Every finding on record at Restore Health Rehabilitation Center

Based on interviews and record reviews, it was determined that the facility failed to report (1.) misappropriation of residents' property and (2.) an injury of unknown origin to the state agency. This was evident for 2 (Resident #78 and #91) out of 2 residents who were reviewed for reporting during the recertification survey.The findings include: 1. On 06/22/2026 at 9:37 AM, an interview with Resident #78 was conducted. They reported that they had lost a ring while at the facility about a month ago. The ring was worth about $680. On 06/23/2026 at 11:10, an interview with Staff #3, Activities Director and facility Administrator was conducted. They confirmed that they were aware that Resident #78's ring was lost. They further reported that upon the facility's internal investigation, they found out that the ring was given to a facility staff member who had left with the ring to go shopping but never came back with it. The facility's administrator stated that the resident's property should not have left the facility. On 06/23/2026 at 1:19 PM, a review of the internal investigation report was conducted. The review revealed that the facility became aware of the lost ring on 3/27/2026. On 06/23/2026 at 2:25 PM, during a brief follow-up interview with the administrator, when asked if the lost ring was reported to the state agency, the administrator stated that she did not report but had notified the local police after the incident. She further stated that at the time of the investigation, she did not consider the concern as misappropriation of property and therefore did not report the concern to the state agency 2. On 6/24/2026 at 11:16 AM, a review of the facility's investigation documentation regarding Resident #91's injury of unknown origin was completed. The facility became aware of Resident #91 having a new right upper forehead hematoma on 5/3/2026 at 9 AM. The facility initially reported the incident to the State Office of Health Care Quality (OHCQ) on 5/4/2026 at 6:07 PM. On 6/24/2026 at 2:18 PM, an interview with the Nursing Home Administrator (NHA) was conducted. The surveyor made the NHA aware that the submission of the initial report was past the 24-hour required reporting time. The NHA acknowledged and stated that they were aware that the initial reporting of this incident was submitted late.

Based on record review and staff interviews, the facility failed to ensure adequate supervision and safe positioning during activities of daily living (ADL) care for a dependent resident who required staff assistance with bed mobility. This deficient practice was determined to be past noncompliance that resulted in the resident falling from the bed during care and sustaining multiple fractures for 1 of 3 sampled residents (Resident #7). Findings:Resident #7 was admitted to the facility with diagnoses including fracture of right humerus, chronic heart failure, atrial fibrillation, anemia, hypertension, chronic pain, obesity, and osteoarthritis.Review conducted on 3/31/26 at 5:46 PM of the quarterly Minimum Data Set (MDS) assessment dated [DATE], completed by the MDS Coordinator, revealed that Resident #7 was cognitively intact (BIMS score of 15) and was dependent on staff for toileting hygiene.Review conducted on 3/31/26 at 5:46 PM of the same MDS assessment, completed by the MDS Coordinator, revealed that Resident #7 required partial/moderate assistance with bathing and was always incontinent of bowel and bladder.Review conducted on 3/31/26 at 5:46 PM of the same MDS assessment, completed by the MDS Coordinator, revealed that Resident #7 required substantial to maximum assistance for rolling left and right, defined as the ability to roll from lying on back to left and right side and return to lying on back in bed.Review conducted on 3/31/26 at 5:57 PM of the care plan, developed by the interdisciplinary team, revealed that Resident #7 required extensive assistance with ADL care, including being a three-person assist with ADLs, and had fall risk interventions including use of environmental supports such as handrails and frequent monitoring.Review conducted on 3/31/26 at 6:13 PM of a nursing progress note dated 12/14/25 at 8:11 AM, written by Staff Nurse #6 (LPN), revealed that Resident #7 was found on the floor after reportedly letting go of a grab rail while being cleaned during ADL care.Review conducted on 3/31/26 at 6:17 PM of a physician progress note dated 12/14/25, written by the attending physician, indicated that Resident #7 experienced a fall during care and later reported generalized pain.Review conducted on 3/31/26 at 6:20 PM of a nursing progress note dated 12/14/25 at 7:16 PM, written by Staff Nurse #9, revealed that Resident #7 reported severe generalized pain following the fall.Review conducted on 3/31/26 at 6:22 PM of a physician progress note dated 12/15/25 at 4:58 AM, written by the physician, revealed that Resident #7 presented with lethargy, pain, and suspected fractures following the fall.Review conducted on 3/31/26 at 6:25 PM of a nursing progress note dated 12/15/25 at 6:43 AM, written by Staff Nurse #10, revealed that Resident #7 exhibited abnormal positioning of the arm and increased pain with movement.Review conducted on 3/31/26 at 6:31 PM of a nursing progress note dated 12/15/25 at 12:02 PM, written by Staff Nurse #5, revealed that Resident #7 required transfer to the hospital for further evaluation due to worsening condition following the fall.Review conducted on 3/31/26 at 6:34 PM of a nurse practitioner progress note dated 12/15/25 at 9:58 PM, written by Nurse Practitioner #4, revealed that Resident #7 was transferred to the hospital due to concern for head/neck injury and functional decline following the fall.Review conducted on 3/31/26 at 6:37 PM of documentation by the Director of Nursing dated 12/19/25 revealed that Resident #7 was hospitalized and diagnosed with multiple fractures, including bilateral humerus fractures and fractures of the femur.Review of policies and procedures conducted on 4/1/26 at 6:51 PM revealed that facility staff were required to perform resident care in accordance with established standards for safe positioning, assistance, and fall prevention during activities of daily living (ADL) care. Policies indicated that staff should utilize appropriate turning techniques, including use of a turning pad, maintain control of the resident during repositioning, ensure proper body alignment, and return the bed to a safe position to prevent falls.Review of facility-provided timeline conducted on 4/2/26 at 12:55 pm revealed that the facility identified the root cause of the incident as improper turning and repositioning during ADL care. The timeline further indicated that staff required re-education on safe turning and repositioning techniques following the incident, including return demonstration of proper technique.During interview on 4/1/26 at 2:25 PM, Staff Nurse #6 indicated that Resident #7 was found lying on the floor after being turned during care. Staff Nurse #6 confirmed that the side rail on the side from which the resident fell was down at the time of the incident.During interview on 4/1/26 at 5:45 PM, GNA #11 indicated that they provided incontinence care to Resident #7 on the day of the incident. GNA #11 stated that Resident #7 required extensive assistance with turning and repositioning and was unable to turn independently. GNA #11 indicated that they first positioned themselves on one side of the bed and pulled the resident toward them prior to assisting the resident to turn onto their side facing the window. GNA #11 stated that they provided care while the resident was in that position. GNA #11 indicated that they then returned the resident to a supine position (lying on their back). GNA #11 stated that they then moved to the opposite side of the bed and assisted the resident to turn toward the door. GNA #11 indicated that during this second turn, they instructed the resident to hold onto the side rail while care was being provided. GNA #11 did not indicate that the resident was repositioned toward the center of the bed prior to the second turn. GNA #11 stated that while they were cleaning the resident's rectal area, they were not holding the resident and were positioned on the opposite side of the bed. GNA #11 stated that the resident let go of the side rail and fell from the bed. GNA #11 confirmed that the bed remained in the highest position at the time of the fall.During interview on 4/1/26 at 1:54 PM, GNA #13 indicated that Resident #7 required hands-on assistance to turn and could not reposition independently.During interview on 4/1/26 at 2:27 PM, GNA #17 indicated that Resident #7 could not turn independently and required staff assistance for repositioning and ADL care.During interview on 4/1/26 at 3:30 PM, GNA #14 indicated that Resident #7 was unable to turn independently and required hands-on assistance for repositioning during care. During interview on 4/2/26 at 2:41pm Staff Nurse #10 indicated that upon entering the room to assess Resident #7, the resident had already been placed back in bed by GNA #11 and Staff Nurse #7. Staff Nurse #10 indicated that during follow-up, GNA #11 reported that while providing care, the resident was turned and positioned close to the edge of the bed and subsequently fell.During interview on 4/2/26 at 2:01 pm, the Director of Nursing (DON) indicated that the resident was positioned too close to the edge of the bed during repositioning. The DON stated that while staff were removing linen from under the resident, the resident went over the edge of the bed. The DON indicated that the facility had since provided education to staff on proper turning and repositioning techniques, including demonstration and return demonstration using a mannequin, and reinforced that such incidents should be reported.The facility provided the following corrective action plan.Resident #7 had a fall on 12/14/25 at 6:50 AM. It was reported to the Third Eye provider (telehealth video provider call) on 12/14/25 at 7:00 AM by Staff Nurse #7, who had already completed an initial assessment. When asked by Staff Nurse #7, Resident #7 stated, I let go of the grab bar railing and rolled over to the floor.GNA #11, who was providing care for Resident #7 at the time of the incident, stated that they were providing ADL care to Resident #7, who was holding onto the 1/4 rail, and while they were washing the resident's back side, the resident let go of the 1/4 rail and rolled off the bed. During the call with the Third Eye provider, an exam was conducted via video, and the provider indicated there was no evidence of injury, and determined that the resident should remain in the facility.On 12/14/25, immediately after placing the resident back into bed, verbal education was provided to GNA #11 by Staff Nurse #7 and Staff Nurse #10 regarding safe turning and repositioning of residents as well as safety during ADL care.Facility-wide education was initiated for GNAs on fall prevention in the elderly. Education for those not present at the time was to be provided at a later date and during new hire orientation.On 12/15/25 at 4:58 AM, Staff Nurse #7 contacted the Third Eye provider due to the resident presenting as lethargic and complaining of right-sided pain. An exam was conducted via video, which resulted in the provider ordering stat laboratory tests and stat x-rays.On 12/15/25 at 12:02 PM, the Nurse Practitioner assessed the resident, and an order was placed to transfer the resident to the emergency department for status post fall with right-sided pain.On 12/15/25 at 2:47 PM, the resident's responsible party presented to the facility and reported that the resident was being seen in the hospital due to confusion.On 12/15/25, the Director of Nursing (DON) contacted the hospital to obtain the status of the resident, who remained under observation in the emergency department.On 12/16/25, interviews were conducted with GNA #11, Staff Nurse #10, and Staff Nurse #7 by the DON to determine the root cause of the fall. The root cause was identified as improper turning and repositioning during ADL care. Education continued for staff, including return demonstration of proper technique.Education was provided to unit managers by the DON regarding incident and fall audits, including proper investigation of falls, documentation, interventions, care planning, and state agency notification.Facility-wide interviews were conducted with alert and oriented residents, and no additional concerns were identified. Nursing leadership examined residents unable to communicate, and no new skin abnormalities or injuries were noted.On the afternoon of 12/18/25, the resident's responsible party presented to the facility and reported that the resident had been admitted to the hospital and continued to be treated for confusion.On 12/18/25 at approximately 4:00 PM, the DON contacted the hospital to obtain a clinical update. The treating nurse informed facility staff that the resident was admitted due to multiple fractures. Hospital documentation indicated bilateral humerus fractures, right knee fracture, impacted fracture of the distal femur, hairline fracture of the distal femur, and nondisplaced fracture along the intercondylar notch of the femur, with osteoporosis.On 12/18/25, the incident was reviewed in the QAPI meeting, and training was provided. Education for staff not present was to be conducted at a later date and during orientation for new employees.On 12/22/25 at 10:37 PM, the resident was readmitted to the facility.On 12/23/25 at approximately 12:30 PM, therapy staff, the DON, the Assistant Director of Nursing, and a Unit Manager entered the resident's room to coordinate repositioning and provide ADL care. The resident's responsible party was present. Following assessment, therapy staff explained the clinical need to reposition the resident to prevent skin breakdown and promote circulation.On 12/24/25 at approximately 4:45 PM, the resident was transferred from a bed with a pressure-relieving mattress to a bed with an air mattress with built-up sides using six staff members for assistance.On 1/19/26, staff were re-educated by the DON regarding falls documentation and follow-up. Education for those not present was to be provided at a later date and during orientation.On 1/22/26, a QAPI meeting was held, during which falls and falls with major injury were discussed. Nursing leadership proposed a return-to-acute charted performance improvement plan and fall reduction action plan for 2026-2027.On 2/26/26, a QAPI meeting was held to discuss falls and incidents in the facility. Nursing leadership introduced a return-to-acute charted performance improvement plan and fall reduction action plan for 2026-2027 to reduce the likelihood of similar events.In February 2026, abuse and neglect education was provided to facility staff. Education for those not present was to be provided at a later date and during orientation.Continuous monitoring and auditing included daily discussion of incidents and accidents during clinical morning meetings, daily monitoring of high fall risk residents, interdisciplinary team discussions, and weekly analysis of falls compiled into QAPI and DON reports.

Based on observation, record review, and staff interviews, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being of residents by failing to ensure complete and thorough bathing and hygiene care and failing to provide an alternative method for showering when residents were unable to use a shower chair, for 3 of 3 sampled residents (Resident #9, Resident #10, and Resident #17).Findings: Resident #10 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, epilepsy, bipolar disorder, hypertension, polyneuropathy, low back pain, muscle spasm, dementia, hypothyroidism, chronic pain, hyperlipidemia, GERD, and anxiety. Review conducted on 4/1/26 at 11:00 AM of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #10 was cognitively intact and dependent on shower/bathe (the ability to bathe self including washing, rinsing, and drying self; excludes washing of back and hair and does not include transferring in and out of tub/shower). The assessment also indicated that Resident #10 was always incontinent of both bowel and bladder. Review conducted on 4/1/26 at 12:11 PM of the care plan initiated on 6/12/23 revealed that Resident #10 had limited ability to transfer self related to Parkinson's disease, generalized weakness, and unsteady gait, with interventions including, but not limited to, keeping the call light within reach. The care plan did not indicate how much assistance Resident #10 required for bathing or showering and did not address showers or bathing preferences. Observation conducted on 4/1/26 at 10:41 AM revealed that GNA #13 provided bathing, incontinence care, and bed linen change to Resident #10 while the resident was in bed. During the observation, GNA #13 rinsed only portions of Resident #10's face, including the forehead, cheeks, chin, and nose; however, GNA #13 did not wash or rinse the ears, back of the ears, or back of the neck. GNA #13 proceeded to provide upper body care but did not wash or rinse Resident #10's hands, fingers, or fingernails. GNA #13 continued bathing and washed and rinsed the resident's arms, underarms, legs, and feet; however, GNA #13 did not wash or rinse the resident's back at any time during the bathing process.During interview on 4/1/26 at 11:18 AM, GNA #13 indicated that they did not wash certain areas during bathing, including the back of the ears and neck, and stated that those areas were missed during care. GNA #13 further indicated that they did not routinely wash the resident's hands, fingers, and fingernails during bathing and instead would clean the resident's hands at mealtime. Resident #17 was admitted to the facility on [DATE] with diagnoses of hemiplegia, polyneuropathy, benign prostatic hyperplasia, hypertension, pain, depression, and atrial fibrillation. Review conducted on 4/2/26 at 12:52 PM of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #17 was moderately impaired and dependent on shower/bathe self (the ability to bathe self, including washing, rinsing, and drying self; excludes washing of back and hair and does not include transferring in and out of tub/shower). Review conducted on 4/2/26 at 12:54 PM of the care plan initiated on 5/18/25 indicated that Resident #17 had limited ability to transfer self related to impaired mobility. Review conducted on 4/2/26 at 12:56 PM of progress notes dated 9/6/26 at 8:24 PM written by Staff Nurse #6 indicated that Resident #17 was alert and oriented times four. Review conducted on 4/2/26 at 12:57 PM of progress notes dated 2/25/26 at 12:52 PM written by NP #7 indicated that Resident #17 was oriented times two with impaired insight. Review conducted on 4/2/26 at 12:58 PM of point of care history dated 3/4/26 through 4/2/26 indicated that GNA #36 was the only staff member documented to have provided Resident #17 with a shower. During interview on 4/2/26 at 12:25 PM, GNA #36 indicated that Resident #17 did not receive showers due to pain and inability to tolerate a shower chair. GNA #36 indicated that the resident received bed baths and confirmed that the resident had never received a shower and that no alternative method, such as a shower bed, was available. During interview on 4/2/26 at 12:38 PM, Resident #17 indicated that they had never received a shower and stated that no one had attempted to provide a shower. Resident #17 indicated that not receiving a shower made them feel not clean. During interview on 4/2/26 at 11:23 AM, Staff Nurse #22 indicated that Resident #17 was not able to tolerate sitting in a shower chair and that the facility did not have a shower bed to provide an alternative method for showering. Resident #9 was admitted to the facility on [DATE] with diagnoses of diabetes, hypertension, congestive heart failure, benign prostatic hyperplasia, peripheral vascular disease, gastritis, xerosis cutis, osteoarthritis, and pressure ulcer.Review conducted on 3/31/26 at 9:55 PM of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #9 had a PASRR Level II screening due to intellectual disability, was rarely or never understood, and was severely impaired. The MDS assessment indicated that Resident #9 was at risk of developing pressure ulcers/injuries and had a diabetic foot ulcer with moisture-associated skin damage (MASD). Review conducted on 4/1/26 at 1:04 PM of the care plan initiated on 2/21/25 indicated that Resident #9 had limited ability to transfer self related to a fall with left tibia fracture status post ORIF, with interventions including follow PT/OT recommendations and keeping the call light within reach. The care plan did not indicate the amount of assistance required for bathing or address resident preferences for bathing or showering or alternative methods for showering. Review conducted on 4/1/26 at 1:07 PM of wound consult notes dated 10/23/25, 12/4/25, 12/24/25, and 12/31/25 written by the wound physician indicated that Resident #9 may shower with wound dressing protected from moisture. During interview on 4/1/26 at 1:40 PM, GNA #13 indicated that Resident #9 received bed baths and did not receive showers due to wounds and discomfort with use of a shower chair. During interview on 4/1/26 at 2:15 PM, GNA #17 indicated that Resident #9 did not receive showers and received bed baths while in bed due to inability to tolerate a shower chair. During interview on 4/2/26 at 10:26 AM, Staff Nurse #19 indicated that Resident #9 was admitted with a left post-surgical wound and later developed a left heel deep tissue injury. Staff Nurse #19 indicated that the left heel wound healed and later reopened, but both wounds eventually healed. Staff Nurse #19 indicated that Resident #9 was admitted with diabetic ulcers. Staff Nurse #19 indicated that wound cultures were obtained and were negative for all wounds. Staff Nurse #19 indicated that Resident #9's wounds were always dressed appropriately and protected from moisture and would not prevent the resident from having a shower. During interview on 4/2/26 at 11:23 AM, Staff Nurse #22 indicated that Resident #9 was not able to tolerate sitting in a shower chair and that the facility did not have a shower bed to provide an alternative method for showering. During interview on 4/2/26 at 11:37 AM, the Director of Nursing (DON) indicated that due to the lack of a shower bed, residents who were unable to tolerate a shower chair received bed baths. The DON indicated that the facility should exhaust all options to meet the needs of residents. During interview on 4/2/26 at 11:39 AM, the Administrator indicated that the facility did not have a shower bed available for residents to use.

Based on record review and staff interviews, the facility failed to ensure that resident records were accurate and reflected the care and services provided, by documenting that showers were provided when staff interviews revealed that showers were not performed, for 2 of 3 sampled residents (Resident #9 and Resident #17).Findings included:Resident #17 was admitted to the facility on [DATE] with diagnoses of hemiplegia, polyneuropathy, benign prostatic hyperplasia, hypertension, pain, depression, and atrial fibrillation.Review conducted on 4/2/26 at 12:52 PM of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #17 was moderately impaired and dependent on shower/bathe self (the ability to bathe self, including washing, rinsing, and drying self; excludes washing of back and hair and does not include transferring in and out of tub/shower).Review conducted on 4/2/26 at 12:54 PM of the care plan initiated on 5/18/25 indicated that Resident #17 had limited ability to transfer self related to impaired mobility.Review conducted on 4/2/26 at 12:58 PM of point of care history dated 3/4/26 through 4/2/26 indicated that Resident #17 was documented to have received showers, with GNA #36 identified as the staff providing care. GNA #36 documented in the point of care history that they provided a shower on 3/30/26, 3/26/26, 3/19/26, 3/16/26, 3/12/26, 3/9/26, and 3/5/26.Review conducted on 4/3/26 at 9:50 AM of the GNA shower/skin worksheet provided by the facility indicated that GNA #36 provided a bed bath to Resident #17 on 3/30/26, 3/26/26, 3/19/26, 3/16/26, 3/12/26, 3/9/26, and 3/5/26.During interview on 4/2/26 at 12:25 PM, GNA #36 indicated that Resident #17 did not receive showers due to pain and inability to tolerate a shower chair. GNA #36 indicated that the resident received bed baths and confirmed that the resident had never received a shower. GNA #36 further indicated that they were instructed to document in the electronic system that a shower was provided; however, on the shower paper sheet, they documented the actual care provided, which was a bed bath.Resident #9 was admitted to the facility on [DATE] with diagnoses of diabetes, hypertension, congestive heart failure, benign prostatic hyperplasia, peripheral vascular disease, gastritis, xerosis cutis, osteoarthritis, and pressure ulcer.Review conducted on 3/31/26 at 9:55 PM of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #9 had a PASRR Level II screening due to intellectual disability, was rarely or never understood, and was severely impaired. The MDS assessment indicated that Resident #9 was at risk of developing pressure ulcers/injuries and had a diabetic foot ulcer with moisture-associated skin damage (MASD).Review conducted on 4/1/26 at 1:04 PM of the care plan initiated on 2/21/25 indicated that Resident #9 had limited ability to transfer self related to a fall with left tibia fracture status post ORIF, with interventions including following PT/OT recommendations and keeping the call light within reach. The care plan did not indicate the amount of assistance required for bathing or address resident preferences for bathing or showering or alternative methods for showering.Review conducted on 4/1/26 at 12:54 PM of point of care history dated 12/28/25 through 1/27/26 indicated that GNA #36 documented on 1/15/26 and 1/26/26 that they provided a shower to Resident #9.Review conducted on 4/3/26 at 9:50 AM of the GNA Q-shift skin/shower worksheet provided by the facility indicated that GNA #36 provided a bed bath to Resident #9 on 1/15/26 and 1/26/26.During interview on 4/2/26 at 12:24 PM, GNA #36 indicated that they recalled Resident #9 and had never provided a shower. GNA #36 indicated that they documented showers in the system but provided bed baths. GNA #36 indicated that they were instructed to document showers despite not providing them. GNA #36 indicated that Resident #9 was not able to stand or transfer safely to a shower chair and was transferred using a mechanical lift. GNA #36 indicated that they had never attempted to provide a shower due to safety concerns and had not observed other staff provide a shower. GNA #36 indicated that the resident required at least a two-person assist.During interview on 4/1/26 at 1:40 PM, GNA #13 indicated that Resident #9 received bed baths and did not receive showers due to wounds and discomfort with use of a shower chair.During interview on 4/1/26 at 2:15 PM, GNA #17 indicated that Resident #9 did not receive showers and received bed baths while in bed due to inability to tolerate a shower chair.During interview on 4/2/26 at 12:25 PM, GNA #36 indicated that staff were instructed to document in the electronic system that a shower was provided even when a shower was not performed, and that actual care provided was documented on a separate paper shower sheet.During interview on 4/2/26 at 11:37 AM, the Director of Nursing indicated that staff were expected to document only the care and services actually provided in the electronic medical record.During interview on 4/2/26 at 11:39 AM, the Administrator indicated that staff were expected to document only the care and services actually provided. The Administrator further indicated that the nurse who instructed staff to document showers that were not performed was no longer employed at the facility and had been terminated. The Administrator did not disclose the reason for the termination.

Based on interviews with staff and Residents and surveyor record review it was determined that the facility failed to develop and implement comprehensive care plans for Residents. This finding was found to be evident for 4 (Resident #21, #51, #54, and #61) out of 7 Residents reviewed for the development and implementation of comprehensive care plans. The findings include: 1. In an interview with Resident #51 on 6/16/2025 at 11:49 AM, the Resident stated that he/she had one fall in the bathroom a few weeks ago. The Resident stated that he/she had pain in both knees and received pain patches for the knee pain. The surveyor conducted a record review of Resident #51's medical record on 6/18/2025 at 11:15 AM. Record review revealed a progress note that Resident #51 had a fall on 5/27/2025 at 4:00 PM when Resident attempted to transfer self from toilet to wheelchair and lost balance. Additionally, review of Resident #51's care plan revealed that Resident did not have a comprehensive care plan developed or implemented for the actual fall on 5/27/2025, however, there was a plan of care for at risk for falls. In an interview with the Director of Nursing (DON) at 1:40 PM on 6/18/2025 the surveyor conveyed that Resident #51 had a fall on 5/27/2025 and the incident report and the fall investigation that were provided by the DON substantiated the fall on 5/27/2025. Further review of Resident #51's care plan on 6/23/2025 at 11:00 AM revealed that a plan of care time stamped 6/18/2025 at 2:28 PM for an actual fall was now included in Resident's comprehensive care plan after surveyor intervention. 2. The surveyor conducted a record review of Resident #54's medical record on 6/23/2025 at 11:05 AM. Resident #54 was admitted to the facility on [DATE] at 7:43 PM for short term rehabilitation. Review of the medical record revealed that Resident #54 had physician orders for two medications Furosemide (Lasix) which was a diuretic medication and Quetiapine (Seroquel) which was an anti-psychotic medication. Further review of the Resident #54's medical record revealed that the care plan was not reflective of the Resident receiving these two medications. Resident #54 had been receiving Seroquel at home and Lasix was ordered on 6/5/2025 at the facility. There was not a plan of care developed or implemented for Lasix and Seroquel for Resident #54. In an interview with the RN MDS Coordinator #3 at 12:15 pm on 6/24/2025 the surveyor asked who was responsible for the development/implementation of comprehensive care plans for the Residents and the RN MDS Coordinator stated that the nursing staff were responsible for the Resident care plans. The surveyor conveyed to the RN MDS Coordinator that Resident #54 had physician orders for Seroquel and Lasix but there were no care plans to address either of these two medications. The RN MDS Coordinator acknowledged the surveyor and stated that she would share this information with the staff. At 3:45 PM on 6/26/2025 the surveyor reviewed the care plan concerns with the Regional Nurse, Director of Nursing (DON) and the Licensed Nursing Home Administrator/Executive Director (LNHA/ED) and they acknowledged the surveyor. No additional information was provided by the facility. 3. A nasal cannula is a device used to deliver oxygen to a resident, it consists of a flexible tube that is placed under the nose and has two prongs that go inside the nostrils to deliver oxygen. During an observation on 6/16/25 at 11:11 AM Resident #61 was observed lying in bed with oxygen being administered by a nasal cannula. During a medical record review for Resident #61 on 6/16/25 at 12:45 PM it was discovered he/she was admitted on [DATE] and required oxygen to assist with breathing. The initial orders for the resident after being admitted to the facility included Oxygen at 2 liters per minute via nasal cannula every shift and Observe for any symptoms of SOB or trouble breathing every shift. During a continued review of the Resident's medical records, it was discovered that the Resident had an order for Eliquis, an anticoagulant, to be taken twice daily. The Resident's Medication Administration Record (MAR) revealed that Eliquis had been administered twice daily since 6/05/25. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. During a review of the Minimum Data Set (MDS) for Resident #61 it was found that based on the Assessment Reference Date of 6/08/25 the Resident was identified as having shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat. It also identified the resident required oxygen and had been taking an anticoagulant. During further review of the Resident's medical records, it was determined that Oxygen and anticoagulant medication had not been included in the Resident's Care Plan. During an interview with the Director of Nursing (DON) on 6/17/25 at 1:28 PM she reviewed the chart for Resident #61 and confirmed that oxygen and Eliquis were not included in the Resident's Care Plan. She agreed they should have been included in the Care Plan. During a review of the Care plan for Resident #61 on 6/17/25 at 3:26 PM it was discovered that the Care Plan was updated on 6/17/25 at 1:38 PM with the Resident requires oxygen therapy related to COPD and Potential for complications related to anticoagulant therapy. 4. During a review of the Medical Records for Resident #21 on 6/23/25 at 12:10 PM it was discovered that he/she had a history of diabetes. A review of the Medication Administration Record (MAR) revealed the Resident was taking insulin for diabetes, the medications included a Novolog Flexpen Insulin which was started on 12/26/24 and an Insulin Glargine insulin pen which was started on 2/04/25. It was also found that the Resident was taking Clopidogrel, an anticoagulant, which was started on 4/30/25. A Care Plan is used in nursing facilities to summarize a resident's health conditions and care needs. It is used to ensure resident's needs are met and consistent care is provided to the resident based on those needs. During a continued review of the Resident's medical records on 6/23/24 at 2:46 PM it was determined that Diabetes, Insulin administration and anticoagulant medication were not included in Resident #21's Care Plan. During an interview with the Director of Nursing on 6/23/25 at 2:50 PM she confirmed diabetes, insulin and the anticoagulant were not in Resident #21's care plan but should've been and advised it's not updated. She reported, We need some work on care plans. During a medical record review for Resident #21 on 6/24/25 at 7:51 AM it was discovered that the Care Plan was updated on 6/23/25 with Resident is taking clopidogrel for prevention of thrombotic events, placing them at increased risk for bleeding and Resident has insulin-dependent diabetes mellitus related to impaired glucose metabolism.

Based on record review, observation and interview, it was determined that the facility staff failed to provide privacy to a resident during the administration of a subcutaneous injection. This was evident in 1 (Resident #54) of 1 resident observed for injection administration. The findings include: A review of Resident #54's clinical record revealed that the resident was admitted to the facility with diagnoses including Dementia and Diabetes Mellitus. On 06/16/2025 at 10:10 AM the surveyor observed Registered Nurse (RN) #2 administer medications to Resident #54. The medications included Heparin 5,000 units to be administered by subcutaneous injection twice a day. During the observation, RN#2 failed to provide privacy to the resident while administering the Heparin injection. After going into Resident #54's room, RN#2 did not close the door or pull the privacy curtain. RN#2 informed the resident that she was going to administer a Heparin injection, then pulled up the resident's hospital-type gown and administered the injection to the right side of the resident's abdomen. In an interview during the medication observation, the surveyor enquired about the practice for providing privacy during injection administration. RN #2 confirmed that she did not provide privacy by pulling the curtain or by closing Resident #54's door. RN #2 stated I apologize, I should have provided privacy. On 06/26/2025 at 07:52 AM in an interview with the surveyor, the Director of Nursing stated that staff members are required to provide privacy to residents during injection administration. She stated that if a resident is in a private room, the door should be closed and if the resident was in a semi-private room the curtain should be drawn. The surveyor informed the DON of the findings during the observation of a Heparin injection administration.

Based on clinical record review, staff interviews and an investigation into a complaint, it was determined that the facility failed to report an allegation of suspected resident abuse to the Office of Health Care Quality (OHCQ). This finding was evident for 1 (#166) of 2 residents reviewed for abuse during the annual survey. This finding is related to complaint #MD00185506. The findings include: The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Allegations of abuse are to be reported to the Office of Healthcare Quality in a timely manner. A review of complaint intake MD00185506 on 6/30/2025 revealed that on 11/10/2022, Resident #166 alleged that staff members washed him/her in a rough manner while providing assistance with activities of daily living (ADL) care. A review of Resident#166's clinical record on 06/30/2025 at 11:18AM revealed a nursing progress note dated 11/10/2022 at 2:02 PM which stated Resident refused to be changed by two aides this shift. S/he stated that s/he does not want to be abused. GNAs made writer and ADON aware. Further record revealed a nursing progress note dated 11/10/2022 at 4:13 PM which stated, Resident observed to be combative and physically abusive towards staff during care, patient was offered a shower by a staff members, two therapy staff and two nursing assistant, patient consented to the shower, patient was transfer from bed to the shower chair by 4 staff member with a Hoyer lift, during the shower process the above patient started punching and hitting on staff, throwing towels with feces on it, the shower was stop, patient was dried up by staff and transfer back to bed safely, the police was called in, patient refused to talk to the police officer regarding the allegation of been physically abusive to the staff, patients medicated for pain with Tylenol 650mg x1 for pain.call place to the responsible party about patient aggressive behavior towards staff, refusing therapy services, P.O.A verbalized understanding of the patients behavior, writer request for a psych consult request as per MD order and RP consented On 6/30/2025 at 2:05 PM, the surveyor requested the facility's investigative record regarding the incident that occurred with Resident #166 on 11/10/2022. During an interview with the Administrator on 6/30/2025 at 2:22PM, the Administrator stated that she was unable to locate an investigative file related to the incident that occurred with Resident #166 on 11/10/2022. When asked if the allegation of abuse was reported to OHCQ, the Administrator stated, I'm not sure if it was reported to the state because I was not here at that time, but I can look into it and get back to you. During a follow up interview with the Administrator on 6/30/2025 at 2:52 PM, theAdministrator was not able to confirm that the allegation of abuse made by Resident #166 on 11/10/2022 was reported to the OHCQ. The Administrator further stated that it is the expectation that the facility reports all allegations of abuse to OHCQ in a timely manner. At the time of exit interview, the facility did not provide any additional evidence that the OHCQ was notified of Resident #166's allegation of abuse on 11/10/2022.

Based on facility staff interview and surveyor record review it was determined that the facility failed to investigate an alleged violation of abuse. This finding was found to be evident in 1 (Resident #187) out of 1 Resident that was reviewed for investigation of an alleged violation of abuse. The findings include: The Office of Healthcare Quality (OHCQ) received a facility reported incident (FRI)/self-report on 6/29/2023 at 8:56 AM from the facility's Assistant Director of Nursing (ADON) for an allegation of Resident abuse (family to Resident) - Intake#MD00193872. Resident #187 was linked to the Intake#MD00193872. The surveyor requested the facility investigation file for the facility reported incident (FRI) for Resident #187 on 6/17/2025 at 7:15 AM from the Licensed Nursing Home Administrator/ED (LNHA/ED). In an interview with the Licensed Nursing Home Administrator/Executive Director (LNHA/ED) on 6/17/2025 later in the day, she stated that she was unable to locate an investigation file for this facility reported incident (FRI) for Resident #187, but that she would continue to look for the investigation file. In a follow-up interview with the LNHA/ED on 6/23/2025 at 4:15 PM she stated she would have the company's IT/IS Department see if they were able to locate the self-reports in her email file for Resident #187. The surveyor conducted a record review of Resident #187's closed electronic medical record on 6/25/2025. Review of the medical record revealed a progress note written on 6/28/2023 at 4:54 PM by a licensed nurse which indicated that Resident #187's son was visiting Resident and yelled at him/her to stop screaming and then he/she left the facility. Additionally, there was a progress note written on 6/29/2023 at 5:16 PM by Social Services which indicated that Resident #187 responded no then yes when asked if his/her son grabbed his/her face and the Resident responded yes when asked if he/she felt safe. The surveyor reviewed on 6/25/2025 at 2:55 PM the facility's policy for Abuse, Neglect, and Misappropriation of Property dated 10/23/2019. The policy indicated that the facility collects, retains, and safeguards all information and evidentiary material pertinent to the investigation of the alleged abuse or neglect. The LNHA/ED provided the surveyor on 6/26/2025 with the initial self-report and final self-report for the facility reported incident (FRI) for 6/29/2023 that the company's IT/IS Department was able to locate in the LNHA/ED's email account. However, the facility was unable to produce an investigation file of the alleged violation of abuse (family to Resident) for Resident #187. No additional information was provided by the facility at the time of exit.

Based on clinical record review, facility staff interviews and surveyor review of a facility reported incident and a complaint, it was determined that facility failed to provide written notice to the Office of the State Long Term Care (LTC) Ombudsman of a Resident's discharge, and failed to ensure that a discharge summary was completed by a Resident's physician. This finding was found to be evident for 2 (Resident #62 and #171) out of 3 residents reviewed for discharge process during the annual survey. The findings include: 1. On [DATE] at 12:15 PM, a review of Resident #62's clinical record revealed that Resident #62 was admitted to the facility on [DATE] and discharged home on [DATE]. Further review of Resident #62's electronic clinical record revealed no documentation that the local ombudsman was notified of the resident's discharge from the facility. On [DATE] at 03:01 PM, an interview conducted with the Administrator revealed that discharge notices are sent to the ombudsman via email each time a resident is transferred to hospital by the Admissions Director #6. On [DATE] at 03:10 PM, an interview conducted with the Admissions Director #6 confirmed that an email is sent to the ombudsman each time a resident transfers / discharges to the hospital, however the Admissions Director #6 was unable to confirm that the ombudsman is notified when a resident discharged to home. On [DATE] at 03:23 PM, a review of the facility provided documentation of transfer/discharge notices sent the ombudsman via email from [DATE] to [DATE] was conducted by the surveyor. The review did not reveal any evidence that the ombudsman was notified of Resident #62's discharge to home on [DATE]. On [DATE] at 11:55 AM, an interview conducted with Regional Clinical Nurse #5 revealed that she could not locate any evidence that a written notice of discharge was given to the local ombudsman for Resident #62's discharge to home on [DATE]. At the time of exit conference, the facility did not provide any evidence that a written notice of discharge was given to the local ombudsman for Resident #62's discharge to home on [DATE]. 2. On [DATE] at 7:15 AM the surveyor conducted an investigation of a complaint (MD#00193420) that was received at the Office of Healthcare Quality (OHCQ) on [DATE] at 15:07 PM. The complainant alleged that Resident #171 was found unresponsive by the nursing staff, and it was unknown if a physician was present to determine the Resident's status at the time. The complainant alleged that the cause of Resident #171's death was unknown at that time. Medical Orders for Life-Sustaining Treatment (MOLST) is a program designed to improve the quality of care for patients with serious illnesses by translating patient preferences into medical orders that can be followed across different healthcare settings. The MOLST helps ensure that a patient's end of life wishes are honored by providing clear, portable medical orders that guide healthcare providers. The key aspects of the MOLST focus on patient preferences, portable and standardized, specific medical orders, collaboration and communication, and not a replacement for other advance directives. The surveyor conducted a record review of Resident #171's closed electronic medical record. Review of the medical record revealed that there was a progress note from the nursing staff that indicated that Resident #171 was observed unresponsive, no pulse at 7:07 PM on [DATE] by the nursing staff. The physician was notified via phone by the nursing staff and the physician pronounced Resident #171 deceased . Further review of the medical record revealed that Resident #171 had a MOLST which indicated that Resident was Do Not Resuscitate (DNR) status. In an interview on [DATE] at 8:00 AM with the Director of Nursing (DON) the surveyor asked what the expectation was for physician documentation of a death in the facility. The DON stated that the expectation was that a progress note/discharge note was to be completed by the physician that pronounced the Resident. The surveyor conveyed to the DON that there was not a progress note/discharge note in Resident #171's medical record. The only progress note was from the nursing staff and there was a Record of Death and Mortician's Receipt form from Maryland Cremation Services which indicated that the remains was released from the facility and received by the mortician. The surveyor interviewed the Medical Records Coordinator (MRC) at 10:15 AM on [DATE]. The surveyor conveyed to the MRC that there was not a physician progress note/discharge note for Resident #171. The MRC acknowledged the surveyor and stated that there should be a discharge summary/progress note from the physician and that she had contacted the Maryland Cremation Services for a death certificate. In a follow up interview later that day with the Medical Records Coordinator (MRC) on [DATE] she stated that she was waiting for the death certificate as she had sent an email to Maryland Cremation Services requesting the certificate. Additionally, the MRC stated that the physician that pronounced Resident #171 on [DATE] was no longer employed with Adfinitas Health-Physician Services as of [DATE]. The surveyor received a copy of the death certificate via email from the facility on [DATE].

Based on observation, interviews with Residents and staff and surveyor record review it was determined that the facility failed to ensure that Resident's care plans were revised and updated timely. This finding was found to be evident in 2 (Resident #51 and #54) out of 2 Residents reviewed for care plan timing and revision. The findings include: The surveyor toured the nursing unit on 6/16/2025 at 8:44 AM and observed Resident #51 in his/her room in the wheelchair. The Resident stated that he/she had a fall in the bathroom when he/she attempted to transfer from the toilet to the wheelchair and lost balance and had pain in both knees a few weeks ago. A record review was conducted by the surveyor on 6/18/2025 at 11:15 AM of Resident #51's medical record. Record review of the progress notes revealed that Resident #51 had a fall on 5/27/2025 at 4:00 PM when Resident attempted to transfer self from toilet to wheelchair and lost balance. Bilateral knee x-rays were performed which revealed no fractures. Additionally, review of Resident #51's care plan revealed that Resident had a care plan for at risk for falls but not a care plan for an actual fall, and there was not an intervention added to the care plan when the Resident had the fall on 5/27/2025. In an interview with the Director of Nursing (DON) at 1:40 PM on 6/18/2025 the surveyor conveyed that Resident #51 had a fall on 5/27/2025 and the incident report and the fall investigation that were provided by the DON substantiated the fall on 5/27/2025. Additionally, the surveyor conveyed that there was not an intervention added to the care plan when Resident #51 had the fall on 5/27/2025 at 4:00 PM. Further record review of Resident #51's care plan on 6/23/2025 at 11:00 AM revealed that a plan of care time stamped 6/18/2025 at 2:28 PM for an actual fall was now included in Resident's care plan. Resident #51's care plan was updated to reflect an actual fall after surveyor intervention. An MDS assessment nurse, also known as a nurse assessment coordinator, is a Registered Nurse (RN) who specializes in the Minimum Data Set (MDS) assessments for Residents in nursing homes and other long-term care facilities. They play a crucial role in ensuring accurate and timely assessments, which are essential for Resident care planning, facility funding, and regulatory compliance. In an interview with the RN MDS Coordinator #3 at 12:15 pm on 6/24/2025 the surveyor asked who was responsible for the update and revision of Resident care plans and the RN MDS Coordinator stated that the nursing staff were responsible for updates and revisions to the Resident care plans. A Foley catheter is a thin, flexible tube inserted into the bladder to drain urine. It's also known as an indwelling urinary catheter and is held in place by a small balloon inflated inside the bladder. Foley catheters are used for various reasons, including urinary retention, incontinence, and after certain surgeries, and they allow for continuous urine drainage into a collection bag. On tour of the facility on 6/16/2025 at 8:44 AM the surveyor observed Resident #54 in bed with a Foley catheter drainage bag attached to the frame of the bed. The Resident stated that he/she has the catheter for edema. The surveyor conducted a record review of Resident #54's medical record on 6/23/2025 at 11:05 AM. The record review revealed that Resident #54 had a physician order for an indwelling Foley catheter for urinary retention as of 6/13/2025. Further review of the medical record, specifically the care plan revealed that there was not a plan of care for the indwelling Foley catheter. In an interview with the RN MDS Coordinator #3 on 6/24/2025 at 12:15 PM the surveyor conveyed that Resident #54 had an indwelling Foley catheter in place since 6/13/2025 but there was not a care plan for the catheter. The RN MDS Coordinator acknowledged the surveyor. At 3:45 PM on 6/26/2025 the surveyor reviewed the care plan concerns with the Regional Nurse, Director of Nursing (DON) and the Licensed Nursing Home Administrator/Executive Director (LNHA/ED) and they acknowledged the surveyor. No additional information was provided by the facility.

Based on record reviews and interviews, it was determined the facility failed to initiate wound care upon admission for a Resident with Pressure Ulcers. This was evident for 1 (Resident #191) out of 4 residents reviewed for pressure ulcers during the survey. The findings include: A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), and Stage IV (full thickness skin loss with extensive damage to muscle, bone, or tendon). Deep Tissue Injuries (DTIs) are characterized by intact skin that is discolored (purple or maroon) or a blood-filled blister, indicating damage to underlying soft tissue due to pressure or shear. DTIs are considered unstageable pressure injuries until the wound fully evolves and can be numerically staged. During a review of Compliant #MD00203067 for Resident #191 on 6/24/25 at 12:56 PM it revealed, after just one week under their care, he/she developed bedsores and blisters across his/her body. During a medical record review on 6/24/25 at 1:06 PM for Resident #191 it was discovered that the Resident was admitted on [DATE] at 6:14 PM. The Discharge/Transfer summary from the transferring hospital reported Resident #191 had a right thigh decubitus in clean dressing and the Hospital Discharge Diagnosis/Plan stated, Decubitus lesion, Continue wound care. During continued review of the medical records for Resident #191 it was discovered that the Observation Report for admission was completed on 2/16/24 at 7:33 PM and the skin assessment identified a Bruise right upper arm. A Nursing progress note written on 2/17/2024 at 12:41 AM reported A head-to-toe examination revealed dry skin, a dry scar on the right foot, and a nonbleeding bruise on the right forearm. No open wound was noted. During additional medical record review it was revealed that physician orders were added for wound care for Resident #191 on 2/19/24 at 4:47 PM. The orders included: wound treatment: Location bilateral heel, Apply skin prep Twice a day, Right upper thigh, clean with wound cleanser, apply hydro gel and cover with boarded gauze twice a day and Sacral wound, clean with wound cleanser, Apply Medi honey and cover with boarder gauze. It was discovered that the Resident had no wound care documented prior to these orders. During further medical record review for Resident #191 it was discovered that a Nursing Progress note written on 2/19/24 at 9:54 PM stated, Please note the following addendum to the admission note: Upon further examination, a DTI of 1.7 x 2 was indicated on the resident's right lateral foot, with an additional area of 1.5 x 1.2 on the middle of the foot and an area of 6 x 4 cm on the right heel. Also, a DTI of 1.1 x 1.3 has been noted on the left lateral foot. In addition, the resident has an open wound measuring 7 x 2 cm with dry blisters measuring 6 x 2 cm on the right upper thigh and an open wound of 1.2 x 1 cm on the sacrum, including the left ischium DTI of 6X2.2cm. An order has been placed to manage the skin and monitor the wounds. During an additional medical record review for Resident #191 a Wound Management Detail report dated 2/22/25 was discovered and the following wounds were documented as being present upon admission: DTI - Right big toe, DTI - Left big toe, Trauma - Right Buttock Right Ischium, Pressure Ulcer - Sacrum Stage 3, a DTI - Right top of foot and to the right lateral foot. During an interview with the Director of Nursing (DON) on 6/27/25 at 11:50 AM she reported the Resident would get a head-to-toe assessment upon admission and if any bedsores are found they should be documented, assessed, treated and redressed if necessary. She advised any wound care provided to the Resident should have been documented in the Resident's medical record. She reported treatment for the wounds should have been started earlier because the goal is to catch it before it gets worse. She is not sure what may have caused the delay in wound care because she was not working in the facility at the time Resident #191 was a Resident. During an interview with the Unit Manger for the [NAME] Oak Unit on 6/30/25 at 10:07 AM it was discovered that upon admission nursing staff should perform a head-to-toe skin assessment and if any issues are found the doctor should be notified. She confirmed that pressure ulcers are a reason for the doctor to be notifed. The doctor would provide orders and care for the pressure ulcers should start care as soon as orders are obtained. She advised she is not sure what the wound care delay would have been for Resident #191 because she wasn't working at the facility at that time; however, she believes care should have started sooner.

Based on observation, interview and record review it was determined that the facility failed to ensure that the posted nurse staffing information was accurate and current. This finding was found to be evident in the review of sufficient and competent Nurse staffing. The findings include: The facility's staffing data document may be a form or spreadsheet, and all the required information displayed clearly and in a visible place. The information should be displayed in a prominent place that was readily accessible to residents, staff, and visitors and presented in a clear and readable format. This information posted must be up-to-date and current. The facility must post the nurse staffing data on a daily basis at the beginning of each shift. The facility must ensure staffing information was accurate and current. At 1:20 PM on 6/18/2025 the surveyor observed in the facility lobby on the receptionist desk the posted nurse staffing information in a clear standing frame. The date that was indicated on the posted nurse staffing information form was 6/17/2025. In an interview with employee #9 at 1:22 PM on 6/18/2025 she stated that the posted nurse staffing information form was posted daily by the Administrator-In-Training (AIT) employee #8. The surveyor conveyed to employee #9 that the date was incorrect on the posted nurse staffing information form. Employee #9 requested an updated nurse staffing information form from employee #8. Employee #9 posted on the receptionist desk the updated nurse staffing information form with the correct date of 6/18/2025. At 1:40 PM on 6/18/2025 the Director of Nursing (DON) was notified of the nurse staffing information form not posted on the receptionist desk with the correct date of 6/18/2025. The surveyor conveyed to the DON that the nurse staffing information sheet was posted but not with the correct date. The DON acknowledged the surveyor and stated, yes they told me about the incorrect date of 6/17/2025 and an updated nurse staffing information form was posted with the correct date of 6/18/2025.

Based on observations and interviews it was determined that the facility failed to store food in a manner that ensures food safety. This was evident in 1 out of 2 dining areas observed during the survey. The findings include: During an observation of the Refrigerator in the [NAME] Oak Dining Room on 6/16/25 at 8:12 AM there were food containers found that were expired and that had no name or date. These foods included: A disposable plastic food container for Resident #51 dated 6/11/25 A plate of salad without a date made or date placed into the refrigerator A plastic container of food with no name or date written on it Two containers with a room number but no date A plastic bag of food for Resident #61 with no date A plastic bag of food with no name or date During an interview with the Director of Dining Services on 6/16/25 at 8:18 AM he reported the refrigerator was for Residents to store food brought into the facility. He advised anything put into the refrigerator should be labeled fully with the name of the Resident and the date that the item was put inside. He reported items would be considered expired and thrown out after three days. He confirmed the food for Resident #51 should have been removed from the refrigerator and wasted. During a review of the facility's Nutrition Policies and Procedures: Food From Outside Sources, Safe Handling Of on 6/17/25 at 1:46 PM it stated that Foods are labeled to identify the patient/resident's name, container contents, and the date it was prepared and that Items will be stored for three days. Expired and unlabeled items will be discarded.

Based on Record Reviews, Observations and Interviews it was determined that the facility failed to ensure medical records were complete and accurate. This was evident for 2 (Resident #61, #46) out of 5 Residents reviewed for complete and accurate medical records. The findings include: 1. During a medical record review on 6/18/25 at 9:23 AM it was discovered that Resident #46 had an order for a Pressure relieving Mattress present on bed for skin integrity protection that was ordered on 3/28/25 and an Air Mattress for pressure relieving to wounds every shift that was ordered on 5/01/25. During a review of the Treatment Administration Record (TAR) for Resident #46 it was discovered that the order for the Pressure Relieving Mattress and the order for Air Mattress was documented as being completed from 6/01/25 to 6/20/25. During an observation of Resident #46 with LPN #16 on 6/20/25 at 10:52 AM she confirmed the Resident dId not have an air mattress but dId have a pressure relieving mattress. During an interview with the Unit Manager for the Sycamore Unit on 6/20/25 at 11:04 AM she confirmed that the Resident had orders for two different types of mattresses and was unsure which order should be followed. She advised the Air Mattress order was placed most recently so that was probably the correct order to follow, but she would investigate. During an interview with the Director of Nursing (DON) on 6/20/25 at 2:45 PM she reported the order for the Air Mattress should have been removed because after the order was placed, the family and physician decided to not use the Air Mattress. During a review of the TAR 6/23/25 at 9:23 AM it was discovered that the order for the Air Mattress was discontinued on 6/20/25. 2. During a medical record review on 6/18/25 at 10:54 AM it was discovered that Resident #46 had a physician order for Resident to be out of bed Mon-Wed-Fri for 1-2 hours that was placed on 6/09/25. During a continued review of the Resident's medical records it was discovered that the order did not transfer to the Resident's Treatment Administration Record (TAR). During an interview with the Director of Nursing (DON) on 6/20/25 at 2:45 PM she confirmed the order should appear on the TAR for nursing staff to see and sign off as completed. She reported the order wasn't put in correctly so it didn't transfer to the TAR and advised we will have to do some training on putting in orders. During a Record review on 6/23/25 at 11:29 AM it was found that the order was corrected and appeared on the TAR on 6/20/25. 3. During a medical record review for Resident #61 on 6/23/25 at 9:47 AM it was discovered that a Nursing Progress note was written on 6/21/25 at 7:17 AM which stated, Pain meds was given at 6:30 am. During a continued review of the Resident's medical records, it was discovered that the Medication Administration Record (MAR) had no documentation of any medications being administered during that time. The MAR showed the only medication administered for Resident #61 on the morning of 6/21/25 was Lorazepam at 9:00 AM and Morphine was given at 10:08 AM. During an interview with the Unit Manager from [NAME] Oak on 6/26/25 at 2:51 PM she reported medications should be signed off in the Medication Administration Record immediately after given. She confirmed there was no documentation of medications being given on 6/21/25 at 6:30 AM in the MAR for Resident #61. During an interview with the Director of Nursing on 6/26/25 at 3:01 PM she confirmed medications should be documented in the MAR when given and was unable to determine what medications were given to Resident #61 on 6/21/25. During a review of the Controlled Drug Receipt/Record/Disposition Form on 6/30/25 at 11:13 AM it was revealed that Resident #61 had a sign off sheet for Morphine and for Lorazepam. The Morphine Form showed the last two administrations were at 10:00 PM on 6/20/25 and at 9:00 AM on 6/21/25. The Lorazepam form showed the last 2 administrations were on 6/02/25 at 8:00 PM and 6/21/25 at 8:10 AM. There was no documentation for medication being administered at 6:30 AM on 6/21/25.

Based on record review, observation and interview, it was determined that the facility staff failed to perform hand hygiene during medication administration. This was evident in 1 (Resident #40) of 5 residents observed during medication administration. The findings include: A review of Resident #40's clinical record revealed that the resident was admitted to the facility with diagnoses including Hypertension and Myocardial Infraction. On 06/16/2025 at 09:45 AM during a medication administration observation, the surveyor observed Registered Nurse (RN) #2 take Resident #40's Blood Pressure. RN #2 reported the Blood Pressure as 137/80 then walked to the medication cart and wrote the Blood Pressure down on paper. RN #2 unlocked the medication cart and proceeded to dispense the resident's medication without performing hand hygiene. The surveyor intervened and asked about hand hygiene. RN #2 then performed hand hygiene using hand sanitizer solution. Later, at around 09:50 AM while RN #2 was dispensing medications, a visitor walked up to the medication cart. RN #2 conversed and shook hands with the visitor. After the conversation, RN #2 went back to the medication cart and continued to dispense medications without performing hand hygiene. When the surveyor pointed out the need for hand hygiene, RN #2 reached for a bottle of hand sanitizer which was on the medication cart and sanitized her hands. In an interview on 06/16/2025 during the medication pass, RN #2 confirmed the surveyor's observations, apologized and stated that she should have performed hand hygiene before handling the medications and after shaking the visitor's hands. On 06/26/2025 at 07:52 AM in an interview with the Director of Nursing (DON) regarding the process for medication pass, the DON stated that staff members are required to perform hand hygiene before and after taking care of a resident and after leaving a resident's room. Also, staff members are required to perform hand hygiene before touching the medication cart to dispense medications. In addition, hand hygiene should have been performed by the staff member after shaking the visitor's hand. The DON was notified of the surveyor's findings.

Based on observations and interviews, it was determined that the facility failed to maintain a functional and sanitary environment. This was found evident in 1 out of 2 dining areas observed during the survey. The findings include: During observations on 6/16/25 at 8:14 AM it was discovered that a non-operating ice and water dispenser was on top of the counter in the Sycamore Café. Further observation revealed the cabinet below the dispenser was missing the handle to the right door. The floor inside the cabinet was broken into pieces and crumbled in the center. The interior of the cabinet had brownish stains running down the walls and on the broken flooring. A broken pipe was found inside the cabinet. During an observation and interview with the Director of Maintenance on 6/17/25 at 2:12 PM he reported that he had been employed with the facility for about four and a half months. He advised he was not aware of the damaged cabinet and described the crumbled flooring as pressed wood. During an interview with the Administrator on 6/17/25 at 2:21 PM she advised the cabinet had been like that for a while. She added we are planning on fixing it, it's a process, it's a big expenditure. During an observation on 6/30/25 at 8:47 AM it was discovered that the cabinet floor had been replaced, and the interior of the cabinet had been cleaned. The non-operating dispenser remained on the cabinet, the doors to the cabinet were lopsided and the handle to the right door remained absent.

Based on observation, staff interviews, and review of medical record documentation it was determined that the facility failed to maintain a safe and effective system for securing medication, treatment supplies, and hazardous medical equipment in their designated carts on nursing units with residents with documented cognitive deficits and wandering behaviors. This practice was noted on 8/31/22 and included five (5) medication/treatment carts that were observed unlocked and unattended. The facility's failure to secure medications and treatment supplies was evident throughout the facility's two (2) nursing units. The deficient practice was observed on 4 out of 4 medication carts and 1 of 3 treatment carts. Additionally, the facility failed to ensure that 2. medications and biologicals were labeled with and dated after opened and medications stored in medication storage areas were unexpired. This was evident for 2 out of 3 medication carts and 1 of 1 medication storage room and 3. ensure that resident nasal cannulas (oxygen tubing) were accurately labeled, and the resident oxygen concentrators were adequately serviced. This was evident for 2 (Resident #36 and Resident #54) of 13 residents reviewed during the investigative portion of the annual survey. The findings include: 1a) On 8/30/22 at 8:27 AM, the surveyor observed an unlocked and unattended and unlabeled treatment cart on the Sycamore nursing unit. The treatment cart had the following medications in it: 10 packs of povidone iodine, 1 pack of alcohol swab stick, 1 tube of Thera Honey, 1 tube of Santyl, 1 large and blue-handled pair of scissors, 1 pair of silver-handled small scissors, 2 bottles of sterile normal saline, 2 bottles of ammonium lactate 12% solution, 2 tubes of Skintegrity hydrogel, 1 tube of silver sulfadiazine cream (US 1%), 3 bottles of iodoform package strips, 1 bottle of PVP prep solution, and 1 packaged skin staple remover. During an interview that took place on 8/30/22 at 8:35 AM, licensed practical nurse (LPN) #6 stated the treatment cart was shared by herself and LPN #7 and was not aware that the treatment cart was unlocked and locked it after surveyor notification. b) During an observation that took place on 8/31/22 at 5:58 AM, the surveyor noted one medication cart and one treatment cart unlocked and unattended on the Sycamore unit near the nurse's station. During an interview conducted on 08/31/2022 at 6:00 am, the registered nurse (RN) #8 stated the medication and treatment carts had remained unlocked and unattended while he opened the side entrance to the facility. The entrance was around a corner and out of sight of both carts. The carts were not labeled with designated numbers, just identified with their immediate location on the identified unit. c) On 8/31/22 at 6:19 AM on the White Oak nursing unit, the surveyor observed a medication cart that was labeled as the Station 1 Team 1 medication cart unlocked and unattended. Further observation revealed multiple medications on top of the cart including: a yellow tablet in a medicine cup, a packaged 20mg) omeprazole tablet labeled for Resident #24, a packaged 200 mg carbamazepine labeled for Resident #10, and a bottle of extra strength 500mg acetaminophen tablets. Within the vicinity of the medication cart, approximately 10 feet, Resident #10 was observed sitting in his/her wheelchair outside his/her room facing the medication cart for an unknown time frame. The resident remained in area of the unlocked medication carts and nursing station during the continued interactions with the survey team and the nursing staff. LPN #10 was observed returning to the White Oak unit on 8/31/22 at 6:22 AM. LPN #10 was interviewed at that time and confirmed that the yellow tablet was left open in a medication cup on top of the cart but could not explain why it was there. LPN #10 stated that the yellow tablet was a Pantoprazole tablet for a resident. 30428 d) On 8/31/22 at 6:19 AM on the White Oak nursing station, a medication cart was observed in front of room [ROOM NUMBER] unlocked and unattended. Surveyor continued to observe Resident #10 wandering the unit in his/her wheelchair alone at that time. At 6:21 AM, LPN #10 was observed walking past the medication cart, turned, and then returned to the medication cart. LPN #10 placed her hand on the cart and made eye contact with this surveyor, who was still standing near the unlocked medication cart, and then LPN #10 walked away from the cart without securing it. The surveyor proceeded to verify that the cart could still be opened and observed that the cart was stocked with a variety of house stock medications as well as medications prescribed to residents in rooms assigned to the cart. On 8/31/22 at 7:50 AM a review of Resident #10's record revealed on 3/29/222 the facility initiated a care plan goal for the Resident #10 to remain free of injury related to a dementia diagnosis. On the 5/28/22 quarterly Minimum Data Set (MDS) assessment the resident scored a 0/15 on a Brief Interview of Mental Status (BIMS) assessment, indicating severe cognitive impairment. The resident was care planned to remain free of injury related to his/her dementia with an approach that states, remove resident from other residents' rooms and unsafe situations with an initiation date of 3/29/22. Resident #10 is also a noted wanderer and elopement risk based on a facility reported incident where s/he eloped from the facility. This event with Resident #10 occurred on 7/18/22. S/he had an elopement assessment completed on 7/19/2022 documenting that s/he is not aware of his/her surroundings, is confused and lacks safe decision-making capabilities. Multiple residents were observed to gather in this area where the unlocked medication carts were located, throughout the day. These observations included Resident #7 who was known to wander the facility based on surveyor observations starting on 8/30/2022. Additionally, per medical record review completed on 9/2/2022, Resident #7 had an order for a wander guard and was noted with diagnosis including schizophrenia and mood disorder and a BIMS of 3/15 indicating severe cognitive impairment. The facility policy on 'Medication Management Program,' was reviewed on 8/31/22 at 12:00 PM and stated under Security and Safety Guidelines 3. The medication cart is locked when not in use and in direct line of sight. 4. Keys to the medication room and cart are kept with the authorized staff and are the responsibility of the person assigned those keys. The Administrator and Corporate Consultant, Staff #14 confirmed that this policy, revised and effective 7/13/21 was in place and enforced. The Maryland Office of Health Care Quality (OHCQ) determined that these concerns met the Federal definition of Immediate Jeopardy, and the facility was verbally notified of this determination at 12:30 PM on 08/31/2022. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 5:00 PM on 8/31/2022, after two initial plans were submitted at 3:06 PM and 3:35 PM respectively. The plan included the reeducation of the licensed nurses and certified medication aids regarding the expectation that all drugs and biologicals are to be stored in locked compartments and permit only authorized personnel to have access to the keys. The facility plans of removal included the following: if a cart is observed unlocked and unattended, staff are to lock the cart or remain with the cart until a nursing staff member is available to lock the cart. A department head or nursing manager will be assigned to validate that the carts are locked and secure and round hourly for the next 6 shifts and report the findings to the Quality Assurance Performance Improvement (QAPI). An ad-hoc QAPI meeting was held on 8/31/2022 to review and approve this plan to be completed by 9/2/2022. e) On 9/2/2022 at 7:37 AM upon entry into the facility on the Sycamore unit, Surveyor observed two (2) unlocked medication carts on opposite ends of the nursing station, approximately 10 feet on either side. LPN #7 was observed at the nursing station on the telephone. LPN #6 and RN #8 were also observed behind the nursing station talking. LPN #6 was asked if she worked last night, and she stated that she just came in to work the day shift. LPN #7 was then observed snapping her fingers at RN#8 and pointing towards the medication cart to the right, he walked over and locked it and LPN #6 then proceeded to walk to the cart to the left and lock that medication cart. RN #8 was interviewed at 7:43 AM. He confirmed that he was responsible for both medications' carts and that they were both unlocked. The facilities initial plan of removal had a completion date of 9/2/2022 that all trainings would be implemented. However, secondary to the noted observations with RN #8 the facility was placed out of compliance. These findings were reviewed with the Administrator at 9:27 AM on 9/2/22 and the OHCQ. The Administrator was notified that a new plan of removal would need to be submitted to the OHCQ. On 9/2/22 secondary to observed noncompliance with the original plan of removal the facility had to submit a new plan of removal. This plan was submitted at 12:59 PM on 9/2/22 and accepted by the OHCQ at 1:46 PM. After confirmation of the plan and implementation, the immediacy was removed, and the deficient practice remained at a potential for more than minimal harm with a scope/severity of D for the remaining residents. The second plan of removal initiated on 9/2/2022 after noncompliance was established included to discipline identified staff and re-education by the Clinical Consultant Staff #14. The facility also implemented having a department head assigned to make continuous rounds during medication pass and at a minimum of every hour for five additional shifts through 9/3/22. The facility held an ad-hoc QAPI meeting on 9/2/22 to review and approve the addendum to the plan and continue monitoring. 44440 2) On 9/13/22 at 9:51 AM, the surveyor observed medication stored in medication cart #1 on the White Oak unit in the presence of Certified Medication Aide (CMA) #43. The top drawer contained an open bottle of acetaminophen 500mg with no date written to indicate when the bottle was opened. The surveyor observed medication stored in medication cart #2 of the Sycamore unit. A bottle of Benadryl 25mg was opened but had no open date on the container. Licensed Practical Nurse (LPN) #7 recalled the bottle was opened yesterday and labeled the bottle. A bottle of aspirin EC (enteric coated) 81mg was noted to have a manufactured expiration date of 8/22/22. The surveyor brought this to the attention of LPN #7 and she threw the bottle away. On 9/13/22 at 10:32 AM, during observation of the White Oak medication storage room, the surveyor found a box of expired heparin flushes, with expiration date of 6/7/22. This box was labeled for a resident who was identified by LPN #26 as having been discharged in January 2022. Ongoing observation of the White Oak medication storage room revealed two large bags containing approximately 50 heparin syringes in each bag. The syringes in both bags had expiration dates in 2021. Further observation of the storage room revealed a box of heparin syringes labeled with the expiration date of 3/17/22, for a resident identified by LPN #26 as having been discharged in 2021. However, the individual prefilled syringes had a manufacturer expiration of 2023. LPN #26 was present during the medication storage observation and was made aware of all the expired medications. LPN #26 then disposed of the expired medications. 42828 3) On 08/30/22 at 10:51 AM tour of the Sycamore Unit, the surveyor observed Resident #54 in their room wearing an oxygen tubing without a label. On 8/30/2022 at 10:56 AM tour of the Sycamore Unit, the surveyor observed Resident #36 in their room wearing oxygen tubing without labeling on it. On 8/30/2022 at 11:15 AM LPN #6 with surveyor in Resident #54's room to confirm the oxygen tubing without a label. LPN #6 stated the oxygen tubing will be changed and labeled. On 08/30/2022 at 11:30 AM LPN #6 with surveyor in Resident #36's room to identify the oxygen tubing without a label. LPN #6 stated the oxygen tubing will be changed and labeled. During a subsequent tour of the nursing unit with LPN #6 on 8/30/2022 12:30 PM, surveyors identified dirty filters on the oxygen concentrators in Resident #36 and Resident #54's rooms. The filters were covered in dark gray lint-like substance and the structure of the filters were not identifiable. LPN #6 confirmed the findings during observations. On 9/7/2022 at 10:10 AM the surveyor held an interview with the Maintenance Director regarding who is responsible for maintenance of resident oxygen concentrators in the facility. The Maintenance Director stated that the oxygen concentrators are leased equipment and the Unit Managers are responsible for reporting maintenance issues with the concentrators to the maintenance department via a written report. On 9/7/2022 at 10:52 AM the surveyor interviewed the Administrator who was made aware of the surveyor's observations during the tour of the Sycamore Unit. The Administrator stated that the oxygen concentrators in the facility are scheduled for maintenance once a complaint or work order is submitted by nursing staff then once the maintenance department is aware, the maintenance department would contact the leasing company for the oxygen concentrators. On 9/12/2022 at 11:30 AM the surveyor reviewed a document provided by the Administrator titled the Facility Assessment Tool. Page six of the section titled, Physical Environment revealed that routine preventative maintenance of the oxygen tanks and equipment is scheduled by the Maintenance Director; The process to ensure quality and quantity of physical resources is the responsibility of the Maintenance Director in conjunction with Directors and Department managers. During an interview on 9/12/2022 at 1PM, the Maintenance Director confirmed with the surveyor that all oxygen concentrators were serviced by the maintenance department. During the exit conference on 9/21/2022, the Administrator confirmed that all oxygen concentrators were serviced by the maintenance department.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents' medications were documented at the time of administration, including high risk medications, resulting in a consistent and widespread pattern of medications being documented inaccurately and hours after they were due. This involved multiple staff on all shifts and on both units. This was evident for 5 (Residents #21, #61, #35, #25, and #73) out of 5 residents reviewed in detail for timely medication administration but was also noted in every medication administraion record (MAR) seen during the survey. This practice has the potential to impact all residents. Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any and all medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication error and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles. Late documentation is a form of inaccurate documentation and is worsened if the documentation does not document when medications were actually given. 'Late administation' is defined as giving medication greater than 1 hour after a medication is due. 'Late documentation' is defined as not documenting immediately after administration. The findings include: 1) The surveyor reviewed Resident #21's medical record on 8/31/22 at 8:56 AM. The review revealed that the resident was admitted to the facility in November, 2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was noted to still be present in the facility at the time of the survey. The surveyor reviewed the medication administration record (MAR) for Resident #21 on 9/12/22 at 12:00 PM. The MAR covered the period of 8/17/22 - 9/12/22. The review revealed a significant pattern of late documentation for every medication that the resident was prescribed. It was impossible to tell from the MAR when medications were actually given. Specifically, affected medication administrations documented, late administration: charted late, yet only included the time of charting and not the time of administration. The following medications were affected: - [MEDICATION(S)] for urinary tract infection, given intravenously. Documented late 7 out of 7 opportunities, up to 5 hours and 33 minutes late. - Vitamin B-12, given as injection into muscle. Documented late 1 out of 1 opportunity, 6 hours and 40 minutes late. - normal saline for hydration, given intravenously. Documented late 6 out of 6 opportunities, up to 6 hours and 57 minutes late. - insulin [MEDICATION(S)] for diabetes, given twice a day as subcutaneous injection. Documented late 41 out of 51 opportunities, up to 6 hours and 25 minutes late. - insulin [MEDICATION(S)] for diabetes, given before meals and bedtime as subcutaneous injections. Documented late 72 out of 84 opportunities, up to 8 hours 7 minutes late. This practice resulted in doses being documented one minute apart, doses being documented after the next dose was due (which was then documented as not given), and prevents anyone from determining the timing of administrations for this high risk medication. - [MEDICATION(S)] for [CONDITION(S)], given twice a day as a table. Documented late 46 out of 52 opportunities, up to 7 hours and 46 minutes late. - aspirin given once a day as a tablet. Documented late 26 out of 27 opportunities, up to 8 hours and 13 minutes late. - [MEDICATION(S)] for [CONDITION(S)], given once a day as a tablet. Documented late 26 out of 27 opportunities, up to 8 hours and 34 minutes late. - [MEDICATION(S)] for neuropathic pain, given three times a day as a tablet. Documented late 59 out of 80 opportunities, up to 8 hours and 13 minutes late, sometimes after subsequent doses were due. - glucerna given as a supplement with meals. Documented late 34 out of 36 opportunities, up to 7 hours and 17 minutes late, sometimes after subsequent doses were due. - [MEDICATION(S)] for high blood pressure, given once a day as a tablet. Documented late 25 out of 27 opportunities, up to 8 hours and 19 minutes late. - [MEDICATION(S)] for diabetes, given twice a day as a tablet. Documented late 47 out of 54 opportunities, up to 8 hours and 13 minutes late. - [MEDICATION(S)], given once on Mondays. Documented late 3 out of 3 oppotunities, up to 5 hours and 31 minutes late. - [MEDICATION(S)] for high blood pressure, given once a day as a tablet. Documented late 25 out of 27 oppotunities, up to 8 hours, 19 minutes late. - [MEDICATION(S)] for constipation, given once a day as a supplement. Documented late 25 out of 26 opportunities, up to 8 hours 34 minutes late. The surveyor interviewed Licensed Practical Nurse (LPN #7) on 9/13/22 at 11:40 AM, who was identified as one of the staff documenting medications late. During the interview, LPN #7 stated that when she documented medication as Late Administration: charted late, she was indicating that the medication was given 'on time' but that she could not chart at the time of the administration because she was too busy. When asked what 'on time' meant, LPN #7 stated it meant within an hour before or after the medication was scheduled to be given. On 9/14/22 at 11:00 AM, the surveyor reviewed the facility policy entitled, Medication Management Program with the revision date of 7/13/21. In the section, Administering the Medication Pass, the policy stated, 12. Immediately after administer the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR. Cross reference F658 and F725. 2) On 9/8/22 at 8:25 AM, a medical record review was conducted in response to a complaint from the daughter of Resident #61. The resident's Daughter alleged that Resident #61 received insulin late on March 9, 2018. After reviewing the medical record, it indicated that on the evening of 3/9/18 Resident # 61 was ordered insulin at 5 PM, however the insulin was given at 8 PM by the RN Supervisor #29. The Doctor of Resident #61 was made aware. The Employee (#29) was suspended pending investigation. Upon return from suspension, the employee (#29) received corrective action regarding his/her responsibility for complying with the prescribed medication administration of patients. Nurse #29 also showed how s/he administers insulin and performed the process without any errors. The Surveyor observed that the Administrator was aware of the incident as she had a file on the documented incident. 3) According to the Centers of Disease Control and Prevention insulin is a hormone made by your pancreas that acts like a key to let blood sugar into the cells in your body for use as energy. [MEDICATION(S)] (insulin [MEDICATION(S)]) is a long-acting insulin that helps lower high blood sugar levels. A review of Resident #35's Medication Administration Record (MAR) was conducted on 09/12/2022 at 2:08 PM. The MAR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR for the period of 08/18/2022 to 09/12/2022 revealed the Resident's insulin was documented as charted late 19 out of 26 days. A record review of Resident #35's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4) During the initial tour and interviews with Resident's, the Surveyor interviewed and screened Resident #25. During the interview occurring on 8/30/2022 at 12:48 PM, Resident #25 stated that there was a lack of help and shortage of staffing, this led to a delay in general help with care and the delivery of medications. Further review of the medical record for Resident #25 on 9/12/2022 at 12:00 PM revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the resident's medication administration record (MAR) for August however, the [MEDICATION(S)] was documented beyond the acceptable parameters of administration time frames of 1 hour before and after the scheduled administration time as noted below. Of the 31 opportunities, [MEDICATION(S)] was documented as 'charted late' 9 times that varied from 3 hours late, signed off at 12:00 PM to 7 hours late, signed off at 4:03 PM. [MEDICATION(S)] (cardiac medication administered for high blood pressure) was ordered for administration twice a day at 9 AM and 9 PM. The administration of the medication depended on the results of the resident's blood pressure. The administration of [MEDICATION(S)] also has the potential to influence the results of the resident's blood pressure. Of 62 opportunities for the month of August, [MEDICATION(S)] was documented as administered late 18 times with the times varying from 1.5 hours, with staff signing the medication off at 10:33 PM to over 9 hours late, with the morning dose scheduled at 9 AM with staff signing the medication off at 5:12 PM. Interview with Resident #25 on 9/20/2022 at 11:08 AM revealed that the facility staff is still taking a while to tend to him/her including administering medications. 5) Review of the medical record for Resident #73 secondary to a complaint about general care and welfare, on 9/13/2022 at 2:00 PM revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It is used to help patients with high blood sugar levels It replaces the insulin that your body would normally make. Insulin [MEDICATION(S)] starts working faster and lasts for a shorter time than regular insulin. It works by helping blood sugar (glucose) get into cells so your body can use it for energy). The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the February 2022 MAR on 9/14/2022 at 9:05 AM revealed that out of 53 opportunities for the insulin administration, the insulin was signed as a 'late administration' 30 times. The Surveyor reviewed concerns and findings with the Clinical Consultant (Staff #14) on 9/13/2022 at 3:30 PM and with the facility Administrator throughout the survey. On 9/14/2022 at 11:35 AM the surveyor interviewed LPN staff#17 about medication administration, specifically regarding insulin. He stated that 'with the workload here, after staff get report, everyone scatters to do the finger sticks and give coverage as needed, it may not be signed off right away. He stated there are options in the computer to chart; late entry, unavailable, refuse, etc. however, most times they are completed timely.' The Surveyor reviewed with staff #17 that according to the documentation it appears that the medications are administered late. Staff #17 verbalized understanding.

Based on observations and review of resident medical records and interview with residents and facility staff, it was determined that the facility failed to ensure that there was sufficient nursing staff to: 1) provide for timely and accurate documentation of residents' administered medications. This was evident for 5 (Residents #21, #61, #35, #25, and #73) out of 5 residents reviewed for timely administration of medications. 2) provide sufficient staff to care for residents. This is evident for 2 out of 2 complaints (Resident # 95 and # 81), 3) to answer the call bell in a timely manner. This was found to be evident for 6 (resident #5, #35, #49, #57, 208 and #309) out of 20 residents observed for call bell response time during the Annual Survey, and 4) have the required number of nursing staff to care for residents resulting in delayed resident care and documentation of care. This was found to be true for 2 out of 2 units. This practice has the potential to affect all residents. The findings include: Surveyors reviewed resident medication administration records (MARs) for the following residents: - Resident #21 on 9/12/22 at 11:07 AM for the period of 8/17/22 to 9/12/22 - Resident #35 on 9/12/22 at 2:08 PM for the period of 8/18/22 to 9/12/22 - Resident #61 on 9/19/22 at 2:37 PM for the month of March 2018 - Resident #25 on 9/12/22 at 12:00 PM for the month of August 2022 - Resident #73 on 9/14/22 at 9:05 AM for the month of February 2022 Review of these MARs demonstrated a pattern of multiple staff documenting multiple medications hours late. Specifically, medication documented in this manner read, Late Administration: charted late. This occurred on the majority of the days under review. This practice involved significant medications and was noted on both nursing units. The surveyor interviewed Licensed Practical Nurse (LPN #7) on 9/13/22 at 11:40 AM, who was identified as one of the staff documenting medications late. During the interview, LPN #7 stated that her errors in medication administration documentation were occurring because she was too busy and that there wasn't enough staff to allow her the time to document correctly. She stated that she would sometimes have to stay well past the end of her shift to catch up on all of the documentation that she couldn't complete during her shift. Cross reference F760 2a) On 9/1/22 at 11:32 AM a medical record review was conducted for Resident # 95. Resident # 95 was admitted to the facility 2/24/22. Resident # 95 was admitted for therapy following [CONDITION(S)] treatments in the hospital for brain cancer. The daughter of the resident complained s/he was not getting incontinent care as much as s/he needed. The resident's daughter was very much involved in his/her care. The resident's daughter stated that every time she came in to visit, Resident #95 was wet or had feces on him/her and smelled. There was no evidence that Resident # 95 was being changed or that treatment was not provided according to the medication and treatment records. During the resident's time at the facility the census was about 70 residents, which did change frequently, there were only at times 2 nurses and 2 GNAs (geriatric nursing assistants) scheduled. On 9/1/2022 at 12 PM, the Administrator stated that she was aware of the staffing issues identified throughout the building at different times. 2b) On 9/14/22 at 12:09 PM the medical records and staffing sheets were reviewed. A complaint came from Resident # 81's sister who stated that the resident was left in a soiled diaper to the next day. A review of the treatment records indicated that Resident #81 was changed on 5/15/21 at 8:57 AM and on 5/15/21 at 10:46 PM was not toileted as no help was needed from staff. On May 14, 2021, on the 11PM-7AM shift the facility had 1 Registered Nurse (RN) supervisor, 1 LPN, and 1 GNA for a census of 52 residents. The daughter reported that the GNA told Resident #81 that she had 39 patients to care for and alleged that the patients were being neglected due to the facility's short staffing. The Administrator was made aware of the staffing issues on 9/1/2022 at 12:00 PM. 3) During a tour of the White Oak Nursing Unit on 08/31/2022 at 6:00 AM, the Surveyor heard the call bell alarm and observed the call bell light illuminated above the entry door of resident (Resident #5) room [ROOM NUMBER]. The Surveyor observed Geriatric Nursing Assistant (GNA) #11 enter and exit resident rooms 102, 104, 106, and 108. During the observations the surveyor observed Licensed Practical Nurse (LPN) #10 walk passed resident room [ROOM NUMBER] and enter and exit resident room [ROOM NUMBER]. The Surveyor continued to observe GNA #11 enter and exit resident rooms while resident room [ROOM NUMBER]'s call bell continued to alarm. During an interview conducted on 08/31/2022 at 6:15 AM, GNA #11 confirmed s/he was assigned to resident room [ROOM NUMBER] and stated s/he would go assist the resident. During a tour conducted on the Sycamore Nursing Unit on 08/31/2022 at 10:05 AM the Surveyor heard the call bell alarm ringing and observed Resident #49, #57, and #309 call bell lights illuminated above each of the resident's entry door. The Surveyor observed Licensed Practical Nurse #15 standing at the medication cart at the entrance of the Sycamore nursing hallway. On 08/31/2022 at 10:07 AM Resident #35 stated s/he was soiled and had turned on his/her call bell light. Resident #35 stated GNA #28 came into the resident's room and turned off the call bell light 20 minutes ago and stated s/he would be back. The Surveyor turned back on the call bell light. At 10:22 AM, after 25 minutes the Surveyor went out into the hallway and advised LPN#15 that the resident required assistance and in addition, Resident #49, #57 and #309 call bell lights had been observed illuminated for more than 45 minutes. During an interview conducted on 08/31/2022 at 10:48 AM, the Surveyor asked LPN#15 if there was a shortage of staff for the unit. The LPN#15 stated no, the unit had 1-GNA assigned to the unit. The LPN further stated s/he would assist the residents. The Surveyor observed LPN #15 answer the call bells for Residents #49, #57 and, 309 and GNA #28 answered Resident #35's call bell. During an interview conducted on 08/31/2022 at 12:27 PM, the Surveyor advised the Administrator of the observations of the delayed call bell response time. 4) During an observation on the Sycamore unit on 8/30/22 at 8:30 AM, the unit's posted assignment board showed Geriatric Nursing Assistant (GNA) #18 was assigned to care for 23 residents. An observation of the White Oak's assignment board at 8:45 AM showed that 1- GNA #57 was assigned to care for 32 residents. Upon arrival to the White Oak Unit on 8/30/22 at 11:18 AM the surveyors noted Room # 107's call bell light indicator was lit, and a low chime was heard from an alarm box across from the unit's dining room. Standing in the hallway of the dining room and across from the alarm box, surveyors saw several staff members walk past Room # 208 but no one entered. At 11:52 AM the surveyors heard Resident # 208 call out they needed help. The Surveyors entered the room and found the resident seated in a wheelchair. When the surveyors greeted the resident, s/he said that they were pissed off because they had been waiting for almost an hour for someone to come into the room. During an interview on 9/7/22 at 11:19 AM, GNA #28 stated that they always worked short-staffed and that it is not unusual for them to have at least 28 residents on the day shift with no additional help. She added that there is not enough time during their regular shift to care for all the residents so s/he would work overtime, double shifts, and on their scheduled days off because there is no one else scheduled to care for the residents. The GNA said that although a nurse was also with them on the unit, they would often be scheduled to work alone or on both units at the same time and had the work they needed to do for the residents on the units. An interview conducted on 9/12/2022 at 10:45 AM with Nurse #17 revealed there was one GNA assigned to the unit with her/him that day for the 7:00 AM -3:00 PM shift. The LPN added that s/he always stayed past their scheduled work shift to catch up on documentation and had also given out medications and performed treatments late because they did not have the time to do it during their shift. In addition, the nurse stated that they often worked extra shifts to cover for staff shortages. During an interview at 11:00 AM on 9/12/2022 Nurse #6 revealed that one GNA was scheduled to work on the unit with them that day. At 11:12 AM during an interview with Nurse #18 s/he stated that they were the only nurse scheduled for both units. S/he added that the staffing shortage had been going on for a while. On 09/21/22 at 10:09 AM, a review of the facility's Person Per Day (PPD) (a daily calculated ratio for the number of nursing personnel to the number of residents in the facility) was calculated for 8/30/22, 9/7/22, and 9/12/22 showed that the required number of nursing staff to care for the number of residents in the facility on those days was not met. Further review of the PPDs from 8/28/22 to 9/21/22 found that the facility had less than the standard ratio of staffing to care for residents for 20 out of 25 days.

Based on medical record review, interview with facility staff and observation it was determined that the facility failed to maintain consistent and accurate documentation in the residents' medical records related to care, notification and behaviors respectively. This was evident in 4 of 70 medical records (#99, 95, 26, and #29) reviewed during the annual survey. The findings include: 1) Surveyor reviewed Resident #99's medical record on 9/21/2022 at 9:23 AM secondary to complaints that s/he was not given the appropriate meals during his/her stay at the facility. Record review at that time revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, noted a week later an order was entered to Assist patient with eating during mealtime. A review of the Geriatric Nursing Assistant (GNA) point of care history noted that out of a review of a 2-week period of Resident #99's stay of 42 opportunities to document feeding assistance, GNA staff only documented help 9 times. Nursing documentation however did document that assistance occurred; however, it was documented all as late entries. This concern was reviewed with the facility Director of Nursing and Administrator upon finding on 9/21/2022. 2) A medical record review was conducted on Resident # 95 on 9/1/22 and 9/2/22 at 11:32 AM. Resident # 95 was admitted to the facility on [DATE]. She/he came to the facility for therapeutic services following [CONDITION(S)] treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 95 had cancer and had just finished [CONDITION(S)] treatments when she/he came to the facility. Resident # 95's daughter insisted that he/she receive chemo treatments for her/his cancer against medical advice. Once the Chemo started resident became worse refusing care, medications, food, water, therapy, sitting up in a chair and activities. The resident told Nurses and Geriatric nursing assistants that she/he wanted to be left alone. The resident was weak and lethargic. There was no care plan on chart or documentation of her/his many refusals. On 4/17/22 the resident was sent to the hospital with a change of condition. Resident # 95 was diagnosed with Septic shock, Urinary tract infection and Resp. failure. The resident never returned to the facility and passed away on 4/21/22 of Chronic medical conditions and cancer. The Administrator was interviewed on 9/22 at 8:52 AM and stated, the medical team tried to speak with Resident #95's daughter about starting chemo, however the daughter disagreed. Before [CONDITION(S)] was initiated, Resident # 95 could speak and make his/her own decisions. After chemo started, she/he became very weak, and her voice was very low. The Administrator verbalized that there was no documentation stating the refusal of care. 3) During a phone interview on 09/01/2022 at 11:18 AM, the responsible party of Resident #26 stated s/he received a phone call from LPN #7 at approximately 11:00 AM today. The LPN advised Resident #26 was transferred out of the facility earlier that morning around 8 AM. The responsible party further stated s/he was concerned that s/he was not contacted prior to the transfer. Record review conducted on 09/01/2022 at 11:20 AM revealed documentation dated 08/31/2022 that stated repeat HGB 6.5, resident will be transferred to hospital in am for blood transfusion. [Responsible Party] was made aware. Resident in no distress at this time, no s/s [signs or symptoms] of dyspnea, vss [vital signs stable]. During an interview with the Administrator on 09/01/2022 at 11:25 AM, the Administrator stated it is the facility's expectation that staff contact the responsible party as soon as time allows when a resident is transferred out of the facility. The Surveyor advised the responsible party called concerned that s/he was not advised prior to the transfer but there was documentation in Resident #26 medical record that stated the responsible party was advised on 08/31/2022. The Administrator stated s/he would investigate the matter. On 09/01/2022 at 1:19 PM the Administrator confirmed the responsible party was not advised until after Resident #26 was transferred out of the facility on 09/01/2022. 4) A [CONDITION(S)] is an artificial exit for a patient's bowels created by surgically rerouting where stool leaves a person's body. It is most often placed on the abdomen. The procedure is performed for patients with various gastrointestinal diseases. To contain stool as it leaves the body, a bag called a [CONDITION(S)] bag is attached to the abdomen at the site of the opening. On 08/30/22 at 12:20 PM, during rounds on the Sycamore Unit, the surveyor observed Resident #29 in bed without clothes on. The resident had a sheet and blanket covering him/her, but underneath the sheet, the resident's [CONDITION(S)] bag had been removed. The stoma (the opening in the abdomen where the [CONDITION(S)] bag attaches) was only covered with a towel and it was slightly soiled with stool. The resident was interviewed at that time. The resident complained of not having been changed in a reasonable amount of time when soiled, stating that they only come when they want to. The resident stated that the staff never put the [CONDITION(S)] bag on. During the observation, it was also noted that the room had multiple boxes of [CONDITION(S)] bag supplies in a variety of sizes. On 08/30/22 at 01:50 PM, during a repeat tour of the unit, the resident was noted to had been cleaned and was wearing a gown. On 8/30/22 at 2:44 PM, the surveyor interviewed licensed practical nurse (LPN) #7 who was assigned to Resident #29 from 7:00 AM to 3:00 PM on 8/30/22. When asked about the surveyor's observation of the resident lying unclothed and without a [CONDITION(S)] bag, LPN #7 stated that Resident #29 refuses care regularly, and specified that everyone knows that. LPN #7 suggested that Resident #29 had removed his/her clothing and [CONDITION(S)] bag himself/herself. LPN #7 stated that the resident's assigned geriatric nursing assistant (GNA) later went into the room and performed bed care and cleaned the resident up. LPN #7 agreed that Resident #29 was exhibiting behaviors when removing clothing and [CONDITION(S)] bag. On 8/30/22 at 2:55 PM, the surveyor also interviewed GNA # 17 who was assigned to Resident #29 from 7:00 AM to 3:00 PM on 8/30/22. During the interview, GNA #17 also said Resident #29 refuses care regarding his/her [CONDITION(S)] site and says that s/he does not want the [CONDITION(S)] bag because none of the sizes fit. As a result, even though Resident #29 lets them put bags on, s/he regularly removes them and puts a towel on top. During Record review that took place on 09/07/22 at 10:42 AM, the surveyor reviewed progress notes for Resident #29. The review failed to reveal any documentation of Resident #29's refusal behaviors from the shift on 8/30/22.

Based on medical record review it was determined the facility failed to monitor the urinary output of a resident with an indwelling urinary catheter to ensure that the catheter was functioning properly and the resident had sufficient urinary output. This was evident for 1 of 11 sampled residents selected for review. Resident #2 was affected by the deficient practice. The findings include: Resident #2 was admitted to the facility 10/9/15 after being hospitalized and undergoing extensive surgery for [REDACTED]. The resident's medical record was reviewed on 3/10/16 and 3/11/16. Medical record review revealed that the resident was admitted with an indwelling urinary catheter. On 10/19/15 the physician gave a telephone order for in and out self catheterization 5 times per day. (The resident had a history of [REDACTED]. Medical record review revealed that on 10/19/15 the nurse documented in the progress notes that the indwelling urinary catheter was discontinued. Review of the nursing progress notes revealed that on 10/19/15 through 10/29/15 the resident was performing in and out self catheterization. On 10/29/15 at 21:30 (9:30 P.M.) the nurse documented in the progress note that the resident stated he/she had not been self catheterizing himself and could not remember the last time he/she had performed it. The nurse assisted the resident to self-catheterize. The nurse documented that 800 ccs of dark amber urine with a foul odor was noted. The physician was notified and gave an order to obtain a urinalysis with a culture and sensitivity and to reinsert an indwelling urinary catheter. The catheter was inserted and the resident's output was 200 ccs of dark amber urine. Medical record review revealed that the nursing assistant documented that the resident's urinary output was noted as follows: 10/30/15 19:58 (9:58 P.M.) 450 ccs 10/30/15 22:29 (10:29 P.M.) 600 ccs 10/31/15 - There is no documentation related to urinary output 11/1/15 06:24 (6:24 A.M.) 0 ccs notified nurse 11/1/15 22:28 (10:28 P.M.) 0 ccs 11/2/15 06:09 (6:09 A.M.) customer did not void any urine on this shift 11/2/15 14:48 (2:48 P.M.) 100 cc's Review of the nursing progress notes revealed that there is no documented evidence that the resident's indwelling urinary catheter was assessed or urinary output monitored on 10/31/15. On 11/1/15 at 21:30 (9:30 P.M.) the nurse documented that the resident's Foley catheter was intact and patent, and draining amber urine. The nurse failed to note the quanity of the resident's urinary output. This too, conflicts with the nursing assistant's documentation on 11/1/15 at 22:28 (10:28 P.M.) that the resident's urinary output was 0 ccs. On 11/2/15 at 04:30 (4:30 A.M.) the nurse documented that the resident's Foley catheter was intact and patent. Again, this conflicts with the nursing assistant's documentation on 11/2/15 at 06:09 A.M. that the customer did not void any urine on this shift. Medical record review revealed that on 11/2/15 the nurse documented in the progress notes that upon entering the resident's room, the resident had increased confusion, anxiety and agitation. The resident was unable to follow spoken commands. The nurse documented that the resident's indwelling urinary catheter drainage bag was noted with blood in the urine. The nurse further documented that he/she was unable to give the resident his/her tube feeding or medications due to the resident was combative. The resident was examined by the physician. The physician documented that the resident was confused, flushed, shouting out and was [MEDICAL CONDITION] (elevated heart rate). On 11/2/15 at 9:40 A.M. The physician gave an order to send the resident to the hospital secondary to confusion, fever, tachypnea and [MEDICAL CONDITION] The resident was medicated with an antianxiety medication, [MEDICATION NAME], prior to being transported to the hospital. On 3/17/16 Resident #4's hospital medical record was reviewed. Additional information was provided by the hospital on [DATE]. A CT scan of the resident's abdomen and pelvis was ordered in the emergency department and revealed that the resident had a very distended urinary bladder with the Foley catheter bulb in the prostatic urethra. Findings were compatible with bladder outlet obstruction. The resident was diagnosed with [REDACTED]. The Foley catheter was replaced in the emergency department.