Every finding on record at Rossville Rehabilitation and Healthcare Center

Based on a review of a complaint, medical records, interviews, and facility investigative documents, it was determined that the facility failed to have an effective system to prevent 2 residents with cognitive impairment, exit-seeking behavior, and an assessed risk for elopement from leaving the facility without appropriate supervision. This failure placed both residents at risk for harm due to hazards, including no sidewalk, which forced them into a road, which led them to a heavily traveled road and one resident not being properly dressed. These actions resulted in an Immediate Jeopardy (cited as past non-compliance). This was evident for 2 (Resident #6, #7) out of 8 residents reviewed for elopement/wandering risk during a complaint survey.The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facility's plan and action were verified during this survey; therefore, this deficiency was found to be past noncompliance with a compliance date of 4/23/26.The findings include:On 5/11/26 at 8:30 AM a review of complaint 2988135 stated on 4/16/26 at 5:51 PM a passerby stated that Resident #6 had a fall while pushing someone in a wheelchair (Resident #7). Resident #6 and Resident #7 were located on a sidewalk next to a closed restaurant on the corner of a heavily traveled road. This location was down the street from the facility. The complaint alleged Resident #7 was rambling incoherently and that Resident #6 had minor skin tears on the left leg. Resident #7 was observed standing behind the wheelchair, not wearing pants, and wearing only hospital-style grip socks. On 5/11/26 at 8:31 AM a review of Resident #6's medical record was conducted. A review of a 3/24/26 at 22:52 (10:52 PM) admission note documented that Resident #6 had short-term memory loss and a BIMS (brief interview of mental status) score of 7.0, indicating severe impairment.A review of a 3/27/26 at 12:48 PM practitioner's note documented that Resident #6 was admitted from an acute care facility following Adult Protective Services concerns regarding the resident's inability to care for self and spouse in an unsafe home environment. It was determined that Resident #6 lacked capacity due to multiple prior chronic lacunar infarcts and a Vitamin B12 deficiency. Chronic lacunar infarcts are small, healed areas of dead tissue deep within the brain caused by the blockage of tiny penetrating blood vessels. Resident #6 was assessed for elopement and had an elopement score of 8.0 which indicated low risk.On 5/11/26 at 8:45 AM a review of Resident #7's medical record (Resident #6's spouse) documented a 3/24/26 nursing admission assessment showing an elopement risk score of 10.0, high risk for elopement.Review of a 3/27/26 at 12:49 PM practitioner note for Resident #7 documented a history of severe baseline dementia. It was documented that Resident #7 could not care for him/herself, experienced poor hygiene, was malnourished, and had an incapacitated status.Review of a 3/31/26 at 1:29 AM practitioner note for Resident #7 documented, severe dementia with behavioral symptoms (wandering) and safety risk. Baseline severe cognitive impairment with wandering behavior and supervision provided in hallway. Continue staff supervision.Continued review of Resident #6's medical record revealed a second elopement risk assessment done on 4/13/26 documented a score of 14, indicating a high elopement risk.Review of Resident #6 and Resident #7's care plans revealed an elopement care plan initiated for each resident on 4/13/26 with interventions including, placed wanderguard on, picture of ID to front desk.A 4/13/26 at 18:19 (6:19 PM) progress note for Resident #6 documented, wanderguard applied to the patient's left ankle due to identified risk of elopement. A 4/13/26 at 18:20 (6:20 PM) progress note for Resident #7 documented, wanderguard applied to the patient's left ankle due to identified risk of elopement.Review of Resident #6's April 2026 Treatment Administration Record (TAR) documented the physician's order written on 4/13/26 at 23:00 (11:00 PM), wanderguard: check placement to left ankle every shift for safety. The wanderguard was checked off as on during the 4/13/26 night shift and 4/14/26 day shift. The 4/14/26 evening shift denoted a 9 which indicated the wanderguard bracelet was not on. A corresponding eMAR (electronic medication administration record) note documented, pt. removed. The note did not say how the wanderguard bracelet was removed.Continued review of Resident #6's April 2026 TAR revealed 4/14/26 night shift documented the bracelet was on and on 4/15/26 all 3 shifts documented the bracelet was on. On 4/16/26 all 3 shifts documented a 9, indicating the bracelet was not on. A corresponding eMAR note dated 4/16/26 at 11:22 AM documented, not on.Review of Resident #7's April 2026 TAR documented the physician's order written on 4/13/26 at 23:00 (11:00 PM), wanderguard: check placement to left ankle every shift for safety. The wanderguard was checked off as on during the 4/13/26 night shift and 4/14/26 day shift. The 4/14/26 evening shift documented a 9. There was a corresponding eMAR note dated 4/14/26 at 20:26 (8:26 PM) that stated, rt removed. Continued review of Resident #7's April 2026 TAR for 4/15/26 day shift denoted a 9, indicating the bracelet was not on, however the evening and night shifts documented the bracelet was on. A corresponding eMAR note dated 4/15/26 at 12:13 PM documented, none. On 4/15/26 night shift the bracelet was documented as on, however on 4/16/26 day shift it was documented as 9 and on 4/16/26 the evening shift was blank. A corresponding eMAR note dated 4/16/26 at 11:22 AM documented, not on. There was no documentation in either medical record as to why the bracelet was not on and how the bracelets were removed.Further review of the medical record failed to produce documentation of the elopement of Resident #6 and Resident #7 on 4/16/26. There was no documentation on 4/16/26 until a 10:14 PM nursing note that documented a wanderguard was applied to Resident #6 and a 10:26 PM note that the wanderguard was applied to Resident #7.On 5/11/26 at 12:37 PM an interview was conducted with Registered Nurse (RN) #17, the evening shift supervisor. RN #17 was asked if anyone had recently eloped from the facility. RN #17 stated that Resident #6 and Resident #7 eloped on 4/16/26 around 5:55 PM to 6:00 PM when she was alerted by the front desk that paramedics were in the lobby. They said they saw 2 residents down by the corner of Ridge Road and Philadelphia Road, were alerted by someone calling 911, and brought them back to the building. RN #17 stated that Resident #6 had scrapes on the knees. RN #17 was asked if she documented the assessment of the residents in the medical record or wrote a note about the elopement. RN #17 stated that she did not document the incident and that the nurse working that evening would document the findings.During the continued interview, RN #17 was asked how the residents got out of the building. RN #17 stated that the front door was locked so someone buzzed them out. RN #17 stated there was a book at the front desk with pictures of residents' faces to identify those at elopement risk. The person at the front desk should have contacted the nurse to verify if they could go out, checking if they were with a family member or had a doctor's order allowing them to leave. The nurse should have been notified, or the supervisor should have been called. On 5/11/26 at 12:51 PM an interview was conducted with Licensed Practical Nurse (LPN) #8, who worked the evening shift on 4/16/26. LPN #8 stated both residents previously had wanderguard bracelets, but when she came on duty at 3:00 PM she noticed they did not have them on. Management told her they were getting the bracelets and would bring them to her. LPN #8 stated, we were trying to watch them while taking care of other residents.During the continued interview, LPN #8 stated, that week Resident #6 kept cutting the wanderguard off and I made management aware. We searched the resident's room the first time the wanderguard was cut off and found scissors. The second time the wanderguard was found cut off we found nail clippers. We realized the wanderguard bracelets were too small, therefore an order was placed for larger bracelets, and they had not been placed on the residents the day they eloped.LPN #8 stated, I feel like they were strategically waiting for us to be busy to make their exit. It was quick. I gave them their medication, and I was in another patient's room and then I was made aware that the fire department was here letting us know that they had them both.LPN #8 was asked if she documented the incident and the assessment of Resident #6 and Resident #7 in their medical records. LPN #8 stated that she documented it in risk. She didn't know she was supposed to document in the medical record also. The risk file is part of the electronic medical record system. The electronic medical record system also contains reports and administrative files and is not considered part of the resident's electronic medical record.On 5/11/26 at 1:07 PM the Nursing Home Administrator (NHA) and the current Director of Nursing (DON) were interviewed and confirmed that Resident #6 and Resident #7 left the building on 4/16/26. The NHA was asked if the elopement was reported to the state survey agency, the Office of Health Care Quality (OHCQ). The NHA stated the incident was not reported to OHCQ because it was not related to abuse. The NHA stated, there was no abuse, so it was not reported. If there was no abuse involved you don't report it. I asked my superiors and they told me just abuse is reported.During the continued interview, the DON confirmed there was no documentation of the elopement in the medical record, but it was documented in risk. The DON was asked if risk was part of the medical record and the answer was, no.On 5/11/26 at 1:15 PM the NHA provided the surveyor with a copy of the facility's investigation regarding the elopement which included a copy of the abatement plan for IJ (immediate jeopardy) - patients took a walk without notifying staff. Review of the investigation with the NHA and the DON revealed a written statement from Receptionist #9 documenting that on 4/16/26 at approximately 5:30 PM, while entering a new admission into the computer at the front desk, 2 individuals exited the building. They were dressed in regular clothing, and based on that, I believed they were visitors, as we frequently have elderly couples entering and exiting the building. I understand that the residents were listed in the wanderguard/elopement book at the front desk. Receptionist #9 documented that he was not specifically instructed or trained that he was required to review and memorize the contents of the book at the start of each shift or use it as a primary method of identifying elopement risk residents in real time and that he was not informed that these residents were elopement risks. The NHA stated during the 5/11/26 interview at 1:15pm that Receptionist #9 was suspended and then resigned from the facility.On 5/11/26 at 1:28 PM the DON, who was the Assistant Director of Nursing (ADON) at the time of the incident, stated that prior to the elopement, wanderguard bracelets were placed on both residents on 4/13/26, but Resident #6 cut them both off. The DON stated the nurses put new wanderguard bracelets on and they were cut off again. The DON stated she told the previous DON that they needed larger strapped wanderguard bracelets, which the facility was ordering, and in the meantime, she felt both residents needed one-to-one supervision. The DON stated the previous DON informed her they did not have enough staff for one-to-one supervision, so nothing further was done.The DON stated that after the 4/16/26 elopement, wanderguard bracelets were placed on Resident #6 and Resident #7. The DON stated the residents were monitored every 15 minutes until they were moved upstairs to the locked dementia unit the next day.On 5/13/26 at 2:36 PM Physician #13 was asked if he was aware of the elopement. Physician #13 stated, yes, and how? I raised a stink about it. If anyone is at risk for wandering and has enough dexterity to manipulate a door and frequently come out of the room you have to let me know so I can intervene. We have to figure out why they are wandering. I can't believe it happened.On 5/14/26 at 10:01 AM Geriatric Nursing Assistant (GNA) #21 was interviewed and stated, they were exit seeking. Usually, Resident #6 was exit seeking. Resident #6 would put Resident #7 in a wheelchair and start to walk down the hall, and they would say that they were leaving.Review of the abatement plan provided to the surveyors included staff education, audits, elopement assessments on all residents, and QAPI (Quality Assurance and Performance Improvement) ad hoc sign-in sheets. Immediate interventions included:Resident #6 and Resident #7 were both assessed and placed on one-to-one supervision after the elopement on 4/16/26 until midnight, then placed on every 15-minute checks until they were relocated to the second-floor locked dementia unit on 4/17/26.Wanderguard bracelets were placed on their wheelchairs and left ankles.The care plan for Resident #6 was updated to include the behavior of clipping off the wanderguard bracelets.The physician, Medical Director, and family were notified.The QAPI Ad hoc meeting was conducted.On Friday, 4/17/26 both residents were moved to the second floor locked dementia unit.The exits and stairwell door alarms were checked for functionality by the maintenance assistant.The ADON coordinated and initiated education on the Elopement and Wandering Policy for current staff. Staff not educated on the policy will not work until the Elopement Prevention and Wandering Inservice is completed.A facility-wide elopement assessment audit was coordinated by the ADON on Friday, 4/17/26, on current residents to determine like residents and was completed on 4/23/26.Residents with wanderguards were inspected by the unit manager on Thursday, 4/16/26, to assure the devices were present and functioning.No additional residents were determined to require wanderguards.Daily audits began and then weekly audits were conducted.

Based on documentation review and interview, it was determined the facility failed to ensure nurse aide competency training occurred no less than 12 hours per year as determined in nurse aides' performance reviews. This was evident for 5 of 5 personnel files reviewed during the complaint survey.The findings include: On 5/15/26 at 10:30 AM a review was conducted of Geriatric Nursing Assistant (GNA) personnel files. A review of GNA #25's personnel file revealed GNA #25 was hired on 9/29/21. There was no evidence found that the required 12-hour yearly training was done within the past 12 months. A review of GNA #26's personnel file revealed GNA #26 was hired on 2/3/22. There was no evidence found that the required 12-hour yearly training was done within the past 12 months. A review of GNA #27's personnel file revealed GNA #27 was hired on 4/13/22. There was no evidence found that the required 12-hour yearly training was done within the past 12 months. A review of GNA #28's personnel file revealed GNA #28 was hired on 5/20/24. There was documentation that on 5/20/24 the 12-hour yearly training was completed. There was no documentation that the 12-hour yearly training has been done since 2024. A review of GNA #29's personnel file revealed GNA #29 was hired on 9/5/17. There was no evidence found that the required 12-hour yearly training was done within the past 12 months. On 5/15/26 at 11:00 AM an interview was conducted with the Human Resources Manager (HR #30). HR #30 stated there was no documentation in personnel files or in the computer when the last 12-hour training occurred. HR #30 stated that there could be documentation in the previous Director of Nursing (DON)'s office but was not sure. HR #30 stated that they were switching to a new system in order to track the education and other personnel documentation.On 5/15/26 at 12:00 PM an interview was conducted with the Nursing Home Administrator (NHA) who stated that he could not find documentation in the previous DON's office related to any 12-hour training for the GNAs.

Based on medical record review, observation and interview, the facility staff failed to ensure residents had a curtain to maintain privacy during care. This was evident for 2 (Resident #10 and #13) of 25 residents observed during a complaint survey.The findings include:Observation of Resident #10 on 5/12/26 at 8:02 AM revealed no privacy curtain between the Resident and his/her roommate (Resident #13). At that time the Surveyor asked the Resident how long the curtain had been missing and the Resident stated, quite some time. The Resident was asked if he/she would like to have a privacy curtain and the Resident stated yes.Review of Resident #10's medical record on 5/12/26 revealed the Resident was assessed by facility staff to be dependent for care on the 3/19/26 MDS (Minimum Data Set) Assessment Section GG0130 Functional Abilities/Self Care.On 5/12/26 at 8:40 AM, the Surveyor brought Unit Manager (UM) #11 to Resident #10 and #13's room. At that time UM #11 confirmed there was no privacy curtain between Resident #10 and #13. UM #11 confirmed at that time Resident #10 is dependent for care by facility staff.On 5/12/26 at 9:00 AM the Administrator notified the Surveyor that a privacy curtain was just put in place for Resident #10 and #13.

Based on medical record review, facility documentation review and interview, it was determined the facility failed to maintain an effective grievance system for residents. This was evident for 1 (Resident #10) of 4 residents reviewed for complaints during a complaint survey. The findings include:Review of Resident #10's medical record on 5/11/26 revealed the Resident was admitted to the facility in 2014.During interview with Resident #10's RP (Resident Representative) on 5/11/26 at 10:14 AM, the RP stated he/she came into visit the Resident on Christmas day in the afternoon. At that time the Resident was lying in a soiled diaper that was leaking on his/her resident gown. The RP stated he/she wrote up a grievance regarding the incident and personally handed it to the Administrator a few days later since the grievance contained names of staff working on Christmas day. The RP stated he/she has had no resolution to that grievance.Further review of Resident #10's medical record on 5/12/26 revealed the Resident was assessed by facility staff to be dependent for care on the 3/19/26 MDS (Minimum Data Set) Assessment Section GG0130 Functional Abilities/Self Care.The Surveyor requested the grievance logs from December 2025 through 5/12/26.On 5/12/26 the Surveyor reviewed the grievance logs provided by the Administrator. There were no grievances recorded for any residents in the month of December. There were no grievances on any of the logs from December 2025 through 5/12/26 for Resident #10.Interview with the Administrator on 5/12/26 at 9:12 AM, the Administrator stated that Social Work spear heads the grievance process and all grievances are reviewed by Social Work, the Administrator and the Department involved. The Administrator stated all grievances should be recorded on the log and they try to resolve them in 48-72 hours if possible. The Surveyor asked the Administrator if he remembered Resident #10's RP handing him a grievance related to Resident #10's care on Christmas Day 2025. The Administrator stated he did. The Administrator was asked why this grievance wasn't on the grievance log. The Administrator stated he was not sure why it was not on the log, but he may have a soft file on it.The Administrator followed up with the Surveyor on 5/12/26 at 10:59 AM. The Administrator stated he could not find any file on the grievance and even called the former Unit Manager #14. The Administrator confirmed at that time he was unable to provide any documentation that the grievance was investigated and resolved for Resident #10.

Based on complaint, record review, and staff interview, it was determined the facility failed to report an incident of elopement to the state survey agency, the Office of Health Care Quality. This was evident for 2 (Resident #6, #7) of 8 residents reviewed for elopement during the complaint survey.The findings include: On 5/11/26 at 8:30 AM a review of complaint 2988135 alleged on 4/16/26 at 5:51 PM a passerby stated that Resident #6 had a fall while pushing someone in a wheelchair (Resident #7). Resident #6 and Resident #7 were located on a sidewalk next to a closed restaurant on the corner of a heavily traveled road. This location was down the street from the facility. The complaint alleged Resident #7 was rambling incoherently and that Resident #6 had minor skin tears on the left leg. Resident #7 was observed standing behind the wheelchair, not wearing pants, and wearing only hospital-style grip socks. On 5/11/26 at 8:31 AM a review of Resident #6's medical record was conducted. Review of a 4/13/26 at 18:19 (6:19 PM) progress note for Resident #6 documented, wanderguard applied to the patient's left ankle due to identified risk of elopement. On 5/11/26 at 8:45 AM a review of Resident #7's medical record (Resident #6's spouse) was conducted. Review of a 4/13/26 at 18:20 (6:20 PM) progress note for Resident #7 documented, wanderguard applied to the patient's left ankle due to identified risk of elopement.On 5/11/26 at 12:37 PM an interview was conducted with Registered Nurse (RN) #17, the evening shift supervisor. RN #17 was asked if anyone had recently eloped from the facility. RN #17 stated that Resident #6 and Resident #7 eloped on 4/16/26 around 5:55 PM to 6:00 PM when she was alerted by the front desk that paramedics were in the lobby.On 5/11/26 at 1:07 PM the Nursing Home Administrator (NHA) and the current Director of Nursing (DON) were interviewed and confirmed that Resident #6 and Resident #7 left the building on 4/16/26. The NHA was asked if the elopement was reported to the state survey agency, the Office of Health Care Quality (OHCQ). The NHA stated the incident was not reported to OHCQ because it was not related to abuse. The NHA stated, there was no abuse, so it was not reported. If there was no abuse involved you don't report it. I asked my superiors and they told me just abuse is reported.The NHA and DON were informed that the incident should have been reported to OHCQ as the safety and welfare of Resident #6 and Resident #7 were jeopardized.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#6, #2, #17) of 24 residents reviewed during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1)On 5/11/26 at 8:30 AM a review of Resident #6's medical record was conducted. A review of Resident #6's March 2026 Medication Administration Record (MAR) documented Resident #6 received Cyanocobalamin Solution 1000 mcg/ml injection on 3/28/26. The medication is a synthetic form of Vitamin B12 which is used to treat and prevent Vitamin B12 deficiency, which can cause severe anemia, stomach/bowel issues, and nerve damage. Review of Resident #6's admission MDS assessment with an Assessment Reference Date (ARD) of 3/30/26, Section N0300 Injections, was coded 0. The facility failed to capture the injection. On 5/14/26 at 11:56 AM MDS Coordinator #24 was interviewed and confirmed the injection was not captured.2)On 5/12/26 at 12:31 PM a review of Resident #2's medical record was conducted. Review of a 6/28/25 at 01:00 AM physician's history and physical note the chief complaint/nature of presenting problem was, admission to SNF (skilled nursing facility) for rehabilitation and continued medical management following fall with left lower extremity DVT (deep vein thrombosis), patellar fracture, and cognitive concerns. The note documented was admitted to the acute care facility on 6/19/25 after being found down on the floor of his/her home. The resident had apparently fallen and was unable to get up.Review of Resident #2's admission MDS with an ARD of 7/3/25, Section J1700, fall history on admission/entry or reentry; A: did the resident have a fall any time in the last month prior to admission/entry or reentry? documented, no. This was an error as the resident fell on 6/19/25 at home. The facility failed to capture the fall.Continued review of Resident #2's medical record revealed documentation that Resident #2 had a fall on 8/17/25, 8/18/25, and 8/21/25.Review of Resident #2's Discharge MDS with an ARD of 9/23/25: Section J1800, any falls since admission/entry or reentry or Prior Assessment, documented, no. This was incorrect as the resident had 3 falls since the 7/3/25 admission MDS assessment.On 5/14/26 at 11:49 AM an interview was conducted with MDS Coordinator #24. He reviewed the hospital discharge summary and the change in condition forms and confirmed the errors. He said he didn't know how he missed them.3)On 5/14/26 at 10:30 AM a review of the elopement binder at the front desk revealed 8 names of residents that were an elopement risk. The binder included Resident #17. On 5/14/26 at 10:40 AM a review of Resident #17's medical record revealed an April 2026 Treatment Administration Record (TAR) and a January 2026 TAR that documented Resident #17 wore a wanderguard bracelet every shift.Review of Resident #17's significant change MDS Assessment with an ARD of 1/17/26 and a quarterly MDS assessment with an ARD of 4/19/26, Section P0200 E, wander/elope alarm, was coded no. This was an error as the nurses checked off each shift that the resident was wearing a wanderguard bracelet.On 5/14/26 at 1:44 PM MDS Coordinator #24 reviewed the MDS with the surveyor and confirmed the errors.

Based on medical record review and interview, the facility staff failed to 1) assess a resident's wounds weekly to include measurements and 2) failed to follow wound care provider's orders for a resident. This was evident for 1 (Resident #8) of 3 residents reviewed for wound care during a complaint survey.The findings include:Review of Resident #8's medical record on 5/11/26 revealed the Resident was admitted to the facility in January 2026 from the hospital with a diagnosis to include peripheral vascular disease (PVD). PVD is a slow and progressive circulation disorder characterized by narrowing, blockage or spasms in blood vessels, commonly affecting the legs. Review of the Resident's hospital discharge summary revealed the Resident had a wound from a right 4th toe amputation. Further review of Resident #8's medical record revealed on admission the facility staff assessed the Resident to also have a right heel wound.1)The facility staff failed to do a weekly assessment with measurements of Resident #8's wounds.Further review of Resident #8's medical record revealed the Resident was assessed by the Wound NP on 1/27/26. Review of the Wound NP notes revealed the Wound NP included assessment, measurements and treatment orders for the Resident's right 4th toe amputation and right heel wounds.Further review of Resident #8's medical record revealed on 2/2/26 the Wound NP documented: Patient was unable to be evaluated by the skin and wound team today; patient out of bed times 3 at time of visit. On 2/4/26 the Wound NP documented: Patient was unable to be evaluated by the skin and wound team today; patient at dialysis during time of visit. On 2/9/26 the Wound NP documented: Patient was unable to be evaluated by the skin and wound team today; patient at dialysis during time of visit.Further review of Resident #8's medical record revealed the next wound assessment with measurements was completed by the Wound NP on 2/11/26, 15 days later.During interview with the Director of Nursing (DON) on 5/12/26 at 12:00 PM, the DON confirmed the facility staff failed to assess Resident #8's wounds weekly with measurements from 1/27/26 until 2/11/26. 2)The facility staff failed to administer all wound treatments as ordered for Resident #8.Review of Resident #8's January, February and March 2026 Treatment Administration Records on 5/12/26 revealed the facility staff failed to administer right heel and 4th right toe wound treatments on 1/28, 2/4, 2/7 and 3/15/26.Interview with the Director of Nursing on 5/12/26 at 12:00 PM confirmed the facility staff failed to administer right heel and 4th right toe wound treatments on 1/28, 2/4, 2/7 and 3/15/26 for Resident #8.

Based on complaint, medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 3 (#6, #7, #10) of 10 residents reviewed for complaints 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 should be legible and accurate. 1) On 5/11/26 at 8:30 AM a review of complaint 2988135 stated on 4/16/26 at 5:51 PM a passerby stated that Resident #6 had a fall while pushing someone in a wheelchair (Resident #7). Resident #6 and Resident #7 were located on a sidewalk next to a closed restaurant on the corner of a heavily traveled road. This location was down the street from the facility. The complaint alleged Resident #7 was rambling incoherently and that Resident #6 had minor skin tears on the left leg. Resident #7 was observed standing behind the wheelchair, not wearing pants, and wearing only hospital-style grip socks. On 5/11/26 at 8:31 AM a review of Resident #6's medical record was conducted. Review of a 4/13/26 at 18:19 (6:19 PM) progress note for Resident #6 documented, wanderguard applied to the patient's left ankle due to identified risk of elopement. On 5/11/26 at 8:45 AM a review of Resident #7's medical record (Resident #6's spouse) was conducted. Review of a 4/13/26 at 18:20 (6:20 PM) progress note for Resident #7 documented, wanderguard applied to the patient's left ankle due to identified risk of elopement. Review of Resident #6 and Resident #7's April 2026 Treatment Administration Records documented several shifts where the wanderguard was not applied to Resident #6 and Resident #7. There was no documentation in either medical record as to why the bracelet was not on and how the bracelets were removed. Further review of the medical record failed to produce documentation of the elopement of Resident #6 and Resident #7 on 4/16/26. On 5/11/26 at 12:37 PM an interview was conducted with Registered Nurse (RN) #17, the evening shift supervisor. RN #17 was asked if anyone had recently eloped from the facility. RN #17 stated that Resident #6 and Resident #7 eloped on 4/16/26 around 5:55 PM to 6:00 PM when she was alerted by the front desk that paramedics were in the lobby. RN #17 stated that Resident #6 had scrapes on the knees. RN #17 was asked if she documented the assessment of the residents in the medical record or wrote a note about the elopement. RN #17 stated that she did not document the incident and that the nurse working that evening would document the findings. There was no documentation found in the medical record about Resident #6's scrapes on the knees. On 5/11/26 at 12:51 PM an interview was conducted with Licensed Practical Nurse (LPN) #8, who worked the evening shift on 4/16/26. LPN #8 was asked if she documented the incident and the assessment of Resident #6 and Resident #7 in their respective medical records. LPN #8 stated that she documented in risk. She didn't know she was supposed to document in the medical record also. On 5/11/26 at 1:07 PM the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed. The DON confirmed there was no documentation of the elopement in the medical record, but it was documented in risk. The DON was asked if risk was part of the medical record and the answer was, no. Risk is a part of the electronic medical record system. The electronic medical record system also contains reports and administrative files and is not considered part of the resident's electronic medical record. On 5/11/26 at 1:28 PM the DON stated that prior to the elopement Resident #6 had cut off the bracelets a couple of times, however there was no documentation that Resident #6 had cut the bracelets off and what the resident used to cut them off. Continued review of the medical record failed to produce documentation that the family was notified of the elopement. On 5/11/26 at 1:51 PM the NHA and the Regional Director of Clinical Operations (RDCO) #7 gave the surveyor a copy of the incident where it was documented that the family was notified. They were asked where the family notification was located in the resident's medical record and they stated, it is in risk, to which the surveyor stated, which is not part of the medical record. RDCO #7 confirmed that it was not in the resident's medical record. Review of the incident report that RDCO #7 showed the surveyor had documented on the bottom of the form, privileged and confidential – not part of the medical record – do not copy test. On 5/13/26 at 2:15 PM an interview was conducted with the Owner of the Facility #16. The elopement was discussed and the failure to have documentation about the elopement in the medical record that anything happened. Facility Owner #16 stated that he agreed that there should have been documentation and he would have to make a change to make sure when the staff are documenting, it should go into risk and the medical record. 2) The facility staff failed to document in Resident #10's medical record notification to the RP (responsible party) for a change of condition. Review of Resident #10's medical record on 5/11/26 revealed the Resident was admitted to the facility in 2014. The Resident's medical diagnosis includes Dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life. Further review of Resident #10's medical record revealed the facility staff assessed the Resident on 3/19/26 to have a BIMS (Brief Interview for Mental Status) of 10 of 15, indicating moderate cognitive impairment. In an interview with Resident #10 on 5/11/26 at 9:50 AM, Resident #10 was asked if she wanted her RP to have updates on his/her changes in condition. Resident #10 stated yes. During interview with the Resident's RP on 5/11/26 at 10:14 am, the RP stated the facility staff don't keep him/her updated on all the Resident's changes in condition. The RP gave an example of recently the Resident had a skin tear and the facility staff didn't notify him/her. The RP stated he/she didn't find out until a few days later when he/she came to visit the Resident and a staff member was providing wound care. Further review of Resident #10's medical record on 5/12/26 revealed a change of condition on 2/4/26. Registered Nurse #15 documented the Resident had a skin tear measuring 2 cm by 3 cm. Registered Nurse #15 documented on 2/4/26 the physician was notified, the physician ordered treatment and the Resident was notified. Further review of the Resident's medical record revealed no documented notification of Resident #10's 2/4/26 skin tear to the RP until 2/9/26, 5 days later. Interview with the Director of Nursing on 5/13/26 at 9:30 AM confirmed the facility staff failed to document notification to the RP of Resident #10's skin tear on 2/4/26 in the medical record.

Based on observation and interview it was determined the facility failed to serve food in a sanitary manner. This was evident during the initial tour of the kitchen during the recertification/complaint survey. The findings include:On 11/17/2025 at 7:31AM, during the initial tour of the kitchen an observation of Staff #1 (Dietary Supervisor) and Staff #2 (Dietary aid) were observed in the tray line serving food on breakfast plates with no hair net. On 11/17/2025 at 7:40AM, during an interview with Staff #1(Dietary supervisor) confirmed that both she and Staff #2 were not wearing hair nets. Staff #1 acknowledged that staff working on the tray line, who handle food, should be wearing hair nets. The Dietary Supervisor was made aware of the concern at this time.On 11/21/2025 at 3:30 PM, the Administrator and Director of Nursing was made aware of the concern.

Based on staff interviews and record reviews, it was determined that the facility failed to ensure governing body oversight of the facility's Quality Assurance and Performance Improvement (QAPI) Program and activities. This was evident during the recertification/complaint survey.The findings includeThe governing body and/or executive leadership are organized groups or individuals who assume full legal authority and responsibility for operation of the facility.On 11/21/25 at 2:00 PM the Director of Nursing (DON), who is also the QAPI contact person was asked in an interview if the QAPI committee have governing bodies, and she responded, Not sure''. She was asked who the governing bodies are, and she said: she did not know. She was asked if the facility's governing body and/or executive leadership maintain oversight of their QAPI program and activities per S483.75(f)(1)-6) and she said No.In another interview with the administrator on 11/21/25 at 2:35 PM, he was asked if the facility has a governing body that oversees their QAPI program activities, and he said no, and asked if they were supposed to have one. He was made aware that it is a federal requirement that the facility should have one and that it also says so in their QAPI policy.On 11/21/25 at 2:40 PM the administrator came back to report that their governing body is Atlas, but they do not report their QAPI activities to them. He was made aware that this was a concern.

Based on surveyor observations and interviews with facility staff, it was determined that the facility failed to maintain an effective pest control program. This was found to be evident during the facility's recertification/complaint survey.The findings include:During the survey several observations were made of gnats in the building. On the first day of entry into the facility on [DATE], the surveyor observed multiple flying gnats in the facility's conference room.On 11/20/25 at 2:27 PM as the surveyor entered the laundry area with the Managing Partner and on the tour observed 2 rooms on the dirty side and 2 rooms that were considered clean (one with the dryers and a folding table and one separate room where two laundry staff were folding clothes. Upon entering the dirty side of the laundry area (one smaller room where the laundry chute empties and a larger, rectangular room with 3 washing machines), the surveyor observed gnats flying around in both rooms on the dirty side. There were more observed in the small room where the laundry chute empties into the gray tub. During an interview with Laundry #23 when asked about the fruit flies she stated, Yes, most of the time there are fruit flies. I think it is from the urine (and pointed to the two heaping mounds of dirty laundry in the smaller room). The surveyor shared that it was a concern and Laundry #23 verbalized understanding. An interview was conducted with the Managing Partner on 11/20/25 at 2:34 PM when he entered the dirty side. During the interview, a dual observation of the gnats was made, and he stated the facility had an insect/pest maintenance program with Allstate who comes at least once a month. The surveyor shared the concern of the gnats and the Managing Partner acknowledged understanding. Additionally, he stated I'll make sure they treat the drain here like they do in the kitchen. Throughout the survey conducted from 12/17/25 through 12/21/25, there were several observations made each day of gnats in the conference room from all members of the survey team. On 12/21/25 at 1:25 PM the surveyor shared the concern of the gnats in the conference room with the Nursing Home Administrator (NHA). He stated that he had never seen gnats in the conference room. This surveyor asked the three surveyors who were in the conference room at that time if they had seen gnats throughout the survey and they all verified they had. The surveyor shared this was a concern and the NHA confirmed understanding.

Based on record review and interviews, it was determined that the facility failed to notify the resident's physician and resident representatives of a facility acquired pressure ulcer. This was true for 1 (Resident #9) of 2 residents reviewed for pressure ulcer during the recertification/complaint survey process.Findings included:According to the Center for Medicare and Medicaid services (CMS), a stage 1 wound is describe as, an observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence; may include changes in skin temperature, tissue consistency and/or sensation. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues.Change of Condition (CoC) is a standardized tool for health professionals to communicate important details about resident's care to include significant changes in a resident's physical, mental, or psychological status. This tool/form helps ensure early detection and timely intervention, as unaddressed changes can lead to serious complications. This tool will also prompt the writer to indicate who the changes have been communicated to.On 11/17/2025 2:57 PM, a review of Resident #9's wound care consult notes revealed that on 11/14/2025 a new facility acquired Pressure Ulcer, Stage 1 was identified on the left heel. The wound care consult notes described the wound as Epithelial: 100% intact epithelium with evidence of superficial damage (red/pink nonblanchable discoloration). Wound care treatment identified as: Skin Prep; Other Dressings: Leave open to air. On 11/21/2025 12:54 PM, in a Director of Nursing (DON) interview, she was asked to explain the facility's process for a new facility acquired wound. She explained that if a wound of unknown origin was identified on a resident, they would investigate how the wound developed and if they were able to find out the cause, they would educate staff and put interventions in place to prevent further incidents from happening. The nurse would notify the resident's physician to obtain treatment and/or interventions, and the Resident Representative would be notified of the newly identified wound and the treatment plan moving forward. The wound care team would also reach out to the family as well to notify them of the wound care treatment plan. The DON was asked how the facility documents wound notification, and she explained that new skin issues were documented on the e-interact Change of Condition form that would generate a progress note in the electronic medical record (EMR) chart. She was asked the timeframe of when the documentation should be placed in the Resident's chart, and she explained that it should be placed in the EMR the same day the wound was identified. The DON was asked to provide documentation to support that Resident# 9's physician and resident representative were notified of the newly developed left heel pressure ulcer.On 11/21/2025 at 3:00 PM, in a DON interview, the DON stated that there was no documentation to suggest that the facility notified the physician and resident's representatives that the resident developed a new wound in the facility. The DON was asked if the expectation that documentation should have been available and she stated yes. She was informed that it would be a concern, and she acknowledged the concern. The Nursing home administrator was also present for this notification.

Based on interviews and record reviews it was determined that the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold, including reserve bed payment. This was evident for 1(Resident #10) of 3 residents reviewed for hospitalization during the recertification/complaint survey.The findings include:On 11/17/2025 at 12:06 PM during the initial tour of the facility, Resident #10 was asked if he has been sent out to the hospital emergently and he said he went sent out recently but was not sure if he was given a bed hold policy at the time.Review of the facility census on 11/19/25 at 1:42 PM revealed that Resident #10 was hospitalized on [DATE] due to abnormal MRI result and came back to the facility on [DATE]. Notice of facility-initiated transfer was given to the residents and was signed and dated 10/2/25. Further review however did not show that a bed hold policy was given to the resident or their representatives.On 11/9/25 at 2:02 PM, the administrator was asked in an interview if a copy of the bed hold policy was given to Resident #10 when s/he was transferred to the hospital and he said yes, he was asked to provide the copy.On 11/19/24 at 2:25 PM the administrator came back to report that it was not given to this resident, that the nurses said they were not aware they have to give it to the resident. They thought it was only the notification of transfer that was required to be given. He was made aware that this was a concern.

Based on Observation, record review and facility staff interviews, it was determined that the facility 1) failed to update the care plan of Resident #2 who is on isolation precaution to reflect the actual status of the isolation and, 2) failed to conduct care plan meetings of the interdisciplinary team for Resident #11 at the time of the quarterly revision of their care plan. This was evident for 2 (Resident #2 and #11) out of 56 residents reviewed for care plans during this recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's health status, functional abilities, and needs. It is administered to all residents upon admission, quarterly, yearly, and whenever a significant change in an individual's condition occurs. It is the foundation for creating an individualized care plan and ensures the appropriate care and services are provided to each resident. Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). Contact Precautions include the use of a gown and gloves every time a caregiver enters a resident's room, regardless of care provided to the resident. Residents on Contact precautions should be in private rooms and restricted to their rooms except for cares that are medically necessary. EBP involves the use of gowns and gloves for high-contact resident care activities. Residents on Enhanced Barrier Precautions may share rooms with other residents. EBP do not impose the same activity and room placement restrictions as Contact Precautions. Residents can remain on EBP until their wound heals or their indwelling device is removed. Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that is resistant to many common antibiotics, making infections more difficult to treat. 1) On 11/19/25 at 10:20 AM during the initial tour of the facility, the surveyor observed an enhanced barrier precaution sign posted outside Resident #2's door secondary to a wound infection. The resident also shares a room with 2 other residents on EBP. Review of Resident #2's care plan on 11/21/25 at 10:02AM however revealed that resident still had an active care plan related to being on contact isolation written as: I have MRSA- Colonized in wound. Date Initiated was 05/19/2025. Further review revealed another care plan that reads: I require contact isolation precautions, R/T Multidrug-resistant Pseudomonas aeruginosa. Date Initiated: 05/19/2025 Revision on 05 /19/25. Some of the interventions were to place the resident in a private room. Review of the physicians order dated 5/19/25 revealed orders written as: Contact Precautions for MRSA in Wound: Maintain contact precautions for the duration of the infection. Discontinue precautions 72hrs after antibiotics unless symptoms continue every shift for Precautions until 06/02/2025 23:40. On 11/21/25 at 10:14 AM In an interview with staff #4, a unit manager, she was asked what sort of isolation precaution Resident #2 was on, and she said resident was on enhanced barrier precaution. She was asked if the resident was still on contact precaution and she checked the records and said that resident had an order to be on contact precaution from 5/19/25 and to come off of isolation on 6/2/25. She was asked who updates the care plan and she said it's done mostly by herself or the nurses. She was made aware that the resident's care plan has not been updated to reflect that resident was no longer on contact isolation precaution. She confirmed that the care plan was not updated. On 11/21/2025 at 11:50 AM the Director of Nursing (DON) was made aware of the concern. 2) On 11/19/25 at 2:43 PM in an interview with the Director of Social Work (DSW #14) when asked about care plans and care plan meetings, she stated, Basically discussing the plan of care and if they want to keep their MOLST (Medical Orders for Life-Sustaining Treatment, a medical form that translates a patient's wishes for end-of-life care into a set of doctor's orders) the same and answering questions or concerns. During the interview when asked how often care plan meetings were held, she stated, Upon admission within 21 days and quarterly for long term care residents. Additionally, she stated whenever their quarterly assessment was completed. The surveyor asked if a resident had a MDS assessment completed, for example, on 1/1/25, when would the care plan meeting be held and DSW #14 stated, Within 14 days. Finally, when asked what documentation would be in the resident's medical record after a care plan meeting, she stated, IDT (Interdisciplinary Team) Care Plan Meeting Note. During a review of Resident #11's medical record on 11/19/2025 3:01 PM, it was revealed that Resident #11's MDS assessments were completed on 5/14/24, 8/14/24, 11/14/24, 2/14/25, 5/15/25, and 8/15/25. Further review revealed the following IDT Care Plan Meeting Notes completed on 5/21/24, 8/27/24, 11/11/24, 2/10/25, 5/12/25 and 8/15/25. However, for the following dates: 11/11/24, 2/10/25, 5/12/25, the IDT Care Plan Meeting Note was held prior to the completion of the MDS assessments. On 11/19/2025 at 3:38 PM in an interview with DSW #14 she verified and confirmed that the care plan was based on the MDS assessment. When asked how 3 out of 6 care plan meetings were held prior to the completion of the MDS assessment she stated, If there's a bunch of care plans due for people, it's possible that we held the care plan meeting earlier since it was close to the MDS. During the interview when asked if care plan meetings should be held prior to the completion of the MDS assessment, DSW #14 sated, No. The surveyor shared the care plan meetings held prior to the MDS assessment being completed were a concern. DSW #14 verified and confirmed understanding.

Based on a complaint, record review and staff interviews, it was determined that the facility failed to administer medications to a resident timely, and as ordered by the physician. This was evident for 1 (Resident #105) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey.The findings include,On 11/18/25 at 10:15 AM in an interview with a complainant, they revealed that a hospital physician told them that Resident #105 had a stroke because s/he was not getting their blood thinning medications as prescribed. The complainant also stated that the blood thinner was later switched to a different one that required closer monitoring.A review of the residents ordered medication on 11/18/25 at 10:29AM revealed that Resident #105 was prescribed on 1/30/25 a blood thinning medication Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Deep vein thrombosis (DVT) a blood clot to the lower extremities. This medication was later switched on 10/7/25 to a different brand - Warfarin Sodium Oral Tablet 5 MG (Warfarin Sodium) Give 5 mg by mouth at bedtime for DVT.Further review of the actual medication administration time for September and October 2025 on 11/18/25 at 10:38 AM revealed that these medications, including others, were given on some days 2-6 hours late with no documentation as to why the meds were given late. Some examples of these medications include:Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day for Anxiety. Start time 09/05/2025 at 08:00. Given on 09/05/2025 at 11:58. Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT Start time 09/05/2025 at 08:00. Given On 09/05/2025 at 11:58. Metformin HCl ER Tablet Extended Release 24 Hour 500 MG Give 2 tablet by mouth every 12 hours for DM. (Diabetes Meletus). Start time 09/06/2025 at 08:00. Given on 09/06/2025 at 15:28. Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT. Start time 09/06/2025 at 08:00. Given on 09/06/2025 at 15:28.Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 500 mg by mouth two times a day for DM Give with Food. Start time 10/28/2025 at 18:00. Given on 10/29/2025 at 01:26.Warfarin Sodium Oral Tablet 1 MG (Warfarin Sodium) Give 1 tablet by mouth in the evening for CVA GIVE WITH 2.5 MG FOR A DOSE 3.5 MG. Start time 10/28/2025 at18:00. Given on 10/29/2025 at 01:27.Warfarin Sodium Oral Tablet 2.5 MG (Warfarin Sodium) Give 1 tablet by mouth in the evening for CVA GIVE WITH 1MG FOR TOTAL DOSE OF 3.5 MG. Start time 10/28/2025 at 18:00. Given on 10/29/2025 at 01:27.On 11/18/25 at 12:15 PM in an Interview with staff #10 a Registered Nurse (RN) she was asked about their med pass policy, and she said the window is 1 hour before and 1 hour after the scheduled administration time. She was asked if the nurse should document the reason why a medication was given late, she said the nurse should. She was asked if Resident #105 refuses her medications sometimes and she said the resident did not. She was made aware that she gave meds 3-6 hours late to Resident #105 without documenting the reason for the lateness and that this was a concern.On 11/18/25 at 12:43 PM in an interview with the Director of Nursing (DON) about med administration policy, she was asked about their medication administration policy. She confirmed that it should be given one hour before or one hour after the scheduled time. She was asked if she was aware that meds are being given 3-6 hours late. She stated that she provided education to staff on med. policy. She was made aware that this was still a concern.

Based on observation, record review, and interview it was determined the facility failed to assist with feeding for a resident at risk for aspiration. This was evident for 1 (Resident #16) of 2 residents reviewed for Nutrition during the recertification/complaint survey.The findings include:According to guidelines from the Centers for Disease Control and Prevention (CDC) Aspiration is the inhalation of foreign material such as food, liquids, saliva, stomach contents (including acid/vomit), or foreign objects/airborne particles into the respiratory tract or lungs. Aspiration precautions are the practices used to prevent these substances from entering the airway and lungs instead of the esophagus and stomach.On 11/18/2025 at 8:43 AM, an observation was made of Resident #16 attempting to feed his/herself while lying in bed, there was no staff member present.On 11/18/2025 at 3:21 PM, a review of Resident #16's medical record revealed a physician order for Aspiration Precautions, dated 06/23/2025. Instructions included: position patient upright during meals, provide oral care before and after meals, 1:1 meal assistance, small sips/bites, alternating liquids and solids, allowing extra time for swallowing, and discontinuing the meal if increased coughing or difficulty swallowing solids/thin liquids occurs. On 11/18/2025 at 3:26 PM, a review of Resident #16's medical records showed a care plan (dated 06/24/2025, revised 07/21/2025) identifying an actual/potential aspiration risk due to dysphagia, evidenced by coughing or choking during meals or medication swallowing. An intervention dated 06/24/2025 included 1:1 assistance with meals.On 11/19/2025 at 8:25 AM, an observation was made of Resident #16 lying in bed, with a tray of food, and no staff member present. On 11/19/2025 8:28 AM, during an interview, Staff #11 Licensed Practical Nurse (LPN, Unit manager) defined a 1:1 assist: sitting facing the resident, assisting with each bite and drink, and immediately reporting choking, pocketing, or changes to the nurse. She confirmed Resident #16 was alone with a breakfast tray and there were no staff members present. She was made aware of the concern, which included this second observation that Resident #16 was not receiving 1:1 assistance for feeding from staff during the meal.On 11/19/2025 at 9:18 AM, the Director of Nursing (DON) clarified her expectation that a physician order and care plan for 1:1 feeding assistance (due to aspiration/choking risk) requires continuous staff presence with the resident. The DON was informed of this concern during the interview.

Based on observation, medical record review, and interviews, it was determined that the facility failed to 1) maintain a nasal cannula in a sanitary manner and administer Oxygen according to the prescribed physician order (Residents #6), and 2) failed to provide necessary respiratory care services for Resident #30. This was evident for 2 (Residents #6 and #30) of 3 residents reviewed for respiratory care during the recertification/complaint survey.The findings include: 1) On 11/17/2025 at 11:20 AM, during an observation and interview, Resident #6 was seated in a wheelchair. The oxygen tubing was on the floor next to the bed, not dated, and not connected to the oxygen concentrator. Resident #6 was observed without oxygen and stated that oxygen causes his/her nose to bleed. On 11/17/2025 at approximately 11:25 AM, during an interview, Staff #3, Registered Nurse (RN), confirmed that Resident #6 was not receiving Oxygen (O2) as ordered by the physician. Staff #3 verified that the oxygen tubing was on the floor, was not bagged or dated, and was disconnected from the oxygen concentrator. Staff #3 stated that the oxygen tubing should be properly bagged, dated, administered according to the physician's order, and should not be on the floor. On 11/18/2025 at 8:37 AM, an observation was made of Resident #6 sitting up in a wheelchair, no oxygen was present. The Oxygen concentrator was in the room and had no further supplies available of nasal cannula tubing or water bottle (humidifier used to add moisture to oxygen to prevent dryness and irritation to the nasal passages). On 11/18/2025 at 8:56 AM, in review of Resident #6's medical record revealed a Physician order dated 10/24/2025 for Oxygen at 2L/min (Liters per minute) via Nasal Cannula continuously. Further review of Resident #6's Medication Administration record revealed the oxygen was administered on 11/17/2025 and 11/18/2025 during the day shift. However, during observation on those dates Resident #6 was not receiving any Oxygen. On 11/18/2025 at 9:04 AM, further review of Resident #6's Treatment Administration Record (TAR) revealed a physician's order, dated 10/27/2025, for weekly oxygen tubing changes, including changing and dating the tubing, washing the filter, and changing and dating the water bottle (if applicable). Although the TAR indicated that this was completed during the Monday night shift on 11/17/2025, an observation made on 11/18/2025 at 8:37 AM of Resident #6 sitting in a wheelchair without wearing oxygen, and the oxygen concentrator in the room had no oxygen supply tubing attached. On 11/18/2025 at 9:16 AM, an interview with Staff #5 Licensed Practical Nurse (LPN), confirmed that Resident #6's continuous oxygen was signed as it was administered for the 11/17/2025 night shift. Staff #5 verified that Resident #6 was not receiving the prescribed oxygen, the tubing for Oxygen and a water bottle were absent from the room. Staff #5 stated that a resident ordered continuous oxygen should have the oxygen in place. On 11/18/2025 at 9:29 AM, a continued review of Resident #6's medical record revealed a care plan for Oxygen with an intervention to administer Oxygen per Physician orders. On 11/18/2025at 12:06 PM during an interview, the Director of Nursing (DON) stated that night shift staff change oxygen supplies weekly, adhering to the physician's order. If a continuous oxygen order is in place, the DON expects the oxygen concentrator and necessary supplies to be in the room and the oxygen administered continuously. This concern was shared with the DON at the time of the interview. 2) On 1/17/2025 at 12:49 PM, the surveyor observed Resident #30 resting in bed with eyes closed, no acute distress noted. The resident had a tracheostomy which was connected to machine via a trachea mask and tube. The surveyor observed a bag of clear fluid hanging on the humidifier machine dated 10/31/2025; there was no identifiable descriptive label of the fluid that is connected to the machine. There was an undated open bottle of distilled water stored underneath the humidifier machine. The surveyor also observed that the resident's suction canister and tubing was dated 11/5/2025. On 11/17/2025 at 12:55 PM, the surveyor asked the resident's nurse (Staff #29), if there was a Respiratory Therapist (RT) in the facility, he explain that there was a contract agency that provides respiratory care services, but he was uncertain how often they provide service to Resident #30. He stated that whenever the respiratory therapist visits, they would change all the tubing related to the tracheostomy including suction. The surveyor alerted him to the unlabeled open bottle of distilled water at the bedside, he was asked about the purpose of the distilled water, and he explained that the distilled water was used in the humidifier machine by pouring the water in the clear pouch that hung above the humidifier machine. He was asked when the distilled water bottle was first opened and he explained that he was not sure, but he knew it was not there for very long because the bottles were used and emptied often. He was informed that the distilled water bottle was not labeled. On 11/17/2025 at 1:00 PM, The surveyor spoke with Staff #4 (unit manager), she was asked about how often the RT comes into the facility to provide care and she stated she was not sure. She was asked who was responsible for changing the tubing related to the suction and she stated that the nurses were capable to change the tubes but she was not sure how often they were required to change it, she explained that the Director of Nursing (DON) could provide further clarification. On 11/18/2025 12:17 PM, the DON was informed about the above-mentioned respiratory care findings for Resident #30. She was asked who is responsible for changing the respiratory tubing for residents with a tracheostomy and she stated that the RT (who comes in weekly) or the unit manager. She was informed that the unit manager was questioned but she was unable to provide an answer to the surveyor. On 11/18/2025 1:10 PM, a second observation made for Resident #30's respiratory care equipment and the surveyor observed the same concerns minus the open distilled water bottle. On 11/18/2025 at 2:30 PM, an observation of Resident #30's room was made with the DON and nursing consultant. The DON was shown the hanging fluid that was connected to the humidifier with a date of 10/31/2025. The suction set-up and tubes were dated 11/5/2025. The DON was asked who was responsible for suctioning and she stated the nurses are responsible for suctioning the resident. She was then asked about the responsibility of the RT company for changing the tubing and she stated that she would have to reach out to the respiratory company to get the frequency of change required and report back. They were also shown the concern for the unidentified hanging fluid attached to the humidifier and the DON acknowledged the concern. On 11/18/2025 3:39 PM, a review of the Treatment Administration Record revealed that resident had an order for: Tracheostomy Collar Equipment: change and date corrugated tubing, water bottle if applicable, oxygen tubing, and tracheostomy mask, a review of the suction tubing and canister every night shift every Tue -Start Date: 03/04/2025 11 PM. The documentation on the TAR suggested that the above-mentioned respiratory care services was provided on 11/4/2025 and 11/11/2025 by staff; however, the surveyor's observation on 11/17/2025 and 11/18/2025 revealed that the suction tubing and canister was last changed on 11/5/2025 and the water pouch was last changed on 10/31/2025. On 11/19/2025 3:04 PM, the DON stated that the suction tubing and the water pouch were to be changed every month according to the respiratory company. On 11/20/2025 10:35 AM, The DON was notified that an order for weekly change of the respiratory equipment was ordered and documented on the TAR. Therefore, was still a concern for the surveyor, no additional comments offered by the DON at that time.

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure parameters used to determine if a resident was to be administered pain medication was adhered to by nursing staff, and failed to have a physician's order for non- pharmacological interventions for residents on pain medications. This was evident for 3 (Resident #6 and #84, #4) out of 3 residents reviewed for pain during the recertification/complaint survey. The findings include: A pain scale is a numerical scale, usually 0-10, used to determine the severity of a person's pain. Parameters (Instructions in order on when a medication can be given) for a pain scale are used to determine which pain medication would be given according to a person's severity of pain. Non-pharmacological interventions are methods that manage or reduce pain without the use of pain medication. 1) On 11/17/2025 at 11:09 AM, during an interview with Resident #6 he/she reported pain and inadequate pain medication, noting he/she had informed multiple staff members. On 11/18/2025 at 9:37 AM, review of Resident #6's medical record revealed a Physician order that was dated 10/24/2025 for Oxycodone to be given every 8 hours as needed for a pain level scale for 6-10. On 11/18/2025 at approximately 9:40 AM, review of Resident #6's medical record revealed a physician's order dated October 28, 2025. The order was for Acetaminophen Oral Tablet 500 MG (Acetaminophen), with instructions to give 2 tablets by mouth every 8 hours as needed for pain. Do not exceed more than 3 grams per day from all sources. The order, however, lacked any pain parameters to indicate the appropriate pain scale for administering the medication. On 11/18/2025 at 9:43 AM, further review of Resident #6's MAR (medication administration record) for the month of November 2025, showed Oxycodone was administered 17 times for a pain level below a pain level of 6. And the Tylenol was given twice for a pain level of 6 and 7 on 11/16/2025 and 11/17/2025. On 11/18/2025 at approximately 9:45 AM, further review of Resident #6's physician orders indicated that there was no physician order for non-pharmacological interventions. 2) On 11/17/2025 at 12:39 PM, during an interview with Resident #84, he/she reported having to wait on pain medications. On 11/18/2025 at 10:34 AM, Resident #84's medical record revealed two physician orders for pain management. The first order, dated 10/27/2025, was for oxycodone Oral Tablet 15 MG, to be given 15 mg by mouth every 4 hours as needed for pain. The second order, dated 10/21/2025, was for Acetaminophen Oral Tablet 500 MG, instructed to give 2 tablets by mouth every 8 hours for pain. However, the record lacked any specified pain parameters to guide the administration of either medication. Furthermore, there was no corresponding order for non-pharmacological interventions. On 11/18/2025 at 11:59 AM, during an interview with the Director of Nursing (DON), the DON stated the expectation that residents receiving as needed (PRN) pain medication must have pain parameters established and followed. Non-pharmacological interventions, which are documented as a physician's order, should be implemented prior to administering pain medication. At this time, the DON was informed of the concerns. 3) This surveyor reviewed Resident #4's clinical record on 11/20/25 at 8:30 AM. This review revealed that the resident's primary physician wrote an order on 10/17/25 for Oxycodone 150 mg every 6 hours as needed for breakthrough pain (6-10). A review of the Medication Administration Record (MAR) revealed the resident reported a pain level of 4 on 10/29/25 and 5 on 10/30/25. The medication was administered even though the pain scores were below the threshold. The Director of Nursing was interviewed on 11/20/25 at 9:10 AM. She was shown the MAR, the finding was explained, and she was asked if she had an explanation. She said she would review the clinical record.

Based on record review and staff interviews, it was determined that the facility failed to report irregularities identified by the pharmacist to the attending physician for follow up. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medication during the recertification/complaint survey.The findings includeOn 11/19/2025 at 9:22 AM review of the physician's order revealed orders for pain medication written as: Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug*give 1 tablet by mouth every 8 hours for Pain and Oxycodone HCl Oral Capsule 5 MG (Oxycodone HCl) *Controlled Drug*Give 1 tablet by mouth every 3 hours as needed for breakthrough pain. The facility was asked to provide a monthly pharmacy review from January to October 2025.On 11/20/2025 at 9:02 AM review of the pharmacist monthly report revealed that the pharmacist recommended in March 2025 to add Narcan, a drug used to reverse the effect of narcotics. Resident #7 was on oxycodone which is a narcotic medication used to treat moderate to severe pain. The facility did not follow the pharmacist recommendation and documented that Resident #7 was hospitalized at the time. Review of the census, however, revealed that the resident was not hospitalized . The Director of Nursing (DON) was asked to clarify.On 11/20/2025 at 10:03 AM the DON confirm that the March recommendation was not carried out and that resident was still in the facility and not hospitalized at the time when the recommendation was made. She was made aware that this was a concern.

Based on observation and interview it was determined that the facility staff failed to 1) ensure treatment carts were locked and secure, and 2) failed to store all drugs in a locked compartment as required. This was evident for 1 out of the 4 nursing units observed in the facility during the recertification/complaint survey.The findings include: 1) This surveyor observed on 11/17/25 at 8:23 AM the treatment cart across from room [ROOM NUMBER] was unlocked. The contents included: gauze pads, a tube of triple antibiotic ointment, a tube of hydrocortisone ointment, a container of wound cleanser solution, a tube of Lidocaine cream (name of resident was worn out), a container of hydrogel, a tube of Mupirocin ointment labelled for Resident #145, Medi honey wound and burn dressing patches sizes 4x5 and 2x2, one pair of bandage scissors, a tube of Vitamin A&D ointment, a tube of antifungal cream, a tube of Santyl ointment labelled for Resident #102, a tube of Nystatin cream, a tube of ketoconazole cream, a tube of bacitracin, a container of Triamcinolone acetonide cream, a container of terbinafine hydrochloride cream, a tube of ACTi vice gel for pain relief, a container of Greer's goo with a label for Resident #42, Bisacodyl suppositories, 2 containers of Vashe wound solution -- one labelled for Resident #145 and another for Resident #117. This surveyor stood at the unlocked treatment cart with the drawers open till 8:36 AM. While standing by the cart, no one approached or spoke to this surveyor. This surveyor approached staff #5 who was an LPN at 8:39 AM and told him that the treatment cart was unlocked. He acknowledged what was said, verified that he could see the unlocked treatment cart, and walked up to the cart and locked it. 2) On 11/17/2025 at 10:19 AM, the surveyor observed an unattended open bottle of aspirin 81mg (containing several white pills) on top of a medication cart on the Ocean Pines Unit (odd side, adjacent to room [ROOM NUMBER]). On 11/17/2025 at 10:20 AM, in an interview with the unit manager (Staff #4), she was notified and shown the bottle of aspirin left unattended on the top of the medication cart. She said she would talk to the nurse who was responsible for that medication cart. The unit manager spoke with nurse #28 and she reported to the surveyor that the nurse stated that it was an oversight. The surveyor notified the unit manager that the unattended medication will be a concern, and she acknowledged the surveyor's findings.

Based on review of medical records and other pertinent documentation and interviews, it was determined that the facility failed to have an effective system in place to ensure that a resident's wishes regarding cardiopulmonary resuscitation (CPR) were clearly and accurately communicated to facility staff. This was found to be evident for 3 out of 7 residents reviewed for advance directives or death. (#184, #53, and #91) This failure resulted in an Immediate Jeopardy for Resident #184. The findings include: Review of Resident #184's medical record revealed the resident was admitted to the facility secondary to the initiation of hemodialysis. The resident's diagnosis included but was not limited to, chronic kidney disease, heart disease, high blood pressure and diabetes. The resident was less than [AGE] years old at the time of admission, was cognitively intact as evidenced by a BIMS (Brief Interview for Mental Status) score of ,d+[DATE], and was his/her own responsible party. Review of the electronic health record revealed the resident had an order for Full Code (Attempt CPR) in effect from [DATE] until it was struck out by the unit nurse manager (Staff #23) on [DATE] at 4:54 PM. Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form that includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. It is valid in all healthcare facilities and programs throughout Maryland. Section 1 includes orders to Attempt CPR or No CPR. Included in the No CPR section are three options: A-1 Intubate; A-2 Do Not Intubate but comprehensive efforts may include limited ventilatory support by CPAP or BiPAP; or Option B No CPR, Palliative and Supportive Care, do not intubate or use CPAP or BiPAP. During review of the paper chart on [DATE] the surveyor found an active MOLST, dated [DATE], that included an order to Attempt CPR (full code). A copy of this MOLST was requested and received on [DATE]. After a meeting with the DON, the Nurse Practitioner (NP), Staff #37, and the corporate nurse, Staff #15, on [DATE] at 12:10 PM, in which the resident's code status was discussed, a MOLST with orders for No CPR Option A-2, dated [DATE] and signed by the NP, Staff #37, was provided by the Director of Nursing. The DON reported s/he had found it in the paper chart. On [DATE] at 3:12 PM the DON reported s/he was not aware of documentation by NP, Staff #37, to indicate a visit was conducted with the resident on [DATE] (date of the DNR MOLST). Earlier in the survey, the surveyor had identified a concern regarding the failure to ensure NP, Staff #37's notes were available in either the electronic health record, or the paper chart, and this concern had been addressed with the DON and corporate nurse on [DATE] at 3:45 PM. On [DATE], the DON provided copies of several progress notes written by NP, Staff #37, including a note dated [DATE]. Review of this note revealed a visit was conducted on [DATE] in which the MOLST (Maryland Orders for Life Sustaining Treatment) was reviewed with the patient who wanted Option A-2 (No CPR, Do Not Intubate (DNI): Comprehensive efforts may include limited ventilatory support by CPAP or BiPAP, but do not intubate). This note also included a notation that the primary care physician (PCP), Staff #48, was Made aware of pt's change in code status and agreed with the POC (plan of care) for now. PCP will review with patient. Further review of the medical record revealed the Primary Care Physician (PCP), Staff #48, also visited the resident on [DATE]. Review of the note for this visit revealed in the Advanced Directives section: [DATE]- patient has the capacity to make decisions and requests full code and will accept blood transfusion and dialysis, tube feeding to be determined. This [DATE] notation in the Advanced Directives section of the PCP note continued to appear in all of the PCP's notes, including the most recent PCP note found in the medical record, which was dated [DATE]. No documentation was found in the [DATE] progress note to indicate the resident wished to change his/her code status to No CPR (DNR). Further review of the electronic health record revealed multiple social service notes that indicated the resident's code status was reviewed and that the resident wished to remain a full code. These progress notes include: - On [DATE] Social Service Worker, Staff #39, met with the resident. The note included the following: Current code status was reviewed and the resident would like to remain under a full code status according to the MOLST on file. -On [DATE], there was a care plan meeting. The corresponding note was written by the Social Service Worker, Staff #40, and included a statement that the resident was able to participate in person at the care plan meeting with the IDT (interdisciplinary team). The corresponding sign-in sheet for this meeting revealed one of the IDT members in attendance was the unit nurse manager, Staff #23. The note for this meeting included: Code status was reviewed and will remain Full Code. - On [DATE] social services worker, Staff #40, completed a quarterly assessment. The note for this assessment revealed the resident was his/her own RP [responsible party] and able to make needs known and that the code status was reviewed and will remain at Full Code as outlined on MOLST. - On [DATE] there was a care plan meeting. The corresponding note revealed the resident attended the meeting and included the following statement: Full Code status at this time. The corresponding sign-in sheet for this meeting revealed one of the IDT members in attendance was the unit nurse manager, Staff #23. - On [DATE], social service worker. Staff #40, completed a quarterly assessment. The note for this assessment revealed the resident was able to make his/her needs known; and Code status was reviewed and will remain at Full Code. Review of notes completed by the NP, Staff #37, for visits on [DATE], [DATE] and [DATE], all included the notation Code Status: Full/EMS. These notes were provided by the NP to the surveyor on [DATE] at 2:34 PM, at which time the surveyor reviewed the concern with NP #37 that none of the NP notes were found in either the EHR (electronic health record) or the paper chart. Interview with the NP on [DATE] revealed confirmation that the Full/EMS notation indicated the resident was a full code (Attempt CPR). Of note, a version of these same notes that were provided by the DON on [DATE] did not include the references to Code Status. Further review of the paper chart on [DATE] revealed the dialysis communication sheets, dated [DATE] and [DATE] with notations that the resident was a full code. On [DATE] at 1:20 PM, the surveyor observed that residents who attended dialysis had a communication notebook which was separate from the paper chart on the unit. Review of the communication notebook, for a Resident #91, who was currently receiving dialysis, revealed that a copy of the MOLST was kept in the communication notebook. Further review of several months worth of Resident #184's dialysis communication sheets failed to reveal a notation other than Full Code in the Code status section. A review of facility self-report MD00181520 revealed that, on [DATE], the Resident's breathing ceased related to potential complications at the IV access point, the resident's MOLST was DNR and no CPR was performed. Further review of the EHR order for full code, that was struck out by the unit nurse manager, Staff #23, revealed it was struck out on [DATE] at 4:54 PM with a notation of wrong chart. Additionally, on [DATE] at 4:50 PM, the unit nurse manager, Staff #23, put a new order in the electronic health record for a DNR, with an order date of [DATE]. This DNR order was electronically signed by the primary care physician (PCP), Staff #48, on [DATE]. On [DATE] at 10:59 AM, the unit nurse manager was interviewed regarding the events that occurred on [DATE]. S/he reported that, based on the MOLST that was in the resident's chart, the resident was a DNR/DNI with hospital transfer. S/he confirmed that the EHR said full code but the MOLST said DNR. When the surveyor reviewed the concern that the MOLST found in the paper chart documented the resident was a full code, the unit manager reported the MOLST s/he saw was a DNR with hospital transfer. S/he reported that s/he entered the DNR order in the EHR based on the MOLST and that s/he had not spoken to the PCP prior to entering the order. On [DATE] at 12:10 PM, an interview was conducted with PCP, Staff #48, with the NP, Staff #37, DON, and corporate nurse present. When asked why s/he signed the DNR order after the resident expired, the PCP reported: s/he did not know where the DNR order came from, did not recall a change in code status, had not read every word when signing the monthly orders, was not aware that s/he signed the DNR order and would not have signed it if s/he had known it was there. Based on the above findings the facility had failed to identify the issue that the resident repeatedly indicated they wished to be a full code despite having an active MOLST for DNR. On [DATE] at 12:40 PM a determination of immediate jeopardy was made in regard to the continued failure to have clear and accurate documentation of a resident's code status putting residents at risk of not receiving CPR when indicated. On [DATE] at 3:00 PM, the first version of a plan to remove immediacy was provided but was not accepted. At 5:30 PM a second plan was provided but was not accepted. At 7:23 PM, a third plan was provided but was not accepted. At 8:35 PM, a fourth plan was provided and accepted. The plan to remove the immediacy included the following: 1. 100% of current alert and oriented residents re-interviewed by Social Worker to confirm their code status. 2. Residents with Advance Directives will have them honored. 3. Residents with responsible parties will be contacted by Social Services to confirm resident code status. 4. If any changes are requested the medical providers will be contacted to make the change 5. System Change a. Current scanned-in copies of the MOLST will be moved to the Do Not Use Section by [DATE] b. Current MOLST previously removed will be returned to the residents ' charts by the medical records designee by [DATE] c. Current MOLST will be placed in the resident ' s chart located at each nurse ' s station by the charge nurse with each new admission, re-admission and change of status. d. The medical director will educate the physicians when there is a revised MOLST to flag the chart, notify nursing leadership of changes to the MOLST and void the old MOLST. e. Nursing leadership will review the MOLST to ensure the old one is voided and the revised one is in the resident chart. Nursing leadership will ensure old MOLST is voided. Changes in code status will be documented on the twenty-four-hour report. f. Physician orders reflecting the resident code status in the EHR will say: See MOLST g. 100% audit was completed to validate current code status say : See MOLST by the DON. 6. Nurses will be educated on the process by the DON or designee by [DATE]. 7. The medical director will educate the medical providers on ensuring they confirm and document the residents wishes on the MOLST. 8. The medical director will educate the medical providers that the NPs are responsible for notifying the attending physicians of MOLST changes. 9. The NHA or designee will re-educate the medical providers on the importance of notifying the Unit Manager, Supervisor, ADON, or DON regarding changes in the MOLST. 10. The DON or designee educated current nurses on the facility ' s policy for initiating CPR and location of code status for each resident, which is in the resident ' s chart on each unit. 11. Agency nursing staff will be educated prior to start of their shift by DON, nursing supervisor or designee. 12. Social Service will audit new admissions, re-admissions to compare the resident ' s MOLST to the physician orders for accuracy to assure it reflects See MOLST. This is ongoing. On [DATE] at 2:33 PM, based on review of credible evidence, resident medical records, and interviews, it was determined that the facility completed the plan to remove the immediacy. After removal of the immediacy the non compliance remained at a D level. 2) Review of Resident #53's medical record revealed the resident was admitted to the facility in February of 2023. The resident is his/her own responsible party and is cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of ,d+[DATE]. Maryland Medical Orders for Life Sustaining Treatment (MOLST) is a form that includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR)and other life-sustaining treatment options for a specific patient. It is valid in all health care facilities and programs throughout Maryland. Section 1 includes orders to Attempt CPR or No CPR. Included in the No CPR section are three options: A-1Intubate; A-2 Do Not Intubate but comprehensive efforts may include limitedventilaroty support by CPAP or BiPAP; or Option B No CPR, Palliative and Supportive Care, don not intubate or use CPAP or BiPAP. On [DATE], a review of the current active MOLST, completed in [DATE] and found in the paper chart, revealed an order for NO CPR. A previously voided MOLST, dated [DATE], revealed the resident had been a full code. Review of the electronic health record (computer) revealed an order for full code, indicating CPR should be performed. On [DATE] at 2:21 PM the nurse (Staff #22) assigned to care for the resident during that shift was interviewed in regard to the resident's code status. At first, the nurse stated she thought the resident was a full code and indicated she would check. After looking at the computer, the nurse reported the resident was a full code and confirmed that she would perform CPR. Surveyor then requested that the nurse review the paperchart. At 2:23 PM, after reviewing the current MOLST, the nurse confirmed that there was conflicting orders and indicated she would follow the MOLST. On [DATE] at 2:30 PM, surveyor asked the Director of Nursing (DON) to access the resident's current orders. When asked what the resident current code status was, the DON responded: full code. Surveyor then reviewed with the DON that the July MOLST is for No CPR and the nurse's report that she would perform CPR. On [DATE] at 9:56 AM, further review of the electronic health record (EHR -computer) a new order was put in place on [DATE] for DNR. On [DATE] at 2:29 PM the DON reported the process was supposed to be when medical provider changes the MOLST they should notify the nurse to change in the electronic health record system. She went on to report: We did an audit to make sure everybody matched. 3) On [DATE] at 1:20 PM, review of Resident #91's medical record revealed the resident attended dialysis 3 days a week. Review of the paper chart found at the nursing station revealed a MOLST, dated [DATE], that included an order for No CPR Option B. Review of the dialysis communication book, also found at the nursing station, revealed a MOLST, dated [DATE], that included an order for No CPR Option A-2. On [DATE], at approximately 1:30 PM, the existence of the two active MOLSTs was reviewed with the corporate nurse (Staff #15) who reported that, moving forward, the MOLST would only be located on the paperchart. On [DATE] at approximately 2:20 PM, the DON and NHA confirmed that dialysis and facility staff have been educated to send the paperchart to dialysis with the resident, and that the MOLST was located on the paperchart only. On [DATE] at 2:25 PM, interview with nurse (Staff #22) confirmed that they have started sending the hard paper chart with the residents to dialysis.

Based on a review of facility self report MD00181520 investigation documentation, medical records, observations, and interviews, it was determined that the facility failed to ensure nursing staff had the appropriate competencies and skills to access a permacath for the IV administration of antibiotics. This was found to be evident for 1 (#184) of 2 residents reviewed for death during the survey. This deficient practice led to an immediate jeopardy for Resident #184. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey, therefore this deficiency will be cited as past noncompliance. The date of correction was 8/14/22. The findings include: Review of Resident #184's medical record revealed the resident was admitted to the facility secondary to the initiation of hemodialysis. The resident's diagnoses included but was not limited to, chronic kidney disease, heart disease, high blood pressure, blindness, and diabetes. The resident was cognitively intact as evidenced by a BIMS (Brief Interview for Mental Status) score of 15/15 and was his/her own responsible party. Observations made throughout the survey revealed a dialysis center is located within the facility's building but is a separate entity run by dialysis center staff. Hemodialysis is a process in which blood is removed from the body, passed through a machine to clean out waste products and then returned to the body. This procedure can take several hours and is often required to be completed 3 times per week. To access a resident's blood for the hemodialysis procedure an AV (arteriovenous) fistula is usually created which is a connection between an artery and a vein. A surgical procedure is required to create the AV fistula and it can take up to several months for the fistula to mature and be used for dialysis. Prior to the creation and maturation of the fistula, a permacath can be utilized to access the resident's blood during hemodialysis. Review of the December 2021 hospital discharge summary revealed a PermCath (also known as a permacath) was placed prior to discharge to the facility. The permacath is a tube inserted into a vein in the neck and the tip is located in or near the right atrium of the heart. It consists of two channels, each channel has its own clamp and a cap. One channel has a red cap used to withdraw blood during dialysis and the other with a blue cap is used to return blood during dialysis. Permacaths can remain in place for several months. Review of the primary care physician notes revealed an AV (arteriovenous) fistula was created by 1/11/22. The 7/19/22 PCP note revealed the AV fistula was now being used for dialysis. Review of the 7/28/22 NP (Staff #37) progress note revealed the patient remained on dialysis Monday - Wednesday- Friday, and that the permacath that was placed in December 2021 needed to be removed because the left arm fistula was now being utilized for dialysis. The resident had an upcoming appointment to have the permacath removed on 8/4/22. This note also revealed a plan to obtain a culture of a foot ulcer and to start pt on Vanco to treat empirically for Osteomyelitis [bone infection]. Review of a wound care consultation progress note, completed by the Medical Director, Staff #5, on 7/28/22, revealed a plan to start vancomycin and Zosyn according to dialysis parameters after a wound culture was obtained. Review of nursing progress notes revealed that, on 7/28/22 at 4:20 PM, the licensed practical nurse (LPN) Staff #35, documented that the Nurse Practitioner (NP) gave orders for a midline insertion for antibiotic therapy and wound treatment. A midline is type of intravenous access line that can be used for the administration of medicine or fluids. A midline is usually inserted in a vein in the resident's arm and can remain in place for 2 - 4 weeks. A regular IV would need to be changed every few days. Further review of the nursing progress notes revealed the following, documented by LPN #35 on 7/28/22 at 10:03 PM: Resident alert and oriented x3. [name of infusion company] was in the building, to access the dialysis line to see if it can be used for the ABT [antibiotic] therapy. [infusion company] personnel stated that type of dialysis line can only be accessed at dialysis. Resident was given an option for a midline insertion, resident declined, [s/he] stated 'I do not want it, I want the antibiotic to be done at dialysis, if not it can wait till Monday. Supervisor was also present when the resident made the above statement Review of the physician orders revealed that, on 7/29/22, there was an order for Zosyn 2.25 grams intravenously two times a day for Osteomyelitis for 4 weeks. Review of the Medication Administration Record (MAR) revealed the doses were scheduled to be given at 12 noon and 10:00 PM. The first dose was documented as administered by LPN #36 on 7/29/22 at 12 noon. Review of the progress notes revealed that on 7/29/22, LPN #36 wrote that the Zosyn was given via right chest perma cath and flush with NS [normal saline], with no issue, no adverse effect noted or reported. Further review of the MAR revealed five IV Zosyn doses were administered when due from the evening of 7/29 through the evening of 7/31 by LPN #35. On 1/23/24 at 3:50 PM, LPN #35 was interviewed, s/he confirmed s/he had previously administered an antibiotic through a dialysis site and named Resident #184. When asked if anyone had instructed her, LPN #35 replied : we had an order so I did like a regular IV. At the end of the interview, LPN #35 was given her statement from 8/4/22 for review, s/he then confirmed the accuracy of the statement. Review of this statement revealed that s/he had administered the Zosyn over the weekend and that s/he knew what to do with the IV line because [name of LPN #36] told me what port to use, I double checked to be sure I was doing the right thing. Further review of the medical record revealed a progress note for a visit conducted by the NP #37 on 7/30/22. This note revealed the following statement: .Pt initially refused to use the perma cath on Rt upper chest (formal [former] dialysis port) for ABT [antibiotic] but later agreed. Staff administered the Zosyn as ordered . Further review of the nursing progress notes revealed a note written by LPN #34 on 8/1/22 at 4:07 PM. This note revealed that around 2:00 PM, the nurse attempted to administer the resident's Zosyn but the machine was faulty and she was having a hard time getting the infusion to run. The patient was alert and oriented at that time. At about 2:20 PM, the nurse left the resident for a few minutes and when s/he returned the patient was not responsive. The nurse lifted the resident's shirt and saw blood and immediately called for help. Review of a progress note written by the unit nurse manager (#23) on 8/1/22 at 4:25 PM revealed they were unable to stop the resident's bleeding, the paramedics arrived and pronounced the resident dead at 2:30 PM. The medical director (Staff #5) was interviewed regarding Resident #184 on 1/24/24 at 4:22 PM. The medical director reported he remembered the resident because he used to do the wound care for the facility. He reported having consulted with the nephrologist regarding the use of the permacath for the antibiotic administration since the resident was refusing another IV access line and indicated that the nephrologist was in agreement with using the permacath. The medical director went on to report that it was his understanding that the nurses here were instructed by the dialysis nurses and if the nurses were trained by dialysis it would be safe. LPN #36 was interviewed regarding Resident #184 on 1/25/24 at 1:22 PM. The LPN reviewed the statement s/he signed on 8/4/22 regarding the use of the resident's permacath for the IV administration of Zosyn and confirmed it's accuracy. Review of the statement revealed that, on 7/29/22, the NP #37 and LPN #36 went to the dialysis center where a nurse showed them which port to use and to clamp it after use. During the interview on 1/25/24, LPN Staff #36 reported that she told the NP directly that s/he had never done that before [accessed a permacath] and was not comfortable and then the two of them went to the dialysis center. S/he was not sure if his/her supervisor was aware of this or not. S/he went on to report that s/he actually observed the dialysis nurse set up the Zosyn and then the LPN took the resident to his/her unit. S/he reported s/he did not give the dose, but did do the flush when it was finished. S/he also reported that s/he explained to the nurse that relieved him/her what the dialysis nurse told him/her about accessing the permacath. During an interview on 1/24/24 at 3:32 PM, the NP #37 confirmed that only one nurse had gone with him/her for training by the dialysis staff and reported that the training included how to clamp, how to open and to use sterile technique. The NP #37 also confirmed that when she arrived at the facility on the weekend (7/30/22 was a Saturday) the morning dose was already administered and that the resident had reported that the nurse did very well. During an interview with unit nurse manager, RN, Staff #23 on 1/26/24 at 10:59 AM revealed that s/he was off duty on Friday 7/29/22 and returned to work on Monday 8/1/22. S/he reported s/he was not aware that [name of infusion company] came out and said they could not use the permacath and that the note on Thursday should of raised an alarm somewhere. S/he reported that it was not until after the event that s/he realized the only IV access was the permacath. The unit nurse manager reported if s/he had known the permacath was the only access s/he would of objected to the order. On 1/24/24 at 3:32 PM, an interview was conducted with NP #37. S/he confirmed his/her statement, dated 8/3/22, which states: . On Friday afternoon, I took the nurse [name of LPN #36] to the dialysis room and the dialysis nurse gave training on how to use the catheter. A decision was made after talking to [Name of Medical Director #5] on the route of administration. Since the patient didn't want to be stuck for an IV line, and [s/he] had the permacath that was due to be removed, it was decided to use the permacath . During the 1/24/24 interview, the NP reported that she did not know if there was documentation of the education but that the Director of Nursing (DON) (Staff #52) and the Assistant Director of Nursing (ADON) (Staff #4) told him/her on Friday if they were going to use the permacath there would have to be education. The NP reported that they asked me if I got training and that is why I wrote that statement. The NP went on to state that she was not aware that the nurse who was administering the IV antibiotic was not the nurse who was trained. Review of the investigation documentation revealed a statement signed by Registered Nurse (RN), Staff #53, on 8/1/22. This statement revealed that, at around 2:30 PM, a staff member indicated they needed help, RN, Staff #53 responded and Resident [name of Resident #184] was observed unresponsive, the nurse assigned was next to the resident clamping the port. Further review of the investigation documentation revealed a witness statement dated 8/1/22, that consisted of LPN, Staff #34 answering questions from ADON, Staff #4. The ADON, Staff #4 confirmed the accuracy of the documentation during an interview on 1/24/24 at 11:39 AM. This statement revealed the following from LPN, Staff #34: I went to give the IV antibiotic around 2 PM and I flushed the site and forgot to clamp the site; I went to get the IV pump and came back at 2:20 and saw the blood. Attempts to interview LPN, Staff #34 on 1/23/24 and 1/24/24 were unsuccessful. During an interview on 1/24/24 at 11:39 AM, ADON Staff #4 reported s/he had not been aware the staff was accessing the permacath for the administration of IV antibiotics prior to the event on 8/1/22. On 1/24/24, review of the skills assessment documentation for LPN, Staff #34 revealed a self-assessment dated [DATE], which was after the incident occurred. On 1/24/24 at 9:40 AM, the concern that the facility was unable to provide documentation of basic IV skills assessment prior to the incident was reviewed with the DON. The DON reported s/he would contact the staffing agency that had sent LPN, Staff #34. Further review of the documentation provided by the facility revealed that starting on 8/1/22 they began education of licensed staff on: Management of Central Venous device complications Change in Condition Licensed Nurses Skills and Techniques Evaluation - Phlebotomy/infusion therapy. Do not access the dialysis site: permacath or fistula Providers were educated not to write orders for floor nurses to access dialysis catheters. All like residents in the facility with IV access or dialysis access devices were evaluated. A quality assurance (QA) plan was put in place for ongoing monitoring of the planned interventions. Documentation was provided that the LPN, Staff #34 was put on the do not return list and a report was submitted to the state board of nursing. On 1/25/24 at 3:45 PM, after review of the credible evidence of education, QA audits, and interviews with multiple staff it was determined that the facility had recognized this deficient practice and implemented interventions to prevent re-occurrence. The date of compliance, as identified by the date on which the training was completed was determined to be 8/14/22. The DON and corporate nurse were made aware of the determination of immediate jeopardy past non-compliance at this time. -

Based on interviews and record review it was determined that the facility failed to provide residents with an environment that was free from abuse. Due to this deficient practice Resident #505 suffered physical and psychosocial harm. This was evident for 1 (MD00204162) of 2 facility reported incidents of abuse. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. A medical record review for Resident #505 on 4/25/24 at 9:39 AM revealed an admission Minimum Data Set (MDS) with an assessment reference date of 3/7/24 in section C revealed the resident scored a 12 out 15 on the brief interview of mental status indicating moderate cognitive impairment. However, on a note from psychiatric services dated 4/1/24, the provider documented that the resident had intact cognitive function. An interview with the Unit Manager #12 confirmed that the resident was cognitively intact and was able to verbalize his/her needs and concerns. On 4/25/24 at 9:05 AM a review of the facility's investigation file revealed a final self-report form that was submitted to the State Agency. According to the document Resident #505 reported that on 3/28/24, the night shift GNA (geriatric nursing assistant who was later identified as GNA #9) came into the resident's room, did not say anything to the resident, and yanked the covers off the resident. GNA #9 pointed for the resident to roll, and the GNA grabbed the resident's arm and pushed him/her over to the side and when it came time to roll the opposite way the GNA grabbed the other arm and pushed the resident. The report documented that the facility verified that abuse had occurred. A statement written by GNA #10 on 3/29/24 documented that she was giving Resident #505 a shower on 3/29/24 at 2:15 PM and noticed bruising on the resident's left forearm and left bicep. She further documented that when she asked the resident how s/he got the bruises, the resident reported that the GNA on night shift (later identified as GNA #9) was very rough with him/her while changing them and grabbed their arms while turning them. Also, she noted that the resident reported that GNA #9 would not acknowledge or speak to them during care. GNA #10 reported that Resident #505's roommate corroborated the GNA's roughness while changing them and she noted the name of the roommate. Further review of the file revealed a statement from the roommate. The statement handwritten on 3/29/24 by GNA #9, the staff member accused of abusing Resident #505, revealed she had reported that when she came on shift it was reported to her that the resident had bruising. However, this could not be corroborated as all other staff who cared for this resident had reported the bruises were new. She also reported that she had changed Resident #505 and Resident #543, but had not assisted them to roll from side-to-side as they were able to do so on their own. A review of the resident interviews in the investigation file revealed that multiple residents had reported concerns about the night shift GNA #9. The following interview statements were obtained by Unit Manager #5 on 3/29/24: Resident #520's interview statement revealed the resident turned on their call light several times and GNA #9 would turn off the call light and leave before tending to their needs. The resident reported another GNA had to come in and care for their needs. The facility failed to further investigate to determine the GNA who assisted Resident #520 and obtain a statement from them. Resident #543's interview statement revealed that s/he had been roommates with Resident #505 at the time of the incident. Resident #543 reported that GNA #9 had been ignorant-rude and did not speak. The resident had asked for soap, water, and a washcloth to wash off before leaving for an appointment and GNA #9 only provided the washcloth. Resident #542's interview statement revealed that when s/he put on the call light for assistance GNA #9 came in the room and complained about the resident messing up his/her bed. When Resident #542 asked for a change of clothes (that they brought from home) GNA #10 said no and handed the resident a hospital gown. The resident reported that while being changed, GNA #9 was rough. Resident #541's interview statement revealed that on 3/28/24 at 11:15 PM, the resident had turned on the call light to be changed. A staff member turned the light off and reported that someone would be in to tend to the resident's needs. However, an hour later no one had come in. The resident turned on the call light on again and GNA #9 came in and turned off the call light, looked at the resident, but said nothing and walked back out. The resident reported s/he continued turning on the call light every hour and GNA #9 continued to come in and turn the light off without providing care. The resident reported that at 4 am another GNA came in the room and provided the care. The facility failed to determine who the GNA was and obtain a statement. Review of the incident report completed by Unit Manager #12 revealed that Resident #505 had redness to the left forearm measuring 3 cm (centimeters) x 3 cm, bruising to the left elbow measuring 5 cm x 5 cm, bruising to the right outer forearm measuring approximately 3 cm x 3 cm, left upper arm bruising measuring 1 cm x 4 cm. The report indicated the resident was able to move all extremities without difficulty and was not in pain. However, this incident report was clearly marked at the bottom of the page that it was not a part of the medical record. A subsequent review of the medical record revealed that Unit Manager #12 failed to document an assessment of the resident's change in condition following the abuse allegation and injuries. A handwritten note that was not signed or dated noted, In house NP (nurse practitioner) full head to toe assessment. However, a subsequent medical record review failed to reveal documentation that a nurse practitioner or physician examined the resident following the abuse allegation and injuries. The note also had a statement that pt (patient) declined psych (psychiatric) services, however the resident was seen by a psychiatric provider on 4/1/24. The documented visit noted that the provider had spoken with staff and reviewed the medical record, but the provider did not indicate in the note that they were aware of the resident's recent allegation of abuse and injuries. The provider could not have obtained the information from the medical record because facility staff had failed to document the allegation and injuries in the medical record. There was a copied form from local law enforcement's domestic violence unit that read an officer had been sent to the facility and included a case # and phone #. The facility reported they had not received a copy of the police report. On 4/30/24 at 9:50 AM an attempt was made to call the responding officer for an interview but was unsuccessful. An interview with GNA #13 on 4/25/24 at 3:42 PM revealed that he had been assigned to Resident #505 the evening shift prior to the alleged abuse incident. He stated that during that shift on 3/28/24, he had not noticed any bruising on the resident's arms while providing care. Furthermore, he reported that he had not told the oncoming GNA, GNA #10, that the resident had any bruises. On 4/25/24 at 3:55 PM an interview with Unit Manager #12 confirmed that she had been the staff member who conducted the investigation for the abuse allegation. She reported that she had observed bruising on the resident's arms. She stated that during her investigation staff reported the resident had no bruising the day before (3/28/24) on day and evening shift and then had the bruising the next day on 3/29/24, following the night shift that GNA #9 had cared for the resident. She stated the interviews with other resident's confirmed that GNA #9 would not speak to the resident's during care and had been rough with residents. She stated she determined the abuse had occurred. On 4/30/24 at 9:20 AM an attempt to interview Resident #505 was made via telephone call, however, the resident did not return the call. On 4/30/24 at 9:25 AM a telephone call was made to Resident #505 representative (RP). The RP reported that s/he had been made aware of the abuse allegations and the injuries that occurred. When asked if Resident #505 seemed different after the incident the RP reported that when Resident #505 was discharged home s/he reported nightmares about being in the facility. An interview with GNA #10 on 4/26/24 at 6:27 AM confirmed that they were the GNA who found the bruises on Resident #505 during a shower on 3/29/24. They reported that when they asked Resident #505 how s/he got the bruises the resident stated they did not want to get anyone in trouble. The resident further reported that GNA #9 on night shift, had been rough with him/her during care and grabbed their arms to roll them over. GNA #10 reported that when they looked at the left arm above the elbow the bruising was in the shape of a handprint. During an interview with Registered Nurse (RN) #11 on 4/30/24 at 8:49 AM they reported that Resident #505 had expressed fear of getting GNA #9 in trouble and that GNA #9 might retaliate against them. An interview with the Certified Registered Nurse Practitioner (CRNP) #5 on 4/30/24, at 10:26 AM revealed that they had assessed the resident on 3/29/24, however, the CRNP had not written a note in the medical record due to billing concerns. They reported that the left arm bruising was in the shape of a handprint. On 4/30/24 at 1:30 PM the surveyor reviewed the concerns with the Nursing Home Administrator NHA, with the Director of Nursing and Regional Nurse #4 present. The NHA reported that the facility reported GNA #9 to their licensing board for the abuse, however, this was done only after surveyor intervention on 4/26/24.

Based on interviews and record review it was determined that the facility failed to provide residents with an environment that was free from abuse. Due to this deficient practice Resident #505 suffered physical and psychosocial harm. This was evident for 1 (MD00204162) of 2 facility reported incidents of abuse. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. A medical record review for Resident #505 on 4/25/24 at 9:39 AM revealed an admission Minimum Data Set (MDS) with an assessment reference date of 3/7/24 in section C revealed the resident scored a 12 out 15 on the brief interview of mental status indicating moderate cognitive impairment. However, on a note from psychiatric services dated 4/1/24, the provider documented that the resident had intact cognitive function. An interview with the Unit Manager #12 confirmed that the resident was cognitively intact and was able to verbalize his/her needs and concerns. On 4/25/24 at 9:05 AM a review of the facility's investigation file revealed a final self-report form that was submitted to the State Agency. According to the document Resident #505 reported that on 3/28/24, the night shift GNA (geriatric nursing assistant who was later identified as GNA #9) came into the resident's room, did not say anything to the resident, and yanked the covers off the resident. GNA #9 pointed for the resident to roll, and the GNA grabbed the resident's arm and pushed him/her over to the side and when it came time to roll the opposite way the GNA grabbed the other arm and pushed the resident. The report documented that the facility verified that abuse had occurred. A statement written by GNA #10 on 3/29/24 documented that she was giving Resident #505 a shower on 3/29/24 at 2:15 PM and noticed bruising on the resident's left forearm and left bicep. She further documented that when she asked the resident how s/he got the bruises, the resident reported that the GNA on night shift (later identified as GNA #9) was very rough with him/her while changing them and grabbed their arms while turning them. Also, she noted that the resident reported that GNA #9 would not acknowledge or speak to them during care. GNA #10 reported that Resident #505's roommate corroborated the GNA's roughness while changing them and she noted the name of the roommate. Further review of the file revealed a statement from the roommate. The statement handwritten on 3/29/24 by GNA #9, the staff member accused of abusing Resident #505, revealed she had reported that when she came on shift it was reported to her that the resident had bruising. However, this could not be corroborated as all other staff who cared for this resident had reported the bruises were new. She also reported that she had changed Resident #505 and Resident #543, but had not assisted them to roll from side-to-side as they were able to do so on their own. A review of the resident interviews in the investigation file revealed that multiple residents had reported concerns about the night shift GNA #9. The following interview statements were obtained by Unit Manager #5 on 3/29/24: Resident #520's interview statement revealed the resident turned on their call light several times and GNA #9 would turn off the call light and leave before tending to their needs. The resident reported another GNA had to come in and care for their needs. The facility failed to further investigate to determine the GNA who assisted Resident #520 and obtain a statement from them. Resident #543's interview statement revealed that s/he had been roommates with Resident #505 at the time of the incident. Resident #543 reported that GNA #9 had been ignorant-rude and did not speak. The resident had asked for soap, water, and a washcloth to wash off before leaving for an appointment and GNA #9 only provided the washcloth. Resident #542's interview statement revealed that when s/he put on the call light for assistance GNA #9 came in the room and complained about the resident messing up his/her bed. When Resident #542 asked for a change of clothes (that they brought from home) GNA #10 said no and handed the resident a hospital gown. The resident reported that while being changed, GNA #9 was rough. Resident #541's interview statement revealed that on 3/28/24 at 11:15 PM, the resident had turned on the call light to be changed. A staff member turned the light off and reported that someone would be in to tend to the resident's needs. However, an hour later no one had come in. The resident turned on the call light on again and GNA #9 came in and turned off the call light, looked at the resident, but said nothing and walked back out. The resident reported s/he continued turning on the call light every hour and GNA #9 continued to come in and turn the light off without providing care. The resident reported that at 4 am another GNA came in the room and provided the care. The facility failed to determine who the GNA was and obtain a statement. Review of the incident report completed by Unit Manager #12 revealed that Resident #505 had redness to the left forearm measuring 3 cm (centimeters) x 3 cm, bruising to the left elbow measuring 5 cm x 5 cm, bruising to the right outer forearm measuring approximately 3 cm x 3 cm, left upper arm bruising measuring 1 cm x 4 cm. The report indicated the resident was able to move all extremities without difficulty and was not in pain. However, this incident report was clearly marked at the bottom of the page that it was not a part of the medical record. A subsequent review of the medical record revealed that Unit Manager #12 failed to document an assessment of the resident's change in condition following the abuse allegation and injuries. A handwritten note that was not signed or dated noted, In house NP (nurse practitioner) full head to toe assessment. However, a subsequent medical record review failed to reveal documentation that a nurse practitioner or physician examined the resident following the abuse allegation and injuries. The note also had a statement that pt (patient) declined psych (psychiatric) services, however the resident was seen by a psychiatric provider on 4/1/24. The documented visit noted that the provider had spoken with staff and reviewed the medical record, but the provider did not indicate in the note that they were aware of the resident's recent allegation of abuse and injuries. The provider could not have obtained the information from the medical record because facility staff had failed to document the allegation and injuries in the medical record. There was a copied form from local law enforcement's domestic violence unit that read an officer had been sent to the facility and included a case # and phone #. The facility reported they had not received a copy of the police report. On 4/30/24 at 9:50 AM an attempt was made to call the responding officer for an interview but was unsuccessful. An interview with GNA #13 on 4/25/24 at 3:42 PM revealed that he had been assigned to Resident #505 the evening shift prior to the alleged abuse incident. He stated that during that shift on 3/28/24, he had not noticed any bruising on the resident's arms while providing care. Furthermore, he reported that he had not told the oncoming GNA, GNA #10, that the resident had any bruises. On 4/25/24 at 3:55 PM an interview with Unit Manager #12 confirmed that she had been the staff member who conducted the investigation for the abuse allegation. She reported that she had observed bruising on the resident's arms. She stated that during her investigation staff reported the resident had no bruising the day before (3/28/24) on day and evening shift and then had the bruising the next day on 3/29/24, following the night shift that GNA #9 had cared for the resident. She stated the interviews with other resident's confirmed that GNA #9 would not speak to the resident's during care and had been rough with residents. She stated she determined the abuse had occurred. On 4/30/24 at 9:20 AM an attempt to interview Resident #505 was made via telephone call, however, the resident did not return the call. On 4/30/24 at 9:25 AM a telephone call was made to Resident #505 representative (RP). The RP reported that s/he had been made aware of the abuse allegations and the injuries that occurred. When asked if Resident #505 seemed different after the incident the RP reported that when Resident #505 was discharged home s/he reported nightmares about being in the facility. An interview with GNA #10 on 4/26/24 at 6:27 AM confirmed that they were the GNA who found the bruises on Resident #505 during a shower on 3/29/24. They reported that when they asked Resident #505 how s/he got the bruises the resident stated they did not want to get anyone in trouble. The resident further reported that GNA #9 on night shift, had been rough with him/her during care and grabbed their arms to roll them over. GNA #10 reported that when they looked at the left arm above the elbow the bruising was in the shape of a handprint. During an interview with Registered Nurse (RN) #11 on 4/30/24 at 8:49 AM they reported that Resident #505 had expressed fear of getting GNA #9 in trouble and that GNA #9 might retaliate against them. An interview with the Certified Registered Nurse Practitioner (CRNP) #5 on 4/30/24, at 10:26 AM revealed that they had assessed the resident on 3/29/24, however, the CRNP had not written a note in the medical record due to billing concerns. They reported that the left arm bruising was in the shape of a handprint. On 4/30/24 at 1:30 PM the surveyor reviewed the concerns with the Nursing Home Administrator NHA, with the Director of Nursing and Regional Nurse #4 present. The NHA reported that the facility reported GNA #9 to their licensing board for the abuse, however, this was done only after surveyor intervention on 4/26/24.

Based on a review of the medical record and other pertinent documentation, interviews, and observations it was determined that the facility failed to provide immediate action, ongoing supervision, or plan of care interventions to address a resident (Resident #1) who was known to have exit seeking/elopement behaviors on 9/1/20 when the emergency door alarms were found to be not functioning. This resulted in Resident #1 exiting the Emergency exit door on the second floor (Unit 2) on 9/1/2020 and falling down three flights of stairs. Resident (#1) sustained a laceration to the back of the head and a skin tear to the fourth and fifth digit on the left hand and was transferred out 911 to the hospital. This was evident for 1 of 4 residents reviewed for exit seeking behavior. Based on the findings, on Thursday 9/3/2020, at 3:00 PM an Immediate Jeopardy was called related to the supervision of Resident #1. The facility submitted a plan of action at 10:04 PM on 9/3/20, which was reviewed by the surveyor and the Office of Health Care Quality. The plan was accepted but the Immediate Jeopardy was not removed until Wednesday 9/9/20 at 3:00 PM after the plan of correction was verified to have been implemented. After removal of the Immediate Jeopardy, the deficient practice remained for 5 days with the potential for more than minimal harm and scope and severity of a D. The finding included the following: During an investigation of complaint #MD 719, and review of Resident #1's medical record on 9/2/20 at 9 AM revealed Resident #1 had a [DIAGNOSES REDACTED]. A care plan for exit seeking/elopement risk related to dementia was initiated on 7/7/18 and was last updated for resident wandering on 5/18/2019. Interventions included placement of a wander guard device and to monitor resident. Details regarding what monitoring entailed where not included in the care plan. During the observation tour on 9/2/2020 at 9:20 AM, a staff member was noted sitting outside of each Emergency exit door; 2 staff observed on the first floor and 3 staff observed on the second floor. According to the Charge Nurse (LPN #3) for Unit 1 and 2, the staff were placed there because the doors were not working. Interview with the Administrator at 9:30 AM on 9/2/20 revealed Resident #1 was able to enter the stairwell on Unit 2 thru the Emergency exit door in his/her wheelchair on 9/1/2020. The door alarms were not working and as a result, the resident fell three flights of stairs in the wheelchair landing at the bottom of the terrace level stairwell. Interview with the Maintenance Director on 9/2/20 at 10 AM revealed the following: On 9/1/20 at approximately 8 AM, the Maintenance Director received an alert from the fire alarm letting him know the fire doors were not working properly in the building. He stated he, checked all 5 doors inside the facility and none of the doors were alarming. The doors located on the outside of the building were working. They are on a separate system. I notified the alarm company. Around 9 AM went to the 1st and 2nd floor and made nursing aware since the facility had wanderers. I was specifically concerned about (Resident #1) this resident tries to go through the fire doors every day. I had to cover the fire alarms to keep (Resident #1) from pulling them. Interview with the Charge Nurse (LPN #3) on 9/2/2020 at 10:30 AM, she stated she heard an overhead page at around 11:00 AM for fall huddle (this means someone had fallen). She stated she then called the front desk and was told Resident #1 had fallen down the stairs, on getting to the scene Resident #1 was noted sitting on the floor with skin alteration to the back of the head and skin tear to the third finger. No change to mental status resident noted at baseline. The resident was assessed by the Director of Nursing (DON) and the (CRNP) Certified Registered Nurse Practitioner was made aware and ordered the resident sent to the hospital via 911 for further evaluation. Interview with Geriatric Nursing Assistant (GNA) #4 on 9/2/20 at 11:00 AM, she stated she was always assigned to Resident #1 when she was working. She stated the resident was always trying to go thru the emergency door or the elevator. The elevator has a wander guard alarm on it and will not shut. The emergency doors usually alarm when the resident pushes on it, but it did not sound on 9/1/20. GNA #4 also stated I had no idea the alarm on the doors were not working. I saw the resident last around 11:15 AM sitting in (his/her) wheelchair outside of (his/her) room. I was in another resident room when I heard the code fall huddle around 11:30 AM. According to GNA #4, a fall huddle means a resident has fallen. Interview with the Floor Tech (Staff #5) on 9/2/20 at 1 PM, he stated, I was downstairs on terrace level moving a bed. I heard an alarm noise when I opened the door the (Resident #1) was laying on the floor with (his/her) wheelchair beside (him/her). The resident was trying to get up. I called the front desk to have Maintenance and nursing to come to the terrace level. Interview with the DON on 9/2/20 at 2 PM, she stated I heard the overhead page for the back stairwell. When I arrived, the resident was assessed for injuries. (Resident #1) was able to move all 4 extremities. The resident was stable. 911 was called due to the fall. The resident returned to the facility later the same evening. A staff member was assigned to each Emergency exit door after (Resident #1's) fall. Interview with the medical director at 2:15 PM on 9/2/20, revealed the resident would be put on one to one supervision until the emergency doors were fixed. Further review of Resident #1's medical record on 9/3/20 at 9 AM failed to reveal a care plan for exit seeking behaviors involving the emergency fire doors, although Resident #1 was known to exhibit this behavior every day per staff interviews. The care plan for the resident initiated on 7/17/2018 only referenced exit seeking behavior/elopement risk and the update to the plan on 5/18/2019 did not include interventions to address the exit seeking behavior at the emergency fire door exits. During a follow-up interview on 9/3/20 at 9:30 AM, the Maintenance Director stated, I check the doors in the entire facility monthly. The emergency doors are now working. It was a faulty relay that caused the mag locks on the doors to deactivate. During observation rounds by the surveyor at 11 AM on 9/3/20, the emergency doors were alarmed. No staff were stationed at the emergency doors. On Thursday 9/3/20, at 3:00 PM an Immediate Jeopardy was called related to the neglect of Resident #1. The facility submitted an initial plan of action to the surveyor and the Office of Health Care Quality for review at 5:25 PM on 9/3/20. This initial plan was not accepted. A revised plan was submitted at 7:14 PM on 9/3/20, which was not accepted. The facility submitted a subsequent revised plan of action at 10:04 PM on 9/3/20, which was reviewed by the surveyor and the Office of Health Care Quality. The plan was accepted but the Immediate Jeopardy was not removed until Wednesday 9/9/20 at 3:00 PM after the plan of correction was verified to have been implemented. The Immediate Jeopardy Abatement Plan included: The facility Quality Assurance/ Performance Improvement (QAPI) Committee initially met on September 3, 2020 regarding the Immediate Jeopardy and implemented an internal plan of correction. The facility emergency door exits to the stairwell were back to function on 9/2/20 approximately 730pm. The following plan of correction was developed: 1) On 9/1/20 @ 10:08am- VSC Fire and Security Contractor on site to evaluate mag lock system. 2) On 9/1/20 @/about 12:30pm- Resident #1 was transferred to the hospital for further evaluation s/p fall and returned the same day at baseline with no new orders. 3) On 9/1/20 @ 4:00pm- Q-15 min safety checks initiated for identified like residents. 4) On 9/1/20 @ 4:30pm- The facility-initiated door monitors to ensure the safety of the patients until the doors were returned to proper function. 5) On 9/1/20 @5:30pm- An Ad-Hoc QAPI meeting was held to discus the findings as it relates to patient safety with the HCR-ManorCare Leadership team (Administrator; DON; RDO; AVP; Quality Assurance Consultant; Regional Manager of Plant operations; Director of Plant Operations). 6) On 9/2/20 @ 9:30am- An investigation was initiated, and Performance Improvement Plan was developed based on the findings. 7) On 9/2/20 @ 12:57pm- VSC Fire and Security Contractor on site to evaluate mag lock system 8) On 9/2/20- Door Monitoring continued 9) On 9/2/20 1:1 sitter was assigned 3-11 and 11-7 for Resident #1. 10) On 9/2/20 @/about 1:00pm- Securetec-Contractor (work order # 10) arrived to assess Emergency power supply on door maglock system. 11) On 9/2/20- Door monitoring concluded @ 4:30pm for Terrace T-level, Rising Sun, Severn Middle stairwell 12) On 9/2/20 Door monitoring concluded @ 7:15pm for Clear Spring and Ocean Pine. 13) On 9/2/20 @/about 7:15pm- The doors were repaired; the egress was disabled and emergency doors will now only open if a security code is entered or if the fire alarm system is activated. 14) On 9/3/20 @/about 4:30pm- Like residents' care-plans were reviewed and updated to reflect egress has been disabled and security code is needed to disarm door to stairwell. EDUCATION: If a door is found to be malfunctioning, Administrator/DON and Maintenance Director will be made aware immediately and door monitors will be put into place, until the door is repaired and back to proper function. The facility plans to complete 100% education of staff by 9/8/2020. Monitoring phase: The Administrator/DON and department heads will interview staff to ensure they are aware of the procedures to follow if there is door malfunction. The Maintenance Director, Maintenance Assistant or House Supervisor will conduct door checks daily X 4 weeks; then weekly X 8 weeks and monthly on a continuous basis. The findings from the audits will be forwarded to the Quality Assurance and Assessment Committee for review and determination of further actions needed. 1) An additional Ad-Hoc QAPI meeting was held on 9/2/2020 to discuss findings and surveyor notes. 2) As of 9/2/2020, Maintenance Director was educated regarding immediately notifying Administrator/DON and department heads if doors are malfunctioning. 3) On 9/2/20 @ 2:30pm The Medical director was contacted and informed of the facility plan he visited the resident and initiated 1:1. 4) On 9/3/20 the Medical director was updated on the planned interventions. 5) The facility is alleging compliance as of 9/8/2020. 6) The QAPI Committee will meet and determine further actions and audits based on trend and analysis.

Based on a facility reported incident, observation, investigation, interview, tour and review of medical records, it was determined that the facility failed to maintain a safe environment for a resident with documented exit seeking behavior as evidenced by a multi system breakdown in which 1) Resident #320 was able to elope from the facility on 4/12/15. 2) 35 out of 41 residents identified as wanderers that currently still reside in the facility (#6, #13, #14, #30, #40, #44, #46, #48, #59, #63, #76, #87, #95, #104, #110, #118, #119, #127, #131, #143, #162, #164, #174, #182, #188, #190, #194, #198, #199, #213, #250, #256, #259, #273, #297, #309) whose TAR (treatment administration records) for the month of June showed lack of documentation and inconsistent documentation for the placement and/or functionality of the wander guard daily as ordered. 3. Six of the 41 residents identified as wanderers did not have a physician order [REDACTED].#6, #30, #134, #199, #248 and #297). 4. Staff failed to observe a cognitively impaired resident while transporting the resident in a geri-chair. This was evident for one (#168) out of two residents observed being transported by staff by being pulled backwards. The findings include: 1. Review of the facility reported incident and interview with facility staff revealed that Resident #320 was buzzed out of the facility on 4/12/15 by a staff member who was distracted watching Netflix. The resident was ordered to have a Wander Guard anklet placed but no alarm sounded when the resident exited the building. The facility administrative staff, after their investigation, assumed that the resident must have 'wiggled' out of the wander guard that was on his ankle and that is why the door did not alarm when he exited the building. Facility reported incident revealed that Resident #320 was reported to have been found on the side of the road by a good samaritan who called 911 regarding an individual who 'looked lost.' A Rossville RN was notified by Franklin Square Hospital at 6:00 PM that the resident was in the emergency room , brought in by the Baltimore County Police Department. Interview with the corporate nurse #1 revealed that after the facility's investigation of the incident, they determined that the resident's wander guard was not checked yet for that shift. Review of nursing notes for Resident #320 revealed that on 4/12/15 at 12:30 PM he was noted pulling on the wander guard and at 5:15 PM the resident was noted wandering around both units and stated 'I dont want to stay here.' The resident was documented as agitated and redirecting him to his room and the internet cafe were not successful. The Nursing note further documented that 'staff was aware that he did not want to sit in the tv room.' No further note or documentation of interventions or redirections were noted for the resident. Surveyor review of the resident's medical record on 6/25/15 at 3:00 PM revealed [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment dated [DATE] assessed the resident with a BIMS (brief interview for mental status) score of 3 out of 15 (severe cognitive impairment. Medical record review revelaed that there was no care plan in place regarding wandering for the resident, and therefore, no interventions in place for the prevention and deterrence of aimless wandering or potential elopement episodes. Facility intervention for the prevention of further elopements was to assess all residents that had the potential for wandering. The determining factors were: 1. A BIMS (brief interview for mental status) of less than 12, (Results of; 13-15 cognitively intact, 8-12 moderate impairment and 0-7 severe impairment) and/or 2. A history or exhibiting wandering behavior. The facility would place a wander guard bracelet on a resident if they met either criterion. Because of the failure that resulted in resident #320 being able to elope from the facility on 4/12/15, and the risk posed to the other residents identified as wanderers, an immediate jeopardy was called at 3:40 PM on 6/25/15 by the Office of Health Care Quality. An initial plan of action was given to the survey team and the Office of Health Care Quality for review at 6:55 PM on 6/25/15 by the facility and was not accepted. A new plan of action was given to the survey team and the Office of Health Care Quality for review at 7:45 PM and was accepted. A housewide audit of all residents who were identified as wanders and/or may be at risk of elopement took place. Care plans for those individuals was reviewed as well. The immediate jeopardy was removed at 8:25 PM after acceptance by the survey team and review and acceptance by the Office of Health Care Quality. 2. Review of the 41 residents that were identified as 'wanderers' on 6/25/15 at 12:30 PM, revealed that 36 were identified as not having their wander guard checked for placement daily as ordered and/or for functionality. Residents were ordered to have their wander guard alert bracelets checked for functionality daily and the actual wander guard checked every shift-3 times a day. Review on 6/25/15 revealed the following: A. On 6/2/15 and 6/15/15 Residents #188 and #199 were not checked for placement on multiple shifts. B. On 6/3/15 Residents #40, #95, #119, #143, #256 and #309 had not had their wander guards checked for placement on the evening shift. C. On 6/6/15 Residents #14, #59, #63, #118, #127, #131 and #273 were not checked for placement or functionality on the night shift. D. On 6/1/15, 6/7/15 and 6/22/15 Residents #48, #164, #190, #194 and #198 were not checked for functionality or placement on the night shift. Additionally, Residents #48 and #198 were not checked for placement or functionality on 6/24/15, the night before the immediate jeopardy was called. E. On 6/1/15, 6/6/15 and 6/7/15, Residents #13, #46, #76, #162, #162, #174, #182 and #259 were not checked for placement or functionality or various shifts. Additionally, Residents #13, #76, 162 and #174 were not checked for placement or function on 6/16/15 and Residents #13, #46, #76, #162, #182 and #259 were not checked for placement or function on 6/24/15, the night before the immediate jeopardy was called. F. On 6/1/15, 6/5/15, 6/6/15, 6/7/15, 6/16/15 and 6/24/15 Residents #44 and #104's wander guard was not assessed for placement of functionality on various shifts. G. Resident #87 was not assessed on 6/24/15 for the placement or function of the wander guard on the night shift. H. According to medical records review for Residents #6, #30, #213, #248 and #297, the actual checking each shift for placement was not documented on any of the residents for the month of June. Failure to check placement and or functionality on any shift places the resident at risk of elopement from the facility should the wander guard not be present or working. 3. Additionally, on 6/26/15 at 7:40 AM after a follow up review of the 41 residents identified as wanderers that remained in the facility, it was determined that 6 of the 41 (#6, #30, #134, #199, #248 and #297), did not have orders to check for functionality of the wander guards until the immediate jeopardy was called and it was brought to the facility's attention on 6/25/15 at 3:40 PM. Corporate Nurse #1 and Corporate Staff #3 were notified of the surveyor findings on 6/26/15 at 8:00 AM. They stated that a facility wide audit was completed the night before as part of the immediate jeopardy removal and they were aware that those residents did not have orders prior to the audit. 4. Review of Resident #168's medical record revealed that the resident is severely cognitively impaired and totally dependent on staff for activities of daily living, including locomotion. On 6/25/15 at 12:50 PM the nurse unit manager (staff #9) was observed transporting Resident #168 down the hallway that leads from the Ocean Pines nursing unit to the Morning Glory Room. The unit manager was noted to be transporting the resident by holding on to the resident's geri-chair with one hand while walking forward, the resident was seated in the geri-chair facing the opposite direction and the chair was noted to be swinging back and forth as the resident was transported. The resident's stockinged feet were also observed to be touching the floor as the resident was transported. On 6/25/15 at 1:52 PM the Director of Nursing (DON) was asked how she expected staff to transport a resident down the hall. The DON reported: with the person in front of them with their feet elevated on the foot rest. When asked if it is acceptable for staff to pull a resident down hall with the resident facing backwards, the DON responded, 'No, absolutely not.' Surveyor then informed the DON of the above observation of staff #9 transporting the resident while resident facing backward. On 6/25/15 at 2:15 PM surveyor 1 & 2, corporate nurse 1 & 2, the DON and the administrator reviewed the security video (time stamp on video was noted to be 12:41) of the above described incident of the unit manager pulling the resident down the hall backward. Corporate nurse #1 stated, 'that's unacceptable.' On 6/25/15 at 5:19 PM Resident #260 was observed being transported down the second floor hallway being pulled backward in a geri-chair by the geriatric nursing assistant (staff #11). At 7:53 PM surveyor informed the DON of this observation. The DON reported that staff had reported that some of the geri-chairs are difficult to push and that she wants to identify those chairs and have maintenance look at them due to concern for the safety of the residents. Cross Reference to F241