Every finding on record at Turtle Creek Rehabilitation and Wellness Center

Based on interview, observation and record review it was determined the facility staff failed to address resident needs and preferences by failing to assist a resident out of bed and into a chair. This was evident for 1 (#3) of 3 residents reviewed during the survey.The findings include: Review of complaint #3136345 revealed a concern that the resident was not provided with a wheelchair and is left in his/her room. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #3's medical record on 8/21/26 at 9:52 AM revealed Resident #3 was admitted in May of 2026 with diagnoses which included but were not limited to hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction (stroke) affecting left non-dominant side.Resident #3's 5-day admission MDS assessment submitted by the facility on 6/2/26 revealed Section F: Preferences for Customary Routine and Activities reflected that Resident #3 indicated it was very important for him/her to do things with groups of people, to do his/her favorite activities, to go outside to get fresh air when the weather is good and to participate in religious services or practices. Section C: revealed Resident #3's Brief Interview of Mental Status (BIM's) score was 14 out of 15 which indicated normal cognition with little to no impairment.Resident #3 was assessed by the physician to be capable of making his/her own medical decisions.Resident #3's plan of care did not include a plan to address Resident #3's mobility. On 8/25/26 at 10:15 AM Resident #3 was observed in his/her room, lying on the bed, wearing a hospital gown. There was no wheelchair, Geri-chair, nor any other chair in the room. Resident #3 was asked if the facility provided him/her with a wheelchair or other type of chair to utilize when out of bed. S/he stated no, they haven't gotten me out of bed. I don't know why. The Director of Physical Therapy (PT) #6, was interviewed on 8/25/26 at 11:59 AM. When asked if Resident #3 was evaluated for ability to use a wheelchair, she indicated the resident's PT evaluation goal was to be able to sit up in a wheelchair for 2 hours. She was unable to identify why there was no wheelchair, Geri-chair or other chair for the resident to utilize out of the bed and indicated she would get back to the surveyor. At 12:47 PM she returned and indicated that Resident #3 was unable to tolerate sitting in a wheelchair due to pain, poor core engagement and poor sitting balance. She was asked if PT evaluated Resident #3 for use of another type of chair such as a Geri-chair or Broda chair to enable the resident in getting out of bed. She did not answer but indicated that she could evaluate Resident #3 again. When asked if Resident #3 had been evaluated for use of a Geri-chair (recliner) she stated Geri-chairs are something nursing would provide, I can't speak to that. During an interview on 8/25/26 at 2:48 PM Licensed Practical Nurse (LPN) #7 was asked if staff assisted Resident #3 out of bed. She stated [s/he] refuses. When asked to identify which chair the resident was offered she stated if [s/he] wants to get out of bed, we will get a chair from therapy. She was asked what type of chair the resident would use if s/he accepted, she did not answer. This concern was reviewed with the [NAME] President of Clinical Services on 8/26/26 at 1:25 PM.Cross reference F 656

Based on observation and interview it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, comfortable and homelike environment. This was evident for 1 (#147) of 3 resident rooms observed for environment.The findings include: Review of complaint #3136345 on 8/20/26 at 12:15 PM revealed concerns related to ceiling tiles with signs of a leak in resident(s) room(s). 3 resident rooms were observed on 8/25/26 at approximately 10:15 AM. In room [ROOM NUMBER] the surveyor observed 4 ceiling tiles directly above the first bed (A) with large brown stains. The stains were widest along the edge of the tile adjacent to the wall and extended in a semicircle toward the center of each tile. The stains covered an area approximately 2 feet wide by 5-6 feet long. A similar brown stain approximately 1 1/2 feet square was observed on a ceiling tile in the corner of the bathroom directly above the hand sink. During the same observation an exhaust fan/vent was observed in the center of the bathroom ceiling. The fan/vent housing hung below the ceiling tile revealing a 1-2-inch gap between the housing and the ceiling tile. The open space above the ceiling was visible through the gap. The slats on the ceiling fan/vent were covered in a layer of gray dust-like material, approximately 1-2 mm (millimeters) thick. These concerns were reviewed and observed with the [NAME] President of Clinical Services on 8/26/26 at 1:25 PM. She indicated that these areas should have been identified during Ambassador Rounds. The Administrator, Director of Maintenance, Director of Nursing and Regional Director of Clinical Services were also present during the observation.

Based on record review, observation and interviews it was determined the facility staff failed to utilize an appropriate assistive device to prevent a resident fall during transfer. This was evident for 1 (#2) of 3 people reviewed during the survey.The findings include:A Hoyer Lift is a specialized mobile mechanical device used to safely lift, suspend, and transfer patients with limited mobility between a bed, wheelchair, toilet, or shower. Complaint #3156770 was reviewed on 8/19/26 at 10:30 AM. The complaint included but was not limited to an allegation that Resident #2 fell on 7/9/26 during a transfer from their bed to a wheelchair due to staff utilizing a Hoyer Lift that was too small.Review of Resident #2's medical record revealed a Post Fall Evaluation dated 7/9/26 00:00 by Staff #5 a Registered Nurse (RN) . The evaluation indicated the suspected root cause of the fall was wrong Hoyer Lift.Resident #2 was evaluated at the hospital determined to have no apparent injury and returned to the facility.The record revealed Resident #2's weight assessment on 7/6/26 was 414.9 pounds. Th 3 GNA's involved in the transfer of Resident #2 on 7/9/26 were interviewed on 8/20/26. All 3 GNA's indicated in their interviews that the Hoyer began to tilt, they all grabbed the sling and lowered Resident #2 to the floor. At 1:35 PM GNA #2 indicated they worked in the facility for about 3 years and has been a GNA for a long time. They confirmed that the facility had several Hoyer Lifts and stated we used a bigger one. It holds up to 600 pounds, and indicated the facility just got 2 new lifts. At 1:41 PM GNA #4 indicated they have been a GNA for over 1 year and worked in the facility since April. They indicated the facility had several Hoyer Lifts of different sizes and stated, the one we used was for [Resident #2's] size, basically. GNA #3 was interviewed at 1:55 PM and indicated they worked in the facility for about 4-5 months and was a new GNA. When asked what they thought caused the fall they stated, honestly I don't know, maybe the resident was too heavy. When asked if there was a weight limit for the lift they stated, it should be on the lift and we used the big lift. On 8/21/26 at 9:55 AM the Regional Director of Clinical Operations and Director of Nursing (DON) confirmed that the facility had several Lifts. When asked how staff know what the weight limit is for each of the lifts, they indicated that it was indicated on the lift. In another interview on 8/21/26 at 12:57 PM the Regional Director of Clinical Operations confirmed the weight rating for the Hoyer Lift that was utilized by the staff during Resident #2's transfer on 7/9/26 was 340 pounds. On 8/25/26 at 9:50 AM the Maintenance Director and surveyor observed 4 Hoyer Lifts in the facility. 2 lifts were rated as 600-pound capacity, 1 lift was rated as 700-pound capacity, and 1 lift was rated as 340-pound capacity. The Maintenance Director indicated that the facility had 1 more lift but it was out of the facility for repairs. When asked, he identified the lift with the 340-pound capacity was the lift utilized on 7/9/26 when Resident #2 fell. All the lifts had visible, handwritten weight capacity labels on their arms. Most of them also had smaller manufacturers stickers located on the arm or near the handles which identified their weight capacity. These concerns were reviewed with the [NAME] President of Clinical Services on 8/26/26 at 1:25 PM.

Based on record review, observation and interviews it was determined the facility staff failed to develop and implement a comprehensive person-centered care plan based on resident centered goals. This was evident for 1 (#3) of 3 residents reviewed during the complaint survey.The findings include:The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #3's medical record on 8/21/26 at 9:52 AM revealed he/she was admitted in May of 2026. Resident #3's 5-day admission MDS assessment submitted by the facility on 6/2/26 revealed Section F: Preferences for Customary Routine and Activities reflected that Resident #3 indicated it was very important for him/her to do things with groups of people, to do his/her favorite activities, to go outside to get fresh air when the weather is good and to participate in religious services or practices. Section C: revealed Resident #3's Brief Interview of Mental Status (BIM's) score was 14 out of 15 which indicated normal cognition with little to no impairment. Resident #3 was assessed by the physician to be capable of making his/her own medical decisions. The resident's diagnoses included but were not limited to hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction (stroke) affecting left non-dominant side. Resident #3's plan of care did not include a plan to address Resident #3's mobility. On 8/25/26 at 10:15 AM Resident #3 was asked if the facility provided him/her with a wheelchair or other type of chair to utilize when out of bed. S/he stated no, they haven't gotten me out of bed. I don't know why. No chair was observed in the resident's room at that time.The Director of Physical Therapy (PT) #6, was interviewed on 8/25/26 at 11:59 AM. She was unable to identify why there was no wheelchair, Geri-chair or other chair readily available for the resident to utilize but did identify that Resident #3 was unable to tolerate sitting in a wheelchair due to pain, poor core engagement and poor sitting balance. During an interview on 8/25/26 at 2:48 PM Licensed Practical Nurse (LPN) #7 was asked if staff assisted Resident #3 out of bed. She stated [s/he] refuses. When asked to identify which chair the resident was offered she stated if [s/he] wants to get out of bed, we will get a chair from therapy. She was asked what type of chair the resident would use if s/he accepted, she did not answer. A plan of care for Activities indicated Resident #3 was self-directed for activities in and out of room daily. Resident #3 is dependent on staff for activities, cognitive stimulation or social interaction due to disease process of Cerebral Infarction.The resident's goal was: will participate in activities of choice through review date.The interventions staff identified to assist the resident in meeting his/her goal were: Assist with transport to activities as needed; Assure that the activities are compatible with resident's physical and cognitive capabilities; Encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations and religious activities; Interview to determine residents activity preferences; invite resident to scheduled activities; provide a schedule of activities available; and Provide activity materials of interest, i.e. library books, word puzzles, magazines.The plan did not identify Resident #3's activity preferences or include the resident's needs related to transportation to his/her activities of choice.No plan of care was developed to address Resident #3's mobility including limitations and the type of chair s/he needed to meet his/her mobility needs including refusal to get out of bed if applicable.This concern was reviewed with the [NAME] President of Clinical Services on 8/26/26 at 1:25 PM.Cross reference F 558.

Based on review of facility reported incident investigations and staff interview it was determined that the facility failed to thoroughly investigate allegations of neglect. This was evident for 1 (#4) of 2 residents for neglect.The findings include: On 6/10/26 at 9:35 AM, a review of the facility's investigation file for the self-report 2964230, which alleged Resident #4 was left to feed him/herself with the door closed, spilling food on him/herself, was conducted. The self-report indicated the alleged incident occurred on 3/7/26 and was reported to the facility on 3/25/26. The Facility Reported Incident Follow-Up Investigation Report Form documented a skin assessment was completed on Resident #4, who was non-verbal, and other non-interviewable residents and interviewable resident were interviewed. Continued review of the documents included with the facility's investigation found no evidence that interviews had been conducted with interviewable residents and there was no evidence skin assessments had been completed with any non-interviewable residents. On 6/10/26 at 11:13 AM, during an interview, the Nursing Home Administrator (NHA) was made aware that no resident interviews and no skin assessments of non-verbal residents were found with the facility's investigation documents provided to the surveyor. The NHA acknowledged the concern and stated he would look for the documents. On 6/10/26 at approximately 3:45, PM, [NAME] President of Clinical Operations (Clinical VP) was informed the facility's investigation failed to include evidence of resident interviews and skin assessments of non-interviewable residents. The Clinical VP acknowledged the concerns and stated she would have the NHA speak to the surveyor. On 6/10/26 at 3:58 PM, the concern with failing to thoroughly investigate the above allegation of neglect was discussed with the NHA and Clinical VP. At that time, the NHA acknowledged the concerns and stated he was still looking for the documentation to indicate residents were interviewed and skin assessments of non-interviewable residents had been conducted. As of time of exit from the survey, on 6/10/26 at approximately 5:00 PM, no documentation of resident interviews and no skin assessments of non-interviewable residents was provided to the surveyor.

Based on record review and interviews, it was determined the facility staff failed to notify the practitioner when a resident was assessed to have extremely high blood glucose levels. This was evident for 1 (#2) of 2 residents reviewed for neglect.The findings include:Finger stick blood sugar (BS) readings are obtained from a small drop of blood from a poke to a finger. The American Diabetes Association and Centers for Disease Control (CDC) suggest the recommended pre-meal blood glucose (sugar) readings should range between 80-130 mg/dL and less than 180 mg/dL 1-2 hours after the beginning of a meal; Target ranges may be different based on age, health status and diabetes management plan; Follow physician recommendations specific to each individual. However, results above 600 mg/dL are considered a life-threatening medical emergency. Complaint #3201771 and Resident #2's medical record were reviewed on 6/8/26 at 1:00 PM.The medical record revealed physicians orders written on 5/9/26 for finger stick blood sugar (BS) testing before meals and at bedtime. Resident #2's May and June Medication Administration Record's (MAR) included documentation of the resident's BS readings from 5/9/26 to 6/8/26.On 5/11/26 Licensed Practical Nurse (LPN) #9 documented at 4:30 PM and 9:00 PM Resident #2's BS levels were 515, on 5/13/26 at 9:00 PM she documented 524. On 5/14/26 at 6:30 AM LPN #10 documented Resident #2's BS was 524. Further review of the medical record failed to reveal the nurses notified the physician or on call provider of Resident #2's extremely high blood sugar test results. On 6/10/26 at 8:30 AM the surveyor asked Medical Records Director #5 to provide documentation reflecting the provider notification of Resident #2's high finger stick BS levels. None was provided.At that time, the Regional Director of Clinical Services #3 provided a copy of Resident #2's MAR for May 2026 and indicated that a physician order to notify the provider of finger stick BS levels higher than 400 was not written until 5/13/26. When asked if she would expect a licensed nurse to recognize the significance of extremely high blood sugar levels and call a provider in the absence of an order, she indicated that she would. She was made aware of the above findings and the 0630 BS level on 5/14/26 was obtained after the physician order was written on 5/13/26. In an interview on 6/10/26 at 3:19 PM LPN #9 was asked what she did after identifying extremely high finger stick blood sugar results. She indicated that she should call the doctor and recheck it again. She indicated that she was informed earlier that she didn't document the rechecked blood sugar levels.She was made aware that she documented Resident #2's extremely high blood sugar levels on the MAR However, no repeat BS levels or notification of the provider were documented. When asked if there was a reason she didn't notify the provider, she indicated that she was a new nurse and is still learning the policies. When asked if she was familiar with the standards of nursing practice, she indicated again that she is a new nurse and that she should have called the provider when the resident's blood sugar was higher than 400. The above concerns were reviewed with the [NAME] President of Clinical Operations on 6/10/26 at approximately 3:45 PM.

Based on observation, interview, and record review, it was determined that the facility failed to 1) ensure that Personal Protective Equipment (PPE) was available for staff to provide Enhanced Barrier Precautions (EBP), and 2) ensure the clean area of the laundry room, including clean linens and laundry staff, were protected from exposure to wastewater from the washing machines. This was evident 1) for two (Residents #9 and #73) of 2 residents reviewed for EBP, and 2) during an observation of the laundry room, and this deficient practice had the potential to affect all residents.The findings include:1). Resident #73 had a medical history that included but was not limited to: acute osteomyelitis of the right lower extremity, complete traumatic amputation of two or more right lesser toes, atherosclerosis of native arteries of the extremities with gangrene, cellulitis of the right lower extremity, and moderate protein-calorie malnutrition. Resident #9 had a medical history that included, but was not limited to, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes, stage 4 pressure ulcer, dysphagia, adult failure to thrive, and vascular dementia. Resident #9 also has a G-tube (feeding tube) and was under hospice care. On 4/13/26 at 9:30 AM, Resident #9's room door and Resident #73's room door were observed with Enhanced Barrier Precaution signs posted. However, no PPE for staff use was observed on the supply racks, one of which was located outside the resident's room, and one was located immediately inside the room. On 4/14/26 at 10:40 AM, during an interview with Staff #6, the Geriatric Nursing Assistant (GNA) assigned to the resident's care, they walked with the surveyor to Resident #9's room and Resident #73's room to confirm that each resident was to be on EBP and its intended purpose; however, no PPE was available for staff use, as Staff #6 confirmed. On 4/17/26 at 3:45 PM a summarized review of the facility's EBP policy, revised in April 2026, revealed that EBP required gown and glove use during high contact resident care activities that included: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care: any skin opening requiring a dressing. On 4/21/26 at 2:30 PM, during an interview with the Director of Nursing, she acknowledged the concern regarding the deficient practice of not providing EBP supplies to Residents #9 and #73. 2). An observation of the facility's laundry room was conducted on 4/13/26 at 9:47 AM. The facility had and was utilizing 3 washing machines. Behind them was a canal-like concrete structure where the 3 washers, including a utility sink with a leaking faucet, drained into. The floor and the base of the washers were wet and the wetness was traced back from the canal. The wet area extended about 2.5 ft in front and about 5 feet to the left side of the washer. On 4/13/26 at 9:54 AM, The laundry tech (Staff #8) who was in the laundry room during the observation reported that there was a problem with the drain in the canal causing the wastewater to overflow as observed. She stated, It's not draining fast enough so it overflows. Staff #8 reported that she had to step onto the wet floor whenever she needed to access the washers. Also, she knew it was dirty water so she would have to remove or clean her shoes she went home and she indicated that the problem started a couple of weeks ago and that management was already aware of the situation. The Nursing Home Administrator (NHA) was interviewed on 4/13/26 at 10:14 AM. During the interview, the NHA reported that he was aware that there was a concern with the laundry room that the maintenance staff was working on but would clarify with the Maintenance Director (Staff #10) and report back to the surveyor. On 4/13/26 at 10:26 AM, the NHA accompanied Staff #10 to meet with the surveyor. Staff #10 confirmed the problem with the drain for the washing machines. Staff #10 reported that a contract had been submitted and was in the process for approval in March 2026, but since the facility had a change of ownership, he was not sure when the contractors would start the rebuild of the laundry room for the drainage system. The NHA confirmed that they don't have a date for the job to be done. Staff #10 reported that as a temporary mitigation of the issue, he installed an electronic pump to drain the wastewater collecting in the canal to the septic system. The concern was discussed with the NHA and the Maintenance director that the temporary mitigation they had put in place was ineffective as it was observed that the wastewater was overflowing and posed a significant risk for cross contamination with clean linens. Both staff acknowledged the concern.

Based on observation, record review, and staff interviews, it was determined that the facility failed to ensure medications were administered in accordance with physician orders and accepted standards of practice. This deficient practice resulted in a medication error rate of 17.24% (5 errors out of 29 opportunities), exceeding the allowable 5% error rate.The findings include:On 4/15/26, a medication pass observation identified 5 medication errors out of 29 opportunities (17.24%).On 4/15/26 at 2:25 AM, a Licensed Practical Nurse (LPN) #3 was observed to have partially dispensed medications for Resident #38 prior to completing the administration for another resident. The medications included: Levetiracetam 750 mg, Divalproex sodium DR 500 mg, and Lactulose 30 mL. These medications were unlabeled and placed in a non-resident-specific drawer within the medication cart. LPN #3 then proceeded to administer medications to Resident #3, leaving three of Resident #38's medications unsecured and not identifiable for the intended resident. Constituting three errors.On 4/15/26 at 9:50 AM, LPN #3 obtained and dispensed a 'house stock' supplement of Magnesium 500 mg for Resident #3. Upon review, LPN #3 removed the incorrect medication after the surveyor intervened and obtained the correct dose. Constituting as one error.On 4/15/26 at 10:00 AM, during medication administration for Resident #55, LPN #3 received a hard stop alert in the electronic medication administration record (eMAR) for a late medication, Gabapentin. LPN #3 did not initially acknowledge or administer this medication. After the surveyor's intervention, LPN #3 reviewed the eMAR and identified the missed dose. Constituting as one error.On 4/21/26 at 2:30 PM, during an interview with the director of nursing, they acknowledged the concern related to the deficient practice with medication administration.

Based on record reviews, observations, and interviews, it was determined that the facility failed to treat residents with respect and dignity during mealtime. This was evident in one of two dining observations during the recertification survey.The findings include:1a) Record review for Resident #10 showed that he/she had a limited range of motion in both upper extremities and required full assistance from staff with his/her self-care needs, including eating.An observation of breakfast at the Potomac Unit on 4/14/26 at 8:23 AM showed staff #12, a nursing assistant, feeding Resident #10 in the Resident's room. Resident #10 was lying in bed while staff #12 stood by the left side of the bed. The observation also noted 2 chairs in the Resident's room, and staff #12 continued to stand while feeding Resident #10.During an interview with staff #12 on 4/14/26 at 8:40 AM, she stated she was unaware that feeding a resident while standing was a dignity concern. In an interview on 4/21/26 at 1:00 PM, the director of nursing (DON) reported that staff were expected to sit at eye level when assisting residents with eating and to avoid standing to maintain dignity. The DON also added that staff would be educated regarding the concern.1b) A meal observation at the Chesapeake unit on 4/14/26 at 9:05 AM showed staff #13, a nursing assistant, standing over Resident #41, who was lying in bed while assisting him/her in eating breakfast. In a follow-up interview, the surveyor asked Staff #13 what was expected of her while assisting with residents' feeding. Staff #13 stated that she preferred to stand whenever she assisted with feeding Resident #41. A medical record review for Resident #41 showed that the Resident had a history of stroke with right-sided weakness and required full assistance from staff for his/her care needs.During an interview on 4/22/26 at 9:26 AM, the vice president of clinical operations stated that staff were expected to sit while feeding residents to respect residents' dignity.

Number of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives when new orders for life-sustaining treatment were implemented. This was evident for 1 (Resident #58) out of 5 residents reviewed for advance directives.The findings include:The Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form that includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. It is valid in all health care facilities and programs throughout Maryland. Section 1 includes orders to perform CPR or Not Perform CPR. The No CPR section includes three options: A-1 Intubate; A-2 Do Not Intubate, but comprehensive efforts may include limited ventilatory support by CPAP or BiPAP; or Option B, No CPR, Palliative and Supportive Care, do not intubate or use CPAP or BiPAP.A review of Resident #58's medical record on [DATE] at 10:44 AM showed that the Resident had resided in the facility since [DATE]. Resident #58's cognitive status was moderately impaired, as evidenced by a BIM score of 12 on a nursing admission assessment dated [DATE]. Further review included an assessment by Resident #58's attending provider, which noted that the Resident lacked capacity to make medical decisions due to a Dementia diagnosis. The review also showed an advance directive naming the Resident's son as the decision-maker for Resident #58.A continued review of Resident #58's electronic health record included a MOLST signed on [DATE] that indicated Attempt CPR in the event of cardiac and/or pulmonary arrest and stated that the provider discussed the MOLST with the Resident's health care agent. The MOLST was labeled VOIDED by the facility; however, there was no documentation on the form itself indicating it was voided.A follow-up review of the current active MOLST for Resident #58, completed on [DATE], revealed an order for NO CPR in the event of a cardiac and/or pulmonary arrest. The review lacked documentation that the provider discussed the change in the MOLST orders for Resident #58 with the Resident and/or his/her representative. In an interview on [DATE] at 12:12 PM, the director of nursing reviewed Resident #58's medical record and confirmed that the Resident's current MOLST order had not been discussed with the Resident's representative.During an interview on [DATE] at 1:31 PM, an attending provider for Resident #58 reported that, when a resident lacked capacity, it was required to discuss a change to the Resident's MOLST order with the representative; however, she had missed discussing the change in Resident #58's MOLST order with his/her representative. The provider added that she would take care of it right away after the surveyor's intervention.

Based on medical record review and interview it was determined that the facility failed to ensure the resident and the resident's representative were provided the written notice of transfer when the resident was transferred to the hospital. This was found to be evident for one (Resident #4) out of one resident reviewed for hospitalization.The findings include: Review of Resident #4's medical record revealed the resident's diagnosis included, but was not limited to, a mental disorder. The resident had an identified representative listed as an emergency contact. On 12/30/25 the resident was sent to the hospital for treatment and was admitted . On 4/21/25 further review of the resident's medical record failed to reveal documentation to indicate the required transfer notice information was provided to the resident or the resident's representative related to the 12/30/25 transfer. On 4/21/26 at 1:52 PM the Director of Nursing (DON) was interviewed about information provided to the resident and the representative at time of hospital transfer. The DON reported that the bed hold policy is provided and they notify the representatives that their loved one is being sent to the hospital. When asked specifically about the transfer notice, the DON responded that that the eInteract Transfer goes with the resident. She also reported that she did not think social worker provided anything other than the bed hold notice. According to the regulation the resident and the resident's representative should be provided with a notice of transfer in writing. This notice is required to include: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. Review of the eInteract Transfer form revealed it did not include the required transfer notification information but was a summary of information provided to the hospital regarding the resident's representative information, primary care provider and list of documents being sent that were needed to provide care for the resident. On 4/21/26 at 1:59 PM interview with Corporate Nurse #9 revealed that she was aware of the need to provide a transfer notice that included appeal information. Surveyor informed corporate nurse that review of the medical record failed to reveal documentation that a written transfer notification was provided for the December discharge to the hospital. On 4/21/26 at approximately 3:00 PM Corporate Nurse #9 confirmed they cannot find a notice of transfer for this resident but indicated they have a paper form they use for this notification. Corporate Nurse #9 reported that staff sometimes cannot find the paper.

Based on record review and interviews, it was determined that the facility failed to ensure that a Pre-admission Screening and Resident Review (PASARR) was completed for 1 (Resident #59) of 1 Residents reviewed for PASARR. The findings include: PASARR is a federally mandated program implemented by the Maryland Department of Health to ensure individuals with serious mental illness, intellectual disabilities, or related conditions are not inappropriately placed in Medicaid-certified nursing facilities or long-term care. On 04/13/26 at 2:45 PM, the medical record for Resident #59 revealed they had a medical history that included, but was not limited to: non-ST-elevated myocardial infarction (NSTEMI), delusional disorders, bipolar disorder, encephalopathy, paranoid personality disorder, unspecified psychosis, and type II diabetes. On 04/14/26 at 9:44 AM, there was no indication of a Level I PASARR screening having been completed for Resident #59. The PASARR completed was for a recent hospitalization and a 30-day exemption for a short-stay nursing facility admission. There was no evidence that a Level I PASARR evaluation was completed to screen for a Level II beyond the 30-day exemption dated 12/14/2025. Resident #59 was admitted from Holy Cross Hospital with medical diagnoses of schizoaffective disorder, bipolar type, and non-ST-elevated myocardial infarction. Further review of Resident #59's medical record revealed an original admission date of 11/16/2022, and frequent hospitalizations where Resident #59 is documented to call 911 themselves on their personal device to be transported by emergency medical services out of the facility for a multitude of reasons since their time of admission to the facility. On 04/15/26 at 11:55 AM, during an interview with Staff #4, the Social Services Director, the surveyor inquired about the facility's PASARR process. Staff #4 stated that the PASARR process was multifactorial with staff involvement, and could not clearly define a facility-specific process. When asked for a facility policy on the PASARR process, Staff #4 provided the surveyor with a printout from the Maryland Department of Health's (MDH) website, a current printout from the code of federal regulations (CFR), and a PowerPoint presentation that was provided by MDH for community providers in November 2023, and stated they would refer to their corporate consultant for facility-specific information. On 04/16/26 at 10:41 AM, Staff #4 was unable to provide a facility-specific policy related to PASARR. Resident #59's PASARR evidence provided by Staff #4 has an end date of 12/14/25 for a 30-day approval. However, there is no indication that a Level I screening evaluation was completed at the facility for the resident to remain long-term, as indicated by their census status. They continued to reside at the facility as of that date, 04/16/26. On 04/16/2026 at 12:10 PM, during an interview with Staff #4, the surveyor inquired about the status beyond the 30-day exemption for the resident's Level I PASARR screening to determine if a Level II evaluation was ever needed. Staff #4 stated that they would need to consult with their regional support to provide an answer. On 04/17/26 at 11:25 AM, Staff #4 confirmed there was no additional evidence that Resident #59 had a Level I PASARR evaluation accurately completed beyond the initial 30-day exemption that was provided, dated 12/14/2025, to determine if a Level II evaluation would be needed. During the interview, Staff #4 acknowledged that they completed and submitted a Level I PASARR screening for a Level II evaluation determination with the facility's new name and identification number as of 04/17/26, indicating Resident #59 had medical diagnoses that included, but weren't limited to: delusional disorder, unspecified psychosis, and encephalopathy. On 4/21/26 at 2:30 PM, during an interview with the director of nursing, the director acknowledged the concern regarding the deficient PASARR practice for Resident #59.

Based on medical record review and interview, it was determined that the facility failed 1) failed to review and revise a resident's care plan, and 2) to ensure interdisciplinary care plan meetings were held to address residents' care needs after the completion of the Minimum Data Set assessment. This was found to be evident for 1) one resident (Resident #6) of five reviewed for advance directives, and 2) two residents (Resident #108 and #51) of four residents reviewed for neglect. The findings include:1). MOLST stands for Medical Orders for Life-Sustaining Treatment. It is an actionable medical document used for patients with serious, advanced illnesses to stipulate specific preferences for end-of-life care—such as intubation, resuscitation, and feeding tubes—that are recognized across various healthcare settings, including hospitals, nursing homes, and emergency care. A review of Resident #6's medical records was conducted on [DATE] at 12:09 AM. The review revealed that the resident's most recent MOLST form which was dated [DATE], indicated to attempt cardiopulmonary resuscitation (CPR) if cardiac and/or pulmonary arrest occurs. However, Resident #6's care plan initiated on [DATE] and revised on [DATE], indicated the resident's code status as do not resuscitate (DNR) as it was related to his/her MOLST. Also, a review of the resident's current medical record revealed an active DNR order dated [DATE]. The nurse (Nurse #14) who was currently assigned to Resident #6 care was interviewed on [DATE] at 1:42 PM. During the interview, Nurse #14 confirmed that Resident #6 had conflicting information regarding code status and when asked what she would do if the resident's heart stopped, she answered, I wouldn't provide CPR and indicated that her decision was based on the resident's current care plan and medical orders. Nurse #14 then reported that she would discuss the finding with the Nurse Practitioner (Staff #15). The surveyor accompanied Nurse #14 to discuss the findings with Staff #15 on [DATE] at 1:56 PM. Staff #15 reported that the resident was full code and had the capacity to make medical decisions. She also confirmed the finding of conflicting information regarding the resident's code status and reported that the Social Worker should have updated Resident #6's medical record when the MOLST was changed. A subsequent review of Resident #6's medical record was conducted on [DATE] at 2:32 PM. The review revealed a note from the social worker (Staff #4) that indicated the most recent care plan meeting/conference was held on [DATE] at 2:15 PM where the code status was reviewed and indicated as a DNR. On [DATE] at 9:49 AM, the Director of Nursing (DON) was interviewed and reported that she was already aware of the concern with Resident #6's conflicting code status information and that an audit was started to review medical records of random residents to ensure they are updated and accurate. Resident #6's medical record was reviewed with the DON and revealed that the current care plan still indicated DNR. The DON then updated the care plan and acknowledged that it should have been reviewed and updated on [DATE] when the new MOLST was done. 2.a) The Minimum Data Set (MDS) is a federally mandated assessment that nursing home staff use to collect information about each Resident's strengths and needs. This information is then used to make care planning decisions for the Resident. Maryland state regulations require the nursing home to hold the care planning conference not later than 7 calendar days after completing the assessment but may hold the conference sooner if agreed to by the resident, a family member, or a resident's representative. On [DATE] at 12:20 PM an interview with Social Worker #4 revealed that she had identified an issue with failure to have care plan meetings when they were due and had initiated a quality assurance/performance improvement plan in either December or January. On [DATE] a review of Resident #108's electronic health record revealed that an MDS assessment was completed in November, and a Care Conference Note revealed a meeting took place on [DATE]. Further review of the medical record revealed an MDS assessment with an assessment reference date (ARD) of [DATE] but no Care Conference Note was found to indicate a meeting had occurred after the [DATE] assessment. On [DATE] at 4:35 PM the surveyor reviewed with the Director of Nursing the concern that the facility failed to have a care plan meeting after the [DATE] MDS assessment. 2.b) A review of Resident #51's medical records was conducted on [DATE] at 11:51 AM. The review revealed that a quarterly assessment was completed on [DATE]. However, the last care conference note had an effective date of [DATE] created by the Social Worker (Staff #4). In an interview with Staff #4 on [DATE] at 11:57 AM, she reported that care plan meetings are held on Wednesdays and Thursdays and that her timeframe was to have one within 7 days prior to and 7 days after the resident's ARD of comprehensive and quarterly assessments. Staff #4 confirmed that her understanding of the regulation with regards to care plan meetings was that she had 7 days before or after the MDS ARD dates. A review of Resident #51's medical record was conducted with Staff #4 on [DATE] at 12:06 PM. She confirmed the resident's most recent MDS assessment had an ARD of [DATE]. Staff #4 was asked if she had or scheduled a care plan meeting based on that MDS assessment. She reported that she met with the resident's guardian on [DATE] and wrote a progress note about it but did not write it as a care conference note. She also reported that she was trying to schedule a care plan meeting with the guardian, however he could not make that date and she stated, I need to have the guardian present for the care plan meeting. Further review of Resident #51's medical record with Staff #4 revealed the progress note she wrote on [DATE] that described her talking to the resident regarding a concern with his/her behavior. There was no indication on the note that the guardian was present nor was there any indication that the resident's care plan was reviewed and/or discussed. The concern was discussed with Staff #4 that the regulation does not require the residents, guardian and family members to attend the care plan meeting, however the facility is still required to hold a care plan meeting within 7 days after a comprehensive or quarterly MDS assessment is completed. Staff #4 verbalized understanding and acknowledged the concern.

Based on observation and staff interviews, it was determined that the facility failed to ensure physician-ordered medications were administered as prescribed, including the correct medication, dose, and timing, for 3 (Resident #3, Resident #38, and Resident #55) of 3 Residents observed during the medication administration observation. This deficient practice has the potential to affect all residents receiving medications on all nursing units.The findings include: On 4/15/26 at 9:25 AM, LPN #3 was observed to have prepared medications for Resident #38, which included: Levetriacetam 750 mg, Divalproex sodium 500 mg, and Lactulose 30 mL. These medications were left unlabeled by LPN #3 and placed in a non-resident-specific drawer. LPN #3 then proceeded to administer medications for Resident #3, demonstrating a failure to ensure medications were administered to the intended resident in accordance with physician orders.On 4/15/26 at 9:50 AM, LPN #3 prepared a Magnesium 500 mg for administration to Resident #3. Upon review, the physician's order was for: Magnesium Oxide 400 mg (240 mg elemental magnesium) once daily. LPN #3 demonstrated a failure to administer medication in accordance with the physician's order for the correct medication and the correct dose, and LPN #3 acknowledged the discrepancy after surveyor intervention and removed the medication.On 4/15/26 at 10:00 AM, during medication administration for Resident #55, a hard stop alert in the eMAR (electronic Medication Administration Record) indicated a late dose of gabapentin. LPN #3 did not initially acknowledge or administer the medication. After the surveyor's intervention, LPN #3 reviewed the eMAR and identified the missed medication for Resident #55.These observations are separate from the calculated medication error rate and reflect failure to implement physician orders as written.On 4/21/26 at 2:30 PM, during an interview with the director of nursing, the director acknowledged the concern regarding the deficient practice related to professional standards.

Based on record reviews and interviews, it was determined that the facility failed to have an effective system in place to ensure residents only had one active Maryland Order for Life-Sustaining Treatment (MOLST). This was evident for 1 (Resident #6) of 5 residents reviewed for advanced directives. The findings include:The Maryland Orders for Life-Sustaining Treatment (MOLST) form is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. It was designed to ensure that healthcare providers throughout Maryland have a uniform system of communicating a resident's end-of-life wishes in the event of cardiac or respiratory arrest. Cardiopulmonary Resuscitation (CPR) is the act of attempting to revive someone once their heart or breathing have stopped.A review of Resident #6's electronic health record on [DATE] at 12:09 PM revealed a MOLST dated [DATE], that indicated do not attempt CPR if cardiac and/or pulmonary arrest occurs. The resident's facesheet and current medical orders also indicated a do not resuscitate (DNR) order dated [DATE]. No other MOLST was found in the resident's electronic health record.On [DATE] at 12:25 PM, Resident #6's hard chart was reviewed and revealed another MOLST dated [DATE], that indicated attempt CPR if cardiac and/or pulmonary arrest occurs. A floor nurse (Nurse #16) was interviewed on [DATE] at 12:28 PM. Nurse #16 explained the process when a resident suddenly experiences a cardiac and/or pulmonary arrest. She reported that the resident's code status should be quickly checked and can be found in the electronic health record and/or hard chart and stated, the record on PCC (point click care- electronic health record that the facility was utilizing) should match the hard chart.The nurse (Nurse #14) who was currently assigned to Resident #6 care was interviewed on [DATE] at 1:42 PM. During the interview, the resident's medical record was reviewed and Nurse #14 confirmed that Resident #6 had conflicting information regarding code status as the hard chart had the MOLST that indicated to attempt CPR, and PCC had a different MOLST and medical orders that indicated DNR. When asked what she would do if the resident's heart stopped, she answered, I wouldn't provide CPR, I'll go with what's indicated in PCC.Nurse #14 then reported that she would discuss the finding with the Nurse Practitioner (Staff #15). The surveyor accompanied Nurse #14 to discuss the findings with Staff #15 on [DATE] at 1:56 PM. Staff #15 reported that Resident #6 was full code and had the capacity to make medical decisions. She also confirmed the finding of 2 active and conflicting MOLST information. Staff #15 reported that the Social Worker should have updated the resident's medical record when the MOLST was changed.A subsequent review of Resident #6's medical record was conducted on [DATE] at 2:32 PM. The review revealed a note from the social worker (Staff #4) that indicated the most recent care plan meeting/conference was held on [DATE] at 2:15 PM where the code status was reviewed and indicated as a DNR.On [DATE] at 9:49 AM, the Director of Nursing (DON) was interviewed and reported that she was already aware of the concern with Resident #6 having 2 active MOLST with conflicting code status information and that an audit was started to review medical records of random residents to ensure they are updated and accurate. She also reported moving forward, the resident's hard chart will also be reviewed during care plan meetings.Cross reference F657

Based on record reviews, interviews, and observations, it was determined that the facility failed to provide activities based on the resident's comprehensive assessment. This was evident for 1 (Resident #51) of 4 residents reviewed for neglect. The findings include:The concerns related to Complaint2795585 included a report that staff was mistreating Resident #51 by showing other residents more attention. On 4/14/26 at 10:08 AM, Resident #51 was observed in room, watching TV.On 4/17/26 at 12:10 PM, a review of Resident #51's most recent comprehensive assessment with a reference date of 7/15/25 section F, indicated that it was very important for the resident to do things with groups of people and to go outside to get fresh air when the weather is good.On 4/17/26 at 12:15 PM, Resident #51's care plan for activities included interventions such as, encouraging attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities; and invite resident to scheduled activities.A review of April 2026 activities and activity participation was conducted on 4/17/26 at 12:17 AM. The review failed to show documentation that the resident attended or was offered and refused to attend group and/or outdoor activities.The Activity Director (Staff #7) was interviewed on 4/17/26 at 12:22 PM. During the interview, Staff #7 reported that Resident #51 usually prefers to do independent activities in his/her room. Staff #7 was asked if he or activity staff document the refusal when group and outdoor activities are offered to the resident. He reported that refusals are documented and group activities are done daily. A review of Resident #51's medical record was conducted with Staff #7, and he confirmed that there was no documentation to indicate that the resident had attended or refused to attend group and/or outdoor activity for April and March 2026. The concern was discussed with Staff #7 that the facility failed to provide activities to the resident based on the comprehensive assessment and individualized care plan. Staff #7 verbalized understanding and acknowledged the concern.

Based on medical record review and interview it was determined that the facility failed to ensure lab tests that were required to determine if a specific medication needed to be administered were obtained. This was found to be evident for one (Resident #40) out of five residents reviewed for unnecessary medications.The findings include:Review of Resident #40's medical record revealed the resident has leukopenia, which is a lower than normal white blood cell (WBC) count. A low white blood cell count leaves a resident vulnerable to infections.The resident had an order, in effect from 11/20/25 through 2/21/26 for Zarxio to be administered once every 14 days for leukopenia when the WBC (white blood count) is less than 4. The resident had an order from 9/26/25 until 4/17/26 for a CBC (complete blood count - which includes WBC) every two weeks on Tuesdays and to fax the results to the pharmacy for neupogen delivery. Neupogen and Zarxio have the same active ingredients. Review of the lab results revealed the resident had a WBC of 2.7 on 2/12/26 and the Zarxio was administered. On 2/22/26 the order for the Zarxio was changed from being given every 14 days to being given every 7 days when the WBC was less than 4. This order had a start date of 2/22/26. No documentation was found to indicate the order for the CBC testing was changed in February when the order for the Zarxio was increased to weekly. Review of the Medication Administration Record (MAR) revealed the Zarxio was scheduled to be given on Sundays, starting on 2/22/26. No documentation was found to indicate the medication was administered on 2/22/26, no nursing notes were found for 2/22/26 to indicate why the medication was not administered that date, or if the primary care provider was notified. No documentation was found to indicate the CBC was obtained when due later in February. Review of the March MAR revealed documentation that the Zarxio was administered on 3/1/26 but staff documented NA for not applicable in the space on the MAR to document the WBC result. The most recent WBC count found in the medical record prior to 3/1/26, was the result from the 2/12/26 CBC, which was more than two weeks prior. The next CBC results found in the medical record were dated 3/5/26 and revealed a WBC of 3.9. This would indicate the Zarxio should be administered. Further review of the MAR failed to reveal documentation to indicate the Zarxio was administered when scheduled on 3/8/26. No corresponding nursing note was found to indicate why the medication was not administered on 3/8/26.Further review of the March MAR revealed staff documented a 9 indicating see nurse's note when the Zarxio was scheduled to be given on 3/15/26. The corresponding nursing note revealed the lab was contacted for the results of a 3/13/26 WBC and were informed that the results were not in yet. Staff documented: Zarxio was not given.The surveyor requested from the Director of Nursing on 4/17/26 at 2:04 PM the CBC results since January. Review of the CBC results provided failed to reveal documentation to indicate a CBC was drawn on 3/13/26 as indicated in the 3/15/26 nursing note. A report was provided that indicated a CBC was drawn on 3/20/26 with a WBC result of 4.0. Review of the March MAR failed to reveal documentation in the space provided to document when the Zarxio was scheduled to be given on 3/22/26. When scheduled on 3/29/26 staff documented 9. Review of the corresponding nursing note revealed: Zarxio was not administered due to the resident's most recent lab result on 3/20/26 showing a WBC count of 4.0.Review of the MAR for April revealed that when scheduled to be given on 4/5/26 staff wrote 4.0 in the space to document the WBC and a 9 indicating see nursing note. On 4/22/26 the DON confirmed there was no nursing note for 4/5/26. The Zarxio was not administered when scheduled on 4/12/26, the corresponding nursing note revealed Resident WBC 4.0.On 4/17/26 no documentation was provided to indicate a CBC was obtained since 3/20/26. Blood was drawn for labs on 4/6/26, but these did not include a CBC.On 4/22/26 at 9:15 AM surveyor reviewed with Corporate Nurse #9 the concern regarding the failure to ensure the CBCs were obtained as ordered and the failure to ensure the Zarxio was administered as ordered. Corporate Nurse #9 acknowledged the deficient practice and reported that there was no change in the lab order when the Zarxio order was changed in February, and that she had spoken to the provider and obtained a new order for weekly labs.Further review of the medical record on 4/22/26 revealed an order, dated 4/17/26 for CBC weekly on Monday and to fax the results to the pharmacy for Zarxio delivery. There was also an updated order for Zarxio, dated 4/17/26 to be administered every Wednesday for leukopenia when WBC is less than 4.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure residents at risk for developing pressure injuries receive appropriate services for treatment and prevention. This was evident for 1 (Resident #45) of 4 residents reviewed for pressure injuries. The findings include:Resident #45 had been a resident of the facility since early 2018. On 4/13/26 at 11:10 AM, the resident was observed in bed equipped with an air mattress. The control unit for the air mattress was located at the foot of the bed and was observed to be set at 550 lbs.A review of Resident #45's medical record was conducted on 4/13/26 at 1:32 PM. The review revealed the resident's most recent weight was 252.4 lbs. taken on 4/3/26. Current orders included for nursing to check air mattress to be set per manufacturers guidelines and check for proper placement and function every shift.The Braden Scale is a widely used healthcare tool to assess a patient's risk of developing pressure injuries/ulcers. Scores range from 6 to 23, with lower scores indicating higher risk. Resident #45's scored 11.0 that was indicated as a high risk in the Braden scale done on 3/15/26.On 4/15/26 at 1:53 PM, the nurse (Nurse #17) who was currently assigned to care for Resident #45 was interviewed. Nurse #17 reported that the order to check the air mattress meant to ensure that it was plugged into the electrical outlet, inflated with no leaks, no beeping sound and/or alerts for any malfunction.Nurse #17 was then invited to observed Resident #45's bed with the surveyor on 4/15/26 at 1:58 PM. Nurse #17 confirmed that the air mattress weight setting was set at 550 lbs. and indicated that it should be changed since the resident's weight was in the 250 lbs. range. Nurse #17 reported that it was the responsibility of maintenance staff to ensure weight settings and cycle time were appropriate to the residents.The Director of Nursing (DON) was interviewed on 4/15/26 at 2:09 PM. During the interview, the DON confirmed that the air mattress was maintenance staff's responsibility. She was asked how maintenance staff were informed of the setting specific to the resident, and she answered, I'm not sure.The Maintenance Director (Staff #10) was then interviewed on 4/15/26 at 2:18 PM. During the interview, he reported his department's process when an air mattress is requested for a resident. He indicated that he or his staff installs the air mattress in the room requested and then sets to static to inflate fully to ensure there are no leaks. But as far as the specific weight setting and cycle time, he reported that it was the nursing department's responsibility. He also reported that air mattress requests are given to him through verbal orders/communication and indicated that he does not get resident specific information like their names and/or their weight.The findings were reviewed and the concern was discussed with the Nursing Home Administrator (NHA) on 4/15/26 at 2:34 PM that no one in the facility was checking to ensure air mattress settings were appropriate to the resident utilizing them. The NHA stated, looks like we dropped the ball. There is a disconnect with the process with air mattress. The NHA verbalized understanding and acknowledged the concern.On 4/16/26 at 9:10 AM, the NHA reported that a facility wide audit was conducted to ensure air mattresses were set up appropriately to the resident and that staff education was being done as well.

Based on medical record review and interview it was determined that the facility failed to ensure urology appointments for monthly suprapubic catheter changes were scheduled in a timely manner. This was found to be evident for one (Resident #40) out of two residents reviewed for urinary catheter care.The findings include:Supra pubic catheters require a surgical procedure in which a small incision is cut through the abdomen to allow for insertion of a tube into the bladder. The tube remains in place to allow for continuous drainage of urine into a drainage bag. Review of Resident #40's medical record revealed the resident was admitted to the facility in 2025. The resident has a suprapubic catheter, with orders in effect from 9/3/25, to change the supra pubic catheter monthly at the urologist office. Review of the medical record revealed documentation that the resident was seen by the urologist for a supra pubic catheter change on 10/9/25 with a recommendation to follow up in 4 weeks for a catheter change. Review of a 10/9/25 nursing progress note revealed the resident's next appointment was scheduled for 11/6/25.Further review of the medical record revealed a nursing note, dated 11/6/25, which stated: Resident returned from follow up appointment with report that the scheduled appointment did not take place due to the absence of the doctor. Appointment to be rescheduled tomorrow.Further review of the medical record failed to reveal documentation to indicate the resident was seen by the urologist again until 12/29/25.Further review of the medical record revealed the resident was seen by the urologist on 12/29/25. A nursing note dated 12/29/25 revealed a recommendation to continue monthly supra pubic catheter changes. Further review of the medical record failed to reveal documentation to indicate attempts were made to schedule follow-up urology appointments in January or February 2026. On 3/9/26 there was an order put in for a follow-up urology consult on 3/19/26 at 10:40 AM.On 3/19/26 there was a Care Plan Note written by the Unit Nurse Manager #5 that the resident refused to go to the appointment and wanted it to be rescheduled due to not wanting to get up at 8 am to get ready for the appointment. The note indicated that the nurse practitioner was made aware of the missed appointment.On 4/13/26 at 12:21 PM Resident #40 expressed a concern to surveyor about a recently missed urology appointment for the suprapubic catheter change. The resident also expressed concern about the scheduling of the appointment by the unit manager. On 4/13/26 at 12:34 the Unit Nurse Manager #5 approached the surveyor and reported the urology appointment had been scheduled twice and the resident refused.On 4/15/26 an order was put in the medical record for a follow-up urology appointment on 4/23/26. Further review of the medical record failed to reveal documentation of attempts to reschedule the urology appointment prior to 4/15/26.On 4/16/26 at 9:48 AM the Unit Nurse Manager #5 was interviewed in regard to the process for scheduling appointments outside of the facility. She reported that the unit managers are responsible for scheduling appointments and that the process involved obtaining an order from the physician, checking for insurance coverage, calling the offices to schedule the appointment and then arranging transportation. When asked about documentation of these appointments, the Unit Manager reported once the appointment is scheduled they put an order in the medical record, so they don't forget the appointment, and they add it to a calendar. In regard to Resident #40, the Unit Nurse Manager #5 indicated she had attempted to reschedule the appointment prior to this week but was told no appointments were available until June. The Unit Nurse Manager confirmed she had not scheduled an appointment in June. She went on to report the urology office recently contacted her about a cancellation and the resident now has an appointment next Thursday in the afternoon. On 4/17/26 at 1:00 PM the surveyor asked the Director of Nursing (DON) what her expectation is if a resident needs to be seen monthly, but the next available appointment is several months away. The DON indicated the staff should document the call, let the provider know and talk to the office to see if they can schedule sooner. She confirmed that she would have expected staff to schedule the appointment and then work on getting an earlier appointment.On 4/21/26 at 11:41 AM surveyor reviewed the concern with the Corporate Nurse #9 that no documentation was found to indicate the urologist office was contacted in January or February regarding the scheduling the supra pubic catheter change and that the resident had expressed a concern that the UM had not scheduled the appointment in a timely manner. Corporate Nurse #9 indicated she would check to see if there was a note about scheduling the appointment.On 4/21/26 at 12:39 PM Corporate Nurse #9 confirmed that there was no additional documentation found regarding the scheduling for the urology appointment.

Based on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to a resident requiring such services according to professional standards of practice. This was evident for 1 (Resident #6) of 2 residents reviewed for pain management. The findings include:Resident #6 had been a resident of the facility since mid-2019. The medical record indicated that the resident was cognitively intact.Resident #6 was interviewed on 4/13/26 at 11:52 AM. During the interview, the resident reported that s/he was in severe pain and that the facility had run out of his/her pain medication. The resident stated, they have a box upstairs for emergency if you run out but they won't do that for me.A review of Resident #6's medication orders was conducted on 4/16/26 at 1:37 PM. The review revealed that the resident was on a routine narcotic pain medication (Oxycodone 5 MG capsule every 6 hours) for chronic pain scheduled at 12 AM, 6 AM, 12 PM and 6 PM. The administration record for April 2026 revealed that the resident missed doses on 4/12/26 at 6 AM, 4/12/26 at 12 PM, 4/12/26 at 6 PM, 4/13/26 at 12 AM, 4/13/26 at 6 AM and 4/13/26 at 6 PM. A one-time order for Oxycodone 5 MG tablet was administered on 4/13/26 at 12:07 by the charge nurse (Nurse #17).Nurse #17 was interviewed on 4/16/26 at 3:34 PM regarding Resident #6's routine narcotic pain medication. Nurse #17 reported that the resident was not given the routine narcotic pain medication from 4/12/26 at 6AM until 4/13/26 at 6 PM, including 4/13/26 at 12 PM, because it was not delivered by the pharmacy. She stated, the capsule form of the medication was not available at the pyxis (Pyxis is an automated medication dispensing system) that's why we did not use it.The Director of Nursing (DON) was interviewed regarding pain management on 4/17/26 at 10:20 AM. During the interview, the DON explained that when there is a concern with medication delivery from the pharmacy, nurses can check the pyxis to see if the medication is available there. Once they confirm availability, nurses should inform the providers to get an order, then the pharmacy will send them a code so they can get the supply from the pyxis. The DON was asked to provide the list of medications kept in stock in the pyxis.On 4/17/26 at 1:21 PM, the DON provided the list of medications kept in the pyxis. The list included 8 counts of Oxycodone 5 MG tablet, 8 counts of Oxycodone 10 MG tablet, and 8 counts of Oxycodone/Acetaminophen 5/325 MG tablets. The DON was asked, prior to Resident #6 reporting the concern to the surveyor, is there any documentation that the nursing staff tried to access the supply from the pyxis and she stated, I don't know, it wasn't brought to my attention. The DON was also asked if the provider was informed that Resident #6's routine narcotic pain medication was not delivered and she answered, No. The concern was discussed with the DON that pain management was not provided to the resident, as there was no documentation to indicate efforts from nursing staff to access available medication from emergency supply, until the resident had reported the concern to the surveyor. The DON verbalized understanding and acknowledged the concern.

Based on review of facility incident 2735892, documentation review, medical record review, interview, and observation, it was determined the facility failed to have an effective system in place to prevent residents from smoking in their room. The failure to monitor residents with recent behaviors of smoking in their rooms resulted in a fire in a resident's room that placed other residents at risk and caused other residents to be relocated in the facility. This deficient practice was evident for 3 (Residents #1, #2, #3) of 35 smokers in the facility and had the potential to affect all residents that resided at the facility.As a result of these findings an Immediate Jeopardy was called on 2/6/26 at 1:59 PM. The facility submitted a plan to remove the Immediacy on 2/6/26 at 5:23 PM. The survey team verified that the facility obtained compliance with the removal plan, and the Immediate Jeopardy was abated on 2/8/26.The findings include:On 2/6/26 at 8:15 AM a review of facility reported incident 2735892 revealed on 2/4/26 at 11:30 PM there was thick smoke that was coming out of room [ROOM NUMBER] where Resident #1 resided. On 2/6/26 a review of Resident #1's medical record revealed Resident #1 had diagnoses that included but were not limited to unspecified psychosis, not due to a substance and non-compliance with medication regimen. Review of a 2/2/26 at 14:00 (2 PM) change in condition note documented, resident [#1] was observed continuously smoking in the room and hallway, resident was redirected multiple times but refused to yield to correction, continued smoking with the resident in room [ROOM NUMBER]A (Resident #2). The recommendation was, notify social worker and continue to monitor behavior.Review of a 2/5/26 at 8:42 AM behavior note for Resident #1 documented, resident refused head to toe assessment x 3 after fire marshal noted smoke coming from [his/her] mattress. On 2/6/26 a review of Resident #2's medical record revealed Resident #2 was admitted to the facility in August 2025 with diagnoses that included but were not limited to tobacco use. Review of a 1/27/26 at 15:28 (3:28 PM) change in condition note for Resident #2 documented, nursing observations, evaluation, and recommendations are: resident picking up cigarette buds from trash in smoke porch. Review of a 1/31/26 at 14:29 (2:29 PM) change in condition note for Resident #2 documented, resident was observed smoking multiple times in the room, bathroom, room [ROOM NUMBER] (Resident #1) and hallway. Resident was redirected to stop smoking multiple times, resident refused to yield to teaching but responded to nurse that [he/she] has the right to smoke anywhere [he/she] wants, nobody can stop [him/her] and [he/she] does not care about the adverse effects of [his/her] smoke on the non-smokers. Review of a 2/1/26 at 14:47 (2:47 PM) note for Resident #2 documented, resident continues to smoke in the room, will not yield to any teaching but instead curses the writer each time caught smoking in the room. Review of Resident #3's medical record revealed Resident #3 was admitted in May 2019 with diagnoses that included but were not limited to tobacco use, intermittent explosive disorder, opioid abuse, bipolar disorder, and generalized anxiety disorder. Review of a 1/31/26 at 00:13 (12:13 AM) nursing note for Resident #3 documented, the resident was observed smoking in the room. Education provided about danger of such behavior. On 2/6/26 at 8:18 AM Staff #5 was interviewed and asked if she had ever seen Resident #1 smoking in his/her room. Staff #5 stated, yes, I have seen twice in the last week. Staff #5 stated she has seen Resident #1 and Resident #2 with lit cigarettes in the hallway and when she has tried to confront them, they go into Resident #1's room and block the door. Staff #5 also stated Resident #2 will try to run her over if she attempts to get him/her to stop smoking. Staff #5 stated she reported it to the Unit Manager. Staff #5 stated at that time she did a change of condition, care planned the issue, provided education and made sure the residents didn't have any smoking materials.On 2/6/26 at 8:29 AM, Staff #6 (unit manager for the second floor) stated she was made aware from social services and Staff #5 that Resident #1 and #2 were smoking in the last week but could not remember the day but it was before the fire on 2/4/26. Staff #6 stated at that time Resident #1 and #2 were caught smoking by Staff #5 and she did a change of condition, care plan the issue, provided education and made sure the residents did not have any smoking materials. Staff #6 stated she was not at the facility when the fire occurred because that was at night time, but again she said the residents were educated, and she was not sure how they were getting the smoking materials. On 2/6/26 at 8:31 AM the Assistant Director of Nursing (ADON) was interviewed and stated the incident happened during the night on the 11 to 7 shift early Thursday morning. When I came in the room was sealed up. There had been smoke in the room. The ADON stated that Resident #1 was a smoker and non-compliant. The ADON stated, A lot of times we tell the provider. We have a cart where we store the cigarettes and the lighter. I do not know how [he/she] got it. We have people that take them outside to the smoke porch and there must be someone there to supervise them. We have other people that don't follow the rules with smoking. We give a behavioral contract. The ADON was asked what was done if they did not follow the contract, and the response was, we continue to get a medical consult and psych consult.On 2/6/26 at 8:35 AM the Director of Nursing (DON) was interviewed and stated, Sometimes we have residents that do go out and secretly bring things in. No one knows how [Resident #1] got it. The supervisor when it happened, stated he/she smoked in the room. The DON stated, we started in-services yesterday, to be aware when the residents are in the room, the night shift should make sure no one is attempting to smoke in the room. We contacted the guardian and notified that the resident was smoking in the room. On 2/6/26 at 9:20 AM an interview was conducted with the Social Worker who stated they had a meeting with all of the smokers yesterday after the fire and reviewed the smoking policy with them. She informed the surveyors that Residents #1, #2, and #3 had known behaviors of smoking in their rooms prior to the fire. They can't have smoking materials on their person. They have a cart where the materials can be locked up. The residents can obtain smoking materials from the Social Worker. After hours the residents can obtain the smoking materials from their nurse. The Social Worker stated, no residents are to have smoking materials in their room.On 2/6/26 at 10:30 AM Staff #7 stated he was assigned to Resident #1 on 2/2/26 when Resident #1 was caught smoking in his/her room. Staff #7 stated social work and Staff #5 came to him and reported Resident #1 and #2 were smoking in Resident #1's room so he completed a change in condition note. Staff #7 also stated that he has seen Resident #2 smoke in his/her room in the last week and tried to obtain the smoking materials from the resident, but the resident would bunch up his/her fist and cuss at him. Staff #7 stated Resident #2 stated that he/she was a smoker, and this was a smoking facility and that staff have no right to stop him/her from smoking. Staff #7 stated the facility changed the smoking times a few months ago and that they used to be able to smoke all day but now the smokers have set times.Observation on 2/6/26 at 10:38 AM on the nursing unit where Resident #1 and #2 resided revealed a sign that stated: Smoking schedules from 11/14/25 are 9:00 AM-9:30 AM, 11:00 AM-11:30 AM, 1 PM-1:30 PM, 3 PM-3:30 PM, 5 PM-5:30 PM. There were no smoking times for residents between 5:30 PM-9:00 AM or for 15.5 hours.On 2/6/26 at 11:00 AM the DON gave the surveyor a folder with an abatement plan that they started working on prior to the surveyors entering the building. The surveyor asked exactly what was in the abatement plan. The DON stated, we started education of staff but since it just happened yesterday we have not gotten to everyone yet. The DON stated they assessed Resident #1, did a change in condition, did house wide skin sweeps, did smoking assessments on all residents, removed residents in the area, did room changes, and updated the care plans. The initial abatement plan dated 2/5/26 stated that IDT (Interdisciplinary team) ambassador observational rounds would be conducted daily times 4 weeks and monthly times 3 weeks for resident smoking material compliance. The DON also stated they changed the times of smoking to extend later in the day.On 2/6/26 at 12:04 PM Staff #8 stated he walked in Resident #2's room yesterday afternoon (2/5/26) and he/she had a cigarette that was not very long. The cigarette was lit and smoke was coming from it, and he/she was smoking. Staff #8 stated, I told him/her you can't do that and he/she didn't respond. I told maintenance and he said he smelled it and figured somebody was doing something. I went to the admissions office and she took me to the social worker, and I told the Social Worker that the resident was smoking in his/her room after hearing that he/she was being watched for smoking. Staff #8 was asked if he had ever seen the resident smoking before and he stated, about a week before that he/she was smoking in his/her room at his/her bed. He said, there was no one at the nursing station and no one was on the unit, so I didn't tell anyone. Before that I hadn't seen Resident #1 or Resident #2 smoking before. On 2/6/26 at 12:35 PM Resident #3 was observed to have 2 cigarette lighters on the bedside table, which was confirmed by the nurse, Staff #9. This was after the fire in room [ROOM NUMBER]. This was after the facility had started education to staff and after the residents who were smokers were educated that they could not have smoking materials in their room.The facility submitted a plan to remove the Immediacy on 2/6/26 at 4:19 PM that was rejected. The facility submitted a second plan to remove the Immediacy on 2/6/26 at 4:54 PM which was rejected. The facility submitted a third plan to remove the Immediacy on 2/6/26 at 5:08 PM which was accepted on 2/6/26 at 5:23 PM.The facility's plan included:1. The facility smoking policy will be reviewed with all identified smoking residents. All residents have been asked to turn in all smoking materials. All resident rooms have been visually inspected for smoking materials. Any smoking materials collected have been placed in the smoker's box. Residents #1, #2, and #3 refused to turn in their smoking materials and have been assigned one-on-one supervision. These residents will remain on one-on-one supervision until it is determined that they no longer have smoking materials in their possession and demonstrate no behaviors of smoking in their rooms.2. All staff will be educated by the department head team and regional support team that a) all residents may not have any smoking materials on them; b) residents may only smoke at designated smoking times in designated area; c) if they become aware of a resident smoking in their room or having smoking materials on them, they are to ask the resident for the materials. Should the resident refuse to turn in their materials, they are to be placed on one-on-one supervision immediately and the staff member is to notify the ED (executive director) or nursing supervisor.3. The DON will ensure that all nursing notes of the identified residents who smoke are audited in the daily clinical meeting for documentation of illegal smoking activity. This will be ongoing. The room of each resident identified as a smoker will be inspected daily Monday thru Friday by the Ambassador and on weekends by the manager on duty for smoking materials or evidence of smoking in the room. This will be ongoing.4. The ED will audit all Ambassador round reports for residents identified as smokers and the DON will audit all nurses' notes daily for 14 days, weekly for 4 weeks, and then monthly for 2 months to evaluate whether violations of the smoking policy have been discovered. Results of the audits will be submitted to the Quality Assurance and Performance Improvement Committee for review and approval.

Based on review of a facility reported incident, medical record review, facility documentation review, and staff interviews, it was determined the facility failed to honor a resident's wishes to not change position which resulted in a staff member pulling a resident's contracted fingers which resulted in a fractured finger. The failure to honor a resident's wishes while assisting in bed mobility resulted in actual harm to Resident #2. This was evident for 1 (#2) of 20 residents reviewed for facility reported incidents. The findings include: Review of facility reported incident MD00195473 on 9/26/24 at 8:22 AM revealed Resident #2 was admitted to the facility in June 2023 with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, type 2 diabetes mellitus, chronic kidney disease, and contracture of the muscles with multiple sites. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #2's admission MDS assessment with an assessment reference date of 6/13/23, Section G, Functional Status, documented A: Bed mobility - how a resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture as (3) extensive assistance with (2) which was one-person physical assist. Section G0400 functional limitation in range of motion, upper extremity, documented, impairment on one side, lower extremity - impairment on 1 side. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Review of Resident #102's initial activities of daily living care plan (ADL), that was created on 6/12/23 documented, has ADL self-care performance deficit, requires assistance with ADL disease process with interventions, assistance required with ADL's may fluctuate based on time-of-day, mood, pain, or fatigue. Adjust and document as indicated. Report significant changes to charge nurse. There was nothing documented on the initial care plan as to how many staff were required to help the resident with bed mobility. The facility reported incident documented that the assigned GNA (geriatric nursing assistant) came to Resident #2's room on 8/10/23 at 3:00 PM and wanted to turn the resident while the resident was in bed. The resident stated that he/she told the GNA I am comfortable facing the wall, I don't want to be turned. The resident stated that the GNA ignored his/her request and proceeded in pulling his/her left contracted fingers to turn him/her, and the resident heard a pop at the pulling site. The facility documented on assessment, swelling was noted to the left second and third metatarsals of the left hand and the resident reported that the area was painful. Review of the progress notes in Resident #'2 medical record dated 8/11/23 at 12:54 PM documented the resident verbalized mild pain of 4 on a pain scale of 1 to 10. Tylenol was offered but refused, however a stat (immediate) x-ray was ordered. The results of the x-ray that was done at the facility were negative for fracture. The x-ray documented, hand arthritis w/contraction. No fracture. An 8/13/23 at 11:54 AM a physician's telehealth visit documented that the patient was aware of x-rays and that there was no fracture but was insistent on going to the emergency room (ER) for evaluation. The note documented that the resident was alert and oriented and did not want to follow up with the PCP (primary care physician) but wanted to go the ER instead. The resident was transported to the hospital at 12:40 PM. An 8/13/23 physician's telehealth visit documented, resident returned from ER after transfer this morning. Reason for visit is finger injury. Diagnosis is closed non-displaced fracture of proximal phalanx of left index finger. A splint is placed on the index finger. On 9/26/24 at 9:33 AM an interview was conducted with the Director of Nursing (DON) who stated that the GNA that was involved in the incident, GNA #31, was initially suspended and then terminated. Review of GNA #31's personnel file revealed an Employee Corrective Action form that documented on 7/8/22 GNA #31, used foul or abusive language, conduct issues. It was reported to the DON by one of the residents that GNA #31 was verbally abusive. On 2/14/23 an employee corrective action form documented GNA #31, was written up for falsification of documentation. On 8/16/23 an employee corrective action form documented, termination. Safety/carelessness violation: resident abuse to police - after 3 days suspension, decided to terminate. On 9/26/24 at 12:49 PM an interview was conducted with Resident #2. Resident #2 was showing the surveyor his/her left-hand fingers and stated that he/she was receiving electric therapy to those fingers and stated that therapy was helping and that his/her left hand and left leg were doing pretty good. Resident #2 stated to the surveyor, my fingers were broken by an aide here. The aide grabbed and pulled and tried to roll me over. I said you can't do it that way and he said you are going to go, meaning roll over. I went to the hospital, and they said they were broken. Resident #2 was asked if the aide was by himself or if he had help. Resident #2 stated the aide was by himself and the bed was against the wall. It happened between 10 and 11 in the morning. He was rough with me all the time. He was hardheaded and said it was his way or the highway. The resident was asked if he had any pain because the surveyor did not see that the resident received pain medication. Resident #2 stated, yes, I had pain, and I still do when it rains. I don't believe in taking pills. I will take Tylenol every once in a while, but I don't believe in it. Resident #2 was asked why he insisted on going to the hospital when the facility told him/her that the x-ray was negative. Resident #2 stated, because my fingers hurt. On 9/26/24 at 1:40 PM the Nursing Home Administrator (NHA) was interviewed and stated she was the RN supervisor at that time. The NHA stated, I remember that employee. That was not his first incident. Not only the way [resident #2 name] described it but he had previous incidents. The NHA stated that Resident #2 stated something about him (GNA) trying to turn Resident #2 a certain way and the guy said, no, that is how I am going to turn you. He has had incidents in the past, so this was the last thing and that is why he was terminated. Residents complained about the GNA's approach to them and how he talked to them. The NHA stated, we did not know if the resident tried to hit the GNA first. On 9/26/24 at 1:57 PM a call was placed, and a voice mail message was left for GNA #31. As of 10/2/24 at 3:30 PM, GNA #31 had not returned the surveyor's call.

Based on surveyor review of closed clinical records, review of facility administrative records and interviews with the facility staff, it was determined that the facility staff failed to ensure Resident #172 was free from abuse. This finding was evident for 1 of 7 residents selected for review of the abuse care area, which resulted in actual harm. This finding was identified during the investigation of a facility reported incident MD 216. A review of the facility's plan of correction implemented after the facility gained knowledge of the abuse incident resulted in the deficiency being cited as past non-compliance. The correction date was 10-14-2020. The findings include: On 10-27-2020 a review of the closed clinical record for Resident #106 revealed on 10-09-2020 at 1:25 AM a concurrent review noted that Geriatric Nursing Assistant (GNA) #2 responded to the resident's room after hearing a loud noise. Upon entering the room, GNA #2 found Resident #106 holding a lamp stand. The resident's roommate (Resident #172) was bleeding from a [MEDICAL CONDITION]. GNA #2 summoned Licensed Practical Nurse (LPN) #3 for assistance as he remained in the room with both residents. LPN #3 initiated an assessment of Resident #172, while Resident #106 was removed from the room by GNA #2. Further record review revealed that Registered Nurse (RN) #1, who was assigned to one to one (1:1) supervision of Resident #106 at the time of the incident, left the residents unattended for a bathroom break. RN #1 had thought that Resident #106 was asleep at the time of her leaving the room, which left Resident #106 in the room unsupervised with Resident #172. Facility staff immediately notified local law enforcement of the incident and they responded to the facility at 1:35 AM on 10-09-2020. Staff requested for law enforcement to transfer Resident #106 to the hospital secondary to violent behavior. However, law enforcement refused the transfer of Resident #106 after their assessment indicated that the resident did not display current violent behavior. Later on 10-09-2020, the attending physician responded to the facility and completed an emergency psychiatric petition in order to transfer Resident #6 for a hospital evaluation. Staff again notified law enforcement, who declined the emergency psychiatric petition citing that the information was documented on the wrong form. On 10-27-2020 closed record review of Resident #172 revealed upon LPN #3's assessment of the [MEDICAL CONDITION] that first aid was provided, and the resident's attending physician and responsible party were notified. The physician ordered that the resident should be transferred to the hospital for an evaluation. The resident returned to the facility around 10:00 AM on 10-09-2020 and was transferred to a new room. At 10:15 AM the resident was transferred back to the hospital after a Computed Tomography (CT) (combination of X-rays and a computer to show more detail than a regular X-ray) results revealed Resident #172 had sustained a subdural hematoma. A subdural hematoma can occur from sudden blow to the head that tears blood vessels that run along the surface of the brain. Surveyor interview on 10-28-2020 at 6:38 AM with GNA #2 revealed on 10-09-2020 around 1:30 AM GNA #2 had been in the hallway and heard a loud noise from the room of Resident #106 and Resident #172. Upon entry, he observed Resident #106 holding a bedside lamp and was standing over Resident #172's bed. In addition, he observed Resident #172 bleeding from the forehead. GNA #2 summoned LPN #3 for assistance. Further interview revealed that RN #1 had been assigned to Resident #172 for 1:1 supervision for the shift, but was not in the resident's room when GNA #2 arrived. RN #1 also had not informed GNA #2 that she had planned to leave the resident unattended for a bathroom break. On 10-28-2020 at 6:47 AM interview with LPN #3 revealed that RN #1 had assigned herself for 1:1 supervision with Resident #106 when the initial assigned 1:1 worker had called out for the shift. Then around 1:34 AM she heard GNA #2 ask for assistance in the residents' room. Upon arrival, Resident #106 was observed standing over resident #172, who was in bed and bleeding. LPN #3 immediately applied pressure to the bleeding [MEDICAL CONDITION] until RN #1 arrived. Upon RN #1's arrival, the police and ambulance were notified. Resident #172 was transferred to the hospital by 911 after their arrival. Interview on 10-28-2020 at 6:55 AM with RN #1 revealed, at the beginning of the 11:00 AM-7:00 PM shift on 10-08-2020, that the assigned 1:1 for Resident #106 had called out and the outgoing supervisor had been unsuccessful in finding a replacement. Therefore, RN #1 decided to be Resident #106's 1:1 sitter for the shift. Then around 1:23 AM, she left Resident #106's bedside when she thought the resident was sleeping, and went for a bathroom break. RN #1 admitted that she had not asked any other staff members to supervise the resident during that time, but had seen that GNA #2 was in close proximity to the resident's room. Further interview revealed that RN #1 had previously done 1:1 supervision with Resident #106 multiple times and had taken previous bathroom breaks without any incidents. RN #1 further stated she was aware that another staff member should have maintained the 1:1 supervision and the resident should not have been left unsupervised. On 10-28-2020 at 9:53 AM surveyor interview with the Director of Nursing and the facility's Staff Development Nurse revealed that Resident #106 had not returned to the facility and the hospital was looking into a more appropriate psychiatric placement. In addition, Resident #172's family had made the decision not to return the resident to the facility, but transferred to another facility after the hospitalization . Further interview revealed education and counseling was provided to RN #1 after the incident on 10-09-2020. Education was initiated to all licensed staff on 10-09-2020 regarding Abuse Prevention and 1:1 supervised responsibilities, which includes the coverage requirement of the resident. The coverage must be maintained even when the assigned worker needs any form of a break, that involves another staff member is informed to relieve the 1:1 worker, so the resident is not left unsupervised at any time. The facility staff had failed to ensure Resident #172 was free of abuse from Resident #106 when staff did not maintain the 1:1 supervision of Resident #106. This resulted in the actual harm of Resident #172. This incident was found to be past noncompliance. Surveyor review of the administrative records on 10-28-2020 revealed immediate actions taken by the facility included: 1. Resident #106 was immediately removed from the room on 10-09-2020 after the incident. Unsuccessful attempts were made to transfer the resident for hospital psychiatric evaluation on 10-09-2020 and 10-12-2020. 2. Resident #106 was successfully transferred out of the facility on 10-13-2020 on an emergency psychiatric petition and has not returned to the facility since that transfer. 3. Resident #106 was remained on 1:1 supervision and in a private room immediately after the incident with a plan, upon the resident's return to the facility, to be maintained in a private room. 4. Resident #172 was immediately assessed after the incident on 10-09-2020 and transferred to the hospital for evaluation. Resident returned a few hours later to the facility on the same day, but was transferred back to the hospital after CT results revealed the resident had a subdural hematoma. The resident did not return to the facility after return to the hospital on 10-09-2020. 5. The facility on 10-09-2020 submitted an initial self report to the Office of Health Care Quality (OHCQ) and initiated an investigation into the incident. Employee statements were obtained that included statements from RN #1, GNA #2, and LPN #3. The final investigation was submitted to OHCQ on 10-14-2020. 6. On 10-09-2020 the facility conducted an Quality Assessment and Performance Improvement (QAPI) Ad Hoc meeting to review the incident with a Root Cause analysis completed. 7. Education on 10-09-2020 was completed by the facility to RN #1 regarding the reporting of abuse allegations, as well as 1:1 supervised responsibilities. 8. Education was also initiated on 10-09-2020 to all facility licensed staff regarding Abuse Prevention and 1:1 coverage and responsibilities, including when breaks are necessary that another staff member must relieve the 1:1 first. In addition, education was provided on how to deescalate a situation if a resident is agitated and around another resident. Education was completed for licensed staff as of 10/15/2020. At that point, Resident #106 was no longer in the facility and there were no other residents requiring 1:1 supervision within the facility.

Based on the review of clinical records, observations, and interviews with the facility's staff, it was determined that the facility failed: 1) to implement an infection control program that ensured newly admitted residents were properly isolated to prevent mixing new admissions with residents from the general population and; 2) to cohort residents appropriately by not separating newly diagnosed Coronavirus Disease 2019 (COVID-19) positive residents from their roommates with either negative COVID-19 test result or an unknown COVID-19 status. The facility's noncompliance with infection control practices placed seven (7) of 18 residents reviewed at an increased risk for contracting COVID-19 (Residents #2, 4, 5, 6, 7, 8 and #9). As a result of these findings, an immediate jeopardy was declared on 07-09-2020 at 1:00 PM. The facility submitted a plan of removal at 5:22 PM. This plan was accepted by the State Agency at 10:32 PM. The immediate jeopardy was lifted by the State Agency on 07-14-2020 at 3:20 PM. After removal of the immediacy, the deficiency remained at a potential for more than minimal harm, with a scope and severity of E. The findings include: 1. According to the Maryland Department of Health guidance Preparing for and Responding to COVID-19 in Long-term Care and Assisted Living Facilities published on March 23, 2020, if a new resident screens negative, they should be admitted to this observation unit/area for 14 days. They can mix with other residents in this unit/area but not with other residents in the facility. They should also be screened daily with temperature and symptom checks and placed on strict isolation if they screen positive. After 14 days on the observation unit, if the resident does not ever screen positive, they can be released to mix with the general population. On 07-01-2020 at 9:30 AM, a review of the facility's COVID-19 Education, Observation and Monitoring Plan implemented on 01-28-2020, and revised on 03-14-20, 04-22-2020, and 06-04-2020, revealed the facility's policy and procedure required all new admissions and positive residents to be isolated in a private room when available and monitored for 14 days. After 14 days without any COVID-19 symptoms, the resident will then be transferred to other units with the general resident population. Further review of the facility's COVID-19 Education, Observation and Monitoring Plan revealed the facility established three zones (green, yellow, and red) to separate the general resident population, new admissions or readmissions, and COVID-19 positive residents. The rooms in the green zone were for general population residents who were negative. The rooms in the yellow zone, established on 04-23-2020, was the observation area for newly admitted and readmitted residents. Rooms in the red zone were for residents with COVID-19. The red zone rooms were established on 04-09-2020. a. On 07-01-2020 at 10:15 AM during a tour of the dedicated observation unit a surveyor observed Resident #4 and Resident #5 sharing a semi-private room (room100). Resident #4 was observed in bed A (100-A) and Resident #5 was observed in bed B (100-B). On 07-08-2020 a review of the clinical records for Resident #4 and for Resident #5 revealed that Resident #4 was admitted to the facility on [DATE] and assigned to room [ROOM NUMBER]-A. On 06-24-2020, 25 days later, Resident #5 was admitted to the facility and assigned to 100-B. On 07-01-2020 a review of the facility's daily census record for 06-24-2020 revealed that room [ROOM NUMBER], a room on the observation unit, was unoccupied. On 07-02-2020 at 10:20 AM, interview with the Admission Coordinator revealed that Resident #5 was admitted to room [ROOM NUMBER]-B, because two other new admissions were expected to arrive on 06-24-2020. However, the expected admissions did not come. The admission coordinator further stated, I didn't know that all new admissions to the observation unit should be placed in a single-person room (without a roommate). My understanding was that we could admit to the observation unit as long as there was an available bed. On 07-02-2020 at 10:25 AM an interview with the DON revealed that Resident #4 should have been moved from the observation unit (the yellow zone) to the general population (the green zone) since the resident had been in the room for more than 14 days without COVID-19 symptoms. b. On 07-01-2020 at 10:15 AM a surveyor observed Resident #4 and Resident #5 sharing a semi-private room (room [ROOM NUMBER]). Resident #4 was observed in 100-A and Resident #5 was observed in 100-B. On 07-01-2020 a review of Resident #5's clinical records on 07-01-2020 revealed a hospital screened the resident for COVID-19 symptoms on 06-24-2020, prior to discharging the resident. Based on the screening assessment, Resident #5 did not show signs or symptoms of COVID-19. Resident #5 was admitted to the facility on [DATE] and assigned to room [ROOM NUMBER]-B with Resident #4, who had been in 100-A for 25 days prior to Resident #5's admission. On 07-08-2020 a review of the Resident #4's clinical record revealed the hospital tested Resident #4 for COVID-19 on 05-21-2020. The resident's results were negative. Further review of the record revealed that Resident #4 was admitted to the facility's observation unit on 05-30-2020. On 07-08-2020 a review of the daily census record for 06-24-2020 revealed that room [ROOM NUMBER] in the green zone was unoccupied. On 07-08-2020 at 2:34 PM, an interview with the infection control nurse revealed that all direct care staff were in-serviced on 04-22-2020 regarding the facility's policies on COVID-19. In addition, all management staff were briefed on the policies during regular morning meetings. On 07-02-2020 at 10:25 AM in an interview, the DON was unable to explain why Resident #4 was not moved to an area with the general population after completing the required observation period. The DON stated, I think I dropped the ball because there was too much going on. No additional information was provided. On 07-08-2020 at 1:10 PM, an interview with the Unit Manager revealed she lost track of the number of days Resident #4 was on the observation unit. The unit manager stated that the Director of Nursing (DON) usually kept track of the number of days residents stayed in the observation unit. c. On 07-07-2020, a review of Resident #2's clinical record revealed that on 04-06-2020 the resident was admitted from a hospital to the facility and assigned to an observation unit in a semi-private room (room [ROOM NUMBER]-B). Resident #2 was screened negative for COVID-19 symptoms/fever prior to being admitted to the facility. Further record review revealed Resident #2's roommate (Resident #8 in 200-A) was also admitted from a hospital on 04-06-2020. A continued review of Resident #2's clinical record revealed that after two days of admission, on 04-08-2020, the resident was moved to room [ROOM NUMBER]-A with Resident #6, a general population resident who had resided in room [ROOM NUMBER] since 09-24-2019. Further review of Resident #2's clinical record revealed that on 04-15-2020, nine days after admission, the resident was moved a second time and placed in a semi-private room (room [ROOM NUMBER]-A) with Resident #7. Resident #7 is another general population resident who had occupied bed 217-B since 08-15-2017. On 07-07-2020 at 5:13 PM, an interview with DON revealed Resident #2 was moved with general population because Resident #2 had screened negative for signs and symptoms of COVID-19 prior to admission to the facility. The DON stated that Resident #2 was not believed to be at risk of exposing the general population to COVID-19. On 07-08-2020 at 12:47 PM, an interview with the Administrator revealed Resident #2 was moved multiple times because the facility's staff were trying to expand the red zone, rooms available for COVID-19 positive residents. On 07-08-2020 at 1:19 PM, an interview with the ICP confirmed Resident #2 was moved to different rooms before completing the required 14 days of observation period to create additional bed availability for COVID-19 positive residents. d. On 07-07-2020 a review of Resident #8's clinical record revealed the resident was screened negative for COVID-19 symptoms/fever on 04-06-2020 at a hospital prior to admission to the facility. The same day the resident was admitted to room [ROOM NUMBER]. Resident #2 shared a room with Resident #8 (200-A). On 07-07-2020 a review of Resident #2's clinical record revealed Resident #2 in 200-B was also admitted from a hospital on 04-06-2020. Resident #2 was screened negative for COVID-19 symptoms/fever prior to being admitted to the facility on [DATE]. On 07-07-2020, an additional clinical record review of Resident #8 revealed the resident was moved to a semi-private room (room [ROOM NUMBER]-A) on 04-09-2020, three (3) days after admission. Resident #9, a general population resident, had resided in that room (room [ROOM NUMBER]-B) since 12-12-2018. On 07-07-2020 at 5:20 PM, an interview with the DON (Director of Nursing) revealed Resident #8 was moved to room [ROOM NUMBER] with Resident #9 because Resident #8 had screened negative for signs and symptoms of COVID-19 prior to admission to the facility. The DON stated that Resident #8 was not believed to be at risk of exposing the general population to COVID-19. On 07-08-2020 at 12:47 PM, an interview with the Administrator revealed Resident #8 was moved to room [ROOM NUMBER] because the facility's staff were trying to expand the red zone, rooms available for COVID-19 positive residents. On 07-08-2020 at 1:19 PM, an interview with the ICP (infection control preventionist) confirmed Resident #8 was moved to room [ROOM NUMBER] before he/she completed the required 14 days of observation to create additional bed availability for COVID-19 positive residents. 2. The Centers for Medicare for Medicare and Medicaid Services (CMS) defines cohorting as the practice of grouping residents infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible residents (State Operations Manual, Appendix PP last revised 11/22/17). On 04-02-2020 CMS released COVID-19 Long-Term Care Facility Guidance. Section five states, Long-term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status. On 04-24-2020, the Maryland Department of Health (MDH) issued Directive and Order Regarding Nursing Home Matters on, Staff Assignment: Nursing homes shall immediately implement, to the best of their ability, the following personnel practices: Designate a room, series of rooms, unit, or floor of the nursing home to care for residents with known or suspected COVID-19. On 07-08-2020 a review of the facility's COVID-19 Education, Observation and Monitoring Plan revealed the facility established three zones (green, yellow, and red) to separate the general resident population, new admissions or readmissions, and COVID-19 positive residents. The rooms in the green zone were for general population residents who were negative. The rooms in the yellow zone, established on 04-23-2020, was the observation area for newly admitted and readmitted residents. Rooms in the red zone were for residents with COVID-19. The red zone rooms were established on 04-09-2020. a. On 07-01-2020 at10:30 AM, Resident #2 and Resident #7 were observed in room [ROOM NUMBER]. Resident #2 was in 217-A and Resident #7 in 217-B. On 07-07-2020, a review of Resident #7's clinical record revealed the resident tested positive for COVID-19 on 04-29-2020. On 07-07-2020 a review of Resident #2's clinical record revealed the resident tested negative for COVID-19 on 05-03-2020. On 07-08-2020 a review of the facility's since records revealed there were two unoccupied rooms in the red zone on 04-29-2020. On 07-07-2020 at 5:13 PM in an interview, the DON reported that Resident #7 was not separated from Resident #2 after Resident #7 had tested positive, because Resident #2 and Resident #7 were already exposed to each other for more than a week and since both residents were asymptomatic, the residents were not separated or moved to designated units. On 07-01-2020 at 12:10 PM, an interview with the ICP revealed the facility did not have a cohorting policy in place until after 04-22-2020, when the National Guard reviewed the facility's cohorting practices and advised the facility to develop a subsequent policy. According to the ICP, prior to the arrival of the National Guard all direction on COVID-19 related issues were relayed from facility corporate headquarters. All of the department heads met each morning and discussed how to implement the recommendations from the corporate office. On 07-08-2020 at 12:47 PM, an interview with the Administrator revealed he was unable to explain why Resident #2 continued to share a room with Resident #7 after facility staff knew Resident #7 was positive for COVID-19 and Resident #2 had tested negative for COVID-19. On 07-08-2020 at 1:19 PM, in an interview the ICP (infection control person) stated that after Resident #7 tested positive for COVID-19 and Resident #2 tested negative for COVID-19, Resident #7 should have been moved to the positive unit and Resident #2 should have been isolated for at least 14 days. He was unable to explain why the two residents continued to share a room. b. On 07-07-2020 a review of Resident #8's clinical record revealed Resident #8 was screened negative for COVID-19 symptoms and fever on 04-06-2020 at the hospital prior to admission to the facility. That same day the resident was admitted to room [ROOM NUMBER]-A. On 07-07-2020, an additional clinical record review revealed on 04-09-2020, three days after being admitted to the facility, Resident #8 was moved to a semi-private room (room [ROOM NUMBER]-A). Resident #9, a general population resident, had resided in that room (208-B) since 12-12-2018. Resident #9 tested positive for COVID-19 on 04-28-2020. Resident #8 refused to be tested for COVID-19. However, Resident #8 and Resident #9 continued to share room [ROOM NUMBER] until Resident #8 was discharged home on 05-08-2020. On 07-08-2020 a review of the facility's since records revealed there were two unoccupied rooms in the red zone on 04-29-2020. On 07-07-2020 at 5:20 PM, in an interview, the DON reported that Resident #8 was not separated from Resident #9 after Resident #9 tested positive for COVID-19, because Resident #8 and Resident #9 were already exposed to each other for more than a week and since both residents were asymptomatic, the residents were not separated or moved to designated units. On 07-01-2020 at 12:10 PM, an interview with the IP (infection preventionist) revealed the facility did not have a cohorting policy in place until after 04-22-2020, when the National Guard reviewed the facility's cohorting practices and advised the facility to develop a subsequent policy. According to the IP, prior to the arrival of the National Guard all direction on COVID-19 related issues were relayed from facility corporate headquarters. All of the department heads met each morning and discussed how to implement the recommendations from the corporate office. On 07-08-2020 at 12:47 PM, an interview with the Administrator revealed he was unable to explain why Resident #8 continued to share a room with Resident #9 after facility staff knew Resident #9 was positive for COVID-19 and Resident #8 had unknown COVID-19 status. On 07-08-2020 at 1:19 PM, an interview with IP revealed Resident #9 was tested COVID-19 positive and Resident #8 refused to be tested so Resident #9 should have been moved to the positive unit, the Red Zone. IP was unable to explain why the residents continued to share the room. As a result of these findings, an immediate jeopardy was declared on 07-09-2020 at 1:00 PM. The facility submitted a plan of removal at 5:22 PM. The State Agency accepted the State Agency plan of removal at 10:32 PM. The immediate jeopardy was lifted by the State Agency on 07-14-2020 at 3:20 PM. The provisions of the plan to remove the immediacy included but not limited to the following: A. The facility has established room numbers 100 to 108, which are located on the first floor as the designated location for the observation unit (yellow Zone) for new admissions and readmissions. New admissions and readmissions who are negative or unknown will be admitted to these rooms and remain for a minimum of 14 days and will not commingle with the general population. room [ROOM NUMBER]-A and 201-B have been designated as the COVID-19 positive unit (Red Zone). Residents admitted that are COVID-19 positive will be admitted to the COVID-19 positive unit. B. Resident #8 is no longer in the facility. Resident #9 remains in the facility and shows no sign or symptoms of COVID-19 so has been moved to the general population. Resident #4 has been moved from the observation unit to the non-COVID unit (Green Zone). Resident #5 has completed 14 days of observation with no sign or symptoms of COVID-19 and has been moved to the general population. Resident #2, #6 and #7 are still in the facility with no sign or symptoms of COVID-19. They are all currently residing in the non-COVID-19 unit with the general population. C. The Director of Nursing completed a 100% audit of signs and symptoms of COVID-19 of all residents on 7-8-2020 to ensure they are in the appropriate quarantine area. Audits will be on-going and will be completed by shift supervisor on the weekends and holidays. Currently, the facility does not have any COVID-19 positive residents. All residents in the observation unit (yellow unit) are in private rooms and are within their 14 days of quarantine post admission. D. The facility instituted a tracker that is reviewed daily by the clinical team during stand up meetings and daily clinical meetings to track the number of days in the observation unit for all new admissions. Residents who have remained symptom free for 14 days post-admission are moved to a COVID-19 free area of the facility (green zone). Facility cohorting areas for observation and COVID- 19 positive areas are clearly identified. Red unit is located on the second floor, room [ROOM NUMBER]-A and room [ROOM NUMBER]-B are assigned rooms. E. Staff education was provided by either shift supervisor, staff development, infection control person or Director of Nursing. Education was provided either in-person or via phone calls. Nursing, administrative, housekeeping, activities, maintenance, dietary, rehab and weekend staff have been educated by staff development on facility's COVID-19 infection control program to ensure new admissions remain on observation unit for 14 days before mixing with general population, staff transfer newly diagnosed COVID-19 positive residents to isolation area and cohorting COVID-19 residents on same unit. F. Admissions Coordinator was educated on placement of new and readmitted residents per latest MDH guidance dated June 16, 2020. In addition, the admission coordinator will present admissions and readmissions to the Director of Nursing and/or the Nursing Home Administrator who will determine appropriateness of the admission and the proper room assignment for the resident. This process will also be followed on the weekends staff. Infection preventionist will be back up in case the Administrator and DON are not available. G. Facility has instituted the use of a COVID-19 tracker on 07-09-2020 to manage observation days for all new admissions, and COVID-19 positive residents quarantine days to determine when isolation should be discontinued. The COVID-19 tracker is reviewed daily during department head meetings and clinical reviews. The COVID-19 tracker will be reviewed by shift supervisors, manager on duty personnel on weekends and holidays. H. The facility administrator and/or the Director of Nursing will communicate to the team about New guidance from MDH, CDC, and/or CMS during department head meetings daily. I. The administrator will review the resident tracker with the Director of Nursing and Admissions Director to ensure new and readmitted residents are quarantined for the required 14 days in the observation unit, (red unit monitoring). COVID-19 Tracker Audit findings will be reviewed in facility QAPI meeting monthly until pandemic resolves. J. The Director of Nursing will review clinical changes of residents daily during clinical meetings, to ensure that all COVID-19 positive residents were placed in the appropriate quarantine area. COVID-19 Tracker Audit findings will be reviewed in the facility monthly QAPI meetings until pandemic resolves. Director of Nursing and/or designee will monitor all residents for signs and symptoms of COVID-19. The immediate jeopardy was removed on 07-14-2020 at 3:20 PM after confirmation of the facility's plan of removal by the surveyor who was on site at the facility.

Based on surveyor review of clinical records, administrative documents, surveyor observations and staff interviews, it was determined that the facility failed to implement adequate interventions for one resident's risk (Resident #2) with known abusive behavior. The facility further failed to implement sufficient measures necessary to protect residents from physical abuse by Resident #2, a resident with a history of aggressive behaviors and wandering into the rooms' of other residents. The facility's failure resulted in actual harm to one (1) of 4 residents reviewed (Resident #1). This finding was identified during the investigation of complaint MD 641 and facility reported incident MD 649. The findings include: On 01-07-2020 a review of Resident #2 clinical record revealed Resident #2 had a care plan in place for behavior problem [related to] disease process with behaviors including aggression, wandering and going to other residents' room. Interventions included: Administer medications as ordered, Monitor/document for side effects and effectiveness, Intervene as necessary to protect the rights and safety of others, Monitor behavior episodes and attempt to determine underlying cause .Document behavior and potential causes, Re-direct as needed, and minimize potential for disruptive behaviors by offering task which divert attention. There was no documented evidence of close monitoring of Resident #2's wandering/agitated behavior. There was no evidence that the staff consistently offered the Resident #2 task to divert the resident' attention. This care plan is dated as initiated on 04/30/2019 and updated on 11/24/2019. A continued review of the clinical record revealed a behavior note on 05-09-2019 which documents the use of PRN (as needed) medication Benzodiazepine medication in the control of the resident's behavior with good effect. Resident #2's clinical record contained assessments completed by the attending Psychiatric Nurse Practitioner (NP) 09-13-2019 and 09-26-2019. The assessments described Resident #2 as a resident that can ambulate independently, has poor attention and judgement, and noted behavior of 'intermittent aggressiveness'. Further review revealed on 09-26-2019 the attending Psychiatric NP ordered staff to resume the administration of [MEDICATION(S)] 50 mg IM (intramuscular) injection once a month for the management of Resident #2's [CONDITION(S)] and behaviors. Additionally, staff were to monitor the resident's mood and redirect behaviors. On 01-07-2020 a review of nursing documentation for Resident #2 revealed on 12-14-2019 at 7:22 AM, staff documented that Resident #2 paced hallways and at times was observed going in and out of residents' rooms throughout the shift. Resident #2 became very combative and aggressive when staff attempted to redirect the resident. On 12-19-2019 the Psychiatric NP conducted a follow-up assessment of Resident #2 due to the resident presenting behavior problem of combativeness with facility staff. The Psychiatric NP ordered the addition of [MEDICATION(S)], five (5) mg three (3) times daily for behavior management. Staff were instructed to continue monitoring of the resident's mood and behaviors. Further review of the clinical record revealed no documented evidence of Resident #2's response to medications, such as any impact on the resident's identified behaviors and/or mood. (Refer to 758). On 01-07-2020 surveyor review of RN #2's nursing documentation for 01-04-2020, revealed that Resident #2 and Resident #1 had a physical altercation that was noted at 8:30 PM that night. Resident #1 sustained a laceration on the left side of the lower lip and discoloration around the right eye. RN #2 had initially obtained a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Later when noted Resident #1's blood pressure had dropped to 100/62 mmHg, staff notified the physician. The physician ordered that Resident #1 be sent to the hospital via emergency services for further evaluation. On 01-07-2020 surveyor review of the clinical record for Resident #1 revealed the resident is totally dependent on staff for care and is unable to ambulate. A concurrent review, dated 01-04-2020 and documented by LPN (Licensed Practical Nurse) #1, revealed: Resident #1 was assessed and sent to [emergency room ] for further evaluation. A review of the skin assessment, dated 01-04-2020 at 22:51 (10:51 PM), also documented by LPN # 1, confirmed that Resident #1 sustained a laceration on the lower lips, right black eye. On 01-10-2020 surveyor review of the emergency services report for the incident, dated 01-04-2020 at 9:49 PM, revealed the facility requested an interfaculty transfer of Resident #1 due to a problem of high blood pressure and that the resident was conscious, breathing. Further review of the timeline revealed the Emergency Services Technicians' (EMTs) assessment described Resident #1 as having a decreased level of consciousness. Resident #1 was transferred to an area hospital for further evaluation. On 01-10-2020 surveyor review of the police report related to the incident revealed that on 01-04-2020 a police officer observed, Resident #1 in the hospital with fresh bruises on the face. Hospital staff reported to the police that the resident had dementia and presents at the hospital as nonverbal. On 01-07-2020 surveyor review of Resident #1's clinical record revealed nursing documentation by LPN #1, dated 01-05-2020 at 3:29 AM, that stated Resident #1 returned to the facility from the ER. A head to toe assessment was completed and Resident#1 was noted with discoloration to face around both eyes persist. Upon return to the facility, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1]'s bruises to both eyes and swollen lower lip each shift and report any changes and the administration of pain medication every 8 hours as needed. On 01-07-2020 at 11:50 AM surveyor observed Resident #1 in a recliner chair in the resident's room. The resident's right eye was noted black/blue and the sclera (white area around eye) of eye was redden, while the skin area around the left eye was dark. Further observation revealed the resident's lower lip was slightly swollen with a laceration on the bottom lip area. Upon interview, the resident made few verbal responses, which were inconsistent with the questions regarding the 01-04-2020 incident; however, the resident recalled that a [identified the gender] resident entered the room and began to hit him/her in the face. Surveyor observation on 01-07-2020 at 12:00PM and 4:00PM revealed resident was observed as a tall and thin frame. On 01-07-2020 at 1:55 PM surveyor interview with LPN #1 revealed that Resident #2's behavior usually consisted of wandering throughout the unit, and at times entering other residents' rooms. The resident could usually be redirected by staff. On 01-04-2020 LPN #1 was assigned to care for Resident #1 during the 3:00 PM-11:00 PM shift. At approximately 8:30 PM, Geriatric Nursing Assistant (GNA) #4 came to nurse's station and yelled for assistance with Resident #2, who was in Resident #1's room. RN #2, also responded to Resident #1's room. They observed Resident #2 standing over Resident #1, who was lying in bed. Resident #2 had blood on the chest area. Resident #1 was observed with discoloration around the right eye and a laceration on the lip with some blood noted. On 01-07-2020 at 4:24 PM interview with LPN #3 revealed she was assigned to care for Resident #2 on 01-04-2020 during the 3:00 PM-11:00 PM shift. According to LPN #3, Resident #2 ambulated independently throughout the unit during the shift on 01-04-2020. She reports her last observation of Resident #2 was after dinner time. After 8:00 PM staff requested that LPN #3 respond to Resident #1's room. LPN #3 observed Resident #2 standing at the bedside of Resident #1, while Resident #1 was lying in bed. Further interview revealed that Resident #2 at times goes into other residents' rooms, but staff usually can redirect Resident #2. On 01-07-2020 at 4:30 PM the surveyor conducted an interview with Resident #1's responsible party (RP). The RP recalled being notified about the incident between Resident #1 and Resident #2 on 01-04-2020 by RN #2. According to the RP, RN #2 reported that Resident #1 had been involved in a physical altercation with another resident and was transferred to the hospital. The RP verbally expressed being upset that the incident happened to Resident #1. The RP stated she had previously observed Resident #2 wandering throughout the unit and going in and out of other residents' rooms, including Resident #1's room. Further interview revealed that the RP had requested to meet with the facility's social worker and administrator on 01-06-2020, and in the meeting the RP asked, Why didn't the facility protect [Resident #1]? The RP further stated that the day after the incident, other residents in the facility began to report to him/her that Resident #2 had prior issues of entering their rooms and they had to notify staff to intervene. On 01-08-2020 at 9:30 AM an interview with GNA #4 revealed he was assigned to care for Resident #1 on 01-04-2020 and 01-05-2020 during the 3:00 PM -11:00 PM shift. On 01-04-2020 around 8:15 PM, GNA #5 who was assigned to care for Resident #2, asked staff about the whereabouts of Resident #2. Resident #2 was located in Resident #1's room. GNA #4 observed Resident #2 standing over Resident #1, who was lying in bed. Both residents were observed hitting one another. GNA #4 then yelled out for staff assistance and immediately separated both residents. Both LPN #1 and RN #2 responded to the room. Resident #2 was noted with scratches on the chest area, while Resident #1 had bruising around both eyes. GNA #4 confirmed that Resident #2 usually wanders throughout unit unattended. Interview with RN #2 on 01-08-2020 at 12:15 PM revealed on 01-04-2020 around 8:30 PM GNA #4 yelled out for assistance in Resident #1's room. Resident #2 was observed standing at the bedside of Resident #1, who was lying in bed. Initially, blood was observed on each residents' lip and Resident #1's pillow. An assessment was initially completed on Resident #1 with findings of a laceration of lip and discoloration of the right eye. The facility's on call physician was notified of the altercation and injury and ordered an X-ray of Resident #1's head. During the assessment Resident #1 had a drop in blood pressure, and the on call physician was notified of the change. The physician then ordered for the resident to be transferred to the hospital via 911 for evaluation. In addition, an assessment of Resident #2 was completed. Resident #2 was noted to have a swollen lip and scratches on the chest area that were not open. RN #2 further stated that Resident #2 ambulates independently on the unit and can be redirected by staff. On 01-08-2020 at 2:25 PM an interview with RN #6 revealed Resident #2 ambulates independently throughout the unit and can be redirected by staff. RN #6 acknowledged awareness Resident #2 had a previous history as a boxer . Interviews with the Administrator and the Director of Nursing on 01-07-2020 at 4:00 PM, and on 01-08-2020 at 4:00 PM and 6:00 PM revealed no additional information. On 01-08-2020 at 6:00PM the Administrator and DON were notified that as a result of the facility's failure, harm was identified to Resident 1, who suffered physical abuse and required hospital intervention.

Based on surveyor review of the closed clinical record and staff interview, it was determined that the facility staff failed to provide timely, appropriate, and effective interventions to prevent resident #1 from committing a sexually abusive act against resident #2. This finding was identified during the investigation of facility reported incident MD 506 and is valid. The findings include: On 04-17-17, review of the closed clinical record revealed that resident #1was alert, oriented, and capable of self-determination. The resident was mobility impaired and wheelchair dependent, although able to move independently throughout the facility. Record review revealed that a yearly comprehensive assessment of resident #1's health status was completed by nursing staff on 06-26-16. This assessment identified that the resident had behavioral symptoms that had impact on others by significantly intruding on their privacy or activity, and by significantly disrupting care or the living environment of others. Record review revealed no evidence that a care plan was developed by staff to address these identified behavioral symptoms at the time. However, a consulting psychiatric group to the facility was providing routine oversight of the resident's mental status and management of the psychoactive medications prescribed for the resident's mental illness and mood disorders. Continued record review revealed a nursing note entry on 10-25-16 regarding a witness report of resident #1 approaching a female resident for sexual favor, which was refused by the female resident. The nursing note indicated a plan for further investigation. Additionally, on 10-25-16 nursing staff notified the attending physician caring for resident #1 and received the following order for Psych (psychiatric) consult for inappropriate behavior in AM. On 04-17-17 at 4:00 PM, interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed the contents of the investigation, regarding this incident on 10-25-16. Two written statements were provided by a resident witness and the female resident involved in the incident. Both written statements confirmed that sexually inappropriate verbal behavior was exhibited by resident #1. There was no statement or documented evidence provided that resident #1 was questioned about the incident. Based on interview with the NHA and DON, no further action was taken by the facility because the resident witness statement, reporting that a sexually inappropriate physical act did occur, was denied by both the female resident and resident #1. There was no evidence of a plan of care to address the sexually inappropriate behavior exhibited by resident #1 at this time. Additionally, based on record review and interview with the NHA and DON, the psychiatric consult for inappropriate behavior was not done in the AM (on 10-26-16) as ordered by the attending physician on 10-25-16. Three weeks later on 11-16-16, resident #1 was seen by a nurse practitioner in the consulting psychiatric group. Review of the nurse practitioner's consult report revealed no identified information or assessment of sexually inappropriate behavior exhibited by the resident, and as referred for evaluation on 10-25-16. Continued record review for resident #1 revealed a nursing note entry on 11-29-16 stating that resident #1 was observed sitting at the edge of a resident's bed (resident #2 as identified by room number) at about 9:45 PM. Both resident #1 and resident #2 were residing on the same nursing unit in the facility at the time. On 04-17-17, review of the closed clinical record revealed that resident #2 was non-verbal, bedbound, unable to perform any self care, and receiving hospice services due to advanced [MEDICAL CONDITION]'s Disease. [MEDICAL CONDITION]'s Disease is a progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability. Based on the nursing note entry on 11-29-16, resident #1 was re-directed to his room and staff were educated to monitor resident #1's behavior. Additionally, on 11-29-16 nursing staff notified the attending physician caring for resident #1 and received the following order for Psych (psychiatric) consult for wandering to another resident's room. A nursing note entry the following day on 11-30-16 stated that the resident was seen by the psychiatric nurse practitioner and that there was no new order given. However, there was no evidence of a psychiatric evaluation or progress note on this date. A repeated physician order [REDACTED]. Continued review of the nursing progress notes revealed the following entry on 12-05-16: Resident remains on 1:1 close monitoring. Assigned GNA (geriatric nursing assistant) educated to stay close to Resident and monitor his location on the Unit at all times. Resident makes inappropriate sexual advances to staff and residents .Resident also has a history of offering money for sex or offering cigarettes for sex. An electronic record of a treatment order, not written in the medical chart, revealed a phone order from the attending physician for 1:1 monitoring for sexual advances every shift for safety on the same date, 12-05-16. Additionally, on 12-05-16, nursing staff first developed and initiated a care plan to address resident #1's sexual advances to other residents and staff, although the behavior had been evident as a problem on 10-25-16, based on the documented incident of sexually inappropriate behavior. The care plan interventions included the new order for 1:1 monitoring every shift and administering medication as ordered. After the attending physician gave an order on 11-29-16 for Psych (psychiatric) consult for wandering to another resident's room, and a repeated physician order [REDACTED].#1 was seen eight days later on 12-07-16 by the psychiatric nurse practitioner for making sexual advances and touching female residents. Review of the nurse practitioner's consult report on 12-07-16 revealed the following: .per staff patient is continuing to make sexual advancement to female residents and entering their rooms without consent, and noncompliant sometimes with direction and care .Staff reports no improvement in symptoms. Based on the evaluation, the psychiatric nurse practitioner documented a plan to increase [MEDICATION NAME] to 750 mg q am (every morning) and 250 mg at night and VPA level in 6 weeks . A new medical order was written by the nurse practitioner on the same date, 12-07-16, for [MEDICATION NAME] 750 mg QD (every day) daytime, [MEDICATION NAME] 250 mg QHS (every night) bedtime for sexually inappropriate behavior. [MEDICATION NAME] is a medication often used in psychiatric management of behavior or impulse control disorders. Psychiatric management with this medication includes laboratory blood test monitoring to evaluate the blood level (VPA level) for therapeutic effectiveness of the drug. Historical review of the clinical record, and specifically, the initial psychiatric evaluations completed when resident #1 was originally admitted to the facility in June 2015, revealed that the resident's psychoactive medication regimen included [MEDICATION NAME] 500 mg twice a day since his admission until the new order written by the nurse practitioner on 12-07-16. The new [MEDICATION NAME] order did not change or increase the total daily dosage amount of 1,000 mg a day, but rather only changed the divided amount given in the morning and at night from 500 mg twice a day to 750 mg and 250 mg a day. It is unknown if the nurse practitioner intended to increase the total daily dosage amount, or the rationale for the adjustment of the divided dose amount, in response to the treatment for [REDACTED]. In addition, review of the laboratory test reports revealed the VPA level, to evaluate the therapeutic effectiveness of [MEDICATION NAME], was done on 12-21-16 and again on 01-11-17. The results of the VPA level on 12-21-16 were low at 40.5, in comparison to the therapeutic reference range of 50.0 - 100.0. This laboratory report was noted and signed by the attending physician, although without indication of an assessment or action taken for the low level. Following, the psychiatric nurse practitioner evaluated resident #1 on 12-28-16 for follow up of inappropriate behavior and medication review. However, review of the nurse practitioner's consult report on 12-28-16 revealed no identified information, assessment or action taken regarding the low VPA level on 12-21-16. The VPA level was done again on 01-11-17, as ordered by the nurse practitioner on 12-07-16, when the [MEDICATION NAME] dose was adjusted. The results of the VPA level on 01-11-17 were significantly lower at 26.3, compared to the previous low of 40.5. Again, this laboratory report was noted and signed by the attending physician, although without indication of an assessment or action taken for the lower level. Following, the psychiatric nurse practitioner evaluated resident #1 on 02-22-17 for follow up of inappropriate behavior and medication review. However, review of the nurse practitioner's consult report on 02-22-17 revealed no identified information, assessment or action taken regarding the low VPA level on 01-11-17. On 04-17-17 at 4:00 PM, interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that a review of resident #1's psychiatric case management was in progress by the consulting psychiatric group to the facility. Noncompliance in taking the [MEDICATION NAME] could be considered one probable cause for the low, subtherapeutic VPA level, in addition to other possible metabolic abnormalities. However, there was no evidence that ineffective medication management was considered as a contributing factor or addressed as a plan of correction in relationship to the facility self-reported incident of resident #1 committing a sexually abusive act against resident #2. On 04-17-17 at 4:00 PM, interview with the NHA and DON revealed that resident #1 remained on 1:1 monitoring for sexual advances every shift for safety from 12-05-16, as ordered by the attending physician, until the physician's orders [REDACTED]. Interview with the NHA and DON revealed the order was changed and the 1:1 monitoring was stopped because the resident had not displayed inappropriate sexual behaviors during that period. On 02-10-17, based on an electronic record of a treatment order, not written in the medical chart, the attending physician gave a new verbal order to monitor for sexual advances every shift for safety, although there was no specific order to discontinue the previous order for 1:1 monitoring. Review of the nursing progress notes, following the entry on 12-05-16, revealed documented evidence of daily 1:1 monitoring until 01-09-17. On 01-09-17, a nursing note entry stated resident #1 had a room change that day to another nursing unit, which was done for close monitoring of the resident. Following this nursing entry on 01-09-17, the clinical progress notes are infrequent and without any documentation for monitoring of sexually inappropriate behavior. In addition, review of the Daily Staffing Sheets provided from 01-09-17 to 02-10-17 revealed inconsistent or missing documentation of staff assignment for 1:1 monitoring of resident #1, although the monthly Treatment Administration Records (TARs) for January and February 2017 revealed a daily check-off on each shift that 1:1 monitoring was provided. Following the change in the order on 02-10-17, the monthly TARs for February, March, and April 2017 revealed a daily check-off on each shift that monitoring for sexual advances was done. However, review of the care plan to address resident #1's sexual advances to other residents and staff revealed no revision of the care plan interventions when the 1:1 monitoring was stopped, and when the monitoring for sexual advances every shift was started. Without revision of the care plan regarding this change, it is unclear what the procedures were or how the monitoring was being provided by facility staff from 02-10-17 until 04-02-17 when resident #1 committed a sexually abusive act against resident #2. Review of the facility self-report submitted to the State authority on 04-03-17, review of the facility's investigation of the abuse incident, and review of the local police department report revealed that resident #1 was observed seated on the bed of resident #2 by facility staff on 04-02-17 at approximately 5:00 PM. Resident #2 was observed disrobed, with her incontinence product removed, lying in her bed. Upon questioning of the facility staff and the local police authorities, resident #1 stated he had committed a sexual act against resident #2, who lacked the capacity to respond and consent to the sexual act. Resident #1 was removed from the facility and taken into police custody. Resident #2 was transported to a local hospital where a forensic exam was conducted.

Based on surveyor review of the clinical record, review of the facility's policy and procedure, surveyor observation and interview with facility staff, it was determined that the facility staff failed to ensure the safety of resident #3, who was a risk for elopement, on 05-24-16. These failures resulted in a past non compliance immediate jeopardy, identified on 07-20-16 for the date of 05-24-16. The facility had identified the concern and had implemented an acceptable plan of correction before the survey. This finding was identified during the investigation of a facility reported incident MD 482 and is valid. The finding was evident in 1 of 16 residents reviewed in the complaint survey. The findings include: On 07-19-16, record review revealed resident #3 was initially admitted to the facility after a hospitalization in July 2015. Record review revealed documentation by the transferring hospital of the resident's history of eloping and being placed on a more secured unit in the hospital. The Brief Interview for Mental Status (BIMS) is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. a. Further record review and review of the facility's investigation revealed that, on 05-24-16 at 1:30PM, staff # 1 observed resident #3 first exiting the facility's Chesapeake unit door with a visitor (not associated with resident #3) and proceeded to exit the main front door from the lobby and began walking down the driveway heading to the neighborhood street. Staff #1 contacted another staff member to inform the nursing unit, and then proceeded to follow the resident down the driveway. The resident informed staff #1 that they wanted to get out of here. I gotta go to the store. Staff #1, after 10 minutes of following the resident, was successful in bringing the resident back to the facility. However, further review of clinical record revealed no evidence of any interventions put into place by the facility staff to ensure a decrease in the resident's risk of elopement after the 1st attempt to leave the facility. b. Around 3:30PM on 05-24-16, resident #3 was observed trying to leave the facility via the lobby of the facility's front entrance. The resident was observed fighting with LPN #2(licensed practical nurse) and shouting wanting go to the store to buy cigarettes. Staff #3 and a visitor to the facility were successful, after intervening and blocking the front door, they able to calm the resident down and return the resident back to the unit. Record review revealed the resident was last seen by staff at 4:30PM on the unit. However, further review revealed no evidence of staff documentation of a plan put into place to decrease the risk of elopement after the second attempt, which was 2 hours after the first attempt on the same day. c. Further review revealed documentation by LPN #4 that the assigned GNA (geriatric nursing assistant) reported, at 6PM on 05-24-16, that resident #3 was not located on the unit. The facility's alert code for a missing resident was activated and the initiation of room searches as well as building and grounds searches were conducted, but the resident was not located. Local law enforcement was notified, as well as the attending physician and the resident's responsible party. Facility interviews with other residents revealed that, around 5:30PM, residents outside on the facility's grounds observed resident #3 asking for directions to the store and stating they had signed out and walked out the front door in the lobby area. Resident #3 was last seen leaving the facility's grounds to the neighborhood. The facility staff conducted a search for the resident within the neighborhood community, as well as the home of the resident's significant other outside of the facility's neighborhood, where staff were informed that the resident had eloped previously and went missing for almost a month. d. Further review revealed that resident #3 was not located until four days after elopement, when the resident showed up at a family member's home. A medical evaluation was completed at an area emergency room , and the resident was readmitted to the facility on [DATE] at 12:55AM. On 07-20-16, record review revealed physician orders [REDACTED]. The Wanderguard system is an alarm system used in wandering or elopement management. Residents who are at risk wear a wrist or ankle transmitter, when if the transmitter comes in contact close to the door that is protected by this type of system, the antenna singles out the transmitter of the resident. In addition, a comprehensive plan of care of Elopement Risk R/T (related to) actual elopement was initiated on 05-28-16 by facility staff that included 1:1 monitoring for safety and a Wander guard on at all times for safety . There was no evidence that the facility staff documented resident #3's risk for elopement until 05-28-16, although at the time of the initial facility admission, there was documentation of the resident's history of elopement. On 06-18-16 at 4PM, and 06-20-16 at 1PM, surveyor observation of resident #3 revealed no evidence of a Wanderguard bracelet in place, but a 1:1 staff member was present with the resident at the time of observations. On 06-20-16 at 1:15PM, surveyor interview with the Severn unit manager revealed that staff have observed resident #3 removing the Wanderguard bracelet due to the noise made when entering and exiting the elevator. Staff have maintained the resident on 1:1 monitoring with the resident's removing of the Wanderguard On 06-20-16 at 4PM, surveyor interview with the Director of Nursing and the facility administrator revealed no additional information.

Based on surveyor review of the closed medical record, review of the facility investigation, and staff interviews, for facility reported incident MD# 335 it was determined that the facility staff failed to honor the resident's wishes for Advanced Directives regarding cardiopulmonary resuscitation (CPR). This was evident for 1 of 16 records reviewed. (#10) This was determined to be a past non- compliance harm deficiency related to a resident's advanced directive. The facility had identified the concern and had implemented an acceptable plan of correction before the survey. The findings include: On [DATE], surveyor review of the closed medical record for resident #10 revealed a MOLST form (Maryland Medical Orders for Life Sustaining Treatment) on file. The MOLST form is used for documenting a resident's specific orders related to life-sustaining treatments for a resident suffering cardio-pulmonary arrest. The MOLST form indicated that the resident's wishes were to have CPR performed, if cardio-pulmonary arrest occurred. Further review of the clinical record revealed resident #10 was admitted to hospice on [DATE]. Review of the hospice comprehensive nursing assessment under Summary/Plan revealed Patient remains full code. Surveyor review of the social service progress notes revealed a quarterly progress note written on [DATE] which stated that the brother of resident #10, who was the guardian and decision maker, wishes a full code status. Surveyor review of the nursing progress notes for resident #10 revealed a note, written on [DATE] at 7:35 AM, that stated writer was called and informed that resident has change of condition. On assessment resident was warm to touch, no respiration, no pulse, no blood pressure for more than four minutes. The note also stated the family was notified of the resident's death. In addition, a note written on [DATE] at 8:26 AM, stated resident noted on a decline condition during rounds with shallow breathing . 10 mins (minutes) later, resident had a change of condition, on assessment resident remains warm to touch, no respiration, no pulse, and no BP (blood pressure) noted for more than 5 minutes, the supervisor called to the unit {physician} notified via phone . gave order to release the human remains to funeral home per family request. There was no evidence that the facility staff performed CPR in the event of the cardio-pulmonary arrest as instructed on the MOLST. On [DATE] at 3:30 PM, surveyor interview with the Director of Nursing provided no additional information.

Based on clinical record review, observation of staff practice, interview with staff and interview with residents, it was determined that the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial welling being for resident #21, #5 #4, #8, #3, #17, #10, #26, #16, #1, #12, #11,and #7. This finding was identified in 13 of 26 residents selected for review. The findings include: 1). Based on clinical record review, observation of staff practices and interview with the nursing staff and medical staff, it was determined that the facility staff failed to provide adequate pain management for resident #21 during dressing changes and positioning. The findings include: On 10-07-2010, surveyor review of the clinical record revealed resident #21 was originally admitted to the facility in May 2006 following a hospitalization . The resident's [DIAGNOSES REDACTED]. Review of the October 2010 Treatment Administration Record (TAR), revealed that the resident has a stage IV pressure sore at the sacrum (A stage IV pressure sore is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures), a right hip wound, a left hip wound and a skin tear between the left fourth and fifth toes. In addition, [MEDICATION NAME] 5 mg was documented as administered to this resident prior to the daily dressing change since 04-23-2010. Additionally, routine [MEDICATION NAME] 25 mcg was ordered for chronic pain. On 10-05-2010, the primary physician/nurse practitioner ordered two antibiotics, [MEDICATION NAME] 250 mg and [MEDICATION NAME] 600 mg, intravenously to treat osteo[DIAGNOSES REDACTED] of the right hip wound. Osteo[DIAGNOSES REDACTED] is an infection of the bone. On 10-08-2010 at 2 PM, this surveyor observed GNA #3 and GNA #4 provide personal care to resident #21. The resident was observed to cry out in pain when re-positioned from the back to the right side (facing the wall). On 10-08-2010 at 2:05 PM, interview with GNA #3 and GNA #4 revealed that this resident " always cries out in pain during turning, positioning and/or personal care " . In addition, observation of the resident's sacral area revealed no dressing covering the pressure sore and the resident had had a bowel movement. Two surveyors observed the resident intermittently cry out in pain when GNA #3 and GNA #4 cleaned the resident's buttocks. On 10-08-2010 at 2:50 PM, the Unit Manager on the Chesapeake Unit obtained a one time verbal order from the primary physician/nurse practitioner to give [MEDICATION NAME] 5 mg prior to the dressing change because this unit manager stated that she " believed the resident would experience pain during the dressing change ". On 10-08-2010 at 3 PM, the resident received [MEDICATION NAME] 5 mg as ordered. On 10-08-2010 at 3:20 PM, observation revealed that this resident was lying on the left side (facing the door) without any sign of pain. However, the resident cried out in pain when the wound nurse, GNA #6 and GNA #7 moved the resident's right leg. The resident had another bowel movement and when staff provided care the resident stated, "I want to go home, I want to get out of here and I don't want a dressing change." The wound nurse left the resident's room for approximately 10 minutes. On 10-08-2010 at 3:30 PM, observation of the dressing change to the sacral pressure sore revealed that the wound nurse placed Hydrogel instead of the ordered Santyl ointment to the base of the sacral pressure sore. The surveyor then notified the assistant Director of Nursing and the Vice President of Regional Operations. The ADON replaced the wound nurse and continued with the dressing change. The Vice President of Regional Operations assisted by handing the medical supplies to the ADON during the dressing change. At this time the resident did not show any signs or symptoms of pain. Then, the ADON and the Vice President of Regional Operations left the resident's room. The ADON told this surveyor that the Chesapeake Unit Manager would continue the dressing change to the resident's bilateral hip wounds and skin tear between the resident's left fourth and fifth toes. On 10-08-2010 at 3:45 PM, observation of the dressing change revealed RN #5 was assisting the Chesapeake unit manager do the dressing change on the resident's right hip. When the Chesapeake unit manager shot 1/4 strength Dakin's Solution with a syringe into the resident's right hip wound, two surveyors observed the resident cry out in pain. When the Chesapeake unit manager shot more Dakin's solution into the resident's right hip wound, the resident cried out again. In addition, the resident cried out in pain when the Chesapeake unit manager packed the right hip wound with an [MEDICATION NAME] strip using a Q-tip. The right hip wound was then covered with a dry dressing. When the dressing change to the right hip wound was completed, the resident did not show any more signs or symptoms of pain. On 10-08-2010 at 4 PM, when The Chesapeake unit manager and GNA #7 turned the resident from left to right (facing the wall), the resident cried out in pain. The Chesapeake unit manager proceeded to clean the resident's left hip wound with normal saline solution and apply a dry dressing. During the dressing change to the left hip wound, the resident did not show any signs or symptoms of pain. On 10-08-2010 at 4:10 PM, the Chesapeake unit manager continued the dressing change to the resident's skin tear, which was between the left fourth and fifth toes. When the Chesapeake unit manager placed a soaked 4x4 gauze with normal saline solution between the resident's left fourth and fifth toes, the resident cried out in pain. When the soaked 4x4 gauze was moved up and down between the resident's forth and fifth toes, the resident cried out in pain even louder. When the Chesapeake unit manager manipulated the resident's left toe, the resident cried out in pain again. At this time the surveyor observed bone on the resident's left fifth toe. The surveyor asked the Chesapeake unit manager to stop the dressing change. Based on observation on 10-08-2010 between 2 PM and 4:15 PM, the resident experienced pain during personal care, turning and positioning and the dressing changes to the right hip and the skin tear between the left fourth and fifth toes even after [MEDICATION NAME] 5 mg was given to the resident at 3:00 PM. On 10-08-2010 at 4:40 PM, the primary physician/nurse practitioner was called and gave the following verbal orders: x-ray to rule out abnormality, two tablets of [MEDICATION NAME] now for pain, two tablets of [MEDICATION NAME] twice a day prior to dressing changes and two tablets of [MEDICATION NAME] every 6 hours PRN (as needed) for breakthrough pain. Further review of the October 2010 MAR and TAR revealed LPN #11 performed a dressing change to the resident's right hip wound in the evening of 10-03-2010, 10-05-2010, 10-06-2010 and 10-07-2010. However, record review and interview of staff revealed no evidence that pain medication was given to the resident prior to the evening dressing change. In addition, there was no order for pain medication to be given to the resident prior to the evening dressing change. On 10-08-2010 at 5:15 PM, interview with LPN #11 revealed the resident cries out sometimes during dressing changes and re-positioning. In addition, the resident sometimes states " I am falling; I am falling" during the dressing changes. When asked, LPN #11 could not explain why pain medication was not administered during the evening dressing changes. On 10-08-2010 at 5:30 PM, interview of GNA #6, GNA #14 and GNA #15 revealed they were assigned to this resident during the past six weeks. They told two surveyors that the resident cries out in pain during re-positioning and personal care. On 10-11-2010 at 11 AM, interview with LPN #12 revealed that two tablets of [MEDICATION NAME] were given to the resident at 9:30 AM prior to the dressing change. Observation of the dressing change at 11AM on 10-11-2010 revealed the resident was lying on her left side (facing the door) without any signs of pain. However, the resident cried out in pain when LPN #12 and LPN #13 moved the resident's right leg. They stopped re-positioning the resident and left the room for pain medication. On 10-11-2010 at 11:30 AM, another two tablets of [MEDICATION NAME] were given to the resident prior to the dressing change. On 10-11-2010 at 12:25 PM, observation of the dressing change revealed the resident was lying on her left side (facing the door) without any pain. When LPN #12 removed the [MEDICATION NAME] strip from the right hip wound, the resident started crying out in pain. When LPN #12 cleaned the right hip wound with 1/4 strength Dakin's solution the resident stated loudly "Oh that hurts and really hurts". The resident was observed with a grimaced facial expression when LPN #12 packed an [MEDICATION NAME] strip into the resident's right hip wound. LPN #13 told LPN #12 to stop the dressing change because the resident was experiencing excruciating pain. Based on observation on 10-11-2010 between 11AM and 12:30 PM, this surveyor observed the resident experience pain during re-positioning and the dressing change to the right hip wound after two tablets of [MEDICATION NAME] were given to the resident prior to the dressing change. On 10-11-2010 at 2 PM, interview with Physician Wound Specialist revealed that the resident's sacral pressure sore, right hip wound and left hip wound was assessed in the morning on 10-08-2010. The physician Wound Specialist stated that the resident did not show any pain in the past two months during the wound assessments except during re-positioning. Further review of the Physician Wound Specialist wound assessments, dated 09-17-2010, 09-24-2010 and 10-01-2010, revealed that the Physician Wound Specialist applied a topical anesthetic agent to the resident's right hip wound before assessing the right hip wound. On 10-11-2010 at 4 PM, interview with the Director of Nursing and LPN #13 revealed no dressing changes could be performed on 10-11-2010 because the resident's pain was " uncontrollable " . The primary physician/nurse practitioner ordered to postpone all the dressing changes until the next day. In addition, new orders were obtained to administer [MEDICATION NAME] 2mg twice a day prior to dressing changes and PRN [MEDICATION NAME] 2 mg every 6 hours for breakthrough pain. On 10-12-2010 at 1 PM, interview with the Pain Specialist revealed that the resident is expected to be in pain during physical movement due to contractures of both legs. The physician further stated that routine [MEDICATION NAME] 25 mcg patch is adequate pain management for the resident related to positioning. However, the physician did not observe the resident's behavior during the dressing changes. On 10-13-2010 at 2:30 PM, interview with the Vice President of Regional Operations revealed that the facility believed routine [MEDICATION NAME] 25mcg and [MEDICATION NAME] 5 mg prior to the daytime dressing changes was adequate pain management for this resident and "there was nothing more they could do. " 2). Based on clinical record review, interview with staff and observation of the resident, it was determined that the facility staff failed to arrange a pain consult and a physical therapy evaluation for resident#5 as ordered. In addition, the facility staff failed to apply ted stockings on resident#5's bilateral lower extremities as ordered. The findings include: On 10-05-2010, review of the clinical record revealed resident #5 was admitted to the facility on [DATE] following a hospitalization . The resident's [DIAGNOSES REDACTED]. a) On 08-10-2010 upon admission, the primary physician ordered a pain consult for the resident. However, there was no evidence this pain consult was completed as ordered. On 10-06-2010 at 3 PM, interview with the Assistant Director of Nursing (ADON) revealed no pain consult was completed as ordered. b) On 09-23-2010, the primary physician ordered a physical therapy evaluation for the resident. However, there was no PT evaluation done until surveyor's intervention on 10-06-2010. On 10-06-2010 at 3 PM, interview with ADON revealed a referral was made to rehabilitation services on 09-23-2010. However, interview with the Director of Rehabilitation Services on 10-07-2010 at 9 AM revealed the rehabilitation department did not receive this referral. c) On 10-05-2010, review of the clinical record revealed the primary physician ordered TED stockings to the resident's legs in the morning and removed in the evening. On 10-5-2010 at 2 PM during the initial tour, revealed the resident complained of pain to her back. At that time, the resident was not wearing ted stockings. On 10-06-2010 at 2:30 PM, observation of the dressing change revealed the resident was not wearing ted stockings as ordered. 3). Based on resident record review and staff interview, it was determined that the facility staff failed to follow up in a timely manner for an ENT consult ordered for resident #4. The findings include: Resident #4 was admitted in 2009 for rehabilitation. Review of the medical record revealed that this resident has a history of recurrent ear infections. On 4-8-10, the primary physician ordered an ENT (ear, nose, and throat) consult which was scheduled on 5-4-10. However, this consult was not done. On 5-21-10, the primary physician again ordered "schedule ENT appointment". The consult was scheduled on 6-14-10. Further record review revealed that on 6-3-10 the resident had another ear infection requiring antibiotics for treatment before the resident's scheduled ENT consult. Interview of the unit manager on 10-7-10 revealed no further information. The staff failed to ensure the resident received a timely ENT consult ordered by the physician. In addition, the facility staff failed to follow the physician's orders [REDACTED]. Review of the resident's record revealed a swelling in the resident's bilateral feet and legs on 6-23-10 by nursing staff. The physician ws notified and ordered [MEDICATION NAME] 20 mg twice a day for 5 days for [MEDICAL CONDITION]. On 6-25-10, the physician evaluated the resident and discontinued the previous [MEDICATION NAME] order and started [MEDICATION NAME] 40mg twice a day for the [MEDICAL CONDITION]. Review of the MAR revealed that staff failed to discontinue the previous [MEDICATION NAME] order on 6-25-10 when transcribing the new order. On 6-26-10 at 9 AM, staff administered both [MEDICATION NAME] 20mg and [MEDICATION NAME] 40mg. Interview of the Director of Nursing on 10-7-10 revealed no further information. The staff failed to administer [MEDICATION NAME] as ordered. Further review of the physician orders [REDACTED]. However, staff did not administer the potassium supplement on 6-26 and 6-27 as ordered. There was no explanation documented as to why this medication was not administered. 4). Based on resident record review and staff interview, it was determined that the facility staff failed to provide timely and adequate care for resident #8's constipation and failed to identify when a calcium supplement order was missed for resident #8. The findings include: a). Resident #8 is a long term resident with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. On 2-28-10 at 10 AM, orders were received to do a stat abdominal x-ray to rule out bowel obstruction and to give a fleet enema. There was no explanation as to what happened and why these orders were given. Interview of the unit manager on 10-12-10 revealed no further information. Review of the nursing note revealed no assessment related to the resident's bowel problem. In addition, there was no documentation that the fleet enema was given. Further review of the record revealed a note by the evening nurse that the x-ray company was called to follow-up on the x-ray results. Review of the record revealed no documentation when the stat x-ray order was called to the company and when the follow up call was made. Review of the x-ray report revealed that the xray was done close to midnight and the results were received in the facility around 10:100 AM the following day. The results indicated severe constipation. The physician was informed and ordered an additional fleet enema and magnesium [MEDICATION NAME] for the constipation. Additional fluid was also ordered. The facility staff failed to adequately assess, monitor and document the resident's constipation problem. Further review of the resident's medical record revealed [REDACTED]. Review of the admission orders [REDACTED]. However, this medication order was not carried over to the next month and staff did not identify that this medication order was missed. On 8-4-10, the pharmacist recommended a calcium supplement since the resident was also on a Vit D supplement routinely. However, the staff failed to inform the physician of this recommendation until 9-7-10. At this time the physician ordered a calcium supplement as recommended. 5). Based on clinical record review, observation and interview with facility staff, it was determined that facility staff failed to follow physician orders [REDACTED]. The findings include: Record review on 10-05-10 revealed resident #3 is a long term resident with [DIAGNOSES REDACTED]. Further review revealed the attending physician ordered [MEDICATION NAME] 100mg twice daily and vitamin D-3 2000 units once daily. Both medications were scheduled to be administered at 9 AM with other 9 AM medications. Surveyor observation of medication pass on 10-05-10 at 9:50 AM revealed Staff #1 administered the resident's 9 AM medications and documented after administration on the October 2010 MAR. However, Staff #1 omitted administering the [MEDICATION NAME] and the vitamin D-3 as scheduled during the medication pass. Surveyor interview with the DON and Staff #1 on 10-05-10 at 10:15 AM and 12 PM revealed no additional information. b). In addition, staff failed to follow physician orders [REDACTED].#3. The findings include: Record review revealed documentation on 08-16-10 and 09-22-10 of resident falls with no apparent injuries sustained. Further review revealed that on 09-22-10, the physician ordered a physical therapy evaluation due to the falls and an evaluation for possible use of a scoop mattress. However, further review revealed no evidence of a physical therapy evaluation initiated until surveyor intervention on 10-06-10. Surveyor interview with the Severn unit manager on 10-06-10 at 2 PM, revealed no additional information. c). Additionally, the staff failed to follow physician orders [REDACTED]. The findings include: Record review revealed documentation on 09-27-10 at 2:00 AM, that the resident was observed in bed, but refusing to sleep and "very agitated" behavior. Staff then contacted the facility's nurse practitioner who gave orders, that included but not limited to, a one time only dose of [MEDICATION NAME] 0.5mg for the agitation and a psychiatric consult for the increased agitation. However, further record review revealed no evidence that a psychiatric evaluation had been completed until surveyor intervention on 10-06-10. Surveyor interview with the Severn unit manager on 10-06-10 at 2 PM revealed no additional information. d). In addition, the staff failed to follow physician orders [REDACTED]. resident #3. The findings include: Record review revealed the resident's diet consistency included a pureed diet with nectar thickened liquids secondary to dysphagia (difficulty in swallowing). Surveyor observation on 10-06-10 at 12:30 PM revealed the resident's lunch tray contained a pureed diet meal with containers of nectar thickened consistency of both cranberry juice and 2 % milk. However, during surveyor observation of medication pass on 10-05-10 at 9:50 AM, Staff #1 administering a thin consistency of juice and water to the resident. Further observation revealed episodes of coughing experienced by the resident during the intake of the fluids. On 10-06-10 at 2 PM, after surveyor intervention and interview with the Severn unit manager, staff proceeded to obtain a physician order [REDACTED]. 6). Based on record review of the clinical record, surveyor observation and interview with facility staff, it was determined that facility staff failed to follow physician orders [REDACTED]. The findings include: Record review on 10-05-10 revealed resident #17 is a long term resident with [DIAGNOSES REDACTED]. The attending physician ordered the administration of calcium antacid chewable 500mg twice daily for supplement and [MEDICATION NAME] oral suspension 400mg for the promotion of good intake once daily. Both medications were scheduled for administration at 9 AM with other 9 AM medications. Surveyor observation of medication pass on 10-05-10 at 10:05 AM revealed Staff #1 administered the resident's 9 AM medications and documented after administration on the October 2010 MAR. However, Staff #1 omitted administering the calcium and [MEDICATION NAME] during the medication pass. Surveyor interview on 10-05-10 with the DON at 12 PM and Staff #1 at 10:15 AM revealed no additional information b). In addition, staff failed to follow physician orders [REDACTED]. The findings include: Further review revealed that on 08-17-10 a progress report, documented by the facility's dietician, of the resident's poor intake/appetite also noted by speech therapy. Based on the dietician's recommendations, the attending physician ordered on 08-17-10 for staff to perform weekly weights for 4 weeks, to assess nutritional status and to administer [MEDICATION NAME] 400mg once daily to promote good intake. However, there is no evidence of weekly weights for 4 weeks completed by staff. Surveyor interview with the Severn unit manager on 10-06 and 10-07-10 revealed no additional information. 7). Based on record review, surveyor observation and interview with resident and facility staff, it was determined that staff failed to ensure an accurate pain assessment and management for resident #10's pain. The findings include: On 10-07-10 record review revealed resident #10 is alert and oriented and able to verbalize her needs. [DIAGNOSES REDACTED]. Further review revealed the physician ordered on 09-08-10, [MEDICATION NAME] 10 mg twice daily (10 AM, 10 PM) for pain management and [MEDICATION NAME] 5mg every 8 hours as needed for pain. Surveyor observation on 10-07-10 at 12:30 PM in the Severn unit shower room revealed Staff #5 initiating wound care to the resident's left lower extremity. The resident complained of pain in the left lower extremity during the initiation of care. Further observation revealed the Severn unit manger administering [MEDICATION NAME] 5mg to the resident as Staff # 5 continued with wound care. The resident complain of pain during the care after pain medication administration and continued to tell Staff #5 to "hurry up and finish". In addition, surveyor observation on 10-08-10 at 8:20 AM revealed that during the wound assessment by the facility's wound physician and as the physician manipulated the left lower extremity including the toe wound, the resident complained of pain at times. Staff did not enter the resident's room until 9 AM to administer the 10 AM scheduled [MEDICATION NAME] 10mg as the wound assessment and wound care proceeded. Surveyor interview with the resident on 10-07-10 at 2:20 PM revealed no relief in the pain in the left lower extremity even an hour after receiving the 12:30 PM [MEDICATION NAME]. Review of the October 2010 pain management log revealed documentation by staff at 12:30 PM that the resident's level of pain was 6 out of 10 (level 0 is no pain and 10 is the worst pain ) However, staff documented at 1:30 PM that the resident's level of pain was 1 out of 10. Interview with Staff #5 on 10-07-10 at 1:30 PM and the Assistant Director of Nursing on 10-11-10 at 3 PM revealed no additional information. b). In addition, staff failed to adhere to physician orders [REDACTED]. Record review revealed the following wound care treatment ordered on 10-01-10 by the resident's attending physician: - clean the left groin open area with normal saline and apply [MEDICATION NAME] ointment and leave open to air twice daily - left toe wound clean with 1/4 strength Dakins solution, apply xeroform dressing and wrap once daily. However, surveyor observation of the wound care treatment on 10-07-10 at 12:30 PM in the Severn shower room, revealed the following observations: - left groin open area cleaned with normal saline and [MEDICATION NAME] ointment applied and left open to air. - left toe wound cleaned with a previous unopened bottle of full strength Dakins solution , then xeroform dressing and dry dressing and wrap with Kling. Surveyor interview with Staff #5 on 10-07-10 at 1:30 PM and on 10-08-10 at 9:30 AM revealed [MEDICATION NAME] ointment was used for the left groin wound becasue there was no [MEDICATION NAME] available. Interview with the Severn unit manager on 10-08-10 at 2 PM revealed a tube of [MEDICATION NAME] was in the Severn Unit treatment cart, which included a label with the resident's name and date of 10-01-10. In addition, a bottle of 1/4 strength Dakins solution was also located in the treatment cart that included a label with the resident's name and date of 10-01-10. Both the tube and bottle had been previously open and contents were used. 8). Based on surveyor record review and interview with the physician, it was determined that the facility staff failed to coordinate the frequency of wound treatments for resident #26 as requested by the wound specialist. The findings include: On 10-11-10 clinical record review and observation revealed resident #26 had a venous stasis ulcer (from poor circulation) on the left shin area. Interview of staff and record review revealed the dressing to the leg is changed once daily. Review of the physician order [REDACTED]. Review of the primary physician progress notes [REDACTED]. Review of the wound specialist progress notes revealed an order for [REDACTED]. On 10/11/10 at 1:55PM, interview with the wound specialist revealed he thought the wound dressings were being done twice daily. Prior to September, the dressings were ordered daily. The primary physician needs to agree to the final order, however, since this was referred to the wound specialist, his recommendations should be addressed. There was no explanation noted that the primary physician was notified of the recommendation and did not agree to twice a day dressing changes or that staff clarified the order with either physician. 9). Based on surveyor review of the clinical record and interview with the Director of Nursing it was determined that facility staff failed to provide insulin coverage as ordered by the physician for resident #16. The findings include: Record review revealed this resident has multiple [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the Medication Administration Records revealed that coverage was administered in incorrect doses on the following days: September, 2010: 09-11-10 at 4:30PM - coverage for a value of 302: 6 units was administered instead of the 8 units ordered 09-17-10 at 4:30PM- coverage for a value of 316: 10 units was administered instead of the 8 units as ordered. 09-20-10 at 4:30PM and 9:00 PM - no blood sugar values or coverage is noted October, 2010: 10-09-10 at 11:30AM- coverage for a value of 350: 10 units was administered instead of the 8 units as ordered. 10-01-10 at 4:30PM - coverage for a value of 320: 6 units was administered instead of the 8 units as ordered. 10-05-10 at 4:30PM - coverage for a value of 344: 10 units was administered instead of the 8 units as ordered. 10-09-10 at 4:30PM - coverage for a value of 382: 6 units was administered instead of the 10 units as ordered. Further record review revealed this resident is noncompliant with his diet and his blood sugar values fluctuated to"high", above the glucometer's ability to read. 10). Based on clinical record review and interview with the facility staff, it was determined that the facility failed to follow a physician orders [REDACTED]. On 10-05-10 record review revealed that on 08-31-10 the attending physician ordered Liquid Prosource to be given three times a day for healing. Further review revealed that Prosource was not given for the month of September, 2010. However, the Prosource was given for the 1st. four days in October. Interview with the unit manager revealed that the original order must of been missed. 11). Based on surveyor review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to follow physician orders [REDACTED]. The findings include: On 10-11-10, review of the clinical record revealed resident #12 is an alert and oriented long term care resident in the facility with [DIAGNOSES REDACTED]. Further review revealed an order for [REDACTED]. Fingersticks 3 times daily before meals and at bedtime FSBS 101 - 150 = 2 units FSBS 151-200 = 4 units FSBS 201 - 250 = 6 units FSBS 251 - 300 = 8 units FSBS 301 - 350 = 10 units FSBS > 351 = 12 units/ call MD <60 = orange juice/call MD Further review of the MAR for September 2010 revealed that on 09-10-10 at 9 PM, the FSBS was 142 and staff documented that no insulin was administered. Review of the MAR for October 2010 revealed that on 10-02-10 at 11:30 AM, the FSBS was 116 and staff documneted that no insulin was administered. On 10-11-10 at approximately 1 PM, interview of the unit manager revealed no additional information. 12). Based on surveyor review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to follow the attending physician's orders [REDACTED]. The findings include: On 10-06-10, review of the clinical record revealed resident #11 is a resident in the facility for rehabilitation after a hospitalization with a [DIAGNOSES REDACTED]. A Stage IV pressure ulcer has damage to underlying muscle, bone, and even supporting structures such as tendons and joints. a). Further review revealed an order dated 09-27-10 to cleanse the sacral wound area with normal saline, apply Santyl, a [MEDICATION NAME] agent, and to cover with Calcium Alginate, a highly absorbent, biodegradable dressing. Then cover the area with a 4 X 4 dressing daily. On 10-06-10 at 1:30 PM, observation of the dressing change to the sacral area revealed the wound nurse after applying the Santyl to the area, applied hydrogel to the area, not the calcium alginate as ordered. The calcium alginate was then placed over the hydrogel. The