Every finding on record at Oakwood SNF LLC

Based on record review and staff interview, it was determined that the facility failed to ensure notice of resident transfers and discharges were submitted to the representative of the Office of the State Long Term Care Ombudsman. This deficient practice was identified during annual survey and had the potential to affect all residents who experienced a transfer or discharge.The findings include:On 02/27/2026 at 9:40 AM, during an interview with the Administrator, the surveyor requested documentation indicating that the Ombudsman has been notified of monthly transfers and discharges between October 2025 to December 2025. The Administrator stated that she would gather the requested information and follow up with the surveyor.At 12:30 PM, the Administrator followed up with the surveyor and stated that the facility had failed to submit monthly transfer and discharge notices to the Ombudsman. The surveyor inquired when the Ombudsman was last notified of resident transfers and discharge. The Administrator stated that notices had not been submitted since she began employment at the facility in September 2025.

Based on interviews and record reviews, it was determined that the facility failed to ensure residents were offered the opportunity to formulate Advanced Directives. This was found to be evident for 6 (#1, #2, #90, #11, #7, & #8) out of 7 residents reviewed for Advanced Directives planning during the recertification survey. The findings include:1) On 02/25/2026 at 9:17 AM, the surveyor requested the Director of Social Services provide documentation that Residents #1, #2, and #90 were provided opportunities to formulate Advanced Directives. On 02/25/2026 at 11:58 AM, The Director of Social Services stated that he was unable to find documentation that Advance Directives were offered to Residents #1, #2 and #90. 2) On 2/24/26 at 1:50 PM, the surveyor reviewed Resident #11's medical record. The review revealed that Resident #11 was admitted to the facility in April of 2025 and was deemed capable of making his/her own medical decisions. On further review there was no documentation to indicate if Resident #11 was asked if he/she would like to formulate them. On 2/26/26 at 8:41 AM, the surveyor conducted an interview with the Director of Social Service Staff #14. During the interview Staff #13 stated he also could not find documentation to indicate advanced directives were offered. On 2/26/26 at 9:47 AM, the surveyor conducted a follow-up interview with Staff #14. During the interview Staff #14 stated that he had reviewed and assisted Resident #11 in initiating advanced directives 3) On 02/25/2026 at 8:13 AM, review of Resident #7's medical record failed to reveal indication that they had an advanced directive nor that they were asked about advanced directives upon admission. 4) On 02/25/2026 at 8:20 AM, review of Resident #8's medical record failed to reveal indication that they had an advanced directive nor that they were asked about advanced directives upon admission. On 02/25/2026 at 10:10 AM, an interview with the Director of Social Services (Staff #14) revealed that each resident who was admitted to the facility was asked if they had an advanced directive, and if not the facility would ask if they would like to be provided information to make one. The surveyor indicated they were unable to find documentation regarding advanced directives for Resident #7 and #8, and Staff #14 indicated he would provide documentation. On 02/25/2026 at 11:48 AM, Staff #14 provided a document titled, Social Service Initial Evaluation, dated 2/28/2024 for Resident #7 which indicated the resident did not have an advanced directive, but failed to reveal indication that the facility offered the resident information to create one. At the same time, the surveyor was provided the same document titled, Social Service Initial Evaluation, dated 9/10/2025 for Resident #8 which failed to indicate advanced directives were addressed with the resident as it did not indicate whether the resident had an advanced directive or not, there was only mention of the resident's code status. On 02/25/2026 at 11:51 AM, an interview with Staff #14 revealed he was unable to provide further documentation for advanced directives for Resident #7 and #8. The surveyor reviewed the concern and he indicated that he understood.

Based on interviews and record review, it was determined that the facility failed to ensure residents were provided with summaries of their baseline care plans. This was found to be evident for 1 (#13) out of 8 residents reviewed for care planning during the recertification survey. The findings include: During a record review on 02/26/2026 at 12:11 PM, documentation could be found that a baseline care plan was initiated, however there was no documentation that the care plan was reviewed and a copy provided to Resident #13 or the responsible party. The Administrator was requested to provide the information to the surveyor.On 02/26/2026 at 11:46 AM, the Administrator stated that she was unable to find documentation of a baseline care plan being given to Resident #13 and/or the responsible party.

Based on observations and staff interviews, it was determined that the facility staff failed to provide services necessary to maintain a sanitary environment. This was observed on 1 (room [ROOM NUMBER]'s) bathroom during the initial tour. The findings include: On 2/24/26 at 10:29 AM, the surveyor observed a toilet plunger next to the toilet inside a plastic bag in room [ROOM NUMBER]. On further observation a brown liquid substance was noted coating the bottom of the plastic bag. On 2/26/26 at 7:01 AM, the surveyor conducted an interview with the Maintenance Director Staff #17. During the interview Staff # 17 stated that when there is a plunging need identified, maintenance will get a work order to fix the concern. He confirmed that plungers should not be kept in soiled plastic bags in Resident's bathrooms and would remove it from room [ROOM NUMBER]'s bathroom.

Based on record review and interview, it was determined that the facility failed to ensure a resident's PRN (as needed) psychotropic (mental health) medication order was no longer than 14 days without a provider's rationale. This was evident for 1 (Resident #10) of 5 residents reviewed for unnecessary medication.The findings include:On 02/25/2026 at 11:17 AM, review of Resident #10's medical record revealed an active order for Hydroxyzine (a medication that calms anxiety/stress) 10mg every 12 hours as needed for anxiety, with a start date of 1/23/2026.On 02/26/2026 at 9:44 AM, an interview with the Director of Nursing regarding PRN psychotropic medication orders revealed that they should be limited to 14 days at a time unless the provider had given a rationale for the extended need. The surveyor requested a copy of Resident #10's active order and the psychotropic medication policy. On 02/26/2026 at 11:42 AM, the surveyor was provided the documents requested above. Review of the document titled, Antipsychotic Medication Use, revealed indication that PRN psychotropic medications should be limited to 14 days unless a provider documented a rationale for the extended order. On 02/26/2026 at approximately 11:45 AM, the surveyor reviewed the concern with the Director of Nursing and she indicated that she understood the concern.

Based on interviews, observations, and record reviews, it was determined the facility failed to ensure a residents right to self-determination by honoring the resident's preference regarding the timing of blood sugar monitoring. This deficient practice was evident for one (#4) resident reviewed for self-determination during the annual survey.The findings include:On 02/24/26 at 7:30 AM, the surveyor conducted an initial tour of the facility. At 8:07 AM, the surveyor asked a Certified Medication Aide (CMA) #4 what time breakfast trays typically arrive to the unit. The CMA #4 stated trays usually arrive between 8:30AM and 9:00AM.On 02/24/26 at 8:10 AM, the surveyor observed Resident #4 in their room. At 1:37 PM, an interview with Resident #4 revealed the resident had concerns regarding elevated blood sugar levels.On 02/25/26 at 11:31 AM, a review of Resident #4s Medication Administration Record (MAR) revealed a physician order to check fasting blood sugar daily at 6:00 AM. Between 02/01/2026 to 02/25/2026, the resident refused fasting blood sugar checks on 21 of 24 occasions. A separate order to check bedtime blood sugar daily at 10:00 PM, revealed the checks were completed on 23 of 24 occasions.A review of progress notes from Nephrology, the Primary Physician, and Endocrinology Nurse Practitioner from January and February 2026 all documented that the resident refused blood sugar checks.At 11:58 AM, during an interview, Resident #4 stated they refused blood sugar checks because staff were waking them between 5:00 AM-6:00 AM, and they did not want to be woken that early. The resident further stated they had communicated this to staff on multiple occasions, but nothing had been done.At 12:26 PM, during an interview with the Director of Nursing (DON), she confirmed she was aware of Resident #4s history of refusing blood sugar checks but stated she did not know the reason for refusals. The surveyor informed the DON of the resident's preference.On 03/02/2026, at 12:04 PM, during an interview, the Endocrinology Nurse Practitioner (NP) #33 acknowledged he was aware of the resident's history of refusing blood sugar checks but stated he did not know the reason. The survey informed the NP of the resident's preference.At 2:46 PM, a review of Resident #4s medical record revealed a new progress note from NP #33 recommending the fasting blood sugar checks be conducted at 7:30 AM per the resident's preference.

Based on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 2 (Resident #74 and #90) of 2 residents reviewed for dental services during the survey. The findings include: 1) On 2/26/26 at 1:33 PM, the surveyor reviewed Resident #74's medical record. The review revealed that on 1/31/26 an order was placed for Resident #74 to have orajel to be given every 6 hours as needed for tooth pain. Additionally, an order was placed on 2/6/26 that stated Resident #74 had a dental appointment made for early March. It was also noted that on 11/4/25 Resident #74 had an order for several consulting services to be consulted as needed. Dental was listed as one of the consults. Next the surveyor reviewed the progress notes. A progress note written on 11/27/25 stated the reason for the visit was to follow up on tooth pain. It further stated that Resident #74 was treated with Motrin (ibuprofen) for two to three days and the tooth pain had resolved. On 12/28/25 a progress note was written with one of the reasons for the visit noted as dental pain. The note stated Resident #74 was having intermittent sharp lower anterior (front) tooth pain without fever, swelling or drainage. The note further advised to arrange a dental evaluation for a suspected odontogenic source. The next several providers' notes documented that Resident #74 had a history of tooth pain and that a dental consultation was pending. Date of service 12/31/25 reason for visit -dental pain dental consult pending Date of service 1/3/25 reason for visit – dental pain dental consult pending Date of service 1/6/26 reason for visit – dental pain dental consult pending Date of service 1/8/26 reason for visit – dental pain dental consult pendingDate of service 1/10/26 reason for visit – dental pain dental consult pendingDate of service 1/17/26 reason for visit – dental pain dental consult pending Date of service 1/20/26 reason for visit – dental pain, arrange dental evaluation for source control and treatment planning. Date of service 1/22/26 reason for visit – dental pain, arrange dental evaluation for source control and treatment planning.Date of service 1/23/26 pain consult -dental discomfort is resolved and dental evaluation is pending. Next the surveyor reviewed a change of condition written on 1/31/26 at 7:19 PM by Licensed Practical Nurse (LPN) #40. The change of condition stated that Resident #74 reported having extreme toothache. The recommendations by the provider were to apply orajel as needed to relieve tooth pain. On 2/26/26 at 3:04 PM, the surveyor requested any dental consult Resident #74 had arranged after the 11/27/25 documentation of dental pain and recommendation for a dental consultation. On 2/27/26 at 9:44 AM, the surveyor conducted an interview with the acting Director of Nursing (DON). During the interview the acting DON stated that Resident # 74's family member had made arrangements for Resident #74 to see a dentist this coming March and that appointment was noted in the orders. The surveyor asked when the appointment was made. The acting DON stated that when the family member was made aware of the dental pain during the last care meeting he/she made the appointment. The surveyor reviewed the concern that Resident #74 had been noted to have dental concerns with repeated recommendations for a dental consult for 2 months before any appointments had been arranged. 2) On 02/24/2026 at 9:21 AM, Resident #90 stated, I need dentures and the facility hasn't followed up. On 02/27/2026 at 11:47 AM, the surveyor requested dental assessments for Resident #90. The acting Director of Nursing stated that Resident #90 would be seen by dentist on their next visit to the facility. The surveyor requested information about prior dental visits and assessments. The record review on 02/27/2026 12:03 PM of Annual MDS assessments dated 10/16/24 and 10/18/2025 revealed that Section L read: Obvious or likely cavity or broken natural teeth on both assessments. The Annual MDS from admission dated 10/19/2023 did not indicate any dental concerns. The surveyor requested any documentation showing that any dental care was provided based on the assessments from the Administrator and the Regional Director of Clinical Operations. On 02/27/2026 at 12:50 PM the Administrator reported that she was unable to find any follow up dental care after the MDS assessments were made.

Based on observations, review of facility's policy and interviews with staff, it was determined that the facility failed to properly store a Resident's medication. This was found evident on 1 random observation during the survey. The findings include: On 2/27/26 at 8:57 AM, the surveyor observed Certified Medications Assistant (CMA) #4 walking between two medication carts in the 100's hallway. One of the medication carts was noted to have turned front side against the wall between room [ROOM NUMBER] and 111. On 2/27/2026 at 9:10 AM the surveyor observed a nurse and CMA #4 had walked into the resident's rooms and were no longer in the hallway. Next the surveyor walked to the medication cart pushed against the wall. The surveyor was able to open the side drawer which contained colestipol oral suspension, lactulose and lidocaine patches. The top draw contained multiple bottles of floor stock medication. The second draw contained bubble packs of Resident's medications. The third drawer contained a personal water bottle along with additional medications. On 2/27/26 at 9:13 AM, the surveyor conducted an interview with CMA #4 as she walked over to the cart. CMA #4 confirmed that she was responsible for the medication cart. She further stated that she was supposed to lock the door before leaving it and was also not supposed to keep personal time in the cart. She stated that she turned the cart to the wall because she was returning to it shortly and had to share keys with the other nurse. On 2/27/26 at 9:16 AM, the surveyor conducted an interview with the acting Director of Nursing (DON) and made her aware of the observations. The acting DON stated that all staff should have their own keys and that the medications carts should be locked when unattended. She further confirmed that personal items should not be stored in the med cart. On 2/27/26 at 10:53 AM, the surveyor reviewed the policy titled, Medication Storage. The policy states, compartments, such as, medication carts, containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on review of the clinical record and staff interview, it was determined that the facility staff failed to adequately monitor a resident's drug regimen which allowed an unnecessary duplicate order for medication. This finding was evident for 1 (Resident #49) of 6 residents reviewed for unnecessary medications during the survey. The findings include: On 3/2/26 at 9:40 AM, the surveyor observed Licensed Practical Nurse (LPN) #5 prepare medications for Resident #49. During the preparation LPN #5 pulled Resident #49s Cholecalciferol (Vitamin D) tablet of 1000 units. Next the surveyor observed LPN #5 administer one tablet of Vitamin D to Resident #49. Following the observation the surveyor reconciled the medications administered observation to Resident #49's medication orders. The review revealed Resident #49 had two orders for Cholecalciferol 1000-unit table. The two orders, even though duplicate, gave the impression to give 2, 1000-unit tables, one for each order. There were two areas to document the medication on the Medication Administration Record (MAR) and it appeared both areas were marked as given even though the surveyor observed LPN #5 give one dose. On 3/2/26 at 1:14 PM, the surveyor conducted an interview with LPN #5. During the interview the surveyor reviewed Resident #49's Cholecalciferol order with LPN #5. After review, LPN #5 stated that she had only given one dose because she noticed the duplicate of order. She further stated that she was going to contact the provider later to remove the duplicate of order but had not yet contacted them. On 3/3/26 at 1:48 PM, the surveyor conducted an interview with the acting Director of Nursing (DON). During the interview the surveyor showed the acting DON the duplicate of order. The acting DON stated that on review of the order the physician entered the order once but checked two routes in error, allowing the order to show up twice on the MAR. She stated that she had already contacted the provider, clarified the order, and updated it so it would only be administered once per intention. The surveyor reviewed the additional concern that the duplicate order was in since February 13th and only now was clarified. The acting DON agreed the delay in addressing the duplicate order was concerning.

Based on observations, record reviews, and interviews, it was determined that the facility failed to administer medications according to procedures that ensure accurate dispensing. This was evident for 1(Resident #82) out of 4 residents reviewed for medication administration. The findings included:On 3/2/26 at 8:55 AM, the surveyor observed Licensed Practical Nurse (LPN) #5 prepare medications for Resident #82. During the preparation LPN #5 pulled Resident #82's bupropion hydrochloride extended-release oral tablet 150 MG (antidepressant) and placed one tablet into the medication cup with Resident #82's other medications. Next the surveyor observed LPN #5 administer the medications to Resident #82. Next the surveyor reconciled the medications administered observation to Resident #82's medication orders. The review revealed Resident #82 had an order for 3 tablets of bupropion hydrochloride extended-release oral tablet 150 MG with instructions to give that dose once a day. On 3/2/26 at 1:14 PM, the surveyor conducted an interview with LPN #5. During the interview the surveyor reviewed Resident #82's bupropion order with LPN #5. After review LPN #5 stated that she didn't realize that she had only given Resident #82 one tablet instead of 3 and that she would need to administer two additional tablets to give the dose that was ordered.

Based on observation and interview with facility staff, it was determined that the facility failed to post all of the required staffing information on a daily basis. This was evident on 1 out of 6 days on the survey. The findings include: On 3/2/36 at 6:06 AM, the surveyor observed the Plexiglas tray on the front desk empty. On the previous days of the survey this tray had staffing hours posted. On 3/2/26 at 6:09 AM, the surveyor asked Licensed Practical Nurse (LPN) #31 who the night shift supervisor was. LPN #31 stated that she was not sure but would ask her coworker LPN #41. The surveyor followed LPN #31 to the nurses' station between the 500 and 100 hallways where LPN #41 was located. On 3/2/26 at 6:11 AM, the surveyor observed the whiteboard in the nurses' station, where the assignments had been posted during the other days of the survey, and noted it was blank. The surveyor asked LPN #41 if the assignments should be posted on the board. LPN #41 stated that the board was wiped clean so the unit clerk could put up the new assignment. The surveyor asked if the unit manager was on site. LPN #41 stated she had not shown up yet. The surveyor brought up the concern that staffing was not posted as required and asked who the night shift supervisor was. LPN #41 stated she did not believe there was a nighttime supervisor last night and that the daytime supervisor would be in shortly. On 3/2/26 at 7:54 AM, the surveyor interviewed the acting Director of Nursing (DON). The surveyor relayed the concern that there was no staffing posted with staffing hours when entering and on the unit. The DON confirmed the posted staffing should have been available.

Based on observations and interviews with staff, it was determined the facility failed to 1) have a designated nurse supervisor/charge nurse and 2) have sufficient staff dispense medications in a timely manner. This was found to be evident during one early hour observation and during an observation of medication administration. Findings include: 1) On 3/2/26 at 6:09 AM, the surveyor asked Licensed Practical Nurse (LPN) #31 who the night shift supervisor was. LPN #31 stated that she was not sure but would ask her coworker LPN #41. The surveyor followed LPN #31 to the Nurses' station between the 500 and 100 hallways where LPN #41 was located. On 3/2/26 at 6:11 AM, the surveyor asked LPN #41 who the night shift supervisor was. LPN #41 stated she did not believe there was a nighttime supervisor last night but the day time supervisor would be in shortly. On 3/2/26 at 7:54 AM, the surveyor interviewed the acting Director of Nursing (DON). The surveyor relayed the concerns that the nighttime staff was unaware of who the night time supervisor was. The acting DON stated she would look into the concern. On return the acting DON stated that LPN #31 was the nighttime supervisor and was given the supervisor materials. The acting DON did not understand why LPN #31 did not know she was assigned supervisor. The surveyor reviewed the staffing sheet with the acting DON and noted that there was no designated supervisor on the staffing sheet for night shift while on other days the supervisor was listed. 2) On 3/2/26 at 8:24 AM, the surveyor observed Licensed Practical Nurse (LPN) #5 push a medication cart down the hall. The surveyor asked LPN #5 if she was administering medications. She stated that she would be today but normally a Certified Medication Assistant (CMA) would do it. She explained the CMA was scheduled off. LPN #5 stated she was responsible for both jobs, nurse and medication administrator, and that before she could start, she had to provide nursing cares for a resident down the hallway. LPN #5 left the cart to assist a resident. On 3/2/26 at 8:29 AM, LPN #5 walked past the medication cart and noted a call light on. At this time, she enters into the room and responds to the Resident's needs and then proceeds to the nurses' station. LPN #5 was then seen walking back into a resident's room and back to the nurses' station with a laboratory specimen.On 3/2/26 at 8:42 AM, LPN# 5 returns to the medication cart. At this time Geriatric Nursing Assistant (GNA) #42 walked up to LPN #5 and asked to get report on her assignment. On 3/2/26 at 8:55 AM, the surveyor observed LPN #5 now be able to start medication administration. LPN then prepared and administered medications to Resident #82. This was 31 minutes from when LPN #5 first pushed the medication cart down the hallway to start medication administration. On 3/2/26 at 9:11 AM, the surveyor observed LPN #5 prepared and administered medications to Resident #24. At this time LPN #5 was alerted by another staff that the resident in room [ROOM NUMBER] needed LPN #5. At this time LPN #5 left the medication administration cart. On 2/3/26 at 9:17 AM, LPN #5 returned to prepare and administer medications to Resident # 58. On 3/2/26 at 9:40 AM, LPN #5 prepared and administered medications to Resident #49. Some of the medications scheduled administration times were for 8am. The medications were administered an hour and 40 minutes after the scheduled time. Upon exiting Resident #49's room two residents came to LPN #5 and request their medications. One asking to have it so now he/she could attend the 10 AM, coffee hour. On 3/2/26 at 1:48 PM, the surveyor conducted an interview with the acting Director of Nursing (DON). During the interview the surveyor relayed the staffing concerns that during the medication administration the nurse was delayed in administration medications due to having to attend to resident needs on top of administrating medications.

Based on observations, interviews, review of facility's policy and record review, it was determined that the facility failed to provide appropriate treatments to prevent complications for a resident who required enteral nutrition. This was evident for 1 (Resident #12) out of 1 resident reviewed for tube feeding during the survey. The findings include: Enteral nutrition, also known as tube feeding, is a way to deliver dietary needs directly to the stomach or small intestine. A gastrostomy tube or (g-tube) is used when nutrition is delivered to your stomach. A common g-tube placed is called a percutaneous endoscopic gastrostomy (PEG) tube. On 2/26/26 at 11:24 AM, the surveyor observed a bag of water handing along side resident #12's tube feeding bottle. The bag labeled H2O (water) was dated 2/23/26 and timed 2 PM. The tube feeding bottle was dated 2/25/26 and timed 11 PM. On 2/27/26 at 8:50 AM, the surveyor observed Resident #12's tube feeding bag was dated 2/27/26. However, the water bag had what appeared to be the same label as the day before except over the date a 7 was placed over the 3 and 7-11 was written over the 2 PM. On 2/27/26 at 9:50 AM, the surveyor conducted an interview with the acting Director of Nursing (DON). During the interview the surveyor asked what the expectation was for changing tube feeding and water hydration bags. The acting DON stated that they both should be changed every 24 hours. The surveyor reviewed the observation with the acting DON. The acting DON stated that the water hydration bag should have been changed and relabeling the bag was not the accepted practice. The surveyor next reviewed the facility policy titled Enteral Feeding -Safey Precautions. In administration set changes it states, change sets every 24 hours and as needed. It further states, label tubing with date and time of change.

Based on observation, medical record review and interviews, it was determined the facility staff failed to clarify appropriate care measures to prevent complications from a hand contracture. This was evident for 1 (resident #74) of 1 resident reviewed for mobility. The findings include: A contracture is an abnormal shortening of muscle, tendons, skin, or tissues, causing the resistance to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand. On 2/24/26 at 9:38 AM, the surveyor observed Resident #74 resting in bed and noted his/her left hand was contracted. On further observation the surveyor noted a hand splint was on the bedside table next to the resident's bed. On 2/26/26 at 11:20 AM, again the surveyor observed Resident #74 in bed and the hand splint on the bedside table. On 2/26/26 at 11:51 AM, the surveyor reviewed Resident #74's orders. The review revealed two orders for his/her left hand splint. On 11/4/25 an order was written for Resident #74 to have palm guard splint to left hand at all times except bathing and hygiene activities. On 11/5/25 and order was written for Resident #74 to wear a left palm protector 6-8 hours or as long as tolerated everyday. Next the surveyor reviewed Resident #74's February and March Treatment Administration Records (TAR). The review revealed that both orders were being documented as completed. On 2/26/26 at 11:57 AM, the surveyor reviewed Resident #74's care plan. A care plan was written that Resident #74 refused to wear a palm guard at times. However, the documentation on the TARs did not capture this behavior. On 3/2/26 at 7:41 AM, the surveyor reviewed Resident # 74's Occupational Therapy (OT) discharge notes dated 1/23/26. The discharge recommendations were to have a palm guard on the affected hand at all times, 27/7 care. Again on 3/3/26 at 7:43 AM, the surveyor observed Resident #74 with his/her splint not on but on the floor next to the bed. On 3/3/26 at 8:24 AM, the surveyor conducted an interview with the acting Director of Nursing (DON). During the interview the surveyor showed the acting DON the documentation that both splint orders were being signed off on, the observation of Resident #74 not having the splint on, as well as the OT discharge recommendations.The acting DON stated that Resident #74 should not have two conflicting orders and the most recent recommendation should be the active. She further stated that the TAR should reflect the care provided.

Based on interviews and record reviews, it was determined that the facility failed to ensure services were provided to address a resident's hearing needs. This deficient practice was evident for one Resident (#48) reviewed for hearing services during the annual survey.The findings include:On 02/24/2026 at10:39 AM, during an interview, Resident #48 reported that they had requested a hearing screening some time ago; however, the resident stated that the request had not been addressed and they were still waiting to receive a hearing test.A review of Resident #48's medical records on 2/26/2026 at 12:06 PM failed to reveal documentation of a hearing screening appointment or consultation.On 02/27/26 at 12:51 PM, during an interview with the Director of Nursing (DON), the surveyor inquired about outside consultants used by the facility to assess resident's hearing, vision, and dental needs. The DON reported that the facility uses a company consultant service. The surveyor informed the DON of resident #48s concern. The DON stated that she would investigate the matter and follow up with the surveyor.On 03/02/2026 at 7:38 AM, the surveyor followed up with the DON regarding the status of Resident #48's hearing consultation. The DON acknowledged that the facility failed to submit the required Audiology documentation to the hearing consultant for the resident in July 2025. As a result, the resident did not receive the hearing screen.The DON provided the surveyor with a consultation form for Resident #48 dated 02/27/2026.

Based on record review and interviews it was determined that the facility failed to identify and provide appropriate interventions and notifications for a resident's condition. This was found evident of 2 (Resident #63 & 4) out of 2 residents reviewed for insulin during the survey. The findings include: 1) On 2/24/26 at 10:18 AM, the surveyor conducted an interview with Resident #63. During the interview Resident #63 stated that he/she thought that he/she did not receive the right amount of insulin because his/her blood sugars were off. On 2/26/26 at 10:48 AM, the surveyor reviewed Resident #63's Medication Administration Record (MAR). The review revealed Resident #63 had an order for Humalog (fast acting insulin) 6 units ordered to be given subcutaneously with meals (to cover the carbohydrate in the meal) for diabetes mellitus. On 2/24/26 the administration was coded with 14. On 2/26/26 at 1:48 PM, the surveyor conducted an interview with the acting Director of Nursing (DON). During the interview the surveyor asked the acting DON what the code 14 meant. The acting DON stated it meant parameters out of range. The surveyor confirmed that there was no range on the Humalog orders and medication should have been given with Resident #63's meal. The surveyor further reviewed the blood glucose documented at 6:30 am that same day and noted it was 89 and at 11:30 am (after not receiving the insulin with the meal) the blood glucose was 400. The surveyor next reviewed Resident #63's blood glucose level on 2/25/26. At 11:30 AM, Resident #63's blood glucose was 411 and at 8 PM it was 449. An additional order for correction dose insulin (per scale) was written for Resident #63. The instructions stated to give 8 units of Humalog if blood glucose was between 351-400. This insulin (correction dose per scale) was to be given with meals and along with the covering carbohydrate dose ordered to cover the meal (the 6 units as ordered above). The instructions further stated that if blood glucose was greater than 400 to call the provider. Both of these administrations were labeled 9, see progress note but there was no note to indicate what the response was. The surveyor continued the interview with the acting (DON) and asked if the staff contacted the providers with the two-blood glucoses greater than 400. The acting DON stated that she had no documentation to demonstrate that the staff called the providers per instructions in the medication order. 2) On 02/24/2026 at 1:33 PM, during an interview, Resident #4, expressed concerns regarding elevated blood glucose levels. On 02/25/2026 at 11:39 AM, a review of Resident #4's Medication Administration Report (MAR) for February 2026 revealed bedtime blood glucose readings documented as high as 410 mg/dL during 23 documented reading. Further review of the blood glucose readings from November 2025 through January 2026 revealed readings ranging from 100mg/dl to 328mg/dl. A review of the medical record did not reveal documentation indicating the physician had been notified of blood glucose reading at or above 400 mg/dl. On 02/25/2026 1:31 PM, during an interview, the surveyor informed the Director of Nursing (DON) of resident concerns and reviewed the February 2026 blood glucose readings. The surveyor asked what the facility's expectation is for staff when abnormal blood glucose levels are identified. The DON stated that nursing staff are expected to notify the physician. The DON acknowledged that blood sugar readings at or above 400 mg/dL should have been reported to the physician. The surveyor requested documentation indicating the physician had been notified of the resident's blood glucose reading at or above 400 mg/dL. On 03/03/2026, the surveyor followed up with the DON regarding physician notification. The DON stated that there was no documentation indicating the physician had been notified of the elevated blood glucose readings.

Based on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent Residents. This was found evident in 2 (Resident #63, #9) out of 5 residents reviewed for Activity of Daily Living (ADL) cares. The findings include: 1.On 2/24/26 at 10:17 AM, the surveyor interviewed Resident #63. During the interview Resident #63 reported that he/she had to wait a long time to get cleaned up. On 2/26/26 at 11:07 AM, the surveyor requested shower records for Resident #63 On 2/26/26 at 2:30 PM, the surveyor reviewed the shower documentation with the acting Director of Nursing (DON). During the review it appeared that Resident #63 was scheduled to receive showers on Mondays and Thursdays. It was also noted that Resident #63 had been out of the facility several days in the middle of February (those days were x'd out), however the days when Resident #63 was in the facility, shower days were open for documentation On Monday 2/3/26 and Thursday 2/19/26 the shower day was coded NA (not applicable). On 2/5/26 and 2/23/26 the shower day was coded that the Resident refused. The surveyor asked the acting DON why on two of the shower days were coded not applicable. The acting DON stated she would look into the shower documentation. On 2/26/26 at 3 PM, the acting DON stated she could not find any additional documentation to indicate a shower was offered/provided to Resident #63 on his/her 2/3/26 and 2/19/26 shower days. 2. On 2/24/26 at 9:25 AM, the surveyor conducted an interview with Resident #9. During the interview Resident #9 stated that he/she was only offered to shower once a week however was scheduled to shower twice a week on Mondays and Thursdays. On 2/25/26 at 6:34 AM, the surveyor requested shower documentation for Resident #9 for February of 2026. On 2/25/26 at 1:32 PM, the surveyor reviewed the shower documentation. Showers were documented as given on 2/6/26, 2/9/26 and 2/16/26 with a tub bath documented on 2/19/26. No refusals were noted. On further review it was noted that Resident #9 was assessed to need partial to moderate assistance on the Minimum Data Set showering assessment dated [DATE]. On 2/26/26 at 8:09 AM, the surveyor conducted an interview with Unit Manager #40. During the interview UM #40 confirmed that Resident #9 was scheduled to receive showers twice a week and did not recall any refusals from him/her. She confirmed that the documentation demonstrated that Resident #9 received only one shower per week even though he/she was scheduled for two.

Based on interviews and record reviews, it was determined that the facility staff failed to ensure residents received services to maintain or improve the ability to perform Activity of Daily Living (ADL). This deficient practice was evident for one (#4) resident reviewed for assistive devices during the annual survey.The findings include:On 02/24/2026 at 1:33 PM, during an interview with Resident #4, the resident reported that they have difficultly hearing and stated that they were evaluated last summer and informed they were a candidate for hearing aids. The resident further reported that there had been no follow up. During the interview, the surveyor observed that Resident #4 spoke loudly which is consistent with the resident's report of hearing loss.On 02/26/2026 at 11:54 AM, the surveyor conducted a review of Resident #4s medical record, which failed to reveal documentation indicating the resident hearing had been assessed. On 02/27/2026 at 7:37 AM, during an interview with the Director of Nursing (DON), the surveyor inquired about Resident #4's hearing screening from summer 2025. The DON stated that she believed the resident's hearing has been screen in July 2025 and reported she would follow up after she locates the documentation.On 02/27/2026, the DON provided the surveyor with Resident #4's hearing assessment dated [DATE]. A review of the document indicated the reason for referral was the resident's complaint of newly decreased hearing. The clinical findings documented that the resident has moderate to severe mixed hearing loss in the right ear and moderate to severe sensorineural hearing loss in the left ear. The assessment included recommendations for staff to communicate using clear, slow speech with visual cues, and to favor the resident's left ear when speaking. The document further indicated that the resident was a candidate for hearing aids and recommended a medical consultant to obtain clearance for hearing aid use.After reviewing the assessment with the DON on 02/27/2026 at 7:39 AM, the surveyor inquired about the facility's process for addressing outside consult recommendations for residents. The DON explained that consult recommendations are forward to the Unit Manager or Assistant Director of Nursing (ADON) for review. The Unit Manager or ADON are responsible for reviewing the recommendations and notifying the provider. If the provider agrees with the recommendations, staff are expected to enter the new physician orders within 24 hours. The DON stated there was no documentation indicating the physician had been notified of the hearing recommendations for Resident #4.

Based on interview and record review, it was determined that the facility failed to ensure residents received quarterly care plan meetings. This was evident for 4 (Resident #7, #8, #16, and #129) of 4 residents reviewed for care planning.The findings include:1) On 02/24/2026 at 8:02 AM, an interview with Resident #7 revealed that the last time they had a care plan meeting was during the previous summer.2) On 02/24/2026 at 9:22 AM, an interview with Resident #129 revealed that they were unaware that the facility had care plan meetings and further indicated he/she had never participated in one at the facility.3) On 02/24/2026 at 10:07 AM, review of Resident #8's medical record failed to reveal indication of when their last care plan meeting was.4) On 02/24/2026 at 1:31 PM, an interview with Resident #16 revealed he/she was unsure when their last care plan meeting was.On 02/24/2026 at 1:47 PM, review of Resident #16's medical record revealed a progress note dated 1/7/2026 at 1:16 PM, that indicated a care plan meeting was scheduled to be held that day, but that the resident was admitted at the hospital at the time. Further review of the medical record failed to reveal indication that the care plan meeting was rescheduled and completed.On 02/25/2026 at 10:17 AM, an interview with the Director of Social Services (Staff #14) revealed that care plan meetings were held for residents at least quarterly, after the comprehensive assessment. During the same interview, the surveyor asked Staff #14 to provide documentation of the last care plan meeting for the five residents noted above. On 02/25/2026 at 11:48 AM, review of the last care plan meeting documentation provided by Staff #14 revealed:Resident #7's last care plan meeting was 8/6/2025.Resident #129's last care plan meeting was 9/3/2025.Resident #8's last care plan meeting was 9/25/2025.Resident #16's last care plan meeting was 7/23/2025. On 03/02/2026 at approximately 9:00 AM, the surveyor reviewed the concern with the Director of Nursing and she indicated that she understood the concern.

Based on record reviews, interviews, and observations, it was determined that the facility staff failed to ensure services were provided in accordance with professional standard of practice when staff failed to administer medications according to physician orders. This deficient practice was evident for two (#129, #49) of two residents review for medication administration during the annual.The findings include:1)On 02/27/2026 at 9:54 AM, a review of Resident #129's medical record revealed the resident was admitted to the facility with multiple diagnoses, including opioid dependence. A review of the Medication Administration Record (MAR) for February 2026 revealed a physician's order for Oxycodone 10mg by mouth every six hours as needed for a pain rating between 7-10. Further review of the February 2026 MAR revealed that Oxycodone 10mg was administered to Resident #129 on 23 occasions when the pain score was documented between 0-6. A review of January 2026 MAR revealed Oxycodone 10mg was administered 24 occasions, and a review of the December 2026 MAR revealed Oxycodone 10mg was administered 17 occasions outside of ordered parameters.On 03/02/2026 at 7:36 AM during an interview with the Director of Nursing (DON), the DON stated that nursing staff are expected to follow physician's ordered parameter when administering medication. The surveyor informed the DON that a review of Resident #129's MAR between December 2025-Feburary 2026 revealed multiple occurrences in which Oxycodone 10 mg was administered outside physicians ordered parameters. The DON reviewed the findings with the surveyor and acknowledged the MAR documentation. 2) On 02/26/2026 at 10:08 AM, during an interview with Licensed Practical Nurse (LPN) #22 the surveyor observed an empty medication blister card for Resident #49's Pregablin at the nurse's station. The LPN stated she was in the process of contacting the pharmacy because the resident ran out of Pregablin. The LPN further explained that the facility's process for controlled substances is to request a refill when the medication reaches eight tablets; however, staff failed to request the refill prior to the medication running outAn interview was conducted with the DON at 10:28 AM. The DON confirmed that facility staff are expected to contact the pharmacy to request a refill before medications run out, specifically for controlled substances that require a pharmacy refill request. A review of Resident #49s MAR at 10:41 AM revealed two active physician orders for Pregablin. The first order directed staff to administer Pregablin 100mg by mouth twice a day at 8:00 AM and 4:00PM. The second order directed staff to administer Pregablin 150 mg by mouth at 8:00PM.At 2:09 PM, LPN #22 informed the surveyor that she had not contacted the pharmacy to request a refill for Resident #49's Pregablin.At 2:24 PM, the DON informed the surveyor that Resident #49's Pregablin had been ordered and was expected to arrive during the pharmacy's next schedule delivery run.On 02/27/2026 at 9:40 AM, the surveyor requested to review the medication audit report for Resident #49 dated 02/26/2026. A review of the documentation revealed that Resident #49 received the scheduled 4:00PM dose of Pregablin 100mg and the scheduled 8:00PM dose of Pregablin 150mg at 8:33 PM. Further review of the medical record failed to reveal documentation indicating the physician was contacted for guidance regarding the delayed administration of medication.On 03/02/2026 at 7:23 AM, the surveyor informed the DON of the concerns regarding the administration of Resident #49's Pregablin. The DON acknowledged the concern and stated that disciplinary action has been taken, and education was provided to the nurse involved.

Based on resident interview, staff interview, clinical record review, and a review of the facility investigation of intake #MD00207612, it was determined that the facility staff failed to ensure residents were free from abuse. This was evident for 1 (#97) out of 6 residents reviewed for abuse. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Actual Harm Past Non-compliance (PNC). The findings include: This surveyor started an investigation into intake #MD00207612 on 10/2/24. It was revealed that on 7/12/24 at 8:30 AM, Geriatric Nursing Assistant (GNA) #8 was providing AM care to Resident #97 but the resident was resisting her. She asked GNA #9 for assistance. GNA #9 entered the room and held the resident's arms while GNA #8 began changing the resident. The resident got an arm free and hit GNA #9. GNA #9 responded by punching the resident 2-4 times in the face. GNA #8 ran out and got the Unit Manager. The roommate, Resident #31, witnessed the incident. Further review revealed that Resident #97 had a facial injury just below the left eye as a result. Staff evaluated the resident after the incident. Resident #97 was evaluated as stable and safe. Resident #97 was also evaluated for psychosocial distress. The resident's responsible party was told on 7/12/24 at 8:30 AM. On 7/17/24, a facility-wide abuse interview/audit was conducted. GNA #9 was terminated and reported to the Maryland Board of Nursing (MBON). The statements of the two GNA's were reviewed on 10/7/24. GNA #8's statement to the police: I was attending to [Resident #97's room number]. As I was putting on [his/her] clothes. [He/She] started to kick and scream. I then stop[ped] doing [him/her] and went to ask [name of GNA #9] to help me get [him/her] changed and dress. The patient still began to kick and fight. [Name of GNA #9] was holding [him/her] down. [Name of GNA #9) then strike [him/her] in the face. The patient started to yell. I looked at the patient's face and [his/her] eye started to bleed. I went to report to [name of unit manager] immediately. GNA #9's statement was: At about 8 AM this morning another GNA asked me to assist her to dress the resident. I immediately moved to assist [him/her] as [he/she] started kicking and punching myself and [GNA #8] and I told [him/her] to stop while [he/she] continue to kick us and punch us then I hold [his/her] hand to prevent [him/her] from hurting us and asked [GNA #8] to put on [his/her] pants and shirt while we get [him/her] up as the resident keep on yelling in the process [his/her] nails cut [his/her] face. This surveyor interviewed GNA #8 on 10/7/24 at 11:40 AM. She said that she had the resident that day. She stated she was in the resident ' s room and declared that [he/she] is a fighter. She said she asked [name of GNA #9] to help her. She said he held the resident down by both hands while she put the resident ' s pants on. She stated that GNA #9 hit the resident in the eye twice. The resident ' s roommate yelled you didn ' t have to hit [him/her]. She saw that the resident had a cut just below the eye, left the room, and told the Unit Manager immediately. This surveyor interviewed the former roommate on 10/07/2024 at 1:28 PM. Resident #31 said the male aide held the resident down while the female changed the resident's pants, he held the resident's hands down across the chest, at some point the resident got free and started hitting the male aide. The male aide punched the resident four times [Roommate demonstrated the punching by punching the air four times]. The female aide let go and she said, I don ' t want any part of this. She left the room and talked to the Unit Manager. This surveyor interviewed the Regional Director of Clinical Operations on 10/8/24 at 1:15 PM. Informed him the survey team reviewed the intake, reviewed the facility's investigation, conducted interviews, and determined that the resident was harmed. The Administrator was interviewed on 10/9/24 at 1:29 PM. He said as soon as he arrived at 8 AM the nurse came to him and said you need to handle this. He said they suspended the GNA after they got a statement. He added that he instituted a mass facility-wide questionnaire for all the residents. This surveyor interviewed the Regional Director of Clinical Operations and the Administrator on 10/11/24 at 8:00 AM. Explained that the abuse had been substantiated and that the resident was harmed. Both said they agreed that there was abuse and confirmed that an investigation was conducted. The investigation included a whole house audit of interviewable residents. They confirmed the alleged perpetrator was terminated and they educated the staff. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Actual Harm Past Non-compliance (PNC).

Based on administrative record review and interviews with the facility staff, it was determined that the facility failed to permit a resident to return to the facility after being transferred to the hospital by emergency petition for threats to self and others. According to Resident #5's medical record, the facility did not accurately evaluate the resident, rather they used the resident's status prior to transfer as the basis to refuse to accept the resident back into the facility. This was found to be evident for 1 of 7 residents reviewed for transfers during a complaint survey conducted at the facility (Resident # 5). The findings include: Review of the medical record for Resident #5 on 4/6/2022 at 9:25 AM revealed admission to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #5's medical record revealed a 2/8/2022 minimum data set section 'C' which is an assessment of his/her cognitive patterns. Staff documented that there were no concerns or issues with his/her memory or cognitive ability. According to Resident #5's profile sheet and nursing documentation throughout the medical record, s/he is their own responsible party, and is able to make needs known. Resident #5 had a care plan initiated on 2/8/2022 regarding fluctuations in cognitive ability as evidenced by overt behaviors due to lack of executive functioning/reasoning secondary to his/her mental illness. On 2/14/2022 a care plan related to his/her behavioral issues which includes verbally aggressive towards staff and other residents i.e., using profanity and racial slurs, related to ineffective coping skills was initiated on 2/14/2022 with interventions to intervene before agitation escalates, provide positive feedback and assess and anticipate resident's needs. Behavior notes completed on 3/1 and 3/2 documented Resident #5 yelling at staff for not getting his/her way and further throwing water and paper on the floor. On 3/6/2022 s/he was documented as using racial slurs towards his/her roommate. These continued disruptive behaviors were documented in the progress notes on 3/10, 3/12, 3/14, 3/17, 3/23 and 3/24. On 3/24/2022 according to an Emergency Petition completed by the facility psychiatrist. Resident #5 was Emergency Petitioned to the hospital related to attempts to hit staff/residents, calling 911 and refusing care. These documented behaviors in the nursing notes were also noted and documented in the residents' record since 2/25/2022. The DON, Administrator and Admissions staff #13 were interviewed on 4/6/2022 at 1:04 PM regarding Resident #5. Congruently they stated Resident #5 had disruptive behaviors towards staff. The Administrator stated that the facility just could not care for him/her secondary to his/her behaviors and refusals for treatment. In addition, s/he was denied an appeal to remain Medicare and refused to provide financial information to apply for long term care. They also stated that for readmission she wouldn't qualify for Medicare again as s/he has no diagnoses or treatment currently that would qualify for skilled services under that guidance. The Administrator was asked if she had reviewed any hospital paperwork for Resident #5 since 3/25/2022 and she stated 'no.' Surveyor asked how they were certain there were no changes in the resident status that could require skilled care. They had no answer. Interview with LPN staff #16 on 4/7/2022 at 12:42 PM, who worked the corresponding hall on 3/24/2022, the day Resident #5 was emergency petitioned out, stated that he did not notice anything different on 3/24/2022 than any other day, that Resident #5 would yell and scream at staff and other residents. LPN Unit Manager #10 was interviewed on 4/7/2022 at 12:52 PM. This revealed that Resident #5 was verbally abusive to staff and roommates regularly and the only change on 3/24/2022 was that s/he was not redirectable. Interview on 4/7/2022 at 9:51 AM with the hospital SW revealed that Resident #5 was ready for discharge back to the facility on [DATE]. She was asked if she had any communication with the facility since she spoke with them on 3/25/2022 and she stated 'no.' Surveyor reviewed the admission paperwork for Resident #5 on 4/7/2022 at 12:00 PM. The initial assessment completed on 3/24/2022 at 1:02 PM by the emergency room (ER) physician assistant (PA), documented Resident #5 was oriented x4. Further that Resident #5 was transferred to the hospital for threatening his/her roommate and hitting staff. The hospital Social Worker also consulted with Resident #5 on 3/24/2022. She documented that Resident #5 admitted being frustrated with his/her roommate and staff but denied any physical or verbal aggression. She also documented multiple attempts to contact the facility, however, was unable to get in touch with anyone. At the end of the assessment, Resident #5 stated that s/he wants to return to the facility. The LCPC (licensed clinical professional counselor) documented seeing Resident #5 on 3/25/2022 at 1:00 PM. She documented multiple calls were made to the facility and when the Administrator was finally reached the Administrator reported that 'the patient is not allowed to return to the facility due to his/her yelling and screaming constantly, refusing to do [his/her] financials and not participating in [his/her] treatment. According to the SW documentation the Administrator also stated that Resident #5 threatened to kill his/her roommate. Resident #5 was seen on 3/25/2022 at 3:24 PM by the hospital Psychiatry attending. He documented that s/he was currently 'calm and pleasant, and mood is good.' He also noted some chronic suspiciousness that was believed to be part of his/her 'personality accentuated by life circumstances.' The psychiatrists plan for Resident #5 documented the following moving forward; 'S/he is generally calm and well behaved. Psychiatry will sign off as there are no acute issues and does not meet criteria for inpatient psychiatry and s/he will be referred to social work for placement.' On admission to the facility on [DATE] [MEDICATION(S)] was recommended for Resident #5 by the resident's personal psychiatrist and the ER psychiatrist, however, Resident #5 refused. Hospital records through 4/7/2022 were reviewed and noted that Resident #5 was still refusing the [MEDICATION(S)] but remained stable and appropriate for discharge. Interview with the facility Administrator on 4/7/2022 at 12:00 PM revealed that the facility felt that the resident's needs could no longer be met here at the facility and that is why they did not accept him/her back. She stated that Resident #5 was a threat to her staff and residents. The Administrator was asked on 4/6 and 4/7 if she had reviewed any hospital paperwork for Resident #5 since 3/25/2022 and she stated 'no.' As a result of these findings, a state of immediate jeopardy was declared on 4/7/2022 at 3:08 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 4/7/2022 at 5:56 PM and the State Agency was able to accept this plan. The immediate jeopardy was removed on 4/7/2022 at 6:09 PM after confirmation of all staff training and education was verified. The facility's abatement plan included the following: 1. The director of case management at the hospital was contacted on 4/7/2022 at 4:15 and notified, after ensuring clinical stability, that Resident #5 could return to the facility. 2. The IDT met to discuss other residents that could potentially be affected and at the time of the immediate jeopardy, 3 other residents were currently at the hospital with no noted concerns regarding return to the facility on ce they are clinically stable. 3. Staff directly involved in admissions were educated by the Medical Director and the Regional Clinical Consultant on the rights of residents regarding return to the facility post hospitalization or therapeutic leave. 4. The DON is responsible to audit all readmission referrals to the facility weekly x4 then monthly x3 and report the results to key members of the Quality Assurance team for further review. The date of compliance for all interventions and plans was identified and confirmed on 4/7/2022.

Based on medical record review, interview with facility staff and residents, it was determined that the facility failed to protect Resident #8, from Resident #5 who has documented verbal aggression towards others. This failure led to the emotional degradation and potential psychosocial harm of Resident #5. This was evident during the review of a complaint and 1 of 2 roommates (#8) for Resident #5. The findings include: Review of the medical record for Resident #5 on 4/6/2022 at 9:25 AM revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/2022 Resident #8 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A behavior note for Resident #5 for 3/23/2022 documented that s/he was calling out multiple times for the supervisor and angrily asked [Supervisor] to kick [his/her] roommate out .[Resident#8] is not supposed to be here. They brought [Resident #8] here and to spite me and I will not tolerate it. Nursing notes at 7:45 PM on 3/23/2022 documented that Resident #5 started screaming at [his/her] roommate . at the top of [his/her] lungs approximately at 7:45 PM for no particular reason, calling [Resident #8] all kinds of names like white trash, [explicative] and telling [Resident #8] that she will die very soon to the extent that [his/her] roommate started crying. Staff tried to reason with [Resident #5] to no avail until she got tired of screaming. This staff had to talk to [Resident #8] to get her to stop being upset and to calm down. On 3/24/2022 at 12:12 PM nursing documented another behavior note that stated: Writer saw Pt trying to reach out for her roommate's curtain and tried to pull it out while screaming and yelling you piece of white trash. When staff tried to calm her down, he/she screams even harder and wanted his/her roommate to move out of the room. Pt is verbally abusive to staff as well as she calls one of the EVS personnel white trash. Pt per report from last night called police several times and throughout this week also. She is threatening staff. Refuses V/S and her morning meds today saying, give my meds to that piece of white [explicative] pointing to her roommate. Resident #5 was emergency petitioned out of the facility on 3/24/2022 related to said documented behaviors. On 4/7/2022 at 8:30 AM Surveyor interviewed Resident #8 regarding his/her previous roommate, Resident #5. S/he immediately started crying. S/he stated that Resident #5 degraded him/her, constantly, every second and that I would not amount to anything, that I was a skeleton as I had lost a lot of weight and I was going to die. I already am dying, so for [him/her] to say that [s/he] kept threatening death to me. Resident #8 continued to state that these incidents were something that s/he wishes s/he could forget but knows they never will. S/he was asked if staff ever helped or offered a room change. S/he stated that s/he was left in the room in the fetal position crying, that s/he couldn't even eat dinner. They would check on him/her but just say you have to ignore [Resident #5]. On 4/7/2022 at 9:30 AM the census for 3/23/2022 was reviewed. According to the census sheet and the rooms designated for rehabilitation residents, there was another room available that Resident #8 could have been placed in or transferred to on 3/23/2022 instead of with Resident #5 who was noted with maladaptive behaviors towards others, or into another room when the two were noted not getting along cohesively. Staff #13 who is responsible for admissions and room assignments was interviewed on 4/7/2022 at 9:35AM. She was asked why Resident #8 was placed with Resident #5, especially after the documented behaviors and the potential effects on other residents and roommates. She stated that she was unaware that there were any effects on roommates and that Resident #5 just yelled at employees not at other residents. Surveyor interviewed occupational therapy (OT) staff #12 on 4/7/2022 at 9:41 AM regarding care that was provided to Resident #8 on 3/24/2022. She stated that she was unable to provide treatment in the morning as s/he was so upset and curled up in the bed, so she just let her/him be. We reviewed the Service matrix log regarding treatment that occurred on 3/24/2022. OT staff #12 stated that her and Resident #8 did some therapy in the afternoon and Resident #8 continued to stay in the therapy room for a few hours to just be out of the room cohabitated with Resident #5 and to get him/herself together. The rehab director, staff # 17, was interviewed at 1:53 PM on 4/7/2022. He stated that Resident #8 was removed from his/her room the morning of 3/24/2022 and stayed in the rehabilitation gym for a few hours. He stated it was around 9:00 AM but could not confirm the actual time. He also could not confirm how long Resident #8 was in their room that morning alone with Resident #5 without other staff intervention. The concerns related to the ongoing abusive and inappropriate verbal treatment Resident #8 suffered by Resident #5 was reviewed throughout the survey and again on 4/7/2022 and during exit from the facility on 4/8/2022 with the facility Administrator.