Every finding on record at The Village at Rockville

Based on observation and interview, it was determined that the facility failed to ensure residents were treated in a manner that maintained dignity. This was evident for 2 (Resident #168 and Resident #57) out of 12 residents observed.The findings include:On 02/27/2026 at 12:16 PM, this surveyor observed residents on the 2 Virginia Memory Care floor being served food in the dining area.On 02/27/2026 at 12:33 PM, it was observed that a group of residents were seated together at a dining table. One resident seated at the head of the table (Resident #153) had been served at that time.On 02/27/2026 at 12:39 PM, it was observed that the remaining residents seated at the table (Residents #153, #84, #69, #59, #107, #17, #21, and #93) had received their meal trays and were eating. However, Resident #168 had not yet been served. Resident #168 was observed looking around at the other residents while they were eating.On 02/27/2026 at 12:41 PM, Resident #168 was observed receiving his/her meal tray.On 02/27/2026 at 12:45 PM, this surveyor observed Resident #87 being assisted with lunch at a dining table. Resident #57 was seated at the same table and had not yet received a meal tray.On 02/27/2026 at 12:56 PM, Resident #57 had still not been served. At that time, Resident #87 had completed his/her entire meal.On 02/27/2026 at 12:57 PM, Resident #57 was observed receiving his/her lunch tray.On 02/27/2026 at 2:22 PM, this surveyor conducted an interview with GNA #10. GNA #10 confirmed that she had been working in the 2 Virginia Memory Care Unit dining room earlier that day, assisting with tray service and feeding residents. She reported that meal trays are served in the dining room based on meal tickets and that trays are prepared and delivered in the order the tickets are received. She stated that resident seating at tables is random and that residents are assisted with meals based on when they receive their trays.GNA #10 further reported that she feeds the residents assigned to her and that additional nursing staff assist if needed. When asked whether there have been instances of residents becoming upset when others have food and they do not, GNA #10 stated that there have been occasions where residents attempt to take food from another resident's tray. She reported that, to prevent this, staff attempt to ensure that residents seated together receive their trays around the same time.On 02/27/2026 at approximately 3:00 PM, this surveyor conducted an interview with the Administrator and the Director of Nursing (DON). The concern regarding resident dignity was discussed, specifically the observations of residents seated at dining tables while other residents were eating and they had not yet received meal trays. It was explained that, in both instances observed, residents were without meal trays for approximately eight minutes or longer, including one instance in which a resident seated across the table had already completed the meal before the other resident was served. It was communicated that this practice raised concerns related to maintaining resident dignity and ensuring meals are served in a manner that allows residents seated together to begin dining at approximately the same time. The Administrator and DON acknowledged and expressed understanding of the concern.

Based on observations and interviews, it was determined that the facility failed to ensure that 1) the environment was in good repair in 3 (Resident rooms #3142, #3145, & #3147) out of 32 Resident rooms and 2) Residential hot water temperature was safe in 5 (#2390, #2391#2220, #2215, and #2212) out of 5 Resident rooms observed for the environment during the recertification and complaint survey. The findings include: 1) During a tour of the facility conducted on 02/25/26 at 9:07 AM, the Surveyor observed Resident room [ROOM NUMBER], #3145, and #3147 with large areas of peeling paint behind the Resident beds. The Surveyor also observed in Resident room [ROOM NUMBER] the nightstand with peeling contact paper on top. During a tour with the Maintenance Director conducted on 03/02/26 at 9:33 AM the Surveyors and Maintenance Director observed Resident room # 3142, #3145, and #3147 peeling paint on the walls behind the Resident beds and peeling contact paper on top of the nightstand in Resident room [ROOM NUMBER]. During an interview conducted on 03/02/26 at 9:52 AM, the Maintenance Director reported that he was not aware of the damage to walls or the nightstand and stated that he would get right on it.2) According to Centers of Medicare and Medicaid (CMS) regulations and state guidelines generally require that hot water temperatures at nursing home resident plumbing fixtures (sinks, showers, tubs) be maintained between 100 F and 120 F to prevent scalding while ensuring hygiene. Temperatures should not exceed 120 F, and in some areas, 110 F is recommended for residents unable to regulate water temperature.During the continued tour the Surveyors and Maintenance Director tested the hot water with the Maintenance Director's thermometer. The sink hot water was tested in the private bathrooms of the following Resident rooms: #2391 had a temperature of 123 degrees Fahrenheit (F), #2390 had a temperature of 124 degrees F, room [ROOM NUMBER] had a temperature of 125 degrees F, room [ROOM NUMBER] had a temperature 123 degrees F, and room [ROOM NUMBER] had a temperature of 124 degrees F. During an interview conducted with the Maintenance Director conducted on 03/02/26 at 10:30 AM, the Maintenance Director reported that the Residential hot water had a set point of 125 degrees F because the water temperature will decrease by a few degrees as it reached the Resident. During an observation conducted on 03/02/26 at 10:40 AM, the Surveyors observed the Residential hot water temperature set point at 124.8 degrees F in the boiler room. The Maintenance Director reported that he would reduce the hot water temperature. During a follow up interview conducted on 03/02/26 at 11:49 AM, the Maintenance Director reported that he had adjusted the set point hot water temperature down to 115 degrees F.

Based on observation and interview, it was determined that the facility failed to ensure food items were stored in accordance with professional standards for food service safety. This was identified during the kitchen facility task conducted as part of the annual/complaint survey.The findings include:On 02/25/2026 at 8:41 AM, this surveyor observed items in the refrigerator of the facility's kitchen that were labeled for discard but had not been removed, including:Salad bar cut vegetables labeled Discard by 02/23/2026 07:27 PM.Cut green and red peppers wrapped in plastic wrap with no label or date.On 02/25/2026 at 9:02 AM, this surveyor observed items in the deep freezer that were labeled for discard or were unlabeled and undated, including:A tray of carrots labeled Veg with a discard date of 02/15.Pieces of naan bread in an opened bag with no label or date.Red velvet iced sheet cake labeled Discard 02/20.A bag of meatballs (unopened) with no label or date.A bag of chicken (opened) labeled Good thru 02/23.An additional unopened bag of chicken with no label or date.A bag of croissants labeled Discard 02/16/2026.Mashed potatoes labeled Discard 02/22/2026.On 02/25/2026 at 9:10 AM, this surveyor conducted an interview with the Dining Director regarding the process for discarding food items. The Dining Director reported that night shift staff are responsible for reviewing items in the refrigerator and freezer each evening and discarding expired items during closing. She stated that she routinely reminds staff of this responsibility but acknowledged that items are sometimes missed.On 02/25/2026 at approximately 10:00 AM, this surveyor and the Dining Director conducted a dual observation of the refrigerator and freezer items identified as expired or unlabeled. The Dining Director was shown the items past their discard dates as well as those without labels or dates (including the meatballs, chicken, naan bread, and peppers). It was explained that unlabeled or undated items present a food safety concern because staff are unable to determine the appropriate discard date. During the dual observation, the Dining Director acknowledged understanding of the concern and began discarding the identified items.On 02/27/2026 at 2:42 PM, this surveyor conducted an observation of the 3rd floor kitchen pantry on the Maryland Unit. It was observed that there were no temperature recordings documented for 02/27/2026 at the time of observation. Signage posted on the refrigerator door indicated: Follow these easy steps to keep food safe: Guest Food Only. All food must be labeled with Guest's name, room number and date. All food will be discarded after 3 days. Store food tightly in sealed container. Label with name or number and date. Food will be discarded after 3 days. A second sign stated: Refrigerator cleaning: Refrigerator will be cleaned every other Friday at 2:30 PM. Any food not labeled or out of date will be discarded. The date of observation was Friday after 2:30 PM. Inside the freezer, this surveyor observed a box of spicy chicken sandwich melts labeled with a room number but no date; a box of Stouffer's roast turkey dated 01/09/2026; and a box of Eggo waffles dated June 11, 2021. These findings were inconsistent with posted labeling, dating, and food safety practices.On 02/27/2026 at approximately 3:00 PM, this surveyor conducted an interview with the Administrator and the Director of Nursing (DON). The concerns identified in the main kitchen and in the 3rd floor kitchen pantry on the Maryland Unit were reviewed. The Administrator and DON confirmed understanding of the findings and stated they would ensure the identified food items were addressed.On 03/03/2026 at approximately 11:30 AM, this surveyor conducted a follow-up observation of the 3rd floor kitchen pantry on the Maryland Unit. It was observed that the spicy chicken sandwich melts, box of Stouffer's roast turkey, and box of Eggo waffles had been discarded. The temperature log was up to date for 03/03/2026.

Based on observations, record reviews and interviews it was determined that the facility failed to keep residents free from injury. This was evident for 1 (Resident #10) of 1 resident reviewed for injuries during the annual recertification survey. The findings include:02/25/2026 at 9:10 AM, Resident #10 was observed to have a dressing in place on their left lower leg that was clean, dry, and intact. The Minimum Data Set (MDS) is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified and care is planned based on these individualized needs.Brief Interview for Mental Status (BIMS): A screen used to assist with identifying a resident's current cognition. The BIMS score ranges from 00 to 15. A score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 00-07 indicates severe cognitive impact. Care plans provide direction for individualized care of the resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 2/26/2026 8:36 AM, a review of Resident #10 medical records revealed an MDS assessment completed on 12/17/25 with a BIMS of 07 indicating severe cognitive impairment and was assessed to require substantial / maximal assistance with transfers. A review of Resident #10 care plans showed they were care planned for risk for falls related to weakness, poor safety awareness, attempted self-transfers, and confusion.On 03/02/2026 at 12:04 PM review of Resident #10 medical records confirmed they sustained an injury during a transfer from the bed to the wheelchair on 1/29/26. The progress note documented the laceration to be 6cm x 5cm with a depth of 2cm requiring a transfer to the hospital emergency room (ER) for acute care of the laceration.A skin assessment note dated 2/7/26 documented the presence of 7 superficial stitches and 3 deep sutures for treatment of the laceration. On 03/03/2026 at 8:40 AM, an Interview with Licensed Practical Nurse (LPN #5) confirmed that Geriatric Nurse Aide (GNA #20) came to her and asked her to come to the Resident #10 room to look at a cut. LPN #5 looked at the cut and called her Nurse Manager to come look at the laceration. She reported the Nurse Manger called the Nurse Practitioner (NP) to come and assess resident #10 injury. LPN #5 stated that GNA #20 reported to them it must have happened when she was transferring the resident from the bed to the wheelchair. LPN #5 stated the Nurse Manager completed an in-service for transfers with the nursing staff after the incident. On 03/03/2026 at 8:45 AM, an interview with GNA #20 confirmed the cut to Resident#10 leg happened when she stood the resident up to transfer them. GNA #20 stated that when she stood the resident up from the bed, they immediately complained to her about becoming dizzy but at that point she decided it was safer to sit the resident in the wheelchair since Resident #10 had already started to pivot. GNA #20 looked down at Resident #10 leg as they sat down in the wheelchair, and she could see a cut. Once they were seated in the wheelchair, GNA #20 went and called LPN #5 to the room to assess the cut. GNA #20 confirmed she received education and training for proper transferring from the Nurse Manager.A Power of Attorney (POA) is a legal document granting authority to a trusted person (the agent or attorney-in-fact) to act on behalf of another (the principal) regarding financial, legal, or medical matters. It is essential for incapacity planning, allowing decisions to be made without court intervention On 03/03/2026 at 8:49 AM, an interview with the Nurse Manager confirmed Resident #10 sustained an injury to the left leg that resulted in a laceration to their left shin. She reported that LPN #5 called her to assess Resident #10 leg and she determined it was going to need further care than they could provide in-house. The Nurse Manager called the on-call NP to come and assess Resident #10 injury. When the NP arrived, they agreed Resident #10 should be sent to the ER for further treatment. The Nurse Manager stated they cleaned and wrapped the leg and administered pain medication while waiting for the transfer. She also stated they called the Power of Attorney (POA) to let them know of the incident and transfer to the ER as well as completed a change of condition assessment. The Nurse Manager confirmed she provided education and training for her nursing staff on proper transfers after the incident.

Based on medical record reviews and interviews it was determined the facility staff failed to follow procedures for Residents with a pressure ulcer. This was evident for 2 (#7 & #122) out of 2 residents reviewed for pressure ulcer care during the recertification survey. The findings include:A pressure ulcer, also known as a bed sore or decubitus ulcer, is a localized area of skin damage that develops when prolonged pressure or shear forces disrupt blood flow to the tissues resulting in damage to the underlying tissue. Pressure ulcers are staged based on their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). 1. During a review of the Treatment Administration Record (TAR) for Resident #7 on 3/03/26 at 8:07 AM it was revealed that the Resident was being treated for a Stage II pressure ulcer. He/she had an order that stated, Left buttock stage II: Cleanse with Normal Saline Solution, pat [NAME]. Apply xeroform and cover with bordered gauze every dayshift for wound management for 14 days. The order ended on 2/06/2026. It was discovered that this order for pressure ulcer wound care was not renewed until 2/09/2026. There was no documentation of this wound treatment being completed on 2/07/2026 and 2/08/2026.During continued medical record review for Resident #7 a Skin: Pressure Ulcer Assessment form completed on 2/05/2026 was discovered, it reported the Stage II pressure ulcer would be treated with xeroform. There was no documentation of this wound treatment being completed on 2/07/2026 and 2/08/2026.During an interview with Registered Nurse #28 on 3/03/26 at 8:50 AM she reported pressure ulcer treatment should have an order to be completed. She advised if there was a time frame for the order and it ended; there should be an updated order to continue treatment for the pressure ulcer. During an interview with the 3rd floor Nurse Manager on 3/03/2026 at 9:57 AM she reported that when a wound order ends after a set time frame, the wound should have a reassessment completed and the order renewed. She confirmed that the order for Resident #7 was not reinstated until 2/09/2026 and there was no documentation of that wound care order being completed on 2/07/2026 and 2/08/2026.During an interview with the Director of Nursing on 3/03/2026 at 11:10 AM she reported nurses have to put an order in after assessing the wound and calling the doctor for the orders. She confirmed the order should have been renewed and the order continued on 2/07/2026 and not on 2/09/2026 for Resident #7.2. During a review of the TAR for Resident #122 on 3/03/26 at 11:27 AM it was revealed that the Resident was being treated for a Stage II pressure ulcer. He/she had an order that stated, Cleanse left buttock with Normal Saline Solution, pat dry and apply xeroform and cover with optiform one time a day for three weeks and the order ended on 2/18/2025. The order was not renewed until 2/28/2025. There was no documentation of this wound treatment being completed on 2/19/2026 through 2/27/2025.During additional medical record review, a Skin: Pressure Ulcer Assessment form dated 2/19/25 was discovered which reported the left buttock wound was a stage II pressure ulcer and would be treated with Xeroform. This order was not found in the TAR and was not shown as being completed from 2/19/25 through 2/27/25. During an interview with Licensed Practical Nurse (LPN) #29 on 3/03/26 at 1:29 PM she reported that when the pressure ulcer assessment is completed, the doctor is notified and treatment orders would be obtained. She advised the order would be listed in the treatment section on the Skin: Pressure Ulcer Assessment form. She confirmed that the Treatment section on the Skin: Pressure Ulcer Assessment form date 2/19/2025 showed the wound would be treated with Xeroform. She confirmed the treatment section would be completed after getting orders from the doctor. She was not aware of a reason the order wasn't continued on 2/19/2025 for Resident #122.During an additional interview with the DON on 3/03/2026 at 1:40 PM she confirmed the nurses have to put the order in after assessing the wound and calling the doctor for the orders. She agreed the treatment listed on the Skin: Pressure Ulcer Assessment form would be what the doctor wanted to treat the wound and would be the treatment for Resident #122. She agreed the xeroform treatment order was not continued as ordered for Resident #122 on 2/19/2025.

Based on record review and interview, it was determined that the facility failed to ensure that a resident received care that met acceptable standards of quality. This was evident for 1 (Resident #6) out of 1 resident reviewed during review of a facility reported incident.The findings include: On 03/02/2026 at 9:43 AM, a record review was conducted of the investigation file related to a facility reported incident. The facility reported incident involved an allegation of abuse and neglect against Geriatric Nursing Assistant (GNA) #16 toward Resident #6, which reportedly occurred on 03/04/2025 and 03/05/2025.During review of the investigation file, an interview with Resident #6's Patient Decision Aide (PDA), conducted on 03/11/2025, was reviewed. The PDA reported that she worked with Resident #6 on 03/04/2025 and 03/05/2025 and confirmed that GNA #16 was also providing care to Resident #6 during that time. From the interview questions, the PDA confirms that she observed GNA #16 slamming cabinet doors in the resident's room, moving quickly while opening and closing doors, and had left a dirty blanket on the Resident's bed.An additional interview contained in the investigation file was conducted on 03/11/2025 with a family member of Resident #6. During the interview, the family member reported observing GNA #16 rapidly opening and closing cabinet doors in Resident #6's room and reported that GNA #16 did not appear compassionate while providing care.Another interview contained in the investigation file was conducted on 03/11/2025 with Resident #6. During the interview, the resident was asked about the care provided by GNA #16. The resident reported that she moves too quickly.On 03/02/2026 at 12:21 PM, an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed that GNA #16 is no longer employed at the facility. The DON was informed that review of the facility investigation file did not reveal sufficient evidence to substantiate abuse; however, concerns were identified related to the quality of care provided by GNA #16. It was explained that multiple interviews described GNA #16 moving quickly, slamming cabinet doors in a resident's room, and leaving a dirty blanket on the resident's bed. Additionally, another resident interview described the staff member as moving too quickly while providing care. While these findings did not substantiate abuse, they raised concerns regarding the quality of care provided to residents. The DON acknowledged and confirmed understanding of the concern.

Based on observation, record review and interview it was determined that the facility failed to ensure a Resident's enteral feeding was labeled. This was found to be evident for 1 (Resident #34) out of 1 Resident observed for tube feeding during the recertification and complaint survey. The findings include: Enteral feeding, or tube feeding, delivers liquid nutrition directly into the stomach or small intestine via a tube for individuals with a functioning gut who cannot consume enough calories orally. It is used for short-term (<4-6 weeks, e.g., nasogastric) or long-term support (e.g., G-tube/PEG) to treat malnutrition, swallowing difficulties, or critical illness.A gastrostomy tube (G-tube) is a medical device inserted through the abdomen into the stomach to deliver nutrition, fluids, and medication directly, bypassing the mouth and esophagus. It is used for individuals, often children, with swallowing difficulties, chronic illness, or failure to gain weight.During an observation conducted on 02/25/2026 at 9:45 AM, the Surveyor observed Resident #34 in bed asleep, head of the bed (HOB) raised at 45 degrees, and an enteral feeding infusing from an electronic feeding pump through the Resident's PEG tube. The Surveyor observed the enteral feeding bottle of Glucerna 1.5 without a date and time when the enteral feeding began infusing. A photo was taken of the Glucerna enteral bottle unlabeled by the Surveyor. Dysphagia is the medical term for difficulty swallowing, causing pain, coughing, or food to feel stuck in the throat or chest. It is caused by neurological damage (stroke, dementia), muscular disorders, or obstructions like tumors. Diagnosed via imaging (barium swallow), endoscopy, or motility studies, it is classified as oropharyngeal or esophageal.During a record review conducted on 02/25/26 at 10:39 AM, Resident #34 had the following order: Enteral Feed Order one time a day for dysphagia Glucerna 1.5 cal via PEG tube using pump at 50 ml (milliliter) /hr. (hour) x 20 hrs. (Start at 2pm). This provides 1000ml total volume of enteral formula. Pump to flush 50 ml water q (every) 1 hr. while running (1000ml). Provides 1500kcal (kilocalorie), 82g prot (protein), 1759 ml free water. Order Date 02/24/2026.During an interview conducted on 2/25/2026 at 11:19 AM the Director of Nursing (DON) advised that the expectation was that the staff labeled the enteral feeding bottle with the date and time of when the enteral feeding began infusing.

Based on observation and interviews it was determined that the facility failed to ensure staff practiced infection control. This was evident for 4 (Residents #138, #3, #65 and #131) out of 6 Residents observed for infection control during the recertification survey.The findings include: 1) Enhanced Barrier Precautions (EBP) are infection control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at high risk of spreading multi-drug-resistant organisms (MDROs). They prevent transmission of resistant bacteria like C. auris or MRSA, especially for those with wounds or medical devices. On 02/25/2026 at 9:32 AM The Surveyor observed a sign on the Resident's entry door for Enhance Barrier Precaution (EBP). The Surveyor entered the Resident's room and observed GNA/PDA #30 cleaning Resident #138's face with a white cloth. The GNA/PDA was not wearing gloves and a gown while she provided high contact care. During an interview GNA/PDA #30 stated that she was familiar with EBP that was why she washed her hands before and after providing care. The Surveyor and the GNA/PDA reviewed the sign posted on the entry door, the GNA/PDA stated that she should have worn gloves and a gown when she provided care. During an interview conducted on 02/25/2026 at approximately 12:30 PM, the Director of Nursing (DON) reported that GNA/PDA was not an employee of the facility she was hired by the Resident or the Resident Representative. The DON reported that she personally educated the PDA on EBP right after the Surveyor expressed concern of the observation. The DON further explained that when the facility was made aware that a PDA had been hired, the facility would provide the PDA education and expectation of facilities policies and procedures. The Surveyor requested the records for the education that was provided to GNA/PDA #30. The DON stated that she would obtain the records however the records were never provided to the Surveyor. 2) During an observation on 2/27/2026 at 8:47 AM Licensed Practical Nurse (LPN) #21 was observed using a rolling blood pressure machine on Resident #3. After using the device to obtain a blood pressure and heart rate, she returned the machine to the hallway beside her medication cart. She then returned to Resident #3 to administer medications. The blood pressure machine was not cleaned. During an observation on 2/27/2026 at 9:06 AM LPN #21 was observed taking the rolling blood pressure machine that was used on Resident #3 to Resident #65, the device was not cleaned prior to taking to the Resident. After she obtained a blood pressure and heart rate she returned the machine to the hallway beside her medication cart. She then returned to Resident #65 to administer medications. The blood pressure machine was not cleaned. During an observation on 2/27/2026 at 9:28 AM LPN #21 was observed taking the rolling blood pressure machine that was used on Resident #65 to Resident #131, the device was not cleaned prior to taking to the Resident. After she obtained a blood pressure and heart rate she returned the machine to the hallway beside her medication cart. The blood pressure machine was not cleaned. During an interview with LPN #21 on 2/27/26 at 9:32 AM she advised the blood pressure machine was supposed to be cleaned after use and prior to taking it to a new room. She confirmed that she did not clean the machine between the Residents. During an interview with the Director of Nursing on 2/27/2026 at 12:51 PM she reported that the blood pressure cuffs should be cleaned between residents and advised she would do training to reinforce the cleaning of the machines between Residents.

Based on record reviews and interviews, it was determined that the facility failed to thoroughly investigate a resident's allegation of abuse. This was evident for 2 (Resident #74 and Resident # 140) of 4 residents reviewed for abuse during the annual recertification and complaint survey. The findings include:1) On 03/02/2026 at 11:12 AM, a review of the initial report form for the facility reported incident #357580 regarding Resident #74 submitted on 04/23/2025, for the injury of unknown origin, the steps listed by the facility immediately to ensure residents are protected did not list resident interviews or assessments. The action items listed were: investigation initiated; family notified; physician notified; medical director notified and ombudsman notified. On 03/02/2026 at 11:14 AM, a review of the facility's investigation for abuse revealed no resident interviews or assessments were located within the facility's investigation file. However, there were 8 documented staff interviews.On 03/03/2026 at 11:15 AM, A review of the follow up investigation report form under the steps taken to investigate the allegation confirmed interviews were only completed with staff. On 03/03/2026 at 12:19 PM, an interview was conducted with the Nursing Home Administrator (NHA) for completion of allegations of abuse investigations. The NHA confirmed that the copy in my possession was the full investigation. When asked why resident interviews were not included, she responded I know its best practice to include both. NHA stated she was under the impression the social worker had done them. When asked how they would assess residents that are non-interviewable, she responded we interview residents that they can speak to and staff.She stated that usually the nurse managers or social workers complete resident interviews. On 03/03/2026 at 1:03 PM an interview with the Director of Nursing (DON) was conducted and she stated they do not interview residents that are nonreviewable, instead they look for signs or symptoms for abuse, and they will reach out to family to ask if they have noticed any changes. When asked how or where the facility would document the screening the DON stated through skin assessments. When questioned about the incomplete investigation the DON stated she was not sure why the assessments were not included in the facility incident investigation. On 03/03/2026 at 1:23 PM, The DON brought in copies of Resident Treatment Administration investigations (TARs) for residents that reside in the same hallway as the Resident and it showed that the residents had ongoing orders to be monitored daily for any change in condition. The monitoring orders on the TAR were not related to the investigation of abuse. On 03/03/2026 at 1:30 PM, The DON provided copies of skin assessments for 4 of 14 non-interviewable residents. 2 resident skin assessments were completed on 04/22/2025 and 2 resident skin assessments were completed on 4/23/2025. The DON was not able to produce any other documentation. 2)On 03/02/2026 at 10:00 AM, a review of the initial report form for the facility reported incident #2709082 regarding Resident #140 submitted on 01/05/2026, for the injury of unknown origin, the steps listed by the facility immediately to ensure residents are protected did not list resident interviews or assessments. The action items listed were: investigation initiated; Head to toe assessment completed; Resident medicated for pain; physician notified; responsible party notified, medical director notified; x-ray ordered; care plan updated. Resident interviews and assessments were not listed as an action item. On 03/02/2026 at 10:05 AM, a review of the facility investigation for abuse revealed no resident interviews or assessments were located within the facility investigation. There were 9 documented staff interviews included in the facility investigation.On 03/02/2026 at 10:10 AM, a review of the follow up investigation report form under the steps taken to investigate the allegation confirmed that only staff and the Resident were interviewed for the incident. On 03/03/2026 at 12:19 PM, an interview was conducted with the Nursing Home Administrator (NHA) for completion of allegations of abuse investigations. The NHA confirmed that the copy in my possession was the full investigation. When asked why resident interviews were not included, she responded I know its best practice to include both. NHA stated she was under the impression the social worker had done them. When asked how they would interview residents that are non-interviewable, she responded we interview residents that they can speak to and staff.She stated that usually the nurse managers or social workers complete resident interviews. On 03/03/2026 at 12:59 PM, NHA was able to provide a copy of an email where the social worker reported she interviewed three residents in the same hallway on the day of incident. The NHA stated if they are not interview-able then we can't conduct an interview. The NHA could not provide copies of documented interviews with the three residents. 03/03/2026 1:03 PM interview with The Director of Nursing (DON) and she stated they do not interview residents that are nonreviewable, they look for signs or symptoms for abuse, and they will reach out to family to ask if they have noticed any changes. She was not sure why the assessments were not included in the facility incident chart. DON given time to make copies of the assessments. On 03/03/2026 at 1:33 PM, the DON was not able to provide any documentation of completed Resident assessments.

Based on medical record reviews and interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of the resident's disenrollment in hospice services. This was evident for 1 (Resident #43) out of 2 residents reviewed during recertification survey process. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected on the MDS drives Resident care planning decisions. The nursing home should complete a Significant Change in Status MDS assessment within 14 days of a major decline or improvement in a resident's status after the determination that a significant change has occurred.On 2/27/2026 at 1:48 PM, review of Resident #43's electronic medical record revealed that the resident was admitted to [NAME] Hospice Services on 12/23/2023.On 03/01/2026 at 11:15 AM, record review of the resident's medical record revealed a hospice physician certification of terminal illness for the benefit period beginning 12/23/2023 under services provided by the [NAME] Hospice Services, indicating the resident was receiving hospice services during that period.Further review of records on 03/01/2026 at 2:00 PM revealed a physician's progress note documenting that Resident #43 was disenrolled from [NAME] Hospice Services due to extended prognosis, effective 1/23/2026, indicating the end of the hospice benefit period. On 3/2/2026 at 7:00 AM, a review of Resident #43's significant change Minimum Data Set (MDS) assessment revealed a reference date of 2/5/2026. The assessment was completed and signed in Sections V0200B2 and Z0500B on 2/11/2026, 20 days after the resident's disenrollment from hospice services and 5 days late. On 03/02/2026 at 9:59 AM, the Director of Nursing (DON) was interviewed and stated that Resident #43 was admitted to hospice services on 12/24/2023 and disenrolled from hospice on 1/23/2026. The DON further confirmed that a significant change MDS assessment with a reference date of 1/5/2026 was completed and signed on 2/11/2026.On 03/02/2026 at 11:15 AM, the surveyor reviewed the significant change Minimum Data Set (MDS) assessment for Resident #43 with the Director of Nursing (DON). During the review, the DON confirmed that the assessment was completed late.

Based on interviews and record reviews it was determined that the facility failed to ensure a Resident care plan was developed. This was found to be evident for 1 (Resident #166) out of 32 Resident care plans reviewed during the recertification and complaint survey.The findings include: A review of complaint #2607648 submitted to the Office of Health Care Quality (OHCQ) was conducted on 02/27/26 at 8:00 AM. The complainant reported that the facility failed to provide accommodations for Resident #166. During a phone interview conducted on 02/27/26 at 8:46 AM, the complainant reported that Resident #166 was blind and that the facility failed to have interventions in place to accommodate the Resident's needs. Category 4 blindness is a severe classification of vision impairment defined by the World Health Organization (WHO) as having a best-corrected visual acuity worse than (roughly) but still retaining light perception. It often includes severe visual field restrictions (less than), indicating very limited functional vision compared to total blindness.During a review of Resident #166's medical records conducted on 02/27/26 at 9:02 AM, it was discovered that the Resident had a diagnosis of blindness in right and left eye category 4. A care plan is a personalized, living document that outlines a person's health conditions, specific care needs, goals, and the tailored interventions required to manage their well-being. Developed collaboratively between individuals, families, and professionals, it guides caregivers by organizing, prioritizing, and ensuring consistent care.During a review of Resident #166's care plan conducted on 02/27/26 at 9:07 AM, it was discovered that the Resident did not have a care plan for his/her blindness. During an interview conducted on 3/02/26 at approximately 10:30 AM, the Director of Nursing (DON) reviewed Resident #166's care plan with revisions with the Surveyor and confirmed the Resident did not have a care plan for blindness. The DON explained that it is the facility's expectation that a Resident with a vision impairment such as blindness has a care plan with interventions that would address the needs of the Resident.

Based on record reviews and interviews it was determined that the facility failed to provide services that met professional standards of practice. This was found to be evident for 1 (Resident #166) out of 1 Resident reviewed for professional standards of practice during the recertification and complaint survey. The findings include: 1)A review of complaint #2607648 submitted to the Office of Health Care Quality (OHCQ) was conducted on 02/27/26 at 8:00 AM. The complainant reported that the facility failed to hold a blood pressure medication and notify the physician when the Resident blood pressure was low. Systolic blood pressure, the top number in a reading (e.g., the 120 in 120/80 mmHg), measures the maximum pressure in your arteries when your heart muscle contracts and pumps blood. It indicates how hard your heart is working to pump blood to the rest of the body with each beat.A review of Resident #166's Medication Administration Record (MAR) conducted on 03/02/26 at 8:19 AM showed the following orders: Amlodipine Besylate Oral Tablet 10 mg (milligram) (Amlodipine Besylate). Give 1 tablet by mouth at bedtime for HTN (hypertension) hold for SBP (Systolic Blood Pressure) less than 110. Metoprolol Succinate ER (Extended Release) Tablet 24 Hour 50 mg. Give 1 tablet by mouth one time a day for HTN hold for SBP less than 110. HR (Heart Rate) less than 60. Further review of the MAR showed that Registered Nurse (RN) #28 administered Metoprolol Succinate ER (Extended Release) Tablet 24 Hour 50 mg on 03/13/25 between 8-10 am. However, the Resident's Systolic Blood Pressure reading was 101 which was less than 110 and should have been held. During a review of Resident #166's Blood Pressure (BP) readings conducted on 03/02/26 at 8:24 AM it was discovered that the Resident's Systolic Blood Pressure reading was below the acceptable parameter of 110. On 03/13/25 the BP was 103/57, on 03/13/25 the BP was 101/58, on 03/14/25 the BP was 102/57, and on 03/16/25 the Resident had two readings 94/51 and 98/56. A review of Resident #166's medical records conducted on 03/02/26 at 8:29 AM did not show that the physician was notified of the Resident's Systolic Blood Pressure reading was less than 110 and the medication was not administered. During an interview conducted on 03/02/26 at approximately 9:10 AM, the Director of Nursing (DON) reported that she reviewed the MAR and confirmed Resident #166 was administered the Blood Pressure medication in error. She also confirmed that the physician was not notified that the Resident's Systolic Blood Pressure was less than 110 and the BP medication was not administered. The DON explained that it is the facility's expectation that the physician is notified when a Resident falls below a parameter and/or a medication cannot be administered.2) During a review of the Maintenance hot waterlogs conducted on 03/02/26 at 11:00 AM, the Surveyor discovered the following: 02/16/26 the hot water temperature was recorded at 120 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature.02/17/26 the hot water temperature was recorded at 119 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature.02/21/26 the hot water temperature was recorded at 120 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature.02/22/26 the hot water temperature was recorded at 120 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature.02/23/26 the hot water temperature was recorded at 119 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature.02/24/26 the hot water temperature was recorded at 119 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature.02/25/26 the hot water temperature was recorded at 120 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature.02/26/26 the hot water temperature was recorded at 120 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature.2/27/26 the hot water temperature was recorded at 119 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature. 02/3/26 the hot water temperature was recorded at 121 F with a line and an arrow pointing downward through each box for each resident room in place of the actual temperature.During an interview conducted on 03/02/26 at 11:52 AM, the Maintenance Director acknowledged that the hot waterlogs were not documented completely or accurately. The Maintenance Director stated that he reviewed the logs and was in the process of educating his staff on the importance of capturing the accurate hot water temperature for each room accurately completing the sheet.

Based on record review and staff interviews, it was determined that the facility failed to provide Cardiopulmonary Resuscitation (CPR) to an unresponsive resident whose active Maryland Orders for Life Sustaining Treatment (MOLST) instructed to Attempt CPR if cardiac and/or pulmonary arrest occurs. This was evident for 1 (#137) of 21 residents reviewed for abuse during the survey. This deficient practice led to an immediate jeopardy for Resident #137 on [DATE]. Following the incident, the facility implemented effective and thorough corrective measures. The facility's plan and action were verified during this survey; therefore, this deficiency was cited as past noncompliance. The date of correction was [DATE]. The findings include: Cardiopulmonary resuscitation (CPR) refers to any medical intervention used to restore circulatory and respiratory function that has ceased. Maryland MOLST is a portable and enduring form for orders about cardiopulmonary resuscitation and other life-sustaining treatments. It makes one's treatment wishes known to healthcare professionals. Do Not Resuscitate (DNR)Order refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Code Status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops. A review of Resident #137's medical record revealed a MOLST, completed on [DATE], with Resident #137 as the decision maker and instructed to Attempt CPR. A review of a facility self-report MD00203965 for Resident #137, dated [DATE] indicated that, at approximately 4:30 AM on [DATE], staff #7, a geriatric nurse aid (GNA), noticed that Resident #137 was unresponsive upon entering his/her room. Staff #7 alerted the assigned nurse for Resident #137, staff #8, a registered nurse (RN). Further review revealed a clinical note for Resident #137 written by staff #8 and dated [DATE]. The note recorded that during routine check, resident was observed to have a cold clammy skin, no rise and fall of chest wall, pupils dilated to bright light. Vitals signs [respiration, pulse, blood pressure, temperature] weren't recordable. However, the review failed to show that staff #8 initiated CPR on Resident #137, as indicated on his/her MOLST form. A continued record review showed that staff #8 notified staff #9, the RN nurse supervisor, that Resident #137 was unresponsive and had a DNR order. Staff #9 then checked the resident's physical chart, which contained a MOLST that instructed staff to attempt CPR. The review failed to show that CPR was initiated at this point. In an interview on [DATE] at 1:04 PM with staff #1, an RN supervisor, she revealed that the form the nurses previously used for their change of shift report used to contain residents' code status. Staff #1 added that, due to inconsistencies, staff were educated to review the residents' physical charts for code status. In an interview on [DATE] at 9:06 AM, the director of nursing (DON) indicated that her investigation revealed that staff #8 used a form for her change of shift report with a code status for Resident #137. However, the DON was unaware of the form and expected staff # 8 to review Resident #137's MOLST for his/her code status. During an interview on [DATE] at 3:10 PM, staff #8 reported that this was her first time working with Resident #137 on [DATE]. Staff #8 continued to say that she did not initiate CPR on Resident #137 on that day because she was handed a report form at the start of her shift by the off-going nurse, which indicated that Resident #137's code status was DNR. Staff #8 added that she notified staff #9, who called Resident #137's attending provider. The provider ordered not to initiate CPR at that point because the resident was already cold to the touch and had no vital signs. A review of the certificate of death showed that Resident #137's date and time of death was [DATE] at 5:00 AM. In an interview on [DATE] at 8:33 AM, staff #16, a licensed practical nurse (LPN), indicated that the nursing staff used a form for their change of shift report, which contained residents' code status. However, after Resident #137's incident on [DATE], the nursing staff had been educated to check residents' physical charts for code status. A corrective action plan was developed and started on [DATE] after the incident occurred: 1) The staffing agency was notified of the occurrence, and staff #8 was placed on the Do Not Return list for the facility. 2) A document review was conducted on all units to ensure code status information was only available on the MOLST form in the residents' physical charts. 3) Nursing staff were re-educated on MOLST and the CPR process on [DATE]-[DATE] by the RN unit managers. 4) Policy on MOLST and CPR and education were activated in the facility's training software program for nursing staff review and acknowledgment. 5) The 3 Unit Managers (Care Coaches) also provided in-person training to all nursing staff. 6) The Medical Director provided education to all attending physicians (including Resident #137's attending provider) on [DATE]. 7) The facility audited and reviewed all residents' MOLST forms and orders. On [DATE] at 12:28 PM, after a review of the credible evidence of education, audits, and interviews with multiple staff, it was determined that the facility had identified this deficient practice and implemented interventions to prevent a recurrence. The date of compliance, as identified by the date on which the training was completed, was determined to be [DATE].

Based on record review and interview, it was determined that the facility failed to ensure that direct care staff had mandatory communication training. This was evident for 8 staff (#15, #17, #18, #19, #20, #21, #22, #23), of 8 staff training records reviewed for communication training during the extended survey portion of the recertification survey. The findings include: On 10/08/24 at 10:34 AM, eight randomly selected employee files were requested as part of the staffing facility task of the standard survey, and included Geriatric Nursing Assistants, Licensed Practical Nurses, and a Registered Nurse. On 10/09/24 at 3:53 PM, the extended survey task was triggered due to an Immediate Jeopardy situation determined during the standard survey. As a result, the survey team determined the need to review the randomly selected direct care staff for evidence of communication training. On 10/10/24 at 9:10 AM, a record review revealed a lack of evidence of communication training for GNA #15, GNA #17, GNA #18, GNA #19, GNA #20, and LPN #21, LPN #22, and RN #23. On 10/11/24 at 11:55 AM, the Nursing Home Administrator was made aware of the lack of evidence of mandatory communication training for direct care staff. No further evidence was provided.

Based on record review and interview, it was determined that the facility failed to 1) report allegations of abuse within two hours, and 2) identify and report potential abuse to the administrator. This was evident for 1) four facility reported incidents (FRIs) (#MD00202347, #MD00198954, #MD00181634, MD00187540) of seventeen FRIs, and 2) one (Resident #33) of twenty-one residents reviewed for potential abuse. The findings include: 1a) On 10/08/24 at 11:55 AM, a review of the facility reported incident #MD00202347 revealed that Resident #36's responsible representative made the facility aware of an allegation that female residents on the second floor were being compromised at night. Staff were made aware of the allegation on 2/06/24 at 3:15 PM, but failed to report the allegation to the Office of Healthcare Quality until 2/07/24 at 6:07 PM. On 10/09/24 at 8:24 AM, the surveyor reviewed the concern with the Director of Nursing (DON) regarding the failure to report an allegation of abuse within 2 hours. 1b) On 10/09/24 at 9:03 AM, a review of the facility self reported incident #MD00198954 revealed that Resident #67's responsible representative made the facility aware of an allegation that Resident #67 told him a staff member put his/her head in the toilet but could not indicate if it happened at the facility. Staff were made aware of the allegation on 10/25/23 at 2:40 PM but failed to report the allegation to the Office of Healthcare Quality until 10/26/23 at 7:17 AM. On 10/09/24 at 08:25 AM, the surveyor reviewed the concern with the Director of Nursing (DON) regarding the failure to report an allegation of abuse within 2 hours. 51213 1c) On 10/10/24 at 8:50 AM, facility report MD # 00181634 was reviewed. This review revealed that Resident # 139 reported an allegation of abuse on 8/2/22 at 4:30 PM. The date of the initial email regarding the self-report was sent to the state survey agency on 8/3/22 at 11:23 AM. On 10/10/24 at 4:04 PM, the Director of Nursing was asked what the time frame was to report an allegation of abuse. The DON's response was 2 hours. She confirmed that the facility reported incident #MD00181634 was reported after the required timeframe. 37276 1d) On 10/10/24 9:40 AM, a review of facility reported incident, MD00187540 revealed documentation that, on 1/9/23 at 1:16 PM, a family member of Resident #138 reported to facility staff that Resident #138 alleged s/he was being abused and retaliated against by the staff. Review of email confirmation of when the facility's initial self-report was sent to the state agency revealed documentation that the incident was reported to the state agency on 1/9/23 at 6:34 PM. The facility failed to forward a first report of an allegation of abuse to the state agency immediately, but not later than 2 hours once the facility staff became aware of the abuse allegation. On 10/10/24 at 4:05 PM, during an interview, the concerns with failing to report an allegation of abuse immediately, but not later than 2 hours were discussed with the Director of Nurses (DON). At that time, the DON acknowledged the concerns and stated that the time to report an allegation of abuse was within 2 hours. 16218 2) A review of Resident #33's medical record revealed the resident required staff assistance with transfers from bed to wheelchair and back to bed. A review of the facility reported incident (MD00189254) revealed that on 2/19/23 the geriatric nursing assistant (GNA Staff #15) refused to assist Resident #33 back to bed when the resident requested assistance. The incident was reported to the state survey agency on 2/20/23. A review of the facility's interview with Resident #33, dated 2/21/23 revealed that on 2/19/23 the resident was in the dining room for lunch. After lunch the resident asked GNA #15 to take the resident back to his/her room. The GNA said No, and indicated when she (GNA) was ready she would take the resident back. The resident then told the GNA that his/her legs hurt and that he/she wanted to go back to his/her room. The GNA again refused to assist the resident and, according to the resident's statement, said: Shut up. I don't want to hear you complaining. You're going to have dinner there. At 3:00 PM the resident said I'm going back, the GNA responded: No, I'll take you after dinner. The resident then got upset and called the GNA a son of a #####. The resident then proceeded to wheel him/herself back toward his/her room until another staff person (GNA #24) came to assist the resident. A review of the facility's interview with GNA #15, dated 2/21/23, revealed the statement of events on 2/19/23: After lunch [the resident] said that [s/he] wanted to go back to [his/her] room and I told [the resident], 'no'. [The resident] also asked a few visitors if they could help [him/her] to bed and I told the visitors, 'no' and that we would assister [him/her] to bed later. Did [the resident] tell you that [s/he] called me a '#####'? A review of the facility's interview with Nurse #16, dated 2/20/23, revealed that on 2/19/23 Resident #33 requested to be put to bed. The Nurse #16 asked the assigned GNA (#15) to assist the resident back to bed but GNA #15 said: No, she is not going to put [the resident] to bed because [the resident] called her a #####. Nurse then asked GNA #24 to assist the resident. The Nurse #16 then informed the Care Coach (Staff #1) what happened on the unit. A review of the interview statement from Care Coach (Staff #1), dated 2/21/23, revealed she spoke with the GNA #15 after Nurse #16 had reported that the GNA did not assist a resident to bed when requested. The statement included: [GNA #15] stated to me that she just got the resident up and that she wanted to wait until after dinner to assist the resident back to bed. She told me that the resident called her a son of a ##### Further review of the Care Coach's interview statement failed to reveal documentation to indicate the Care Coach spoke with the resident on the evening of 2/19/23. On 10/10/24 at 9:35 AM an interview was conducted with Care Coach (Staff #1). She reviewed her statement from 2/21/23 and confirmed that it was correct. The Care Coach was unable to recall if she spoke with the resident that evening. When asked if she told anyone else about the incident that evening, the Care Coach reported that she did not think it was a customer complaint, she was not aware at the time that the resident had requested, and GNA had refused, to assist; and that she just thought it was the GNA telling the nurse no. Further review of the investigation documentation revealed the resident reported the incident to the then Assistant Director of Nursing (ADON) on the morning of 2/20/23. On 10/10/24 at 10:39 AM the Director of Nursing (DON) was interviewed. The DON confirmed that she was not aware of the incident until the day the report was sent in, and stated: I wasn't made aware until the 20th, from what I understand he/she (Resident #33) requested to speak with the ADON. When the surveyor expressed the concern that there was no follow up with the resident that evening, the DON reported they did identify the concern that the incident was not identified as abuse when it occurred. The DON went on to report that she did inform the Care Coach that she should have spoken with the resident and taken the GNA off the schedule. The facility also provided documentation that training was conducted with staff on 2/23/23 and 2/25/23 regarding the Resident's [NAME] of Rights and Reporting Abuse.

Based on observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent prior to the initiation of bed rails. This was evident for 2 (Resident #23 and #120) of 4 residents reviewed for physical restraints. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. The facility should obtain a signed consent form before the use of bedrails. 1) On 10/02/24 at 9:59 AM, the surveyor observed Resident #120 in bed with two bed rails up on either side of the top end of the bed. On 10/03/24 at 11:33 AM, a review of Resident #120's medical record failed to reveal a consent form for the bed rail use. On 10/09/24 at 7:47 AM during an interview with the Director of Nursing (DON), the DON explained that the facility used enabler quarter rails, the residents were assessed prior to their initiation, and the rails were assessed and maintained quarterly. The DON further explained that the consent could be found on the assessment form. During the interview with the DON on 10/09/24 at 7:47 AM, the surveyor reviewed the bed rail assessments for Resident #120 which failed to reveal consent. The surveyor requested documentation of consent for the resident's bed rail use. On 10/10/24 at 7:33 AM, the Nursing Home Administrator (NHA) informed the surveyor that there was no consent for Resident #120's bed rail use. On 10/10/24 at 7:49 AM, the surveyor reviewed the concern with the DON regarding the failure to ensure that consent was obtained prior to bed rail use. 2) On 10/02/24 at 9:38 AM, the surveyor observed Resident #23 in bed with two bed rails up on either side of the head end. On 10/03/24 at 11:33 AM, review of Resident #23's medical record failed to reveal a consent form for the bed rail use. On 10/09/24 at 7:47 AM in an interview with the DON, she explained that the facility used enabler quarter rails, the residents were assessed prior to their initiation, and the rails were assessed and maintained quarterly. The DON further explaind that the consent could be found on the assessment form. During the interview with the DON on 10/09/24 at 7:47 AM, the surveyor reviewed the bed rail assessments for Resident #23 which failed to reveal consent. The surveyor requested documentation of consent for the resident's bed rail use. On 10/10/24 at 7:33 AM the NHA informed the surveyor that there was noconsent for Resident #23's bed rail use. On 10/10/24 at 7:49 AM, the surveyor reviewed the concern with the DON regarding the failure to ensure consent is obtained prior to bed rail use.

Based on record review and interview, it was determined that the facility failed to ensure the pharmacists recommendations regarding medications irregularities were communicated to the resident's physician. This was evident for three residents (Resident #51, # 111, and #117) of 5 residents reviewed for unnecessary medications during a survey. The findings include: 1) On 10/04/24 at 9:30 AM, Resident #51's medical records were reviewed. The review revealed that Resident #51 was a long-term resident at the facility and was receiving multiple medications. Further review revealed that a pharmacist reviewed Resident #51's medications for irregularities every month from November 2023 through September 2024. On 10/04/24 at 10:09 AM, a review of progress notes revealed a pharmacy note, dated 11/06/23, that indicated Resident #51's medications were reviewed and included that statement See report for any noted irregularities and or recommendations. On 10/04/24 at 12:20 PM, the Director of Nursing (DON) was interviewed and reported that she was unable to provide the 11/06/23 pharmacy report for Resident # 51. In addition, the DON failed to provide information about whether any irregularities were noted in the 11/06/23 pharmacy review and if they were addressed by the resident's physician. On 10/04/24 at 2:23 PM in another interview with the DON, she explained that the pharmacist reviewed residents' medications every month. If the pharmacist did not note any irregularities, they would document t in the progress notes as, No Irregularities noted. If the pharmacist found irregularities they would document see report for any noted irregularities and or recommendations. The pharmacist then emailed this report to the facility clinical management staff which included nursing supervisors (care coaches). The care coaches then printed the report out and gave it to the appropriate physician. The physician reviewed and signed the report, and documented on the report if he/she agreed or disagreed with the pharmacist recommendations and any new orders. After the physician documented on the report, it was then faxed back to the pharmacist. The report was kept in a binder at the unit nurses' station for three years. On 10/10/24 at 4:20 PM, the above concerns with discussed with the Director of Nursing (DON) and Administrator. The DON confirmed that there was no documentation that the above pharmacist recommendations were communicated to the Physician. 2). On 10/04/24 at 10:56 AM, Resident # 111's medical record was reviewed and revealed that the he/she was a long-term resident of the facility and had numerous medications ordered. Further review revealed that a pharmacist had reviewed the resident's medications for any irregularities every month between October 2023 and September 2024. On 10/04/24 at 12:20 PM, the Director of Nursing (DON) was interviewed interview and reported that she was unable to provide the 10/10/23 pharmacy review for Resident #111. In addition, she failed to provide what the noted irregularities were in the 10/10/23 pharmacy reviews and if they were addressed by the resident's physician. On 10/04/24 at 2:23 PM, the Director of Nursing was interviewed and she reported that the pharmacist reviews every resident's medication every month. If the pharmacist does not note any irregularities, they will document this in the progress notes as No Irregularities noted. If the pharmacist finds irregularities, this will be documented in the progress notes as see report for any noted irregularities and or recommendations. The pharmacist emails this report to the facility, clinical management staff, including the nurse unit's supervisor (care coaches). The care coaches print the report out and give it to the appropriate physician. The physician reviews and signs the report. In addition, he documents on the report if he agrees or disagrees with the pharmacist recommendations and any new orders. After the report is completed by the physician, the report is then faxed back to the pharmacist. The report is kept in a binder at the unit's nurses' station and kept for three years at the nurse's station. On 10/10/24 at 4:20 PM, the above concerns with discussed with the Director of Nursing (DON) and Administrator. The DON confirmed that there was no documentation that the above pharmacist recommendations were communicated to the Physician. 37276 3.) On 10/08/24 at 2:00 PM, a review of Resident #117's medical record was conducted and revealed the resident resided in the facility since for long term care since February 2024. Review of Resident #117's progress notes revealed the pharmacist documented a review of Resident #117's medications monthly in a Consultant Pharmacist Note/Medication Regimen Review note, and when no irregularities were identified, the pharmacist wrote no irregularities noted, in the monthly note. Further review of the pharmacist's monthly medication regimen notes for Resident #117 revealed on 3/11/24 at 2:07 PM, 6/10/24 at 2:54 PM, and 8/2/24 at 4:15 PM, the pharmacist wrote see report for any noted irregularities and/or recommendations. Continued review of Resident #117's electronic medical record and paper hard chart, failed to reveal documentation as to what the pharmacist identified and/or recommended on these 3 pharmacy review dates. On 10/08/24 at 1:45 PM, the surveyor requested Resident #117's pharmacist's reports for the dates 3/11/24, 6/19/24 and 8/2/24. Shortly after, the Director of Nurses (DON) provided the surveyor with 3 pharmacist report forms for Resident #117 that were labeled, Note to Attending Physician/Practitioner/Prescriber, and dated 3/11/24, 6/10/24, and 8/02/24 that documented the irregularity identified by the pharmacist, the pharmacist's recommendations, and the physician/prescriber's response to the pharmacist's recommendations. At that time, the DON indicated the pharmacist's reports were kept in a binder, and were not in the resident's medical record. In the pharmacist's report, dated 6/10/24, the pharmacist identified that Resident #117 was receiving antipsychotic therapy and recommended the physician order an Abnormal Involuntary Movement Test (AIMS) now and every 6 months. The report documented the practitioner agreed with the pharmacist and was signed and dated by the Psychiatric-Mental Health Nurse Practitioner (PMHNP) on 7/04/24. There was no documentation in the report to indicate the attending physician reviewed the pharmacist's report, or documentation of the attending physician's potential response to the pharmacist's recommendation. In the pharmacist's report, dated 3/11/24, the pharmacist identified that Resident #117 had 2 orders for similar eye drop medication, and recommended the physician discontinue one of the orders to prevent duplication of therapy. The report documented the attending physician did not agree with the pharmacist's recommendations and the report was signed and dated by the attending physician on 3/13/24. In the pharmacist's report, dated 8/02/24, the pharmacist identified that Resident #117 had duplicate medication orders for GERD (gastroesophageal reflux disease) and recommended that one of the orders be discontinued. The report documented the attending physician agreed with the pharmacist's recommendation and attending physician signed and dated the report on 8/13/24. Continued review of Resident #117's medical record failed to reveal documentation that the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. On 10/11/24 at 11:00 AM, the guidance regarding the attending physician documenting a response to the pharmacist's recommendation in the medical record was discussed with the DON, and the DON was made aware of the above concerns, who acknowledged the concerns at that time.

Based on observation and interview, it was determined that the facility failed to 1) ensure the eanvironment in the facility was in good repair, and 2) failed to have an effective system in place to ensure that maintenance issues were reported to and addressed by maintenance staff in a timely manner. This was evident for 1) one housekeeping closet and three hallway bathrooms, and 2) for two out of thirty-two rooms observed during the survey. The findings include: 1a) On 10/02/24 at 1:00 PM, an observation of the Potomac Unit on the 2nd floor of the facility was conducted. A housekeeping closet was located across from room [ROOM NUMBER]. The closet door opened when the handle was turned. A keypad lock device was present on the door, but was partially separated from the door. The closet contained a vacuum, cleaning liquids in a wall dispenser, and large bottles of hand sanitizer. On 10/02/24 at 1:05 PM, Registered Nurse (RN #1) was interviewed, and she said the door should be locked. She turned the door handle and opened the door without using the keypad lock. She said she was unaware that the door lock was broken but said she could see that it was loose. On 10/02/24 at 1:57 PM, an interview was conducted with the Director of Nursing and Staff #1. They confirmed that the housekeeping closest was unlocked and that this was a deficiency. They said they had contacted Maintenance to make the repair. 45139 1b) On 10/04/24 at 12:30 PM, a random observation in the Potomac hallway bathroom, located across from the 2nd-floor dining room, revealed a hole in the wall opposite the toilet. Further observation revealed that the hole in the wall was in the shape of the bathroom door's handle. The hole was approximately 7 inches long, and the widest portion was 3- 1/2 inches. Continued observation revealed that the hole was stuffed with toilet paper. A second observation of the same Potomac Hall bathroom on 10/10/24 at 12:35 PM, revealed no change in the hole in the wall. On 10/10/24 at 1:25 PM, the Maintenance Director (Staff #12) and surveyor made a joint observation of the hole in the wall of the Potomac hallway bathroom. The hole in the wall was filled with toilet paper. Staff # 12 stated that he was unaware that the hole was there and said that it would be repaired immediately. On 10/10/24 at 4:20 PM, in an interview with Staff #12 and the Nursing Home Administrator, they reported that repair of the hole in the wall was in progress. On 10/11/24 at 8:55 AM, an observation of the Potomac Hall bathroom revealed that the hole was no longer visible. The area where the hole had been was covered by spackle and white primer paint. 51213 2) On 10/02/24 at 10:46 AM in room [ROOM NUMBER], the surface of the dry wall behind the residents bed was observed to be gouged in three different areas exposing the white chalk like surface beneath. On 10/03/24 at 11:09 AM in room [ROOM NUMBER], the surface of the dry wall behind the resident's bed was observed to be gouged in five different areas exposing the white chalk like surface beneath. During observation on 10/10/24 at 11:22 AM in room [ROOM NUMBER], the drywall directly behind the bed still had the same drywall missing from five places exposing the white chalk like surface beneath. On 10/10/24 at 11:50 AM during an interview, the maintenance director (Staff #12) was asked how work orders were processed and received by his department within the facility. Staff #12 stated that if the situation was non-emergent, the staff would call the front desk. The front desk would enter a work request into the computer system, which is what the facility uses to retrieve and track work orders. Once the front desk has put the work order in the computer, the maintenance department can retrieve and track the work orders. When Staff #12 was asked if he was aware that the dry wall in rooms [ROOM NUMBERS] had dry wall gouged in several places exposing the bare surface beneath Staff # 12 replied that he was not aware. The surveyor asked if there was documentation to indicate that the maintenance director received work orders for these two rooms. He said he would check. On 10/10/24 at 1:21 PM, Staff #12 reported that the rooms need to be vacant in order to complete the repairs and the two rooms were not currently on the vacant list. Staff #12 provided documentation to indicate that work had been completed for some rooms on the same unit in July and August, however, he failed to provide documentation to indicate there were current work orders for Rooms 3146 or 3149.

Based on record review and interview with facility staff, it was determined that the facility failed to ensure that a primary care provider was notified of a lab result. This was evident for 1 (Resident #120) of 3 residents reviewed for urinary tract infections. The findings include: On 10/02/24 at 1:42 PM, review of Resident #120's electronic medical record revealed a urine culture and sensitivity result from the lab, dated 9/20/24 at 12:00 PM, which indicated the urine specimen was spilled in transit and that Registered Nurse, Staff #14 was informed. On 10/08/24 at 9:19 AM, an interview with the second floor Registered Nurse Care Coach/Unit Manager (Staff #1) revealed that the responsibility of the nurse with lab results is to review and notify the primary care provider of the results. Further interview revealed the nurse should document the communication with the provider of the result and the provider response. Further review of Resident #120's medical record failed to reveal any documentation to indicate that the urine was spilled in transit was communicated to a primary care provider. On 10/09/24 at 7:59 AM, the surveyor reviewed the concern with the Director of Nursing (DON) regarding the failure to notify the provider of Resident #120's lab result from 9/20/24.

Based on record review and interview, it was determined that the facility failed to respond timely when residents called for assistance. This was evident for 1 complaint (#MD00206835) of 6 complaints reviewed during the recertification survey. The findings include: On 10/08/24 at 3:00 PM, a review of complaint #MD00206835 was conducted. It alleged that staff were slow to answer Resident #152's call bell on 11/20/23, 11/21/23, 11/25/23, 11/26/23, and 12/04/23. On 10/11/24 at 10:15 AM - the Nursing Home Administrator (NHA) was asked to provide the call bell response log for Resident #125 for the days of concern. A review of those records revealed that on 11/20/23, 11/21/23, 11/25/23, 11/26/23, and 12/04/23, Resident #152's call bell went unanswered for 42 minutes or longer at least once. On 11/20/23, 11/25/23, and 12/04/23, this occurred twice. On 10/11/24 at 10:20 AM in an interview with Geriatric Nursing Assistant (GNA #13), she described how the call bell system worked. She said that when the resident pressed their call device, the GNAs received a phone notification on an app. The app showed the room number and if it was from the bed or the bathroom. She further explained that the expectation was to answer the call bell within 8 minutes, that she was told this in staff meetings and in orientation. On 10/11/24 at 10:26 AM, an interview with Licensed Practical Nurse (LPN #1) was conducted. She explained that call bell alerts went to the GNAs first, and if the GNA does not turn it off in 5 minutes, the nurses were alerted. The expectation was that the call bell was answered within 5 minutes. She also said the supervisor was notified when the call bell was answered. When asked if a call bell response time of 40 minutes or more was acceptable, she said No. On 10/11/24 at 10:41 AM, an interview with the Director of Nursing (DON) was conducted. When she was asked to provide the facility's call bell policy she replied that the facility does not have one. On 10/11/24 at 11:10 AM, an interview was conducted with the NHA and DON and they confirmed the delay in call bell response time and said they knew this was a deficiency.

Based on clinical record review, the review of administrative documents, and facility staff interviews, it was determined that the facility's staff failed to use the proper technique when transferring a resident using a mechanical lift device. This finding was evident in 1 of 3 residents reviewed for transfers with a mechanical lift during a complaint survey (Resident #3). This facility's failure resulted in actual harm related to the resident. The findings include: This finding was identified during the investigation of complaint MD 977. On 12-31-2019, review of the clinical record for Resident #3 revealed a comprehensive care plan for at risk for falls with an intervention of a hoyer lift with two-person assist for all transfers. Also, the review of the annual minimum data set (MDS) assessment date 05-11-19 Section G0110 transfers was coded for two-persons physical assist. The minimum data set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. On 12-31-2019 further review of Resident #3's clinical record revealed a nursing progress note on 06-02-2019 where the nurse documented the geriatric nursing assistant (GNA) reported that during a transfer to the bed with a mechanical lift device, the resident fell and hit their head on the floor. The nurse went to assess the resident who was already back in bed but sustained a laceration to the forehead. The nursing assessment revealed the resident needed stitches. The resident was sent to the emergency room for further care. The continued review of the Resident's clinical record revealed a provider follow-up progress note, dated 06-03-2019, that Resident #3 received 18 stiches to the left side of the forehead. On 12-31-2019 at 10:00 AM in an interview, the Administrator stated an internal investigation was completed on Resident #3's fall and a statement from the GNA was obtained. The GNA admitted to using a mechanical lift device to transfer the resident without the assistance from a second staff member. In addition, the administrator stated there must always be two staff members using a mechanical lift device to transfer residents. On 12-31-2019 at 10:30 AM surveyor review of the facility's mechanical lift machine policy states at least two nursing assistants are needed to safely move a resident with a mechanical lift. On 12-31-2019 at 11:00 AM surveyor review of the GNA's statement revealed the GNA stated she used a mechanical lift device without a second staff member present to transfer resident #3 to the bed and during the transfer the resident fell hitting their head on the floor.

Based on surveyor observation(s), review of clinical records, facility policies and procedures, and resident and staff interview(s), it was determined that facility staff failed to implement preventive measures to prevent a pressure injury for residents identified at low (mild) or moderate risk for impaired skin integrity. These failures resulted in 3 of 3 residents with facility acquired pressure injuries that were reviewed during the survey (#105, #221 and #11). On 10-21-19 at 4:15 PM, an immediate jeopardy (IJ) for residents at low (mild) to moderate risk for pressure injury was determined. On 10-21-19 at 6:43 PM, the facility staff submitted an IJ removal plan related to residents at low (mild) to moderate risk for pressure injury to the Office of Health Care Quality (OHCQ) which was accepted. On 10-23-19 at 8:25 AM, the IJ related to low (mild) to moderate risk for pressure injury was removed. After removal of the immediacy the deficient practice remained at a scope and severity level H. The findings include: 1. On 10-21-19 at 8:50 AM, review of the facility policy on Pressure Injury Prevention and Wound Care with a revision date of (MONTH) 2019, revealed there were no preventive interventions for residents identified by the Braden Scale as being at risk for alterations in skin integrity. On 10-21-19, review of the clinical record for Resident #105 revealed the resident was admitted on [DATE]. An admission Braden Scale risk for pressure ulcer development completed by registered nurse (RN) #1, dated 08-04-19, identified Resident #105 as being at a low (mild) risk for pressure ulcer development with a score of 15. However, the admission summary, also completed by RN #1, conflicted with the Braden Scale. The admission summary indicated that Resident #105 needed 2 people to assist with turning and repositioning and stated the resident was incontinent of bowel and bladder. The Braden Scale risk assessment tool is an evidenced-based tool that predicts the risk for developing a hospital or facility acquired pressure injury. The Braden Scale uses scores from less than or equal to 9 to as high as 23. The higher the score, the lower the risk. Further review of the clinical record revealed that the interventions implemented in the plan of care for Resident #105 on 08-04-19 did not include turning and repositioning the resident, who required 2-person assistance for bed mobility as described during interview and in the admission summary, nor did they include any specific toileting interventions for this resident identified as being incontinent of both bowel and bladder. On 10-11-19 Resident #105's Braden Scale was reassessed with [REDACTED]. A stage III injury involves a full thickness loss of skin with adipose (fat) visible in the ulcer and slough, and/or eschar (dead tissue) may also be visible. Further review of the clinical record revealed that Resident #105 was seen by the wound doctor on 10-11-19, who documented the resident's immobility and nutrition as clinical factors affecting healing. A new Braden Scale, completed on 10-11-19, did not reflect the wound doctor's assessment of Resident #105's mobility and nutrition as contributing factors to the impaired skin integrity. These factors, along with the resident's continued urinary and bowel incontinence, would have resulted in a Braden Scale score change from low (mild) risk to a score of 12 (high risk). The wound doctor also documented in the 10-11-19 comprehensive wound care notes for Resident #105 that he/she had discussed pressure reduction and turning precautions with facility staff and recommended extensive turning precautions and pressure reduction to reduce pressure related injury at time of visit. On 10-15-19, Resident #105 developed two additional facility acquired areas. On this date, the facility staff obtained a physician's order for ProSource (protein supplement) to be administered twice daily to promote wound healing, and an air mattress and pressure relieving cushion to be used when the resident was in the wheelchair. On 10-17-19, facility staff obtained a physician's order to turn and reposition Resident #105 every 2 hours. It should be noted that this intervention came six days after the wound doctor recommended extensive turning precautions, and two days after the development of two additional pressure areas. On 10-21-19 at 10:15 AM, interview with RN #1 and geriatric nursing assistant (GNA) #6 revealed that Resident #105 was very weak and required the assistance of 1-2 staff for all activities of daily living (ADLs) at the time of admission. Both RN #1 and GNA #6 stated the resident was totally incontinent of urine and had a groin rash which required treatment. Both also stated that the resident was constantly moist. However, the Braden Scale did not reflect the constant moisture, nor did the Braden Scale reflect the moderate to maximum assistance in moving that the resident required (2 person assist). These changes would have decreased the overall risk score and increased the risk category. On 10-21-19 at 11:00 AM, interview with registered nurse (RN) #2 confirmed that Resident #105 was dependent in all ADLs at the time of admission. On 10-21-19 at 11:10 AM, interview with GNA #3 revealed Resident #105 was totally dependent at the time of admission, however, began to get a little better sometime toward the end of September. GNA #3 stated that the resident continued to remain incontinent of bowel and bladder. On 10-21-19 at 9:00 AM, interview with the Assistant Director of Nursing (ADON) (who was the designated facility wound nurse) revealed that facility staff did not implement turning and repositioning or other preventive measures (i.e. pressure relieving devices) unless the Braden Scale reflected a severe risk for skin breakdown. 2. On 10-21-19, review of the clinical record for Resident #221 revealed that the resident was admitted on [DATE] with a physician's order for a left boot to be worn at all times, secondary to foot drop. There were no orders at the time of admission for donning or doffing (putting on or taking off) the boot to assess the skin integrity underneath the boot. On 10-04-19, a nursing skin assessment revealed that Resident #221 developed a blister which opened. (pressure injury-stage II) on the left calf area due to pressure from the boot. Further review of the clinical record revealed that the facility staff continued to document that the boot remained on at all times as previously ordered. On 10-11-19, facility staff documented that Resident #221's left calf area wound had deteriorated to an unstageable pressure injury; full thickness tissue loss,in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) dead tissue in the wound bed. The attending physician for Resident #221 wrote an order on 10-11-19 for the facility staff to discontinue application of the left boot. There was no evidence documented in the clinical record to indicate that the facility staff assessed resident #221's skin or provided care to the skin underneath the boot prior to the development of the left calf wound on 10-04-19. There was documented evidence in the clinical record that the facility staff continued to apply the boot after the pressure injury was identified on 10-04-19. The facility staff failed to adequately assess, in a timely manner, the risk for impairment of Resident #221's skin integrity as a result of continuous use of the boot which resulted in a facility acquired pressure injury. On 10-21-19 at 1:00 PM, interview with the ADON revealed no additional information regarding the care or assessment of resident #221's wound. 3. On 10-21-19, review of the clinical record for Resident #11 revealed that the resident was admitted on [DATE] with score of 19 on the Braden Scale for pressure ulcers/injury. (low risk for impaired skin integrity) The facility staff implemented three interventions at that time: (1-encourage good nutrition and hydration in order to promote healthier skin; 2- keep skin clean and dry, use lotion on dry skin and 3-offer or assist to the bathroom as needed.). On 03-10-19, Resident #11 developed a stage II lumbar (low back) pressure injury measuring 1.5cm x 1.5cm x 0.1cm. (A Braden scale done on the day the wound developed (03-10-19) revealed the resident remained at moderate risk for pressure injury. The resident's care plan had the following revisions added on 03-10-19: Air mattress every shift, check pump for proper functioning & setting, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Orders for scheduled toileting for bowel and bladder upon arising, before and/or after meals & activities, before bedtime, and during the night as needed added to the care plan on 03-17-19. The area healed on 04-19-19. Further review of the clinical record revealed that subsequent Braden scale scores for Resident #11 (completed on 06-10-19 and 09-10-19) continued to reflect a score of 13 (moderate risk for impaired skin integrity). In addition, on 10-11-19, the facility wound doctor documented that resident #11 developed a pressure injury of the [MEDICATION NAME] spine that was unstageable at the time of his assessment. The National Pressure Ulcer Advisory Panel describes an unstageable injury as one in which the extent of tissue damage within the?ulcer?cannot be confirmed because it is obscured by slough or eschar (dead tissue). The wound doctor recommended extensive turning precautions and pressure reduction to reduce pressure related injury at the time of this 10-11-19 visit, however, the facility staff did not obtain an order to turn and reposition the resident until 10-18-19 (9 days after development of the 2nd facility acquired pressure injury). The facility staff failed to implement turning and repositioning for resident #11 after the initial development of the 1st pressure injury. On 10-21-19 at 12:00 PM, surveyor interview with the assistant director of nursing (ADON-designated facility wound nurse) revealed that the facility staff does not implement preventive measures unless resident is identified as severe risk for skin breakdown pursuant to the Braden Scale. On 10-21-19 at 4:15 PM, an immediate jeopardy (IJ) for residents at low (mild) to moderate risk for pressure injury was determined. On 10-21-19 at 6:43 PM the facility staff submitted the following removal plan for the immediate jeopardy citation which included the following measures: -On (MONTH) 21, 2019, for Resident #105: the following orders and interventions were put in place, turning and repositioning, pressure relieving wheelchair cushion, float heels, nutritional supplement, and, air loss mattress. For resident #221: the following orders and interventions were put in place, turning and repositioning, float heels, pressure relieving wheelchair cushion, air loss mattress, and daily skin checks under brace when in use. For resident #11: the following orders and interventions were put in place, turning and repositioning, pressure relieving wheelchair cushion, nutritional supplement, and, air loss mattress, and float heels. -In addition, on (MONTH) 18, 2019, members of the clinical team reviewed 100% of residents Braden scale score. The clinical team reviewed residents identified as High Risk, as well as a few identified as moderate risk, totaling twenty-seven (27) residents, and updated care plans to reflect interventions, completed a Braden Scale assessment as needed, and, orders added as appropriate. -By (MONTH) 23, 2019, 100% of residents with splints/braces will be assessed for potential skin breakdown. Appropriate preventative measure intervention(s) in care planning, and orders, including turning and repositioning, will be added as clinically indicated. -Clinical Director worked with electronic medical record to place the prompt for an order of turning and repositioning, as clinically indicated, for newly admitted residents effective Friday, (MONTH) 18, 2019. -By (MONTH) 23, 2019, each newly admitted resident ' s Braden Scale Assessment will be reviewed by the Assistant Director of Nursing or Director of Nursing for accuracy, preventative measure intervention(s) in care planning, and orders, including turning and repositioning, as indicated. -By (MONTH) 23, 2019, one-hundred twenty-one (121) residents identified as low risk or moderate risk on the Braden scale, as well as residents with orders for a splint or brace, will be reviewed for appropriate preventative measures in care plan, interventions, orders in place, and referral to Registered Dietitian, if appropriate. -By (MONTH) 23, 2019, 100% of licensed nurses will be in-serviced regarding Braden Scale assessments, preventative measures for pressure ulcer, and updated policy. PRN licensed nurses and those on leave (FMLA, PTO, Leave of Absence) will not work until they have had the necessary in-service. -By (MONTH) 23, 2019, to prevent skin breakdown, the clinical team will update policy to reflect appropriate preventative actions and/or interventions within each Braden Scale risk category (Low, Moderate, High). The updated policy will address residents with an order for [REDACTED]. -If residents go from one risk level to another (i.e. moderate risk to high risk), Registered Dietitian will assess for appropriate nutritional interventions. -Clinical team, including Registered Dietitians, will conduct 100% audit of new admissions, residents with Minimum Data Set (MDS assessments) of significant change of condition, and, residents with splint/brace orders weekly x3 months, then, monthly x3, then, quarterly x2; and, will report findings to Quality Assurance Performance Improvement (QAPI) committee monthly x3, then, quarterly x2 for further recommendations. The licensed nursing home administrator was designated as ultimately responsible for oversight of this plan. -On 10-23-19, surveyors verified in-service training as stated in removal plan, revision of facility policy on Pressure Injury Prevention and Wound Care which included interventions for residents at low (mild) and moderate risk for pressure injury, and auditing of new interventions for all residents who had been identified as low (mild) and moderate risk for pressure injury. As a result, the immediate jeopardy was abated on 10-23-19 at 8:25 AM.

Based on record review and interviews with staff and residents, it was determined that the facility failed to allow resident #2 to return to the facility following a hospitalization . This finding was evident for 1 of 6 residents (#2) reviewed during the complaint survey and resulted in actual harm and was related to complaint #MD 855. The findings included: On 08-16-19, record review of resident #2's clinical record at the facility revealed that he/she was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. The resident exhibited behavioral disturbances such as shouting and repeatedly calling staff for assistance on 05-10-19, 05-15-19, 05-18-19, 05-19-19, 05-20-19, 05-23-19, 05-24-19, 05-25-19, and 05-30-19. Review of the facility assessment revealed that the facility had the capability to admit residents with dementia and behavioral disturbances. On 06-04-19, resident #2 was transferred to the acute hospital for a medical procedure. The transfer was necessary for the resident's welfare and the resident's needs could not be met by the facility at the time. The resident was private pay status at the time of transfer and the family declined the facility's bed hold. Review of the facility bed hold policy revealed that, if the resident or responsible party does not wish to pay to hold a bed, they can request discharge from the facility and would need to reapply for admission upon return. Surveyor review of the bedhold agreement signed by resident #2's Power of Attorney on 06-04-19 revealed that the bedhold was declined. Furthermore, the bedhold agreement stated that, if the resident declines the bedhold but chooses to return to the facility after their absence, the facility will readmit the resident and assign the next available appropriate bed, unless the facility can no longer meet the resident's needs. On 06-04-19, a written notice of transfer was signed by the resident and his/her medical power of attorney acknowledging the transfer. The notice did not state that the resident was discharged from the facility. Review of the Minimum Data Sheet (MDS) discharge assessment, with an assessment reference date of 06-04-19, revealed the resident was discharged with return anticipated. MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. On 06-07-19, resident #2's family submitted an application for Medicaid to the facility staff after the resident was hospitalized and no longer in the facility. On 08-21-19, surveyor review of the acute hospital case management notes, written on 06-11-19, revealed that the facility denied resident #2 for readmission because they felt that resident #2 required a bed in the dementia unit, which was full at the time. There was no evidence that the facility conducted an assessment of the resident's clinical condition at the hospital. Review of the facility census report on 06-11-19 revealed 4 empty beds, including 1 empty bed on the dementia unit. Review of resident #2's medical record revealed no [DIAGNOSES REDACTED].#2 previously stayed in a non-dementia unit at the facility. Case management notes, written on 06-19-19, revealed that resident #2 requested to see the hospital case manager because he/she wanted the case manager to see that he/she was normal. Resident #2 stated that no one wanted him/her. Additional case management notes, written on 06-19-19, stated the resident's family were eager to have the resident readmitted back to the facility, however, the facility declined the resident for readmission with the reason being that Resident #2 required a bed in the dementia unit. Review of the facility census report on 06-19-19 revealed there were 5 empty beds in the facility and no available beds in the dementia unit. Review of the hospital psychiatrist notes on 06-20-19 revealed that the resident's behavioral disturbances improved after their medical procedure and the resident was calm and cooperative. Previous behavioral disturbances were attributed to [MEDICAL CONDITION] secondary to a medical condition which was resolving. The psychiatrist further stated that the primary care team at the hospital reported that the resident had been very calm since the medical procedure, and there were no episodes of agitation or behavior disturbances. A case management note, dated 06-20-19, stated the resident was evaluated by the psychiatrist and cleared from a psychiatric standpoint. The note further documented that the facility stated they were unable to readmit the resident and the case was closed. There was no evidence that the facility reviewed hospital notes or conducted an assessment of the resident's clinical condition at the hospital before denying resident #2's readmission on 06-20-19. Review of the facility census report on 06-20-19 revealed that there were 4 empty beds in the facility but none in the dementia unit. The hospital transfer summary, written on 06-24-19, revealed documenation that resident #2 remained in the acute care hospital because the resident was still pending placement. Resident #2 was discharged from the acute hospital to another facility on 06-27-19 for skilled nursing facility services and physical therapy needs. Review of [MEDICAL CONDITION] revealed that residents, whose hospitalization or therapeutic leave exceeded the bed-hold period under the State Medicaid Plan, have a right to be readmitted to the nursing facility immediately upon the first availability of a bed in a semiprivate room if the resident requires the services provided by the nursing facility and is eligible for Medicaid coverage for the nursing facility's services. On 08-16-19 at 10:50 AM, interview with the Director of Nursing and Administrator revealed that the resident was not denied readmission for behavioral issues. The Administrator stated the facility felt they could not meet resident #2's needs, but was not able to elaborate. There was no documentation to verify the reasons the facility could not meet resident #2's needs. On 08-21-19 at 11:10 AM, interview with resident #2 revealed that he/she remembered being in the hospital and being told that the facility would not accept them back. The resident started crying and stated that he/she felt depressed and anxious at the time because they worked all their life and felt no one wanted them. The resident felt he/she was back to normal after the medical procedure and was no longer exhibiting behavioral disturbances. Resident #2 stated he/she still feels depressed whenever they think about it. On 08-21-19 at 1 PM, interview with the Administrator and Executive Director revealed that resident #2 was private pay status at the time of transfer to the hospital and the family declined the bed hold. Per facility bed hold policy, the resident was discharged from the facility and would need to reapply for admission to the facility. When the hospital contacted the facility for readmission, the facility denied resident #2's readmission because they felt they could not meet his/her needs, however, per the hospital case management note on 06-11-19, the facility told the hospital that the resident was denied because there were no beds available on the dementia unit.