Every finding on record at South Mountain Rehab Center

Based on a pertinent document review and interviews, it was determined that the facility failed to provide an Emergency Medical Service (EMS) transport crew with the correct Medical Orders for Life-Sustaining Treatment (MOLST) for a resident being transported to the hospital, This deficient practice contributed to the resident not receiving life-sustaining treatment prior to cardiac arrest and resulted in the resident's death during transport. This was evident for one (Resident #200) of one resident reviewed for an unexpected death during a complaint survey. Consequently, an Immediate Jeopardy was called on [DATE] at 3:26 PM.The findings included:A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used to document a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient.On [DATE] at 8:00 AM, a review of complaint #2981632 revealed that on [DATE], an EMS crew responded to a 911 call placed by Resident #200. Prior to transport, the EMS crew was not provided with the correct MOLST form for Resident #200; instead, they were provided with the MOLST form belonging to Resident #200's roommate (Resident #201).On [DATE] at 12:00 PM the survey team received the facility's final report of their internal. Review of the report revealed the following.Resident was anxious, GNA reported to the nurse that resident was short of breath. The nurse went to the resident's room. The resident did not appear short of breath. Vital signs checked and were within normal limits. O2 sat was 93% on 2 liters nasal cannula. and s/he kept removing the oxygen, so the nurse stayed with the resident until s/he was comfortable and stopped removing his/her oxygen. Continued review of the facility's internal investigation revealed that the Deputy arrived and went to the resident's room with the nursing supervisor. The resident was unable to convey why s/he called 911. The deputy asked the resident if she wanted to go to the hospital and s/he stated yes. The deputy radioed for an ambulance at that time. EMS arrived and asked why s/he was going to the hospital. The Nurse reported her complaint of shortness of breath and desire to be transferred to the hospital. EMS left with the resident. Nurse reported s/he appeared calm and comfortable with an oxygen sat of 94% as s/he went by her on the stretcher. On [DATE] at 8:30 AM, the [NAME] County EMS incident report #2610270 was reviewed. The review revealed that Resident #200 called 911 and reported to the first arriving officer, a deputy, that they wished to go to the hospital. The deputy requested EMS, and upon arrival, the EMS crew prepared the resident for transport. Further review confirmed that the EMS crew documented that they did not receive the correct medical documentation for Resident #200, but instead received Resident #201's medical documentation, including the MOLST form.Continued review of the EMS report revealed the following: Staff made no effort to come to the room, leave the desk or help the crew, but did present EMS with the face sheet and MOLST. MOLST said Resident #201. Resident 201 as well as name tag on room. Patient is called by the name of (Resident #201 name) and does not correct EMS. On [DATE] at 9:36 AM, the Director of Nursing (DON) provided Resident #200's medical (paper) chart. A review of the chart revealed a MOLST form dated [DATE] with an order for DNR-A-2. This designation, Comprehensive Efforts to Prevent Arrest, requires that prior to cardiac arrest, staff administer all indicated treatments to stabilize the resident, including medications and limited ventilatory support such as CPAP or BIPAP, while not initiating resuscitation in the event of cardiac arrest.At 9:42 AM on [DATE], a review of the SNF/NF to Hospital transfer form dated [DATE] revealed a section titled Copies of Documents Sent with the Resident/Patient. Although the MOLST form was listed as one of seven documents to accompany the resident, none of the listed documents were indicated as having been sent.On [DATE] at 1:36 PM, a review of Resident #201's (the roommate's) medical (paper) chart revealed a MOLST dated [DATE] with an order for DNR-B. This designation, Palliative and Supportive Care, directed that prior to cardiac arrest, only passive oxygen and comfort measures, such as pain relief, were to be provided and prohibited additional interventions including medications, intubation, CPAP, or BIPAP.A continued review of EMS records on [DATE] at 10:00 AM revealed that the treatment provided to, or withheld from, Resident #200 during transport was based on the DNR-B MOLST orders belonging to Resident #201, rather than Resident #200's own DNR-A-2 MOLST orders. As a result, Resident #200 did not receive the comprehensive interventions intended to prevent cardiac arrest that were consistent with their physician orders. Resident #200 experienced cardiac arrest during transport and was pronounced deceased at the hospital.On [DATE], an interview with the Quality Assurance EMS Captain revealed that upon arrival at the hospital, the EMS crew provided hospital staff with the documentation received from the facility. Hospital staff reviewed the documentation and informed the EMS crew that it did not belong to Resident #200. The EMS Captain reported that the crew had the capability to provide comprehensive care consistent with DNR-A-2 orders; however, those interventions were not initiated due to the incorrect MOLST orders provided by the facility. The EMS Captain also reported that they reviewed the 911 call, which confirmed that Resident #200 requested assistance. This was corroborated by the deputy, who confirmed the resident requested transport to the hospital.On [DATE] at 10:39 AM, the facility Administrator, DON, and Clinical Regional Manager were interviewed. They reported that the unusual circumstances, including the resident independently calling 911 and a deputy arriving prior to EMS, may have contributed to confusion regarding the resident's documentation. They also stated that the 911 call center had notified the facility that EMS was dispatched.A review of the initial facility report revealed that the resident was documented as DNR; however, the facility failed to specify the resident's designation as DNR-A-2. The MOLST form does not include a generic DNR designation, but instead identifies specific No CPR options, including Option A-1, Option A-2, and Option B.On [DATE] at 11:00 AM, a review of the facility's internal investigation notes included an interview with Staff #6, who documented that the emergency room was notified of Resident #200's transport and subsequently informed by the hospital that an incorrect MOLST form had been sent. The notes indicated that, following notification-and after the resident had expired during transport-the correct MOLST form was faxed by the unit secretary.On [DATE] at 2:26 PM, the Nurse Unit Supervisor (Staff #3) who was working at the time of the transfer was interviewed. She reported that Staff #6 provided the documentation to the EMS crew and that she was unaware of any error. During the interview, Staff #3 stated she believed there was only one type of DNR designation and was unable to differentiate between the MOLST optionsXXX[DATE] at 2:37 PM Nurse (Staff #7) was interviewed about what she reviews on a resident's MOSLT form prior to signing off. Nurse #7 reported she would review the MOLST for dates and signatures. When surveyor asked, Are there different types of DNR orders, Nurse #7 answered,No .a DNR is a DNR. On [DATE] at 11:22 AM During an interview the survey team shared with the Regional RN Staff #4 that interviews were conducted with a staff nurse regarding the different types of DNRs. Staff #4 confirmed that they had recognized this knowledge deficit and have added this to their nurse MOLST education. Additionally, Staff # 4 reported they are considering bringing in a nurse consultant that could more concisely explain the intricacies of the MOLST form. On [DATE] at 11:30 AM, the Regional Nurse (Staff #4) was interviewed. She confirmed that the hospital notified the facility that the incorrect MOLST form had been sent and reported that the correct MOLST was subsequently provided. She further stated that the facility was informed that Resident #200 had expired during transport On [DATE] at 3:30 PM, the Administrator was interviewed and confirmed awareness of the concerns and the Immediate Jeopardy determination.The facility submitted a plan to remove the immediacy on [DATE]th at 4:36 PM 2026. The facility's plan included. 1. Continuing education on the Facility's MOLST policy with all Licensed nurses. 2. The audit will be ongoing for 3 months and results will be sent to the Quality Assurance Performance Improvement committee. On [DATE] at 4:36 PM the facility was notified that the first plan was not accepted.A second abatement plan was submitted on [DATE] at 5:45 PM. This plan was approved and included the MOLST policy with a clarification that nurses will receive the education prior to returning to work. The facility's MOLST policy requires two people to check the MOLST prior to transport. On [DATE] at 1:15 PM a review of the plan was made. The facility was informed that they needed to add how they would educate nurses that were unavailable to immediate education. The facility identified the nursing the staff that had extended absence and a plan to ensure education prior to returning to work On [DATE] at 4:30 PM, the plan was verified and the IJ was abated. On [DATE] at 12:30 PM an extended survey was completed.

Based on observation, record review, 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 recertification 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. Cross-contamination refers to the transference of harmful substances or pathogenic microorganisms to food by hands, food contact surfaces, sponges, cloth towels, kitchen equipment and/or utensils that have not been properly cleaned after contacting raw food and then touching ready-to-eat foods. Cross-contamination can also arise from inadequate dishwashing procedures that fail to effectively wash, rinse, sanitize, air-dry, and/or stored in sanitary conditions. On 03/04/2026 at 10:10 AM, surveyors conducted a tour of the kitchen with the Certified Dietary Manager (CDM). The following deficient practices and unsanitary conditions were identified:Ice Machine and Prep Sink 1. The interior and exterior surfaces of the ice machine were observed to be unclean. 2. The overflow cover of the prep sink was cracked, chipped and damaged 3. The overflow cover of the prep sink was cracked, chipped, and damaged. 4. The drain stopper of the prep-sink was broken preventing the vats from being filled with water. 5. The drain line of the prep-sink was leaking. 6. The floor sink covers were rusted and unclean.Coffee Machines 6. The prep table supporting the coffee machine exhibits multiple jagged holes preventing a smooth, cleanable surface. 7. The coffee machine drain line lacked a backflow prevention device.Hand Sink and Food Prep Areas 8. The hand sink was not properly sealed to the wall to provide a smooth and cleanable surface areas to prevent bacterial proliferation. 9. Nonfunctional ceiling-mounted heating furnaces were identified in the kitchen. Placements of Fountain Soda Bag in a Box on Wire Stand and Rolling Food Cart 10. The electrical panel doors in the kitchen were not maintained in a closed position exposing significant accumulation of dust, debris, and dirt. Canopy Hood Area 11. The laminated wooden panels wrapped around the prep table were warped and water damaged. 12. The walls and floors beneath the cooking equipment were unclean.Hand Sink and Prep Table by the Cookline 13. The caulking around the hand sink at the wall was torn off. 14. The drain stopper of the in-counter prep sink was nonfunctional.Dropdown Ceiling Area 15. The ceiling tiles were improperly fitted and exhibited accumulations of dust and debris. Walk - in Refrigerator 16. The compressor fan covers were unclean. 17. The walk-in refrigerator was had one light bulb requiring replacement. 18. The door gaskets were unclean. 19. The casters on the shelving units were rusty and unclean.Walk - In Freezer 2 20. Walk-in freezer 2 was nonfunctional and turned off. Walk - In Freezer 1 21. Compressor fan covers were unclean. Warewashing Area 22. The warewashing hand sink was not securely sealed to the wall. The caulking around the unit was torn off, creating large gaps between the wall and the hand sink. 23. The 3-compartment sink dump test failed. The floor drain overflowed with greywater onto the kitchen floor. A review of the last local Health Department inspection report revealed that the floor sink previously had a clogging issue. 24. The 3-compartment gooseneck faucets were not securely fitted onto the unit. 25. The drain lines of the 3-compartment sink were manifolded. High-Temperature Conveyor Dish Machine 26. The wall behind the high-temperature conveyor dish machine was exposed. 27. The grouting around the [NAME] tiles underneath the dish machines was not smooth and unleveled. 28. The dish machine ventilation failed to capture steam and vapors escaping from both ends of the unit. 29. The ceiling tiles around the dish machine vent stacks with adjustable dampers were unfitted. 30. The chemical bucket was not elevated off the floor to facilitate cleaning. 31. The left feed catch drain line leaked greywater onto the top of the 30-gallon dish detergent drum and onto the kitchen floor. 32. Numerous fruit flies were observed beneath the pre-rinse area and on top of the 30-gallon dish detergent drum. 33. The unused garbage disposal drain line was placed on the floor at the back of the dish machine.Self-Closing Entrance Doors Missing Doorknobs 34. Two kitchen entrance doors were missing doorknobs, which prevented the doors from being opened into the kitchen. 35. The bumper guards on the wall behind the food carts were damaged.Throughout the Kitchen Areas 36. The paint on the kitchen wall was chipped and scrubbed off in various places. In addition, several ceiling tiles were stained from food/drink splashes.Food Contact Surfaces 37. The utility rolling food service carts were cracked and damaged preventing units to be properly cleaned and sanitized. At 11:30 AM, a follow-up tour of the kitchen was conducted with the Maintenance Director and Staff #5 to identify the findings listed above. Both the Maintenance Director and Staff #5 confirmed that the deficiencies will be addressed promptly.

Based on observation and interviews, it was determined that the facility failed to ensure staff performed hand hygiene when entering and exiting a room in which a resident was on neutropenic precautions. This was evident for 1 (Resident #84) of 1 resident on neutropenic precautions reviewed during the initial screening process of the annual survey.The findings include:Neutropenic precautions are critical safety measures for individuals with low white blood cell counts (neutropenia) to prevent life-threatening infections. Key actions include strict hand hygiene, avoiding crowds and sick individuals, consuming only well-cooked foods, avoiding raw fruits and vegetables, and removing fresh flowers or plants from the environment.On 3/03/26 at 9:00 AM, the surveyor observed a sign posted on Resident #84's door indicating the resident was on neutropenic precautions.On 3/03/26 at 9:36 AM, the surveyor observed a geriatric nursing assistant (GNA #21) entering and exiting Resident #84's room without performing hand hygiene. The surveyor asked GNA #21 to explain the sign posted on the door indicating Neutropenic Precautions. GNA #21 stated, It is very important that we wash our hands before entering and when leaving the room. She further explained that the resident must avoid undercooked and raw foods, cannot have live plants, and staff should wear personal protective equipment (PPE) when providing direct care.The surveyor asked GNA #21 why she did not perform hand hygiene if it was so important. GNA #21 made a facial expression and stated, I forgot, and then stated, but I didn't provide direct care. The surveyor asked for clarification as to whether hand hygiene was only required if providing direct care. GNA #21 confirmed, No, we must always perform hand hygiene when entering and exiting the room.On 3/05/26 at 9:20 AM, an interview was conducted with the facility Infection Preventionist nurse (IP #8), who reported that she managed isolation precautions for residents. She stated that neutropenic precautions require staff to perform hand hygiene before entering the room.On 3/05/26 at approximately 1:13 PM, the surveyor notified the Director of Nursing that GNA #21 did not perform hand hygiene before entering or after exiting the room of Resident #84. The Director of Nursing confirmed that she should have known better and stated that hand hygiene is required when entering and exiting the room of a resident on neutropenic precautions.

Based on interviews, observation, and record review, it was determined that the facility failed to provide a clean, homelike environment. This was evident in 2 (Resident #4 and Resident #103) of 2 residents' rooms reviewed during the recertification survey.The findings include:1) On 03/04/2026 at 3:27 PM, Resident #103 expressed a complaint to the surveyor regarding the cold temperature of the room while resting in bed, utilizing a heavy blanket obtained from home. A family member seated next to the resident indicated that they had previously voiced concerns about the cold room temperatures and the inadequacy of the thin vinyl rolling window treatment in blocking sunlight.The surveyor inspected the window and determined that the corner of the windowsill exhibited significant damage. In addition, the warped window frame, where sealant had been previously applied showed evidence of torn material resulting in slow air drafts. The ambient room temperature measured with a calibrated stem thermometer, placed on the nightstand adjacent to the resident's bed, was recorded at 70.6 degrees Fahrenheit. At 3:30 PM, the surveyor interviewed the [NAME] unit Nurse Manager and the Administrator. These interviews revealed no complaints were filed from the resident or their family members regarding the room temperature or a request for the installation of an alternative window treatment to mitigate significant sun exposure. In addition, a review of the grievance logs, spanning from the resident's admission date in February through March of 2026, also confirmed that no complaints were documented.At 3:35 PM, both the Administrator and the Maintenance Director assessed the resident's room and confirmed that the windowsill would be repaired and a new window treatment would be ordered immediately.On 03/05/2026 at 3:45 PM, the surveyor conducted a follow-up assessment with the resident, who was observed seated in a chair without the heavy blanket next to a family member watching television. The resident confirmed that the room temperature was comfortable. The surveyor verified that the damaged windowsill had been repaired. However, a new window treatment had not yet been installed.2) On 03/05/2026 at 12:55 PM, the surveyor observed a large exposed wall underneath the hand sink in Resident #4's room where both the drywall and concrete blocks were separated from the wall, exposing the waterline behind the wall. At 2:30 PM, the Maintenance Director was provided photographs of the resident's room taken by the surveyor. The Maintenance Director confirmed that the wall required removal to access and repair the waterline. He confirmed that the wall underneath the hand sink will be repaired/replaced promptly.

Based on record review and staff interviews it was determined that the facility failed to provide a bed hold notice and hospital transfer documents to a resident and failed to provide written notice of the hospital transfer to resident's representative. This was evident for 1 (Resident #1) of 2 residents reviewed for hospitalization during the survey.The findings include:On 3/6/26 at 8:52 AM a record review of Resident #1's electronic health record revealed Resident #1 was transferred to the hospital on 2/25/26. Further review revealed that Resident #1's family representative was notified via telephone.On 3/6/26 at 9:47 AM in an interview, Licensed Practical Nurse (LPN #18) confirmed that the hospital transfer process was the same throughout the facility and described that once a physician order was obtained, the unit clerk prints and assembles pertinent medical records and places them into an envelope titled: Acute Care Transfer Document Checklist. The transferring nurse verifies the contents and sends the packet with the resident.On 3/6/26 at 10:38 AM the Unit Clerk (Staff #19) confirmed LPN #18's description of the hospital transfer process. She stated that the bed hold notice was in the resident's paper chart. She did not know who was responsible for notifying the family representative. I put the packet together, and give it to the nurse, I don't know what happens after that.On 3/6/26 at 11:00 AM a record review of Resident #1's paper chart revealed a lack of bed hold notice. LPN #18 confirmed the finding and stated, every resident should have one. The Director of Admissions stated that the Bed Hold notice is included in the admission packet. On 3/6/26 at 11:08 AM a review of the Hospital Transfer/bed hold policy revealed, in part, that when the facility transfers a resident, specific information is documented in the medical record, and the residents (or resident representatives) are notified.in writing. A record review of the Bed hold Policy Mailing to Responsible Party log did not include Resident #1's name which indicated that the resident's representative was not notified in writing.On 3/6/26 at 12:07 PM in an interview, the Director of Nursing and the Assistant Director of Nursing acknowledged that they cannot confirm that Resident #1 received the bed hold notice, hospital transfer documents nor that written notice of the transfer was provided to the resident representative.

Based on observation and interview it was determined the facility failed to ensure bathroom and floor tiles were maintained in good repair and that the exhaust ventilation system was working. This was found to be evident on 4 out of 4 units observed during the survey. The findings include: 1) Tour of the first-floor bathrooms/shower room secondary to reported complaints of cleanliness revealed substantiated concerns related to a sanitary environment for Residents to bathe. Tour initiated on 12/18/24 at 9:32 AM of the Antietam shower room revealed hair on both shower stall walls, a caked white substance on the wooden seats, the molding along the entrance into both shower stalls was missing or peeling off. There was noted black areas where the molding was missing. The soap dish in both shower stalls was missing porcelain and the netting under the porcelain was exposed making it rough and uncleanable. There was no safety mat on the left side. A repeat tour was conducted on 12/19/24 at 3:50 PM with the maintenance director, staff #35. The bathroom on Antietam was entered first. The findings from 12/18/24 were still identified and presented to staff #35 including the hair still on the shower walls. Additionally, there was a shower chair with dried stool on the seat and the cushion. Additionally, it was noted in the shower to the left, there were 2 tiles that were broken and jagged. Tour of the bathroom/shower room on [NAME] revealed, upon entry, there was a wall corner that was missing the end cap exposing jagged metal. The area was 15 inches long and accessible to any resident or their legs in a wheelchair. There was blue tape over the area that changed from the 2 floor styles making a trip hazard and infection control concerns as it was not able to be cleaned appropriately. The molding at the entrance to the shower stalls was also peeling and dirty as in the Antietam bathroom/shower room. 16218 2) A tour of the facility was conducted with the Maintenance Director on 12/19/24 between 3:40 - 4:30 PM. During this tour the exhaust vent in the bathroom of room [ROOM NUMBER] and the 200 unit shower room was found to not be working. The Maintenance Director reported one system pulls the exhaust for the entire unit and indicated a belt might be broken. In addition to the exhaust vent not working, at least 4 (1 x 1 inch) tiles were noted to be cracked in the shower room on the 200 unit. 3) On 12/12/24 observation of room [ROOM NUMBER] revealed a crack in the tiles running from the resident's sink to the area under the bed. On 12/19/24 at approximately 4:00 PM during the tour of the facility with the Maintenance Director (Staff #35), surveyor again observed the crack extending through several tiles of room [ROOM NUMBER]'s floor. The Maintenance Director reported these cracks were due to the building settling and indicated he could fix the tiles. Surveyor and Maintenance Director also observed multiple cracks in the tile of the 300 unit shower room. And a random check of the bathroom vent in room [ROOM NUMBER] revealed it was not working. Maintenance Director indicated the same system pulls exhaust for both the 200 and 300 units. 4) On 12/17/24 at 1:24 PM a urine odor was noted in the hallway of the [NAME] unit, observation at that time of the shower room revealed missing tiles near the shower. Observation, with the Maintenance Director, of the shower room on the [NAME] Unit at approximately 4:15 PM on 12/19/24 failed to reveal the presence of an exhaust fan/vent. The Maintenance Director indicated he would investigate this finding. Additional observation of the [NAME] Unit shower room at this time revealed at least 15 (approximately 3/4 x 3/4 inch square) missing tiles at the entrance to the shower and a quarter inch round hole noted in the shower itself. The Maintenance Director reported the hole was from a shower rod that was no longer in place. On 12/20/24 the Maintenance Director confirmed that he has not identified an exhaust fan/vent in the [NAME] unit shower room. On 12/20/24 the Maintenance Director also provided a work history report that indicated the Exhaust Fans were inspected for proper operation and cleaned if necessary each month from December 2023 through November 2024.

Based on review of medical records, facility policies, investigation documentation, and interviews, it was determined the facility failed to ensure that allegations involving abuse were reported to the State Agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident for 5 (Resident #421, #214, #468, #469, #264) of 13 residents reviewed for abuse allegations. The findings include: 1) a. Review of a complaint from 2/1/23 on 12/19/24 at 11:51 AM revealed that resident's family member was notified by the facility that Resident #421 had a fall from [resident] shoes and was sent to the emergency room where a cat scan was completed. Resident #421 at the time of the fall had diagnosis including dementia, muscle wasting and Alzheimer's disease. S/he was also residing in the secure unit of the facility. Care plan and GNA task list report had resident documented as requiring 2 staff for transfers. Review of the nursing progress notes completed on 1/23/23 at 11:04 AM noted that Resident #421 was found on the floor in his/her room, right forehead swollen, vital signs stable. The area was not documented as bleeding, however the resident reported that the area was sore and was noted guarding their forehead and stated oooh that really hurts. On 12/19/24 at 2:24 PM the Director of nursing was asked if this fall, an injury of unknown origin, was reported to the state agency as they did not know at the time how the resident fell . She stated that she was not here at the time, so she did not know. She was further asked if she could look and see as there was no record with the state agency that this fall was reported. This surveyor reported at the time of the concern that there should be a report to the office. b. Continued review of the progress notes for Resident #421 then revealed that on 1/28/23 another fall with significant injury. According to the progress notes entered on 1/28/23 at 10:30 AM, Resident #421 was found lying on the floor in front of his/her bed. S/he had complaints of pain on the right leg and hip. An x-ray was ordered. According to an interview completed on 12/20/24 at 8:00 AM with staff #7, who was the Unit manager at the time, the x-ray was delayed so Resident #421 was sent to the hospital where x-rays were completed and determined that Resident #421 had a femur fracture. Staff #7 was also asked at the time if either fall from 1/23/23 or 1/28/23 was reported to the state agency. She stated that she knows the second fall was reviewed under quality assurance as there was a delay with the x-ray, however she did not know about it being reported. She was asked if injuries of unknown origins are reported and she stated yes and agreed that they both should have been reported to the state agency. 16218 2) Review of Resident #214's medical record revealed resident had diagnosis of, but not limited to, dementia and anxiety. The Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Procedure was provided by the Nursing Home Administrator on 12/17/24. Review of this policy failed to reveal an effective or revision date. This policy indicates allegations of abuse will be reported within 2 hours if there is serious bodily injury but within 24 hours if the allegation does not meet the definition of serious bodily injury. On 12/19/24 review of facility report MD00189201 revealed that on 2/16/23 at 10:00 PM the resident alleged being inappropriately touched by a Geriatric Nursing Assistant on the evening shift. The report was submitted to the state survey agency on 12/17/23 at 11:00 AM. Further review failed to reveal documentation to indicate who the resident made the initial allegation to or that a follow up interview was conducted/attempted with the resident by an individual responsible for conducting the investigation. No documentation was found to indicate when this allegation was initially reported to the Nursing Home Administrator (NHA) or the Director of Nursing (DON). On 12/19/24 at 10:53 AM Surveyor requested a copy of the investigation documentation from the NHA and also requested any additional documentation they may have regarding this investigation that they would like surveyor to review. On 12/19/24 at approximately 1:30 PM the Assistant Director of Nursing (ADON) provided copies and denied that there was any additional documentation to be provided. On 12/19/24 at 1:59 PM Director of Nursing reported she would expect herself or the NHA to be notified immediately of an abuse allegation and would report it to the survey agency if it was an abuse or actual harm within two hours. Surveyor then reviewed the concern regarding the policy stating they have 24 hours to report abuse allegation if it does not meet definition of serious bodily harm. Surveyor also reviewed the concern that there was no documentation of the initial interview or report from the resident and no documentation found to indicate to whom or when the initial allegation was made or who reported it to the NHA or the DON. 50458 3) On 12/12/2024 at 11:52 AM, a review of investigation MD009196714 and review of the facilities self-report form, revealed that the alleged incident with Resident #468 for sexual abuse, occurred between January and April 2023. The facility was made aware of the incident on 9/8/2023 at 4:00 PM. The incident was reported to the State Agency on 9/11/2023 at 10:04 AM. On 12/17/2024 at 10:00 AM, during an interview with the facility Director of Nursing (DON), she verbalized submission of facility reported incident number MD00196714 to the State Agency outside of the 2 hour time frame. 4) On 12/13/2024 at 12:29 PM, a review of investigation MD00203916, and review of the facilities self-report form revealed that the facility was made aware the alleged incident of abuse with Resident #469 on 3/22/2024 at 8:30 AM. The incident was reported to the state agency on 03/22/2024 at 1:47 PM. No other notification to other agencies were documented. There was no documentation that the final report was submitted to the State Agency. On 12/19/2024 at 11:00 AM, during an interview with the Director of Nursing (DON), she verbalized submission of facility reported incident number MD00203916 to the State Agency outside of the 2 hour time frame and there was no final report submitted to the State Agency on file. 45139 5) On 12/19/24 at 9:13 AM review of Intake # MD00182150 revealed that the facility allegation of abuse was made 2/27/2022 on behalf of Resident #264, a long-term resident of the facility. On 12/19/24 a review of the facilities reported incident (FRI) for intake # MD00182150 revealed that the facility was notified on 2/27/2022 at 5:30 PM. However, that the alleged abuse was not reported to the Office of Health Care Quality until 2/28/22 at 11:30 AM. Further review of the FRI revealed that the facility began interviewing staff on 2/27/2022. On 12/19/24 at 2:33 PM the Director of Nursing and the Assistant Director of Nursing confirmed that the alleged incident was not reported within the required 2 hours.

Based on records review and interviews, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse. This was evident for 4 (Resident #416, #264, #213 #44) in 13 residents reviewed for abuse. The Findings include: 1) Resident #416 was admitted to the facility in late 2022. On 12/19/24 at 7:56 AM, a review of the investigation packet related to MD00203250 was conducted. The review revealed that the resident had an injury of unknown origin to his/her left thigh. The investigation packet also indicated that the resident was not interviewed due to not having the capacity and having a diagnosis of Dementia. Dementia is a general term for a decline in mental abilities that affects a person's daily life. It's characterized by a loss of cognitive functioning, including memory, thinking, and reasoning. The investigation packet also indicated that a head-to-toe assessment was conducted on the resident and documentation was confirmed on 12/19/24 at 8 AM. However, further review of the investigation failed to reveal that other residents with the same capacity and diagnosis were assessed The Director of Nursing (DON) was interviewed on 12/19/24 at 9:14 AM and she indicated that she was not employed at the time of the incident and referred to the Assistant DON (ADON) who was also present during the interview. The concern was discussed with both staff that the investigation did not indicate that other like residents were assessed to complete a thorough investigation. The DON and the ADON reported that they would review the census for the date of the incident and see if a skin sweep/skin assessment was done for the facility. On 12/19/24 at 11:22 AM, a staff member (Staff #7) introduced herself and indicated that she was a unit manager and that she was covering the unit where Resident #416 was residing at the time of the incident. Staff #7 confirmed that she did the assessment only on the resident at the time of the incident and does not know if an assessment was done to the other residents of the unit. At the time of survey exit on 12/20/24 at approximately 3 PM, no further information was provided by the facility to support that a thorough investigation was conducted regarding the incident. 45139 2) On 12/19/24 at 9:13 AM a review of Intake # MD00182150 revealed that the facility received an allegation of abuse on 2/27/2022 from a family member on behalf of Resident # 264, a long-term resident of the facility. Further review revealed the date of the alleged abuse occurred on 2/23/22. On 12/19/24 a review of the facilities reported incident investigation file for intake # MD00182150 revealed that the facility interviewed 6 staff (FRI) members on 2/27/2022. Of the 6 staff interviewed only two staff reported they worked on the same unit, on the same date (2/23/22) of the alleged abuse. On 12/19/24 at 9:30 AM review of the staffing schedule for the Antietam [NAME] unit revealed that 10 staff worked on that unit on 2/23/22. On 12/19/24 at 2:33 PM during an interview with the Director of nursing, she confirmed that the employees that worked on the same unit and on the date that the alleged abuse occurred, should be interviewed. She provided no additional information prior to the end of the survey. 16218 3) Review of Resident #213's medical record revealed a May 2024 Brief Interview for Mental Status score of 14 out of 15 indicating the resident was cognitively intact. On 12/19/24 review of facility report MD00206294 revealed that on 5/28/24 at 1:23 PM the Business Office Mananger (Staff #36) made the administrator aware that Resident #213 reported a geriatric nursing assistant was inappropriate during care. Further review of the investigation documentation failed to reveal a statement from Staff #36. The documentation included a summary that indicated the resident was interviewed on 5/31/24, but no documentation was found to indicate an individual responsible for conducting the investigation spoke with the resident about this allegation prior to 5/31/24. On 12/19/24 at 12:08 PM Staff #36 denied knowledge of an abuse report from Resident #213, but confirmed she would report immediately to the administrator if a resident reported staff was rough with them. On 12/19/24 at 1:59 PM the Director of Nursing (DON) reported that if she was made aware of an abuse allegation she would ask the original reporter to provide a statement and would write a statement after an interview of the resident, if able to be interviewed, which would include the date and time of the interview. On 12/19/24 at 2:15 PM surveyor reviewed the concern with the DON that no documentation was found to indicate that an interview was conducted with the resident prior to 5/31/24. Surveyor also reviewed that there was no written statement from the Business Office Manager. 4) Review of Resident #44's medical record revealed the resident had a September 2024 BIMS score of 15 out of 15 indicating the resident was cognitively intact. During an interview on 12/10/24 the resident reported staff having yelled at him/her, the resident was unable to provide specifics but stated that it had been reported to the big boss. On 12/12/24 at 12:20 PM surveyor requested from the DON any facility reported investigations involving Resident #44. At 12:40 PM the DON reported that there were no facility reports involving this resident. At 12:43 PM surveyor informed the DON of the resident's report. On 12/19/24 surveyor reviewed the facility investigation documentation regarding this allegation. This review failed to reveal documentation to indicate an interview was conducted, or attempted to be conducted, with the resident by facility staff regarding these allegations. On 12/20/24 at 1:05 PM the DON confirmed that no one interviewed the resident about the allegation of abuse.

Based on observations, resident and staff interviews, and medical records review, it was determined that the facility staff failed to adequately meet residents' personal hygiene needs and provide a resident with the amount of assistance needed during meals. This was evident for 5 (Residents #10, #68, #66, #62, #369) of 5 residents reviewed for activities of daily living during the survey process. The findings included. The Minimum Data Set (MDS) assessments are an integral part of the RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic non-comprehensive MDS assessments which facilities conduct to maintain an accurate understanding of each resident's most current needs and strengths, and to ensure care planning remains current and effective. 1) On 12/11/24 at 9:00 AM Resident #10, a long-term resident of the facility, was observed awake and lying in bed awake. Further observation revealed the resident had long fingernails with black and brown spots under the nails. Continued observation revealed that the resident's hair was matted with thick strands of hair clumped together. On 12/12/24 at 7:24 AM review of MDS dated [DATE] revealed that Resident #10 required supervision or touching assistance for Personal hygiene. On 12/12/24 at 8:15 AM the unit manager nurse (Staff #11) was interviewed and said that she was familiar with Resident #10's care. Staff #11 reported that the nursing assistants provided nail care with clippers or nail files when residents were bathed/showered. She confirmed that Resident #10 required assistance with nail care. On 12/12/24 at 8:16 AM the unit manager and surveyor made a joint observation of Resident #10 as the resident ate breakfast. The unit manager confirmed that Resident #10's fingernails were long with black and brown spots under them and that the resident's hair was matted and stuck together in clumps. On 12/12/24 at 8:17 AM during a brief joint interview with Resident #10. The unit manager asked the resident if he/she would like his/her nails trimmed. On 12/17/24 a review of Resident's #10 care plan revealed that facility staff was to check nail length and trim and clean on bath days and as necessary. Further review revealed Resident #10 required assistance by one staff with showering twice weekly and as necessary. On 12/20/24 at 8:07 AM, shared all concerns with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) and no additional information was provided. 2) On 12/10/24 at 12:55 PM Resident #68, a long-term resident of the facility, was interviewed. During the interview, Resident #68 reported that his/her dentures had not been cleaned for a while and he/she did not know where his/her denture cup was. On 12/12/24 at 7:07 AM a review of Resident #68's orders revealed an order for dentures to be put in the morning and to be taken out in the evening cleaned and stored. On 12/12/24 a review of Resident #68's care plan revealed a care plan for dentures dated 8/27/23. The care plan documented that staff are to offer Resident #68 dentures in the AM and remove them in the PM, clean them, and then place them in an appropriate container. On 12/12/14 at 7:09 AM a review of Geriatric Nursing Assistant (GNA) documentation revealed that Resident # 68's dentures were taken out on the evening of 12/11/24. However, the Nurse's Treatment Administration Record documentation (TAR) revealed the dentures were kept in the evening on 12/11/24. On 12/13/24 at 6:58 AM the GNA (Staff # 10) who provided care to Resident #68 was interviewed. She reported that she worked at the facility for about 2 years on the day shift. She reported that Resident #68 did wear dentures, and needed assistance to take care of them, On 12/13/24 a review of MDS dated [DATE] revealed that Resident # 68 required supervision and or touching assistance from the facility staff to use suitable items to clean dentures. On 12/13/24 at 7:04 AM an observation was made in Resident #68's room with GNA (Staff #8). An observation was made of the GNA. Observation revealed that the GNA retrieved a green denture cup and reported it was empty. Continued observation confirmed that the denture cup was empty. 12/13/24 07:05 AM Resident #68 was awake and stated he had his dentures in. On 12/13/24 a review of GNA tasks documentation failed to reveal any documentation that the dentures were put in after the dentures were taken out on the evening on 12/12/24. On 12/17/24 at 4:02 PM the ADON reported that there were computer issues with some of the GNA task documentation. The facility addressed this issue by providing the GNAS with a paper copy to document Resident's #68's denture care. The ADON confirmed that the paper documentation for dental care had not been completed since 12/10/24. In addition, she confirmed that the dental care had not been provided as ordered. On 12/20/24 at 08:07 AM, shared all concerns with the ADON and the DON and no additional information was provided 48259 3) In an interview on 12/10/24 at 3:03 PM, Resident #66 reported, I was supposed to get a shower today, but I didn't get it. Record review on 12/18/24 at 12:11 PM found that Resident #66 had been residing in the facility since September 2022 with diagnoses that included Multiple Sclerosis (MS) with spastic paraparesis (Spastic paresis is a common symptom of MS that causes stiff, heavy, and difficult to move muscles) and Bell Palsy. The continued review contained an admission minimum data set assessment (MDS- a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs) for Resident #66, dated 10/3/22. The MDS recorded that Resident #66 required extensive to total assistance from staff for most of his/her self-care needs and was dependent on staff for bathing. Further review of the shower schedule and Geriatric Nursing Assistant (GNA) ADL documentation for Resident #66 from September 1 to November 30, 2024, was completed. The review showed that Resident #66 was to receive showers twice weekly on Tuesdays and Fridays. However, the review noted a record of bed baths (washing a resident in bed) on 9/3/24, 9/13/24, 9/17/24, 9/20/24, 9/24/24, 9/27/24, 10/1/24, 10/4/24, 10/8/24, 10/11/24, 10/15/24, 10/22/24, 11/8/24, 11/12/24, 11/15/24, 11/16/24, 11/29/24. Showers on 9/10/24, 10,4/24, 10/8/24, 10/22/24, 10/25/24, 10/29/24, 11/1/24, 11/5/24, 11/19/24, 11/22/24 and 11/26/24. Staff had also documented N/A (not applicable) on 10/18/24. In an interview with the Unit Manager (RN #31), she stated that Resident #66 sometimes refused her showers. However, an earlier GNA ADL documentation review lacked documentation that the resident refused her showers. In an interview on 12/19/24 at 10:13 AM, a geriatric nurse (GNA #32) reported that she recorded it in the electronic health record for residents who refused showers and notified the resident's nurse. GNA #32 also added that for those residents who refused showers in the past, she only gave them bed baths subsequently. During an interview with the director of nursing on 12/19/24 at 2:18 PM, she stated that she expected staff to offer residents their showers all the time and document refusals in their electronic health records. 4) In an interview on 12/11/24 at 10:00 AM, Resident #62 said, I should get showers twice a week, but I don't get them. A record review for Resident #62 showed that the resident had a history of stroke with left-sided weakness. The review also contained an Admission MDS dated [DATE] that had recorded that Resident #62 required substantial/maximal assistance for showers/baths. A review of Resident #62's shower records for August 1-November 30, 2024, revealed Bed baths on 8/8/24, 8/12/24, 8/15/24, 8/24/24, 8/26/24, 9/12/24, 10/14/24, 10/21/24, 10/24/24, 11/16/24, 11/19/24, and 11/29/24. Showers on 9/2/24, 9/9/24, 9/23/24, and 10/7/24. Partial baths on 10/28/24, 10/31/24, 11/7/24, 11/11/24, 11/26/24, 8/19/24, 8/22/24, 8/29/24 and staff documented N/A (not applicable) on 8/1/24, 8/5/24, 9/5/24, 9/19/24, 9/30/24, 10/17/24, 11/4/24, 11/15/24 and 11/22/24. A further review of Resident #62's shower schedule revealed that he/she was supposed to receive two weekly showers and eight monthly. In an interview on 12/12/24 at 12:40 PM, a geriatric nurse aid (GNA #33) said that every resident was expected to have two showers every week and bed baths on non-shower days. However, an earlier record review failed to show that Resident #62 received eight showers monthly and bed baths on non-shower days. 5) An Observation on 12/13/24 at 8:10 AM showed Resident #369 lying in bed with the head of the bed elevated. The resident's eyes were closed, and a breakfast tray was noted on the bedside table. The meal was untouched. Continued observation on 12/13/24 at 8:24 AM showed that Resident #369's eyes remained closed, and the breakfast tray was untouched. Subsequent observation on 12/13/24 at 8:45 AM showed Resident #369 was asleep, and his/her breakfast tray was no longer on the bedside table. In an interview at that time with the Admissions director, she said all the breakfast trays had been picked up and placed into the meal cart. She took Resident #369's breakfast tray from the meal cart to check how much the resident ate and confirmed that the resident's meal was untouched. A record review on 12/13/24 at 10:00 AM showed that Resident #369 had been admitted to the facility in December 2024, was confused, and diagnoses included Dementia and acute stroke. The continued review contained an occupation therapy evaluation and plan of treatment dated 12/11/24 stating that Resident #369 required partial/moderate assistance from staff for eating. Further review of a speech therapy evaluation and plan of treatment dated 12/12/24 noted: swallowing [evaluation] warranted [due to] CNA report pt with difficulty feeding and swallowing. The review also indicated that Resident #369 required assistance with eating. However, earlier observations failed to show that Resident #369 was assisted with eating his/her breakfast. In an interview on 12/13/24 at 10:31 AM, the director of therapy reported that, per Occupational and speech therapy documentation, Resident #369 required some assistance with eating. She also said that she expected staff to set up the resident's meal and provide supervision to see how the resident did with his/her meal. During an interview with the assistant director of nursing on 12/19/24 at 8:27 AM, she indicated that the concern had already been reported to her, so she would ensure that the resident was helped with her meals.

Based on records review and interviews, it was determined that the facility failed to: a) ensure the attending physician address irregularities identified on the pharmacy recommendation, b) implement the attending physician's response to the pharmacy recommendation, and c) specify timeframes in the steps of the Medication Regimen Review (MRR) process. This was evident in 2 (Resident #38, #21) of 5 residents reviewed for unnecessary medications. The findings include: 1) Resident #38 was a newly admitted resident of the facility. On 12/17/24 at 1:29 PM, a review of the admission medication review revealed 2 irregularities identified by the pharmacist. The irregularities were: a) Vitamin B12 Sublingual liquid 3000 mcg/ml (Cyanocobalamin)- dose differs from discharge summary, (400 mcg feeding tube, once daily) please re-evaluate and address noted irregularities. b) Eliquis oral tablet 5 mg.- initiate or increase medication monitoring- Please consider the following monitoring parameters: Monitor/document/report to doctor/Nurse practitioner signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden change in mental status, significant or sudden change in vital signs. The attending physician hand wrote on the bottom of the form, give 1500 mcg every other day, then signed and dated the response. The attending physician did not indicate a response to the pharmacy recommendation to initiate medication monitoring for the anticoagulant use. On 12/17/24 at 1:58 PM, Resident #38's orders were reviewed and revealed the order for Cyanocobalamin Oral Liquid 1000 mcg/15ml, Give 2.5 ml via peg tube one time a day for supplement. Further review of the resident's orders failed to reveal medication monitoring for the anticoagulant use. The Assistant Director of Nursing (ADON) was interviewed on 12/17/24 at 4:11 PM. During the interview, the ADON reported the facility's process with MRR and indicated that responses or orders from the attending physician are put in the system by the unit managers. The concern was discussed with the ADON that Resident #38's Vitamin B12 order does not match what the attending physician wrote on the pharmacy recommendation; and the resident's orders failed to reveal a medication monitoring order for the use of anticoagulant as recommended by the pharmacy. Later in the interview at 4:17 PM, the ADON reviewed Resident #38's medical record and confirmed the findings. The ADON then called the unit manager (Staff #2) to her office to ask what had happened with the attending physician's response to the pharmacy recommendation. Staff #2 reported that she would investigate the resident's medical record to find out. On 12/18/24 at 7:49 AM, the facility's MRR policy was reviewed. The review revealed the policy was titled Protocol for Facility Recommendations and was dated 1/21/23. Further review of the policy failed to define timeframes for the different steps in the MRR process. On the same day at 8:32 AM, the concern with the facility's MRR policy was discussed with the ADON. The ADON acknowledged the concern and indicated that she would review the regulation regarding the MRR. At the time of survey exit on 12/20/24 at approximately 3 PM, no further information was provided by the facility. 45131 2.)On 12/18/24 at 11:49 AM, a review of Resident #21 medical record revealed the following: 2a.)On 8/26/24 a pharmacy review recommendation was made to discontinue vitamin B12 because the medication was usually used for a short period of time. On 8/27/2024 the healthcare practitioner acknowledged the recommendation and agreed to discontinue the medication; however, the medication was not discontinued on the medication administration record until 10/03/24. 2b,)On 08/26/24, a pharmacy review recommendation was made to discontinue Zofran due lack of use for more than 90 days. On 8/27/24 the healthcare practitioner acknowledged the recommendation and agreed to discontinue the medication; however, the medication was not discontinued on the medication administration record until 10/03/2024. On 12/18/24 at approximately 12:15 PM, a review of progress notes for August and September 2024 revealed no documentation about why the medication was not discontinued in a timely manner. On 12/19/24 at 5:23 PM, in an interview with Staff #46, she was asked about the pharmacy review process. She was unsure of the process for medication record review and how the pharmacist's recommendations were being communicated. However, she stated that new physician ' s orders are usually in a pending status in the electronic health record, and it can be reviewed by any nurse on the floor. Nurse #46 stated that she will investigate the above-mentioned concerns and report back to the surveyor. On 12/20/24 at 9:51 AM, in an interview with Nurse #46, she reported back to the surveyor that she was unsure why the Zofran and vitamin B12 order was not discontinued as ordered. On 12/20/2024 at approximately 11:15 AM, the Director of Nursing was made aware of the above-mentioned findings, and it was acknowledged.

Based on record review and staff interviews, it was determined that the facility failed to comply with the State and Local Laws and Professional Standards as evidenced by: 1) a failure to ensure a registered nurse (RN) was on duty 24 hours a day 7 days a week and 2) a failure to maintain Hours Per Patient Day (HPPD) above 3.0. This was evident for: 1) 8 out of 16 days reviewed for RN coverage and 2) 13 out of 106 days reviewed for low staffing. The findings include: On 12/19/24, during the staffing task of the survey process, a review of the posted staffing for the two weeks prior to the start of the survey failed to reveal a RN on duty for 6 of these 14 days reviewed. There was no RN on duty for the night shifts on November 26, 28, 29, 30 or December 3, or 5, 2024. During the survey process, the surveyors received 8 separate residents reports about low staffing, particularly on the weekends. On 12/20/24 at 11:05 AM, the staffing coordinator (Staff #37) reported that their goal is at least one RN for each shift but confirmed that they are not meeting that goal every day. On 12/20/24 at 12:08 PM, the surveyor reviewed the concern with the Director of Nursing (DON) about the failure to have an RN on duty 24 hours a day 7 days a week. On 12/19/24 at 3:50 PM, a review of the Payroll Based report revealed that the facility was triggered for low weekend staffing prior to the survey process. A review of the facility's staffing revealed the following: Review of the HPPD hours for July, August and September 2024 revealed the PPD was less than 3.0 on July 13, 14, 21; September 1, 8, 14, 21, 22, 28, 29 and 30. Review of the hours provided by the Nursing Home Administrator for the two weeks prior to the start of the survey revealed the facility had less than 3.0 hours PPD on November 26, 29, or 30; or December 1, 2, 3, 4, 5, 6, 7, 8, or 9. On 12/20/24 the Business Office Manager (Staff #36) and the staffing coordinator (Staff #37) reported these hours only included nurses and geriatric nursing assistants. They then provided additional documentation for November 30 thru December 9 that indicated more than 3.0 PPD for those dates. No additional documentation was provided for November 26th or 29. Further review of the hours provided by the facility for July, August, September and December revealed they included dietary employees in the total number of bedside hours of care. On 12/20/24 at 2:23 PM Staff #36 confirmed that the dietary workers do not bring the trays directly to the residents.

Based on record review and interview it was determined that the facility failed to inform and provide written information to all residents concerning their right to formulate an advance directive. This was evident for 1(Resident #68) out of 3 residents reviewed for advanced directives during a survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. On 12/10/24 at 1:06 PM, a review of the medical records of Resident #68 revealed that resident #68 had cognitive decline. Continued review failed to reveal that Resident #68 had an advanced directive. On 12/19/24 at 7:53 AM the social work assistant (SW assistant staff #12) was interviewed regarding the facilities process to inform a resident about their right to have an advanced directive. She reported that when a resident is admitted to the facility their social history assessment is completed. During this assessment the residents are asked if they have an advanced directive. If the resident has an advanced directive, the resident is asked to provide a copy to the facility. If the resident has cognitive decline and is not capable to make an advanced directive the resident's Power of attorney (POA) is contacted. On 12/17/24 at 4:21 PM the social work assistant (Staff #12) was interviewed. During the interview the social work assistant reported that she did not have any documentation that the advanced directive was discussed in the Resident # 68's initial social assessment. In addition, she reported that she did not have any documentation that an advanced directive was discussed in the resident quarterly care plan meeting. On 12/17/24 at 04:06 PM the assistant director of nursing (ADON) confirmed that Resident # 68 did not have an advanced directive. She reported that Resident #68's Power of attorney (POA) had been contacted regarding the advanced directive, however the ADON failed to provide any documentation regarding the contact with the POA. On 12/20/24 at 08:07 AM the concerns were discussed with ADON and Director of nursing . No additional information was provided prior to the end of the survey.

Based on complaint, closed record review and staff interview, it was determined that the facility failed to notify Resident #217's representative in a timely manner after a significant change occurred. This was evident for 1 out of 24 complaints reviewed during an annual certification survey. The findings include: On 12/17/24 Complaint MD00179215 was reviewed involving Resident #217. An allegation that Resident #217's family was not immediately made aware of a change in condition that occurred during the morning of 02/28/22 was investigated. Resident #217 was admitted to the facility during the afternoon on 02/25/22 with diagnoses that included an acute embolic stroke, expressive and receptive aphasia, paralysis in the extremities, a new feeding tube, and a Foley catheter. A review of Resident #217's closed medical record on 12/17/24 revealed a nurses note, dated 02/28/22 at 6:52 AM, that indicated a GNA (geriatric nursing assistant) staff member informed the charge nurse, staff member #19, that Resident #217 was observed with a large amount of emesis. Staff member #19 documented that Resident #217's tube feeding was stopped and that the on-call physician was called. Staff member #19 also documented that the on-call physician did not answer the phone call and that the night shift nursing supervisor (staff member #17) was notified and that Resident #217's day shift nurse would also be notified. In an interview with the 02/27-28/22-night shift supervisor (staff member #17) on 12/20/24 at 8 AM, staff member #17 stated that S/he had reviewed Resident #217's closed medical records but could not recall seeing Resident #217 during the night shift on 02/28/22. Staff member #17 stated that S/he usually would write a nursing progress note if a staff nurse calls her/him during the shift to come and assess a resident. Staff member #17 confirmed that there was not a progress note from him/her for Resident #217 during the early morning hours of 02/28/22. Further review of Resident #217's closed medical record revealed a nursing skilled charting -V3 that was initiated at 7:01 am on 02/28/22 and closed/locked at 3:43 PM on 02/28/22. At 10:58 am on 02/28/22, the nursing skilled note indicated that Resident #217 had an oxygen saturation level of 88% while receiving oxygen via nasal cannula, a heart rate of 115 beats per minute, was anxious and agitated, his/her abdomen was distended and firm with hypoactive bowel sounds, and noted that Resident #217 had emesis x 7 this shift and was to be seen by the facility nurse practitioner. The facility's records showed that Resident #217's representative was called on 02/28/22 at 1:08 PM, and a message was left for the representative to call the facility staff.

Based on medical record review and staff interview it was determined that the facility failed to ensure the required transfer information was documented in the medical record when a resident was transferred to the hospital. This was evident for 1 (Resident #267) of 4 residents reviewed for hospitalization during the annual survey. The findings include: On 12/13/24 at 8:36 AM review of intake #MD00184369 revealed a concern regarding Resident #267's elopement from the facility and subsequent hospitalization . On 12/13/24 at 10:22 AM review of progress notes revealed a nursing note dated 10/11/2022. Review of this note revealed that Resident # 267 returned to the facility at 07:40 AM from the Hospital emergency room the morning on 10/11/22 at 7:40 AM, in a stable condition, with an abrasion on both bilateral lower extremities. Further review of the progress notes failed to reveal documentation that the resident was transferred to the hospital or the reason for the transfer. Continued review failed to reveal a hospital transfer note indicating what documents were sent with the resident to the hospital or if the Physician and/or the Resident #267's family were notified of the transfer. In addition, the review failed to reveal how the resident was transferred to the hospital. On 12/19/24 the assistance director of nursing (ADON) provided a Document Titled Sterling-Care South Mountain Hospital Transfer Document Checklist. Review of this hospital transfer check list revealed that when a resident is transferred to the hospital the following should be documented in the medical record: hospital transfer note should include reason for transfer, the physician and resident's personal representative notified, and how the resident was transferred to the hospital. On 12/19/24 at 8:08 AM the ADON was interviewed regarding the documentation for Resident's #267 transfer to the hospital. The ADON failed to provide any of the documents listed in the Sterling-Care South Mountain Hospital Transfer Document Checklist, for Resident # 267's transfer to the hospital on 10/10/22. On 12/19/24 at 8:11 AM the above concerns regarding the missing transfer documentation were discussed with Director of Nursing and ADON. No additional information was provided prior to the end of the survey.

Based on record review and interviews, it was determined that the facility failed to complete Quarterly Minimum Data Set (MDS) assessments for a resident within the regulatory time frames to facilitate appropriate care planning and maintain the current assessment record. This was evident for 1 (Resident #42) in 3 residents reviewed for Resident assessments. The findings include: The Minimum Data Set (MDS) assessment is a federally mandated assessment tool that nursing home staff use to gather information on each resident's strengths and needs. The information collected is used in the resident's care planning decisions. The Quarterly assessment must be completed within 92 days of the MDS Completion Date of the last OBRA assessment. It must also be completed no later than 14 days after the ARD, which is the ARD + 14 days. The last day of the observation period is the Assessment Reference Date (ARD). This date provides a common reference point for all team members participating in the assessment. In completing sections of the MDS that require observations of a resident over specified periods, such as 7, 14, or 30 days, the ARD is the common endpoint of these look back periods. A record review on 12/19/24 at 1:20 PM showed that Resident #42 was admitted to the facility in June 2024. The resident's admission MDS assessment dated [DATE] was completed on 6/28/24. The facility was required to complete a quarterly MDS assessment by 9/26/24. However, the review failed to show that the facility staff had completed and submitted a quarterly MDS for Resident #42 as of this review, making it 174 days since the last MDS assessment was completed. In an interview on 12/19/24 at 3:29 PM, the cooperate staff in charge of MDS confirmed that the facility missed completing a quarterly MDS for Resident #42 on 9/26/24.

Based on record review and interview, it was determined that the facility failed to complete and submit Minimum data set (MDS) Discharge assessments as required for residents discharged from the facility. This was evident for 3 (#105, #112, #64) of 4 residents reviewed for Resident assessments. The findings included: The MDS assessment is a federally mandated assessment tool that nursing home staff use to gather information on each Resident. Discharge assessments include items for quality monitoring. Discharge assessment reporting is required for all residents in the nursing home who have been physically discharged from the facility. 1a) A record review for Resident #105 on 12/19/24 at 1:35 PM showed that the Resident was admitted to the facility in October 2024. The continued review contained a nurse's note dated 12/9/24 that stated that Resident #105 was discharged to another facility. Further review of Resident #105's MDS record showed a lack of discharge assessment for the Resident. 1b) A review of Resident #112's record contained a nurse's note dated 9/27/24 that indicated that the Resident was admitted to the facility from the hospital. Further review showed that the Resident's family [picked] up the resident after [AMA-against medical advice] form signed. Resident left with all [his/her] belonging. The review failed to show that a discharge assessment was completed for Resident #112. 1c) A review completed on 12/19/24 at 1:52 PM, found that Resident #64 was admitted to the facility in September 2024. Further review contained a nurse's note that stated that the Resident was discharged from the facility on 9/25/24. However, the facility failed to complete a discharge assessment for Resident #64. In an interview on 12/19/24 at 3:29 PM, the corporate MDS person confirmed that the facility failed to complete discharge assessments for Residents #105, #112, and #64.

Based on observation, record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 1 (#66) of 7 residents reviewed for position and mobility and 1 (Resident #111) of 4 residents reviewed for hospitalization . The findings include: The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. 1) An observation on 12/10/24 at 3:14 PM showed that Resident #66's fingers were bent on the right hand, pressed into his/her palm, and stated, I've not been able to move my right hand and both legs in the last year. A review on 12/18/24 at 12:10 PM showed that Resident #66 had been residing in the facility since September 2022. Diagnoses included Multiple Sclerosis (MS), with spastic paraparesis (stiffness and weakness in the legs) and Bell Palsy. A continued review contained occupational therapy (OT) evaluations dated 9/19/23, and 5/14/24. The therapy evaluations recorded an impairment to Resident #66's range of motion (ROM) to both shoulders, elbows, forearms, wrists, and fingers. The review also included a neurology consult report dated 9/26/24 that stated that Resident #66 had right hemiplegia, bilateral lower extremities weakness, more so on the right side. Additionally, [he/she] has contractures in flexion in both ankles, knees, and hips along with impaired range of motion in [his/her] right shoulder. A subsequent review on 12/20/24 at approximately 7:10 AM, of another OT evaluation dated 12/19/24 had noted impaired ROM to Resident #66's bilateral upper extremities. The review also contained a statement that Resident #66 had a longstanding limited AROM [active range of motion] of UE's [upper extremities] from MS. However, Resident #66's MDS assessments dated 9/28/23, 6/30/24, 9/27/24, and 12/3/24 were all recorded that Resident #66 had no functional limitation in range of motion to his/her upper and lower extremities. In an interview on 12/19/24 at 3:15 PM, the corporate MDS person confirmed that Resident #66's MDSs dated 9/28/23, 6/30/24, 9/27/24, and 12/3/24 were recorded inaccurately. During an interview on 12/20/24 at 7:27 AM, the director of rehab said that per the OT evaluation completed on 12/19/24, Resident #66's right shoulder contracture was longstanding. 48470 2) Resident #111 resided at the facility for a little over a month in 2024. The MDS indicator identified the resident as discharged and was selected as being hospitalized . On 12/13/24 at 9:26 AM, Resident #111's closed record was reviewed. The review revealed a progress note documented by the Unit Manager/Registered Nurse (RN #2) on 10/2/24 at 11:31 AM. The progress note indicated that the resident was discharged to home with the family via a private vehicle. Further review of Resident #111's closed record revealed an MDS assessment with a reference date of 10/2/24. Section A of the assessment coded the resident as having a planned discharge to a Short-term General Hospital with return not anticipated. Section Z indicated that Licensed Practical Nurse/MDS coordinator (LPN #42) was the staff that completed section A of the assessment. In an interview with LPN #42 on 12/17/24 at 10:58 AM, she was asked if Resident #111 was discharged to the hospital or the resident's home. LPN #42 reviewed the resident's MDS assessment with a reference date of 10/2/24 and confirmed that she coded the resident as being discharged to the hospital. LPN #42 stated, I specifically remember this resident because s/he was scheduled to be discharged to home but then I was told that something had happened and that we were to send him/her to the hospital and then discharged to home, that's why I coded him/her that way. LPN #42 continued to review Resident #111's medical records to verify the resident's discharge status. After the review, on 12/17/24 at 11:04 AM, LPN #42 confirmed that there was no record that the resident was discharged to the hospital and reported that she coded the MDS assessment inaccurately. On 12/20/24 at approximately 12:40 PM, the concern was discussed with the Director of Nursing (DON) and the Assistant DON of the failure to accurately complete an MDS assessment. All staff acknowledged the concern.

Based on record review and staff interview, it was determined that the facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) form completed at the time of admission appropriately reflected the resident's diagnosis. This was true for 1 (Resident #16) of 2 PASARR forms reviewed for accuracy. The findings include: Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals with intellectual disability or a serious mental illness are not inappropriately placed in nursing facilities for long term care. The requirement ensures that all applicants receive care in the most suitable setting and are provided with all the necessary resources available. Review of Resident #16's initial nursing admission assessment on 6/20/2019 revealed a diagnosis of bipolar disorder; however, the most recent PASRR form completed on 2/14/2020 failed to reflect that resident had mental illness diagnosis on Section C. question #1. Section C of the PASRR form has questions to identify if the resident has serious mental illness and includes: 1. Diagnosis: Does the individual have a major mental disorder? On 12/17/2024 at 10:19 AM, in an interview with Social Service Assistant (Staff #12), she was made aware that Resident #16's bipolar diagnosis was active as of 2/10/2020 but it was not identified on the PASRR form completed 2/14/2020. She stated that she will clarify. On 12/17/2024 at 10:39 AM, in an interview with Staff #12, she acknowledged that the most recently completed PASRR form (2/14/2020) did not reflect the resident's bipolar diagnosis. She stated that a new PASRR was supposed to be completed to reflect the bipolar diagnosis; however, it was not done. On 12/20/2024 at approximately 11:45 AM, the DON was made aware that the facility failed to ensure that the PASARR form appropriately reflect Resident #16's mental illness diagnosis.

Based on record review and staff interview, it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan. This was evident for 3 (Residents #34, #74, and #101) of 6 residents reviewed for baseline care plans. The findings include: 1) On 12/13/24 at 10:40 AM, an interview was conducted with Director of Nursing (DON). When asked if a baseline care plan given to Resident #34 or their Representative (RP), the DON stated, I cannot provide any documentation to confirm that Baseline Care plan was given to RP or resident. On 12/13/24 12:49 PM, a review of Resident #34's medical record was conducted. Resident #34 was admitted [DATE]. No documentation of baseline care plan being given to Resident Representative or Resident in the medical record. On 12/19/2024 at 2:00 PM, the DON provided a Care Plan Conference Appointment scheduled for 10/17/2024 addressed to Resident #34. 2) On 12/17/24 at 11:20 AM, a review of Resident #74's record was conducted. There were no notes or record indicating the baseline care plan was discussed or given to Resident #74 or their Representative. On 12/17/24 at 12:32 PM, an interview with the Director of Nursing (DON) was conducted. When asked if the baseline care plan was given to resident/resident representative, the DON stated that she will get back to the surveyor with an answer. On 12/17/24 at 12:40 PM, an interview was conducted with the DON. When asked if a baseline care plan was given to Resident #74 or their Representative (RP), the DON stated, I cannot provide any documentation to confirm that Baseline Care plan was given to RP or resident. 3) On 12/17/2024 at 10:00 AM, Resident #101's baseline care plan was reviewed. There were no indications that the care plan was discussed with the Resident or the resident representative. On 12/17/24 at 12:40 PM, an interview was conducted with the DON. When asked if a baseline care plan was given to Resident #101 or their Representative (RP), the DON stated, I cannot provide any documentation to confirm that Baseline Care plan was given to RP or resident.

Based on observation, interview and pertinent document review it was determined that the facility failed to provide activities according to the resident's preferences. This was evident for 1 (Resident #91) out of 3 residents reviewed for activities during a survey. The findings include 12/11/24 at 8:49 AM Resident #91, a long-term resident of the facility, was observed lying in bed with her/his breakfast sitting on the bed side table. Further observation revealed that Resident #91 was awake and about 1/4 of their breakfast was eaten. Further observation failed to reveal either music or the television (TV) being on. 12/12/24 02:45 PM An observation made in Resident # 91's room revealed the resident sitting behind the door, not visibly observing the TV, which was on a news channel. 12/17/24 at 7:54 AM Resident # 91 was observed eating in her/his room and not facing the TV. Further observation revealed a football game on the TV. On 12/18/24 several observations were made of Resident 91's room at the following times: 8:04 AM, 8:44 AM, and 12:03 PM. All these observations revealed the resident had the TV on a movie channel and that the resident was not facing the TV. On 12/17/24 at 9:26 AM a review of MDS ARD date 5/17/24, section F0500, for Resident # 91 revealed that it was very important for her/him to do her/his favorite activities. Further review revealed that it is somewhat important for Resident # 91 to listen to music. On 2/17/24 at 12:30 PM review of the document, initial review assessment, dated 5/17/2024 revealed that Resident # 91 likes music, and TV game shows. On 12/17/24 at 7:25 AM review of the care plan revealed that Resident # 91 preferred activities are: doing word search and watching game shows. On 12/17/24 Review of the quarterly participation reviews, dated 11/10/24 and 8/1/24, revealed that Resident #91's current care plan was still appropriate regarding the resident preferred activities. On 12/17/24 at 12:16 PM the Activity Director (Staff #15) was interviewed. She was unable to report how the GNA staff are informed about the resident's preference with activities other than through the resident's care plan. On 12/17/24 at 3:12 PM during an interview with activity staff #44, she reported that Resident # 91 loves music, however the remote for the music has not been working for a long time. In addition, she reported that she has observed Resident #91 engaging with the TV when game shows are on by answering the game show questions. On 12/17/24 at 3:14 PM GNA Staff #45 was interviewed. She reported that she has worked at the facility for over a year and is familiar with the care of Resident # 91. GNA #45 stated that she was unable to report what TV programming Resident 91 prefers to watch or if she has the availability to listen to music in her room. On 12/20/24 at 08:07 AM the surveyor shared all concerns with the Assistant Director and the Director of Nursing. No additional information was provided prior to the end of the survey.

Based on observation, review of a medical record, and staff interview, it was determined that facility staff failed to provide a resident adequate supervsion and a safe environment. Resident #1 tripped over a piece of rehab equipment and sustained left sided facial bruising and a laceration to the left eye brow that required treatment at a community hospital. This was evident for 1 (Resident #1) of 4 residents reviewed during a follow up survey. The findings include: On Saturday, 05/28/16, the facility air-conditioning system broke which required the facility staff to move 22 residents off of the Manor unit to the Lincoln unit. The Lincoln unit houses the facility's rehab unit. There are several pieces of rehab equipment that are utilized on the Lincoln unit. During the tour of the facility on 06/02/16 at 11:30 AM, the surveyor observed Resident #1 ambulating on the Lincoln unit. Resident #1 was observed with a left sided facial bruise at that time. At the conclusion of the tour of the Lincoln unit, the surveyor went back to interview Resident #1. Resident #1 was not found in the main dining area of the Lincoln unit. Upon further observation, Resident #1 was found alone in the rehabilitation office which is located on the Lincoln unit. Resident #1 was not able to answer any questions regarding his/her bruising due to a history of cognitive deficits. Further observation of Resident #1's facial bruising revealed sutures to the left eyebrow. In an interview on 06/0216 at 4 PM, the Lincoln unit nurse manager stated that Resident #1 fell during the evening hours on 05/31/16. The Lincoln unit nurse manager stated that Resident #1 wandered over into the rehab area and fell over a piece of rehab equipment. Review of Resident #1's clinical record revealed a nursing entry, dated 05/31/16 at 10 PM, in which LPN (licensed practical nurse)#1 noted that he/she was standing at the medication cart and heard a crash . LPN #1 documented that Resident #1 was observed lying between the rehab equipment with a large laceration to the left eye brow. Resident #1 told LPN #1 that he/she tripped over the equipment. In an interview with GNA (geriatric nursing assistant) #1 on 06/02/16 at 4:25 PM, GNA #1 stated he/she was working the 3 PM to 11 PM shift on 05/31/16. GNA #1 stated he/she was feeding another resident the dinner meal at the time Resident #1 wandered into the rehab area and fell over the rehab equipment, GNA #1 also stated that he/she was not aware that Resident #1 had fallen. In an interview on 06/03/16 at 3:00 PM, GNA #2 stated that he/she worked the 3 PM till 11 PM evening shift on 05/31/16. GNA #2 stated that Resident #1 took his/her dishes over to the rehab unit to use the sink to wash his/her dishes. GNA #2 stated that he/she was aware of this behavior because Resident #1 does this daily after a meal. In an interview with the facility rehab manager on 06/03/16 at 1:40 PM, the surveyor asked how Resident #1 was allowed to enter the rehab office on 06/02/16 at 11:30 AM. The facility rehab manager stated that he/she and the rehab administrative staff member had just left the rehab office when Resident #1entered the office. The facility rehab manager stated that Resident #1 had fallen a few days ago, over the rehab weight lifting machine, and received the left eye brow laceration. The facility rehab manager stated that the reason Resident #1 fell over the rehab equipment on 05/31/16 was because no staff were watching Resident #1. The facility staff must provide all residents adequate supervision and a safe environment to prevent injuries and accidents.

Based on staff interviews and review of medical records and facility policies, it was determined that the facility failed to ensure that nutritional needs of residents were met when staff failed to restrict access to juices for a diabetic resident, failed to address systems that allowed the diabetic resident access to excessive amounts of juices that resulted in need for hospitalization (Resident #1), and failed to ensure timely assessment input from a dietitian consistent with facility policy, when a resident was readmitted on [DATE] (Resident #2). These interrelated concerns were evident for 2/11 residents reviewed during survey and contributed to the need for emergent stabilizing treatment in a hospital emergency department for both of these two residents. The findings include: 1. Review of the medical record for resident #2 revealed that he/she had [DIAGNOSES REDACTED]. Resident #2 had a known history of poor control of blood sugar. For example, on 11/26/15 at 1630, resident #2 had a recorded blood sugar of 482 (normal is 70 - 110); on 11/26/15 at 2147 resident #2 had a recorded blood sugar of 497 and additional [MEDICATION NAME] (an insulin formula) was provided as an intervention; and on 11/27/15 at 0200, resident #2 had a recorded blood sugar of 437 and was given an additional 2 units of [MEDICATION NAME]. Resident #2 was discharged from the nursing home on 12/24/15 and was admitted again on 12/31/15. Facility policy D-365 provided that residents at high nutritional risk will be assessed with [REDACTED]. However, on readmission on 12/31/15, no nutrition assessment was completed when resident #2 returned, and no weights were obtained. Without the necessary dietary assessment, nursing staff did not order the diabetic diet that resident #2 had been on before, but rather, ordered a regular diet with puree consistency; and in the dietary order sheet, nursing staff did not check off that resident #2 should not receive concentrated sweets. On 1/1/16, resident #2 was sent out to a local hospital Emergency Department (ED) after making statement(s) about suicidal thoughts. No documentation in the nursing home record revealed that staff reported to the transport staff or to the hospital, that resident #2 again had a dangerously high blood sugar. When he/she arrived in the ED on 1/1/16, the resident's blood sugar was 632. After return, a note entered in the nursing home record at 0700 on 1/2/16, revealed that resident #2 again had a very high blood sugar (545). Review of the medical record revealed that, on 1/6/16, resident #2 had still not been seen by the facility dietitian and he/she continued to receive a regular diet. On this date, Resident #2 had another series of very high blood sugars documented and the facility attempted to address the high blood sugar levels with repeated administration of additional insulin. An order was then obtained to send resident #2 back out again the local ED. The order was not timed, but the ambulance transport staff documented that they obtained vitals at 1440, and the transfer form indicated that the resident left the faciity on [DATE] at 1500. On 1/6/16, in the hospital ED it was determined that resident #2 had a blood sugar of 588, was profoundly dehydrated and the dehydration had by then had caused acute [MEDICAL CONDITION]. In an interview on 3/31/16, the dietitian indicated that she was out from 12/31/15 until 1/5/16 and the reason that the dietary consult was not completed on 1/5/16 may have been that the paper chart was unavailable on 1/5/16, which she indicated does happen. Without input from the facility dietitian, resident #2' s diet was changed to a regular diet on admission on 12/31/15, and this change contributed to subsequent high blood sugars that eventually required transfer to a higher level of care for stabilization. 2. Resident #1 was admitted with a history including diabetes and swallowing difficulties. On 9/4/15, an initial nutrition assessment and evaluation was documented in the medical record indicating that resident #1 would be placed on a Carbohydrate Controlled Diet (CCD) to help maintain safe levels of blood sugar. Review of the medical record revealed that, on 11/3/15 at 1500, resident #1 had a documented blood sugar that was very high at 498 (normal is 70 - 110). A nursing note in the medical record revealed that Resident #1 was drinking a lot of juice with meals. At 1700 on this same date, resident #1 had a documented blood sugar of 495, and a nursing note indicated that the resident was noncompliant and continued to drink excessive amounts of juices. At 2100 on this same date, resident #1 had a documented blood sugar of 579, and documentation was entered in the medical record that the resident continued to drink and was noncompliant. In interview with the kitchen manager on 3/31/16, she indicated that residents do not have access to snacks and drinks, and that they need to get staff assistance to obtain them. However, no evidence was found that staff restricted Resident #1' s access to the high sugar drinks during this week in November, nor that any care plan changes were ever developed to address the specific concern where resident #1 somehow had access to excessive amounts of juice drinks that contributed to the need for hospitalization . (Resident #1 required emergency stabilization in the local hospital ED to stabilize his/her blood sugar after ingesting these drinks). On 2/4/16, resident #1 returned from a local hospital with a new gastrostomy tube in place for tube feeding due to the ongoing swallowing difficulties. In the hospital, the resident had been placed on continuous tube feeding at 70 mL/hr. No evidence was found in the nursing home record that the dietitian assessed the resident's nutritional needs when he/she returned to the nursing home. The 2/4/16, untimed, physician orders [REDACTED].#1. Review of the medical record revealed that, on 2/4/16, with no clarification of the incomplete orders found in the medical record, instead of following the parameters from the hospital for gradual and continuous tube feeding; staff provided resident #1 bolus feeding through the [DEVICE], and resident #1 immediately began vomiting (a bolus feeding provides a quantity of tube feed formula at one time instead of providing it over time at a gradual rate.) No rationale for changing the resident to bolus feeding was found, and in interview on 3/31/16, the dietitian indicated that she did not recall anyone consulting with her prior to changing the plan to provide bolus feeds, instead of continuous feeds as was established in the hospital. A record entry, just after midnight into the early minutes of 2/5/16, revealed that resident #1 had coarse lung sounds, was vomiting, and was not tolerating tube feeding. This note also referenced use of a specific brand of tube feeding formula for this bolus, but use of this brand was not found supported in any orders in the medical record. In interview with the facility dietitian on 3/31/16, she indicated that she would not be comfortable starting a resident with a brand new [DEVICE] on bolus feedings. Resident #1 was then sent back out to the local hospital ED in the very early hours of 2/5/16. Review of the hospital record revealed that Resident #1 arrived with acute [MEDICAL CONDITION] (low oxygen), acute aspiration pneumonia, and was again in acute [MEDICAL CONDITION]. The hospital documentation added that resident #1 had just been discharged from the same hospital hours before and the ED record corroborated that the nursing home staff had reported that the resident had aspirated during tube feeding. Resident #1 was admitted and was stabilized again, and then returned to the nursing home on 2/10/16.

Based on review of the medical record and facility documentation and interviews with staff, it was determined that the facility staff failed to provide appropriate urgent interventions timely for resident #93 when there was a more than 24 hour delay sending the resident out to a higher level of care after the facility was notified of a suicidal threat the resident made via social media to his/her girlfriend/boyfriend. This resulted in an Immediate Jeopardy past non-compliance. This was evident for 1 (Resident #93) of 3 residents reviewed for hospitalization . The facility staff also failed to immediately notify the physician and dietician of a significant weight gain for 2 of 34 (Resident #85, #63) residents reviewed during stage 2 of the survey. The findings include: 1. Review of Resident #93's medical record on 10/28/15 at 10:56 AM revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's sister is his/her court appointed guardian. The review of the record revealed that on 9/16/15 the Resident was admitted to a general hospital. The hospital documentation confirmed that the resident was admitted for [DIAGNOSES REDACTED] (low blood sugar) and suicidal ideation, was evaluated and returned to the facility on [DATE]. Further review of Resident #93's interdisciplinary progress notes revealed that a nursing progress note was written on 9/15/15 at 10:55 PM, one day prior to the Resident's transfer to the hospital, by LPN#4. This progress note indicated that a phone call was received from the resident's girl/boyfriend that the Resident had told him/her that his sister had brought him/her some Crystal Light; that the resident had opened it Him/Herself; and was drinking it just as a liquid, thinking he/she would asphyxiate him/herself. The resident's record failed to reveal that an SBAR had been completed on that date when reported to LPN#4. Further review of the record failed to reveal documentation that the physician, the resident's guardian and a facility supervisor had been notified of the resident's [MEDICAL CONDITION]. The resident's medical record also revealed that an SBAR (Situation, Background Assessment Recommendation, a form used to document and report a change in condition, assessment, and interventions and/or response), was completed by the facility staff on 9/16/15. The SBAR indicated that the resident's girl/boyfriend reported that he/she was receiving social media messages from Resident #93 indicating that the resident was going to drink thin liquids to aspirate (choke) and kill her/himself. The resident's girl/boyfriend called the nurses' station and told the nurse. The form indicated that the resident's Primary Care Physician was notified of his/her suicide ideations on 9/16/15 at 5 PM. A nursing Home to Hospital Transfer Form dated 9/16/15 5:22 PM indicated that the reason for transfer was [MEDICAL CONDITION]. During an interview on 10/28/15 at 9:50 AM Unit Manager #1 was asked what had been done on the evening of 9/15/15 when Resident #93's boy/girlfriend notified the staff of the Resident's suicidal statements. Unit Manager #1 indicated that he/she knew that the staff removed the Crystal Light from the resident's room and that the staff continued to monitor the resident. He/she was then asked for documentation reflecting the interventions that were put in place and notification of the physician. He/she replied that it would be there, in the progress notes if there were any. Unit manager #1 was made aware that the progress notes did not reflect that anyone was notified or that interventions were initiated on 9/15/15 after LPN #4 was made aware of the resident's suicidal statements. During an interview on 10/28/15 at 1:28 PM the Administrator was made aware of these findings and indicated that QA (Quality Assurance) was aware and that in-service education had been provided to the staff regarding reporting of change in condition which included suicidal ideation. During an interview on 10/29/15 at 7:45 AM the Administrator was asked and indicated that he/she was not immediately notified of Resident #93's [MEDICAL CONDITION] on 9/15/15 and that he/she believed that Unit Manager #1 notified him/her the next day. An interview was conducted with Unit Manager #1 on 10/29/15 at 8:17 AM. He/she indicated that LPN #4 had written the progress note on 9/15/15 related to Resident #93's [MEDICAL CONDITION] unbeknownst to anyone and that more than 24 hours later, the day shift nurse on 9/16/15 found the note when he/she went to write a shift note at the end of his/her shift, and he/she notified Unit Manager #1 at that time. The SBAR was completed at that time and the physician was notified at 5 PM. The resident's guardian was also notified and Resident #93 was sent to the hospital for evaluation at 5:22 PM. A telephone interview was conducted on 10/29/15 at 9:52 AM with LPN #3. LPN #3 confirmed that he/she was the supervisor during the evening shift of 9/15/15. He/she indicated that he/she was not made aware at any time during the shift, that any resident had [MEDICAL CONDITION]. He/she further indicated that if he/she were to receive such a report, he/she would immediately notify her superior on call to get further guidance, would call the physician and family immediately after making sure that the resident was safe, and would assign someone to stay with the resident. On 10/29/15 at 10:01 AM an interview was conducted with the Staff Development Nurse who provided sign in sheets for the education that was conducted with the staff on 9/29/15 and 9/30/15. He/she indicated that the education included but was not limited to reporting changes in condition including residents having suicidal thoughts, that the physician is to be notified, an assessment should be done as to any suicidal plans, and that the resident should be sent to the emergency room for further evaluation. An interview with Unit Manager #1 on 10/29/15 at 10:18 AM revealed that he/she verbally educated LPN #4 on 9/17/15 on notifying the physician if any resident has [MEDICAL CONDITION], that it should be determined if they have a suicide plan, that the resident is to be kept safe and has to be sent out 911. The facility completed corrective action and provided documentation that education of the nursing staff of notification of changes in condition including [MEDICAL CONDITION] was completed on 9/30/15. As a result of these findings, a condition of Immediate Jeopardy past non-compliance was declared for failing to notify other staff on the team and failing to develop and provide urgent intervention(s) after resident #93 had expressed suicidal ideation with a plan. The notification of this condition was made to the Administrator of the facility on 10/29/15 at 4:03 PM.

Based on complaint, review of a closed medical record and staff interviews, it was determined that the facility staff failed to provide a resident with a safe environment and enough supervision during care, to prevent the resident from sliding out of a mechanical tub chair onto the floor and receiving injuries requiring a hospital admission. This occurred for 1 of 10 (#1) residents reviewed during a complaint survey. The findings include: Review of resident #1's closed medical record, on 2/28/2014, revealed that resident #1 is totally dependent upon the facility staff for all aspects of care is unable to protect him/her from any accidents. Review of complaint MD 778, on 02/28/2014, revealed an allegation that resident #1 fell from the bath chair while being elevated 4 feet off the ground and suffered injuries requiring hospitalization . Review of resident #1's closed medical record revealed a monthly order for February 2014 which included a physician's orders [REDACTED].#1 with an assist of 2 staff members. In an interview with Geriatric Nursing Assistant (GNA) #1 on 2/28/2014 at 1:52 pm and follow up phone call on 3/04/2014 at 11:24 am, GNA #1 stated that he/she was rendering care to resident #1 on 2/01/2014. GNA #1 stated that resident #1 requested to have a bath before the evening meal. GNA #1 stated he/she obtained assistance from one of the nurses to help place resident #1 in the tub using the tub's mechanical chair lift. GNA #1 stated after completing resident #1's bath he/she applied the seat belt to resident #1's waist and raised resident #1 out of the tub. GNA #1 stated he/she did not obtain any assistance from another staff member to transfer resident #1 out of the tub. GNA #1 stated, during the transfer out of the tub, resident #1's towel started to fall and resident #1 tried to grab the towel and that is when GNA #1 heard a pop and resident #1 slid out of the tub's mechanical chair lift onto the floor. GNA #1 stated the chair strap broke and that is when resident #1 slide out of the chair to the floor. GNA #1 stated, prior to the fall, he/she was standing to the side of the tub's mechanical chair while resident #1 was being elevated out of the tub. GNA #1 stated there was a second safety strap that could have been applied across resident #1's shoulders but the shoulder strap was too small to apply to resident #1. GNA #1 stated he/she did not receive any education on how to use the tub's mechanical chair lift. In conclusion, GNA #1 failed to minimally obtain assistance from another staff member on 2/1/2014, as directed by resident #1's February 2014 physician orders, when transferring resident #1 out of the tub on 2/1/2014. Resident #1 suffered a fall out of the mechanical chair lift which resulted in resident #1's being sent and admitted to the hospital with [REDACTED]. The facility had performed a quality assurance review of the resident's fall with injury immediately after the resident's injury. The facility supplied the surveyor documentation

Based on an administrative review completed January 30, 2014 of a complaint investigation that was conducted for the survey ending December 12, 2013 and additional information, the facility failed to ensure that Resident # 1 was transferred using an assistive device in accordance with orders, medical condition, and generally accepted clinical nursing standards of practice which resulted in a fall with significant injuries requiring hospitalization . Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident ' s nursing assessments on admission and the next four days indicated that she/he was alert and oriented to person only. A physical therapy (PT) initial evaluation completed on 12/8/2013 indicates under precautions heading that the resident has poor recall related to total hip replacement (THR) precautions. The evaluation under cognitive status also reflects that the resident does need verbal and visual cues frequently for many activities and " has no recall or understanding of THR precautions. " In addition, the evaluation shows that the resident maintains balance unsupported sitting for 60 seconds, standing balance is fair and dynamic with rolling walker, and baseline pain level is 6 of 10 ( 10 being severe). The interim order form reflects orders from 12/8/2013 that staff are to transfer resident with one assist with walker and the resident has total hip replacement (THR) precautions. On 12/9/2013 occupational therapy (OT) staff conducted an initial evaluation which noted the following that the resident ' s current assessed level for toilet use was a 2 which means requires substantial help. Under complexities section of the evaluation, it reflects the resident is confused, has cognitive deficits, is impulsive and has reduced recognition of routine tasks. Additionally, the evaluation shows that the resident has flexion contractures of the upper extremities and arthritis. The reason for the referral is new onset of impaired activities of daily living, impaired balance and impaired functional activity tolerance. The resident is utilizing a walker for transfers and standing while receiving PT and OT services. The December 2013 Medication Administration Record [REDACTED]. An incident report dated 12/10/2013 at 5:50am reveals that the resident was taken to the bathroom and fell . Wheelchair was checked off on the document. A written statement dated 12/10/2013 from the licensed practical nurse (LPN) reveals that the resident's call light was on and the nurse transferred the resident from the bed to the wheelchair with the help of a gait belt. She then transferred the resident from the wheelchair to the toilet asking the resident to hold onto the sidebars on each side of the toilet rather than transferring him/her with support of the walker. The resident fell forward while the nurse was trying to help lower the resident's pants; the walker was not used to help the resident with support and stability during the transfer from the wheelchair to the toilet. According to the nurse's statement the resident let go of the bars on the sides of the toilet. The resident sustained [REDACTED]. Facility readmission documents from 12/16/2013 indicate the resident's [DIAGNOSES REDACTED]. The Acting Director of Clinical Services confirmed in a written document on 1/24/2014 and during a telephone conversation on 1/29/2014 with OHCQ staff that the nurse did not use the walker for transfers and support while toileting the resident on 12/10/2013.

Based on observation, medical record review, and interview with facility staff, it was determined that the facility failed to provide a safe environment for residents as evidenced by 1) an observed space heater in a resident's room that did not have a working safety shut off switch/sensor, 2) side rails being in place when the resident had been assessed not to need side rails, and 3) failed to ensure that a resident received adequate supervision and assistance to prevent accidents. This was evident for 3 out of 62 residents reviewed during Stage 2 investigation. As a result of the space heater not having a working safety shut off switch an Immediate Jeopardy was called. The findings include: 1) Observation was made, on 12/3/13 at 9:00 AM, of a Titan portable ceramic space heater in Resident #32's room. The ceramic heater was observed sitting on top of a piece of paper (calendar of events) which was lying on top of a stool and turned on in the high position. The heater was plugged into an extension cord, which in turn, was plugged into a surge protector along with a portable refrigerator, phone, and electric razor. The surveyor showed Staff #100 the heater, and asked if it had been inspected. Staff #100 stated "I didn't know it was here. If we inspect anything we put a sticker on the item". Staff #100 inspected the heater, and was placing the sticker on the heater when the surveyor advised that the COMAR regulation states that space heaters are not permitted. Staff #100 unplugged and removed the space heater and said "Oh, I didn't know that". On 12/12/13 at 9:20 AM, a space heater was again observed in Resident #32's room. This space heater was not ceramic; it was a plastic Climate Keeper TM space heater, which was observed sitting on top of a piece of paper, on top of the same stool that was observed previously on 12/3/13. The surveyor went to find Staff #100 to ask why the space heater was back in the resident's room. Staff #100 came to the surveyor, on 12/12/13 at 9:58 AM, and stated he did not know that the heater was back in the room. When the surveyor and Staff #100 went in the room, the space heater had been removed. It was found on the roommate's chair. Staff #100 was asked to perform a safety check on the space heater to see if it would shut off if tipped over. Staff #100 plugged the heater back in and turned it on. Staff #100 was then asked to demonstrate if the heater, when tipped over, would it automatically shut off. Staff #100 tipped the plastic heater over and it did not turn off. There was no automatic shut off when it fell . The side of the heater states "Caution - High temperature, Keep electrical cords, drapery and other furnishings at least 3 feet (0.9m) from the front of the heater and away from the sides and rear. In case the ambient temperature gets too high or a foreign object blocks the air passage, the internal protection thermostat will temporarily cut off the power supply until the causes are removed. At 10:50 AM on 12/12/13, Staff #100 was asked to come to the conference room to demonstrate to the surveyors if the heater fell forward and blocked the front of the heater, would the heater automatically shut off. The heater was plugged in and after approximately 30 seconds Staff #100 pushed the heater forward so that the face of the heater was lying face down on the floor. After approximately 40 seconds, Staff #100 stated "it is getting hot, how long do you want to keep it there?" The surveyor asked "are you afraid of a fire starting and Staff #100 said "yes". Staff #100 stated " this is not going to turn off " and he picked up the heater. Staff #100 stated "I have a heater at home and as soon as it tips over it shuts off. This heater is not doing that". As a result of the heater not shutting off, a condition of Immediate Jeopardy was declared at 12:25 PM. The Immediate Jeopardy was abated at 1:50 PM after a plan of correction was given to the surveyors. The facility staff is responsible for making sure the environment is safe and free from hazards. 2) On 7/27/13, resident #161 had a "Side Rail Assessment" completed. No side rails were recommended at that time. A physician's orders [REDACTED]. There are risks involved with the use of side rails thus requiring assessments to make sure residents can safely use them. This resident was assessed not to need them, and the physician's orders [REDACTED]. On 10/26/13, the resident was found on the floor next to his bed with his left arm between the bed rail. Interview, on 12/5/13 at 12:15 PM, of Staff #99 revealed the resident's arm was between the rail and the mattress. The staff also stated "He only had those little quarter rails." The physician had ordered half rails during care, and review of the resident care plan dated 8/5/13 also indicated half rails not quarter rails. Resident #161 was also treated for [REDACTED]. After being found with his arm between the rail and the mattress, no side rail assessment was completed until a quarterly one, 3 days later on 10/29/13. The Side Rail Evaluation, at that time, recommended bilateral half rails to serve as enablers to promote independence and noted that the resident was not ambulatory. However, the resident had a MDS (minimum data set - a complete comprehensive assessment of the resident which directs the resident's plan of care) completed on 10/28/13, and noted that the resident is totally dependent for bed mobility. This means the resident requires staff assistance to move about in the bed, and can not use the rails on his own. The facility staff placed this resident at risk for injury, by the use of bed side rails (that he was initially not assessed to need),and, according to staff, had quarter rails on the bed instead of half rails. The half rails were to be used only at times when the staff provided care, as opposed to all times. Subsequently, resident #161 was found on the floor by his bed with his arm between the rail and the mattress. After the fall the resident was not assessed for 3 days for the safe use of side rails and the resident's MDS shows he can not use side rails for bed mobility. 3) Resident #197 was admitted from an acute care facility due to sustaining a fall. Upon admission, Resident #197's functional status was 2 people assist and wheelchair. On 8/11/13, safety precautions put in place were: Seatbelt for wheelchair with an alarm, however, resident kept removing seatbelt, bed alarm, mobility alarm, low bed, bilateral side rails and PT/OT. There was an order to check functions of the alarms every shift. No documentation was found to verify that this was done. On 8/16/13, Resident #197 complained of left knee pain. The knee was swollen and warm and he informed the nurse he was having a problem standing. On 8/19/13, the resident was found on the floor in the bedroom. Resident #197 complained of feeling dizzy when transferring. He had been receiving physical therapy since 8/12/13. Per the fall investigation report dated the same day, the bed alarm was used, but it did not function properly. On 10/10/13, Resident #197 had a medication change. Trazodone, used for insomnia was discontinued, and Ambien 10 mg at hour of sleep was added for insomnia; Buspar 5 mg, a medication for anxiety, was added also. On 10/13/13, Resident #197 was found on the floor in the bedroom at 8:15 PM. The resident was sent out to the hospital. Resident #197 sustained a hematoma (blood bruise) on the right side of his forehead, a contusion to the right elbow, a bruise to the right buttocks, and a slightly swollen right thumb. He was returned to the facility. On 10/15/13, Resident #197 was found on floor at 10:05 PM, Resident was sent to the hospital. Per the Fall Investigation report, visual inspection of pressure alarm indicated in was in the off position. On 11/3/13 Resident #197 was found lying on the floor in the bedroom at 6:30 AM. Per the SBAR (Situation, Background, Assessment, and Request) communication form/progress note, the resident sustained [REDACTED]. Per the Fall Investigation form, the floor had water on it that the resident had spilled. On 11/5/13, Resident #197 had a witnessed fall in front of the nurse's station at 11:30 PM. Per the witness statement from Staff #30 on the Fall Investigation Form, the resident's "alarm had fallen off his chair, resident must have been pulling at it " . On 11/25/13 at 11:20 PM, Resident #197 was left in the living room in his wheel chair. The Resident fell , and was found on the floor underneath the ice machine. According to the SBAR Communication Form/progress note and the Fall Investigation Form, both of the alarms (seat belt alarm, wheel chair alarm) were in place, but the alarms were not turned on. Resident #197 was sent to the emergency room . Per nurse's note, the resident returned at 4:20 AM after being treated for [REDACTED]. A review of a safety check form for Resident #197,dated 12/5/13, revealed that the 11:00 PM - 7:00 AM shift staff initialed the form at 11:00 PM, drew a line through to the bottom of the sheet at 2:45 AM, and again initialed the form at 3:00 AM and drew another line to the bottom of the form at 6:45 AM. During the day shift of the same date, 12/5/13,the surveyor reviewed the same safety check list at 2:00 PM,and found that no one had documented any of the observation times for this resident from 7:00 AM until 2:00 PM. As surveyor requested Staff #34 to make a copy of the form Staff #34 stated "they've been so busy they haven't had time to do that yet" . Per the interview with Staff #34 on 12/5/13 at 9:15 AM, "the alarms are turned off for toileting and are supposed to be turned back on when the resident is put back in chair or bed. There is some question as to whether alarms are turned back on". Staff #34 introduced surveyor to Resident #197,who had on a seatbelt alarm,and a mobility alarm and demonstrated how they worked. When Staff #34 removed the attached alarms, they activated, as they should have. The facility failed to ensure the resident received adequate supervision and assistance to prevent accidents.

Based on medical record review, resident and staff interview, it was determined that the facility failed to keep a resident free from abuse for 1 facility reported incident MD 593. The findings include: Resident #145, with a [DIAGNOSES REDACTED].#152, who was alert and oriented. Review of the facility reported incident MD 593, that was written by Staff # 99 revealed that "on 11/4/13 at 9:00 PM staff heard someone calling for help. The staff found Resident #152, seated on the floor with his w/c (wheelchair) on top of him, and Resident #145, his roommate, standing next to him with his leg raised and his knee bent, as if he were about to kick Resident #152. The 2 residents were separated and Resident #152 had a raised red area on his forehead. Resident #152 stated that he heard Resident #145 getting up from his bed. He mobilized in his w/c to the curtain that separated their beds, and requested Resident #145 get back into bed. At that time he claims Resident #145 took a hold of his w/c, and toppled it with him in it." Resident #145 was transferred the following day to the dementia unit on the second floor. The following review of the medical records for Resident #145 and Resident #152 revealed issues from 9/27/13 to 11/4/13: The nursing note, written on 9/30/13 at 1:30 AM in Resident #145's chart, stated "patient up out of bed, wandering in roommates side of room, picking up all his things. Not easily re-directed. Doesn't want toileted. Patient is up walking, taking off clothing". At 3:30 AM, the note states "patient up in wheelchair until 3:00 AM - laid down but again, OOB (out of bed) wandering over to roommates side of room - attempted to urinate on roommates bed (or roommate?)". The note continues "roommate is quite upset and yelling at patient". During this same day on the 7-3 shift, the nursing note stated "resident wandering all shift. Trying to kiss another resident". The nursing note that was written in Resident #152's medical record on 9/30/13 at 2:30 AM stated "awake since 12 midnight, roommate was up and wandering about, in patient's side of room picking up his belongings, etc". The note continued "reassured that we will monitor the other patient's movements, etc." At 3:15 AM, the notes stated "roommate went back to bed - patient has since "dropped" urinal x 3, TV remote x 1, put on call bell to tell staff "he' s getting up!" The nursing note continues "patient in w/c, at nurse's desk, screaming at GNA (geriatric nursing assistant) and myself "why am I the bad one? I can't sleep with all that racket going on! Now he's laying in there reciting the Malaysian dictionary. Make him come back out here!" The nurse writes "we look at roommate; he is laying quiet in bed. Patient however has had enough and is furious with us" "if it was anyone else, you'd do something!" On 10/2/13 at 4:15 AM, Resident #152's nursing note stated "pt awake all night, as roommate is also awake - while staff have kept roommate in dining room or with staff as possible, he has gone in room several times - we attempted to get him to lay down, he is bothering patient by standing over him, staring, picking up his items, etc. Patient is understandably upset - his voice is getting louder". "He has been to nurses desk x 2 demanding "someone do something! I can't babysit him!" On 10/3/13 at 1:40 AM, the nursing note for Resident #145 stated "staff heard roommate calling out " hey ...don't do that ...help ..." "patient was standing over roommates bed, inches from his pillow, pulling down his pants as if about to urinate". The nursing note that was written in Resident #152's chart at 5:30 AM stated "woke x 1 with roommate "ready to piss on me, but tragedy was averted". On 10/4/13 at 2:30 AM, the nursing note stated "roommate has tried to redirect patient to bed, chair in room, etc to no avail. Patient urinated in dining room". The nursing note for Resident #145 of 10/6/13 at 2:30 AM stated "wandering on unit, in other resident's rooms, trying to get in roommate's bed repeatedly." The note continued "found in kitchenette behind nurses desk, voiding in trash can, on outside of trash can and on floor." At 1:05 PM, the note stated "resident continues to wander in and out of other resident rooms. Resident hitting and grabbing staff member's arms when trying to toilet. Voided in other resident rooms and in dining area." On 10/12/13 at 11:00 PM, resident continued to urinate on floor and in hall outside his room. On 10/13/13 at 2:00 AM, Resident #152's nursing note stated "I can't sleep..that man keeps pacing around, staring at me (he does, (that is what the writer of the note wrote) - I can't sleep - I'm afraid he's gonna piss on me! He pissed all over the floor last night!" The nurse continues to write "patient getting upset - voice high, loud and speech fast. Reassured. Patient has had similar complaints before (see n.n.9/30, 10/13 ...) seems to forget about these crises by morning time but is very upset at night. Very shaky - dropping/spilling things". On 10/13/13 at 3:30 AM, Resident #145's chart, "pt up wandering up and down halls, follows other pts who are up. 8:30 PM voiding in tv room corner. On 10/30/13 at 5:00 AM, "pt awake 11pm to 4am, pacing, picking up anything he finds, brings to nurse. voided on med cart, in DR after taken to void and did x 2. On 11/3/13 at 1:30 PM, "during am care gna's were trying to get res (resident) wet clothes off and put dry ones on and res continuously hit them. they called for this writer to help and res punched all 3 of us". 11/4/13 incident happened with roommate, moved to different room 11/5/13 nursing note for Resident #152 at 2:00 AM stated " complained of headache at 11:15 PM, given 2 Tylenol with effect stated, "upset about events of the day - relives the experience - we did permit him to tell us in his words what happened, but was encouraged to try to relax and settle down. " Resident #152 was interviewed on 12/12/13 at 2:05 PM by the surveyor while in his room, and stated in regard to resident #145 "I was afraid of what he would do at night. He was always standing over me while I was laying in bed, trying to piss on me. I was afraid to shut my eyes because I didn't know what he would do to me". "I couldn't go to sleep because of him". When asked if he told anyone, Resident #152 stated "they knew". He was again asked "who knew?" He stated, "the nurses and Staff #99." He was asked "what did Staff #99 say to you?" He stated "she said just live with it for now, I have to meet him (meaning roommate)half way". Staff # 99 was interviewed on 12/12/13 at 4:00 PM. When asked what interventions were put in place to protect resident #152 from resident #145, Staff #99 stated that Staff #85 offered him a new room, but he declined. When asked to show where the notes were in the medical record, Staff #99 could not find any. Staff #99 also stated that Resident #152 kept the bathroom door closed and that is why the resident was trying to urinate on him. There was no documentation presented to the surveyor or found in either resident's medical record of the issue with Resident #145 urinating all over the facility due to the bathroom door being shut. There is documentation that staff took Resident #145 to the bathroom on many occasions, and the behavior continued. Resident #145 continued to urinate all over the unit, even after moving to his new room according to the nursing documentation. Staff #99 just sat at the table and shrugged her shoulders. In summary, from 9/27/13 to 11/4/13, the day that resident #152 was pushed over in his wheelchair by resident #145, the resident was afraid to go to sleep for fear of what his roommate would do to him and his belongings. The staff allowed the behavior to continue until a resident altercation occurred.

Based on medical record review and staff interview, it was determined that the facility staff failed to assure that each resident's drug regimen is free from unnecessary drugs. This was evident for 3 of 26 residents selected for review in the stage 2 sample. The findings are as follows: 1). The facility staff administered pain medication at a higher dose than was ordered. Resident # 153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed admitting physician orders [REDACTED]. However due to a pharmacy error (refer to CMS 2567 F 425) the resident had been given 6 doses of [MEDICATION NAME] 100 milligrams on the following dates and times: 3/30/10 at 9:30 AM, 3/30/10 at 9 PM, 3/31/10 at 9 AM, 3/31/10 at 9 PM, 4/1/10 at 9 AM, and 4/2/10 at 9 AM. Further review of the medical record revealed a nurses note dated 4/2/10 at 11:30 PM that stated the following: "Res (resident) pale responsive only to tactile stimuli. Skin warm and dry. VS (vital signs) 100.2 (temperature), 90 (pulse), 16 (respirations), SPO2 80-84% (blood oxygen saturation, normal values are between 95-100%) O2 (oxygen) started." According to the Nurses notes 911 was activated and the resident was sent to the hospital. According to the hospital records the resident was admitted to the hospital on [DATE] due to [MEDICATION NAME] overdose. During an interview with the pharmacy's general manager on 6/10/10, he acknowledged that the pharmacy made an error and dispensed 6 doses of [MEDICATION NAME] 100 milligrams rather than the 10 milligrams that was ordered. The general manager researched the error and the following was discovered: The front of the medication punch card stated the name and dosage of medication to be the following: [MEDICATION NAME] ([MEDICATION NAME]) 100 mg. However, on the reverse side of the card each capsule had a foil back that indicates each capsule as [MEDICATION NAME] 10 mg. The research determined that the computer program that creates the foil backs was incorrectly setup. [MEDICATION NAME] 100 mg had been incorrectly associated with 10 mg, meaning when a bottle of [MEDICATION NAME] 100 mg is scanned it was producing 10 mg foil backs. During an interview with the Director of Nursing on 6/10/10 she acknowledged that the resident was administered the medication that was sent from the pharmacy. 2). The facility's staff administered a blood pressure medication without adequate indications for it's use. Resident # 208 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. Further review of the medical record revealed that on 3/10/10 the dosage of the medication was lowered to 5/10 mg one tablet every day for high blood pressure. The blood pressure parameters remained the same. Review of the medication administration records revealed that the facility's staff administered the medication on the following days when the blood pressure was below the ordered parameters: 3/31/10 BP = 120/58, 4/3/10 BP = 108/62, 4/12/10 BP = 120/59, 5/4/10 BP = 109/62, 5/5/10 BP = 106/66, 5/12/10 BP = 108/70, 5/13/10 BP = 107/67, 5/14/10 BP = 106/70, 6/2/10 BP = 104/64, 6/5/10 BP = 106/69, 6/6/10 BP = 104/62, and 6/7/10 BP = 106/64. During an interview with the unit manager on 6/10/10, she acknowledged that the medication should not have been administered when the BP was below the ordered parameters. 3). The facility staff had been administering duplicate therapy of [MEDICATION NAME]. Resident # 77 was admitted to the facility in 2004. [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident is on the following medications: [REDACTED]. This drug is indicated for seasonal and [MEDICATION NAME] allergic rhinitis. The resident has been on this medication since 2007. Further review revealed that the resident is also on [MEDICATION NAME]-D 240-10 mg 1 tablet every day for allergies [REDACTED]. The resident has been on this medication since 4/21/10. Both of these medications are [MEDICATION NAME] and serve the same purpose. Further review of the medical record revealed that the pharmacist did a medication review on 5/26/10 and made the following comment: Resident takes duplicate therapy of [MEDICATION NAME] D and [MEDICATION NAME] D. The pharmacist made the following recommendation: Please re-evaluate the need for both agents, perhaps giving consideration to discontinuing use of [MEDICATION NAME] D. If dual therapy is to continue, it is recommended that a) the prescriber document an assessment of risk verses benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences. On the pharmacist Consultation Report is an area for the physician's response. The physician wrote the following: D/C (discontinue) [MEDICATION NAME] D and dated the form 6/2. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the Unit Manager, she stated that sometimes the physician writes the order for the physician's response but if the physician does not the nurse will write the order. Review of the physician orders [REDACTED]. Further review of the physician orders [REDACTED].

Based on medical record review, review of the Controlled Medication Utilization Record, review of the medication punch card, and interviews with the resident, the resident's physician, the resident's daughter, the general manager of the pharmacy, and the facility's staff it was determined that the pharmacy failed to dispense the proper dose of pain medication as ordered by the physician. This was evident for 1 of 26 residents selected for review in the stage 2 sample. The findings are as follows: Resident # 153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed admitting physician orders [REDACTED]. However due to a pharmacy error the resident had been given 6 doses of Kadian 100 milligrams on the following dates and times: 3/30/10 at 9:30 AM, 3/30/10 at 9 PM, 3/31/10 at 9 AM, 3/31/10 at 9 PM, 4/1/10 at 9 AM, and 4/2/10 at 9 AM. Further review of the medical record revealed a nurses note dated 4/2/10 at 11:30 PM that stated the following: "Res (resident) pale responsive only to tactile stimuli. Skin warm and dry. VS (vital signs) 100.2 (temperature), 90 (pulse), 16 (respirations), SPO2 80-84% (blood oxygen saturation, normal values are between 95-100%) O2 (oxygen) started." According to the Nurses notes 911 was activated and the resident was sent to the hospital. According to the hospital records the resident was admitted to the hospital on [DATE] due to morphine overdose. During an interview with the pharmacy's general manager on 6/10/10, he acknowledged that the pharmacy made an error and dispensed 6 doses of Kadian 100 milligrams rather than the 10 milligrams that was ordered. The general manager researched the error and the following was discovered: The front of the medication punch card stated the name and dosage of medication to be the following: Kadian (Morphine Sulfate) 100 mg. However, on the reverse side of the card each capsule had a foil back that indicates each capsule as Kadian 10 mg. The research determined that the computer program that creates the foil backs was incorrectly setup. Kadian 100 mg had been incorrectly associated with 10 mg, meaning when a bottle of Kadian 100 mg is scanned it was producing 10 mg foil backs. According to the general manager the computer system is corrected and a new policy and procedure has been implemented requiring additional pharmacist verification of any product added to the computer program that creates the foil back, internal check performed, verifying no additional foil backs had been incorrectly created for any other facility or patient, this was determined to be a singular occurrence. A Performance Improvement Action Plan and Monitoring has been established by pharmacy's Director of Operations. This is cited as past non-compliance