Every finding on record at Roland Park Rehabilitation and Healthcare Center

Based on complaint review, medical record review, and interview, it was determined the facility failed to ensure a resident went to a surgical follow up appointment following eye surgery. This was evident for 1 (Resident #5) of 12 residents reviewed during a complaint survey.The findings include: Review of Complaint 3064692 was conducted on 8/13/26 regarding the care Resident #5 is receiving at the facility. During interview with Resident #5 on 8/13/26 at 12:30 PM, Resident #5 stated he/she had eye surgery, and he/she called the eye surgeon's office to find out about follow up. Resident #5 stated they told him/her that he/she had an appointment scheduled for 5/15/26 and he/she was a no show. Review of Resident #5's medical record on 8/13/26 revealed the Resident was admitted to the facility in 2021 and has a diagnosis to include bilateral cataract. A cataract is a cloudy area in the lens of the eye that impairs vision. Further review of Resident #5's medical record revealed the Resident was seen by the eye surgeon on 4/25/26. Review of the eye surgeon's recommendations revealed the Resident was to follow up in 1-2 weeks. Review of Resident #5's medical record on 8/13/26 revealed no further appointments with the eye surgeon. During interview with the Director of Nursing (DON) on 8/13/26 at 1:34 PM, the DON was asked to see if the Resident went to a follow up appointment with the eye surgeon following the 4/25/26 appointment. During interview with the eye doctor office scheduler on 8/14/26 at 9:14 AM, the Scheduler stated the Resident did have a follow up appointment scheduled on 5/15/26 at 9:30 AM but was a no show. The Scheduler stated the Resident now has an appointment scheduled for 9/9/26. Interview with the DON on 8/18/26 at 8:15 AM confirmed the facility staff failed to ensure the Resident went to a follow up appointment with the eye surgeon on 5/15/26 and now has scheduled an appointment on 9/9/26.

Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers . This is evident for 1 (Resident #7) of 3 residents reviewed for pressure ulcers during a complaint survey.The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). Review of Complainant 2733741 was conducted on 8/13/26 regarding wound care for Resident #7. Review of Resident #7's medical record on 8/13/26 revealed the Resident was admitted to the facility in 2025 with pressure ulcers. Further review of Resident #7's medical record revealed the Resident was readmitted to the facility on [DATE] following a hospitalization. Review of an 8/8/26 2:32 PM nurse's note revealed the Resident returned from the hospital with an unstageable wound to sacrum, redness to right and left heels and ulcer to right and left hips. Further review of Resident #7's medical record revealed the facility staff failed to order pressure ulcer wound treatment for Resident's right and left hip wounds after readmission to the facility on 8/8/26. Further review of Resident #7's medical record revealed the facility staff failed to notify the physician and obtain any treatment orders for the Resident's bilateral heel redness after readmission to the facility on 8/8/26. Review of an 8/11/26 Weekly Skin Check for Resident #7 revealed the facility assessed the Resident to have pressure ulcers to the sacrum, bilateral hips and redness to bilateral heels. Interview with the Assistant Director of Nursing (ADON) on 8/14/26 at 12:44 PM confirmed the facility staff failed to put in the wound treatment orders for the Resident's bilateral hips on readmission to the facility on 8/8/26. The ADON stated interviews with the Resident and facility staff revealed the facility staff were doing wound treatments to the Resident's bilateral hips that were ordered prior to the hospitalization but failed to obtain new orders and document the wound treatments. The ADON at that time also confirmed the facility staff failed to notify the physician and obtain any treatment orders for the Resident's bilateral heel redness. During interview with Resident #7 on 8/17/26 at 8:50 AM, Resident #7 stated the facility has been treating his/her bilateral hip wounds daily. Resident #7 added his/her heels being red is something new that he/she believes started in the hospital and the staff hasn't been doing any treatment for them. After Surveyor intervention, the facility staff contacted the Resident's physician and obtained orders for the Resident's bilateral hip pressure ulcers and bilateral heel redness on 8/14/26.

Based on a review of complaint 3104878, medical record review, and staff interviews, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #3) of 12 residents reviewed during a complaint survey.The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record must be legible and accurate.A Foley catheter is a thin, flexible plastic tube that is inserted into the bladder to drain urine. The urine then empties continuously into a urinary drainage bag.On 8/17/26 at 8:39 AM a review of complaint 3104878 alleged that Resident #3 was transferred to the hospital on 5/24/26 after having a seizure and was diagnosed with septic shock and a urinary tract infection.Review of Resident #3's medical record revealed the resident was admitted to the facility in May 2025 with diagnoses that included dysphagia following a nontraumatic subarachnoid hemorrhage, obstructive and reflux uropathy, urinary tract infection, and mild cognitive impairment.Review of a 5/24/26 at 17:21 (5:21 PM) change in condition note documented that Resident #3 was observed during routine rounds experiencing a generalized seizure involving the entire body. PRN (when necessary) Lorazepam was administered as ordered, and the resident was positioned in the left lateral position with intranasal oxygen initiated at 4L/min. Despite interventions, the seizure activity persisted, and SpO2 (oxygen saturation) remained in the low 80s. There were no vital signs documented during the resident's seizure on 5/24/26. The only vital signs listed in the change of condition form were from 16 hours prior (01:47).Review of the vital sign section of Resident #3's electronic medical record revealed the last set of vital signs that were documented on Resident #3 were dated 5/24/26 at 01:47.Continued review of Resident #3's medical record revealed a 5/19/26 at 14:52 (2:52 PM) eMar (electronic Medication Administration Record) note that documented, foley cath (catheter) blocked unable to flush. The note was created on 5/24/26 at 14:54 (2:54 PM) which was 5 days after the documented blockage. There was no other documentation in the medical record related to the blockage. Review of Resident #3's May 2026 Treatment Administration Record (TAR) documented the order, acetic Acid Irrigation Solution 0.25% (Acetic Acid) use 15 ml via irrigation every shift for Foley irrigation Bladder Flush. The TAR lacked nursing initials to confirm that physician ordered bladder irrigations were completed on the 5/17/26 day shift and the 5/18/26 evening shift. On 8/17/26 at 10:06 AM an interview was conducted with Licensed Practical Nurse (LPN) #12 who stated that she did the bladder irrigation on 5/17/26. LPN #12 stated, I probably missed that one click. Sometimes I click it as done when I do the treatment at that time and sometimes I click it as done at the end of my shift. I know I did the irrigation because it came up on the TAR.On 8/17/26 at 10:23 AM LPN #10, who was also the unit manager, was interviewed about the 5/19/26 eMar note. LPN #10 stated that the nurse that wrote the note was on vacation and if the tube was clogged on that day there would have been a note written on that day. LPN #10 stated that she did not understand why the note was written 5 days later unless someone was reviewing the chart when the resident was sent out to the hospital. On 8/17/26 at 10:55 AM the Assistant Director of Nursing (ADON) was interviewed about the documentation related to the blocked tube and stated, she might have changed the catheter.On 8/17/26 at 11:21 AM the ADON came back to the surveyor and showed documentation that the nurse got a prn (when necessary) order and changed the foley catheter on 5/19/26 at 14:52. The ADON did confirm that the nurse did not document a change in condition at that time and if the resident experienced any pain in the bladder region prior to the nurse getting the prn order. The ADON stated, that would have been the correct thing to do is document.On 8/18/26 at 9:18 AM the concern was discussed with the Regional Director of Clinical Services who agreed with and confirmed the surveyor's findings.

Based on observations and interviews it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment for Residents. This finding was found to be evident during the tour of the facility for review of the physical environment.The findings include: On 4/14/26 at 8:19AM during an initial tour of the facility, the surveyor observed dark patches all over the bedroom floor. The vinyl chair cover was also torn in 3 different places, measuring about 1x6, 1x8 and 1x3 inches respectively. In room [ROOM NUMBER] bathroom, the floor vinyl behind the toilet, extending all the way to the bathroom sink and measuring about 3 x1.5 feet was raised and coming/peeling off. Behind the entrance door to room [ROOM NUMBER], the vinyl siding (Cove base) measuring about one foot long was observed hanging off the wall. In an interview with the maintenance director on 4/16/26 at 11:44 AM he was asked how things needing repair were brought to his attention and how he keeps the building maintained. He said he does a walk around on each wing and floor daily to see if staff or residents needed something fixed. They have a TELS system where maintenance /repair issues are logged in for him to see, residents can tell nurses or let him know directly. He was asked how soon he gets things fixed once he sees them in TELS and he said it depends on the urgency but relies mostly on staff to be his eyes and ears. The maintenance director #26 was made aware of the concerns, he said he will take care of them. During the initial tour of the Mount [NAME] Nursing Unit on 4/14/2026 at 8:00 AM the surveyor observed several areas in the Resident rooms not in good repair. room [ROOM NUMBER] – marred bathroom door; room [ROOM NUMBER] – marred bathroom door, marred wall behind head of Resident's bed; room [ROOM NUMBER] – bathroom door marred with chipped wood; room [ROOM NUMBER] – marred bathroom door, hole in wall in Resident's room; room [ROOM NUMBER] – marred bathroom door, black substance on the ceiling and the wall near the ceiling vent above the entrance door to the Resident's room; room [ROOM NUMBER] – bathroom door marred; and room [ROOM NUMBER] – bathroom door marred, toilet stopped up and will not flush. Additionally, there were missing wall tiles on the lower 1/3 of the wall in the nourishment room. At 12:30 PM on 4/17/2026 the surveyor toured Mount [NAME] Nursing Unit with the Maintenance Director and observed the hole in the wall in Resident room [ROOM NUMBER], the marred and chipped wood on Resident bathroom doors, and the missing wall tiles in the nourishment room. The Maintenance Director indicated that he does scheduled maintenance in the facility, and that he would get right on these areas that needed repair and order the necessary items to complete the repairs. No additional information was provided by the facility at the time of survey exit.

Based on record reviews and interviews, it was determined that the facility failed to ensure 1) written information was provided to a resident's representative regarding the facility's bed hold policy, and 2) written notice of the transfer was provided to a resident's representative upon transfer to the hospital and 3) failed to provide timely notification to the facility's Ombudsman when Residents transferred to the hospital. This was evident for 3 (Resident #3, #13, and #73) out of 6 residents reviewed for hospitalization and discharge process.The findings include:1) On 04/14/2026 at 9:12 AM, review of Resident #3's medical record revealed he/she was sent to the hospital on 2/11/2026. At the same time, further review of Resident #3's medical record revealed a document titled, Bed Hold Agreement, dated 2/11/26 which had hand written wording of, consent over the phone, and a signature below it on the bottom of the document. On 04/16/2026 at 11:29 AM, an interview with the Director of Nursing revealed that if a resident was able to acknowledge and sign the document they would provide the document to them, but otherwise staff would call the resident representative, note the communication on the document, and sign. The surveyor reviewed the concern. 2) On 04/14/2026 at 9:37 AM, review of Resident #3's medical record revealed a document titled, SNF/NF to Hospital Transfer Form, dated 2/11/2026 which indicated that the Resident's representative was notified of the transfer and aware of the clinical situation at the time of transfer, along with their telephone number. Further review of the document and medical record failed to reveal indication that there was a written form of notice provided to the Resident's representative upon transfer to the hospital. On 04/16/2026 at 11:29 AM, an interview with the Director of Nursing revealed that resident representatives were informed via telephone when a resident is transferred to the hospital. She confirmed the notice was not in written form. The surveyor reviewed the concern. 3) The surveyor reviewed Resident #13's medical record on 4/15/2026 at 9:30 AM. Record review revealed that Resident #13 transferred to the hospital on [DATE] for critical abnormal lab values. There was no indication in the medical record that the facility's Ombudsman was notified of the transfer to the hospital. On 4/15/2025 at 9:45 AM the surveyor conducted a record review of Resident #73's medical record. Review of the medical record revealed that Resident #73 transferred to the hospital on [DATE], 2/18/2026 and 3/8/2026. There was no indication in Resident #73's medical record that the facility's Ombudsman was notified of these transfers to the hospital. At 10:15 AM on 4/15/2026 the surveyor asked the Director of Nursing (DON) who was responsible for notification to the Ombudsman of hospital transfers. The DON acknowledged that Social Services Department was responsible for notification and requested documentation of these transfers to hospital for Resident #13 and #73. In an interview with the Social Services Director (SSD) at 11:17 AM on 4/15/2026 the surveyor asked what the process was for notification to the Ombudsman when Residents transferred to the hospital. SSD indicated that he sends an email to the Ombudsman monthly with a list attached from the electronic medical record platform of Resident transfers and discharges from the previous month. The surveyor requested a copy of the email notifications to the Ombudsman for the months of October 2025, November 2025, February 2026 and March 2026. The surveyor reviewed on 4/15/2025 at 12:30 PM the emails and the electronic medical record list of discharges that were sent to the Ombudsman by the SSD. On 3/2/2026 at 1:58 PM the SSD emailed the 2025 discharge report to the Ombudsman, and on 3/2/2026 at 2:02 PM the SSD emailed the January 2026 discharge report to the Ombudsman, and on 4/15/2026 at 11:01 AM the SSD emailed February 2026 and March 2026 discharge report to the Ombudsman. In a follow up interview at 2:45 PM on 4/15/2026 with the SSD he stated that on 3/2/2026 he sent an email to the Ombudsman with all the Resident transfers and discharges for year 2025 as he was not notifying the Ombudsman of Resident transfers to the hospital until 3/2/2026 when he sent the email. Additionally, SSD stated that for January of 2026 he sent the email to the Ombudsman on 3/2/206 and for February and March 2026, he sent the email today (4/15/2026). At 3:35 PM on 4/15/2026 the Licensed Nursing Home Administrator (LNHA) was notified of the lack of Ombudsman notification of Resident transfers to the hospital. On 4/20/2026 at 1:30 PM the surveyor asked the Ombudsman if she was being notified of the hospital transfers, and she indicated that she had not been notified of Resident hospital discharges until recently.

Based on observations, interviews and record reviews it was determined that the facility failed to ensure that the Residents received the posted menu meal timely and the meal ticket matched the provided meal on Resident trays. This finding was found to be evident in 10 (Resident #80, #123, 6, 31, 60, 77, 91, 92, 100 and 111) out of 10 Residents reviewed for food and nutrition services.The findings include:In an interview with Resident #80 at 11:10 AM on 4/14/2026 the Resident stated that the food was awful, there were not enough portions, and the meal on the tray did not match the meal ticket. Resident further stated that he/she was supposed to get 2 juices and double portions of the meal, but he/she only received 1 juice and not enough portions of the meal. The surveyor reviewed Resident #80's meal ticket for breakfast on 4/14/2026 which the Resident had laying on the overbed table and the meal ticket indicated give 2 juices, entree x2 portions.In an interview with Resident #123 at 11:20 AM on 4/14/2026 the Resident stated that the food was not good and that there was not enough food provided. The Food Services Director at 11:30 AM on 4/14/2026 was notified of the concerns from Residents regarding the food not good, awful, and not enough portions of food.The surveyor conducted a record review of Resident #80's medical record on 4/17/2026 at 11:33 AM. Record review revealed that Resident #80 had a physician order for Heart Healthy, Controlled Carbohydrate, regular consistency diet. The surveyor conducted a record review of Resident #123's medical record on 4/17/2026 at 2:15 PM. Record review revealed that Resident #123 had a physician order for Regular diet, Regular texture, Regular (thin) liquid consistency.The surveyor observed the tray line for the lunch meal on 4/16/2026. The tray line began at 11:27 AM and completed at 1:15 PM. The menu posted for lunch consisted of Farmer's Meatloaf, mashed garlic potatoes, green peas, brown gravy and strawberry shortcake parfait. During the lunch tray line service on 4/16/2026 the dietary department ran out of 2 food items (meatloaf and peas) and did not have enough food to prepare the posted menu meal for 8 Residents (# 6, #31, #60, #77, # 91, #92, #100 and #111) on the Cross Keys Nursing Unit. These 8 Residents received a substitute lunch meal which consisted of beef slices, corn, mashed garlic potatoes, brown gravy and strawberry shortcake parfait.The facility's Food Service Director (FSD) and the District Food Services Director were present in the kitchen when the dietary staff ran out of the 2 food items (meatloaf and green peas) that were on the posted menu for the lunch meal on 4/16/2026. The FSD at 1:00 PM prepared the substitute beef slices for the 8 Residents, and the District Director went to another facility to obtain the meatloaf.At 1:50 PM on 4/16/2026 the Licensed Nursing Home Administrator (LNHA) was notified that the kitchen ran out of the posted menu meal for lunch (meatloaf and green peas). The LNHA acknowledged the surveyor and indicated that he had been notified by the FSD.No additional information was provided by the facility at the time of survey exit.

Based on observations, interviews and record reviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for sanitation and food service safety. This finding was found to be evident in the kitchen and on the Mount [NAME] Nursing Unit during the annual recertification survey.The findings include:On tour of the facility's kitchen on 4/14/2026 at 7:10 AM with 3 dietary employees (#7, #8 and #11) in attendance the surveyor observed sanitation concerns: 1) employee's personal items - pink mug, foil wrapped food, and bottle of water on the small utility cart, 2) no running water in one of the hand sinks and standing water not draining in the other hand sink, 3) hole in the wall by the kitchen window where the telephone had fallen off the wall, 4) reach-in refrigerator missing documentation of temperature readings for 4/12 and 4/13, 5) food items not dated in the walk-in freezer - cardboard box of sandwich slices and waffles opened not dated, vegetables opened not dated, 6) build-up of ice on the freezer ceiling and the freezer door, 7) food items not dated in the walk-in freezer - cardboard box of bacon strips opened 2/3 full not dated, jar of grape jelly opened not dated, and 8) dry storage room with a black substance near the baseboard behind the center metal shelf.At 7:45 AM on 4/14/2026 the Licensed Nursing Home Administrator (LNHA) was notified of these concerns with the sanitation in the kitchen.On 4/14/2026 at 9:15 AM the Food Services Director was notified of these concerns with the sanitation in the kitchen. At 1:30 PM on 4/16/2026 the surveyor observed the food delivery cart sitting at the elevator on the Mount [NAME] Unit. There were 2 meal trays sitting on top of food delivery cart and the meal trays inside the food delivery cart had not been delivered to the Residents. At 1:37 PM the surveyor notified the Unit Manager who observed the food delivery cart sitting at the elevator with meal trays inside the cart. The Unit Manager indicated that she thought that meal trays on the food delivery cart had already been delivered to the Residents.The Director of Nursing (DON) was notified at 1:45 PM on 4/16/2026 of the concern with the delivery of the meal trays on the Mount [NAME] Unit.The surveyor observed the nourishment refrigerator on the Mount [NAME] Nursing Unit at 2:10 PM on 4/16/2026. Observation revealed that food items were not labeled with the Resident's name and dated: 1) Pepsi bottle, 2) cranberry juice bottle, 3) plastic bag of grapes, and 4) gray lunch bag with orange trim.In an interview with the Nurse Unit Manager at 2:15 PM on 4/16/2026 the surveyor asked what the expectation was for labeling and dating food items in the nourishment refrigerator. The Unit Manager indicated that the food items were to be labeled with the Resident's name and date. Additionally, the surveyor confirmed with the Unit Manager that the nourishment refrigerator was for storage of Resident's food.The surveyor on 4/16/2026 at 3:10 PM conducted a record review of the facility's policy for Foods Brought by Family and Visitors dated 11/25. The policy indicated that foods stored in the refrigerator are labeled with Resident's name and dated.No additional information was provided by the facility at the time of survey exit.

Based on interviews and surveyor record reviews it was determined that the facility failed to develop and implement a comprehensive care plan for a Resident. This finding was found to be evident in 1 (Resident #119) out of 1 Resident reviewed for anticoagulant medication usage. The findings include:Anticoagulants or blood thinners are medications that prevent blood clots from forming or growing by inhibiting clotting factors. The primary side effect of anticoagulants is increased bleeding, requiring careful monitoring. Minimum Data Set (MDS) Assessment is a standardized, federally mandated clinical assessment tool used in Medicare/Medicaid- certified nursing homes to evaluate Resident functional capabilities, health needs, and preferences. The MDS assessment drives care planning, quality monitoring, and reimbursement, with assessments conducted upon admission, quarterly, annually, and upon significant status changes. The MDS assessment is completed by licensed health care professionals in nursing homes. Data is submitted electronically to state databases.Care Plan is a written document that outlines a person's care needs and how they will be met. The care plan includes health information related to medical history, current treatments, medications, and health care providers. Care plans should be regularly reviewed to monitor their effectiveness. The care plan guides the health care professionals in delivering care to Residents.At 10:24 AM on 4/14/2026 in an interview with Resident #119 the Resident stated that he/she takes a blood thinner.The surveyor conducted a record review of Resident #119's medical record on 4/16/2026 at 2:15 PM. Record review revealed that Resident #119 had an active physician order for Rivaroxaban (Xarelto)10 mg by mouth at bedtime for DVT (deep vein thrombosis) with an order date of 2/12/2026. Rivaroxaban (Xarelto) is an anticoagulant medication. Additionally, there was an active physician order for Anticoagulant Side Effect Monitoring every shift for Anticoagulant use. Further review of the medical record revealed that the MDS assessment Medicare 5 Day dated 2/19/2026 was coded that Resident was taking an anticoagulant medication. Upon review of Resident #119's comprehensive care plan there was not a plan of care for anticoagulant medication usage. In an interview with the Director of Nursing (DON) at 3:10 PM on 4/16/2026 the surveyor asked what the expectation for care planning was for Resident usage of anticoagulant medication. The DON stated that the expectation was that the anticoagulant medication should be addressed on the Resident's care plan. The surveyor conveyed that Resident #119 had an active physician order for Rivaroxaban (Xarelto), but there was no comprehensive care plan for anticoagulant medication usage and that the MDS assessment was coded that Resident was taking an anticoagulant medication. The surveyor reviewed with the DON Resident #119's physician orders, MDS assessment and comprehensive care plan and the DON acknowledged that Resident did not have a comprehensive care plan for anticoagulant medication usage.No additional information was provided by the facility at the time of survey exit.

Based on interview and record review, it was determined that the facility failed to ensure that a resident received quarterly care plan meetings. This was evident for 1 (Resident #6) of 4 residents reviewed for care planning.The findings include:On 04/14/2026 at 8:01 AM, an interview with Resident #6 revealed that they were unaware of the last care plan meeting they had, but that it had been a while. On 04/14/2026 at 12:36 PM, review of Resident #6's medical record revealed the last documented care plan meeting was 7/30/2025.On 04/16/2026 at 9:08 AM, an interview with the Social Services Director (Staff #9) revealed that care plan meetings were done quarterly after each quarterly comprehensive assessment. The surveyor requested documentation of the last care plan meeting for Resident #6.On 04/16/2026 at 12:57 PM, review of the last care plan meeting note provided by the facility was dated 7/30/2025. Staff #9 had no further documentation that would indicate a care plan meeting was held since 7/30/2025.On 04/16/2026 at 1:34 PM, the surveyor reviewed the concern with the Director of Nursing and she indicated that she understood.

Based on observation, interviews and record reviews, it was determined that the facility failed to provide communication tools for a resident who is unable to communicate appropriately. This was evident for 1 (Resident #12) of 1 resident reviewed for language and communication during the annual survey.The findings includeOn 4/14/2026 at 11:07 AM Resident #12 was observed on a wheelchair to the right side of the bed in their room. The bed was between the wheelchair where the resident was sitting and the nightstand. The resident is alert and oriented. In his neck is a trach stoma, a surgical opening in the neck to facilitate breathing. An oxygen (o2) humidifier was attached to the trach site. The resident can only mouth words, so it was difficult to understand all they were trying to say. There is no communication board in sight or at the bedside. The surveyor was trying to communicate with the resident but was unable to read lips or understand everything the resident was trying to say. The surveyor requested to speak with the resident's nurse.On 4/14/2026 at 11:22 AM In an Interview with the residents nurse a License Practical Nurse (LPN) 25, she was asked how she communicates with Resident #12 and she said that she read lips, that resident takes time to communicate. She was asked if the resident has an alternate means to communicate like a communication board. LPN #12 said that the resident use to have one at the bedside but there is none currently. The surveyor asked about people who couldn't read lips or understand what the resident was trying to say and asked how they communicate with the resident and if there was another form of communication for the resident and she said there was none. Review of Resident #12's care plan on 4/14/2026 at 11:37 AM documented that resident has a trach and to provide means of communication, there was none at the bedsideIn an Interview with the Director of Nursing (DON) #3 on 4/16/2026 at 11:27 AM, she was asked about the expectations for residents who have trouble communicating to help the staff communicate with them. She stated that staff are expected to do frequent rounding and make sure things are within reach. She was asked if there should be an alternate form of communication and she said those residents should have a communication board at the bedside. The DON #3 was made aware of the concern that Resident #12 did not have one and she acknowledged it.

Based on observation, medical record review, and staff interviews, facility staff failed to provide adequate supervision to prevent Resident #1, a vulnerable, cognitively impaired resident with a history of falls, from experiencing a fall that resulted in a major injury. This was evident for 1(Resident #1) of 64 residents reviewed during the annual survey.The findings included:On 04/14/2026 at 8:57 AM: During the initial observation, a blue fall mat was observed on the floor, located just behind the curtain upon entering Resident #1's room.On 04/16/2026 at 8:46 AM: A record review of Resident #1's progress notes from 6/24/2025 at 8:11 AM revealed a fall had occurred. The documentation stated that a nurses' aide on the 11-7 shift informed the nurse that, while providing morning care and turning the resident on their side for cleanup, the aide could not control the resident and lowered them to the floor. The resident was helped back to bed, assessed, and no injuries were noted at that time; the physician was notified. 6/24/2025 at 3:26 PM: Further record review of the progress notes revealed that Resident #1 complained of pain in their left hip. Pain medicine was given and an X-ray was ordered. 6/24/2025 at 11:23 PM: The physician was made aware of the X-ray results and gave an order to send the resident to the hospital. A review of the discharge summary from the hospital revealed Resident #1 was admitted to the hospital on [DATE], at 3:42 AM with diagnoses including Left Femur Subacute Fracture, COPD, Pneumonia, Hypoxia, and Dementia. On 04/16/2026 at 12:15 PM: A review of the Minimum Data Set (MDS) assessments dated 11/10/24, 2/10/25, and 5/13/25, section GG (Functional Abilities), showed Resident #1 was consistently documented as dependent (01) for roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. The MDS coding guide specified scoring assistance based on the amount of help required for safety and quality of performance. Documentation showed the resident was dependent for repositioning for over a year. On 04/16/2026 at 1:45 PM: The Director of Nursing (DON), Staff #3, was asked to provide documentation regarding the required staffing assistance for Resident #1. The DON provided documentation dated 7/2/2025, which showed Resident #1 was designated as a two-person assist starting on 7/2/2025, the day the resident returned from the hospital. Further record review revealed Resident #1 was placed in Hospice care on 7/3/2025, the day after returning from the hospital. On 04/17/2026 at 6:53 AM: Staff #17, Geriatric Nursing Assistant (GNA), was interviewed. Staff #17, GNA confirmed their witness statement from the incident on 6/24/25, stating they were doing morning care alone and, while attempting to turn the resident, could not control them, leading the aide to guide the resident to the floor between the bed and the cabinet. Another GNA then assisted using a Hoyer lift to return the resident to bed. On 04/17/2026 at 7:49 AM: The DON was shown the MDS assessments (11/10/24, 2/10/25, and 5/13/25, section GG) which documented that Resident #1 had been dependent on turning from side-to-side safely since at least 2024. Resident #1 was not designated as a two-person assist until 7/2/2025, after the resident fell, sustained a fracture, and returned from the hospital. The DON verbalized understanding that Resident #1 not being a two-person assist prior to the fall was an issue and provided documentation that an audit for residents requiring assistance with bed mobility was completed on 6/30/25.

Based on observations, interviews and surveyor record reviews it was determined that the facility failed to maintain appropriate respiratory care and services. This finding was found to be evident in 2 (Resident #27 and #66) out of 2 Residents reviewed for oxygen usage.The findings include:Oxygen concentrators are FDA-regulated medical devices that filter nitrogen from ambient air to deliver concentrated, high purity oxygen to Residents with chronic lung conditions. They offer a continuous, non-refillable supply of oxygen for home or portable use. Oxygen concentrators pull in surrounding air, compress it, remove nitrogen, and deliver purified oxygen through a nasal cannula or mask. A prescription is required.At 11:42 AM on 4/14/2026 the surveyor observed Resident #27 in bed in no distress with an oxygen concentrator at the bedside with oxygen in use. There was no no smoking/oxygen in use signage on the Resident door or the door frame that indicated oxygen was in use.At 12:05 PM on 4/14/2026 the surveyor observed Resident #66 in bed in no distress with an oxygen concentrator at the bedside with oxygen in use. There was no no smoking/oxygen in use signage on the Resident door or the door frame that indicated oxygen was in use.The surveyor conducted a record review on 4/15/2026 at 10:00 AM of Resident #27's and #66's medical record. The review revealed that both Residents had physician orders for oxygen 2 Liters via nasal cannula.In an interview with the Director of Nursing (DON) at 10:23 AM on 4/15/2026 the surveyor conveyed that Resident #27 and Resident #66 both had oxygen concentrators in their rooms with oxygen in use, but there was no oxygen signage on their room doors or door frames which indicated that oxygen was in use. The DON stated that she was surprised as the facility used a lot of oxygen. The surveyor with the DON in attendance observed both Resident #27 and #66 in bed with oxygen in use with an oxygen concentrator and did not have oxygen signage on the room doors or door frames. On 4/15/2026 at 12:30 PM the surveyor reviewed the facility's Oxygen Therapy Policy dated 12/25. The policy indicated that The purpose of this procedure is to provide guidelines for safe oxygen therapy and Steps in the procedure indicated 2. Place an Oxygen in Use sign on the outside of the room entrance door.No additional information was provided by the facility at the time of survey exit.

Based on record review and interview, it was determined that the facility failed to ensure a resident received pharmaceutical services to meet their needs regarding timely medication administration. This was evident for 1 (Complaint #2968846) of 5 complaints reviewed during the annual survey.The findings include:Medications are ordered by the physician to meet a resident's needs. They are ordered for specific times for a reason to reflect the resident's plan of care and needs.Medications should be administered an hour prior or after the ordered/scheduled time.On 04/14/2026 at 1:02 PM, review of Complaint #2968846 revealed a concern that medications were not administered to Resident #136 timely based on the order.On 04/14/2026 at 1:14 PM, review of Resident #136's medical record revealed he/she was admitted to the facility on [DATE] and was discharged on 2/14/2026.On 04/16/2026 at 11:24 AM, review of Medication Administration Record (MAR) Audit for January 2026- February 2026 requested by the surveyor revealed the following dates and medications which the Resident received late:1/21/2026 Atovaquone (prevents lung infection) oral suspension 750MG/ML ordered for 6:00 PM was administered at 8:41 PM.1/23/2026 Atovaquone oral suspension 750MG/ML ordered for 6:00 PM was administered at 7:54 PM.1/23/2026 Tramadol (strong pain medication) HCI oral tablet 50 MG ordered for 6:00 PM was administered at 7:53 PM.1/24/2026 Vitamin D-3 (vitamin supplement) oral tablet 125 MCG ordered for 8:00 AM was administered at 11:43 AM.1/24/2026 Dexamethasone (reduce inflammation/weaken immune system) oral tablet 2 MG ordered for 9:00 PM was administered on 1/25/2026 at 7:18 AM.1/24/2026 Flomax (helps men urinate) oral capsule 0.4 MG ordered for 9:00 PM was administered on 1/25/2026 at 7:19 AM.1/24/2026 Levetiracetam (prevents seizures) oral tablet 750 MG ordered for 9:00 PM was administered on 1/25/2026 at 7:19 AM. 1/24/2026 Apixaban (blood thinner) oral tablet 5 MG ordered for 9:00 PM was administered on 1/25/2026 at 7:19 AM.1/24/2026 Temozolomide (chemotherapy) oral capsule 140 MG ordered for 9:00 PM was administered on 1/25/2026 at 7:19 AM.1/25/2026 Vitamin D-3 oral tablet 125 MCG ordered for 8:00 AM was administered at 10:18 AM.1/26/2026 Tramadol HCI oral tablet 50 MG ordered for 12:00 PM was administered at 1:42 PM.1/28/2026 Vitamin D-3 oral tablet 125 MCG ordered for 8:00 AM was administered at 10:11 AM.1/29/2026 Amlodipine Besylate (reduces high blood pressure) oral tablet 2.5 MG ordered for 9:00 AM was administered at 2:34 PM.1/29/2026 Tramadol HCI oral tablet 50 MG ordered for 12:00 PM was administered at 2:36 PM.1/30/2026 Amlodipine Besylate oral tablet 2.5 MG ordered for 9:00 AM was administered at 11:54 AM.1/31/2026 Vitamin D-3 oral tablet 125 MCG ordered for 8:00 AM was administered at 9:51 AM.1/31/2026 Tramadol HCI oral tablet 50 MG ordered for 12:00 PM was administered at 2:01 PM.1/31/2026 Amlodipine Besylate oral tablet 2.5 MG ordered for 9:00 AM was administered at 3:46 PM.2/03/2026 Oxycontin (strong pain medication) oral tablet 10 MG ordered for 9:00 PM was administered at 10:34 PM.2/03/2026 Dexamethasone oral tablet 2 MG ordered for 9:00 PM was administered at 10:34 PM.2/03/2026 Apixaban oral tablet 5 MG ordered for 9:00 PM was administered at 10:34 AM.2/03/2026 Flomax oral capsule 0.4 MG ordered for 9:00 PM was administered at 10:34 PM.2/03/2026 Levetiracetam oral tablet 750 MG ordered for 9:00 PM was administered at 10:34 PM.2/04/2026 Tramadol HCI oral tablet 50 MG ordered for 6:00 PM was administered at 8:18 PM.2/04/2026 Atovaquone oral suspension 750MG/ML ordered for 6:00 PM was administered at 8:18 PM.2/05/2026 Gabapentin (muscle relaxer) oral tablet 100 MG ordered for 9:00 PM was administered at 10:35 PM.2/05/2026 Dexamethasone oral tablet 2 MG ordered for 9:00 PM was administered at 10:35 PM.2/05/2026 Apixaban oral tablet 5 MG ordered for 9:00 PM was administered at 10:35 PM.2/05/2026 Flomax oral capsule 0.4 MG ordered for 9:00 PM was administered at 10:35 PM.2/05/2026 Levetiracetam oral tablet 750 MG ordered for 9:00 PM was administered at 10:36 PM.2/05/2026 Oxycontin oral tablet 10 MG ordered for 9:00 PM was administered at 10:36 PM.2/07/2026 Tramadol HCI oral tablet 50 MG ordered for 12:00 PM was administered at 2:28 PM.2/07/2026 Tramadol HCI oral tablet 50 MG ordered for 6:00 PM was administered at 8:26 PM.2/07/2026 Atovaquone oral suspension 750MG/ML ordered for 6:00 PM was administered at 8:26 PM.2/08/2026 Vitamin D-3 oral tablet 125 MCG ordered for 8:00 AM was administered at 10:00 AM. 2/08/2026 Tramadol HCI oral tablet 50 MG ordered for 12:00 PM was administered at 2:10 PM. 2/10/2026 Tramadol HCI oral tablet 50 MG ordered for 12:00 PM was administered at 1:47 PM.2/10/2026 Gabapentin oral tablet 100 MG ordered for 9:00 PM was administered at 10:41 PM2/10/2026 Dexamethasone oral tablet 2MG ordered for 9:00 PM was administered at 10:41 PM.2/10/2026 Levetiracetam oral tablet 750 MG ordered for 9:00 PM was administered at 10:41 PM.2/10/2026 Apixaban oral tablet 5 MG ordered for 9:00 PM was administered at 10:41 PM.2/10/2026 Flomax oral capsule 0.4 MG ordered for 9:00 PM was administered at 10:41 PM.2/11/2026 Gabapentin oral tablet 100 MG ordered for 9:00 PM was administered at 10:58 PM.2/11/2026 Dexamethasone oral tablet 2MG ordered for 9:00 PM was administered at 10:58 PM.2/11/2026 Levetiracetam oral tablet 750 MG ordered for 9:00 PM was administered at 10:58 PM.2/11/2026 Flomax oral capsule 0.4 MG ordered for 9:00 PM was administered at 10:58 PM.2/11/2026 Apixaban oral tablet 5 MG ordered for 9:00 PM was administered at 10:58 PM.2/12/2026 Apixaban oral tablet 5 MG ordered for 9:00 AM was administered at 12:00 PM.2/12/2026 Pantoprazole (acid reflux reducer) oral tablet 40 MG ordered for 9:00 AM was administered at 12:01 PM.2/12/2026 Dexamethasone oral tablet 2MG ordered for 9:00 AM was administered at 11:59 PM.2/12/2026 Ondansetron (helps reduce nausea) oral tablet 8 MG ordered for 9:00 AM was administered at 12:00 PM.2/12/2026 Levetiracetam oral tablet 750 MG ordered for 9:00 AM was administered at 12:00 PM.2/12/2026 Oxycontin oral tablet 10 MG ordered for 9:00 AM was administered at 12:00 PM.2/13/2026 Oxycontin oral tablet 10 MG ordered for 9:00 PM was administered at 01:32 AM.2/13/2026 Levetiracetam oral tablet 750 MG ordered for 9:00 PM was administered at 01:32 AM.2/13/2026 Dexamethasone oral tablet 2MG ordered for 9:00 PM was administered at 01:32 AM.2/13/2026 Flomax oral capsule 0.4 MG ordered for 9:00 PM was administered at 01:32 AM.2/13/2026 Apixaban oral tablet 5 MG ordered for 9:00 PM was administered at 01:32 AM.2/13/2026 Gabapentin oral tablet 100 MG ordered for 10:00 PM was administered at 01:32 AM.On 4/17/26 at 7:44 AM, an interview with the Director of Nursing revealed the expectations of staff was to administer medications between an hour before to an hour after the ordered/ scheduled time. She further indicated the time noted to be administered on the MAR audit was the time that the nurse would have administered the medications.At the same time, the surveyor revealed the list of dates and medications that were found to be administered late. The surveyor reviewed the concern and she indicated that she understood.

Based on observations and interviews it was determined that the facility failed to dispose of garbage and refuse properly. This finding was found to be evident in review of the outside dumpster area during the annual recertification survey. The findings include: The surveyor toured the outside dumpster area at 1:17 PM on 4/16/2026 with the Floor Technician in attendance. There were 2 dumpsters for trash and garbage and 1 dumpster for recyclables. Outside of the trash dumpster was multiple pieces of trash lying on the ground, a bag of trash behind the dumpster and the trash dumpster was not closed with the attached lid on top of the dumpster. The Licensed Nursing Home Administrator (LNHA) was notified of the concern with the outside dumpster area at 1:50 PM on 4/16/2026. At 6:45 AM on 4/17/2026 the surveyor followed up on the outside dumpster area with the Housekeeping Manager in attendance. Observed on the ground outside the dumpster was multiple pieces of trash, an empty large can of beans, empty juice cups, plastic gloves, and paper towels. At 8:45 AM on 4/17/2026 the Licensed Nursing Home Administrator (LNHA) was notified and stated that he had staff clean up the trash around the dumpster area that was observed the previous day.No additional information was provided by the facility at the time of survey exit.

Based on interview and surveyor record review it was determined that the facility failed to maintain an accurate medical record for a Resident. This finding was found to be evident in 1 (Resident #27) out of 1 Resident reviewed for Resident records.The findings include:Anticoagulants or blood thinners are medications that prevent blood clots from forming or growing by inhibiting clotting factors. The primary side effect of anticoagulants is increased bleeding, requiring careful monitoring. Minimum Data Set (MDS) Assessment is a standardized, federally mandated clinical assessment tool used in Medicare/Medicaid- certified nursing homes to evaluate Resident functional capabilities, health needs, and preferences. The MDS assessment drives care planning, quality monitoring, and reimbursement, with assessments conducted upon admission, quarterly, annually, and upon significant status changes. The MDS assessment is completed by licensed health care professionals in nursing homes. Data is submitted electronically to state databases.Care Plan is a written document that outlines a person's care needs and how they will be met. The care plan includes health information related to medical history, current treatments, medications, and health care providers. Care plans should be regularly reviewed to monitor their effectiveness. The care plan guides the health care professionals in delivering care to Residents.The surveyor conducted a record review of Resident #27's medical record on 4/15/2026 at 10:00 AM. The review of the medical record revealed that Resident #27 had an active physician order for Anticoagulant Side Effect Monitoring: Observe for Signs and Symptoms of Bleeding/Bruising every shift, document unusual findings in progress note and notify provider, every shift for Anticoagulant use. Further review of the medical record revealed that Resident #27 did not have an active physician order for an anticoagulant medication. Additionally, the MDS assessments dated 1/30/2026 Quarterly and 8/8/2025 Medicare 5 Day were not coded that Resident was taking an anticoagulant medication. Review of the current care plan for Resident #27 revealed that there was no care plan for usage of an anticoagulant medication.In an interview at 12:50 PM on 4/15/2026 with the Director of Nursing (DON) the surveyor conveyed that Resident #27 had a physician order for Anticoagulant Side Effect Monitoring every shift for Anticoagulant use; however Resident #27 did not have a physician order for an anticoagulant medication. Additionally, the surveyor conveyed that the MDS assessments dated 1/30/2026 Quarterly and 8/8/2025 Medicare 5 Day were not coded that Resident was taking an anticoagulant medication, and that there was no care plan for anticoagulant medication usage. The DON confirmed that Resident #27 did not have a physician order for an anticoagulant medication.No additional information was provided by the facility at the time of survey exit.

Based on interviews and surveyor record reviews it was determined that the facility failed to have a physician order for a Resident to receive Hospice care. This finding was found to be evident in 1 (Resident #73) out of 2 Residents reviewed for Hospice Services.The findings include:Minimum Data Set (MDS) Assessment is a standardized, federally mandated clinical assessment tool used in Medicare/Medicaid- certified nursing homes to evaluate Resident functional capabilities, health needs, and preferences. The MDS assessment drives care planning, quality monitoring, and reimbursement, with assessments conducted upon admission, quarterly, annually, and upon significant status changes. The MDS assessment is completed by licensed health care professionals in nursing homes. Data is submitted electronically to state databases.Care Plan is a written document that outlines a person's care needs and how they will be met. The care plan includes health information related to medical history, current treatments, medications, and health care providers. Care plans should be regularly reviewed to monitor their effectiveness. The care plan guides the health care professionals in delivering care to Residents.The surveyor conducted a record review of Resident #73's medical record on 4/15/2026 at 10:45 AM. Record review revealed that the Census tab of Resident #73's electronic medical record indicated that the primary payer was Hospice Medicaid MD. As of 3/12/2026. Further review revealed that there was a significant change MDS assessment dated [DATE] which was coded for Hospice and a comprehensive care plan initiated 3/13/2026 for Resident #73 receiving Hospice services with [NAME] Hospice Care, INC. Continued review of the medical record revealed that there was no physician order for Hospice care and services by Resident #73's attending physician at the nursing home.Additionally, the surveyor reviewed [NAME] Hospice progress notes, evaluations and plan of care found in Resident #73's electronic medical record on 4/15/2026.At 1:30 PM on 4/15/2026 in an interview with the Director of Nursing (DON) the surveyor conveyed that Resident #73 was under Hospice Services with [NAME] Hospice Care, INC and there was a significant change MDS assessment coded for Hospice care and a care plan for Hospice Services from [NAME], but there was no physician order for Hospice care and services from the attending physician at the nursing home. DON acknowledged the surveyor and indicated that Resident #73 should have a physician order for Hospice care.In a follow-up review of Resident #73 medical record on 4/16/2026 at 9:30 AM the review revealed that there was now a physician order from the Resident's attending physician at the nursing home for Admit to Hospice. The order date and time stamp was by phone on 4/15/2026 at 23:18 (11:18 PM) with the current primary physician. At 9:55 AM on 4/16/2026 the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a copy of this Hospice order and the payer report for Resident #73 which indicated Hospice Medicaid MD as the payer as of 3/12/2026.No additional information was provided by the facility at the time of survey exit.

Based on staff interviews, review of pertinent documentation including the facilities Quality Assurance and Performance Improvement (QAPI) policy, and survey findings, it was determined the facility staff failed to 1.) track performance to ensure improvements are realized and sustained and 2.) failed to conduct at least one Performance Improvement Plan/Project (PIP) annually that focuses on problem prone areas identified by the facility through data collection and analysis. This was evident during review of the facilities Quality Assurance program.Findings include:1.) On 04/20/2026 at 11:11 AM, the Director of Nursing (DON), Staff #3, and the Assistant Director of Nursing (ADON), Staff #4, were interviewed regarding responsibility for the QAPI meeting and its operational process. Both stated that they are jointly in charge of QAPI. Staff #4 (ADON) further specified that all departments meet monthly and submit data for the QAPI meeting.When Staff #4 ADON was asked how data collected from QAPI meetings are regularly reviewed, analyzed, and acted upon, they responded by citing examples such as staff in-services or meeting weekly with the facility's wound team.Staff #3 DON and Staff #4 ADON were then shown documentation from their QAPI meeting minutes:10/22/25 QAPI Minutes:Antipsychotic benchmark: The total number of residents receiving Antipsychotics was 23, with 19 having a qualifying diagnosis. The goal met column was marked no, but the columns for action and PIP were blank.Other Areas (Call light response time, MOLST, UTI, wounds, and residents with significant weight loss greater than 5% in 30 days): For these items, the number of residents with significant weight loss was 8. Nothing was documented for goal met or not met, action plan, or PIP for the other areas listed above.11/26/25 QAPI Minutes: Documented a total of 5 resident falls. The listed actions included PT/OT, fall mats, toileting schedule, and purposeful rounding.12/11/25 QAPI Minutes: Documented a total of 24 falls, 3 residents with multiple falls, and 2 residents with injuries related to the fall. No action plan or PIP was documented. When asked to explain the increase in falls from November to December, no reply was given.1/29/26 QAPI Minutes: The documentation provided did not address falls, wounds, weights, or infections, and no actions or goals were documented.Staff #3 DON and Staff #4 ADON were again asked how they regularly review, analyze, and act on QAPI data and if they could provide documentation. Staff #4 ADON replied that they were lacking documentation, and no other information was provided.2.) On 04/20/2026 at 12:30 PM, the DON, Staff #3 was asked to provide a Performance Improvement Plan (PIP) addressing a high-risk issue or problem identified during QAPI meetings.On 4/20/2026 at 12:42 PM, the Staff #3, DON provided an audit for residents requiring assistance with bed mobility. When documentation for a PIP was specifically requested, the surveyor instead was shown an in-service related to medication administration. No other documentation was provided.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that the environment of resident care was maintained in a manner that minimized the potential spread of infection as evidenced by an unwrapped toilet tissue roll placed on top of the red sharps bio-hazard container. This was evident for 1 (Resident #8) of 64 residents investigated during the annual survey.The findings include:On 04/14/2026 at 8:33 AM during the initial observation, an unwrapped roll of white toilet tissue was observed in Resident #8's bathroom sitting on top of the red sharps container. On 04/14/2026 at 8:46 AM the unwrapped toilet tissue in Resident #8's bathroom was shown to Staff #36, Licensed Practical Nurse, LPN. Staff #36, LPN stated they would call housekeeping to dispose of the tissue on top of the sharps container.On 04/14/2026 at 9:04 AM the Director of Nursing, (DON) was made aware of the issue and verbalized understanding that unwrapped tissues on the sharps container was an infection control issue. Housekeeping later removed the tissue.

Based on observation and staff interviews, it was determined that the facility failed to have call bells within reach of a dependent resident. This was evident for 1 (Resident #12) of 1 resident reviewed for language and communication during the annual survey.The findings includeOn 4/14/2026 at 11:07 AM Resident #12 was observed in a wheelchair sitting to the right side of the bed. The bed was between the wheelchair and the nightstand. The call bell was tucked away on the top drawer of the nightstand to the left and away from residents reach. The resident is alert and oriented. In his neck is a trach stoma, a surgical opening on the neck to facilitate breathing. An oxygen (o2) humidifier was attached to the trach site. The resident can only mouth words and has weaknesses to the right side. The surveyor requested to speak with the resident's nurse.On 4/14/2026 at 11:22 AM In an Interview with the residents nurse a License Practical Nurse (LPN) #25. She was asked how the resident calls for help and she said that resident can use the call bell. She was asked where the call bell was, she saw it left inside the resident's nightstand top drawer. LPN #25 said that whoever made residents bed that morning must have placed the call bell there. She was asked how Resident#12 who is non-verbal and wheelchair bound will be able to call for help in case of emergency if they are unable to reach the call bell. She said resident always have their call bell within reach and proceeded to pull the call bell out of the nightstand top drawer and place it on the resident's bed within reach. She was made aware that this was a concern. She agreed that it was and said she will speak to the Staff about it. In an Interview with the Director of Nursing (DON) #3 on 4/16/2026 at 11:27 AM she was asked about the expectations regarding call bells. She stated that staff are expected to answer them within 5 minutes and make sure they always have them within reach of the residents. DON #3 was made aware of the above concerns; she acknowledged that it was a concern.

Based on observation and interview, it was determined that the facility failed to ensure residents and staff had a safe and comfortable environment. This was evident for 1 of 1 observation made in the facility laundry room.The findings include:On 04/17/2026 at 7:59 AM, an observation of the laundry room revealed a dryer closest to the wall in the laundry room, which had an exterior piece at the bottom that was leaning against the dryer.When the surveyor moved the exterior piece, it revealed parts of the dryer that lay below the area where items are placed to dry. Further observation of the laundry room revealed a portion of the wall to the right of the door prior to walking into the dirty laundry room from the clean laundry room which had a horizontal shaped hole in the wall, approximately 8 inches long and 2 inches wide.On 04/17/2026 at 8:03 AM, an interview with Laundry Aide (Staff #35) revealed she started at the facility about a month ago and the hole in the wall and lower part of the dryer noted above had been like that since she started.On 04/17/2026 at 10:03 AM, the surveyor reviewed the concern with the Nursing Home Administrator.

Based on medical record review and interview with facility staff and residents, it was determined that the facility failed to provide adequate supervision of Resident #10 with known wandering, aggressive, and inappropriate behaviors to ensure the safety of Resident #10 and other residents. This finding was evident during the review of multiple complaints for 4 of 4 residents(#5, # 8, #7, and #1 ) on the 3rd floor.The Maryland Office of Health Care Quality (OHCQ) determined that concerns met the Federal definition of Immediate Jeopardy and the facility was notified in writing of this determination at 3:10 PM on 2/19/26.The findings include:1. Review of the medical record for Resident #10 revealed diagnoses including unspecified dementia with unspecified severity with agitation. On 8/24/24 Resident #10 was certified incapable of making any medical decisions secondary to cognitive impairments. Resident #10 was seen by psychiatry on 12/8/25 secondary to assaulting another resident. At that time s/he was assessed as having Vascular dementia, unspecified severity, with other behavioral disturbance, Agitated, Anger, Irritable, Mood Swing, wandering and physical aggression, noncompliance with treatment, short tempered, easily annoyed. The licensed clinical professional counselor also noted that 'The patient is unable to interact meaningfully with assessment due to an unwillingness to communicate thoughts and needs.'On 12/9/25 Resident #10 was seen again for a psychiatric evaluation and consultation. This noted that Resident #10 was still 'noncompliant with rules regarding staying out of other patients' rooms but was not aggressive or combative at this time.'However, at the time of this initial review there were no further available consultations on the medical record since the 12/9/25 visit. This concern was presented to the NHA and DON on 2/19/26. On 2/19/26 at 9pm and 11pm progress notes from psychiatry visits on 12/23/25 and 1/2/26 were uploaded that were not previously available. The 12/23/25 psychiatric notes stated that Resident #10 is seen for a follow-up visit due to [resident] ongoing behaviors that are difficult to redirect. [Resident] appeared confused and disoriented, stating, I don't know where I'm at, and needed reminders about location. The psychiatric note continued that the [resident] exhibits behavior and mood issues, [resident] is unpredictable, sometimes becoming agitated, however no changes were made, only to continue monitoring resident. The 1/2/26 visit stated Resident #10 was assessed and noted as 'noncompliant with rules regarding staying out of other patients' rooms but was not aggressive or combative at this time. Staff are aware of [resident] behavior and are monitoring [resident] to ensure [resident] safety and that of other residents. The speech is disorganized, with loose connections and tangential responses. The patient often provides nonsensical answers to questions and struggles to maintain a coherent conversation. Insight is poor. The patient lacks awareness of hallucinations and disorientation and is confused.' There were no recommendations from the provider, only to continue monitoring Resident #10. Resident #10 was seen again on 1/22/26 for a gradual dose reduction of his/her medications. Although residents on the 3rd floor continued to report Resident #10 entering their rooms, acting inappropriately and making them feel unsafe and scared since the 12/6/25 occurrence, no additional interventions or changes were implemented or recommended at any of the subsequent visits from psychiatry. On 2/19/26 multiple residents reported to the survey team that a 'staff member' was hit the day prior and suffered a black eye. Again, at the time of the review there was nothing in the medical record for Resident #10 regarding this allegation. The survey team requested from the facility any information or investigation into this allegation and the name of the employee.Interview on 2/19/26 at 11:28 AM with GNA staff #2 revealed that on 2/18/26 while cleaning Resident #10's room after a particularly messy bowel movement, she stated that Resident #10 was notably agitated when s/he was brought back and left in his/her room by the DON. Then while GNA #2 was not looking, and busy cleaning the room Resident #10 hit her in the face. GNA staff #2 had a visibly large left black eye, however she stated she has a lot of makeup on so it was actually worse than it appeared. A change in condition note, entered on 2/18/26 by the facility DON documented that the resident was falling and GNA #2 attempted to catch him/her and that is how the black eye occurred. When GNA #2 was asked if that was what occurred, she stated that the resident was agitated when the DON brought the resident to their room and left them in a chair. GNA #2 continued to say that she was not totally focused on the resident because she was cleaning up the mess in the room. She further stated before she knew it, Resident #10 was getting up, was agitated and she ended up with a black eye. She stated that she is not sure if the resident was falling, and that is not what she reported to the DON, though that was what was entered in the change in condition report by the DON.Further interview with GNA #2 revealed that those type of incidents with Resident #10 'happen maybe once a month as [resident] had punched Resident #5 last month, December' and as far as wandering in resident rooms, we just try to redirect him/her.The DON was interviewed on 2/19/26 at approximately 12:00 PM. She was asked about the state of Resident #10 on 2/18/26 and what was reported to her on 2/18/26 from GNA #2. She stated that GNA #2 told her that she was helping Resident #10 from falling. The DON then demonstrated her arm flinging back as that was how GNA #2 acquired a black eye. The DON, also in the presence of the NHA at this time, was asked if there was anything put in place regarding this incident and the other alleged incidents regarding Resident #5, #8 , #7 and #1 who had yet to be interviewed by the survey team but had reportedly put in grievances. The DON stated that they had sent out referrals and the staff are familiar with the resident so they redirect him/her as needed. 1a. On 2/19/26 at 9am, an interview with Resident #5, who was A & O x3 sitting in the dining room, revealed that the perpetrator, Resident #10, came into his/her room on 12/6/25 around 7pm. Resident #5 stated that s/he was in bed and that Resident #10 grabbed both of his/her hands at once and then released one of his/her hands and punched him/her in the face about five times. Resident #5 stated that s/he screamed for help and 3 nurses and a few GNA's came to the room. The police were called and responded at 7:45 PM. The perpetrator was removed from the room and redirected to his/her room. The perpetrator was placed on one-to-one for 2 days. Resident #5 stated that the perpetrator has dementia and nothing could be done. Resident #5 was tearful and stated that the week of 2/9/26 the perpetrator walked in and out of Resident #5's room. Resident #5 stated, I'm in fear and afraid to go to sleep at night. I'm scared when the perpetrator walks in the dining room and when he/she gets close to me I always back up. The Resident was tearful. Resident #5 stated I'm scared of him/her. I want to cry. Resident #5 stated that s/he was never offered another room and that the facility staff did not put up the STOP sign banner to remind him/her not to come in the room. On 2/19/26 at 9 AM, an observation by a surveyor revealed that the STOP banner was not being used.On 2/19/26 at 9:00 AM, a medical record review of Resident #5 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition (scores 13-15), assessed on 11/9/25. Resident #5 has mobility issues and relies on a wheelchair.1b. Interview with Resident #8 on 2/19/26 at 8:16 AM revealed multiple concerns related to Resident #10 who s/he reported comes into his/her room often and will go under the 'STOP' sign banner that is posted at his/her door. Resident #8 further stated that yelling at Resident #10 to leave the room doesn't work. When asked what s/he does when coming in the room, Resident #8 stated that s/he will grab items off of the tables and dressers. Resident #8 also reported to this surveyor that there was an incident recently when Resident #10 was in the room and went to the roommates side of the bed by the window, pulled his/her pants down and was about to pull his/her pull up down and the roommate, [Resident #1], started yelling and I [Resident #8] was yelling and s/he was hitting [Resident #10] with his/her grabber. Resident #8 became tearful at this time and was asked by this surveyor if s/he is scared and s/he stated, oh yeah we are all scared.Medical record review of Resident #8 on 2/19/26 at 9:30 AM revealed an assessed brief interview for mental status (BIMS assessment tool used to measure cognitive impairment in long-term care residents 13-15 intact cognition) score of 15 from 12/31/25. Additionally, Resident #8 has diagnoses of depression, anxiety and often relies on a wheelchair for mobility. 1c. Resident #7, observing the interview with the surveyor and Resident #8, flagged this surveyor over and wanted to discuss 'the resident who wanders into everyone's room.' At 8:28 AM in Resident #7's room we began discussing his/her concerns related to Resident #10. S/he stated that secondary to his/her medical condition s/he is not able to fend off an intruder in the room and it is very stressful and scary. S/he said look at me, I only have one leg. S/he continued reporting that Resident #10 comes into this room when the roommate is not present and it is very scary. Resident #7 is observed in the 'b' bed by the window and the roommate's bed is by the door, so it would be visible walking by the doorway when the roommate is not in the room. Resident #7 stated I yell at [resident] to leave then [resident] will go into the bathroom. This surveyor asked if staff was aware of his/her concerns of Resident #10 coming into the room and Resident #7 stated 'yes, I have told them and keep telling them.' S/he further stated that 'it's a lot of stress when you try to sleep in a room alone and here [resident] comes in.' Medical record review on 2/19/26 at 9:30 AM of Resident #7 revealed an assessed BIMS score of 15 from a 10/19/25 minimum data set. S/he has a dependence on staff for some activities of daily living including meal setup and bathing and the reliance on a power wheelchair to mobilize around the facility. 1d. Resident #1 was interviewed on 2/19/26 at 12:32 PM. S/he was interviewed secondary to a complaint submitted by a family member who had considerable concerns about Resident #1 as they are bedbound, and Resident #1 called them about Resident #10 coming into the room and exposing themselves on repeated occasions. Resident #1 stated to this surveyor that Resident # 10 'will come in at night and pull his/her pants off and stand at my bed. S/he has hit my friend and staff, what makes me think that s/he won't hit me? Next time s/he comes in here and invades my privacy I'm going to fight [resident] back.' Medical record review for Resident #1 on 2/19/26 at 12:50 PM revealed a 1/16/26 BIMS revealed a score of 15, showing s/he is cognitively intact. Resident #10 was observed on the unit on 2/19/26 at approximately 12:40 PM walking up and down the halls. Resident #10 was observed walking up the hallway and stopping at each doorway. Residents, male and female, could be heard from inside of their rooms yelling for Resident #10 to 'stay out/stay away/get out.' Resident #10 would then proceed and continue walking to the next room, during this observation, staff were observed at the nurses station or walking around the unit. At no time did any staff intercede and direct Resident #10 elsewhere as most of the residents in their rooms were observed eating and this was an interruption and potential intrusion. On 2/19/36, at 3:10 PM an Immediate Jeopardy was called related to a lack of supervision which resulted in a resident inappropriately wandering into multiple resident rooms and verbally or physically assaulting residents with no documented interventions in place after 12/10/25.The facility submitted an initial plan of action to the surveyor and the Office of Health Care Quality for review at 5:10 PM on 2/19/26. This initial plan was not accepted. A revised plan was submitted at 5:18 PM on 2/19/26, which was not accepted. Another revised plan was submitted at 5:50 PM on 2/19/26, which was not accepted. The facility submitted a subsequent revised plan of action at 6:32 PM on 2/19/26, which was reviewed by the surveyor and the Office of Health Care Quality. The plan was accepted at 6:35 PM on 2/19/26 but the Immediate Jeopardy was not removed until 2/24/26 at 1:58 PM after the plan of correction was verified to have been implemented.The facility plans of removal included the following: The identified resident was evaluated by the medical director and prescribed antianxiety medication 3 times a day and put on a 1:1 assignment starting at 3:00 PM until further notice. Additionally, the residents with the identified concerns are to be assessed by the social worker. An ad hoc quality assurance meeting was held with the interdisciplinary team and education will be completed with the facility staff on the Dementia protocol and Unmanageable Residents. The plans were presented on 2/19/26 at 5:10 PM, with adjustments made and resubmitted at 5:18 PM, again at 5:50 PM and a final plan submitted and accepted at 6:32 PM on 2/19/26.

Based on record review, staff interview and resident representative interview it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was evident for 1 of 5 residents (#5). This failure resulted in actual harm to Resident #5. The findings include: On 9/2/20 an investigation of complaint MD 332 was conducted in regard to allegations of a worsening pressure ulcer for Resident #5. Review of Resident #5's medical records at 11:54 AM on 9/2/20 revealed that Resident #5 was admitted to the facility on [DATE] with a wound described on the facility's admission paperwork as excoriation on the sacrum. An excoriation is an abrasion on the skin usually only involving the epidermis or top layer of the skin. Resident #5's [DIAGNOSES REDACTED]. Further review of the record revealed that Resident #5 had a Percutaneous Endoscopic Gastronomy (PEG) which is a medical procedure where a tube (PEG tube) is passed through the patient's abdominal wall and into their stomach to provide a means of feeding when oral intake is not sufficient. These [DIAGNOSES REDACTED].#5 at higher risk of developing pressure ulcers. Upon admission on 5/27/20 the facility completed a Braden Scale for Predicting Pressure Sore Risk which is a tool used to assess a resident's risk for developing pressure ulcers. Resident #5 was assessed as a 13.0 out of 18.0 which is a Moderate Risk. On 9/2/20 at 12:00 PM review of Resident #5's orders revealed a physician's orders [REDACTED]. Z guard is a skin protectant paste used to protect skin from irritation and seal out moisture. Resident #5's electronic Treatment Administration Record (eTAR) for May 2020 revealed that Z guard was not applied as ordered on [DATE] for the 3-11 pm shift or the 11-7 shift. Further review of June 2020's eTAR revealed that Z guard was not applied as ordered on [DATE] during the 3-11pm shift. Further review of Resident #5's medical record revealed a 6/6/20 progress note which stated excoriation to buttocks has upgraded, supervisor made aware and present to take measurement photo of wound and obtaining new orders. The facility could not provide documentation that the physician or resident's representative was notified. The skin assessment dated [DATE] had the wound measured 10.8 x 4.6 with an area of 33 sq. cm. The next physician visit was via telemedicine (online) on 6/9/20 where Resident #5's physician wrote skin - coccyx - 10.8 x 4.6 x 0.2 cm - stage IV under the Physical Exam section. Further down on the telemedicine visit under the Plan section the physician wrote Patient has developed stage IV ulcer on the coccyx. Continue wound care apply central dressing. Continue nutritional support change of position. Prosource (protein supplement) 30 mL twice a day. Wound consult. The skin assessment dated [DATE] had the wound measured 4.8 x 7.3 with an area of 29.6 sq. cm The skin assessment dated [DATE] had the wound measured 10.3 cm x 10.3 cm with an area of 82.3 cm. Review of Resident #5's orders revealed that the order for Prosource 30 mL twice a day was not ordered until 6/17/20, eight days after Resident #5's telemedicine visit. Further review of Resident #5's electronic Medication Administration Record [REDACTED]. On 9/3/20 at 10:00 AM the Director of Nursing (DON) provided a wound consult dated 6/12/20, three days after the physician's telemedicine visit. The DON confirmed at this time that the wound consult on 6/12/20 was the only time Resident #5 was seen by the facility's wound physician. Further review of the wound consult dated 6/12/20 revealed the wound was referred to as Unstageable (due to necrosis) sacrum. Wound size was noted to be 5 x 8 x Not Measurable cm. At 11:15 AM on 9/3/2020 the facility's 3 skin assessments for Resident #5 were reviewed. These skin assessments showed an increase in size of 33 square cm to 82.3 square cm from 6/6/20 to 6/17/20 when Resident #5 was discharged per their representative's request. The Administrator and DON were made aware of these findings on 9/3/2020 at 3:00 PM. Cross reference F 580 and F 684.

Based on medical record review and interviews with facility staff, it was determined that the facility staff failed to prevent a cognitively impaired resident who had a known history of igniting a fire in his/her room in the facility, from starting another fire, due to multiple failed systems including: 1) not implementing care plan interventions 2) lack of adequate supervision 3) not communicating previous incident to medical professionals involved in resident's care and 4) no thorough investigation of previous incident in the facility. After the fire occurred on 12/3/18, the facility staff failed to establish a process to ensure the interdisciplinary team was aware of the incident to put a system in place to assure it did not recur. This systemic breakdown has the potential to affect all the residents in the facility. As result of these findings an Immediate Jeopardy was called at 1:15 PM on 2/5/19. The facility submitted a plan to remove the Immediacy on (MONTH) 5th, 2019 at 11:08PM. The findings include: Review of Resident #1's medical record on 2/5/19 revealed the Resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Resident had physician certifications of incapacity to make an informed decision dated 12/16/15 and 1/2/16. The psychiatrist's note dated 12/18/18 states the Resident has been noted by staff to trigger fire alarm at end of hallways in the past. The physician noted dated 12/30/18 states the Resident is a former smoker. Further review of Resident #1's medical record revealed a nursing note dated 12/3/18 at 8:00 AM that stated: Was called to resident's room by GNA (Geriatric Nursing Assistant) and room smelt like smoke. Found fire in top drawer of night stand of newspaper and pull up. Water was poured on it and flame went out. Resident was asked where he got the matches or lighter and resident denied it. A second flame was noted in the second drawer and water was poured on it. A lighter was found on resident while he was laying in bed. And didn't know where he got it. Review of the medical record revealed a nurse's note 12/3/18 at 2:38 PM that states NP (nurse practitioner) #1 was notified. There is also an order [REDACTED].#1 for a psych consult. 1. Review of Resident #1's medical record on 2/5/19 revealed after the fire on 12/3/18 the facility staff initiated a care plan on 12/3/18 titled: Resident noted with cigarette lighter with a goal of Resident will not have a cigarette lighter or any matches per facility policy. On 12/4/18 the facility staff added an intervention to the care plan: Staff to check resident's pockets before going to bed. Review of Resident's medical record revealed no documentation of checking the Resident's pockets for a lighter. Review of the staffing schedule provided by the facility for the 2 weeks prior to the incident on 2/2/19 revealed GNA #3 and GNA #4 regularly cared for the Resident on evening shift (3pm to 11pm). During interview with GNA #3 on 2/5/19 at 12:52 PM, with the Director of Nursing present, GNA #3 stated he/she was not aware of the fire on 12/3/18, not aware that the Resident had ever been found to have a lighter in the past and not aware he/she was to check the Resident's clothing at bedtime for lighters. During interview with GNA #4 on 2/5/19 at 12:54 PM, with the Director of Nursing present, GNA #4 stated he/she was not aware of the fire on 12/3/18, not aware that the Resident had ever been found to have a lighter in the past and not aware he/she was to check the Resident's clothing at bedtime for lighters. 2. Further review of Resident #1's medical record on 2/5/19 revealed the Bedside Kardex Report for safety stated 1:1 staff observation. The Resident had a care plan with a focus of Inappropriate dressing/undressing (found in resident another resident (female) room with genital expose) related to cognitive impairment created on 5/3/16 with an intervention of 1:1 staff observation that was created on 1/31/17. There was no documentation in the medical record that the Resident was receiving 1:1 staff observation. During interview with the DON (Director of Nursing) on 2/5/19 at 9:31 AM, he/she stated, they probably should of taken that (1:1) off, as far as I know he/she was not a 1:1. DON reported he/she did not know why they had the Resident on 1:1 intervention. 3. Further review of Resident #1's medical record on 2/5/19 revealed the Resident was seen by the Psychiatric Nurse Practitioner on 12/4/18. Review of his/her progress note failed to reveal any documentation about the Resident setting a fire on 12/3/18. During interview with the Psychiatric Nurse Practitioner on 2/5/19 at 10:35 AM, he/she stated that he/she had no knowledge of the Resident starting a fire on 12/3/18 and if he/she did it would have been included in his/her progress note. During interview with the Resident's physician on 2/5/19 at 10:44 AM, he/she stated that he/she had no knowledge of the Resident previously setting a fire on 12/3/18 in the facility. Interview with the Resident's NP #1 on 2/5/19 at 11:09 AM revealed he/she was notified by the facility staff the Resident was found with matches but does not recall anything about a fire. NP #1 stated he/she ordered a psych consult at the time of the notification. NP #1 stated the facility staff then notified him/her of the psych NP recommendations and he/she ordered an increase in [MEDICATION NAME]. The surveyor asked NP #1 what the increase in [MEDICATION NAME] was for and the NP #1 stated for the incident of the matches and his/her behavior of wandering in other residents' rooms. The surveyor asked NP #1 if he/she had any conversation with the psych NP or Resident's physician about the matches and he/she stated not that he/she recalls. 4. Review of the facility's investigation of the fire that occurred on 12/3/18 revealed the Facility staff completed an Incident report. Interview with the DON on 2/5/19 at 12:51 PM revealed the incident was not reported to the Office of Health Care Quality. Also, in the interview, the DON stated he/she could not find any further documentation of any staff/resident interviews or evidence of searches of the facility for smoking materials regarding the fire on 12/3/18. On 2/2/19 at approximately 1:00 PM, the facility staff identified a fire in Resident #1's room. Interview on 2/4/19 at 2:48 PM with GNA #1, he/she stated he/she was coming out of a resident room and smelled something, at that time saw Resident #1 coming out of his/her room and trying close the room door behind him/her. GNA #1 then stated opened Resident #1's door, saw smoke and a flame, yelled fire and tried to use a fire extinguisher. GNA #1 stated the fire alarm went off and the sprinklers in the room. GNA #1 also stated they were unable to remove Resident #2 from the room with the fire and when the fireman arrived approximately 10-15 minutes later they evacuated Resident #2. Interview with Nurse #1 on 2/4/19 at 2:37 PM, he/she stated on 2/2/19 he/she was sitting at the desk and heard someone yell smoke, then GNA #1 and #2 grabbed the fire extinguishers. Nurse #1 stated the staff then started grabbing the residents and getting them out of their rooms. Review of the facility investigation statements revealed a statement from the Administrator on 2/4/19 that he/she found a lighter in Resident #1's pocket when he/she was evacuating Resident #1 from the building. During interview with the Administrator on 2/4/19 at 3:00 PM, he/she confirmed he/she found a lighter in the Resident's pocket on 2/2/19. After fire on 2/2/19 four residents were sent to the hospital, Resident #1, #2, #4 and #5. Review of Resident #1's hospital medical record revealed an emergency room physician note on 2/2/19 stating Emergency Petitioned by police for evaluation status [REDACTED]. Review of Resident #2's hospital medical record revealed a physician note on 2/2/19 stating from nursing home after a fire broke out, with smoke inhalation, elevated CO (carbon monoxide) levels. The hospital documented [MEDICATION NAME] given, receiving oxygen therapy, [MEDICATION NAME][MEDICATION NAME] and incentive spirometry. [MEDICATION NAME] is a medication used as an antidote to treat suspected cyanide toxicity. As of 2/4/19 Resident #2 is still in the hospital. Review of Resident #4 and #5's medical record revealed both residents returned to the facility on [DATE] after being evaluated in the emergency room . The facility submitted a plan to remove the Immediacy on (MONTH) 5th, 2019 at 11:08PM. The facility's plan included: 1. Review of last 90 days of Incident reports to identify any other incidents that need further investigation 2. Education to nursing staff on how to conduct an effective investigation, care planning and communication of changes in condition. 3. Education to physician and physician extenders on communication of changes in condition 4. Validation of current residents' care plan interventions accuracy. 5. Ensure that any resident that has been identified as needing increased supervision is receiving. The survey team verified completion of the plan on (MONTH) 8th, 2019 at 2:15 PM.

Based on medical record review and interview, the facility staff failed to protect a resident from sexual abuse (Resident #2) 1 out of 11 residents reviewed for abuse. This failure had the potential to affect all the residents in the facility. As result of these findings an Immediate Jeopardy was called at 3:25 PM on 2/5/19. The facility submitted a plan to remove the Immediacy on (MONTH) 5, 2019 at 11:08 PM. The survey team verified completion of the plan the immediate jeopardy was abated on (MONTH) 8, at 2:15 PM. The findings include: Review of Resident #1's medical record on 2/5/19 revealed the Resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Resident had physician certifications of incapacity to make an informed decision dated 12/16/15 and 1/2/16. Further review of Resident #1's medical record revealed the Resident had been discharged from the facility for inpatient psychiatric care from 2/2/17 until 2/23/17. Per the physician note from the hospital dated 2/22/17, He had been wandering in to other patient's rooms and exposed himself to another resident. Further review of Resident #1's medical record on 2/5/19 revealed the Bedside Kardex Report for safety stated 1:1 staff observation. The Resident had a care plan with a focus of Inappropriate dressing/undressing (found in resident another resident (female) room with genital expose) related to cognitive impairment created on 5/31/16 with an intervention of 1:1 staff observation that was created on 1/31/17. There was no documentation in the medical record that the Resident was receiving 1:1 staff observation. During interview with the DON (Director of Nursing) on 2/5/19 at 9:31 AM, he/she stated, they probably should of taken that (1:1) off, as far as I know he/she was not a 1:1. DON reported he/she did not know why they had the Resident on 1:1 intervention. Review of Resident #2's medical record on 2/5/19 revealed the Resident was admitted to the facility on [DATE], legally blind and non-ambulatory for 3 years. The Resident had physician certifications of incapacity to make an informed decision dated 2/27/17 and 2/28/17. On 2/5/19 at 2:30 PM during Interview with GNA (Geriatric Nursing Assistant) #1, he/she stated approximately 9:00 AM on 2/2/19, he/she went into Resident #1 and #2's shared room and found Resident #1 naked with his/her genitals between the toes of Resident #2. GNA #1 stated he/she immediately told Resident #1 to stop, the Resident did and returned to his/her bed. GNA #1 stated he/she told Nurse #1, who was seated at the nurses' station, and then went back into the residents' room and found Resident #2 with whitish secretions on Resident #2's feet. GNA #1 also stated during the interview, he/she had bathed the Resident on 2/2/19 at approximately 6:30 AM so GNA #1 proceeded to clean Resident #2's feet of the whitish secretions. The surveyor asked GNA #1 if Nurse #1 gave him/her any instructions related to Resident #1 after he/she told Nurse #1 what he/she observed. GNA #1 stated no, the only instruction he/she received from Nurse #1 was how to document the incident. During the same interview with GNA #1, the surveyor asked if Resident #2 was aware what happened. GNA #1 stated the Resident asked why someone was biting at my feet? Also, during the interview with GNA #1, he/she stated Resident #1 stayed in his/her room with Resident #2 until approximately lunch time when he/she was in the day room with other residents. The surveyor asked GNA #1 if anything was put in place different on 2/2/19 after the incident for Resident #1's supervision and he/she stated no. GNA #1 stated he/she observed Resident #1 exiting his/her room at approximately 1:00 PM and shutting the door behind him/her. Review of Resident #2's medical record revealed no assessment by Nurse #1 of Resident #2 or notification to the Resident's physician or responsible party of the incident between Resident #1 and #2. Review of Nurse #1's statement, provided by the facility, revealed on 2/2/19 Nurse #1 stated GNA #1 told him/her that he/she just caught Resident #1 naked in his/her room trying to get his penis between the roommate toes. Interview with the Administrator on 2/5/19 at 3:25 PM, he/she stated the incident was not reported to the Office of Health Care Quality and he/she would have expected the staff to separate the residents at the time of the incident. During the interview, the surveyor asked when the Administrator became aware of the incident, the Administrator stated on 2/4/19 while investigating a fire at the facility that occurred on 2/2/19. During interview with the DON (Director of Nursing) on 2/5/19 at 5:19 PM, the surveyor asked when he/she became aware of the incident. The DON stated the Administrator advised him/her on 2/4/19. The DON also stated Nurse #1 had confirmed to him/her in an interview that GNA #1 did tell her about the incident on 2/2/19 at approximately 9:00 AM and he/she failed to notify the Administrator, physician and responsible party at that time. As result of these findings an Immediate Jeopardy was called at 3:25 PM on 2/5/19. The facility submitted a acceptable plan to remove the Immediacy on 2/5/19 at 11:08 PM. The plan included: 1. Resident, family and employee interviews to identify any issues of safety and/or resident abuse. 2. Education to all staff on Patient Protection Policy and Procedures regarding Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention. The survey team verified completion of the plan on 2/8/19 at 2:15 PM, and the immediate jeopardy was abated.

Based on medical record review and interview, it was determined the facility staff failed to follow the resident's interdisciplinary care plan and put additional safeguards in place to prevent the resident from obtaining lighting materials and setting a fire (Resident #1). This was evident for 1 of 11 residents reviewed during a complaint survey. This failure resulted in a fire at the facility on 2/2/19 that resulted in smoke inhalation to a second resident (Resident #2). 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. The findings include: Review of Resident #1's medical record revealed a nursing note dated 12/3/18 at 8:00 AM that stated: Was called to resident's room by GNA (Geriatric Nursing Assistant) and room smelt like smoke. Found fire in top drawer of night stand of newspaper and pull up. Water was poured on it and flame went out. Resident was asked where he got the matches or lighter and resident denied it. A second flame was noted in the second drawer and water was poured on it. A lighter was found on resident while he was laying in bed. And didn't know where he got it. Further review of Resident #1's medical record on 2/5/19 revealed after the fire on 12/3/18 the facility staff initiated a care plan on 12/3/18 titled: Resident noted with cigarette lighter with a goal of Resident will not have a cigarette lighter or any matches per facility policy. On 12/4/18 the facility staff added an intervention to the care plan: Staff to check resident's pockets before going to bed. Review of Resident's medical record revealed no documentation of checking the Resident's pockets for a lighter. Further review of Resident #1's medical record on 2/5/19 revealed the Bedside Kardex Report for safety stated 1:1 staff observation. The Resident had a care plan with a focus of Inappropriate dressing/undressing (found in resident another resident (female) room with genital expose) related to cognitive impairment created on 5/31/16 with an intervention of 1:1 staff observation that was created on 1/31/17. There was no documentation in the medical record that the Resident was receiving 1:1 staff observation. During interview with the DON (Director of Nursing) on 2/5/19 at 9:31 AM, he/she stated, they probably should of taken that (1:1) off, as far as I know he/she was not a 1:1. DON reported he/she did not know why they had the Resident on 1:1 intervention. On 2/2/19 at approximately 1:00 PM, the facility staff identified a fire in Resident #1's room. Interview on 2/4/19 at 2:48 PM with GNA #1, he/she stated he/she was coming out of a resident room and smelled something, at that time saw Resident #1 coming out of his/her room and trying close the room door behind him/her. GNA #1 then stated opened Resident #1's door, saw smoke and a flame, yelled fire and tried to use a fire extinguisher. GNA #1 stated the fire alarm went off and the sprinklers in the room. GNA #1 also stated they were unable to remove Resident #2 from the room with the fire and when the fireman arrived approximately 10-15 minutes later they evacuated Resident #2. Interview with Nurse #1 on 2/4/19 at 2:37 PM, he/she stated on 2/2/19 he/she was sitting at the desk and heard someone yell smoke, then GNA #1 and #2 grabbed the fire extinguishers. Nurse #1 stated the staff then started grabbing the residents and getting them out of their rooms. Review of the facility investigation statements revealed a statement from the Administrator on 2/4/19 that he/she found a lighter in Resident #1's pocket when he/she was evacuating Resident #1 from the building. During interview with the Administrator on 2/4/19 at 3:00 PM, he/she confirmed he/she found a lighter in the Resident's pocket on 2/2/19. Review of the staffing schedule provided by the facility for the 2 weeks prior to the incident on 2/2/19 revealed GNA #3 and GNA #4 regularly cared for the Resident on evening shift (3 PM to 11 PM). During interview with GNA #3 on 2/5/19 at 12:52 PM, with the Director of Nursing present, GNA #3 stated he/she was not aware of the fire on 12/3/18, not aware that the Resident had ever been found to have a lighter in the past and not aware he/she was to check the Resident's clothing at bedtime for lighters. During interview with GNA #4 on 2/5/19 at 12:54 PM, with the Director of Nursing present, GNA #4 stated he/she was not aware of the fire on 12/3/18, not aware that the Resident had ever been found to have a lighter in the past and not aware he/she was to check the Resident's clothing at bedtime for lighters. After fire on 2/2/19 four residents were sent to the hospital, Resident #1, #2, #4 and #5. Review of Resident #1's hospital medical record revealed an emergency room physician note on 2/2/19 stating Emergency Petitioned by police for evaluation status [REDACTED]. Review of Resident #2's hospital medical record revealed a physician note on 2/2/19 stating from nursing home after a fire broke out, with smoke inhalation, elevated CO (carbon monoxide) levels. The hospital documented [MEDICATION NAME] given, receiving oxygen therapy, [MEDICATION NAME][MEDICATION NAME] and incentive spirometry. [MEDICATION NAME] is a medication used as an antidote to treat suspected cyanide toxicity. As of 2/4/19 Resident #2 is still in the hospital. Review of Resident #4 and #5's medical record revealed both residents returned to the facility on [DATE] after being evaluated in the emergency room . Interview the Director of Nursing on 2/5/19 at 3:00 PM confirmed the facility staff failed to implement a resident's care plan.

Based on medical record review and staff interviews, it was determined that the facility staff failed to follow physician orders [REDACTED]. (Resident #2). This was evident for 1 of 8 residents reviewed during a complaint survey. After the incident occurred on [DATE], the facility responded with training to nursing staff but did not complete the training for all facility registered nurses and all licensed practical nurses. This resulted in an immediate jeopardy for the facility on [DATE] at 3:30 PM. The findings include: Review of resident #2's medical record on [DATE] revealed he/she was admitted to the facility [DATE]. On [DATE] the Resident's physician completed a [NAME]land Medical Orders for Life-Sustaining Treatment (MOLST). [NAME]land MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's directions about medical treatments. The completed MOLST form dated [DATE] indicated resident #2 was Attempt CPR: If cardiac and/or [MEDICAL CONDITION] arrest occurs, attempt cardiopulmonary resuscitation (CPR). This will include any and all medical efforts that are indicated during arrest, including artificial ventilation and efforts to restore and/or stabilize cardiopulmonary function. Further review of the medical record on [DATE] revealed resident #2 had a physician order [REDACTED]. Review of the resident #2's medical record revealed on [DATE] at 11:40 PM the resident was observed with no respirations and no vital signs obtainable. Employee #1 documented the on-call nurse practitioner (Employee #2) was called immediately and given the information. Per the nurse's note Employee #1 received an order to release the body to funeral home. There is no evidence the facility staff performed CPR on resident #2 or called 911. Interview of Employee #1 on [DATE] at 11:26 AM revealed although he/she was assigned to Resident #2, he/she was on break when Resident was found unresponsive and Employee #3 was covering for him/her. Interview of Employee #2 (on call nurse practitioner) on [DATE] at 11:05 AM revealed when he/she was called on [DATE], he/she was only notified resident #2 was a hospice patient and he/she had passed on. Employee #2 stated he/she was never advised at that time resident #2 was a full code and if a resident is hospice and full code would have expected the facility staff to do CPR. Interview of Employee #3 on [DATE] at 4:00 PM revealed he/she was notified by Employee #4 that resident #2 was unresponsive. Employee #3 stated he/she went to the resident's room and found the resident was unresponsive and had no pulse. Employee #3 stated he/she knew resident #2 was hospice but was not aware of the resident's code status. He/she then stated he/she retrieved the resident's chart from the nurses' station and saw resident #2 was a full code but stated it was really outdated. Employee #3 states the evening shift nursing supervisor (Employee #5) was at the nurse's station and Employee #3 stated he/she asked Employee #5 if he/she should code resident and Employee #5 told her no. Per review of the statement Employee #3 gave to facility on [DATE], Employee #3 stated when he/she entered room of Resident #2, Employee #6 was in the Resident's room. Interview of Employee #6 on [DATE] at 5:50 PM revealed he/she was on his/her first night of orientation to the facility. He/she was also alerted by Employee #4 that Resident #2 was unresponsive and had alerted Employee #3. Employee #6 stated did not perform CPR and did not look at Resident's chart for code status. Employee #6 stated other staff took over due to him/her being on orientation. Surveyor attempted to interview Employee #5 (evening shift nursing supervisor) but per interview with Administrator on [DATE], Employee #5 was out of the country. Review of Employee #7's (night shift nursing supervisor) statement on [DATE] to the facility revealed he/she was notified in report from Employee #5 (evening shift nursing supervisor) Resident #2 had expired. Employee #7 stated I don't think anything else as far as CPR was done because he was a hospice patient. Per facility policy for Cardio-Pulmonary Resuscitation: Adult, with a revision date of (MONTH) 2014, the purpose is to attempt cardio-pulmonary circulation to a patient without a pulse or respirations. Included in the policy is the key point: Be aware of patient's wishes including: Do Not Resuscitate (DNR), advanced directives or limited treatment orders before proceeding. The facility responded with training to nursing staff on Code Status Identification with the purpose to educate nurses on understanding the difference between a Full code and a DNR/DNI as well as a comfort care in Hospice residents on [DATE] and [DATE] but did not complete the training for all facility registered nurses and all licensed practical nurses. Review of the list of all current nurses working in the facility on [DATE] was 34. Review of the program attendance record revealed 25 out of 34 nurses had signed they had received education. Interview with Director of Nursing and Administrator on [DATE] at 11:15 AM revealed the facility also continues to provide monthly education in the form of Code Status Emergency management mock drills monthly. Interview with the Director of Nursing (DON) and Administrator on [DATE] at 3:30pm revealed the facility staff failed to educate all nurses on Code Status Identification and failed to provide CPR to a resident that was a full code. Per interview on [DATE] with the Administrator, the 9 nurses that did not receive education on [DATE] and [DATE] had all worked in the building since the incident on [DATE] occurred. At the time the Immediate Jeopardy was called there were 4 hospice residents residing in the facility. 1 out of the 4 hospice residents residing in the facility was also a full code. Per the interview with the DON and Administrator on [DATE] at 7:00 PM and review of in-service education documentation provided by the facility, Employee #10 completed education on [DATE], Employees #8, #9, #11, #12, #13, #15 and #16 completed education on [DATE]. Employee #14 was suspended from working until his/her education can be completed. The Immediate Jeopardy was abated on [DATE] at 7:20 PM when the Director of Nursing and Administrator completed the education of Code Status Identification to the nurses who the facility had no evidence they received the education and were currently working in the facility.

Based on complaint, review of a closed medical record, a hospital record, and staff interview, it was determined that the facility staff failed to document wound assessments and initiate interventions to treat a resident's wound. This was evident for 1 of 6 residents reviewed during a complaint survey. The findings include: Review of complaint MD 64, on 07/16/2013, revealed an allegation that resident #4 developed a stage IV sacral wound which required hospitalization and surgery on 04/19/2013. Review of resident #4's closed medical record, on 07/16/2013, revealed a physician's orders [REDACTED].#4's sacral wound with normal saline, then apply Santyl ointment to the sacral wound, and then cover with a dry dressing daily. Santyl is a medicated ointment used to help clean a wound to promote healing. In an interview with nurse #3 on 07/18/2013 at 1:30 pm, nurse #3 stated that he/she was the nurse who called resident #4's physician for orders to treat resident #4's sacral wound on 04/04/2013 at 1:30 pm. Nurse #3 stated he/she and a GNA provided resident #4 with a bed bath, on 04/04/2013, in preparation for application of a cream treatment for [REDACTED].#4 at this time. Nurse #3 stated that he/she measured and documented on resident #4's sacral wound. Nurse #3 reviewed resident #4's closed medical record, but was unable to locate the documentation that he/she produced on 04/04/2013 regarding resident #4's sacral wound. Nurse #3 stated that he/she recalled that resident #4's sacral wound measured 11 cm x 14 cm, with no depth, but had slough around the edge of the wound. Nurse #3 stated that resident #4 was not on a specialty mattress at the time he/she observed the sacral wound on 04/04/2013. Nurse #3 stated that the facility wound team was responsible to document on resident #4's sacral wound weekly. Nurse #3 stated that resident wounds are documented on the facility skin sheet. Nurse #3 was unable to locate any weekly wound assessment of resident #4's sacral wound. Nurse #3 stated that he/she assessed resident #4's sacral wound again on 04/17/2013, and recalled that resident #4's wound had depth ,and also had some serous/bloody drainage. Nurse #3 could not recall the measurements to resident #4's sacral wound for 04/17/2013. A pressure wound means an inflammation, a sore, or breakdown of tissues overlying a bony prominence that has been subjected to pressure, friction or shear. The staging system presented below is one method of describing the extent of tissue damage in the pressure ulcer. Stage I - A persistent area of skin redness (without a break in the skin) that is nonblanchable. Stage II - A partial thickness loss of skin layers either dermis or epidermis that presents as an abrasion, blister, or shallow crater. Stage III - A full thickness of skin is lost, exposing the subcutaneous tissues - presents as a deep crater with or without undermining adjacent tissue. Stage IV - A full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone. In an interview with the facility nutritionist on 07/22/2013 at 1:45 pm, the facility nutritionist stated that he/she was on the wound team that reviewed all of the wounds on a weekly basis. The facility nutritionist stated that he/she was not aware that resident #4 had a sacral wound from 04/04/2013 through 04/19/2013 prior to resident #4 being sent to the hospital. The facility nutritionist stated that resident #4's sacral wound was not discussed in the daily 9 am, Monday through Friday, administrative meetings. In an interview with the facility Director of Nursing (DON) on 07/22/2013 at 4:25 pm, the DON stated that he/she was not aware that resident #4 had a sacral wound. The DON stated that resident #4's sacral wound was not discussed during the daily administrative meeting. The DON stated that the facility had no other documentation, regarding resident #4's sacral wound, except for the 04/04/2013 physician's orders [REDACTED]. Review of resident #4's hospital record, on 07/22/2013, revealed that resident #4 was admitted to the hospital, on 04/19/2013, with an unstagable deep pressure wound on the sacrum that measured 6 cm in depth and that extended up to the lumbar region of the spine. The wound required surgical intervention at the hospital on [DATE]. In conclusion, the facility nursing staff failed to 1) document detailed assessments of resident #4's sacral wound from 04/04-19/2013, 2) failed to update a care plan with nursing interventions to treat resident #4's sacral wound, 3) failed to document that resident #4's responsible party was notified of a new sacral wound on 04/04/2013, 4) failed to readdress resident #4's nutritional needs to promote wound healing, 5) failed to notify the interdisciplinary that team resident #4 had a sacral wound from 04/04-19/2013.

Based on complaint, medical record review, and staff interview, it was determined the facility staff failed to 1) take steps from placing a resident into a hypoglycemic state for an extended period of time, 2) to address a preliminary sonogram report, which indicated a resident had a blood clot in their extremity, with a physician which resulted in a 2 day delay in treatment for [REDACTED]. This was evident for 3 of 7 residents reviewed during a complaint survey. The findings include: 1) [MEDICATION NAME] is an antidiabetic injectable drug used to control high blood sugar. [MEDICATION NAME] is 24-hour, or long acting, insulin that is administered once a day. Humalog is an injectable rapid-acting, shorter acting, man-made insulin. Humalog is used to treat people with high blood sugar. The most common side effect of insulin, including [MEDICATION NAME] and Humalog, is low blood sugar ([DIAGNOSES REDACTED]), which may be serious. Mild low blood sugar is treated by drinking or eating something sugary right away (fruit juice, sugar candies, or glucose tablets). It is important to treat low blood sugar right away because it could get worse and the person could pass out (become unconscious). If the person passes out, someone else will need to contact emergency medical services right away. The person will need treatment with [MEDICATION NAME] injection or treatment at a hospital. Resident #6 is an [AGE] year old female who was admitted to the facility on [DATE]. Resident #6 suffers from diabetes and was placed on hospice on 02/27/2010 Review of complaint MD 302 revealed an allegation resident #6 was given her morning insulin which made her lethargic and uncommunicative. Review of resident #6 ' s closed medical record on 11/29/2011 revealed resident #6 suffers from diabetes which requires her to receive insulin. Resident #6 ' s physician instructed the nursing staff to administer [MEDICATION NAME], 10 units, subcutaneously, every morning, Humalog insulin, 4 units, subcutaneously, with every meal, and to obtain a finger stick glucose on resident #6 at every meal and at bedtime. If resident #6 ' s glucose reading is elevated, the nursing staff was instructed to administer regular [MEDICATION NAME]using the following parameters: 0 - 200, no [MEDICATION NAME] insulin. 201 - 250 administer 2 units of [MEDICATION NAME] insulin. 251 - 300 administer 4 units of [MEDICATION NAME] insulin 301 - 350 administer 6 units of [MEDICATION NAME] insulin 351 - 400 administer 8 units of [MEDICATION NAME] insulin If less than 60 or greater than 400, call the physician. It should be noted that a normal/stable blood sugar reading is within a 70-120 mg/dl range. Review of resident #6 ' s March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No insulin coverage was administered to resident #6 at 9 pm on 03/01/2011. Resident #6 received an evening diabetic snack at 9:54 pm as documented nursing in the medical record. Further review of resident #6 ' s closed medical record revealed nursing documentation, dated 03/01/2011 at 11 pm, indicating resident #6 had a finger stick glucose reading of 60 mg/dl. The nurse documented resident #6 had become dyspneic and agitated during a respiratory treatment. The nurse intervened by administering a cup of orange juice orally, with extra 3 packets of sugar added to the orange juice, to resident #6. Further review of resident #6 ' s March 2011 MAR indicated [REDACTED]. The nursing staff documented resident #6 also received her 7:30 am morning dose of Humalog, 4 units, and her 9 am dose of [MEDICATION NAME], 10 units, subcutaneously. Review of resident #6 ' s meal intake record for breakfast on 03/02/3011 revealed resident #6 ate 25% of her breakfast. On 03/02/2011 at 11 am, nurse #2 documented that resident #6 was found nonresponsive to verbal or tactile stimulation. In an interview with nurse #2, on 11/29/2011 at 1:32 pm, nurse #2 stated she was aware resident #6 had a finger stick glucose result of 60 mg/dl at 6:30 am on 03/02/2011. Nurse #2 stated she administered resident #6 ' s doses of [MEDICATION NAME] and Humalog on the morning of 03/02/2011. Nurse #2 stated she was following the physician orders [REDACTED]. Nurse #2 stated the finger stick result was 38 mg/dl. Nurse #2 stated she called resident #6 ' s hospice nurse, who was in the facility, and also called resident #6 ' s nurse practitioner. Nurse #2 stated she obtained new orders for resident #6 from the nurse practitioner. Nurse #2 stated resident #6 ' s family was at the bedside and was made aware of the current status of resident #6. Nurse #2 stated she obtained another finger stick glucose, approximately 1 hour after the 11:30 am finger stick on 03/02/2011, and the result read " low " . A reading of low indicates the resident ' s sugar level is too low for the machine to obtain a reading. In an interview with resident #6 ' s hospice nurse on 11/29/2011 at 2 pm, resident #6 ' s hospice nurse stated she was called " stat " (to respond immediately) to resident #6 ' s room on 03/02/2011 at approximately 10 am and was informed by nurse #2 that resident #6 was actively dying. Resident #6 ' s hospice nurse stated she called resident #6 ' s family and informed them they needed to come to the facility that resident #6 was doing badly. Review of resident #6 ' s 03/02/2011 hospice nurse documentation on 11/29/2011, revealed resident #6 ' s family and pastor were called and visited resident #6 on 03/02/2011 and was given spiritual comfort at the bedside. In a continued interview with resident #6 ' s hospice nurse on 11/29/2011 at 2 pm, after learning resident #6 ' s glucose reading was low, resident #6 ' s hospice nurse stated she administered 2 packets of sugar under resident #6 ' s tongue. Resident #6 ' s hospice nurse stated it took approximately 1 hour for resident #6 to become more conscious and talking again. Further review of resident #6 ' s closed medical record, on 11/29/2011, failed to reveal any other nursing interventions or monitoring after it was discovered resident #6 was having a hypoglycemic event on 03/02/2011. Resident #6 became was placed in a serious condition by the nursing staff by administering the morning doses of insulin, on 03/02/3011, after having 3 consecutive finger stick glucose results of 60 mg/dl which started on the evening of 03/01/2011. The facility staff failed to timely identify resident #6 in a hypoglycemic state which caused the resident to be unresponsive for approximately 1. 5 hours. 2) Review of resident #1's closed medical record, on 11/28/201, revealed nursing documentation, dated 09/23/2011 at 7:30 pm, that resident #1 developed swelling to his right hand. The nurse documented the swelling was 3+ (a large amount of swelling) in appearance. The nurse documented notifying resident #1's physician who in turn ordered an x-ray and an ultrasound of the right hand. On 09/24/2011, an x-ray was obtained and was negative for a fracture. Also on 09/24/2011, an ultrasound of resident #1's right hand was obtained. Review of the 09/24/2011 Preliminary Technician Impression indicated resident #1 was positive for a [MEDICAL CONDITION] (blood clot) of the right upper extremity. Resident #1's blood clot was not allowing his blood to return to his body which produced swelling to the right hand. On 09/26/2011, resident #1's physician was made aware of the sonogram result and ordered the anticoagulant, [MEDICATION NAME] 60 mg to be given subcutaneously. The facility staff failed to take steps to follow up with the radiologist or the resident ' s attending physician, between 09/24/2011 through 09/26/2011, regarding the initial positive result on 09/24/2011 of the presence of a [MEDICAL CONDITION] in the right upper extremity. This constitutes a two day delay in treatment regarding resident #1 ' s [MEDICAL CONDITION] in the right upper extremity. 3) Review of complaint MD 871 on 11/28/2011 revealed an allegation resident #3 was found in December 2010 with trouble breathing. Review of resident #3 ' s closed medical record on 11/28/2011 revealed nursing documentation; dated 12/21/201 at 2 pm, indicating resident #3 ' s oxygen saturation was 70%. Resident #3 had a chest x-ray, on 12/21/2010, which showed " an extensive pneumonia involving most of the right lung. There is also a patchy infiltrate in the left upper lung. " Resident #3 was placed on an antibiotic that was prescribed by the facility nurse practitioner. Further review of the nursing documentation, dated 12/21/2010 at 2 pm, failed to indicate a lung assessment by the nurse. A lung assessment is accomplished by placing a stethoscope on a resident ' s anterior and posterior chest wall and listening to breath sounds. In an interview with the facility administrator on 11/28/2011 at 3:05 pm, the administrator could not locate a lung assessment for resident #3 on 12/21/2010 at 2 pm. The nurse failed to document a lung assessment for resident #3 on 12/21/2010 at 2 pm in the presence of low oxygen saturation reading, 70% (normal 95 -100 5 on room air), with an associated double pneumonia.