Every finding on record at Residences at Vantage Point

Based on record review and staff interview it was determined that the facility failed to develop and implement policies and procedures for medication regimen reviews, as evidenced by 1) failing to ensure that pharmacist identified irregularities reviewed by the attending physician, along with the action taken or not taken including rationale, was documented in the resident's medical record, and 2) failing to ensure medication irregularities were identified during monthly medication regimen reviews. This was evident for 4 (#6, #5,#16, #13) of 5 residents reviewed for unnecessary medication.The findings include: 1) On 3/11/26 at 2:45 PM, a review of Resident #6's February 2026 Medication Administration Record (MAR) revealed a 1/31/26 physician order for Metoprolol (lowers blood pressure) ER (extended release) by mouth one time a day for hypertension (HTN) (high blood pressure (BP)), hold for systolic (S) (top BP number) less than 110, or Pulse (P) less than 60 that documented Resident #6 received the Metoprolol every day in February. There was no documentation in the MAR to indicate that prior to the administration of metoprolol, Resident #6's BP and P was obtained, and metoprolol administered within the prescribed parameters. Review of Resident #6's March 2026 MAR revealed a 1/31/26 physician order for Metoprolol ER by mouth every day for HTN, hold for SBP less than 110 or P less than 60. The MAR documented Resident #6 received Metoprolol every day 3/1/26 to 3/12/26 with no documentation to indicate that prior to the administration of metoprolol, Resident #6's BP or P was obtained, and the metoprolol was administered within the prescribed parameters. On 3/18/26 at 9:02 AM, a review of Resident #6's electronic medical record (EMR) revealed monthly Pharmacist medication regimen reviews (MRR) on 2/2/26, 2/9/26 and 3/11/26 that documented see report for any noted irregularities and/or recommendations with no corresponding written reports of the pharmacist identified irregularities and recommendations found in the medical record and no documentation of the physician's potential response to the recommendations found in the medical record. A review of a binder located on the nurse's station and labeled, Note to Attending Physician/Prescriber, dated 1/26/26 - 3/2026, revealed pharmacist reports for resident MRR reviews conducted since 1/1/26. Review of the written reports for Resident #6's MRR reviews conducted on 2/2/26, 2/9/26 and 3/11/26 found documentation of irregularities identified by the pharmacist and the physician response to the pharmacist's recommendation which was not documented in the medical record. In addition, Resident #6's MRR reports revealed the pharmacist failed to identify the irregularity related to administration of medication without evidence of adequate monitoring. Cross Reference F 757 2) On 3/18/26 at 9:02 AM, a review of Resident #5's EMR revealed Pharmacist monthly MRR reviews on 3/10/25, 4/22/25, 5/20/25, 8/11/25, 9/9/25, 11/12/25 that documented see report for any noted irregularities and/or recommendations with no corresponding reports of the irregularities identified by the pharmacist, or the physician's potential response to the recommendations were found in the medical record. The Nursing Home Administrator (NHA) provided the surveyors with written reports dated 1/24/25 – 12/9/25 for all residents with pharmacist recommendations and indicated the pharmacist reports were in the Director of Nurses (DON) office and in a binder at the nurses station and had not bee uploaded into resident records. Review of the written pharmacist reports revealed a written reports for Resident #5 dated 3/10/25, 4/22/25, 5/20/25, 8/11/25, 9/9/25, 11/12/25 which documented pharmacist identified irregularities and recommendations, along with the physicians response which had not been documented in the medical record. On 3/19/26 at 12:15 PM, the above concerns were discussed with the NHA, who acknowledged the concern and offered no further comments at that time. 3) Resident #16's medical record was reviewed on 3/18/26 at 10:20 AM. Review of the monthly Pharmacist Consult Notes reflected that irregularities were identified for Resident #16 on 3/11/26, 2/9/26, 1/20/26, 11/12/25, 10/21/25, 7/22/25, 6/17/25, 5/20/25 and 4/22/25 and indicated see report. No reports of the irregularities identified by the pharmacist including physician response were found in the record. An unidentified unit staff member produced a binder from a shelf in the nurses' station containing the consultant pharmacist reviews for all residents titled Note to Attending Physician/Prescriber dated from 1/2026 – 3/2026. The reports for Resident #13 were in the binder with dated notation and signature of the provider. However, the resident's medical record did not reflect the irregularities identified by the pharmacist and the physician's response. The binder contained no record of reviews conducted prior to 1/2026. On 3/18/26 at 1:05 PM the Administrator provided a stack of Pharmacy review reports titled Notes to Attending Physician/Prescriber dated 1/24/25 – 12/9/25. She indicated they were for all of the residents with pharmacist recommendations and were in the DON's (Director of Nursing's) office. She was asked where to find the documentation of the irregularities/recommendations identified by the pharmacist and the physician's response, in the residents' medical records. She indicated the review forms would be placed in the resident's records and confirmed that the forms were in the DON's office and in the binder on the unit and were not yet uploaded in the resident records. Therefore, the irregularities/recommendations and the providers response were not currently documented in residents' records. 4) Review of Resident #13's medical record and the consultant pharmacist review forms on 3/18/26 at 2:31 PM revealed that irregularities/recommendations were identified by the pharmacist for Resident #13 on 4/22/25, 5/20/25, 7/22/25, 8/18/25, 9/9/25, 11/12/25, and 1/20/26. These reports were included in the documents located in the binder or DON's office and were not documented in the resident's medical record with the physician's response. These concerns were reviewed with the Administrator on 3/19/26 at 10:00 AM.

Based on medical record review and staff interview, it was determined the facility staff failed to reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive, and failed to ensure that a current copy of a resident's advance directive was in the resident's medical record. This was evident for 3 (#5, #12, #4) of 11 residents reviewed for advanced directives. The findings include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual are not able to make their own decisions. 1) On 3/10/26 at 11:50 AM, a review of Resident #5's paper medical record failed to reveal an advance directive for Resident #5. Review of the electronic medical record (EMR) on 3/13/26 at 11:07 AM revealedResident #5 resided in the SNF since March 2023, and no documentation was found in the EMR to indicate the resident had an advance directive, whether the resident/representative was informed of the right to formulate an advanced directive or wished to formulate an advanced directive. 2) On 3/10/25 at 12:00 PM, a review of Resident #12's paper medical record failed to reveal an advance directive for Resident #12. Review of the EMR on 3/13/26 at 10:00 AM, revealed Resident #12 resided in the SNF since December 2025, and no documentation was found to indicate the resident had an advance directive, or whether the resident/representative was informed of his/her right to formulate an advanced directive or wished to formulate an advanced directive. 3) On 3/10/25 at 12:49 PM, a review of Resident #4's paper medical record failed to reveal an advance directive for Resident #4. Review of the EMR on 3/13/26 at 11:07 AM revealed Resident #4 resided in the SNF since October 2025 and no documentation was found to indicate the resident had an advance directive, or whether the resident/representative was informed of his/her right to formulate an advanced directive or wished to formulate an advanced directive. On 3/13/26 at 1:19 PM, during an interview, when asked how, when a resident was admitted to the SNF, it was determined whether the resident had an advance directive and, if not, whether the resident wished to formulate an advance directive, Staff #9, Social Worker, Staff #9 stated that prior to January 2026, the SNF, which is part of a continuing care retirement community (CCRC), only admitted residents within the CCRC and s/he could get a copy of a resident's advanced directive from the CCRC' s wellness center (health clinic). When asked the process for addressing advanced directives with newly admitted residents who were not the CCRC, Staff #9 stated a marketing person addressed those resident admissions and indicated that s/he recently created a check list for admissions that included advanced directives. Following the interview, Staff #9 was made aware of the above concerns with advanced directives not being found in the resident's medical record with no documentation to indicate the resident and/or the resident's representative had been informed of the right to formulate an advanced directive. On 3/13/26 at 3:10 PM, Staff #9 provided the surveyor with a copy of an advanced directive for Resident #5, a copy of an advanced directive for Resident #4 and stated s/he still had to get one for Resident #12. As of the end of the survey, no additional documentation was provided to the surveyor. On 3/19/26 at 12:15 PM, the Nursing Home Administrator (NHA) was made aware of the above concerns. At that time, the NHA acknowledged the concerns and offered no further comments. No additional documentation was provided to the surveyor regarding as of the time of exit on 3/19/26 at approximately 12:30 PM,

Based on record review and interview it was determine the facility staff failed to notify the physician when a resident was identified to have a significant weight loss. This was evident for 1(#13) of 5 residents reviewed for Nutrition.The findings include:Resident #13's medical record was reviewed on 3/10/26 at 1:12 PM. The resident's weight record in the EMR (Electronic Medical Record) revealed that on 12/5/25 the resident weighed 320 lbs.(pounds). No weights were recorded for January or February 2026. Resident #13's next documented weight was 3/4/26 by Staff #4 the MDS nurse. The resident's weight at that time was 281.8 lbs. It was checked and recorded again the next day 3/5/26, as 281.8 lbs. by Staff #6 an LPN (Licensed Practical Nurse). The weights obtained on 3/4/26 and 3/5/26 reflected a 38.2 lb. or 11.94% significant weight loss over 3 months. A weight change note was written on 3/5/26 by the DON (Director of Nursing) for Weight Warning and reflected Resident #13's significant weight loss and included Dietitian will address, will have him/her on weekly weight. A Quarterly Nutrition Evaluation dated 3/5/26 by the Dietician addressed Resident #13's significant weight loss, his/her nutrition diagnoses and indicated that the resident had no nutritional deficiency per available labs. and that his/her Glycemic control was adequate.Resident #13's Nutrition Plan of Care developed on 12/5/24 was revised on 3/5/26. One of the Care Plan intervention initiated on 12/5/24 was: Weigh per orders and alert MD (Physician)/RD (Registered Dietician) of any significant weight changes. There was no indication that the physician or another medical provider was notified when Resident #13 was assessed to have a significant weight loss on 3/4 and 3/5/26. Further review of the medical record on 3/12/26 at 2:08 PM revealed a monthly provider note written by Staff #10, a CRNP (Certified Registered Nurse Practitioner) on 3/11/26 at 3:42 PM. The note included Appetite satisfactory, weight stable. There was no documentation to indicate that the CRNP was aware that Resident #13 was assessed to have a significant weight loss on 3/4/26. An interview was conducted on 3/17/26 at 11:21 AM with Staff #4 the MDS (Minimum Data Set) nurse, who was filling in while the Director of Nursing was away. She was made aware of the above findings. When asked if it would be documented in the resident's record that the physician was notified of the resident's weight changes she indicated that it should be. The Administrator was made aware of these findings on 3/19/26 at 10:00 AM.

Based on observation, medical record review and staff interview it was determined that the facility failed to develop and implement comprehensive resident person-centered care plans with measurable goals and interventions. This was evident for 1 (#18) of 3 resident's reviewed for respiratory care, and 2 (#6, #5) of 5 residents reviewed for unnecessary medications.The findings include: The MDS (Minimal Data Set) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. 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. 1.) On 3/9/26 at 11:53 AM the surveyor observed Resident #18 lying in bed wearing a nasal cannula (NC). A nasal cannula is a tube used to administer oxygen through the nose. The cannula was connected to an oxygen concentrator (a machine that concentrates and delivers oxygen from room air). Review of Resident #18's medical record on 3/13/26 at 11:21 AM revealed a physician order for Oxygen at 2L/min (2 Liters per minute) via NC as needed for SOB (shortness of breath). The order was included on Resident #18's TAR (Treatment Administration Record) with spaces for staff to document and sign off when they administer the oxygen. For the month of March 2026 Resident #18's oxygen was signed off as administered on 3/6/26, and 3/10/26. It was not signed off as administered on 3/9/26 as observed by the surveyor. The February 2026 TAR revealed that supplemental oxygen was administered to Resident #18 on 2/13/26. Review of Resident #18's Plans of Care revealed the facility staff failed to develop a Plan to address Resident #18's respiratory/pulmonary problems or the need for or use of supplemental oxygen. During an interview on 3/13/26 at 12:28 PM Staff #8 the CRNP (Certified Registered Nurse Practitioner) indicated that Resident #18 was prescribed oxygen for Diastolic Heart Failure and history of Pulmonary Embolism. Staff #4 the MDS (Minimum Data Set) nurse was made aware of these findings on 3/17/26 at 11:28 AM. She provided no explanation as to why the Plan of Care did not identify Resident #18's need for and the provision of supplemental oxygen. The facility Administrator was made aware of these concerns on 3/19/26 at 10:00 AM. Cross reference F 695. 2.) On 3/12/26 at 10:00 AM, a review of Resident #6's electronic medical record (EMR) was conducted. The medical record documented Resident #6 was admitted to the facility in late January 2026 for rehabilitation following a revision of a left hip hemiarthroplasty (a surgical procedure to treat hip fractures). A hospital Discharge summary dated [DATE] documented Resident #6 required a left knee immobilizer and hip abduction brace and would be required to wear the brace for 3 months and could only be removed for showers with care to hold the leg in a neutral position. Review of Resident #6's physician orders revealed a 2/1/26 order, Resident to be in bed with pillows for pressure relief 24/7. Bed cannot be rolled up past 60 degrees. Resident cannot be up in wheelchair unless cleared by ortho, a 2/2/26 order, Left Hip abductor brace and left knee extension brace to be worn at all times, May be removed briefly for showers with someone holding the left leg to support the left leg during shower; a 2/9/26 order, Abductor pillow to be worn at all times. Check for skin integrity; a 2/27/26 order, Abduction wedge to be used at all times while patient is in bed. Resident #6's admission MDS assessment with an assessment reference date (ARD) of 2/5/26 documented that the resident had severe cognitive impairment, that s/he had functional limitations in range of motion (ROM) of one of his/her lower extremities, and the resident was dependent on staff for all activities of daily living. The MDS further documented Resident #6's had diagnosis that included dislocation of internal left hip prothesis, presence of left artificial hip joint, and the resident also had a diagnose of a seizure disorder. Review of Resident #6's care plans failed to reveal evidence that a comprehensive care plan, with measurable goals, and resident centered interventions had been developed to address Resident #6's limited range of motion, immobility and positioning needs following his/her surgical revision of left hip hemiarthroplasty, and use of a left hip abduction brace and left knee extension brace which the resident was required to wear 24 hours a day, as well as the abduction pillow required to maintain proper leg alignment. Further review of Resident #6's care plans failed to reveal a comprehensive care plan had been developed to address Resident #6's ADL (Activity of Daily Living) and functional care needs. Resident #6's had care plan, Current ADL (Activities of Daily Living) - Functional Status initiated 1/30/26 with the goal, Resident #6 will maintain or improve current functional ADL abilities, had one intervention, Ambulation: 2 person assist. The care plan's only intervention was inaccurate, as Resident #6 was non-ambulatory. In addition, the resident had a care plan, Resident #6 at risk for functional abilities, decline, initiated on 1/30/26, with the goal, the resident will return to desired level of function with the interventions, assess [Resident #6] current functional level, and Physical therapy, Occupational Therapy and Speech Therapy to eval and treat per physician order. The care plan was not comprehensive and failed to included interventions specific to the resident. Continued review of Resident #6's care plans failed to reveal a comprehensive care plan had been developed to address Resident #6's ADL and functional care needs. Review of Resident #6's February 2026 Medication administration record (MAR) revealed a 1/31/26 physician's order for Topiramate (Topamax) (ant-seizure medication) by mouth in the morning for seizures that was documented as given every morning in February and the resident's February 2026 treatment administration record (TAR) had a 2/2/26 order for seizure precaution (safety measures to prevent injury to the resident during a seizure). Continued review of the resident's care plans failed to reveal a comprehensive, resident centered care plan, with measurable goals and interventions had been developed to address Resident #6's seizure disorder. On 3/17/26 at 12:24 PM, when asked who responsible for developing resident care plans, Staff #6, Licensed Practical Nurse (LPN) indicated resident care plans would be initiated by the nurse, then modified, or made resident centered by MDS and MDS was responsible for reviewing care plans and making any changes. During an interview on 3/17/26 at 3:03 PM, Staff #4, Registered Nurse, MDS Coordinator stated s/he was responsible for initiating and updating resident care plans. The above concerns were then discussed with Staff #4, who confirmed the findings and offered no further comments at that time. 3) On 3/18/26 at 9:02 AM, a review of Resident #5's medical record was conducted and revealed the resident resided in the skilled nursing facility for long term care since the end of March 2023. Review of Resident #5's Significant Change MDS with an ARD of 1/15/26 documented Resident #5 was moderately cognitively impaired and had an active diagnosis of Non-Alzheimer's dementia and anxiety disorder. Review of Resident #5's progress notes revealed, on 3/9/26, in a Health Services note, the Certified Registered Nurse Practitioner - Psychiatric Mental Health (CRNP-PMH) wrote the reason for the visit was for follow-up evaluation of mood and management of psychotropic [medication]. The CRNP-PMH documented Resident #5's had psychiatric history of dementia, aggressive behavior and agitation, with target symptoms of intermittent insomnia, intermittent depressive symptoms and intermittent dementia related agitation/anxiety. In a practitioner encounter note for routine follow-up, on 3/11/26, the CRNP wrote that Resident #5's medical history included unspecified dementia, moderate mood disorder, mild cognitive impairment, and generalized anxiety disorder. The CRNP's assessment and plan documented Resident #5 had moderate dementia with mood disturbance, stable baseline with decline anticipated due to natural disease progression, and agitation due to dementia; continue Depakote. Review of Resident #5's February 2026 MAR revealed a 7/9/24 order for Depakote (divalproex) (anticonvulsant, mood stabilizer) by mouth 2 times a day for mood disorder that was documented as given 2 times a day, every day in February. Resident #5's March 2026 MAR documented the resident received Depakote by mouth 2 times a day, every day from 3/1/26 to 3/17/26 for a mood disorder. 3a.) Review of Resident #5's care plans revealed a care plan, Resident #5 uses antipsychotic medications: Depakote, with the goal, will be free from side effects due to the use of antipsychotic medication through the review date, and the interventions, 1. administer medication as ordered, 2. AIMS Test every six months and as needed, 3. Behavior Health Services Consult as ordered, 4. Consult with MD to consider dose reduction at least every three months, 5. Educate the resident/family/caregivers on the risk, benefits, potential side effects, reason for medication, and alternatives to antipsychotic medications, 6. Monitor Vital Signs as ordered. Report abnormalities to HCP, 7) Monitor/record/report to MD side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person, and 8) Monitor/Document behaviors and side effects on Behavior Monitoring Form The care plan erroneously identified Depakote as an antipsychotic, which was inaccurate and prescribed as mood-stabilizer for Resident #5. In addition, the care plan had no resident centered interventions that addressed Resident #5's mood disorder or the behaviors for which the Depakote had been prescribed. Continued review of the resident's care plans failed to reveal a person-centered care plan had been developed that addressed Resident #5's mood disorder and the behaviors for which Depakote had been prescribed. Resident #5 had a care plan, Behavior management, delusional behavior (episodic), wandering behavior, behavior toward staff (cursing, yelling) with the goal, undesirable behavior(s) will be monitored managed, and the interventions, 1. Attempt an alternate time to provide care refused,2. Ensure wanderguard is in place and functioning properly,3. Evaluate elopement risk, 4. Monitor for cognitive factors that may contribute to new behavior, 5. Monitor for emotional factors that may contribute to new behaviors.6. Monitor for signs/symptoms of infection, 7. Provide emotional support regarding new onset delusions. Provide emotional support regarding onset disruptive behavior, and 8. Provide verbal feedback to resident regarding behavior. The behavior care plan was not comprehensive, the goal was not resident centered and measurable. There was no indication of the underlying reasons for the resident's behavior and the interventions failed to include nonpharmacological approaches directed at understanding, preventing, and relieving the behavioral and psychological symptoms of the resident's distress. Continued review of Resident #5's care plans, failed to reveal a person-centered care plan that addressed Resident #5's cognitive decline and dementia care needs with measurable goals and resident centered interventions that addressed the resident's symptoms and rate of progression. The Nursing Home Administrator (NHA) was made aware of the above concerns on 3/19/26 at approximately 12:15 PM. The NHA acknowledged the concern and offered no further comments at that time.

Based on observation, record review and interview it was determined the facility staff failed to ensure that each resident received necessary respiratory care and services consistent with professional standards of practice by failing to administer oxygen at the prescribed rate, failing to assess and document the resident's immediate and ongoing need for, provision of and response to supplemental oxygen. This was evident for 1 (#18) of 3 residents reviewed for Respiratory Care.The findings include:On 3/9/26 at 11:53 AM the surveyor observed Resident #18 lying in bed wearing a nasal cannula (NC) - a tube used to administer oxygen through the nose. The cannula was connected to an oxygen concentrator - a machine that concentrates and delivers oxygen from room air. The concentrator was set to deliver oxygen at 3 L/min (Liters per minute). Review of Resident #18's medical record on 3/13/26 at 11:21 AM revealed a physician's order for Oxygen at 2L/min via NC as needed for SOB (shortness of breath); not 3L/min as observed by the surveyor. The order for 2L/min was included on Resident #18's TAR (Treatment Administration Record) including spaces for staff to sign off when the oxygen was administered.Review of Resident #18's Plans of Care revealed the facility staff failed to develop a plan to address Resident #18's Respiratory/Pulmonary problems or Oxygen use.During an interview on 3/13/26 at 12:28 PM Staff #8 the CRNP (Certified Registered Nurse Practitioner) indicated that Resident #18 was prescribed oxygen for Diastolic Heart Failure and history of Pulmonary Embolism. The resident was observed again on 3/13/26 at 2:16 PM and 3/17/26 at 9:06 AM, lying in bed with Oxygen via NC from the concentrator which was set at 3L/min.Review of the residents TAR (Treatment Administration Record) record on 3/17/26 at 9:13 AM revealed that staff signed off administration of oxygen to Resident #18 on 3/6/26, and 3/10/26. It was not signed off as administered on 3/9/26, 3/13/26 or 3/17/26 as observed by the surveyor.No progress notes related to the administration of Resident #18 oxygen were found in his/her medical record, including but not limited to an assessment of the resident, his/her oxygen saturations, presence of respiratory symptoms and effectiveness of the oxygen intervention.Staff #7 an LPN (Licensed Practical Nurse) was assigned to provide care for Resident #18 and was interviewed on 3/17/26 at 10:45 AM. She confirmed that administration of Resident #18's oxygen was signed off for 3/6/26 and 3/10/26. She confirmed that the resident was currently receiving oxygen and indicated that she had not signed it off yet for that date.She was asked to identify what parameters were used to determine if and when the resident required the oxygen. She stated, our protocols indicated that any resident with an oxygen saturation less than 90% needs to have oxygen. When asked to provide resident #18's oxygen saturation readings for that day she indicated that she had not checked it. When asked to explain what protocol she used to determine that Resident #18 required supplemental oxygen on that date she stated: I will check him/her with the oxygen on if more than 90% I will take it off, recheck then reapply if needed and notify the Nurse Practitioner and doctor, then document it in the progress note. There was no evidence that she had done that, that morning.Staff #7 observed the resident with the surveyor at that time and confirmed that the oxygen concentrator was set at, and delivering 3L/min instead of 2L/min as ordered by the physician. Staff #4 the MDS (Minimum Data Set) nurse who was filling in for the Director of Nursing, was made aware of these findings on 3/17/26 at 11:28 AM. The facility Administrator was made aware of these concerns on 3/19/26 at 10:00 AM.Cross reference F 656

Based on a review of the medical record and interview with staff it was determined that the facility failed to ensure that the physician addressed a significant weight gain/weight loss. This was evident for 1 (#3) of 5 residents reviewed for weight gain/weight loss.The findings include:On 3/12/26 at 9:30 AM, a review of Resident #3's medical record revealed, in a weight tracking system report, Resident #3's weight was documented as 181 pounds on 2/24/26 and 195 pounds on 3/1/26, which was a 7.7 % weight gain in 8 days. Further, the record review revealed that the dietician did not document in the medical record that the resident had a 7.7% gain in 8 days, and no other follow-up was noted by the dietician in the medical record.Continued review of the medical record failed to reveal that the physician did not evaluate and addressed the resident's significant weight gain when it was identified. Progress notes were reviewed in the medical record on 3/9/2026, with no mention of a 7.7% weight gain for Resident #3.On 3/12/26 at 10:40 AM during an interview, the Administrator Director confirmed that no documentation was present to indicate that the physician had addressed Resident #3's weight gain

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician orders to follow blood pressure and pulse parameters for administering a blood pressure medication. This was evident for 1 (#6) of 5 residents reviewed for unnecessary medications. The findings include: On 3/11/26 at 2:45 PM, a review of Resident #6's February 2026 Medication Administration Record (MAR) revealed a 1/31/26 physician order for Metoprolol Succinate (lowers blood pressure) ER (extended release) tablet by mouth one time a day for hypertension (HTN) (high blood pressure (BP)) and hold for systolic (S) (top number of BP) reading) less than 110, or Pulse (P) (heart rate) less than 60 that documented Resident #6 received the Metoprolol every day in February. There was no documentation in the MAR to indicate that prior to the administration of the metoprolol, Resident #6's BP and P were monitored and the metoprolol administered within the parameters of the physician's order. Review of Resident #6's March 2026 MAR revealed a 1/31/26 physician order for Metoprolol by mouth every day for HTN and hold for SBP less than 110 or P less than 60 that documented Resident #6 received Metoprolol every day from 3/1/26 to 3/12/26. There was no documentation in the MAR to indicate that prior to the administration of the metoprolol, Resident #6's BP and P was monitored and the metoprolol administered within the parameters of the physician's order. The above concerns were discussed with Staff #4, Registered Nurse (RN), Minimum Data Set (MDS) Coordinator on 3/17/26 at 3:29 PM. Staff #4 acknowledged the concerns and offered no further comments at that time.

Based on medical record review and staff interview, it was determined that the facility staff failed to keep complete and accurate medical records. This was evident for 5 (#4, #12, #11,#18, #16) of 10 residents reviewed for Advanced Directives and 1 (#13) of 5 residents reviewed for nutrition. The findings include Maryland Orders for Life Sustaining Treatment (MOLST) includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options based on a patient's wishes. It is valid in all healthcare facilities and programs throughout Maryland. Section 1 includes orders to Attempt CPR or No CPR. Included in the No CPR section are three options: A-1 Intubate; A-2 Do Not Intubate but comprehensive efforts may include limited ventilatory support by CPAP or BiPAP; or Option B No CPR, Palliative and Supportive Care. Section 2 to 9 have options for situations other than cardiopulmonary arrest. Per the MOLST instructions: Updating the Form: The MOLST form shall be voided and a new MOLST form prepared when there is a change to any of the orders. If modified, the physician, NP, or PA shall void the old form and complete, sign, and date a new MOLST form. Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. Keep the voided order form in the patient's active or archived medical record. 1) On [DATE] at 10:19 AM, a review of Resident #11's paper medical record revealed a voided MOLST and an unvoided MOLST: - Resident #11 had a MOLST, signed and dated [DATE], with VOID handwritten across the MOLST. - The resident had an unvoided (active) MOLST, that elected Option A-1, Intubate, and options in Section 2-9, that was signed and dated [DATE]. On [DATE] at 9:00 AM, a review of scanned documents in Resident #11's EMR revealed the resident had more than one unvoided (active) MOLST in the medical record: - Resident #11 had an unvoided MOLST, that elected Attempt CPR, and options selected in sections 2-9, that was signed and dated [DATE]. - Resident #11 had an unvoided (active) MOLST that elected Option A-1, Intubate, and options in Section 2-0 that was signed and dated [DATE] and matched the unvoided MOLST in the resident's paper medical record. The practitioner failed to void Resident #11's previous MOLST when a new MOLST was created as evidenced by more than one unvoided MOLSTs in the resident's medical record. 2) On [DATE] at 12:00 PM, a review of Resident #12''s paper medical record revealed an unvoided (active) MOLST and an unsigned MOLST. - Resident #12 had an unvoided MOLST that elected No CPR, Option A-2, Do not intubate (DNI), with options selected in Section 2-9, that was signed and dated [DATE]. - There was an unsigned, undated MOLST labeled with Resident #12's name, date of birth , and gender, that elected, No CPR, Option B, Palliative and Supportive Care, and options in Section 2-9. A MOLST that has not been signed by the practitioner is not a valid order. There is potential to cause confusion when the invalid MOLST is kept with active orders in the resident's medical record. On [DATE] at 10:00 AM, a review of scanned documents in Resident #12's EMR revealed the resident had 2 unvoided (active) MOLSTs in the medical record: - Resident #12 had an unvoided MOLST that elected, Attempt CPR, and was signed and dated [DATE]. - Resident #12 had an unvoided MOLST that elected No CPR, Option A-2, Do not intubate (DNI), that was signed and dated [DATE] and matched the unvoided MOLST dated [DATE] in the resident's paper medical record. The practitioner failed to void Resident #12's previous MOLST when a new MOLST was created as evidenced by more than one unvoided MOLSTs in the resident's medical record. 3) On [DATE] at 12:49 PM, a review of Resident #4's paper medical record revealed copies of 2 unvoided MOLSTs and one voided MOLST in the resident's paper record, - There were 3 copies of an unvoided MOLST for Resident #4 that elected No CPR, Option A-2, Do not intubate (DNI), with no options selected in section 2-9, that was signed and dated [DATE] at 1:58 PM. - Resident #4 had a voided MOLST that had VOID handwritten across the MOLST. The voided MOLST elected No CPR, Option A-2, Do not intubate (DNI), was signed and dated [DATE] at 1:58 PM and matched the [DATE] unvoided MOLST in the paper record. - There were 2 copies of an unvoided (active) MOLST for Resident #4, that elected No CPR, Option A-2, DNI and options in Section 2 -9 that was signed and dated [DATE]. On [DATE] at 11:07 AM, review of scanned documents in Resident #4's EMR revealed more than one unvoided MOLST in Resident #4's medical record: - Resident #4 had an unvoided MOLST that elected No CPR, Option A-2, Do not intubate (DNI), with no options selected in section 2-9, that was signed and dated [DATE] at 1:58 PM. The unvoided MOLST matched the unvoided MOLSTs dated [DATE] in the resident's paper record. - Resident #4 had an unvoided MOLST that elected No CPR, Option A-2, DNI and options in section 2 -9 that was signed and dated [DATE] and matched the unvoided MOLST dated [DATE] in the resident's paper record. The facility failed to ensure that when an updated MOLST was completed, all older forms were voided in accordance with the form's instructions. The concerns with resident's having more than one unvoided MOLST in the medical record were discussed with the Nursing Home Administrator on [DATE] at 3:40 PM. The NHA acknowledged the concerns at that time and stated they were looking at their process. 4) Maryland 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 patient's wishes about medical treatments. The instructions for completing the MOLST includes: Health care facilities and programs shall maintain this order form (or a copy of it) with other active medical orders or in a section designated for MOLST and related documents in the patient's active medical record. Updating the Form: The MOLST form shall be voided and a new MOLST form prepared when there is a change to any of the orders. If modified, the physician, NP, or PA shall void the old form and complete, sign, and date a new MOLST form. Voiding the Form: To void this medical order form, the physician, NP (Nurse Practitioner), or PA (Physician's Assistant) shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. Keep the voided order form in the patient's active or archived medical record. 4A) Resident #18's medical record was reviewed on [DATE] at 11:58 AM. A MOLST signed and dated [DATE] by Staff #8 a CRNP (Certified Registered Nurse Practitioner) indicating NO CPR Option B. Palliative & Supportive Care. The form was in the front of the paper record behind the face sheet. Another MOLST form signed and dated by Staff #8 on [DATE] included the notation Social worker discussed with pt (patient) on [DATE]. This form also identified No CPR Option B, and was located behind the Advance Directive tab in Resident #18's paper record with a photocopy of the form. Resident #18's EMR (Electronic Medical Record) contained a scanned copy of the MOLST form dated [DATE] as well as a MOLST signed and dated by Staff #8 on [DATE] indicating Attempt CPR. None of the MOLST forms were voided as per the MOLST instructions. 4B) Resident #16's medical record was reviewed on [DATE] at 10:20 AM. The paper chart contained a MOLST form signed and dated by Staff #8 on [DATE] indicating No CPR option A-2 DNI (Do Not Intubate). The dates [DATE], [DATE] and [DATE] with 0 changes and initials were written across the bottom of the first page. Another MOLST form signed and dated by Staff #8 on [DATE] was in the Social Services section of the paper record. The word VOID was written diagonally across the form without a signature or date. This MOLST was also scanned into the EMR however it did not include the VOID. An interview was conducted with Staff #8 the CRNP on [DATE] at 12:18 PM. She was asked to explain the process for completing MOLST forms. She indicated that she walks the resident or their responsible party through the whole form. She stated, If I'm the one doing a new MOLST, I void the old one and put it in the Social Work section of the paper chart. When asked to explain why there were unvoided copies of previous MOLST forms in the records she stated: That's the tragedy of the MOLST form, some things are in the paper chart, some have to be scanned into the EMR. An interview was conducted with Staff #9 the Social Worker on [DATE] at 1:02 PM. She indicated that old MOLST forms were put into the Social Service section of the resident's record. When asked what happened to the MOLST's that were scanned into the EMR she stated, I thought you can't delete it. When asked who voids the previous MOLST forms she stated, I do, sometimes it's (Staff #8), usually it's one of us but sometimes it's Staff #5 (the physician). She indicated that she was not familiar with the instructions for MOLST forms. The Administrator was made aware of these concerns on [DATE] at 10:00 AM. 5) Resident #13's medical record was reviewed on [DATE] at 1:12 PM. The resident's weight record in the EMR (Electronic Medical Record) revealed that on [DATE] the resident weighed 320 lbs.(pounds). No weights were recorded for January or February 2026. There was no notation as to why his/her weight was not obtained. Resident #13's next documented weight was 281.8 pounds on [DATE] by Staff #4 the MDS (Minimum Data Set) nurse and on [DATE] by Staff #6 an LPN (Licensed Practical Nurse). On [DATE] at 11:26 AM the surveyor requested copies including but not limited to Resident #13's weight log for the past year. The Administrator provided a list with the print date [DATE] 12:22 PM which reflected entries for September and [DATE] and [DATE]. She returned a short time later with another list with the print date [DATE] 13:16 (1:16 PM) which included weight entries for April, May, June, August, September, October, November and [DATE] as well as [DATE]. She indicated that this was a revised list and that all the weights were not entered when she provided the first list to the surveyor. During an interview on [DATE] at 4:13 PM Staff #4 provided 6 paper Monthly Vital Sign Sheets which listed resident's names. Review of the logs revealed: 1 page hand labeled Monthly Weights [DATE] shift 7-3. No weight was listed in the space for Resident #13 or notation of why it wasn't obtained. 2 pages were labeled Monthly Weight February 2026, and a second page labeled Weights [DATE], 7-3 which included a weight of 213.4 beside Resident #13's name. The page labeled Monthly Weights, [DATE] included 281.8 which was heavily scribbled out, and 320.4 written beside it. There was no other notation related to this weight recording. Staff #4 was unable to identify who obtained the weights, why his/her February weight was not documented in the resident's record. She was unable to identify who changed Resident #13's March weight or when and why it was done. When asked why there were weights recorded on the paper forms that were not recorded in each resident's medical record, she indicated that she will usually enter the resident weights into the EMR quarterly, prior to completing the resident's MDS assessment. She was unable to identify the facilities policy or procedure for ensuring accurate and timely documentation of the residents' weights into the medical records.

Based on observation, record review, and interview it was determined the facility staff failed to ensure respiratory care equipment was 1) properly date labeled, and 2) cleaned and stored as per the manufacturer's instructions. This was evident for 2 (#18 and #13) of 3 residents reviewed for Respiratory Care.The findings include: 1) On 3/9/26 at 11:53 AM the surveyor observed Resident #18 lying in bed wearing a nasal cannula (NC) (a tube used to administer oxygen through the nose). The cannula was connected to an oxygen concentrator (a machine used to concentrate and deliver oxygen from room air). A piece of white tape was attached to the nasal cannula tubing with the date 3/1/26 in black marker. Another observation on 3/17/26 at 9:06 AM revealed Resident #18's nasal cannula tubing had no date label. On 3/17/26 at 10:45 AM Staff #7 an LPN (Licensed Practical Nurse) observed the resident in his/her room with the oxygen running via NC and confirmed the nasal cannula was not labeled. She indicated that she did not know why the tubing wasn't labeled. Review of Resident #18's medical record on 3/13/26 at 11:21 AM revealed a physician's order for Oxygen at 2L/min via NC as needed for SOB (shortness of breath). The order was included on Resident #18's TAR (Treatment Administration Record) including spaces for staff to document the oxygen administration. No information was found in the resident's record regarding how and when staff were to clean and/or replace the equipment used to administer the resident's oxygen. The facility policy/procedure for Oxygen Administration, provided by the Administrator revealed: The purpose of this procedure is to provide guidelines for safe oxygen administration. However, the policy/procedure did not include instructions related to cleaning or replacement of oxygen administration equipment to minimize risk of infection. The policy revision date was October 2010. The Centers for Disease Control and Prevention (CDC) recommends: Nasal cannulas should be cleaned weekly with soap/water and replaced every 2-4 weeks, while filters are cleaned weekly. 2) CPAP stands for Continuous Positive Airway Pressure, a common, non-invasive therapy for breathing disorders, particularly obstructive sleep apnea (OSA). It uses a machine to deliver a continuous, gentle stream of pressurized air through a mask, keeping the airway open during sleep to prevent apnea episodes, snoring, and to improve oxygen levels. Resident #13 and his/her room were observed on 3/10/26 at 10:30 AM. The resident was lying in bed. A CPAP machine was on the nightstand beside the head of the bed. The humidification/water chamber was in the machine. The CPAP tubing was draped over the table with the face mask hanging down over the right side of the table approximately 18 inches above the floor, uncovered. The resident was asked but unable to identify how the facility cleans and maintains his/her CPAP machine, s/he was unable to identify where the manufacturers' instructions were located. Another observation was made on 3/12/26 at 9:17 AM. The water chamber was in the CPAP machine, and the mask was hanging over the top of the machine uncovered.Review of Resident #13's medical record on 3/12/26 at 12:52 PM revealed several physician orders and TAR (Treatment Administration Record) for:CPAP on at bedtime;Remove water chamber and allow to air dry;Change distilled water in water chamber every day shift;CPAP filter - change every 2 weeks on night shift every Friday;Inspect the filter weekly on night shift Friday;Clean CPAP and tubing with soap and water every week on Wednesday.There were no specific directions on how to clean and dry the machine or the tubing, how or when to clean the water chamber, and face mask, how often to replace the face mask, water chamber and tubing, or storage of the face mask when not in use. Resident #13's Plan of Care for Sleep Apnea included the use of the CPAP Machine. The resident's goal was (Resident #13) will have no complications with CPAP or sleep apnea. Interventions included: apply CPAP at night as ordered and Clean CPAP per manufacturer's instructions. An interview was conducted with Staff #7, the LPN (Licensed Practical Nurse) providing care for Resident #13 on 3/17/26 at 10:33 AM. When asked where to find the manufacturer's instructions for the care of Resident #13's CPAP equipment she initially indicated that they were in the EMR (electronic medical record). When asked to show the surveyor the cleaning/replacement instructions for the machine and equipment she showed the surveyor the TAR. When asked specifically where to find the instructions regarding the care/cleaning of the water chamber and face mask as well as storage/replacement of components other than the filter she indicated that she was not sure. She accompanied the surveyor to Resident #13's room at that time and observed that his/her CPAP face mask was lying on the floor under the head of the resident's bed. She confirmed the water chamber was still in the machine and began tipping the machine around and over in an attempt to determine if it contained water, potentially spilling water into the electronic components of the machine. When asked where to find the manufacturer's instruction manual for the CPAP machine she indicated that it may be in the back of the resident's paper medical record but was not sure. Further review of Resident #13's paper medical record on 3/17/26 at 10:58 AM failed to reveal manufacturer's instructions for the CPAP machine. Review of the facility policy for CPAP/BiPAP Support revealed General Guidelines for Cleaning 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device. On 3/17/26 at 11:00 AM Staff #4, the MDS (Minimum Data Set) nurse was made aware that there was no evidence the facility staff had a process to ensure that Resident #13's CPAP equipment was cleaned, maintained and stored in a sanitary manner and as per the manufacturer, as indicated in Resident #13's Plan of Care and the facility policy. The Administrator was made aware of these concerns on 3/19/26 at 10:00 AM.

Based on observations, interviews and facility record review it was determined the facility failed to ensure food handling practices were followed in accordance with professional standards for food service safety, ensure the dishwashing system met the required minimum temperatures and chemical concentration, ensure monitoring of dishwasher chemical concentration and food service equipment functioning, ensure thorough environmental cleaning of the kitchen, and ensure the monitoring of food temperatures and food storage. These deficient practices have the potential to affect all residents. The findings include: On 12/2/24 at 8:00AM during the surveyor's initial tour of the facility's kitchen the surveyor noted the following signage was present: Attention team! All food items must have the following: label, date, item covered. On 12/2/24 at 8:03AM during the surveyor's initial tour of the facility's kitchen the surveyor noted the following signage present on the facility's walk-in refrigerators/freezers: All product stored in this walk-in must be: covered, labeled, dated, any product over five (5) days old must be discarded. On 12/2/24 at 8:04AM the surveyor observed baking trays on a movable rack within the walk-in freezer containing the following items: an open, spilled bag of frozen corn mix on a baking tray, scattered pieces of ginger, a package containing two squares of brown meat-type product in which the label read: If frozen, best by 10JAN2023 which was noted to have lost the vacuum type seal, an unlabeled brown meat product loosely wrapped in saran wrap with uncovered areas exposed, unlabeled white meat product in a bag, an open unlabeled bag of cream puffs, an opened unlabeled bag of biscuit/cookie type dough, a package of brown meat with a label which read 10/7/24 and did not identify what the product was, assorted, spilled, uncovered pieces of foods/crumbs, a pan of prepared meat with a label which read 11/28 and did not identify what the product was, an open bag of turnover pastries with uncovered areas, an unlabeled bag of meat type product, a pan of prepared food with a label which read: 10/24 and no information identifying what the food was, a pan of what appeared to be chicken with a label which read: 11/28 with no identifying information as to what the food product was, an open and exposed package of pie crusts, 2 pans of frozen meat with no labeling, a package of open and spilled okra, and another pan of meat-type product with a label which read: 5/7 with no information indicating what the food was. Concerns were shared with [NAME] #5 who observed the concerns and reported they did not know when the foods should be thrown away, and was unable to identify what many of the food items were. On 12/2/24 at 8:10AM the surveyor observed 8 metal pans containing food products in the walk-in refrigerator with a label indicating a prep date of 12/1 with no information identifying the food products. One container of raw meat was observed stored next to a container of ready to eat salad. A bag of saran wrapped chopped cooked meat-type product was observed with a label dated 11/24, however there was no indication on the labeling of what the product was. Another bag of meat type product was observed dated 11/24 with no other identifying information completed on the labeling. Concerns were shared with [NAME] #5 who acknowledged and confirmed understanding of the concerns. On 12/2/24 at 8:11AM the surveyor observed a pan of roast beef slices in the walk in refrigerator with a label which read: 10/30. [NAME] #5 confirmed with the surveyor that this should have been discarded. On 12/2/24 at 8:12AM the surveyor observed a container of labeled teriyaki sauce in the walk in refrigerator with a date of 11/24. [NAME] #5 confirmed with the surveyor that this should have been discarded. On 12/2/24 at 8:12AM the surveyor observed a meat-type mixture in a pan in the walk in refrigerator that had a label dated 11/21. The label did not identify what the food product was. [NAME] #5 confirmed with the surveyor that this should have been discarded and removed the item from the refrigerator. Observation by the surveyor on 12/2/24 at 8:13AM of the walk-in refrigerator near the kitchen's office revealed a saran wrapped tray which included cheese, strawberries, and grapes on it with a label dated 11/19. [NAME] matter/growth and brown areas was observed on strawberries. The circular thermometer located on the outside of the walk in refrigerator was observed to have masking tape on it, and was covered with frost on the inside. Observation of the temperature on the exterior thermometer of the walk in refrigerator read approximately -20 degrees, as compared to the surveyor's observation of the interior thermometer which read approximately 41 degrees. Foods within the walk-in refrigerator were noted to be refrigerated, not in frozen condition, indicating the exterior temperature gauge was not properly functioning. Concerns were shared with [NAME] #5 who observed the concerns, and removed the fruit and cheese tray. On 12/2/24 at 8:17AM the surveyor observed an unlabeled baking tray in the reach-in refrigerator which contained 6 slices of pie and one brownie dessert. Further observation of the reach-in refrigerator revealed a tray of cherry jello dated 11/14. On 12/2/24 at 8:21AM the surveyor observed the ice cream refrigerator chest and requested from [NAME] #5 to review the temperature log, at which time they reported to the surveyor that there was not a temperature log for it. On 12/2/24 at 8:22AM the surveyor observed the facility's conveyor dishwasher and noted that the circular wash and rinse temperature gauges appeared inoperable and had cracks present on both clear covers. The surveyor observed that the dishwashing machine was marked with signage indicating the following: Notice: This machine is currently in hot water sanitizing mode. Thick white matter was observed to be present on a plumbing piece which connected to the dishwasher chemical lines. On 12/2/24 at 8:24AM the surveyor observed a plastic container with broken edges and corners on it's lid located in the walk-in refrigerator which held chopped greens. A pan of cream based orange colored mixture was observed to have a label dated 11/27 with no other identifying information present. On 12/2/24 at 8:25AM an uncovered opening was observed to be present on a carton of mustard potato salad in the walk-in produce refrigerator which had no labeling present indicating a date or time of opening. On 12/2/24 at 8:26AM the surveyor observed mixed cut fruit in an unlabeled plastic container with broken corners of the lid where the fruit was observed to be uncovered. On 12/2/24 at 8:27AM the surveyor requested to [NAME] #5 to review food internal cooking temperature logs, to which they responded: I haven't seen it, we have to get temp logs and start recording temperatures. [NAME] #5 further reported to the surveyor that the facility does not keep any documentation of food temperatures taken during the cooking process. [NAME] #5 referred the surveyor to the skilled nursing unit where temperature logs were kept when taken on the steam table. On 12/2/24 at 8:30AM the surveyor observed the contents of a smaller refrigerator located near the food preparation and cooking areas. A plastic pan with a label dated 8/6 was observed within the refrigerator containing several individually packaged portion size packages of thawed pureed chicken, and condiment containers of cranberry orange sauce. 6 out of 13 cranberry orange sauce condiments were observed by the surveyor to have a green, fuzzy material present on them. An additional container of mint jelly was observed to be dated 11/14. An opened, saran wrapped package of pita bread was observed to be labeled 9/29. A saran wrapped container of red sauce was present with a label present with no identifying information of what the sauce was. [NAME] #5 reported this was strawberry glaze. A pan labeled with a date of 11/12 was observed containing individual cups of cole slaw. An unlabeled disposable soup container with mashed potatoes in it was observed within the fridge. A dual observation of the concerns was conducted with [NAME] #5 who acknowledged and confirmed understanding of the concerns. On 12/2/24 at 8:37AM the surveyor observed a metal pan of cookies with a label which read: 11/26. Upon further observation of the container, the surveyor observed flies through the saran wrap, flying around within it. The surveyor conducted a dual observation of the concern with [NAME] #5 who acknowledged observation of the flies, and confirmed understanding of the concern. The surveyor observed them pick up the pan and move it to a food preparation table. When the surveyor further inquired as to what [NAME] #5 would do with the pan, they stated to the surveyor that they were leaving the flies in the container in order to show their supervisor the concern and would be discarding the cookies, and ensured they would not be served. On 12/2/24 at 9:17AM the surveyor conducted an interview with Dietary Aide #13 who stated the following information regarding food temperatures in the skilled nursing unit food serving area: I microwave it if it's not up to temperature, then we see and check again. On 12/2/24 at 9:20AM the surveyor observed the skilled nursing unit food serving area and requested to review the food temperature logs. The surveyor reviewed the logs and observed there was no documentation of any food temperatures taken for the dinner meal on 12/1/24. The following items were recorded for the dinner meal without any temperatures documented: crab cake, vegetable lasagna, salmon, fish chowder, mashed potato, sweet potato, peas, corn, and spinach. On 12/2/24 at 9:24AM the surveyor conducted an interview with Dining Services Director (DSD) #2 who confirmed with the surveyor that there was no internal food temperature log. When the surveyor inquired as to if a temperature log should be in place for this, they stated: Sure it should be. The surveyor conducted a dual observation of the food temperature log for the 12/1/24 dinner meal with DSD #2 and shared the concern with DSD #2, who acknowledged the concern. The surveyor shared all concerns with DSD #2 who stated the following to the surveyor: Oh yeah, so do I, We threw a bunch of stuff out. DSD #2 confirmed they were able to visualize concerns the surveyor had, and acknowledged and confirmed understanding of the concerns. The surveyor made a request to DSD #2 for a copy of the 12/1/24 dinner temperature log. On 12/2/24 at 9:25AM the surveyor conducted an interview with Certified Dietary Manager (CDM) #3 who reported the following information to the surveyor: Temperatures should be taken at the start and at the end; the raw and finished product. CDM #3 confirmed with the surveyor that cooking of the food occurs in the facility's kitchen and when the food goes upstairs, we temp it before it goes in the steam table. On 12/5/24 at 11:12AM the surveyor observed the reach-in refrigerator temperature log was completed and filled out prior to lunchtime for the lunch and closing time temperatures for 12/5/24, and the open, lunchtime, and closing temperatures recorded, were documented as 51F for all three temperatures. The surveyor noted that 51F did not meet the minimum requirement of 41F or below for refrigerator temperatures, and the reach-in refrigerator was holding items which included: milk, sour cream, butter, caesar salad and other salads, pumpkin, and fruit. Observation of the food in the reach-in refrigerator revealed that labels present on foods now included identifying information of what the foods were. The surveyor shared concerns with CDM #3, and inquired as to if the elevated reach-in refrigerator temperatures on the log had been brought to their attention. CDM #3 confirmed they were not aware of any elevated temperatures and reported to the surveyor that no staff had notified them of any issues with the temperature of the refrigerator. On 12/5/24 at 11:23AM the surveyor was approached by CDM #3 who reported to the surveyor that gaskets had been replaced on the reach-in refrigerator in the summertime, and they had a vendor coming to check on it again, because when you shut the door, the other one opens, and we are constantly, shut, shut, shutting it. On 12/5/24 at 11:25AM CDM #3 showed the surveyor the issue occurring with the double doors to the reach-in refrigerator. The surveyor observed that when the door on the left shut, the door on the right popped open and was no longer closed. On 12/5/24 at 11:27AM surveyors observed thick grey matter on approximately 7 cords located on/above the food prep area near the cooking area. On 12/5/24 at 11:30AM the surveyor conducted a dual observation of the thick grey matter and shared concerns with CDM #3 who observed the concern and stated the following: We'll get it taken care of. CDM #3 acknowledged and confirmed understanding of the concerns. On 12/5/24 at 11:31AM CDM #3 was observed directing Dishwashing Staff #7 to cover the food area and and clean the dust. On 12/5/24 at 11:35AM the surveyor observed the reach-in refrigerator temperature log now had white out present on it, and an opening temperature of 37 degrees was now written over the white out. On 12/5/24 at 11:52AM the surveyor observed that dishes were in a metal pan on the steam table with a cloth over them for warming of the plates. When the surveyor inquired as to why the plate warming system present was not being used, Health Center Supervisor #14 stated the following to the surveyor: We have always done it this way, it has been broke for a long time. CDM #3 was observed flipping the switch to the plate warming system which revealed there was no indicator light turning on, and the system did not begin to heat. On 12/5/24 at 1:12PM the surveyor shared concerns with the facility's Administrator, who acknowledged and confirmed understanding of the concerns. On 12/6/24 at 8:21AM the surveyor requested from the facility Administrator to be provided with all policies and procedures relating to the kitchen. On 12/6/24 at 10:10AM the surveyor observed the items previously identified on 12/2/24 at 8:05AM continued to be present in the freezer. The surveyor additionally observed several trays of pies were present in the freezer which were partially uncovered. On 12/6/24 at 10:17AM the surveyor observed the dishwasher monitor to be red in color with a triangle and exclamation point symbol present on it. The temperature for the wash was observed to be reading 94.1F, and the temperature for the rinse was observed to be reading 116.2F on the monitor. Continued observation by the surveyor of dishes being put through the dishwashing system on 12/6/24 at 10:18AM revealed a wash temperature of 94.1F and a rinse temperature of 127.6F on the monitor. The following was observed on the monitor: Low rinse temperature. Continued observation of the circular temperature gauges for rinse and wash revealed the needles were barely moving throughout the dishwashing process, indicating they were not properly functioning. On 12/6/24 at 10:19AM the surveyor observed the dishwasher was connected to a container of liquid chemical, indicating that the dishwasher was being utilized in chemical sanitizing mode for sanitization. Review of the manufacturer plackard located on the machine indicated the following requirements for chemical sanitizing: minimum wash tank temperature 140F, minimum final rinse temperature 120F, minimum chlorine required 50ppm. The surveyor noted that signage present on the machine indicated the machine was in hot water sanitizing mode although the machine was currently operating in chemical sanitizing mode. On 12/6/24 at 10:26AM the surveyor reviewed dishwasher temperature logs which revealed consistent documentation that the minimum required temperatures were not reached. Review of the facility's food receiving and storage policy revealed the following information in the policy: Food services, or other designated staff, will maintain clean food storage areas at all times, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date), Such foods will be rotated using a first in first out system, Uncooked and raw animal products and fish will be stored separately in drip proof containers and below fruits vegetables and other ready-to-eat foods. On 12/6/24 at 10:30AM the surveyor conducted an interview with CDM #3 who stated to the surveyor that the dishwasher's booster heater (a type of water heater which heats water to the proper temperature for sanitizing dishes in a dishwasher) had failed earlier in the year and the UltraSan chemical was now being used. On 12/6/24 at 11:27AM the surveyor conducted an interview with DSD #2 who reported to the surveyor that the liquid chemical for dish washing was ppm (parts per million) tested (for adequate levels of chemical concentration needed for effective sanitization) every other week by their vendor. When the surveyor inquired as to what range the chemical concentration should result at, they reported that they did not know. On 12/6/24 at 11:42AM the surveyor conducted an interview with contact information provided by the facility for vendor technician #15 who reviewed the facility's vendor records and reported to the surveyor that 11/11/24 was the last time the vendor's assigned technician had visited the facility, and there was no documentation of the ppm test result in their report for that visit. Vendor technician #15 advised the surveyor that there were no future appointments presently scheduled with the facility, and that in addition to technicians checking the ppm at service calls, facility staff are recommended to be checking the ppm every day, every shift, and the circular temperature dials should be working in addition to the monitor. Vendor technician #15 confirmed with the surveyor that if the minimum water temperatures for the machine were not met for the wash cycle, the machine is not able to effectively clean grease and heavy soil prior to the rinse cycle which then utilized the chemical sanitizer. On 12/6/24 at 1:25PM multiple surveyors observed the dish washing system in operation as dishes were being put through the machine. The wash temperature was observed at 100F for the wash, and 117F for the rinse on the monitor, which were both below the minimum temperatures located on the machine's plackard for chemical sanitization. On 12/6/24 at 1:34PM surveyors observed the circular temperature gauges on the dish washing machine while in operation and noted that the left sided gauge needle was barely moving and read 109F, and the right sided gauge needle was not moving and read 114F. When the surveyor inquired as to the condition of the circular gauges, DSD #2 stated: It's calibrated through (vendor) we have no way of checking that, honestly, I don't know. When surveyors inquired as to where the ppm testing log was kept, CDM #3 informed surveyors that there was no log. When surveyors inquired as to how the ppm testing of the chemical concentration was tested , DSD #2 stated the test strips were in their office. DSD #2 retrieved test strips from their office, and returned with Hydrion QT-40 test paper which was observed being put through the dish machine, and the test paper did not return at the end of the dishwashing process. Surveyors observed Chef #16 wrap another piece of the test paper around a fork, and send it through the machine, which returned with no color change having resulted. Chef #16 then obtained a different container of test strips that were labeled for chlorine testing and wrapped it around a fork and sent it through the dishwasher, which revealed a pale yellow test result which did not closely match any of the color indicator test results on the guide on the test strip bottle. On 12/6/24 at 2:03PM the surveyor conducted an interview by phone with Vendor Technician #15 who reported to the surveyor that a chlorine strip should be used for ppm testing and should have a result of 50-100ppm, indicating appropriate chemical concentration levels. Vendor Technician #15 further advised that the test strip should be testing the water that is present after dishes are put through the dish washing system. On 12/6/24 at 2:17PM the surveyor observed Chef #16 dipping a test strip into the water pan within the machine, and no color change was noted to the strip. When the surveyor asked the procedure to be performed according to the vendors recommendation, the test strip color was observed to change, and when compared to the test strip bottle color indicators, was resulting at 25ppm, which was below the recommended concentration level for chemical sanitization. The 25ppm test result was acknowledged and confirmed by DSD #2, Chef #16, and multiple surveyors. On 12/6/24 at 3:13PM the surveyor conducted an interview with the facility Administrator. When the surveyor inquired as to when they had assumed the role of Administrator they stated: I'm going to get back to you on that. When the surveyor inquired to the Administrator if they were aware of issues concerning the dishwasher, they stated: I heard about it today from DSD #2, the p level was barely off with the sanitization, the color was slightly off, just the booster was not working, that's why they have the sanitization, but that's it, I'm not sure, I would have to get back to you. The surveyor shared all concerns with the Administrator and informed them that 25ppm was 25ppm below the minimum of the range for the ppm chemical concentration for effective sanitization. The Administrator acknowledged and confirmed understanding of the surveyor's concerns. On 12/9/24 at 11:10AM the surveyor observed the skilled nursing unit nutrition refrigerator located in the dining room which revealed one thermometer was present, and was observed to be in broken condition. The area on the inside of the thermometer where the result is read was in a diagonal position and read 46F, which did not meet the minimum required temperature. The surveyor reviewed the temperature log for the refrigerator which had last been recorded as 40F at opening for 12/9/24. At this time, the surveyor noted the temperature log for 12/8/24 was incomplete with no closing temperature recorded on the refrigerator or freezer logs. On 12/9/24 at 11:11AM the surveyor observed the skilled nursing unit nutrition freezer located in the dining room which contained an unlabeled disposable beverage cup with white contents, and a damaged container of lactaid ice cream with the contents visible. Further observation of the skilled nursing unit refrigerator on 12/9/24 at 11:11AM revealed a plastic bin of thawed magic cups and a plastic bin of strawberry shakes with no labeling present. When the surveyor inquired to Dietary Aide #13 as to when the products would be discarded, they confirmed the products should be dated, and responded: I will date and time them from now on, and only put 5 or 6 in there at a time, I don't know when these trays were put into the refrigerator. On 12/9/24 at 11:15AM the surveyor requested and performed a dual observation of the concerns with the facility Administrator. Dietary Aide #13 reported to the Administrator that no dates were put on the plastic containers. On 12/19/24 at 11:20AM the surveyor observed the Administrator throw away the cup from the freezer and stated: that's gross. When the surveyor inquired as to what further action would be taken, the Administrator reported the magic cups would be thrown away and a thermometer was observed being removed from the freezer and placed into the refrigerator. When the surveyor inquired as to if any other action would be taken, they stated: We will review the food that is in there and wait until it recalibrates, and we will see how accurate that temperature gauge is with the new one. The surveyor noted that it could not be ensured that the refrigerator had maintained minimum required temperatures for the food items it contained. On 12/9/24 at 11:43AM multiple surveyors observed the thermometer within the skilled nursing unit refrigerator which read: 50F. On 12/9/24 at 11:45AM the surveyor was informed by Dietary Aide #13 that DSD #2 was ordering a new refrigerator. On 12/9/24 at 3:07PM the surveyor conducted an interview with the facility's Executive Director who reported the following to surveyors regarding kitchen concerns: I was made aware on Friday, no I have not been made aware of any issues, not since I have been here February of 2023. They confirmed with the suveyor that if equipment fails, they would be expect to be notified, but if equipment was malfunctioning, that information would be provided to the DSD. The Executive Director further reported the following to surveyors: Staff would only come to us if they weren't able to resolve the issue, the DSD and CDM are responsible for ensuring kitchen compliance. The surveyor inquired to the Executive Director as to what issues were found to be present with the facility dishwashing system, to which they replied: They did their testing of the strips and that was within normal limits, and the vendor came out again Friday, and same with the plumber, and I'm waiting for updates, they were looking at the booster, I would have to get back to you on that. On 12/10/24 at 9:45AM the surveyor conducted an interview with DSD #2 who reported the dishwasher booster had failed since 2021, We had planned to get the booster fixed, but for whatever reason they left us on a chemical sanitizer which was working for us, We knew it was running at 110, it fluctuates due to whatever is happening, it wasn't a steady under 110 continual, we were just notified last week the guys just told us last week the hot water wasn't as hot as it should be. Surveyor's continued review of the dishwasher temperature logs revealed the dishwasher was repeatedly not meeting minimum required temperatures and temperature re-checks were performed, with results that still did not meet minimum required temperatures during the re-checks. On 12/13/24 at 12:24PM the surveyor conducted an interview with the Operations Director #17 who acknowledged ongoing water temperature control issues and cold water flow occurring affecting the kitchen operations, and stated the facility's mixing valve issue was being looked at, and additionally stated: now we have the proper person to look at the booster and fix that.

Based on observation and interview it was determined the facility failed to ensure privacy of protected health information was maintained for residents of the facility (#8, #16, #12, #122, #2, #3, #11, #14, #7, #1, #17). This was evident for 11 out of 21 residents during the facility's recertification/complaint survey. The findings include: On 12/11/24 at 3:13 PM surveyors observed an unlocked, unattended monitor screen in the resident hallway which displayed the photo images of 11 residents of the facility (#8, #16, #12, #122, #2, #3, #11, #14, #7, #1, and #17) with their medical record numbers listed next to their photo images. The monitor screen also displayed various tabs and applications. Geriatric Nursing Assistant (GNA) #12's name was observed on the screen. On 12/11/24 at 3:17 PM surveyors observed GNA #12 enter the resident hallway at which time surveyors shared their concerns and conducted an interview. GNA #12 observed the concern and stated the following during the interview: Okay, let me close it. On 12/11/24 at 3:18 PM surveyors requested a dual observation of the concern with the facility's Director of Nursing (DON) #8 and shared the concern. The DON observed the concern and acknowledged and confirmed understanding of the concern and was observed stating the following information to GNA #12: You can't leave it unlocked. At this time, the DON was observed locking the monitor screen for GNA #12. On 12/13/24 at 9:47 AM the surveyor shared all concerns with the facility's Executive Director who acknowledged and confirmed understanding of the concerns. On 12/13/24 at approximately 3:45 PM the concern was again shared during the facility's exit conference with surveyors.

Based on interview and record review it was determined the facility failed to timely report an injury of unknown origin to the Office of Health Care Quality. This was evident for 2 (#MD00200761, and #MD00162737) out of 2 facility reported incidents reviewed for injuries of unknown origin for Resident #220 during the facility's recertification/complaint survey. The findings include: 1.) On 12/6/24 at 8:22AM the surveyor requested the complete investigation file for facility self-report #MD00200761 from the facility's Administrator. On 12/6/24 at 8:42AM the surveyor received the investigative file from the Administrator who confirmed this was the complete investigation file. Review of the facility's initial self-report revealed Resident #220's hip fracture was reported as an injury of unknown source to the Office of Health Care Quality on 12/19/23 at 10:30AM. Review of the follow-up self-report revealed the following information was documented: Resident had a fall on 11/28/23 from his/her wheelchair. On 12/10/24 at 9:58 AM the surveyor conducted a review of the medical record of Resident #220 which revealed the following was documented in a nursing progress note dated 11/28/23 at 2:01PM: At 11:30AM nurse was called to resident's room, observed resident laying face down in front of w/c (wheelchair), Resident slid out of w/c, sustained hematoma to left side of forehead size of a golf ball, ice applied, Root cause determine from constant agitation, always reaching and trying to grab things around him/her, Frequent yelling at all times on going behavior, Neuro check initiated WNL (within normal limits), on routine pain management . On 12/10/24 at 10:53 AM the surveyor conducted an interview with the facility Administrator who reported the following information to surveyors regarding the root cause analysis process for Resident #220: We think through what could be done for this resident, s/he can't communicate, does s/he need a new cushion, did s/he slide out of it because of the traction? At this time, the surveyor provided opportunity to the Administrator for all documentation and actions taken by the facility regarding Resident #220's 11/28/23 incident to be provided to the surveyor for review. On 12/10/24 at 11:50AM the surveyor conducted an interview with the facility's Administrator who reported to surveyors the following information regarding the 11/28/23 incident for Resident #220: S/he slid out of his/her wheelchair, s/he was in a room by her/himself, Staff do rounds every two hours typically, a lot of staff walk by, someone was walking by and from the note s/he was found there on the floor. When the surveyor inquired as to if there was an investigation performed and an investigation file for the incident, the Administrator replied: No, we don't keep investigation files for every single fall, we don't report every single fall to your office, it's only when they have injuries, it was part of the investigation because we said the fracture was related to the fall. At this time the surveyor inquired as to how staff ruled out abuse and neglect and how staff knew that Resident #220's hematoma was from a fall sliding from the wheelchair; to which they replied: because s/he was on the floor. At this time, the surveyor shared their concerns and noted that the 11/28/23 incident resulting in an injury of unknown origin with the resident having been documented as sustaining a hematoma to the left side of their forehead the size of a golf ball in which neuro checks were instituted, was not reported to the Office of Health Care Quality. Review by the surveyor on 12/10/24 at 11:53AM of the facility's incident report dated 11/28/23 documented the following was selected on the report: alleged fall, unattended. Other options present on the incident report were: abuse investigation for unknown injury, and abuse ruled out, in which neither of these options were observed selected. On 12/10/24 at 4:47 PM the surveyor reviewed the facility's initial self-report for injury of unknown source dated 12/19/23 at 10:30AM and noted the following information was present on the self-report for the hip fracture reported on 12/19/23: Date/time/Name of when staff became aware of the incident: 12/19/23 at 8:15AM, Director of Health Services. Review of the email submittal for the initial self report was observed to be dated 12/19/23 at 10:28AM. Further review of the final report radiology results which notified the facility of the hip fracture was observed to be dated 12/19/23 at 1:56AM. 2.) On 12/6/24 at 8:22 AM the surveyor requested the complete investigation file for facility self-report #MD00162737 from the facility's Administrator. On 12/6/24 at 8:42 AM the surveyor received the investigative file from the Administrator who confirmed this was the complete investigation file. Review by the surveyor of the facility's self-report of an injury of unknown origin revealed the following information was reported to the Office of Health Care Quality dated 1/19/21 at 4:15PM: Resident complained of left hand pain, Order for x-ray was completed, X-ray was performed and found acute anterior humeral head dislocation, Resident was taken to the hospital where s/he had a successful closed reduction of dislocation. The following date and time of the incident was observed documented on the facility's initial self-report form: 1/18/2021 6:40PM. Review of the resident's final radiology report to the facility of the dislocation revealed a date of 1/18/21 at 6:40PM. Review of email documentation by the surveyor revealed the self-report was documented as sent to the Office of Health Care Quality on 1/19/21 at 5:37PM with the following information in the subject line: Self report 1/18/2021. On 12/9/24 at 12:36 PM the surveyor reviewed the medical record for Resident #220 which revealed the following documentation by Licensed Practical Nurse #22 dated 1/18/21 at 22:40PM: Results for x-rays ordered earlier this shift received, Left shoulder x-ray shows acute anterior humeral head dislocation. The surveyor noted that the Resident #220's serious injury was not reported to the Office of Health Care Quality until approximately 22 hours and 57 minutes after notification to the facility of the resident's x-ray results which revealed the acute anterior humeral head dislocation. Review of Certified Registered Nurse Practitioner's visit summary dated 1/18/21 documented the resident was being seen at the request of nursing for inability to use his/her left arm and left arm pain.

Based on record review and interview it was determined the facility failed to ensure a thorough investigation was performed for an injury of unknown origin. This was evident during the surveyor's review of facility reported incident #MD00200761 reviewed by the surveyor during the facility's recertification/complaint survey. The findings include: On 12/6/24 at 8:22AM the surveyor requested the complete investigation file for facility self-report #MD00200761 from the facility's Administrator. On 12/6/24 at 8:42AM the surveyor received the investigative file from the Administrator who confirmed this was the complete investigation file. Review of the facility's initial self-report revealed Resident #220's hip fracture was reported as an injury of unknown source to the Office of Health Care Quality on 12/19/23 at 10:30AM. Review of the follow up self-report revealed the following information was documented: Resident had a fall on 11/28/23 from his/her wheelchair. On 12/10/24 at 9:58AM the surveyor conducted a review of the medical record of Resident #220 which revealed the following was documented in a nursing progress note dated 11/28/23 at 2:01PM: At 11:30AM nurse was called to resident's room, observed resident laying face down in front of w/c (wheelchair), Resident slid out of w/c, sustained hematoma to left side of forehead size of a golf ball, ice applied, Root cause determine from constant agitation, always reaching and trying to grab things around him/her, Frequent yelling at all times on going behavior, Neuro check initiated WNL (within normal limits), on routine pain management . On 12/10/24 at 10:53AM the surveyor conducted an interview with the facility Administrator who reported the following information to surveyors regarding the root cause analysis process for Resident #220: We think through what could be done for this resident, s/he can't communicate, does s/he need a new cushion, did s/he slide out of it because of the traction? At this time, the surveyor provided opportunity to the Administrator for all documentation and actions taken by the facility regarding Resident #220's 11/28/23 incident to be provided to the surveyor for review. During the interview, the Administrator reported to the surveyor that the risk meeting documentation that had been provided to the surveyor was the risk meeting minutes and there was no other documentation for the risk meetings. On 12/10/24 at 11:50AM the surveyor conducted another interview with the facility's Administrator who reported to surveyors the following information regarding the 11/28/23 incident for Resident #220: S/he slid out of his/her wheelchair, s/he was in a room by her/himself, Staff do rounds every two hours typically, a lot of staff walk by, someone was walking by and from the note s/he was found there on the floor. When the surveyor inquired as to if there was an investigation performed and an investigation file for the 11/28/23 incident, the Administrator replied: No, we don't keep investigation files for every single fall, we don't report every single fall to your office, it's only when they have injuries, it was part of the (12/19/23) investigation because we said the (12/19/23) fracture was related to the (11/28/23) fall. At this time the surveyor inquired as to how staff ruled out abuse and neglect and how staff knew that Resident #220's hematoma was from a fall sliding from the wheelchair; to which they replied: because s/he was on the floor. At this time, the surveyor shared their concerns and noted that the 11/28/23 incident resulting in an injury of unknown origin with the resident having been documented as sustaining a hematoma to the left side of their forehead the size of a golf ball in which neuro checks were instituted, was not reported to the Office of Health Care Quality. There was no investigation file that could be provided to the surveyor for the 11/28/23 incident. Review by the surveyor on 12/10/24 at 11:53AM of the facility's incident report dated 11/28/23 documented the following was selected on the report: alleged fall, unattended. Other options present on the incident report were: abuse investigation for unknown injury, and abuse ruled out, in which neither of these options were observed selected. On 12/10/24 at 12:53PM the surveyor reviewed the root cause analysis for the 11/28/23 incident which was risk meeting documentation that consisted of the following: On 11/28/23 before lunch resident was found on the floor in front of his/her bed, Resident slid off his/her wheelchair, Offer to lay down after breakfast, New cushion in place by rehab team. The surveyor noted that there was no documentation of a thorough investigation to support how the interdisciplinary team came to those conclusions.

Based on interview with residents, review of resident medical records, and interview with facility staff, it was determined that the facility failed to hold care plan meetings at least quarterly. This was evident for 1 (Resident #17) of 1 resident reviewed for care planning during the recertification/complaint survey. The findings include: On 12/03/24 at 03:02 PM, Resident #17 was interviewed. During the interview, the resident indicated that s/he did not recall ever being invited to a care plan meeting but would like to attend one. On 12/12/24 at 10:34 AM, Resident #17's medical record was reviewed. The review revealed that the resident was admitted to the facility in June, 2024. The review failed to reveal evidence that a care plan meeting was held after the initial care plan meeting in June. On 12/12/24 at 11:16 AM, the Health Center Social Worker (SW) #9 was interviewed. During the interview, SW #9 indicated that residents should receive a care plan meeting on admission and quarterly. She stated that she creates a sign-in sheet for the meeting, a letter inviting the resident's responsible party (or the resident themselves) to the meeting, and documents a summary of the meeting. All of these documents should be stored in the electronic health record. When asked for evidence of Resident #17's most recent quarterly care plan meeting, SW #9 could only find a letter inviting family to the initial care plan meeting in June. After looking in the resident's paper medical record, current and previous electronic medical record, and in her personal computer files, she found no evidence that a care plan meeting occurred since June for Resident #17. She stated, [the resident] should have had one in September. I missed that.

Based on observation during medication administration it was determined that the facility failed to follow infection control practices consistent with accepted standards of practice. This was evident for 3 (Residents #5, #10 and #13) of 4 residents reviewed for medication administration during the recertification/complaint survey. The findings include: On 12/06/24 at 8:17AM, surveyors observed LPN #10 drop Resident #5's medication bottle on the floor in the hallway on Cedar Place. LPN #10 picked up the medication bottle for Resident #5 off the floor and placed the medication bottle back in Resident #5's medicine drawer in the medication cart without sanitizing the medicine bottle or their hands. On 12/06/24 at 8:35AM, surveyor observed LPN #10 give Resident #5 their medications and leave Resident #5's room without sanitizing their hands. LPN #10 then retrieved the Blood Pressure (BP) cuff from the hallway on Cedar Place and entered Resident #13's room and took Resident #13's blood pressure. On 12/06/24 at 9:19AM, LPN #10 went to get another computer because the computer on the medication cart no longer worked. LPN #10 returned and hooked up a different computer on the medication cart. LPN #10 did not sanitize their hands and picked up the water pitcher, poured water in a clear plastic cup and went into resident #10's room and gave Resident #10 their medications. On 12/06/24 at 10:12AM, on Cedar Place during medication administration, surveyor observed two syringes sitting in the top part of the sharps container attached to the side of the medication cart. The two syringes appeared to be used and were accessible due to staff not pulling the lever on the side of the sharps container to discard the syringes in the bottom of the sharps container where they cannot be retrieved.

Based on medical record review and interviews with the resident family and facility staff it was determined the facility failed to ensure that the appropriate equipment used to transfer a resident who receives [MEDICAL TREATMENT] was in place prior to the resident going to the scheduled [MEDICAL TREATMENT] appointment. This was found to be evident for 1 resident (Resident # 9) reviewed during the facility's annual Medicare/Medicaid survey. The findings include: An interview was conducted with Resident # 9's family representative Responsible Party (RP) on 12/2/19 at 12:10 PM to discuss concerns regarding the resident. The RP stated that on [DATE] the resident missed his/her scheduled [MEDICAL TREATMENT] appointment because the nurse improperly placed a sling that could not be used to transfer the resident at the [MEDICAL TREATMENT] facility. An interview was conducted with the Nursing Home Administrator (NHA) on [DATE] at 10:29 AM and she was asked about the resident not receiving [MEDICAL TREATMENT] on [DATE]. The NHA stated that she recalled that this did occur. The NHA went on to say that the nurse who cared for the resident on that date was a new nurse and when asked about the sling, the nurse stated that she did not remember if she placed a sling on the resident. The NHA stated that the resident had refused [MEDICAL TREATMENT] in the past. The NHA returned to the survey team on 12/5/19 at 9:30 AM and stated that the nurse who cared for Resident # 9 on [DATE] only worked on Mondays. The NHA further explained that on this date the nurse placed the facility sling on the resident and not the sling that is used for [MEDICAL TREATMENT], so the resident had to be brought back to the facility and did not receive [MEDICAL TREATMENT].

Based on medical record review and staff interview it was determined the facility failed to conduct a thorough investigation of a fracture of unknown origin sustained by a functionally and cognitively impaired resident (Resident #7). This was evident for 1 of 3 residents reviewed for resident's rights during this annual recertification survey. The findings included: The facility failed to thoroughly investigate the circumstances of a fracture sustained by Resident #7. Medical record review on 12/2/19 revealed that Resident #7 was a long-term care resident with [DIAGNOSES REDACTED]. Review of facility reported incident #MD 5[AGE] revealed that on 11/12/18 Geriatric Nursing Assistant (GNA) #3 noted that Resident #7 had swelling and discomfort to the right ankle. An x-ray confirmed that the resident had an acute [MEDICAL CONDITION]. The facility report noted that Resident #7 had significant [MEDICAL CONDITION] and was unable to report how the injury occurred. [MEDICAL CONDITION] is the loss of ability to understand or express speech, caused by brain damage. A Skin Condition Record for Non-Pressure Ulcer Skin Conditions, dated 11/12/18, noted that the resident's right ankle had light purple discoloration and [MEDICAL CONDITION]. In a written statement, dated 11/13/18, GNA #3 documented that s/he did not note anything unusual on the morning of 11/12/18 but upon transferring the resident to the bed at 2:30 PM noticed the resident showing signs of discomfort and notified the nurse. A physician's note dated 11/13/18 reported that the resident was seen for a right ankle fracture with pain. It was noted that Resident #7 was aphasic and did not answer questions regarding pain due to advanced Dementia. Review of the annual Mimimum Data Set (MDS) assessment dated [DATE] revealed that facility staff coded the resident in Section C- Cognitive Patterns, as severely cognitively impaired. The assessment noted that the resident utilized a wheelchair for mobility. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. During an interview with the surveyor on [DATE] at 2:15 PM the Director of Nursing (DON) stated the facility hosted nursing students on the unit the weekend of 11/10/18 -11/11/18. The surveyor inquired if statements were obtained from the students assigned to the resident or the instructor. The Director of Nursing stated that she spoke to the instructor who did not report anything that would be considered an accident. The surveyor asked if the instructor was in the room for transfers and other care and the DON responded that she did not know. The surveyor, also, inquired if transfer techniques were reviewed with nursing staff to ensure competency and safety during transfers. Further review of the facility's investigative materials failed to include interviews and education for the nursing student (s) assigned to Resident #7's care to ensure that the students received the appropriate level of supervision and adhered to the residents plan of care.

Based on medical record review and interviews with the resident family and facility staff, it was determined the facility failed to notify the resident and/or family representative in writing that they were being transferred out of the facility to the hospital and the reason for the hospital stay. This was evident for 2 (Resident # 24 and Resident # 9) of 3 residents reviewed for hospitalization during the facility's annual Medicare/Medicaid survey. The findings include: 1. An interview was conducted with the resident representative (RP) on 12/2/19 at 12:10 PM and they stated that Resident # 9 went out to the hospital on [DATE] and the facility did not provide him/her with any documentation about the transfer. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on [DATE] at 9:55 AM and they were asked to provide a copy of the written transfer summary that was sent with the resident and that was given to the resident representative upon transfer to the hospital on [DATE]. On 12/5/19 at 9:30 AM the NHA provided the survey team with documentation that contained a face sheet, a Maryland Medical Orders for Life Sustaining Treatment (MOLST) form and a copy of physician orders [REDACTED]. There was no documentation or notes about [MEDICAL TREATMENT] or any other care concerns that were specific to the resident. No documentation about bed hold policy provided. The NHA was made aware that this is a concern. 2. Review of Resident #24's medical record on 12/5/19 at 11:49 AM revealed that on 4/6/19 at 8:20 PM the resident was transferred to the hospital for an evaluation of a possible [MEDICAL CONDITION]. Further review of the medical record failed to a reveal a written notice that the Responsible Party (RP) was notified. During an interview with the residents' RP on 12/5/19 at PM s/he stated' the facility did not inform me verbally or in writing. An additional review of the medical record, within the Clinical Note Entry dated 4/6/2019 at 11:56 PM, revealed that the resident was sent to the hospital by ambulance at around 11:40 PM. The DON and family member also notified. The medical record noted on 4/06/2019 at 10:03 PM, Awaiting response Resident call his wife and notified her of the [MEDICAL CONDITION]. DON notified. During an interview with the Director of Nursing on 12/6/19 at PM, she stated, the notice was not given as required, but the RP was notified.

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (# 24) of 3 residents reviewed for hospitalization . The findings include: Review of Resident #24's medical record on 12/5/19 at 11:49 AM revealed that on 4/6/19 at 8:20 PM the resident was transferred to the hospital for an evaluation of a possible [MEDICAL CONDITION]. Medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party was notified in writing of the bed-hold policy. During an interview with the Director Of Nursing on 12/5/19 at 3 PM, she stated, the transfer/discharge information is included in the admission packet. When given the citation tag by this surveyor, the DON stated the information will now be given for all residents transferred or discharged from the facility.

Based on medical record review and staff interview, it was determined facility staff failed to conduct a comprehensive assessment when a significant decline occurred in the Resident #19's condition. This was evident for 1 of 3 residents reviewed for a change in condition during this annual recertification survey. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The MDS assessment directs the facility staff on issues that may need to be addressed. The findings include: Medical record review revealed that Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed that facility staff coded the resident in Section G Functional Status G0110 A Bed Mobility and B Transfers as a 3/2 (required extensive assistance of 1 staff). Review of section K- Swallowing/Nutritional Status revealed that the resident weighed 161 pounds and no significant weight loss was noted. Review of the quarterly MDS assessment dated [DATE] revealed that facility staff coded the resident in Section G Functional Status G0110 A Bed Mobility and B- Transfers areas as a 4/3 (required the total assistance of 2 staff). In Section K-Swallowing/Nutritional Status the resident was noted to have weight loss (149 pounds) that was not physician prescribed. A Dietary Note dated 11/19/19 reported the resident's weight continued to trend down and s/he continued to trigger for significant weight loss. It was noted the weight loss was likely due to refusal of oral nutrition and advanced Dementia. The findings were discussed with the MDS Coordinator on [DATE] at 1:15 PM.