheets were hand-written and failed to reveal any documentation as to which staff person was completing the checks. Two of the eight sheets failed to include the resident's name or a date. Each sheet had spaces to document for an approximate 12-hour period. Three of the eight safety check log sheets had documentation for less than 5 hours. The latest date shown on these sheets was 9/2/17. Further review of the physician orders [REDACTED]. No documentation was found as to why the 10-minute checks were not continued beyond 9/2/17. The only physician ordered intervention, found in the electronic health record for (MONTH) (YEAR), was an order to monitor for elopement every shift. This order was originally written on 1/6/16. On the evening of 3/1/18 the Maintenance Director reported, regarding the events of 8/29/17, that a contractor had left a ladder in the courtyard. He also reported that the resident did not make it over the fence. Review of the medical record as well as a written statement by a GNA (Staff #36) who was a witness to the 8/29/17 elopement revealed the resident climbed a ladder and got over the fence. Further review of the medical records revealed a second elopement care plan that was initiated on 8/31/17 which stated: (name of resident) is an elopement risk AEB (as evidenced by): Actual Elopement and attempt. Interventions included: observe for changes in behavior and/or verbalizing desire to leave the facility and notify appropriate parties; and provide 1 on 1 supervision as needed. Further review of the care plan for elopement failed to reveal any information regarding the 8/29/17 order for 10-minute checks, which were documented on the Safety check log on 8/29/17. Further review of the care plan failed to reveal who the appropriate parties were that were to be notified of verbalization of desire to leave. Nor was there any clear indication as to when 1 on 1 supervision would be needed and provided. Review of the psychologist notes revealed a note written on 9/15/17 which indicated the resident reported that he/she was ready to get out of there. The note also revealed that the resident was delusional. An additional note written on 9/22/17 documented the resident stated, I wanna get the (explicative) outta here. No documentation was found that the psychologist notified any staff of the resident's verbalization of a desire to leave the facility, as was indicated in the care plan. Review of facility reported incident MD 352 revealed that Resident #240 was last seen in the facility on 9/23/17 during change of shift at 3:00 PM. At 3:25 PM the resident was not in the facility. A review of the facility investigation revealed that on 9/23/17 Resident #240 eloped from the facility by going through an open gate in the courtyard. Details of the investigation revealed that on 9/23/17 at 3:50 PM, the resident walked out of the gate. A resident informed the staff at the reception desk that the resident walked out of the open gate and went up the street pointing upward (up the street). The facility self-report indicated measures to prevent further incidents included: 1. 5 second lock has been installed to the door leading to the courtyard. 2. A stronger self-closing spring has been ordered for outside gate 3. A new keypad access to open outside gate has been installed 4. New policy implemented for staff to escort all vendors to the outside gate to ensure it is properly locked after their exit. The facility provided Elopement In-service sign-in sheets with staff signatures dated 9/26/17 but failed to provide any documentation on what in-service was provided. On 3/1/18 at 2:15 PM the Administrator reported that at present when a vendor arrives they can call the reception desk, the receptionist can enter a code that unlocks the access gate to allow the vendor to enter. The receptionist will then stay on the phone with the vendor and watch (via video) to ensure the gate is locked. The Administrator also reported that prior to the (MONTH) elopement the gate lock could be unlocked by simply pushing a button which was located at the reception desk and another at the lower level nursing station. He went on to state that they discovered that the button could be pushed by accident and the gate could unknowingly be unlocked. On 3/1/18 at approximately 3:00 PM the surveyor asked Nurses #1 and #2 if a key pad was present at the nurse's desk, and they both confirmed there was and that they knew the code. When asked if anyone escorts the vendors out of the building, they replied no. They indicated that sometimes they (staff) watch them; they (the vendors) are familiar with the area and sometimes security walks them out. On 3/1/18 at 3:08 PM the gate was checked for the new spring to observe the self-closing gate. The gate did not close on its own. This was observed by the Administrator as well at 3:13 PM. On 3/1/18 review of the facility's policies regarding elopement revealed they were most recently revised in (YEAR). No documentation was found in these policies regarding staff escorting vendors to the outside gate to ensure it was properly locked after their exit. Observation throughout the survey revealed the reception desk is located on the main floor of the facility. The main entrance to the facility is not wheelchair accessible. This access gate is used for any entrance to the facility requiring wheels, i.e.: wheelchairs, stretchers, x-ray equipment, and large deliveries. The access gate is in a courtyard which enters the lower level of the facility. The access gate can only be observed from the reception area and the lower level nurse's station via video. The courtyard contains the facility's smoking area. The facility has six scheduled smoking times per day. At the time of the survey the facility had 35 residents who smoked. On 3/2/18 the psychologist wrote a progress note which revealed the following: At no time did this writer seek to notify staff that pt (patient) was an imminent risk of elopement because there was no indication of such. This note went on to state: When pt was seen by this writer on 9/15/17 and 9/22/17, (s/he) continued to express (his/her) feelings of anger and desire to leave but had no plan and no outward signs of exit-seeking. (His/her) behavior during those two days was similar to that of (his/her) other sessions, with no indication of an escalation of (his/her) behavior. This behavior is fairly commonplace with many of my patients in nursing homes and assisted living facilities. On 3/6/17 at 4:14 PM the Administrator confirmed that in (MONTH) the resident made it over the fence, down to the street and around the corner. He confirmed that this incident was not reported to the State Agency and stated that this does not commonly happen but was not an elopement because the resident was within staff sight the entire time. As a result of these systematic failures, an immediate jeopardy situation was identified on (MONTH) 1, (YEAR) at 6:37 PM. The facility submitted an acceptable plan of removal on (MONTH) 1, (YEAR) at 11:30 PM that included the following: -All staff to be re-educated on the policy regarding escorting vendors in and out of the facility. -All staff currently working were educated immediately, all others will be educated prior to working their next scheduled shift. -A 1:1 will be placed on the back door leading to the courtyard until a stronger self-closing mechanism can be installed. -All door codes will be changed immediately and a schedule to change monthly will be implemented. -All residents at risk for elopement will be assessed to assure the appropriate interventions are in place to prevent any elopement occurrence. -The Interdisciplinary team will review each resident identified as an elopement risk upon admission, quarterly, and after any documented attempt to leave the building to assure appropriate interventions are in place. -The Director of Nursing will review all residents to determine to be at risk for elopement weekly to assure all interventions are being followed. The results of the audit will be discussed at the Monthly QAPI meeting for six months. -A copy of the Vendor Access Protocol, which was used in the training for all staff was also provided and reviewed. -Review of the Vendor Access Protocol, which was used as the training for all staff, included the following: 1. Once a vendor arrives to the facility they must check in with the front desk and sign in. 2. Prospective department head/director/supervisor must meet vendor and bring them in to the building either through the back gate or front door. Vendors must be accompanied through the building while making the deliveries. Ancillary service providers (x-ray, lab, pharmacy) will be met at the gate, however will be allowed to go to their location without an escort. 3. Once the vendor has completed their business, they must sign out and be escorted out of the building. Ancillary service providers will notify the Nursing Designee (Supervisor/DON/unit manager) who will then escort them off the property. 4. At no time is the gate to be unlocked from the front/nurse station without an escort available. 5. No vendor may call in to request the gate to be unlocked. They must come in and sign in when they arrive. The immediate jeopardy was removed on (MONTH) 2, (YEAR) at 12:00 AM after confirmation by the survey team that the facility's plan had been implemented.

Based on staff interviews and review of the facility's investigation, it was determined that the facility staff failed to protect a resident from physical abuse. This was evident for 1 of 3 residents reviewed during a complaint survey. The findings include: Resident #3 is a cognitively impaired resident who suffers from effects from a stroke and difficulty speaking. Review of the facility documents, dated 05/06/2013 at 6:45 pm, on 06/12/2013, revealed that resident #3 was observed in a verbal altercation with GNA #1 over nourishments. The facility documents indicated that resident #3 cursed at GNA #1, snatched the nourishments from GNA #1, and also hit GNA #1. GNA #1 was then witnessed calling a family member and asking the family member to come to the facility. The facility documents then indicated that GNA #1 was observed entering the security code, to the front door, which allowed GNA #1's family member access to the facility. GNA #1's family member was then observed running to resident #3's room and physically abusing resident #3 by slapping and beating resident #3 until he fell to the ground. Resident #3 was then observed with a cut to the left side of the lip. GNA #1 was then observed entering the security code to the front door which allowed GNA #1's family member to exit the facility. In an interview with GNA #2 on 06/26/2013 at 6:48 pm, GNA #2 stated that attempts were made to calm GNA #1 down. GNA #2 stated that GNA #1 was encouraged not to call a family member. GNA #2 stated that GNA #1 was then witnessed going the front door and entering the door code to allow GNA #1's family member to enter the facility. GNA #2 stated that GNA #1's family member was witnessed running down the hall towards resident #1 and then witnessed GNA #1's family member start beating resident #1 until he fell to the ground. The facility staff failed to protect resident #1 from physical abuse.