Every finding on record at Ridgeway Rehab Center

Based on clinical record review and staff interviews, it was determined that the facility failed to: 1) ensure that a resident or their responsible party (RP) was offered the opportunity to develop an advanced directive, and 2) ensure two certificates of incapacity included a diagnosis or reason for the incapacity. These failures affected three residents (Resident #8, #10, and #15) out of a sample of three reviewed for advanced directives during the recertification/complaint survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment—often including a living will—made to ensure those wishes are carried out should the person be unable to communicate them to a physician. A physician's certification of decision-making capacity confirms whether a patient can understand their medical situation, appreciate the consequences of their choices, use reasoning, and communicate a treatment preference. Under specific legal standards, such as Maryland law, a certification of incapacity requires the signatures of two physicians (one being the attending physician) and must include the documented reason for the incapacity to ensure the process remains consistent with patient rights. 1) On 2/05/26 at 1:10 PM, a review of Resident #15's medical record revealed the resident was admitted on [DATE] and was cognitively alert and oriented. Further review of the record showed a social service note dated 8/29/25 that contained no information regarding the resident's advance directive status. Additionally, the baseline care plan—which was not completed until 9/25/25 (one month after admission)—left the section review resident's advance directive status blank. During an interview on 2/05/26 at 1:40 PM, Staff #3 (Social Worker) stated that facility staff are required to assess a resident's advance directive status upon admission and offer guidance in completing the forms if the resident is capable and willing. Staff #3 noted that this status should be documented in the social work progress notes. Upon reviewing Resident #15's medical record with the surveyor and noting the absence of this information, Staff #3 validated the concern. 2) On 2/05/26 at 1:13 PM, the surveyor reviewed Resident #8's medical records. The review revealed a Physician Certification of Capacity form signed by Staff #26 (Attending Physician) on 8/23/25 and Staff #27 (Nurse Practitioner) on 8/22/25. However, the form did not include a diagnosis or a clinical reason for the incapacity. In an interview with the Director of Nursing (DON) and Staff #25 (Regional DON) on 2/06/26 at 8:55 AM, they confirmed that providers must evaluate a resident's capacity and document the specific reasons for incapacity on the form. After reviewing Resident #8's certification form with the surveyor, they validated that the form had not been completed properly. 3) A review of Resident #10's clinical record on 2/9/26 revealed that the resident had two certificates of incapacity. The first one was signed by the physician on 8/2/24 but did not include a diagnosis or reason for the incapacity. The second one was signed on 8/8/24 and included the diagnosis of dementia as the reason for the incapacity. The Director of Nursing (DON) and Regional DON (Staff #25) were interviewed on 2/6/26 at 9:05 AM. They were shown the two certificates and expressed an understanding of the need for a diagnosis and/or a reason for any incapacity.

Based on clinical record review and staff interview it was determined that the facility staff failed to 1) ensure a resident had baseline care plan / care plans within the required timeframe and provided the resident and/or family with a copy of the care plans, and 2) provide evidence in the resident's medical record that this summary had been delivered. This was evident for Four (Resident #8, #9, #40, and #15) out of 18 residents reviewed during the investigation phase of the facility's recertification survey. The findings include: A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility. It must include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and a current medication list must be given to each resident and/or their representative and documented in the medical record. The completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur immediately after admission. The Minimum Data Set (MDS) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned for based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1a) A review of Resident #9's clinical record on 2/9/26 revealed that the resident was admitted on [DATE]. The resident had care plans developed by the facility staff on the same day as admission, 12/4/25. Further review revealed that the resident's first care plan meeting was held on 12/12/25, 8 days after the care plans were developed. Care plans are to be developed as a result of the care plan meeting and within 7 days of the comprehensive MDS assessment. Review revealed the facility staff completed an MDS on 12/18/25 which was 6 days after the care plan meeting not prior to the meeting. On 02/09/2026 at 1:40 PM the survey team interviewed the social worker (Staff #3) about the care plan meeting process, she was asked to explain the process for care plan meeting and she stated that: On admission, she sets up an initial care-plan meeting to discuss what the goals are for the resident and what they need to accomplish while in the facility. She stated that each discipline explains their plan of care to the resident/representative during the care plan meeting. They will hold another meeting in 14 days depending on the residents insurance, then every 90 days thereafter. The proper order is to have the assessment first then have a care meeting to discuss what care plans needed to be developed. After the interdisciplinary team makes the decisions as to what care plans would be created, then the care plans are created. 1b) The Social Worker was interviewed on 2/9/26 at 2:03 PM. She was asked how she provided copies of the care plans to the resident and/or family. She replied that she puts a copy of the care plan into the electronic health record (EHR) and a notation if the resident and/or the family requested a copy of the care plan. Review of the EHR revealed no evidence of the family of Resident #9 receiving a copy of the care plan. 2) A review of Resident #40's clinical record on 2/10/25 revealed the resident was admitted on [DATE]. The first care plan invitation was sent on 6/28/25. This surveyor could not locate an invitation to a care plan meeting prior to 6/28/25. There was also no evidence in the EHR that a copy of the care plans was provided to the resident and/or the family. 3) On 2/06/26 at 7:12 AM, a review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Further review showed that while the electronic medical record (EMR) contained a section for the BLCP, the form was incomplete. The medication list reconciliation, the confirmation of the medication list provided to the resident/representative, physician orders, the BLCP summary, and the signature sections were all blank. 4) On 2/06/26 at 10:00 AM, the surveyor reviewed Resident #15's medical records. The review revealed the resident was admitted to the facility on [DATE]. However, the BLCP form was not created until 9/26/25 (one month after admission). Furthermore, the BLCP summary and signature sections were not filled out; while the form contained the signature of the staff member completing the plan, it lacked required information for the resident. In an interview with the Assistant Director of Nursing (ADON) and Staff #25 (Regional DON) on 2/06/26 at 12:06 PM, they explained that the facility utilizes a remote nurse to create the baseline care plans. This nurse creates the BLCP based on the hospital discharge summary, and on-site nurses are then responsible for adding the medication list and other resident-specific information. They stated that the facility's social worker is intended to hand the BLCP to residents and/or families within 72 hours and noted, All of that data should be documented in the electronic medical records. The surveyor reviewed the medical records of Residents #8 and #15 with the ADON and Staff #25. They validated that there was no evidence to support that the BLCPs were completed for these two residents or that the information was provided to the residents or their family members.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that care plan meetings were held concurrently with quarterly care plan revisions, and resident and/or their representatives were invited to care plan meetings. This deficiency affected six residents (Resident #5, #7, #9, #17, #40, and #51) of 6 residents reviewed for care planning during the recertification/complaint survey. The findings include: Care plans serve as essential guides for the care residents receive within the facility. They must be developed within seven days of a resident's comprehensive admission Minimum Data Set (MDS) assessment and revised at least quarterly, or more frequently as necessitated by a change in condition. The facility is required to ensure these care plans are developed and revised by an IDT, which includes the attending physician, a registered nurse, a nursing assistant, a representative from dietary services, the resident, and the resident's representative, as practicable. 1) A review of Resident #5's medical records on 2/06/26 at 11:53 AM revealed the resident has resided at the facility for more than four years. A review of the MDS assessments showed quarterly assessments were completed on 5/26/25, 7/21/25, 10/21/25, and 12/23/25, with an annual assessment completed on 4/03/25. However, documentation of care plan meetings was inconsistent with these dates: meetings were dated 7/18/25 (prior to the MDS completion), 8/29/25 (not related to a regular quarterly meeting), and 12/22/25 (prior to the MDS completion). There was no documentation of a care plan meeting corresponding with the May 2025 assessment. 2) A review of Resident #17's medical records on 2/09/26 at 10:05 AM revealed MDS assessments completed on 1/31/25, 4/22/25 (annual), 7/21/25, 10/21/25, and 1/21/26. However, documentation of care plan meetings/revisions occurred on 7/25/25, 10/24/25, and 1/30/26. There was a lack of documentation for care plan meetings for the January and April 2025 assessment periods. During an interview on 2/10/26 at 11:55 AM, Staff #3 (Social Worker) and Staff #12 (Social Work Consultant) explained the facility's care plan process. Staff #3 stated that the Social Worker schedules meetings based on the MDS Coordinator's Assessment Reference Date (ARD) from a shared calendar. The meeting is supposed to be held within one week of the ARD. Upon reviewing the lack of documentation for Resident #5 and #17, Staff #12 noted that Staff #3 was a recent hire (less than three months). Staff #12 acknowledged the missing documentation and stated the facility was aware of the issue and was currently monitoring the Social Work department's role more closely. Additionally, in a phone interview on 2/05/26 at 1:04 PM, the Ombudsman shared concerns that residents were experiencing a lack of assistance due to issues within the Social Work department. During an interview with the Nursing Home Administrator (NHA) on 2/11/26 at approximately 12:00 PM, the surveyor shared these concerns regarding the timing and documentation of care plan meetings and revisions. The NHA validated the findings. 3) On 2/05/2026 at 9:17 AM Resident #51 was asked if s/he has attended a care plan meeting or was invited to one and the resident stated they have not had a care plan meeting since admission. Review of the progress notes and social work notes on 2/09/2026 at 8:48 AM did not reveal that a care plan meeting has been held for this resident since admission on [DATE]. On 2/09/2026 at 1:40 AM staff #3 a social worker director (SWD) was asked to check if Resident #51 had a care plan meeting since admission. The SWD checked the resident's medical records and said she could not find any documentation to indicate that a care plan meeting was held or that the resident or her family members were invited. She was asked how often care plan meeting were held and she said every 90 days or quarterly. She was made aware that this was a concern, she explained that the facility did not have a social worker at that time and agreed that a care plan meeting was missed. 4) A review of Resident #9's clinical record on 2/9/26 revealed that the resident was admitted on [DATE]. The resident had care plans developed by the facility staff on the same day as admission, 12/4/25. No evidence in the clinical record that reflected involvement of the resident and/or family in the development of the care plans. Further review revealed that the resident's first care plan meeting was held on 12/12/25, 8 days after the care plans were developed. Care plans are to be developed as a result of the care plan meeting and within 7 days of the comprehensive MDS assessment. Review revealed the facility staff completed an MDS on 12/18/25 which was 6 days after the care plan meeting not prior to the meeting. The social worker (Staff #3) was interviewed on 2/9/26 at 2:03 PM. She said that she puts a copy of the care plan into the electronic health record (EHR) and a notation if the resident and/or the family requests a copy of the care plan. Review of the EHR on 2/9/26 revealed no evidence of the family receiving a copy of the care plan. 5) A review of Resident #7's clinical record on 2/10/26 revealed that the resident was admitted on [DATE]. Further review revealed that since January 1, 2025, the resident only had care plan meetings on 7/11/25 and 2/6/26. Care plan meetings are held quarterly. The resident should have had four care plan meetings in 2025. On 02/09/2026 at 1:40 PM the survey team interviewed the social worker (Staff #3) about the care plan meeting process, she was asked to explain the process for care plan meetings and she stated that: On admission, she sets up an initial care-plan meeting to discuss what the goals are for the resident and what they need to accomplish while in the facility. She stated that each discipline explains their plan of care to the resident/representative during the care plan meeting. They will hold another meeting in 14 days depending on the residents insurance, then every 90 days thereafter. The proper order is to have the assessment first then have a care meeting to discuss what care plans needed to be developed. After the interdisciplinary team makes the decisions as to what care plans would be created, then the care plans get developed. The Social Worker was interviewed on 2/9/26 at 2:03 PM. She was asked how she provided copies of the care plans to the resident and/or family. She replied that she puts a copy of the care plan into the electronic health record and a notation if the resident and/or the family requested a copy of the care plan. 6) A review of Resident #40's clinical record revealed they were admitted on [DATE]. The resident had a falls care plan that was initiated on 11/7/24 and revised on 12/19/25 but there was no evidence of a care plan meeting on 11/7/24 nor was there evidence of a care plan meeting on any date except 12/19/25 when social worker wrote a note.

Based on resident interview and clinical record review it was determined that the facility staff failed to facilitate resident self-determination through support of resident choice. This was evident for 1 (Resident #23) out of 9 residents reviewed for dining related concerns during the recertification/complaint survey.The findings include: A member of the survey team interviewed Resident #23 on 2/5/26 at 9:41 AM. Resident said their portions of food were too small and he/she had been asking for larger portions but the facility refused. This surveyor interviewed Resident #23 at 12:25 PM on 2/6/26. The resident was asked about the portions that were served. The resident said the portions served were too small. It was observed on 2/6/26 at 12:25 PM that the resident's meal slip said Roasted Red skin potatoes which was the resident's choice, but the resident was served mashed potatoes. The resident only became aware of the change in food items when the meal tray was served. The dietician (Staff #23) was interviewed on 2/9/26 at 1:15 PM. She said the resident was ordered to receive double portions. This surveyor asked how much fish a resident on double portions would receive. She replied that they would get a little bit of everything. Approximately half of an additional portion. She said that the resident had a 12/26/25 care plan meeting. The care plan team discussed that the resident's Body Mass Index (BMI) was high, resident was eating well, and that the team agreed to keep the resident's weight stable. She added the resident's BMI was 44.6 which is incredibly high. She said she did not remember him being part of a plan to lose weight. This surveyor interviewed Resident #23 on 2/9/26 at 11:30 AM and asked if they agreed to a weight loss plan. The resident replied No. The resident said that he/she was okay with the fact that they lost weight. Resident said they were admitted with a weight of almost 400 pounds and had lost close to 180 pounds. However, he/she stated that they never asked if I wanted to lose weight.

Based on observation and staff interview it was determined that the resident failed to ensure a resident room had two chairs and to ensure a resident's furniture was maintained in a homelike manner. This was evident for one nursing unit (Rose Hall) out of the two nursing units.The findings include:A survey team member observed on 2/5/26 during the initial tour of the facility that one room (205) did not have any chairs, and another room (206) had a bedside table that had chipped edges. This surveyor toured on 2/20/26 at 2:48 PM the rooms noted to have had issues on the initial tour. This surveyor knocked on the door for room [ROOM NUMBER]. The resident acknowledged the surveyor and nodded when asked for permission to enter the room. This surveyor looked around the room and observed that there were no chairs in the room. Visitors, as well as the residents themselves, did not have a place to sit.This surveyor then went to room [ROOM NUMBER]. This surveyor observed that the bedside table for B bed was chipped around the edges. The chipped areas were not only unsightly but could have scratched the resident. This surveyor took the Administrator for a tour of these two rooms on 2/11/26 at 12:55 PM. He was taken to room [ROOM NUMBER] which did not have chairs. He confirmed the absence of chairs and stated that he would get chairs for the room. He was then taken to room [ROOM NUMBER] on 2/11/26 at 1:02 PM. He observed the bedside table and confirmed that it was chipped. He was then shown that the plastic edging from around the footboard of B bed was off of its track and dangling from the footboard. The edging had not been observed to be off its track during previous observations. He stated that he would have both fixed immediately.

Based on medical record reviews, a review of complaint #2734220, and staff interviews, it was determined that the facility failed to make prompt efforts to resolve resident grievances. This deficiency was evident for one of three residents (Resident #5) reviewed for grievances during the recertification/complaint survey.The findings include:During the investigation of complaint #2734220 on 2/05/26 at 9:31 AM, it was revealed that Resident #5's family expressed safety concerns regarding a roommate (Resident #41). The family reported that Resident #41 had been standing over Resident #5 in an intimidating manner.In a phone interview on 2/05/26 at 11:30 AM, the complainant stated that Resident #41 exhibited several behavioral issues, including taking other residents' items, appearing undressed, and blocking doorways. The complainant stated, We did not feel safe with the roommate . We requested a room change, but the facility did not take it seriously. The room was finally changed the day after the incident occurred.A review of Resident #5's medical records on 2/10/26 at 9:31 AM revealed a progress note written by RN #13 on 2/01/26 at 2:50 PM. The note indicated that Resident #5's family had requested a room change because Resident #41 continued to enter Resident #5's personal space and bother them.In a phone interview on 2/10/26 at 12:53 PM, RN #13 stated that a nurse aide reported a conflict between Resident #5 and Resident #41. RN #13 said, I went to the room to de-escalate the situation; Resident #41 was sitting in a chair, and there was no aggressive behavior between the two residents. Because a family member requested a room change, I documented the request. When asked by the surveyor if any further action was taken, RN #13 verified that no further steps were taken by facility staff at that time.Further review of the medical record on 2/10/26 at 1:30 PM showed that Resident #5's room was eventually changed on 2/02/26 at approximately 10:00 PM following the family's request.On 2/11/26 at 8:30 AM, the surveyor requested all grievance forms for Resident #5. The Director of Nursing (DON) provided only one form, dated 9/15/25, regarding a bed issue. The DON stated, This was the only grievance for [Resident #5].During an interview on 2/11/26 at 1:31 PM, Staff #25 (Regional Director of Nursing) confirmed that the facility should have addressed the request timely, as the resident did not feel comfortable with the roommate. Staff #25 validated the surveyor's concerns.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that each resident's medication regimen was free from unnecessary medications and/or chemical restraints. This was evident by the facility utilized psychotropic medications without adequate clinical indications for use. This deficient practice was identified in one (Resident #8) of five residents reviewed for unnecessary medication regimens during the recertification/complaint survey.The findings included:Lewy Body Dementia (LBD): A progressive brain disease associated with abnormal protein deposits (alpha-synuclein). It is characterized by fluctuating alertness, vivid visual hallucinations, and Parkinsonian motor symptoms.Psychosis: A symptom involving a loss of contact with reality, often manifesting as hallucinations or delusions.Clonazepam: A benzodiazepine used to treat anxiety, panic disorders, and seizure disorders by slowing the central nervous system.Clozapine: A potent antipsychotic medication primarily indicated for treatment-resistant schizophrenia or schizoaffective disorder.On 2/06/26 at 7:27 AM, a review of Resident #8's medical records revealed that the resident had diagnoses including, but not limited to, Lewy Body Dementia (LBD), Parkinson's disease, anxiety, and depression. Current medication orders included:Clozapine 12.5 mg scheduled for AM administration for AntipsychoticClozapine 25 mg scheduled for PM administration for AntipsychoticClonazepam 0.5 mg scheduled for bedtime for antipsychotic.During an interview on 2/09/26 at 10:24 AM, Staff #8 (Psychiatric Nurse Practitioner) reviewed Resident #8's medications with the surveyor. Staff #8 stated, Clonazepam should be used for schizophrenia or the treatment of anxiety. The resident might have some schizophrenia symptoms.However, upon a joint review of the attending provider's documentation and the resident's past medical history, there was no diagnosis or clinical documentation of schizophrenia to justify the use of these medications in this manner. Staff #8 validated the concern, confirming there was no documented indication for the current antipsychotic and benzodiazepine regimen relative to the resident's specific diagnoses.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for one resident (Resident #8) out of five reviewed for active diagnoses and unnecessary medications during this recertification/complaint survey.The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each resident receives appropriate care.A review of Resident #8's medical record on 2/06/26 at 7:27 AM revealed diagnoses including, but not limited to, Lewy Body Dementia (LBD), Parkinson's disease, anxiety, and depression. However, the most recent MDS, dated [DATE], failed to code psychiatric/mood disorders. Specifically, Section I (Active Diagnoses, items I5700-I6100), which includes anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, and Post-Traumatic Stress Disorder (PTSD), was not completed for this resident.During a phone interview on 2/11/26 at 10:14 AM, Staff #2 (MDS Coordinator) verified that Resident #8's most recent MDS only coded dementia and Parkinson's disease. Staff #2 stated, I tried to refer to all the records from providers. I missed Resident #8's diagnoses. I should have included the other mental health conditions like anxiety and depression.In a subsequent interview on 2/11/26 at approximately 11:00 AM, Staff #25 (Regional Director of Nursing) was informed of these concerns and validated the findings.

Based on observation, record review, and staff interviews, it was determined that the facility failed to ensure that a resident who was unable to carry out ADL's, was provided the necessary services to maintain good grooming and personal hygiene. This was evident for 1 (Resident #1) of 1 resident reviewed for grooming during the recertification/complaint survey.The findings include:Activities of daily living (ADL) are skills required to manage one's basic physical needs, including personal hygiene and grooming, dressing, toileting, transferring or ambulating and eating.On 2/05/2026 at 10:59 AM Resident #1 was observed lying in bed, their fingernails were outgrown with brown stains on the inside. Their facial hair was unshaven, about 4 inches long, with dry food particles stuck on it. Resident #1's toenails were thick, protruding out, about 3/4 inch long. The resident was wearing a hospital gown; it had brownish stains towards the chest area. A shirt with a pair of pants was placed on top of the baseboard at the foot of the bed, the resident looked unkept.A second observation was done on 2/10/2026 at 2:00 PM. Resident was observed again in bed with only a diaper on, they were not wearing any personal clothing, their fingernails and toenails were still not trimmed and had brown stains underneath.On 2/10/2026 at 2:07 PM a review of the care plan documented: Resident has ADL self-care deficit related to (r/t) infection. Some of the interventions written under the grooming tab had: Assist to groom. Personal Hygiene Keep nails short. Body check by geriatric nursing assistant (GNA) with AM care every day (qd). Body checks by nurse every week'.On 2/10/2026 at 3:05 PM in an interview with Staff #15, a GNA assigned to the resident's care, she was asked who was responsible for the residents grooming and she said it's the GNA's. She was asked if she noticed that resident's fingernails were dirty and needed trimming and that resident needed a shave. She stated that resident's son visited that day and requested that resident be given a shower, that grooming will be done during the shower.On 2/10/2026 at 3:19 PM Staff #6, the assistant director of Nursing (ADON) was brought to the resident's room and made aware of the observations. She was asked who cuts the toenails for the residents and she said it's done by the podiatrist. She inspected them and confirmed that the nails were dirty and outgrown, the facial hair needed to be trimmed and that resident looked unkept. She said she will talk to the GNA.

Based on record review, staff and resident's interviews, it was determined that the facility failed to 1), act on a physician's recommendations for Resident #51 and 2), administer medications as ordered by the physician for Resident #3. This was evident during the recertification/complaint survey.The findings include1) On 2/05/2026 at 9:10 AM Resident #51 told the surveyor that they were ordered Mirtazapine 15mg for appetite/ antidepressant. Resident #51 stated that the medicine makes them drowsy and s/he can't wake up or function normally and would consider taking half a dose instead of the full dose. The Resident was asked if they told any of the staff and the Resident said they made the nursing staff and their physician aware of it.A review of the physician's order on 2/11/26 at 9:30 AM revealed an order written on 2/2/26 for Resident #51. It read: Mirtazapine Tablet 15 MG, Give 1 tablet by mouth at bedtime for depression/poor appetite. Further review of the February 2026 medication administration record (MAR) revealed the resident has been getting the full dose of the medication every night.On 2/11/26 at 9:45AM, review of a consulting physician's progress note revealed that Resident #51 was seen on 2/6/26 by the Physiatrist-a medical doctor who specializes in helping people regain function after surgery, stroke or injury. The physician documented in his progress note that Resident #51 complained of dizziness and loopiness since starting the above medication. The physician recommended to reduce the dose of Mirtazapine to 7.5 mg to improve tolerance while still providing therapeutic benefits because the resident was experiencing significant loopiness and dizziness .The physician documented that the resident was in agreement and that he discussed the dose reduction with the assistant director of nursing (ADON).Further review did not indicate that the facility acknowledged his recommendation or acted on it.On 2/11/2026 at 12:10 PM, the Interim director of nursing (DON) was asked if she was aware of the residents' complaints and of the doctor's recommendations, and she said no. She was asked the process for addressing recommendations from consulting physicians. She stated that the consulting physician would send emails to the primary team about his recommendations. The primary team or attending physicians would follow up by approving or disapproving the recommendation with a written note or with a new order to effect a change. The Interim DON was made aware that a recommendation was made but was not followed up by the primary team and that this was a concern. She agreed and said she will bring it to the attention of the primary team.2) On 2/06/2026 at 10:57 AM review of the physician's order for Resident #3 revealed an order written on 1/6/26. It read, Hydralazine HCL oral tab 25mg. Give 1 tab by mouth every 8 hours for Hypertension (HTN). Further review of the medication administration record (MAR) for January 2026 revealed that this medication was not signed off to indicated they were given on 3 different days. The dates were 1/7/26 at 2200, 1/16/26 at 2200 and 1/17/26 at 0600. Review of the nurse's notes did not indicate that a note was written as to why the blood pressure medication was not given.In an interview with the director of nursing (DON) on 2/9/26 at 2:15PM, she was asked to explain the process for med administration and documentation. She stated that once medications are given, the nurse is expected to sign to indicate that they were given. If the resident refuses the med, there is a code to chart to indicate so. She was shown the MAR with the 3 days that were not signed and asked what that indicated. She stated that it meant that the medication was not given on those days. She was made aware that the resident did not get her medications on those 3 days and there was no explanation for it. She agreed that this was a concern.

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to timely address and communicate significant weight loss. This deficiency was evident for one (Resident #5) of two residents reviewed for nutrition during this annual survey.The findings include:During a phone interview on 2/05/26 at 11:53 AM, Resident #5's family stated the resident did not receive adequate hydration, which resulted in multiple hospital transfers. As part of the investigation into this concern, the surveyor reviewed Resident #5's medical records regarding hydration and nutritional status.A review of medical records on 2/09/26 at 8:57 AM revealed a pattern of hospital transfers and readmissions: the resident was transferred on 9/08/25 and readmitted on [DATE]; then transferred again at the resident's request on 9/12/25 and readmitted on [DATE]. The medical record documented the following weights:9/02/25: 185 lbs (Bed scale)9/11/25: 161.4 lbs (Bed scale) - Significant loss of 23.6 lbs (12.7%)9/12/25: 161.4 lbs (Bed scale)9/18/25: 165 lbs (Mechanical lift)10/17/25: 166.2 lbs (Mechanical lift)10/23/25: 155 lbs (Mechanical lift) - Significant loss of 11.2 lbs (6.7%)A review of the Registered Dietitian (RD) progress notes on 2/09/26 at 10:10 AM showed that Staff #9 (RD) documented the following on 9/19/25: Weight loss has been noted upon readmission . loss has not been planned and may be due to a history of nutrient intake less than needs. Interventions included adding cookies and pudding at bedtime and 30ml of liquid protein twice daily. On 10/24/25, Staff #9 noted a recommendation for a re-weight and an additional 30ml of liquid protein. However, there was no evidence in the record to support that these significant weight changes were reported to the family or the attending physician.During an interview on 2/09/26 at 9:31 AM, the Director of Nursing (DON) and Staff #25 (Regional DON) stated that the RD communicates daily with nursing leadership via email, and this information is passed to floor nurses and Geriatric Nurse Aides (GNAs) for monitoring. When asked how significant weight changes are reported to responsible parties and providers, the DON stated, The Dietitian notifies the family and contacts providers regarding changes. It should be documented in the electronic medical record.In a phone interview on 2/09/26 at 11:09 AM, Staff #9 (RD) contradicted this, stating she only provides recommendations to facility staff and does not contact families or providers directly. She stated, I believe it's the nurses' job. Regarding the 9/11/25 weight loss, Staff #9 acknowledged the note was not written until eight days later, stating, I had been out when it was noted. When asked why the same intervention was used for the second weight loss on 10/23/25, Staff #9 stated, I don't know why there were the same interventions.During a follow-up interview on 2/09/26 at 11:45 AM, the Assistant Director of Nursing (ADON) stated their role was to follow up on labs or medications, but not to notify the family of changes in condition, claiming, It's the dietitian's role. The surveyor shared concerns regarding the lack of evidence that Resident #5's weight loss was timely addressed or communicated. The ADON and Staff #25 validated these concerns.

Based on a review of employee files and interviews, it was determined that the facility failed to implement a system to ensure nursing staff were competent in their respective skill sets. This deficiency was evident in 3 (Staff #29, #30, #31) out of 5 employee files reviewed for competencies during the recertification/complaint survey.The findings include:On 2/10/26 at 7:00 AM, the surveyor reviewed the competency records of five randomly selected staff members. The review revealed the following:-Staff #29: Hired in December 2024 as a GNA, resigned, and was rehired in December 2025. The employee file lacked documentation of competency upon their rehire in 2025.-Staff #30 and #31: Hired in December 2024 as RNs. The employee files for Staff #30 and #31 lacked records verifying clinical skill competency.During an interview on 2/10/26 at 7:18 AM, Staff #1 (Business Officer) stated that HR verifies competency records for new hires and that the nursing department conducts annual evaluations. However, upon a joint review of the files for Staff #29, #30, and #31, Staff #1 verified that no skills or competency evaluations were present in the records.In an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 2/11/26 at 2:30 PM, the above concerns were shared with them, and they validated it.

Based on Observation and staff interviews, it was determined that the facility failed to appropriately label and store drugs and biologicals in accordance with accepted professional standards. This was evident for 2 of 4 medicine (Med) carts, including the med room fridge observed on the nursing unit during the recertification/complaint survey.The findings include:On [DATE] at 10:20 AM the nurse med cart was checked in the pink hall with Staff #24 a licensed practical nurse (LPN). These meds were found with no labels to indicate when they were opened: -Fluticasone Propionate 50 mcg/inhale nasal spray 16gm-Tuberculin Purified Protein Derivative Diluted/Aplisol, 5 Tu/0.1 ml-5ml bottle These medications were also found expired in the pink hall med cart:-Levetiracetam 100mg/ml solution oral solution with expiration of [DATE]-H-Chlor 120.125% solution with expiration date of [DATE]. On [DATE] at 10:50 AM Observation of the med room with Staff #6 the assistant director of nursing (ADON) revealed expired meds kept in the med fridge. They include:-Cath-Flo Activase 2mg injection. Expired [DATE]-Trulicity 0.75mg/0.5ml Pen- Inject 0.75mg sq once a day every Friday. Expired [DATE].-Tresiba Flex touch 200 unit /ml- Inject 62unit sq 2 times a day-Expired [DATE]/25.-Gabapentin 250mg/5ml liquid -500mg bottle -Give 10ml by mouth3x daily.-3 bags of Intravenous (IV) Daptomycin 700mg/100ml in-0.9% NSS, Infuse IV at 100ml/hour once daily for bacteria for 15 days. Expired[DATE].-3 Mils of 12 ml pen -Novolin N flex pen vial 100unit/ml inject per sliding scale for Expired. [DATE].-Intravenous (IV) Imipenem/Cilastatin 1gm/250ml in 0.9% Normal Saline-Infuse iv at 166 ml/hour over 90 mins q6h for UTI Expired. [DATE] at 2PMOn [DATE] at12:21 PM in an interview with Staff #20, a registered nurse (RN), she was asked the process for checking for expired meds and she stated that it's supposed to be done weekly and with each med administration by each nurse. If expired meds are found, they should be discarded and a replacement ordered.On [DATE] at 2:26 PM the director of nursing (DON) was made aware of the concern. She stated that it is the responsibility of night shift nurses to check the med room fridge and med carts daily. She explained that a new unit manager has been hired and part of their responsibility would be to provide oversight. She agreed that this was a concern.

Based on staff interview and clinical record review it was determined that the facility failed to obtain a dental consult and/or a dental visit for all residents. This was evident for one (#10) out of one resident reviewed for dental concerns. The findings include: This surveyor reviewed Resident #10's clinical record on 2/5/26. The clinical record review revealed that the resident was admitted on [DATE]. Further review revealed that there were no dental consults since admission in the clinical record. The Director of Nursing (DON) was interviewed on 2/9/26 at 3:30 PM. She was asked about the lack of dental consults. She replied that there have been no complaints from the resident or from the family, so a dental consult/visit was never obtained. This surveyor explained that the regulation states that an evaluation from an outside source needs to be done on an annual basis. She expressed an understanding of the findings.

Based on a review of meal service times and staff interview it was determined that the facility staff failed to ensure meals were served less than 14 hours apart. This was evident for all residents receiving a meal tray. The findings include: A review of meal service times revealed that the facility serves dinner with the last food cart having a delivery time of 5:20 PM and the first breakfast cart has a delivery time of 7:40 AM. This represents a 14 hour and 20-minute gap. The Food Service Manager (Staff #28) was interviewed on 2/11/26 at 10:30 AM. This surveyor shared the above finding with her. She stated that the time listed for the food cart that is delivered to the assisted living does not count. She said she understood the finding and would adjust the time the carts went up to reflect a time span of less than 14 hours.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that key essential personnel were present during monthly Quality Assurance (QA) meetings. This deficiency was evident in three of the eight monthly QA meeting attendance sheets reviewed during this recertification/complaint survey.The findings include:On 2/11/26 at 11:29 AM, the surveyor reviewed the facility's Quality Assurance and Performance Improvement (QAPI) meeting attendance sheets from February 2025 to the present. The review revealed that key essential personnel did not sign in for the following dates:-04/30/25: The Infection Preventionist was not in attendance.-06/25/25: There was no evidence of attendance by the Medical Director.-December 2025 (date not clearly documented): There was no evidence of attendance by the Director of Nursing.During an interview with the Nursing Home Administrator (NHA) on 2/11/26 at 12:40 PM, the NHA reviewed the QAPI attendance sheets with the surveyor and validated the absence of documentation regarding the attendance of these key personnel.

Based on Observation and staff interviews, it was determined that the facility failed to 1), ensure that laundry staff utilize appropriate Infection control measures in the laundry room and 2), have hand sanitizers available in the resident's room for infection prevention in 14 of 31 residents' rooms. This was evident during the recertification/complaint survey.The findings include1) On 2/10/26 at 9:14 AM, an inspection of the facility's laundry room was conducted and on the clean folding table were observed personal items such as: a black handbag, an animal print material , 2 cells phones, one plugged into the wall socket and charging on the table, 2 clear 12 oz plastic soda cups, one containing a small amount of brown liquid, an open bottle of Pepsi cola about 3/4 full. On the dirty side were also observed the absence of a gown or mask for sorting/handling dirty laundry, only gloves were seen.In an interview with the laundry aid, Staff #21 on 2/10/26 at 9:20 AM, she was asked about the process for sorting laundry. She explained that dirty laundry are not sorted, because they come in a special laundry bag. They are put in the washer with the clothing. She was asked what sort of personal protective equipment (PPE) was required for use in handling dirty laundry and she said, just gloves. She was asked about gowns, and she said there are no gowns provided by the facility for use and that she was not taught to use gowns when handling dirty laundry. She was asked if she got any training on infection control and the use of PPE's and she said no. She was asked if she was told not to leave any personal items including food and drinks on the clean laundry folding table and she said no.On 2/10/26 at 9:26 AM, Staff # 22, the director of housekeeping, was asked in a separate interview if the laundry staff were trained on the use of PPE and she said that staff do get monthly training on infection control processes such as handwashing and PPEs use. She was asked what sort of PPE the laundry staff are required to use with dirty laundry. She said that when the linens are heavily soiled, staff are expected to use gloves, gowns and facemasks. She was asked about the folding table in the clean side and what was allowed on it and she said no food, drinks or personal items. She was made aware of the findings and that this was a concern. She stated that the laundry aides should not put personal items on the clean folding table.2) On 2/11/2026 at 11:03 AM -an observation of the resident's rooms in the pink hall was conducted and revealed that some rooms (200, 211, 210, 214, & 212) did not have any hand sanitizers. Rooms 101,103, 104, 105,110, 112,114, 113, and 115 on the green hall were also observed not to have any hand sanitizers.Staff #8 a certified medicine aide (CMA) was asked on 2/11/26 at 11:13 AM the expectation on staff before entering or leaving any resident's room and between resident's care. She stated that the staff are expected to perform hand hygiene by either washing their hands or sanitizing with alcohol-based rubs. She was asked where the sanitizers are located, she said on the walls or in the resident's room. She confirmed with the surveyor that there were no hand sanitizers in the above rooms.On 2/11/2026 at 12:10 PM the Interim director of nursing (DON) was made aware of the above concerns, and she stated that hand sanitizers were placed outside the resident's rooms but were taken down during painting and facility renovation. The sanitizers were placed in each resident's room and housekeeping was supposed to make sure that each room had them. She agreed that it was a concern.

Based on administrative record reviews and staff interviews, it was determined that the facility failed to implement a process for tracking nurse aide participation in required training. Specifically, the facility did not ensure all aides received the mandated 12 hours of annual training, including abuse prevention and dementia management, nor did it address areas of weakness identified in performance reviews. This deficiency was evident for two of two Geriatric Nursing Assistants (GNA #29 and #32) reviewed during the recertification/complaint survey.The findings included:On 2/09/26 at 11:23 AM, the surveyor reviewed randomly selected employees' files. The review revealed that as below:-GNA #29: Hired in December 2024, resigned, and re-hired in December 2025. There was no evidence to support the employee receiving dementia training upon re-hire.-GNA #32: Hired in April 2025. There were no records indicating the employee received dementia training upon hire.During an interview on 2/10/26 at 8:56 AM, Staff #25 (Regional Director of Nursing) stated that the previous Director of Nursing (DON) maintained the training records; however, the facility was having difficulty locating or organizing them. Staff #25 noted, Those [found in the files] were all we could find for their training. Staff #25 validated the findings and the absence of dementia training records for newly hired staff.

Based on staff interviews and record review, it was determined that the facility failed to follow up on a resident's statement of possible abuse during another investigation for abuse. This was evident for 1 (Resident #1 ) out of 1 resident reviewed for medical records during this complaint survey. The findings include:On October 14th, 2025, at 2 PM, during the review of records for Resident #11's facility-reported incident, it was found that Resident # 1 had stated yes to all the questions asked on the Resident Interview form for abuse. No comments were added, nor any additional information to the claim.On October 15th, 2025, at 1:15 PM, the DON was questioned about the reported incident and if she knew that there was a resident who responded that they thought abuse was occurring in the facility during that investigation. The acting DON stated that she was unaware of the resident's claim and that the prior DON was present during this investigation and would have asked the questions to the residents. The acting DON made the surveyors aware that the resident was still at the facility.At 2:55 PM, the surveyor went to find Resident #1, but they were not in their room. The acting DON stated that Resident #1 can be found in the rehabilitation center, working with physical therapy. The surveyor interviewed Resident #1 at that time. The resident was asked if s/he remembered the situation back in May 2025, when s/he reported that they felt as though staff had abused them in any way, physically or verbally. Resident #1 stated that s/he remembered and that the staff member who was the problem was no longer working at the facility. The resident was asked if they felt as though any of their personal property was used or taken without permission. Resident #1 stated, no. The resident was asked if they had seen any abuse at the facility. Resident #1 stated, yes, but the staff was no longer working at the facility. The resident was asked if they had any concerns or problems with a roommate or other resident. Resident # stated, not anymore. The resident was asked if s/he felt safe at the facility or if anyone was abusing resident. Resident #1 stated that they liked it at the facility and denied any abuse at this time. At 3:15 PM, the surveyor notified the acting DON of the findings and that Resident #1 had no concerns at this time; however, all possible abuse statements must be investigated completely. The acting DON acknowledged that she understood.

Based on record review and staff interview, it was determined that the facility failed to ensure care plans were reviewed and revised at least quarterly and as necessary to address changes in residents' conditions. This deficient practice was evident for 2 of 2 residents reviewed (Residents #1 and #2) during a complaint survey.The findings include:On 10/14/25 at 12:13 PM, record review for Resident #2 revealed the most recent care plan was dated 3/18/25. On 10/14/25 at 12:22 PM, record review for Resident #1 revealed the most recent comprehensive care plan was dated 4/9/25. During an interview with the Director of Nursing at 12:37pm, it was confirmed that the quarterly care plans were significantly past due for Residents #1 and #2.

Based on administrative and medical record review, interviews with the facility staff, it was determined that the facility staff failed to provide a totally dependent resident with bilateral wheelchair foot rests when transporting the resident throughout the facility. This led to Resident #2 placing his/her right foot on the ground which caused Resident #2's right leg to be fractured. The facility determined that Resident #2's right leg fracture was due to neglect by the GNA (Geriatric Nursing Assistant) transporting Resident #2 without foot rests on 07/31/17 at approximately 11:20 AM. This was evident for 1 of (Resident #2) 4 residents reviewed during a complaint survey. The findings include: Review of facility reported incident #MD 317 and the facility investigation on 03/22/18 revealed that the facility had substantiated neglect based on staff interviews. The facility investigation had revealed that a GNA (Employee # 5) was the staff member who transported Resident #2 without foot rests on 07/31/17 at 11:20 AM. While doing rounds at 2:30 PM, an RN (Employee #6) observed Resident #2's right knee cap to be slightly swollen and Resident #2 complained of pain to the right knee when touched. Resident #2's physician was notified, and an x-ray was ordered and obtained. At 6:02 PM on 07/31/18, an x-ray result received at the facility indicated Resident #2 had an acute nondisplaced [MEDICAL CONDITION] femur. Resident #2's physician was notified of Resident #2's x-ray result and instructed the nurse to send Resident #2 to the hospital emergency room . Resident did not require surgery for [REDACTED]. Review of Resident #2's activities of daily living care plan revealed a nursing goal that indicated Resident #2 would not be injured. Nursing interventions in place prior to the 07/31/17 incident, instructed the nursing staff to Hoyer lift Resident #2 into a wheelchair which then would transport Resident #2 through the facility. After identifying Resident #2 had a fractured femur, the facility staff added nursing interventions instructing the nursing staff to apply the addition of a pillow to the right foot rest. A review of the facility policy for Assisting a Client into a Wheelchair revealed the following: #5 Swing the footrests to the front and fold down the footplates. If required, assist the client to place their feet on the footplates, with their heels well back. #6 Ensure that the client's elbows are not sticking outside the wheelchair when going through doorways. Also ensure that their hands are on their laps and not hanging outside the chair where they can catch in the spokes. In an interview with the facility Physical Therapist (Employee #3) on 03/23/18 at 10:40 AM, Employee #3 stated that Resident #2 is totally dependent upon the nursing staff for all aspects of his/her care and is also non-ambulatory. Employee #3 stated that the facility has been labelling each resident's equipment for over ten years so that staff can accurately identify each resident's equipment. The nursing staff are to place the correctly labelled resident's foot rests on that resident's wheelchair. This would be in preparation to transport a resident throughout the facility. In an interview with GNA (Employee #5) on 03/23/18 at 10:53 AM, Employee #5 stated that he/she was aware that all staff members must apply foot rests to a resident's wheelchair before attempting to transfer any resident. Employee #5 stated it slipped his/her mind to place the leg rests on Resident #2's wheelchair before transferring Resident #3 to the dining room. Employee #5 also stated that he/she never transported Resident #2, while seated in his/her wheelchair, without foot rests before. In an interview with the facility administrator and director of nurses on 03/23/18, the facility director of nursing supplied the surveyor with credible evidence to cite this deficiency as past noncompliance. The credible evidence included staff signature records of all staff members regarding the application of foot rests and positioning residents before transporting residents in wheelchairs. The quality assurance nurse was tasked to monitor weekly, for 4 weeks, that the nursing staff were applying wheelchair foot rests to each resident's wheelchair before transporting each resident. The charge nurses are to monitor the daily nursing staff assignments to assure each resident, that is transported in a wheelchair, has their needed foot rests applied. The facility conducted a thorough investigation and determined this incident to be neglect, educated the staff on the proper use of wheelchair leg rests, reported the incident to the State survey agency, and reported the employee to the [NAME]land Board of Nursing. The facility completed an effective plan of correction and corrected the actual harm on (MONTH) 3, (YEAR).

Based on medical record review, review of the facility's investigation and interview with the Administrator and the Director of Nursing, it was determined that the facility staff failed to protect a resident from injury. This was evident for 1 of 20 sampled residents selected for review. Resident #3 is an [AGE] year old female with [DIAGNOSES REDACTED]. The resident requires extensive assistance with bed mobility. Interview with the Administrator and the Director of Nursing and review of the facility's investigation revealed that on 6/12/11 the geriatric nursing assistant (GNA) was providing morning care to the resident. According to the GNA's statement, when the GNA turned the resident toward her to clean her bottom and pull up her pants, the resident fell to the floor from the bed. The physician was notified and gave an order to transfer the resident to the hospital via 911. The resident was subsequently admitted to the hospital with [REDACTED]. Had the GNA utilized proper technique when turning the resident to provide care, the resident would not have fallen out of the bed. Interview with the Administrator and the Director of nursing revealed that the GNA was terminated for unsatisfactory job performance in the safety of the resident and the incident was reported to the Office of Health Care Quality.