Every finding on record at Towson Rehabilitation and Healthcare Center

Based on record review and interview and observation, it was determined that the facility failed to provide an environment that was free of accidents and hazards for residents. This deficient practice resulted in harm to Resident #7 and was evident for 1 (Resident #7) of 2 residents reviewed for quality of care complaints and 1 (Resident #4) of 3 residents reviewed for complaints of neglect. This was also evident during random observations on 3 of 3 nursing units. The findings include: 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. Fall Risk Assessment – is a tool that facilities use to determine the level of risk that a resident has for falling. Each question on assessment is assigned points and based on the answer there is a score at the end of the assessment which indicates the level of risk the resident has for falling. A review of the facility's Fall Prevention Program dated 11/2023 and last updated in 7/2026 revealed the nurse was to complete the resident's fall risk assessment and implement interventions based on the score. A low to moderate risk they were to implement the following: evaluate the resident's environment for interventions to decrease risk; implement a rounding schedule; monitor changes in the resident's cognition, balance, gait, and ability to rise/sit; ensure resident had proper foot ware and eye ware; monitor vital signs; and complete a fall risk assessment every 90 days and when a change indicated one. If they were high risk for falls, the following interventions were to be implemented in addition to the ones indicated for the low to moderate risk section: indicate the resident was high fall risk on the fall care plan; provide interventions to address unique risk found during the fall risk assessment; provide the following as indicated on the risk assessment which included assistive devices, increasing levels of supervision, and toileting schedule to name a few. 1) A medical record review for Resident #7 on 7/20/26 at 2:25 PM revealed a history and physical examination conducted by the attending physician on 4/5/26. According to this document the resident had diagnoses that included but were not limited to the following: severe cognitive impairment (the ability to think and process information in the brain), Parkinson's disease, heart disease, high blood pressure, and incontinence (the inability to hold urine and bowels) and had been recently hospitalized following a syncopal (fainting) episode. The attending physician noted in his plan and assessment that the residents blood pressure should be taken at routine intervals and due to syncopal episodes, the resident should be assessed for orthostatic blood pressure (this is a condition in which the blood pressure drops when a person changes positions such as sitting to standing). However, there was no evidence that this was ordered or implemented. A review of the nursing admission assessment revealed the fall risk assessment completed on 4/5/26 deemed the resident a low fall risk. This score was inaccurate because the nurse failed to complete the balance assessment and failed to include the resident diagnoses of orthostatic blood pressure and Parkinson's Disease. A review of the fall care plan revealed it was initiated on 4/5/26 with a focus that the resident had an actual fall and remained at risk for falls related to impaired balance, mobility, and impulsivity, but failed to mention the syncope or orthostatic blood pressure as possible causes. The following interventions were implemented: to assist resident with transfers and keep the bed in a low position. A review of the physical therapy evaluation on 4/6/26 revealed the resident was able to get in and out of bed with supervision and was able to transfer to the toilet with minimal assistance. However, staff failed to reevaluate the resident's fall risk as they progressed in therapy. A review of the SBAR (Situation, background, assessment, and resolution tool that nurses use to gather information to give the provider and complete overview of the issue, so they can order the appropriate treatment) related to falls was conducted. On 4/26/26 at 6:30 AM the resident had a fall; however, the nurse included the diagnosis of syncopal episodes but marked the cardiovascular evaluation as not clinically applicable to the fall. This was applicable because syncopal episodes can be directly related to cardiovascular (heart or blood pressure) issues. A review of the SBAR dated 4/26/26 at 12:00 PM revealed the resident had a second fall that day; however, the nurse included the diagnosis of syncopal episodes but marked the cardiovascular evaluation as not clinically applicable to the fall. The resident was ordered a stat x-ray of the right and left hands and wrist. After having 2 falls in one day there were no new interventions implemented to prevent further falls. A review of the SBAR dated 4/27/26 at 5:23 AM revealed the resident had a fall and the nurse failed to include the cardiovascular assessment and marked it as not clinically applicable to the fall. There was no evidence that staff evaluated the resident's falls to determine if there were additional interventions that could have prevented future falls. A review of the progress note dated 4/27/26 revealed the x-ray results determined the resident had sustained a chip fracture of the 3rd finger on the right hand. Further review of the care plan for falls revealed on 4/28/26 facility staff added the following interventions to the resident's care plan: assist with mobility, encourage the use of assistive devices but failed to mention what the assistive device was, clutter free environment, adequate lighting, observe for changes in gait, and call bell within reach. Facility staff failed to address the fall risks associated with syncopal episodes, orthostatic blood pressure, and to determine the level of supervision required for this resident. A review of the fall risk assessments revealed one was completed after each fall on 4/26/26 and on 4/30/26. On each of the assessments the nurse failed to assess the resident's balance and failed to include the orthostatic blood pressure and Parkinson's Disease. The resident scored less than 10 on each of these assessments and the resident was not considered high risk for falls. A review of the SBAR dated 5/6/26 the resident had a fall; however, the nurse included the diagnosis of syncopal episodes but marked the cardiovascular evaluation as not clinically applicable to the fall. Facility staff continued to fail to address the fall risks associated with syncopal episodes, orthostatic blood pressure, and to determine the level of supervision required for this resident. The fall risk assessment completed on 5/6/26 revealed the nurse assessed the resident's balance and marked the resident was unsteady. Staff continued to omit the resident's diagnoses of Parkinson's Disease and orthostatic blood pressure, but by assessing the balance the resident scored an 11 placing the resident at a high risk for falls. It was later determined during a review of the resident's 15-minute check documentation on 7/22/26 at 12:58 PM that the resident was started on 15-minute checks on 5/6/26 as per facility policy. Further review of the SBARs revealed the resident continued to have falls on 5/18/26 and 5/22/26; however, facility staff continued to fail to address the fall risks associated with syncopal episodes, orthostatic blood pressure, and to determine the level of supervision required for this resident. There were no other falls as the resident was discharged on 5/23/26. On 7/23/26 at 9:24 AM the Director of Nursing (DON) brought in the incident reports that were completed for the resident and reported that the nurse failed to complete one for the second fall on 4/26/26 and the fall on 4/27/26. (Incident reports allow the facility interdisciplinary team (IDT) to review falls to determine root cause and ensure interventions were put in place to prevent future occurrences.) During the interview, the surveyor reviewed the fall risk assessments, fall care plan, and each fall with the DON. She reported that staff should have been more thorough during the fall risk assessments and the assessments after each fall. She stated that the IDT to include the attending physician, reviewed each fall for this resident. However, they failed to ensure that there were interventions, to include supervision, to prevent further falls. She reported that they had a performance improvement plan (PIP) in place due to an increase in falls. A review of the PIP dated 7/10/26 revealed that they failed to identify that staff were not completing the fall risk assessments accurately and that staff failed to complete a full assessment of the resident after each fall. 2) A medical record review for Resident #4 on 7/15/26 at 9:59 AM revealed a fall risk assessment dated [DATE]. The nurse failed to assess the resident's balance and failed to mark the resident was on narcotic, psychotropic, hypoglycemic, and antihypertensive medications the resident was taking. Based on the incomplete and inaccurate assessment the resident scored a low risk of falls. A review of the history and physical conducted on 6/19/26 revealed the resident had a recent humerus (upper arm bone) fracture, dementia, failure to thrive, diabetes, and heart disease. A review of the care plan for falls that was initiated on 6/19/26 revealed there were interventions in place to include frequent monitoring. On 6/19/26 the resident was found sitting on the floor next to the bed. The fall risk assessment completed on 6/19/26 after the fall revealed the nurse failed to assess the resident's balance, failed to mark the resident had a previous fracture, and failed to mark 2 of the 4 medications the resident was taking. Again due to the incomplete and inaccurate assessment, the resident scored a low risk of falls. A review of the SBARs related to falls revealed the following. The resident had a fall in the hallway on 6/21/26 and was found on the floor on 6/25/26. The fall risk assessment that was completed on 6/23/26 revealed the nurse failed to assess the resident's balance and failed to include that the resident was on a hypoglycemic medication, therefore the fall risk score was low/moderate. A fall risk assessment after the fall on 6/25/26 revealed the nurse assessed the resident's balance as unsteady but failed to include the diagnoses and that the resident was on a narcotic and psychotropic medications. With this inaccurate assessment, the resident was deemed at a high risk for falls. With a change in the level of the fall risk, a review of the care plan revealed facility staff updated the care plan on 6/29/26, 8 days after the first fall and 4 days after deeming the resident a high risk. They added the following interventions: place fall mats beside the resident's bed, make sure the wheelchair was locked, and assessing for pain. On 6/30/26 the attending physician wrote in his notes that the resident needed 1:1 supervision. However, further review of the medical record revealed no evidence of the 1:1 supervision. The resident had an additional fall on 7/5/26. On 7/16/26 at 9:00 AM there was a review of the facility's 1:1 Supervision policy that had no date that it was implemented or the last review date. The document stated that during 1:1 supervision the staff member should have visual sight of the resident and be within arm's reach. The staff member assigned was to document, the time monitoring, beginning and ending. During an interview on 7/16/26 at 9:12 AM with Unit Manager (UM) #24 she was shown the 1:1 Supervision policy and reported she was not familiar with the policy. She stated that when a resident was ordered 1:1 supervision she assigned it to a staff member on the daily assignment sheet. She stated that the assigned staff stayed with the resident and she was unaware that they were to document during the assignment. She was asked to provide evidence that the 1:1 was assigned for Resident #4. On 7/16/26 at 11:41 AM a review of the staffing assignment sheets for 5/6/26 – 5/23/26 revealed that a 1:1 was split between each nursing assistant for 2 hours at a time. The assignment sheet failed to document which resident the 1:1 supervision was assigned. Except for 1 schedule noted a room number (that was not Resident #4's room number). Each of the nursing assistants assigned had a full assignment of other residents to care for during the shift. An interview with Nursing Assistant (Aid) #25 on 7/16/26 at 12:23 PM, who had been one of the nursing assistants assigned to 1:1, revealed that when shown the schedules, she reported that it was not for a particular resident. She reported that during the assigned 1:1 time the nursing assistant would sit in the resident café area and watch all the residents who were fall risks. When asked about Resident #4, she reported that while Resident #4 was one of the residents in the café that they would watch, she does not recall the resident having 1:1 supervision assigned just to them. She stated that when they have an actual 1:1 supervision assignment they would fill out a paper. The concerns were reviewed with the Director of Nursing (DON) on 7/16/26 at 12:41 PM. She reported that there should have been a nursing assistant assigned to provide 1:1 supervision that included being within arm's reach of the resident at all times. She reported staff were expected to complete 1:1 documentation. 3a) During an initial tour of the 1st floor nursing unit on 7/15/26 at 7:25 AM an medication cart sitting outside room [ROOM NUMBER] (which was the opposite end of the hallway from the nurses' station) was unlocked and unattended. At 7:31 AM Registered Nurse (RN) #26 was making her way down the hallway checking in the resident's room and by 7:35 AM she stopped at the medication cart, laid her stuff on the top of the cart and proceeded to check two other resident rooms. An interview with RN #26 on 7/15/26 at 7:37 AM revealed she was the dayshift nurse and had not received a report from the off going nurse. On 7/15/26 at 8:31 AM an interview with the Unit Manager (UM) #4 revealed that she was assigned to the unlocked medication cart found on the 1st floor. She reported that she had a phone call from a family member and when she went to answer the phone call she forgot to lock the medication cart. 3b) On 7/17/26 at 4:33 AM this surveyor observed an unlocked treatment cart in front of Resident #1's room. This surveyor was able to open and go through the drawers and identified in the top drawer, easily accessible scissors and wound treatment medication. Resident #1 was observed at this time sleeping in his/her bed directly across from the cart with no staff around observing Resident #1. There was a staff member observed with her back to the unit sitting at the window and another staff member sitting at the nursing station. At 4:42 AM RN #13 approached the cart. She identified that the cart was unlocked and locked it. This surveyor asked her if this was her treatment cart and if she was the last to use it. She stated 'yes,' and that she was looking for something and that she should have locked it before she walked away. 3c) During tour of the 1st floor on 7/22/26 at 7:07 AM in front of room [ROOM NUMBER] a medication cart was sitting with a new delivery of lidocaine patches for Resident #9. At 7:10 AM Unit Manager (UM) #4 approached the cart with a handful of other medications. She acknowledged that she left the lidocaine patches on the cart when she picked up the other medications in error and that they were just delivered this morning. The concern that this was the second occurrence with this staff and that she was a Unit Manager was reviewed with her at this time. She was adamant that she has never done this before, however in 4 days of observations, as this was observed previously on 7/15/26. 3d) This surveyor proceeded to the ground floor at 7:11 AM and identified that the stock room was propped open. There was initially a staff member at the medication cart halfway down the hall who walked away and proceeded further down the hall. The 2nd floor unit manager, staff # 14 also was observed clocking in then walked away. This surveyor then entered the stock room and noted that there was no staff in the stockroom. There were sharp instruments including scissors observed accessible to anyone at this time. This surveyor entered and exited the room multiple times looking for staff until 7:15 AM when LPN #16 was observed and asked about the stockroom door. He said staff were in there and that is why it was propped open. This surveyor brought to his attention the accessibility to the scissors and that there were no staff around. He stated, 'now that you mention it, it is concerning.' GNA #15 who had propped the door open then approached and stated that yes she had left the door open and acknowledged that she should not have done that. This surveyor proceeded down the hall and to the right a sitting room at 7:17 AM observed a pair of plyers were on the floor with a wrench and 4 [NAME] wrenches were observed scattered on the floor and the table with plastic wrap. This surveyor proceeded to get the LPN #16 and question him about the findings. He was asked if he worked all night, he stated yes and he was then asked about the items on the floor. He states that the maintenance director #17 was working on 'something.' At this time staff #17 was observed through the window in the courtyard and was waved to come inside. He came in and was asked about the tools scattered on the floor and table. He stated 'yes,' he was just working on something. This surveyor reviewed with him the concern about resident safety, he nodded and proceeded back outside. During a follow up tour on the second floor at 8:52 AM on 7/22/26 in front of room [ROOM NUMBER] hanging on the treatment cart was a messenger bag full of treatment equipment. At 8:55 AM NP #15 exited room [ROOM NUMBER] and confirmed the bag was hers. This surveyor asked her to identify exactly what was in the bag. She stated that it was debridement tools (scalpels, scissors, forceps, and curettes). The concern that the bag was left open and unattended was reviewed with her at this time and she verbalized understanding the concern. At 9:10 AM on 7/22/26 the NHA and DON were notified of the plethora of observations throughout the facility on all 3 floors, and that occurred with multiple disciplines at this time.

Based on multiple observations and interviews with staff, it was determined that the facility failed to keep a safe, sanitary and clean environment for the residents. This was noted on 2 of 3 floors throughout the course of the survey. The findings include: 1. The facility was toured on 7/17/26 at 5:15 AM on the 2nd floor identified multiple concerns for resident safety and comfort starting in the resident lounge area. At the entrance to the immediate right there were 2 white square tiles adjacent to another set of tiles then a rug, none of which were aligned creating an uneven floor further tripping hazards for residents. Continued observations of the lounge area also noted 3 tables of varying heights next to each other. The tables had gray and white patterned tablecloths that had various stains on top of each in varying colors from blue to brown and yellow. There were heavy black dusty flecks and debris found in the corners and under the furniture in the room. At 6:10 AM on 7/17/26, using a white piece of toilet paper this surveyor dampened it with water, then wiped the floor in front of the nursing station, where residents are frequently placed in Geri-chairs. The appearance of the toilet paper after one pass and wipe of the floor was thick dark and black. Tour and observation of room [ROOM NUMBER] was observed at 9:03 AM with food on the floor after breakfast. This surveyor followed up and toured again on 7/17/26 at 10:45 AM and the food was still on the floor in a pile in front of the door. Tour of the facility on 7/22/26 at 6:55 AM of the second-floor unit and lounge revealed the same identified concerns as noted on 7/17/26, including the same tablecloths with the same stains. The floor was also noted sticky; there were cheerios noted under the table observable from the doorway and chip crumbs on the opposite side of the room under the table. Touring down the hallway, there was a pile of chip crumbs and plastic directly in the middle of the doorway outside of room [ROOM NUMBER] and Fritos twists style chips in front of room [ROOM NUMBER]. A single, alone housekeeping cart was then observed when this surveyor returned from touring the ground and 1st floor sitting in front of the lounge at 7:20 AM. Follow up tour at 8:43 AM of the lounge, revealed the same observations, as well as pile of chip crumbs in front of room [ROOM NUMBER] and Fritos twists in front of room [ROOM NUMBER]. A housekeeping staff member # 21, was observed down this same hall by room [ROOM NUMBER] at a stock room putting trash bags in her cart at that time. She was asked if she was the only housekeeper assigned to this floor and she stated 'yes,' and that she starts from one end of the hall and works her way to the other. She was asked if she was only assigned to this floor and she stated 'yes.' Tour at 10:20 AM of the lounge on unit 2, noted that the cheerios observed from the doorway were cleaned up, however the chips and crumbs that were present and observable from the other side of the table were still present. Continued tour of the remainder of unit 2 revealed the same observations as completed at 6:55 AM. At 10:26 AM during the 2nd floor tour and observations, the facility NHA approached the surveyor and then was asked by this surveyor to proceed on this tour. The observations noted from 6:55 AM, 8:43 AM and 10:26 AM were reviewed and the presence of the same debris, chips and crumbs from rooms 217, 223 and the lounge all remained and he photographed and documented as well along the way. As this surveyor was showing the NHA the observations in the lounge, including the unlevel floor, a resident who was visibly independently mobile in a wheelchair came into the lounge and then turned right. The tires of the wheelchair became stuck between the uneven tiles and carpet in front of the ice machine with the handwritten sign saying 'broken.' This resident needed assistance to maneuver the tiles and rug, and this was provided by the NHA. On 7/22/26 at 10:50 AM staff #22, the housekeeping supervisor, was interviewed. She was asked about her expectations of her staff and what shifts they work. She stated there are no housekeepers at night. They come in, in the morning and start at one end of the unit and work their way around. The observations just from today and in the 3-hour window of blatant and obvious food and debris being left on the floor at the entrance to resident rooms, in addition to the blackness that was found on the floor. She stated again she doesn't have staff at night. She further stated that everyday the floor is scrubbed using an Auto-Scrubber machine daily. This surveyor asked the floor care process, do they change the pads, how are they ensuring that the floor is actually getting clean? Staff #22 stated that the floor is done 3 times a day and that they can just start wet mopping at the nursing station where the dirty area was found. This surveyor asked if staff #22 was stating that the dirt acquired from the surveyor's observation and test of the wet toilet paper on the floor was just dirt that had acquired from the night shift and she said yes as they do the auto-scrubber after breakfast, after lunch and before dinner. The concern was still not addressed that the Auto-Scrubber being used on the floors is not sufficiently cleaning the entirety of the floors and further using a wet mop just around the nursing station wouldn't correct the problem. The overall concerns were discussed throughout the survey and again during exit on 7/23/26. 2. An observation on 7/28/26 at 8:02 AM of the 1st floor nursing unit revealed straw papers and debris lying on the floor throughout the unit. An observation of a carpeted room with a sign, Café revealed the carpet appeared dirty, there was debris and food crumbs on the floor. A piece of orange candy and a needle lid was lying next to the trashcan in the room. The tan colored blinds were broken on the right side and were visibly grayish colored. The white heating and cooling units below the windows had blackened spots and run marks as if fluid had been spilled and ran down. There was a TV stand that had missing handles on some of the drawers. A second observation of the 1st floor nursing unit on 7/17/26 at 5:25 AM revealed debris and trash on the floor throughout the unit. The Café room was in the same condition as described in the 7/15/26 observation as well as a water cup sitting at the computer. During an interview on 7/20/26 at 1:45 PM the Environmental Director Staff #22 reported that staff were on duty between 6:30 AM and 4:00 PM. She stated that after dinner it was the nursing assistant's responsibility to clean the café area. The surveyor and Staff #22 toured the Café on the 1st floor, she was shown the concerns and how the Café' continued to be in the same condition with food crumbs and debris on the floor, the broken, dirty blinds, and the dirty heating and cooling units below the windows. She acknowledged the concerns.

Based on observations completed during tours of the facility on the second floor, it was determined that the facility failed to ensure the furniture provided in each resident room including dressers were functional and accessible to each resident. This was evident for 13 of 28 rooms observed on the second floor. During general observations and tour on 7/17/26 at 9:03 AM of the functionality and cleanliness of rooms, secondary to complaints 3047231 and 3029891 the following rooms were observed to have non-functioning dressers, determined by either; dresser drawers on observation hanging open off the tracks, observed from the doorway or drawers were unable to easily be opened, when tested after permission obtained from the resident. A follow-up tour with the facility NHA was completed on 7/22/26 at 10:26 AM. This tour occurred down the halls of unit 2 regarding the surveyors' observations and concerns. He too identified and verbalized the concern for the white dressers in the multiple residents' rooms as follows: 203, 205, 206, 208, 212, 214, 216, 218, 219, 220, 221, 223 and 225.

Based on observation, record review, and interview, it was determined that facility staff failed to implement an effective infection prevention and control program. This was evident during a medication administration observation and evident during random observations on the nursing units conducted during the complaint survey.The findings include:1) During a medication administration observation on 7/17/26 at 5:54 AM, Registered Nurse (RN) #13 was observed emptying the trash bag from the medication cart on the long hallway on 1st floor nursing unit. She handled it with her bare hands and took it to the soiled utility room and placed in the trash can. Without sanitizing her hands, she proceeded to the short hallway medication cart and prepared to administer medications. She stopped and signed paperwork from the lab technician and then proceeded down the hallway. She sanitized her hands prior to applying gloves to check a resident's blood sugar via a fingerstick.A continued observation of RN #13 on 7/17/2026 at 6:17 AM revealed she dropped a pill on the floor. She used a napkin to pick of the pill with her bare hands and threw it away. She failed to sanitize her hands as she continued to prepare Resident #11's medications.2) Observations of 1st floor nursing unit's short hallway on 7/17/26 at 4:31 AM revealed a linen cart sitting outside room [ROOM NUMBER] with a drawsheet draped over the top however, the 2nd and 3rd shelf were exposed to the air. There were bags of linen and trash laid on the floor between rooms [ROOM NUMBERS]. An observation on the 1st floor long hallway on 7/17/26 at 4:39 AM revealed a linen cart with a fitted cover sitting between rooms [ROOM NUMBERS]. The front flap was thrown over the top with briefs laid on top. The linen on the cart was exposed.During an interview with nursing assistant (Aid) #29 on 7/17/26 at 4:40 AM, she was asked about infection prevention and control related to clean linen. She reported that it was to stay covered to protect the linen from germs in the air. When shown the cart she stated she should have kept it covered. When she put the flap back down, it was observed to be frayed and had holes in it. She reported that bags of linen and trash were to be taken directly to the soiled utility room and not laid on the floor. An interview with Licensed Practical Nurse (LPN) #31 on 7/17/26 at 4:44 AM revealed she agreed that the linen cart on the short hall on 1st floor nursing unit was not adequately covered. She reported that they do not have a cart with a fitted cover like the long hallway. She stated that it may be because they have a linen closet in the hallway. The concerns were reviewed with the Director of Nursing on 7/23/26 at 12:11 PM.

Based on record review and interview, it was determined that facility staff failed to ensure that the resident's medication records were complete (Resident #4 and #7) and failed failed to provide residents with an updated bed hold policy when there was a change in Administration (Resident #1 and #5). This was evident for 4 of 9 medical records reviewed during the complaint survey. The findings include: Neurocheck sheets are a template used by nurses to document a neurological assessment at timed intervals following a fall with possible/actual head injuries. 15 – minute check sheets are a template used by nursing staff to document what a resident is doing every 15 minutes to show that they were being monitored. (SBARs) -Situation, background, assessment, and resolution tool that nurses use to gather information to give the provider and complete overview of the issue, so they can order the appropriate treatment 1. A electronic medical record (EMR) review for Resident #4 on 7/15/26 at 9:59 AM revealed in the assessment tab there were SBARs that documented the resident had falls on 6/19/26, 6/21/26, and 6/25/26. However, there was no evidence that neurochecks were completed after the falls. 2. An EMR review for Resident #7 on 7/20/26 at 2:25 PM revealed in the assessment tab there were SBARs that documented the resident had falls on 4/26/26 at 6:30 AM and at 12:00 PM, 4/27/26, 5/6/26, 5/18/26, and 5/22/26. However, there was no evidence in the EMR that neurochecks were completed. On 4/30/26 the resident was placed on 15-minute checks however; there was no evidence in the EMR that they were completed. During an interview with Unit Manager (UM) #24 on 7/16/26 at 9:12 AM she reported that the neurocheck sheets and 15-minute check sheets were kept in a notebook at the nurses station. She reported that they were supposed to be uploaded into the EMR under the miscellaneous tab by the Unit Secretary. An interview with the Unit Secretary Staff #30 on 7/16/26 at 8:58 AM revealed that she was unaware that she was supposed to upload the neurocheck sheets and 15-minute check sheets into the EMR. The concerns were reviewed with the Director of Nursing on 7/23/26 at 9:24 AM. She confirmed that the facility did not maintain a paper medical record for the residents. She stated that the Unit Secretary was assigned the responsibility to upload paper documents into the EMR. 3. Resident #1's medical record was reviewed on 10:15 AM on 7/15/26 regarding complaint 3029891. There were concerns regarding not providing an appropriate discharge notice. This review noted that there were 6 bed hold notices given to the residents between 5/7/26 and 7/1/26. However, a closer review noted that on the line for 'Name of Facility's Authorized Agent' the previous Nursing Home Administrators (NHA) name was pre-printed on the form as well as her signature. 4. Resident #5's medical record was reviewed on 11:23 AM on 7/15/26 regarding complaint 3047231. This review revealed that S/he was hospitalized on [DATE] according to progress notes and transfer assessments completed. There was a 'bed-hold' notice uploaded into Resident #5's medical record on 6/16/26, however, there was no date. This record review did reveal that the resident did not return to the facility after this discharge. Additionally noted on the bed hold notice initiated for Resident #5, the 'Name of Facility's Authorized Agent' was entered as the previous Nursing Home Administrators (NHA) pre-printed on the form as well as her signature. The current facility NHA was interviewed on 11:11 AM on 7/15/26 regarding the findings. He reported that he started on 5/18/26 and that the previous NHA was no longer in the building at that point. He also stated that he identified this concern when he came to the facility as well, however, had not yet implemented a new bed hold policy so the previous one with the previous NHA's name on it was still being used. This review also revealed that the bed hold policy's provided to the residents and or their representatives are copies of copies and therefore, the ink/toner has become streaky and smudged and illegible. This was also reviewed as part of the concern related to the bed hold policy administration and was reviewed again during exit on 7/24/26.

Based on observation, record review, and interview, it was determined that facility staff failed to ensure the resident had a medication error rate of less than 5%. This was evident for 2 (#10 and #11) of 3 residents' observed for medication administration. The findings include:Hypothyroidism - is thyroid hormone deficiency. Symptoms include cold intolerance, fatigue, and weight gain. Signs may include a typical facial appearance, hoarse slow speech, and dry skin. (Merkmanual.com 2026). Levothyroxine (Synthroid) is a medication that acts as the thyroid hormone and is used to treat hypothyroidism (low thyroid levels). (merkmanual.com 2026). Levothyroxine tablets are absorbed better when a resident has been fasting and should be administered 30 - 60 minutes before breakfast. The medication should be given 4-5 hours before administering medications that can interfere/interact with the effectiveness of the medication. One type of medication is a proton pump inhibitor (decreases the secretion of stomach acid) such as pantoprazole (Protonix). (Nursing Drug Handbook 2026). Pantoprazole delayed release capsules can affect the concentration and absorption of other medications. (National Institute of Health). Therefore, it is a standard of practice to give the medication 30 - 60 minutes before administering other medications. 1) On 7/17/26 at 5:54 AM an observation of Registered Nurse (RN) #13 administering medications for Resident #10. During this observation she was observed to administer levothyroxine 50 mcg (micrograms) and pantoprazole delayed release 20 mg (milligrams) at the same time. A medical record review for Resident #10 on 7/23/26 at 10:11 AM revealed a physician note dated 7/12/26 that documented under the assessment and plan the resident had hypothyroidism and was to continue to take levothyroxine on an empty stomach. The physician noted that the last time the resident's thyroid levels were checked was 2/26. Further review of the medical record revealed that the nurse failed to notify the physician of the medication error.RN #13 was interviewed on 7/17/26 at 7:58 AM about the observation and stated that she thought the pantoprazole was supposed to coat the stomach for the levothyroxine. She was not aware that the pantoprazole was not to be given with the levothyroxine because it would affect the absorption of the medication.2) On 7/17/26 at 6:17 AM RN #13 was observed administering the following medications to Resident #11: pantoprazole delayed release 40 mg, gabapentin 300 mg, carbidopa/levodopa 25 - 100 mgOn 7/23/26 at 9:49 AM a medical record review for Resident #11 revealed a visit note dated 7/20/26 by Nurse Practitioner (NP) #27. NP #26 wrote that the resident was taking pantoprazole for management of GERD (gastroesophageal reflux disease a condition in which the gastric juices overflow into the esophagus and cause damage to the lining), the gabapentin was to treat neuropathic pain (chronic discomfort caused by damage to the nervous system), and the carbidopa/levodopa was treating the resident's Parkinson's disease. Further review revealed that the three medications were scheduled for 6:00 AM, however this should have been clarified by the nurse given the standard of practice to give pantoprazole before the other medications. During an interview with RN #13 on 7/17/26 at 7:58 AM she failed to offer a rationale as to why she would have administered these medications together. An interview on 7/22/26 at 11:48 AM with NP #26 revealed that the medications were not intended to be administered at the same time. The concerns were reviewed with the Director of Nursing on 7/23/26 at 12:05 PM and she was informed of the 8% medication error rate.

Based on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing the resident and to have the most accurate resident medical information in the physician notes. This was evident for 2 of 2 residents (Resident #9 and #1) reviewed during a complaint survey.The findings include: 1.Review of the medical record for Resident #9 on 7/16/26 at 12:03 PM revealed that on 4/14/26 Nurse practitioner (NP) #27 visited with Resident #9 and discussed with the power of attorney the plan for a below the knee amputation. Although the note documented that the resident was visited on 4/14, the note was not available on record until 4/18/26. 2. Review of the medical record for Resident #1 on 7/15/26 at 9:31 AM revealed multiple hospitalizations requiring new history and physicals (h and p) on each readmission. A history and physical is a review of the residents' health, medications, care and includes a plan for ongoing care. According to the electronic health records (EHR), on 5/14/26, NP #27 initiated a progress note, the effective date was documented as 5/15/26, however, the note was not available on the EHR until 5/17/26. Further review noted another admission note from NP #27 on 6/23/26, however, it was not signed or available for staff review until 6/25/26.The progress notes completed by the residents attending physician, including history and physicals from 5/17/26-6/24/26 were all initiated and posted after more than 24 hours of seeing the resident and reviewing his/her orders. Further, there was an Attending # 28 note with a date of service initiated on 7/2/26 that was not available until 7/10/26 and a 7/5/26 note, not available until 7/10/26. Additional review of Resident #1's medical record also revealed that a gradual dose reduction (GDR) was completed on his/her Seroquel on admission in the fall of 2025. However, both the NP #27 and Attending #28 documented that Resident #1 remained on the admission dose of Seroquel from August 2025 through January 2026. Np #27 was interviewed on 7/22/26 at 11:28 AM regarding the findings and the delay of the notes entered in the residents' charts. She stated that when she visits the residents, she tries to have the notes published within 48 hours so if there is anything acute it is available. She further stated that she should update the records sooner when she dictates if there is a change as she is aware of the delay in the dictation as it goes out to another country for transcription then by the time it comes back and she reviews, it is about 48 hours. She was then asked specifically about the Seroquel and Resident #1. It was determined through this interview that the psychiatrist would order the medication, the nurse would report the recommendation of the psychiatrist to the NP or physician and then the NP or physician would put the order in the computer. It was further determined that NP #27 was the one who signed off for the Seroquel GDR order in the computer, although in her notes she continued to document that Resident #1 was still on the same dose. The concerns related to the physician documentation and delay was reviewed with the facility DON and NHA throughout the survey and again during exit on 7/23/26.

Based on medical record review and interview with facility staff and the review of a facility reported incident (FRI), the facility failed to implement appropriate interventions for the prevention of future occurrences of all types of abuse. This was evident during the review of 1 of 2 facility reported incidents. (Resident #2)The findings include: On 7/17/26 at 6:02 AM a review of the facility's self-reported incident 2746331 regarding an allegation of physical abuse occurring on 2/16/26, perpetrated by nursing aide (Aide) #19 towards Resident #2 was reviewed. This review revealed that as part of the investigation, in-service training was completed for the staff starting on 2/16/26. Closer review of the in-service list revealed that the staff present and interviewed on the shift when the allegation of abuse occurred were not on the list of staff educated for 'Abuse recognizing, reporting and preventing abuse, neglect and exploitation and misappropriation.'The investigation for incident 2746331 was reviewed with the facility DON and NHA on 7/22/26 at 1:2:45 PM. The DON was interviewed on 7/23/26 at 12:30 PM and asked for her expectations on post incident in-service training. She agreed that all staff, especially those potentially involved in the allegation should be involved in any post educational in-service.

Based on the kitchen tour and staff, it was determined that the facility failed to ensure that stored food items were labeled and were not expired. This was evident during the initial kitchen tour during the recertification/complaint survey. Findings Included:During the initial kitchen tour on 02/09/2026 at 7:44 AM, the following deficient practices were revealed:An initial observation of the kitchen staff revealed that one staff member, Staff #27 (the cook) was preparing breakfast; however, Staff #27 did not wear a hairnet as required.On 02/09/2026 at 7:54 AM, An observation of the refrigerators revealed the following conditions: Wholesome Farm Low-Fat Cottage Cheese (5 lbs): One open container was present. A second, un-opened container, both had a Best If Used By date of 1/30/2026; Prepared Cheese: A container was labeled with a prep date of 1/3/26 and a Used By date of 1/27/2026; Sysco Classic Sliced Strawberries (5 lb): An open container lacked an expiration date; Sysco Imperial Thickened Apple Juice (1.36 L): An open box container had a Best If Used By date of November 2025; Marinara Sauce: A large plastic container, identified by the cook as marinara sauce, lacked an open or expiration date/time; Fruit Cocktail: A plastic container lacked an open or expiration date; Chicken Gravy: A metal storage container with a white/cream sauce, identified as Chicken gravy by Staff#27 (cook), lacked an open or expiration date; Pre-Made Sandwiches: Staff identified grilled cheese, turkey and cheese, and peanut butter sandwiches; all were observed without dates or proper labels. A wilted head of lettuce had a Used By sticker date of 02/02/2026. Saran-wrapped, wilted, sliced raw red onions had a Used By sticker date of 1/26/2026.On 02/09/2026 at approximately 08:00 AM, in an interview with Staff #28, he stated that everyone is responsible for checking the date of each item to make sure they are used by the expiration date or thrown away if unused.On 02/13/2026 at 8:50 AM, in an interview with the food service director, he was informed of the surveyor finding as it relates to the above-mentioned concern.

Based on medical record review and staff interviews, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by the failure to timely 1) implement physician orders pertaining to wound consultations or wound treatment, and 2) implement recommended wound care treatments following wound consultations. This was evident for 3 (Resident #14, #5, and #16) of 4 residents reviewed for wounds during the recertification/complaint survey.The Findings include:According to the Centers for Disease Control (CDC), pressure ulcers (bed sores, pressure sores, or decubitus ulcers) are wounds from unrelieved pressure on the skin, per the CDC. They are staged by severity: Stage 1 is persistent skin redness; Stage 2 is partial thickness loss (abrasion, blister, shallow crater); Stage 3 is full thickness loss exposing subcutaneous tissue (deep crater); and Stage 4 is full thickness loss exposing muscle or bone. An unstageable ulcer involves full-thickness skin and tissue loss where the extent of damage is obscured by slough or eschar.The standard of practice for the care of pressure ulcers is for the facility staff to conduct weekly assessments and document findings that include the location, measurement, stage, and characteristics of a pressure ulcer. This information provides facility staff with information to determine whether the pressure ulcer is healing or worsening at future assessments and to evaluate which treatment plan would be most effective to heal the pressure ulcer. 1) On 02/10/2026 at 3:09 PM, a review of Resident #14's progress notes revealed a late entry from 01/04/2026, at 1:05 PM. This entry documented a scheduled skin check during which a new skin impairment was noted: redness on the sacrum area. However, the notes lacked any further description of the skin impairment.On 02/10/2026 at approximately 3:16 PM, a continued review of Resident #14's medical record revealed a physician order dated 01/5/2026 for an in-house wound team consult.On 02/10/2026 at 3:19 PM, a further review of Resident #14's medical record revealed a wound consult dated 01/13/2026. This consult documented a stage 3 cluster wound in the coccyx region. The wound measured 1.00cm in length, 5.50cm in width (LXW 5.50cm), and 0.20cm in depth, with 40% slough and 60% granulation. However, the wound consult was completed 9 days after the initial physician order for the wound consult.On 02/11/2026 at 11:25 AM, a review of Resident #5's progress notes indicated a change in condition dated 09/17/2025 at 11:02 AM. The reported change was a skin wound or ulcer. The physician was informed and recommended the following treatment for the sacrum pressure ulcer: cleanse with normal saline solution (NSS), pat dry, apply Medihoney to the wound bed, followed by calcium alginate, and cover with a border foam dressing.On 02/11/2026 at 11:12 AM, a continued review of Resident #5's wound consult dated 09/19/2025 indicated a Stage 3 wound on the left buttock, acquired 09/17/2025, measured 1.00 CM x 2.00 CM x 0.20 CM (2.00 CM^2), with 100% granulation. Recommendations included daily and as-needed normal saline cleansing, medical-grade honey, and bordered foam.On 02/11/2026 at 11:34 AM, further review of Resident #5's treatment administration record for September 2025 revealed a physician order, dated 09/20/2025, for wound care to the left buttock pressure ulcer. The order specified to Cleanse with NSS, pat dry, apply medihoney to wound bed, and cover with border foam dressing every day shift. This physician order, however, was implemented 3 days after the wound was first identified and a physician treatment was given (on 09/17/2025).On 02/11/2026 at 11:48 AM, during an interview, the Director of Nursing (DON) confirmed that wound orders to include wound consults/physician orders should be implemented right away. The DON described the facility's wound identification process: a nurse evaluates the wound (including size, drainage, pain, and description) and calls the primary physician for treatment. The concern was shared with the DON at this time regarding timely completion of wound consults and implementation of physician orders for wounds.2) On 02/17/2026 at 8:57 AM, a review of Resident #16's physician order dated 01/20/2026 for the left dorsal foot (arterial ulcer) was reviewed: Cleanse with NSS, pat dry, apply Xeroform 4x4 and an ABD pad, and wrap with rolled gauze every other day for wound care and as needed for soilage. Monitor for infection. Offload in Prevalon boots as tolerated every day shift.On 02/17/2026 at 9:01 AM, a continued review of Resident #16's wound consult dated 02/10/2026 for the left dorsal foot specified: daily cleanse with soap and water, pat dry, apply Xeroform, cover with dry gauze/Kerlix, secure with tape, and maintain a Prevalon boot while in bed, per the surgeon's request and facility protocol.On 02/17/2026 at 9:19 AM, further review of Resident #16's February 2026 treatment record showed a wound care order for a left dorsal foot arterial ulcer (cleanse with NSS, apply Xeroform, 4x4, ABD pad, wrap with rolled gauze, monitor, and offload in Prevalon boots every other day) that started on 01/22/2026. However, this order was not updated, despite a 02/10/2026 wound consult that provided new, daily treatment orders.On 02/17/2026 at 10:00 AM, during an interview with the Director of Nursing (DON) regarding the wound consultation process. The DON stated that recommendations from wound consults are to be implemented immediately or, at the latest, by the following day. This process involves the DON and managers reviewing the recommendations, making necessary changes, informing the physician, modifying orders, and completing all required documentation. The concern was shared with the DON during this time.

Based on interviews with facility staff and residents and review of the medical record, it was determined that the facility failed to ensure medications were stored properly. This was evident for 1 (Resident #51) out of 41 residents reviewed during the facility's recertification survey.The findings include:On 2/10/26 at 11:10 AM in an interview with the Nursing Home Administrator (NHA), who had just finished speaking with Resident #51, she stated, He/she's a hoarder and he/she's an admitted hoarder. He/she has a safety inhaler in his/her pocket. He/she always has one. The surveyor asked, The resident always has an inhaler? for clarification. The NHA replied, He/she had one just now when I was down there. When asked if there was medication in the inhaler, the NHA stated, I didn't really look. I guess I should have, but I saw a blue inhaler in his hand. When asked if residents should have medications at the bedside, she stated, If they have an order. I don't even know if he has an order to keep meds at the bedside. I'll check with [Director of Nursing's first name] to see if he/she has that order. On 2/10/26 at 11:26 AM in an interview with Resident #51, he/she verified and confirmed he/she had his/her rescue inhaler, albuterol with medication in it in his/her pocket but refused to show the surveyor. During the interview Resident #51 stated he/she was going to have his/her medication on him/her in case he/she could not breathe. Furthermore, he/she stated that he/she was not going to rely on some nurse down the hallway to give him/her his medication, he/she would decide when he/she needed it. On 2/10/26 at 1:01 PM review of Resident #51's medical record revealed he was originally admitted to the facility on [DATE] with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, heart failure, and other nonspecific abnormal finding of lung field. Further review revealed an assessment completed on 1/5/25 Atlas- NSG (Nursing): Admission/readmission Evaluation. In the Self Medication section, was the following question: Does the resident WANT to Self-Administer his/her own medications? and No was marked. Continued review revealed an order for Albuterol Sulfate HFA (hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) MCG (microgram)/ACT (actuation) (Albuterol Sulfate) 1 puff inhale orally every 4 hours as needed for Wheezing r/t (related to) COPD; however, failed to reveal an order for self-administration of any medication(s). Furthermore, in the Albuterol Sulfate order, the section titled, Administered By had 4 options: 1) Clinician, 2) Assisted Non-Clinical Staff, 3) Supervised Self-Administration, and 4) Unsupervised Self-Administration and on the order Clinician was selected. On 2/10/26 at 1:31 PM the above concerns were shared with the NHA who acknowledged understanding of the concerns.

Based on observations, record review, and interview with facility staff, it was determined that the facility failed to ensure the medication error rate was less than 5%. This was evident for 2 medication errors out of 37 opportunities which resulted in a medication error rate of 5.41%. The findings include: A Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with:1. The prescriber's order;2. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils.1) On 2/11/26 at 9:13 AM the surveyor observed Licensed Practical Nurse (LPN #11) prepare medications to administer to Resident #32. The medications included Methadone and LPN #11 stated she was going to administer 75 mgs (milligrams) of Methadone and passed the Methadone container to the surveyor. At that time the surveyor noticed that the bottle was labeled 74mgs. At 9:26 AM LPN #11 stated she had finished dispending the medications and was about to enter Resident #32's room to administer the medications. The surveyor asked LPN #11 to read the dosage on the Methadone bottle, and she stated, Methadone 74 mgs. LPN #11 did not register that there was a discrepancy. The surveyor asked LPN #11 to read the Methadone dosage from the order. LPN #11 looked at her computer and stated Methadone 75mg; however, did not register there was a discrepancy. After surveyor intervention, when asked if the dosage on the Methadone container matched the dosage on the order, LPN #11stated, No, it doesn't match. I'm going to hold onto this and talk to my unit manager. The surveyor shared this was a concern and LPN #11 acknowledged understanding of the concern.Review of Resident #32's medical record on 2/11/26 at 11:32 AM revealed a physician order dated 9/15/25 for Methadone HCl (hydrochloride) Oral Solution 5 MG/5ML (milliliter) Controlled Drug Give 75 mg by mouth two times a day for maintenance. On 2/11/26 at 2:58 PM in an interview with LPN #11 when asked about Resident #73's Methadone, she stated, I checked the paper that comes with the Methadone bottles. I looked in the new pack, and it was a 74/75mg split of 28 total doses; 14 were 74 mg and 14 were 75 mg. We tried to call the center, but it was closed so we talked to the Nurse Practitioner (NP) and the resident because he/she is alert. The resident said the center told him/her they were going to send a 74/75 split, so the NP updated that going forward he/she will get 75mg in the morning and 74mg at bedtime. For today, the NP put in a one-time order for 74 mg in the morning and evening because there are two doses left and they are both 74 mg. 2) On 2/11/26 at 10:28 AM the surveyor observed Registered Nurse (RN #13) administer medications to Resident #73. During the administration, RN #13 gave Resident #73 a dose of his/her Ellipta inhaler. After receiving his/her puff of the medication, Resident #73 took a sip of water. RN #13 failed to provide instructions to Resident #73 regarding rinsing his/her mouth with water and expectorating (spitting) after, and Resident #73 did not do so. Review of Resident #73's medical record on 2/11/26 at 1:23 PM revealed a physician order dated 1/24/26 for Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACT 1 puff inhale orally one time a day for COPD (Chronic Obstructive Pulmonary Disease) Rinse mouth with water and expectorate after use.On 2/11/26 at 1:51 PM in an interview with RN #13, the surveyor shared the concern that Resident #73's order for the Anoro Ellipta inhaler had instructions to rinse mouth with water and expectorate after use, and the resident was not observed following those instructions. RN #13 acknowledged and verified understanding of the concern.

Based on interviews with facility staff, review of pertinent documentation and medical record reviews, it was determined that the facility failed to ensure providers responded to the monthly pharmacy review reports and took action to address the recommendations. This was evident for 2 (Resident #3 and # 8) of 6 residents reviewed for unnecessary medications during the facility's recertification/complaint survey.The findings include: The Medication Regimen Review (MRR) is a review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. 1) On 2/11/26 at 7:49AM in an interview with the Director of Nursing (DON) when asked about the facility's MRR process, she stated the pharmacist comes usually about the 3rd week of the month, she sends them, we [myself and the Unit Managers (UMs)] print them off to distribute to the physicians, we get them back, see what kind of order there is and make sure the orders are completed. I have a book I keep them in and we now put them in the resident's medical record. We started about 2 months ago. If there are any order changes, we do a change in condition so the family would know. During the interview when asked how the report was sent, she stated it was emailed to the Regional, herself and the UMs. When asked whose responsibility it was to print the MRRs, she stated, There is not one designated person, but since I've been here, I have printed them off and have them ready for clinical meeting. When asked about the process for the provider, she stated, We have a Nurse Practitioner (NP) and we're physically handing the printed MRRs to the her. Then, she physically hands them back to the UMs or myself. When asked the timeline for the provider to address the MRRs, she stated, 7-10 days. When asked who was responsible for discontinuing orders and/or putting in new orders, she stated the UMs. Additionally, she stated it was the facility's expectation that the provider checked one of the boxes (agree, disagree, other) and if they disagreed, the provider was to write a rational for why they disagreed. She also said the expectation was that the provider signed and dated the MRR. The surveyor requested MRRs from the past 6 months for Resident #3. On 2/11/26 at 9:12 AM review of the facility's Medication Regimen Reviews policy revealed, Physician Response 1. Upon receiving the MRR report from the pharmacist, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them. On 2/11/26 at 9:48 AM the DON provided MRR's dated 8/22/25, 9/21/25, and 11/16/25 MRR's for Resident #3. The recommendations were as follows: -8/22/25 Oxycodone HCl Oral Tablet 5mg (milligrams) Give 1 tablet by mouth two times a day for lower extremity pain. CMS (Centers for Medicare/Medicaid Services) encourages healthcare providers to co-prescribe naloxone for residents on narcotics. The resident is on a routine narcotic. Please consider adding naloxone -9/21/25 Uzedy Subcutaneous Suspension Prefilled Syringe 100 mg/0.28ml (milliliters) Inject 100mg subcutaneously one time a day every 2 months starting on the 20th for 1 days(s) for Schizophreniform disorder. Resident is due for gradual dose reduction (GDR) in an attempt to find the lowest effective dose. Please consider a trial dose reduction. If the medication cannot be reduced at this time, please check the appropriate rationale below related to the GDR being clinically contraindicated at this time and make a brief clinical rationale note that benefits outweigh the risks.The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility.An attempted GDR is likely to result in impairment of function or increased distressed behaviors.Other: (Please state below) -11/16/25 Cefepime HCl Intravenous Solution Reconstituted 2 gm Use 2 grams intravenously every 8 hours for wound infection. Please provide stop date for antibiotic therapy.Please add probiotic while on antibiotic therapy. On 2/11/26 at 10:02 AM review of Resident #3's medical record revealed the following for each recommendation: -8/22/25: The provider had checked agree and signed and dated the MRR and the resident had an active order for oxycodone; however, he/she did not have an active order for naloxone.-9/21/25: The provider has checked disagree and signed and dated the MRR; however, the provider did not check one of the 3 boxes the pharmacist's recommendation asked to be checked if they disagreed with the recommendation. Furthermore, the provider did not provide a brief clinical rationale note as to why they disagreed with the pharmacist's recommendation. -11/16/25: The provider checked other and wrote, Pt (patient) has stop date of 12/3/25. The first part of the recommendation was addressed and acted upon; however, the second part regarding probiotics was not responded to on the MRR report. On 2/11/26 at 11:57 AM in an interview with the DON the surveyor shared they had requested 6 months of MRRs for Resident #3 and had received MRRs for August, September and November 2025. The surveyor made a second request for the MRRs for October and December 2025 and January 2026. The DON stated, I'll check for these. On 2/11/26 at 1:16 PM in an interview with the DON stated there was no recommendations for Resident #3 for December 2025 and that the resident was in the hospital during the January 2026 review, so a MRR was not conducted because all his/her medications were discontinued. When asked about the October 2025 MRR, she stated, He/She did have one and it looks like it was missed. The surveyor requested a copy and shared this would be a concern. The DON verbalized understanding of the concern. On 2/11/26 at 1:23 PM the DON provided a copy of Resident #3's 10/26/25 MRR which the provider had not responded to. In an interview with the DON, she confirmed that the MRR report was not completed by the provider (no check for agree, disagree, other and no signature or date) nor was any action taken to address the recommendation. The surveyor shared this was a concern and the DON confirmed understanding of the concerns. On 2/17/26 at 7:33 AM in an interview with the DON, she stated The provider put the rationale for disagreeing in his psychiatry note, but I talked to him yesterday and told him he needed to put the rationale on the MRR report (for Resident #3's 9/21/25 MRR). During the interview she stated, Naloxone was ordered, but he/she went to the hospital, and it dropped off, so the NP put it back on. When asked if prior to surveyor intervention, the resident should have had a current, active order for Naloxone, the DON stated, Yes, the facility did still want him/her to have Naloxone since he/she's prescribed narcotics (for Resident #3's 8/22/25 MRR). Additionally, the DON stated, I spoke with the NP, and she didn't feel he/she needed a probiotic. So, I did tell her that she needs to complete the MRR report and address it in some kind of way (for Resident #3's 11/16/25 MRR). When asked about the 10/26/25 MRR for Resident #3, the DON stated, I looked at that and don't see where the provider addressed that one, which I'll get him to do today. The surveyor shared the concern that this MRR was not addressed and almost 4 months later still had not been addressed. The DON acknowledged understanding of the concern. 2) During an interview on 2/11/26 at 7:49AM with the Director of Nursing (DON), when asked about the facility's MRR process, she stated the pharmacist conducted monthly medication record review and emailed the reviews to the Regional staff, the DON and the Unit Managers. The physician or facility Nurse Practitioner are given the medication reviews for reconciliation, and a copy is given back to the DON or the Unit Managers to be placed in an MRR binder. When asked for the timeline for the provider to address the MRRs, the DON stated, 7-10 days. The DON also stated that the facility's expectation is that the provider would check one of the boxes (agree, disagree, other) and if they disagreed, the provider would write a rational for why they disagreed and that the provider signed and dated the MRR. On 2/12/2026 at 8:39 AM, the DON provided the Medication Regimen Review (MRR) for August 2025 – December 2025 for Resident #8, which revealed the following: The MRR dated 10/26/2025 had a psychiatry recommendation for Olanzapine tablet dispersible 10 MG give 1 tablet by mouth at bedtime for Paranoid Schizophrenia, ordered on 6/19/2025. It stated that the resident is due for a gradual dose reduction to find the lowest effective dose. Please consider a trial dose reduction. The form was blank for agree, disagree, and other. There was no response noted and no signature and date noted. The MRR dated 1/19/2026 had a physician recommendation for Trazadone HCL tablet 50 MG Give 1 tablet by mouth at bedtime for depression/insomnia (take one tablet at bedtime) ordered on 10/2/2025. The recommendation was that if an antidepressant is used for sleep or to manage behavior, stabilize mood, or treat a psychiatric disorder, it must be reviewed for a possible gradual dose reduction in an effort to find the lowest effective dose. If a dose reduction is deemed clinically contraindicated at this time, please state the rationale below and the risk vs. benefit of continuing the drug at the current dose. The signed and dated form was checked off as disagree, but there was no written response to the brief clinical rationale note if disagree. On 2/12/2026 at approximately 10:00 AM, the physician's progress notes for Resident #8 failed to address a disagree reason for the Trazadone 50 MG tablet GDR. In addition, there was no indication that the medication regimen review recommendations for Olanzapine 10 MG tablet were completed. On 2/12/2026 at 10:32 AM, the DON was made aware that there was a concern regarding the reconciliation of the MRRs. The DON acknowledged the concern.

Based on observations, interviews, and medical record review, the facility failed to provide necessary respiratory care, specifically the care of the oxygen nasal cannula. This was evident for 1 (Resident #12) of 1 resident reviewed for oxygen during the recertification/complaint survey.The findings include: On 02/09/2026 at 9:30 AM, during an observation, Resident #12 was lying in bed with oxygen at 2 liters via a nasal cannula. The oxygen tubing was not dated, and the oxygen concentrator did not have a humidifier attached.On 02/10/2026 at 9:00 AM, during an interview, Staff #7, a Licensed Practical Nurse (LPN), was asked about oxygen administration. Staff #7 (LPN) stated that a physician's order is required to change the nasal cannula, the oxygen tubing is changed every 24 hours, and staff also date the humidifier bottle. Staff #7 (LPN) confirmed the oxygen tubing was undated and no humidifier was in use. Staff #7 (LPN) reviewed Resident #12's orders with the surveyor present, which included a physician order dated 11/20/2025 for Oxygen 2 liters via nasal cannula as needed but lacked physician orders that detailed respiratory equipment care. On 02/10/2026 at 9:11 AM, during an interview with Resident #12 with Staff #7 (LPN) present, Resident #12 shared that his/her nose gets dry from the oxygen.On 02/10/2026 at 9:15 AM, during an interview, Staff #12, Registered Nurse (RN Unit Manager), described the oxygen administration process. She stated that oxygen therapy requires a physician's order that must include specific instructions for the care of the respiratory equipment, such as orders for the oxygen tubing and humidifier to be changed and dated weekly on Wednesdays. She expected an order for the weekly oxygen tubing change and humidifier to be in place. At this time the concern was shared with the unit manager.On 02/10/2026 at approximately 1:44 PM, a continued review of Resident #12's treatment administration record revealed a physician's order, dated 02/10/2026, for weekly, Wednesday night-shift changes and dating of oxygen tubing/water bottles, and washing of the filter, if applicable. However, prior to surveyor intervention, there were no respiratory care instructions for oxygen equipment for the preceding three months (November 2025, December 2025, and January 2026).On 02/10/2026 at 1:40 PM, during an interview, the Director of Nursing (DON) confirmed that a physician's order is required for the care of respiratory equipment, including oxygen tubing changes (weekly or as needed) and the humidifier. The DON acknowledged that physician orders for the respiratory care of oxygen equipment were only initiated after the surveyor's intervention. The concern was shared with the DON at this time.

Based on a record review and interviews, it was determined that the facility failed to ensure that residents received appropriate treatment to maintain vision abilities. This was evident for 1 (Resident #64) of 2 residents reviewed for communication and sensory problems during the recertification/complaint survey process.Findings Included:On 02/09/2026 at 1:00 PM: During an interview, Resident #64 reported experiencing visual impairment, a need to see an ophthalmologist, and that this request had not been fulfilled. The resident reported that the glasses at bedside did not work and special glasses were needed.On 02/11/2026 at 9:56 AM: Staff #22 (unit manager) was interviewed regarding the ophthalmologist process. She explained the standard procedure: after resident notify the the nurse of their concern, the nurse notifies the resident's healthcare practitioner for an assessment order, the order is placed in the computer, the unit secretary schedules the appointment, and the appointment is noted on the calendar. She stated she was unsure if the facility had an in-house ophthalmologist but would check.On 02/11/2026 at 10:32 AM: A review of the admission Minimum Data Set (MDS) assessment, completed on 8/26/2025, indicated the resident's vision (with glasses or visual appliances) was adequate.On 02/11/2026 at 10:45 AM: A review of progress notes revealed the following: 8/18/2025 (PCP Note): Vision was documented as WNL (Within Normal Limits - No abnormalities noted); 9/15/2025 (Nutrition Note): Resident #64 required setup/clean-up assistance related to vision loss; On 10/16/2025 (PCP Note): A note regarding a vision problem stated, Ophthalmology follow-up appointments should be scheduled as necessary. Ensure regular monitoring and evaluation by an ophthalmologist to address any concerns. Follow-up intervals depend on individual needs, medical conditions, and treatment; 02/10/2026 (Provider Note): Documented the patient's verbalization of Dry eyes, and new orders were written for artificial tears.On 02/11/2026 at 11:18 AM: In a follow-up interview, Staff #22 reported that the facility utilized one specific in-house ophthalmology company, and appointments were dependent on insurance qualification; otherwise, residents were sent to an outside ophthalmologist.On 02/11/2026 at 11:20 AM, in an interview with Geriatric Nursing Assistant (GNA#23), when asked she reported that Resident #64 was partially blind and required assistance with care.On 02/11/2026 at 11:38 AM, in an interview, the License Practical Nurse (LPN #17) reported the resident had glasses at the bedside that he/she reported did not work, but the resident had not specifically told the LPN about current vision issues. The LPN noted the resident was able to see her from a far distance down the hallway.On 02/11/2026 at 11:48 PM, in an interview, the Nurse Practitioner (NP#24) explained that the resident reported difficulty seeing and requested eye wash. NP #24 reported that she could not prescribe eye wash without an ophthalmologist assessment and had been attempting to schedule an appointment but was unsure about insurance coverage. Documented evidence supported the facility's awareness of the vision issues but showed a failure to obtain an ophthalmologist visit. NP #24 was notified that these findings were a concern.On 02/11/2026 at 12:05 PM, in an interview, the Director of Nursing (DON) was notified of the concern. She reported that the resident was being reviewed for an ophthalmologist assessment but was unsure of the conclusion. She was notified that there was no documented evidence to support that the facility had appropriately assessed and/or treated the resident's vision impairment issues.

Based on record review and interviews with facility staff, it was determined that the facility failed to ensure that physician orders were carried out accurately to ensure patient safety and quality care. This was evident for 1 (Resident #3) out of 5 residents reviewed for unnecessary medications during the facility's recertification/complaint survey.The findings include:The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's functional, medical, psychosocial and cognitive status. It is administered to all residents at admission, quarterly, annually, and whenever a significant change in an individual's condition occurs. It is the foundation for creating an individualized care plan and ensures the appropriate care and services are provided to each resident. MDS assessments must be accurate to ensure each resident receives the personalized and resident specific care they need.Brief Interview of Mental Status (BIMS) is a standardized test used to assess a resident's cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. On 2/11/26 at 8:19 AM review of Resident #3's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses including, but not limited to, schizophreniform disorder, bipolar disorder, generalized idiopathic epilepsy, type 2 diabetes mellitus (DM) with foot ulcer, and unspecified intellectual disabilities. Further review revealed his/her MDS dated [DATE] documented a BIMS of 5 indicating severely impaired cognition. Continued review revealed an order for Insulin Aspart Injection Solution 100 UNIT/ML (milliliter) inject subcutaneously before meals for DM2. The order was written to obtain a fingerstick (to obtain blood glucose or blood sugar levels) before meals. On 2/11/2026 at 8:51 AM review of Resident #3's MAR (Medication Administration Record) revealed the following:-11/5/25 at 8:00 AM and 12:00 PM blood sugar (BS) was documented as NA with a chart code of 2. According to the Chart Codes, a 2 meant Drug Refused. -11/12/25 at 5:00 PM BS was documented as NA with a chart code of 9. According to the Chart Codes, a 9 meant Other/See Nurses Note. -11/14/25 at 5:00 PM BS was documented as NA with a chart code of 2.-11/17/25 at 5:00 PM BS was documented as X with a chart code of NI. According to the Chart Codes/Follow Up Codes, NI meant No insulin required. -12/19/25 at 7:30 AM BS was documented as NA with a chart code of 2.-12/19/25 at 12:00 PM BS was documented as NA with a chart code of 9.-12/28/25 at 7:30 AM BS was documented as NA with a chart code of 2.-1/26/26 at 5:00 PM BS was documented as NA with a chart code of 9.-1/29/26 at 8:00 AM and 12:00 PM BS and insulin were blank. There was no BS or insulin or documentation of any form for this date and times. -1/30/26 at 12:00 PM BS was documented as NA with a chart code of 9.On 2/13/26 at 1:58 PM in an interview with the Director of Nursing (DON) when asked for residents diagnosed with intellectual disabilities, what was the facility's expectation if they refused a medication, she stated, We're going to encourage. We're going to let the doctor know. We're going to let the RP know. Those contacts should be documented as a change in condition or progress note. During the interview when asked for residents diagnosed with intellectual disabilities, what was the facility's expectation if they were sleeping during medication administration, she stated, You could wait a little bit within the timeframe and come back later and see if they're still sleeping. If it's getting too late, you should attempt to wake the patient up. Additionally, the DON stated, No, it would not be acceptable to mark sleeping and not administer the medication. On 2/17/26 at 7:46 AM in an interview with the DON, a dual observation was conducted of Resident #101's November and December 2025 and January 2026 MARs. When asked what NA meant, she stated, What I get is the NA was put in because they didn't get a BS, so they just put 'NA' instead of just putting some kind of documentation explaining. When asked if for each shift where NA was documented should the nurse have obtained a BS, she stated, Yes they should have gotten a BS. When asked if a resident sleeping was a legitimate/acceptable reason to not obtain the resident's BS, she stated no. When asked if for the shifts documented that Resident #101 refused, was there any documentation that the provider was notified, she stated, I didn't see any documentation. The surveyor shared these were concerns and the DON acknowledged understanding of the concerns.On 2/17/26 at 11:28 AM in an interview with the DON regarding Resident #3's Nov-Jan MAR and insulin, when asked why on 1/29/25 at 8:00 AM and 12:00PM the BS and insulin boxes on Resident #3's MAR, she stated, It probably means they didn't do it, but I have to verify.On 2/17/26 at 12:36 PM in an interview with the DON she stated, The boxes (1/29/26 at 8:00 AM and 12:00 PM) were blank because there was no documentation. During the interview when asked if the expectation was for nurses to carry out physician orders and document, she stated, Yes, the expectation is that the nurses are documenting the BS, that insulin was administered, and the amount of insulin administered. The surveyor shared this was a concern. The DON acknowledged and confirmed understanding of the concern.

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP) and documented in the medical record. This was evident for 2 (Resident #51 and #3) out of 41 residents reviewed during the facility's recertification/complaint survey.The findings include:A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and current medication list must be given to the resident and/or RP and there must be evidence in the medical record that it was provided. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission.On 2/10/26 at 10:43 AM review of Resident #51's medical record revealed he/she was admitted to the facility on [DATE]. Further review of the medical record failed to reveal a BLCP and/or evidence from the medical record that a copy was given to the resident and/or RP.On 2/10/26 at 12:51 PM review of Resident #3's medical record revealed he/she was admitted to the facility on [DATE]. Further review of the medical record failed to reveal a BLCP and/or evidence from the medical record that a copy was given to the resident and/or RP.On 2/10/26 at 1:03 PM in an interview with the Director of Nursing (DON) when asked to describe the facility's BLCP process, she stated, They get a BLCP when they're admitted . We give them a copy within 48-72 hours. When asked where it was located, she stated, They don't print it out separately. They add to the BLCP as the comprehensive care plan and write a progress note it was given to the resident and/or RP. The surveyor requested a copy of the BLCP and evidence from the medical record that it was provided to the resident and/or RP for Resident #51 and Resident #3. On 2/10/26 at 1:35 PM in an interview with the DON, she stated, Those 2 we don't have evidence. Most of the time they [facility staff] write a progress note they [resident and/or RP] received it. Well, that's the policy that they're supposed to write a note. When asked if there was a copy of the BLCP summary for either resident she stated, I didn't see anything in medical records. The surveyor shared this was a concern and the DON acknowledged understanding of the concern.

Based on interviews with facility staff and review of medical records, it was determined that the facility failed to ensure that physicians and resident representatives (RPs) were notified of changes in resident conditions. This was evident for 1 (Resident #101) out of 3 residents reviewed for skin conditions (non-pressure related) during the facility's recertification/complaint survey. The findings include:On 2/10/26 at 10:35 AM in an interview with Licensed Practical Nurse (LPN #17) she stated that Resident #101 had a new wound on his/her left toe. On 2/17/26 at 9:50 AM review of Resident #101's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction, peripheral vascular disease, epilepsy, and type 2 diabetes mellitus. Further review revealed a Weekly Skin Check dated 2/11/26 that documented No New Skin Alterations; however, the assessment also documented Left great toe wound: cleanse with normal saline, pat dry, apply silver alginate, cover with dry bordered dressing every other day, Tuesday-Thursday-Saturday-Sunday. Monitor for s/s (signs and symptoms) of infection. Continued review revealed a Weekly Skin Check dated 2/4/26 that documented Skin is intact.On 2/17/26 at 10:08 AM the surveyor requested documentation of when the facility first became aware of the wound on Resident #101's left toe. On 2/17/26 at 11:24 AM in an interview with the Director of Nursing (DON) she stated the first documentation on Resident #101's left toe was from the Weekly Skin Check on 2/11/26 and provided a copy of the 2/11/26 Weekly Skin Check. During the interview, the surveyor stated the Weekly Skin Check prior to this one dated 2/4/26 documented Skin is intact and this one dated 2/11/26 documented No New Skin Alterations. The DON stated, the nurse should have documented New Skin Impairment Noted as this was newly identified. On 2/17/26 at 11:46 AM review of Resident #101's medial record revealed an order, Appraise and observe every shift for changes in physical and mental condition. Notify Provider if observed. Every shift. with an order date of 8/1/25. Further review revealed on Resident #101's TAR (Treatment Administration Record) for 2/10/26 a check mark for each shift that the order was completed; however, failed to reveal that the provider was notified of the physical changes (left toe wound) in Resident #101's physical condition. On 2/17/26 at 12:15 PM the surveyor asked what the Doxycycline Hyclate Oral Tablet 100 MG was ordered for. On 2/17/26 at 12:36 PM in an interview with the DON, she stated it was ordered for his/her left great toe and provided a copy of an updated order to reflect that. The surveyor stated there was a wound treatment order for Resident #101's left great toe wound dated 2/10/26, showing the facility was aware of the wound on 2/10/26. The surveyor shared that there was an order for appraising and observing for physical changes and to notify the provider if observed and requested evidence that the provider was notified on 2/10/26 when the wound was first observed. On 2/17/26 at 1:36 PM in an interview with the DON she stated, I didn't see any documentation that the provider was notified on 2/10/26. The surveyor shared this was a concern. The DON verbalized and acknowledged understanding of the concern.

Based on observation, interview, and record review, it was determined the facility failed to appropriately assess and determine the clinical appropriateness of self-administration of medications. This was evident for 1 (Resident #14) of 1 resident reviewed for medication self-administration during the recertification/complaint survey.The Findings include: On 02/09/2026 at 9:33 AM, during an observation, Resident #14 was observed in his/her room, lying in bed. On the bedside table to Resident #14's left, the following items were noted: one bottle of Tylenol 500 mg tablets, one bottle of Tylenol PM, and one bottle of TUMS.On 02/09/2026 at 9:36 AM, during an interview, Staff #4 (Registered Nurse) described the facility's medication procedure, stating that medication bottles should not be kept at the bedside. Staff #4 confirmed that Resident #14 had medication bottles at the bedside and stated, I am going to remove the medications and call Resident #14's complainant to get the medications. On 02/10/2026 at 12:39 PM, a review of Resident #14's medical record included an admission assessment from December 15, 2025. This assessment, under the Self-medication administration section, indicated NO to the question, Does the resident WANT to self-administer his/her own medications? Further review of Resident #14's medical record lacked a physician's order for Tylenol PM, authorization for self-administration of Tylenol 500 mg or TUMS, or a care plan confirming the resident's capacity for self-administration.On 02/10/2026 at 1:35 PM, during an interview with the Director of Nursing (DON), the DON confirmed the process for medication at the bedside. For a resident to self-administer medication, a physician's order is required, an assessment must be completed, and the medication must be kept locked up in the bedside table. This information would be documented on the medication administration record and included in the care plan. The concern regarding this process was shared with the DON at the time of the interview.

Based on record observation and interviews, it was determined that the facility failed to serve food at an appetizing temperature. This was evident during the completion of the kitchen facility task during the recertification/complaint survey. Findings Included:On 02/09/2026 at 9:12 AM: Resident #10 reported hot foods were not hot. Resident #12 reported that food was sometimes served hot and sometimes not, and the taste was poor.On 02/09/2026 at 12:46 PM, another resident, Resident #4, reported that food was being served cold and sometimes it is due to the wait for assistance with feeding.On 02/13/2026 at 08:50 AM, the Food Service Director was informed to provide a test tray (sample tray) on the last food cart for delivery to the unit during the lunch time.On 02/13/2026 at 12:30 PM, observation of the last food cart delivery to the Terrace unit began. Lunch tray service started at 12:36 PM. The surveyor observed staff deliver all resident trays before removing the last tray (test tray) from the cart.On 02/13/2026 at 12:44 PM: The surveyor pulled the test tray/sample tray as served from the delivery cart.On 02/13/2026 at 12:53 PM: Test tray temperature results were recorded using two thermometers: Candied Sweet Potatoes measured 115.3 degrees/112.8 degrees; Fish measured 108.5 degrees/107.7 degrees; and Vegetables measured 108.1 degrees/105.0 degrees.On 02/13/2026 at 2:13 PM: The Director of Nursing (DON) was informed that the warm lunch test tray temperatures were low/abnormal.

Based on medical record review and interview it was determined that the facility failed to prevent a known wandering resident from leaving the facility. This was evident for 1 of 6 ( #18) residents reviewed for elopements. This failure resulted in an Immediate Jeopardy for Resident #18. After the elopement incident the facility developed, initiated and completed a plan of correction to prevent further elopements. Therefore, this deficiency will be cited as a past non-compliance. The date of correction was 5/27/2023. The findings include: Review on 5/16/24 at 9:59 AM of the facility reported incident MD00192701 revealed that on 5/19/23, Resident #18 eloped at approximately 9:15 AM. Record review on 5/16/24 at 10:10 AM revealed Resident #18 had a diagnosis of Parkinson's disease of which s/he had been refusing medication, delirium, and dementia with behavioral disturbances. A wander guard was placed on Resident #18 upon admission. Further review of the facility report revealed that Resident #18 was able to leave the facility undetected, and was found by police 5 hours later at a hotel approximately 14 miles away. The facility report further noted that upon the resident return to the facility, his/her wander guard bracelet, that was located on the resident's wrist prior to the elopement was checked for functioning and it was working, even alarmed upon reentry to the facility, however, it did not alarm when s/he left the facility. A new wander guard was placed on Resident #18's ankle, the care plan was updated, and staff education was completed related to elopement procedures. Additionally, the facility report and nursing progress notes stated that on readmission, Resident #18 refused any assessment, became aggressive, and combative, and was sent to the hospital for further treatment and evaluation. According to the facility report and investigation, the receptionist, staff #16 stated that she thought Resident #18 was a visitor and opened the door for him/her to leave with other visitors. Further, according to the incident report, when Staff #16 was interviewed about Resident #18 and the incident, she stated that she was unaware of the elopement binder that had the resident's picture and information in there. Review on 5/17/24 at 9:44 AM revealed that upon hire, staff #16 was educated on the facility elopement procedures, including the elopement binder. The Administrator was interviewed on 5/17/24 at 8:22 AM and she provided the survey team with training, education, and interventions that were completed related to the elopement for Resident #18. The changes and intervention implementations completed by 5/27/23 after the occurrence on 5/19/23 included: Staff re-education on the elopement process and procedures and education related to the elopement binder at the front desk. Additionally, there are daily checks completed on the exit doors. According to the TELS (an electronic communication with maintenance and work order tracking) logbook documentation provided on 8:20 AM at 5/17/24, the operation of the door monitors and patient wandering systems are checked daily and all noted as pass. Based on the above actions taken by the facility and verified by the surveyor on-site, it was determined that the facility had corrected the deficient practice by 5/27/23, prior to the start of the survey.