Every finding on record at Sligo Creek Healthcare

Based on observation, record review, and interview, it was determined that the facility failed to maintain effective infection control practices to prevent the potential spread of infection by 1) allowing clean and dirty laundry to be processed in the same room, and 2) ensuring appropriate infection control practices related to hand hygiene and the handling, storage, and maintenance of medical equipment and clinical devices. This was identified during the annual, recertification, and complaint survey processes and had the potential to affect all residents. The findings include: 1) Laundry includes resident's personal clothing, linens, (i.e., sheets, blankets, pillows), towels, washcloths, and items from departments such as nursing, dietary, rehabilitative services, beauty shops, and environmental services. During a record review on [DATE] at 9:00 am, it was discovered that the facility had a waiver that expired on [DATE] for not having a receiving area for contaminated and or dirty laundry that is clearly separated from the clean laundry area in the dedicated laundry room. The facility cited the age of the facility and physical environment in which the laundry is processed as reason for the waiver. During an interview conducted on [DATE] at approximately 1:15 PM, the Nursing Home Administrator (NHA) reported that the facility submitted 2 letters requesting a continuation of the waiver for the laundry room. He stated they did not hear back from the Office of Healthcare Quality (OHCQ). The Surveyor advised the NHA that the appropriate process was to submit the request for a waiver through Smartsheet on the OHCQ website. During an observation conducted on [DATE] at approximately 10:30 am, the surveyor observed the laundry room. The laundry room consisted of one room where the dirty and clean laundry was processed in the same area. The room did not have a clearly separated area for processing contaminated or dirty laundry from the clean laundry to prevent cross contamination. On [DATE] at approximately 11:30 am, the NHA came to the conference room and asked for assistance in locating the waiver form on the OHCQ website. The surveyor provided the form via email to the NHA. The NHA returned with the completed form and the surveyor scanned and submitted the form to OHCQ. On [DATE] at approximately 4:00 PM the NHA was notified that his response to question #3 on the waiver form was not accepted by the OHCQ. 2) On [DATE] at 9:37 AM, a tour of the second-floor shower room was conducted with the Maintenance Director. The surveyor observed that the shower room and all shower stalls and handwashing sink were obstructed with an IV pole, wheelchair cleaning machine, commodes, and trash/soiled linen hampers. At 9:40 AM, the surveyor and the Maintenance Director toured the second-floor used linen room. The surveyor observed that the handwashing sink was obstructed by multiple boxes stored on the sink countertop and by hampers located in the room. The handwashing sink was not supplied with paper towels. In addition, the clinical hopper was clogged, preventing its proper use for the disposal and cleaning of clinical waste and bodily fluids. At 9:43 AM, an interview with Staff #15 revealed that the second-floor shower room would be cleaned and that equipment obstructing the shower room would be cleaned, sanitized, labeled, and stored in the central medical supply room. At 9:45 AM, the surveyor toured the first-floor shower room and used linen room with the Maintenance Director. The surveyor observed that the shower room and shower stalls were similarly obstructed with IV poles and trash/soiled linen hampers. At 10:08 AM, an interview with Staff #14 confirmed that the first-floor shower room would be decluttered and that IV poles would be properly cleaned, sanitized, labeled, and stored in the central medical supply room. At 10:30 AM, a tour of the central medical supply room was conducted. The surveyor observed three oxygen concentrators that were not labeled to indicate their status as clean, in use, awaiting repair, or otherwise removed from service. During an interview, Staff #33 stated that the oxygen concentrators were awaiting pickup by the supplier for repair. On [DATE] at 2:20 PM, the surveyor conducted a follow-up tour of the central medical supply room with the Environmental Services Director and the Administrator to verify the storage location of clean IV poles. The surveyor observed that all three oxygen concentrators were covered with plastic bags. Staff #33 confirmed that cleaned and sanitized equipment was covered and stored in the central medical supply room.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that local exhaust ventilation systems were maintained in proper working order to provide adequate airflow. This was evident for all shower rooms and used linen rooms reviewed during the annual survey. The findings include: Airborne transmission occurs when pathogens are so small that they can be easily spread in the air, and because of this, there is a risk of transmitting the disease through inhalation. These small particles containing infectious agents may be spread over long distances by air currents and may be inhaled by individuals who have not had face-to-face contact with (or been in the same room with) the infectious individuals. According to the Centers for Disease Control and Prevention (CDC), preventing the spread of pathogens that are transmitted by the airborne route requires the use of special air handling and ventilation systems. On 06/02/2026 at 9:37 AM, a tour of the second-floor shower room was conducted with the Maintenance Director. The surveyor observed that the room was humid and had a foul odor. At 9:40 AM, a tour of the second-floor used linen room was conducted with the Maintenance Director. The surveyor observed that the room was humid and lacked adequate air movement. The Maintenance Director acknowledged that both the second-floor shower room and used linen room had no airflow, resulting in humid conditions and foul odors. At 9:45 AM, a tour of the first-floor used linen room was conducted with the Maintenance Director. The surveyor observed that the room was humid and lacked adequate airflow. At 9:47 AM, a tour of the first-floor shower room was conducted with the Maintenance Director. The surveyor observed that the room was humid and lacked adequate airflow. The Maintenance Director confirmed that the exhaust fans serving both the first-floor and second-floor shower rooms and linen rooms were nonfunctional. He acknowledged that the exhaust fan belts or the motors would be repaired or replaced promptly.

Based on observation, and interview with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the kitchen tour of the annual survey. The findings include: A food-contact surface refers to any surface of equipment and utensils that typically comes into contact with food; or from which food may drain, drip, or splash onto food; or a surface that is usually in contact with food. On 06/02/2026 at 8:00 AM, the surveyor conducted a tour of the kitchen alongside the Food Service Director and identified the following deficient practices: The dish plate heating unit was nonfunctional. In addition, the inside and outside surfaces of the unit were unclean. The food steamer located underneath the canopy hood was damaged. Observed steam, vapor, and heat escaping from the bottom corners of the unit and into the kitchen area. Multiple bussing/service carts were heavily damaged. The carts were warped, chipped, cracked, and pitted, which prevented effective cleaning and sanitization. The single-rack high-temperature dishwasher was damaged and unclean. During operation, the unit leaked grey water directly onto the kitchen floor. The wall located behind the dishwasher was damaged. Four different types of materials had been used in an attempt to cover the damaged wall. However, an exposed wall penetration measuring approximately 2 inches by 3 inches remained. This opening could potentially harbor pests, moisture, and bacterial proliferation. The walk-in cooler doors were not self-closing, resulting in gaps that allowed cold air to escape and warmer ambient air to enter the cooler. Condensation from the temperature differential had damaged the doors, walls, and flooring. In addition, mold-like substances buildup was observed on conduit lines and fan covers in the unit. Lighting inside the walk-in cooler was very dim, making it difficult to view stored products and read product labels. A few unlabeled bottles were identified and discarded during the survey. The cutting board affixed to the steam table was observed to be unclean. Multiple black-stained areas and deep knife grooves were present on the food contact surfaces. At 9:30 AM, a follow-up tour of the kitchen was conducted with the Maintenance Director and Food Service Director to go over the findings listed above. On 06/03/2026 at 2:00 PM, a second follow-up of the kitchen was conducted with the Administrator to review the identified findings. During the interview, the Administrator acknowledged the deficiencies and confirmed that the damaged equipment would be repaired and/or replaced promptly.

Based on resident and staff interviews, and record review conducted during the complaint investigation, it was determined the facility failed to ensure resident grievance regarding missing personal belongings were promptly addressed and resolved. This was evident for 1 (Resident #17) of 2 residents reviewed for grievances during the complaint and recertification survey process. The findings include: On 06/02/2026 at 10:25 AM, Resident #17 reported missing clothing items, including more than two white sweatshirts, one black shirt, and one black blouse, for the past few weeks. The resident stated that the items were sent to laundry and were never returned. The resident reported informing the 3:00 PM–11:00 PM shift nurse and several GNA (Geriatric Nursing Assistant) regarding the missing clothing. On 06/04/2026 at 10:27 AM an interview was conducted with the Director of Nursing (DON) regarding the facility's process for addressing missing resident items. The DON stated that upon notification of a missing item, staff review the resident's inventory record, search the resident's room, and check the laundry area with the Laundry Manager. The DON further stated that if the item is not located, the resident is notified, a grievance form is completed by the resident, family, or resident representative (RP), and forwarded to Social Services #31 for follow-up. The DON stated that items documented on the resident's inventory sheet are replaced by the facility if not found. On 06/04/2026 at 10:15 AM interview conducted with Social Services #31 regarding the process for reporting grievances related to missing items. The SW stated that the resident or responsible party (RP) reports the missing item to the GNA or nurse. The staff member receiving the grievance completes a grievance form and places it in the SW's mailbox for follow-up. On 06/04/2026 at 10:33 AM an interview was conducted with the Social Services #31 regarding Resident #17's report of a missing item. The SW stated that Resident #17 reported a missing white sweatshirt and had previously spoken with the laundry department prior to notifying the SW of the concern. The SW further stated that the resident reported the missing item a few weeks earlier; however, the exact timeframe was unknown. On 06/04/2026 at 10:36 AM surveyor review of the grievance binder with the Social Services #31 revealed no documentation indicating that Resident #17's grievance regarding the reported missing item had been initiated, investigated, or addressed. On 06/04/2026 at 10:42 AM following surveyor intervention, the SW stated that she would follow up with Resident #17 regarding the reported grievance related to the missing item in an effort to investigate and resolve the concern. On 06/05/2026 at 11:48 AM surveyor follow-up interview with Resident #17 revealed that no staff had spoken with him/her regarding the reported missing items. Resident #17 further stated that the Business Office Manager (BOM) and the SW came to the room to discuss the appeal process and provided a denial letter; however, the resident reported that the concern regarding the missing items was not discussed or addressed. On 06/05/2026 at 12:00 PM during an interview, the Director of Nursing (DON) confirmed that the Social Services #31 was expected to follow up with Resident #17 regarding the reported missing items. The DON further stated that the facility was in the process of replacing the items; however, Resident #17 had not been informed of the plan for replacement. On 06/08/2026 at 11:19 AM following surveyor intervention, the DON reported that the facility had purchased the missing items for Resident #17 and stated that she would speak with the resident regarding the replacement of the items.

Based on observations and interviews with facility staff, it was determined the facility failed to ensure residents had access to call lights. This was evident for 2 (Resident #2, and #75) out of 4 residents observed during the complaint and recertification survey process.The findings include: A call light is a communication device used in healthcare facilities that allows residents or patients to alert staff when assistance is needed. Call lights are typically located within the resident's reach and may include a button, cord, handset, or bedside control panel. They are used to request help for needs such as toileting, pain, repositioning, emergencies, or other assistance. 1. On 06/02/2026 at 10:32 AM during first floor unit rounds, the surveyor observed Resident #75's call light lying on the floor behind the bed, out of the resident's reach. On 06/02/2026 at 10:38 AM an interview was conducted with Geriatric Nursing Assistant (GNA) #24 regarding expectations for call light placement. The GNA stated that call lights are expected to remain within residents' reach. The GNA confirmed that Resident #75's call light was not within reach and repositioned it by clipping it to the resident's blanket.2. On 06/02/2026 at 10:50 AM the surveyor observed Resident #2's call light clipped to the privacy curtain and resting on the floor, out of the resident's reach. On 06/02/2026 at 10:54 AM an interview was conducted with GNA #24 regarding expectations for call light accessibility. The GNA stated that call lights are expected to remain within residents' reach. The GNA acknowledged that Resident #2's call light was not within reach and repositioned it by clipping it to the privacy curtain; however, the call light remained out of the resident's reach as the GNA left the room. On 06/02/2026 at 10:59 AM an interview was conducted with Unit Manager #14 regarding expectations for call light placement. The Unit Manager stated that call lights are to be answered promptly and maintained within residents' reach. The Unit Manager #14 confirmed that Resident #2's call light was not within reach, removed it from the privacy curtain, and clipped it to the resident's blanket.

Based on observation, record review, and interviews it was determined the facility failed to keep accurate and up to date records. This was evident for 1 resident (Resident #41) of 18 resident records reviewed during the recertification and complaint survey.The findings include:On 6/02/2026 at10:57 AM, during an interview with Resident #41, they reported several items had gone missing: $30 centu hairbrush, cotton balls, oil of [NAME] deep hair relaxer, 2 multicolored scarves, oil of [NAME] body wash, and face cleanser. Resident #41 stated they reported it to social services with no follow up on the replacement of the missing items. On 06/04/2026 at 9:52 AM, a review of Resident #41 medical chart confirmed a personal inventory was completed at admission. No other personal inventory sheets were in the medical chart. On 06/04/2026 at 11:25 AM, a review of the facility grievance binder showed a grievance was initiated on 4/28/26 by Resident #41 for the missing items. Social services documented in a progress note that they were able to go to Resident #41 room and locate the missing items in their nightstand and show them to the resident.On 06/04/2026 at 11:39 AM, an Interview with Unit Manager confirmed Resident #41 has not had a personal inventory sheet completed since admission almost a year ago. When asked what the process is for updating the personal inventory sheet when family or friends bring in personal items, she stated they will fill out another personal inventory sheet and file it in the resident's medical chart. When questioned about what staff were responsible for educating family, friends, and residents in the process for adding items to the personal inventory sheet she stated the charge nurse or unit manager. The Unit Manager stated that Resident #41 only has hair products, and they found most of them in the nightstand drawer when the resident reported them missing. When asked if the inventory sheet was updated with the located personal care items not provided by the facility she stated no. It was also pointed out that Resident #41 was observed to have 2 satin like hair scarves in the nightstand drawer and the Unit Manager verified she observed 2 scarves in the drawer at the time of the investigation for the missing personal items. The unit manager confirmed all of Resident #41 personal items that were in the nightstand drawer should have been added to a personal inventory list.

Based on observations and staff interviews, it was determined the facility staff failed to provide respect and dignity to residents by failing to knock on the resident's door prior to entering the resident's room. This was evident for 1 (Resident#17) out of 1 resident observed during complaint and recertification survey process. The findings include: On 06/02/2026 at 10:18 AM during the complaint investigation, Resident #17 reported concerns that staff do not knock prior to entering the room, stating that this occurs on an ongoing basis. On 06/02/2026 at 10:39 AM the surveyor observed GNA#23 enter Resident#17's room without knocking or introducing herself prior to entry. During an interview, the GNA stated that the expectation is to knock before entering a resident's room and confirmed that she did not knock or introduce herself before entering. On 06/05/2026 at 11:46 AM the surveyor observed GNA#25 enter Resident #17's room with a Hoyer lift without knocking on the door prior to entry. During an interview, the GNA stated that the expectation is to knock before entering a resident's room and confirmed, I am sorry I did not knock before entering. On 06/05/2026 at 11:50 AM Resident #17 stated, I am glad you witnessed what I always complain about. Something needs to be done. On 06/05/2026 at 12:00 PM an interview was conducted with the Director of Nursing (DON), who stated that the expectation is for staff to knock before entering residents' rooms. The surveyor shared her observation with the DON. The DON further stated that in-service education for staff regarding this expectation is ongoing.

Based on observation, record review, and interviews with the residents and facility staff, it was determined that the facility failed to ensure that residents received meals consistent with their food preferences and physician's prescribed therapeutic diets. This was evident for 3 (Resident #10, Resident #38, and Resident #62) of 3 residents reviewed for dietary services. The findings include: On 06/03/2026 at 8:10 AM, the surveyor observed the meal ticket for Resident #10. The meal ticket included the resident's name, room number, date, and prescribed diet. However, the beverage selection was listed as N/A, and the Food Likes, and Food Dislikes sections were blank. At 8:30 AM, record review revealed that Resident #10 had an order dated 07/09/2025 for a low sodium, regular texture, and regular liquid consistency diet. At 9:40 AM, during an interview, Resident #10 stated that meals were not consistently served according to personal preferences. The resident reported repeatedly receiving cornflakes and two hard boiled eggs everyday for breakfast instead of the preferred raisin bran cereal. At 11:50 AM, the surveyor observed Resident #38's meal ticket, which identified the diet as Regular/CCHO. The resident was served Salisbury Steak with gravy, mash potato with gravy, and green beans. When asked about the diet order, the Food Service Director explained that CCHO stood for Controlled Carbohydrate and was intended for resident with diabetes. However, Resident #38 received the same meal and portion sizes as residents on regular diets. The surveyor asked how resident food preferences were incorporated into meal service. The Food Service Director stated that preferences were entered upon admission and could be updated through requests submitted by nursing staff. In addition, residents could request alternative menu by calling down to the kitchen or by asking a staff member at any time of the day. At 12:15 PM, the surveyor reviewed Resident #62's meal ticket, which identified a regular diet, 2mg of sodium, and shellfish allergy. Staff #10 prepared a grilled cheese sandwich with white cheese, which was listed as a preferred item. When questioned about the meal selection, Staff #10 stated that kitchen personnel were aware of residents receiving alternate menu items such as baked chicken, white rice and steamed carrots, even when those items were not clearly identified on the meal ticket. At 12:36 PM, Resident #62 approached the Food Service Director and asked what was being served for lunch. After being informed that a grilled cheese sandwich had been prepared, the resident became upset and stated that the kitchen frequently served food that had not been requested, particularly food made with white cheese. The resident further stated that other residents were receiving Salisbury steak or baked chicken and did not understand why an alternate meal had been provided. At 1:30 PM, record review revealed that Resident #38 dietary order had last been updated on 01/28/2025 and Resident #62 dietary order had last been updated on 01/29/2024. Neither resident's documented food preferences had been updated in the care plans since those dates. At 2:00 PM, the surveyor informed the Administrator that the meal tickets were difficult to interpret because alternative menu selections and resident food preferences were not clearly identified. The Administrator was also informed that multiple residents had voiced concerns regarding meal service and food selections. At 3:30 PM, during the preliminary exit interview, the Regional Clinical Director, Director of Nursing, Nursing Home Administrator, Maintenance Director, Environmental Services Director, and the Food Service Director were notified of the meal ticket discrepancies. Based on observation, record review, and interviews with the residents and facility staff, it was determined that the facility failed to ensure that residents received meals consistent with their food preferences and physician's prescribed therapeutic diets. This was event for 3 (Resident #10, Resident #38, and Resident #62) of 3 residents reviewed for dietary services.

The findings include:(1.) During an observation of Medication Cart B on the First Floor with Licensed Practical Nurse (LPN) #16 on 6/03/2026 at 11:03 AM it was revealed to have a Lantus Solostar insulin pen for Resident #42 that had 3/15/2026 written on the label of the bag it was stored in and no other dates were found on the pen or bag. The bag also had a label that that stated 'Store using directions provided. Use a pen for up to 28 days after first use then throw away. During an interview with LPN #16 on 6/03/2026 at 11:17 AM she confirmed the Lantus Solostar insulin pen for Resident #42 had been used and the date written on the bag was the date it was opened. She reported that the insulin pen is good for 28 days after opening. She advised that the medications should be thrown out when expired or the Resident is discharged . She confirmed that the Lantus Solostar pen was considered expired and should have been taken out of the medication cart.During an observation of Medication Cart A on the First Floor with LPN #19 on 6/03/2026 at 11:28 AM it was revealed to have undated and expired medications. The following medications were found:A Lantus Solostar insulin pen for Resident #55 that had a label on the pen was not filled out, the Date opened and Date Expired were blank. There was no other identification on the pen or the bag that it was stored in showing when the pen was opened or when it expired after opening. A Novolog insulin pen for Resident #55 had a label on the pen that identified the date opened as 4/19/2026 and had no date expired on the label.A Lantus Solostar insulin pen for Resident #22 had a label on the pen that identified the opened date as 4/22/2026 and the date expired as 5/22/2026. Under the date was a sticker on the bag that stated 'Store using directions provided. Use a pen for up to 28 days after first use then throw away and a label is located on the pen stating.A Novolog Insulin pen for Resident #22 had a label on the pen that identified the date opened as 4/13/2026 and had no date expired on the label.A Novolog insulin pen for Resident #64 had a label on the pen that identified the date opened as 4/19/2026 and had no date expired on the label.During an interview with LPN #19 on 6/03/2026 at 11:28 AM she reported that the insulin pens should be dated the day you open it and they are good for 28 days. She confirmed that the insulin found undated should have had an open and expiration date on the label. She confirmed that the insulin pens over 28 days were past their expiration date and should have removed from the cart.During a review of the facility Insulin Storage Recommendations on 6/03/2026 at 11:43 AM it was revealed that Lantus and Novolog insulin pens are good for 28 days after being opened and stored at room temperature.During an interview with the Director of Nursing (DON) #2 on 6/03/2026 at 12:57 PM she confirmed that after the Lantus and Novolog insulins are opened they should be labeled and are stored for 28 days.During a review of the facility's Medication Storage in the Facility Policy on 6/03/2026 at 12:59 PM it stated that All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining.(2.) During an observation of the vaccine refrigerator in the Medication Prep Room on the second floor with Registered Nurse (RN) #20 on 6/03/2026 at 11:40 AM it was discovered to contain vaccines, tuberculin solution and a piece of cake in a clear plastic disposable container.During an interview with RN #20 on 6/03/2026 at 11:41 AM she reported that no food should be stored in the vaccine refrigerator and advised it should be vaccines only.During an interview with the Director of Nursing (DON) #2 on 06/03/2026 at 1:17 PM she confirmed that no food should be stored in the medication and vaccine refrigerators.During a review of the facility's Medication Storage in the Facility Policy on 6/03/2026 at 12:59 PM it stated that Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator.

Based on observations, record reviews and interviews it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 8 medication errors out of 37 opportunities which resulted in a medication error rate of 21.62%.The findings include:During an observation on 6/04/2026 at 8:31 AM Licensed Practical Nurse (LPN) #21 was observed preparing for medication administration for Resident #20. LPN #21 was observed crushing the medications for Resident #20 and reported that the medication for Resident #20 would be crushed because that is the way the Resident likes it. The medications that were crushed were:Losartan potassium 50 MG Oral Tablet [Cozaar]Escitalopram 10 MG Oral TabletClopidogrel 75 MG Oral TabletAmlodipine 5 MG Oral TabletTylenol 500 MG Oral Tablet [Tylenol]Cholecalciferol Oral Capsule 25 MCG (1000 UT) (Cholecalciferol)Senna Oral Tablet 8.6 MG (Sennosides)Omeprazole 20 MG Disintegrating Oral TabletContinued observation of the medication administration revealed the medications were administered to Resident #20 after being crushed and being placed into a Med Pass 2.0 Vanilla DrinkDuring a review of the medical orders for Resident #20 on 6/04/2026 at 9:53 AM it was discovered that the Resident did not have any orders for medications to be crushed.During an interview with Director of Nursing #2 on 6/04/2026 at 10:10 AM she reported that the facility doesn't have a Do Not Crush med list. She advised that the medication packaging would tell you if it could be crushed or not.During an observation with LPN #21 on 6/04/2026 at 10:25 AM it was revealed that the box for the Omeprazole Disintegrating Oral tablet stated Do not crush or chew.During a review of the facility's Medication Administration - General Guidelines policy on 6/04/2026 at 12:03 PM it was revealed that for tablet crushing, The pharmacist should be contacted to review all medications being considered for crushing and The pharmacist can assists in finding appropriate alternatives to medications that should not be crushed.During an interview with DON #2 on 6/04/2026 at 1:10 PM she reported a doctor's order is needed to crush medications. She advised that even Residents that request their medication to be crushed should have a doctor's order to crush the medication. She reported that if a Resident has an order to crush medications, then Pharmacist would provide a list of medications to crush and not crush. She advised Resident #20 did not have an order so the pharmacist would not have known he/she was receiving crushed medications so the pharmacist would not have reviewed the Resident's medication list for crushable medications or alternative medications.

Based on record review and interviews it was discovered that the facility failed to ensure a Resident's nutritional assessment needs were implemented. This was found to be evident for 1 (Resident #96) out of 1 Resident reviewed for nutrition during the recertification and complaint survey. The findings include: During a review of complaint #2992596 conducted on 06/11/26 at 7:30 am, the complainant reported that staff did not attend to Resident #96's needs for eating. During an interview conducted on 06/08/26 at 8:34 AM, the complainant reported that Resident #96 required to be fed. However, when the complainant visited the Resident there would be meal tray that sat on the bedside tray table untouched and covered. The complainant further reported that he/she would ask staff to heat the meal and he/she would feed the Resident. The complainant stated that Resident lost weight as a result. The Minimum Data Set (MDS) is a standardized assessment tool that measures health status in nursing home residents. MDS assessments are completed every 3 months (or more often, depending on circumstances) on nearly all residents of nursing homes in the United States. These assessments are performed and recorded by nursing home staff and include information on a number of aging-relevant domains including functional and cognitive status, psychosocial functioning, geriatric syndromes, and life care wishes.During a review of Resident 96's MDS assessment conducted on 06/08/26 at 9:00 am, it was discovered that the resident was assessed for requiring substantial/maximal assistance for eating. The Centers for Medicare & Medicaid Services (CMS) defines Activities of Daily Living (ADLs) as the basic, routine personal care tasks required to live safely day to day. In long-term care (LTC), these functional abilities measure an individual's need for assistance or qualification for benefits. There are 6 core ADLs: Bathing/Showering: Washing one's body or using a sponge bath. Dressing: Selecting clothing and physically putting it on or taking it off. Eating: Getting food or fluids into the body (once prepared and available). Toileting: Getting to/from the toilet, sitting/rising, and personal hygiene. Transferring: Moving into or out of a bed, chair, or wheelchair. Continence: Controlling bladder and bowel functions.A review of Resident # 96's ADL task documentation for March 2026 for eating was conducted on 06/08/26 at 9:19 am. It was discovered that the staff documented that the resident was independent or only required assistance in setup although the resident's MDS comprehensive assessment required substantial/maximal assistance for eating. A review of Resident #96's weight documentation conducted on 06/08/26 at 9:26 AM showed that the resident had a weight loss of 5% from 1/14/26 through 03/06/26.

Based on record review, observation, and interview, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as is possible. This was evident for 1 (Resident #94) out of 1 resident reviewed for accidents during the investigation into facility reported incident #2988228.The findings include:On 06/03/2026 at approximately 7:00 AM, this surveyor conducted an interview with the Director of Nursing (DON) regarding a facility-reported incident involving Resident #94. The DON confirmed that the facility investigated and verified the allegation after reviewing security camera footage, which showed Resident #94 exiting the facility through a secured door located adjacent to the resident lounge area. The DON reported that a staff member had opened the door to allow a visitor to exit the facility, and before the door had fully closed and secured, Resident #94 was able to exit through the same door and leave the facility. The DON confirmed that this was how the resident eloped from the facility.On 06/03/2026 at approximately 8:30 AM, this surveyor conducted a dual observation with the Maintenance Director of the exit door identified as the door used by Resident #94 during the incident. During the observation, the door was found to require approximately 15 seconds to fully close and secure after being opened.On 06/03/2026 at approximately 9:30 AM, this surveyor conducted a record review of the facility's investigation related to the elopement incident involving Resident #94 that occurred on 04/18/2026. The investigation revealed that Resident #94, who had a BIMS score of 0 and diagnoses including dementia with behavioral disturbance, metabolic encephalopathy, cognitive communication deficit, and dysphagia requiring enteral feeding, was observed on 04/18/2026 sitting in the lounge area near the exit door at approximately 9:00 AM by Geriatric Nursing Assistant (GNA) #34 and again at 10:10 AM by Registered Nurse (RN) #35. The investigation further revealed that at approximately 11:00 AM on 04/18/2026, RN #35 identified that Resident #94 was no longer present in the lounge area, prompting an immediate facility-wide search. At approximately 11:10 AM, the DON notified local law enforcement that the Resident was missing. During the search, the facility was contacted by a physician from Holy Cross Hospital who reported that Resident #94 had been found in the community attempting to enter a stranger's vehicle and was subsequently transported to the hospital by ambulance. A continued review of the investigative file revealed that security camera footage confirmed Resident #94 exited the building through the secured unit door located adjacent to the lounge area. The facility determined that the door had not fully closed and secured prior to staff disengagement, allowing the Resident to exit the facility. The investigation further revealed that although Resident #94 had previously been assessed as low risk for wandering, the Resident required supervision due to impaired safety awareness and significant cognitive impairment. Documentation showed the resident had a BIMS score of 0 and diagnoses including dementia with behavioral disturbance, metabolic encephalopathy, cognitive communication deficit, and dysphagia requiring enteral feeding. The facility verified the allegation of neglect based upon the investigative findings.On 06/03/2026 at approximately 9:51 AM, this surveyor conducted a telephone interview with Resident #94's daughter. She reported receiving notification from Holy Cross Hospital that Resident #94 had been found in the community and transported to the emergency department after attempting to enter a stranger's vehicle.On 06/03/2026 at approximately 10:17 AM, this surveyor contacted the local police department, which confirmed that it received a missing resident report from the facility on 04/18/2026 at approximately 11:10 AM.Following the incident, the facility implemented corrective actions including restricting use of the exit door involved in the incident, reassessing residents for elopement risk, updating care plans and interventions, providing staff re-education regarding elopement prevention and door security protocols, and implementing ongoing monitoring through audits and QAPI oversight. Therefore, the deficient practice was corrected prior to the survey and the facility achieved substantial compliance; this citation is issued as past noncompliance.

Based on observation, record review, and interviews it was determined that the facility failed to ensure care plans were revised based on medical provider assessment and recommendations. This was evident for 1 (Resident #41) out of 18 residents reviewed for care plans during the recertification and complaint survey. The findings include: Activities of Daily living: Activities of daily living are basic routine tasks that most healthy individuals can perform without assistance. These activities include: eating, dressing, bathing, toileting, managing continence, and transferring (moving from 1 position to another). The ability to perform activities of daily living is an essential measure of an individual's functional status. The inability to perform basic activities of daily living may lead to unsafe conditions and a poor quality of life. Mechanical Hoyer lift: a medical device used to transfer non-ambulatory individuals between beds, wheelchairs, toilets, and vehicles by using a support sling that the resident is placed in and lifted. On 06/02/2026 at 11:54 AM, during an interview with Resident # 41 reported they have only been out of bed once since admission. The resident was admitted to the facility on [DATE]. Resident #41 stated they would like to get up and staff have not offered. Resident #41 confirmed they need a Hoyer lift for transfers from the bed to the chair or wheelchair. On 06/02/2026 at 11:56 AM, during an observation of the resident and their room, no wheelchair, chair, or Hoyer sling was observed to be in the resident's room. On 06/04/2026 at 8:20 AM, a review of Resident #41 care plan revealed that they care planned for activities of daily living (ADL) deficit related to limited mobility with an intervention of 2 staff assistance for mechanical Hoyer lift transfers initiated on 12/22/2025. Resident #41 also care planned for limited physical mobility related to resident is bedbound initiated on 06/24/2025. On 06/05/2026 at 8:28 AM, a review of Resident #41 medical record progress note showed a progress note from the Nurse practitioner (NP) dated 02/19/ 2026 where they recommended continue with activities as tolerated, encouraged to get out of bed to chair with assistance from the staff. This recommendation was included in every monthly progress note by the NP reviewed from February 2026 through May 2026. On 06/05/2026 at 9:57 AM, in an Interview with Unit Manager, they confirmed Resident #41 is care planned for being bedbound for ADL's. The unit manager stated they are responsible for ensuring care plans are revised. When this surveyor showed the NP progress note from February 2026 through May 2026 showing the recommendation to get the resident up out of bed to chair with staff assistance, the unit manager stated she has only been here 2 months. The unit manager expressed she will look at the NP notes closer and revise the care plan to include interventions to ADLS that align with NP recommendations. On 06/08/2026 at 12:45 PM, this surveyor discussed concerns with the Director of Nursing about revising care plans to align with medical provider recommendations.

Based on observation and interview with the resident and facility staff, it was determined that the facility failed to ensure clean, safe, and comfortable environment. This was evident for 2 (Resident #10 and Resident #71) of 2 residents reviewed during the annual survey. The findings include: On 06/03/2026 at 9:50 AM, the surveyor observed that in Resident #71's bathroom wall-mounted light fixture above the hand sink was flickering. The wall surfaces surrounding the hand sink were cripped, cracked and pitted. The baseboards beneath the sink were lifting, peeling, and cracked with a buildup of mold-like substance present. The surveyor also observed that the resident's nightstand was missing a lockable drawer, and the cabinet door that was detached and hanging off its hinge. An interview with Resident #71 revealed that the Maintenance Director had been notified of the damaged nightstand and repairs had been requested. On 06/03/2026 at 11:00 AM, the surveyor observed Resident #10 bathroom was missing a towel rack, with only the two mounting brackets remaining attached to the wall. During an interview, Resident #10 stated that washcloths and personal hygiene items were stored on top of a trashcan due to the lack of available storage space. However, the placement of these items on the trashcan also obstructed access to the hand sink. On 06/03/2026 at 2:30 PM, the surveyor revisited Resident #71 and Resident #10 with the Administrator and the Environmental Services (EVS) Director. The Administrator confirmed the observations and stated that repairs or replacement of the damaged bathroom fixtures, deteriorated baseboards, and damaged nightstand would be completed promptly.

Based on medical record review and staff interviews, it was determined that the facility failed to ensure required notifications were completed during the resident transfer/discharge process. This was evident for 3 residents (Resident #4, Resident #34, and Resident #93) out of 6 total residents reviewed for transfer/discharge requirements during the complaint and recertification survey. The findings include: On 06/02/2026 12:37 PM review of Resident # 4's medical record revealed that on 3/19/2026 the Resident was transferred to the hospital and returned on 3/26/2026. On 06/03/2026 at 1:05 PM a review of Resident #4's medical records revealed no documentation indicating that the facility informed the Ombudsman of the resident's transfer to the hospital. On 06/03/2026 at 2:00 PM Social Services #31 submitted a report for March 1 through March 31, 2026. A review of the report revealed that Resident #4 was not listed on the report. On 06/04/2026 at 11:16 AM interview conducted with Social Services #31 regarding Ombudsman notification. Social Services #31 stated that reports are sent via email monthly. Review of the Ombudsman report for the month of March 2026, conducted with Social Services #31, revealed that the resident's transfer to the hospital was not communicated to the Ombudsman. Social Services #31 confirmed that the resident was not listed on the report. On 06/04/2026 at 1:30 PM, a review of Resident #34 medical record revealed a progress note dated 5/6/2026 documented by social services, stating that the facility issued a notice of discharge to Resident #34 for Tuesday May 12, 2026. On 06/05/2026 at 10:00 AM, the facility provided the requested written discharge notice for Resident #34 that was issued for 5/12/2026. It confirmed Resident #34 was given a letter signed by the Nursing Home Administrator informing the resident of the impending discharge by the facility with 6 days' notice to a Red Lion Inn with 4 nights paid for by the facility. The letter provided to Resident #34 did not include the required notice of discharge information that included reason for discharge and rights to hearing and mediation. On 06/05/2026 at 10:54 AM, an interview with the Nursing Home Administrator (NHA) revealed he was the one who wrote and signed the letter for Resident #34. The NHA stated the letter was an agreement and not a notice of discharge. He reports he verbally informed the resident of their rights and that they agreed to the 4 nights of hotel stay instead of a 30-day notice. He then stated Resident #34 changed their mind and asked for the 30-day notice which is when the facility then provided the written 30-days' notice on 6/1/26. The NHA stated he was not aware that Social Services documented the letter given to Resident #34 as a notice of discharge date in a progress note. Concerns were shared with the NHA that the facility's discharge process and policy were not followed for the letter of agreement given to the resident and that Resident#34 was not provided the required notice of discharge information that included the reason for discharge and rights to hearing and mediation. On 06/08/2026 at 8:39 AM, a review of Resident #93 medical record revealed in a nursing progress note dated 4/7/2026 the resident left the faciity on 4/7/2026 for approved leave of absence. The next entered progress note in Resident #93 medical record was dated 4/15/2026 and confirmed the resident was not able to be seen for wound care rounds due to being discharged home. On 06/08/2026 at 9:00 AM, an interview Social Services #31 confirmed Resident #93 left the faciity on 4/7/2026 for an approved leave of absence and did not return when the resident was scheduled to. Social Services #31 stated the facility reached out to the resident and let them know they would be discharged against medical advice (AMA) if they did not return to the facility. Social Services #31 then confirmed that the facility did not document any of the phone contacts they had with Resident #93 or any discharge progress notes in the resident's medical record. Social Services #31 also confirmed that the facility did not mail any written notice of discharge to Resident #93 or provide the required notice of discharge information that included reason for discharge and rights to hearing and mediation. On 06/08/2026 at 9:17 AM, a review of the facility's discharge policy confirmed the facility had a process for AMA discharge that included contacting the residents to inform them of their rights, notification to medical provider, discharge progress note to be written by social services or nursing, and contacting other community entities as needed for AMA discharge. On 06/08/2026 at 1:00 PM following the surveyor's intervention, Social Services #31 submitted a Hospital Tracking Portal report and emailed it to the Ombudsman on 06/08/2026 at 12:52 PM.

Based on observations, interviews and review of facility reports it was determined that the facility failed to prevent a cognitively impaired Resident with exit seeking behaviors from exiting the facility. This was found to be evident for 1 (resident #5) out of 1 Resident reviewed for an elopement. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy Past Non-compliance.The findings include: Brief Interview for Mental Status (BIMS) is a five-item screening that assesses memory and orientation by asking patients to recall words and state the current year, month, and day. Scores from 13-15 indicate intact cognition, 8-12 suggest moderate impairment, and 0-7 point to severe impairment.During a review of the facility reported incident #2639738 conducted on 10/17/25 6:30 AM, it was discovered that Resident #5 with a BIMS of 5 and a history of exiting seeking behaviors eloped from the facility on 10/09/25. During an interview conducted on 10/17/25 at 6:45 AM, Resident #5 gave the Surveyor multiple different accounts of the day he/she eloped on 10/09/25. During an interview conducted on 10/17/25 at 7:42 AM, the Maintenance Director (MD) reported that on the day of the incident, Resident #5 was seen on the camera footage entering the first-floor nursing unit from the second-floor elevator. The Resident was seen pushing on the locked exit door by the activities room. When unable to open the door the Resident then walked into the service hallway through the unlocked double doors. The MD explained that in viewing the camera footage it was discovered that Resident #5 entered the unlocked laundry room where he/she exited the facility. The MD stated that there was an exit door in the laundry room that led directly outside. The door did not have a lock, wanderguard sensor, or an alarm at the time the Resident exited the facility. The MD reported that the laundry tech failed to lock the door behind him when he left the laundry room. He further stated that at the time of the incident the door could only be locked with a key. During a tour of the facility conducted on 10/17/25 at 8:00 AM, the MD and Surveyor observed the laundry door that now had an automatic lock. The exit door inside of the laundry room was bolted shut. During the continued tour each exit door was observed locked with a wander guard sensor and a pin pad.During an interview conducted on 10/7/25 at 8:32 AM, the Director of Nursing (DON) reported that she called Resident #5's family member on 10/09/25 about a room change and that's when she was made aware that the Resident was no longer in the facility. The DON stated that the family member notified the DON that the Resident was at the Silver Spring Metro Station (about 2.3 miles from the facility). However, several minutes later the family member called again and notified the DON that the Resident was no longer at the Silver Spring Metro station, and they were en route to the facility. The DON reported that while the family member was at the facility he/she received a call that Resident #5 had arrived in a cab to the formerly known St Elizabeths Hospital located in the Southeast District of Columbia seeking help. The DON stated that the Social Service Director, Director of Rehab, Regional Director of Clinical and herself drove to the location, assessed the Resident and returned to the facility around 4:00 PM on 10/09/25. The DON stated that after an investigation the facility determined that the Resident was last seen in the facility around 10 AM when he/she received their medication. A Wanderguard is a type of wander management system used in senior living communities and healthcare facilities to prevent residents at risk of wandering from leaving the premises unsupervised. The system uses discreet wearable bracelets for residents and can include other components like door sensors to create a protective environment. If a resident wearing a bracelet attempts to go beyond a designated area, the system triggers an alert to notify staff, who can then provide immediate assistance. During a record review conducted on 10/17/25 at 9:45 AM, it was discovered that Resident #5 was assessed as an elopement risk and a wanderguard was placed on the right ankle on 08/19/25. A care plan is a written document that outlines the specific healthcare and support needs of an individual. It serves as a roadmap for providing personalized care and ensuring that all aspects of the patient's well-being are addressed. During record review conducted on 10/17/25 at 9:55 AM, it was discovered that Resident #5 had a care plan for wandering on 08/19/25 with an intervention that stated, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.During a phone interview conducted on 10/17/25 at 10:00 AM, the Resident's family member reported that a bus driver at the Silver Spring Metro station called at 12:04 PM on 10/09/25 at the request of the Resident. The family member stated that he/she told the Resident that he/she would be there to pick him/her up. A few minutes later the bus driver called back and reported that the Resident was no longer at the bus terminal and did not know where or what direction the Resident went in. The family member reported that later that day he/she received a call from the formerly known St. [NAME] Hospital located in Southeast District of Columbia (approximately 14 miles from the Silver Spring Metro station) notifying him/her that the Resident was at that location seeking help to get home. During the continued interview, the family member stated that he/she believed the Resident left the facility and caught a bus with his/her bus pass. The family member advised that there is a bus stop located at the corner entrance of the facility grounds. During a review of an aerial map conducted on 10/17/25 at 10:15 AM, it was discovered that there is a bus stop located 149 ft from the entrance of the facility located on a two-way road. During a phone interview conducted on 10/17/25 at 10:17 AM, the Silver Spring Metro bus driver reported that on 10/09/25 around 12:00 PM Resident #5 was seen sitting on a bench at the bus terminal. The Resident walked over and knocked on the bus door and asked if the bus driver could help him/her find their way back home. The bus driver reported that the Resident stated, I don't know where I am, but I live near a hospital. The bus driver stated that the Resident went into his/her purse and retrieved a paper with phone numbers and asked the bus driver to call the family member. The bus driver stated that she called the family member who stated that they would be there to pick up the Resident. The bus driver explained that she had to drive a quick loop and so she told the Resident to stay seated on the bench. However, when the bus driver returned to the bus terminal the Resident was no longer there. The bus driver stated that she called the family back and notified him/her that the Resident was no longer there.A review of the facility's abatement plan was conducted on 10/17/25 at 11:00 AM, it was discovered that the facility implemented the following corrective measures: The facility replaced the laundry entry door with a self-locking door on the day of the incident 10/09/25. The facility bolted shut the exit door located inside of the laundry room where the Resident exited the facility on 10/09/25. All elopement risk residents were reassessed, and the wanderguard functionality was tested on all residents with wanderguard bracelets on 10/09/25. In-service education for all staff on elopement, wandering, and monitoring were completed on 10/16/25. The Environmental Service Director (EVS) completed the in-service on safety procedure in laundry area on 10/14/25. A maglock to secure and lock the double doors of the service hallway was ordered on 10/10/25 and installed on 10/20/25. Random audits to be performed on elopement risk residents and staff implementing interventions weekly for 4 weeks and monthly for 3 months and the findings from these audits will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for review and further recommendations. The Director of Nursing (DON) and/ or Assistant Director of Nursing (ADON) will audit for proper transcription of the wanderguard orders, elopement risk assessment present, care plan update for new residents identified to be a risk. Weekly for 4 weeks and monthly for 3 months and the findings from the audits will be submitted to the QAPI committee for review and further recommendations. The Engineering Director will audit the exit doors to ensure they are always locked weekly for 4 weeks and monthly for 3 months. The findings from these audits will be submitted to the QAPI committee for review and further recommendations. Based on the review of the facility's abatement plan the facility's compliance date of the removal of the immediacy was 10/16/25.

Based on record reviews and interviews, it was determined that the facility failed to ensure a thorough investigation was completed for an allegation of abuse. This was found to be evident for 3 (Resident #2, & #7) out of 4 Residents investigated for abuse during the compliant survey.The findings include: During a review of the Facility Reported Incident (FRI) # 2598686 conducted on 10/20/2025 at 9:55 AM, it was discovered that Resident #2 reported that two Nursing Assistants came into his/her room to provide care and pounded on him/her and broke the phone. The facility's investigation included law enforcement notification, a statement from the resident, alleged perpetrators, other staff, and cognitively intact residents. However, the facility failed to assess the cognitively impaired residents that were assigned to the alleged perpetrators. During a review of the FRI #331192 investigation conducted on 10/20/25 at 12:59 PM, it was revealed that Registered Nurse (RN) #3 observed Resident # 11 standing beside Resident #7's bed. She stated that she observed Resident#11 hit Resident #7 on the left side of the head with an object.During a continued review of the investigation, it was discovered that the facility obtained statements from staff and notified law enforcement but failed to interview and assess residents that may have had an interaction with Resident #11.During a review of the FRI #331177 investigation conducted on 10/21/25 at 10:20 AM, it was discovered Resident #10 reported that a Geriatric Nursing Assistant (GNA) slapped him/her in the face and sat on both of their hands while the GNA provided care. A further review of the investigation revealed that law enforcement was notified, a statement was obtained from the resident, alleged perpetrator, other staff and cognitively intact residents. However, cognitively impaired residents were not assessed for abuse that were assigned to the alleged perpetrator.During an interview conducted on 10/21/25 at 10:33 AM, the Director of Nursing acknowledged that cognitively impaired residents had not been included in the investigation of abuse. She further stated that she understood the importance and would be implementing a practice that would include assessing the most vulnerable residents who were cognitively impaired when investigating abuse allegations.

Based on record reviews and interviews it was determined that the facility failed to ensure medical records were provided when requested. This was found to be evident for 1 (Resident # 8) out of 1 Resident reviewed for medical records during the complaint survey.The findings include: During a review of complaint #331189 conducted on [DATE] at 9:00 AM, the complainant reported that he/she requested Resident #8's medical records on [DATE] however the facility did not fulfill the request. The complainant further reported that when he/she requested a copy of the Resident's medical records for a second time the facility requested that he/she provide a letter of administration because the Resident was now deceased . During an interview conducted on [DATE] at 9:44 AM, the medical records staff member explained that the process for requesting medical records is as follows: once he received a request, he verified if the person is authorized to receive the medical records. Once verified the person will complete a form. The form is then sent to corporate who sends the request to a legal firm who approves the request. Once approved the medical records staff member would gather the medical records and either electronically send the records or send them via mail. He stated that he kept an electronic copy of the request and medical records that were sent out. The Medical records employee returned on [DATE] at 10:36 AM, provided this surveyor with an email that confirmed that the complainant requested Resident #8's medical records on [DATE]. He further stated that he recalled that the complainant came to facility and notified the facility that the Resident had passed away a couple of weeks ago. The complainant requested medical records but was told that he/she must have a letter of Administration now that the Resident was deceased . This Surveyor expressed concern that the complainant requested the medical records prior to the Resident passing away. During an interview conducted on [DATE] at 10:40 AM, the Director of Nursing (DON) acknowledged that the complainant first requested the medical records on [DATE] prior to Resident #8 passing away, however the request for medical records was not fulfilled at the time of the request.

Based on observation and interview it was determined that the facility failed to have an effective system in place to ensure temperature monitoring of unit refrigerators used to store resident food brought in from outside sources; and facility failed to ensure potentially hazardous food items were cooled according to acceptable standards. This was found to be evident for 3 out of 3 refrigerators observed in resident areas; and during the initial tour of the main kitchen and has the potential to affect all residents. The findings include: 1) Refrigerator temperatures for food storage should be kept at or below 41 degrees Fahrenheit (F). This will ensure food items being stored avoid the Danger Zone (temperatures above 41 degrees and below 135 degrees F) that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. On 2/19/25 at 10:52 AM when asked about storage of resident food brought in from the outside, the 2nd floor unit manager (Staff #21) reported that the activities department has a refrigerator downstairs (on first floor). She went on to state the food would be labled with the resident's name, date and room number. On 2/19/25 at approximately 11:00 AM the Environmental Services Director (ESD) reported that there are resident refrigerators on each floor and proceeded to show the surveyor the location of the first floor refrigerator. Observed of this refrigerator, located in the cafe area near the main entrance, revealed that it had a sign indicating it was for resident food only and that the food should be labeled with name and date; and that the food would be disposed of after 3 days. No temperature log was found to indicate the temperature was being monitored, but there was a thermometer inside the refrigerator that read 45 degrees. Surveyor and ESD also observed three containers of food in this refrigerator but there was no date or label on any of the three items. ESD indicated dietary staff are responsible for monitoring the food items. During this observation the unit nurse manager (Staff #21) arrived to clarify that the activity refrigerator is for snacks. On 2/19/25 at 11:12 AM the ESD and the surveyor observed the resident refrigerator located in the second floor dining room. This fridge had the same sign as the one on the first floor. No temperature log was found to indicate the temperature was being monitored. The thermometer was found inside the refrigerator on the door and the temp read 49 degrees, but this was noted after the door was opened for a few minutes. This fridge contained three bags of food: one bag with a room number only; one bag with room number and name; and one with a room number and a date. On 2/19/25 at 11:17 AM the Food Service Director (FSD Staff #7) reported that after three days they pitch the food. After observation of the items in the second floor resident refrigerator the FSD stated: this is not properly labeled; I was here two days ago and cleared it out. The FSD reported she checks the temperature of the refrigerator on the second floor but confirmed no written log was kept. The FSD also reported the nurses check the temperature of the refrigerator downstairs and that activities is responsible for monitoring the refrigerator in their area. Surveyor informed the FSD of the observation of the thermometer reading 49 degrees, the FSD changed to location of the thermometer. On 02/19/25 at 11:47 AM interview with the activity aide (Staff #27) reported that he sometimes stores resident's food in the activity refrigerator. After observation of the inside of the activity refrigerator the activity aide #27 confirmed there was no thermometer inside the refrigerator. Surveyor observed a bag labeled with a resident's name (Resident #7) and a date; and several bulk items that the activity aide #27 reported were for baking activities. The bulk items in the refrigerator failed to have labels to indicate what they were, instruction for storage or cooking, or expiration dates. On 2/19/25 at 11:54 AM the FSD reported she has now added a temperature log to the first floor resident refrigerator and indicated she would be responsible for monitoring. On 2/19/25 at 12:00 PM surveyor reveiwed the concerns with the NHA #2 regarding the unlabled food items in the resident refrigerators and the failure to monitor the temperature of the resident and activity refrigerators. Surveyor also reviewed the concern of no thermometer in the activity fridge. At 12:05 PM the NHA #2 confirmed there was no thermometer in the Activity refrigerator. At 12:19 PM the NHA #2 reported the activity fridge does read the temperature on the display panel but confirmed the temperature was not being monitored. She reported the activity refrigerator has been cleared out. 48470 2) An inspection of the stand-up refrigerator was conducted with the Food Service Director (FSD Staff #7) on 2/10/25 at 9:58 AM. During the inspection, a number of cooked food items were observed. These food items include: a) Oatmeal dated 2/9/25 b) pureed bread dated 2/10/25 c) grits dated 2/10/25 d) beef stock dated 2/9/25 e) gravy dated 2/7/25 f) pureed vegetable dated 2/9/25 g) ground chicken dated 2/10/25 The FSD #7 reported that the ground chicken was cooked about two hours ago. The FSD #7 was interviewed about the facility's cool down process and where documentations are kept for the cool down logs. The FSD #7 reported that they don't have a cool down process and that they don't monitor temperatures of cooked potentially hazardous food items when cooling them down. The FSD #7 stated, we just had a sanitary inspection done about a month ago and there were no concerns. The FSD #7 also reported that she knew about the regulation of monitoring the temperature for the cool down process for potentially hazardous food items but was under the impression that she was not required to do it in the facility. Later that day, at 10:40 AM, FSD #7 printed and provided the surveyor a copy of a document titled Cooling log and stated, we will start doing them now. FSD #7 reported that she had educated the cooks on how to use the cooling log and that all the cooked items observed earlier would be discarded. On 2/19/25 at 2:43 PM, the concern was discussed with the Director of Nursing (DON) that the facility did not have a process to monitor temperatures of cooked potentially hazardous food items when being cooled down. The DON verbalized understanding and acknowledged the concern.

Based on observation, interviews, and review of medical records and facility policy and procedures it was determined that the facility failed to follow enhanced barrier precautions and perform hand hygiene when indicated; and failed to ensure linens were processed so as to prevent the spread of infection. This was found to be evident for 2 (Resident #19 and #66) out of 24 residents observed during the initial phase of the survey but has the potential to affect all residents. The findings include: 1a)Resident #19 has a care plan, initiated in April 2024, addressing the risk of infection due to the use of a feeding tube. The interventions include: Enhanced Barrier Precautions when providing resident care secondary to the use of a feeding tube. Enhanced barrier precautions (EBP) are a set of infection control practices that use gowns and gloves to reduce the spread of infections. A gastrostomy tube (G-tube), also known as a feeding tube, is a surgically placed device used to give direct access to a person's stomach for feeding, hydration, or medicine. On 2/10/25 at 11:23 AM surveyor knocked on Resident #19's door. The door was answered by the geriatric nursing assistant (GNA-Staff #18) who indicated she was currently performing care for the resident. Surveyor noted that the GNA was not wearing a gown at this time. Surveyor waited in the hallway until the staff came out of the room. The GNA reported she had given the resident a bed bath and confirmed she did not put on a gown while providing care. When asked if she was supposed to wear a gown when providing care for this resident, GNA #18 responded: yes, I forgot. The Director of Nursing was made aware of this observation on 2/19/25 at 3:40 PM. 1b) During an observation of Nurse (Staff #14) on 02/13/25 at 10:10 AM two surveyors witnessed nurse #14 remove Resident #66's G-tube feeding tubing from the residents G-tube without performing hand hygiene immediately prior to touching the tube, and did not DON gloves or a gown. Review of Resident #66 medical record revealed the resident was on enhanced barrier precautions. Review of the facility's Enhanced Barrier Precautions Policy and Procedure indicates that Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Review of the facility's Standard Precautions Policy and Procedure states that Hand Hygiene is to be performed before and after contact with a resident, before performing an aseptic (a set of practices that prevent the spread of infection) task, after contact with items in a resident's room, and after removing gloves. On 2/13/25 around 12:30 PM the surveyors informed the Director of Nursing and the Assistant Director of Nursing that nurse #14 was observed removing G-tube tubing without performing hand hygiene or wearing a gown or gloves. 2) On 2/13/25 at 3:40 PM, the surveyor observed the laundry room and interviewed Staff # 19. The surveyor observed that to the left of the door, there was a linen bin with a closed lid, two washing machines and two dryers in the center of the room- side by side, a table to the right of the room with two levels that held clean linen and a covered linen cart to the right of the table. The surveyor asked Staff #19 to explain the process of handling the laundry. He stated that dirty linen is sorted upstairs and then brought to the bin to the left of the washers, which is designated as the dirty linen area. The dirty clothes and linens are brought to the laundry room already sorted and in plastic bags. Further, he stated that residents' clothes and linens are washed separately from the other laundry. On 02/14/25 at 8:26 AM the surveyor interviewed Staff #20 in laundry services. The surveyor had noticed a container, without a lid, that held wet linens piled above the top of the container that was placed in front of the dryers and asked what it was. Staff #20 stated that it was clean laundry waiting to be put in the dryer. This container was approximately two feet from the dirty laundry bin and no can liner was noted to be in the clean laundry can. There was no writing on the container to indicate that this was a designated clean linen container. The surveyor asked Staff #20 how he processes laundry, and he stated that he separates the laundry in the laundry room to the left of the clean area. He explained that the nurses usually separate the clothing from linens and bag it up before sending it to the laundry. He then lifted the lid off the designated dirty laundry bin and the surveyor observed that there were loose linens unbagged mixed with bagged linens and clothes. Staff #20 then closed the lid and stated again that they are usually bagged before coming to the laundry room. The Surveyor observed that Staff #20 was not wearing any Personal Protective Equipment (PPE), such as a gown or gloves, and asked what the expectation is for staff and the use of PPE in the laundry facilities. Staff #20 stated that he doesn't wear a gown between handling clean and dirty laundry but that instead he takes off his top shirt (he was wearing two layers, a long sleeve shirt with a short-sleeved shirt underneath) when handling clean laundry. The surveyor interviewed the Environmental Services Director (ESD) on 02/14/25 at 9:35 AM, who stated that there was a waiver on file due to not having a physical barrier between the clean and dirty areas of the laundry room. The surveyor asked what the process is for handling dirty and clean linens and what the expectation is about wearing PPE while handling laundry. She explained that when processing dirty laundry, isolation gowns, gloves, and masks are to be worn, that laundry is presorted on the units in designated linen closets, and that the dirty laundry arrives pre-sorted and bagged. The Surveyor notified the ESD that Staff #20 stated that he changes his shirt instead of using a gown. She confirmed that she had just seen him in the hall in his t-shirt and re-educated him about the use of PPE. The surveyor then asked about the container that was being used to hold clean linens and informed her that the container had been observed as overflowing, without a lid, and was not marked as clean linen. She stated that there should have been a lid that designated that container as clean laundry. When asked if there is an official onboarding or annual training for Environmental Services Employees, she stated that while there is no official education, she tries to tell them everything within a few days of hire. A review of the facility policy and procedure titled Departmental (Environmental Services)- Laundry and Linen States the following: Separate soiled and clean linen at all times; Employees sorting or washing linen must wear a gown and gloves and must wear heavy-duty rubber gloves for sorting laundry; Clean linen will remain hygienically clean through measures designed to protect it from environmental contamination, such as covering clean linen cart.

Based on surveyor review of residents' clinical records, interview of facility staff, residents' attending physicians, interview of staff at [MEDICATION NAME] County Communicable Disease and Epidemiology (CD&E)/local health TB department and review of facility administrative records, it was determined that the facility failed to ensure timely follow up of the treatment and management of multiple residents who were identified at risk for exposure to a serious infectious disease. In addition, the facility failed to record in residents' clinical records the rationale for treatment/non treatment for [REDACTED]. On 10-06-16 at 6:10 PM, an immediate jeopardy to residents' health and safety was determined by the State Office of Health Care Quality. The immediate jeopardy was abated on 10-06-16 at 10:30 PM following the facility's implementation of corrective actions to ensure the health and safety of all residents that are identified at risk for exposure to a serious infectious disease. The following is the facility's abatement plan developed on 10-06-16: 1.) Immediately upon identification of the immediate jeopardy, the results of [MEDICATION NAME] Skin Tests were reviewed. 2.) For residents who have a written history of a positive TST, documentation of a previous Chest x-ray was reviewed, as well as their most recent symptom surveillance to ensure that residents were without signs and symptoms of Active Disease. 3.) It should be noted that there were 20 residents receiving [MEDICATION NAME] Medications for a Positive [MEDICATION NAME] Skin Test. It should further be noted that none of these residents are exhibiting signs and symptoms of Active Disease. 4.) All residents will be screened for [DIAGNOSES REDACTED] on admission to the Center according to Centers for Disease Control & Prevention and local /state Health Department regulations and recommendations. 5.) If a [DIAGNOSES REDACTED] exposure occurs in the Center, management will notify the State and/or Local Health Department and conduct an investigation per State Regulations. All residents exposed to [DIAGNOSES REDACTED] will be screened based on guidelines from state/local agency. 6.) The Physicians have been contacted by the Medical Director on the necessity to document the rationale for post exposure treatment/non treatment. This documentation will occur within the next 48 hours. 7.) In the event there is a future exposure at the Center, the Medical Director will confer with the Medical Director at the State/Local Health, but will make the final treatment decisions or recommendations. 8.) All positive [MEDICATION NAME] skin tests will be reviewed by the Center Nurse Executive or Designee to ensure that final treatment decisions or recommendations have been completed and documented. 9.) The findings of the above will be provided by the Center Nurse Executive or Designee and reviewed by the Quality Improvement Committee monthly for 6 months and managed by the Center Executive Director 10.) Date of compliance is October 6, 2016. This finding was identified during the investigation of complaint MD 942 and is valid. Four of 4 resident records were reviewed during this complaint survey (#1, #5, #6, #7) The findings include: On 09-27-16 at 10AM, surveyor interview with the ADON (Assistant Director of Nursing) revealed that resident #1 was hospitalized since August 2016 and was diagnosed with [REDACTED]. [DIAGNOSES REDACTED] is caused by a bacterium called [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. Further interview revealed that the county CD&E/TB clinic was involved and contacted the facility in August 2016 to initiate an investigation of the residents in the facility. Line lists were developed including results of PPDs and chest X-rays conducted on both residents and staff involved. TST ([MEDICATION NAME] Skin Test)/ PPD (Purified Protein Derivative) is the standard method of determining whether a person is infected with [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] and is performed by injecting 0.1 ml of [MEDICATION NAME] PPD into the inner surface of the forearm. The skin test reaction should be read between 48 and 72 hours after administration and is measured in millimeters (mm) of the induration (palpable, raised, hardened area or swelling). Per CDC Guidelines, a positive IGRA (serum testing/ Quanteferon) result or a TST reaction of 10 or more millimeters of induration, is considered positive in residents and employees of high-risk congregate settings (e.g., nursing homes, hospitals, and other health care facilities). People with latent TB infection do not have symptoms, and they cannot spread TB bacteria to others. However, if TB bacteria becomes active in the body and multiplies, the person will go from having latent TB infection to being sick with TB disease. For this reason, people with latent TB infection are often prescribed treatment to prevent them from developing TB disease. Groups who should be given High Priority for Latent TB Infection (TB bacteria live in the body without making one sick), treatment include people with a positive IGRA result or a TST reaction of 10 or more millimeters and are residents and employees of high-risk congregate settings (e.g., nursing homes, hospitals, and other health care facilities). 1. On 09-27-16, closed record review revealed that resident #1 was administered a PPD skin test by the facility staff with results read on 05-26-15 by staff, with positive results of 10 mm. A chest X-ray was completed secondary to the positive PPD on 05-29-15, with a determination of no active disease. However, record review of resident #1's attending physician notes revealed no documented evidence from May 2015 to August 2016 addressing resident #1's positive PPD results in May 2015. Review of the change in condition and transfer summary revealed that resident #1 was transferred to an area hospital for bright red moderate bleeding from the mouth with intensity during coughing and tenderness to touch around both sides of the lungs. Further review revealed that, on 06-14-16, chest X-ray results revealed modest left lower lobe and modest right upper lobe patch infiltrates. At this time, the attending physician ordered nebulizer treatment every 6 hours x 3 days, [MEDICATION NAME] for cough and an antibiotic for bronchitis. On 09-29-16 at 1PM, surveyor interview with CD&E/TB staff #2 and CD&E/TB staff #3 revealed that the facility and CD&E/TB staff were involved in the May 2015 investigation regarding a staff member diagnosed with [REDACTED]. However, not until the current August 2016 investigation was CD&E/TB staff aware that 18 of the 19 residents, who were identified in 2015, had not received the [MEDICATION NAME] medication. In addition, resident #1 as well as 6 other residents, who were identified in 2015, were again identified during the August 2016 investigation. On 09-29-16 at 4PM, surveyor interview with the ADON revealed that the facility was waiting for CD&E/TB guidance, and a list of residents identified for [MEDICATION NAME] medication. On 10-04-16 at 10AM, surveyor interview with CD&E/TB staff #2 revealed that a list of residents who were recommended by the CD&E physician for [MEDICATION NAME] treatment was compiled and provided to the facility. The facility's physician ordered the PPD and chest x rays for the residents and were notified of the results by their lab. Residents identified for Quanterferon (QTF) serum testing were identified and tested by the CD&E/TB staff who notified the facility staff of the results. The only confidential results were regarding facility staff tests. (QTF is a whole-blood tests that can aid in diagnosing [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] infection with a positive test result suggesting that a M. [DIAGNOSES REDACTED] infection is likely) On 10-06-16 at 11:30AM, surveyor interview with resident #1's attending physician revealed that they were unable to recall if resident #1's 2015 test results, including the rationale for treatment/non-treatment, were addressed during the physician follow up visits. No additional information was provided. 2. On 10-06-16, surveyor review of the clinical record revealed that, on 05-21-15, resident #5 was administered a PPD with negative results. On 10-10-16 at 9AM, interview with CD&E/TB staff #2 revealed that, on 05-27-15, a QTF was obtained with positive results and resident #5 was included with other residents recommended for [MEDICATION NAME] medication. Further interview revealed another recommendation for [MEDICATION NAME] treatment in September 2016. Continued record review revealed a change in condition documented on 09-15-16 that resident #5's PPD results were positive and chest X-ray and QFT test was negative. The CD&E/TB staff recommended [MEDICATION NAME] treatment of [REDACTED]. On 10-06-16 at 11:30AM, surveyor interview with resident #5's attending physician revealed that she was aware of the resident's recent (2016) testing results and treatment. In addition, she was unable to recall if this was addressed with the 2015 testing. Record review revealed no documented evidence that the attending physician addressed resident #5's 2015 testing and results, including a rationale for treatment/non-treatment of [REDACTED]. 3. On 10-06-16, surveyor review of the clinical record revealed tht resident #6 was administered a PPD test on 05-20-15, with positive results of 12 mm. On 05-22-15, a chest X-ray was obtained with negative results for active disease, while on 05-27-15 an order for [REDACTED]. However, record review revealed no documented evidence of the results for the QFT testing. In addition, there was no documented evidence by the attending physician or attending nurse practitioner addressing the 2015 test results, or if treatment/non treatment was required for resident #6. On 10-04-16 at 10AM, surveyor interview with CD&E/TB staff #2 revealed that a recommendation for [MEDICATION NAME] medication in 2015 for resident #6 was provided to facility staff. On 10-06-16, further record review revealed that facility staff documented a late entry note, dated 10-05-16, that resident #6 was recommended by CD&E/TB staff to begin treatment of [REDACTED]. Orders were received for the treatment plan. 4. On 10-06-16, surveyor review of the clinical record revealed that resident #7was administered a PPD test on 05-19-15 with positive results of 15 mm. On 05-25-15 a chest X-ray was done with negative results. On 05-27-15, the medical director ordered a QFT test to be completed per the request of the CD&E/TB staff. However, there was no documented evidence in the clinical record of the QFT results. In addition, there was no documented evidence that the attending physician or attending nurse practitioner addressed the 2015 test results, and if treatment/non treatment was required for resident #7. On 10-04-16 at 10AM, surveyor interview with CD&E/TB staff #2 revealed that a recommendation for [MEDICATION NAME] medication for resident #7 was provided to facility staff in 2015. Further record review revealed that, on 09-08-16, resident #7 was transferred to a hospital to rule out TB due to a history of a positive PPD and recent TB exposure at the facility. The resident's QFT was positive, while the chest X-ray did not indicate any active TB, rather right lobe pneumonia was diagnosed . In addition, the resident was started on [MEDICATION NAME] INH and vitamin B-6 for 9 months and readmitted to the facility on [DATE]. On 10-06-16 at 9AM, surveyor interview with the facility's current medical director and the ADON revealed that the facility was aware of the residents that the CD&E/TB staff were recommending for [MEDICATION NAME] medication, the medication was ordered and the rationale for treatment was documented. However, there was no documented evidence of the rationale for treatment/non-treatment of [REDACTED]. Further interview with the current medical director, who was in place as the medical director in November 2015, revealed that they had not been informed by the previous medical director of any TB issues not resolved, and or pending information from the local health department. Further interview with ADON and DON revealed that the CD&E/TB/ local health department was taking the lead and the facility was waiting for the plan for residents in the facility. On 10-06-16 at 2:50PM, surveyor interview with the facility's former medical director revealed that, in May 2015, there was an index case involving a staff member, and the local health department was in contact with the facility. The facility did perform PPD tests on both residents and staff, including chest X-rays. The CD&E/local health department provided guidance, while initially the information was confusing. There was discussion regarding QTF testing on individual residents and the medical director ordered the tests, while the testing was completed by CD&E staff. However, the facility was not aware of the results for the residents and told this was due to confidentiality. Further interview revealed numerous conversations between the medical director and CD&E including co-signing letters sent by the local health department to residents/responsible parties and staff members regarding the initial testing and results to be provided. When inquired if the facility had contacted the local health department/CD&E/TB regarding residents who were recommended for [MEDICATION NAME] medication in 2015, the former medical director responded No. (Refer to F 520)

Based on surveyor review of the medical record and interviews with the resident, the complainant, the family, and the facility staff, it was determined that the facility staff failed to monitor and act upon the documented bowel status of resident #1 leading to a hospitalization for fecal impaction and failed to obtain the services of an interpreter when the resident tried to communicate with them. These findings were identified during the investigation of complaint MD 530 and are valid and considered to be Immediate Jeopardy. The Immediate Jeopardy was called on June 20, 2014 at 8:30 a.m. The deficient practice was abated on June 20, 2014 at 2:00 p.m. The findings included: On 06-19-14, a surveyor review of the medical record revealed that resident #1 was admitted to the facility on [DATE] following a hospitalization for nausea and vomiting and a urinary tract infection [MEDICAL CONDITION] and kidney stones. Additional [DIAGNOSES REDACTED]. The resident is alert and oriented and speaks another language with a very limited understanding and ability to speak English. On 06-19-14 at 8:45 AM, a phone interview with the complainant revealed that the resident was "severely impacted" with abdominal pain on arrival at the emergency room (ER). The physician in the ER was unable to disimpact (remove the hard stool manually) the resident and she was admitted to the hospital for additional treatment which included enemas. Review of the ER documentation, dated 05-26-14, revealed that the resident complained of constipation and abdominal and rectal pain with no bowel movement for the two weeks she had been in the facility. The report indicated that the resident received no help from the facility for this and called 911 for help. The resident was admitted to the hospital on 05-26-14. The physician attempted to disimpact the resident, removing 2 "hard, brown, fecal balls" but the resident would not allow further attempts and was admitted . Review of the consulting physician's report revealed that the resident had a "large fecal impaction". On 06-07-14, the resident was released from the hospital and returned to the facility. On 06-19-14 at 2:20 PM, an interview with the resident through the use of a phone interpreter revealed that she had not been able to have a bowel movement since she was admitted to the nursing home. She said she felt like she needed to have a BM and "pushed and pushed" but nothing would come out. She said that she tried to tell the staff "many times" that she was constipated. When asked what the staff responses were, she said that they were "silent". She said that the pain from the constipation was so bad that she called 911 for help. She resident said that now she is no longer constipated and has a daily BM. The facility has a bowel protocol in place for each resident. This protocol includes: if no BM in 2 days - offer 6 to 8 oz. prune juice. If no BM in 3 days - give 30 cc of MOM x 1 dose. If no BM by the 4th day - give a Fleet's enema. If no BM after the Fleet's enema - notify the physician. Additionally, if the resident requires 2 Fleet's enema in an 8 day period, notify the physician. This protocol was not followed for resident #1 because staff were not reporting or monitoring the resident's bowel status. On 06-19-14 at 2:15 PM, interview with LPN charge nurse #1 revealed that the resident came to the facility for rehab and was alert and oriented. She said that the nurses were able to communicate with the resident through "gestures and hand signals". She said the only time they used an interpreter was for a concern when they couldn't understand the resident but did not elaborate on what the concern was. She also said that the resident "has enough English to communicate". LPN #1 said that the GNAs complete the bowel records each shift. She denied that any bowel problems for this resident had been reported to her by the GNAs. LPN #1 stated that she does not routinely review the GNAs bowel records unless the resident was not eating, had nausea and vomiting, or received a report of no BM from the GNAs. She said that the resident was eating well. On 05-26-14 while making rounds on her residents, she observed that the resident was holding her stomach. She asked the resident if she wanted to use the bathroom and the resident said she did. The resident did not have a BM. She said that the resident did not say how long it had been since she had a BM. LPN #1 knew that the resident called 911 on 05-26-14 but didn't know why because the RN supervisor handled the call. On 06-19-14 at 1:20 PM, interview with RN supervisor #2 revealed that she was contacted by the 911 staff because they were unable to determine who called them from the facility. She was able to determine it was resident #1. She stated that the resident was "constantly complaining of burning with urination". She stated that she did not do a physical examination of the resident's abdomen or check for an impaction. She said that she had to call the interpreter's line to find out why the resident had called 911. She said that the resident said she had "abdominal discomfort and no BM for one week - I think". She said that LPN #1 had given the resident MOM without results that morning. On 06-19-14 at 1:30 PM, interview with the RN unit manager revealed that the resident understands "a little English". She stated that they got an interpreter for the initial nursing assessment. They also obtained pictures from the SW for interpretation of what the resident wanted. She said that she spoke with the resident's attending physician on admission about a laxative for the resident since the hospital discharge summary documented constipation as a problem while in the hospital. The physician did not want the resident to have a laxative because the resident was on antibiotic therapy for the UTI from the hospital. Review of the nurse and physician's documentation revealed no evidence of a problem with constipation or the resident's inability to have a BM prior to the resident's hospitalization . The facility initiated an investigation after the resident was sent to the hospital via 911 on 05-26-14. All GNAs on all shifts were interviewed and one mentioned a "small loose stool", and another a "smearing of stool". The remainder of the GNAs stated that the resident had not had a stool, with the exception of one GNA. This GNA stated during the facility interviews that she was "uncertain of her documentation since it was written over". Review of the nursing assistants' ADL flow record bowel documentation revealed that all entries for each shift documented no bowel movement until 05-16-14 when a small formed stool was documented. However, clearly underneath that documentation was a "zero" for no stool. This kind of overwriting was identified again on the evening shift on 05-17-14, on the day and evening shift on 05-19-14, the day shift on 05-22-14 and an unclear entry on the day the resident called 911 when the GNA documented that the resident had a medium formed stool. Additionally, the night shift entered no documentation for May 16, 19, 21 and 22, 2014. No evidence was identified that the GNAs reported this lack of a BM to nursing or that nursing was reviewing the GNAs documentation. The facility had no information on the entries on the GNAs bowel records which appeared to have been written over. Upon notification that the resident had a fecal impaction, the facility developed an abatement plan for June 2-4, 2014. Their plan reads in part: "All bowel records reviewed to determine that any resident identified with a potential for constipation have been having regular bowel movements. Any resident identified as not having a regular bowel movememnt have had the bowel protocol initiated and completed as per guidelines. Residents' attending physician will be notified if results of the bowel protocol are not positive for stool. Any additional orders given at that time will be carried out as ordered. Education will be given to all nursing staff on the documentation and reporting of constipation to the unit nurse or unit manager by the Nurse Practice Educator on June 2, 2014 through 6/11/2014. Daily review of ADL records by the nursing leadership on each shift to identify any resident in need of the initiation of the bowel management protocol." Following surveyor intervention on 06-20-14, the facility provided an abatement plan of actions they would take to assure that interpretation services would be used with each resident whose first language was not English. Their plan included: 1. identifying and assessing residents for interpretive or other communication needs 2. interviews with resident and family to determined interpretive needs 3. assure 24/7 access to interpreters 4. assess all new residents for interpretive needs 5. Education for all facility staff on communication with residents and how to access the interpretation lines 6. Ongoing interviews to assure communication needs are met 7. Weekly QI committee meetings for 4 weeks to evaluate the plan and make necessary changes.

Based on surveyor review of the closed clinical records and interviews with the staff and the complainant, it was determined that the facility staff failed to assure that the advanced directives were included in the information accompanying the resident when transported to the emergency room . This finding was identified during the investigation of complaint MD 922 and is valid and considered to be harm done. The findings include: Resident #1 was admitted to the facility on [DATE] following a hospitalization [MEDICAL CONDITION] and altered mental status. The resident had lived with his wife at home prior to the hospitalization . Other [DIAGNOSES REDACTED]. The resident was alert and required extensive assistance with all activities of daily living. On [DATE] at 3:40 PM, a telephone interview with the complainant, the documented POA (power of attorney), revealed that she advised the staff on admission that the resident was to be a DNR - do not resuscitate - and DNI - do not intubate (a breathing tube into the trachea). The resident was DNR/DNI while hospitalized prior to admission to the facility and she advised the staff that she would bring the Advanced Directive paperwork to them the next day, on [DATE]. The Advanced Directive is a legal document which appoints a health care agent to make medical decisions. Review of this directive revealed that it was formulated in 2007, appointed the complainant (the resident's wife) as the medical decision maker, and became effective upon signing. Record review revealed that the complainant was in the facility on [DATE] because she signed the immunization documents and the Advanced Directive documents were observed in the closed record. Further review of the nursing documentation revealed that on [DATE] at 6 AM, the RN (registered nurse) observed the resident to be unconscious with cold and clammy skin. The breathing was described as "rapid" with a pulse ox of 85 % on 3 liters of oxygen via nasal cannula. The pulse oximetry is a non-invasive measurement of the amount of oxygen in the blood. A normal pulse ox is considered to be above 92 % on room air. The nurse contacted the physician who ordered the resident to be sent to the emergency room . The nurse documented "no advanced directives in place". Further record review revealed that a MEMS (Maryland Emergency Medical Services) form was in the record which documented that the resident did not want to be resuscitated. This form was signed by the physician. The MEMS form needs to be given to the ambulance staff when a resident who has requested a DNR/DNI status is transferred to the hospital. If the resident's breathing or heart stops while in the ambulance, the EMS staff would not perform CPR or intubate the resident. Additionally, the MEMS form is then given to the hospital emergency room staff for the same purpose. On [DATE] at 10:15 AM, an interview with the DON (director of nursing) revealed that the MEMS form was from the hospital but agreed that it was still valid for the facility because it documented the resident's wishes. Review of the physician's admission orders [REDACTED]. On [DATE], review of the hospital emergency room (ER) record revealed that this resident was in respiratory distress on arrival via ambulance and a non-rebreather mask was placed to administer oxygen to the resident. The resident continued to be unconscious with periods of apnea (temporary cessation of breathing) [MEDICATION NAME] 20 seconds. The physician then inserted a breathing tube (intubated the resident) to allow for breathing with the assistance of a ventilator. Further review of the ER record revealed that when the family arrived at the hospital, they "maintained that the patient was a DNR/ DNI" (do not intubate). The physician documented that "after extensive discussion with the family, the resident was made a DNR/DNI and was extubated" (removal of the breathing tube). The resident was admitted to hospice from the hospital on [DATE] and expired a week later. On [DATE] at 9:10 AM, an interview with the RN who worked nights on [DATE] revealed that she was "rushing to get him ready to go to the ER and thought that because he had only been in the facility a short time, he probably didn't have an advanced directive". She also said that she "didn't have time to look for an Advanced Directive due to the need to get the resident to the ER". The facility staff failed to honor the resident's and POA's Advance Directive which specified no intubation.