Every finding on record at Sterling Care Bel Air

Based on observation, interview, and record review, it was determined that the facility failed to provide necessary respiratory care services. This was evident for 5 (Residents #102, #33, #22, #8 and #136) of 6 residents reviewed for respiratory care during the recertification survey. The findings include: Oxygen (O2) therapy is a treatment that provides a person with extra O2 to breathe in. It is also called supplemental O2. A nasal cannula is a thin, flexible tube that delivers O2 through the nose. A humidifier in O2 therapy is a device that adds moisture to dry, concentrated O2 to prevent drying and irritation of a patient's nasal passages, throat, and lungs. These humidifiers typically consist of a bottle filled with water that attaches to an O2 concentrator. On 3/09/2026, during the initial tour of the facility, the following were observed: At 6:11 AM, an unlabeled O2 tubing for Resident #102. At 6:17 AM, a humidifier bottle on the floor, an O2 tubing left on top of the nightstand without any protective bag and no Oxygen in Use sign posted outside Resident #33's room. At 6:25 AM, an unlabeled 02 tubing and humidifier bottle, no Oxygen in Use sign posted outside Resident #22's room. At 6:36 AM, an unlabeled 02 tubing of Resident #8. At 6:41 AM, no Oxygen in Use sign posted outside Resident # 136's room. On 03/11/2026 at 9:40 AM, during an interview with Staff #16, he/she confirmed that when caring for residents on O2 therapy, it was expected that nurses would label the O2 tubing and mask based on facility's policy and should be stored inside a clean plastic bag when not in use. On 3/11/2026 at 9:59 AM, the Director of Nursing (DON) was notified of the concern and acknowledged the findings. On 3/12/2026 at 8:35 AM, a review of the facility's Oxygen Administration policy reviewed on 1/20/26 confirmed the following:- Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.- Oxygen warning signs must be placed on the door of the residents' room where oxygen is in use.- Cleaning and care of equipment shall be in accordance with facility policies.

Based on a review of employee files and interviews with facility staff, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) demonstrated competency in essential skills and techniques prior to providing resident care. This deficiency was identified in 4 out of 4 of the newly hired GNA employee charts (Staff #23, #24, #25, and #26) reviewed during the recertification/complaint survey.The findings include:The American Nurses Association defines nursing competence as an expected level of performance that integrates knowledge, skills, abilities, and judgment.On 3/10/26 at 9:52 AM, the surveyor requested employee files for four randomly selected GNAs. A review of these records confirmed that Staff #23 was hired in March 2025, Staff #24 and #25 were hired in October 2025, and Staff #26 was hired in January 2026. However, none of the files contained competency records to verify that their skills were assessed before providing care to residents.During an interview with Staff #11 (Educator) on 3/10/26 at 12:35 PM, she stated that the facility provided education to newly hired nursing department staff, including both nurses and aides. Upon reviewing Staff #23's file with the surveyor, the Educator verified there were no skill verifications or evaluations for GNAs upon hire. Staff #11 stated, I do nurses' skill checklists, but not for aides.In an interview with the Nursing Home Administrator (NHA) on 3/10/26 at 1:03 PM, the surveyor shared the above concerns. The NHA stated, The facility gave a checklist to new hires; they just didn't return them. The NHA acknowledged that there was no supportive evidence to prove the competencies of newly hired GNAs had been completed.

Based on observation, clinical record review, resident interview, and staff interview it was determined that the facility failed to 1) follow a physician's order to turn and position a dependent resident and 2) failed to administer medications on time. This was evident for 1 (Resident #102) out of 1 resident reviewed for turning and positioning and for 1 (Resident #2) out of 2 residents reviewed for pain medication during the recertification/complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. 1) On 3/09/2026 at 6:11 AM, Resident #102 was observed sleeping on his/her left side and slanted leaning with head pushed against the left side rail. On 3/09/2026 at 8:34AM and 9:46 AM, during the follow-up visits, Resident #102 remained in the same position with his/her head against the left side rail and feet on the right side of the bed. On 3/11/2026 at 9:03 AM, a review of Resident #102's care plan confirmed the following: Activity of daily living self-care performance deficit related to activity intolerance, fatigue, limited Mobility, shortness of breath and morbidly obese. (initiated 2/12/2026) Bed Mobility: The resident is totally dependent on (2) staff for repositioning and turning bed as necessary. (initiated 2/12/2026) Further review of Resident #102's medical records revealed an admission MDS section GG (Functional Assessment)with an Assessment Reference Date (ARD) of 2/17/2026 that indicated: Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. An order also confirmed, Turning and Repositioning every 2 hours and as needed (PRN) as tolerated every shift. Although the Treatment Administration Record (TAR) was signed by nursing staff indicating this was performed, the observations on 3/09/2026 contradict these records. On 3/11/2026 at 9:34 AM, Staff #17 and #16 confirmed that dependent residents should be assisted with repositioning every 2 hours and as needed. On 3/11/2026 at 9:59 AM, the Director of Nursing (DON) was notified of these concerns. 2) Resident #2 was interviewed on 3/09/26 at 12:12 PM. The resident stated that their pain medication was often late. Resident said the pain medications often come every 10 hours. A review of Resident #2's clinical record revealed that the resident's primary physician ordered Acetaminophen 500 mg two tablets by mouth two times a day for pain. The resident was scheduled to be administered the medication at 8:00 AM and 8:00 PM. A review of the resident's Medication Admin Audit Reports for February and March of 2026 on 3/12/26 at 11:27 AM revealed that the resident received the ordered medication late on these dates: 2/3/26 at 9:16 PM, 2/4/26 at 9:56 AM, 2/5/26 at 9:34 AM, 2/9/26 at 10:02 AM, 2/11/26 at 10:19 AM, 2/13/26 at 9:32 AM, 2/14/26 at 11:32 AM, 2/15/26 at 10:01 AM, 2/16/26 at 9:35 AM, 2/16/26 at 9:19 PM, 2/19/26 at 9:41 AM, 2/20/26 at 10:18 AM, 2/21/26 at 9:49 AM, 2/22/26 10:44 AM, 2/23/26 at 9:54 AM, 2/24/26 at 9:54 AM, 2/26/26 at 10:31 AM, 1/26/26 at 9:33 PM, 2/27/26 at 9:51 AM, 2/28/26 at 9:39 AM, 2/28/26 at 9:33 PM, 3/2/26 at 10:00 AM, 3/3/26 at 9:42 AM, 3/4/26 at 9:30 AM, 3/6/26 at 9:58 AM, 3/7/26 at 9:43 AM, 3/9/26 at 9:44 AM, 3/10/26 at 9:28 AM, 3/11/26 at 9:16 AM, and 3/12/26 at 9:46 AM. The Director of Nursing (DON) was interviewed on 3/12/26 at 11:16 PM. She was shown the ordered times as well as the times the medications were administered. She confirmed that the medications were administered late.

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure residents were properly evaluated for decision-making capacity, specifically failing to document the rationale for incapacity, and failed to ensure a resident either had an Advance Directive or was offered the forms to create one. This was evident for 4(#4, #147, #30, and #157) residents out of the 7 reviewed for Advance Directives during the recertification/complaint survey. The findings include:A physician's certification of decision-making capacity confirms whether a patient can understand their medical situation, appreciate the consequences of their choices, use reasoning, and communicate a treatment preference. Under specific legal standards, such as Maryland law, a certification of incapacity requires the signatures of two physicians (one being the attending physician) and must include a documented reason for the incapacity to ensure the process remains consistent with patient rights. 1) A review of Resident #147's medical record on 3/09/26 at 9:10 AM revealed a Brief Interview for Mental Status (BIMS) score of 6 on 1/28/26, indicating severe cognitive impairment. Although two physicians completed the certification of decision-making capacity on 1/27/26 and 1/28/26 marking the resident as unable to make decisions, neither physician documented a diagnosis or specific rationale for the incapacity. 2) A review of Resident #4's medical record on 3/09/26 at 9:36 AM revealed a Medical Orders for Life-Sustaining Treatment (MOLST) form completed on 1/09/26 as Full Code per the patient's surrogate. A review of the physician certification forms found that while one form (dated 1/09/26) listed dementia as the reason for incapacity, the second required form (also dated 1/09/26) lacked any diagnosis or rationale. During an interview on 3/11/26 at 7:52 AM, Staff #19 (Social Worker) stated that all newly admitted residents are required to be evaluated for decision-making capacity. She noted that physicians are expected to complete the certification form with a diagnosis or reason, which social workers then review. Upon reviewing the forms for Resident #4 and #147 with the surveyor, Staff #19 validated the concerns, acknowledging that the documentation should have included the diagnosis or reasons for incapacity. 3) A review of Resident # 30's medical record on 3/09/2026 at 12:03 PM revealed that resident was admitted on [DATE] and had a Brief Interview for Mental Status (BIMS) of 05 indicating severe cognitive impairment. Further review of the medical record on 03/09/2026 at 12:15 PM, noted 2 signed copies of physician certifications related to medical condition, substitute decision making and treatment limitations forms, dated 10/15/2025 and 10/17/2025, indicating that resident is unable to comprehend information and make decisions based on examination. However, there was no documented diagnosis or specific rationale for the resident being incapable of comprehending information and or making decisions. During an interview on 3/11/26 at 7:52 AM, Staff #19 (Social Worker) stated that all newly admitted residents are required to be evaluated for decision-making capacity. She noted that physicians are expected to complete the certification form with a diagnosis or reason, which social workers then review. The surveyor reviewed the form with staff #19, who validated the concern that the documentation on the forms should have included the diagnosis or reasons for any incapacity. 4) A review of Resident #157's clinical record on 3/10/26 at 10:04 AM revealed that a copy of the resident's Advance Directive, if it existed, was not in the clinical record. A review of the social worker notes revealed that the social worker did not ask the resident if they had one or offered an Advance Directive to complete. The Director of Social Services (Staff #19) was interviewed on 3/12/26 at 8:42 AM. She confirmed that there wasn't a note showing that she asked the resident if they had an Advance Directive or had provided the resident with a copy to be completed later. She replied that the section had not been completed yet. This surveyor stated that the resident had been in the facility almost two weeks and that it should have been completed on admission. She acknowledged that she should have asked if the resident had an Advance Directive or offered if they did not. The Administrator was in the room during the interview.

Based on observation, record reviews, and interviews, it was determined that the facility failed to provide adequate privacy to the resident by exposing their body parts. This was evident for 1 (Resident #136) of 1 resident sampled for privacy during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. On 3/09/2026 at 8:40 AM, Resident #136 was observed with incontinent brief and blanket pulled down, and the privacy curtain was pulled all the way to the wall, making the resident's mid to lower body visible to visitors and staff. Staff #6 was immediately notified. On 3/10/2026 at 12:54 PM, a review of Resident #136's medical records revealed a BIMS (Brief Interview for Mental Status) score of 11.0 which indicated moderately impaired cognition. Further review of the medical records indicated the following:-admission MDS Section GG (Functional Assessment)with an Assessment Reference Date (ARD) 2/4/2026, Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.-A Care Plan initiated on 1/29/2026, Activities of Daily Living (ADL) self-care performance deficit related to disease process. Resident #136 will receive the appropriate staff support with (bed mobility, transfers, eating, dressing, toilet use, personal hygiene, through next review. Dressing: The resident is able to: one person assist On 3/11/2026 at 9:34 AM, Staff #17 confirmed that staff were expected to provide privacy to the residents. On 3/11/2026 at 9:59 AM, the Director of Nursing (DON) was notified of the concern.

Based on observations, record reviews, and interviews, it was determined that the facility failed to develop and implement comprehensive care plans for oxygen therapy. This was evident for 3 (Residents #22, #8 and #136) of 31 residents reviewed for care planning during the recertification survey.The findings include: A care plan is a guide that addresses the unique needs of each Resident. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. The care plan consists of focus, goal and interventions. Oxygen (O2) therapy is a treatment that provides a person with extra O2 to breathe in. It is also called supplemental O2. On 3/9/2026 between 6:25 AM and 6:41 AM, Residents #22, #8 and #136 were observed using O2 via nasal cannula.On 3/11/2026 at 9:10 AM, a review of the active physician orders confirmed the following:-Resident # 22- O2 continuous at 2 liters via nasal cannula (NC) every shift.-Resident #8- O2 at 2 liters via NC continuous every shift for oxygen supplement.-Resident #136- O2 continuous at 2 liters via NC every shift. However, a review of the medical records revealed no evidence that care plans have been initiated or implemented to address the use of O2 therapy for Residents #22, #8 and #136. On 3/11/2026 at 9:40 AM, Staff #16 confirmed that care plans were initiated by the nurse supervisors on admission. It is then reviewed and completed by the Unit Managers (UM) the following day. On 3/12/2026 at 8:35 AM, the Nursing Home Administrator (NHA) provided copies of oxygen care plans for Resident #22, #8, and #136 which were only initiated on 3/12/26 after surveyor intervention. The facility's O2 Administration Policy revised on 1/20/26 confirmed that The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. On 3/12/2026 9:11 AM, the Director of Nursing (DON) was notified of these findings.

Based on observation, interview and record review, it was determined that the facility failed to provide necessary personal hygiene to dependent resident. This was evident for 1 (Resident #136) of 1 resident reviewed for Activities of Daily Living (ADLs) during the recertification survey.The findings include:ADL care is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. On 3/09/2026 at 8:37 AM, during the initial tour of the facility, Resident #136 was observed with fingernails extending approximately half an inch beyond fingertips. Resident #136 stated he/she had repeatedly requested nail trimming from the staff without success.On 3/10/2026 at 12:39 PM, a medical record review of an admission MDS with an Assessment Reference Date (ARD) of 2/4/26 revealed that Resident #136 had a functional status of partial/moderate assistance for personal hygiene. (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort). Resident #136's care plan initiated on 1/29/26 also confirmed one person assist for personal hygiene.On 3/11/2026 at 9:33 AM, a follow-up visit confirmed that Resident #136 still had long fingernails.On 3/11/2026 at 9:40 AM, Staff #17 and Staff #16 confirmed that staff and Geriatric Nurse Assistants (GNA) were expected to provide nail care as part of regular ADL assistance.On 3/11/2026 at 9:59 AM, the Director of Nursing was notified of the concern and at 10:22 AM, the DON confirmed that Resident #136's fingernails had been trimmed.

Based on observation and staff interviews, it was determined that the facility failed to consistently monitor and document the temperatures of its medication refrigerators. This deficiency was identified in two medication refrigerators of two temperature logs reviewed during the recertification/complaint survey.The findings include:During an observation of the medication storage room on 3/10/26 at 7:05 AM, conducted with Staff #6 (Night Shift Supervisor), two refrigerators were identified: one for residents' prescribed antibiotics and another for the Pyxis (emergency medication storage). A review of the temperature logs for these refrigerators revealed the following omissions:-Pyxis Refrigerator Log: The log requires the recording of the exact time (AM/PM) along with staff initials for twice-daily checks. However, the log lacked staff initials for the period of 3/03/26 through 3/06/26. Additionally, only one temperature was documented per day during this period, despite the requirement for both AM and PM checks.-Prescribed Medication Refrigerator Log: This log lacked staff initials from 3/01/26 through the AM of 3/09/26. Furthermore, only a single checkmark was recorded for the dates of 3/07/26 through 3/09/26, failing to meet the twice-daily monitoring requirement.During the observation, Staff #6 validated the findings, acknowledging that the temperature logs were not appropriately completed or maintained.

Based on resident interview, staff interview, and clinical record review, it was determined that the facility staff failed to 1) ensure that residents' names were accurately displayed at their room entrances, 2) failed to perform an accurate oral assessment, and 3) failed to ensure a resident's clinical records were in their most accurate form and free of another resident's information. This was evident for 2 residents (#39 and #57) out of a sample of 141 residents reviewed for room identification, and 2 (#64 and #157) residents out of 43 residents reviewed as part of the survey sample. The findings include:1) During an initial tour of the facility on 3/09/26 at 6:10 AM, the surveyor observed that each resident's room had a nameplate posted on the wall using the designations D (Door side) and/or W (Window side). The posting for room [ROOM NUMBER] displayed: W – [Resident #39] D – [Resident #57] On 3/09/26 at 7:50 AM, Resident #39—who was physically located on the door side of room [ROOM NUMBER]—verbally confirmed their identity to the surveyor. During an interview on 3/09/26 at 7:55 AM, Staff #22 (Licensed Practical Nurse) confirmed that D indicates the door side and W indicates the window side. Upon reviewing the nameplates for room [ROOM NUMBER], Staff #22 stated, Oh. it should be changed. Resident #39 is inside [door side] and Resident #57 is on the window side. On 3/09/26 at 8:02 AM, the surveyor observed Staff #4 (Registered Nurse) performing vital signs for Resident #57 and documenting them on a paper labeled 306B. Staff #4 stated that she relies on the wall-mounted nameplates to identify residents. In an interview with Staff #5 on 3/09/26 at 8:05 AM, she stated that when assigned to unfamiliar residents, she relies on other staff, the residents themselves, and the nameplates outside the rooms for identification. During an exit interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 3/12/26 at 2:10 PM, the surveyor presented these findings. Both the NHA and DON validated the concerns, acknowledging the identification errors. 2) During the survey screening process on 3/9/2026 at 8:33 AM, the surveyor asked Resident #64 if she/he had any dental complaints. The Resident stated that she/he had dentures in the drawer, and that the bottom denture hurt at times. The surveyor noted that the Resident did not have any teeth in his/her mouth. A medical record review on 03/11/2026 at 9:20 AM for Resident #64, revealed the following oral assessments on 10/23/25 and 1/24/2026: Does Resident have dentures? No; Does Resident have upper dentures? No; Does Resident have lower dentures? No; Does Resident have natural teeth? Yes. On 03/11/2026 at 1:35 PM, an interview was conducted with the DON, who explained that the nursing staff performed quarterly oral evaluations, and if the resident complained about dental pain, they will be added to a list to be seen by National Preventive Solutions (NPS), an outsourced dental company. The surveyor requested a copy of the most recent dental visit report for Resident # 64. On 03/11/2026 at 1:43 PM, the DON provided the NPS dental hygiene encounter form dated 10/9/2025 for Services Performed: D9410- skilled nursing facility visit; D1110 -Hygiene prophylaxis; D5899- Denture Prophylaxis: Complete Maxillary Denture and D5899- Complete Mandibular Denture. Notes: Deliver tooth brush and toothpaste for individual use and Deliver denture case and cleansing tablets. On 3/12/2026 at 09:30 AM, a follow up interview was conducted with the DON to share the concern of staff inaccurate documentation of oral / dental assessment resulting in inaccurate information in the resident's medical record. The DON agreed with the concern and had nothing further to add. 3) During the initial screening of the facility residents, Resident #157 was interviewed on 3/9/26 at 1:26 PM and asked if they had been invited to their care plan meetings. Resident #157 alleged that they had not been invited to any care plan meetings. The clinical record was reviewed and evidence of attendance was found. Further review revealed that the resident's care plans included a care plan with another resident's name on it. The Director of Nursing (DON) was interviewed on 3/11/26 at 2:14 PM. She was shown the care plan with another resident's name on it. She said she would investigate. The DON was interviewed on 3/11/26 at 2:25 PM. She said Resident #157 does not have a CPAP (Continuous Positive Airway Pressure) machine and the goal was for another resident. She then said she thought the person who developed the goals probably had multiple computer screens up and wrote on the wrong resident's clinical record. She said she removed the care plan belonging to another resident.

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to use appropriate infection control practices for 1) the use and care of oxygen administration equipment and 2) urinary catheter maintenance and 3) failed to ensure that resident food stored in the nourishment room was properly dated to minimize the potential spread of infection. This was evident for 3 (Residents #33, #8, #133) of 31 residents reviewed for infection control practices during the recertification/complaint survey. The findings include: Oxygen (O2) therapy is a treatment that provides a person with extra O2 to breathe in. It is also called supplemental O2. A nasal cannula is a thin, flexible tube that delivers O2 through the nose. A humidifier in O2 therapy is a device that adds moisture to dry, concentrated O2 to prevent drying and irritation of a patient's nasal passages, throat, and lungs. These humidifiers typically consist of a bottle filled with water that attaches to an O2 concentrator. A urinary catheter drainage bag is a sterile, soft plastic container that connects to a catheter to collect urine. 1) On 3/9/2026 at 6:17 AM, during the initial tour of the facility, the surveyor observed a humidifier bottle on the floor and an O2 tubing left on top of the nightstand without any protective bag in Resident #33's room. The surveyor immediately informed Staff #6. On 03/11/2026 at 9:40 AM, during an interview with Staff #16, he/she confirmed per facility policy, O2 tubing should be labeled and stored in a clean plastic bag when not in use. 2) On 3/09/2026 at 9:04 AM, the surveyor observed Resident #8's catheter drainage bag lying on the floor. On 3/11/2026 at 9:59 AM, the Director of Nursing (DON) was notified of these concerns and acknowledged the findings. On 3/12/2026 at 9:31 AM, Resident #8's catheter drainage bag was again observed lying on the floor. On 3/12/2026 at 11:49 AM, Staff #11 confirmed that infection prevention and control education is being provided to all the staff. He/she also stated that nursing staff must ensure that the foley catheter bags should be off the floor and below the level of the bladder to prevent backflow. Oxygen tubing or any respiratory equipment on the other hand should be changed based on facility policy and placed in bags when not in use. 3) During a tour of the medication storage rooms on 3/10/26 at 7:05 AM, conducted with Staff #6 (Night Shift Supervisor), it was noted that the facility utilizes two separate storage rooms. Staff #6 stated that one room is used for medication storage and the other for tube feeding materials, referred to as the nourishment room. An observation of the nourishment room refrigerator revealed a plastic bag labeled with Resident #133's name with room [ROOM NUMBER]; however, the bag lacked a documented date of entry or opening. Also, the record review on 3/10/26 at 9:00 AM revealed that Resident #133 was not in room [ROOM NUMBER]. At the time of the observation, Staff #6 validated the concern, acknowledging that the residents' food did not have a date on it. During a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 3/11/26 at 2:10 PM, the surveyor shared the findings. Both the NHA and DON validated their concerns.

Based on record reviews and interviews, it was determined that the facility failed to update a resident's discharge plan to reflect the information received from home health services referral. This was evident for a discharged resident (Resident #3) during a complaint survey.The findings include: On 10/16/2025 at 7:59 AM A review of complaint #2602798 was conducted. The review alleged that Resident #3 was discharged home on 7/22/25 without home health wound care services arrangement and as of 8/28/25 the resident had no wound care services.On 10/16/2025 at 8:20 AM A review of Resident #3 medical records was conducted. The review revealed that the resident was initially admitted into the facility on 2/3/2024 and was discharged on 8/1/2025. The records indicated that the resident had a wound on the right Below Knee Amputation (BKA) stump and received wound care services while at the facility.Further review of the records indicated that on 7/22/2025, the facility contacted a home health agency to request services for Resident #3 post discharge. On 8/1/2025 at 1:39 PM, the facility was notified that the home health agency would not be able to provide services to Resident #3. On 8/1/25 at 14:37 PM Resident was discharged from the facility.On 10/16/2025 at 10:40 AM An interview with Staff #5 was conducted. The staff confirmed that they discharged Resident #3 home. When asked if the time of discharge was a late entry, Staff #3 stated that they documented the actual time when the resident was discharged from the facility. On 10/16/2025 at 10:44 AM Review of the records revealed a social service note dated 8/4/25 that stated the staff spoke with the resident regarding discharge planning follow up. The note also indicated that the resident was accepted for home wound care services. Further review of records revealed a wound care note that stated the resident was educated on performing wound care dressing and that if the wound vac seal broke, Resident #3 was to contact home health services.Additionally, A review of Resident #3's discharge summary written by the provider revealed an assessment and plan for the resident to have wound care Monday, Wednesday and Fridays, and to maintain the wound care therapy. Additionally, the note stated that the resident was discharged with home health services. On 10/16/2025 at 11:46 AM An interview with Resident #3 was conducted. The resident stated that at time of discharge they were told that the home health services were set up and that they were to be seen for wound care follow up every Monday, Wednesday and Friday.On 10/16/2025 at 11:57 AM An interview with the complainant was conducted. The complainant stated that the resident was discharged home with a wound vac machine, and no wound care arrangements were conducted. The complainant reported that the discharge instructions the resident was sent home with indicated that home health was set up. On 10/16/2025 at 1:50 PM An interview with the Social Services Director was conducted. When asked if she was aware that the home health services were declined prior to resident's discharge, she responded that she was aware. She also stated that a resident can be discharged from the facility without home health confirmation of a start of care date.On 10/16/2025 at 2:15 PM The Administrator was notified regarding the concern with discharge planning.On 10/17/2025 at 7:44 AM The surveyor received documentation from the Director of Nursing (DON) that indicated the medical director had a consultation with the Resident #3 prior to discharge. The note stated that the resident was educated on the risks of being discharged home without home health setup, but the resident preferred to be discharged home.On 10/17/2025 at 11:45 AM During the exit conference, the Medical Director stated that he spoke to the resident about the risks of leaving the facility without home health services and that the resident insisted on going home. When asked if the resident should have been discharged as Against Medical Advice (AMA), the Medical Director stated no. When asked if the resident's discharge plan should have been updated to reflect that the resident had no home health services and no wound care arrangements, he responded, yes, that the discharge instructions should have been revised.

Based on medical record review, review of facility documentation and interview, it was determined the facility staff failed to prevent abuse of a resident resulting in psychosocial harm to the resident (Resident #5). This was evident for 1 of 3 residents reviewed for abuse during a complaint survey. The findings include: The findings include: A review was conducted on Facility Reported Incident 302934 on 8/18/25 related to Resident #5's allegation of sexual abuse by Staff #11 on 1/25/25. Resident #5 alleged on 1/29/25 to Staff #12 that Staff #11 kissed the Resident on the lips and attempted to kiss the Resident's private area during care on 1/25/25. Review of Resident #5's medical record on 8/18/25 revealed the Resident was admitted to the facility in July 2024 with a diagnosis to include cerebral infarction (stroke). The facility staff conducted an MDS (Minimum Data Set) assessment on 8/6/25 and coded the Resident as dependent on facility staff for toileting. During interview with Resident #5 on 8/18/25 at 11:05 AM, the Resident was asked if he/she was okay telling the Surveyor what happened on 1/25/25, the Resident stated he/she was but began crying while giving his/her statement. The Resident stated on 1/25/25 Staff #11 kissed him/her on the lips and then attempted to kiss his/her private area. Resident #5 stated he/she told Staff #11 F*** No. The Resident then stated Staff #11 put the Resident in a wheelchair and took the Resident to the bathroom where Staff #11 took the Resident's hand and put it on Staff #11's penis on top of Staff #11's clothes. Resident #5 stated he/she has to go to court in September 2025 for the incident and Staff #11 is currently in jail and has a history of the same thing. The Resident stated he/she has been interviewed by the States Attorney over the phone. The Surveyor reviewed Maryland Judiciary Case Search on 8/18/25 which revealed Staff #11 was found guilty from a 5/31/19 case of 2nd degree assault and 4th degree sexual assault. Further review of Maryland Judiciary Case Search revealed on 3/18/25 Staff #11 was charged with abuse of vulnerable adult, 2nd degree rape and 4th degree sexual offense for an offense date of 1/25/25 and a hearing is scheduled for September 2025. During interview with Resident #5 on 8/19/25 at 7:28 AM, the Resident was asked if he/she could review the incident again with the Surveyor, the Resident stated no he/she can't because he/she had nightmares last night regarding the incident. The Surveyor asked the Resident if he/she is seeing a counselor, the Resident stated he/she did after the event, but that Counselor (Staff #23) has left and has not even met the new Counselor (Staff #27). The Resident states he/she is stressed about going to court, he/she doesn't want to mess up because he/she wants to make sure he (Staff #11) is not able to do this to someone else. The Resident stated after the incident he/she feels like he/she has become more withdrawn. During interview with the DON on 8/19/25 8:08 AM, the DON stated the Counselor (Staff #23) left in May 2025 and a new counselor (Staff #27) started in June 2025. The Surveyor asked for a list of residents receiving counseling services. Review of the list revealed Resident #5 wasn't on the list. The last documented visit by a Counselor was on 2/10/25. The Resident was seen by the Psychiatrist on 1/29/25, 2/22/25 and 5/19/25. Further review of Resident #5's medical record revealed the Resident had diagnoses to include anxiety and depression. After admission the Resident was seen by the Counselor (Staff #23) on 8/5/24 and 10/14/24. After the allegation of sexual abuse was made on 1/29/25 by Resident #5, the Resident was seen by the Counselor on 1/29/25, 2/3/25 and 2/10/25. Review of the Counselor's note on 1/29/25 revealed it stated: I was asked to see the patient to provide support as he/she had accused a male aide of sexually inappropriate behaviors. Patient reports feeling very anxious related to the situation. Mood testing reflects symptoms exacerbated by this situation as well as his/her general sadness about being in this setting. Review of the Counselor's note on 2/10/25 revealed it stated: I feel alright now, I just have to decide what I am going to do. He/she reports he/she is not anxious about the incident and feels safe. The Counselor documented will follow up with 1:1 therapeutic visits. During interview with the Psychiatrist on 8/19/25 at 9:02 AM, the Psychiatrist was asked why he changed the Resident's medications on 5/19/25 and he stated the Resident has a history of chronic anxiety and depression, he was aware of the Resident's allegation but can't say the medication change was related to the incident or the Resident's chronic anxiety and depression. The Psychiatrist stated he did tell the facility the Resident should not have male care givers. The psychiatrist was asked if he was aware the Resident has not been seen by a Counselor since 2/10/25, the Psychiatrist stated no that is a third party and not sure how that works but the Resident should be followed by a counselor regularly. Review of Resident #5's medical record on 8/19/25 revealed the Resident was seen by the Primary Care Physician on 3/7/25, 4/4/25, 5/27/25, 6/17/25 and 7/26/25 who documented under Assessment and Plan for Anxiety: We are continuing to provide the patient with emotional support. We will also have psych follow up with the patient. During interview with the Counselor (Staff #23) on 8/20/25 at 1:44 PM, Staff #23 stated he/she was not aware Staff #11 had a criminal background and was charged with a crime related to the allegation of sexual abuse on 1/25/25. Staff #23 also stated she was not aware Resident #5 was going to court in September 2025. Staff #23 stated Resident #5 would need more support now since going to court and she would update the Counselor (Staff #27) so he could follow up with the Resident immediately. Interview with Director of Nursing on 8/20/25 at 1:00 PM confirmed Resident #5 made an allegation of sexual abuse by Staff #11 who has a criminal record on 1/25/25, has not been seen by the Counselor since 2/10/25 and was not on the facility's list of residents who were receiving counseling services.

Based on medical record review, review of facility documentation and interview it was determined the facility failed to ensure a criminal background check was completed on an agency GNA (geriatric nursing assistant) which allowed a GNA (Staff #11) with a criminal background of assault and sexual assault to care for vulnerable residents. This was evident for 1 of 4 agency GNAs reviewed for criminal background checks during a complaint survey. Resident #5 alleged Staff #11 sexually abused him/her on 1/25/25. This resulted in psychosocial harm to Resident #5. The findings include:A review was conducted on Facility Reported Incident 302934 on 8/18/25 related to Resident #5's allegation of sexual abuse by Staff #11 on 1/25/25. Resident #5 alleged on 1/29/25, to Staff #12, that Staff #11 kissed the Resident on the lips and attempted to kiss the Resident's private area during care on 1/25/25.Review of Resident #5's medical record on 8/18/25 revealed the Resident was admitted to the facility in July 2024 with a diagnosis to include cerebral infarction (stroke). The facility staff conducted a MDS (Minimum Data Set) assessment on 8/6/25 and coded the Resident as dependent on facility staff for toileting. During interview with Resident #5 on 8/18/25 at 11:05 AM, the Resident was asked if he/she was okay telling the Surveyor what happened on 1/25/25, the Resident stated he/she was but began crying while giving his/her statement. The Resident stated on 1/25/25 Staff #11 kissed him/her on the lips and then attempted to kiss his/her private area. Resident #5 stated he/she told Staff #11 F*** No. The Resident then stated Staff #11 put the Resident in a wheelchair and took the Resident to the bathroom where Staff #11 took the Resident's hand and put it on Staff #11's penis on top of Staff #11's clothes. Resident #5 stated he/she has to go to court in September 2025 for the incident and Staff #11 is currently in jail and has a history of the same thing. The Resident stated he/she has been interviewed by the States Attorney over the phone. Review of Staff #11's employee file on 8/18/25 provided by the Director of Nursing revealed a criminal background check that was conducted 1/12/24 and it was incomplete. The criminal background check did not indicate if Staff #11 had a criminal background or not.During an interview with Human Resources (HR) on 8/18/25 at 1:41 PM, HR stated the agency provides the agency staff's criminal background checks. HR stated she reviews all criminal background checks the agency provides prior to the agency staff working at the facility. HR stated she missed that Staff #11's was incomplete.The Surveyor reviewed Maryland Judiciary Case Search on 8/18/25 which revealed Staff #11 was found guilty from a 5/31/19 case of 2nd degree assault and 4th degree sexual assault. Further review of Maryland Judiciary Case Search revealed on 3/18/25 Staff #11 was charged with abuse of vulnerable adult, 2nd degree rape and 4th degree sexual offense for an offense date of 1/25/25 and a hearing is scheduled for September 2025. During interview with Resident #5 on 8/19/25 at 7:28 AM, the Resident was asked if he/she could review the incident again with the Surveyor, the Resident stated no he/she can't because he/she had nightmares last night regarding the incident. The Surveyor asked the Resident if he/she is seeing a counselor, the Resident stated he/she did after the event, but that Counselor has left and has not even met the new counselor. The Resident states he/she is stressed about going to court, he/she doesn't want to mess up because he/she wants to make sure he (Staff #11) is not able to do this to someone else. The Resident stated after the incident he/she feels like he/she has become more withdrawn. During interview with HR on 8/19/25 at 7:45 AM, HR stated Staff #11 began working at the facility on 1/26/24. HR stated the facility stopped using agency staff on 7/6/25.Interview with the Director of Nursing (DON) on 8/19/25 at 8:37 AM confirmed the facility failed to have a complete background check on Staff #11 that included Staff #11's criminal record. The DON confirmed Resident #5 made an allegation of sexual abuse by Staff #11 on 1/25/25 and the Resident has no other allegations of sexual abuse by staff since admission in July 2024.

Based on review of complaint 302936, observation, interviews, review of resident council meeting minutes, attendance at the food committee meeting, and observations of the kitchen, it was determined that the facility failed to serve food that was attractive, palatable, matched what was on the tray ticket, timely, and at the proper temperature. This was evident for 19 (#34, #25, #18, #17, #19, #12, #13, #15, #16, #23, #10, #11, #35, #21, #31, #30, #32, #36, #5) of 19 residents interviewed or observed with the deficient practice having the potential to affect all residents. The findings include:On 8/18/25 at 10:14 AM a review of complaint 302936 was conducted and revealed concerns with meals. The complaint alleged that a resident for dinner received a scoop of mashed potatoes, string beans, and a peanut butter and jelly sandwich. The complaint alleged that the food service was contracted out and that they are not providing sufficient food. The complaint alleged that something needs to be done.On 8/18/25 at 11:30 AM observation was made of residents going into the dining room for lunch. Lunch was not served until 1:00 PM. Review of Resident #34's meal ticket documented that the resident was to have a turkey club sandwich and a peanut butter sandwich. The turkey club sandwich that was served was sparse. The tray ticket documented there was to be lettuce and tomato on the sandwich along with turkey. The club sandwich that was served consisted of 2 slices of white bread that was not toasted, 1 folded in half piece of turkey breast and 2 slices of rubbery bacon. There was no lettuce or tomato on the sandwich, no cheese, and no condiment on the sandwich. There was no peanut butter sandwich on the tray as stated by the tray ticket. The resident stated that the staff told them they were out of lettuce and tomatoes.Resident #25 and Resident #18 did not have lettuce or tomato on the sandwich. Resident #18 complained about the sandwich and that the facility served chicken too many times.Resident #17's family complained about the food's appearance and the meal being served late. Resident #19 was sitting at the same table, and his/her lunch was served on a napkin. They did not bring the resident a plate. Resident #19's tray ticket stated that he/she was to have the macaroni salad. There was no macaroni salad served to the resident.At that time the surveyor went into the kitchen to observe. There was chaos in the kitchen by the plating table. The Dietary Manager was attempting to plate the food and instruct the staff on the tray line what to do with the trays. The Dietary Manager stated that the cook called out and the other cook had quit and so she had to hire new people, therefore they were short a cook and there were new people on the tray line. There were piles of bread slice diagonally and no lettuce or tomatoes were observed. The surveyor walked out on the units and saw a pattern of the same appearance of club sandwich served to all residents that were to receive a sandwich.On 8/18/25 at 1:00 PM interview of LPN #10 revealed that lunch was to be served between 12:00 PM and 12:30 PM and it was late.On 8/19/25 at 7:10 AM a dietary staff member brought in decaffeinated coffee to the conference room. The dietary staff member stated, we don't have any regular coffee in the facility to give the residents this morning. When asked if the residents were aware that they would be served decaffeinated coffee, the response was, no. On 8/19/25 at 8:08 AM observation was made on the nursing units of the serving of breakfast. Resident #12's tray ticket was reviewed and revealed there was no coffee, no salt, pepper, or sugar packets. According to Resident #12, they sent 2% milk that the resident did not like.On 8/19/25 at 8:13 AM Resident #13 stated that they typically miss something that should be on the tray. Resident #14 did not have coffee on the tray per the tray ticket. On 8/19/25 at 8:15 AM Resident #15 stated they had taken the packets off the tray. Resident #15 stated, I never get coffee. I have to ask for it. Unless I ask for condiments I don't receive them with my food. Every single time I have to ask. I order food out daily because the food is horrible. It is embarrassing. No one will complain because they are afraid of retaliation.On 8/19/25 at 8:18 AM Resident #16 stated, I like to drink tea, but I don't because it tastes like coffee. The water is terrible. I only have tea at 10:00 AM. I never get sugar. I have to ask for it. Condiments are hard to get. They don't put condiments on the tray.On 8/19/25 at 8:20 AM Resident #23 complained, the toast is overdone, too crunchy.On 8/19/25 at 8:21 AM Resident #10 stated that he/she did not have coffee even though it was listed on the tray ticket. Resident #10 stated, I want coffee but never get it.On 8/19/25 at 8:23 AM Resident #11 stated, some days we have to wait to eat. Are we being punished? We complained and nothing changed. We have to ask for sugar packets and condiments. We are scared to say anything because the aides will get blamed. They don't take individual diets seriously. They only bring so much coffee. They run out of coffee.On 8/19/25 at 12:15 PM an interview was conducted with the Resident Council President, Resident #35. Resident #35 stated, every time we have a meeting the main complaint is the food doesn't get out on time. It is late as dinner does not come out until 7 PM. Lunch is late every day. Dinner you get there at 4:30 PM and sit until 7:00 PM. They don't pay attention to the diet, so much salt. The coffee is often cold. By the time they pour 6 cups and give them out they are cold. They don't get delivery from Sysco (food distributor) and then they don't have things. We had a prayer service because of the food.On 8/19/25 at 12:24 PM observation was made of the serving of lunch. The tray tickets were compared to what was on tray.Resident #18, Resident #21, Resident #31, Resident #16, and Resident #30 did not have margarine served with the roll.Resident #32 did not have a cookie, roll, or margarine as the tray ticket documented.Resident #36 stated that the chicken was rubbery and did not look good and Resident #5 was not happy with how the chicken looked.At that time the corporate Nursing Home Administrator, Staff #32 was in the dining room. He was informed about the number of food complaints and the appearance of the club sandwich and the other food on the trays.On 8/19/25 at 1:00 PM a review of the Resident Council Meeting Minutes per authorization from the Resident Council President revealed on 2/5/25 the concern of tray tickets not matching diet restrictions. Residents discussed the time their meals arrive. Suggestions were made about putting seasoning on the side like salt and pepper, etc.On 3/5/25 the residents mentioned wanting their food delivered on time. Residents mentioned wanting their meat cooked well done. On 8/20/25 at 10:30 AM the surveyor was invited to attend the food committee meeting by the Resident Council President. The dietary manager opened up the meeting with issues from last month that included that meals were late, the soup had no flavor, needed assorted dressings for salad, and the coffee and tea could be hotter.Some of the current concerns that were voiced by the residents were:Blueberries were put on the hot plate and by the time they get to the room they are mushy. They serve too much chicken, 4 to 5 times a week, which is too much.The food was not always served at the proper temperature if it was not served when it was brought to the unit. They stated this issue had been addressed 3 months in a row, so they were reminding them that it was still a problem.The residents stated that the scheduled time for meals was accepted if they were served on time. The residents stated 7:00 PM for dinner is too late. The residents stated that there were residents that have-to-have medications with food along with have to go out to appointments in the morning. The residents complained it was hard to get an alternative meal. They don't know what to do. They were told that they should notify a GNA and they should bring them the form. The Nursing Home Administrator (NHA) stated he was checking on the process.The residents stated that evening snacks were not coming on some units.The residents stated that there were no beverages between meals and that they never bring salad dressing with meals. It was stated the change would be that they are going to have condiments going down to the halls. The residents complained that they have to ask for them.The residents stated there was frustration of over a year to get things changed.After the meeting, the Resident Council President called the surveyor over and gave the surveyor a list of concerns from him/her and another resident. The surveyor asked why they did not bring the concerns up in the meeting, and the response was, because they never do anything about it. The following were the concerns that were written down: Frozen and raw biscuit, English muffins not toasted, bagel not toasted, French toast cold and pancakes hard and cold. Bacon and sausage cold and raw. Meals sit at nurse's station for 10 minutes waiting to be served. Meals are cold and are served 30 minutes late or later. Use paper plates due to dish washer not working. One or more times a month, meals are on paper plates. Bugs on tray holder due to not being taken out to wash, silverware not clean, plate and glasses not clean. Meals are consistently late. Dining room meals are at least one-half hour to 1 hour late coming out. Trays to the floor (rooms) are then much later also.On 8/20/25 at 11:30 AM the concerns related to food were discussed with the NHA, Corporate Staff and the Director of Nursing. They were also informed of the fear of retaliation if the residents spoke up about the food as verbalized by some residents.

Based on observation and interviews, it was determined the facility staff failed to provide maintenance services necessary to maintain resident wheelchairs. This was evident for 15 (#25, #26, #27, #14, #12, #28, #29, #30, #19, #20, #13, #16, #33, #34, #8) of 37 residents reviewed during a complaint survey. The findings include:The following maintenance concerns were observed during the initial rounds of the facility on 8/18/25 at 7:30 AM and throughout the survey until 8/21/25.Resident #25: There was no armrest on the left side of the wheelchair and the vinyl on the right side was cracked throughout.Resident #26: The vinyl on the left wheelchair armrest was torn approximately an inch from the top of the armrest exposing yellow foam. This could be seen from the hallway.Resident #27: There was no wheelchair armrest on the right or left side of the wheelchair. Resident #27 was noted with several bruises to the resident's arms.Resident #14: There was no armrest on the left side of the wheelchair.Resident #12: The vinyl was cracked along the edge of the left wheelchair armrest, and the yellow foam padding was exposed.Resident #28: The vinyl was cracked on the left wheelchair armrest.Resident #29: There was no padding on the left wheelchair armrest as the vinyl was pulled back and there was nothing underneath.Resident #30: There was no left or right wheelchair armrest on the wheelchair.Resident #19: The vinyl was cracked on the left and right wheelchair armrests.Resident #20: There was no wheelchair armrest on the right side of the wheelchair.Resident #13: The vinyl on the right wheelchair armrest was torn along the edges.Resident #16: The vinyl on the right and left wheelchair armrests was torn along both edges.Resident #33: There was a piece of vinyl approximately 1 inch that was missing from the left wheelchair armrest exposing the underneath foam padding.Resident #34: There was no left or right wheelchair armrest.Resident #8: The vinyl on the entire left wheelchair armrest was ripped and frayed.On 8/21/25 at 10:40 AM an interview was conducted with the Director of Maintenance, Staff #31. Staff #31 stated that most of the repair orders came through the electronic system, TELS. Staff #31 stated that all staff, including the geriatric nursing assistants (GNAs) had access to put work orders in when they saw that repairs were needed. Staff #31 stated that a lot of times staff would just tell him about the issue, and he would fix it when told about it. Staff #31 stated that they do maintenance on the wheelchairs once a month that includes armrests and brakes. Staff #31 stated it was his expectation that staff would notify him of the issues with the wheelchairs. At that time Staff #31 and the Director of Nursing were informed of the condition of the wheelchair armrests. Staff #31stated, we have extra wheelchairs, and they (staff) can swap out the wheelchairs and can put a notification in TELS.

Based on review of complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health (Resident #7, #8, #4, #6). This was evident for 4 of 9 complaint residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to properly perform, and document neuro checks after a fall for Resident #7. A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. Review of Resident #7’s medical record on 8/18/25 revealed the Resident was admitted to the facility in April 2025 for rehabilitation following a hospitalization with a diagnosis to include muscle weakness. Review of Resident #7’s medical record revealed a Change in Condition Assessment on 5/10/25 at 3:35 AM that stated “During rounds around 2 AM patient was found in the bathroom on the floor lying on his/her right side. Patient was assisted back to bed with the help of the nursing supervisor, nursing aide and another nurse on duty. Patient vitals were assessed blood pressure 135/76, temperature 97.2, oxygen saturation 98 %, respirations 18, heart rate 89. Neuro checks was assessed and range of motion was performed, patient was noted with weakness to the right hand and was unable to talk, patient was also noted with the mouth switch to the side. On call APN (Advanced Practice Nurse) was made aware and order given to transfer to ER. Further review of the Resident’s medical record revealed an APN note on 5/10/25 at 2:28 AM stating “Patient found on floor unresponsive. Patient seen he/she is not responding to his/her name or any directions. Transfer to Emergency Department”. The only neuro check documented after the fall for Resident #7 was on 5/10/25 at 3:24 AM with vitals signs from 5/10/25 at 3:24 AM. No other neuro checks documented. After the fall, Resident #7 was transferred to the emergency room on 5/10/25 at an unknown time and the Resident did not return to the facility. During interview with the Director of Nursing (DON) on 8/19/25 at 2:45 PM, the DON stated the expectation is neuro checks are to be done every 15 minutes for the first hour after a fall. The DON confirmed the neuro checks for Resident #7 are inaccurately documented since the Resident fell on 5/10/25 at approximately 2 AM and there is only one neuro check documented at 3:24 AM. 2a. The facility staff failed to properly perform, and document neuro checks after a fall for Resident #8. A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. Review of Resident #8’s medical record on 8/18/25 revealed the Resident was admitted to the facility in April 2023 with a diagnosis to include weakness. Further review of Resident #8’s medical record revealed a nurse’s note on 3/28/25 at 8:57 PM that stated: around 7 PM writer was passing medication and found resident sitting on the floor beside his/her wheelchair. Further review of Resident #8’s medical record revealed an APN note on 3/28/25 that stated the Resident was seen 3/28/25 at 7:02 PM for fall with injury and to transfer to Emergency Department. Review of Resident #8’s neuro checks after the fall on 3/28/25 revealed neuro checks were completed for 3/28/25 at 8:00 PM with vital signs from 3/29/25 at 6:00 AM. The next neuro checks are documented for 3/29/25 at 12:02 AM with vital signs from 3/28/25 at 9:00 PM. During interview with the Director of Nursing (DON) on 8/20/25 at 9:20 AM, the DON stated the expectation is neuro checks are to be done every 15 minutes for the first hour after a fall. The DON confirmed the neuro checks for Resident #8 are inaccurately documented since the Resident fell on 3/28/25 at approximately 7:00 PM and there is only one neuro check documented on 3/28/25 8:00 PM and the next is documented at 3/29/25 at 12:02 AM using vital signs from 3/28/25 at 9:00 PM. 2b. The facility staff failed to accurately assess Resident #8 during a change in condition. Review of Resident #8’s medical record revealed the Resident had a change in condition 8/7/25 at 1:29 PM. Review of the Change in Condition Assessment on 8/7/25 revealed the Resident was noted to be coughing and lungs sound noted congested. Further review of the Change in Condition revealed vital signs including oxygen saturation level from 8/7/25 at 3:08 AM, 10 hours earlier. Interview with the Director of Nursing on 8/20/25 at 9:20 AM confirmed the facility staff failed to get current vital signs to accurately assess Resident #8 when there was a change in condition on 8/7/25. 3) On 8/18/25 at 10:14 AM a review of Resident #4’s medical record revealed Resident #4 was admitted to the facility in August 2019 and was currently on Hospice care. Review of Resident #4’s August 2025 physician’s orders revealed the order, “float bilateral heels when in bed.” Review of Resident #4’s care plan, “has the potential for pressure ulcer development r/t immobility and incontinence of B&B (bowel and bladder)” and the care plan, “has potential for actual and impaired skin r/t immobility, incontinence, and pain” had the interventions, “float heels.” On 8/19/25 at 1:55 PM observation was made of Resident #4 lying in bed. With permission from the resident, the surveyor looked at the resident’s feet and the resident’s feet were not elevated off of the mattress. The heels were lying directly on the mattress. Review of the August 2025 Treatment Administration Record (TAR) had documented the nurse had signed off for that shift that Resident #4’s heels were elevated while in bed. On 8/20/25 at 8:55 AM observation was made of Resident #4 lying in bed. There was a pillow between the resident’s knees, however the heels were not elevated and were lying directly on the mattress. On 8/20/25 at 2:55 PM a second observation that day was made of Resident #4 lying in bed. The resident’s family was visiting, and they looked at the resident’s heels with the surveyor. The heels were lying directly on the mattress and were not elevated. The nurse had already signed off on 8/20/25 at 2:55 PM on the TAR that the heels were elevated. On 8/20/25 at 3:00 PM the Director of Nursing (DON) went into the resident’s room with the surveyor and observed the resident’s heels. The DON confirmed the heels were not elevated and at that time placed a pillow under the resident’s heels. The DON was informed that the nurse had signed off for 2 consecutive days that the resident’s heels were elevated when they were observed not elevated. 4) On 8/18/25 at 11:10 AM a review of complaint 302921 alleged unacceptable and negligent care provided to Resident #6 while under the care of the facility. Review of Resident #6’s medical record revealed Resident #6 was admitted to the facility in December 2024 from an acute care facility with diagnoses including but not limited to generalized weakness, peripheral artery disease, COPD, slurred speech, history of falls, and hypertension. Review of a 1/10/25 at 8:58 AM eMar – Medication Administration Note documented, “amlodipine Besylate tablet 10 mg. give 1 tablet by mouth one time a day for HTN (hypertension). Med not given due to low b/p (blood pressure). Review of the medical record failed to reveal what the low blood pressure was as it was not documented on the MAR (medication administration record) or the vital sign section of the medical record or in any nursing progress notes. Continued review of the medical record failed to produce documentation that a follow-up blood pressure was taken or that the physician/nurse practitioner (NP) was made aware that the blood pressure medication was held, what the blood pressure was, and if any interventions should be put in place. The next documentation related to Resident #6 was on 1/10/25 at 15:04 (3:04 PM) that documented a change in condition that stated, “resident observed by staff with increased confusion, lethargic, unable to swallow at this time, low b/p.” Review of the b/p on the change in condition documented it as 76/56. The resident was transferred to the emergency room. Review of the hospital emergency room triage notes documented, “altered mental status: BIBA (brought in by ambulance) from [name of facility] for AMS (altered mental status) starting at 1245. Decreased LOC and low BP 87/40. SpO2 (oxygen level) 87 on room air, rhonchi. Received 1L fluids from EMS.” On 8/20/25 at 12:17 PM an interview was conducted with geriatric nursing assistant (GNA) #18 who stated, “when I was getting [him/her] ready to go to the hospital, [he/she] did not look good.” GNA #18 stated Resident #6 ate very little that morning, maybe about 25 percent of the food which was unusual for the resident. GNA #18 stated she thought that the resident didn’t feel well. On 8/20/25 at 1:45 PM an interview was conducted with Nurse Practitioner #19 (NP). NP #19 stated that she did not see Resident #6 that morning and that she was not notified of the low blood pressure. There were no parameters as to when the nurse should have held the medication, so she would have expected to be notified. “I was in the building that morning and I was not notified. I could have seen the resident and started [him/her] on IV fluids or Midodrine. They informed me at lunch that the resident’s condition changed, but they did not notify me about the low blood pressure and holding the medication. Normally I would tell all the managers that if I am at the building to call me and let me know. They did not tell me until [he/she] was not arousable. I was concerned because [he/she] was a stable patient. I was concerned that [he/she] went down that quickly. I feel I could have stabilized [him/her] and [his/her] b/p. On 8/21/25 at 10:55 AM the concern was reviewed with the Director of Nursing (DON). The DON agreed that the NP should have been notified about the low blood pressure and holding the medication and there should have been more follow-up from the nurse.

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #4, #7 and #9). This was evident for 3 of 9 residents reviewed for complaints during a complaint survey. The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1.The facility staff documented completed assessments and medication administration of Resident #7 when the Resident was not in the facility. Review of Resident #7’s medical record on 8/18/25 revealed the Resident was admitted to the facility in April 2025 for rehabilitation following a hospitalization with a diagnosis to include muscle weakness. Review of Resident #7’s medical record revealed a Change in Condition Assessment on 5/10/25 at 3:35 AM that stated “During rounds around 2 AM patient was found in the bathroom on the floor lying on his/her right side. Patient was assisted back to bed with the help of the nursing supervisor, nursing aide and another nurse on duty. Patient vitals was assessed blood pressure 135/76, temperature 97.2, oxygen saturation 98 %, respirations 18, heart rate 89. Neuro checks was assessed and range of motion was performed, patient was noted with weakness to the right hand and was unable to talk, patient was also noted with the mouth switch to the side. On call APN (Advanced Practice Nurse) was made aware and order given to transfer to ER.” After the fall, Resident #7 was transferred to the emergency room on 5/10/25 at an unknown time and the Resident did not return to the facility. Further review of Resident #7’s medical record revealed on 5/11/25 the following assessments were completed by Staff #13 even though the Resident had been discharged from the facility: Change in Condition Follow up, Neurological Check List, Pain Assessment, and Nursing Skilled Charting. Review of Resident #7’s May 2025 Medication Administration Record revealed on 5/11/25 Staff #13 documented he administered the following medications on 5/11/25 to the Resident even though the Resident had been discharged from the facility: Albuterol Inhaler 12 AM and 4 AM, Levothyroxine 175 mcq at 6 AM, Calcium Carbonate 500 mg at 6 AM and Sevelamer Carbonate at 6 AM. Interview with the Director of Nursing on 8/19/25 at 2:45 PM confirmed Staff #13 inaccurately documented nursing assessments and administration of medications to Resident #7 on 5/11/25. 2.The facility staff documented medication and treatment administration for Resident #9 even though the Resident was not in the facility. Review of Resident #9’s medical record on 8/19/25 revealed the Resident was admitted to the facility in October 2024.Further review of Resident #9’s medical record revealed a nurse’s note on 2/11/25 at 3:06 PM that stated the Resident was transferred to the hospital. The Resident did not return to the facility. Review of Resident #9’s February 2025 Medication Administration Record revealed Staff #18 documented she administered Aspirin 81 mg, Clopidogrel Bisulfate 75 mg, Metoprolol 100 mg, Prednisone 5 mg, Cyclosporine 5 ml, Levetiracetam 5 ml, flushed the Resident’s tube feeding with 200 ml water on 2/12/25 when the Resident was not in the facility. Review of Resident #9’s February 2025 Treatment Administration Record revealed Staff #18 documented they cleansed the Resident’s gastric tube site, did a left buttock wound treatment, did a sacrum wound treatment, applied betadine to the Resident’s right great toe, applied skin prep to the Resident’s heels, elevated the Resident’s heels and provided catheter cleaning on 2/12/25 when the Resident was not in the facility. Interview with the Director of Nursing on 8/21/25 at 11:54 AM confirmed Staff #18 inaccurately documented administration of medications and treatments to Resident #9 on 2/12/25. 3) On 8/18/25 at 10:14 AM a review of Resident #4’s medical record revealed Resident #4 was admitted to the facility in August 2019 and was currently on Hospice care.Review of Resident #4’s August 2025 physician’s orders revealed the order, “float bilateral heels when in bed.” On 8/19/25 at 1:55 PM observation was made of Resident #4 lying in bed. With permission from the resident, the surveyor looked at the resident’s feet and the resident’s feet were not elevated off of the mattress. The heels were lying directly on the mattress. Review of the August 2025 Treatment Administration Record (TAR) had documented the nurse had signed off for that shift that Resident #4’s heels were elevated while in bed.On 8/20/25 at 8:55 AM observation was made of Resident #4 lying in bed. There was a pillow between the resident’s knees, however the heels were not elevated and were lying directly on the mattress.On 8/20/25 at 2:55 PM a second observation that day was made of Resident #4 lying in bed. The resident’s family was visiting, and they looked at the resident’s heels with the surveyor. The heels were lying directly on the mattress and were not elevated. The nurse had already signed off on 8/20/25 at 2:55 PM on the TAR that the heels were elevated.On 8/20/25 at 3:00 PM the Director of Nursing (DON) went into the resident’s room with the surveyor and observed the resident’s heels. The DON confirmed the heels were not elevated and at that time placed a pillow under the resident’s heels. The DON was informed that the nurse had signed off for 2 consecutive days that the resident’s heels were elevated when they were observed not elevated.

Based on review of complaint, medical record review, and interview, it was determined the facility violated the rights of a resident's representative (RP) by failing to follow the RP's wishes in where to send their loved one following their death in the facility. This was evident for 1 (#2) of 3 residents reviewed for death during a complaint survey.The findings include:On [DATE] at 10:00 AM a review of complaint 302938 was conducted. The complainant alleged that Resident #2 passed away in the evening on [DATE] and the nurse called the wrong place for Resident #2's body to be transferred. The complaint alleged that Resident #2 was to be transferred to the Anatomy Gifts Registry, however the facility called the State of Maryland Anatomy Board to pick up the resident.Review of Resident #2's medical record revealed on [DATE] Resident #2 signed that the healthcare agent's power to make decisions for the resident was effective immediately after the resident signed the form. Further review of the medical record revealed the resident had dementia and was receiving Hospice services.Review of Resident #2's medical record revealed a [DATE] Social Services (SS) note that documented SS spoke with Resident #2's daughters to inquire about end-of-life arrangements for the resident. The note documented that the resident's body was to be donated to Anatomy Gifts Registry.A [DATE] at 19:30 (7:30 PM) nursing note documented that Resident #2 was noted with no palpable pulse, no respirations and was pronounced deceased at 19:15. Hospice and the family along with the Nurse Practitioner were notified.A [DATE] at 2:48 AM nursing note documented, body released to Maryland State Anatomy Board at 0220 as noted in social worker progress note.Review of the miscellaneous section of Resident #2's medical record revealed a document dated [DATE] that stated, the donor is officially registered with our program. The note continued that after the passing occurred their office was to be called, and they would arrange transportation. The note was from the Anatomy Gift Board.Continue review of the miscellaneous section of Resident #2's medical record revealed a form dated [DATE], that was signed by Resident #2 that stated the resident was donating his/her body to the Maryland State Anatomy Board and in the event the resident died, the anatomy board was to be called immediately.On [DATE] at 3:10 PM the Director of Nursing (DON) was interviewed and stated the family wanted Resident #2's body to be donated to the Anatomy Gift Registry and prior to that the resident had already set up something with the state anatomy board. The DON stated that they called the gift registry first and they didn't come to pick the resident up and they deferred to the anatomy board.On [DATE] at 3:20 PM an interview was conducted with Staff #35, the RN supervisor who stated that she looks at the resident's face sheet as to who to call when the resident passes. The face sheet has demographic information.On [DATE] at 8:23 AM a call was placed to the Anatomy Gifts Registry. The staff member from the gift registry stated it was within the residents' rights to sign up for both boards. The staff member pulled up the information in her system and stated the facility never called the Anatomy Gift Registry, and they did not know the resident passed away until the RP called and was looking for the body. The staff at the Anatomy Gift Registry called and confirmed the body was sent to the Maryland State Anatomy Board. By the time the family called the anatomy board it was too late as the body was already injected with fluid. The staff member stated that the family was upset because the state board would have the body for 2 years and the gift registry would only have the body 4 to 6 weeks. The family wanted to [NAME] the ashes with the spouse.On [DATE] at 8:48 AM the Director of Social Work (DSW) was interviewed and stated, the family wishes were for the resident's body to be donated to the gift registry. The DSW stated that she was aware that the resident was registered with the state anatomy board and the family was aware too, but they wanted the resident to go to the gift registry. When asked who was responsible to put on the face sheet where the body was to go once the resident passed, the DSW stated, I guess I am.On [DATE] at 9:13 AM a second interview was conducted with the DON. Resident #2's face sheet was reviewed with her, and she confirmed the external facility (where the body was to go once deceased ) was blank. The DON stated, it is not a solid system as to who puts the information on the face sheet. It is evolving.On [DATE] at 9:14 AM Staff #29 was interviewed and stated, I called the anatomy board. I was told later it should have been the gift registry. Staff #29 stated the information was usually on the face sheet as who to call but she got the information out of the resident's chart. She stated, I do not know whose responsibility it is to put it on the face sheet. Staff #29 stated it was an honest mistake as she didn't know there were 2 different anatomy boards.On [DATE] at 9:15 AM an interview was conducted with the complainant who was also the RP. The complainant stated, they had all the paperwork in the file to go to anatomy gifts. The complainant stated that if Resident #2 went to the state anatomy board they could have the body for up to 2 years. If the Resident went to the gift registry it would be for 4 to 6 weeks, and they would be able to get the ashes back. The complainant stated that by the time she called the anatomy gifts it was too late because the anatomy board had already put fluid in Resident #2's body. The complainant stated, I called the anatomy board and they said it was too late. I asked them if they had already started using the body and they said yes. The whole thing was awful. You shouldn't have to deal with all of this when you already have to deal with a loss.

Based on complaint, medical record review, and staff interview, it was determined the facility staff failed to timely notify a resident's physician/nurse practitioner of a change in condition. This was evident for 1 (#6) of 9 residents reviewed for complaints during a complaint survey. The findings include: On 8/18/25 at 11:10 AM a review of complaint 302921 alleged unacceptable and negligent care provided to Resident #6 while under the care of the facility. Review of Resident #6's medical record revealed Resident #6 was admitted to the facility in December 2024 from an acute care facility with diagnoses including but not limited to generalized weakness, peripheral artery disease, COPD, slurred speech, history of falls, and hypertension. Review of a 1/10/25 at 8:58 AM eMar - Medication Administration Note documented, amlodipine Besylate tablet 10 mg. give 1 tablet by mouth one time a day for HTN (hypertension). Med not given due to low b/p (blood pressure). On 8/20/25 at 1:45 PM an interview was conducted with Nurse Practitioner #19 (NP). NP #19 stated that she did not see Resident #6 that morning and that she was not notified of the low blood pressure. There were no parameters as to when the nurse should have held the medication, so she would have expected to be notified. I was in the building that morning and I was not notified. I could have seen the resident and started [him/her] on IV fluids or Midodrine. They informed me at lunch that the resident's condition changed, but they did not notify me about the low blood pressure and holding the medication. Normally I would tell all the managers that if I am at the building call me and let me know. They did not tell me until [he/she] was not arousable. I was concerned because [he/she] was a stable patient. I was concerned that [he/she] went down that quickly. I feel I could have stabilized [him/her] and [his/her] b/p. On 8/21/25 at 10:55 AM the concern was reviewed with the Director of Nursing (DON). The DON agreed that the NP should have been notified about the low blood pressure and holding the medication.

Based on medical record review and interview, it was determined that the facility staff failed to meet professional standards of practice as evidenced by licensed nursing staff documenting assessments, administration of medications, and treatments were completed when the resident was not in the facility (Resident #7 and #9). This was evident for 2 of 9 residents reviewed during a complaint survey. The findings include: According to the American Nurses Association Standards for documentation emphasize that records should be clear, accurate and accessible is essential element of safe, quality, evidence-based nursing practice. Accurate entries must be factual and reflect the patient's status and care without errors.A violation of the American Nurses Association standards for documentation includes inaccuracies and falsification. 1.The facility staff documented completed assessments and medication administration of Resident #7 when the Resident was not in the facility. Review of Resident #7's medical record on 8/18/25 revealed the Resident was admitted to the facility in April 2025 for rehabilitation following a hospitalization with a diagnosis to include muscle weakness. Review of Resident #7's medical record revealed a Change in Condition Assessment on 5/10/25 at 3:35 AM that stated During rounds around 2 AM patient was found in the bathroom on the floor lying on his/her right side. Patient was assisted back to bed with the help of the nursing supervisor, nursing aide and another nurse on duty. Patient vitals was assessed blood pressure 135/76, temperature 97.2, oxygen saturation 98 %, respirations 18, heart rate 89. Neuro checks was assessed and range of motion was performed, patient was noted with weakness to the right hand and was unable to talk, patient was also noted with the mouth switch to the side. On call APN (Advanced Practice Nurse) was made aware and order given to transfer to ER. After the fall, Resident #7 was transferred to the emergency room on 5/10/25 at an unknown time and the Resident did not return to the facility. Further review of Resident #7's medical record revealed on 5/11/25 the following assessments were completed by Staff #13 even though the Resident had been discharged from the facility: Change in Condition Follow up, Neurological Check List, Pain Assessment, and Nursing Skilled Charting. Review of Resident #7's May 2025 Medication Administration Record revealed on 5/11/25 Staff #13 documented he administered the following medications on 5/11/25 to the Resident even though the Resident had been discharged from the facility: Albuterol Inhaler 12 AM and 4 AM, Levothyroxine 175 mcq at 6 AM, Calcium Carbonate 500 mg at 6 AM and Sevelamer Carbonate at 6 AM. Interview with the Director of Nursing on 8/19/25 at 2:45 PM confirmed Staff #13 inaccurately documented nursing assessments and administration of medications to Resident #7 on 5/11/25. 2.The facility staff documented medication and treatment administration for Resident #9 even though the Resident was not in the facility. Review of Resident #9's medical record on 8/19/25 revealed the Resident was admitted to the facility in October 2024.Further review of Resident #9's medical record revealed a nurse's note on 2/11/25 at 3:06 PM that stated the Resident was transferred to the hospital. The Resident did not return to the facility. Review of Resident #9's February 2025 Medication Administration Record revealed Staff #18 documented she administered Aspirin 81 mg, Clopidogrel Bisulfate 75 mg, Metoprolol 100 mg, Prednisone 5 mg, Cyclosporine 5 ml, Levetiracetam 5 ml, flushed the Resident's tube feeding with 200 ml water on 2/12/25 when the Resident was not in the facility. Review of Resident #9's February 2025 Treatment Administration Record revealed Staff #18 documented they cleansed the Resident's gastric tube site, did a left buttock wound treatment, did a sacrum wound treatment, applied betadine to the Resident's right great toe, applied skin prep to the Resident's heels, elevated the Resident's heels and provided catheter cleaning on 2/12/25 when the Resident was not in the facility. Interview with the Director of Nursing on 8/21/25 at 11:54 AM confirmed Staff #18 inaccurately documented administration of medications and treatments to Resident #9 on 2/12/25.

Based on record review and interview, it was determined the physician failed to intervene and ensure the end of life wishes for Resident (# 117) were honored. This was evident for 1 of 54 residents selected for review during the survey process. The findings include: An advance directive is a useful legal document for an adult of any age to plan for future health care needs. The advance directive is the legal document prepared after discussing, deciding and putting into writing your choices for treatment and care and appointing a health care decision maker for care in the event you are not able to make medical decisions for yourself. This type of planning can make a critical difference in your life, and the lives of the ones who care about you, either in emergency situations or when facing end-of-life care situations. You can name anyone you want to be your health care agent. Your agent will speak for you and make decisions based on what you would want done or your best interests. You decide how much power your agent will have to make health care decisions and can also decide when you want your agent to have this power-right away, or only after a doctor says that you are not able to decide for yourself. In the event, the resident does not have an advance directive, and no one is appointed a health care agent, a surrogate decision maker is appointed for the resident in accordance with the Health Care Decision Act. A surrogate decision maker are advocates for incompetent patients. A surrogate may consent to the withholding or withdrawal of life-sustaining procedures if the patient's attending physician and a consulting physician certify, to a reasonable degree of medical certainty, that the patient has a terminal or end-stage condition or is in a persistent vegetative state. The [NAME]land MOLST (Medical Orders for Life-Sustaining Treatment) order form makes the treatment wishes known to health care professionals about artificial ventilation, blood transfusion, transfer to hospital, medical workups, antibiotics, artificial administered fluids and nutrition and [MEDICAL TREATMENT]. A do not resuscitate or DNR is a legal order written either in the hospital or on a legal form to respect the wishes of a patient not to undergo CPR or advanced cardiac life support if their heart were to stop or they were to stop breathing. The DNR request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect their wishes. DNI (Do Not Intubate) the insertion of a tube into the lungs for breathing. Resident # 117 was admitted to the facility on [DATE]. Review of the medical record revealed the resident was admitted with a MOLST from [DATE] and indicated he/she was a DNR. A History and Physical was completed by MD # 1 on [DATE]. Per the doctor's notes MD # 1 reviewed the [DATE] MOLST and entered an order on [DATE] for the resident's code status to be DNR/DNI A2. MD # 1 also noted that the resident had been started on hospice care at the outside facility. Hospice care is a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs. Medical record review for Resident # 117, in collaboration with his/her spouse as surrogate, completed a MOLST on [DATE] at an outside facility. The MOLST at that time indicated the resident was a DNR/DNI A2, to reflect his/her end of life wishes. DNR/DNI 2- Do not intubate (a tube in the lungs to assist with breathing): comprehensive efforts may include limited ventilatory support with not intubation On [DATE] and [DATE] Resident # 117 was assessed by two physicians and was determined to be in End Stage Condition due to [MEDICAL CONDITION]. End Stage condition which is an advanced, progressive, irreversible condition caused by an injury, disease of illness that has resulted in server and permanent deterioration indicated by incompetency and complete physical dependency; and or which to a reasonable degree of medical certainly, treatment of [REDACTED]. [MEDICAL CONDITIONS] is a chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing. It's caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke. People with [MEDICAL CONDITION] are at increased risk of developing [MEDICAL CONDITIONS] and a variety of other conditions. On [DATE] and [DATE] Resident # 117 was assessed by two physicians and determined to be incapable of making informed medical decisions. Physicians' Certification of Incapacity to make an Informed Decision determined the resident was assessed and is incapable of making informed decisions about the provision, withholding, or withdrawing of medical treatment and that the resident in unable to understand the nature, extent, or probable consequences of the proposed treatment or the course of treatment and is unable to make a rational evaluation of the burdens, risks, and benefits of the treatment or course of treatment. On [DATE] the physician ordered Resident # 117 to be a DNR. The resident remained as a DNR. On [DATE] the facility conducted Care Plan Conference with the following note in the medical record: Resident MOLST reviewed with resident 's (spouse), resident's (spouse) reports that resident has expressed that he/she does not want CPR in the past. Social Work will follow up with (outside hospital) to see if they have a recent MOLST on file. Current MOLST on file is incorrect due to it not being filed out correctly. Continued record review revealed on [DATE], Social Worker # 1 indicated the present MOLST was not valid because the top portion of the MOLST had two indicators marked, although directions for that section instruct the writer to select all options that apply. The marked sections indicated the resident along with surrogate completed the MOLST, indicating the resident was to be a DNR. On [DATE] MD # 1 updated the MOLST form to change the resident's Code Status to Full Code. On [DATE] at 12:50 PM physician # 1 stated I was told by the Social Worker that they cannot be made DNR unless there is something in writing from them in the past or a POA. I think at that point we were not sure if Resident # 117 was going to be one of those people who would survive or not survive (CPR). We kept the resident Full Code because we did not have a clear cut MOLST and he/she was without a POA or Advanced Directive. I was told by Social Work that we must keep them Full Code unless we have something from the court or there is definite probability that he/she will not survive the CPR. I did not know that if a patient is made end stage that a surrogate could withhold life sustaining treatment. I'd never heard that before. The physician also stated at that time, she believed Resident # 117 could benefit from CPR and when and if the time came that she thought Resident (# 117) would not benefit from CPR, physician # 1 would proceed and make the resident medically ineffective. Medically ineffective treatment is defined as treatment that, as certified by the attending and a consulting physician to a reasonable degree of medical certainty, will neither prevent or reduce the deterioration of the health of an individual nor prevent the impending death of an individual. It is the expectation the physician be aware of and honor the end of life wishes of the resident. As noted, in the interview with the physician on [DATE] at 12:50 PM, the physician relied on the Social Worker for information and then stated that she felt Resident # 117 would benefit from CPR (although there are numerous documentations that he/she wanted to be a DNR) and when the physician felt CPR would not be beneficial, she would then proceed with obtaining DNR orders. Interview with the Director of Nursing on [DATE] at 2:00 PM confirmed the physician failed to ensure the end of life wishes for Resident # 117 were honored and failed to intervene so those wishes were attainable. Refer to 578

Based upon medical record review, staff and family interview it was determined the facility staff failed to honor a resident's (Resident #117) and resident's surrogate decision maker's right to forego cardiopulmonary resuscitation (CPR) in the event of the resident's death. This was demonstrated by the facility's failure to maintain a [NAME]land Medical Orders for Life Sustaining Treatment (MOLST) form that was consistent with the end of life wishes that were expressed by the resident's surrogate decision maker. This was evident for 1 of 54 residents selected for review during the survey process. The facility's failure to honor the resident's right to refuse CPR placed this resident and others at risk for potential adverse consequences. As a result, a condition of Immediate Jeopardy was declared by the Office of Healthcare Quality on (MONTH) 22, (YEAR) at 12:55 PM and the plan to remove the immediacy was accepted on (MONTH) 22, (YEAR) at 8:00 PM. The facility staff also failed to ensure Resident # 110 presented the correct Power of Attorney documentation to ensure the resident's decision maker was in compliance with the Health Care Decision Act. The finding includes: An advance directive is a written document, electronic document, or oral directive that indicates a patient's wishes about medical treatment and/or appoints a health care agent to make medical decisions. In the event, the resident does not have an advance directive, and no one is appointed a health care agent, a surrogate decision maker is appointed for the resident in accordance with the Health Care Decision Act. A surrogate decision maker are advocates for incompetent patients. A surrogate may consent to the withholding or withdrawal of life-sustaining procedures if the patient's attending physician and a consulting physician certify, to a reasonable degree of medical certainty, that the patient has a terminal or end-stage condition or is in a persistent vegetative state. [NAME]land MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's wishes about medical treatments. A do not resuscitate or DNR is a legal order written to respect the wishes of a patient not to undergo CPR or advanced cardiac life support if their heart were to stop or they were to stop breathing. Review of the medical record on [DATE] revealed that Resident # 117 was admitted from another long-term facility to the facility on [DATE]. The resident was admitted with a MOLST form dated [DATE] that indicated he/she did not want CPR. Review of the History and Physical from the hospital revealed Resident # 117 on [DATE] revealed Resident # 117 was a DNR. A History and Physical was completed by the physician (MD # 1) on [DATE]. Per the physician's notes MD # 1 reviewed the [DATE] MOLST and entered an order on [DATE] for the resident to be DNR/DNI A2. DNR/DNI A2- Do not intubate (a tube in the lungs to assist with breathing): comprehensive efforts may include limited ventilatory support with not intubation. MD # 1 also noted that the resident had been started on hospice care at the outside facility. Medical record review revealed an [DATE] MOLST form that was discussed in collaboration with the resident and his/her spouse as surrogate at an outside facility. The MOLST at that time indicated the resident was a DNR/DNI A2, to reflect his/her end of life wishes. DNR/DNI A2- Do not intubate (a tube in the lungs to assist with breathing): comprehensive efforts may include limited ventilatory support with not intubation Medical record review for Resident # 117, in collaboration with his/her spouse as surrogate, completed a MOLST on [DATE] at an outside facility. The MOLST at that time indicated the resident was a DNR/DNI A2, to reflect his/her end of life wishes. On [DATE] and [DATE] Resident # 117 was assessed by two physicians and was determined to be in End Stage Condition due to [MEDICAL CONDITIONS]. End Stage condition which is an advanced, progressive, irreversible condition caused by an injury, disease of illness that has resulted in severe and permanent deterioration indicated by incompetency and complete physical dependency; and for which to a reasonable degree of medical certainly, treatment of [REDACTED]. [MEDICAL CONDITION] is a chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs. On [DATE] and [DATE] Resident # 117 was assessed by two physicians and determined to be incapable of making informed medical decisions. On [DATE] the physician wrote an order for [REDACTED]. On [DATE] and [DATE] Resident # 117 was assessed by two physicians and determined to be incapable of making informed medical decisions. Physicians' Certification of Incapacity to make an Informed Decision determined the resident was assessed and is incapable of making informed decisions about the provision, withholding, or withdrawing of medical treatment and that the resident in unable to understand the nature, extent, or probable consequences of the proposed treatment or the course of treatment and is unable to make a rational evaluation of the burdens, risks, and benefits of the treatment or course of treatment. On [DATE] the physician wrote an order for [REDACTED]. On [DATE] the facility conducted a Care Plan Conference with the following note in the medical record: Resident MOLST reviewed with resident's (spouse), resident's (spouse) reports that resident has expressed that he/she does not want CPR in the past. Social Work will follow up with (outside hospital) to see if they have a recent MOLST on file. Current MOLST on file is incorrect due to it not being filed out correctly. Continued record review revealed on [DATE], Social Worker # 1 indicated the [DATE] MOLST was not valid because the certification section of the MOLST form indicated the resident and the resident's surrogate were involved in the discussion and informed consent indicating that the resident did not want CPR. Although surveyor review of the certification section instructions on the MOLST form demonstrated that multiple options and parties can be chosen as the basis for certification. Social Worker # 1 is no longer employed at the facility and not available for interview. Social Worker # 2 had been employed at the facility since the middle of January. She further revealed that she was not familiar with the case and failed to follow up with obtaining a new MOLST. On [DATE] MD # 1 updated the MOLST form to indicate that the resident was to receive CPR. The MOLST form indicated the orders were entered because of discussion with and the informed consent of the patient's surrogate; however, review of progress notes in the medical record failed to reflect any conversation between the physician and the resident's spouse. On [DATE] interview at 12:50 PM, physician # 1 stated I was told by the Social Worker that they cannot be made DNR unless there is something in writing from them in the past or a power of attorney (POA). I think at that point we were not sure if Resident # 117 was going to be one of those people who would survive or not survive (CPR). We kept the resident Full Code because we did not have a clear cut MOLST and he/she was without a POA or Advanced Directive. I was told by Social Work that we must keep them Full Code unless we have something from the court or there is definite probability that he/she will not survive the CPR. I did not know that if a patient is made end stage that a surrogate could withhold life sustaining treatment. I'd never heard that before. The physician also stated at that time, she believed Resident # 117 could benefit from CPR and when and if the time came that she thought Resident # 117 would not benefit from CPR, physician # 1 would proceed and certify that CPR and other medical interventions would be medically ineffective for the resident, that the resident would not benefit from CPR. Medically ineffective treatment is defined as treatment that, as certified by the attending and a consulting physician to a reasonable degree of medical certainty, will neither prevent or reduce the deterioration of the health of an individual nor prevent the impending death of an individual. Interview with the resident's spouse on [DATE] at 5:20 PM revealed he/she had no idea that Resident' # 117's medical orders had been changed to attempt CPR and was under the assumption it had remained a DNR-DNI. Resident # 117's spouse was adamant that the resident wished to be a DNR-DNI A2. The resident's spouse also denied any conversation with the physician with regards to the MOLST and needing the change the code status. The facility's failure to honor the resident's right to refuse CPR placed this resident and others at risk for potential adverse consequences. As a result, a condition of Immediate Jeopardy was declared by the Office of Healthcare Quality on (MONTH) 22, (YEAR) at 12:55 PM. The Plan of Correction submitted by the facility to remove the immediacy of the Immediate Jeopardy included some of the interventions: A. The surrogate for Resident # 117 was contacted and confirmed the resident's desire to be a DNR/DNI. MOLST form corrected at that time and new MOLST reflecting the DNR/DNI placed on the medical record. B. A house wide audit was conducted of all residents to review MOLSTs in honor of the honor/surrogates wishes. C. The Corporate nurse provided education to the current Social Worker as well as the Director of Nursing, Assistant Director of Nursing and Unit Manager on the specifics of honoring resident's wishes and ensuing the accuracy of each resident's MOLST upon admission. D. The nursing staff educated on topics that include but not limited to, ensuring each resident's wishes/code status is being honored. E. Physician # 1 was provided education on (MONTH) 23, (YEAR) by the Corporate nurse related to surrogates and their ability to make changes to the MOLST per the Health Care Decision Act. All other physicians will be educated by (MONTH) 24, (YEAR). F. The Corporate nurse notified the Medical Director and the Medical Director was educated by the Corporate nurse related to surrogates and the ability of the surrogate to update MOLST. The Immediate Jeopardy was abated on (MONTH) 22, (YEAR) at 8:00 PM. 2. The facility staff failed to ensure Resident # 110 presented the proper Power of Attorney. Medical record review for Resident # 110 revealed the resident was admitted to the facility [DATE]. Further record review revealed the facility staff completed a MOLST on [DATE]. At that time, the physician indicated the MOLST was completed in collaboration with the resident's health care agent as named in the resident's Advance Directive. Advance directives are legal documents that allows the resident or their appointed Health Care Agent to spell out their decisions about end-of-life care ahead of time. They give the resident a way to tell wishes to family, friends, and health care professionals and to avoid confusion later. A living will tell which treatments you want if you are dying or permanently unconscious. You can accept or refuse medical care. You might want to include instructions on: the use of [MEDICAL TREATMENT] and breathing machines, if you want to be resuscitated if your breathing or heartbeat stops, tube feeding and/or organ or tissue donation. Further record reviews no evidence of an Advance Directive. The medical record contained a: Durable General Power of Attorney and Nomination of Guardian of Property. A durable general power of attorney is a legal document which allowed the resident to appoint someone trusted to make financial, legal and other business decisions on the resident's behalf during any period in which the resident is incapacitated and unable to do so themselves. Durable general powers of attorney are virtually unlimited in scope. They allow your agent to act as your authorized legal representative in relation to the whole cross-section of your legal and financial affairs until that authorization is terminated. Although, some Durable General Power of Attorney may address medical care, review of this Durable General Power of Attorney failed to offer any provisions that addressed health care decisions for the resident. The Durable General Power of Attorney addressed topics such as: Collection of Debts; Acquisition, Management, and Disposition of Property; Borrowing and Lending; Deposits, Withdrawals and Payments; Life Insurance; Gifts; Funeral and Burial Arrangements and Tax Returns. Interview with the Director of Nursing on [DATE] at 2:00 PM confirmed the facility staff failed to ensure Resident # 110 possessed and provided to the facility the proper Advance Directive that named a Health Care Agent to decide medical decisions for him/her.

Based on medical record review and interview, on [DATE], physician #4 changed the code status of resident #187 with no documented rationale, no engagement of the decision-maker, and no documented reassessment of capacity for the resident. (The record revealed that the resident did not have capacity and defined that the decision maker for the resident was the resident's daughter). Staff were aware of the inconsistencies between the new order, the resident's certified capacity, and the decision-maker's known wishes, but did not notify the decision-maker of the change in code status and allowed the newly ordered code status to remain in the record for 15 days, and until surveyor intervention, without sufficient clarification of the resident's actual capacity and contrary to the decision-maker's known wishes. This directly violated the resident's and family's right to participate in care decisions and left the clinically compromised resident at significantly increased risk for serious harm to dignity should the resident have coded during the 15 days that elapsed prior to surveyor intervention. This was evident for 1 of 35 residents selected for review in the stage 2 survey sample. The findings include: Medical record review of resident # 187's record on [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A history and physical was completed by Physician #3 on [DATE] that read DNR Do Not Resuscitate: His/Her DNR status is DNR-A per my discussion today with both his/her family and his/her daughter. The patient is not competent to decide this issue. Medical record review revealed an order stating No CPR, Option A, Comprehensive Efforts to Prevent Arrest. Prior to arrest, administer all medications needed to stabilize the patient. If cardiac and/or [MEDICAL CONDITION] arrest occurs, do not attempt resuscitation (No CPR) Allow death to occur naturally. The medical record included 2 physician certifications of incapacity to make an informed decision completed by physician # 2 and physician # 3 in ,[DATE]. Review of the resident's last quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was coded in Section C-0500 to be scored a ,[DATE] on the BIMS scale. The MDS is a multidisciplinary tool that assesses all aspects of the resident. A component of the MDS is cognition which is assessed by the BIMS. The BIMS is a brief interview for mental status is a required screening tool used, in nursing homes to assess and document each resident ' s current cognition status. Once the facility staff assessed the resident on [DATE], it was revealed the resident had a score of 6 which indicated severe cognitive impairment. Review of the resident's mental health notes on [DATE] revealed the resident was seen by the psychiatrist and the progress note stated Memory is impaired/inconsistent. Patient with poor judgment/insight. Review of the medical record on [DATE] revealed a medical order form completed on [DATE] by Nurse Practitioner # 1 per discussion with resident's daughter, the resident was ordered to be No CPR, Option B, Palliative and Supportive Care. Record review revealed an order stating No CPR, Option B, Palliative and Supportive Care- Prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use [MEDICAL CONDITION] or [MEDICAL CONDITION]. If cardiac and/or [MEDICAL CONDITION] arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. Review of the medical record on [DATE] revealed a medical order form completed on [DATE] by Physician # 4 per discussion with resident; the resident ' s code status was changed to be Attempt CPR. There was no evidence in the physician notes and social services notes for [DATE] that indicated how the physician deemed the resident capable to make informed decisions and why the resident ' s code status was changed. There were also no subsequent notes or medical orders related to the resident's capacity or code status after [DATE]. Interview with the Unit Manager on [DATE] at 2:00 PM revealed the Unit Manager was told by resident #187's nurse on [DATE] that physician #4 changed the resident's code status to full code. The unit manager stated he/she asked physician #4 why it was changed because he/she felt the resident was not capable and physician #4 stated resident is capable. The unit manager then stated he/she and the social worker met with physician #4 to discuss their concerns and the physician stated again that the resident was capable to decide code status. The unit manager stated he/she took his/her concerns that the resident was not capable to the Director of Nursing. There was no evidence the Medical Director was notified of those concerns by the Director of Nursing, who is no longer employed by the facility. Interview with the interim Director of Nursing and Administrator on [DATE] at 11:45 AM confirmed the facility staff were aware of and expressed concerns about the order change given the resident's documented capacity status but still failed to ensure that the rationale for the change in the resident's code status was documented and that concerns regarding the change were fully addressed by the family and administration. Interview with the Administrator and interim Director of Nursing on [DATE] at 3:30 PM, confirmed the facility staff failed to notify the resident's daughter, who was also the responsible party, of the change in the resident's code status on [DATE]. Further review of the medical record further corroborated that fact that the facility staff failed to notify the resident's responsible party of the change in code status. In summary, for 15 days, the medical record was maintained with a medical order documenting his/her code status that was entered with no documented rationale, was entered without any documented reevaluation of resident capacity, and was not what the decision-maker wanted. This directly violated the resident and family rights to participate in care decisions and to dignity, and left the clinically compromised resident at significantly increased risk for serious harm should the resident have coded during the 15 days that elapsed prior to surveyor intervention. The above findings resulted in an Immediate Jeopardy for the potential harm of resident # 187 on [DATE] at 3:15 PM. The facility staff obtained 2 physician certifications of incapacity to make informed decisions on [DATE] at 4:00 PM. The facility staff conferred with the resident's daughter (responsible party) at that time and the resident's code status was changed to reflect the NO CPR, Option B, Palliative and Supportive Care. In addition, the facility reviewed all residents under the care of physician #4 and no other residents had their code status changed. The Corporate Nurse completed education with unit managers, social work and nursing about if a resident's code status is changed that is not consistent with previous assessments or without new assessments to declare competency the medical director is to be notified. Staff was also educated about if a resident's code status is changed the responsible party needs to be notified. The facility abated the Immediate Jeopardy on [DATE] at 4:35 PM. Refer to F 157, F 387