Every finding on record at Patapsco Healthcare

Based on observations and interviews it was determined that the dietary staff failed to wear hairnets or beard nets while in the kitchen. This deficient practice was discovered during two observations of four staff during the complaint survey.The findings include:On 07/08/26 at 8:14 am while in the kitchen the surveyor observed Dietary Aide #3 on the tray line without a hairnet covering. The surveyor observed Dietary Aide #4 and Dietary Aide #6 in the kitchen without a hairnet or beard covering.During an interview with Dietary Manager #8 the surveyor asked what measures were in place to prevent hair from getting into the residents' food. Dietary Manager #8 verbalized the staff are required to wear hair nets or a hat to cover their hair. The cook is to ensure the policy is being reinforced if they are not present. The male staff that have beards, they will reinforce the need to wear a beard net.During an interview with Dietary Aide #3 the surveyor asked what measures are in place to prevent hair from getting into the food. Dietary Aide #3 verbalized not being sure and they just wear a hair net while serving food and while in the kitchen. The surveyor asked why they were not wearing a hairnet before the cook instructed them to put the hairnet on. Dietary Aide #3 verbalized they didn't realize they were not wearing a hair net.During an interview with Dietary Aide #4 the surveyor asked why they were not wearing a hair net. Dietary Aide #4 verbalized they were rushing and forgot to put on a hair net.On 07/10/26 at 10:52 am the surveyor observed [NAME] #19 in the kitchen without a beard covering.

Based on medical record review and interviews it was determined that the facility staff failed to administer medications according to the scheduled times. This deficient practice was evidenced in 1 (#12) of 1 medication administration audit record reviewed during the complaint survey.The findings include:On 07/16/26 a review of Resident #12's medication administration audit record revealed on 07/02/26 during the 7:00 am - 3:00 pm and 3:00 pm - 11:00 pm shifts the resident's medications were administrated outside of the 1 hour before or 1 hour after the designated time frame when the medication was scheduled for administration.On 07/02/26 at 9:00 am the resident was scheduled to receive Nifedipine 90 mg for high blood pressure (HTN), Valporic Acid 250 mg for seizures, Carvedilol 25 mg for HTN, Losartan Potassium 100 mg for HTN, and Pantoprazole 40 mg for acid reflux. Licensed Practical Nurse (LPN) #31 documented on the medication administration record (MAR) that the medications were administered at 12:05 pm. The resident was scheduled to receive Gabapentin 100 mg at 4:30 pm for neuropathy pain; the medication was documented as administered at 9:18 pm by LPN #13. Carvedilol 25 mg for HTN & Valporic Acid 25 mg for seizures were scheduled for administration at 5:00 pm. The medications were documented as given at 9:18 pm by LPN #13. Oxycodone 5 mg for pain was scheduled for administration at 6:00 pm and LPN#13 documented that the medication was administered at 9:18 pm.On 07/20/26 at 11:21 am during an interview with Director of Nursing #18 the surveyor asked who was responsible for ensuring the residents receive their medications during the scheduled times. DON #18 verbalized the floor nurses and anyone who has clinical capabilities can see on the dashboard and Resident #12 requested to receive their medications after dialysis. They need to update the residents' care plan to reflect their request to receive their meds after dialysis. However, the date in question was Thursday 07/02/26; the resident received dialysis on Monday, Wednesday, and Friday.

Based on medical record review and interviews it was determined that the facility staff failed to adhere to professional nursing standards by not documenting on the medication administration record (MAR) when narcotics were administered but removed from the narcotic inventory and write legibly on the narcotic inventory sheet. This deficient practice was evidenced in 1(#9) of 2 resident narcotic records reviewed during the complaint survey. The findings include:The Maryland Nurse Practice Act guide and governs nursing practice in the state of Maryland. Registered Nurses, Licensed Practical Nurses, and certificate holders are expected to practice within the established regulations defined by the Nurse Practice Act. According to 10.27.10.02 B (3) (c) (i) (ii)The LPN contributes to the nursing assessment by communicating the assessment on records that reflect data recorded in a manner which is complete, timely, accurate and consistent with general standards of nursing practice. On 07/14/26 at 2:30 pm a record review revealed Resident #9 was ordered Hydromorphone 2 mg give 1 tablet by mouth (PO) every 4 hours as needed (PRN) for moderate pain 5-8 & give 2 tablets PO every 4 hours PRN for severe pain 9-10. A review of narcotic card revealed Licensed Practical Nurse (LPN) #28 signed the narcotic card as removing Hydromorphone 2 mg (1 tablet) on 07/02/26 at 8:10 pm and documented on the medication administration record (MAR) the resident had a pain score of 10.On 07/03/26 at 8:20 LPN #28 failed to document if the narcotic was removed during am or pm. On 07/03/26 at 3:45 am LPN #28 documented they removed Hydromorphone 2 mg (2 tablets) the narcotic was signed off as administered on the MAR.On 07/06/26 LPN #28 failed to document the time and how many Hydromorphone tablets were removed from the narcotic stock.On 07/07/26 LPN #28 documented the removed Hydromorphone 2 mg (2 tablets) and Hydromorphone 2 mg (1 tablet) the times the medication was removed was not legible. There was one entry on the MAR dated 07/07/26 that LPN #28 administered the medication.On 07/08/26 at 6:30 am LPN #28 removed Hydromorphone 2 mg (2 tablets) from the narcotic stock. LPN # 28 documented on the MAR the resident had a pain score of 8. LPN #28 administered Hydromorphone 2 mg (2 tablets) when Resident #9 should have received 1 tablet according to the physician's order.On 07/14/26 at 3:05 pm while on the unit Liberty the surveyor reviewed the narcotic book on Medication Cart #1 and Medication Cart #2. The narcotic books did not include a Master Signature Sheet. The surveyor asked LPN #17, LPN #20, and LPN #30 where the Master Signature Sheet were located, but they were able to locate the sheets. The surveyor asked if they typically use a Master Signature Sheet and they all replied, yes.At 3:12 pm the surveyor asked DON #18 if the facility use a Master Signature Sheet for the narcotic books. DON #18 verbalized it was not mandatory for them. The surveyor made DON #18 aware Resident #9's Hydromorphone narcotic card had multiple signatures that were illegible. The surveyor provided DON #18 a copy of the narcotic card and they identified each illegible signature.At 3:44 pm the surveyor went to the unit [NAME] and observed a Master Signature Sheet in the narcotic book on Medication Cart #1. Medication Cart #2 did not have Master Signature Sheet.During an interview with Director of Nursing (DON) #18 on 07/15/26 at 10:48 am the surveyor asked who was responsible for oversight of the narcotics including audits. DON #18 verbalized the nursing leadership team including themselves after responsible for oversight of the narcotics. DON #18 was responsible for completing the narcotic audits. Typically, the narcotic audits were completed weekly on Thursday, that is when the unused discontinued narcotics are destroyed. Any of the nurses can complete the task. The surveyor reported LPN#28 had multiple illegible signatures on the narcotic card, multiple entries that did not coincide with the narcotic stock and MAR, and administered a narcotic not according to the physician's order. DON #18 verbalized LPN #28 received a disciplinary action with a final warning for their medication errors.On 07/15/26 at 4:46 pm during an interview with LPN #28 the surveyor discussed they removed Hydromorphone 2mg for Resident #9 several times but did not sign the MAR that the medication was given. Also, the medication was not consistently given as ordered and their signature was illegible. LPN #28 verbalized they pulled the narcotic and were supposed to document on the MAR the medication was administered. LPN #28 verbalized they did not document accurately.

Based on medical record review and staff interview, the facility staff failed to provide supervision to prevent a mentally unstable resident (Resident #15) from physically abusing a vulnerable residents (Resident # 4 and Resident #14). This was evident for 1 out of 15 residents reviewed during a complaint survey.The findings include: Facility Reported Incident 3046303 reviewed on 7/14/26 at 9:35am revealed Resident #15 struck Resident #4 in the face on 6/11/26 at approximately 4:15pm. Both residents were located on the memory care unit at the time of the incident. The face strike by Resident #15 caused Resident #4 to have a swollen lip. The incident report stated that Resident #15 was removed from the memory care unit and relocated to another room. Review of Resident # 4's medical record on 7/14/26 at 10:30am revealed the resident has a Brief Interview for Mental Status (BIMS) assessment score of 0, which revealed the resident had been assessed as having severe memory issues. Review of Resident #15's medical record on 7/14/26 at 10:45am revealed the resident had a BIMS assessment score of 0. Resident #15 was also being treated for anxiety and visual hallucinations. Resident #15 was moved on 6/11/25 to a new room outside of the memory care unit to a room on the 2nd floor. The resident had another abuse incident on July 4, 2026 when he/she was observed hitting another Resident #14 in the face. Resident #15 was eventually moved to a private room on the 1st floor. Further review of Resident #15's medical record on 7/14/26 at 12:00pm revealed that the resident's only wandering assessment was in April 2026. There was no evidence of the resident receiving a new wandering assessment after being moved from the memory unit on 6/11/26 to a 2nd floor room outside of the memory unit or when the resident was moved to the 1st floor in July 4, 2026. Review of the facility reported incident on 7/14/26 at 1:30p revealed witness statements from nursing staff that revealed that prior to the 6/11/26 incident, Resident #15 was agitated and wandering the unit. The resident was standing at the nursing station and hit Resident #4. Nursing staff separated the residents. Resident #15 continued to try to strike other residents in the memory care unit and nursing staff stopped Resident #15 from striking the other residents. A change in condition form dated 6/11/26 revealed Resident #15 was observed wandering around the unit prior to the incident. The surveyor attempted to interview Resident #15 about the 6/11/26 incident. The surveyor asked the resident about the 6/11/26 incident and the resident was unable to remember the incident. The resident was observed no issues with behavior. Interview with GNA #34 on 7/16/26 at 11:30am confirmed that the Resident#15 was agitated and hit Resident #4 in the face. The surveyor asked GNA #34 if Resident #15 wandered the unit normally prior to the 6/11/26. GNA #34 confirmed that Resident #15 normally wandered on the memory unit and became agitated frequently. The surveyor asked GNA #34 about the 7/4/26 incident when Resident #15 hit Resident #14. GNA #34 confirmed that Resident #15 hit Resident #14 and when Resident #15 was located outside of the memory care unit. Resident #15 was observed as being agitated. The surveyor asked GNA #34 if Resident #15 had any changes in how to supervise the resident after being moved from the memory care unit. GNA #34 stated there were no changes in the GNA tasks regarding supervision of Resident #15 for behavioral issues. Interview with the Assistant Director of Nursing (ADON) on 7/16/26 at 9:20am revealed that the DON interviewed both residents after the 6/11/26 incident. The ADON confirmed that Resident #15 had two incidents of hitting residents before he/she was moved to a private room on the 1st floor. The ADON confirmed the facility failed to update the elopement assessment after any of the abuse incidents. The surveyor also asked if any changes to Resident #15's behavior plan after the 6/11/26 or the 7/4/26 incidents and the ADON stated no changes were made to the resident's behavior plan after the incidents.

Based on record review and interviews it was determined that the pharmacy failed to provide accurate medication labels of the narcotic that was distributed to the facility. This deficient practice was evidenced in 1 (#12) of 2 resident medication regimens reviewed during the complaint survey.The findings include:On 07/20/26 at 11:30 am during an interview with Director of Nursing (DON) #18 the surveyor asked why the nurses were signing two separate Oxycodone 5 mg tablet narcotic administration cards for Resident #12. The surveyor asked if the nursing staff were administering Oxycodone 10 mg to the resident. Resident #12's narcotic order read Oxycodone 5 mg give one and one-half tablet (7.5 mg) by mouth (PO) every 6 hours for pain. DON #18 verbalized the pharmacy distributes Oxycodone 5 mg tablets and Oxycodone 5mg in half tablets which is Oxycodone 2.5 mg. The pharmacy label did not indicate that half tablets were provided. The surveyor verbalized Resident #12 Oxycodone 5 mg narcotic cards does not indicate Oxycodone 2.5 mg tablets were distributed. During a telephone interview with pharmacy Operations Manager #33 who verbalized the Oxycodone prescription for Resident #12 was Oxycodone 7.5 mg. The pharmacy did not have Oxycodone 2.5 mg tablets. They distribute Oxycodone 5 mg 1/2 tablet which equates to Oxycodone 2.5 mg. The surveyor verbalized the label on the Oxycodone 5 mg narcotic card did not indicate a half tablet was distributed. The pharmacy label appeared confusing and inaccurate. Operations Manager #33 verbalized they can check with their compliance team to determine whether the label needs to be adjusted. The Oxycodone 5 mg tablets were cut into half tablets at the pharmacy and packaged individually on the narcotic card.On 07/20/26 at 4:05 pm the surveyor received an email from Pharmacy Manager #29 which read they dispensed Oxycodone 5mg 60 whole tablets and Oxycodone 5 mg 30 half tablets for 60 doses for Resident #12. They do not stock Oxycodone 2.5mg tablets as the medication was not made in that strength.

Based on medical record review and interviews it was determined that the facility staff failed to ensure they used the five rights before administering a narcotic and administered the wrong medication. This deficient practice was evidenced in 1 (#12) of 3 medication administration records for 1 resident (Resident #12) reviewed during the complaint survey.The findings include:On 07/14/26 at 3:53 pm the surveyor reviewed Resident #12's narcotic sign out sheet for Hydromorphone 2 mg. The pharmacy sticker with the order on the narcotic card read Hydromorphone 2 mg give one tablet by mouth every four hours as needed for pain.Continued review revealed that on 07/02/26 at 9:30 pm Licensed Practical Nurse (LPN) #13 signed off they administered 5 tablets to the resident and 7 tablets remained.However, on 07/15/26 at 9:48 am a review of Resident #12's electronic health record revealed the order Hydromorphone 2 mg 1 tablet every 4 hours by mouth was discontinued on 07/02/26 at 6:56 am. The nursing staff confirmed the medication was discontinued on 07/02/26 at 12:23 pm. LPN #13 had removed Hydromorphone 2 mg (5 tablets) from Resident #12's narcotics at 9:30 pm on 7/2/2026, after the order was discontinued.On 7/14/26, the surveyor observed Unit Manager #25 and LPN #13 taking narcotics into an office to dispose of the medications. The surveyor asked Unit Manager #25 how many tablets were left on Resident #12's Hydromorphone 2 mg narcotic card. Unit Manager #25 verbalized there were 7 tablets left before they were disposed.At 4:15 pm, during an interview with LPN #13 the surveyor asked why they administered 5 tablets which equated to Hydromorphone 10 mg to Resident #12 when the resident supposed to receive Hydromorphone 2 mg which was one tablet. LPN #13 verbalized there was a separate order that he faxed to the pharmacy for Hydromorphone and the pharmacy could not get Hydromorphone 10 mg tablets. The surveyor asked where the order was. LPN #13 verbalized there was a separate order for the resident to receive Hydromorphone 10 mg when the resident came to the facility from the hospital and the order was in the electronic health record.A review of Resident #12's medication administration record (MAR) for July 2026 revealed LPN #13 did not sign the MAR that Hydromorphone was administered to the resident. The surveyor did not see an order for Resident #12 to receive Hydromorphone 10 mg as LPN #13 reported. During an interview with Director of Nursing (DON) #18 the surveyor asked who was responsible for oversight of the narcotics including audits. DON #18 verbalized the nursing leadership team including themselves were responsible for oversight of the narcotics. DON #18 was responsible for completing the narcotic audits. Typically, the narcotic audits were completed weekly on Thursday, that's when the unused discontinued narcotics are destroyed and any of the nurses can complete the task. The surveyor asked at what point are the unused or discontinued narcotics destroyed. DON #18 verbalized ideally it would be best to destroy them immediately but per their policy at least weekly. The surveyor provided DON #18 with their policy and asked to point out where the Controlled Substance Administration Policy stated the narcotics could be destroyed weekly. After reviewing the policy DON #18 confirmed the policy did not indicate when discontinued narcotics would be destroyed by the nursing staff. Resident #12's Hydromorphone was discontinued on 07/02/26 but the remaining 7 tablets were not destroyed until 07/14/26.At 10:55 am the surveyor made DON #18 and ADON #2 aware LPN #13 signed off Resident #12 narcotic card Hydromorphone 2 mg 5 tablets when the order called for 1 tablet as needed. DON #18 verbalized they spoke with LPN #13 who verbalized they were mistaken and signed off they gave Hydromorphone and thought they were giving Hydrocodone. DON #18 verbalized Resident #12 received Hydromorphone 10 mg instead of Hydrocodone 10 mg. DON #18 verbalized they had no knowledge of the incident until the surveyor brought it to their attention.At 3:05 pm during an interview with LPN #13 the surveyor reported there was not an order for Resident #12 to receive Hydromorphone 10 mg. LPN #13 verbalized the order was for another resident and they made a medication error. There was another order for Hydrocodone 10 mg, and they thought that's what they were administering. LPN #13 revealed the resident was very agitated and they were thinking the Hydromorphone was Hydrocodone. Normally they would do the five rights of medication administration, but the resident came from the hospital and was in a lot of pain. Further review of Resident #12's medication administration record revealed LPN #13 signed off administering Hydrocodone Extended Release 12-hour 10 mg 1 capsule by mouth on 07/02/26 at 9:30 pm and Oxycodone 7.5 mg (1 1/2 tab) by mouth on 07/02/26 at 9:30 pm. The Oxycodone 5 mg narcotic cards verified the medication was taken from the narcotic stock. LPN #13 administered two separate Opioid narcotics to Resident #12 on 07/02/26 at 9:30 pm.

Based on medical record review and interview it was determined that the facility staff failed to implement a person-centered care plan when a resident refused medications and when a resident refused personal care. This deficient practice was evidenced in 2 (#1 & #9) of 3 resident records reviewed for care plans during the complaint survey.The findings include:1a. On 07/09/26 at 3:38 pm the surveyor spoke with Resident #1 and the resident verbalized they don't like the staff to touch them sometimes when personal care is needed. Assistant Director of Nursing (ADON) #2 was present during the interview. A review of Resident #1's electronic medical record (EMR) revealed the resident was refusing personal care including showers.1b. On 07/13/26 at 3:01 pm a review of the Resident #9's EMR revealed there were several days that the resident refused to take their medications. A review of the resident's care plans revealed the resident did not have a care plan for refusing to take their prescribed medications. On 07/14/26 at 12:58 pm during an interview with ADON #2 the surveyor asked if a resident was consistently refusing medication or personal care that's necessary should the nursing staff initiate a care plan? ADON #2 verbalized a care plan should be initiated and Resident #1's refusal of ADL care and showers should have been care planned as well as Resident #9's refusing their medication should have been care planned. Care plans was an area the nursing leadership team was working to improve.

Based on medical record review and interview, the facility failed to update a resident's (resident #15) care plan after two altercations with other residents. This was evident in 1 of 15 residents reviewed during a complaint survey.The findings include: Facility Reported Incident 3046303 reviewed on 7/14/26 at 9:35am revealed Resident #15 struck Resident #4 in the face on 6/11/26 at approximately 4:15pm. Both residents were located on the memory care unit at the time of the incident. The face strike by Resident #15 caused Resident #4 to have a swollen lip. The incident report stated that Resident #15 was removed from the memory care unit and relocated to another room. Review of Resident # 4's medical record on 7/14/26 at 10:30am revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 0, which revealed the resident had been assessed as having severe memory issues. Review of Resident #15's medical record on 7/14/26 at 10:45am revealed the resident had a BIMS = 0. Resident #15 was also being treated for anxiety and visual hallucinations. Resident #15 was moved on 6/11/25 to a new room outside of the memory care unit to a room on the 2nd floor. The resident had another abuse incident in July 4, 2026 when he/she was observed hitting Resident #14 in the face. Resident #15 was eventually moved to a private room on the 1st floor. Further review of Resident #15's medical record on 7/14/26 at 12:00pm revealed that the resident's only wandering assessment was in April 2026. There was no evidence of the resident receiving a new wandering assessment after being moved from the memory unit on 6/11/26 to a 2nd floor room outside of the memory unit or when the resident was moved to the 1st floor in July 2026. Review of the facility reported incident on 7/14/26 at 1:30p revealed witness statements from nursing staff that revealed that prior to the 6/11/26 incident, Resident #15 was agitated and wandering the memory unit. The resident was standing at the nursing station and hit Resident #4. Nursing staff separated the residents. The resident continued to try to strike other residents in the memory care unit and nursing staff stopped the resident from striking the other residents. Change in condition form dated 6/11/26 revealed Resident #15 was observed wandering around the unit prior to the incident. The surveyor attempted to interview Resident #4 about the 6/11/26 incident. The surveyor asked the resident about the 6/11/26 incident and the resident was unable to remember the incident. The resident was observed as being pleasant and did not appear to be in pain. The surveyor attempted to interview Resident #15 about the 6/11/26 incident. The surveyor asked the resident about the 6/11/26 incident and the resident was unable to remember the incident. The resident was observed with no issues with behavior. Interview with GNA #34 on 7/16/26 at 11:30am confirmed that the Resident#15 was agitated and hit Resident #4 in the face. The surveyor asked GNA #34 if Resident #15 wandered the unit normally prior to the 6/11/26. GNA #34 confirmed that Resident #15 normally wandered on the memory unit and become agitated frequently. The surveyor asked GNA #34 about the 7/4/26 incident when Resident #15 hit Resident #14. GNA #34 confirmed that Resident #15 hit Resident #14 and when Resident #15 was re-located outside of the memory building and was observed as being agitated. The surveyor asked GNA #34 if the resident had any changes to supervise the resident after being moved from the memory care unit. GNA #34 stated there were no changes in the GNA tasks regarding supervision of the Resident #15 for behavioral issues. Interview with the Assistant Director of Nursing (ADON) on 7/16/26 at 9:20am revealed that the DON interviewed both Resident #4 and Resident #15 after the 6/11/26 incident. The ADON confirmed Resident #15 had two incidents of hitting residents before he/she was moved to a private room on the 1st floor. The surveyor pointed out the change in condition on 6/11/26 which stated that the resident was wandering when he/she was on the memory unit but there was no evidence of a updated elopement assessment when he/she was moved after the 6/11/26 incident or the 7/4/26 incident. The ADON confirmed the facility failed to update the elopement assessment after any of the abuse incidents. The surveyor also asked if any changes to the resident's behavior care plan after the 6/11/26 or the 7/4/26 incident. The ADON stated no changes was made to the resident's behavior care plan after the incidents.

Based on record review and staff interview; it was determined that the facility failed to protect a resident (resident #13) from physical abuse from a facility staff member. This was evident for 1 of 15 residents reviewed during a complaint survey. The findings include: Facility Reported Incident #3090504 reviewed on 7/15/26 at 9:40am revealed an incident that occurred on 7/11/26 at approximately 8:00pm. The report revealed LPN #35 was alleged to have hit the Resident #13 with the resident's reacher aid. The report stated LPN #35 was suspended on 7/11/26 and his/her employment was terminated on 7/16/26. Review of the Resident #13's medical records on 7/15/26 at 11:05am revealed the resident had no issues of pain or other discomfort after the 7/11/26 incident. Resident #13 was evaluated by the facility's mental health provider and the resident denied any trauma because of the alleged abuse incident. There was no changes to medication or other treatments. Interview of Resident #13 on 7/16/25 at 9:00am confirmed the alleged abuse incident on 7/11/26. The resident denied hitting LPN #35 his/her reacher aid. The resident stated that he/she was upset that LPN #35 wasn't giving the resident the requested eye drops and he/she was using the reacher aid to get something on the floor. The resident stated LPN #35 took the reacher aid from the resident and hit him/her with it while yelling at him/her. Interview with LPN #35 on 7/16/26 at 2:18pm regarding the alleged abuse incident on 7/11/26 revealed LPN #35 denied that he/she verbally and physically abused the resident. LPN #35 stated that he/she attempted to explain to Resident #13 that there weren't any eye drops available for the resident to use. LPN #35 then stated that the resident became upset and shouted obscenities about LPN #35 and his/her family. LPN #35 then stated that the resident used his/her reacher aid to try to hit him/her causing their glasses to be broken. LPN #35 denied raising their voice at the resident but admitted that he/she she took the reacher aid from the resident and accidentally hit the resident on the arm with the reacher aid. Interview with the Director of Nursing (DON) on 7/20/26 at 10:30am revealed LPN #35's employment was terminated on 7/16/26. The DON confirmed that LPN #35's behavior was an inappropriate response Resident #13's alleged behavior.

Based on observations and interviews it was determined that the facility staff failed to ensure the freezer located in the kitchen was properly sealed to prevent air from getting into the freezer and ice build-up inside of the freezer. This efficient practice was discovered during the complaint survey.The findings include:On 07/08/26 at 8:25 am while in the kitchen the surveyor observed the freezer door opened with ice throughout the freezer including boxes of food, the shelves, the floor, and the ceiling of the freezer. Under further inspection the surveyor observed the seal on the freezer's door was compromised.During an interview with Dietary Manager #8 reported a new freezer door was ordered and Maintenance Director #9 was handling the issue with the freezer door and the door was ordered but they haven't seen an invoice. When the door doesn't shut properly ice builds up in the freezer.During an interview with Maintenance Director #8 they reported the seal around the freezer door is bad and the door had been beaten up over the years. A new door had not been ordered although they requested a new freezer door be purchased. The contractor requested the freezer door be replaced.On 07/09/26 at 12:13 pm the surveyor received and reviewed two work order reports received from Maintenance Director #8. The report dated 04/02/26 indicated the walk-in freezer door was damaged and solutions were offered. Also, there was documentation that stated the door frame was damaged and would not properly accept a new door gasket. The surveyor could not verify if the repairs were completed. Another work order report dated 05/19/26 did not indicate the seal around the freezer was replaced. The surveyor did not receive verification that a new walk-in freezer door was ordered or was scheduled to be repaired.

Based on record review and interview with staff, it was determined that the facility failed to ensure the care and services it delivers meet acceptable standards of quality, maintain documentation on how the facility obtains feedback, collects data, monitors adverse events, identifies areas for improvement, identifies improvement activities, implements corrective and preventative action, tracks performance, and conducts performance improvement projects. The was found to be evident by repeated citations from the previous annual survey and for QAPI review during the current annual survey.The findings include: According to the Centers of Medicare and Medicaid Services (CMS), QAPI stands for Quality Assurance and Performance Improvement, a systematic, data-driven, and proactive approach to maintaining and improving the safety and quality of care in nursing homes, as mandated by the Affordable Care Act. It combines Quality Assurance (QA), which sets and ensures standards for care, and Performance Improvement (PI), which involves continuously studying and improving processes to prevent problems and enhance services and quality of life for residents. The QAPI framework involves staff, residents, and families in identifying problems and implementing solutions through comprehensive programs and detailed plans. On 2/9/2026 at 4:15PM, the Surveyor reviewed the facility's most recent Quality Assurance Performance Improvement (QAPI) plan dated 10/12/2022. On 2/9/2026 at 4:30PM, a review of QAPI committee meeting documentation from 10/30/2025, 11/21/2025, 12/26/2025, and 1/29/2026, provided by the NHA, failed to reveal how data was obtained to identify areas of concern with facility systems, the process for identifying and correcting deficiencies, and how the facility used the data to track and trend those areas of concern for improvement, implement corrective actions, and evaluate effectiveness. The facility failed to establish goals for the next review period, prioritize quality deficiencies to develop a performance improvement project (PIP), and ensure progress toward correction or improvement is achieved and sustained. The facility failed to maintain meeting agendas, minutes, attendance records, and QAPI program progress reports for January 2025 through [DATE]. During an interview conducted with the Nursing Home Administrator (NHA) on 2/9/2026 at 4:40PM, the Surveyor was informed that the NHA was the QAPI Coordinator. The Surveyor was informed that the facility had been conducting continuous audits for the deficiencies the facility acquired during the last recertification survey. The Surveyor expressed the concern that the facility's action plan did not resolve the quality deficiencies identified during the last recertification survey and a review of the QAPI documents from 10/30/2025 through 1/29/2026 failed to identify how the facility tracked and trend areas of concerns and implemented corrective action during that time for improvement in those areas and how they evaluated for effectiveness. The Surveyor was informed that the QAPI committee reviews the basic concern areas such as falls, pressure ulcers, pain management, employee retention, and housekeeping; but, has no performance improvement projects that the facility has worked on since they began in May of 2025. The NHA acknowledged that the facility failed to maintain meeting agendas, minutes, attendance records, and QAPI program progress reports for January 2025 through [DATE].

Based on record review and interview with staff, it was determined that the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) meetings had the required committee members in attendance and conducted meeting at least quarterly. This was found to be evident for 1 out of 2 quarterly committee attendance sheets reviewed during the survey and due to no documentation made available for 3 out of 4 quarterly meetings in 2025. The findings include: During a review of the QAPI attendance sheets conducted on 2/9/2026 at 4:30PM, the Surveyor discovered that the facility had documented QAPI meetings on 10/30/2025 (quarterly), 11/21/2025, 12/26/2025, and 1/29/2026 (quarterly). A review of the quarterly committee attendance sheet for January 29,2026 revealed that the Medical Director or his/her designee did not attend the meeting. Further review failed to reveal documentation of QAPI meetings held from January 2025 through September 2025. During an interview conducted with the Nursing Home Administrator (NHA) on 2/9/2026 at 4:40PM, the Surveyor was informed that the NHA oversaw the QAPI program. The Surveyor expressed the concern that the facility failed to provide documentation that the QAPI committee meets at least quarterly and the Medical Director did not attend the last quarterly meeting on January 29, 2026. The NHA informed the Surveyor that the goal for the facility is to meet on a monthly basis and facilitate quarterly meetings which include a representative from all disciplines and departments within the facility, which includes, but not limited to, the Medical Director, Infection Preventionist, Director of Nursing, and the NHA. Going forward, the NHA would ensure the required QAPI committee members attend quarterly meetings.

Based on observation, interview and record review it was determined the facility failed to ensure: 1. & 2 .) medical record documentation from outside consult providers was present within the medical record. This was evident for: 1.) 1 out of 1 Resident (#55) reviewed for urinary catheter and 2.) 1 out of 1 Resident reviewed for Neglect (#134) and during the surveyor's review of Complaint #2694340 during the facility's recertification survey.The findings include: Based on observation, interview and record review and review of Complaint #2694340 it was determined the facility failed to: 1) maintain medical records in accordance with accepted professional standards and practices. This was evident for 7 (Resident #5, #23, #7, #99, #115, #61, and #125) out of 57 residents reviewed; 2) ensure that a hospital transfer form document contained current and accurate documentation. This was found to be evident for 1 (Resident # 11) of 3 residents reviewed for hospitalizations; 3) ensure medical record documentation from outside consult providers was present within the medical record. This was evident for 1 out of 1 Resident (#55) reviewed for urinary catheter and 1 out of 1 Resident reviewed for Neglect (#134) during the facility's annual survey. The findings include: 1. On [DATE] at 2:00PM, a review of the facility's Smoker's List as of [DATE] revealed that Residents #99, #115, #61, and #125 were independent smokers. The facility completed Safe Smoker Assessment quarterly and as needed for Resident's who are smokers. On [DATE] at 8:10AM, during a review of Resident #99's electronic medical record, the Surveyor discovered that the resident was admitted to the facility on [DATE] and was a smoker prior to admission. A smoking contract was completed on admission. Further review failed to reveal a Safe Smoker Assessment completed at the time of admission. On [DATE] at 8:27AM, during a review of Resident #115's electronic medical record, the Surveyor discovered that the facility failed to complete a quarterly Engage Safe Smoker Assessment between the assessment on [DATE] and [DATE]. On [DATE] at 9:10AM, during a review of Resident #61's electronic medical record, the Surveyor discovered that the facility failed to complete a quarterly Engage Safe Smoker Assessment between [DATE] and [DATE], and [DATE] and [DATE]. On [DATE] at 9:35AM, during a review of Resident #125's electronic medical record, the Surveyor discovered that the facility failed to complete quarterly Engage Safe Smoker Assessments between [DATE] and [DATE]. During an interview conducted with the Director of Nursing on [DATE] at 10:00AM, the Surveyor expressed the concern that Resident #99, #115, #61, and #125 were identified as independent smokers according to the facility's smokers list and had missing quarterly Engage Safe Smoker Assessments. The DON confirmed that Safe Smoking Assessments should be completed quarterly and as needed for residents who smoke. 2. On [DATE] at 1:31PM, during a review of Resident #5's electronic medical record, the Surveyor discovered the resident had a history of falls. A review of the residents Fall Risk Evaluation completed on [DATE], indicated the resident was a low fall risk with a score of 3; however, the fall assessment was incomplete and failed to include medications used and gait analysis. A review of a Fall Risk Evaluation completed on [DATE], indicated the resident was a low fall risk with a score of 4; however, the fall assessment was incomplete and failed to include all medications used and gait analysis. A review of a Fall Risk Evaluation completed on [DATE], indicated the resident was a low fall risk with a score of 5; however, the fall assessment was incomplete and did not include medications used and gait analysis. 3. Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Cardiopulmonary resuscitation (CPR) is a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped. Full code. Do Not Intubate (DNI) is an order placed in a person's medical record by a doctor informs the medical staff that chest compressions and cardiac drugs may be used, but no breathing tube will be placed. On [DATE] at 10:20AM, during a review of Resident #5's paper chart, the Surveyor discovered a MOLST form dated [DATE]. According to the MOLST form, within Option A, prior to arrest, administer all medications needed to stabilize the patient. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. Option A-2, Do Not Intubate (DNI) was selected. Further review revealed another MOLST form dated [DATE]. According to this MOLST form, attempt CPR was selected. On [DATE] at 11:00AM, a review of Resident #5's electronic medical record revealed an active physician's order for full code and an uploaded copy of the MOLST dated [DATE] which stated to attempt CPR. On [DATE] at 11:50PM, during an interview conducted with Unit Manager (UM)#13, the Surveyor confirmed that Resident #5 had a MOLST form dated [DATE] indicating DNI and a MOLST form dated [DATE] indicating attempt CPR within the resident's paper chart. During a review of Resident #5's electronic medical record, UM #13 and the Surveyor confirmed that the resident had a physician's order for full code and an uploaded copy of the MOLST form dated [DATE] indicating full code. The Surveyor asked the UM #13 to confirm the resident's code status. UM #13 stated they would review the resident's medical record and the physician for clarification. On [DATE] at 12:49PM, the Surveyor informed the Director of Nursing (DON) and the Regional Director of Clinical Operations of their findings in Resident #5's paper and electronic medical record. The DON stated that the resident was a DNI code status and that Full code was documented in the resident medical record in error. The Surveyor asked the DON to verify the code status with the resident/resident representative and the physician to ensure the correct code status was placed in the medical record. On [DATE] at 3:00PM, a review of Resident #5's electronic medical record revealed a new physician order for DNI. The DON confirmed the resident code status with the physician who completed the MOLST dated [DATE] indicating DNI code status. On [DATE] at 2:50PM, the DON provided the Surveyor with a copy of the Medical Provider Visit note where the resident's code status was reviewed with the resident and the resident representative. On [DATE] at 11:00AM, during a review of Resident #5's electronic medical record, the Surveyor reviewed the Engage Care Conference Meeting dated [DATE] which documented the resident as a Full Code. A review of the Dialysis Services Communication Forms reviewed from [DATE] through [DATE] revealed that the nursing staff did not complete, in full, the Pre-Treatment Report/SNF Nurse section on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Further review of [Dialysis Company] SNF Dialysis Service Communication Forms, the Pre-Treatment Report/SNF Nurse section to be completed by nursing staff, on [DATE],[DATE], and [DATE] the code status checked was Full Code and on [DATE], [DATE], and on [DATE] the code status was DNI. On [DATE] at 9:00AM, during an interview conducted with the DON, the Surveyor expressed the concern that due to inaccurate documentation of Resident #5's code status in the medical record, the Resident's code status was inaccurately documented on a care conference meeting note on [DATE] and in the Pre-Treatment Report/SNF Nurse section of the Dialysis Services Communication Forms from [DATE] through [DATE]. The Surveyor also expressed the concern that the Dialysis Services Communication Forms were not completed in full by nursing staff. The DON stated that they would review the resident's medical record and provide staff education for completing the Pre-Treatment Report/SNF Nurse section of the Dialysis Services Communication Form prior to the resident going to dialysis. 4. Physician certification of incapacity requires written documentation. Personal examination-based evaluation determines a resident's decision-making capacity due to physical or mental health issues and requires 2 qualified professionals, often the attending physician and a second physician. On [DATE] at 10:30AM, during paper chart review on the Liberty Hall Unit, the Surveyor discovered Resident #23 had Physician Certifications completed on [DATE], [DATE], and [DATE] determining the resident lacks adequate decision-making capacity (including decisions about life sustaining treatments) with only one physician signature. During continued paper chart review, the Surveyor discovered Resident #7 had a Physician Certification completed on [DATE] determining the resident lacks adequate decision-making capacity (including decisions about life sustaining treatments) with only one physician signature. On [DATE] at 1:00PM, during an interview with the DON on the Liberty Hall Unit, the Surveyor expressed the concern that Resident #23 had Physician Certifications completed on [DATE], [DATE], and [DATE] with only one physician signature and Resident #7 had a Physician Certification completed on [DATE] with only one physician signature. The DON and the Surveyor reviewed the documentation, and the DON confirmed the Surveyor's findings. The DON stated that the facility will ensure the physicians address the residents' Physician Certifications and the staff will be completing audits for Physician Certification. 5. On [DATE] at 12:42PM, during an interview with Resident #23, the resident informed the Surveyor people are taking my belongings. The resident stated that he/she had some long sleeve shirts and pants that were missing. The resident could not give further description of the missing clothing. On [DATE] at 8:40AM, a review of Resident #23's electronic medical record failed to reveal documentation of personal property. On [DATE] at 10:30AM, a paper chart review failed to reveal documentation of personal property. On [DATE] at 1:34PM, during an interview with the DON, the Surveyor was informed that resident belongings should be documented on a personal belongings form during admission and updated when the resident gets new belongings. The form should be filed in the resident's medical record. The Surveyor expressed the concern that Resident #23 stated that people were taking their belongings and a review of the resident's medical record failed to reveal documentation of personal property to determine what he/she could be missing. The DON stated that they would review the resident's medical record and ensure that the resident has a completed personal belongings form. 6. On [DATE] at 8:55AM the surveyor conducted a review of Resident #55's electronic medical record at which time no urology specialist provider documentation could be found. On [DATE] at 9:15AM the surveyor conducted a review of Resident #55's hard chart medical record at which time no urology specialist provider documentation could be found. On [DATE] at 9:16AM the surveyor conducted a dual observation of Resident #55's hard chart and conducted an interview with Unit Manager, LPN #13 who confirmed there was no urology consult documentation present. At this time, the surveyor requested for Unit Manager, LPN #13 to provide urology documentation to the surveyor. On [DATE] at 9:35AM the surveyor observed documentation in the medical record by facility staff regarding Resident #55 having attended and also having refused urology visits, however, no urology specialist provider documentation could be found. On [DATE] at 10:25AM the surveyor conducted an interview with the facility's Director of Nursing who provided documentation of a urology visit and reported that they had obtained the documentation today from urology, because they could not find any in the medical record. On [DATE] at approximately 11:45AM the surveyor shared all concerns with the facility Administrator and Director of Nursing. 7. On [DATE] at 9:21AM the surveyor conducted an interview of the facility's Director of Nursing (DON) who stated the following information when the surveyor inquired as to if Resident #134 had a foley catheter: Oh absolutely, s/he had a long term catheter. On [DATE] at 9:46AM the surveyor began requesting documentation relating to Resident #134's medical care from the facility's Administrator. On [DATE] at 12:20PM the surveyor conducted an interview with the facility's DON who stated that they were unable to provide a Nurse Practitioner's visit note because they had to reach out to obtain them. This surveyor requested to the DON to observe the complete hard copy of Resident #134's medical record and be provided access to the Resident's complete medical record, at which time access to the paper medical records was not provided by the facility's Director of Nursing who stated they would have to bring them to the surveyor. On [DATE] at 1:22PM the surveyor reviewed the medical record of Resident #134 at which time no urology specialist provider documentation could be found. On [DATE] at 1:49PM the surveyor requested to the facility's Director of Nursing to provide Resident #134's urology consult documentation from [DATE] forward. On [DATE] at 8:35AM the surveyor conducted an interview of the facility's Director of Nursing at which time they reported they had asked for all of the Resident's urology consults and had requested the Resident's entire medical record from the outside provider and that it would take more than three days to receive it. At this time, the facility's Director of Nursing stated to the survey team: I can't confirm or deny whether the facility has the urology records at this time. At this time, the surveyor additionally noted that the Director of Nursing had not provided the urology documentation previously requested by the surveyor on [DATE]. At this time, the surveyor provided another opportunity for the medical record to be reviewed by the DON and facility staff to provide a clear response to the survey team as to if the urology consult documentation was or was not present within the facility's medical record of the Resident. On [DATE] at 10:11AM the facility's Director of Nursing provided one urology consult provider note with a date of encounter on [DATE] which was dated with the following information at the top: 02-05-2026 11:22AM along with fax information. On [DATE] at 11:16AM approximately six more urology consult notes were provided to the surveyor which were dated Feb. 6 2026 along with fax information. On [DATE] at 8:41AM the surveyor conducted an interview with the facility's DON who reported to the survey team that they were not aware that the urology consult information was not on the Resident's chart, and confirmed that the surveyor was correct that the documentation was not present in the Resident's medical record and confirmed with the surveyor that after surveyor intervention, they then requested the Resident's medical documentation. During the interview, both the DON and Regional Clinical Director of Operations acknowledged and confirmed that the urology consults were not present within the Resident's medical record. On [DATE] at approximately 11:45AM the surveyor shared all concerns with the facility Administrator and Director of Nursing. 8. A medical record review was conducted on [DATE] at 1:21 PM for Resident # 11. The review revealed that on [DATE] the resident made a 911 call indicating that s/he wanted to go to the hospital. The resident went to the hospital. Further review reveals the resident was evaluated on [DATE] for concerns of difficulty breathing. The resident was sent to the hospital for further evaluation. The survey team requested documentation of the resident hospital transfer forms. The DON stated that the resident did not have a transfer form for [DATE] because the resident dialed 911. At this time the DON provided the survey team with a hospital transfer form and upon review, it revealed the following varying documentation. The date of the transfer to hospital was [DATE] 02:02. The date the specified hospital was notified was [DATE] 03:20. The other side of the hospital transfer form had clinical information such as vital signs with dates of [DATE]. The DON was asked to explain why the hospital transfer form had a transfer date of [DATE] and clinical information dated [DATE] and she was unable to explain the varying documentation. When asked how she ensures that accurate information is provided on the transfer form she confirmed that the information should have been reviewed to ensure that it is accurate and reflects the resident's status. All concerns were discussed with the Administration team at the exit conference.

Based on observation, interview and record review it was determined the facility failed to ensure the monitoring and oversight of food temperatures in accordance with professional standards for food service safety, failed to ensure sanitary practices were followed in accordance with professional standards for food service safety, failed to ensure food and food equipment was stored in accordance with professional standards for food service safety, failed to ensure thorough environmental cleaning and a sanitary environment of the kitchen, failed to ensure monitoring and oversight of kitchen equipment and environment, and failed to ensure kitchen wall paint was in good repair to prevent potential for contamination of food and food contact surfaces. This was evident during surveyor review of the kitchen task during the facility's recertification survey. The findings include:During the surveyor's initial tour of the facility's kitchen on 2/2/26 at 8:13AM the surveyor conducted an interview with Certified Dietary Manager #11 who confirmed that the dishwasher was used and was used in hot water mode. At this time the surveyor requested for CDM #11 to perform a dual observation of the kitchen. On 2/2/26 at 8:14AM the surveyor observed dishwashing area with multiple areas of pooling water present on the floor.On 2/2/26 at 8:14AM the surveyor observed a lower portion of the wall located behind the dishwasher with a thick black coating of debris present and an area of flooring near to this with a brown appearance.On 2/2/26 at 8:14AM the surveyor observed a layer of black and brown debris present on the wall above and below the dirty side of the dishwashing area extending several feet in width. On 2/2/26 at 8:14AM the surveyor observed black speckled areas of debris present along the corners where the ceiling met the walls. On 2/2/26 at 8:15AM the surveyor observed the side of the dishwashing conveyor where clean dishes exit the conveyor. On this side of the dishwashing area, dish racks were observed sitting directly on the floor's surface which was observed to be dirty in appearance with dark areas of debris present with one dish rack observed to be chipped and extensively worn in appearance. Several black dish buckets were observed sitting below the conveyor area observed to have a white film present on them sitting next to a disposable plastic lid. On 2/2/26 at 8:15AM the surveyor observed an area of pooling water present underneath and directly in front of the conveyor dishwasher on the floor with a brown and yellow film present with debris.On 2/2/26 at 8:15AM the surveyor observed a disposable glove sitting on top of an area of white debris located on top of the the facility's dishwasher.On 2/2/26 at 8:15AM the surveyor observed a layer of grey debris with a fuzzy appearance sitting on the lines which extended from the top of the dishwasher over to the area above where clean dishes exited the conveyor dishwasher.On 2/2/26 at 8:16AM the surveyor observed a cooking pot with a severely worn appearance with a dark area present on the inside of the pot.On 2/2/26 at 8:17AM the surveyor observed the hand washing sink area in the dish room which contained a broom, dustpans, a trash container lid, and a mobile cleaning bucket with a mop sitting in front of it which was extensively dirty with dark grey debris present on it. The flooring surrounding the hand washing sink area in the dish room was observed to have an extensive layer of dark debris present. The handwashing sink was observed to have a pooling of dark liquid within it and the sink surfaces were observed to have brown, black, and white debris present. On 2/2/26 at 8:20AM the surveyor observed an electric fan present in the dish room with an extensive layer of grey matter present on and within it. On 2/2/26 at 8:20AM the surveyor observed a cloth rag which was wrapped around a wall fixture in the kitchen which appeared to have wiring present extending from it.On 2/2/26 at 8:21AM the surveyor observed an extensive layer of dark debris present around and behind the floor drain and on the wall behind the three compartment sink. On 2/2/26 at 8:22AM the surveyor observed various cookware, serving ware, and food storage ware including a coffee pot drink and food storage containers and container lids with various crumbs and debris present on the surfaces. An area on the wall directly behind the rack which held the wares was observed to have various crumbs and debris present on the surface. On 2/2/26 at 8:23AM the surveyor observed a cart located near to the food serving and cook line which held food plates and pellets which had a broken plastic clipboard sticking out from in between a stack of pellets on top of it and food plates beneath it. The food plates, clipboard surface, and cart surface in which the plates and items were sitting on were observed to have various debris present. A sleeve of unopened condiment containers and a stack of uncovered condiment containers were observed to have speckled debris present on their surfaces. After surveyor intervention, the surveyor observed CDM #11 obtain a rolling cart and they began removing the unclean items and placed them onto the cart to be cleaned. On 2/2/26 at 8:29AM the surveyor observed a damaged and missing area of plastic wall in refrigerator curtain.On 2/2/26 at 8:30AM the surveyor observed a food slicing prep table with a lower level shelf observed with an unclean appearance with food crumbs present. On 2/2/26 at 8:30AM the surveyor observed the walk in freezer floor surface located approximately 2 inches beneath packaged hot dog rolls and other packaged bread items. Various pieces of beverage ice was present on the floor's surface and various dark matter and debris was observed to be present with a bottle of water and two small containers of frozen dessert on the floor. On 2/2/26 at 8:31AM the surveyor observed the kitchen trash can with no lid which was nearly full of trash sitting directly next to the bread rack which was holding packaged bread. The corner wall adjacent to both the rack holding packaged bread, and the trash can was observed to have various splattering and food debris present on the wall's surface. Peeling paint was observed on the corner wall's surface. On 2/2/26 at 8:33AM the surveyor observed the microwave located within the kitchen with instructions of how to use it posted on it, which upon further inspection, was noted to not be a commercial grade microwave. At this time the surveyor conducted an interview and inquired to CDM #11 as to if the microwave was a commercial grade, at which time CDM #11 was observed turning the microwave around to observe the labeling on it and confirmed with the surveyor that the microwave was not commercial grade. CDM #11 confirmed with the surveyor that the microwave was used for re-heating of Resident food. All concerns were shared with CDM #11 who acknowledged understanding of the concerns. On 2/2/26 at 8:52AM the surveyor observed the ice cooler cart located on the Liberty Unit dining area with one ice scooper in which the handle was sitting in a pool of water within the ice scoop holder container. On 2/2/26 at12:27PM after surveyor intervention, CDM #11 approached the survey team and stated: We cleaned up and got all dusty areas and ran everything through the dish machine, the dish room is in better shape, you can come take a look. On 2/6/26 at 12:35PM the surveyor entered the facility's kitchen and observed [NAME] #32 on the tray line plating food with no hair net on and Dietary Aide #31 assembling food trays with no hair net on. CDM #11 was observed to be present and assisting with the food service line and at this time, the surveyor informed CDM #11 of the concerns at which time they acknowledged the concerns and stated: I will re-educate and in-service, and the tray line was observed by the surveyor to continue. This surveyor then further inquired as to what actions they planned to take to ensure food service safety at this time, to which CDM #11 responded, I'll have her put it on. After surveyor intervention, [NAME] #32 and Dietary Aide #31 obtained and put on a hair net. On 2/6/26 at 12:39PM after surveyor intervention, CDM #11 informed the surveyor that the cloth had been removed from the horn, extensive cleaning had taken place in the dish room, and they had plumbers coming to replace the plumbing to the dishwasher, however, they had to wait on a plumbing part. On 2/6/26 at approximately 12:47PM the surveyor observed a stack of dishes being used to plate food was out of the heat warmer equipment and was sitting on the tray line food area and utilized for Resident meal trays. Additionally, the surveyor observed milk and other beverages on a cart near the food line in a deep clear plastic container in which there was a low level of ice within it. On 2/6/26 at 1:01PM the surveyor observed the last food cart leaving the kitchen to be distributed to Residents on the Ground floor for the lunch meal service. At this time, CDM #11 confirmed with the surveyor that this was the last food cart for lunch service.On 2/6/26 at 1:14PM the surveyor observed the plastic lid covers to the Resident meals within the food cart to be loose fitting and sliding off. On 2/6/26 at 1:27PM the surveyor confirmed with nursing staff that all Residents had been provided their meals, at which time a Resident refused their meal and their meal tray was immediately tested for temperature with CDM #11. Breaded fish patty was found to have a temperature of 123F and an assorted vegetable medley was found to have a temperature of 119F. On 2/6/26 at 1:33PM the surveyor conducted temperature testing of a carton of milk which was on the tray line in the kitchen with CDM #11 which was found to have a temperature of 53F. Subsequently, the surveyor tested an additional carton of milk from within the walk in refrigerator with CDM #11, at which time the temperature was found to be 42F. At this time the surveyor conducted an interview of CDM #11 who stated the following information: Milk should be 40F or below, food should be 135-140F leaving the food line, and about 135F the Residents should receive it.On 2/6/26 at 2:02PM the surveyor conducted an interview and shared concerns with the facility's Administrator who stated to the survey team: I'm embarrassed because we did so much education with staff. The facility Administrator further reported during the interview that they took this surveyor's concerns seriously and ordered the parts for the dishwasher plumbing, however, they would not arrive soon. At this time the surveyor offered an opportunity for all documentation they wished to provide to be provided for surveyor review.On 2/9/26 at 8:27AM the facility Administrator provided documentation of education performed beginning on 2/7/26 with dietary staff regarding sanitation, cleanliness, and food temperatures in response to the previously shared surveyor concerns. On 2/9/26 at approximately 11:45AM the surveyor shared all concerns with the facility Administrator and Director of Nursing.

Based on observations and interviews with residents and facility staff it was determined the facility failed to accommodate residents by allowing residents to smoke at the designated facility times. This was found to be evident for all residents who smoked including 2 Residents (# 4 and # 121) of 25 residents reviewed for smoking during the facility's survey. The Findings include: A recertification survey was conducted at the facility between 2/2/2026 and 2/9/2026. During the survey resident interviews were conducted and resident observations were made as follows:1. Resident # 4 was interviewed on 2/2/26 at approximately 12:22 PM. The resident was asked the question regarding smoking, are you able to smoke when you want to and the resident replied, no. I have not been allowed to go outside to smoke for approximately two weeks. The resident went on to say that the facility has designated times in which they can go outside and smoke, but were being told that the temperature outside has been less than 32 degrees each day, which was a facility restriction, preventing residents from going outside during this time. The resident further stated that there was another time around Christmas Eve in which the elevator that goes down to the ground level was not working and residents on that level were not allowed to go outside and smoke for approximately one week. The resident expressed feelings like being trapped inside of the building.2. Resident # 121 was interviewed on 2/2/26 at approximately 3:25 PM and was asked the question, are you able to make choices regarding your care and/or interests while at the facility? The resident replied, I have not been allowed to go outside to smoke for a long time. The resident stated that the facility has a sign posted on the window next to the designated courtyard where the residents go out to smoke that states if the temperature is a certain degree the smoke breaks will be cancelled. The resident stated, I don't mind going outside to smoke when it is cold outside because I have a heavy coat and a hat, and besides, I have enough sense to come back in afterwards. Observations were made by the survey team on day 1 of the survey on 2/2/26, and on day 2 of the survey on 2/3/26 at each of the facility designated smoke times of: 9:00AM, 12:00PM and 3:00PM no residents were observed smoking outside in the designated area.During a follow-up interview with resident # 4 on the same date at approximately 3:30PM, the resident again expressed concerns about not being allowed to go outside and smoke. The resident told the two surveyors that it does not matter what the temperature is outside, s/he wants to be able to go outside to smoke. The resident stated that this is a violation of his/her right to be able to smoke when they want to.An interview was conducted with the Nursing Home Administrator (NHA) on 2/2/26 at approximately 3:40PM and he was asked to explain to the survey team why residents were not allowed to smoke. The NHA stated that it is the facility's policy to implement restrictions when the temperature is at a certain degree of 32 degrees or less. When asked by the survey team if residents have a right to make the decision to go outside and smoke at the facility designated times, he stated that the facility will continue to follow the facility's policy and not allow residents to smoke at the facility designated times. He stated that the Medical Director (MD) provided input into the smoking restriction policy.The policy was reviewed by the survey team and was as follows:Smoke Break and Cigarette Policy. Winter Smoke Break policy 1/8/26 posted:9:00AM smoke break will occur as scheduled unless otherwise cancelled.For 12:00PM, 3:00PM, and 6:00PM, smoke breaks, an activities team member will check the temperature 15 minutes prior.If the temperature is 32 degrees or below, the smoke break will be cancelled due to extreme cold. A phone interview was conducted with the facility's Medical Director (MD # 7) on 2/4/26 at 2:06 PM and he was asked if he provided input into the facility's smoking restrictions that were implemented by the facility due to cold weather. The MD #7 stated that he has no recollection of any input regarding restrictions. He went on to say that if a resident is alert and oriented and has appropriate attire, the resident can go outside and smoke. It is the resident right to do so. He went on to say that if a resident does not have appropriate attire to wear outside to smoke, a care plan should be created.During follow-up visits with Resident #4 and Resident #121, on 2/4/26 and 2/5/26 they both stated that they were not allowed to smoke at the designated smoke time of 6:00PM on 2/2/26, and 2/3/26. They both confirmed that the facility provided inconsistent smoking times to residents beginning on 2/4/26 and they were not consistent at the facility designated smoke times.All concerns were discussed with the Administration team at the exit conference on 2/9/26.

Based on observation and interviews with staff, it was determined that the facility failed to provide the residents with respect and dignity by failing to 1.) knock/ask permission to enter prior to entering the residents' rooms, evident for 5 resident rooms (#222, #221, #223, #224, # 227) out of 15 resident rooms observed on the Liberty Hall Unit; 2.) ensure dependent residents were clothed and out of bed to chair, evident for 3 (Resident #23, Resident #124, and Resident #74); 3.) ensure residents clothing was timely laundered, evident for 5 (Resident #61, Resident #87, Resident #53, Resident #2, and Resident #125); and 4.) maintain privacy and appropriate covering during care and transfers, evident for 2 (Resident #13 and Resident #63) out of 57 residents reviewed during the survey. The findings include: 1. On 2/2/2026 at 8:55AM through 9:13AM, the Surveyor observed Geriatric Nursing Assistant (GNA) #29 as they passed out breakfast trays on the Liberty Hall Unit. The Surveyor observed GNA #29 enter rooms #222, #221, #223, #224, and #227, without knocking or asking permission to enter prior to entering the residents' rooms. On 2/2/2026 at 9:22AM, during an interview conducted with GNA #29, the Surveyor expressed the concern that as they passed out breakfast trays to rooms #222, #221, #223, #224, and #227, they did not knock or ask permission to enter before entering the residents' rooms. GNA #29 apologized for their actions. During an interview conducted with Unit Manager (UM) #13 on 2/2/2026 at 11:25AM, the Surveyor expressed the concern with multiple observations of GNA #29 entering residents' rooms and failing to knock or request permission to enter prior to entering the residents' rooms. UM #13 acknowledged the Surveyor's concern and informed the Surveyor that staff will be educated on knocking and announcing themselves prior to entering resident rooms. On 2/2/2026 at 11:36AM, the Nursing Home Administrator (NHA) was made aware of the Surveyors concerns. 2. On 2/2/2026 at 8:20AM the Surveyor observed Resident #23 laying in bed with a gown and an adult brief on. The resident stated that he/she used to have a Geri chair and a wheelchair in his/her room, but the staff took them out of the room. The resident stated that he/she was supposed to get out of the bed on Mondays, Wednesdays, and Friday; however, the staff have not gotten him/her out of the bed in over a week. An observation of the resident's closet/cabinet space revealed a couple pairs of unfolded clothes in a bag and random unhung, unfolded clothes scattered at the bottom of the closet/cabinet space with an open pack of adult briefs and other resident belongings. The resident was unsure if the clothing was clean or dirty. On 2/2/2026 at 8:42AM, the Surveyor observed Resident #124 awake in bed with a gown on and covered with a blanket. The resident was aphasic (difficulty expressing words) with mild cognitive impairment. An observation of the resident's closet/cabinet space revealed a jacket on a hanger, a dark gray suitcase, and random unhung, unfolded clothing scattered at the bottom of the closet/cabinet space with other resident belongings. It was unclear if the clothing was clean or dirty based on the presentation. On 2/2/2026 at 8:50AM, the Surveyor observed Resident #74 awake in bed with a gown on and covered with a blanket. The resident was nonverbal with involuntary bodily movements and severe cognitive impairment. An observation of the resident's closet/cabinet space revealed random unhung, unfolded pants and shirts scattered at the bottom of the closet/cabinet space with other resident belongings. It was unclear if the clothing was clean or dirty based on the presentation. On 2/3/2026 between 10:50AM and 11:00AM, the Surveyor observed Resident #23, Resident #124, and Resident #74 lying in bed with a gown on. On 2/5/2026 between 12:45PM and 1:00PM, the Surveyor observed Resident #23, Resident #124, and Resident #74 lying in bed with a gown on. On 2/5/2026 at 1:33PM during a review of Resident #23's electronic medical record, the Surveyor discovered an annual Minimum Data Set (MDS) assessment completed on 9/11/2025. Section F for Preferences and Customary Routine and Activities stated that it was very important for the resident to choose what clothes to wear. Further review revealed the resident was dependent on staff for activities of daily living (ADLs) and transfers. On 2/5/2026 at 1:45PM during a review of Resident #74's electronic medical record, the Surveyor discovered an annual Minimum Data Set (MDS) assessment completed on 11/10/2025. Section F for Preferences and Customary Routine and Activities stated that it was very important for the resident to choose what clothes to wear. Further review revealed the resident was dependent on staff for activities of daily living (ADLs) and transfers. On 2/5/2026 at 2:00PM, a review of Resident #124's electronic medical record revealed a care plan with a focus, [Resident #124] has an ADL self-care performance deficit [related to] impaired balance and limited mobility, with interventions which state The resident is totally dependent on 1 staff for dressing and The resident is totally dependent on 2 staff for transferring using mechanical lift. During an interview conducted with the Director of Nursing (DON) on 2/9/2026 at 3:00PM, the Surveyor made the DON aware that Resident #23, Resident #74, and Resident #124 were observed, on multiple days and times during the survey, in bed with a gown on. The Surveyor informed the DON that Resident #23 stated that they had not been out of bed in over a week and was supposed to get up out of bed to a chair via mechanical lift on Mondays, Wednesdays, and Fridays; however, the staff took his/her chair out of the room and never replaced it. Resident #23 was not observed out of bed on those days. Also, Resident #23, Resident #74, and Resident #124 had random unhung, unfolded clothing in their closet/cabinet space and it was unclear if the clothing was clean or dirty based on its' presentation. The Surveyor expressed the concerns facility failed to ensure residents who are dependent on staff for ADLs and transfers get dressed for the day and get out of bed to chair. The DON informed the Surveyor that they would review the resident's medical record to determine a plan of care. 3. On 2/2/2026 between 8:20AM and 9:30AM, during a tour of the Liberty Hall unit, the Surveyor observed: room [ROOM NUMBER], Resident #61 had a tall laundry basket full of dirty clothes. Resident #87 had a tall laundry basket full of dirty clothes with additional dirty clothes piled on top leaning against the wall. Resident #87 could not recall the last time his/her clothes had been washed. room [ROOM NUMBER], Resident #53 had a large tote full of dirty clothes. Resident #2 had a tall laundry basket, next to the nightstand, full of dirty clothes. On 2/3/2026 at 8:00AM, the Surveyor observed room [ROOM NUMBER], Resident #125 had a tall laundry basket full of dirty clothes with additional dirty clothes piled on top. On 2/5/2026 at 12:50PM, during an interview with Resident #61, the Surveyor was informed that the washing machine had been broken for weeks and he/she just had his/her clothes washed. Any longer, and the resident would have to wear dirty clothes. On 2/5/2026 at 12:53PM during an interview with Resident #53 and Resident #2, Resident #53 informed the Surveyor that the washing machine was broken for a while, but he/she had his/her clothes washed on 2/4/2025. Resident #53 stated that the facility usually washed his/her clothes on Tuesdays but came a day later this week. Resident #2 still had a full basket of dirty clothes. Resident #2 stated he/she would like to get dressed but did not have any clean clothes. During the interview, Geriatric Nursing Assistant (GNA) #29 came to the doorway. The Surveyor asked if they knew about the resident's laundry schedule because Resident #2 needed his/her clothes washed. GNA #29 was unsure and stated they would find out for the resident. On 2/6/2026 at 11:30AM, during an interview with Environmental Service and Laundry Manager (EVSM) #23, the Surveyor was informed that a washing machine was down for the day on 1/27/2026. The washing machine was serviced that day and up and running by the evening. The Surveyor expressed the concern that multiple residents had laundry baskets full and even overfull of dirty laundry, leaving some without clean clothes to wear. EVSM #23 acknowledged the Surveyor's concern and stated that because of the broken washing machine on 1/27/2026, the laundry department had been playing catch up with washing the resident's dirty laundry. Each resident had a specific day, Monday-Friday, and shift, morning and evening, when the laundry aide goes to their rooms to collect the dirty laundry. Dirty laundry is bagged, washed, dried, and folded. Clean laundry is bagged and returned to the resident. Friday through Sunday, laundry is done by request only. According to the Personal Laundry Collection Schedule, Resident #61's, Resident #87's, Resident #53's, and Resident #2's collection day was Tuesday evenings, and Resident #125 was Tuesday morning. EVSM #23 stated that the department was working on getting back to the regular collection schedule and would ensure to provide staff education on collecting, washing, and returning resident's laundry timely. 4a. On 02/02/2026 at approximately 8:15 a.m., during observation rounds, Resident #63 was observed lying in bed in room [ROOM NUMBER] with his/her hospital gown positioned in a manner that exposed his/her adult brief (pull-up). The resident was not covered with a top sheet or blanket, and no top sheet was present on the bed at the time of observation. The resident's room door was open, and the resident was visible from the hallway, making it possible for staff and visitors walking past the room to view the resident in this exposed condition. The surveyor proceeded down the hallway to locate the nurse or Geriatric Nursing Assistant (GNA) assigned to Resident #63. Upon reaching the nurses' station, GNA Staff #17 stated that the assigned nurse had just walked down the hall toward room [ROOM NUMBER]. The surveyor then spoke with Nurse #16, who stated he had just placed linen in the resident's room. The surveyor accompanied Nurse #16 back to room [ROOM NUMBER]. Upon entering the room, Resident #63 remained in the same exposed condition, visible from the hallway, and still without a top sheet or covering. Clean linen had been placed on a chair inside the room; however, the resident had not been covered. After surveyor intervention, a top sheet was applied to cover Resident #63. 4b. On 02/09/2026 at approximately 2:00 p.m., Resident #13 was observed on Unit 1 being transferred from a Hoyer lift to the bed by two licensed nurses, LPN Staff #14 and RN Staff #15. During the transfer, the resident's room door was open to the hallway. The resident was positioned in the Hoyer lift with his/her brief exposed and visible to staff and visitors passing in the hallway. Both nurses were observed standing on the same side of the bed while raising and lowering the bed to adjust the mechanical lift. During the transfer, the resident repeatedly yelled, Please don't let me fall, and continued crying out throughout the transfer process. On 02/09/2026 at approximately 2:30 p.m., the Director of Nursing (DON) confirmed that both staff observed were licensed nurses. The DON acknowledged that the resident's room door should have been closed during the transfer to maintain privacy and dignity and stated that education would be provided to both nurses regarding resident dignity. On 02/09/2026 at approximately 2:45 p.m., Staff #14 and Staff #15 were interviewed and acknowledged that the residents' door should have been closed during the transfer to provide privacy and dignity.

Based on review of Facility Reported Incident #2728128, interview, and record review it was determined the facility failed to ensure a thorough investigation. This was evident for 1 out of 1 facility reported incident (#2728128) reviewed by the surveyor during the facility's recertification survey.The findings include:On 2/4/26 at 9:30AM in response to the surveyor's request to the facility Administrator to provide the complete investigative file and all documentation relating to Facility Reported Incident #2728128, the surveyor was provided with the complete investigative file. At this time, the surveyor conducted an interview with the facility Administrator who confirmed with the survey team that the file being provided was the facility's complete investigative file. On 2/4/26 at 9:42AM the surveyor reviewed the facility's complete investigative file for Facility Reported Incident #2728128 which revealed an initial self report made to the Office of Health Care Quality by the facility's Administrator dated 1/27/26 in which the allegation type was documented as sexual and additionally documented under the suspected crime section: allegation of physical abuse. Further review of the initial self report revealed that Resident #86 was documented as an alleged victim and Resident #69 was documented as an alleged perpetrator. Continued review of the facility's initial self report form revealed the following documented allegation details: On 1/27/26 at approximately 5:15PM, the evening shift supervisor informed the DON (Director of Nursing) that Resident (#69) was observed touching male employees and Resident (#86) inappropriately.During the surveyor's review of the initial self report form, the following information was noted which was documented by the facility on the form under the section outlining all steps taken immediately to ensure resident(s) are protected: Psychiatric Nurse Practitioner was notified of new onset of inappropriate touching behaviors . Review of the documentation in the facility's initial self-report also revealed that Resident #69 was placed on direct 1:1 staff supervision, and that law enforcement was not contacted, and other agencies were not notified. Further review of the complete investigative file revealed there was no evidence present that any other agencies besides the Office of Health Care Quality were notified.On 2/4/26 at 10:09AM the surveyor conducted an interview of the facility's Administrator at which time they stated during the interview: This was on the memory care unit, when I initially got it, we reported it as if it was an allegation of abuse because of the inappropriate touching. During the interview the surveyor inquired as to if the Administrator had reported the incident to law enforcement and the ombudsman, at which time the Administrator confirmed in the presence of the survey team that they did not report the incident to law enforcement and had called the Ombudsman but did not hear back from them and also confirmed they did not leave the details of the incident in a message for the Ombudsman. When the surveyor asked if the Administrator had any documentation showing contact was made, they stated: I do not. At this time the surveyor shared the concerns and the Administrator acknowledged the concerns and stated: Okay. After surveyor intervention, the Administrator stated: We have a consistent record with the police, I'll look into that. On 2/4/26 at 10:29AM the surveyor conducted a review of the facility's final self-report made to the Office of Health Care Quality by the facility's Administrator dated 1/31/26 which revealed the following information was included regarding Resident #69: 1.) On 1/28/26 wandering behaviors present, continued to attempt to touch other Residents and staff but was redirected with each episode, 2.) On 1/29/26 patient continued to show unsafe behaviors involving ambulating into other Resident rooms, maintained on 1:1 supervision by female staff, attempting to grope other Residents but was frequently redirected, refused AM medication and was subsequently EP'd (emergency petitioned) at 1456 to Northwest Hospital.Further review of the facility's final self report revealed the following documentation under the conclusion section of the form under the verified section: The facility investigation confirmed Resident #69 did inappropriately touch Resident #86 and male staff, Resident #86 did not have any injury, mental distress, or behavior change because of the incident. Further review of the facility's self report revealed the following information was also documented under the section of the form which directs the facility to provide as a result of a finding of abuse, such as physical, sexual, or mental abuse, identify counseling or other interventions planned and implemented to assist the Resident: Resident (#86) did not suffer any physical or emotional distress because of the incident. The surveyor noted that on the facility's final self-report, the facility's Director of Nursing was documented as being the facility's individual with primary responsibility for conducting the investigation.On 2/4/26 at 10:29AM the surveyor reviewed the facility's complete investigative file which revealed the following documented statement from Geriatric Nursing Assistant (GNA) #33 dated 1/27/26 at 5:23PM: When dinner trays came up, (Resident #69) was walking around in the hallway, I observed him/her reach and touch another male Resident's buttocks, outside of his pants, Like s/he smacked him lightly on the butt as s/he was walking by. The documented statement by GNA #33 further identified the other Resident as Resident #86.Further review of the complete investigative file revealed the following documented statement from Activities Assistant #34: Earlier in the afternoon (Resident #69) tried to touch my butt while I was on the unit initiating activities for the Residents, I was able to redirect him/her and give him/her an activity to do, I told the nurse about this. Continued review of the complete investigative file revealed the following documented statement by GNA #35: I witness (Resident #69) slap (Resident #39) on his/her buttocks as s/he walked by him/her during dinner time.Continued review of the facility's complete investigative file on 2/4/26 at 10:29AM revealed the facility's follow up self-report made to the Office of Health Care Quality which documented the following information: If the allegation was reported to law enforcement or another state agency, where applicable and if available, what is the status or provide conclusions of their investigation: N/A. Review by the surveyor of the facility's follow up self report revealed there was no evidence of other agencies having been contacted.The surveyor noted that no further investigation into the concern by the facility regarding Resident #39 was present within the complete investigative file, and they were not mentioned or documented as an alleged victim on the facility's self report forms. One of five paper documented staff statements was observed to be handwritten and signed with the corresponding staff name, the remaining four statements were documented by the facility's Director of Nursing (DON) as verbal statements signed by the DON. Two staff statements were observed dated as documented by the DON on 1/27/26 at 5:23PM, one statement was observed dated as documented by the DON on 1/27/26 at 5:24PM, one statement had no time of documentation and was dated 1/27/26, and another statement was dated as documented by the DON on 1/27/26 at 5:26PM, and there was no documented evidence of interview questions asked. There was no further documentation found in the complete investigative file of further investigation and assessment in response to the written statement regarding Resident #39 in which documented observation of Resident #69 slapping Resident #39 on his/her buttocks. On 2/4/26 at 11:25AM the surveyor shared concerns with the facility's Administrator which included that there was no evidence within the facility's complete investigative file of any assessments or interviews of other facility Residents residing on the memory care unit. On 2/4/26 at 11:40AM after surveyor intervention, the facility provided a witness statement form which was not part of the complete investigative file in which the DON documented they had attempted to interview other Residents and no Residents were identified that were capable of interview on 1/27/26 at 5:44PM. The surveyor noted that there were no documented assessments of Residents deemed incapable of interview on the unit included within the complete investigative file. On 2/5/26 at10:25AM the surveyor conducted an interview with a facility Ombudsman who stated that they received no notification from the facility regarding facility reported incident #2728128 and additionally stated: This incident, nobody called me.On 2/6/26 at 10:13AM the surveyor conducted another interview of the facility Ombudsman who reported having further confirmed with their office that the incident was never reported by the facility to the Ombudsman's. On 2/9/26 at approximately 11:45AM the surveyor shared all concerns with the facility Administrator and Director of Nursing.

Based on record review and interview it was determined the facility failed to ensure an allegation of abuse was timely reported and failed to ensure all applicable agencies were notified. This was evident for 1 out of 1 facility reported incident (#2728128) reviewed during the facility's recertification survey.The findings include:On 2/4/26 at 9:42AM the surveyor reviewed the facility's complete investigative file for Facility Reported Incident #2728128 which revealed an initial self report made to the Office of Health Care Quality by the facility's Administrator dated 1/27/26 at 7:45PM in which the allegation type was documented as sexual and additionally documented under the suspected crime section: allegation of physical abuse. Further review of the initial self report revealed that Resident #86 was documented as an alleged victim and Resident #69 was documented as an alleged perpetrator. Continued review of the facility's initial self report form revealed the following documented allegation details: On 1/27/26 at approximately 5:15PM, the evening shift supervisor informed the DON (Director of Nursing) that Resident (#69) was observed touching male employees and Resident (#86) inappropriately. During the surveyor's review of the initial self report form, the following information was noted which was documented by the facility on the form under the section outlining all steps taken immediately to ensure resident(s) are protected: Psychiatric Nurse Practitioner was notified of new onset of inappropriate touching behaviors . Review of the documentation in the facility's initial self report also revealed that Resident #69 was placed on direct 1:1 staff supervision, and that law enforcement was not contacted, and other agencies were not notified. Review by the surveyor of the email confirmation of submission form for the initial self report made to the Office of Health Care Quality revealed it was dated and timed with the following: Tue 1/27/2026 7:46PM. Further review of the complete investigative file revealed there was no evidence present that any other agencies besides the Office of Health Care Quality were notified.On 2/4/26 at 10:09AM the surveyor conducted an interview of the facility's Administrator at which time they stated during the interview: This was on the memory care unit, when I initially got it, we reported it as if it was an allegation of abuse because of the inappropriate touching. During the interview the surveyor inquired as to if the Administrator had reported the incident to law enforcement and the ombudsman, at which time the Administrator confirmed in the presence of the survey team that they did not report the incident to law enforcement and had called the Ombudsman but did not hear back from them and also confirmed they did not leave the details of the incident in a message for the Ombudsman. When the surveyor asked if the Administrator had any documentation showing contact was made, they stated: I do not. At this time the surveyor shared the concerns and the Administrator acknowledged the concerns and stated: Okay. After surveyor intervention, the Administrator stated: We have a consistent record with the police, I'll look into that. Continued review of the facility's complete investigative file on 2/4/26 at 10:29AM revealed the facility's follow up self report made to the Office of Health Care Quality which documented the following information: If the allegation was reported to law enforcement or another state agency, where applicable and if available, what is the status or provide conclusions of their investigation: N/A. Review by the surveyor of the facility's follow up self report revealed there was no evidence of other agencies having been contacted.Further review of the facility's final self report revealed the following documentation under the conclusion section of the form under the verified section: The facility investigation confirmed Resident #69 did inappropriately touch Resident #86 and male staff, Resident #86 did not have any injury, mental distress, or behavior change because of the incident. Further review of the facility's self report revealed the following information was also documented under the section of the form which directs the facility to provide as a result of a finding of abuse, such as physical, sexual, or mental abuse, identify counseling or other interventions planned and implemented to assist the Resident: Resident (#86) did not suffer any physical or emotional distress because of the incident. Continued review of the complete investigative file revealed the following documented statement by GNA #35: I witness (Resident #69) slap (Resident #39) on his/her buttocks as s/he walked by him/her during dinner time. The surveyor noted that no further investigation into the concern by the facility regarding Resident #39 was present within the complete investigative file, and they were not mentioned or documented as an alleged victim on the facility's self report forms. On 2/5/26 at10:25AM the surveyor conducted an interview with a facility Ombudsman who stated that they received no notification from the facility regarding facility reported incident #2728128 and additionally stated: This incident, nobody called me.On 2/6/26 at 10:13AM the surveyor conducted another interview of the facility Ombudsman who reported having further confirmed with their office that the incident was never reported by the facility to the Ombudsman. On 2/9/26 at approximately 11:45AM the surveyor shared all concerns with the facility Administrator and Director of Nursing.

Based on review of record review, interview, it was determined the facility failed to ensure facility Residents were free from abuse. This was evident for 1 out of 1 facility reported incident (#2728128) reviewed by the surveyor during the facility's recertification survey.The findings include:On 2/4/26 at 9:30AM in response to the surveyor's request to the facility Administrator to provide the complete investigative file and all documentation relating to Facility Reported Incident #2728128, the surveyor was provided with the complete investigative file. At this time, the surveyor conducted an interview with the facility Administrator who confirmed with the survey team that the file being provided was the facility's complete investigative file. On 2/4/26 at 9:42AM the surveyor reviewed the facility's complete investigative file for Facility Reported Incident #2728128 which revealed an initial self report made to the Office of Health Care Quality by the facility's Administrator dated 1/27/26 in which the allegation type was documented as sexual and additionally documented under the suspected crime section: allegation of physical abuse. Further review of the initial self report revealed that Resident #86 was documented as an alleged victim and Resident #69 was documented as an alleged perpetrator. Continued review of the facility's initial self report form revealed the following documented allegation details: On 1/27/26 at approximately 5:15PM, the evening shift supervisor informed the DON (Director of Nursing) that Resident (#69) was observed touching male employees and Resident (#86) inappropriately. During the surveyor's review of the initial self report form, the following information was noted which was documented by the facility on the form under the section outlining all steps taken immediately to ensure resident(s) are protected: Psychiatric Nurse Practitioner was notified of new onset of inappropriate touching behaviors . Review of the documentation in the facility's initial self report also revealed that Resident #69 was placed on direct 1:1 staff supervision, and that law enforcement was not contacted, and other agencies were not notified. On 2/4/26 at 10:09AM the surveyor conducted an interview of the facility's Administrator at which time they stated during the interview: This was on the memory care unit, when I initially got it, we reported it as if it was an allegation of abuse because of the inappropriate touching. On 2/4/26 at 10:29AM the surveyor conducted a review of the facility's final self report made to the Office of Health Care Quality by the facility's Administrator dated 1/31/26 which revealed the following information was included regarding Resident #69: 1.) On 1/28/26 wandering behaviors present, continued to attempt to touch other Residents and staff but was redirected with each episode, 2.) On 1/29/26 patient continued to show unsafe behaviors involving ambulating into other Resident rooms, maintained on 1:1 supervision by female staff, attempting to grope other Residents but was frequently redirected, refused AM medication and was subsequently EP'd [emergency petitioned] at 1456 to Northwest Hospital.Further review of the facility's final self report revealed the following documentation under the conclusion section of the form under the verified section: The facility investigation confirmed Resident #69 did inappropriately touch Resident #86 and male staff. Resident #86 did not have any injury, mental distress, or behavior change because of the incident. Further review of the facility's self report revealed the following information was also documented under the section of the form which directs the facility to provide as a result of a finding of abuse, such as physical, sexual, or mental abuse, identify counseling or other interventions planned and implemented to assist the Resident: Resident (#86) did not suffer any physical or emotional distress because of the incident. The surveyor noted that on the facility's final self report, the facility's Director of Nursing was documented as being the facility's individual with primary responsibility for conducting the investigation.On 2/4/26 at 10:29AM the surveyor reviewed the facility's complete investigative file which revealed the following documented statement from Geriatric Nursing Assistant (GNA) #33 dated 1/27/26 at 5:23PM: When dinner trays came up, (Resident #69) was walking around in the hallway, I observed him/her reach and touch another male Resident's buttocks, outside of his pants, Like [s/he] smacked him lightly on the butt as [s/he] was walking by. The documented statement by GNA #33 further identified the other Resident was Resident #86.Further review of the complete investigative file revealed the following documented statement from Activities Assistant #34: Earlier in the afternoon (Resident #69) tried to touch my butt while I was on the unit initiating activities for the Residents, I was able to redirect him/her and give him/her an activity to do, I told the nurse about this. Continued review of the complete investigative file revealed the following documented statement by GNA #35: I witness (Resident #69) slap (Resident #39) on his/her buttocks as s/he walked by him/her during dinner time. Review of the documentation on a form titled petition for emergency evaluation, which was dated 1/29/26 regarding Resident #69 documented the following information: The evaluee is demonstrating the following behavior that leads me to conclude that they currently have a mental disorder: sexually and physically assaulting residents and staff, wandering in and out of Resident's rooms, difficult to redirect, requires a one to one supervision, The evaluee presents a danger to the life or safety of the evaluee or others because: physically assaulting, Residents and staff, s/he is not allowing care to be provided, inappropriate sexual touching of staff and Residents.Review of Resident #69's medical record by the surveyor on 2/4/26 at 10:29AM revealed a nursing progress note dated 1/29/26 at 1:52PM which documented the following regarding Resident #69 by Licensed Practical Nurse #36: Resident alert and responsive, continues to require 1:1 supervision due to inappropriate sexual behaviors and physical aggression when redirection is attempted, Writer was able to administer morning medication after encouragement, The Resident continues to wander the memory unit in and out of Resident's rooms, Unit staff must frequently redirect Resident out of occupied rooms throughout the shift despite supervision and redirection the Resident continues to attempt to touch both male and resident staff in a sexually inappropriate manner, this continues to create an unsafe environment, The Resident remains a high elopement risk and continues to require supervision with a 1:1 sitter at all times, Due to elopement risk, the Resident has a wander guard placed on R wrist, Will continue to monitor the Resident for additional behaviors and offer redirection. On 2/9/26 at 10:30AM the surveyor reviewed the medical record of Resident #69 which revealed documentation present of them having been previously emergency petitioned on 1/22/26 for issues which included agitation, aggressive behavior and assaulting of individuals resulting in hospitalization prior to being discharged to this facility. Recommendations on discharge to the facility were observed to be documented which included the necessity of a structured and supervised care environment, continuous monitoring for behavioral disturbances, and ensuring his/her safety and the safety of others. On 2/9/26 at 11:29AM the surveyor conducted an interview of the facility's Director of Nursing who confirmed during the interview with the survey team present, that they did not have any knowledge of Resident #69's documented recent prior medical history of assault of individuals and prior emergency petition. On 2/9/26 at approximately 11:45AM the surveyor shared all concerns with the facility Administrator and Director of Nursing.

Based on observations and interviews with facility staff it was determined the facility failed to ensure the facility environment was kept safe, clean, comfortable, and homelike. This was found to be evident of 4 (Resident # 4, # 41, 31 and # 121) of 40 residents observed and 2 out of 2 ceiling vents observed during the facility's survey. The findings include: During observation rounds conducted during the survey, the following concerns were identified: 1. Resident # 4's room was observed on 2/2/26 at approximately 8:35 AM and a pile of clothes and personal belongings were piled in the corner and extending along the wall and walk space near the resident bed. 2. Resident #41's room was observed on 2/2/26 at approximately 8:40AM and there was an oversized TV on top of the dresser leaning back against the wall. There were no legs observed underneath the TV to stabilize the TV to keep it from falling. 3. Resident # 31's room was observed on 2/2/26 at approximately 8:45AM and inside of the bathroom there was an open area and bubbling noted on the ceiling tile that needed repair. 4. Resident #121's room was observed on 2/4/26 with clothes on top of another bed in his/her room. The resident stated that s/he would like to have a place to put all personal belongings. During an interview with the NHA on 2/4/26 stated to the survey team that an audit would be conducted of the residents' rooms and plastic bins would be provided for the residents. The NHA provided the survey team with a copy of the audit results. A tour was conducted with the maintenance Director on 2/6/26 at approximately 11:55AM and he was shown the concerns regarding Resident # 4's TV and stated that he would fix the TV to prevent any hazards and stated that repairs were made to Resident # 31's room ceiling tile. All concerns were discussed with the Administration team at the exit conference on 2/9/26. 5a. On 2/6/26 at 1:10PM during the food tray pass, the surveyor observed a ceiling vent located on the ground floor hallway outside of room [ROOM NUMBER] with oscillating components that when observed in the open position, had copious amounts of dark matter present within, and grey matter was observed on the outer vent cover and also within and beyond the vent's cover. On 2/6/26 at 1:11PM the surveyor conducted a dual observation of the concern with Certified Dietary Manager (CDM) #11 who observed and acknowledged the surveyor's concern and regarding the grey matter within the vent cover, CDM #11 additionally stated: That's probably a filter that needs changed. 5b. On 2/6/26 at 1:13PM during the food tray pass, the surveyor observed a ceiling vent located on the ground floor hallway near room [ROOM NUMBER] with oscillating components that when observed in the open position, had dark matter present within, and grey matter was observed on the outer vent cover and also within and beyond the vent's cover. During the surveyor's observation, CDM #11 observed and acknowledged the surveyor's concern. On 2/6/26 at 2:02PM the surveyor shared the concern with the facility's Administrator. On 2/6/26 at 3:30PM the surveyor shared concerns with the facility's Regional Director of Clinical Operations #3 who stated to the survey team: Okay I'll let maintenance know. On 2/9/26 at approximately 11:45AM the surveyor shared all concerns with the facility Administrator and Director of Nursing.

Based on record reviews, staff interviews, and review of other pertinent information, it was determined that the facility failed to keep and maintain a safe and effective system for securing and counting narcotic medications. This was evident for 2 out of 7 medication carts reviewed for medication storage. These actions resulted in the finding of an Immediate Jeopardy which was identified on 9/26/24 at 5:45 PM. An IJ summary tool was provided to the facility on [DATE]. The facility submitted a draft of their plan to remove the immediacy on 9/26/24 at 8:36 PM, and it was not accepted. The facility submitted a second draft of their plan to remove the immediacy on 9/26/24 at 9:30 PM, and it was not accepted. The facility submitted a third plan on 9/27/24 at 12:15 AM and it was accepted by the state agency at 9/27/24 at 12:30 AM. After removal of the immediacy, the deficient practice remained with a scope and severity of E. The Immediate Jeopardy was removed on 9/30/24 after on-site confirmation of the completion of the facility's plan of removal. The findings include: 1. On 09/26/2024 at 10:16 AM review of Facility Reported Incident MD00210153 investigation, revealed that on 09/14/24 during the 7:00am-3:00pm shift, agency Licensed Practical Nurse (LPN) #50 left the medication cart and narcotics box unlocked on the Promenade unit. During the change of shift on 9/14/24 at 3:15pm, LPN #50 and LPN# 53 identified there were 4 narcotic pain medications blister packs missing from the narcotic box. The medications belonged to Residents #17, #53, and #115. According to the investigation, Unit Manager #24 was notified of the incident on 09/14/24 at 3:23 pm. Unit Manager #24 notified Director of Nursing (DON) #2 on 9/14/24 at 3:38 pm and a facility investigation was initiated. During an interview with DON #2 on 9/26/24 at 12:15 pm it was reported that the Environmental Service (EVS) Director #36 had been informed by EVS employee #51 about an incident involving Resident #78. EVS #51 called after their shift to report she observed Resident #78 remove medication from an opened medication cart on the Promenade unit on 9/14/24 during the 7:00 am-3:00 pm shift. EVS #51 reported to EVS Director #36 that they followed Resident #78 and asked them to return the medication. Resident #78 responded back and stated, It's not my fault they left the cart open. EVS #51 reported that Resident #78 refused to return the medication. EVS employee #51 failed to report the incident until after the end of their shift. During an interview with the DON and the Administrator on 9/26/24 at 1:00 PM, both confirmed that the resident admitted to taking the medications to the police officer who was at the facility on 9/14/24, which was captured on the officer's body cam. The DON went on to say the resident stated, it's not their fault the nurse left the medication cart open. The DON advised as a result of their investigation the facility placed LPN #50 on a Do Not Return list, and a facility audit was completed on all medication carts to ensure they were locked. All licensed nurses were educated on the importance of securing medication carts properly. Additionally, random observational rounds were being conducted to ensure compliance with medication pass protocols. The involved resident had also been educated about not touching the medication cart. Review of the facility's medication administration policy revealed that areas without automated dispensing systems utilized a substantially-constructed storage unit with two locks and a paper system for 24-hr recording of controlled substance use. Patient-specific controlled substances are stored under double lock until administered to the patient. If any unauthorized person is seen lingering around a location where controlled substances are stored, staff are to call the police and notify their supervisor for such incident. 50904 2. A narcotic observation during medication administration with Agency Nurse #61 was completed on the Promenade unit on 9/26/24 at 8:15 AM. While reviewing the controlled substance shift inventory sheets, four narcotic count sheets in the narcotic log were flagged, and the medications for those sheets could not be accounted for by Nurse #61. When asked about the missing medications, Agency Nurse #61 stated that it was their first day at the facility, and the outgoing LPN #62 had informed them that the medications were missing. Further review of the controlled substance shift inventory sheet with the Agency Nurse #61 revealed that on inventory sheets on 9/15/24 at 7:00AM, there was no signature from the outgoing nurse, although there was a signature from the incoming nurse. The Agency Nurse #61 was unable to provide any further explanation for the discrepancy. On 09/26/24 at 8:35 AM, the DON #2 was notified and confirmed that the four flagged narcotic sheets were related to the missing narcotics from the incident that occurred on 09/14/24 when Resident #78 took the medications from the medication cart. She stated that the investigation was still ongoing. The DON #2 also noted that the narcotic sheets should have been removed and proceeded to take them out of the book. She further confirmed that there should be signatures from both the outgoing and incoming nurses on the narcotic count sheets. 42782 3. On 09/26/24 at 8:33 AM, while on the [NAME] Cove Unit, the surveyor and Agency Nurse #63 checked the narcotics for accuracy. The controlled substance shift inventory form dated 09/26/24 at 7:00 AM, was signed by LPN #64, but had not been signed by the oncoming nurse. Agency Nurse #63 and the surveyor observed Resident #22 was prescribed Tramadol 50mg, take half a tablet by mouth every eight hours. Agency Nurse #63 and the surveyor observed one of the tablets had been removed from the blister pack, a pill was replaced and the blister pack was taped shut. Further review of the narcotic count revealed Resident #2 was prescribed Pregabalin 25 mg, take one capsule by mouth every 12 hours for pain. The surveyor and Agency Nurse #63 observed that a capsule had been removed from the blister pack, replaced and taped shut. On 09/26/24 at 11:23 AM the surveyor called LPN #64 to ask if they had completed the narcotic count that morning on [NAME] Cove as the outgoing nurse. The nurse explained that they had completed the narcotic count with another nurse and the count was accurate. When asked if they had noticed two narcotic blister packets taped shut, LPN #64 stated they did not remember. LPN #64 further explained that the narcotic count must be completed with a second nurse, and both nurses are required to sign the sheet. If a narcotic is wasted it must be witnessed by another nurse and signed by both nurses. On 09/26/24 at 11:32 AM, during an interview with LPN #26 on the [NAME] Cove unit, she was asked why she had not signed the controlled substance shift inventory form. LPN #26 explained that the incoming nurse was responsible for signing the form, as they were not working on that side of the [NAME] Cove unit. LPN #26 verbalized the narcotic count was correct. When asked if they had noticed any tape on medication blister packs, LPN #26 reported seeing one blister pack where the medication had been taped in place. The surveyor then inquired if they had noticed that Resident #38 who had been discharged still had narcotics being counted. LPN #26 explained that, typically, medications for discharged residents are removed from the facility every Thursday. An immediate jeopardy was declared on 9/26/24. The provision of the plan to remove the immediacy had a completion date 9/26/24 and included the following: Agency LPN #50: Agency was contacted and notified of the incident, staff member was DNR DO NOT RETURN Date of compliance: 9/14/24 Pain assessment will be completed on res #53, and #115, Resident #17 has discharged the facility. Date of compliance: 9/26/24 EVS Employee #51 was educated on reporting suspicious activities immediately. Date of compliance: 9/26/24 Agency staff #61 was educated on Controlled Substance Administration and Accountability Policy. Specifically, that two nurses signatures are required to reconsolidate the narcotic sheet. Specifically, that two nurses signatures are required to reconsolidate the narcotic sheet. Date of compliance: 9/26/24 Agency staff #61: Agency was contacted and notified of the incident, staff member was DNR DO NOT RETURN Date of compliance: 9/26/24 Nurse #63 was educated on Controlled Substance Administration and Accountability Policy, specifically not sealing medications with tape once removed from blister pack Date of compliance: 9/26/24 DON #2 will be educated on the Controlled Substance Administration and Accountability Policy by the Administrator Date of compliance: 9/26/24 LPN #26 has been educated on the Controlled Substance Administration and Accountability Policy specifically on transfer of care process highlighting two nurses must sign off on narcotic sheet. Date of compliance: 9/26/24 LPN #26 was educated on not taping meds back into the blister pack. Date of compliance: 9/26/24 Identification: The Director of Nursing, Unit Manager, MDS Coordinators inspected all med carts to ensure they were locked, secured, and all discharged and medications were pulled Compliance Date: 9/26/2024 System change: The DON, unit managers, supervisors, charge nurses, and/or administrator has educated licensed nursing staff including agency staff on the Controlled Substance Administration and Accountability Policy and locking the narcotic box and their med cart when not in use prior to their next shift. Education will be completed prior to licensed nursing staff's shift. Education is on going. Compliance Date: 9/26/2024 Monitoring: Director of Nursing, or designee, will check the medication carts used by licensed nursing staff including agency for five days, weekly for four weeks, and monthly for three months. Compliance Date: 9/26/2024

Based on review of the facility investigation, medical record review, observations, and interviews, it was determined the facility failed to keep Resident #10 safe. This action placed Resident #10 and other residents who wander in the facility at risk for serious harm. This finding was evident for 1 of 26 residents reviewed for wandering. This incident met the requirements of an Immediate Jeopardy and the Director of Nursing, Nursing Home Administrator, and Corporate Resource Nurse were notified at 9:22 AM on 07/31/2023. Findings include: The MDS is part of the Resident Assessment Instrument that 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. The latest MDS assessment dated [DATE], in section G indicated that resident #10 needed assistance with all activities of daily living. Resident # 10 can walk and wander on the Memory Care Unit. BIMS stands for Brief Interview for Mental Status. It is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. A series of standardized questions in the BIMS are scored and when added result in a total score between 0-15. The numeric value falls into one of three cognitive categories: Intact which is 13 to 15 points, Moderate which is 8 to 12 points or Severe cognitive impairment which is 0 to 7 points. After comprehensive assessment completed on 05/06/2023, the facility care planned Resident #10 for impaired cognitive function related to dementia. Resident #10 had a BIMS score of 0, indicating severe cognitive impairment. A Review of facility reported incident MD00192189 on 07/26/2023 revealed resident # 10 wandered into the unlocked dirty utility room on Memory Lane on 5/6/23 at 8:44 AM. Staff # 26 went to empty the trash can and saw resident # 10 with a bottle of disinfectant liquid. Staff # 26 called for help and geriatric nursing assistant (GNA) # 28 came to the utility room and took the bottle of disinfectant from the resident. There was no evidence that the resident ingested the chemical. There were no spills on his/her clothing or the floor around him/her. Resident #10 had no traces of the chemical around his/her mouth. The Doctor was immediately notified and gave the order to send the resident to the ER for evaluation. On 5/6/23 at 9:44 AM Resident # 10 was seen at a local hospital and the discharge summary included instructions to keep the resident away from chemicals or household cleaning agents and follow up with a physician in 2 days. Review of Staff #23 ' s, Director of Plant Operations, interview completed on 5/6/23, revealed, staff # 23 reported to Memory Lane and fixed the door hinge that was broken on the utility closet, and placed a new lock on the door on 05/06/2023. In addition, staff member #10 also checked the locks on all doors in the facility that contained chemicals to ensure safety for all residents. The Director of Plant Operations, Staff # 23 was interviewed on 7/26/23 and stated there was a fixed hinge placed outside of the utility room door, and a combination lock placed on the door. Staff # 23 also stated prior to this, a baby lock was on the door that was plastic and had broken off. Staff #23 stated they were not on duty on 5/6/23, but was called in to fix the door. In an interview with the Director of Nursing (DON) on 7/26/23, the Director of Nursing stated that resident # 10 wandered all over the memory care unit. Resident # 10 wandered into other resident rooms and slept in their beds. Resident hid in closets, under the bed and climbed into the food cart. The DON stated, It is our fault that the doors to the dirty utility room were open and not secured. The door was fixed immediately. On 7/26/23 at 10:27 AM, Staff # 22 was interviewed and revealed that on Sunday 5/7/23, staff #22 was the manager on duty. Staff # 22 stated when they were told about resident # 10, they instructed the nurse on Memory Lane to contact the administrator. On 7/26/23 at 10:33 AM, Housekeeper Staff #24 was interviewed and stated they were not working on 5/6/23. Staff # 24 stated they worked on Memory Lane full time and the door was broken before the incident. Staff # 24 also stated, At one time, they had a baby lock on the utility room door that some staff members did not know how to use, so they would leave it open. Since the incident all the doors have been fixed with a keypad. On 07/26/2023, an Interview of Housekeeper Staff #26, revealed at the time of the incident, he pulled the trash around the units and on Memory Lane. He then took trash to the dumpsters. When he returned to Memory Lane to put the trash can back in the soiled utility room, he noticed a shadow. He opened the door and found resident # 10, inside the dirty utility room. Resident # 10 had a bottle of liquid that the resident was holding up as if the resident was going to drink it. Staff # 26 stated he never saw her/him drink the liquid. Staff # 26 stated No No! and staff # 26 grabbed the bottle. Staff # 26 did not notice any colored solution around resident ' s # 10 mouth or on her/his clothing. Staff # 26 yelled for help and GNA # 28 came right away and asked what happened. Both GNA # 28 and staff # 26 went to the nursing station and reported the incident to the nurse. Staff # 26 reported the soiled utility rooms did not have locks on the doors. He also stated, All utility doors are like this one, you just push the doors open. The facility took immediate action after the resident was found in the dirty utility room with cleaning chemicals. The facility developed, initiated, and completed a plan of correction to prevent injuries to residents who wander. On 07/26/2023 at 11 AM, a review of the facility ' s corrective action plan that was implemented immediately after the incident revealed the following actions taken by the facility: A. Resident # 10 was immediately assessed following the incident on 05/06/2023. B. On 05/06/2023, physician was notified of the incident and resident # 10 was sent to the hospital via 911. C. The Utility room was immediately secured on 05/06/2023. D. The Medical Director was notified on 05/06/2023 of the incident. E. On 05/09/2023, the DON completed a house wide audit of current residents with cognitive impairment and wandering behavior to evaluate if any were attempting to enter the utility rooms or any unsafe room and to ensure redirection is given. F. On 05/08/2023 through 05/10/2023, the Administrator educated housekeeping staff on the importance of securing the center ' s utility rooms, as well as every room that contains hazardous materials for resident safety. G. An emergency Quality Assurance (QA) meeting was held on 5/7/23. The attendance sheet revealed 20 staff attended. A performance Plan of Correction was put in place. H. On 05/09/2023, the Assistant Director of Nursing (ADON) educated the nursing staff on the importance of ensuring that utility room doors are always secured, as well as educated them to ensure that residents are redirected from gaining entrance. I. The Director of Nursing (DON) immediately initiated an audit to validate that no wandering residents gain entrance to utility rooms or unsafe areas. Audits will be conducted weekly for 4 weeks and are currently being done monthly for 3 months. Findings will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for review and further recommendations. J. On 5/9/23, QA (Quality Assurance) committee met regarding the incident, 18 staff in attendance. K. On 05/06/2023, the Plant Operations Director replaced the lock on the memory care unit utility room door. L. On 05/06/2023, the Plant Operations Director checked all utility rooms to see if a lock is present and secure. M. On 05/09/2023, and 05/10/2023, the Plant Operations Director educated all maintenance staff to make sure all utility rooms are secured. N. On 05/08/2023, the Plant Operations Director initiated an audit to ensure utility rooms are secured with a lock. Audits have been completed daily for 3 weeks, weekly for 4 weeks then currently being done monthly for 3 months. Findings will be submitted to the QA committee. On 5/22/23 the remainder of staff were educated via email. All staff received an email regarding the content in the in-services. On 7/26/23 at 1:30PM a tour of the facility was conducted. All soiled utility rooms had a lock on the door and were secured. All possible unsafe areas of the center were checked and had a lock present on the doors. On 7/26/23 and 7/27/23, surveyors verified that all in-services and audits were completed Signatures were verified with the employee list provided by the facility. After review of all interventions and processes that were put in place by the facility, and 100% compliance in educating staff was achieved, a determination of past noncompliance for the immediate jeopardy for allowing a resident access to a dirty utility room with cleaners was confirmed. The date of compliance was 05/22/2023.

Based on medical record review and interviews, the facility staff failed to: 1. keep a resident free from abuse from another resident which resulted in actual harm to Resident #25 and 2. failed to keep a resident free from abuse from facility staff (Resident #68). This was evident for 2 of 28 residents reviewed for abuse during a complaint survey. The findings include: 1. Review of Resident #24's medical record on 7/25/23 revealed the Resident was admitted to the facility on [DATE] with diagnosis to include adjustment disorder. Adjustment disorder is a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event. Further review of Resident #24's medical record revealed the Resident had punched Resident #78 on 6/5/23. Prior to the incident on 6/5/23, Resident #24 had not assaulted any other residents from admission on 12/9/22 until 6/5/23. After the incident Resident #24 was moved to a different unit in a room by him/herself. Review of the investigation of a facility reported incident dated 6/28/23 revealed Resident #25 was observed to have a left black eye. Review of the facility investigation revealed Resident #25 was moved into Resident #24's room on 6/27/23. Resident #24 was witnessed on 6/28/23 by Resident #77 standing at Resident #25's bed, pointing and yelling at the Resident shut the f up. Resident #77 told facility staff who called the night shift supervisor, Staff #9. Staff #9 went to talk to Resident #24 who was calm at the time and pulled the privacy curtain and told Resident #24 to stay in his/her bed. On 6/28/23 at approximately 6:30 AM Resident #25 was noted to have a bruised left eye caused by Staff #8 and was sent to the emergency room . Interview with Staff #9 on 7/25/23 at 7:50 AM, Staff #9 stated he got a call from Staff #19 that Resident #24 was harassing Resident #25 during night shift on 6/28/23. Staff #9 stated after he finished completing what he was doing for the residents he was caring for on another unit, he went to investigate at approximately 1:30 AM on 6/28/23. Staff #9 stated at that time Resident #24 was not exhibiting any behaviors and was in his/her bed. Staff #9 stated he pulled the curtain and told Resident #24 to stay on his/her side and updated Staff #19. Staff #9 stated he did not interview the witness to the event Resident #77 at the time. Staff #9 stated he was suspended for a day by the facility following the incident for not moving Resident #25 out of the room at the time Resident #24 was harassing Resident #25. During interview of the Director of Nursing (DON) on 7/25/23 at 8:22 AM, the DON was asked why Resident #25 was moved into Resident #24's room on 6/27/23 after the incident on 6/5/23 when Resident #24 punched Resident #78. The DON stated the team had decided on the move because Resident #24 had not had any recent behaviors. Interview with Resident #77 on 7/25/23 at 8:50 AM revealed Resident #77 stated he/she was wheeling past the room with Resident #24 and #25 and saw Resident #24 standing by Resident #25's bed yelling and pointing at the Resident, shut the f up, shut the f up b . Resident #77 stated Resident #25 was making the normal noises he/she makes. Resident #77 stated he/she went immediately to the nurse's station and told Staff #19. Interview with Staff #8 on 7/25/23 at 7:15 AM who first observed Resident #25 with a left discolored eye, revealed Staff #8 stated she went in to change Resident #25 on 6/28/23 at approximately 6 AM and that is when she noticed the black eye. Staff #8 stated at the time Resident #25 appeared upset and had tears in his/her eyes. Staff #8 was asked at that time if she had ever seen Resident #24 hit anyone, Staff #8 stated no but Resident #24 often makes a punching motion and she never gets too close to Resident #24. During interview with the DON on 7/26/23 at 11:00 AM, the DON stated she was at Resident #25's bedside on 6/28/23 at 7:15 AM with police when they interviewed Resident #25. The DON stated when the police asked Resident #25 if someone did something to him/her, Resident #25 nodded yes. When Resident was asked if someone hit him/her, Resident nodded yes. When the Resident was asked if his/her roommate hit him/her, the Resident nodded yes. During interview with the DON on 7/26/23 at 11:00 AM, the DON stated the facility concluded Resident #24 hit Resident #25 on 6/28/23. 31145 2. On 7/27/23 at 8:49 AM complaint MD00179566 was reviewed and revealed the police were called to the facility on [DATE] for an allegation that a staff member, geriatric nursing assistant (GNA) #59, threw a cup of water at Resident #68 after Resident #68 threw a cup of water at GNA #59 on 6/13/22. It was also noted that the facility submitted a FRI (facility reported incident) MD00179067 regarding the incident. Review of the facility's investigation revealed that GNA #59 was assisting Resident #68 to the resident's room and gave Resident #68 a bedpan. When GNA #59 went back to the resident's room, Resident #68 became upset and was verbally abusive to GNA #59 and asked GNA #59 to leave the room. As GNA #59 was leaving the room, Resident #68 threw water at GNA #59. GNA #59 responded on impulse and threw water back at Resident #68. The facility documented, In conclusion, the incident that occurred between resident and staff were r/t (related to) resident's behavior and staff unable to control self. On 7/27/23 at 10:06 AM an interview was conducted with Staff #1, Assistant Director of Nursing (ADON). Staff #1 stated that she remembered the incident because the resident threw water on GNA #59 and GNA #59 threw it back on the resident. GNA #59 was suspended. Staff #1 stated that GNA #59 did admit to throwing water back on the resident. Staff #1 stated that the previous ADON was here at the time, and he called the police.

Based on medical and administrative record review, and staff and resident interview, it was determined the facility failed to 1a.) keep a cognitively impaired resident (Resident #2) free of sexual exploitation as evidenced by Staff #4's observation of the resident performing sexual acts on Resident #1 and, 1b.) failure to promptly report and investigate the incident, 1c.) provide ongoing supervision of Residents #1 and #2 to ensure the safety of Resident #2 and other vulnerable residents; and 2) promptly report and investigate allegations that Resident #3 fondled Resident #2. This was evident for 1 of 3 residents reviewed for abuse during this complaint survey. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinary tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications) to be addressed. 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. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive status. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. 1a.) Medical record review revealed Resident #2 was a long-term care resident with [DIAGNOSES REDACTED]. The resident was alert and oriented x1 with a BIMS of 3/15 documented in the quarterly MDS assessment dated [DATE]. [MEDICAL CONDITION] is a language disorder that affects a person's ability to communicate. More specifically, it limits an individual's ability to convey thoughts through the use of speech, language, or writing. Review of Resident #2's medical record revealed two Physician Certifications Related to Medical Condition, Decision Making, and Treatment Limitations, dated 12/4/12 and 1/20/16 that indicated the resident lacked adequate decision-making capacity. Review of facility reported incident #MD 418, dated 9/14/18, revealed that on the evening of 9/13/18 Staff #4 entered Resident #1's room, after knocking on his/her door 3 times, to inform him/her of a change in physician orders. When Staff #4 entered the room, s/he saw Resident #2 performing oral sex on Resident #1. Believing it to be consensual, Staff #4 excused herself/himself, left the room and closed the door. The facility's investigation contained a written statement by Staff #2 that reported on 9/11/18 while s/he was changing Resident#1 s/he became aroused and asked for assistance in calling Resident #2 to come to his/her room. Staff #2 documented that s/he did as asked, then spoke with Staff #4 about the incident. Medical record review revealed a Social Services note, dated 9/14/18, that reported Resident #2 had sexual interaction with Residents #1 and #3 and was suspected of performing the acts in exchange for cigarettes and/or money. The Social Worker documented that s/he contacted the psychiatrist and requested that s/he see the resident to determine if the resident was able to consent. The resident was told by the Executive Director that s/he was not to enter Resident #1's or Resident #3's room, any other man's room and could not go outside to smoke with them. According to the facility report Resident #1 stated during an interview on 9/14/18 that s/he received oral sex from Resident #2 on three separate occasions. Resident #1 reported that Resident #2 came into his/her room and it was Resident #2's idea to perform the sex act. A Behavioral Health Services note, dated 9/16/18, reported Resident #2 had impairment of recall, reasoning and orientation and was not competent to make decisions including those regarding sexual relations. On 9/18/18, Physician #1 evaluated the resident and concluded that Resident #2 was unable to consent to sexual activity. During an interview with the Director of Nursing and Administrator, on 9/25/18 at 11:45 AM, they confirmed that the level of supervision has not been increased for Resident #2 but all staff look out for her/him. The DON and Administrator were asked if Residents #1 and #2 were supervised during smoke breaks and they maintained Resident #1 and #2 now keep their distance from one another. In interview with the surveyor on 9/25/18 at 2:59 PM, Staff #4, described the incident s/he observed between Residents #1 and #2. S/he stated s/he did not report or investigate the matter, believing they were two consenting adults. Staff #4 stated s/he reported the incident to the unit manager 2 days later. According to Staff #4's written statement the incident occurred on 9/3/18. S/he was unable to confirm the date of the incident with certainty. 1b.) Review of Resident #2's medical record failed to reveal a care plan that addressed the potential for sexual exploitation by other residents with interventions to ensure her/his safety. A Transfer Note, dated 9/14/18 at 4:50 PM, written by Staff #3 reported the resident was being transferred to a room on the ground level due to the incidents with 2 residents on the second floor. In interview with the surveyor on 9/25/18 at 10:30 AM Resident #1 stated s/he made a suggestive remark to Resident #2 and Resident #2 indicated s/he should go to his/her room. Resident #1 maintained there was only one sexual encounter with Resident #2. Resident #1 also maintained he/she thought Resident #2 was capable of consent. In interview with the surveyor on 9/25/18 at 11:12 AM, Staff #1 was asked what measures had been put in place to ensure there are no further incidents of sexual exploitation of Resident #2. Staff #1 stated s/he makes sure the resident is fully dressed when s/he goes to the lounge/porch area as opposed to wearing a night gown. Staff #1 also stated that if they do not see the resident for 45 minutes to an hour staff will look for her/him. The surveyor asked how resident concerns and changes in condition are communicated to staff, especially on weekends to ensure ongoing monitoring of this resident and other vulnerable residents. The Unit Manager stated there were communication sheets used to document these concerns. The surveyor attempted to interview Resident #2, on 9/26/18 at 8:45 AM, however the resident was unable to answer questions about the event due to severe [MEDICAL CONDITION]. On 9/26/18 at 8:55 AM the surveyor asked Staff #5 if there were any special interventions staff needed to be aware of regarding monitoring Resident #2. Staff #5 stated s/he was unaware of any incident that occurred with Resident #2 and was not informed of any changes in level of supervision for this resident. Staff #5 stated s/he is an agency staff member who may not be totally familiar with incidents that occur on the unit. Further review of the medical record failed to reveal documentation of the incident by nursing staff that included an assessment of the residents' physical and emotional status and notification to the physicians for Resident #1 and #2 at the time of the incident. Documentation and staff interviews failed to reveal a change in the level of supervision to ensure this cognitively impaired resident remains safe. 1c.) Medical record review revealed Resident #1 was a long-term care resident with [DIAGNOSES REDACTED]. The resident was described in the medical record as alert and oriented to person, place and time and able to communicate his/her needs. Facility staff entered a BIMS score of 15/15 in the quarterly MDS assessment dated [DATE]. Review of the Medication Administration Record [REDACTED]. The medication was signed off as having been administered on 8/3/19, 8/4/18, 8/28/18, 8/30/18, 9/5/18, 9/8/18 and 9/9/18. Review of Resident #1's medical record revealed a care plan, with an initiation date of 9/14/18, that addressed the tendency to exhibit sexual acts towards other male/female residents who may not be able to fully consent to their sexual actions. In interview with the surveyor on 9/25/18 at 10:30 AM Resident #1 stated s/he told Resident #2, while smoking in the courtyard, that because of his/her fingers (contracted) s/he could not pleasure himself/herself. Resident #1 stated that when s/he made the joke about his/her hands Resident #2 pointed to her/his mouth. Resident #1 stated s/he went to his/her room and got in bed and waited for Resident #2. Resident #1 maintained there was only one sexual encounter with Resident #2. Resident #1 also maintained s/he thought Resident #2 was capable of consent and s/he was told s/he had the right to have sex in the facility. During an interview with the Administrator and Director of Nursing (DON), on 9/25/18 at 11:44 AM, they concurred that staff should have promptly notified the Administrator for instructions in addressing the incident. They reported that facility staff have received in-servicing regarding resident's rights to have intimate relationships as well as education regarding sexual abuse. The DON stated a consulting urologist prescribed the [MEDICATION NAME] for Resident #1. The resident reported to staff that it was intended to be used during a visit with a friend from the community. During an interview with the surveyor, on 9/25/18 at 12:47 PM, Staff #2 confirmed that s/he assisted Resident #1 to contact Resident #2 after noting his state of arousal during care on 9/11/18. Staff #2 stated s/he did not ask Resident #2 any questions about his desire to see Resident #1. Further review of Resident #1's medical record failed to reveal documentation of the incident by nursing staff that included an assessment of the residents' physical and emotional status and notification to the physician at the time of the incident. Failure to provide ongoing supervision for Resident #1 created the potential for psychosocial harm for Resident #2 and other cognitively impaired residents who were unable to give his/her consent for sexual activities. 2.) Medical record review revealed Resident #3 was a long-term care resident. Medical record review revealed facility staff entered a BIMS score of 14/15 in the Annual MDS assessment dated [DATE]. Resident #3's medical record contained a care plan, with an initiation date of 9/14/18, that addressed a tendency to exhibit sexual acts towards other females who may not be able to fully consent to their sexual advances. A Social Services note, dated 9/14/18 at 3:53 PM, reported Resident #3 had a sexual history with Resident #2. It was reported that s/he fondled/groped Resident #2. There were no nurse notes regarding the incident or evidence that the physician was notified. Documentation of sexually inappropriate behavior by Residents #1 and #3 that both involved Resident #2 were entered in the medical records of Residents #1, #2 and #3 on 9/14/18 by Staff #3. There was no evidence the incident involving Resident #3 was reported or investigated. During an interview with the surveyor, on 9/26/18 at 8:40 AM, Resident #3 admitted to fondling resident #2. Resident #3 stated s/he and Resident #2 were talked to and Resident #2 was moved. Medical record review and staff interviews revealed inconsistencies in the documentation of the dates of the allegation that Resident #1 was sexually inappropriate with Resident #2. Facility staff failed to promptly report and investigate the incidents, implement measures to maintain the safety of Resident #2, and document the incidents in the medical record with an assessment of the physical and emotional status of Residents #1, #2 and #3 at the time the incidents occurred and notify the physician.

Based on medical and administrative record review, staff and consultant interviews it was determined the facility failed to: 1) observe a resident's full code status when facility staff, upon finding the resident pulseless and breathless, failed to provide Cardiopulmonary Resuscitation; and 2) clarify the resident's code status when there was a noted change in condition that lead to the resident's admission to hospice. This was evident for 1 of 4 hospice residents (#4) reviewed during this survey. The findings included: 1. Medical record review revealed Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Further medical record review revealed a MOLST dated [DATE] that indicated the resident was a full code, meaning in the event of [MEDICAL CONDITION] CPR would be performed. The determination for the resident to be a full code was made by the resident's guardian. MOLST (Medical Order for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments based on a patient's wishes about medical treatments. Cardiopulmonary resuscitation (CPR) refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. A Social Services Note dated [DATE] at 2:33 PM reported the resident was admitted to hospice services. The hospice interview notes dated [DATE] reported the resident was admitted with a [DIAGNOSES REDACTED]. On [DATE] Resident #9's physician documented that the resident experienced an overall decline in condition and the family chose to have staff provide comfort measures. The note did not indicate there was any discussion about the resident's code status or that the guardian was contacted to discuss the resident's MOLST. Hospice care is designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure. The goal is to enable patients to be comfortable and free of pain. On [DATE] at 5:14 PM LPN #1 documented that at 12 noon she/he was called to Resident #9's room where the resident was found to be unresponsive and he/she was unable to read vital signs and pulse. LPN #1 further documented that NP #4 and the hospice nurse (RN #3) were notified. LPN #1 reported that NP #4 directed him/her to call the hospice nurse. The hospice nurse arrived, assessed the resident and pronounced the resident's death according to LPN #1's documentation. There was no evidence in the medical record or provided by the facility that documented any communication between the hospice nurse and NP #4 or any other physician prior to her pronouncing Resident #9 as deceased . In interview with LPN #1 on [DATE] at 11:18 AM he/she stated that because the resident was admitted to hospice he/she assumed the resident's condition was terminal and therefore designated as Do Not Resuscitate (DNR). LPN #1 acknowledged he did not review the MOLST to confirm the resident's code status. He stated that when he opened the record and saw the hospice information sheet, he believed this was an indication that the resident was a DNR. During this interview with LPN #1, he stated that on [DATE] at 12:00 PM upon discovering that Resident #9 was unresponsive, he called RN #2 (unit manager), and when she failed to respond LPN #1 called the resident's physician. When the physician failed to respond, LPN #1 reported he contacted NP #1 who referred him/her to NP #4. NP #4 directed LPN #1 to call the hospice nurse. LPN #1 further stated the hospice nurse arrived in ,[DATE] minutes, retrieved the chart and went into the resident's room. At this time the RN #2 returned to the unit and informed LPN #1 that the resident was a full code. Review of the facility's Health Care Decision Making policy (Rev. [DATE]) on [DATE] revealed the following statement: 9. Upon admission, quarterly, and with a change in condition, the physician, in collaboration with the designated Center staff, will meet with the patient or heath care decision maker to complete or review advance directives, or state specific documents such as POLST, MOLST, etc. and define and clarify medical issues. The facility's Cardiac and/or Respiratory Arrest policy (Rev. [DATE]) included the following statement: The Center will perform CPR on all patients, except in certain limited circumstances, unless there is a written physicians' order, agreed to by the patient or health care decision maker, not to resuscitate (DNR), in accordance with state regulation/law .If a patient does not have a DNR order, CPR/AED certified staff will initiate CPR/AED and emergency medical services (EMS) will be activated. During an interview the hospice nurse (RN #3) on [DATE] at 8:05 AM, she stated on [DATE] at 12:00 noon she received a call from LPN #1, who stated he was not sure the resident was breathing and that the physician was not in the building. RN #3 stated she went to the facility and upon entering Resident #9's room observed staff cleaning the resident and established at that time that respirations and pulse were absent. RN #3 stated he/she was aware that the resident was a full code but during her/his conversation with LPN #1 over the telephone, she did not direct him to initiate CPR and/or call emergency services. During an interview with NP #4 on [DATE] at 8:05 AM she stated that she was not assigned to this case. She reported she received a call from LPN# 1 on [DATE] at 12:00 PM who reported he, did not think the resident was with us. NP #4 reported she asked LPN #1 if he attempted to get vital signs and he reported checking the resident's pulse. NP #4 advised LPN #2 to call the physician to which he responded the physician was not in the building. NP #4 further reported that LPN #1 called back 1 hour later to advise her the resident was to have been a full code. In interview Resident #9's physician (Physician #1) on [DATE] at 9:58 AM revealed she was not in the building that day due to illness. Physician #1 stated the error occurred because the nurse (LPN #1) assumed the resident was a DNR because he/she had been admitted to hospice. During an interview with the Director of Nursing on [DATE] at 10:52 AM she acknowledged LPN #1's failure to provide CPR was due to a breakdown in communication among facility staff and LPN #1's failure to review the resident's MOLST to determine code status. Medical and administrative record review, staff and consultant interviews confirmed the failure to observe Resident #1's full code status as LPN #1 did not review the resident's MOLST upon finding the resident pulseless and breathless. Further medical record review failed to reveal that staff initiated CPR or called 911 for emergency medical services. 2) Facility staff failed to clarify Resident #9's code status when a decline in condition lead to admission to hospice services. Medical Record review on [DATE] revealed a Health Care Decision Making form, dated [DATE], naming a court appointed guardian as the resident's health care decision maker. Certificates of Incapacity dated [DATE] and [DATE] indicated Resident #9 lacked the capacity to make decisions about life-sustaining treatments. Medical record review revealed a MOLST dated [DATE] that indicated the resident was a full code, meaning in the event of [MEDICAL CONDITION] CPR would be performed. The determination for the resident to be a full code was made by the resident's guardian. A Social Services note dated [DATE] at 2:00 PM reported a hospice provider was contacted and on and [DATE] at 2:33 PM, Social Services Specialist #1 reported the resident was admitted to hospice services. There was no mention of the resident's code status or the need to review the resident's/legal representative's health care choices. The hospice interview notes dated [DATE] reported the resident was admitted to hospice services with a [DIAGNOSES REDACTED]. On [DATE] Resident #9's physician (Physician #1) documented that the resident experienced an overall decline in condition and the family chose to have staff provide comfort measures. The note did not indicate there was any discussion about the resident's code status or that the guardian was contacted to discuss the resident's MOLST. MOLST (Medical Order for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments based on a patient's wishes about medical treatments. Review of the facility's Health Care Decision Making policy (Rev. [DATE]) on [DATE] revealed the following statement: 9. Upon admission, quarterly, and with a change in condition, the physician, in collaboration with the designated Center staff, will meet with the patient or heath care decision maker to complete or review advance directives, or state specific documents such as POLST, MOLST, etc. and define and clarify medical issues. In interview with the surveyor on [DATE] at 9:10 PM, NP #4 stated that once there is an order for [REDACTED]. During an interview with the surveyor on [DATE] at 9:58 AM, Social Work Specialist #1 stated it is appropriate for the doctor to initiate conversation regarding a change in code status and she would, collectively address the issue. During an interview with the surveyor on [DATE] at 9:33 AM, Physician #1 stated the resident declined a few weeks ago and the family did not wish to have aggressive treatment and agreed to hospice. The physician stated there is a weekly meeting in which the team discusses changes in residents' conditions but it is the social services staff's responsibility to follow-up on the MOLST reviews. During an interview with the surveyor on [DATE] at 10:52 AM the Director of Nursing (DON) stated NP #4 reviewed the results of Resident #9's CT scan that indicated the resident's condition (cancer) had worsened. The DON stated NP #4 spoke with the family and offered hospice services but failed to review the MOLST. The DON also discussed the expectation that Social Services staff take the lead in ensuring the MOLST is reviewed when there is a change in a resident's condition.

Based on medical records review, facility policy and interview with the facility staff, it is determined that the facility failed to have a system in place to update changes in the Advance Directives of a resident that attended [MEDICAL TREATMENT]. Specifically, the facility failed to update the [MEDICAL TREATMENT] communication book when a change occurred in Resident #161's Advance Directives. Further review of the medical records revealed that the resident had multiple [MEDICAL TREATMENT] treatments in which an incorrect and outdated Advance Directive was sent with the resident stating that the resident was a Full Code, which included cardiopulmonary resuscitation (CPR). The resident had attended [MEDICAL TREATMENT] with an incorrectly documented Advance Directive 11 times since his/her Advance Directive was changed on [DATE]. This deficient practice put the resident at risk for having CPR performed on him/her, against their wishes. On [DATE] at 4:46 PM an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to have a system in place to ensure the desired advance directives of the resident was correctly documented in the resident's [MEDICAL TREATMENT] communication book. The findings include: On [DATE] Resident #161's medical records and [MEDICAL TREATMENT] communication book was reviewed. This review revealed that the resident had multiple readmissions to the facility from an acute care hospital and with [DIAGNOSES REDACTED]. Review of the hospital records revealed that on [DATE] the resident was admitted to the hospital for a change in mental status and urinary tract infection. The resident was given antibiotics, stabilized and returned to the skilled nursing facility. Further review of the hospital records revealed that the resident was treated for [REDACTED]. Review of the physician progress notes [REDACTED]. Physician notes dated [DATE] also revealed that the resident was becoming more de-conditioned. He/she was having difficulty swallowing, experiencing weight loss, and had episodes of altered mental status. Further review of the progress notes dated [DATE] revealed that the resident continued to decline and he/she became frail, nonverbal, and had a poor appetite. Review of the physician orders [REDACTED]. blood pressure. Further review of the physician progress notes [REDACTED].Review of the social work note dated [DATE] revealed that a family meeting was scheduled to be held in regard to the resident's declining condition. Further review of the social work note dated [DATE] revealed that the family meeting was held and Resident #161's Advance Directive orders changed from a full code, which required medical personnel to attempt CPR, to a do not resuscitate or attempt CPR. In addition, documentation regarding the medical ineffectiveness of CPR was placed in the resident's medical record. Documentation of medical ineffectiveness means that two physicians have certified that to a reasonable degree of medical certainty specific treatments, which under generally accepted medical practices are life sustaining in nature, would not prevent his/her impending death.Review of the facility medical records on [DATE] revealed an advance directive form dated [DATE] in the resident's chart that reveal Resident #161 was a no CPR option B. This meant that the facility, or any other medical personnel, would not perform CPR on the resident if he/she went into [MEDICAL CONDITION]. Only palliative and supportive care was to be provided to the resident and the facility or any medical personnel would allow death to occur naturally. Review of the front page of the [MEDICAL TREATMENT] communication book on [DATE] revealed an advance directive dated [DATE] which stated that the resident was a full code. This meant that in the event of [MEDICAL CONDITION] at the [MEDICAL TREATMENT] center, which is physically located in the lower level of the facility, staff at the [MEDICAL TREATMENT] center would perform CPR on the resident.An interview with the clinical reimbursement specialist (CRS) on [DATE] at 11:00 AM revealed that the [MEDICAL TREATMENT] communication book always goes with the resident to [MEDICAL TREATMENT] because that is how the facility staff communicates with the [MEDICAL TREATMENT] department. The communication book contained a copy of the resident's advance directive and a communication sheet. Review of the facility's standard [MEDICAL TREATMENT] communication sheet revealed 2 sections. The top section was completed by the facility staff. It has the resident's name, code status, vital signs prior to [MEDICAL TREATMENT], the resident's mental status, and other pertinent information for the [MEDICAL TREATMENT] department. The resident had attended [MEDICAL TREATMENT] with an incorrectly documented Advance Directive 11 times since his/her Advance Directive was changed on [DATE]. Medical record review revealed the resident attended [MEDICAL TREATMENT] on the following dates with an advance directive that stated he/she was a Full Code, when in fact he should have been a DNR: [DATE] (2:30 PM), [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. An [DATE] [MEDICAL TREATMENT] sheet was also noted. The top portion of the form (to be completed by staff) was incomplete, to include the resident's code status. During the interview with the CRS and while he/she was reviewing the resident's advance directives in the medical records and communication book, the CRS acknowledged that a mistake could easily happen.During an interview with [MEDICAL TREATMENT] nurse (Staff #15) on [DATE] at 11:30 AM he/she revealed that when a resident comes to [MEDICAL TREATMENT] the [MEDICAL TREATMENT] staff depends on the advance directive that is in the front of the communication book and the nurse's communication sheet to provide appropriate care to the residents.During an interview with two nurses (Staff #7 and Staff #16) at 12:45 PM they both verbalized that it was the resident's nurse's responsibility to make sure that an updated advance directive was in the [MEDICAL TREATMENT] communication book. During an interview with the nurse (Staff #4) on [DATE] at 3:15 PM he/she revealed that he/she does not look in the resident's chart for changes in code status. He/she stated that he/she routinely looks at the previous communication sheet and copies that information onto the new communication sheet. The surveyor observed the unit secretary place the correct and updated advance directive into Resident #161's [MEDICAL TREATMENT] communication book at 2:00 PM on [DATE]. The resident was scheduled to go to [MEDICAL TREATMENT] at 2:30 PM that day.During the survey on [DATE] at 4:46 PM an Immediate Jeopardy was determined to exist because the facility failed to have a system in place to ensure the desired advance directives of a resident was correctly documented and updated in the resident's [MEDICAL TREATMENT] communication book. A plan of action was given to the survey team and the Office of Health Care Quality for review on [DATE] at 7:06 PM. The plan to remove the immediate jeopardy included: auditing of medical records and [MEDICAL TREATMENT] communication books for all other residents requiring [MEDICAL TREATMENT] services, education of social services and nursing staff on the process of updating the advance directive in the [MEDICAL TREATMENT] communication book, and a plan to review the communication book and change in advance directive within 72 hours of the change, during the morning meeting. This plan was accepted. The immediate jeopardy was removed at 7:40 PM on [DATE].All findings were discussed with the Director of Nursing and the Administrator during the immediate jeopardy and the exit.

Based on observation, staff interviews, and review of medical records and other pertinent documentation on March 11, 2014, it was determined that the facility failed to maintain a safe environment for residents with documented exit seeking behaviors. This was evidenced by a malfunctioning elopement alarm system, a failure to maintain effective care plans, a failure to develop and revise interventions, and a failure to provide adequate supervision for residents who exhibited and demonstrated risk for unsafe wandering. This was evident for 4 residents of 11 residents reviewed (residents # 3, # 4, #5, and #9) The facility's systemic failures in this case led to the determination that immediate jeopardy existed and the facility was notified of this determination on March 11, 2014 at 1:01 PM. The findings include: During the tour of the facility, on 3/11/14, it was determined that the main entrance doors to the facility did not always close completely nor did the doors seal and lock. When a resident with a WanderGuard in place (a device to alert staff that the resident was near or at a facility exit) stepped within three feet of the front door, the doors locked, but only if and when the doors had closed completely to form a seal. When the doors did not fully close and seal, the system to ensure resident safety was compromised and residents were able to exit the building, despite the sounding of the alarm. Resident #3 eloped from the facility, on 2/10/14 at approximately 9:00 PM, per facility investigation, and resident #4 eloped on 12/28/13 at 8:50 PM. Interview with the Administrator and the Director of Nursing (DON), on 3/11/14 at 1:01 PM, revealed that the doors were not fully closed prior to both Resident #3 and Resident #4 leaving the building. The administrator stated that a review of the videos following both elopements showed that the doors were open during both elopements. During interviews with the Administrator and the DON, on 3/11/14 at 2:45 PM, they could not state how the residents would be supervised should they leave their unit or how they would be redirected if they reached the front entrance, especially during night shift. 1. Review of Resident # 4's clinical record on 3/11/14 revealed an episode of elopement on 12/28/13. Progress notes revealed that the resident was witnessed by a nurse, on 12/28/13 at 8:40 PM, walking down the hall of the lower level unit in the direction of the elevator. Resident #4 entered the elevator and then reached the main level of the facility. A second resident witnessed him/her walking down the hallway and asked where Resident # 4 was going and Resident #4 replied "home". At 8:50 PM, the second resident reported to a nurse that Resident # 4 had left the facility, and that the alarm was sounding. The nursing supervisor was called at 9:05 PM and informed that Resident # 4 had left the building. The main lobby door alarm was on. The alarm was then turned off and the elopement procedure was initiated. The Director of Nursing was called and made aware of the situation. Staff members searched the building and grounds, but could not locate the resident. The nurse called 911 and the police responded. Information, including a picture, was provided. The police officer was still present when the facility received a phone call from another police officer who had located the resident. The resident arrived back to the facility at 10:30 PM. The resident stated that the resident's sister had signed a leave of absence. The resident was escorted back to the unit with a nurse. There were no signs of injury. Later, at 12:15 AM, the resident was observed walking past the nursing station wearing his coat and carrying a gift bag. When asked by the nurse where the resident was going the resident replied "upstairs. The police are waiting for me. They just called me." The resident was redirected back to the resident's room. The resident made no other attempts to leave the unit during the shift. Further review of the clinical records revealed that the facility staff failed to assess Resident #4's elopement risk until 2/22/14, nearly two months after the 12/28/13 elopement. During interview, on 3/12/14 at 12:54 PM, the Director of Nursing confirmed that an elopement risk assessment was not completed during the last year and was not completed after the 12/28/13 elopement until 2/22/14. This two months long delay in assessing resident #4's individualized risk factors, even after a known elopement, increased the risk for resident harm and possible death from any subsequent elopements. 2. A review of Resident # 5's clinical record on 3/11/14 revealed that the resident was at risk for elopement. Interview with the Director of Nursing on 3/12/14 at 12:54 PM confirmed that an elopement risk assessment was not completed for resident #5 during the last year. Failure to complete an elopement risk assessment to determine the individualized level of risk and associated safety needs of the resident, left this resident at increased risk for possible resultant harm. 3. Review of Resident # 3's clinical record, on 3/11/14, revealed that resident #3 eloped from the facility on 2/10/14. Other pertinent documentation revealed that resident #3 was found walking in the facility parking lot at approximately 9:00 PM on 2/10/14. A facility staff member was alerted by the alarm of the WanderGuard system. Additionally, the facility Administrator stated during an interview on 3/11/14 at 10:00 AM, that the GNA reported seeing the resident in the parking lot via room 101's window and went directly to resident. Documentation revealed that resident #3 stated that he 'was going home.' The facility administrator was notified of the event at 9:10 PM and the medical director was notified at 11:00am on 2/11/14. The resident was then transferred to the secure 'Memory Lane' unit for documented 'safety' reasons. Further review of the resident's medical record revealed [REDACTED].#3 needed constant redirection and/or that redirection was unsuccessful. Review of care plan for resident #3 revealed a focus on resident at risk for elopement related to cognitive loss and mental changes status [REDACTED]. The care plan documented goals and interventions indicating that resident #3 would not leave the building without an escort and that the facility would utilize the security bracelet (WanderGuard) per protocol. There was no further documentation of any new interventions placed for this resident regarding documented behavior. Review of resident #3's clinical records revealed that the facility staff failed to do an elopement risk assessment prior to and immediately after the elopement. Failure to complete an elopement assessment on an at risk resident denied the facility the opportunity to address any changes in the resident's risk level as well as any concerns regarding the elopement that the facility staff may need to address. Additional review revealed that the facility failed to address the residents known elopement behavior and failure to 'redirect' the resident therefore, denying the facility the opportunity to intervene in the resident unsafe behaviors. The Director of Nursing was interviewed on 3/12/14 at 12:54 PM, and she stated that an elopement risk assessment was not completed for resident #3 during the last year and was not completed until 2/22/14, more than 10 days after the elopement. 4. Review of Resident # 9's clinical record on 3/11/14, revealed that the resident was at risk for elopement. However, the resident did not have an elopement risk assessment completed for the last 12 months. Failure to complete an elopement risk assessment to determine the individualized level of risk and associated safety needs of the resident left resident #9 at increased risk for possible resultant harm. The Director of Nursing was interviewed on 3/12/14 at 12:54 PM, and she stated that an elopement risk assessment was not completed during the last year. The survey identified noncompliance with Federal and State requirements that were reviewed in relationship to facility reported incidents #MD 256 and #MD 942. Immediate Jeopardy was identified on March 11, 2014 at 1:01 PM. The facility took steps to abate the Immediate Jeopardy on March 11, 2014 at 6:25 PM. The front entrance doors were repaired so that a seal was created when closed, a staff member was assigned to be at the front entrance reception desk until 9:00 PM the first night, and every nursing staff member on duty for the subsequent three shifts were in-serviced on elopement procedures.

Based on a closed medical record review and interviews with staff, it was determined that the medical and nursing staff failed to recognize and address that a dose of [MEDICATION NAME] (an injectable medication used to treat diabetes by lowering blood sugar levels) was incorrectly ordered upon readmission, and placed a resident in a hypoglycemic state that required hospitalization . This occurred for 1 of 5 residents reviewed during a complaint survey. The findings included: Resident #5 was admitted to the facility for short term rehab following a hospitalization on [DATE]. The resident was alert and oriented. Upon admission, resident #5 was ordered to receive 15 units of [MEDICATION NAME] every day. Further review of resident #5's closed medical record revealed that, on 09/09/13, resident #5 was transferred to the hospital for [MEDICAL CONDITION] In the nurse practitioner's 09/09/2013 documentation, the nurse practitioner indicated that resident #5's doses of [MEDICATION NAME] should be lowered to 12 units daily due to [DIAGNOSES REDACTED] (low blood glucose). Resident #5 was readmitted to the facility on [DATE]. Review of resident #5's 09/13/2013 physician's orders [REDACTED]. At the hospital, 09/09/13 thru 09/13/2013, resident #5 was receiving only 15 units of [MEDICATION NAME] daily. Further review of resident #5's 09/13/2013 hospital Transfer Summary revealed physician documentation indicating resident #5 was to be receiving 50 units of [MEDICATION NAME] daily. Review of the medical record revealed that the facility nurse practitioner completed a History and Physical on resident #5 on 09/13/2013. The nurse practitioner signed off on the readmission orders [REDACTED]'s medication on 09/13/2013. Further review of the medical record revealed that resident #5 received 50 units of [MEDICATION NAME], at 9 pm, on 09/14/2013. On 09/15/2013 at 6:00 am, the nursing staff obtained a " low " finger stick glucose reading (the glucose level was too low for the machine to recognize). A normal blood sugar ranges from 70-110. The nursing staff administered 2 doses of intramuscular [MEDICATION NAME] and a tube of glucose gel. Resident #5's finger stick result was repeated at 7 am for a result of 32. The nursing staff contacted resident #5's physician and was subsequently sent to the emergency room . The medical and nursing staff failed to recognize and address that a dose of [MEDICATION NAME] (an injectable medication used to treat diabetes by lowering blood sugar levels) was incorrectly ordered upon readmission and placed a resident in a hypoglycemic state that required hospitalization .