Every finding on record at Roland Park Place

Based on observation, interview, and record review, it was determined that the facility failed to store food in a sanitary manner by ensuring opened food items were properly labeled with the date opened. This is evident for 1 of 1 kitchen areas reviewed.The findings include:On 06/15/2026 at 7:47 AM, an inspection of the spice shelf in the kitchen revealed containers of Montreal chicken spice, ground white pepper, Hungarian style paprika, and ground turmeric without dates indicating when the containers had been opened. Only one spice container was observed on the shelf to have had the opening date correctly labeled on the side of the container.During interview at the time of the observation, Staff #6 stated that opened spice containers should be marked with the date they were opened and confirmed that the dates were missing from the identified spices. On 06/15/2026 at 8:40 AM, the Director of Food and Beverage was informed of the concern regarding the undated spices.

Based on review of a facility reported investigation and staff interviews, it was determined that the facility failed to report an allegation of abuse to the law enforcement agency. This was evident for 2 (Resident #11 and #13) out of 3 residents reviewed for facility reported investigations during the facility's Medicare/Medicaid recertification survey. The findings include: 1. On 04/30/2025 at 12:11 PM, the surveyor reviewed intake MD#00181652 and found that during Resident #11's care plan meeting on 03/14/2022, the resident described the behavior of a Geriatric Nursing Assistant (GNA) #17 as abusive. Resident #11 further characterized GNA #17 as intimidating, abrupt, and dismissive. On 04/30/2025 at 2:24 PM, during an interview with the Nursing Home Administrator (NHA), when she was asked who was notified about the allegations of verbal abuse, she stated that the ombudsman was informed. When she was asked whether a law enforcement agency was notified regarding the incident, she stated that law enforcement was not contacted because the incident involved verbal abuse. When asked to identify the types of abuse, she cited both physical and verbal abuse. In response to reporting such allegations to the law enforcement agency, she expressed that, in her opinion, police involvement was unnecessary, citing that law enforcement agencies were often overwhelmed, and she added that moving forward, she would notify the appropriate law enforcement agency in similar cases On 05/01/2025 at 8:30 AM, in an interview with the Director of Nursing (DON) regarding the reporting of abuse allegations to law enforcement, she stated that all allegations-regardless of the type of abuse or whether they were substantiated-should have been reported to the appropriate law enforcement agency. When she was informed that law enforcement was not notified in the investigation report, she acknowledged that the law enforcement agency was not contacted at the time the allegation was made and agreed that it should have been reported to the law enforcement agency. 51589 2. On 4/30/2025 at 2:00 PM, the surveyor reviewed intake MD#00180814 and found that during a social work (SW) visit on 5/2/2022, Resident #13 informed SW that an agency staff member who worked with the resident on 4/30/2022 was rough and yelling at them during care. During further review of the facility's investigation into alleged abuse against Resident #13, it was revealed that law enforcement was not contacted. On 5/1/2025 at 8:30 AM, the Director of Nursing (DON) was interviewed about Resident #13's abuse allegation. The DON stated that all allegations-regardless of the type of abuse or whether they were substantiated-should have been reported to the appropriate law enforcement agency. When she was informed that law enforcement was not notified in the investigation report, she acknowledged that the law enforcement agency was not contacted at the time the allegation was made and agreed that it should have been reported to the law enforcement agency.

Based on resident interview, record review, and staff interview, it was determined that the facility failed to notify the ombudsman of a resident's transfer to the hospital. This was evident for 1 (Resident #8) out of 1 resident reviewed for hospitalizations. The findings include: On 4/29/25 at 9:44 AM, an interview was conducted with Resident #8. When asked whether they were hospitalized recently, Resident #8 stated that they had just returned from the hospital a few days ago. On 4/29/25 at 1:02 PM, a review of Resident #8's progress notes was conducted. In the note from 4/18/25 at 2:44 pm, it was documented that the resident was transferred to the hospital for further evaluation of shortness of breath. On 4/29/25 at 2:20 PM, an interview with the Nursing Home Administrator (NHA) was conducted. When asked to provide evidence that the ombudsman was notified of Resident #8's transfer on 4/18/25, the NHA stated that they were unaware that the ombudsman needed to be notified of resident transfers to hospital. This surveyor made the NHA aware that notifying the ombudsman of transfers and discharges is a federal and state regulation. On 4/30/25 at 10:45 AM, an interview with the NHA was conducted. The NHA stated that they now have a plan in place to notify ombudsman of transfers to hospitals and have notified the ombudsman of Resident #8's transfer to the hospital after surveyor intervention.

Based on resident interview, record review, and staff interview, it was determined that the facility failed to provide the bed-hold policy to a resident or resident representative before the resident was transferred to the hospital. This was evident for 1 (Resident #8) out of 1 resident reviewed for hospitalizations. A bed-hold policy addresses holding a resident's bed during periods of absence, such as during hospitalization or therapeutic leave. The findings include: On 4/29/25 at 9:44 AM, an interview was conducted with Resident #8. When asked whether they were hospitalized recently, Resident #8 stated that they had just returned from the hospital a few days ago. On 4/29/25 at 1:02 PM, a review of Resident #8's progress notes was conducted. In the note from 4/18/25 at 2:44 pm, it was documented that the resident was transferred to the hospital for further evaluation of shortness of breath. On 4/29/25 at 2:20 PM, an interview with the Nursing Home Administrator (NHA) was conducted. The NHA stated that they would check if a bed-hold policy was provided to Resident #8. On 4/30/25 at 10:45 AM, an interview with the NHA was conducted. The NHA confirmed that a bed-hold policy was not provided to Resident #8 or their Representative. The NHA stated that they were not aware that a bed-hold policy needed to be provided to the resident or resident representative.

Based on interview it was determined the facility failed to have an Infection Preventionist that had completed specialized training in infection prevention and control. This was evident during a focused infection control survey and had the potential to affect all residents and staff. The findings include: On 2/7/22 at 9:52 AM an interview was conducted with the Director of Nursing (DON). The DON was asked who the facility's Infection Preventionist (IP) was at that time. The DON stated that the previous DON was the IP; however, at this time the current DON was filling that role. The DON was asked if she had a certificate of training and her response was that she did not have a certificate of training. The DON stated she was registered to complete the [NAME] Institute Infection Control Program (a state approved training) in March of 2022. The DON stated she was currently taking the CDC (Centers for Disease Control) infection control online training and was half way through the course. The Nursing Home Administrator was informed of the finding on 2/9/22 at 12:25 PM.

Based on interview and documentation review, it was determined the facility failed to inform residents that resided in the facility of suspected or confirmed COVID-19 cases by 5:00 PM the next calendar day following an occurrence of confirmed COVID-19 infection. This was evident for 19 out of 19 individual outbreaks reviewed during a focused infection control survey. This had the potential to affect all residents in the facility that were alert, oriented and cognitively intact. The findings include: On 2/7/22 at 10:59 AM an interview was conducted with the Director of Nursing (DON). The DON was asked how residents and families were notified of suspected or confirmed COVID-19 in the facility. The DON stated that email notifications were sent to all families. The surveyor asked the DON how the alert and oriented residents, that were cognitively intact, that resided in the facility were notified. The DON stated, We tell them. The surveyor asked if there was documentation of notification each time and the response was, it should be but I can't say each time it was. On 2/7/22 at 11:30 AM a review of the facility's COVID-19 outbreak line listing revealed the document contained resident and staff names that tested positive for COVID-19. This document was compared to the dates of email notifications to resident families that was provides to the by the DON. According to the list, the facility notified residents' family members when a staff member or resident tested positive for COVID-19 on the following dates: 12/19/21, 12/21 to 12/23, 12/26 to 12/29, 12/31, 1/1/22, 1/4/22, 1/5/22, 1/7/22, 1/10/22, 1/11/22, 1/12/22, 1/14/22, 1/19/22, and 1/28/22. A review of the medical records for Resident #9 on 2/8/22 at 12:00 PM revealed nursing notes dated 1/12/22 that documented the resident was alert and oriented times 3 (to person, place and thing). A 2/2/22 quarterly note documented that Resident #9 continued to engage in independent, leisure programs and enjoys reading medical journals, newspapers and visiting with his/her family. The note continued, continues to receive wine and crackers every Friday for Happy Hour. Further review of ID notes and other sections of the medical record for Resident #9 failed to produce documentation that the resident was notified each time a staff member or resident tested positive for COVID-19. An interview was conducted with Resident #9 on 2/9/22 at 10:00 AM. Resident #9 was asked if he/she was notified each time there was a positive COVID-19 case in the facility and the reply was, no, I wasn't told anything. The findings were discussed with the Nursing Home Administrator and the Director of Nursing on 2/9/22 at 12:25 PM. No additional evidence was provided.

Based on medical record review and staff interview, it was determined the facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed within 14 days of the assessment reference date for new admissions. These concerns with late completion dates were evident for 1 of 9 residents (Resident #8) reviewed during a focused infection control survey. The findings include: The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualizedneeds of each resident. 1. A review of Resident #8's medical record on [DATE] at 10:30 AM revealed a comprehensive MDS Assessment in the electronic medical record with an ARD (assessment reference date) of [DATE]. An assessment reference date is the date that signifies the end date of the look back period. This date is used to base responses to all MDS coding items. A review of Section Z0500, Signature of RN Assessment Coordinator Verifying Assessment Completion, and item Z0500B, date RN Assessment Coordinator signed assessment as complete, was blank which indicated the assessment was not signed off as completed. The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD. The assessment should have been signed off as complete no later than [DATE]. An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:15 AM. The DON stated that the facility used an MDS contract company to complete the MDS assessments. An interview was conducted with Staff #13 (contract MDS coordinator) on [DATE] at 11:30 AM. Staff #13 stated that her password expired and she was unable to get into the system last week to get the MDS assessments submitted. Staff #13 stated that she goes into the system once a week to do the assessments. The Nursing Home Administrator was informed on [DATE] at 12:25 PM.

Based on medical record review and staff interview, it was determined the facility failed to ensure that Minimum Data Set (MDS) assessments were completed within 14 days of the assessment reference date. These concerns with late completion dates were evident for 3 of 9 residents (Residents #2, #4 and #5) reviewed during a focused infection control survey. The findings include: The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. 1. A review of Resident #2's medical record on [DATE] at 11:00 AM revealed a quarterly MDS Assessment in the electronic medical record with an ARD (assessment reference date) of [DATE]. An assessment reference date is the date that signifies the end date of the look back period. This date is used to base responses to all MDS coding items. Review of Section Z0500, Signature of RN Assessment Coordinator Verifying Assessment Completion, and item Z0500B, date RN Assessment Coordinator signed assessment as complete, was blank which indicated the assessment was not signed off as completed. The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD. The assessment should have been signed off as complete no later than [DATE]. 2. A review of Resident #4's medical record on [DATE] at 9:00 AM revealed a quarterly MDS assessment in the electronic medical record with an ARD of [DATE]. A review of Section Z0500 and Z0500B was blank. The assessment should have been signed off as complete no later than [DATE]. 3. A review of Resident #5's medical record on [DATE] at 9:30 AM revealed a quarterly MDS assessment in the electronic medical record with an ARD of [DATE]. A review of Section Z0500B revealed a completion date of [DATE]. The completion date was late as it should have been on or before [DATE]. An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:15 AM. The DON stated that the facility used an MDS contract company to complete the MDS assessments. An interview was conducted with Staff #13 (contract MDS coordinator) on [DATE] at 11:30 AM. Staff #13 stated that her password expired and she was unable to get into the system last week to get the MDS assessments submitted. Staff #13 stated that she goes into the system once a week to do the assessments. The Nursing Home Administrator was informed of the concern on [DATE] at 12:25 PM.

Based on medical record review and staff interview it was determined the facility failed to have complete and accurate medical records for Resident #4. This was evident for 1 of 5 resident's medical records reviewed during a focused infection control survey. The findings include: On 02/07/22 at 12:15 pm Resident #4's immunization record was reviewed. The immunization section of the electronic medical record revealed Resident #4 received the influenza vaccine on 09/22/21. Further record review on 02/09/22 at 8:18 am revealed a nursing note which documented Resident #4 received an influenza vaccine on 02/08/22. On 02/09/22 at 11:47 am an interview was conducted with the Director of Nursing (DON) who stated Resident #4 did not receive the influenza vaccine on 02/08/22. The DON stated the nurse who wrote the note for 02/08/22 made a documentation error. The DON stated she was certain Resident #4 did not receive the influenza vaccine the previous day. The medical accuracy issue was discussed with the Nursing Home Administrator and DON 02/09/22 at 12:25 pm.

Based on documentation review and staff interview it was determined the facility failed to have a comprehensive COVID-19 Vaccination Policy that addressed, 1) a process for ensuring the implementation of additional precautions for all staff who were not fully vaccinated for COVID-19, 2) a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC, 3) a hiring process for ensuring that all staff hired are fully vaccinated for COVID-19 and 4) a process for any staff member that requests a medical waiver for the COVID-19 vaccine. This was evident during a focused infection control survey and has the ability to affect all residents. The findings include: On 2/7/22 at 10:00 AM a review of the facility's COVID-19 Vaccination Policy was conducted. Review of the policy revealed, as of September 1, 2021, the facility expected all staff and contractors to either be fully vaccinated for COVID-19 or have an approved exemption as an accommodation. The policy stated, associates who do not fulfill one of these two requirements will be placed on unpaid leave and their employment will be subject to termination. The policy documented a procedure on how to request an exemption. Interview of Staff #4 (Human Resources Director) on 2/7/22 at 10:32 AM revealed that all staff and contractors that work at the facility were 100% vaccinated with the exception of 1 staff member that had a religious exemption. Staff #4 stated that they did not want anyone that did not have the vaccine working at the facility. Staff #4 stated that they would not allow anyone to start at the facility unless fully vaccinated and at this time they were not allowing any medical exemptions. An interview was conducted with the Nursing Home Administrator (NHA) on 2/8/22 at 1:00 PM. Reviewed the facility's current policy with the NHA and discussed that the facility only addressed that all associates had to be vaccinated and the process of exemptions. The facility policy did not address how staff that were exempt were monitored for COVID-19 and the precautions they had to take while working. The facility policy did not address the process for medical exemptions related to who would be deciding if the employee could have the medical exemption and what precautions were taken if allowed. The facility policy did not document the steps in the hiring process related to ensuring a new employee was completely vaccinated for COVID-19. The facility policy did not document how the facility was keeping track of employee's that received the COVID-19 booster. The Nursing Home Administrator confirmed that the policy did not have enough information and would be updated.

Based on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses(LPN), and Certified Geriatric Nurse Aides (GNA) per shift. Additionally, the facility name was not on the form. This was observed for at least 4 of the 7 survey days. The findings include. On the Health Care Center 2 unit, review of the day shift staff assignment sheet on 3/9, 3/10, 3/11, and 3/12/21 did not reveal the name of the facility or the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses(LPN), and Certified Geriatric Nurse Aides (GNA) per shift. The staff assignment posting did have individual hours for each staff person but did not include a total number of hours. There were staff assigned to the other nursing home unit and the staff hours worked posting on one unit did not reflect the totals for the entire facility. The posting is to be in a clear and readable format. The total amount of staff by category is divided between two nursing units and all the individual numbers would need to be added up to determine the total number and actual hours worked by category. The nursing home administrator was informed of the concerns on 3/12/21 at 1:46 PM.

Based on medical record review and staff interview it was determined: 1) the pharmacist failed to identify a medication order discrepancy during a monthly pharmacy medication review and 2) facility staff failed to have a process to ensure that pharmacy recommendations were acted upon by the physician. This was evident for 2 (#3, #8) of 5 residents reviewed for unnecessary medications and 1 of 4 residents reviewed for pressure ulcers (Resident #14). The findings include: 1) On 3/11/21 at 1:53 PM, review of Resident #8's March 2021 MAR (medication administration record) revealed an 8/12/16 order for Acetaminophen (Tylenol) (analgesic) by mouth that documented 2 different times to administer the medication. The order read to give Acetaminophen 2 tablets by mouth every 6 hours PRN (as needed) for pain and 2 tablets by mouth every 8 hours. There was no clear indication in the order as to whether the Acetaminophen should be given every 6 hours as needed or if it should be given every 8 hours. The DON (Director of Nurses) was made aware of this finding on 3/16/21 at 11:15 AM and stated the order needed to be clarified. Review of Resident #8's monthly pharmacist medication regimen review (MRR) in the EMR (electronic medical record) failed to reveal evidence that the pharmacist identified the discrepancy with the resident's acetaminophen order. On 4/22/20, 5/28/20, 6/29/20, 7/30/20, 8/28/20, 9/22/20, 10/22/20, 11/20/20, 12/14/20, 1/24/21, and 2/23/21 the pharmacist documented Medication regimen review completed. No recommendations. 2) On 3/16/21 at 10:00 AM, a review of Resident #14's March 2021 TAR (treatment administration record) revealed a 5/21/20 order for Lorazepam (Ativan) (antianxiety medication) 1 mg (milligram) sublingual every 6 hour as needed for anxiety and agitation. The order was not limited to 14 days duration, had no discontinuation/end date, and no documented rational for continuing the order beyond 14 days was found in the resident's medical record. Review of Resident #14's monthly pharmacist MRR documentation in the electronic record revealed on 5/28/20 the pharmacist documented a monthly MRR was completed for Resident #14 and a recommendation was made to the physician. On 9/22/20, the pharmacist documented a monthly MMR was completed for Resident #14 and a recommendation was made to nursing. Continued review of the resident's medical record failed to reveal documentation of the pharmacist's MRR recommendations. On 3/26/21 at 11:15, the DON was made aware of these findings and indicated that the pharmacist's MRR recommendations are documented on a form that is emailed to the DON, the physician, and other clinical staff. The MRR recommendation form is printed, and, once the recommendations are acted upon, the form is filed in the resident's medical record. The DON returned and provided the surveyor with Resident #14's MRR form dated 5/28/20 and a MRR form dated 9/22/20 and indicated the forms were printed from his/her emails. Review of Resident #14's MRR forms revealed, on 5/28/20, the pharmacist wrote All PRN (as needed) psychoactive medication orders require a 14 day stop date as of November 28, 2017. Non antipsychotic PRN orders may be extended if the practitioner feels it is necessary and reasons are well documented in the medical record. Please specify a duration for PRN lorazepam of 14 days. If duration is to extend past 14 days, please document justification in the medical record and specify the duration of the PRN order. Continued review of the medical record failed to reveal evidence that the pharmacist's recommendations had been addressed by the physician, and there was no indication that the medication irregularity was further addressed by the pharmacist when not acted upon by the physician. Review of Resident #14's pharmacist MRR form dated 9/22/20, the consultant pharmacist stated CBC (complete blood count) and CMP (complete metabolic panel) (blood tests) drawn in August per TAR but results not scanned into AOD (Answers on Demand) (EMR ). Continued review of Resident #14's paper medical record and EMR failed to reveal evidence of the resident's August 2020 CBC and CMP lab results in the resident's medical record. On 316/21 at 1:59 PM, during an interview, the DON stated the resident's August 2020 lab results were in the resident's thinned chart in medical records department and confirmed the resident's lab results had not been scanned to the resident's EMR. At this time, the DON was made aware of the above findings and confirmed the facility staff failed to carry out the pharmacist's recommendations. 3) Review of Resident #3's electronic medical record on 3/15/21 revealed that the pharmacist had identified a medication irregularity on 1/22/21. The clinical coordinator (Staff #6) was interviewed at 3:15 PM on 3/15/21 for assistance in finding what was the identified medication irregularity and was it acted upon. The clinical coordinator looked around in her office and the adjacent charting room implied that there was not anything on the clip board. She was able to show me the pharmacist identified medication irregularity of 1/22/21 on her computer monitor. She informed me that she had opened an email. Review of the pharmacist documentation for the blood thinning medication [MEDICATION(S)] revealed that the facility had failed to respond to the pharmacist recommendation of 1/22/21. Review of Resident #3's medical record on 3/16/21 at 11:30 AM revealed that the facility responded to the pharmacist recommendation as it relates to the prescribed [MEDICATION(S)].

Based on resident interview, staff interview and record review it was determined that the facility failed to provide a meal that met a resident's special dietary needs and preferences. This was evident for 3 of 27 residents reviewed during the annual survey (Residents #7, #12 and #31). The findings include: On 3/11/2021 at approximately 12:45 PM, during lunch service, Resident #7, #12 and #21's meal tickets were compared to their meal trays for accuracy. Residents #7 and #12 both had P/PU4 Dilled Baby Carrots on their meal tickets indicating that their meal should contain pureed dilled baby carrot, however, observation revealed that their meals did not include carrots. Further observation of lunch service revealed that Resident #21's meal ticket included Assorted Rolls but no rolls or bread were included in their meal. During an interview on 3/11/2021 at 1:29 PM the Dietary Manager was asked if the kitchen had run out of carrots and responded that the facility had not run out and they were not sure why the residents did not receive the missing carrots and rolls. At 1:46 PM the Dietary Manager provided the survey team with the Lunch Menu for that day which listed Mixed Vegetables and Sautéed Kale under Sides. The Dietary Manager explained that the kitchen had recently upgraded their electronic systems to a different food service software and they believed there were software bugs that were causing the discrepancy between the menu, the tickets and what was being served to residents. The Dietary Manager had submitted a ticket to the software provider at that time to fix the issue. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 3/16/2021.

Based on medical record review and staff interview it was determined that the facility failed to keep complete and accurate medical records. This was evident for 1 of 5 residents reviewed for unnecessary medication (Resident #8). The findings include: On 3/11/21 at 1:53 PM, review of Resident #8's March 2021 MAR (medication administration record) revealed an 8/12/16 order for Acetaminophen (Tylenol) (analgesic) by mouth that documented 2 different times to administer the medication. The order read to give Acetaminophen 2 tablets by mouth every 6 hours PRN (as needed) for pain and 2 tablets by mouth every 8 hours. There was no clear indication in the order as to whether the Acetaminophen should be given every 6 hours as needed or if it should be given every 8 hours. The DON (Director of Nurses) was made aware of this finding on 3/16/21 at 11:15 AM and stated the order needed to be clarified. Cross reference F 756

Based on observation, and staff interview, it was determined that the facility failed to treat resident with dignity and respect by labeling and identifying resident's as feeders. This was identified for 7 of 24 residents in the facility at the initiation of the survey (Residents #6, #11, #13, #15, #23, #29 #74) . The findings include. Observations of the daily staff assignments posting on 3/10/2021, 3/11/2021, and 3/12/2021 revealed that residents were labeled feeder(s) with a corresponding room number. Labeling residents by the type of assistance they require, rather than a human being who needs assistance may be deemed as derogatory. The posting of staff assignments was discussed with the facility administrator on 3/12/2021 at 1:46 PM. The administrator revealed that the staff posting was on an older form that should not have been used.

Based on observation, resident and staff interview it was determined that facility staff failed to have a call bell in reach for a resident who was dependent on staff for activities of daily living. This was evident for 1 of 17 residents observed in the initial resident pool (Resodemt #17) . The findings include: On 3/10/21 at 9:54 AM, an observation was made of Resident #17, sitting in a wheelchair, on the right side of the bed, with a round side table in between the resident and the bed. On the left side of the bed, the call bell cord was observed hanging on the top of the call bell prong attached to the wall, and was not within reach of the resident. The surveyor asked Resident #17 how he/she called for the nurse, and the resident stated that he/she would push the call bell. At that time, the resident looked around, pointed to the side table and stated, it's usually right here. When aware the call bell was hanging on the wall, Resident #17 stated he/she could not reach the call bell. On 3/10/21, at approximately 10:00 AM, Staff # 17, geriatric nursing assistant (GNA), entered Resident #17's room and was made aware the resident's call bell was hanging on the wall and not within the resident's reach. Staff #17 secured the call bell cord to Resident #17's wheelchair and stated he/she did not know who straightened up that morning. The Director of Nurses was made aware of these findings on 3/11/21 at 2:00 PM.

Based on review of a closed medical record and staff interview, it was determined that the facility staff failed to provide a resident with a completed discharge summary. This was evident for 1 of 27 residents reviewed during an annual refortification survey (Resident #24) . The findings include: On 3/16/2021 on review of Resident #24's closed medical record revealed that Resident #24 was discharged from the facility on 12/16/2020. Resident #24's electronic medical record and paper record failed to reveal a completed discharge summary from Resident #24's attending physician that included: a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-discharge medications with the post discharge medications, and a post discharge plan of care. In an interview on 3/16/2021 at 11:22 AM the Director of Nursing confirmed that Resident #24's record did not include a completed discharge summary. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 3/16/2021.

Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that a [CONDITION(S)] medication prescribed as needed was limited to 14 days. This was evident for 1 of 4 residents reviewed for pressure ulcers (Resident #14). The findings include: On 3/16/21 at 10:00 AM, a review of Resident #14's March 2021 TAR (treatment administration record) revealed a 5/21/20 order for Lorazepam (Ativan) (antianxiety medication) 1 mg (milligram) sublingual every 6 hour as needed for anxiety and agitation. The order had no discontinuation/end date, was not limited to 14 days duration. Further review of the medical record fail to reveal physician documented rational for continuing the order beyond 14 days. The Director of Nurses confirmed the findings on 3/16/21 at 11:15 AM.

Based on observations and interviews, it was determined that the facility failed to ensure that medications requiring refrigeration were stored safely. This was found to be evident in 1 out of 1 medication storage rooms and had the potential to affect all residents. The findings include: On [DATE] at 10:02 am, the refrigerator temperature log located in a binder in the locked medication storage room revealed the refrigerator inside temperature was last checked on [DATE] with a temperature logged at 36 degrees Fahrenheit. The facility's refrigerator temperature log stated ,d+[DATE] must check and record temperatures and check and discard expired medication and ensure that all medications are labelled and dated. On [DATE] at 10:03 am, at the time of the observation, a nurse (staff #10) unlocked refrigerator located in locked medication storage room. The surveyor identified the following medications stored in the refrigerator: [MEDICATION(S)] Acetaminophen suppositories 650 mg, Purified Protein Derivative Diluted [MEDICATION(S)] 5 TU/0.1 ml, [MEDICATION(S)] suppositories 10 mg, [MEDICATION(S)] ophthalmic solution 0.005%, [MEDICATION(S)] injection 50 mg /ml (kit), prefilled pneumococcal vaccine pneumococcal vaccine [MEDICATION(S)], Influenza vaccine adjuvanted IM 0.5 ml prefilled syringes and 2 ice packs. The portable thermometer located inside of the refrigerator had an inside reading temperature of 54 degrees Fahrenheit. The bottom of the facility's refrigerator log stated temperature should be between 36 F - 46 degrees F. Please notify facility services if temperature is out of range. On [DATE] at 10:06 am, the Clinical Unit Coordinator (Staff# 6) confirmed the medication storage refrigerator inside reading temperature was 54 degrees Fahrenheit and was above the acceptable temperature range during the interview conducted. On [DATE] at 8:40 am, during observation with Staff # 10 of the medication storage refrigerator located in the locked medication storage room, the inside temperature reading on the portable thermometer was 52 degrees Fahrenheit, RN # 10 confirmed reading at 52 degrees Fahrenheit. On ,d+[DATE] /2021 at 8:47 am, during the interview conducted with the Clinical Unit Coordinator #6, Staff #10 had confirmed the inside temperature reading of the medication storage refrigerator was 52 degrees Fahrenheit. Clinical Unit Coordinator #6 instructed the nurse (Staff #10) to replace medication storage refrigerator.

Based on medical record review and staff interview it was determined that the facility staff failed to evaluate and update a resident's plan of care after each assessment. This was evident for 1 of 2 residents reviewed for accidents (Resident #17). The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. On 3/1621 at 2:53 PM, Resident #17's medical record was reviewed and revealed the resident's most recent quarterly assessment had a reference date of 1/8/21 and the prior quarterly assessment had a reference date of 10/15/20. 1. A review of Resident #17's care plans revealed the resident had multiple care plans, including a cardiovascular care plan: Resident #17 has potential for complications from [CONDITION(S)] (hypertension) and CAD (coronary artery disease), stent placement 6/7/18 with the goal, Resident #17 will have no complications for cardiovascular disease and will no require outside medical intervention x 90 days that included the interventions 1) provide blood pressure (BP) medication and treatment per physician orders. Monitor for side effects of medication and inform physician of concerns [MEDICATION(S)] (BP medication) 80 mg (milligrams) and [MEDICATION(S)] (BP medication) 5 mg po (by mouth) QD (every day). Check BP q (every) Wednesday at 9 AM, (Hold for SPB less than 110). A review of Resident #17's medical record failed to reveal evidence the care plan had been reviewed after the residents most recent quarterly assessment with a reference date of 1/8/21 or following the resident's previous quarterly assessment with a reference date of 10/15/20. Resident #17's March 2021 MAR (medication administration record) revealed a 1/14/19 order for [MEDICATION(S)] 10 mg by mouth every day, which was in contradiction to the care plan intervention which indicated the resident received [MEDICATION(S)] 5 mg. Continued review of the medical record failed to reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to update the care plan in response to current interventions and there was no documentation to indicate the resident's progress or lack of progress towards his/her goal had been evaluated. 2. Resident #17 had a hypothyroid (underactive [CONDITION(S)] disease) care plan: Resident #17 has potential for complications from [MEDICATION(S)] ([CONDITION(S)] medication) TSH ([CONDITION(S)] stimulating hormone) (blood test) ever year in July, initiated on 1/25/20, had the goal, Resident #17 will have no complications from [CONDITION(S)], including weakness, tiredness or outside medical intervention. Review of Resident #17's medical record failed to reveal evidence the care plan had been reviewed after the residents most recent quarterly assessment with a reference date of 1/8/21 or following the resident's previous quarterly assessment with a reference date of 10/15/20. There was no documentation to indicate the resident's progress or lack of progress towards his/her goal had been evaluated or updated based on the needs of the resident or in response to current interventions. 3. Resident #17 had a [CONDITION(S)] (RA) (autoimmune disease that can cause joint pain and damage throughout the body) care plan that had a start date of 1/25/20 with the goal: Resident #17 will not develop complications from [CONDITION(S)] requiring outside medical intervention. Continued review of the resident's medical record failed to reveal evidence the care plan had been reviewed after the residents most recent quarterly assessment with a reference date of 1/8/21 or following the resident's previous quarterly assessment with a reference date of 10/15/20. There were no documented evaluations of Resident #17's RA care plan and there was no documentation to indicate the resident's progress or lack of progress towards his/her goal had been evaluated or updated based on the needs of the resident or in response to current interventions. Staff #6, A Clinical Coordinator, was made aware of the above findings and concerns related to evaluation of the resident care plans on 3/16/21 at 4:30 PM,

Based on medical record review and staff interview, the facility staff failed to protect a resident from injury while providing care (Resident #3). This was evident for 1 out of 4 residents reviewed during a complaint survey. The findings include: The MDS (Minimum Data Set) is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. MDS assessments are completed upon admission, quarterly and for any significant change in condition. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] and on 10/27/18 the resident was assessed to have a sustained a facial laceration after being turned in bed. Review of the facility investigation of the incident revealed that on 10/27/18 at approximately 7:30 AM GNA #1 rolled the resident towards the side rail that had a bed alarm hanging on it and the resident hit his/her head. The resident was assessed by Nurse #1 to have a 0.3 cm by 1.2 cm laceration and a band aid was applied to the area above the resident's right eye brow. At approximately 11 AM, GNA #1 noted the resident to have increased bleeding. The resident was reassessed by Nurse #1 and the laceration depth appeared to have increased in size. The physician was notified and ordered the resident to be sent to the emergency room . Review of the emergency room report revealed the resident had a [MEDICAL CONDITION] maxillary sinus with hemorrhage within the sinus. The resident was admitted to the hospital for observation due [MEDICAL CONDITION] related to a urinary tract infection. Surgery was not indicated for the facial fracture. The resident remained at his/her nonverbal baseline due to [DIAGNOSES REDACTED]. The resident was treated in the hospital with antibiotics for the urinary tract infection and returned to the facility on [DATE]. Review of Resident #3's Resident Care Guide dated 3/18/16 revealed the resident was an assist of 1 for bathing/hygiene/dressing. Review of resident's quarterly MDS Section G Functional Status dated 8/27/18, the resident was coded a one person physical assist for bed mobility. Review of Resident #3's care plans revealed a care plan for basic care needs dated 6/30/17 with an intervention I need 2 people to assist me with my bed mobility. Further review of the resident's care plans revealed a care plan for potential for alteration in skin integrity dated 6/30/17 with an intervention Bed mobility assist of 2 needed to prevent shearing encourage proper body mechanics. The last revision date for the care plans was 9/6/18. During interview with the Clinical Manager on 4/15/19 at 9:58 AM, he/she stated the care plans were not accurate and the resident had always been one person assist for bed mobility. During interview with GNA #1 on 4/15/19 at 9:53 AM, he/she stated on 10/27/18 he/she turned the resident alone and the resident's head hit the alarm box hanging on the siderail. GNA #1 then stated he/she saw a gash above the resident's eye and got Nurse #1. GNA #1 stated he/she has been caring for the resident for a long time and the resident was always a one person assist for bathing and bed mobility. GNA #1 states the Resident's Care Guide tells her/him how many people are needed for transfers and bed mobility. During interview with Nurse #1 on 4/15/19 at 9:59 AM, he/she stated on 10/27/18 GNA #1 told him/her the resident hit the side rail when he/she was being turned. Nurse #1 stated he/she assessed the resident, noted a laceration, cleaned and covered with a band-aid. Nurse #1 stated at approximately 11:00 AM, GNA #1 told her the resident was having more bleeding. Nurse #1 stated the laceration appeared deeper at that time, she notified the physician and sent the resident to the emergency room . Nurse #1 stated he/she had regularly cared for the resident and the resident had always been a one person assist for bathing and bed mobility. Interview with the Clinical Manager on 4/15/19 at 9:58 AM, he/she stated after the incident the facility no longer uses the alarm boxes. Interview with the Clinical Manager on 4/16/19 at 9:28 AM confirmed the facility staff failed to protect a resident from injury while providing care. See F657

Based on medical record review, interview with family, facility staff and review of facility policy, it was determined that the facility staff failed to follow a residents' plan of care and facility protocol when transferring and performing ADL (activities of daily living) care. This was evident for 1 of 29 residents (#14) reviewed during stage 2 and after the review of a facility reported incident (MD 715). The findings include: Review of the medical record for Resident #14 on 7/06/16 10:51 AM revealed [DIAGNOSES REDACTED].e., dressing, bathing, and transferring). A review of the residents most recent MDS (minimum data set) and interview with the MDS coordinator on 7/06/16 1:07 PM, confirmed that Resident #14 was totally dependent on staff for transfers and required 2 staff. Review of the facility reported incident #MD 715, revealed that on 5/11/16 Resident #14 was noted to have a bruise on his/her right upper arm. Further review of the facility investigation revealed staff GNA #10 reported to staff RN #7 that a large bruise was observed on the resident's right upper arm at the beginning of AM care on 5/11/16, that is when the investigation into the injury of unknown origin began. Review of the nursing notes from 5/11/16 revealed, 'the resident was assessed around 7:30 AM at the urging of the GNA. Resident noted to have a hematoma the inner aspect pf the right upper arm 12cm (centimeters) x 13cm. No facial grimaces noted until palpitated. An x-ray was scheduled stat (immediately).' Results of the x-ray showed a fracture involving the proximal humerus (top of the upper arm bone) with medial displacement. The family was notified and agreed on symptomatic, not surgical treatment. The residents arm was placed in a sling and s/he was treated with Tylenol. Results of the facility investigation into the incident ultimately revealed that GNA #10 while doing care for the resident on 5/9/16 and 5/10/16, did not follow proper procedure and that 'may have caused trauma to his/her right arm which resulted in the displaced fracture.' Staff GNA #10 transferred Resident #14 independently without the Hoyer and without additional support from other staff, transferring the resident from the bed to his/her wheelchair during the day shift of 5/9/16 and 5/10/16. Staff was in-serviced on 5/11, 5/12, 5/13 and 5/15. All staff were educated regarding providing care i.e.; proper body alignment, Hoyer lifts, communication of change in condition, family rights, residents rights and on 5/27/16 non-verbal expressions of pain and discomfort was added to the in-servicing completed by the Quality Improvement Specialist. During an interview with staff RN #7 at 12:15 PM and staff GNA #8 at 12:22 PM on 7/6/16 regarding Resident #14 and assessing his/her pain, both were able to verbalize the residents plan of care and how, although s/he is non-verbal, they are assessing/monitoring him/her for pain. The concern regarding the facility reported incident and the subsequent findings were reviewed with the Director of Nursing, Administrator and the Quality Improvement specialist throughout the survey.