Every finding on record at Sterling Care Bethesda

Based on interviews and record reviews, it was determined that the facility failed to accommodate a dependent resident's needs by not ensuring the resident's motorized wheelchair was in working condition. This was evident for 1(Resident #156) of 1 resident reviewed for reasonable accommodation of needs during the annual survey.The findings include:Resident #156 whose diagnoses include Quadriplegia, Contracture of the lower legs and Contracture of the left elbow and wrist, was admitted to the facility in 2014.On 4/20/26 at 11:10 AM in an interview Resident #156 stated that their customized motorized wheelchair had been broken for several months, and the facility neither repaired nor provided a substitute motorized wheelchair. As a result, the resident was unable to move around in the facility.The surveyor interviewed the Director of Rehab on 4/21/26 at 2:10 PM. She stated that the wheelchair had been broken since last year. On 09/26/25, the vendor submitted invoices totaling $441.34 for the repairs. However, the facility did not pay the invoices, which resulted in the wheelchair remaining inoperable.On 4/22/26 at 8:30 AM, the Director of Nursing (DON) stated that the facility did not repair the wheelchair because the resident's condition had declined, and the resident was no longer capable of operating a motorized wheelchair.A review of the resident's clinical record on 4/22/26 at 1:00 PM revealed Resident #156 was assessed by Rehab on 4/13/26 and deemed on that date to be incapable of using a motorized wheelchair. The clinical records did not reveal that the resident was incapable of using a motorized wheelchair prior to 4/13/26.On 04/22/26 at 2:15 PM, the Director of Rehab stated that she also checked the clinical records and confirmed the surveyor's findings. Further, the surveyor noted Resident #156's motorized wheelchair had been broken since 09/26/25. The clinical record also lacked documentation to indicate that the facility provided a substitute motorized wheelchair during the inoperable period.On 04/27/26 at 7:26 AM, the surveyor notified the DON of the findings.

Based on record review and interviews, it was determined that the facility failed to ensure that the Responsible Party (RP) and/or legal guardian was notified of changes in a resident's condition. This was evident for 2 of 3 changes of conditions reviewed for (Resident #6). The findings include: On 4/20/26 at 11:04 AM, the surveyor reviewed Resident #6's medical record. The review revealed that Resident #6 was unable to make medical decisions and had a legal guardian established in 2004. Next the surveyor conducted a phone interview with Resident #6's guardian and established the guardian was involved in Resident #6's care planning. On 4/21/26 at 10:22 AM, the surveyor reviewed Resident #6's change of conditions dated 8/20/25, 11/6/25 and 12/15/25. Only on the 8/20/25 change of condition was Resident #6 guardian documented as notified. On 4/21/26 at 11:44 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON confirmed the legal guardian should have been called and updated on the change of conditions. At the time of exit no additional information was provided to explain why Resident #6's legal guardian was not notified of the change of condition on 11/6/25 and 12/15/25.

Based on observations and interviews, it was determined that the facility failed to ensure a safe, clean, comfortable and homelike environment. This was evident for 2 (Chesapeake and Gateway) out of 5 units, rooms (240 and 252) and 1 of 1 driveway observed during the annual survey. The findings include: Adequate lighting means levels of illumination suitable to tasks the resident chooses to perform or the facility staff must perform. 1) On 04/20/26 at 7:05 AM, a flickering light was observed in the hallway by the conference room leading to the Chesapeake unit. The hallway was frequented by residents who traveled to other units, the dining room and the activity room. There was another flickering light observed in a common room at the end of the hall on the unit. When the surveyor arrived at the unit, the floor was in poor condition. The floor was scattered with debris and trash, and a sticky residue was present in multiple areas. On 04/20/26 at 7:17 AM, the surveyor found the bathroom in room [ROOM NUMBER] unkempt. The trash can was filled, toilet tissue was on the floor, the toilet had a brown substance smeared around the toilet seat, and the bathroom sink had black and brown stains in it. On 04/20/26 at 7:59 AM, the surveyor observed an uncovered food item that was left by a window sill in room [ROOM NUMBER]. Additionally, there were yellow stains on the floor by bed B. On 04/20/26 at 8:04 AM, Resident #8 stated that the rooms are not kept clean. 2) On 04/20/26 at 8:10 AM, a flickering light was observed above the nursing station on the Gateway unit, which made the hallway appear dim. On 04/20/26 at 8:30 AM, the Administrator acknowledged the concerns. 3) On 04/20/26 at 9:41 AM, during initial rounds, Resident #65 stated they used their motorized wheelchair independently to leave the facility and enjoy community activities. However, several potholes scattered the facility's driveway, creating a danger for residents who used wheelchairs. They reported the issue to the Administrator and the Ombudsman over a month ago. Further, on 04/20/26 at 11:31 AM, the Ombudsman gave the surveyor a copy of an email dated 03/23/26 to the Administrator, outlining the dangers of the potholes. The surveyor observed several potholes on the long driveway leading to the main road on 04/20/26 and 04/21/26, noting residents struggling to navigate them. In an interview on 04/21/26 at 11:58 AM the Administrator confirmed the complaints and stated that he had obtained invoices from two contractors for the repairs of the potholes. However, he was advised to wait until after the winter, when it will be warmer, to proceed with the repairs. The surveyor observed the facility did not temporarily fill the potholes, thus failing to address the risks they presented. The residents continued to use the driveway despite the potential danger of the potholes' presence. The facility staff filled in the potholes on 04/21/26 after the surveyor intervened.

Based on record reviews and interviews, it was determined that the facility failed to document the reason for hospital transfer and discharge. This deficient practice was evident for two (Resident #195, Resident #197) residents reviewed for inappropriate discharge during the annual survey.The findings include:1. A review of Resident #195's medical records on 04/22/2026, revealed the resident was admitted to the facility in January 2026. Further review indicated the resident was transferred to the emergency department on 02/20/2026, however, there was no physician note documenting the reason for the transfer. Additional review showed the resident was discharged from the facility on 02/21/2026; however, the medical record lacked physician documentation summarizing the resident's clinical course and care provided. On 04/23/2026 at 9:42 AM, during an interview, the Director of Nursing (DON) #2 explained the facility's transfer and discharge process. She stated; for planned discharges, the physician documents a discharge summary note; however, for residents who are transferred to the hospital and do not return to the facility, the physician does not complete a discharge summary note.On 04/27/2026, the DON #2 followed up with the surveyor and repeated that the physician does not complete a transfer note or discharge note for residents transferred to the hospital for further evaluation and treatment. The DON #2 provided a physician discharge summary note dated 04/27/2026 for Resident #195. 2. On 04/20/2026 at approximately 8:00 AM, the surveyor observed that Resident #197 was not present in their room during the initial unit tour. Review of the medical record failed to include documentation of the resident's whereabouts. Upon inquiry, the Registered Nurse (RN) #25 stated that the resident had been transferred to the hospital earlier that day. A progress note entered at 10:19 AM documented the resident's transfer to the emergency department. A follow-up note at 12:30 PM indicated staff contacted the hospital and were informed the resident had been admitted due to a change in mental status.On 04/27/2026, a review of Resident #197's medical record revealed the resident was discharged from the facility on 04/20/2026; however, records lacked physician documentation supporting the basis for discharge. At the time of exit, the DON #2 was unable to provide a physician discharge summary.

Based on record reviews, and interviews, it was determined that the facility failed to provide the resident's responsible party (RP) with a written bed hold notice upon hospital transfer. This deficient practice was evident for one ( Resident #195) of two residents reviewed for discharge process during the annual survey.The findings include:A review of Resident #195's medical records on 04/22/2026, revealed the resident was transferred to the emergency department on 02/20/2026. Further review indicated the resident's RP was notified of the transfer and verbalized understanding of the bed hold policy; however, the records failed to show evidence that a written copy of the bed hold notice was provided.During an interview on 04/23/26 at 7:54 AM, the Assistant Director of Nursing (ADON) #19 stated that when a resident has a change in medical condition requiring a transfer to the hospital, the assigned nurse completes a bed hold notice and transfer notice at that time. If the RP is not present at the time of transfer, a copy is sent to them. The surveyor requested documentation to confirm that Resident #195's RP was provided with a written bed hold notice.On 04/23/2026, the facility failed to provide evidence that a written bed hold notice was provided to the resident's RP. At 9:42 AM, the surveyor informed the DON of this concern, and she acknowledged the information.

Based on record review, and interviews, it was determined that the facility failed to accurately document a Minimum Data Set (MDS) assessment in a Resident's medical record. This was found evident of 2 (Resident #23 & #6) of 51 residents reviewed in the survey. The findings include:1) During the surveyors review of Resident #23's MDS assessment on 04/23/2026 at 9:06 AM, no documentation was found of a fall with major injury on the MDS assessments for section J1900 Number of Falls Since Admission/Reentry. On 04/23/2026 at 9:44 AM, the MDS coordinator confirmed that the Fall with Major Injury was not documented in the MDS and a correction would be submitted right away. The Director of Nursing and the Administrator acknowledged the concern on 4/23/2026 at 9:45 AM, stating the correction would be made. 2) On 4/20/26 at 11:04 AM, the surveyor reviewed Resident #6's medical record. The review revealed that Resident #6 had an Minimum Data Set (MDS) assessment (section N Medications) completed on 1/27/26 and documented that Resident #6 had 7 days of insulin injection during the time frame listed. On 4/21/26 at 10:22 AM, the surveyor reviewed Resident #6's orders. The review revealed that Resident #6 did not have insulin ordered during this time period. On 4/21/26 at 12:24 PM, the surveyor conducted an interview with the Minimum Data Set Coordinator (MDS) #5. During the interview the MDS #5 confirmed that Resident #6 was not on insulin and the assessment dated [DATE] was coded incorrectly. He further stated that he would modify and correct the assessment.

Based on record reviews, and interviews, it was determined that facility staff failed to ensure a resident's responsible party (RP) received a written summary of the resident's baseline care plan. This deficient practice was evident for one resident (Resident #123 ) reviewed for baseline care plans during the annual survey.The findings include:A review of Resident #123's medical records on 04/21/2026 at 8:02 AM, revealed the resident was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy and cognitive communication deficient. The resident's family member was identified as the RP. Further review of the medical records failed to show evidence that the facility provided the RP with a written summary of the resident's baseline care plan.On 04/21/2026 at 10:04 AM, during an interview, the Social Worker (SW) #14, stated for residents who lack cognitive capacity, baseline care plans are conducted with the resident's RP and that these meetings are documented in residents' records. The surveyor informed the social worker that a review of the resident's electronic and paper medical records failed to show evidence that a baseline care plan was conducted with the RP and that the RP received a written summary of the baseline care plan. The surveyor requested documentation indicating the baseline care plan meeting was completed with the RP and that a written summary was provided. On 04/22/2026 at 9:55 AM, the SW#14 acknowledged that he failed to document a progress note indicating that a baseline care plan meeting was conducted with the resident's RP and failed to maintain evidence that a written summary of the baseline care plan was provided to the RP.

Based on interviews and record review, the facility failed to develop and implement a comprehensive care plan to meet the needs of a Resident. This was evident for 1 (Resident #6) out of 1 resident reviewed for hospice care during the survey.The findings include:On 4/21/26 at 9:48 AM, the surveyor reviewed Resident #6's medical record. The review revealed that Resident #6 had an order for hospice services dated 10/28/25.On further review the surveyor noted Resident #6 had a facility care plan that stated, Resident #6 received hospice services with an interventions to have hospice services provide visits to assist with care needs and additionally for the facility to work cooperatively with the hospice team to ensure Resident #6 's spiritual, emotional, intellectual, physical and social needs were met. On 4/21/26 at 12:50 PM, the surveyor requested all hospice service documentation. Next the surveyor reviewed a joint care plan from the hospice provider and the facility dated 10/24/25. The care plan outlined that both hospice providers and the facility would be responsible for symptom control, medication regimen, skin integrity, bladder/bowel function, personal hygiene, feeding, disease progression, psychosocial support, and spiritual care. However, it was identified that hospice would provide bathing 2 times per week and the facility 5 times. And for feeding, again, it was written that hospice would provide 2 times per week and the facility 5 times. On 2/22/26 at 10:19 AM, the surveyor conducted an interview with Social Service Assistant (SSA) #14. During the interview the SSA#14 stated that the previous Social Service Director may have been more familiar with Resident #6's hospice care but he could validate that he saw the hospice nurse in the facility once a week and was not sure about other supportive hospice staff.On 3/23/26 at 10:17 AM, the surveyor conducted a phone interview with a nurse from the hospice service, Staff #24. During the interview Staff #24 stated the Resident did not receive Geriatric Nursing Assistant (GNA) services of bathing and feeding. She stated that the care plan created was not accurate for the care Resident #6 received. At the time of exit, the facility was made aware that the cares written in the joint hospice and facility care plan were not implemented or corrected if not appropriate for Resident #6.

Based on clinical record review and interviews, it was determined that the facility failed to hold care plan meetings with the interdisciplinary team for a resident at the time of the quarterly and annual revision of their care plans, and also failed to invite the resident/responsible party to these meetings. This was evident for 1 (Resident #114) of 8 residents reviewed for care planning during the survey.The findings include:On 04/21/26 at 7:30 AM, the surveyor reviewed Resident #114's clinical record. The review revealed that Resident #114's quarterly MDS assessment was completed on 1/19/26 and an annual assessment was completed on 10/19/25. The clinical record contained no evidence that the interdisciplinary team held a care plan meeting with the resident/responsible party within 7 days or around the time of either the last quarterly or annual MDS assessment. Furthermore, there was no evidence to indicate that the facility staff invited the resident/responsible party to the meetings.On 04/23/2026 at 8:17 AM, Social Worker Designee #14 (SWD) reviewed Resident #114's clinical record during an interview and confirmed the surveyor's findings. SWD #14 stated that he would further review the clinical record and provide the surveyor with copies of the record.On 04/23/2026 at 1:10 PM, SWD #14 gave the surveyor copies of the documentation of the care plan meetings held for Resident #114 for the past 9 months. The documents confirmed the surveyor's findings.On 04/27/2026 at 7:32 AM the Director of Nursing was notified.

Based on interviews and record reviews, it was determined the facility failed to ensure a resident who required assistance with activities of daily living (ADLs) received scheduled showers. This deficient practice was evident for one resident (#133) reviewed for ADL care during the annual survey.The findings include: During an interview on 04/20/2026 at 12:44 PM, Resident #133 stated they are scheduled to receive showers on Tuesday s and Friday and reported they did not receive a scheduled shower on Friday 04/17/2026.On 04/21/2026, a review of the resident's electronic medical record revealed documentation indicating the resident did not receive a shower on 04/17/2026.During an interview at 12:58 PM, the Unit Manager (UM) #8 stated staff are required to document showers in the electronic medical record and in the shower book. Review of the shower book showed a shower on 04/14/2026, but no entry for 04/17/2026. The surveyor informed the UM #8 of the lack of documentation. The UM #8 stated the resident is capable of reporting shower receipt and acknowledged the resident likely did not receive a shower as scheduled.

Based on observation, medical record review, and interviews, it was determined that the facility staff failed to provide appropriate care measures to prevent complications from a hand contracture. This was evident for 1 (Resident #7) of 2 residents reviewed for mobility. The findings include:A contracture is an abnormal shortening of muscle, tendons, skin, or tissues, causing resistance to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand.On 4/20/26 at 10:07 AM, the surveyor conducted an interview with Resident #7. During the interview, Resident #7 stated that he/she had a splint for his/her left hand but only used it occasionally. Resident #7 further stated that he/she sometimes needed help putting the split on. The surveyor noted that the splint was not on the Resident.On 4/22/26 at 8:16 AM, the surveyor observed that the splint was not on Resident #7 and asked if anyone had offered to put the splint on. Resident #7 answered no.Next, the surveyor reviewed Resident #7's Occupational Therapy (OT) notes from 11/11/25. The note stated that Resident #7's long term goal of wearing the left resting hand splint was for 8 hours per day to decrease the risk of further contracture and discomfort. At the time of Occupational Therapy (OT) discharge, Resident #7 tolerated the splint for 4 hours.On further review, there was no order or Treatment Administration Record (TAR) for Resident #7's left hand splint.On 4/22/26 at 12:50 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview, the surveyor asked how the staff communicated the need for Resident #7's left-hand splint. She stated that she would look into the concern. On 4/22/26 at 2:03 PM, the surveyor interviewed the Functional Maintenance Assistant Staff #26 along with the DON. During the interview, Staff #26 stated that Resident #7 was on the functional maintenance daily schedule. She further stated that she utilizes the schedule to address the splinting needs at the facility. The surveyor reviewed the log provided. It was noted that the functional maintenance date for Resident #7 started on 11/11/25. Every weekend except 2 (1/10/26 & 2/22/26) was left blank in 5 months of logs. The surveyor reviewed the concern that Resident #7 was not offered the splint daily to prevent further contracture as recommended by OT.

Based on observation, interview, and record review, it was determined the facility failed to follow professional standards of practice when administering intermittent intravenous (IV) antibiotic infusions. This was found to be evident in 1 (#200) out of 1 resident observed for intravenous access care. The findings include:On 4/20/2026 at 9:15 AM, Resident #200 told the surveyor that his IV antibiotics were discontinued on Friday but his IV line was still in his left upper arm. Resident #200 showed the surveyor the IV line. The surveyor observed bloody fluid in the IV tube and on the bandage that was dated 4/10/2026.On 04/20/2026 at 9:22 AM, Registered Nurse #3 told the surveyor the IV should have been removed when the antibiotics were finished. When asked how often the dressing should be changed, she responded it should be changed every 7 days, verified that the current dressing had been on for 10 days, and stated she would remove the IV now.The Director of Nursing acknowledged the concern on 04/21/2026 at 11:58 AM.

Based on record review and interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards for accuracy. This was found evident in 4 (Resident #138, #6, #4, & #8) of 51 residents reviewed during the survey. The findings include:1) On 4/20/26 at 9:41 AM, the surveyor conducted an interview with Resident #138. During the interview Resident #138 stated that he/she was admitted to the hospital due to a Urinary Tract Infection (UTI). On 4/22/26 at 9:43 AM, the surveyor reviewed Resident #138's medical record. The review revealed that Resident #138 was hospitalized in August of 2025. The discharge summary from that hospital stay recommended that Resident #138 be followed up by Urology. On further review of the medical record, it was noted that there was no urology consultation notes present. On 4/22/26 at 9:45 AM, the surveyor requested the urology consultation notes for Resident #138. On 4/22/26 at 1:41 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated that the facility did not have the consultation notes but that she reached out to the provider to obtain them. The surveyor reviewed the concern that if the consultation recommends a change to the plan of care and the facility does not have the consultation results, there was a risk the resident wouldn't get the care that was recommended. On review of the urology consultation note dated 2/11/26 the urology consultant recommended obtaining a kidney and bladder ultrasound. The surveyor requested the results of the ultrasound as they were not in the medical record either. On 4/23/26 at 9:27 AM, the surveyor conducted a follow-up interview with the DON. During the interview the DON stated she was still waiting to obtain the ultrasound results. On 4/27/26 at 11:06 AM, the surveyor reviewed Resident #138's ultrasound date 3/2/26 with the DON. The DON confirmed that the ultrasound was not part of Resident #138's medical record. The surveyor reviewed the concern that resident #138's medical record was incomplete and inaccurate. The surveyor reviewed the progress note written on 3/25/26 in which Resident #138's provider referenced that Resident #138 was seen by the previous urology consult team, which was not accurate. It also stated that the sonogram (ultrasound) was completed on 3/2/26 and that no results were in the chart with the notations to follow up with the incorrect urology consult team to obtain the results and for ongoing catheter management. 2) On 4/21/26 at 9:48 AM, the surveyor reviewed Resident #6's medical record. The review revealed that Resident #6 had an order for hospice services dated 10/28/25. On 4/21/26 at 12:50 PM, the surveyor requested all hospice service documentation. Next the surveyor reviewed the hospice documentation and noted on 10/22/25 Resident # 6 was visited by the hospice admissions personnel and a hospice social worker. On 10/24/25 Resident #6 was visited by the hospice nurse. No other notes were documented until 1/6/[25] (sic) (a two-month gap) when a social worker documented a visit followed by a visit by a nurse 1/19/26. The visits noted in February were on 2/2/26 and 2/5/26 and were from the hospice social worker. In March a social worker documented a visit on 3/17/26. No nursing visits were documented in February or March. The next visit documented was by a social worker on 4/17/26 (a month from the last visit) and a nurse's visit after with an eligible April date. On 4/22/26 at 10:19 AM, the surveyor conducted an interview with Social Service Assistant (SSA) #14. During the interview the SSA#14 stated that the previous Social Service Director may have been more familiar with Resident #6's hospice care but could validate that he saw the hospice team in the facility once a week. On 4/23/26 at 10:17 AM, the surveyor conducted a phone interview with a nurse from the hospice service Staff #24. During the interview Staff #24 stated the Resident did not receive Geriatric Nursing Services (GNA) services of bathing and feeding but was seen by a hospice nurse weekly. On 4/27/26 at 11:32 AM, the surveyor reviewed the concerns with the Director of Nursing (DON) that the facility did not maintain all the documentation from the hospice services provided to Resident #6 as well as the concern that there was minimal documentation on the coordination of care from the facility and hospice for those visits. 3) On 04/22/26 at 7:45 AM, the Electronic Health Record (EHR) for Resident #4 and #8 revealed that Certified Medical Assistant, CMA I ( #10), marked No for the enhanced barrier precautions task for multiple dates in April 2026. This task was to ensure staff maintained enhanced barrier precautions by wearing a gown and gloves during care activities involving direct resident contact. On 04/22/26 at 8:00 AM, Staff #9 and CMA I #10 confirmed that the task should have been marked Yes. Staff #9 stated that he/she would provide education for CMA I #10. On 04/22/26 at 8:15 AM, the Director of Nursing acknowledged the concern.

Based on observation and interview, it was determined that the facility failed to handle soiled linen safely. This was found to be evident in 1 (Rosemary) out of 5 units observed during the annual survey. The findings include:On 04/22/2026 at 7:54 AM, the surveyor observed a linen cart in the soiled utility room with the lid off and unbagged linen overflowed onto the floor. Licensed Practical Nurse #17 stated the clothes should be bagged and thought the linen is supposed to be picked up once a week but would call for a pick up. On 04/27/2026 at 8:04 AM, the Director of Nursing acknowledged the concern regarding unbagged, soiled linen in the soiled utility room.

Based on observations and interviews, the facility failed to provide 3 (R24, R25, and R26) of the 3 sampled residents' meals at the designated normal mealtimes and in accordance with their needs, preferences, and requests. The facility census was 174.Record review of the facility's dietary policy, last revised 10/2022 and titled Frequency of Meals, documented that at least three daily meals will be provided, at regular times comparable to normal mealtimes in the community. The policy described the procedures as follows:Dietary Procedures:The Dining Service Director coordinates with the residents, Administrator, and/or Director of Nursing Services to establish the meal and snack times that are comparable with normal times in the community. A schedule of meal service times will be provided to the nursing staff and available in resident/patient care areas. The Dining Services Director will ensure that each meal is served within the designated time frame unless there is an emergency or a resident's request.During observations and interviews of the Chesapeake dining room area on 2/2/2026 from 12:15 PM to 1:00 PM, approximately three residents, R24, R25, and R26, were waiting for lunch to be served. Residents were in the dining room from 12:10 PM until 1:00 PM. A notice on the dining room entrance read Chesapeake Lunch Meal from 12:15 pm to 12:30 PM. Continued observations showed two other residents walked out of the dining room and did not return. R24 sat in their chairs and stated they had been waiting for at least 45 minutes. Some Residents started walking back to their rooms. One of the residents, R24, raised his/her voice and stated He/she was tired of waiting and that something must change.1. Record review of R24's Face sheet showed that R24 was admitted on [DATE]. R24's diagnoses included type two Diabetes Mellitus with Hyperglycemia, Pancreatitis, Disorder of the lung, and Acute Kidney failure. Disorder of Mineral Metabolism.Record review of R24's annual Minimum Data Set (MDS) dated 12/30/2025, revealed R24 had a Brief Interview of Mental Status (BIMS) score of 14. The BIMS score indicated that R24 was cognitively intact.During an interview on 2/2/2026 at 12:20 PM, R24 revealed he/she had been waiting for lunch for over forty minutes. R24 stated staff never brought food on time and explained it was frustrating, as lunch was his favorite meal.During an interview on 2/2/2026 at 12:50 PM, the Director of Nursing (DON) 2 stated that mealtimes should be observed as stipulated and that she would have staff start serving lunch on the Chesapeake ward immediately.During an interview on 2/2/2026 at 1:46 PM, the Dietary Manager (DM)9 stated that he ensured food was brought to the hallways in time and explained that it's up to the nursing staff to pass the food trays in a timely manner. Further observations on 2/3/2026 at 9:46 AM showed that ADON 33 brought a tray full of breakfast; she stated the kitchen staff were late, and he/she stated the kitchen staff may be experiencing logistics problems. Observations of the Potomac dining room showed breakfast was served from 8:45 AM to 9:00 AM.2. Record review of R25's Face sheet showed that R25 was admitted on [DATE]. R25's diagnoses included unspecified Displaced Fracture, Central Cord Syndrome, Sequela, and anxiety disorder.Record review of R25's annual Minimum Data Set (MDS) dated 12/7/2025, showed R25's BIMS score was 15, the BIMS score indicated R24 was cognitively intact.During an interview on 2/2/2026 at 12:45 PM, R25 revealed he/she had been waiting for lunch for over 45 minutes and explained that staff never served meals on time. R25 stated that weekends were worse and explained that by the time staff served Residents their meals, the food was usually cold. R25 concluded that staff always seemed to get upset and agitated when he/she asked for his/her meals to be warmed.3. Record review of R26's Face sheet showed that R25 was admitted on [DATE], with diagnoses that included Anxiety disorder, Depression, and Hypo-Osmolality (refers to a lower-than-normal concentration of solutes in the blood, often leading to hyponatremia, which is characterized by low sodium levels in the blood).Record review of R26s Quarterly MDS dated [DATE] showed R26s- BIMS was 15. The BIMS indicated that R26 was cognitively intact. During an interview on 2/4/2026 at 9:26 AM, R26 revealed he/she was the Resident Council President. R26 stated that for the last six months, staff have been serving meals late. R26 explained that staff rarely served meals to Residents on time. R26 further stated that, at times, staff served Residents cold food. According to R26, when Residents attempted to get their food, reheated staff would display a negative or disrespectful demeanor.During an interview on 2/4/2026 at 10:12 AM, Dietary Aide (DA) 32 revealed that, most of the time, Resident meals were not brought to the floor on time due to staff shortages.During an interview on 2/4/2026 at 2:05 PM, Dietary District Manager (DDM) 31 said food has been running late due to staffing shortages and explained that the facility was working to ensure the dietary department had the right staffing levels.During an interview on 2/5/2026 at 9:30 PM, Facility Administrator 1 revealed that the dietary department was not directly administered by the facility and concluded that his understanding was that the dietary department was taking measures to hire additional staff.Observations showed that there were sufficient nursing and non-nursing staff to assist dietary staff when needed.

Based on observations, records reviews and staff interviews, the facility failed to provide a functional, sanitary and comfortable environment for 5(R#3, R#20, R#21, R#22 and R#23) of 5 sampled residents when a toilet had rust and black mold around the seal of toilet along with leakage with water. The facility census was 174.Findings include:Record review of facility policy Resident/Patient Room Cleaning dated 2/2025, revealed Healthcare Services Group, Inc (HCSG) is committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry best practices. Restrooms will be regularly cleaned and disinfected with a particular focus on disinfecting high-touch surfaces such as light switches, the wall near the toilet, trash cans, grab bars, the sink, and the toilet (including the seat and handle).Record review of facility policy Safe and Homelike Environment dated 1/2026, revealed in accordance with resident rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal items to the extent possible. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.Record review of R#3: Face sheet documented the admission date as 7/13/22. Medical diagnosis included Type II diabetes, dysphagia, hyperlipidemia, depression, hypertension, and gastroesophageal reflux disease (GERD).Record review of R#3 quarterly Minimum Data Set (MDS) dated [DATE]. Section C score of 13/15, indicating cognitive intactness for the interview. Set up for eating, supervision, toileting, oral hygiene, and partial assistance with showering. Section H: Frequent incontinence for bowel and bladder.Record review of care plan dated 7/21/25 of R#3, indicated history of falls related to sliding off the bed. Intervention has a call light in reach and wears nonskid socks. R#3 is dependent on staff for emotional, intellectual, physical, and social needs. Intervention 1:1 bedside/in-room visits.Record review of R#20: Face sheet documented the admission date as 4/26/25. Medical diagnosis included Type II diabetes, dysphagia, hyperlipidemia, dementia, hypertension, gastroesophageal reflux disease (GERD), and chronic kidney disease stage III.Record review of R#20 quarterly Minimum Data Set (MDS) dated [DATE]. Section C scored 12/15, indicating moderately cognitive intactness during the interview. Section GG wheelchair mobility device used. The resident Depended on staff on with eating, toileting, oral hygiene, showering, and dressing. Section H: Frequent incontinence for bowel and bladder.Record review of the care plan dated 11/18/25 for R#20 indicates a fall related to poor balance, poor safety awareness, and unsteady gait. Intervention indicated that resident require staff assistance with toileting and transfers.Record review of R#21: Face sheet documented the admission date as 10/1/25. Medical diagnosis included Type II diabetes, hypertension, and chronic kidney disease stage III.Record review of R#21 quarterly Minimum Data Set (MDS) dated [DATE]. Section C score of 13/15, indicating cognitive intactness for the interview. Section GG wheelchair mobility device used. Supervision with all eating. Depending on staff on toileting, oral hygiene, showering, and dressing. Section H Always incontinent for bowel.Record review of the care plan dated 10/1/25 for R#21 reveals an Activities of Daily Living (ADL) self-care performance deficit due to failure to thrive, hemiplegia, and right-hemisphere post-cerebral infarction affecting the right dominant hemisphere. Resident#21 require assistance with dressing, eating, and toileting, and two staff members assist with transfers.Record review of R#22: Face sheet documented the admission date as 10/9/23. Medical diagnosis included Type II diabetes, aphasia, hyperlipidemia, anxiety, hypertension, schizophrenia, bipolar disorder, and chronic obstructive pulmonary disease (COPD).Record review of R#22 quarterly Minimum Data Set (MDS) dated [DATE]. Section C score of 15/15, indicating cognitive intactness for the interview. Section GG: No mobility device used. Set up with all the eating. Supervision with toileting, oral hygiene, and dressing. Section H: Frequent incontinence for bowel and bladder.Record review of care plan dated 11/30/25 of R#22 ADL self-care performance related to confusion. Intervention: residents require assistance from one staff member for bathing/showering, bed mobility, dressing, personal hygiene, toilet use, and transfer.Record review of R#23: Face sheet documented the admission date as 7/29/24. Medical diagnosis included hyperlipidemia, dementia, hypertension, gastroesophageal reflux disease (GERD), major depressive disorder, and dysphagia.Record review of R#23 quarterly Minimum Data Set (MDS) dated [DATE]. Section C score is blank, indicating no interview occurred. Section GG walker mobility device used. Set up eating and oral hygiene. Supervision with toileting and substantial assistance with showering and dressing. Section H: Frequent incontinence for bowel and bladder.Record review of care plan dated 1/20/26 of R#23 has poor ADL self-care related to dementia. The resident requires staff assistance with personal hygiene, dressing, bed mobility, toileting, and transfers.On 2/2/26 at 11:55 AM, observed toilet commode of R#3, R#20, R#21, and R#22 with a rust stain approximately five inches wide and seven inches long. The toilet commode seal was black, like mildew, and was missing caulk/sealant. The toilet commode was unsteady and shifted side to side. Water was leaking from the toilet because of missing caulk.On 2/3/26 at 10:25 AM, observed that the toilet commode in R#23 had caulking/sealant missing and water leaking in front of the toilet.Interview on 2/2/26 at 11:55 AM, with R#3 stated R#3 stated the toilet rust stain has been there for a while. R#3 stated that housekeeping supposedly cleans daily, and stains would still be present. R#3 stated that the toilet moves and water leaks due to the white tape (caulking) with mildew missing. R#3 stated that no one should live like this with a dirty bathroom. R#3 stated that they go to the bathroom alone.Interview on 2/3/26 at 10:25 AM with R#23 stated that the toilet leaks, and they could slip and fall. R#23 did not know how long the toilet had had a leakage problem. R#23 stated that they go to the bathroom alone. R#23 is ambulatory and uses a walker. Interview on 2/5/26 at 9:00 AM with Housekeeper (HK)21, who has worked at the facility for 16 years stated that they Clean and check the soap, the paper towel, the nightstand table, the bathroom, clean the toilet bowl, sweep and mop the back of the toilet. HK21 said that if they see any problems in the room, they report the concern to the supervisor. HK21stated that the supervisor will put in the work order. HK21 stated they did not see the rust stain behind the toilet. HK21 stated they are assigned to clean the whole unit daily. HK21 stated they couldn't get the stain up and just left it. HK21 stated they will let the supervisor know when this happens again.Interview on 2/5/26 at 9:11 AM, Environmental Service Manager (EVSM) 20 stated that their expectation is to have the facility cleaned each day. EVSM20 stated that a complete daily check is conducted in about 10% of rooms. EVSM20 stated they had not seen any toilets with rust stains but did find some with caulk/sealant issues. EVSM20 stated they reported to maintenance right away. EVSM20 stated they will conduct training for staff in bathroom cleanliness and what to look for.Interview on 2/5/26 at 9:46 AM: Maintenance Supervisor (MS) 19 stated that the administrator does rounds every afternoon. MS19 has been at the facility for two months. MS19 stated they noticed the rust stain about two or three weeks ago. MS19 stated that he notified housekeeping to do another cleaning and also asked the tech to complete the caulking. MS19 stated they did not complete any follow-up to ensure it was done. MS19 stated they are working to get things up to task and just haven't had a chance to follow up.Interview on 2/5/26 at 9:57 AM. Administrator stated MS19, since the starting position has completed many tasks. Administrators' expectations are to meet the minimum standard for a homelike environment and what it takes to maintain it. The Administrator stated they will bring this issue to QAPI, and every Monday, the team reviews facility issues or concerns. The compliance program includes the leadership team, nursing, maintenance, EVSM 20, and the unit manager, and they will conduct a total inspection of one unit to ensure equipment and living environment is safe.

Based on observations, staff and resident interviews, and record reviews, it was determined that the facility failed to treat a resident with dignity by not: 1) ensuring that Resident #429's foley drainage bag was covered; and 2) promoting an environment that enhances the quality of life. This was evident for 2 (Resident #429 and Resident #97) of 17 residents reviewed during the survey. The findings include: A foley drainage bag, or urinary drainage bag, is a medical device used to collect urine from a catheterized resident. The drainage bag is usually worn on the leg or attached to a bed. 1) During observation rounds on 2/27/25 at 10:12 am, Resident #429 was noted to have a foley catheter bag attached to his/her bed. The foley drainage bag was uncovered and contained yellow liquid. The bag was attached to the side of the bed facing the door. Resident #429's door was open, and the foley drainage bag was visible from the hallway. On 2/27/24 at 1:58 pm, the surveyor interviewed the Nursing Home Administrator (NHA). He stated that the expectation was that all foley catheters have a foley bag cover in place and he would make sure the resident had a privacy bag. 51899 2) During observation rounds on 2/27/2025 at 9:00 am, the surveyor observed Resident #97 lying in bed on his/her left side. The residents' bed was located closest to the entrance to the room. During this observation the resident was noted with a dressing to his/her lower extremities dated 2/26/25 (7-3pm shift). The dressings were exposed to the hallway where it could be seen by other residents and visitors. On 2/27/25 at 9:15 AM, this observation was relayed to RN Staff #6. He stated that someone would take care of it. 03/3/25 at 10:25 AM, during observation rounds Resident #97 was noted again lying in bed on his/her left side with his/her lower extremity dressing exposed to the hallway. The GNA (Geriatric Nursing Assistant) staff # 27 was made aware and she put a sheet over the resident lower extremities. During an interview with the resident on 3/3/25 at 10:40am, s/he stated that the staff never cover his/her feet and everyone can see them. 3/3/25 at 12:30 PM, this surveyor spoke with the Director of Nursing (DON) and the Administrator regarding the resident concern, they both stated the issue would be resolved. 3/4/25 at 10am during a follow up interview with the DON she stated that she spoke with the resident and all GNA's and the Charge Nurse on the unit have been in-serviced regarding the resident concern and she is certain the issue will be resolved.

Based on resident record reviews and staff interviews, it was determined that the facility failed to provide residents and/or the resident's representative with an opportunity to formulate an advanced directive. This was evident for 3 (Residents #169, #85, and #173) out of 9 residents reviewed during the survey. The findings include: On 02/28/25 at 09:46 AM, Resident #169's medical record was reviewed. The medical record review revealed that Resident #169 did not have an advanced directive in place. On 02/28/25 at 10:18 AM, Resident #85's medical record was reviewed. The medical record review revealed that Resident #85 did not have an advanced directive in place. On 02/28/25 at 10:33 AM, Resident #173's medical record was reviewed. The medical record review revealed that Resident #173 did not have an advanced directive in place. On 02/28/25 at 10:38 AM, the Director of Social Services #3 was interviewed. During the interview, the Director of Social Services #3 stated that Residents #169, #85, and #173 do not have an advanced directive in place. Also, the Director of Social Services #3 stated that there were no progress notes indicating that Residents #169, #85, and #173 and/or the resident's representative were presented with an opportunity to complete an advance directive.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean, safe, homelike environment. This was evident for 8 (Residents #51, #85, #94, #154, #90, #478, #109, and #117) out of 183 residents observed during the survey. The findings include: 1. On 2/27/25 at 8:34 AM, the surveyor observed Resident #90's room. Marring and scraping were noted on the wall behind the resident's bed. There was a large spackled area of approximately 50% of the wall that required painting. 2. On 2/27/25 at 8:37 AM, the surveyor observed Resident #117's room. There was scraping noted on the wall behind the resident's bed. 3. On 2/27/25 at 12:07 PM, the surveyor observed that Resident #478's room was dirty. The floor was dirty with food and trash around the bedside. The resident was unable to reach the trash can because it was too far away. 4. On 2/27/25 at 12:45 PM, during an interview with Resident #109, the resident reported that the faucet in the bathroom was loose and not secure. The resident further stated that the baseboard was separated from the wall. At this time the resident showed the surveyors the faucet in the bathroom that was not secured and the baseboard that was separated from the wall. On 2/27/25 at 2:00 PM, an interview was conducted with the Administrator and DON, and they were made aware of all concerns. Another observation was made on 3/4/25 at 12:30 PM, and the repairs were made to Resident #90, Resident #109, and Resident #117's rooms. Resident #478's room was clean and free of trash. The resident's trash can was also placed closer to the bedside for the resident. On 3/6/25 at 1:45 PM, an interview was conducted with the Administrator, and it was he stated that the facility is in the process of creating a maintenance prevention program. He stated that the program will help to address all areas of concern and ensure that all of the residents' rooms will be inspected, and repairs will be completed. 51788 5. On 2/27/25 at 7:48 AM, during observation rounds, Resident #51's bathroom had a dried rust colored substance around the base of the toilet, a dried brown substance on the toilet seat, and a broken toilet paper holder. 6. On 2/27/25 at 7:56 AM, during observation rounds, Resident #94 had two cups of a clear yellow substance, which had a strong ammonia, urine-like odor, located by the resident's bed on the bedroom floor. On 2/27/25 at 7:57 AM, Unit Manager #22 was interviewed. During the interview, Unit Manager #22 was told about the two cups of a clear yellow substance in resident #94's room. After surveyor intervention, Unit Manager #22 immediately discarded the two cups of a clear yellow substance in resident #94's room. 7. On 2/27/25 at 8:04 AM, during observation rounds, Resident #85's bathroom had a dried rust colored substance around the base of the toilet, and ceiling tiles with a dried, light brown substance on them. 8. On 2/27/25 at 8:17 AM, during observation rounds, Resident #154's bathroom had a dried rust colored substance around the base of the toilet and a dried brown substance on the wall near the toilet paper holder. On 02/27/25 at 12:52 PM, the Nursing Home Administrator #1 and the Director of Nursing #2 were interviewed. During the interview, the Nursing Home Administrator #1 and the Director of Nursing #2 were made aware of the observations that were made in Residents' #51, #94, #85 and #154 rooms.

Based on resident family interviews and facility record reviews, it was determined that the facility failed to prevent residents from being physically abused. This was evident for 1 (Residents #85) out of 20 residents reviewed during the survey. The findings include: On 02/27/25 at 08:04 AM, the surveyor attempted to interview Resident #85. During the interview, the resident was non-verbal when asked questions regarding his/her stay at the facility and questions about the Facility Reported Intake MD00208175. On 02/27/25 at 10:27 AM, the resident ' s medical record was reviewed. The resident medical record review revealed that Resident #85 had a medical diagnosis of Alzheimer ' s Disease and schizophrenia. On 02/28/25 at 10:53 AM, Resident #85's daughter was interviewed. During the interview, Resident #85's daughter stated that Resident #85 was physically assaulted by a facility staff member in July 2024. On 03/03/25 at 09:36 AM, the facility's records were reviewed. The facility record review revealed that the facility's initial Facility Reported Incident and the follow-up Facility Reported Incident (MD00208175) indicated that, on 07/26/24 at 02:45 PM, the Business Office Director #23 and the Admission Director #26 observed Geriatric Nursing Assistant #27 hit Resident #85 with small, gray bag. The facility's follow-up Facility Reported Incident indicated that after the facility conducted an investigation, the facility substantiated the allegations of abuse against Resident #85 and on 7/26/24 Resident #85 was assessed and showed no signs of pain and trauma, skin discoloration or psychological trauma. Also, facility's follow-up Facility Reported Incident indicated that Nursing Assistant #27 was suspended pending the investigation and was terminated after the investigation, and on 8/5/24, the facility submitted a complaint to the Maryland Board of Nursing regarding Geriatric Nursing Assistant #27.

Based on surveyor observations, review of clinical records and interviews with residents and the facility staff, it was determined that the facility staff failed to provide adequate supervision of unsafe smokers in the facility. On 05-09-10 at 12 PM, an immediate jeopardy (IJ) to resident's safety in the smoking area was determined. On 05-09-10 at 9 PM, the facility provided an IJ Removal Plan to Office of Health Care Quality (OHCQ). The IJ was abated on 05-10-19 at 3 PM following the facility's implementation of corrective actions to ensure all unsafe smokers receive direct supervision in the smoking area. Findings include: On 05-08-19, review of the facility reported incident (FRI) revealed that there was a resident to resident altercation between resident #4 and #5 on 04-28-19 at 1:45 PM in the smoking area. On 05-08-19 at 11:30 AM, review of the facility's investigation report and interview of staff #1 revealed that staff #1 observed staff #2 opened the door for all smokers on 04-28-19 at 1 PM. Then, staff #2 walked back to the Potomac unit nursing station, which was 122 feet away from the smoking area. When staff #1 walked towards the break room, staff #1 heard a commotion coming from the smoking area. Therefore, staff #1 walked towards the door and watched through a 11 in x 11 in window on the door. Staff #1 observed resident #4 and #5 fighting. Therefore, staff #1 called other staff, who were in the break room, to help. Staff #1 told the surveyor that no staff was present in the smoking area on 04-28-19 at 1:45 PM when he/she entered the smoking area to separate resident #4 and #5. On 05-08-19, review of resident #5's safe smoking evaluation, dated 01-30-19, revealed that resident #5 was assessed as an unsafe smoker who required direct supervision while smoking. Further review of resident #4's safe smoking evaluation, dated 02-27-19, revealed that resident #4 was assessed as a safe smoker. No direct supervision was needed while smoking. On 05-08-19, review of the facility's smoker list, which was provided by the Director of Nursing (DON), revealed that resident #5 and #6, were listed as unsafe smokers. Based on the facility's investigation report, resident #6 was present in the smoking area on 04-28-19 at 1:45 PM. Resident #6 was assessed and determined to be an unsafe smoker based on the safe smoking evaluation, which was completed on 03-13-19. In addition, resident #6 required direct supervision and needed to wear a protective apron while smoking. There were two unsafe smokers, resident #5 and #6, in the smoking area on 04-28-19 between 1 PM and 1:45 PM without direct supervision by the facility staff. On 05-08-19 at 12 noon, interview of the DON revealed that staff #3 was assigned to provide monitoring in the smoking area between 7 AM and 6:30 PM on the weekends and holidays. The DON provided a smoking schedule to the surveyor, which was listed as followed: 7- 7:45 AM 9-9:45 AM 11 - 11:45 AM 1-1:45 PM 2:30- 3:15 PM 5:45- 6:30 PM 7:30-8:15 PM 9:15-10 PM In addition, the DON clarified that the evening weekend supervisor was the assigned personnel to provide monitoring in the smoking area between 7 PM and 10 PM on the weekends and holidays. On 05-09-19, review of the facility's investigation report and telephone interview of staff #2 on 05-09-19 at 9:30 AM revealed that he/she was not aware of any smoker list and did not know where the protective aprons were located for unsafe smokers. On 04-28-19 at 1 PM, staff #3 told staff #2 to open the door to the smoking area for the smokers. After the door was opened for the smokers, staff #2 walked back to Potomac unit nursing station, which was 122 feet away from the smoking area. On 05-09-19, review of the facility's investigation report and telephone interview of staff #3 on 05-09-19 at 10 AM revealed that he/she was the designated personnel to monitor the smoking area on the weekends, but he/she was not aware of any smoker list and did not know where the protective aprons were located for unsafe smokers. On 04-28-19 at 1 PM, staff #3 was busy in the dining room with other residents. Therefore, staff #3 asked staff #2 to open the door to the smoking area for smokers. While staff #3 was still in the dining room, other staff reported to him/her that resident #4 and #5 had a fight in the smoking area. On 05-09-19 at 10 AM, the surveyor toured Potomac nursing unit with the DON. There were 6 protective aprons found in a transparent plastic bag. Interview of the staff development nurse, on 05-08-19 at 3 PM, revealed that there was no documented evidence that staff #2 and #3 received in-services related to safe smoking/tobacco use when offered by the staff development nurse on 03-19-19. The staff development nurse further stated that he/she expected the personnel, who was assigned to monitor the smoking area, to stay in the smoking area for direct supervision. See F 867. After the resident to resident altercation on 04-28-19, there was no evidence that the facility staff addressed the issue of no direct supervision in the smoking area for unsafe smokers. In addition, there was no evidence that staff #3 received in-services/training to understand his/her role while in the smoking area. There was also no evidence that staff #3 knew how to identify unsafe smokers and what level assistance each unsafe smoker might need. On 05-07-19 at 11 AM, interview of resident #1 revealed that he/she had an altercation in the smoking area on 04-30-19 with resident #4. As a result of the altercation, resident #1 had a laceration on the lower lip. On 05-07-19, review of resident #1's safe smoking evaluation, which was completed on 03-11-19, revealed that resident #1 was assessed as a safe smoker, but required direct supervision while smoking. On 05-08-19, review of a facility reported incident revealed that resident #1 and resident #4 had a fight in the smoking area on 04-30-19 at 1:40 PM. Further review revealed that staff #4 was the designated personnel to monitor smoking on 04-30-19 between 1 PM and 1:45 PM. Staff #4 reported that he/she watched resident #1 and resident #4 fighting in the smoking area through the video camera. The video monitor was located at Potomac unit nursing station, which was 122 feet away from the smoking area. Therefore, staff #4 asked other staff to help. Interview of staff #4 on 05-08-19 at 10 AM revealed that staff #4 could not tolerate cigarette smoke due to health issues. Therefore, the Human Resource (HR) department allowed staff #4 to open the door for smokers at 1 PM Mondays through Fridays, walk back to Potomac unit nursing station ( 122 feet away from the smoking area) and monitor through the video camera. Staff #4 told the surveyor that there was only one unsafe smoker in the facility, but he/she did not know his/her name. On 05-08-19 at 11:15 AM, surveyor observation and interview with staff #6 revealed that staff #6 was a substitute smoking monitor because the designated personnel, who was assigned to monitor smoking between 11 AM and 11:45 AM, was out of the building. Therefore, staff #6 stood behind the door and watched through the 11 in x 11 in window on the door to monitor the smoking. Staff #6 told the surveyor that there were 3 unsafe smokers in the facility, who were required to wear protective aprons. However, staff #6 did not know their names or what level of assistance they needed while smoking. On 05-08-19 at 11:20 AM, the surveyor took a tour of the smoking area and stood in a few blind spots, where staff #6 could not see the surveyor through the 11 in x 11 in window on the door. On 05-08-19 at 11:30 AM, the surveyor watched the video camera, which was located at Potomac unit nursing station, and was only able to see the legs of the residents that were smoking on the video camera. Facility staff, who were assigned to monitor smoking, had different methods to monitor smokers and different information about unsafe smokers who required supervision and who needed to wear protective aprons. On 05-08-19 at 12 PM, interview of the DON revealed that the assigned personnel could watch smokers through the 11 in x 11 in window on the door or monitor smokers from the video camera, which was located at Potomac unit nursing station (122 feet away from the smoking area). After 04-30-19, there was no evidence that the facility addressed the issue related to direct supervision in the smoking area for unsafe smokers. There was no evidence that staff #4 and #6 knew who the unsafe smokers were and what level of assistance the unsafe smokers needed. In addition, there were different expectations from the staff development nurse and the DON related to the definition of direct supervision and the role and function of the designated personnel to monitor smoking in the smoking area. On 05-08-19 at 3 PM, interview with the DON and the staff development nurse revealed that there was a total of 23 smokers in the facility based on the safe smoking evaluations. Of the 23 smokers, there were 12 unsafe smokers, who required direct supervision. Of the 12 unsafe smokers who required direct supervision, 4 needed to wear a protective apron while smoking. On 05-08-19 at 6 PM, staff # 7 was observed standing in the smoking area and monitoring the smokers. Interview with staff #7 revealed that he/she did not know who the unsafe smokers were or what level of supervision those unsafe smokers needed. On 05-08-19 at 9:15 PM, interview with the administrator and DON revealed no additional information. On 05-09-19 at 12 PM, an immediate jeopardy to resident's safety at the smoking area was determined. On 05-09-10 at 9 PM, the facility provided an IJ Removal Plan to the surveyor. Based on the plan of corrective action, the facility educated all the facility staff, who were designated to monitor smoking for weekdays, weekends and holidays about the responsibilities of the assignment. The smoking monitor duties include reporting to and picking up a smoking book from the nursing home administrator or management designee. The smoking book contains a list of all the smokers with the level of supervision and assistance required, and a tool to document the monitoring of the smokers. The nursing home administrator or management designee are to visit the smoking area periodically to ensure that the monitor is physically present in the smoking area. The smoking monitor is to document any issues during the smoking sessions and report the issues to the nursing home administrator or management designee. The nursing home administrator will bring any issues to the monthly Quality Assurance Performance Improvement (QAPI) meeting. On 05-10-19 at 3 PM, the IJ was abated following the facility's implementation of corrective actions to ensure that all unsafe smokers receive direct supervision at the smoking area.

Based on surveyor review of clinical and administrative records, facility policy, and staff interviews, it was determined that the facility failed to maintain a safe environment for a resident with a history of known memory impairment and exit seeking behavior. This deficient practice placed the resident at risk for elopement and serious harm. When the resident did elope, the facility failed to notify the administrator as soon as the resident was noted as missing, and failed to notify law enforcement authorities and the resident's responsible party when an initial facility search was not successful. The related concerns were evident 1(#1) out of 5 residents reviewed. Review of the facility's plan of correction implemented after the facility gained knowledge of the incident resulted in the deficiency being cited as past non-compliance. This finding was identified during the investigation of facility reported incident #MD 076 and is valid. The findings included the following: On 11-20-17, surveyor review of the clinical record revealed that resident #1 was assessed as a high risk for elopement with exit seeking behaviors. Resident #1 resided on a locked unit (Rosemary Unit). Further review of the clinical record revealed physician's orders for resident #1 to wear a wander guard bracelet and for staff to check for placement and functioning every shift. A wander guard system is an alarm system used to alert staff if a resident who has been determined at risk for elopement is trying to leave the facility or wander into a restricted area. A transmitter is placed on the at risk resident (typically on a band around the wrist or the ankle) and when the resident approaches a door way or area equipped with a wander guard sensor an alarm sounds to notify staff. Surveyor review of the facility investigation of resident #1's elopement revealed that, on 09-27-17 at 5:45 PM, resident #1 was noted to be missing from the facility. Surveyor review of the statement written by the Geriatric Nursing Assistant, (GNA) who was assigned to care for resident #1 on 09-27-17 on the 3-11 shift, revealed that the GNA noted the resident to be missing at dinner time on 09-27-17 and reported that to the charge nurse for Rosemary Unit. Surveyor review of the statement written by the charge nurse for Rosemary Unit revealed that, on 09-27-17 at 5:45 PM, resident #1 was not in the dining room and the charge nurse asked the GNA to check the resident's room. The resident was not in the room so the charge nurse and GNA started a search and informed the evening supervisor. Surveyor review of the statement written by the evening supervisor revealed that the supervisor was informed by the charge nurse that resident #1 was missing at approximately 7 PM. At that time, the supervisor started a room to room search of the entire facility and surrounding perimeter. The 3-11 supervisor noted that the 3-11 staff on Rosemary Unit denied seeing the resident at any time on the 3-11 shift. The 3-11 supervisor notified the Director of Nursing at 7:15 PM and the police at 7:30 PM of the missing resident. The resident's family member was notified at 7:38 PM. Surveyor review of the facility policy for a missing resident instructs staff to notify the administrator and director of nursing and make a thorough search of the building and premises. If the resident is not located, staff should notify the resident's legal representative, the physician, the police and state agency if required. However, the Administrator, Director Of Nursing (DON), police, and legal representative were not notified until at least one and a half hours after the resident was noted to be missing. Surveyor review of the facility's credible allegation of compliance revealed that, on 09-27-17 at 11 PM, it was identified that Rosemary unit's stairwell door would occasionally, not completely shut when staff entered the stairwell. In addition, the fire exit doors in the stairwell did not have an internal locking or alarm system. The pass code to enter the stairwell was changed at that time. Surveyor review of the statement written by the Rosemary Unit manager revealed that on 09-28-17 at 6:55 AM the exit door to the stairwell between rooms 119 and 121 was not closing properly. The unit manager notified maintenance and nursing staff monitored the stairwell door untilthe door was repaired at 9 AM. Surveyor review of resident #1's statement written by the Rosemary Unit manager on 09-28-17 revealed resident #1 stated that the resident pushed on the door located between the rooms 19 and 121, then he/she pushed on the other exit door, walked through the woods. On 11-20-17 at 12:10 PM upon surveyor interview, the Rosemary unit manager stated that resident #1 got out of the stairwell door down here. Maybe someone went through and it didn't close all the way or he/she followed someone through the door. He/she is always trying to go somewhere. On 11-20-17 at 12:15 PM, upon surveyor interview, the Administrator stated that the conclusion of the facility investigation was that resident #1 went through the stairwell door then the exit door. The door to the stairwell required staff to put in a code to open the door. The fire exit door to the outside located in the stairwell did not require a code to open and was not alarmed. Neither door was equipped with a wander guard system. The administrator and the maintenance director, who checked all the doors on the night of 09-27-17, did not notice anything unusual about the door from the stairwell or exit door and the conclusion was that the the resident may have followed a staff member through the stairwell door then went through the outside door that was not coded or alarmed. Immediate actions taken by the facility on 09-27-17 included: The facility identified issue: Resident #1 eloped from the facility due to the facility's failure to maintain a safe and secure environment, placing the resident at risk for serious harm or death. Resident #1 was noted to be missing at on 09-27-17 at 5:45 PM, a search of the building and surrounding premises was initiated and the administrator, the DON, the police, and resident's legal representative were notified. The resident was found on 09-28-17 at 11:15 AM with some scratches on the face and both arms. The primary care physician conducted an evaluation of the resident upon return to the facility. All residents with exit seeking behavior were identified to be affected by the incident. Unit managers, Assistant Director of Nursing, and Director of Nursing conducted a 100% audit on all residents with exit seeking behaviors, as well as those with wander guards. The audit included review/update of elopement risk assessments, care plans, and wander guard check orders. The date of compliance was 09-28-17. The Administrator and the Maintenance Director re-evaluated the wander guard system, as well as security for all interior and exterior doors and windows through out the facility. It was identified at the time of this review that camera #6 on the Rosemary Unit's south corridor was not functional. This camera was immediately replaced. The Maintenance Director/designee will conduct weekly checks on the functions of all cameras in the building and will place all results in the TELs Reporting System. (TELs is a computer program used to track maintenance records). The need was also identified for an additional 14 cameras to enhance the monitoring of the current system. These additional cameras were immediately ordered. It was also identified that the Rosemary Unit's stairwell door would occasionally not completely shut when the staff entered that stairwell. This problem was corrected by the maintenance staff on 09-27-17. On 09-28-17 at 6:55 AM, it was identified that the Rosemary Unit's stairwell door was not closing properly. The door was monitored by nursing staff until maintenance staff corrected the problem on 09-28-17 at 9:00 AM. The stairwells on Gateway, Chesapeake, and the Rosemary Units were changed to emergency egress only on 09-28-17, as the fire exits in those stairwells had no internal locking or alarm system. Local alarms were ordered on 09-28-17 and installed on 10-02-17. The Director of Nursing, Staff Development Coordinator, and Nurse Mangers conducted education with all staff on 09-28-17 on monitoring, reporting and safety measures regarding an incident of elopement, as well as ensuring that doors with keypad/ badge swipe entries are closed after entry. The education also included ensuring staff awareness of the necessity to provide security and supervision for residents. Beginning 09-29-17, no staff was permitted to work until the training was complete. This education was included in the facility's new hire orientation and newly hired licensed nursing staff were not permitted to assume their floor responsibilities until they completed this education. In the weekly at risk meetings, The Interdisciplinary Team (including the Director of Nursing, Administrator, Social Services Director, Activities Director, Therapy Program Manager, Dietary Manager, Unit Coordinator or Unit Manager, Resident Care Management Director, and Medical Director) reviewed those residents who exhibited exit seeking behaviors to ensure that the appropriate measures for their safety had been put in place. The facility's compliance date was 10-02-17.

Based on surveyor observation, review of the clinical records, and interview of the facility staff, it was determined that the facility staff failed to follow physician orders [REDACTED]. This finding was evident in 9 of 42 residents selected in the stage 2 review (#65, #125,#203, #78, #45, #149, #97, #138, #196). The findings include: 1. Based on surveyor review of the closed clinical record for resident #65 and interview of staff, it was determined that the facility staff failed to identify increased risk for alteration in skin integrity related to a brace applied to the left lower extremity, failed to care plan the increased risk, failed to clarify with the physician or develop a schedule for removing the brace and assessing the skin, failed to obtain an order to discontinue or hold the brace upon discovery of open areas for three days, and failed to care plan a treatment for [REDACTED]. This finding was identified during the investigation of complaint MD 334 and is valid. This was determined to be an actual harm deficiency. On 03-08-16 at 8:00 AM, a review of the closed clinical record revealed: Resident #65 was initially admitted with medical conditions which left the resident at high risk for skin concerns based on poor circulation in his/her legs. Review of Care Plans revealed no care plan addressing the resident's potential for skin breakdown. There was no evidence that the facility staff developed an interdisciplinary plan of care related to the brace that was ordered on 12-23-15 to prevent skin breakdown in this resident with decreased circulation to the extremities. In December, resident #65 was seen by an orthopedic doctor. On 12-23-15, she/ he recommended a brace (immobilizing device) to the left leg every shift. The constricting component of the brace had the potential to cause greater decreased circulation. This physician's orders [REDACTED]. There was no order noted in the medical record to reflect when to put on, take off or reposition the leg brace to prevent skin breakdown; and no order to inspect the skin for evidence of breakdown beneath the brace in this resident with inadequate blood flow in her legs. Facility staff failed to initiate a care plan identifying the resident's increased risk for development of skin breakdown related to the continuous use of a brace and decreased circulation. The orthopedist instructed staff to call with any questions, but there was no evidence this was done and no care plan was developed to address the increased risk of using the brace in a resident with other substantial risk factors. The development of this care plan would guide the interdisciplinary approach to address the brace and risks posed by its use for resident #65's left leg. Review of the facility documentation revealed that, on 02-08-16, staff identified two new skin wounds on the left lateral leg and left ankle attributed to the brace indicating wound due to pressure, resident has order for left lower extremity brace. No revisions were made in care planning to address the new skin concern when it was first identified. For 40 days, from 12/24/15 through 2/8/16 with no care plan developed, no evidence was found of any documented assessments of resident #65's left leg, despite the resident's known risk factors and the ongoing use of the brace. Review of the skin weekly pressure ulcer sheets for resident #65 revealed a facility acquired wound documented as unstageable and measuring 7 centimeters in length and 5 centimeters in width on the ankle, and another unstageable wound measuring 14 centimeters in length and 6 centimeters in width on the left lateral leg. Both wounds had a date of onset of 02-08-16. An unstageable wound is one in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown tissue) and/or eschar (tan, brown, or black tissue) in the wound bed with no healthy tissue present. With slough present, the pressure ulcer was unstageable and according to Federal definitions in the Resident Assessment Instrument Unitization Guidelines, the pressure ulcer was therefore at least a stage III. After identifying the serious preventable adverse event (facility acquired Stage III or higher pressure ulcer), still no care plan was developed and no orders were obtained to clarify the use or discontinuation of the brace until three days later when on 02-11-16, the physician gave an order to discontinue the brace to the left lower extremity of resident #65. On 02-16-16, the attending physician documented Patient had brace. Patient had rapidly progressing wound. Wound team is working with patient. On 02-18-16, review of the skin weekly pressure ulcer sheets revealed wounds of the left ankle and left upper leg have combined with the left lower lateral leg to make one wound. Wound was reclassified as vascular in nature related to poor circulation. Wound measured 31.5 centimeters in length by 10 centimeters in width with staging listed as not applicable. There is no evidence that nursing staff obtained an order from the physician to hold the brace secondary to having observed two new open areas in resident #65 with previously identified poor circulation related to the [MEDICAL CONDITION]. Eight charge nurses over nine shifts (3 days) documented active use of the brace in the treatment administration record, from the date the two areas were discovered as unstageable on 02-08-16, until 02-11-16, when the order was obtained to discontinue the brace. On 03-07-16 at 11:00 AM, interview with staff # 3 (one of the eight charge nurses) revealed that he/she initialed the treatment administration record on 02-10-16 because I signed I saw indicating his/+her observation of the brace which was on at the time. This was consistent with her written statement obtained by the Director of Nursing on 03-09-16 that staff #3 did not actually apply the brace on resident #65 during the shift. Following completion of the survey on 03-08-16, interview with the Director of Nursing on 03-09-16 at 1:20 PM, revealed that he/she had spoken with 6 of the eight charge nurses who informed him/her they did not apply the brace although they documented that they had. The failure to follow the prescribed process by ensuring an effective plan for pressure ulcer risk and by failing to develop and implement an effective plan to treat the ulcers once they became evident resulted in resident harm, where resident #65 developed two unstageable wounds (stage III or higher) that progressed to one large wound. 2. On 03-01-16 at 12 noon, surveyor interview of resident #125 revealed that he/she was alert and oriented. Due to arthritis pain in his/her neck, shoulder and right wrist, he/she is under pain management. In addition, he/she could request additional pain medication as needed. On 03-07-16, review of the clinical record revealed a routine pain medication was prescribed for resident #125 three times a day at 6 AM, 2 PM and 9 PM. Further review revealed that the nursing staff signed off on the MAR indicated [REDACTED]. However, review of the controlled medication utilization record revealed no evidence that the routine pain medication was removed from a double locked medicine drawer at 2 PM on 02-08-16, 02-12-16 and 03-06-16, and at 9 PM on 02-19-16. On 03-08-16 at 7:30 AM, interview of the director of nursing (DON) and administrator revealed no additional information. 3. a. On 03-07-16, review of the clinical record revealed resident #203 was admitted to the facility on [DATE] following a hospitalization . Upon admission, a 30 day course of an antibiotic was ordered three times a day due to a [MEDICAL CONDITIONS] infection. [MEDICAL CONDITION]. is a bacteria that can cause inflammation of the colon. On 03-07-16 at 9 AM, review of the MAR indicated [REDACTED]. Therefore, 69 doses of antibiotics were signed off as given to resident #203 per the MAR. On 03-07-16 at 9:30 AM, interview of staff #3 revealed there were 15 tablets of the antibiotic still available in the medicine cart. On 03-08-16 at 7:30 AM, interview of the director of nursing (DON) revealed there was a computer issue in February 2016, which affected the operation of the facility's medical records. However, the DON could not provide documentation indicating antibiotics were given on those exceptional dates. Interview of the Gateway unit manager on 03-08-16 at 12:30 PM revealed a total of 63 tablets of the antibiotic were delivered to resident #203 since February 2016. Therefore, 48 tablets of the antibiotics were given to resident #203 between 02-11-16 at 10 PM and 03-07-16 at 6 AM, which is inconsistent with the documentation in the MAR. b. On 03-07-16, review of the MAR indicated [REDACTED]. On 03-08-16 at 7:30 AM, interview of the director of nursing (DON) revealed there was a computer issue in February 2016, which affected the operation of the facility's medical record. However, the DON could not provide documentation indicating the antibiotics were given on those exceptional dates. c. On 03-07-16, review of the MAR indicated [REDACTED]. Further review revealed resident #203 received [MEDICATION NAME] at 9 AM on 02-15-16 and 02-16-16 when her/his systolic blood pressure was less than 110 mmHg. In addition, the attending physician instructed to hold the antihypertensive, [MEDICATION NAME], if resident #203's diastolic blood pressure was less than 60 mmHg. However, the nursing staff documented that resident #203 received [MEDICATION NAME] when the diastolic blood pressure was less than 60 mmHg on 02-12-16 and 02-15-16. On 03-08-16 at 7:30 AM, interview of the director of nursing (DON) revealed no additional information. d. On 03-07-16, review of the clinical record revealed that a nurse practitioner ordered blood tests on 02-29-16 to be done for resident #203 in the morning on 03-01-16 due to [MEDICAL CONDITION] and weakness. However, there was no evidence these blood tests were done, a week after the order was written. On 03-07-16 at 9 AM, interview of the Gateway unit manager revealed no additional information. 4 a. On 03-04-16, review of the clinical record revealed that,, on 04-16-15, the attending physician ordered finger sticks for resident #78 weekly before meals. On 05-24-15, another physician's orders [REDACTED]. On 06-06-15, the attending physician ordered finger sticks every Tuesday. Further review of the January 2016 MAR indicated [REDACTED]. In February 2016, a finger stick was done at 6:30 AM on Tuesdays and Wednesdays (February 2, 3, 9, 10, 16, 17, 23, 24, 2016) while resident #78 was receiving enteral feedings nightly between 5 PM to 9 AM. On 03-04-16 at 9 AM, interview of the Gateway unit manager revealed no rationale to explain why finger sticks were done at 6:30 AM during enteral feedings, which was inconsistent with all the physician's orders [REDACTED]. On 03-08-16 at 7:30 AM, interview of the DON revealed no additional information. b. On 03-04-16, review of the clinical record revealed an order was written on 02-14-16 to cleanse an abrasion daily for resident #78 with normal saline, pat dry, apply [MEDICATION NAME], and leave it open to air. However, there was no evidence this new treatment was done on 02-14-16 and 02-15-16. On 03-04-16 at 10 AM, observation of the medicine room revealed individual packs of [MEDICATION NAME] available on the unit. On 03-08-16 at 12 noon, interview of the DON revealed no additional information. c. On 03-04-16, review of the February 2016 physician's orders [REDACTED].#78 related to a speaking valve as tolerated. However, there was no application for a speaking valve since the order was written in May 2015. On 03-04-16 at 9:30 AM, interview of the Gateway unit manager revealed no additional information was provided related to this FYI order. On 03-04-16 at 10 AM, interview of a consultant respiratory therapist revealed that she/ he referred the application for a speaking valve to speech therapy services. On 03-04-16 at 2 PM, interview of the rehabilitation manager revealed that resident #78 received speech therapy (ST) services in February 2015, over a year ago. Review of the ST discharge summary dated 02-27-15 revealed that resident #78 could tolerate a speaking valve for more than 30-45 minutes without respiratory distress. In addition, the speech therapist recommended resident #78 for a restorative nursing program (RNP) for communication and cognition with specific strategies. On 03-08-16 at 7:30 AM, interview of the DON and facility's administrator revealed no additional information. 5. On 03-03-16, surveyor review of the clinical record revealed that, on 12-14-15, the attending physician for resident #45, ordered Med Plus 1.7 NSA (No sugar added) 4 oz three times daily between meals for supplement. The Med Plus was scheduled for administration at 9AM, 3 PM and 9 PM daily. On 03-03-16 at 10:30 AM, surveyor interview with the facility dietician revealed that the Med Plus 1.7 NSA was ordered for resident #45 for ongoing weight loss and due to the resident being diabetic, the Med Plus 1.7 has no sugar added. However, on 03-03-16 at 8:25 AM, surveyor observation of the medication pass to resident #45 revealed that RN #6 poured 4 oz of House 2.0 supplement for administration. Further observation revealed the resident consumed 50% of the House 2.0 during the medication observation. On 03-03-16 at 8:40 AM, surveyor interview with RN #6 revealed the House 2.0 supplement was given to her/him by the Shenandoah unit manager from the medication cart. No additional information was provided. On 03-03-16 at 11 AM, surveyor interview with the Director of Nursing revealed no additional information. 6. Based on surveyor review of the clinical record, surveyor observation, and interview with facility staff, it was determined that the facility failed to follow physician orders [REDACTED].#149. This finding was identified during the investigation of complaint MD 205 and is unrelated to the complaint. The findings include: On 03-05-16, surveyor review of the clinical record revealed that resident #149 to be wheelchair bound and resides on the [MEDICATION NAME] unit, which is a locked unit. Further review revealed that, on 02-26-16, the attending nurse practitioner ordered the placement of a Wanderguard bracelet placed on resident #149. The Wanderguard is an alarm system used in wandering or elopement management. The system usually involves some type of antenna system connected to a controller and a door contact switch. Residents who are at risk wear a wrist or ankle transmitter, such that, when the transmitter comes in close contact to the door that is alarmed by this type of system, the antenna singles out the transmitter of the resident. However, surveyor observation on 03-03-16 at 4 PM revealed that resident #149 was in her wheelchair on the [MEDICATION NAME] unit with no Wanderguard bracelet on her upper or lower extremities. On 03-03-16 at 4:30 PM interview with LPN #16 and LPN #17 revealed no additional information. On 03-03-16 at 4:45 PM, interview with the assistant Director of Nursing revealed no additional information. 7. Based on surveyor review of the clinical record, surveyor observation and interview with facility staff, it was determined that the facility failed to follow physician orders [REDACTED].#97. On 03-03-16 record review revealed this is a long term resident with [DIAGNOSES REDACTED]. Further review revealed that on 11-08-15 the attending physician ordered a Wanderguard for this resident to prevent elopement. The resident is ambulatory and is on the [MEDICATION NAME] unit, which is a locked unit. However, surveyor observation on 03-03-16 at 4:15 PM revealed that resident #97 was in the dining room on the [MEDICATION NAME] unit with no Wanderguard bracelet either on her/his upper or lower extremities. On 03-03-16 at 4:30 PM interview with LPN #16 and LPN # 17 revealed no additional information. On 03-03-16 at 4:45 PM, interview with the assistant Director of Nursing revealed no additional information. 8. On 03-07-16, surveyor review of the clinical record revealed resident #138 has a [DIAGNOSES REDACTED]. Further review revealed an order, dated 04-07-15, to measure abdominal girth every Monday/Wednesday/Friday for fluid retention on the 7P-7A shift. Review of the TAR (treatment administration record) for February and March 2016 revealed an area to record the findings. However, there is a check that the girth has been measured, but no evidence of the measurement. On 03-07-16 at 11 AM, interview with the DON revealed no additional information. 9. Review of the clinical record for resident #196 revealed an order dated 11-03-15 for Ted stockings on in the AM, off PM, for [MEDICAL CONDITION]. TED stockings are compression hosiery designed to help prevent the occurrence of [MEDICAL CONDITION] and blood clots. On 03-01-16 at 9 AM, observation of resident #196 revealed no TED stockings were on. The resident had heel protectors and regular short white athletic socks on both feet. On 03-04-16, observation revealed no TED stocking were on, instead the resident had short athletic socks on. Further review of the TAR for March 2016 revealed that staff signed off on both of these days that the TED stockings were on the resident. In addition, there is no evidence of when the TED stockings are to be removed. On 03-07-16 at 11 AM, interview with the DON revealed no additional information.

Based on surveyor review of the clinical records, closed record review and interview with facility staff, it was determined that the facility staff failed to follow physician orders. This finding was evident in 6 of 39 residents selected in the stage 2 review. (#250, #91, #29, #130, #43, #86) The findings include: 1. On 01-29-14, review of the clinical record for resident #250 revealed an order to administer [MEDICATION NAME] 25 mg, 3 tablets, twice per day, and [MEDICATION NAME] 30 ml., three times per day. The [MEDICATION NAME] was prescribed to maintain a low blood ammonia level. Elevated ammonia levels can cause mental confusion. Review of the MAR (Medication Administration Record) for December 2013 revealed the [MEDICATION NAME] was administered only once per day and not twice per day as ordered. In addition, the [MEDICATION NAME] was administered three times per day only 3 out of the 6 days the resident was in the facility. On 01-29-14 at 3 PM, interview of the assistant director of nursing revealed no additional information. 2. On 01-27-14 review of the clinical record revealed resident #91 was hospitalized in October 2013 with a discharge [DIAGNOSES REDACTED]. On readmission to the facility an order was written to administer sodium chloride 1 gram three times per day for 7 days, and then to repeat the basic metabolic panel (BMP) to obtain a new value for the sodium level the next day 10-25-13. Review of the MAR for October 2013 revealed only 16 of the 21 doses ordered were documented as administered. In addition, there is no evidence the sodium level was done as ordered. On 01-29-14 at 3 PM, interview with the assistant director of nursing revealed no additional information. In addition, in August 2013 this resident was having chest pain and was seen by the Nurse practitioner. A new order was written on 08-26-13 to discontinue the [MEDICATION NAME] and to administer [MEDICATION NAME] 50 mg. twice per day. However, review of the MAR revealed that Metroprolol 25mg was administered from 8-27-31-13 and not discontinued as ordered. On 01-29-14 at 3 PM, interview with the assistant director of nursing revealed no additional information. 3. On 01-28-14 surveyor review of the clinical record revealed the following consults were ordered by the physician for resident #29 but were not completed: The findings include: On 09-26-13- Follow up with cardiac surgeon regarding opening of surgical wound (old midline chest incision) with exposed hardware. On 10-31-13- Referral to wound care center for plastic surgery consult for chin/chest wounds On 11-29-13- Follow up with Oral maxillofacial surgeon in 2 weeks and follow up with [MEDICATION NAME] surgeon in 3 weeks On 01-28-14 at 2:15 PM surveyor interview with the [MEDICATION NAME] Unit Manager who was the Potomac Unit Manager during September, October, November, and December 2013 revealed no additional information. 4. On 01-24-14 surveyor review of the closed clinical record for resident #130 revealed the resident had a fall on 12-07-13. Further review of the clinical record revealed a physician order [REDACTED]. However, review of the x-ray results revealed only the lumbar region of the spine was x-rayed. On 01-29-14 at 10:30 AM surveyor interview with the assistant director of nursing provided no additional information. 5. On 01-27-14, review of the clinical record revealed that resident #43 was a long term care resident. [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] R 100 unit/ml Inject SQ (subcutaneously) per sliding scale. Check blood sugar twice daily before lunch and dinner for diabetes mellitus. 000-200=0 units 201-250=2 units 251-300=4 units 301-350=6 units 351-400=8 units Call MD (doctor) if blood sugar <60 or >400 Review of the December 2013 and January 2014 MAR revealed the following: DATE TIME READING UNITS ORDERED UNITS GIVEN 12-02-13 11:30 AM 353 8 U 6 U 12-04-13 11:30 AM 380 8 U 6 U 12-25-13 11:30 AM 222 2 U 4 U 01-08-14 4:30 PM 336 6 U 8 U 01-19-14 11:30 AM 380 8 U 6 U Interview with the assistant Director of Nursing on 01-29-14 at 9:30 AM revealed no additional information. Additionally, on 01-27-14, review of the physician's orders [REDACTED]. [MEDICATION NAME] SDV 6/box 10,000 units/1 ml Inject 1 ml (10,000 units) sub-Q (subcutaneously) every week Hold for hemoglobin greater than 10 Review of the lab report results and November and December 2013 MAR revealed the following results: DATE RESULT ORDER MAR 11-20-13 10.1 hold given 12-30-13 10.2 hold given Review of the MAR and nurses' progress notes revealed no documentation of the [MEDICATION NAME] being held on the above dates. The facility was unable to provide the pharmacy documentation regarding [MEDICATION NAME] not delivered due to lab results. Interview with the assistant Director of Nursing on 01-29-14 at 9:30 AM revealed no additional information. 6. Resident #86 is a long term care resident with dementia and [MEDICAL CONDITION]. Review of the resident's clinical record revealed that this resident has a pacemaker. In May 2013, the resident had a cardiac check up and the pacemaker was also checked. The resident returned with an order for [REDACTED]. However, on 01-23-14, surveyor review of the record revealed no order for the pacemaker check and no scheduled 6 months pacemaker check. Interview of the Unit manager (C unit) on 01-23-14 at 2PM confirmed the pacemaker check was not done and was scheduled after surveyor intervention. Further review of the record revealed that on 09-03-13 the nursing staff noted this resident had a poor appetite and was found with oral thrush. A new order was received for an oral swish treatment to be done 4 times a day for 10 days. Oral thrush is painful and does affect oral intake. However, review of the resident's clinical record revealed the staff failed to transcribe the treatment order and there was no evidence this treatment was provided. In addition, the staff documented on the TAR that the resident did not have any pain during these 10 days. Interview of the assistant director of nursing on 01-28-14 at 3PM revealed no further information.

Based on surveyor observation, review of the clinical records and interview of the staff, physician and wound consultant, it was determined that the facility staff failed to provide the necessary care and treatment to prevent a pressure sore present on admission from worsening resulting in harm done. Additionally, staff failed to prevent the development and infection of pressure ulcers and to provide the necessary services, including a timely wound consult to promote healing. This finding was evident in 3 of 39 residents selected in the stage 2 review. (#95, #29, #86 ) The findings include: 1. Based on surveyor review of the clinical record and interview of the staff, the attending physician and the wound care consultant, it was determined that the facility staff failed to provide the necessary care and treatment to prevent a pressure sore present on admission from worsening resulting in harm to resident #95. This finding was identified during the investigation of complaint MD 247 and is valid. On 01-29-14, review of the clinical record revealed resident #95 was admitted to the facility for rehabilitation after a hospitalization for a fractured right hip and a healing Stage II sacral pressure sore (no necrosis). A Stage II pressure sore is a partial thickness loss of skin layers that presents clinically as an abrasion, blister or shallow crater. A Stage III pressure sore has necrotic tissue, grayish/yellow slough present and/or soft/hard eschar is present. Further review of the clinical record revealed an admission nursing assessment dated 11-27-13 at 9 PM stating "...rt (right) heel with ulcer unstageable, no drainage or odor noted, beefy red wound bed... sacral ulcer stage II without drainage or odor, Duoderm dressing reapplied...". Further review revealed a drawing of the body with a stage II sacral pressure sore measuring 10 X 9.5 cm and an unstageable ulcer on the right heel measuring 4.6 X 4.6 cm. Weekly pressure sore forms were initiated at this time and dated 11-27-13. One form was labeled pressure sore #1, the right heel. Only measurements were recorded on this form. The nursing notes described the pressure sore with no odor or drainage. The second form was labeled as pressure sore #2, for bilateral buttocks. Only measurements were recorded on this form. The nursing notes described the wound without odor or drainage. Review of the admission orders [REDACTED] 1. Wound consult 2. On sacrum apply barrier cream to buttock and cover with Duoderm daily. 3. Please (sic) right foot continue Prevalon boot when in bed, reposition every 2 hours and PRN (as needed). 4. Clean decubitus ulcer with normal saline and apply Santyl (a [MEDICATION NAME] agent), cover with wound dressing daily, until wound consult recommends otherwise. Interview of the nursing staff revealed that they provided this treatment daily to the right heel. Interview of the attending physician on 2-3-14 revealed that this treatment was for the right heel. Review of the record and the TAR (treatment administration record) for November 2013 revealed no evidence that care was provided for any pressure sores on 11-28-13, the day after admission. On 11-29 and 11- 30-13, documentation revealed all wound care orders were signed off as provided. On 11-28-13, the attending physician saw the resident and noted on the history and physical to "see skin assessment". This is the nursing assessment performed by nursing staff the prior day. There is no documented evidence that the physician assessed the resident's pressure sores. Interview of the attending physician on 02-04-14 revealed that he was aware of the pressure sores but did not observe or assess them. Four days after admission, on 12-01-13, the nursing staff obtained a clarification order for the sacral pressure sore: "clean sacrum opening with normal saline, apply Duoderm, change every 3 days until seen by wound team, discontinue previous order to sacral area, apply barrier cream to surrounding buttocks". Review of the TAR for December 2013, revealed the following: On 12-01-13 a set of initials was circled indicating the Duoderm was not provided to the sacral pressure sore. On 12-07-13 and 12-10-13 the Duoderm was documented/signed off as provided. Review of the nursing notes revealed that on 12/6/13 and 12/9/13, staff documented that wound care was done to the sacrum and right heel. If staff changed the Duoderm to the sacral pressure sore on these additional dates this indicates that the Duoderm was changed more frequently than the order for every 3 days. On 2-4-14, interview of the MDS coordinator revealed that staff may have checked the Duoderm to make sure it was in place and not actually changed the Duoderm. There is no evidence in the clinical record from 12-01-13 through 12-06-13 as to why the Duoderm was not changed as ordered every three days and or any assessments of the status of the sacral pressure sore. On 12-08-13, an order was written for this resident to have a specialty mattress placed on the bed. This is 10 days after admission. On 12-11-13, at 4:15 PM a nursing note revealed that the right heel ulcer was covered with eschar and serous drainage was noted to the sacral ulcer. This assessment by nursing staff was 14 days after admission. Record review revealed that other than the 12-11-13 assessment of the pressure sores, there is no evidence of any assessments or descriptions of the pressure sores by nursing staff in the clinical record. On 12-12-13, the wound care consultant assessed, described, and initiated a new treatment plan for the sacral pressure sore. At this time the wound care consultant debrided the sacral pressure sore via surgical excision and removed subcutaneous tissue along with necrotic tissue. The wound consultant further described the area as 40 percent necrotic tissue, 50 percent granulation tissue and 10 percent skin with moderate serous drainage. The Duoderm was discontinued and Santyl was ordered twice a day. Interview of the wound care consultant on 02-04-14 at 12:30PM revealed that when she evaluated the sacral pressure sore on 12-12-13, nursing staff described it as a Stage II, however when she assessed the sore it was Stage III with necrosis in the center of the pressure sore and required debridement. an order for [REDACTED]. Barrier cream should not be placed under Duoderm. In addition, she stated that she questioned the nursing staff as to why she had not been told about this resident prior to 12-12-13 when she was in the facility on 12-05-13. On 02-04-14 at 9 AM, interview with the nurse practitioner revealed she refers residents with wounds to the wound team and that she was not aware this resident was not seen by the wound consultant for 15 days after admission. From the date of admission, 11-27-13 to 12-12-13, the sacral wound worsened from a Stage II to a Stage III pressure sore with necrotic tissue and slough and required surgical debridement. 2. On 01-28-14 surveyor review of the clinical record for resident #29 revealed a physician order [REDACTED]. There was no evidence that any pressure relief device was provided. Further review of the clinical record revealed a change of condition note on 10-07-13 that stated this resident was observed to have developed a wound to the right middle back. However, there was no description, staging, or measurements of the wound on this date. The weekly pressure ulcer record was not initiated by nursing staff until the resident was seen by the wound doctor 3 days later on 10-10-13. Review of the wound consult notes revealed that the back wound, labeled by the wound doctor as site 6, was evaluated on 10-10-13 as a stage 3 pressure wound measuring 2.5 cm x 2 cm x not measurable with 70% necrotic tissue. The 10-17-13 wound consult note revealed that site 6 was improved as evidenced by decreased surface area and increased granulation. A Stage III pressure sore has necrotic tissue, grayish/yellow slough present and/or soft/hard eschar is present. Further review of the clinical record revealed a change of condition note on 10-23-13 that stated the resident had "developed a wound under the chin", that the nurse practitioner was notified and new orders were received for treatment and a wound consult. However there was no description, staging, or measurements of the chin wound until the resident was seen by the wound doctor on 10-24-13. Review of the wound consult note from 10-24-13 revealed that the chin wound, labeled as site 8, was an unstageable pressure wound, measuring 2 cm x 2 cm x 0.1 cm with 50% necrotic tissue and 50% granulation tissue. In addition, the wound care physician notes that the staff were to separate the area between the chest and the chin with a towel but that putting foam between them would work better. In addition site 6 is described as stable. On 10-31-13 the wound consult note revealed that the area on the pressure wound of the chin had deteriorated and was infected. The area had increased in size to 3 cm x 1.7 cm x 0.1 cm with 100% necrotic tissue, "significant [DIAGNOSES REDACTED] (redness) of the chin and wound has greenish brown drainage". In addition the wound doctor noted "possibly mandible involvement" and ordered an antibiotic for the infection, a change in treatment to the wound, and to get a plastic surgery consult at the wound center. Site 6 is described as stable. Review of the nurse's notes revealed no evidence of the condition or progression of the chin wound from 10-24-13 until the resident was seen by the wound doctor on 10-31-13. After the wound doctor had seen the resident a change in condition was documented that noted "infectious wound". On 11-07-13 the wound consult note revealed that the pressure wound of the chin measured 3 cm x 2 cm x 0.5 cm, and that the bone of the mandible was slightly palpable. Also the wound doctor notes that the plastic surgery/wound consult had not occurred and she wanted a "second opinion for management of this wound." Site 6 is described as "not improved". On 11-14-13 the wound consult note revealed the pressure wound of the chin was assessed as a stage 4 measuring 2.6 cm x 2.5 cm x 0.6 cm with 15% bone exposed. The wound doctor requested the attending physician to see the resident with her and after seeing the resident they decided together to culture the wound and start IV antibiotics for "osteo[DIAGNOSES REDACTED] (exposed bone)". Site 6 is described as "not improved". A stage 4 pressure sore is usually classified as a very deep, reaching into muscle and bone and causing extensive damage. The damage may effect deeper tissues, tendons and joints. Further review of the clinical record revealed that the resident was hospitalized on [DATE] with a [DIAGNOSES REDACTED]. While in the hospital the resident was seen by the plastic surgeon as well as by an oral maxillofacial surgeon who debrided the pressure ulcer of the chin and was able to close the wound. On 01-28-14 at 2:15 PM surveyor interview with the nurse who was the Potomac Unit Manager during October and November 2013 provided no additional information. In addition, review of the clinical record revealed that on 12-19-13, after the resident's readmission to the facility after a hospitalization , the wound care doctor noted a stage 2 pressure wound on the resident's right sacrum measuring 1.5 cm x 1.8 cm x not measurable. The wound consult note on 12-26-13 stated the wound measured 3.5 cm x 4 cm x not measurable. On 01-02-14 the wound consult revealed that the wound measured 0.3 cm x 0.3 cm x not measurable. The treatment was changed to apply a barrier cream to the area every shift. On 01-09-14 the wound consult revealed that the wound was unstageable, measured 1.8 cm x 1.5 cm x not measurable with 70% necrotic tissue. On 01-16-14 the the wound consult revealed that the wound was a stage 3 and measured 1 cm x 1.2 cm x not measurable with 20% necrotic tissue. On 01-21-14 the wound consult revealed that the wound measured 1 cm x 0.7 cm x not measurable with 50% necrotic tissue. Surveyor observation on multiple days and times during the survey revealed that this resident was observed in a prone position in the bed or slightly propped towards the left side. On 01-28-14 at 9AM the surveyor observed the dressing change of the sacrum with the wound doctor. The measurements of the wound were 2.5 cm x 5 cm x 0.1 cm. The resident was on an air mattress, however the mattress was covered by a fitted sheet, a draw sheet, two cloth incontinence pads, and the resident was wearing an incontinence brief. This was also observed at 9 AM on 01-29-14. Surveyor interview with the wound doctor on 01-28-14 at 9:50 AM revealed that the resident needs turning side to side but at times is resistant to positioning, but "she has the ability to heal." On 01-28-14 at 2 PM surveyor interview with the Potomac unit manager revealed that the resident was being turned and repositioned but could "maneuver herself to back to back". However there was no evidence of any interventions or attempts of interventions to address this issue for the resident. 3. Resident #86 is a long term care resident with dementia. The resident needs assistance with activities of daily living. Review of the resident's clinical record revealed that this resident is at high risk for pressure ulcers and has a history of pressure ulcers. Record review revealed the resident developed a pressure ulcer on the sacrum on 07-18-13 and was healed several weeks later. On 08-06-13, the resident had a significant weight loss of 10% in a month. However, no further assessment or interventions were initiated related to this significant weight loss. On 08-16-13, the resident's diet order was changed to mechanical soft (from regular). There was no explanation why the resident needed this change in diet and there was no evidence of additional interventions in pressure ulcer prevention. On 08-21-13, the resident's healed sacrum pressure ulcer reopened. The staff obtained an order for [REDACTED]. Further review of the record revealed no evidence of a wound consult as ordered. The TAR indicates the wound consult was "done" on 08-23-13. However, the facility staff could not provide evidence of a wound consult. In addition, there was no treatment ordered for this reopened pressure ulcer. On 08-23-13, a health shake supplement was ordered. There was no other evidence of an assessment, monitoring, interventions, and documentation related to the reopened pressure ulcer and the resident's overall decline in condition. In addition, the staff failed to conduct a weekly pressure ulcer assessment and document when the pressure ulcer healed.