Every finding on record at Pines Nursing and Rehab

Based on record review and interview, it was determined that the facility failed to ensure that Resident #1 received care in accordance with professional standards regarding utilizing 2 persons to transfer with a mechanical lift. This deficient practice resulted in a Harm. This was evident for 1 (#1) out of 3 residents reviewed for hoyer transfers.The findings include:The Facility's policy as it relates to the use of a Hoyer Lift reviewed/revised 10/3/25, 7/15/26 by CNO #9, reads in part: Safe Resident Handling/Transfer Policy- to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines:. 12. Staff will be educated on the use of safe handling/transfer practices including the use of mechanical lift devices as the need arises or changes in equipment occur. 13. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 14. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.On 7/15/26 at 8:52 AM, the facility reported a Facility Reported Incident (FRI) about Resident #1 sustaining an injury of unknown origin, which was a right femur fracture.During the investigation of FRI # 3093733 on 8/19/26 at 11:00 AM, the Surveyor reviewed Resident #1's Electronic Medical Record (EMR), which revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses, including but not limited to, diabetes, stroke, bilateral below the knee amputations and end-stage renal dialysis on hemodialysis. Further review of Resident #1's EMR revealed a progress note written by NP (Nurse Practitioner) #11on 7/14/26 at 12:06 PM stating, Staff report right knee pain beginning yesterday after the knee was bent during hoyer lift transfer. Plan: 1. New right knee pain began after hoyer lift transfer with knee reportedly bent. Obtain Right knee X-ray.A review of the most recent Minimum Data Set (MDS- a federally mandated comprehensive, standardized clinical assessment of all residents in Medicare/Medicaid nursing homes that evaluates functional capabilities and health needs) dated 5/17/26 revealed that Resident #1 was evaluated in Section GG (Functional Abilities) for Roll left to right-01, Sit to lying- 01, Lying to sitting on the side of the bed-01 and Chair/bed-to-chair transfer- 01, with 01 signifying Dependent- helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The 5/17/26 MDS also revealed that Resident #1 scored a 15 on the Brief Interview for Mental Status (BIMS- a structured assessment tool aimed at evaluating cognition in the elderly. BIMS score of 0-7 is reflective of severe cognitive deficit, 8-12 reflects moderate cognition deficit and 13-15 score is reflective of normal cognition).Additionally, Resident #1's Lift Transfer evaluation dated 10/9/24 resulted in a transfer evaluation score of 17 which is associated with Category 4- Caregiver performs 100% of the task, Equipment- Mechanical lift. Of note, the next Lift Transfer evaluation occurred on 7/17/26 with a transfer evaluation score of 29, which is also associated with Category 4- Caregiver performs 100% of the task.A review of Resident #1's Care plan demonstrated that he/she was care planned on 8/2/20 for ADL (Activities of Daily Living) Self care deficit r/t (related to) bilateral below the knee amputations with an intervention for Transfers: the resident requires Mechanical lift with 2 staff assistance for transfers.Ongoing review of Resident #1's EMR revealed that the right leg X-ray results were reported on 7/14/26 at 4:40 PM stating, There is an acute displaced fracture of the mid femur noted. Review of Resident # 1's SNF (Skilled Nursing Facility)/NF (Nursing Facility) to Hospital transfer form demonstrated that Resident #1 was transferred to the hospital on 7/14/26 at 7:30 PM for further evaluation/treatment of the right femur fracture.A review of Resident #1's hospital admission History and Physical exam dated 7/14/26 at 11:34 PM documented, Pt (patient) from the [facility name] for a right femur fracture, pt has bilateral BKA (below the knee amputations). The facility is unsure how the injury happened. Hospital Xray results were contained in the investigation folder and confirmed acute fracture of the femoral diaphysis (main central shaft of a long bone). Of note, the facility reported the initial FRI on 7/15/26 at 8:48 AM.On 8/19/26 at 9:45 AM while reviewing the facility's FRI investigation folder, the surveyor noted that Geriatric Nursing Assistant (GNA) #10 was suspended pending investigation on 7/19/26 and then terminated for failure to follow care plan and failure to follow company policy on 7/22/26. Residents that require hoyer must be done with two employees at all times. The investigation folder contained GNA #12's statement, which was obtained by CNO (Corporate Nursing Officer) #9 via telephone on 7/19/26 at 3:51 PM. GNA #12 was documented as stating, She was on [nursing unit] and came over to assist Gna #10. Upon entering the room the (Hoyer) sling was already in the sling positioned ready to be assisted in the Hoyer. He/she [GNA #12] did not help position [Resident #1] in the sling, only helped move her from the bed to the chair. The folder also contained a statement obtained from Resident #1 on 7/16/26 at 10 AM. The statement documented that Resident #1 stated that his/her (right) leg was positioned abnormally when transferring him/her with the hoyer lift. Resident #1 is documented as stating that he/she did not believe the action was intentional and that the issue (leg fracture) occurred during the transfer. Resident #1 is documented as identifying [GNA #10] as the person transferring him/her and that [GNA #12] was called in to assist with the transfer but Resident #1 was already elevated in the hoyer lift.On 8/19/26 at 10:10 AM during an interview, NHA #1 stated, .On Sunday, [GNA #10] had put [Resident #1] in the sling by herself which is against policy. The caregiver of the roommate said that he/she saw [GNA #10] lift [Resident #10] in the sling by herself and then [Resident #10] yelled because he/she was in pain.After the investigation, we called to terminate her but [GNA #10] never returned our call so technically, he/she abandoned the job.During a telephone interview on 8/19/26 at 10:45 AM, GNA #10 stated, .I have been a GNA for 18 years.I normally work [unit name]. I was reassigned that day to [unit name]. [GNA #12] came and helped me get [Resident #1] in the sling and then transfer her to the chair. [Resident #1] was complaining about his/her right leg when we were transferring her to his/her wheelchair.I don't know how [Resident #1]'s leg got broken. I don't remember if [the facility] did a training about Hoyer lifts during my orientation.On 8/19/26 at 11:42AM, during an interview, GNA #12 stated, I was assigned a different unit that day. I came over to [nursing unit] and asked if [GNA #10] needed help with [Resident #1]. [Resident #1] was already on the sling and the hoyer lift was over top of him/her. I did help put her in the chair.You could tell that [Resident #1] was in a lot of pain. It was in her face, you know that look of pain. I am PRN (part-time) so I work all the units. When I had [resident #1] before, he/she did not look like that. like he/she was in pain. I mean he/she does complain of pain a lot but he/she usually does not look like that.During an interview on 8/19/26 at 12:07 PM, Resident #1 stated, . No, it was not a dialysis day. It was a weekend.

Based on a review of facility documents, interviews, and observation, it was determined the facility failed to maintain an effective grievance system or a process to file a grievance anonymously. This was evident for 4 (#2, #11, #3, #10) of 4 residents reviewed for grievance concerns during the complaint survey. The findings include: Facility's Grievance Policy implemented 2/6/2024 by CNO#9 states in part: Resident and Family Grievances Policy- It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal .Policy Explanation and Compliance Guidelines: 1. The facility social worker has been designed as the Grievance Official and backup is the Administrator .3. Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility . 7. Information on how to file a grievance or complaint will be available to the resident. Information may include, but is not limited to: a. The contact information of the grievance official with whom a grievance can be filed, including his or her name, business address (mailing and email) and business phone number. b. The contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State-Long-Term Ombudsman program or protection and advocacy system. c. The time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his or her grievance .8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official. C. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. e. Via the company toll free Customer Service Line (if applicable). 9. A grievance may be filed anonymously .10. Procedure: a. This facility will not retaliate against anyone who files a grievance or participates in the investigation of a grievance. b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form .g. IN accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued. 1. On 08/19/2026 at 10:10 AM, a review of the facility's Resident and Family Grievances Policy confirmed that residents and family members have the right to voice grievances without discrimination or reprisal. Per policy guidelines, staff receiving a grievance would log the details or assist in completing the designated form. Following an investigation, the grievance official would provide the resident or representative with a written decision. This decision would include the date received, investigation steps, summary of findings, confirmation status (confirmed/not confirmed), corrective actions, and the issue date. On 8/17/2026 at 10:27 AM, a review of intake #3095815 revealed the complainant for Resident #2 reported several concerns that included being served undercooked sausage and rude staff behavior, including leaving the resident in the hallway, refusing room entry with statements to wait all day, and dismissing call lights due to lack of time. As a result, Resident #2 called the police department to report neglect. On 08/19/2026 at 10:06 PM, a review of the police report revealed that an officer had been dispatched to the facility on [DATE]. The officer and the Administrator met with Resident #2 regarding staff neglect complaints. Resident #2 stated that Emergency Medical Services (EMS) hurt their arm and reported facility concerns: receiving an overfilled water glass around 6:30 AM and being told the staff did not have any time to assist Resident #2 after he/she pressed the call button. At about 8:30 AM, Resident #2 received undercooked sausage patties. Following physical therapy and lunch, staff denied Resident #2's request to return to their room, saying Resident #2 had to wait all day to be placed back to bed. The Administrator agreed to address these concerns. On 08/17/2026 at 10:02 AM, during an interview, Resident #2 confirmed that in July 2026, they contacted the police regarding concerns. Police responded to the facility, and a staff member was present. Resident #2 added that they were unaware of the facility's grievance process and received no follow-up on how their concerns were resolved. On 08/19/2026 at 10:05 AM, a review of the facility's grievance log for the month of July 2026 revealed no documented evidence of Resident #2's concerns. On 08/17/2026 at 2:44 PM, during an interview, the Social Worker (SW) stated that grievances are written on a grievance form if they are unable to resolve them immediately. The SW is unaware of verbal concerns raised to staff unless a written grievance is submitted and returned to her. Grievances are investigated without a fixed timeframe, and the SW speaks with the resident once it's concluded. On 08/18/2026 at 3:23 PM, during an interview, the Administrator stated Resident #2 called the police in July 2026. The complaint involved Emergency Medical Services (EMS) hurting Resident #2's arm and a concern regarding therapy, seating the resident at the lunch table. The Administrator, who verified she was present when the concerns were voiced to law enforcement, noted that responding police dismissed them and confirmed the facility had no documentation that addressed the concerns. The concern was shared with the Administrator at this time. 2. On 8/17/26 at 12:02 PM while investigating iQIES complaint #3146026, Resident #11 stated, I filed a grievance last week about the staff being too loud on night shift and sleeping during night shift.I know about the grievance process. you fill out the paperwork. They are still noisy at night. [NHA #1] said he/she made three trips on Saturday night and no one was sleeping. They (the staff) sleep at night. The NHA told me he/she was going to put me on the [locked dementia] unit if I complained again. 3. During an interview on 8/17/26 at 1:14 PM, while investigating iQIES complaint #3075762, the family member of Resident #3 stated, The front walkway is missing mortar. My [family member]'s rollator gets caught in the groves. He/she has almost fallen a couple of times. Inside the building, he/she rides a scooter to the front door when he/she is going out for lunch with us. Then he/she uses a walker to get to our van. He/she almost fell the other day.I don't know about the grievance process. nothing comes of it. My [family member] has been in the facility for several years. I have reported several concerns but nothing happens. At this point, I just bypass the grievance process. I just call the State. I did not file a grievance for the walkway issue. On 8/17/26 at 2:22 PM, the surveyor toured the facility, which revealed only one sign in the entire building about the grievance process. The 8X10 paper flyer about grievances was posted on a bulletin board at standing eye level outside the Social worker's office on the 400 unit. It should be noted that this flyer would be difficult for a resident in a wheelchair to read. Further observation of this hallway revealed a bin outside the Social worker's office door that contained a folder labelled Grievance forms that was empty. A complete tour of the facility on 8/17/26 demonstrated no evidence of any mailbox or bin to collect anonymously filed grievances. During an interview on 8/17/26 at 2:44 PM, SW (Social worker) #7 stated, Typically when I get a grievance, I write it up in a grievance form. I only do the grievance for when something cannot be solved immediately. Typically when the family goes to a nurse with a concern, I typically don't know about it unless it is written up on a forms and it gets to me. I guess you could kind of consider me that (Grievance Officer).We really don't have a process for an anonymous filing of grievances. We don't have a clean official process to file an anonymous grievance. Under the current facility process, no matter how you do it, it can be traced.I feel there is not an official time frame to complete the (grievance) investigation. When the investigation is done, I do go back and talk with them (the person who field the grievance). 4. On 8/17/26 at 3:05 PM, during an interview, Resident #10 stated, .I take Lasix (a diuretic medication). When I am at Activities, if the one bathroom by the dining room is occupied, I have to go all the way to my room to use the bathroom and sometimes because of the Lasix, I don't make it.The grievance process is where you fill out that (grievance) process and they write down the issue and you have to sign the paper. No, I have not filed a grievance about the bathroom being out of order. During an interview on 8/17/26 at 3:22 PM, NHA (Nursing Home Administrator) #1 stated, The bathroom has been out of order since July 2026 when the surveyors were here for the annual survey.I have to give you that.we don't have a process to file a grievance anonymously. On 8/18/26 at 8:10 AM, the Surveyor observed the facility maintenance crew repairing the front walkway by adding sand/cement in the spaces between the bricks. On 8/18/26 at 9:45 AM, the Surveyor reviewed the facility's Resident admission Contract, which stated, D. Your Right to Make Complaints and Suggest Changes in Policies and Services . This section of the contract listed the contact information for the Office of Health Care Administration and the Department of Aging but did not mention the internal grievance process.

Based on record review and interview, it was determined that the facility failed to develop, implement and maintain an effective training program for direct care provider staff regarding safe operation of Hoyer Lifts (a mechanical transfer device used to safely move non-weight-bearing individuals between a bed, chair, commode or shower). This was true for all geriatric nursing assistants (GNA) working in the facility. This deficient practice is being brought forward as past non-compliance.The findings include:The Facility's policy as it relates to the use of a Hoyer Lift reviewed/revised 10/3/25, 7/15/26 by CNO #9, reads in part: Safe Resident Handling/Transfer Policy- to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines:. 12. Staff will be educated on the use of safe handling/transfer practices including the use of mechanical lift devices as the need arises or changes in equipment occur. 13. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 14. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.During the investigation of FRI # 3093733 on 8/19/26 at 11:35 AM, the Surveyor noted that the Employee Validation Checklist Mechanical Lift paperwork for the GNAs in the facility investigation folder all were dated after the hoyer lift Facility Reported Incident (FRI). Further review of the facility's Orientation/Annual Education In-Service Attendance Records check off sheets for new employees on 8/19/26 failed to demonstrated evidence that Safe Resident Handling/Transfers policy and procedure was taught during new employee orientation.During a telephone interview on 8/19/26 at 10:45 AM, GNA #10 stated, I started working at [the facility] in September 2025. I have been a GNA for 18 years. I don't remember if [the facility] did a training about hoyer lifts during my orientation.During an interview on 8/19/26 at 12:36 PM, NHA #1 confirmed, .The Orientation/Annual Education In-Service Attendance Record sheet does not have listed a check off for hoyer transfer trainings. We don't have documentation of that training until 7/15/26.The facility recognized this deficiency and initiated the following actions to correct the issue:-An email was sent to all staff on 7/16/26 from NHA #1 titled Education Hoyer and stated All hoyer transfers require 2 people. *If you are witnessed not using 2 people for hoyer transfers, you can be terminated.-Performed Employee Education on safe handling with content including how to position residents properly in the hoyer sling to ensure safety and reviewed the Safe Resident Handling/Transfer policy.-completed a Validation Checklist Mechanical Lift for all direct care GNAs. Of note, none of the checklists have been signed by the staff educator stating that the GNA demonstrated a hoyer transfer safely. This lack of documentation of staff demonstration of the skill was brought to the facility's attention at the exit conference on 8/19/26 at 3:40 PM.-completed weekly accident audits from 7/15/25 to 8/11/26 to monitor for any trends.The facility is alleging Past-non-compliance as of 8/14/26 at 4PM.

Based on record review, staff and resident interviews, and facility documentation, the facility failed to ensure staff provided incontinent care using safe techniques for 1 (#22) of 1 residents reviewed for incontinent care. Specifically, staff failed to discontinue brief removal after the resident complained of pain and failed to remove the plastic fastening tabs before pulling the incontinent brief from beneath the resident. This deficient practice resulted in a deep laceration to the resident's left posterior thigh, uncontrolled hemorrhage requiring emergency medical services, hospitalization for approximately three weeks, and treatment including transfusion of four units of packed red blood cells and three units of platelets.Findings include:Intake # 3008785 was reviewed on 6/28/26 for allegations that a Geriatric Nurse Assistant (GNA # 48) roughly removed a brief pad from the resident without removing the plastic tab when providing incontinent care, causing a deep wound laceration and severe blood loss.Resident #22 is a resident with diagnoses including muscle wasting and atrophy, morbid obesity, systemic lupus (autoimmune disease), chronic respiratory failure, chronic kidney disease, chronic pain, lymphedema (abnormal swelling due to build up of protein-rich lymph fluid), atrial fibrillation (heart rhythm disorder), generalized edema, and impaired mobility. Medical record review on 6/28/26 confirmed the resident was prescribed anticoagulant therapy (blood thinner medications to prevent, breakdown, or reduce the size of blood clots).The residents' care plan, initiated on 2/22/26, identified the need for extensive staff assistance with activities of daily living and incontinent care due to obesity and impaired mobility. Interventions included providing perineal care after each incontinent episode, assisting with bed mobility, and encouraging participation in care as able.Review of the Emergency Medical Services report for 4/30/26 revealed EMS responded after facility staff reported the resident began bleeding during incontinent brief removal. Facility staff reported bleeding had continued for approximately 35-40 minutes before 911 was activated and staff were unable to identify the bleeding source or control the hemorrhage. EMS documented a large pool of blood beneath the resident, multiple blood-soaked towels, and noted the resident was receiving blood-thinning medication. During transport, the resident developed dizziness, visual changes, and decreased level of consciousness and was transported to the emergency department.The facility nursing progress note dated 5/1/26 at 3:15 a.m. documented that nursing staff were notified of severe bleeding. Assessment revealed approximately one-half of the resident's bed was covered with blood with active bleeding from the left leg. The resident's blood pressure was 99/64 with a pulse of 122. Direct pressure failed to control the bleeding. The nurse practitioner ordered immediate transfer to the hospital due to profuse uncontrolled bleeding while receiving anticoagulant therapy.During an interview on 6/28/26 at approximately 12:05 PM, Resident #22 stated two Geriatric Nurse Assistants (GNA's) were assisting with incontinence care (changing the brief pad). The resident reported staff normally removed the plastic fastening tabs before pulling the brief from underneath him/her. The resident stated s/he felt something sticking into the back of the leg and instructed GNA #48 to stop because it was painful. According to the resident, GNA #48 continued pulling the brief, causing the plastic fastening tab to cut into the back of the left thigh. The resident immediately experienced burning pain, heavy bleeding, required emergency transport, and remained hospitalized for approximately three weeks.On 6/28/26 at approximately 2:55 PM, the Clinical [NAME] President (CVP # 6) was unable to provide an investigative file regarding the incident. The only documentation later produced consisted of written statements from GNA #19 and GNA #48 and an in-service titled How to Handle Resident Safety with Fragile Skin completed only by GNA #48 on 5/27/26. No evidence was provided showing other direct care staff received education following the incident.GNA #19's written statement indicated she assisted GNA #48 during the brief change and did not observe rough handling. During interview on 6/29/26 at approximately 9:40AM, however, GNA #19 stated the resident complained of discomfort while GNA #48 was removing the brief. Because she was positioned at the front of the resident providing support, she could not see the area where GNA #48 was working. She stated GNA #48 continued removing the brief and blood immediately began squirting, prompting her to obtain the nurse.GNA #48's written statement acknowledged the resident complained of burning after the brief was removed and that significant bleeding occurred immediately afterward. During interview on 6/29/26 at approximately 10:20AM, GNA #48 further acknowledged the resident told her something was sticking him/her while the resident was turned on the side; however, she continued removing the brief before assessing the complaint. After turning the resident back, she observed profuse bleeding and notified nursing staff.The nurse supervisor (RN # 22) stated during an interview on 6/29/26 at approximately 5:22 PM, he entered the room and observed a pool of bright red blood on the resident's bed while both GNAs were applying pressure. Despite continued direct pressure, bleeding could not be controlled. He contacted the nurse practitioner and activated emergency medical services. The supervisor stated the resident informed him the injury occurred because the plastic tabs from the brief had not been removed before the brief was pulled from underneath him/her.A second nurse (#33) working at the time of the incident confirmed during telephone interview on 6/30/26 at approximately 5:00PM that Resident #22 reported GNA #48 caused the injury by pulling the brief while the plastic fastening tabs remained attached, resulting in a cut that caused burning and severe bleeding.The facility failed to ensure staff stopped the incontinent care procedure and assessed the resident after the resident complained of pain before continuing brief removal. The facility failed to ensure incontinent care was performed using safe techniques appropriate for a resident requiring extensive assistance with mobility and receiving anticoagulant therapy. As a result, Resident #22 sustained a deep laceration to the left thigh causing uncontrolled hemorrhage, emergency transport, hospitalization for approximately three weeks, multiple blood product transfusions, and actual harm.

Based on observation, interviews, and documentation review, it was determined that facility staff failed to treat each resident in a dignified manner by failing to dress a resident in clothing that was suitable for the resident, failing to place a urinary catheter bag in a dignity bag for residents with a Foley catheter, and failing to allow residents to dine in the dining room for dinner daily. This was evident for 10 (#14, #10, #27, #24, #13, #5, #23, #25, #26, #28) of 28 residents reviewed during a complaint survey. The findings include: 1) On 3/9/26 at 9:06 AM observation was made of Resident #14 lying in bed with no clothes on. Resident #14 was covered with a blanket. Resident #14 was yelling, why don't I have any clothes on. Where are my clothes? There was a dried yellow stain on the top of the blanket, and the fitted sheet was stained with dried food and was yellow. There was half of a diaper on the fall mat next to the bed. There was a hospital gown on the floor that was close to the doorway right outside of the bathroom alcove. On 3/9/26 at 10:57 AM a second observation was made of Resident #14. Resident #14 was sitting in a wheelchair in the dining/activity room crying that he/she had shorts on and women were supposed to wear long pants. Resident #14 stated, I am cold. Resident #14 was wearing a short-sleeved shirt, khaki shorts, and slipper socks. GNA (geriatric nursing assistant) #6 stated Resident #14 did not have any other clothes in his/her room. Staff #16 stated that she would go to the laundry to see if she could find some of Resident #14's clothes. The surveyor accompanied Staff #16 to the laundry room. Observation was made in the laundry room of Staff #4 sitting on a chair folding laundry. Staff #4 stated there was supposed to be a 3-day turn around for doing personal laundry. Staff #4 said that she was last here on Friday and no one did the personal laundry over the weekend. Staff #4 pointed to a very large pile of personal laundry that was piled high in a bin. Staff #4 stated that the pile of laundry still needed to be done. Staff #4 was able to give Staff #16 a couple of Resident #14's clean laundry that included a pair of pants and 2 shirts. Staff #4 also stated that only 1 of the 3 commercial dryers was working. Staff #4 stated there was a small non-commercial dryer that she was drying the personal clothes in. Staff #4 confirmed that it takes at least 4 to 5 days to get laundry done because of the washer and dryer situation. On 3/10/26 at 10:11 AM Staff #11, the Director of Maintenance and Housekeeping was interviewed and confirmed that 2 clothes dryers were not working along with a washing machine. Staff #11 stated as of right now I do not know of any upcoming delivery for a washer and the 2 dryers that are down. The staff are not able to keep up with the laundry. They are not able to keep up with the personal laundry. I also didn't have staff to do the personal laundry this past weekend. Review of Resident #14's personal inventory list that was located in the paper medical record documented the resident had 1 dress, (3) pairs of pants, (1) jeans, (10) shirts, (4) shorts, (1) sweater, and (1) sweatshirt. On 3/11/26 at 2:50 PM the Director of Nursing and the Nursing Home Administrator were informed of the concern. 2) On 3/11/26 at 10:40 AM observation was made of Resident #10 lying in bed wearing a hospital gown. There was a Foley catheter that was hanging on the right side of the bed draining yellow urine. A Foley catheter is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag. Resident #10's foley catheter drainage bag was not placed in a privacy/dignity bag to enhance privacy to the resident. 3) On 3/11/26 at 12:55 PM observation was made from the hallway of Resident #27 lying in bed. There was a foley catheter drainage bag visible from the hallway with yellow urine. Resident #27's Foley catheter drainage bag was not placed in a privacy/dignity bag to enhance privacy to the resident. On 3/11/26 at 1:40 PM the Director of Nursing (DON) was asked if a resident with a Foley catheter should have a dignity bag. The DON stated, yes. On 3/11/26 at 1:49 PM a review of the Catheter Care Policy that was given to the surveyor from the DON stated, #2 under policy explanation, privacy bags will be available and catheter drainage bags will be covered at all times while in use. The DON was informed that Resident #10 and Resident #27 did not have a dignity bag covering the urinary catheter drainage bags. 4) During interview with Resident #24 on 3/9/26 at 11:00 AM, Resident #24 stated he/she would like to be able to use the dining room for dinner, but the staff won't let them. During interview with Resident #13 on 3/9/26 at 11:37 AM, Resident #13 stated the facility does not allow them to eat dinner in the dining room. Resident #13 states he/she would like to be able to socialize with other residents during dinner. During interview with Resident #5 on 3/9/26 at 1:15 PM, Resident #5 stated the facility will not allow them to eat dinner in the dining room or eat any meals on the weekends in the dining room. Resident #5 stated they were told they don't have enough staff for the residents to be able to use the dining room for these meals. The Resident stated he/she didn't believe that was right and the residents should be able to use the dining room. During interview with the Resident council president (Resident #23) on 3/10/26 at 5:32 PM, the Resident stated the residents would like to be able to eat dinner in the dining room and eat their meals in the dining room on the weekends. Resident #23 gave the Surveyor permission to review the Resident council notes. Observation of dinner service on 3/10/26 revealed Wye Oak Unit was served dinner trays at 5:50 PM and Chesapeake unit was served dinner trays at 6:01 PM. The facility staff were observed taking the residents their dinner trays in their rooms. Observation of the dining room on 3/10/26 at 6:15 PM revealed the dining room was dark and no residents were in the dining room. Review of Resident council meeting notes on 3/11/26 revealed on 7/24/25 Resident #5 and #24 are concerned that they cannot eat in the dining room for dinner and weekends. Review of Council Concern/Recommendation Form for Resident #5 and #24 revealed on 8/29/25 the Administrator signed the staff response: The Dining Room is open for breakfast and lunch mon-fri currently. We do not have the staff to support dinner or weekends at this time. During lunch service in the dining room on 3/11/26 at 12:40 PM the Surveyor asked Resident #25 if he/she also eats dinner in the dining room, the Resident stated no they are closed for dinner and on the weekends. The Resident added I don't think it's right. Interview with Resident #26 on 3/11/26 at 12:45 PM in the dining room, the Resident was asked if he/she would like to eat dinner in the dining room, the Resident stated yes. During interview with the Dietary Manager on 3/11/26 at 1:33 PM, the Dietary Manager was asked why dinner is not served in the dining room, Dietary Manager stated she was told because there is not enough staff. During interview with the Activities Director on 3/11/26 at 1:40 PM, the Activities Director was asked if residents complain about the dining room not being open for dinner and weekends. The Activities Director stated she started in September 2025 and only remembers Resident #28 complaining he/she couldn't use the dining room on weekends. She stated I know they have to have someone in there if residents are eating. I don't know how long it has been like that, but residents don't eat in the dining room for dinner or on the weekends. During interview with the Administrator on 3/11/26 at 1:45 PM, the Surveyor reviewed the resident council concern from July 2025 and the residents' interviews during survey that the residents want to have access to the dining room for all their meals. At that time the Administrator was asked why the residents cannot use the dining room for dinner and weekends. The Administrator stated because we don't have the staff to support it.

Based on observations, interview, and medical record review, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed from staff. This was evident for 7 (#16, #17, #18, #19, #14, #21, #22) of 9 residents observed on the Homestead unit during a complaint survey.The findings include: On 3/9/26 at 9:06 AM a tour of the Homestead unit was conducted, and the following observations were made: 1) Observation was made of Resident #16 lying in bed. Resident #16's call bell was observed on the floor behind the bed. A second observation was made on 3/10/26 at 8:34 AM of Resident #16 lying in bed. Resident #16's call bell cord was lying on the floor and wrapped around Amazon boxes in the corner of the room by the bed. Resident #16 was asked where the call bell was and the reply was, they took it from me.Review of Resident #16's care plan, has an ADL (activities of daily living) performance deficit related to decreased mobility had the intervention, Encourage the resident to use bell to call for assistance that was initiated on 1/18/25. Review of Resident #16's care plan, is at risk for falls r/t decreased mobility/recent hospitalization had the intervention, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The facility staff failed to follow the care plans. 2) Observation was made of Resident #17 lying in bed and the call bell was observed hanging under the bed frame and dragging and touching the floor.On 3/10/26 at 8:31 AM a second observation was made of Resident #17 lying in bed. The call bell cord was observed on the floor wrapped under the bed on the bed frame.Review of Resident #17's care plan, resident has an ADL self-care performance deficit r/t dementia, encephalopathy and weakness had the intervention, encourage the resident to use bell to call for assistance that was initiated on 8/26/25. Review of Resident #17's care plan, resident is at risk for falls had the intervention, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The care plan was initiated on 8/26/25. The facility staff failed to follow the care plans. 3) Observation was made of Resident #18 lying in bed. Resident #18's call bell was lying on the floor behind the bed. Resident #18 was asked how he/she called the nurse and Resident #18 stated, with the call button. Review of Resident #18's care plan, resident has an ADL self-care performance deficit r/t schizophrenia and dementia had the intervention, encourage the resident to use bell to call for assistance that was initiated on 5/19/25. A second care plan, resident is at risk for falls r/t poor safety awareness had the intervention, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The care plan was initiated on 5/19/25. The facility staff failed to follow the care plans. 4) Resident #19 was observed sitting on the edge of the bed and the call bell was observed on the floor behind the bed. Resident #19 was asked how he/she calls the nurse and the reply was, I ring the call bell, and they come in and turn it off and don't come back. Review of Resident #19's care plan, resident has an ADL self-care performance deficit r/t (there was nothing documented as related to). There was an intervention, encourage the resident to use bell to call for assistance that was initiated on 3/1/26. The facility staff failed to follow the care plan. 5) On 3/10/26 at 8:33 AM Resident #14 was observed lying in bed. The call bell cord was wrapped on the frame behind the bed.6) On 3/10/26 at 8:34 AM Resident #21 was observed in bed. The call bell was observed on the floor behind the bed.7) On 3/10/26 at 8:35 AM Resident #22 was lying in bed. The call bell was observed under the bed on the floor. Staff #7 was asked to come in the resident's room. Staff #7 was shown the call bell on the floor. Staff #7 stated that they needed to put a clip on the cord so they could clip it to the sheet. At that time, Staff #7 was informed about the rest of the residents that were observed with call bells on the floor. Staff #7 stated that it was a problem.On 3/11/26 at 2:50 PM the Director of Nursing and the Nursing Home Administrator were informed of the concerns.

Based on complaint, observations, and staff interview, it was determined the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident in the common areas of the facility and in 1 of 4 nursing units observed during a complaint survey.The findings include:On 3/9/26 at 8:55 AM a review of complaint 2702826 alleged that the resident room was in deplorable condition on the Homestead unit. The complaint alleged there were feces on the wall and floors and cold air was coming through the air conditioning unit. The complaint alleged that conditions were so deplorable for the residents and unsanitary.A tour of the facility was conducted on 3/9/26 at 9:06 AM. The following environmental observations were observed:There were (3) ceiling tiles in the conference room where the surveyors were located and they had (4) brown stains on the tiles. There were (2) ceiling tiles with brown stains in the entrance hallway that was on the left side of the ceiling which was across from the Human Resources office. This was at the entrance to the nursing units. On the Homestead unit in the hallway outside of room [ROOM NUMBER] there were (2) ceiling tiles that were stained brown and were cracked. In room [ROOM NUMBER] Resident #14 was lying in bed with no clothes on but was covered with a blanket. The resident was yelling, why don't I have any clothes on. Where are my clothes? There was a dried yellow stain on the top of the blanket, and the fitted sheet was yellow and stained with dried food. There was half of a diaper on the fall mat next to the bed. There was a hospital gown on the floor that was close to the doorway right outside of the bathroom alcove. There was a soiled sheet sitting on top of the trashcan by the sink that was in the room. The sheet was covered with gnats. The laminate on the headboard was missing approximately 6 inches by 1 inch.In room [ROOM NUMBER]B there was a soiled sheet with a pink stain that was on the bed. The overhead light in the toilet area was not working and the ceiling tile in the toilet area was cracked.In room [ROOM NUMBER] there was an air conditioner unit in the wall above the radiator. There was cold air coming through the gaps around the unit. The outside was visible through the gaps and holes around the air conditioner unit. There was a bracket around the air conditioner unit that had a black substance on the left side along with dirt, dust, cobwebs, and the top of the radiator was full of dust. The electrical box was hanging away from the wall approximately 1 inch. The footboard to the bed on the left side of the room had laminate that was peeled off over one half of the footboard and the footboard was loose. There was a 2-inch split in the blue covering on the positioning wedge.There were several beds in the unit that did not have linen. An interview was conducted with Staff #6 who stated she was told when she came in that morning that the staff did not have linen during the night.In the dining room in the Homestead unit by the nourishment room door the drywall was peeling off the wall approximately 5 inches by 3 inches. At the bottom of the wall above the baseboard was a 12-inch area that was caved in. There were (4) exhaust fans in the ceiling that were rusted. There was a piece of molding on the ceiling between the dining room and the nurse's station that was hanging down approximately 2 inches.The hallway floor by room [ROOM NUMBER] was dirty, sticky, and discolored.In room [ROOM NUMBER] the floor tile by the bathroom was missing approximately 1 inch by 12 inches. There was gnats by the toilet.In room [ROOM NUMBER] there were (2) ceiling tiles that had (3) large brown circle stains. There was no cover on the overhead light above the toilet, and the ceiling tile was cracked. The laminate on the closet door was missing approximately 2 feet by the door handle.In room [ROOM NUMBER] there were (3) ceiling tiles over the bed that had brown stains. In room [ROOM NUMBER] the floor was sticky.Observation of the ceiling under the front porch revealed hardy board that was hanging down approximately 2 to 3 inches from the top and was 18 inches in length. There was a hole in the hardy board approximately 6 inches by 3 inches.On 3/10/26 at 10:11 AM a tour of the facility was conducted with the Director of Maintenance and Housekeeping, Staff #11. Staff #11 stated he was not aware of the ceiling under the front porch. Staff #11 was informed about the Homestead unit not having linen after the weekend and he confirmed that 2 clothes dryers were down along with a washing machine. He stated, as of right now I do not know of any delivery for a washer and the 2 dryers that are down. They are not able to keep up with the laundry. Staff #11 stated, linen has always been an issue here. The last time I ordered bulk linen, but this weekend I did not have staff at night. I didn't have staff to do the laundry. They didn't have morning linen to start. Staff #11 stated, we don't have enough linen to support the residents in the building. Staff #11 was asked if the staff knew how to put repair requests in the electronic system (TELS). Staff #11 stated staff have been in-serviced and stated, as soon as they put it in TELS it comes to my phone and we fix it. I know the administrator has educated the staff on putting things in TELS.The Homestead unit was toured with Staff #11 to point out the concerns. Staff #11 confirmed the findings. Staff #11 stated he was waiting for the Corporate Director of Maintenance to come help him off hours to paint the exhaust fans in the ceiling. Staff #11 confirmed the condition of the air conditioner unit in room [ROOM NUMBER] and confirmed the holes that were visible to the outside of the building. Staff #11 found the surrounding bracket for the unit on top of the resident's closet. Staff #11 took note of the dust and cobwebs and acknowledge the area had not been cleaned.On 3/11/26 at 2:50 PM the Director of Nursing and the Nursing Home Administrator were informed of the concerns.

Based on complaint, medical record review, and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 4 (#12, #8, #4 #5) of 28 residents reviewed during a complaint survey.The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 3/9/26 at 11:00 AM a review of complaint 2702826 alleged that Resident #12's toenails were so long that they were growing into the resident's skin. Review of Resident #12's paper medical record did not produce documentation that Resident #12 had been seen by a podiatrist. Review of Resident #12's EMR (electronic medical record) failed to produce documentation in the miscellaneous section of any podiatry notes that Resident #12 had been seen. On 3/10/26 at 12:54 PM Staff #7 was asked if Resident #12 had been seen by the podiatrist. Staff #7 stated yes because the resident had thick toenails. Staff #7 was asked where the podiatry notes would be located and she said in the medical record. On 3/10/26 at 12:56 PM the Director of Nursing (DON) was asked how the podiatrist was notified of a resident needing an appointment. The DON stated that social services would know and that they would put the resident on the list if nursing informed them. The DON also said the podiatrist kept a list of regularly scheduled visits. The DON was asked to show the surveyor where Resident #12's podiatry visits were located. The DON could not find them in the EMR. The DON came back to the surveyor and provided the 1/10/26 and 1/31/26 podiatry visit for Resident #12 along with podiatry notes from 9/27/25 for (27) other residents. The DON stated that the office visits were never uploaded into the medical records for Resident #12 and the other (27) residents. 2) On 3/9/26 at 1:30 PM Resident #8's medical record was reviewed and revealed the last care plan meeting was on 10/14/25. Resident #8 had an invite for a January 2026 care plan meeting but there was no documentation found in the medical record that the January 2026 meeting took place. On 3/9/26 at 2:15 PM the social workers, Staff #5 was asked if there was a care plan meeting and if so where was the documentation. Staff #5 stated, I keep them (the notes) on paper and organize them inside the file cabinet. Most days I am by myself and don't have time to upload them in the medical record. I am responsible for 100 to 115 residents. It is really busy. I am not really sure if they need to be in the medical record. On 3/9/26 at 2:47 PM Staff #5 brought a copy of the care plan summary for date of service 1/14/26 and confirmed it was not uploaded in the system. On 3/11/26 at 2:50 PM the Director of Nursing and the Nursing Home Administrator were made aware of the findings. 3) Review of Resident #4's medical record on 3/9/26 revealed the Resident was admitted to the facility in October 2025 and had a care plan meeting scheduled for 1/21/26. Further review of Resident #4's medical record revealed no evidence of the care plan meeting on 1/21/26. During interview with Social Services (Staff #5) on 3/9/26 at 2:13 PM, Staff #5 stated she keeps care plan meeting documentation in a file in her office. On 3/9/26 at 3:04 PM Social Services provided the notes from the care plan meeting with Resident #4 held on 1/21/26 and confirmed they were not in the Resident's medical record. On 3/10/26 at 2:41 PM the Director of Nursing was advised of the Surveyor's findings. 4) Review of Resident #5's medical record on 3/9/26 revealed the Resident was admitted to the facility in 2023. Interview with Resident on 3/9/26 at 1:15 PM the Resident stated he/she was unsure of when his/her last care plan meeting was. Further review of Resident #5's medical record revealed the last care plan meeting documented was on 7/8/25. During interview with Social Services (Staff #5) on 3/9/26 at 2:13 PM, Staff #5 stated she keeps care plan meeting documentation in a file in her office. On 3/9/26 at 3:04 PM Social Services provided the notes from the care plan meeting with Resident #5 held on 1/7/26 and confirmed they were not in the Resident's medical record. On 3/10/26 at 2:41 PM the Director of Nursing was advised of the Surveyor's findings.

Based on observation and interview, the facility staff failed to have all washers and dryers in working order to meet the needs of the residents. This was evident for 1 of 3 washers and 2 of 4 dryers in the laundry room observed during the complaint survey.The findings include:Observation of the laundry room on 3/9/26 at 9:18 AM due to complaints about not receiving personal laundry timely and not having enough linen revealed 1 of 3 washers not working and 2 of 4 dryers not working. The Surveyor observed 1 of the 2 dryers that was working was much smaller in size than the other commercial dryer.During interview with Staff #4 (Laundry) on 3/9/26 at 9:18 AM, Staff #4 states the washer and 2 dryers have not been working for a while and the smaller dryer can not do as much laundry as the bigger dryer.During interview with the Maintenance and Housekeeping Director (Staff #11) on 3/10/26 at 10:45 AM, Staff #11 stated the facility staff have been unable to keep up with the personal laundry of residents. Staff #11 stated they need to get rid of the 2 dryers that are not working and plan to get a new dryer.The Surveyor shared concerns regarding the washer and 2 dryers not functioning on 3/10/26 at 3:30 PM with the Administrator and the facility inability to keep up with the laundry.On 3/11/26 the Administrator provided the Surveyor with a quote for a new dryer dated and signed on 3/11/26.

Based on medical record review and interview, the facility failed to notify the Resident's representative of a resident's physician appointment. This was evident for 1 (Resident #5) of 11 residents reviewed for complaints during a complaint survey.The findings include:During interview with Resident #5 on 3/9/26 at 1:15 PM with the Resident's representative (RP) present, the Resident stated he/she had a doctor's appointment today. The RP stated: I didn't know you had a doctor's appointment. I take you to all your appointments, but I can't today. The RP asked the Resident what the appointment was for and the Resident responded they didn't know, someone just told him/her this morning that he/she had one.Review of Resident #5's medical record on 3/11/26 revealed the Resident went to an orthopedic appointment on 3/9/26 and he/she received a left shoulder injection.Interview with the Director of Nursing (DON) on 3/12/26 at 8:55 AM confirmed the Resident's RP takes the Resident to all his/her doctor appointments. The DON confirmed the Resident did go to his/her orthopedic appointment on 3/9/26 without his/her RP because the facility staff failed to notify the Resident's RP of the doctor's appointment.

Based on medical record review, observation, and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#10, #27) of 2 residents reviewed for urinary catheters during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 3/11/26 at 11:15 AM a review of Resident #10's medical record was conducted and revealed Resident #10 was admitted to the facility on [DATE] from an acute care hospital. Review of the 1/14/26 hospital discharge summary documented Resident #10 was admitted following a fall resulting in left hip pain and inability to ambulate. Initial evaluation revealed a left intertrochanteric femur fracture.Review of a 1/15/26 Nurse Practitioner initial note documented that Resident #10 was admitted to the facility after a recent hospitalization, following a fall that resulted in left intertrochanteric femur fracture with imaging suspicious for pathological fracture.Review of Resident #10's admission MDS assessment with an assessment reference date (ARD) of 1/20/26, Section J1700 Fall History on Admission/Entry or reentry, A did the resident have a fall any time in the last month prior to admission/entry or reentry was documented 9 unable to determine.On 3/11/26 at 2:04 PM the MDS was discussed with the MDS Coordinator, Staff #26 who confirmed the error and said the fall should have been captured.2) On 3/11/26 at 12:55 PM observation was made from the hallway of Resident #27 lying in bed. There was a foley catheter drainage bag with urine that was hanging on the left side of Resident #27's bed that was visible from the hallway.Review of Resident # 27's medical record revealed a physician's order for a foley catheter dated 1/3/26 for urinary retention.Review of Resident #27's quarterly MDS with an ARD of 1/6/26, Section H0300 urinary continence, was coded always incontinent. Since Resident #27 had an indwelling urinary catheter the urinary continence should have been coded, not rated.On 3/11/26 at 2:04 PM the MDS was discussed with the MDS Coordinator, Staff #26 who confirmed the error.

Based on observation, medical record review, and interview, it was determined that the facility staff failed to develop and implement a care plan related to a resident's specific needs related to an indwelling foley catheter. This was evident for 1 (Resident #27) of 2 residents reviewed for an indwelling foley catheter.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 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.On 3/11/26 at 12:55 PM observation was made from the hallway of Resident #27 lying in bed. There was a foley catheter drainage bag with urine that was hanging on the left side of Resident #27's bed that was visible from the hallway.Review of Resident #27's medical record revealed a physician's order for a foley catheter dated 1/3/26 for urinary retention.Review of Resident #27's quarterly MDS assessment with an assessment reference date of 1/6/26, documented in Section H, bladder and bowel, H0100A, indwelling catheter use.Review of Resident #27's January 2026, February 2026, and March 2026 Treatment Administration Records (TAR) documented the use of an indwelling foley catheter.Review of the care plan section of Resident #27's medical record failed to produce a care plan for the indwelling foley catheter.On 3/11/26 at 1:37 PM an interview was conducted with Staff #26, the MDS Coordinator. Staff #26 stated that the nursing team was responsible for creating and implementing care plans.On 3/11/26 at 2:50 PM the Director of Nursing and the Nursing Home Administrator were informed of the findings.

Based on medical record review and interview, the facility staff failed to have a quarterly care plan meeting for a resident (Resident #13). This was evident for 1 of 5 residents reviewed for care plan meetings during a complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. Review of Resident #13's medical record on 3/9/26 revealed the Resident was admitted to the facility in 2022. Further review of Resident #13's medical record revealed the last quarterly care plan meeting was on 10/29/25. The Resident had a quarterly MDS assessment completed on 12/21/25. Interview with Social Services on 3/9/26 at 2:13 PM revealed she keeps care plan meeting documentation in a file in her office. Social Services was asked to provide any documentation the Resident has had a care plan meeting since the last care plan meeting on 10/29/25 and the 12/21/25 MDS Assessment. Interview with Social Services on 3/9/26 at 3:04 PM revealed the facility was scheduled to have Resident #13's care plan meeting on 12/23/25 but it had to be rescheduled. Social Services stated she didn't realize it hadn't been rescheduled. On 3/10/26 at 2:41 PM the Surveyor advised the Director of Nursing that Resident #13 did not have a quarterly care plan meeting after his/her 12/21/25 MDS Assessment.

Based on observation, medical record review, and interview, it was determined the facility failed to provide respiratory services in accordance with professional standards of practice. This was evident for 1 (Resident #15) of 28 residents reviewed during a complaint survey. The findings include: A nasal cannula is a lightweight, flexible tube with 2 small prongs inserted into the nostrils to deliver supplemental oxygen. An oxygen concentrator is a medical device that provides supplemental oxygen to individuals with breathing disorders. It offers a continuous supply of oxygen without needing refills, unlike oxygen tanks. On 3/9/26 at 9:06 AM during a tour of the Homestead Unit observation was made by 2 surveyors of Resident #15 lying in bed. There was an oxygen concentrator next to the bed against the back wall. There was a nasal cannula sitting on top of the concentrator that was wrapped in a coil and sitting under the concentrator handle. The concentrator was off. Resident #15 was observed again at 11:10 AM, 1:30 PM and 4:00 PM. Resident #15 was never observed receiving oxygen.On 3/10/26 at 8:31 AM observation was made of Resident #15 lying in bed by 2 surveyors. The oxygen concentrator was next to the bed, and the power button was off. The nasal cannula tubing was wrapped in a coil and sitting under the concentrator handle. The concentrator was off. Resident #15 was not receiving oxygen.On 3/11/26 at 6:50 AM observation was made of Resident #15 lying in bed. Again, Resident #15 was not receiving oxygen. There were several other observations made of Resident #15 from 8:31 AM to 6:00 PM on 3/11/26 and the resident never received oxygen.Review of Resident #15's medical record revealed a physician's order that was written on 2/24/26 at 1500 (3:00 PM) for oxygen at 2 liters continuous for comfort every shift.Review of Resident #15's March 2026 Medication Administration Record (MAR) revealed nurse's initials every shift for 3/9/26, 3/10/26, and 3/11/26 that documented the resident was receiving oxygen around the clock each shift. The initials were from Staff #7, Staff #14, Staff #27, Staff #28, Staff #29, and Staff #17. On 3/11/26 at 2:50 PM the Director of Nursing and Nursing Home Administrator were informed that 6 of their licensed nurses falsified the medical record by documenting Resident #15 was receiving oxygen each shift.On 3/12/26 at 9:00 AM the Director of Nursing confirmed the findings.

Based on observation and interview, the facility staff failed to maintain the temperatures of the shower on the Wye Oak Unit. This was evident for 1 of 2 showers on the Wye Oak Unit and 1 of 4 nursing units observed during the complaint survey.The findings include:After review of a complaint about not having hot showers on the Wye Oak Unit, the Surveyor went to the Wye Oak shower room on 3/10/26 at 11:55 AM. The shower room contained 2 showers. The left shower water temperature was 87 degrees and the right shower was 110 degrees. The left shower faucet could not be turned towards H for hot.The Surveyor returned with the Director of Maintenance and Housekeeping (Staff #11) on 3/10/26 at 11:48 AM to the Wye Oak shower room. Staff #11 confirmed the left shower water temperature was 87 degrees and the faucet could not be turned toward H for hot. Staff #11 confirmed the water temperature should be between 100 and 120 degrees. Staff #11 stated he was unaware there was an issue with the left shower faucet. Observation of the Wye Oak shower room revealed there were no signs for staff not to use the left shower.The Surveyor shared the findings with the Administrator on 3/10/26 at 3:30 PM.

Based on observations, interviews, and documentation review, it was determined the facility failed to have an effective pest control program as evidenced by numerous gnats seen in resident rooms and on the unit. This was evident on 1 (Homestead) of 4 nursing units during a complaint survey.The findings include: On 3/9/26 at 9:06 AM observation was made of a gnat flying around in room [ROOM NUMBER]. There was also a soiled sheet sitting on top of the trashcan by the sink in the room. The sheet was covered with at least 9 gnats.Observation was made in room [ROOM NUMBER]. There were gnats flying around the toilet area.While on the Homestead unit frequent gnats were observed flying around in the hallway.On 3/10/26 at 8:35 AM observation was made of Resident #22 lying in bed. Empty plastic juice containers were on the bed tray table in front of the resident. Gnats were flying around Resident #22's chin. Staff #7 was called into the room, and she confirmed that gnats were sometimes present because staff did not remove the juice containers. On 3/10/26 at 10:11 AM Staff #11 (Maintenance Director) gave the surveyor a copy of the pest management sheet which documented that the pest control company last treated the Homestead unit on 2/17/26. There was no documentation about gnats in the unit, even though Staff #7 confirmed the problem.On 3/11/26 at 2:50 PM the Nursing Home Administrator and Director of Nursing were informed of the concerns.

Based on observation and interview, it was determined that the facility failed to ensure food was stored and prepared in a sanitary manner. This was evidenced by: (1) undated and unlabeled food items in the facility's kitchen refrigerators and freezers; (2) kitchen staff not wearing proper protective gear while preparing food for residents; (3) failure to label and date food items and monitor temperatures in all unit pantry refrigerators; and (4) water nesting on insulated plates and lids used to serve residents, as well as improper sanitization of kitchen sanitization buckets. These deficiencies were observed during the survey of the kitchen and have the potential to affect all residents.The findings include:Definitions:Tube feeding formula is a liquid mixture containing all the necessary nutrients-protein, carbohydrates, fats, vitamins, and minerals-that is delivered directly into the gastrointestinal tract via a feeding tube when a person cannot eat enough or has difficulty swallowing. Insulated plates and lids are food service equipment designed to be used together to maintain the temperature of prepared meals. They keep plates of food warm during transport from the kitchen to the facility units and while meals are being delivered to residents.Water nesting on plates refers to the presence of pooled or trapped water between stacked or inverted plates that were not allowed to fully air-dry after washing and sanitizing. This condition creates a potential for microbial growth and cross-contamination, as the plates are not maintained in a sanitary, dry manner prior to food service.Sanitization bucket - In commercial food service, a sanitization bucket is a container filled with an approved sanitizing solution used to wipe down and sanitize food contact and non-food contact surfaces. The solution must be maintained at the proper concentration, changed as needed, and the bucket must be stored in a designated location to prevent contamination.(1)On 08/19/2025 at 6:15 AM, this surveyor conducted the initial tour of the kitchen with the Dietary Manager (DM), who confirmed that she was responsible for overseeing the kitchen.On 08/19/2025 at 6:21 AM, this surveyor began the observation of the kitchen fridge and freezer. There is a sign attached to the door of the fridge that reads Everything Is To Be Dated and Labeled NO EXCEPTIONS! Remember to Clean As You Go!. There is a sign attached to the shelf inside fridge that reads Please discard all food that's more than 3 days old. There is also a sign outside the front of theOn 08/19/2025 at 6:26 AM this surveyor observed baked zucchini in the kitchen fridge that was dated 08/13/25. It was observed in the freezer section of the kitchen there was an unlabeled and undated opened package of meatballs. Pictures of the items were taken at this time. On 08/19/2025 at 6:52 AM, it was observed in the kitchen fridge that there were multiple dairy products found, sour cream with a date labeled 08/13/25, cheese labeled 08/13/25, and cream corn labeled 08/14. Pictures of these items were taken at this time. On 08/19/2025 at approximately 6:53 AM, this surveyor conducted an interview and observation with the DM. this surveyor observed with the DM the dairy products that were labeled 08/13 and 08/14. She confirmed that her expectation would be that these products should have been thrown out. On 08/19/2025 at 7:00 AM, this surveyor conducted an observation of the reach-in refrigerator. There is a sign on the front of the reach in refrigerator that states Everything Is To Be Dated and Labeled NO EXCEPTIONS! Remember to Clean As You Go!. Inside the reach in refrigerator there were 3 sandwiches that were labeled with the date 08/13. There were also several sandwiches that were unlabeled and undated. On 08/19/2025 at 7:01 AM, this surveyor observed on the kitchen's bulletin board a message that stated All food must be labeled with date and stating what is in the pan, after the 3rd day if you are not using the food, you need to discard it.On 08/19/2025 at 7:06 AM, this surveyor made the DM aware of the undated and unlabeled sandwiches in the fridge, also made her aware of the date of the sandwiches. She confirmed understanding that this is a concern and reported that these sandwiches would get thrown away. (2)On 08/27/2025 at 1:52 PM, while in the kitchen, this surveyor observed Dietary [NAME] #42 not wearing a beard covering while preparing food. Shortly afterward, Dietary [NAME] #42 was observed retrieving and putting on a beard covering.On 08/28/2025 at 1:54 PM, this surveyor conducted an interview with Dietary [NAME] #42. He confirmed that he was required to wear a beard covering when preparing food.On 08/28/2025 at approximately 2:00 PM, this surveyor conducted an interview with the DM and informed her that Dietary [NAME] #42 had been observed not wearing a beard covering while preparing food. The DM acknowledged the concern, apologized, and subsequently spoke with Dietary [NAME] #42 to remind him that beard coverings must be worn while handling food. (3)On 08/27/2025 at 10:24 AM, this surveyor observed the Homestead Unit pantry refrigerator and freezer and took photographs of the contents. A sign posted on the exterior stated that the refrigerator was to be cleaned out every Monday and that all food must be labeled with the date and name. In the freezer, there was one plastic container of ice cream that was undated and unlabeled. Inside the refrigerator, there were three plastic containers of food, all undated and unlabeled. Several condiment containers were also present without labels or dates. No temperature log was posted on the refrigerator to document the temperature of the unit.On 08/27/2025 at 2:26 PM, this surveyor observed the pantry refrigerator and freezer on the Wye Oak Unit and took photographs of the contents. A temperature log for June 2025 was posted on the exterior of the refrigerator; however, no additional temperature logs were present. A sign posted on the front of the refrigerator stated the unit was for resident food only and not for staff use. The sign further outlined requirements for labeling, including the resident's name, room number, and date of placement for all opened or prepared food items. The sign stated that prepared food, such as sandwiches or pizza, could only be stored for 48 hours before being discarded, and that perishable undated items were to be discarded. Unopened items could be kept in accordance with the manufacturer's expiration date.Inside the freezer, there were five previously opened bottles of water that were undated and unlabeled. A brown substance was observed across the bottom surface. A glove that had been filled with water and frozen was present, along with paper towels adhered to the bottom surface as well. On the freezer door shelf, there were two pints of ice cream that were undated. A brown substance was also noted sprayed along the interior side of the freezer door.Inside the refrigerator, there was one plastic container of noodles, multiple opened plastic bottles, and several opened jars of pickles-all undated and unlabeled. Additional opened condiments were also present without dates or labels. Two opened bottles of Sprite were labeled with a resident's name but lacked a room number or date. A bag of oranges was observed without a date or label; several oranges inside the bag were spoiled. An opened container of iced tea and a small plastic container of fruit were present, both undated and unlabeled. A plastic bag labeled with a resident's name, room number, and date of 07/02/2025 contained spoiled grapes, bananas that were black with mold, and a container of cottage cheese. Another plastic bag, undated and unlabeled, contained multiple food items wrapped in aluminum.On 08/27/2025 at 2:41 PM, this surveyor conducted an observation of the refrigerator and freezer on the Chesapeake Unit and took photographs of the findings. A sign was posted on the front of the refrigerator indicating that the unit was to be cleaned out every Monday and that all food must be labeled with the resident's name and date. A temperature log for the refrigerator was present on the exterior; however, there was no section for tracking freezer temperatures. After looking inside the freezer, it was discovered that the freezer thermometer was positioned in the back, facing away, making it difficult to read.Inside the freezer, a brown paper bag contained food labeled with a resident's name and room number but lacked a date. A plastic bag contained Italian ice, labeled with a room number but no date. A plastic bag held two packaged ice cream sandwiches, labeled with a resident's name but missing a date. Inside the refrigerator, an opened reusable water bottle with a straw was present, undated and unlabeled. An opened bottle of Sprite was labeled with the resident's name and room number but lacked a date. An opened bag of salami was labeled with the resident's name but not dated. An opened container of blue cheese was labeled with the resident's name but missing a date.On 08/28/2025 at 9:25 AM, this surveyor observed the pantry refrigerator and freezer on the Mill Landing Unit and took photographs of the contents. A temperature log for June 2025 was posted on the exterior of the refrigerator; however, no additional temperature logs were present. A sign posted on the refrigerator indicated it was to be cleaned out every Monday and that all food must be labeled with a date and name.Inside the refrigerator, there were several opened or prepared food items that were undated and unlabeled. These included an open tube feeding formula container, a bottle of Caesar dressing, an opened container of nonfat Greek yogurt, a sandwich wrapped in paper, half of a sandwich wrapped in plastic, a plastic bag with food wrapped in aluminum foil, a plastic container of fruit, a plastic container of a dessert, and a plastic Tupperware container with food. In addition, there was an opened bottle of Coke and a Royal Farms bag that were labeled with a resident's name but not dated. A brown substance was observed on the interior door shelf, and the pull-out drawer at the bottom contained a brown residue adhered to the surface. Inside the freezer, there was a container of ice cream labeled with a resident's name but missing a date.On 08/28/2025 at 9:50 AM, this surveyor conducted an interview with the part-time Dietary Director. When asked to accompany the surveyor to observe the unit pantries, he stated that he did not oversee the pantries and that their management falls under nursing staff. He further indicated that nursing staff are responsible for monitoring the temperature logs.On 08/28/2025 at 9:51 AM, this surveyor conducted an interview with Licensed Practical Nurse (LPN) #1 regarding the management of the unit pantry refrigerators. She reported that aides, nursing staff, and housekeeping personnel are responsible for monitoring the refrigerators and their temperature logs. She further stated that the 11:00 PM to 7:00 AM nursing shift handles both monitoring the temperature logs and disposing of expired food and cleaning the refrigerators.On 08/28/2025 at 9:54 AM, this surveyor conducted an interview with LPN #26 regarding monitoring of the unit pantry refrigerators. LPN #26 reported that the 11:00 PM to 7:00 AM nursing shift is responsible for checking the refrigerators and maintaining the temperature logs. Environmental Services (EVS) cleans the refrigerators once a week, although he could not recall which day. LPN #26 also reported working the 11:00 PM-7:00 AM shift the previous day.On 08/28/2025 at 10:09 AM, this surveyor observed the Mill Landing unit refrigerator with LPN #26. The surveyor noted that the temperature log had last been completed in June 2025 and pointed out multiple undated and unlabeled food items. LPN #26 acknowledged the concerns and began reviewing the refrigerator to identify items to discard. On 08/28/2025 at 10:23 AM, this surveyor conducted an interview with LPN #27. She reported that she had worked at the facility for the past two months as the Unit Manager for both the Chesapeake and Wye Oak units. When asked who was responsible for maintaining the unit pantries, she stated that she was not entirely sure but believed the nurses completed this task while working. She explained that when she worked on the floor, typically during the 7:00 AM to 3:00 PM shift, she attempted to complete the refrigerator temperature logs. She acknowledged that this task had not been completed on her most recent shift. She further stated that she believed the dietary department was responsible for cleaning out food items from the refrigerators but would need to verify with administration to be sure. On 08/28/2025 at 10:34 AM, this surveyor observed the Chesapeake Unit refrigerator with LPN #27. During the observation, this surveyor identified concerns that no freezer temperatures were being logged and that the thermometer inside the freezer was positioned at the back, facing away, making it difficult to read when the door was opened. Additional concerns were noted regarding multiple opened, undated, and unlabeled food items in the refrigerator and freezer, despite the posted sign on the door requiring all items to be both labeled and dated. LPN #27 acknowledged these concerns and reported that corrective action would be taken immediately. On 08/28/2025 at 10:44 AM, this surveyor conducted an interview with the Administrator regarding the maintenance of the unit pantry refrigerators. The Administrator reported that Environmental Services (EVS) was responsible for cleaning out the refrigerators once a week on Mondays, and that nursing staff were responsible for completing the temperature logs and labeling and dating food items. At this time, the Administrator was made aware of the surveyor's concerns that staff had provided multiple and inconsistent responses regarding responsibility for cleaning, temperature recording, and labeling of food. Additional concerns were raised that the refrigerators and freezers were not being properly monitored, that multiple items were either undated, unlabeled, or both, and that spoiled food had been found in the Wye Oak Unit refrigerator.The Administrator acknowledged the concerns and stated she believed this represented an education issue and a breakdown in the system. She reported that education would begin immediately, and at that time she began contacting EVS staff to instruct them to clean out the refrigerators on all units. She also stated she would meet with the Unit Managers to educate them on ensuring that temperature logs are consistently updated. (4)On 08/29/2025 at 10:51 AM, during a review of the kitchen, this surveyor observed and photographed several stacks of insulated plates and lids that were visibly wet, with evidence of water nesting.On 08/29/2025 at 10:58 AM, this surveyor made the part-time Dietary Director aware of this concern. He acknowledged the issue.On 08/29/2025 at 11:00 AM, this surveyor requested that the part-time Dietary Director test the concentration of the sanitization buckets in use.On 08/29/2025 at 11:05 AM, this surveyor observed the part-time Dietary Director test all three sanitization buckets with the appropriate test kit. The results showed that none of the buckets met the required concentration for proper sanitization. The part-time Dietary Director stated that all sanitization buckets needed to be changed.On 08/29/2025 at approximately 11:08 AM, this surveyor observed that the sanitization buckets were replaced and re-tested by the part-time Dietary Director. At that time, all three buckets met the required concentration for proper sanitization.On 08/29/2025 at approximately 1:00 PM, this surveyor was provided documentation by the part-time Dietary Director of a rack he intended to purchase that would allow insulated plates and lids to air dry, thereby preventing wet nesting and the potential for bacterial growth.

Based on observations, interviews and record reviews, it was determined that the facility failed to use appropriate infection control practices such as 1) improper storage of clean linens 2) improper storage of urine specimen 3) improper storage of leftover pudding inside the medication cart and 4) failure to implement enhanced barrier precautions for residents with pressure ulcers. This was evident for 1) 1 of 1 linen cart 2) 1 of 4 medication storage refrigerators 3) 2 of 10 medication carts and 4) 2 of 2 (Residents #12 and #116) residents with wound sampled during the recertification survey.The findings include: 1) On 8/19/2025 at 6:12 AM, during an initial tour of the facility, the surveyor observed a cart in the hallway with exposed clean linens, with its cover flipped back. On 8/19/2025 at 6:18 AM, the surveyor informed Registered Nurse (RN #20) about the concern, and he/she acknowledged to cover the cart. On 8/19/2025 at 6:25 AM, a follow-up inspection was done and found that the linen cart remained uncovered. On 8/19/2025 at 6:50 AM, The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were informed of this concern. 2) On 8/20/2025 at 12:01 PM, a urine sample for Resident #24 was found in the medication refrigerator in the Homestead unit storage room, together with various insulin pens. The finding was witnessed by Licensed Practical Nurse (LPN #1 and #16). LPN #1 removed the urine sample from the medication room. LPN #16 confirmed that the urine sample should have been placed in the soiled utility refrigerator. 3) On 8/20/2025 at 12:08 PM, during an inspection of Homestead medication Cart #1, the surveyor observed a leftover pudding inside a maroon plastic bowl with white plastic lid dated 8/19 for 7-3 shift inside the medication cart. Certified Medication Aide (CMA #5) witnessed the finding and removed the pudding from the cart. On 8/20/25 at 12:15 PM, another leftover pudding was found inside the medication Cart #2 of Wye Oak Unit, also dated 8/19 for 7-3 shift. CMA #38 was informed and removed the bowl from the cart. On 8/20/2025 at 12:48 PM, the DON was notified of the findings and stated that staff education would be provided. 4) Per Centers for Disease Control (CDC), Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). A pressure ulcer, also known as a bed sore or decubitus ulcer, is a localized area of skin damage that develops when prolonged pressure or shear forces disrupt blood flow to the tissues resulting in damage to the underlying tissue. Pressure ulcers are staged based on their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). On 8/20/2025 at 9:09 AM, a review of Resident #12's wound evaluation dated 8/5/25 confirmed the presence of a Stage 3 Pressure ulcer of the sacrum which was acquired on 1/1/25. On 8/21/2025 at 7:06 AM, an observation of Resident #12's room showed no EBP sign or PPE cart outside the room. On 8/21/2025 at 7:57 AM, in an interview with Licensed Practical Nurse #16, he/she stated that an EBP was utilized for residents who have external catheters, wounds and tube feedings. He/she added that the staff are expected to wear PPE when giving direct care. On 8/21/2025 at 8:58 AM, LPN #26 stated that EBP is indicated for protection from infection. He/she stated that it is used for residents with dialysis access and intravenous(IV) site. On 8/21/2025 at 10:43 AM, in an interview with the Infection Control Preventionist (ICP) and Staff Educator, she revealed that EBP was used for residents with wounds, foley catheter, IV and drains. She stated that the nurses were expected to enter the EBP orders in the medical record and ensure that the EBP signs and PPE carts were placed in a timely manner. She added that she conducted rounds and audits. The ICP Nurse was informed of the concerns and stated that she will ensure that an EBP sign and PPE cart would be placed for Resident #12. On 8/25/2025 at 10:30 AM, a review of Resident #12's medical record revealed no evidence of an EBP order. However, the facility's EBP policy revised on 3/26/24 stated that An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds such as pressure ulcer. On 8/26/2025 at 7:43 AM, the DON confirmed the absence of the EBP order in the medical record and acknowledged this concern. She indicated that staff in-service training on this matter would be provided. 5. During a Medical Record review on 8/25/25 at 8:35 AM it was discovered that Resident #116 was being treated for a Stage 3 Pressure Ulcer and had no order for Enhanced Barrier Precautions (EBP). During an observation of the room for Resident #116 on 8/28/25 at 2:22 PM it was discovered that there was no Enhanced Barrier Precaution sign or EBP supplies near the resident's room. During an interview with Unit Manager #4 on 8/28/25 at 3:07 PM she confirmed that Resident #116 had a pressure ulcer but didn't believe it was severe enough to require EBP and reported she would find out. During an observation of the room for Resident #116 on 9/02/25 at 9:00 AM it was discovered there was now an Enhanced Barrier Precautions sign and EBP supplies at the resident's doorway. During a medical record review on 9/02/25 at 9:37 AM it was discovered that there was an order placed on 8/28/25 at 4:31 PM for EBP that stated, Enhanced Barrier Precautions: Everyone must wear gloves and a gown for the following High-Contact resident care activities: Dressing, Bathing/showering/transferring, changing linens, Providing Hygiene, changing briefs or assisting with toileting. Wound Care: Any skin opening requiring a dressing. During an interview with the Director of Nursing (DON) on 9/02/25 at 11:06 AM she advised that all Residents with a pressure ulcer should be on EBP no matter how severe. She confirmed that Resident #116 should have been on EBP. She reported the Infection Preventionist is looking into ensuring EBP is implemented when it's required. During a review of the Enhanced Barrier Precautions Policy 9/02/25 at 1:48 PM it stated that An order for enhanced barrier precautions will be obtained for Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers). The policy continued with Implementation of Enhanced Barrier Precautions: Make gowns and gloves available immediately near or outside of the resident's room and ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room.) During a follow up interview with the Unit Manager on 9/02/25 at 3:02 PM she reported that Resident #116 should have been on EBP due to having a pressure ulcer and reported anyone that has a wound that is staged gets an isolation bin for EBP.

Based on observation and interviews, it was determined that the facility failed to ensure there was an effective pest control program for the kitchen. This was evident during the survey of the kitchen. This deficiency has the potential to affect all residents.The findings include: On 08/19/2025 at 06:32 AM, this surveyor conducted an interview with the Dietary Manager regarding pest concerns in the kitchen. She reported that the primary issue observed in the kitchen was the presence of flies.On 08/29/2025 at 10:51 AM, this surveyor observed five flies that were flying above the food preparation area where Dietary [NAME] #44 was preparing crab cakes for the residents. On 08/29/2025 at 10:58 AM, this surveyor informed the part-time Dietary Director of the concerns regarding the flies. He confirmed his understanding of the issue.

Based on observations and interview it was determined that the facility failed to ensure Residents were provided a dignified existence. This was evident for 14 (Resident #116, #84, #12, #91, #107, #57, #36, #14, #31, #21, #61, #115, #155 & #40) out of 38 Residents observed for dining during the recertification survey.The findings include: 1. During an interview with Resident #116 in his/her room on 8/19/25 at 1:58 PM a rapid knock occurred on the closed door, the door immediately opened and Geriatric Nursing Assistant (GNA) #3 entered the room. She yelled out, It's me and continued to the roommates (Resident #84) side of the room. Resident #84 was not in the room at this time. When Resident #116 was asked who the GNA was that entered the room he/she reported they had seen her before but didn't remember her name. During an interview with GNA #3 on 8/19/25 at 2:13 PM she reported that she went to the roommate's side of the room to get something for Resident #84. She said she should have identified herself when entering the room of Resident #116. During an interview with the Director of Nursing on 9/02/25 at 11:14 AM she reported that the expectations are for staff to provide residents with privacy. Staff members should introduce themselves when they enter a resident's room and ask if it's okay to come in. During a review of the facility's Resident Rights Policy on 9/02/25 at 2:22 PM it was revealed that the Resident has a right to personal privacy and includes accommodations, medical treatment, written and telephone communications, personal care, visits. 2. During an observation of Resident #116 on 8/28/25 at 2:23 PM he/she was seen sitting near the nursing station in a wheelchair. He/she asked Geriatric Nursing Assistant (GNA) #45 Can you take me to my room? I've got to pee bad! GNA didn't respond and walked around the backside of the resident. Resident #116 then yelled, I've got to go! GNA #45 then told the resident to hold on. Resident #116 asked, How can I hold on? and appeared anxious. GNA #45 walked down a separate hallway. During an observation of Resident #116 on 8/28/25 at 2:28 PM he/she started yelling for someone to take him/her to their room stating, I really have to go! During an observation of Resident #116 on 8/28/25 at 2:32 PM he/she was yelling for help to return to his/her room. GNA #45 returned, she didn't say anything to Resident #116, she got behind him/her and started pushing them to their room. During an observation of Resident #116 on 8/28/25 at 2:34 PM resident is in his/her room with GNA #45 and was unable to find a urine receptacle. Registered Nurse (RN) #13 entered the room to assist. During an observation of Resident #116 on 8/28/25 at 2:36 PM the resident was anxious and still waiting for a urine receptacle. The resident was yelling Hurry please! GNA #45 had left the room and was seen walking unhurriedly by the nursing station. RN #13 remained with the resident. During an observation of Resident #116 on 8/28/25 at 2:39 PM RN #13 told the resident that they were out of urine receptacles on the unit, so GNA #45 went to get one. During an observation of Resident #116 on 8/28/25 at 2:40 PM he/she was anxious and yelling, I've got to go bad! RN #13 offered him/her to use the commode and Resident #116 reported, No, I can't use that! During an observation of Resident #116 on 8/28/25 at 2:41 PM resident was anxious, Where did she go to get that thing? I need it! Where did she go to get it? RN #13 told him/her Central Supply and reported she will go see what was going on. RN #13 left the room. During an observation of Resident #116 on 8/28/25 at 2:44 PM the resident rolled out of his/her room in a wheelchair. The resident appeared anxious, breathing heavily and holding his/her groin area. Resident #116 was looking down the hallway for assistance. RN #13 was seen coming toward the Resident's room with a urine receptacle. During an interview with RN #13 on 08/28/2025 at 2:52 PM she reported she had asked GNA #45 to get a urine receptacle from central supply and it was taking so long, so she went to go get it. She reported the GNA told her she had to go check on her residents. RN #13 advised she didn't know why the resident didn't already have a urine receptacle. During an interview with GNA #45 on 8/28/25 at 2:54 PM she reported she wasn't looking for a urine receptacle, she stated she had to go check on my people and advised I didn't have him/her today when referring to Resident #116. During an interview with Unit Manager #4 on 8/28/25 at 3:07 PM she reported it is expected that assistance be provided to all residents. It was unacceptable to state that it's not my resident. All of us are here to help all residents. 3. Resident Requiring Assistance with Feeding - A resident who is unable to independently consume meals and requires staff assistance for the physical act of eating, which may include hand-over-hand guidance, cutting or preparing food into manageable portions, or direct feeding. This assistance is provided to ensure the resident receives adequate nutrition and hydration in accordance with their individualized care plan. On 08/28/2025 at 12:21 PM, this surveyor observed the distribution of lunch to residents on the Homestead Unit. At 12:29 PM, Resident #84 was observed seated at a table with other residents. Resident #84 did not have a meal tray in front of them, while all other residents at the table were actively eating. On 08/28/2025 at 12:31 PM, this surveyor interviewed Geriatric Nursing Assistant (GNA) #28 regarding the absence of a tray for Resident #84. GNA #28 reported that Resident #84 is a feeder, requiring staff assistance with eating. She explained that she had been instructed to ensure all trays were distributed to other residents before beginning to serve and assist residents who require help with feeding, as staff were expected to focus first on tray distribution. This surveyor expressed concern that Resident #84 was left without a meal while observing other residents eat, which represented a potential dignity issue. Based on observation and interview, it was determined that the facility failed to protect and value the resident's private space by failing to knock prior to entering a resident's room. This was evident for 1 (Resident #12) of 13 residents reviewed for dignity during the recertification survey. 4. On 8/19/2025 at 9:18 AM, while the surveyor was interviewing Resident #12, Geriatric Nurse Assistant (GNA #17) abruptly opened the resident's door without knocking. He/she stated the need to collect the breakfast trays. Resident #12 confirmed that staff frequently enter their room without knocking. On 8/27/2025 at 9:46 AM, in an interview with Licensed Practical Nurse (LPN #18), he/she stated that the staff were expected to knock and introduce themselves prior to entering residents' room. On 8/27/2025 at 9:56 AM, the Director of Nursing (DON) was informed of this concern and acknowledged the issue. 5) During an observation on 08/24/25 at 12:04 PM this Surveyor observed the lunch meal cart arrive at the Homestead nursing unit. The staff were observed delivering lunch trays to Residents in the dining room and Resident rooms. During the lunch service Residents #91, #107, #57, #36, #14, #31, #21, #61, #115 & #155 were observed sitting at tables in the dining room watching other residents eat their lunch. The residents who received their lunch trays ate their food and their trays were removed by staff and placed back on to the meal cart. Residents #91, #107, #57, #36, #14, #31, #21, #61, #115 & #155 remained seated at the dining room tables still waiting to be served their lunch. During an interview conducted on 08/24/25 at 12:47 PM, Registered Nurse (RN) #13 confirmed that there is a delay between meal carts which resulted in several Residents not receiving their meals with all the other Residents on the Homestead Nursing Unit. During an interview conducted on 08/24/25 at 1:00 PM this Surveyor discussed with the Nursing Home Administrator (NHA) the dignity concern for the Residents who had not received their lunch with all the other Residents. These Residents had to watch the other Residents eat their meal while waiting for over an hour to receive their meal. The NHA stated that she would investigate the delay. The NHA quickly returned and stated the second meal cart is entering the nursing unit now at 1:05 PM. This Surveyor expressed the concern that there was an one hour delay between the meal services. This Surveyor observed the second meal cart arrive at the unit at 1:05 PM. Staff retrieved the meal trays and delivered the trays to Residents #91, #107, #57, #36, #14, #31, #21, #61, #115, & #155. 6) During an interview with the Resident Council conducted on 08/28/25 at 3:00 PM, the Resident Council members unanimously stated that they had been restricted from using the public restrooms located off of the lobby of the facility. During an interview with the NHA conducted on 09/02/25 at approximately 8:30 AM, the NHA stated that the public bathrooms located off of the lobby were for the visitors and staff only. She stated that when the Residents had access to the public bathrooms the bathrooms would become dirty. Therefore, she restricted the Residents from using the public bathrooms. 7) During the initial tour of the facility conducted on 08/19/25 at 6:12 AM, this Surveyor observed Geriatric Nursing Assistant (GNA) #24 without a name badge. When asked if she had a name badge she stated yes. This Surveyor observed the GNA reach into her purse, retrieved her name badge and placed it on her uniform. When asked what the policy was for name badges the GNA replied we are expected to always wear our name badge. During a random observation of the Homestead Nursing Unit conducted on 08/24/25 at 11:47 AM, this Surveyor observed GNA #12 without a name badge. When asked if he had a name badge the GNA responded yes, it is in my car. The GNA returned approximately 10 minutes later and showed this Surveyor his badge. The GNA apologized and stated he knows he should have been wearing his name badge. During another random observation conducted on 08/24/25 at 12:43 PM, this Surveyor observed GNA #12 inside of Resident room # 315 on his personal cell phone. The GNA ended his call and exited the room. When asked if using a personal cell phone allowed, the GNA responded no but he needed to check on something. 8. On 08/20/2025 at 8:13 AM observed Resident #40 in bed receiving G-tube feeding. observed oral secretions drooling from his/her mouth onto his/her gown. The resident's oral cavity was noted to be poorly maintained, with dry yellowish mucous build-up on the tongue. On 08/20/2025 at 8:20 AM observed in bed with dry yellowish mucous and secretions noted on his/her gown, particularly on the left side of the chest. 08/20/2025 9:00 AM observed resident lying in bed on his/her left side, with poor hygiene. Oral secretions were noted drooling from his/her mouth while the G-tube feeding was running. 08/20/2025 10:00 AM observed resident lying in the same position with build-up dry yellowish mucous on the tongue and drooling secretions on the left side of the chest. 08/20/2025 10:03 AM the surveyor called the Director of Nursing (DON) to Resident #40's room and asked about the expectation for the resident's care. The DON stated that the resident required mouth care. When asked how often staff are expected to provide mouth care, the DON stated, Every shift. When asked about the expectation for turning and repositioning, the DON stated that residents are to be turned and repositioned every two hours. The surveyor brought the above concerns to the DON's attention, and she acknowledged receipt, stating, I am going to educate the staff. On 08/24/2025 at 1:05 PM, during rounds in room [ROOM NUMBER], the surveyor observed Resident #40 lying in bed with his/her mouth open. Dry, thick yellowish mucous was noted in her mouth, and her lower lip appeared dry. Licensed Practical Nurse (LPN) #14 and Registered Nurse (RN) #20 were present, confirmed the observation, and acknowledged receipt of the concern. On 08/24/2025 at 1:15 PM, the surveyor informed the Administrator of the concern regarding Resident #40's oral condition. The Administrator stated, Yes, it was brought to my attention on Friday by the DON. I will follow up.

Based on observation, interview, and record review it was determined the facility failed to provide supervision to a cognitively impaired resident with a history of a fall with fracture. This was evident for 1 (#16) of 35 residents in the [NAME] Unit during a complaint survey. As result of these findings an Immediate Jeopardy was called at 4:45 PM on 3/11/25. The facility submitted a plan to remove the Immediacy on 3/11/25 at 8:30PM. The survey team verified completion of the plan on 3/14/25 at 11:08 AM with a compliance date of 3/13/25. The findings include: On 3/11/25 at 2:22 PM in the [NAME] Unit, which is a secured memory care unit, observation was made of Resident #16, who had a history of a fall out of Geri-chair on 8/1/24 at 4:30 PM, that resulted in an acute mildly displaced fracture of the tip of the nasal bones, trying to get out of a Geri-chair that was located in the back of the common area of the unit. There were no nursing staff visible on the unit. The only staff member was Housekeeper (HK) #25 who was sweeping the floors. HK #25 saw the resident and ran over to him/her and attempted to talk the resident into staying in the chair. The housekeeper then walked up to the nurse's station and was looking for staff. HK #25 walked down the opposite hallway calling for staff while the surveyor stood at an unlocked and unattended medication cart observing Resident #16. At that time Resident #16 had his/her legs half way out of the chair. The surveyor ran and stood in front of the Geri-chair and encouraged the resident to sit back in the chair. HK #25 continued to look for staff and could not find anyone. HK #25 returned to the common room and offered to watch Resident #16 until nursing staff came back to the area so the surveyor could stand by the unlocked medication cart until licensed staff could secure the cart. Cross Reference F761 On 3/11/25 at 2:29 PM the AIT (Administrator in Training) came back to the unit and walked up and saw the medication cart and attempted to lock it while the surveyor stood there. At that time the surveyor asked where the nurse on the unit was. The AIT said he would get the unit manager (UM). He was asked again where the nurse on the unit was, and he said I'll get the unit manager. At 2:30 PM the unit manager walked up to the surveyor and the surveyor asked where the nurse on the unit was. UM #28 stated the nurse on the unit left early and the UM was responsible for 2 units. It was revealed that UM #28 was doing patient care on another nursing unit at the time. The surveyor informed UM #28 about Resident #16 trying to get out of the Geri-chair. UM #28 asked where the nursing assistants were. At that time geriatric nursing assistant (GNA) #5 walked into the common area and was told to watch Resident #16. A second GNA, GNA #15 came up the hall and said she was in the middle of changing a resident while doing last rounds and had the bed in a high position and could not leave the resident. A third GNA, GNA #29 was in a resident room doing patient care. Review of Resident #16's medical record revealed the resident had diagnoses that included ataxia, bipolar disorder, unspecified dementia with agitation, and Wernicke's encephalopathy. According to the National Institute of Health (NIH), Wernicke's encephalopathy is traditionally associated with chronic alcohol abuse and characterized by some combination of ataxia (impaired coordination, balance, and movement), ophthalmoplegia (paralysis or weakness of eye muscles), and altered mental status. As stated above, Resident #16 had a fall on 8/1/24 that resulted in injury. Preceding nursing notes dated 7/27/24 documented that Resident #16 had ongoing behaviors that included trying to climb on the floor, sitting on floor, and scooting along on buttocks on the floor. A 7/31/24 health status note documented, increased behaviors, patient lowers self to the floor and constantly attempts to get out of [his/her] chair. An 8/1/24 at 4:50 PM note documented that the resident had a witnessed fall by staff. The resident was trying to get up from the chair and fell on the floor face down. A subsequent note from the Nurse Practitioner (NP) on 8/2/24 documented an acute mildly displaced fracture of the tip of the nasal bones. Nursing notes that lead up to the observation on 3/11/25 documented on 2/26/25 at 10:00 PM that Resident #16 had an episode of psychosis that was reported on 2/21/25 where the resident pulled a dresser down and at some point hit his/her nose which resulted in, slightly distal of the previous fracture without significant fracture fragment displacement. A 3/3/25 note written by the NP documented that the resident had agitation and restlessness and was sitting up in a chair in the common room, rocking back and forth and trying to climb out of the chair. The NP increased the medication Seroquel to 200 mg. twice a day. Seroquel is an antipsychotic medication. A 3/10/25 at 1:36 PM nurse's note and a 3/11/25 at 1:31 PM nurse's note documented that Resident #16 was combative with care and smearing feces on self and the bed. Observation was made in the morning on 3/11/25 at 9:45 AM of Resident #16 in his/her room wearing a hospital gown. Resident #16 had just flipped over the tray table that had a breakfast tray on top. There was fluid and food on the floor and the mattress on the floor. Resident #16 was sitting on the edge of the bed rocking back and forth. Resident #16 was seen by another surveyor smearing feces on the bed and wall. After this intervention the facility did not increase staff supervision of Resident #16. Review of Resident #16's care plan, at risk for falls r/t Gait/balance problems, Psychoactive drug use and impulsiveness, failed to have specific resident centered interventions in place, for this cognitively impaired resident, about monitoring the resident while in a geri-chair. Cross Reference F657 Surveyor and Housekeeper intervention prevented Resident #16 from getting out of the Geri chair without assistance and prevented the other cognitively impaired residents on the dementia unit from accessing the unlocked medication cart. After the Immediate Jeopardy was called the facility submitted a plan to remove the immediacy. The facility took the following actions to address the concerns and prevent any additional residents from suffering an adverse outcome: a) Resident #16 was provided one on one supervision until cleared by Behavioral Health and the medication cart was immediately locked on the unit. b) The staff educator conducted an audit on all falls residents who were cognitively impaired and at risk for falls to ensure that resident specific interventions were in place. Licensed nurses and CMAs were educated to ensure medication carts were secured on all units when unattended. c) The staff educator will educate all licensed nurses and CMAs on medication cart safety. d) Staff educator will educate all licensed staff to ensure common areas are supervised when residents are present in common area. e) Staff educator will educate all nurses, GNAs and CMAs to ensure that residents' specific interventions are in place for residents who are at risk for falls. f) Any licensed nurses, CMAs or GNAs who are currently on leave for medical, vacation, FMLA, or sickness will be educated prior to returning to work g) All med carts will be audited 2 times per day for 2 weeks and 10 times per month for 4 months h) All common areas will be audited to ensure supervision of residents is present 4 times per day for 2 weeks, then 10 times per month for 4 months. i) All cognitively impaired residents at risk for fall will be audited to ensure their resident specific interventions are in place 2 times a week for 4 weeks then monthly times 4. j) All residents will receive a falls evaluation on admission, quarterly and yearly by MDS. k) All results from the audits will be presented to the QAPI team monthly to be reviewed and revised monthly for 4 months.

3) On 3/10/25 at 8:16 PM a review of facility reported incident MD00207981 was conducted, and it alleged that verbal abuse towards Resident #18 was overheard from a unit manager and a wound nurse on 7/23/24 at 10:30 AM. Licensed Practical Nurse (LPN) #23 was overheard telling Resident #18 that he/she needed to get up and also told Resident #18 not to dismiss her. A written statement from Nurse Practitioner (NP) #68 documented that LPN #23 stated to the resident, if you don't get out of this bed and move your arms and legs you will never walk again. Resident #18 responded, okay. LPN #23 responded by saying, you don't answer me like that; that's dismissing me, and I won't be dismissed. A written statement from the previous unit manager (UM) #31 documented, this writer observed [name of LPN #23] being verbally aggressive towards a resident. She was telling the resident [he/she] needed to do more for [him/herself]. When the resident said okay, nurse was very rude telling [him/her] that [he/she] does not get to dismiss her, saying okay is being dismissive to the nurse. I feel she was very rude to the resident. A written statement from Resident #18 documented, nurse came in and told me I needed to more for myself. When I said okay, she looked at me weird and told me not to dismiss her. The facility documented that LPN #23 admitted saying the word dismissive to Resident #18. Review of a psychiatric visit dated 7/23/24 documented Resident #18 had a history of insomnia, depression, and anxiety. The note documented that Resident #18 reported being upset due to an incident that happened with his/her nurse. Resident #18 reported feeling sad about how the nurse spoke to the resident, however Resident #18 was unable to remember the nurse's exact words or the name of the nurse. Resident #18 reported to the psychiatrist that the nurse's words affected his/her mood that day. Review of LPN #23's personnel file revealed the LPN was terminated from the facility on 7/23/24 and reported to the Board of Nursing. On 3/11/25 at 1:53 PM an interview was conducted with Staff #31. Staff #31 stated the nurse was telling Resident #18 that the resident needed to get up for their own good and the nurse was nasty about it, and it made the resident feel uncomfortable and really bad. Staff #31 stated the resident was in tears and that is why Staff #31 reported it to the Director of Nursing (DON). Staff #31 stated she did not say anything to LPN #23 because, she was not very people friendly. The Nursing Home Administrator was informed on 3/18/25 at 5:15 PM. Based on review of a facility-reported incident, medical record review, and interviews, it was determined that the facility failed to keep vulnerable residents on the dementia unit free from physical abuse, which resulted in harm to the residents. This was evident for 3 out of 44 residents (#14, #24, and #18) reviewed during a complaint survey. Findings include: 1a) On 3/11/25 at 10:22 AM, a review of the medical record was conducted for Resident #15. Resident #15 had a history of refusing medication except for seizure medications. He/She takes medications when he/she feels like it. Resident #15 resided in the dementia unit. His/her BIMs (Brief Interview for Mental Status) score was 11/15, indicating he/she had some memory loss. Resident #15 was able to communicate with staff. Resident #15 preferred to be by themselves and did not like other residents entering his/her room. Medical record review conducted for Resident #14 on 03/13/25 at 2:52 PM revealed Resident #14 was admitted to the facility with a diagnosis of dementia, restlessness, and agitation. Further review revealed a progress note that documented on 4/3/24 at approximately 2:30 AM the staff heard yelling and screaming down the hall. Staff observed Resident #14 being punched by Resident #15 in the hallway. The aide observed blood coming from Resident #14 ' s mouth. A red mark was on the face of Resident #14 and a scratch was observed behind Resident #14 ' s left ear. Police were called and responded; however, Resident #15 would not speak to the police. A psych evaluation was ordered for Resident #15. A psychiatric evaluation was conducted on 4/18/24. Resident #15 stated, I do not belong here. When the crazies leave me alone I am ok. He/she denied all altercations but refused to take medications. In addition, on 7/28/24, Nurse Staff #70 on the unit heard yelling and screaming and went to see what was going on. Resident #14 was hit by Resident #15 for going into his/her room. Police were called and responded. Resident #14 was taken to the hospital for evaluation, received stitches, and was sent back to the facility. 1b) On 3/14/25 at 10:00 AM, a medical record review was conducted for Resident #24. Resident #24 had a BIMs score of 99, meaning he/she rarely understands. On 4/13/24, staff saw Resident #24 leaving the room of Resident #15. Resident #24 had a red mark on his/her face after leaving the room. Police were contacted and responded. Resident #15 admitted to hitting all the residents, stating, They were in my room, and I don't like that. An interview was held with the Medical Director, Staff #9, and the Nursing Home Administrator on 3/13/25 at 9:27 AM. The Medical Director stated, I know him/her very well. He/she had a fall resulting in a head injury prior to coming to the facility. I am aware of at least three residents that he/she struck and I reviewed the incidents that happened at the facility. He/she didn't take his/her psych medicine, he/she only took his/her seizure medication. After the first incident I would have expected a psych eval, behavior medication. I would talk to him/her about their meds and do a meds evaluation. I would care plan his/her behaviors. After the second or third time, depending on the circumstances, I would look for alternative settings. Is this the right place for him/her? Looking in retrospect, he/she probably should have had interventions put in place and we could have looked at a more appropriate setting. It was discussed in a risk meeting. There should have been interventions put in place. On 3/13/25 at 9:47 AM, the Medical Director stated, On 4/3/24, we spoke to the Nurse Practitioner (NP) about alternative placement. There was another incident on 06/07/24 and the resident remained in the facility. On 7/30/24 another resident was struck and Resident #15 remained in the facility. The Advanced Practice Registered Nurse (APRN) who conducted the psych evaluation on 4/18/24 revealed, Resident is not a danger to self or others but would benefit from continued behavioral health. There was no incident report for this incident. 2) On 3/10/25 at 8:16 PM, a review of facility-reported incident MD00207981 was conducted, and it alleged that verbal abuse toward Resident #18 was overheard from a Unit Manager and a Wound Nurse on 7/23/24 at 10:30 AM. Licensed Practical Nurse (LPN) #23 was overheard telling Resident #18 that he/she needed to get up and also told Resident #18 not to dismiss her. A written statement from Nurse Practitioner (NP) #68 documented that LPN #23 stated to the resident, If you don't get out of this bed and move your arms and legs you will never walk again. Resident #18 responded, Okay. LPN #23 responded by saying, You don't answer me like that; that's dismissing me, and I won't be dismissed. A written statement from the previous Unit Manager (UM) #31 documented, This writer observed [name of LPN #23] being verbally aggressive towards a resident. She was telling the resident [he/she] needed to do more for [him/herself]. When the resident said okay, the nurse was very rude, telling [him/her] that [he/she] does not get to dismiss her. Saying okay is being dismissive to the nurse. I feel she was very rude to the resident. A written statement from Resident #18 documented, A nurse came in and told me I needed to do more for myself. When I said okay, she looked at me weird and told me not to dismiss her. The facility documented that LPN #23 admitted saying the word dismissive to Resident #18. Review of a psychiatric visit dated 7/23/24 documented Resident #18 had a history of insomnia, depression, and anxiety. The note documented that Resident #18 reported being upset due to an incident that happened with his/her nurse. Resident #18 reported feeling sad about how the nurse spoke to the resident; however, Resident #18 was unable to remember the nurse's exact words or the name of the nurse. Resident #18 reported to the psychiatrist that the nurse's words affected his/her mood that day. Review of LPN #23's personnel file revealed the LPN was terminated from the facility on 7/23/24 and reported to the Board of Nursing. On 3/11/25 at 1:53 PM, an interview was conducted with Staff #31. Staff #31 stated the nurse was telling Resident #18 that the resident needed to get up for their own good and the nurse was nasty about it, and it made the resident feel uncomfortable and really bad. Staff #31 stated the resident was in tears and that is why Staff #31 reported it to the Director of Nursing (DON). Staff #31 stated she did not say anything to LPN #23 because, She was not very people friendly. The Nursing Home Administrator was informed on 3/18/25 at 5:15 PM.

Based on observation, medical record review, review of facility ' s policy and procedures, and interview with staff, it was determined the facility failed to ensure that they were able to provide Cardio-Pulmonary Resuscitation (CPR) in accordance with physician ' s orders and the residents ' wishes. This was evident for 5 of 84 residents (#50, #48, #52, 54 and #51) reviewed for code status accuracy during a follow-up survey. An immediate jeopardy regarding residents #50, #48, #52, #51, was identified on [DATE] at 3:00 PM and the facility was informed on [DATE] at 3:18 PM. The Findings Include: Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a patient ' s wishes about medical treatments. The Maryland MOLST order form: Consolidates important information into orders that are valid across the continuum of care Standardizes definitions, reminds patients and clinicians of available treatment options, Increases the likelihood that a patient ' s wishes regarding life-sustaining treatments are honored throughout the health care system 1. On [DATE] at 1:25 PM, during a tour of the Homestead unit, two paper charts with Resident #50 ' s name on the spine of the charts were observed. Both charts were next to each other in the nurse ' s station. Although both charts had Resident #50 ' s name on it, they were labeled with different bed locations. On [DATE] at 1:26 PM, during an interview with Geriatric Nursing Assistant (GNA) #6 indicated that both paper charts were for the same resident and stated there was only one resident by that name on the unit. On [DATE] at 1:30 PM, the surveyor reviewed both paper charts for Resident #50. The review of the one of the paper charts revealed a MOLST physician order form dated [DATE] that indicated Resident #50 requested Cardio-Pulmonary Resuscitation (CPR) be performed. This was the only MOLST order form found in this chart. The second paper chart for Resident #50 revealed two MOLST physician order forms. One MOLST order form was dated [DATE] indicating CPR to be performed, however this MOLST order form had been stricken through with the word void written on it. The second MOLST order form was dated [DATE] and indicated that Resident #50 requested to be a Do Not Resuscitate (DNR), and additionally, do not intubate. On [DATE] at 1:35 PM, the surveyor interviewed the charge nurse on the Homestead unit, Registered Nurse (RN) #7. During this interview, RN #7 could not recall what the code status for Resident #50 was but indicated she would pull the paper chart to find the code status. RN #7 proceeded to grab both of Resident #50 ' s paper charts. RN #7 then opened one of Residents # 50 ' s paper charts and reviewed the MOLST order form. RN #7 stated she would perform CPR. The surveyor confirmed with RN #7 that there were two paper charts for Resident #50. The surveyor asked RN #7 why she checked that specific chart when there were two paper charts for Resident #50 and RN #7 stated, because that chart was on top. RN #7 indicated the admission staff must have put together an additional paper chart when Resident #50 was readmitted . The surveyor requested RN # 7 review the second paper chart. RN #7 confirmed there were additional MOLST forms in the second paper chart and that the most up-to-date code status for Resident #50 was a DNR. On [DATE] at 1:40 PM, the surveyor observed the Assistant Director of Nursing (ADON) walk over to the nurse ' s station on the Homestead unit. The ADON was updated of the duplicate paper charts with multiple MOLST order forms for Resident #50 by RN#7. The ADON then took both of Resident #50 ' s paper charts and consolidated them into one paper chart. On [DATE] at 2:49 PM, the surveyor interviewed RN #8. During the interview RN #8 described the process for what she would do when finding a resident in cardiac arrest. RN #8 indicated she would call for help and check the MOLST form in the resident ' s paper chart. RN #8 demonstrated where she would find the MOLST order form. She also indicated if there were two MOLST order forms in the resident ' s paper chart she would check the date and would proceed with the most current order. RN #8 stated she could also check the electronic record and look for the MOLST order form that is scanned and placed in the miscellaneous section. On [DATE] at 3:45 PM, the surveyor reviewed Resident #50 medical records. During a review of a physician ' s history and physical for Resident #50 dated [DATE], the surveyor discovered that Resident #50 was readmitted to the facility in October of 2022 from an acute care facility. Further review of Resident #50 ' s medical record revealed an active order written in the electronic medical record on [DATE], for Resident #50 to be a full code. On [DATE] at 3:50 PM, the surveyor conducted an interview with Social Worker (SW) #21. During the interview SW #21 stated she is not involved with the MOLST form process. She stated she does not review resident ' s MOLST order forms with the residents and indicated this responsibility was for the physicians. They surveyor asked SW #21 to describe the process when there are multiple MOLST order forms for a resident. SW #21 stated when a doctor voids a MOLST it should be taken out of the resident ' s paper chart. She also indicated the previously scanned MOLST order form in the resident ' s electronic medical record cannot physically have void written on the document, but the word void should be edited in the title of the document. Review of the facility ' s Advanced Directives policy states in section 10, The plan of care for each resident will be consistent with his or her documented treatment preferences and or advanced directive. Review of the facility ' s policy entitled, Do Not Resuscitate Order states in section 6, The Interdisciplinary Care Planning Team will review advanced directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. On [DATE] at 4:08 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated it was her expectation that staff would refer to the paper chart and check the MOLST order form to obtain a resident ' s code status. She also indicated that the social worker should be reviewing resident ' s MOLST order forms on admission and during care plan meetings with the residents. When asked what the process would be if there were conflicting MOLST order forms or conflicting code status orders in the electronic medical record the DON stated, she would get clarification on the MOLST order form and she would expect the order in the electronic medical record to state, See MOLST for code status. The DON stated she was aware that Resident # 50 had a MOLST order form in the paper chart stating wishes for a DNR as well as an active order in the electronic medical record for a full code, indicating that CPR would be initiated if warranted. The DON confirmed this would need to be corrected. The failure to have one accurate MOLST form in place for a resident #50, and the failure of staff to identify the most up-date MOLST form had the potential for Resident 50 to receive CPR against his/her wishes expressed in the MOLST form (a physician ' s order) in the event Resident #50 had a cardiac arrest. On [DATE] at 6:25 PM the DON submitted a plan to remove the immediate jeopardy. The plan included: Removing all duplicate charts with multiple MOLSTs and having one active chart with one active MOLST. Educating all licensed nurses on the process of locating the most current and active MOLST for residents that had MOLST orders. Only licensed nurses who received the education would be permitted to work. All residents who were noted to have duplicate MOLST within their electronic medical record, that does not correspond with their MOLST in the paper chart, will have electronic MOLST removed. Residents that have orders within their record that do not match with their active MOLST will have their orders changed so they both correspond. Residents with multiple MOLSTs have had their voided MOLST removed from the record and have one active MOLST on file. 18819 2) A review of Resident #51's medical record on [DATE] revealed that Resident #51 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paraplegia, chronic cystitis, adult failure to thrive, hypertension, and gastric reflux. Further review of Resident #51's medical record on [DATE] revealed 2 different MOLST forms and a physician's order that were not congruent. The first MOLST form was completed by the resident's physician on [DATE] which indicated Resident #51 decided that s/he did not want to have CPR performed and did not want to be intubated (option A-2). Resident #51's physician also indicated, under section 2c artificial ventilation, that Resident #51 decided that staff could use only CPAP or BiPAP for artificial ventilation. In a review of section 7c, artificially administered fluids and nutrition, Resident #51 wanted to receive artificial hydration as a therapeutic trial, but do not give artificially administered nutrition. A second MOLST form was completed by Resident #51's physician on [DATE] which indicated Resident #51, as a trial, decided that s/he did not want to have CPR performed and did not want to be intubated (option A-2). Resident #51's physician also indicated, under section 2d artificial ventilation, that Resident #51 decided that s/he did not want to use any artificial ventilation (no intubation, CPAP, or BiPAP). Under section 7b, artificially administered fluids and nutrition, Resident #51 now wanted to receive artificial hydration and nutrition, if medically indicated, as a trial, for 1 week. Resident #51's first MOLST form, dated [DATE], had not been voided prior to being scanned into Resident #51's electronic medical record after the creation of the second MOLST form on [DATE]. Further review of Resident #51's electronic medical record physician's orders on [DATE], revealed that Resident #51's physician indicated that upon admission, on [DATE], Resident #51 was to be a Full Code. The [DATE] physician's FULL CODE order for Resident #51 had not been updated, month to month, to reflect Resident #51's current Life-Sustaining Treatment from [DATE] thru [DATE] and changes in the MOLST forms. In an interview with the facility administrator, on [DATE] at 12:08 PM, the nurse surveyor reviewed the concerns with Resident #51's 2 - incongruent MOLST forms and the incongruent FULL CODE order found in Resident #51's electronic physician's orders. A request for all thinned records for Resident #51 was issued. The facility administrator stated that there were no other thinned records for Resident #51 in the medical records department. 43096 3) The surveyor reviewed residents' electronic medical records (PCC) and paper charts on [DATE] at 10:30 AM. A review of Resident #48's medical records revealed that a scanned MOLST form as Full code dated [DATE] was filed under PCC miscellaneous. However, the paper chart of Resident #48 had a MOLST form dated [DATE] as No CPR option A-2, Do Not Intubate. 4) A review of Resident #52's medical record on [DATE] at 10:40 AM revealed that Resident #52 had a scanned MOLST form as Full code dated [DATE] on his/her electronic medical records. However, the paper chart of Resident #52 had a MOLST form dated [DATE] as No CPR option A-2, Do not Intubate. During an interview with Licensed Practical Nurse (LPN #25) on [DATE] at 10:45 AM, LPN #25 stated she would look at residents' PCC to ensure resident's code status. LPN #25 also added if a resident's electronic medical record did not contain code status, she/he would look up the resident's paper chart. LPN #25 also stated that she did not receive any orientation before working in this facility. 42507 5) On [DATE] at 11:00 AM, a follow up review of the paper charts and electronic medical records (PCC) for residents on the Homestead unit was conducted. Resident # 54 had a MOLST form in her paper chart dated [DATE] that checked No CPR, Option B, Palliative, and supportive Care (Prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use CPAP or BIPAP. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. However, a review of the Electronic Medical Record for Resident #54 revealed a MOLST form dated [DATE] that checked No CPR, Option A-2, Do Not Intubate (DNI): Comprehensive efforts may include limited ventilatory support by CPAP or BiPAP, but do not intubate. On [DATE] at 12:46 PM, in an interview with RN #7, she stated that if a resident went into cardiac arrest or became unconscious, she would immediately start CPR, call for help and ask someone to get the resident's paper chart. They would look at the MOLST form for the resident's code status and would continue CPR if the resident was a full code. If the resident was a DNR (do not resuscitate), RN #7 stated she would stop the CPR. RN #7 further stated that if the MOLST was not in the paper chart, they would look for it in PCC under the miscellaneous section. When asked about Resident #54 having two different MOLST forms, RN #7 stated that based on the dates on the MOLST forms, the one in PCC should have been voided because the MOLST form in the paper chart was the most current. On [DATE] at 6:25 PM the DON submitted a plan to remove the immediate jeopardy. The plan included: Removing all duplicate charts with multiple MOLSTs and having one active chart with one active MOLST. Educating all licensed nurses on the process of locating the most current and active MOLST for resident's that had MOLST orders. Only licensed nurses who received the education would be permitted to work. All residents who were noted to have duplicate MOLST within their electronic record that did not correspond with their MOLST in the paper chart, will have electronic MOLST removed. Residents that have orders within their record that do not match with their active MOLST will have their orders changed so they both correspond. Residents with multiple MOLSTs have had their voided MOLST removed form the record and have one active MOLST on file. The facility submitted a plan of removal on [DATE] at 5:03 PM that was not accepted. On [DATE] at 6:55 PM the facility submitted a third plan of removal that was accepted on [DATE] at 6:55 PM After determination of Immediate Jeopardy concerns, an extended survey was conducted. The Immediate Jeopardy was removed on [DATE] at 2:50 PM after validation that the plan had been implemented.

Based on observation, medical record review, review of facility ' s policy and procedures, and interview with staff, it was determined the facility failed to ensure that they were able to provide Cardio-Pulmonary Resuscitation (CPR) in accordance with physician ' s orders and the residents ' wishes. This was evident for 5 of 84 residents (#50, #48, #52, 54 and #51) reviewed for code status accuracy during a follow-up survey. An immediate jeopardy regarding residents #50, #48, #52, #51, was identified on [DATE] at 3:00 PM and the facility was informed on [DATE] at 3:18 PM. The Findings Include: Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a patient ' s wishes about medical treatments. The Maryland MOLST order form: Consolidates important information into orders that are valid across the continuum of care Standardizes definitions, reminds patients and clinicians of available treatment options, Increases the likelihood that a patient ' s wishes regarding life-sustaining treatments are honored throughout the health care system 1. On [DATE] at 1:25 PM, during a tour of the Homestead unit, two paper charts with Resident #50 ' s name on the spine of the charts were observed. Both charts were next to each other in the nurse ' s station. Although both charts had Resident #50 ' s name on it, they were labeled with different bed locations. On [DATE] at 1:26 PM, during an interview with Geriatric Nursing Assistant (GNA) #6 indicated that both paper charts were for the same resident and stated there was only one resident by that name on the unit. On [DATE] at 1:30 PM, the surveyor reviewed both paper charts for Resident #50. The review of the one of the paper charts revealed a MOLST physician order form dated [DATE] that indicated Resident #50 requested Cardio-Pulmonary Resuscitation (CPR) be performed. This was the only MOLST order form found in this chart. The second paper chart for Resident #50 revealed two MOLST physician order forms. One MOLST order form was dated [DATE] indicating CPR to be performed, however this MOLST order form had been stricken through with the word void written on it. The second MOLST order form was dated [DATE] and indicated that Resident #50 requested to be a Do Not Resuscitate (DNR), and additionally, do not intubate. On [DATE] at 1:35 PM, the surveyor interviewed the charge nurse on the Homestead unit, Registered Nurse (RN) #7. During this interview, RN #7 could not recall what the code status for Resident #50 was but indicated she would pull the paper chart to find the code status. RN #7 proceeded to grab both of Resident #50 ' s paper charts. RN #7 then opened one of Residents # 50 ' s paper charts and reviewed the MOLST order form. RN #7 stated she would perform CPR. The surveyor confirmed with RN #7 that there were two paper charts for Resident #50. The surveyor asked RN #7 why she checked that specific chart when there were two paper charts for Resident #50 and RN #7 stated, because that chart was on top. RN #7 indicated the admission staff must have put together an additional paper chart when Resident #50 was readmitted . The surveyor requested RN # 7 review the second paper chart. RN #7 confirmed there were additional MOLST forms in the second paper chart and that the most up-to-date code status for Resident #50 was a DNR. On [DATE] at 1:40 PM, the surveyor observed the Assistant Director of Nursing (ADON) walk over to the nurse ' s station on the Homestead unit. The ADON was updated of the duplicate paper charts with multiple MOLST order forms for Resident #50 by RN#7. The ADON then took both of Resident #50 ' s paper charts and consolidated them into one paper chart. On [DATE] at 2:49 PM, the surveyor interviewed RN #8. During the interview RN #8 described the process for what she would do when finding a resident in cardiac arrest. RN #8 indicated she would call for help and check the MOLST form in the resident ' s paper chart. RN #8 demonstrated where she would find the MOLST order form. She also indicated if there were two MOLST order forms in the resident ' s paper chart she would check the date and would proceed with the most current order. RN #8 stated she could also check the electronic record and look for the MOLST order form that is scanned and placed in the miscellaneous section. On [DATE] at 3:45 PM, the surveyor reviewed Resident #50 medical records. During a review of a physician ' s history and physical for Resident #50 dated [DATE], the surveyor discovered that Resident #50 was readmitted to the facility in October of 2022 from an acute care facility. Further review of Resident #50 ' s medical record revealed an active order written in the electronic medical record on [DATE], for Resident #50 to be a full code. On [DATE] at 3:50 PM, the surveyor conducted an interview with Social Worker (SW) #21. During the interview SW #21 stated she is not involved with the MOLST form process. She stated she does not review resident ' s MOLST order forms with the residents and indicated this responsibility was for the physicians. They surveyor asked SW #21 to describe the process when there are multiple MOLST order forms for a resident. SW #21 stated when a doctor voids a MOLST it should be taken out of the resident ' s paper chart. She also indicated the previously scanned MOLST order form in the resident ' s electronic medical record cannot physically have void written on the document, but the word void should be edited in the title of the document. Review of the facility ' s Advanced Directives policy states in section 10, The plan of care for each resident will be consistent with his or her documented treatment preferences and or advanced directive. Review of the facility ' s policy entitled, Do Not Resuscitate Order states in section 6, The Interdisciplinary Care Planning Team will review advanced directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. On [DATE] at 4:08 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated it was her expectation that staff would refer to the paper chart and check the MOLST order form to obtain a resident ' s code status. She also indicated that the social worker should be reviewing resident ' s MOLST order forms on admission and during care plan meetings with the residents. When asked what the process would be if there were conflicting MOLST order forms or conflicting code status orders in the electronic medical record the DON stated, she would get clarification on the MOLST order form and she would expect the order in the electronic medical record to state, See MOLST for code status. The DON stated she was aware that Resident # 50 had a MOLST order form in the paper chart stating wishes for a DNR as well as an active order in the electronic medical record for a full code, indicating that CPR would be initiated if warranted. The DON confirmed this would need to be corrected. The failure to have one accurate MOLST form in place for a resident #50, and the failure of staff to identify the most up-date MOLST form had the potential for Resident 50 to receive CPR against his/her wishes expressed in the MOLST form (a physician ' s order) in the event Resident #50 had a cardiac arrest. On [DATE] at 6:25 PM the DON submitted a plan to remove the immediate jeopardy. The plan included: Removing all duplicate charts with multiple MOLSTs and having one active chart with one active MOLST. Educating all licensed nurses on the process of locating the most current and active MOLST for residents that had MOLST orders. Only licensed nurses who received the education would be permitted to work. All residents who were noted to have duplicate MOLST within their electronic medical record, that does not correspond with their MOLST in the paper chart, will have electronic MOLST removed. Residents that have orders within their record that do not match with their active MOLST will have their orders changed so they both correspond. Residents with multiple MOLSTs have had their voided MOLST removed from the record and have one active MOLST on file. 3) The surveyor reviewed residents' electronic medical records (PCC) and paper charts on [DATE] at 10:30 AM. A review of Resident #48's medical records revealed that a scanned MOLST form as Full code dated [DATE] was filed under PCC miscellaneous. However, the paper chart of Resident #48 had a MOLST form dated [DATE] as No CPR option A-2, Do Not Intubate. 4) A review of Resident #52's medical record on [DATE] at 10:40 AM revealed that Resident #52 had a scanned MOLST form as Full code dated [DATE] on his/her electronic medical records. However, the paper chart of Resident #52 had a MOLST form dated [DATE] as No CPR option A-2, Do not Intubate. During an interview with Licensed Practical Nurse (LPN #25) on [DATE] at 10:45 AM, LPN #25 stated she would look at residents' PCC to ensure resident's code status. LPN #25 also added if a resident's electronic medical record did not contain code status, she/he would look up the resident's paper chart. LPN #25 also stated that she did not receive any orientation before working in this facility. 5) On [DATE] at 11:00 AM, a follow up review of the paper charts and electronic medical records (PCC) for residents on the Homestead unit was conducted. Resident # 54 had a MOLST form in her paper chart dated [DATE] that checked No CPR, Option B, Palliative, and supportive Care (Prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use CPAP or BIPAP. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. However, a review of the Electronic Medical Record for Resident #54 revealed a MOLST form dated [DATE] that checked No CPR, Option A-2, Do Not Intubate (DNI): Comprehensive efforts may include limited ventilatory support by CPAP or BiPAP, but do not intubate. On [DATE] at 12:46 PM, in an interview with RN #7, she stated that if a resident went into cardiac arrest or became unconscious, she would immediately start CPR, call for help and ask someone to get the resident's paper chart. They would look at the MOLST form for the resident's code status and would continue CPR if the resident was a full code. If the resident was a DNR (do not resuscitate), RN #7 stated she would stop the CPR. RN #7 further stated that if the MOLST was not in the paper chart, they would look for it in PCC under the miscellaneous section. When asked about Resident #54 having two different MOLST forms, RN #7 stated that based on the dates on the MOLST forms, the one in PCC should have been voided because the MOLST form in the paper chart was the most current. On [DATE] at 6:25 PM the DON submitted a plan to remove the immediate jeopardy. The plan included: Removing all duplicate charts with multiple MOLSTs and having one active chart with one active MOLST. Educating all licensed nurses on the process of locating the most current and active MOLST for resident's that had MOLST orders. Only licensed nurses who received the education would be permitted to work. All residents who were noted to have duplicate MOLST within their electronic record that did not correspond with their MOLST in the paper chart, will have electronic MOLST removed. Residents that have orders within their record that do not match with their active MOLST will have their orders changed so they both correspond. Residents with multiple MOLSTs have had their voided MOLST removed form the record and have one active MOLST on file. The facility submitted a plan of removal on [DATE] at 5:03 PM that was not accepted. On [DATE] at 6:55 PM the facility submitted a third plan of removal that was accepted on [DATE] at 6:55 PM After determination of Immediate Jeopardy concerns, an extended survey was conducted. The Immediate Jeopardy was removed on [DATE] at 2:50 PM after validation that the plan had been implemented. 2) A review of Resident #51's medical record on [DATE] revealed that Resident #51 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paraplegia, chronic cystitis, adult failure to thrive, hypertension, and gastric reflux. Further review of Resident #51's medical record on [DATE] revealed 2 different MOLST forms and a physician's order that were not congruent. The first MOLST form was completed by the resident's physician on [DATE] which indicated Resident #51 decided that s/he did not want to have CPR performed and did not want to be intubated (option A-2). Resident #51's physician also indicated, under section 2c artificial ventilation, that Resident #51 decided that staff could use only CPAP or BiPAP for artificial ventilation. In a review of section 7c, artificially administered fluids and nutrition, Resident #51 wanted to receive artificial hydration as a therapeutic trial, but do not give artificially administered nutrition. A second MOLST form was completed by Resident #51's physician on [DATE] which indicated Resident #51, as a trial, decided that s/he did not want to have CPR performed and did not want to be intubated (option A-2). Resident #51's physician also indicated, under section 2d artificial ventilation, that Resident #51 decided that s/he did not want to use any artificial ventilation (no intubation, CPAP, or BiPAP). Under section 7b, artificially administered fluids and nutrition, Resident #51 now wanted to receive artificial hydration and nutrition, if medically indicated, as a trial, for 1 week. Resident #51's first MOLST form, dated [DATE], had not been voided prior to being scanned into Resident #51's electronic medical record after the creation of the second MOLST form on [DATE]. Further review of Resident #51's electronic medical record physician's orders on [DATE], revealed that Resident #51's physician indicated that upon admission, on [DATE], Resident #51 was to be a Full Code. The [DATE] physician's FULL CODE order for Resident #51 had not been updated, month to month, to reflect Resident #51's current Life-Sustaining Treatment from [DATE] thru [DATE] and changes in the MOLST forms. In an interview with the facility administrator, on [DATE] at 12:08 PM, the nurse surveyor reviewed the concerns with Resident #51's 2 - incongruent MOLST forms and the incongruent FULL CODE order found in Resident #51's electronic physician's orders. A request for all thinned records for Resident #51 was issued. The facility administrator stated that there were no other thinned records for Resident #51 in the medical records department.

Based on a resident complaint, staff interviews, and clinical record reviews, it was determined that 1) the facility failed to ensure a totally dependent resident's tube feeding and hydration nutritional needs were met. This occurred when Resident #45's tube feeding orders were changed without instruction from Resident #45's physician or guidance from the facility nutritionist. These new tube feeding orders were also not monitored. This caused Resident #45 to lose a significant amount of weight (18%) in 2 months which caused Resident #45 harm. Additionally, the facility 2) failed to provide a resident a therapeutic diet, 3) failed to intervene in a timely manner when a weight loss was documented, and 4) failed to re-weigh a resident after a 6 day hospital admission and initiate a physician ordered nutritional supplement. This was evident for 5 (#45, #141, #27, #34, #63) of 12 residents reviewed for nutrition during the annual survey. The findings include: 1) In an interview with Resident #45 on 09/13/22 at 2:43 PM, Resident #45 informed the surveyor that he/she lost weight since the nursing staff was administering Resident #45's tube feeding at a slower rate and was only receiving the tube feeding for 12 hours a day. Resident #45 was admitted to the facility in December 2011 with diagnoses that include but are not limited to traumatic brain injury, quadriplegia, peg tube insertion, seizures, suprapubic catheter, dysphagia, and contractures in the extremities. Resident #45 was totally dependent upon the facility staff for all aspects of his/her care. Resident #45 had a Brief Interview for Mental Status (BIMS) assessment, conducted by a facility staff member, on 05/11/22 and 07/28/22 during the quarterly review process. Resident #45 was assessed to have a 15/15 score during both quarterly assessments. A score of 13 to 15 suggests the resident is cognitively intact. A review of Resident #45's clinical health record on 09/13/22 revealed that on 04/18/22 at 1:13 PM, the nursing staff documented that Resident #45 weighed 133.7 pounds. On 06/21/22 at 3:36 PM, the nursing staff documented that Resident #45 weighed 109.6 pounds. Resident #45 lost 24.1 pounds (18%) from 04/18 thru 06/21/22. A review of Resident #45's previously recorded weights revealed the following: 12/04/21 - 137.7 pounds 02/02/22 - 135.4 pounds 03/01/22 - 131.3 pounds A review of the facility weight monitoring policy, (that was initiated on 09/28/2020 and reviewed/revised on 07/08/21) on 09/16/22 at 2 PM, revealed the following initial statement: The facility is committed to maintaining quality care by implementing below weight practice guidelines to maintain adequate nutritional status and assure the standard of practice is met for residents served. Under the weight process guidelines, #4 revealed the following: Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. Resident #45's weight had been stable on the current physician-prescribed tube feeding and hydration orders which were initiated on 11/10/21. A review of Resident #45's 02/21/22 nutritional assessment documented that Resident #45's calculated nutrient needs are being met with tube feeding. Resident #45 has a usual body weight of 130 pounds, a BMI of 20.6, and an ideal body weight of 154 pounds, with a height of 68 inches. On 02/21/22 the facility dietician noted the physician-prescribed tube feeding orders were as follows: 1) Nothing by Mouth (NPO) 2) Product and Rate - Jevity 1.5, to run at 105 ml/hour, over a 12-hour infusion. 3) Volume 1260 ml. 4) Flush - 150 ml water, every 4 hours 5) Total flush over 24 hours (ml) - 900 ml 6) Total volume infused over 24 hours (ml) - 2160 ml 7) Total calories - 1890. 8) Total protein - 80 grams. 9) Total Free Water - 1858 ml On 04/22/22, RN #31 documented a new physician's order to lower Resident #45's tube feeding to the following: Infuse Jevity 1.5, for Nutrition related to gastrostomy status, Formula: Jevity 1.5 Rate: 75 ml/hr., Duration: 12 hours, Volume: 900 ml. In an interview with the former facility dietician, staff member #63, on 09/20/22 at 12:28 PM, the former facility dietician stated that he/she worked at the facility from February 2022 thru the first week in August 2022 and became aware of Resident #45's significant weight loss that was identified in June 2022. The former facility dietician stated that Resident #45 lost a significant amount of weight in a short period of time with no interventions. The former facility dietician stated that he/she was not made aware when a nurse changed Resident #45's tube feeding orders on 04/22/22. No one contacted me. The former facility dietician stated that there was no communication between nursing and him/her. The former facility dietician stated that the nursing staff also missed obtaining a May 22 weight on Resident #45 which allowed Resident #45's weight to continue to drop. The former facility dietician stated that he/she sent an email to the nursing administration about Resident #45's significant weight loss. The former facility dietician stated, Resident #45 fell through the cracks. After Resident #45's significant weight loss was identified, the former facility dietician stated that the corporate dietician had a meeting with the facility's clinical staff. The former facility dietician stated that he/she would have increased the length of time (duration) of Resident #45's tube feeding and not lowered the rate. Further review of Resident #45's 06/29/22 physician orders, revealed that new tube feeding orders were put into place that instructed the nursing staff to administer Resident #45's tube feeding, Jevity 1.5, one time a day, to infuse at 65 ml/hour over 16 hours from 4 PM to 8 AM. A review of Resident #45's care plans on 09/15/22 revealed a 01/19/2021 focused care plan that indicated Resident #45 needed to gain some weight while receiving tube feeding and flushes. This care plan was revised on 02/14/22 by the facility's Healthcare Virtual Assistant. On 05/10/22, the revised goal for Resident #45 is to tolerate his/her tube feeding and flushes so that he/she is able to gain and maintain weight with a BMI in the range of 22- 25 during the review period. Nursing interventions included: weighing Resident #45 as ordered, monitoring tolerance to TF and flushes, monitoring the need for other nutrition interventions, monitoring and evaluating any weight loss to determine percentage lost, following the facility protocol for weight loss, and if weight decline persists, contact physician and dietician immediately. In an interview with the facility's corporate dietician, staff member #53, the facility dietician stated that he/she recalled having a conversation with the former facility dietician, staff member #63, when Resident #45's significant weight loss was identified at the end of June 2022. The corporate dietician recalled that the former dietician #63 did not recall being informed when Resident #45's tube feeding rate was lowered and that the facility dietician was having difficulty getting answers from staff. The corporate dietician stated that he/she reviewed Resident #45's significant weight loss with the facility clinical team and thought that Resident #45's 06/21/22 weight of 109.6 may have been inaccurate. The corporate dietician stated that he/she was not able to find anything in Resident #45's clinical record as to why Resident #45's tube feeding rate was changed on 04/22/22. The corporate dietician stated that he/she was aware that Resident #45 did have episodes of vomiting and diarrhea and considered that Resident #45 may have had a malabsorption intestinal issue. The corporate dietician stated that she/she had taken Resident #45's significant weight loss to the monthly weight committee (QAPI) in July 2022. Body mass index, BMI, according to CDC.GOV is a value derived from the mass and height of a person. A healthy range is between 18.5 to 24. If your BMI is 18.5-20, you're a bit underweight and can't afford to lose more. In an interview with the current facility dietician, staff member #25, on 09/20/22 at 9:56 AM, the current facility dietician stated that Resident #45's BMI in February 2022 was documented at 20.5 which was within the normal range for Resident #45. The current facility dietician stated that Resident #45's current BMI, as of the 09/14/22 nutritional assessment, is 17.3. The goal now for Resident #45 is to get his/her BMI above 19. In an interview with Resident #45's physician on 09/20/22 at 9:44 AM, Resident #45's physician stated that he/she was unaware why Resident #45's tube feeding orders were changed on 04/22/22. Resident #45's physician stated that he/she recalled having conversations with staff about Resident #45's weight loss and muscle atrophy in June 2022. Resident #45's physician also stated that Resident #45's family was aware of the weight loss. In an interview with the facility interim Director of Nurses (DON) on 09/28/22 at 6 PM, the interim DON stated that she/he looked into Resident #45's significant weight loss and discovered that RN #31 had discussed Resident #45's diarrhea issue with the former facility dietician, staff member #48, in February 2022 before staff member #48 stopped working in the facility. The interim DON stated that RN #31 had taken it upon himself/herself to change Resident #45's tube feeding orders on 04/22/2022 to help Resident #45's issues with diarrhea without notifying Resident #45's physician. 15701 2) The facility staff failed to intervene in a timely manner when a weight loss was documented for Resident #141. A review of Resident #141's medical record related to nutritional concerns on 9/20/22 at 2:15 PM revealed the resident was admitted to the facility on [DATE]. A nutritional assessment was completed on 9/8/22 by the dialysis dietitian. The dietitian documented weight of 200 pounds (Lbs.) that was taken on 9/6/22. The nutritional summary revealed, Resident is at nutrition risk related to inadequate oral intake with elevated nutritional needs for wound healing and likely inadequate nutrient intake. A review of the vital signs weight section of the electronic health record revealed a second weight was documented on 9/19/22 at 10:03 PM as 160.8 Lbs. by a nurse (staff #47). The electronic health record automatically documented a weight comparison noting a 19.6 % significant weight loss of 39.2 Lbs. Further review of the medical record did not reveal any type of physician or dietician notification. A review of the facility's Weight Monitoring policy dated 9/28/20 with a Reviewed/Revised date of 2/11/21 revealed Weight Analysis: The newly recorded weight should be compared to the previous recorded weight and it further defined significant weight change percentages. All weights are to be entered into the Point Click Care (PCC), under the weights and vital signs portal. Unit Managers and/or ADON to validate prior to PCC entry, with a further indication of physician, dietician, and resident's responsible party notifications of weight gain/loss trends need to be documented by a licensed nurse in the clinical record. Multiple care area concerns were shared with the Interim DON on 9/22/22 at 4:29 PM including the documentation of a 39 Lbs. weight loss without further documentation or physician notification. On 9/26/22 at 12:51 PM the Interim DON had a follow-up discussion and had Staff #47 involved. Staff #47 indicated that she entered a post dialysis weight and apologized for not recognizing Resident #141's significant weight loss. 31145 4) On 9/15/22 at 2:21 PM a medical record review was conducted for Resident #27. Resident #27 was admitted to the facility in July 2022 with diagnoses that included, but were not limited to, repeated falls, atherosclerotic heart disease, chronic kidney disease and major depressive disorder, recurrent. The resident was hospitalized for 5 days in August 2022 and returned to the facility after being treated for bacteremia and a urinary tract infection. Resident #27 contracted COVID-19 on 8/30/22. Review of the weight section of Resident #27's medical record revealed the resident weighed 130 lbs. (pounds) upon admission on 7/1/22, 130.8 lbs on 7/5/22, 133.6 lbs. on 7/13/22 and 135.6 lbs. on 7/27/22. Review of hospital notes dated 8/19/22 documented the resident's weight at 130 lbs. Review of the nursing readmission evaluation dated 8/23/22 at 17:10 (5:10 PM) documented the weight of 135.6 lbs. that was taken on 7/27/22, prior to hospitalization . As noted above, the resident lost 5.6 lbs while hospitalized . The nursing staff failed to re-weigh the resident upon re-admission. A nutritional assessment was done on 8/26/22 by the previous dietician and the weight of 135.6 lbs. on 7/27/22 was also used. The dietician did not order any nutritional supplements. Review of the hospital discharge instructions dated 8/23/22 documented, will need continued nutritional supplement. Review of the weight monitoring policy that was given to the surveyor by the Interim Director of Nursing (DON) on 9/16/22 at 12:30 PM revealed the second paragraph which stated, residents are to be weighed upon admission and/or re-admission, as well as monthly and/or on as needed basis. Under the weight process guidelines, #2 documented, A comprehensive nutritional assessment will be completed by the Registered dietician upon or post admission or re-admission. Assessments should include the following information, b. weight. There was no documentation found in the medical record that the previous dietician requested a more recent weight due to the resident being hospitalized for 6 days. On 9/16/22 at 1:38 PM an interview was conducted with Registered dietician, Staff #25 who stated she has only been at the facility since August 15, 2022 and that she has been training and another dietician was filling in. Staff #25 stated she was officially starting Monday, 9/19/22. Staff #25 stated, I would expect the resident to be weighed when they come back from the hospital. If greater than 3 days I would see the resident. I have not seen [him/her] prior to today. The surveyor showed Staff #25 the nutritional assessment dated [DATE] and that the other dietician used the weight from 7/27/22. Staff #25 stated she would have expected Resident #27 to be weighed and should have used the new weight for the assessment. Staff #25 was also shown the discharge summary from the hospital that stated to continue on a nutritional supplement. On 9/19/22 at 9:03 AM a review of medical record revealed Resident #27 still had not been weighed and the nutritional supplement still had not been addressed. Discussed with the Interim DON on 9/28/22 at 12:15 PM. 5) On 9/21/22 at 9:53 AM a record review was conducted for Resident #34 and revealed the resident was admitted to the facility in January 2022 with diagnoses that included, but were not limited to, Parkinson's disease, unspecified dementia, mood disturbance, and anxiety. Resident #34's medical record revealed the resident weighed 156.6 lbs. (pounds) on 6/21/22 and 145 lbs. on 7/13/22, which was a 7.4% weight loss in 1 month. There was no weight obtained in August 2022. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #34's quarterly MDS with an assessment reference date of 7/20/22 coded a 7.4% weight loss in 1 month. Review of a nutritional assessment dated [DATE] documented, Patient has significant weight loss of 7.4% within 1 month with weight history 6/21/2022 156.6#, 7/13/2022 145# BMI 22 (normal). RD (Registered Dietician) does not believe recent weight is accurate. RD requested reweight but this has not been obtained. This was documented from the previous RD who was no longer employed at the facility. Further review of Resident #34's medical record failed to produce documentation that the physician or the responsible party were notified of the weight loss. Review of physician's orders for Resident #34 revealed the order, pt. to utilize kennedy cup during meals daily as tolerated and staff assist with all meals. The physician's order was written on 1/28/22. The Kennedy Cup is a lightweight, easy-to-grip adapted drinking cup designed to prevent spills. On 9/21/22 at 9:20 AM observation was made of Resident #34 in bed with the tray table in front of him/her with a breakfast tray on top. There was scrapple with scrambled egg on top of toast. The butter and jelly containers were not opened. There was a regular plastic cup on the tray with no lid. The plastic cup was sideways and empty. The silverware was still in the plastic wrapper. The resident was pointing to something that the surveyor could not understand. At that time the surveyor went into the hallway and asked Geriatric Nursing Assistant (GNA) #57 if she was assigned to the resident. GNA #57 stated she was not, however she asked what she could do for Resident #34. The surveyor asked if the resident used utensils and GNA #57 said yes. The surveyor showed GNA #57 that the utensils were still in the plastic wrapper. GNA #57 got the utensils out of the package and cut the resident's food into bite size pieces. Resident #34 started picking up the bite size pieces and put them in his/her mouth. The facility staff failed to follow physician's orders for a Kennedy Cup. Furthermore, review of Resident #34's Treatment Administration Record (TAR) documented on 9/21/22 that the nurse signed off that Resident #34 utilized a Kennedy Cup at breakfast (8:00 AM) and lunch (12:00 PM) which was inaccurate. On 9/21/22 at 11:16 AM an interview was conducted with Physician #77 who stated, I was not notified of the weight loss. I would have expected to be notified. Since July many nurses have quit their positions. Notifying me and making sure vitals are done and orders are carried out is what we rely on. It is not feasible to check weights myself. We rely on staff. It is an issue as I rely on staff. The time we have to backtrack to see if these things are getting done, we get paranoid. On 9/21/22 at 1:06 PM an interview was conducted with Dietician #25 who stated she had just started at the facility and was in the process of seeing all residents. Dietician #25 stated she saw the resident yesterday and put Resident #34 on weekly weights. Staff #25 stated she cut up the resident's sandwich and saw the resident get the top of the bread off. I cut it up and [he/she] automatically took the food. I went to the kitchen to go over what finger foods are. [She/He] needs to have wedge like pieces and I wanted to make sure everyone was aware of that. Staff #25 continued, Visually, [he/she] looked like someone I wanted to check in on. On 9/21/22 at 1:43 PM a discussion was conducted with the Medical Director about Resident #34's weight loss. The Medical Director stated, the physician should have been notified of the weight loss. 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. Review of the dietary care plan for Resident #34 documented, is at potential nutritional risk r/t need for modified texture diet that was initiated on 1/24/22 and revised on 2/10/22. The interventions on the care plan were, Encourage good hydration by providing fluids with meals and med pass, Encourage good meal intake according to diet order (allow double portions), RD to evaluate per protocol or PRN to provide updated recommendations, and Diet, weights as ordered. There was no evidence in the medical record that the care plan was evaluated and updated to reflect weight loss. 43096 3) On 9/21/22 at 1:30 PM, Resident #63's medical records were reviewed for a portion of complaint investigation MD00179202. The review revealed that Resident #63 was initially admitted to this facility in June 2021 with the diagnosis of end-stage renal disease and needed hemodialysis three times a week. Resident #63 was transferred to the hospital due to a condition change on 1/20/22 and readmitted to the facility on [DATE]. Further review of Resident #63's weights and vitals summary revealed that the resident's body weight was 171.16 pounds, post-dialysis on 12/11/21 and 157.08 pounds post-dialysis on 2/4/22. However, no documentation (notification to physician, notification to responsible party, care plan, interventions, dietician note, and skilled nursing note) was found in Resident #63's medical record regarding a 14.08-pound weight loss (12.15%) within 57 days. During an interview with the Medical Director (Staff # 34) and the Interim DON on 9/21/22 at 1:51 PM, the surveyor asked what the acceptable weight loss for dialysis residents was. Staff #34 stated that even though the acceptable weight loss would be variable depending on each status, less than 5% loss would be acceptable. The surveyor shared Resident #63's case: staying in the hospital for 16 days, weight checked 9 days later after being readmitted , and 12% weight loss recorded. Staff #34 confirmed that the weight change was not usual and stated he expected to be notified. The facility policy, Weight Monitoring with a revised date of 7/8/21 was reviewed on 9/23/22. The policy review revealed: residents are to be weighed upon admission and/or re-admission as well as monthly and/or on as-needed basis. Dietician assessment and follow-up needs to be documented in resident's clinical record. MD (Doctor of Medicine) /RP (Responsible Party) / RD (Registered Dietician) notification of weight gain/loss trends need to be documented by a licensed nurse in the clinical record. The above concern was discussed with the Interim DON on 9/28/22 at 1:30 PM.

Based on review of medical records, facility documentation and interview with facility staff, it was determined that the facility failed to honor the wishes of a resident (#1) that had elected cardiopulmonary resuscitation (CPR) in the event that a cardiac and/or [MEDICAL CONDITION] arrest occurred. This was demonstrated by the facility's failure to attempt CPR upon Resident #1's cardiopulmonary arrest on [DATE]. These actions resulted in the finding of a past noncompliance immediate jeopardy during the complaint survey. This deficiency was evident for 1 of 14 residents reviewed during the complaint survey. [NAME]land Medical Orders for Life-Sustaining Treatment (MOLST) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's wishes about medical treatments. The findings include: Resident #1 who was alert and oriented to person, place and time was admitted on [DATE] with a MOLST form dated [DATE]. The [DATE] MOLST was discussed with Resident #1 by a hospital physician. Resident #1 had elected to have CPR performed if a cardiopulmonary arrest occurred. The facility nursing staff during the initial admission assessment on [DATE] reviewed the MOLST form and concurred that CPR was to be done. The facility attending physician reviewed the MOLST orders and concurred on [DATE]. On [DATE] around 6:00 AM Resident #1 was found by Staff #3 to be unresponsive. Staff #3 went to get the nurse, Staff #1. Staff #1 requested Staff #3 get the another Nursing Unit's nurse to confirm that Resident #1 had no pulse or respirations. Staff #2 arrived and confirmed Resident #1 had no pulse or respirations. Staff #3 asked Staff #1 if he/she should clean the body and was told yes. Staff #1 then telephoned the on-call physician followed by the family. The facility Assistant Director of Nursing (ADON #1) called in to inquire about staffing for the day on [DATE] and Staff #1 told ADON #1 about Resident #1 found not be breathing or having a heart beat. ADON #1 inquired if CPR was done and Staff #1 said no. Staff #1 then checked the MOLST form in the medical record and saw where CPR should have been initiated and 911 called. During interview on [DATE] at 3:30 PM Staff #1 said he/she assumed Resident #1 was a no CPR since their spouse, also a resident, was a no CPR. Resident #1 never received the CPR as ordered by the physician on the MOLST. The facility Administrator called an emergency Quality Assurance/Performance Improvement (QAPI) meeting on [DATE]. The first action plan was to educate all nursing staff before starting work on emergency medical response which includes verifying the MOLST orders and proceeding as ordered on the MOLST. The Administrator had the [DATE] day and evening nursing staff educated by 4:00 PM on [DATE]. ADON #1 educated the [DATE] night shift before work started. Education continued on [DATE] through [DATE] until 100% of the staff was educated. Nursing staff on maternity or medical leave would be trained upon return. The QAPI committee then assigned all resident's MOLST be reviewed for accuracy with a completion date of [DATE]. An audit of all deceased Residents from [DATE] to [DATE] were reviewed for accuracy of MOLST and if wishes were carried out with a completion date of [DATE]. Additional education by the facility's 2 ADON's on the MOLST form and Advanced Directives was started [DATE] and continues until 100% compliance. On [DATE] mock codes were started to determine compliance with education of following the MOLST orders and emergency procedures are followed. On [DATE] all MOLST forms were assigned to be moved from the front of the order section of the medical record to the front of the medical record. On [DATE] an audit of the facilities response was completed by the surveyor. All nursing staff on duty [DATE] were interviewed and 100% answered that the MOLST form was in the front of the medical record and the signed MOLST orders were to be followed if a cardiopulmonary arrest occurs. Three medical records from each nursing unit were reviewed and all had the MOLST at the front of the chart. Review of the QAPI minutes showed on going review of all new residents weekly for 4 weeks then monthly for 6 months. Current and new residents or death's MOLST's will be monitored until (MONTH) (YEAR) per interview on [DATE] at 10:00 AM with the Administrator QAPI chairman. Staff education will also be monitored through (MONTH) (YEAR) as well as new placement of the MOLST order. Mock code drills will continue through May. These systemic changes are monitored monthly at the QAPI meetings. The Administrator and ADON #1 said the immediacy of situation was removed on [DATE] at 4:00 PM with the action plan in effect. Substantial compliance was achieved by [DATE].

Based on review of MD 991, MD 061, medical records and interviews it was determined that the facility failed to 1) ensure that a resident's environment remained as free from accident hazards as possible as evidenced by the presence of side rails for a resident who had been assessed as not requiring side rails which resulted in bruising to the resident's forehead and eye (Resident #58) ; 2) & 3) ensure staff provided adequate supervision and assistance when utilizing a mechanical lift to prevent accidents as evidenced by two residents falling from the lift while being transferred resulting in a fractured hip for one resident and a head laceration for the second resident (Residents #257 and #81); 4) ensure that residents were transferred in a sit-to-stand lift by two staff members as required by the facility's procedures and nursing standard of care. The findings include: 1) On [DATE] review of Resident #58's medical record revealed the resident had resided at the facility for several years and whose [DIAGNOSES REDACTED]. This evaluation revealed the resident did not need bed rails for positioning/support and/or rising from supine to sitting/standing position as a mobility enabler and that Bed Rails were not indicated as a mobility enabler at this time. Nor were the bed rails a patient or resident representative preference. Review of nursing notes revealed a skin assessment was completed on [DATE] with no skin injury/wounds were noted. Further review of the nursing notes revealed that on [DATE] at 10:42 AM, the nurse documented: new onset/change in skin integrity as evidenced by bruise. Location: Resident noted to have bruise on right forehead as well as right outer eye. On [DATE] at 1:14 PM, nurse documented: (name of resident) has hand tremors and involuntary head movement (baseline) Has used top ,[DATE] rail to aide in independent bed mobility. Staff feels that (name of resident) may have bumped (his/her) head on the rail. Side rails have been removed. Skin is intact. No swelling. No signs of any distress. On [DATE] at 8:20 AM, interview with the Dementia Unit program manager revealed that if side rails were assessed as not being indicated they would either secure the rails in the down position or remove them from the bed. The Director of Nursing (DON) then reported that if the someone had snipped the tie down (securing device) then they would remove the rails from the bed and that if the resident can't use the rails they try to get rid of them. Surveyor then reviewed the concern that the resident had been assessed in December as not needing side rails but investigation into the bruising on the face in January determined it was a result of the side rails. On [DATE], the DON confirmed that side rails were on the resident's bed at the time of the injury and she had them removed from the bed after the injury was noted. 2) On [DATE] review of Resident #257's medical record revealed [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set assessment revealed that the resident was totally dependant for transfers with the assist of at least two staff persons. Review of the nursing notes revealed that on [DATE] Resident fell off hoyer lift while being transferred from the wheel chair to the shower chair with assist of 2 CNAs (certified nursing assistants). One of the sling straps slid out the hook, and resident fell on the floor hitting (his/her) fore head, sustaining a hematoma (bruise). Resident also complained of right knee pain Ice applied to hematoma. Patient sent to ED (emergency department) via 911. On [DATE], a Change in Condition Followup note revealed staff contacted the hospital and was informed that the resident had been admitted with a right hip fracture. On [DATE] at 3:10 PM, interview with GNA Staff #22 revealed that on [DATE] another GNA (Staff #23) had come to assist her with the transfer of the resident; she hooked her side and the other GNA hooked the other side; during the transfer the other GNA's side came loose. When asked if anything could of been done differently she replied: double check; if someone doesn't want to participate the right way get someone else to participate. Review of the employee file for the GNA Staff #23 revealed that on [DATE] an Individual Performance Improvement Plan was put in place regarding the incident on [DATE]. Review of this form revealed Resident (ID number) was being lifted via a mechanical lift when (s/he) slipped out of the sling causing (him/her) to fall to the floor. Patient received a fracture which necessitated transfer to the hospital. Upon investigation, it was determined that 1. the sling was not fastened correctly to the lift and 2. (Staff #23) failed to wait for the second GNA to assist with swinging patient over to the shower chair. On [DATE] at 5:00 PM, surveyor reviewed the concern with the DON and the Administrator regarding the resident's fall during the mechanical lift transfer which resulted in harm to the resident. 3) The facility failed to maintain the safety of resident (#81) during transfer, resulting in a laceration to the forehead and cheek, bruising to the left shoulder and knee - requiring steri-strips and pain medication. Steri Strips are sterile pieces of medical tape used to close wounds. A Hoyer Lift is an assistive device that allows patient/patients to be transferred between a bed and a chair or other similar resting places. By way of history, according to the medical record, (resident #81) has End stage Dementia and is totally dependent on staff for care. An investigation was performed of facility reported incident # MD 747, which included review of the medical record, review of the facility's investigation, and interviews with the DON (Director of Nursing) on [DATE] at 1 pm, GNA (Geriatric Nursing Assistant) #1 on [DATE] at 2 pm, and GNA #2 on [DATE] at 11 am. The investigation reavealed that, on [DATE] at approximately 9:40 am, GNA #1 and GNA #2 were transferring the resident from the bed to the chair using a Hoyer Lift. During the transfer, the sling strap came off the Hoyer Lift's hook and the resident fell to the floor. GNA #1 stated GNA #2 failed to properly secure the straps to the Hoyer Lift, causing the resident to fall out. GNA#2 stated s/he was unsure as to why the strap came off, but verified the allegation that the strap came off during transfer. The resident sustained [REDACTED]. The resident was given PRN (when needed) Tylenol 650 mg by mouth and steri strips were applied to the forehead at the time of the incident. Further review of the medical record revealed the resident was seen and assessed by the physician on [DATE] at 9:45 am, who rendered the following orders: Morphine Sulfate Concentrate (MSIR) 20mg/cc liquid. Give (0.25 cc) 5 mg (milligrams) po (by mouth) every hour PRN for mild pain or distress. Morphine Sulfate Concentrate (MSIR) 20mg/cc liquid. Give (0.5 cc) 10mg (milligrams) po (by mouth) every hour PRN for moderate pain or distress. Morphine Sulfate Concentrate (MSIR) is used to treat moderate to severe pain. On [DATE], the resident received the following doses of pain medication. 10:45 am 5 mg MSIR, 1:02 pm 10 mg MSIR, 2:45 pm 10 mg MSIR and 8:23 pm 10 mg MSIR. On [DATE], at 2:45 pm the resident was seen by the NP (Nurse Practitioner). New order to administer Morphine Sulfate Concentrate (MSIR) 20mg/cc liquid. Give (0.25 cc) 5 mg (milligrams) sublingual (under the tongue) every 12 hours at 6 am and 6 pm for pain. Continue PRN dosing. The resident received the scheduled MSIR (5 mg) at 6 pm on [DATE]. On [DATE], the resident received the following doses of pain medication. 6 am 5 mg MSIR (routine), 8:23 am 10mg MSIR (PRN), 12:30 pm 10 mg MSIR (PRN). On [DATE] at 12:30, a new order was given for Morphine Sulfate Concentrate (MSIR) 20 mg/cc. Give (0.25 cc) 5 mg sublingual every 8 hours for pain. Hold if respirations 14 or below per minute. The resident received MSIR at 6pm (routine) and the MSIR 5 mg (PRN) at 10:10 pm. On [DATE], the resident received the following doses of pain medication: 12 am, MSIR 5mg (routine) 8 am, MSIR 5mg (routine) 9:51 am MSIR 5mg (PRN) 12:31 pm MSIR 5mg (PRN) 4 pm MSIR 5 mg (held) - held respirations 10. 11:58 pm Tylenol Suppository 650 mg for elevated temp (temperature) of 102. On [DATE], the resident received the following pain medications: 12am MSIR 5 mg (routine) and MSIR 10 mg (PRN) 6 a m, MSIR 5mg (routine) 6:48 am Tylenol Suppository 650 mg for elevated temp of 101.8 8 am MSIR 5mg (routine) 12:28 pm MSIR 5mg (PRN) 4 pm MSIR 5 mg (routine) 10:35 pm Tylenol Suppository 650 mg for elevated temp of 100.2 10:37 pm MSIR 10 mg (PRN) On [DATE], the resident received the following pain medication: 12:00 AM: MSIR 5mg (routine) 5:19 AM: Tylenol Suppository 650 mg for elevated temp (temperature) of 102. 8:00 AM: MSIR 5mg (routine) 11:12 AM: MSIR 10mg (PRN) 4:00 PM: MSIR 5mg (routine) The resident expired on [DATE] at 8:40 PM. Review of the medical record revealed a (MOLST) (NAME)land medical Orders for Life-Sustaining Treatment. According to the document the resident was a do not transfer, but treat with options available outside of the hospital. At the time of the incident, the resident was on hospice care for end stage dementia and had been for greater than a year. During interview with the Director of Nursing on [DATE] at 1 pm, he/she stated that GNA #1 and GNA #2 had been in-serviced on the proper use of the Hoyer Lift, pad and straps. 4) During an interview with Resident #125 that took place on [DATE] at 1:26 PM, the resident stated that s/he had been transferred that morning with a sit-to-stand lift with the assistance of only one nursing assistant. The resident idenified Geriatric Nursing Assistant (GNA) #17 as the staff member who assisted him/her with the sit-to-stand lift this morning. A review of the facility's policy of resident transfers with Hoyer Lifts and Sit-to-Stand Lifts reveals that the facility requires two personnel to assist with all transfers. An interview with the Director of Nursing (DON) that took place at 2:00 PM on the same day confirmed this expectation. GNA #17 was interviewed at 2:30 PM and confirmed that s/he transferred Resident #125 that morning all by himself/herself. GNA #17 stated that s/he has had to do it alone other times before, and that the usual reason is not enough staff to help. The GNA stated that was also the reason this morning. These concerns were reviewed with the Administrator during survey exit.

Based on staff interviews and medical record review, it was determined that the facility failed to provide adequate supervision to implement an effective system to ensure the safety of residents at risk for elopement when an ambulatory and cognitively impaired resident, (Resident #1) eloped from the facility on 12/26/15 and was struck and killed by a vehicle on a nearby expressway. Two additional residents (#6 and #13) were identified by the facility as requiring Wander-Guard bracelets during survey, but none were available in the facility, and alternate measures were not in place. These concerns were evident for 3 of 13 residents (#1, #6, and #13) at the time of the survey. Due to the serious harm and immediate potential for additional serious harm an Immediate Jeopardy was called at 1:32 PM, on 12/30/2015. The facility's action plan included identifying other residents at risk, inspecting doors, alarms and Wander-Guard function, ensured front access area would be staffed, reviewed and revised elopement risk care plans, and provided staff education. These actions were taken prior to the start of the survey. Additionally, during the survey on 12/30/15, residents #6 and #13 were put on one-one staffing while the provider obtained Wander-Guard bracelets for the two residents who still did not have them. Immediacy was removed on 12/30/15 at 6:55 PM following this additional intervention. The findings include: Review of Resident #1's medical record on 12/30/15 revealed that he/she was admitted to the facility in December 2015 with [DIAGNOSES REDACTED]. Resident #1 was admitted directly to the keypad locked dementia unit without a Wander-Guard. There was no evidence that an admission elopement assessment was completed for this resident.A care plan, dated 12/18/15, documented cognitive decline with no interventions listed. This same care plan also documented that the resident was an elopement risk with interventions to encourage participation in activities, and engaging in active conversation as a form of redirection. The Resident had a Brief Interview for Mental Status (BIMS) score of 5/15 on 12/22/15, this score indicates the resident had severe cognitive impairment. Based on interview on 12/30/2015 at 12:30 PM, the Administrator reported that, at approximately 7:00 PM on 12/26/15, staff were alerted when the local police came into the facility and asked if Resident #1 was a resident of the facility. Facility staff members began a room-to-room search, but were unable to locate Resident #1. The police then notified the facility that Resident #1 was struck and killed on Route 50 (a local expressway) after being hit by a vehicle.The Administrator reported that, after reviewing the video recording of the camera at the front door, Resident #1 was seen exiting the front door at 6:54 PM dressed and wearing a coat, hat, and with a cane. The administrator stated that he/she was not sure how the resident eloped. The facility was unaware of how the resident was able to leave the locked unit, but noted that the facility had many visitors that evening.Record reviews and interviews determined that there was no incident that evening that would automatically unlock all of the magnetic doors and that there were no activities going on at the time. In an interview with the Administrator on 12/30/15 regarding Resident #1's lack of a Wander-Guard, she indicated that traditionally, this intervention was not utilized on the locked dementia unit and that, in the past, it had been viewed as a double restraint. The Administrator stated that there were some residents with Wander-Guards on the locked dementia unit. Placement of the Wander-Guard for residents on the dementia unit was based on individualized assessments. Resident #1 was known to have a history of exit seeking behaviors, but had not successfully exited the unit prior to this incident. Further interview with the Administrator, on 12/30/15, revealed that visitors to the locked dementia unit were handed a piece of paper with the unit key pad access number printed on it. The front door was also staffed by a receptionist daily approximately until 6:45pm though the front door remained open /unlocked. When the receptionist left the desk at approximately 6:45 PM, there was no additional monitoring of the front door for residents who have exit seeking behaviors. Review of the elopement binder at the front desk of the facility revealed pictures of residents in the facility who were identified as an elopement risk. Resident #1 was not included in the binder. After Resident #1 eloped, the facility conducted a facility-wide analysis to identify other residents who required Wander-Guard placement. Residents #6 and #13 resided in the facility off the locked unit and were identified as requiring Wander-Guard equipment but no Wander-Guard bracelets were available in the facility. During the survey, facility staff placed these two residents on 1:1 staffing while obtaining the additional bracelets. Immediacy was removed following the implementation of this intervention.