Every finding on record at Sterling Care Forest Hill

Based on observation, resident interview, and staff interview it was determined that the facility staff failed to ensure resident rooms were maintained in a homelike environment. This was evident for 5 of the resident rooms observed during the initial tour of the facility during this recertification survey. The findings include: Members of the survey team made observations of the environmental conditions of certain rooms while touring the facility on 12/17/25. room [ROOM NUMBER] had a hole in the wall at the end of the bed and a patched area, room [ROOM NUMBER] had scraping on the wall below the window on the left side of the bed, room [ROOM NUMBER] had peeling behind the bed, room [ROOM NUMBER] had a sink that appeared to be coming off of the wall and had a sign on the bathroom door that said, do not use with a date of 6/8/25, Resident #77 in room [ROOM NUMBER] told surveyor on 12/17/25 at 9:19 AM that the bathroom door does not lock for privacy, and room [ROOM NUMBER] had peeling paint on the walls. This surveyor toured the facility on 12/22/25 starting at 11:00 AM. room [ROOM NUMBER] was observed to have a hole in the wall and an area that was patched with spackling still visible. room [ROOM NUMBER] had a sign on the door that said, do not use bathroom. The sign was dated 6/8/25. This surveyor observed that room [ROOM NUMBER] had bathroom doors that did not lock. The bathroom is shared with another room. Resident #77 was interviewed on 12/22/25 at 12:17 PM. Resident #77 was asked how long the doors have not been able to be locked. The resident replied that it has been like this since the resident was admitted . Resident said when he/she backs the wheelchair into the bathroom it sometimes hits the door to the neighboring room, and it opens. This surveyor observed room [ROOM NUMBER] B and observed scratched up areas on the wall by the B bed resident's bed as well as some missing paint. Resident #120 was interviewed on 12/22/25 at 12:35 PM. This surveyor asked how long the scratches were on the wall and if he/she knew how they got there. The resident said the scratches were from the bed hitting the wall. This surveyor toured the facility with the Administrator and Maintenance Director (#21) on 12/22/25 at 1:00 PM. The Administrator and Staff #21 took notes and photos as appropriate. They offered potential solutions for the sinks and the assorted issues with the walls -- such as using a type of protective sheet that protects the wall while still being cleanable.

Based on observation and staff interview it was determined that the facility staff failed to ensure a call bell was in reach of a resident. This was evident for 2 (#37 and #85) out of 43 residents reviewed as part of the survey sample. The findings include: A member of the survey team observed on 12/17/25 at 10:36 AM the call light cord on the floor on the left side of Resident #37's bed in room [ROOM NUMBER] during the initial tour of the facility. This surveyor toured several rooms noted by the survey team for further observation on 12/22/25. This surveyor observed at 11:13 AM a call light cord below the bed of Resident #85 (roommate of #37) in room [ROOM NUMBER]. Staff #6 was interviewed at 11:15 AM. She identified herself upon request and was informed of the call bell cord being below Resident #85's bed. She asked to be shown and upon observing it herself she said she would take care of it. She knocked on the door, entered the room, and retrieved the call bell cord.

Based on interview, record review, and observation, it was determined the facility failed to provide ADL care related to urine incontinence timely. This was evident for 1 of 1 resident (Resident # 6) reviewed for Activities of Daily Living during the recertification survey.The findings include: Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, toileting, and mobility.On 12/17/2025 at 9:10 AM during an interview, Resident #6 expressed a concern regarding the timeliness of incontinence care. Resident #6 elaborated, When I get up and they put me in the wheelchair, I am raw on my skin from the urine; it hurts and burns my skin. They do not change me the way that they should. I get up in the morning and sometimes it may not be until 3 or 4 pm until I get changed again. On 12/18/2025 at 10:48 AM, a review of Resident #6's medical record showed that the last documented incontinence care, as recorded by the GNA in the TASK section (where the care provided is documented), was at 2:39 AM on 12/18/2025 in the bladder section.On 12/18/2025 at 10:49 AM, continued record review revealed a physician ordered on 10/06/2025 for Resident Toileting Schedule to offer and provide toileting/urinal upon arising, before meals, after meals at bedtime and as needed as tolerated.On 12/18/2025 at 11:35 AM, further review of Resident #6's medical record, specifically a Care Plan dated 10/06/2025, focused on bladder incontinence. Interventions, also dated 10/06/2025, included a Toileting Schedule to offer and provide a urinal or assist with toileting upon waking, before and after meals, at bedtime, and as needed. Additionally, frequent toileting/incontinence care was to be provided every shift, as tolerated. Further review of Resident #6's care plan dated 03/06/2025 revealed Resident #6 has a rash of the peri region related to incontinence.On 12/18/2025 at 11:40 AM, continued review of Resident #6's medical record revealed a skin and wound progress note dated 11/05/2025, that included a recommendation of Resident #6 related to incontinence of (stool/urine) and therefore measures to change Resident #6 should be changed when soiled to prevent breakdown.On 12/18/2025 at 9:51 AM, during a second interview, Resident #6 expressed concern that he/she had last received incontinence care between 5:00 and 6:00 AM and was not offered to be toileted upon awakening and/or prior to breakfast meal. On 12/18/2025 at 9:55 AM, interview with Geriatric Nursing Assistant (GNA) Staff # 4, shared Residents should be provided with incontinent care every 2 hours and as needed. Informed surveyor that GNA Staff # 5 was assigned to care for Resident #6 on this day. On 12/18/2025 at 10:07 AM an interview with GNA #5, confirmed that Resident #6 had not yet received incontinence care or been offered toileting. According to Staff #5, incontinence care should be provided every two to three hours. However, Staff #5 stated that care is not provided to Resident #6 until 11:00 AM, when the resident gets out of bed, claiming this is Resident #6's preference.On 12/18/2025 at 10:11 AM, interview with Resident #6, reported consistent leakage due to the diuretic Lasix, which causes frequent urination. He/She declined to wear an incontinence brief, stating he/she was raw down there. When the Surveyor inquired, he/she agreed to incontinence care and, upon being asked if he/she was wet, he/she responded, I think so. He/She explained the reluctance to request assistance, saying, I try not to bother them as they have a lot of people, and it takes a long time for them to come when you put the light on.On 12/18/2025 10:27 AM, approximately 5.5 to 6 hours after Resident #6's last reported incontinent care, an observation of incontinence care provided by Staff #5 to Resident #6, multiple absorbent materials were noted beneath an open brief (a folded towel, two under pads, and a folded blanket). Staff #5 provided care, and the surveyor observed that Resident #6 had irritated pink skin in the perineal area. Staff #5 confirmed that Resident #6 experienced frequent urination, and wetness was visible through the open brief and folded towel and blanket. After a new brief was applied, Resident #6 voided and voiced, oh gosh, it feels like fire, it hurts, and itches. The resident then added, This has been going on for a year, it just hurts so bad when I pee.On 12/18/2025 at 11:44 AM in an interview, the Director of Nursing (DON) explained the process of incontinence care, that it should be during GNA rounds. The DON continued to explain that incontinence care should be administered frequently, with an expectation of every two hours. A toileting schedule should also be followed as stated in the Physician orders and plan of care for the residents. The DON shared the use of multiple absorbent items underneath a resident; this practice posed a risk for skin breakdown. The concern was shared at this time.On 12/18/2025 at 1:00 PM, during an observation/interview, Resident # 6, was observed sitting in a chair and eating lunch. Resident #6 reported that they had not received incontinence care and were not offered the use of a toilet prior to the meal.On 12/18/2025 at 1:25 PM, the Director of Nursing (DON) provided the surveyor with a paper document, signed by the DON on 12/18/2025, regarding Resident #6. The DON stated she was investigating the surveyor's concern but maintained that the issue was about preference, not timeliness, as Resident #6 preferred bathing and incontinence care at 11:00 AM.On 12/18/2025 at 2:12 PM, during an interview with the complainant for Resident #6 , he/she expressed a concern of excessively long wait times for incontinence care. On 12/18/2025 at approximately 12:15 PM, an observation was conducted of Staff #5 provided toileting assistance to Resident #6. This observation occurred nearly four hours after the surveyor's previous observation at 10:27 AM.On 12/18/2025 at 2:20 PM, during an interview, Resident #6 was shown the paper document, signed by the DON on 12/18/2025, concerning a daily incontinent care schedule at 11:00 AM. Resident #6 explicitly denied that this was their requested choice, stating that a 5-to-6-hour wait was unacceptable and would cause burning and hurt. Resident #6 clarified that this schedule was Staff #5's suggestion. The Speech Therapist (Staff #7) and Resident #6's complainant were present and verified that Resident #6 did not agree to the incontinence care preference detailed in the DON's document. On 12/18/2025 2:45 PM, DON made aware of the continued concern.

Based on interview, observation, and record review it was determined that the facility failed to ensure an ordered consultation that necessitated an outside scheduled appointment was completed. This was evident for 1 of 28 residents (Resident #6) reviewed during the recertification/complaint survey.The findings include:On 12/17/2025 at 9:10 AM, an interview was conducted with Resident #6 who voiced concern of irritated skin with incontinent episodes. On 12/18/2025 at 10:27 AM, during an observation while GNA Staff #5 was providing incontinent care to Resident #6, the resident stated, They said I have a yeast infection, and it just won't go away. They keep using the same stuff. This has been going on for a year, and it hurts so bad when I pee.On 12/18/2025 at 10:46 AM, a review of Resident #6's medical record revealed a physician order dated 9/23/2025 for Gynecology (GYN) consultation related to continuous vaginal discomfort.On 12/18/2025 at 10:50 AM, in an interview, Resident #6 denied that he/she had been to a GYN doctor. On 12/18/2025 at 10:57 AM, in an interview with Licensed Practical Nurse (LPN) Staff #6, the process for consults was discussed. She stated the appointment would be scheduled, the facility would set up transportation, and family would be notified. On 12/18/2025 at 11:30 AM, continued review of Resident #6's medical record revealed a progress note dated 10/10/2025 at 10:25 AM, which indicated that Resident #6's continuous vaginal irritation was discussed at an Interdisciplinary meeting. The record revealed that a GYN consultation was scheduled for December, and the RN was attempting to expedite the appointment. On 12/18/2025 at 11:12 AM, during an interview with Registered Nurse (RN) Unit Manager, Staff #3, he/she confirmed that a GYN appointment for Resident #6 had been scheduled for either December 4th or 5th of 2025 but was subsequently canceled. Staff #3 stated that all appointment-related cancellations would be documented in the electronic medical record's progress notes; however, no documentation regarding the cancellation of the appointment was found.On 12/18/2025 at 12:58 PM, Staff #3 notified the Surveyor that an appointment had been rescheduled for Resident #6 in March. However, this was following surveyor intervention, and six months after the initial September GYN consult ordered by the Physician.On 12/18/2025, at 2:12 PM, an interview was conducted with Resident #6's complainant. The complainant confirmed that the GYN appointment process has been lengthy and stated they had not requested any cancellation. Resident #6's complainant speculated that the delay was related to transportation or an insurance issue.On 12/18/2025 at 3:04 PM in an Interview, Unit Receptionist, Staff #8 confirmed her process of appointment scheduling and transport arrangement as: receive a referral, schedule the appointment and transport, inform the family, and post it on the communication board. She vaguely recalled speaking with Resident #6's complainant, and confirmed the transport van allows two people to accompany the resident.On 12/18/2025 at 3:49 PM, during an interview with the Director of Nursing (DON) and Staff #3 they provided the surveyor with an Appointment request form for a December 4th, 8:30 AM appointment, including physician, address, and phone details. The form also noted if family or transport were contacted, however there was no further detail that this occurred. The DON stated she was unsure why the appointment was canceled. Staff #3 claimed that the Resident's spouse wanted to attend, but only one person could use the transport van, leading the facility to assume the spouse wanted the appointment canceled. At this time the DON was made aware of the concern.

Based on observation, record review, and interview it was determined the facility failed to assist a resident with known difficulty swallowing (dysphagia) with feeding and failed to provide liquids during a meal. This was evident for 1 (Resident #37) of 4 residents reviewed for Nutrition during the recertification survey. The findings include:On 2/17/2025 upon initial tour at 8:40 AM, an observation was made of Resident #37 hollering out in bed, with a breakfast meal tray in front of them on the bedside table positioned over the bed and no staff was present. On 12/18/2025 at 8:07 AM, an observation was made of Resident #37 self-feeding with the head of the bed elevated and leaning to the right side, there was no staff present. The breakfast tray was missing the thickened milk (8 oz) and orange juice (4 oz) indicated on the meal ticket.On 12/18/2025 at 8:13 AM, review of Resident #37's medical record revealed a physician order dated 9/24/2025 that indicated 1:1 assist with meals.On 12/18/2025 at 8:14 AM, continued medical record review for Resident #37 revealed an 08/06/2020 ADL care plan noting an ADL self-care deficit due to weakness, with a 10/11/2024 intervention for 1:1 assist with meals. Further review showed a 06/08/2023 care plan, revised 10/01/2025, focused on dysphagia (difficulty swallowing), with an intervention to monitor for signs of difficulty swallowing, including choking, coughing, holding food in mouth, and multiple swallowing attempts. On 12/18/2025 8:19 AM a continued observation of Resident #37 was conducted, which revealed no staff present in the room. Resident #37 continued to lean to right side self-feeding with left hand, and their head leaning on the side rail. On 12/18/2025 at 8:21AM, during an interview with Registered Nurse (RN) Staff #3, he/she stated that any liquid items listed on a resident's meal ticket should be present on the resident's tray. Furthermore, for residents requiring 1:1 meal assistance as ordered, a staff member is expected to be present and aiding. Staff #3 confirmed that Resident #37 was eating unassisted and that milk and juice were missing from the residents' breakfast tray. At the time of the interview, Staff #3 was notified of this concern. On 12/18/2025 at 8:30 AM, in an interview, the Director of Nursing (DON) expressed her expectation that a staff member must be present to provide one-to-one (1:1) assistance for any resident requiring that level of support. The DON was informed of the concern at this time.

Based on observation, record review, and staff interview, it was determined that the facility failed to label oxygen tubing and humidifier bottles with date of change to indicate maintenance of respiratory equipment for proper hygiene and safety. This was evident of 3 (Resident #1, #24, #66) of 4 residents observed for respiratory care during this recertification/complaint survey.The findings include:During the initial screening phase of the survey process on 12/17/2025 at 11:20 AM, the surveyor observed Resident #1 and Resident #24 receiving oxygen through an unlabeled (not dated) Nasal Cannula (N/C) tubing. Resident #1 did not have a dated label on the humidifier bottle. On 12/18/2025 at 9:37 AM the surveyor observed Resident #1 and Resident #66 sitting in their wheelchairs in the dayroom; both residents were receiving oxygen through unlabeled (not dated) nasal cannula tubing that was hooked to their oxygen tanks.A record review on 12/18/2025 at 10:02 AM noted the following:Resident#1 had an order: Oxygen at 2L/min via nasal cannula PRN for shortness of breathResident # 24 had an order: Oxygen at 2L/min via nasal cannula continuous for shortness of breathResident #66 had an order: Oxygen at 3L/min via nasal cannula continuous for COPDOn 12/19/2025 at 12:45 PM, an additional observation was made that Resident #24 was hooked up to an empty humidifier bottle and both Resident #24 and Resident #1 were hooked up to unlabeled (not dated) N/C tube.On 12/19/2025 at 12:50 PM, the surveyor requested that the unit manager (staff #16) verify that the Resident #24's humidifier bottle was empty, not labeled, and that the N/C tubing was not dated for Resident #24 and Resident #1. Staff #16 verified the concerns and requested that staff change the humidifier bottle and N/C tubing immediately. Staff #16 also stated that all N/C tubing and humidifier bottles should be labeled with a date at the time of a change. During an interview on 12/19/2025 at approximately 1:20 PM with Staff #14, the surveyor asked about the protocol for oxygen administration. Staff #14 stated that oxygen is administered when there is an order. The oxygen tubing and/or the N/C tubing are labeled with the date when they are placed on the resident and are changed every 7 days, and as needed; the humidifier bottles are dated when they are replaced. Staff #14 also verified that there was no date on the N/C tubing for Resident # 66.On 12/19/2025 at 2:27 PM, the DON was made aware of the concern that the oxygen tubing and humidifier bottles were not labeled with a date for the identified residents. The DON acknowledged the concern.

Based on record review and staff interviews, it was determined that the facility failed to act upon a pharmacy identified irregularities. This was evident for 1 (Resident #38) of 5 residents reviewed for unnecessary medications during the recertification survey.The findings includeOn 12/18/25 @10:05 AM review of the pharmacy's monthly medication review from February to November 2025 revealed recommendations for February, August, October and November. Further review revealed that the pharmacist recommended in February 2025 to add, Rinse mouth out after use of this medication to the order written as Fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 MCG/ACT, This pharmacy recommendation was reviewed, signed and approved by the attending physician.Further review of the medication administration record (MAR) from February to November 2025 on 12/18/25 at 1:40 PM indicated that this recommendation was not carried out as ordered.In an interview with the Director of Nursing (DON) on 12/19/2025 at 9:19 AM, she was asked about the process for reconciling pharmacy recommendations. She stated that once the pharmacists were done with the medication reviews, they email them to her to let her know that the reviews are ready for the physician's review and approval. She stated that once reviewed by the physicians the orders are given to the unit managers to enter in the electronic records. The DON was made aware of the pharmacy's recommendation that was not acted upon. She was unable to explain how this happened and was made aware that this was a concern. She acknowledged the concern.

Based on surveyor observation and interview with staff, it was determined that the facility staff failed to properly store drugs and biologicals by not removing expired medications and supplies from the house stock medication cabinet. This was evident for 2 out of 3 stock medication cabinets observed during the recertification survey.The findings include:While conducting the medication storage and labeling facility task on 12/19/2025 at 09:10 AM, the surveyor observed the following expired medications in the house stock medication cabinet located on the 100 Hall: 16 FL OZ Liquid pain relief Acetaminophen 160 mg/5 ml exp date of 9/2025 12 FL OZ Geri Lanta Ant Acid regular strength exp 11/2025 Zinc 50 mg 100 tablets exp 11/2025 Docusate sodium liquid 50 mg/5 ml exp 7/2025 Aspirin 325 mg tabs, 100 tabs exp 8/2025 Gloke Gypopen Glucagon injection 1 mg per 0.2 ml exp 2024 [NAME] clearlink system continuous flo solution set 10 drpos/ml exp 3/15/2025The house stock medication drawer on 200 Hall: Zinc 50 mg 100 tablets exp 8/2025 on 200 hall An interview was conducted with Staff #10 on 12/19/2025 09: 25 AM who stated that the floor stock medications are done by the central supply technician and that staff were probably retrieving the cart replacement medications from the front and not the back of the cabinet. Staff #10 also stated that the nursing staff need to be educated on the rotation of stock. Staff #10 placed the expired medications in a container and informed the unit manager, who shook his/her head.An additional interview was conducted with the central supply Technician (Staff #15), Who stated that she/he supplied the unit with the over-the-counter house stock medications. He/she stated, I supply the units when they are low on meds, and I check the expiration dates. When surveyor asked if there was a log when items would expire, Staff #15 stated, no. The surveyor informed Staff #15 about the expired medications found on the units, and that it was a concern. Staff #15 stated that she/he would check the central supply area for any additional expired medications. On 12/22/2025 at approximately 11:00 AM, the surveyor informed the DON about the expired medications and voiced that this was a concern for medication storage. The DON acknowledged that concern and stated that she was also made aware of the concern by the staff.

Based on a review of medical records and interviews with facility staff, it was determined that the facility failed to ensure that the provider accurately documented residents' current medications. This was evident for one resident (Resident #14) of the one resident reviewed for pain management during this recertification survey.The findings include:During an interview with Resident #14 on 12/17/25 at 11:40 AM, the resident reported that he/she was taking scheduled pain medication every six hours, which was not helping to reduce the pain.A review of Resident #14's medical records on 12/22/25 at 9:19 AM revealed that the resident was prescribed Hydromorphone 2mg every six hours for pain, starting in July 2025. However, the facility's attending Nurse Practitioner (Staff #12) consistently documented in progress notes for Resident #14: pain management: currently managed on Morphine Sulfate oral tablet 15mg, 1 tablet by mouth every 4 hours for pain since 4/21/25.Further review of Resident #14's medical records on 12/22/25 at approximately 10:00 AM revealed that the Morphine Sulfate order was discontinued on 6/11/25, and the Hydromorphone 2mg every 6 hours order was started on 7/01/25.During an interview with the Director of Nursing (DON) on 12/22/25 at 10:41 AM, she stated that attending providers document their assessment each time they assess a resident. She also explained that if a resident's orders changed, the progress notes should reflect those changes. The surveyor reviewed Resident #14's progress notes with the DON, who validated that there were discrepancies between the resident's current orders and Staff #12's progress notes.

Based on a review of medical records, facility records, and staff interviews, it was determined that the facility failed to monitor and track antibiotic usage effectively. Specifically, an antibiotic was prescribed to a resident without clinical evidence of infection, and the facility's Antibiotic Stewardship Program failed to document all prescribed antibiotics. This was evident in one (Resident #3) out of four residents reviewed for antibiotic use and stewardship during the recertification survey.The findings include:On 12/19/25 at 11:58 AM, a review of Resident #3's medical records revealed an order for Ceftriaxone 2g intravenously twice daily for a wound infection, scheduled for seven days starting 11/29/25. However, the medical record lacked detailed information, such as provider progress notes or laboratory results, to support the diagnosis of a wound infection.During an interview on 12/19/25 at 12:49 PM, the Director of Nursing (DON) explained the facility's antibiotic prescribing process: when a resident requires an antibiotic, the wound must be assessed, and the provider must document the specific signs and symptoms before issuing an order. The surveyor requested supporting documentation for the Ceftriaxone order for Resident #3 initiated on 11/29/25.At 1:46 PM on 12/19/25, the DON provided two wound culture reports for Resident #3 (sacral tissue). Both reports were for a specimen collected on 11/14/25.The first report (11/18/25) showed growth of several organisms but noted no further workup.The second report (11/21/25) explicitly stated, no anaerobic organism isolated and normal enteric flora, again noting no further workup.On 12/19/25 at 2:06 PM, the surveyor reviewed these reports with the Infection Preventionist (Staff #9). Staff #9 validated that the most recent report confirmed no active infection was present. Staff #9 also validated that there was no documentation from the provider regarding the wound status and no clinical evidence to justify the antibiotic treatment.Additionally, at 1:50 PM on 12/19/25, the surveyor noted that Resident #3's Ceftriaxone order was missing from the facility's Antibiotic Stewardship Line Listing. In an earlier interview at 8:29 AM, Staff #9 had stated that all antibiotics are reviewed weekly for criteria, risk/benefit, sign and symptoms, and duration, and that every antibiotic must be included on this list. Staff #9 subsequently validated that Resident #3's antibiotic was omitted from the stewardship tracking.

Based on record reviews and staff interviews, it was determined the facility failed to ensure that influenza immunizations were consistently offered or administered during the active flu season. This was evidence one (Resident #124) out of a five-resident sample reviewed during the recertification survey.The Findings include:A review of medical records on 12/19/25 at 9:14 AM revealed that Resident #124, who was admitted in September 2025, lacked documentation of influenza vaccination. The electronic medical record (EMR) listed the resident's status as pending consent.During an interview on 12/19/25 at 10:41 AM, the Infection Preventionist (Staff #9) stated that all residents and staff are offered the vaccine during flu season and that the EMR should be updated to reflect vaccination or refusal.At 1:49 PM on 12/19/25, Staff #9 provided a consent form signed by the resident's family on 9/12/25. She confirmed that although the resident had been scheduled for vaccination on 12/06/25, the dose was not administered. Staff #9 acknowledged the oversight and stated that the vaccine would be administered that day, noting that the scheduling occurred only after the surveyor's intervention.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' COVID-19 vaccine statuses were monitored and maintained in a timely manner. This finding was evident for one (Resident #129) of five residents whose immunization records were reviewed during this recertification survey.The findings include:A COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease.On 12/19/25 at 9:14 AM, the surveyor reviewed five randomly selected residents' vaccination records. The review revealed that Resident #129 was admitted in October 2025; however, the resident's immunization status for COVID-19 was documented only as pending consent.During an interview with the Infection Preventionist (Staff #9) on 12/19/25 at 10:41 AM, she stated that facility staff review residents' vaccination status upon admission and offer vaccines to those who are eligible. The surveyor reviewed Resident #129's Immunization Session tab in the electronic medical record with Staff #9. The review confirmed that the COVID-19 vaccination status remained documented as pending consent for more than 50 days following the resident's admission.On 12/19/25 at 1:49 PM, Staff #9 stated that the facility had contacted Resident #129's family and obtained consent for the COVID-19 vaccine. She stated, I am waiting for the provider to write the order and for the pharmacy to deliver the vaccine. Staff #9 clarified that the facility followed up on Resident #129's vaccination status after the surveyor's intervention. Prior to the surveyor's inquiry, the updated status was not documented in the medical record. The surveyor shared this concern, and Staff #9 validated the finding.

Based on record review, observations, and interviews, the facility failed to provide supervision to a cognitively impaired resident with known elopement risk and exit-seeking behavior from exiting the building unsupervised. This was evident for 1 of 12 residents reviewed for elopement during the survey. This failure resulted in an Immediate Jeopardy for Resident #82. The facility implemented effective and thorough corrective measures following the incident. The facility's plan of correction and actions were verified during the survey; therefore, this deficiency will be cited as past non-compliance. The date of correction was 07.21.22. The facility administrator and director of nursing were provided a copy of the past compliance IJ documentation and both employees signed and dated the documents at 3:15 PM on 08.14.24. The findings include: On 08.08.24 at 10:15 AM the surveyor reviewed MD00181562 which revealed that on 07.21.22 Resident #82 was found approximately 800 feet from the facility at approximately 12:10 AM -12:15 AM at the Royal Farms gas station. Resident #82 was returned to the unit on the second floor by the 11 PM-7 AM nursing supervisor, Registered Nurse (RN) # 28. The resident's wander guard was still in place on the resident's wrist per the facility report, the resident was examined, and the wanderguard was found to be working. Further review of the facility investigations and medical records revealed that on 07.21.22 Resident #82 described as 72 y.o. with a primary diagnosis of dementia with behavioral disturbance, hypertension, and unspecified atrial fibrillation, and a Brief Interview for Mental Status (BIMS) score of 0 on 07.21.22, indicating severe cognitive impairment. The resident was placed on a wander guard because of wandering behavior on 05.22.22, the elopement risk assessment was high on 06.20.22 due to the resident having poor decision-making skills, exit-seeking behavior, wandering, being oblivious to safety needs, and the resident had the ability to exit the facility. Additionally, resident #82's care plan was updated as well. Continued record review revealed that on 07.20.22 resident #82 was seen at approximately 11:35 PM at the second-floor Nurses' station. Also, on 07.20.22 at 11:45 PM, the resident was seen by the soda machine in the hallway on the second-floor clinical area. Geriatric Nursing Assistant (GNA) #27 in her staff interview stated that he/she coached the resident to come back onto the unit. Per GNA #27 the resident continued to follow the GNA until right before the nurses' station. Resident #82 stopped at the nurses' station and started talking to himself. GNA #27 stated that he/she left the resident at the nurses' station to answer the call lights in the hallway. Per the facility report the police were called at 12 midnight. Resident #82 received a head-to-toe assessment by the night shift RN supervisor, #28 and the 11 PM-7 AM licensed practical nurse (LPN) #29 on 07.21.22 after 12:30 AM. No physical or psychological injuries or trauma were noted by nursing staff on 07.21.22 during the time. At the time of the elopement, there was no wanderguard alarm on the kitchen exit door on 07.20.22. According to the facility investigation, the resident exited through the kitchen exit door which was left open after a contractor cleaning the stove hoods left the door open. On 08.09.24 at 11:00 AM the surveyor initiated an interview with the assistant director of nursing (ADON). The ADON stated that the wander guard bracelet was in place as of 05.17.22 related to the resident's history of wandering and exit-seeking prior to the resident eloping. The resident's care plan for the wanderguard was initiated on 05.17.22 as well. The ADON stated that contracted workers were cleaning the kitchen hoods shortly before the elopement and the staff believed that the contractors left the kitchen door unlocked. The kitchen exterior door had a fire safety door with a push handle in July 2022 therefore, the resident pushed the handle and was able to exit outside of the building without an alarm sounding. The wander guard alarm box was not in place at the time of the elopement. The kitchen is located on the second floor as well as Resident #82's assigned room both in July 2022 and at the time of the survey. On 08.13.24 at 2:49 PM the surveyor watched the ADON test the wanderguard on the left wrist of the resident #82. The wander guard worked when the resident was pushed in the wheelchair towards the kitchen door and the wander guard did beep appropriately. On 08.13.24 at 3:15 PM, the administrator and DON explained that the resident was ambulatory in 2022 but now his/her physical strength has declined and is only able to ambulate for short distances. Additionally, the ADON stated that on 07.22.22 the 11 PM -7 AM supervisor received a phone call from the manager at the local Royal Farms gas station stating the resident was there. The 11 PM-7 AM nursing supervisor picked up the resident and brought him back to the nursing home per the ADON 's statement. The 11 PM-7 AM nursing supervisor is no longer an employee of the facility. Also, the ADON stated that she could provide a copy of the root cause analysis and quality assurance performance improvement (QAPI) project that was conducted. The QAPI project notebook was reviewed by surveyor and the staffing assignments were matched against the staff interviews included in the facility report. The detailed list of initiatives and staff in-services were reviewed by the surveyor as well and were initiated on 07.21.22 and provided instructions to the staff regarding elopement risks, reporting of elopement as the prevention of elopement of residents. The facility initiated a sign-in and out sheet process for staff to sign when entering and exiting the kitchen door. On 08.14.24 at 08:27 AM the surveyor spoke with GNA # 27 via telephone, who stated that on 07.21.22 she was informed that Resident # 82 had eloped to the nearby gas station. GNA # 27 stated that elopement occurred approximately 30 minutes after she/he had observed Resident #82, who was fully dressed sitting beside the soda machine on 07.20.22 at 11:45 PM. No further episodes of elopement have occurred related to elopement since 2022. The facility failed to provide ongoing supervision, to address a resident who was known to have exit-seeking/elopement behaviors resulting in Resident #82 eloping from the facility. On 08.13.24 at 3:15 PM the administrator and DON explained the post elopement interventions undertaken by the facility and root cause analysis. The ADON and DON provided the surveyor with a copy of the investigation, the immediate actions taken post the elopement, and the interventions taken to prevent any further elopements: 1. The resident #82's wander guard bracelet was checked and found functional upon his return to the facility on 07.21.22. 2. A thorough physical examination and psychological assessment performed by the registered nurse and the social worker on 07.21.22 found the resident with physical injuries and was still cognitively impaired with a BIMS of 0. 3. Immediately after the incident occurred all doors were checked in the facility by the RN supervisor for 3-11 PM and the nurses on the 11 PM-7 AM shift on 07.21.22. 4. The ADON who was covering for the DON (who was on vacation) was notified at 12:28 P.M on 07.21.22. 5. The ADON performed an audit of the elopement risk book, elopement assessments, wander guards to ensure placement and function, wander guard orders and elopement care plans to ensure the documents were updated on 07.21.22. 6. An elopement drill was performed at the facility to ensure all residents were in the facility on 07.21.22. 7. An assessment of the kitchen door was performed again by the administrator and the maintenance director on 07.21.22. 8. The plan of correction was initiated, and staff education was initiated regarding the kitchen staff signing off in the evening that the kitchen door is locked on 07.21.22. 9. On 07.21.22 a statement signed by the Maintenance Director stated that he educated the vendors on the new policy related to ensuring the kitchen doors remain locked while the vendors are working on kitchen projects. The requirement to have a facility maintenance staff member present during the evening hours when the contracted vendors are present. 10. On 07.29.22 the magnetic lock and the wander guard alarm were installed on the exterior kitchen door. 11. Elopement drills to be conducted on 7-3, 3-11, and 11-7 shifts by 07.22.22 and then quarterly. After surveyor review it was determined the facility corrected the deficiency practice by 07.21.22 prior to the start of the survey, therefore the deficiency will be cited as past non-compliance with a correction date of 7.21.22

Based on observation and interview with facility staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety. This was found to be evident during the facility's survey and has the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: During the initial tour of the kitchen conducted on 08/06/2024 at 8:35 AM with the dietary aide staff #13 accompanying the surveyors. Inside of the stand-alone refrigerator was a large bowl of croutons with a date-in of 06/13/24 and a date-out of 06/19/24. The dietary aide staff #13 immediately removed it after confirming that it should have been out of the refrigerator. During a continued tour of the kitchen on the same day at 08:40 AM, inside the walk-in freezer, the following items were observed, a small bag of sugar cookies was opened, 5 large bags of pancakes and 3 bags of French toast. There was no date label on any of the items observed. The dietary aide staff #13 stated that the items should have been dated and she removed the items immediately. All concerns were discussed with the administration team at the time of exit on 08/14/2024 at 05:00 PM.

Based on observations and interviews it was determined that the facility failed to allow the residents on Unit 300 move freely throughout the facility as evidenced by the unit being locked and requiring a code to enter and exit. This deficient practice was discovered during the survey. The findings include: On 08/07/24 at 10:20 am the surveyor entered Unit #300 which required a code to gain entry onto the unit. Unit #300 is primarily used for residents who require rehabilitations services. On 08/07/24 at 10:37 am the surveyor asked Registered Nurse (RN) Unit Manager #35 why the unit was locked. RN Unit Manager #35 verbalized a resident on the unit was an elopement risk but was easily redirected. The resident's family and visitors receive the codes at the front desk. On 08/07/24 at 11:00 am while the surveyor was interviewing Resident #49 in their room, Geriatric Nursing Assistant (GNA) #34 knocked on the resident's door. Upon entry GNA#34 proceeded to give the resident a piece of paper with the code to enter and exit the unit. When asked does the residents have the code to enter and exit the unit, GNA#34 verbalized the staff usually give the code to the family members and some of the residents who go to the dining room have the code. The surveyor asked Resident #49 did they have the codes to the unit. Resident #34 responded, I've never had the code before. On 08/07/24 at 11:34 am during an interview with Resident #60 the surveyor asked if he/she had the codes to enter and exit the unit. Resident #60 verbalized not having the codes.

Based on resident interview, record review, and staff interviews, it was determined that the facility failed to address and/or follow up on an ophthalmologist's recommendation. This was evident for 1 (Resident #31) of 5 resident's reviewed for vision. The findings include: On 08/06/24 at 10:37 AM, an interview was conducted with Resident #31. The resident stated they needed their eyes checked. The resident stated, my last appointment was January, and nothing has been done about my cataracts. They said I was going to need surgery. On observation the resident was not wearing glasses and glasses were not at bedside. On 8/07/24 at 9:23 AM, Resident #31's medical record was reviewed. There was an order for an Optometrist consult placed on 10/19/2023. On 08/08/24 at 10:10 AM, an interview was conducted with the Unit Manager (Staff #24) for Unit 1. When asked about who schedules the specialty appointments for the residents, Staff #24 stated, I do. When asked about how often the residents see the specialists, Staff #24 stated, The specialists come to the facility at least once a month or see the residents as needed. When asked who updates the resident's care plans, Staff #24 stated, I do. On 08/08/24 at 10:24 AM, Resident #31's last Optometrist appointment consult form was reviewed. The Optometrist appointment was dated 4/18/2024 and stated, No improvement with refraction. Refer for cataract surgery consult. Referred to ophthalmologist. On 08/08/24 at 11:03 AM, an interview was conducted with Staff #24. When asked if there was an Ophthalmologist consult appointment made for Resident #31, Staff #24 states that attempts to schedule an appointment have been made but there were issues with the resident's insurance. On 08/08/24 at 2:30 PM, an interview was conducted with the business manager (Staff #16). When asked whether Resident #31 would have issues scheduling an Ophthalmologist appointment, Staff #16 stated that the resident has no insurance issues that would prevent scheduling an ophthalmologist appointment. On 08/09/24 at 09:40 AM, Staff #24 was interviewed. When asked if there was any progress on scheduling an Ophthalmologist appointment for Resident #31, Staff #24 stated an ophthalmologist appointment has been scheduled for Resident # 31. This Surveyor requested a copy of confirmation for the appointment. On 08/09/24 at 09:57 AM, a copy of the ophthalmologist appointment confirmation was provided to this surveyor and a review of Resident #31's orders were conducted. An order for an Ophthalmologist appointment on 8/27/24 was placed on 8/9/2024 at 9:42 AM.

Based on observations and staff interviews, it was determined the facility failed to maintain facility equipment in good repair and provide a clean homelike environment. This was evident for 2 resident's rooms out of 8 resident rooms reviewed during the survey. The findings include: During observation rounds on 08/06/24 at 9:22 AM in residents' room [ROOM NUMBER] there was a heating and air-conditioning unit not working, with a wet black substance noted on the inside of the unit's grill, the unit's cover was falling off and there was a musty odor permeating throughout the room. During observation rounds on 08/06/24 at 9:25 AM in residents' room [ROOM NUMBER] bathroom, there was approximately a 1-inch layer of dry gray/white substance located on the inside of the air duct vent opening. The bathroom sink was also noted to be detached from the wall. During observation rounds on 08/06/24 at 9:48 AM in residents' room [ROOM NUMBER] there was a heating and air-conditioning unit leaking water onto the floor, there was a musty odor permeating throughout the residents' room, and a large hole approximately 1x1 foot in size noted in the wall adjacent to the heating and air-conditioning unit on the left-hand side. During observation rounds and an interview on 08/06/24 at 10:36 AM with Maintenance Technician staff #4 confirmed observations found by this surveyor and stated that resident's room [ROOM NUMBER] heating and air-conditioning unit would be fixed, the bathroom air duct vent would be cleaned, and the bathroom sink would be repaired. Staff #4 also stated that residents' room [ROOM NUMBER] heating and air-conditioner unit and wall would be fixed. During observation rounds and interview on 08/13/24 at 12:10 PM with Unit Manager staff #35 in residents' room [ROOM NUMBER] the heating and air-conditioning unit was leaking water onto the floor, there was a musty odor permeating throughout the room and the hole in the wall had not been fixed. In residents' room [ROOM NUMBER] there was still a wet black substance noted on the inside of the heating and air-conditioner grill, there still was a musty odor permeating throughout the room and the bathroom air duct vent still had approximately a 1- inch layer of dry gray/white substance located on the inside of the air duct vent opening. Staff #35 confirmed these observations and stated that she would notify the Maintenance Technician right away.

Based on record review and interviews it was determined that the facility staff failed to ensure the assignment sheets were completed daily on Unit 300 and failed to reserve the posted daily nursing staff data for a minimum of 18 months. This deficient practice was discovered during the survey. The findings include: On 08/07/24 at 11:50 am the surveyor asked Geriatric Nursing Assistant #34 for a copy of the assignment sheets dated 08/02/24 - 08/07/24 all shifts. The surveyor reviewed the staffing sheets which revealed the written copy of the schedule for the dates 08/02/24 11pm-7 am, 08/03/24 & 08/04/24 all shifts, 08/05/24 11pm-7am, and 08/06/24 11pm- 7 am were not available. During an interview with RN Unit Manager #35 on 08/07/24 at 11:54 am the surveyor reported some of the assignment sheets were missing. RN Unit Manager #34 verbalized the staff are expected to complete the assignment sheets daily for all shifts. On 08/14/24 at 2:03 pm during an interview with Assistant Director of Nursing #5 they verbalized the assignment should be completed every shift. After one month they are removed from the book on the unit and stored monthly.

Based on observations, interviews with resident and facility staff, it was determined that the facility failed to ensure that repairs were made, as needed, in the resident's room. This was evident for 1 resident (Resident# 32) out of 66 resident's rooms observed during the facility's survey. The findings include: During an observation of Resident #32's room on 08/06/24 at 11:37 AM, surveyors observed a large area of the baseboard (approximately 25 feet) located at the head of the resident's bed was totally separated from the wall with broken pieces of dry walls noted. In addition, observation of the resident's bathroom sink was noted to have a large area of separation along the width of the sink, between the sink and the corresponding wall, that was in need of caulking. During an interview with the resident at that time, he/she stated that some repairs were done but after a flood in the hallway some time ago, the wall located at the head of the bed shifted. The resident also stated that personal shoes and bags were placed in a plastic bag while on the floor. On 08/07/24 at 12:24 PM during a walk through with the Administrator staff #1 the surveyors showed him the observations made in Resident' #32's room and bathroom. He stated that the repairs would be made immediately. A follow-up observation was made to Resident #32's room on 08/14/2024 at 08:10 AM and repairs were observed in progress. All concerns were discussed with the administration team at the time of exit on 08/14/2024 at 05:00 PM.

Based on record review and interview it was determined the facility staff failed to report an allegation of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 resident (Resident #1) reviewed for abuse during the complaint survey. The findings include: On 10/23/2023 at 8:45 AM, during a brief entrance conference, surveyor requested from the Nursing Home Administrator (NHA), all documentation of the investigations related to the Facility Reported Incidents (FRIs) that were sent to OHCQ (Office of Health Care Quality) concerning Resident #1. On 10/23/2023 at 9:40 AM, review of the investigation of a Facility Reported Incident (FRI), MD00197629, revealed that on 9/27/2023 Resident #1 alleged that Geriatric Nursing Assistant (GNA #5), was inappropriate during incontinent care. The report indicated that Resident #1 told the Director of Nursing (DON) on 9/27/2023, that when GNA #5 was applying barrier cream to her/his buttocks, the GNA's finger touched Resident #1's rectum and that made her/him feel uncomfortable. However, a review of the email confirmation of the initial incident report revealed that it was submitted to OHCQ on 9/28/2023 at 3:27 PM. On 10/23/2023 at 1:11 PM, an interview was completed with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). They were informed of the surveyor's concerns regarding the actual date of the above incident and the time it was reported to OHCQ. The surveyor reviewed with DON and ADON their official report of the incident that indicated that the date/time of incident was 9/26/2023, date/time Local law enforcement contacted was 9/27/2023, but date/time report was sent to OHCQ was 9/28/2023 at 3:27 PM. DON stated that she did not file a report on 9/27/2023 because Resident #1 had original told her (DON) that s/he (Resident #1) did not feel like s/he was abused. The ADON stated that she contacted the police after talking with the resident on 9/28/2023 and that the date/time (9/27/2023) indicated on the FRI report to OHCQ that indicated that the police were notified was the wrong date and was written in error. However, the ADON could not provide any documentation to show the time she spoke with the resident on 9/28/2023 or notes documenting the arrival of the police to the facility. Surveyor also reviewed with DON/ADON, the Disciplinary Action Form on file that indicated GNA #5 was suspended on 9/27/2023 for Resident Abuse or Neglect. DON stated that she (DON) must have written the wrong date on the form, and later brought a corrected Disciplinary Action form with 9/28/2023 as the suspension date for GNA #5. On 10/23/2023 at 1:50 PM, review of the facility policy on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was completed. The Abuse & Neglect Prohibition Process, under Reporting and Response: 1) State Reporting Obligations: The facility will report all allegations and substantiated occurrences of abuse and/or neglect to the Administrator, State Survey Agency, law enforcement officials, and adult protective services The timeline for reporting is as follows: a) If the events that caused the allegation involves abuse or result in serious bodily injury, a report is made not later than 2 hours after the facility is notified of the allegation; On 10/23/2023 at 2:55 PM, in an interview with GNA #5, he confirmed providing perineal care to Resident #1 in the early morning of 9/27/2023. He stated that in the early morning of 9/27/2023, Resident #1 had urinated and requested to be changed. After cleaning Resident #1, GNA #5 stated that the resident asked him to apply cream on her/his sacrum which he did. GNA #5 stated that was the last time he took care of Resident #1 as he was later suspended, and the resident taken off his assignment. On 10/24/2023 at 12:50 PM, the surveyor completed an interview with Resident #1. Resident #1 stated that around 5:30 AM on 9/27/2023 the Aide, while applying cream on her/his butt during incontinence care, stuck his finger in the resident's rectum. Resident #1 stated that s/he immediately turned and asked him to stop, the Aide then went over and picked up dirty linen from the floor and left the room. Resident #1 indicated that s/he immediately notified the nurse on duty for the night shift, and later that morning on 9/27/2023, she reported the incident to the day shift nurse, who immediately called the DON. Per Resident #1, the DON came up to their room and (Resident #1) told the DON what had happened. Resident #1 stated that the DON kept asking them Are you sure because he is such a nice guy. Resident #1 stated that s/he told the DON that the Aide was not such a nice guy, and the DON took the statement and left. On 10/24/2023 at 2:20 PM, an interview was completed with the Social Work Director, Staff #6 who stated that she was made aware of the above allegation on 9/28/2023 and she immediately followed up with Resident #1. Staff #6 stated that after Resident #1 recounted the incident, she provided emotional support to the resident, took the report, and submitted it. On 10/24/2023 at 2:22 PM, in a telephone interview with the DON in attendance, the [NAME] County Police Officer who was dispatched to the facility stated that law enforcement was notified of the above incident on 9/28/2023 at 12:30 PM. He added that they responded within 10 minutes of the call to the facility at about 12:40 PM on 9/28/2023. Based on review of facility documentation and interviews, Law enforcement was notified at 12:30 PM on 9/28/2023 but OHCQ was not notified until 3:27 PM on 9/28/2023, which was past the required 2-hour window for reporting an allegation of abuse, and more than 24 hours from when Resident #1 first made the allegation (9/27/2023). On 10/24/2023 at 3:30 PM, the above concern was reviewed with the Nursing Home Administrator (NHA), the DON, and ADON during an exit conference. No further information was given from the leadership team to validate the timely reporting of an allegation of abuse

Based on medical record review and facility investigation, as well as interviews with the resident, director of nursing (DON), and the administrator, it was evident that the facility staff failed to transfer the resident using 2 persons as assessed and identified for the resident's safety. This resulted in pain, swelling, and a fracture of the resident's right ankle. This was evident for 1 of 2 residents selected for review. The findings included the following: On 6/20/12, the surveyor reviewed a Facility Reported Incident involving resident #1. The surveyor also reviewed the medical record: Resident #1 was admitted to the facility on [DATE], with a history of a stroke, and had been assessed by the facility to require 2 persons for assistance with transfers. This was documented on her assessments, plan of care, and Kardex, which were all used by the facility staff for guidance during direct care. These included the minimum data set (MDS); Maryland monthly data set (MMDS); plan of care; and care kardex prior to 5/22/12. On 5/22/12, during the evening shift, GNA #1 transferred the resident from the wheel chair to the bed, alone. The resident's leg became "tangled" in the chair and the GNA's legs. On 5/23/12, the resident complained of pain in her right ankle and described the 1 person transfer and leg entanglement from the previous day to the nurse. The nurse assessed the ankle and described it as swollen, bruised, and painful. The Dr. ordered an X-ray which was positive for a fracture of the medial malleolus with mild displacement. The malleolus is the bony prominence on each side of the ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg, and the fibula on the outer side (lateral) of the leg. The medial malleolus is the prominence on the inner side of the ankle, formed by the lower end of the tibia. The lateral malleolus is the prominence on the outer side of the ankle, formed by the lower end of the fibula. The fracture was described as acute. On 5/23/12, the facility began an investigation and identified the GNA involved in the transfer. During the investigation, the GNA was interviewed and described the same events during the transfer as the resident had described. The GNA was suspended, and then re-educated, about transfer technique and review of pertinent data prior to transfers. On 5/25/12 the facility completed in-servicing to the nursing staff. On 6/20/12, the surveyor interviewed the resident about the incident. She remembered yelling that it hurt, the GNA stopped, but as she stated: "it was too late". She said she did not tell anyone else the day it happened because she did not want to get the "girl" in trouble. The facility investigation concluded that: the GNA transferred the resident alone; the resident's leg became "tangled" which resulted in swelling, pain, and a fracture. The surveyor interviewed the administrator and direcotor of nursing about the events surounding the transfer and fracture. As of 6/23/12, the facility failed to provide any additional information. The facility staff failed to transfer the resident using 2 persons as identified for safety; resulting in pain, swelling, and a fracture of the resident's right ankle.