Every finding on record at Westminster Rehabilitation and Wellness Center

Based on observations and interviews, it was determined that the facility failed to ensure that the facility environment maintained a homelike, safe, and sanitary environment. This was evident during the initial and subsequent observations and tours during the recertification and change of ownership survey.The findings include:Gouges in countertops and walls are major infection control risks in long-term care (LTC) because they create porous and hard-to-clean surfaces that can harbor pathogens (germs). In a setting where residents often have weakened immune systems, these damaged and deteriorated surfaces act as reservoirs for microorganisms and cannot be effectively cleaned or disinfected, increasing the risk for transmission of infection.On 4/28/26 at approximately 9:30 AM, during the initial tour of the facility, the surveyor noted the following environmental concerns:Visitors enter the facility on the second floor. Upon observation, the surveyor noted that the walls throughout the floor exhibited extensive deterioration, including thinning, worn, and chipped paint, as well as multiple gouged areas. These surfaces appeared rough, uneven, and visibly damaged, preventing effective cleaning. There was a large area of peeling and missing wall material and paint outside of room [ROOM NUMBER], exposing underlying surfaces. In room [ROOM NUMBER], the countertop contained two areas with deep gouges, creating irregular, porous surfaces that cannot be properly sanitized.The surveyor noted that the walls on the first floor similarly exhibited thinning, worn, and chipped paint, as well as multiple gouges throughout the hallways and resident care areas, indicating a widespread lack of maintenance and upkeep.The bathroom in room [ROOM NUMBER] was observed to have an area of the wall with visible signs of prior water damage that had been painted over without proper repair. The surface had ridging and bubbling, indicating compromised wall integrity beneath the paint. Additionally, the ceiling tiles were observed to be bowing, misaligned, and not properly seated within the drop ceiling grid, creating a potential fall hazard. The heating vent was rusted with multiple areas of chipped paint, indicating prolonged deterioration. Numerous floor tiles were cracked, and the caulking in the corners was worn, deteriorated, and peeling away, leaving gaps that could allow moisture and debris accumulation.Additionally, there was not a chair for visitors to sit next to each bed in this room. There was also an area of the room with a partially pulled curtain enclosing a bed without a mattress, along with a wheelchair and bedside tables. This area appeared to be used for storage, contributing to a cluttered and non-homelike environment.room [ROOM NUMBER] was observed to have a gouged door with multiple wide black marks across the brown surface, giving the door a heavily worn and damaged appearance. Additionally, there were tiles missing around the pipe under the sink where it enters the wall, leaving gaps and exposed areas that cannot be properly cleaned.When making an observation in room [ROOM NUMBER], it was noted that an electrical outlet was loose and falling out of the wall while still in use with electrical plugs inserted, posing a safety hazard. The walls behind both beds had deep gouges that had been painted over without proper repair, such as spackling or sanding, leaving uneven, damaged surfaces.On 5/01/26 at 10:16 AM, the surveyor interviewed the Maintenance Director, who stated that he had started working at the facility approximately one month ago and that the position had been vacant for several months prior to his employment.He stated that his general duties include plumbing, electrical work, repairs, and overall maintenance of the facility. He further explained that he is aware that there are numerous areas requiring attention but that he has needed to prioritize more urgent issues since starting. He stated that he plans to implement formal rounding logs; however, at the time of the survey, there was no formalized log or systematic process in place to ensure that all environmental issues were identified and addressed. He also explained that the facility utilizes a system called TELLS for staff to report maintenance concerns.The surveyor asked if there was a routine schedule for ongoing maintenance, such as painting and environmental updates. The Maintenance Director stated that he was too new to tackle that yet but acknowledged that he was aware the facility needed to address multiple environmental concerns.On 5/01/26 at 10:26 AM, the surveyor and the Maintenance Director toured the facility together. During this tour, he confirmed the surveyor's concerns regarding the condition of the walls throughout the facility, missing tiles, bowing ceiling tiles, gouged countertops, missing chair, cracked tiles, deteriorated caulking, and the unsafe electrical outlet. He stated that he was aware that gouged and damaged surfaces can present infection control concerns and reported that the facility is actively attempting to hire additional maintenance staff to address the backlog of needed repairs.On 5/01/26 at 11:00 AM, the surveyor reviewed the concerns with the Nursing Home Administrator, who confirmed that the facility had been without maintenance staff for a period and acknowledged awareness of the environmental concerns. The surveyor shared photographs of the identified issues. The Administrator stated that she had not realized the extent of the deterioration and that the facility would begin addressing the concerns.

Based on record reviews and interviews, it was determined that the facility failed to provide a transfer notice to residents. This was evident for 2 (Resident #2 and Resident #105) of 2 residents reviewed for hospitalizations.The findings include:A Transfer Notice is a legal protection for all long-term care residents. Its primary purpose is to ensure that residents are not transferred or discharged without appropriate notice, a safe plan, and information about their rights. It serves as a required safeguard that obligates the facility to provide a valid reason for the transfer, information on bed-hold status, and clear instructions on how to appeal the transfer decision, including access to an independent advocate. 1) Review of Resident #2's medical record on 4/30/26 revealed the resident was transferred to the hospital on 3/20/26. Further review of the medical record failed to reveal documentation to indicate the required transfer notice information was provided to the resident or the responsible representative. On 4/30/26 at 12:45 PM surveyor reviewed the concern with the Director of Nursing (DON) that the transfer notice was not found in the medical record for the resident's 3/20/26 hospital transfer. The DON then indicated she would check the medical record. On 4/30/26 at 1:12 PM surveyor reviewed documentation provided by the DON in regard to the 3/20/26 transfer to the hospital, which included a Hospital Transfer Form. Review of the additional documentation provided, including the Hospital Transfer Form, failed to reveal documentation to indicate the required transfer notice information was provided to either the resident or the responsible representative. On 4/30/26 at 1:24 PM the DON and Regional Nurse #9 confirmed that the transfer notification information was not being provided. 2). On 5/01/26 at 11:54 AM, the surveyor conducted a medical record review of progress notes for Resident #105 and identified documentation dated 3/27/26 indicating the resident was transferred to the emergency room for generalized weakness and a critically low sodium level based on laboratory results. A second note dated 3/27/26 indicated that the resident's family member was notified of the transfer. During this medical record review, the surveyor was unable to find evidence that a written transfer notice had been provided to the resident or representative. The surveyor requested the facility provide evidence that a written transfer notice was issued. On 5/01/26 at 12:09 PM, the Nursing Home Administrator (NHA) provided a bed-hold policy signed by a family member on 3/27/26; however, no transfer notice was included. The surveyor again requested the transfer notice documentation. On 5/01/26 at 12:15 PM, the Director of Nursing (DON) and NHA provided a transfer packet; however, review of the packet revealed that it did not contain a written transfer notice. On 5/01/26 at 12:26 PM, the DON confirmed that a written transfer notice had not been provided to the resident or representative. The DON further stated that the facility had reviewed the regulatory requirements and acknowledged that prior documentation provided to residents did not meet regulatory guidelines, and that changes were being implemented to ensure compliance going forward.

Based on observation, record review, and staff interview, the facility failed to ensure medications were available for administration and failed to administer medications as ordered for 3 (Resident #103, Resident #49, and Resident #32) of 4 Residents observed during a medication pass. This observation of medication administration revealed 3 errors out of 26 opportunities, for an error rate of 12%.The findings include: On 4/30/26 at 9:35 AM, a medication administration observation was initiated on the first floor with Staff #3, a Registered Nurse. Residents observed included Resident #13, Resident #32, Resident #103, and Resident #49.During the medication pass, the following medications were not administered as ordered:Resident #103:Peridex Mouth/Throat Solution 0.12% (Chlorhexidine Gluconate), 15 ml by mouth twice daily for oral hygiene. Staff #3 stated the medication was not available and that the pharmacy had been notified of the refill request.Resident #49:FLUoxetine HCl Oral Capsule 10 mg, give 3 capsules by mouth one time a day for depression.Staff #3 stated the medication was not available. Review of the medical record revealed a progress note dated 4/27/26 at 8:56 AM documenting that the medication was also not administered on that date due to being unavailable.Resident #32:Clozaril Oral Tablet 25 mg, give 1 tablet by mouth in the morning for schizoaffective disorder.Staff #3 stated the medication was not administered due to the pharmacy delivery being awaited.During the observation, Staff #3 did not attempt to escalate the unavailable resident medications, obtain the medications from the unit medication room, alternative medication storage areas, or an automated dispensing system (Pyxis). The medications were not available and were not administered during the observation period. During an interview on 4/30/26 at 12:23 PM, the Director of Nursing (DON) acknowledged concerns regarding omitted resident medications.The DON stated there is a known issue with pharmacy services delivering medications to the facility. The DON further stated that while the facility maintains a supply of certain medications, including pain medications, antibiotics, and other routine medications, the medications omitted during the observation are not commonly stocked in the automated dispensing system (Pyxis).Cross-reference also to F658, F755, and F867.

Based on interviews and record review, it was determined that the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) program identified, implemented, and sustained corrective actions for a known, ongoing systemic issue involving the unavailability of ordered medications from the pharmacy provider. This failure allowed a previously identified performance deficiency to continue without the required systematic analysis or monitoring to ensure residents received medications as ordered. This was evident for 1 (Resident #11) of 2 residents reviewed for pain management and for one QAPI plan reviewed during the recertification and change of ownership survey.The findings include:QAPI is a data-driven, facility-wide system mandated to identify, monitor, and correct performance deficiencies in real time. It is not solely a periodic meeting, but an ongoing process that requires facilities to take timely, effective, and sustained systemic action when risks are identified-particularly when those risks involve essential services such as the provision of medications necessary to manage pain and other medical conditions.On 4/28/26 at 4:00 PM, the surveyor interviewed Resident #11, who reported having multiple spinal conditions that cause significant pain. When asked whether the facility effectively manages their pain, the resident stated that staff are generally timely with medication administration; however, there is an ongoing issue with the pharmacy resulting in medications not being available at times. The resident stated, I go crazy about the medications because they use a pharmacy that is always running out of medications. The resident further reported that it sometimes takes several days for medications to become available.On 4/30/26 at 1:49 PM, the surveyor interviewed the Director of Nursing (DON) and inquired whether she was aware of any issues related to medication availability. The DON confirmed that the facility has experienced ongoing issues with timely medication delivery from Pharm Script, the pharmacy provider, for at least two years. She further stated that the facility had previously been cited for this issue. According to the DON, the pharmacy had indicated plans to hire additional drivers; however, there had been little to no improvement, and the pharmacy continued to fail to fulfill resident medication orders. She stated that the facility is currently exploring transitioning to a different pharmacy provider.On 4/30/26 at approximately 2:00 PM, the Regional Nurse informed the surveyor that the facility was in the process of changing pharmacy providers to Geri Script and stated that she believed the issue had been addressed through QAPI. She further indicated that delays in implementing the change were related to a recent change in facility ownership.On 4/30/26 at 2:11 PM, the surveyor interviewed the Nursing Home Administrator (NHA) and asked whether she was aware that medications were not consistently available from the pharmacy. The NHA confirmed awareness of the issue and stated that the facility was in the process of signing a contract with a different pharmacy provider. When asked whether the issue had been investigated and monitored through the QAPI program, the NHA initially stated that she did not believe it had been addressed.At that time, the NHA independently reviewed the facility's QAPI meeting documentation and reported her findings to the surveyor. The NHA stated that the issue had been discussed in September 2025, and that in October 2025 the QAPI committee documented a plan to implement a new pharmacy provider by the end of the year.The NHA further reported that, based on her review, the issue was not carried forward for continued monitoring after October 2025, despite no evidence that the identified corrective action had been implemented or that the problem had been resolved. The NHA stated that she began working at the facility in November 2025 and confirmed that the issue was not continued under QAPI oversight following that time. She further confirmed that the transition to a new pharmacy provider had not yet occurred and confirmed that the QAPI committee failed to verify if the corrective action (changing pharmacies) was completed before removing the item from the active monitoring agenda.On 5/01/26 at 11:00 AM, the NHA informed the surveyor that the facility had initiated a contract with a new pharmacy provider, Geri Script, with an anticipated start date of July 2026.Cross-reference F755 and F759

Based on record review and interview, it was determined that the facility failed to complete and submit Minimum Data Set (MDS) assessments for residents admitted to the facility. This was evident for one (Resident #110) of one Resident reviewed for Resident assessments. The findings included:The MDS is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. The information collected drives resident care planning decisions. Within 7 days of completing a resident's MDS assessment or tracking record, the facility must encode the MDS data (i.e., enter it into the facility's MDS software). The encoding requirements are as follows: For a comprehensive assessment (Admission, Annual, Significant Change in Status, and Significant Correction to Prior Comprehensive), encoding must occur within 7 days of the Care Plan Completion Date (V0200C2 + 7 days). For a tracking record, encoding should occur within 7 days of the Event Date (A1600 + 7 days for Entry records and A2000 + 7 days for Death in Facility records). Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days)Tracking Information Transmission: For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). A record review on 4/28/26 at 3:23 PM for Resident #110 showed that the Resident was admitted to the facility on [DATE]. The continued review failed to show a completed entry tracking and an admission MDS record for Resident #110 in the facility's electronic health record.A follow-up review on 5/4/26 at 8:47 AM contained an Entry tracking dated 4/3/26, completed and transmitted on 4/30/26, which was 20 days late for encoding and 13 days for transmission. Further review revealed an admission MDS for Resident #110, dated 4/7/26 and signed as completed on 4/8/26, in Section V0200C2. The MDS should have been encoded by 4/15/26, and the data transmitted electronically on 4/22/26. However, continued review showed that the MDS data was entered by staff #8, an MDS Coordinator, into the facility's MDS software on 4/30/36, 22 days after V0200C2 was completed and 8 days late for transmission.During an interview on 5/4/26 at 10:10 AM, staff #8 stated that the facility was undergoing a change of ownership and, as a result, did not have access to the facility's MDS software from April 1-10. Staff #8 said she completed the Entry tracking on paper on 4/4/26 and the admission MDS on 4/8/26. However, she did not enter the data into the facility's MDS software on April 11, when access became available. Staff #8 confirmed that both Resident #110's Entry tracking and admission MDS were encoded and transmitted late.

Based on record review and interviews, it was determined that the facility failed to ensure that a resident had a personalized, resident-specific care plan. This was evident for 1 (Resident #78) of 1 resident reviewed during a communication and sensory investigation.The findings include:Personalized care plans in long-term care are essential to ensure that each resident's unique physical, emotional, cognitive, and communication needs are identified and addressed. Individualized care planning promotes safety, dignity, and effective communication, particularly for residents with cognitive impairment, behavioral concerns, and language barriers.On 4/28/26 at 10:40 AM, during the initial screening process, the surveyor attempted to interview Resident #78. The resident was observed speaking a language that appeared to be a mix of Italian and Spanish, which made it difficult for the surveyor to effectively communicate with the resident. The surveyor also observed that there was no call bell present in the resident's room, limiting the resident's ability to independently request assistance.On 4/28/26 at 3:23 PM, the surveyor conducted a review of Resident #78's care plan. The care plan failed to identify the resident's primary language and did not include individualized interventions to guide staff on how to effectively communicate with the resident. There was no documentation explaining the resident's communication needs or preferences.Additionally, the care plan failed to address the absence of a call bell in the resident's room. There were no interventions, rationale, or alternative measures documented to ensure the resident's safety and ability to summon assistance despite the lack of a call bell.The care plan did include a general intervention related to use of a language line; however, this intervention was not individualized to the resident, as it failed to identify the resident's language. It read in part:[Resident #78] has a communication problem Date Initiated: 08/14/24 Revision on: 09/02/24Press 1 - FOR SPANISH,Press 2 - FOR ALL OTHERS AND CLEARLY STATE THE LANGUAGEPress 0 - IF YOU DON'T KNOW THE LANGUAGEThis intervention lacked resident-specific direction and did not provide staff with clear guidance on how to effectively communicate with Resident #78.On 4/30/26 at 10:56 AM, the surveyor conducted an interview with the Director of Nursing (DON). The DON stated that Resident #78 has dementia and a history of behavioral concerns, including self-inflicting behaviors (banging head) and expressed suicidal ideation without a specific plan. The DON further stated that the resident speaks Spanish and very little English. She indicated that staff utilize a language line, Google Translator, and Spanish-speaking staff to communicate with the resident.When asked about the absence of a call bell, the DON stated that it had been removed due to the resident's behavioral concerns and suicidal ideation.The surveyor asked whether these communication needs, behavioral risks, and the removal of the call bell were reflected in the care plan. Upon review, the DON acknowledged that the care plan did not include the resident's primary language, did not reflect the removal of the call bell, and did not include interventions for increased monitoring or alternative methods for the resident to request assistance. The DON further acknowledged that care plans are expected to be resident-specific and individualized.On 4/30/26 at 11:15 AM, the surveyor discussed these concerns with the Nursing Home Administrator, who confirmed that care plans are required to be individualized and resident specific.

Based on medical record review and interviews, it was determined that the facility failed to hold care plan meetings. This was evident for 1 (Resident #37) of 3 residents reviewed for care planning.The findings include:Care plan meetings are required to be held at least quarterly following the completion of a Comprehensive or Quarterly Minimum Data Set (MDS) Assessment.An MDS assessment is a federally mandated, standardized clinical tool used in Medicare/Medicaid-certified nursing homes to assess a resident's functional, cognitive, and physical health status. It serves as the foundation for comprehensive, person-centered care planning by identifying clinical conditions and risk factors (such as pain, falls, or decline in function) that must be addressed through individualized interventions.On 4/28/26 at 2:25 PM, the surveyor interviewed Resident #37 regarding participation in care plan meetings. Resident #37 stated that they might attend care plan meetings. When asked if meetings were held to discuss their preferences and overall care, the resident stated that discussions sometimes occur regarding medications but not regarding their preferences.On 4/30/26 at 9:59 AM, the surveyor conducted a record review of Resident #37's care plan documentation. Review of the care plan meeting sign-in sheets revealed that the most recent documented care plan meeting occurred on 12/4/25. No additional documentation was identified to evidence that a care plan meeting had been conducted since that date. Further review revealed that an MDS assessment was completed and submitted in February 2026; however, there was no evidence that a care plan meeting was conducted within the required timeframe following completion of this assessment.On 4/30/26 at 10:29 AM, the surveyor conducted an interview with the facility Social Worker, who stated that she has worked in the facility since May of 2024 and is responsible for scheduling all care plan meetings. When asked if she was familiar with Resident #37, she confirmed that she was and stated that the resident and the resident's sister typically attend care plan meetings. At the request of the surveyor, the Social Worker reviewed the resident's care plan meeting notes and associated documentation due to the surveyor's inability to locate evidence of a recent meeting.Upon review, the Social Worker confirmed that a care plan meeting had not been conducted since 12/4/25. She stated that it appeared that the February 2026 MDS assessment had been completed earlier than expected and, as a result, was not captured on her scheduling calendar, leading to the failure to schedule and conduct the required care plan meeting. She further stated that a meeting would be scheduled immediately.

Based on observation, record review, and staff interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by failing to administer medications as ordered for 3 (Resident #103, Resident #49, and Resident #32) of 4 residents observed for medication administration during the annual recertification survey. The findings include: On 4/30/26 at 9:35 AM, a medication administration observation was initiated on the first floor with Staff #3, a Registered Nurse. Residents observed included Resident #13, Resident #32, Resident #103, and Resident #49.During the medication pass, the following medications were not administered as ordered:Resident #103:Peridex Mouth/Throat Solution 0.12% (Chlorhexidine Gluconate), 15 ml by mouth twice daily for oral hygiene. Staff #3 stated the medication was not available and that the pharmacy had been notified of the refill request.Resident #49:FLUoxetine HCl Oral Capsule 10 mg, give 3 capsules by mouth one time a day for depression. Staff #3 stated the medication was not available. Review of the medical record revealed a progress note dated 4/27/26 at 8:56 AM documenting that the medication was also not administered due to being unavailable on that date. Resident #32:Clozaril Oral Tablet 25 mg, give 1 tablet by mouth in the morning for schizoaffective disorder.Staff #3 stated the medication was not administered due to awaiting pharmacy delivery.During the observation, Staff #3 did not attempt to obtain the medications from the unit medication room, alternative medication storage areas, or an automated dispensing system (Pyxis). The medications were not available and were not administered during the observation period.On 4/30/26 at 12:23 PM, during an interview with the Director of Nursing (DON), they acknowledged concerns regarding omitted resident medications.The DON stated that this was a known issue with pharmacy services delivering medications in a timely manner to the facility. The DON further stated that while the facility maintains a supply of certain medications, including pain medications, antibiotics, and other routine medications, the medications omitted during the observation are not commonly stocked in the automated dispensing system (Pyxis). On 4/30/26 at 12:30 PM, there was no evidence that the facility implemented alternative measures to ensure residents received prescribed medications as ordered.Cross-reference also to F755, F759, and F867.

Based on interviews and record reviews, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers. This was evident for one (Resident #23) of five residents reviewed for ADL. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions.An interview with Resident #23 on 4/30/26 at 10:45 AM indicated that he/she had not received a shower in 2 years and wanted to shower regularly. A record review for Resident #23 on 4/30/26 at 10:47 AM included an MDS assessment dated [DATE], which indicated that Resident #23 did not walk and relied on staff for most of his/her self-care needs.A review of the shower schedule for the nursing unit where Resident #23 resided showed that the Resident was scheduled for showers on Wednesdays and Saturday evenings, totaling 8 showers per month.A follow-up review of the GNA (geriatric nursing assistant) shower documentation for Resident #23 from December 2025 to April 30, 2026, was completed. The review documented one RR (Resident refused shower) and four bed baths (washing the Resident in bed) in December; four bed baths in January; five bed baths in February; seven bed baths in March; and five bed baths in April. The review did not indicate that Resident #23 was consistently offered 2 showers per week.During an interview on 5/1/26 at 11:00 AM, the director of nursing (DON) reported that Resident #23 was to be offered showers twice a week by the staff. If the Resident refused the showers, the nursing assistant was to notify the nurse, and the Resident's refusal was to be documented. The DON further stated that Resident #23 consistently refused his/her showers. However, the interview provided no evidence that the Resident consistently refused his/her showers.In a subsequent interview on 5/1/26 at 11:24 AM, the DON said she would provide education to staff if needed to ensure that Resident #23 received his/her showers.

Based on interviews and medical record reviews, it was determined that the facility failed to ensure that residents received medications and treatments as ordered. This was evident for one (Resident #11) out of two residents reviewed for pain management and for 1 (Resident #37) of 1 resident reviewed for dialysis.The findings include:1). On 4/28/26 at 4:00 PM, the surveyor interviewed Resident #11, who reported having multiple spinal conditions that cause significant, ongoing pain. When asked if the facility effectively managed their pain, the resident stated that they do not always receive their medications as ordered.On 4/30/26 at 1:37 PM, the surveyor reviewed Resident #11's March 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR). The review revealed multiple dates where there was no documentation to indicate that ordered medications and treatments were administered, including the following:3/5/26:Vital signs monitoring3/12/26:AspirinLidocaine patches (four separate orders)MirtazapineTizanidine3/13/26:Voltaren3/22/26:VoltarenBiofreezeLidocaine patches (four separate orders)GabapentinMonitoring for painScreening for respiratory or COVID-19 illness signs and symptomsOxycodone3/23/26:Screening for respiratory or COVID-19 illness signs and symptoms3/28/26:Oxycodone3/31/26:AtorvastatinVoltarenLidocaine patches (four separate orders)MultivitaminPantoprazoleSenokotVitamin CFerrous sulfateFluticasone propionateMonitoring for signs and symptoms of anxietyMonitoring for signs and symptoms of side effects of anticoagulant therapyMonitoring for side effects of antidepressant therapyMonitoring for painWear back brace when out of [NAME] 4/30/26 at 1:49 PM, the surveyor interviewed the Director of Nursing (DON), who confirmed awareness of gaps in documentation and stated that when documentation is absent, it indicates that the medications or treatments were not provided. The DON reported that agency staff are often responsible for these occurrences, stating that efforts are made to contact them for clarification or late documentation; however, most do not return her call, and they are subsequently placed on a do not return list. She acknowledged that this is concerning. On 5/1/26 at approximately 4:30 PM, the surveyor discussed concerns with the Nursing Home Administrator (NHA) regarding residents not receiving ordered medications and treatments. The NHA acknowledged that this is a concern.2). Dialysis is a life-sustaining treatment that acts as an artificial kidney to filter waste, toxins, and excess fluid from the blood when a person's kidneys have failed. This treatment prevents the harmful buildup of waste products in the body and assists with regulating blood pressure.Adherence to the full medical treatment plan, including prescribed medications and treatments, is essential, as dialysis replaces only a portion of normal kidney function. Medications are necessary to control blood pressure, manage anemia, and reduce excess phosphorus levels, which dialysis alone cannot adequately regulate. Failure to follow the prescribed regimen can result in serious complications.On 4/28/26 at 2:13 PM, Resident #37 reported to the surveyor that they have kidney failure and attend dialysis treatments three times per week.On 4/30/26 at 11:53 AM, the surveyor conducted a record review of Resident #37's care plan, which confirmed diagnoses of renal failure and end-stage kidney disease requiring dialysis three times weekly. The care plan included multiple interventions aimed at managing the resident's chronic condition.Further review of Resident #37's April 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that ordered medications and treatments were not consistently administered as prescribed, including:-Hydralazine HCl Oral Tablet 25 mg - ordered to be administered every 8 hours for hypertension, including on dialysis days, with instructions to notify the physician if blood pressure is low (Start Date: 08/29/2025 at 1400).Missed doses were identified on 4/20/26 and 4/25/26.-Dialysis shunt assessment - ordered every shift to assess for the presence of a thrill (palpated) or bruit (auscultated), with instructions to notify the physician if absent (Start Date: 04/30/2025 at 0630).Assessments were not documented on 4/6/26, 4/8/26, and 4/20/26.On 4/30/26 at 12:11 PM, the surveyor conducted an interview with the Director of Nursing (DON), who confirmed that Hydralazine was not administered on 4/20/26 and 4/25/26, and that the dialysis shunt was not assessed on 4/6/26, 4/8/26, and 4/20/26. The DON acknowledged that these omissions are a concern.On 5/1/26 at approximately 4:30 PM, the surveyor discussed concerns with the Nursing Home Administrator (NHA) regarding the failure to administer ordered medications and treatments to residents. The NHA acknowledged that this is a concern.

Based on observation, record review, and interview, the facility failed to ensure implementation of physician-ordered pressure-relieving interventions and proper functioning of a pressure-reducing device for 1(Resident #47) of 1 residents reviewed for pressure ulcer care.The findings include: On 4/28/26 at 11:05 AM, during the surveyor's observation of the unit, Resident #47 motioned for the surveyor to enter their room from the hallway.Upon entering, the resident's call bell was not within reach and could not be located.On 4/28/26 at 11:08 AM, the surveyor observed that Resident #47 was lying on a pressure-reducing air mattress that was actively alarming, with a weight setting of 1000 pounds. At that time, Resident #47 stated to the surveyor that they were in pain. The mattress was deflated, and the resident appeared to be lying on the bed frame.Due to the absence of an accessible call bell, the surveyor activated the empty bed call bell to alert staff.On 4/28/26 at 11:18 AM, Staff #6, a Registered Nurse, entered the room in response to the call. The surveyor informed Staff #6 that Resident #47 had motioned for assistance, and the resident's call bell could not be located.On 04/28/2026 at 11:20 AM, Staff #6 located the resident's call bell behind the head of the bed, retrieved it, and secured it to the resident's blanket, making it accessible. Staff #6 also silenced the alarming pressure-reducing air mattress. The surveyor asked Staff #6 if Resident #47 weighed 1000 pounds, as displayed on the mattress setting. Staff #6 did not provide a response.On 4/28/26 at 11:30 AM, a record review revealed Resident #47 had diagnoses including, but not limited to, a Stage 3 pressure ulcer of the sacral region. Review of physician orders revealed an order dated 2/18/25 for an Air mattress to the bed, with settings per the manufacturer's guidelines. Every shift. At the time of observation, the mattress was not set in accordance with manufacturer guidelines, as evidenced by an inappropriate weight setting, and the device was actively alarming without timely correction, indicating the facility failed to ensure proper implementation and monitoring of a physician-ordered pressure-relieving intervention for a resident who had a known pressure ulcer.On 4/30/26 at 12:30 PM, during an interview with the Director of Nursing, they acknowledged the concern regarding the failure related to pressure ulcer prevention for Resident #47.

Based on interviews and record reviews, it was determined that the facility failed to ensure that ordered medications were available for dispensing to residents. This was evident for 1 (Resident #11) of 2 residents reviewed for pain management.The findings include:On 4/28/26 at 4:00 PM, the surveyor interviewed Resident #11, who reported having multiple spinal conditions that cause significant pain. When asked whether the facility effectively manages their pain, the resident stated that staff are generally timely with medication administration; however, there is an ongoing issue with the pharmacy resulting in medications not being available at times. The resident stated, I go crazy about the medications because they use a pharmacy that is always running out of medications. They further reported that it sometimes takes several days for medications to become available.On 4/30/26 at 1:37 PM, the surveyor conducted a record review of the Resident #11's February, March, and April 2026 Medication Administration Records (MARs) and identified multiple gaps in documentation of medication administration on various dates. The surveyor was unable to determine the reason for these gaps based on the record review.On 4/30/26 at 1:49 PM, the surveyor interviewed the Director of Nursing (DON) and inquired whether she was aware of any issues related to medication availability. The DON stated that the facility has experienced ongoing issues with timely medication delivery from Pharm Script (pharmacy provider) for at least two years. She further stated that the facility had previously been cited for this issue and had requested that the pharmacy submit its portion of the plan of correction. According to the DON, the pharmacy had indicated plans to hire additional drivers; however, there had been little improvement, and the pharmacy continued to fail to fulfill resident medication orders. She stated that the facility is currently exploring transitioning to a different pharmacy provider.The surveyor asked the DON what nursing staff are instructed to do when medications ordered are not available. The DON stated that nurses are instructed to document a 9 on the MAR, indicating that the medication was not administered, and to include a rationale, such as the medication being unavailable or out of stock. She further stated that nurses are expected to follow up by contacting the pharmacy. When asked whether residents receive their medications during these periods of unavailability, the DON stated that they do not receive the medication until it becomes available.The DON clarified that the previously identified gaps in MAR documentation represent a separate issue (cross-reference F684) but confirmed that medication unavailability has impacted Resident #11. As an example, the DON provided documentation showing that on 4/25/26, the resident did not receive the ordered medication Tizanidine, which was recorded as a 9 on the MAR with the notation Out of medication/not available.On 4/30/26 at 2:11 PM, the surveyor interviewed the Nursing Home Administrator (NHA), who confirmed awareness of ongoing issues with the pharmacy's failure to consistently deliver ordered medications. The NHA stated that the facility is in the process of transitioning to a new pharmacy provider (the transition was supposed to take place at the beginning of the year). On 5/01/26 at 11:00 AM, the NHA informed the surveyor that the facility had initiated a contract with a new pharmacy, Geri Script, with an anticipated start date of July 2026.Cross-reference F759 and F867

Based on record review and interviews, it was determined that the facility failed to ensure that physicians provide a clinical rationale for not implementing pharmacist recommendations. This was evident for 1 (Resident #113) of 5 residents reviewed for unnecessary medications.The findings include:A pharmacist medication review (Medication Regimen Review or MRR) is a monthly safety evaluation required by federal regulation for nursing home residents. It involves a comprehensive review of a resident's medications by a licensed pharmacist to ensure each medication is necessary, effective, and free from unnecessary risk. When a pharmacist identifies potential concerns, recommendations are made to the attending physician for review and consideration. Federal regulations require that when a physician does not accept or implement these recommendations, a documented clinical rationale must be provided to support that decision.On 4/29/26 at 3:24 PM, the surveyor performed a record review of Resident #113's pharmacy recommendations from January 2026 through April 2026 and identified the following:On 4/13/26, a note titled Recommendations to the Attending Physician/Provider stated: [Resident #113] is receiving multiple medications with anticholinergic effects. Anticholinergic burden is the cumulative effect of medications that block acetylcholine. Higher burden is associated with cognitive decline, delirium, and behavioral symptoms, functional decline, and falls and increased mortality and hospitalization. Please review the medications below for possible dose reduction or alternatives with less cholinergic effects.The pharmacist identified the following medications:TrazodoneMeclizineHydroxyzineDicyclominePRN (as needed) BenadrylThe physician (MD #10) declined the recommendation to reduce dosages or consider alternatives. The documentation stated only MD not in agreement, with no clinical rationale provided.Further review revealed a second pharmacist recommendation dated 4/23/26 stating that Resident #113 was receiving two statins, pravastatin and simvastatin, and recommending discontinuation of one due to duplicate therapy.On 4/28/26, the physician response again documented only MD not in agreement, with no supporting rationale provided.Subsequent review of Resident #113's Medication Administration Record (MAR) showed that as of 4/29/26, the resident continued to receive Trazodone, Meclizine, Hydroxyzine, Dicyclomine, Benadryl, Pravastatin, and Simvastatin despite the pharmacist's recommendations and without documented clinical justification for declining those recommendations.On 4/29/26 at 3:30 PM, the surveyor interviewed the Director of Nursing (DON) regarding the process followed when a physician disagrees with pharmacist recommendations. The DON stated that she writes MD not in agreement and then files it. When asked about the requirement for physicians to document a rationale when declining pharmacist recommendations, she stated that she was not aware of this requirement and added that some doctors don't like to be questioned. She confirmed that the responses for Resident #113 consisted of MD not in agreement without additional explanation documented.On 4/29/26 at 4:02 PM, the surveyor interviewed the Nursing Home Administrator regarding concerns that physician responses to pharmacist recommendations did not include documented rationale. The Administrator acknowledged that this was concerning and stated that the issue would be brought to the Medical Director for awareness and follow-up.On 5/21/26 at 4:30 PM, the surveyor reviewed the facility policy and procedure titled Medication Regimen Review, Policy Number NS 1218-01, revised 9/23/19. The policy under Attending Physician Responsibilities states, If there is to be no change in the medication, the attending physician must document his/her rationale in the resident's medical record. The policy further states, If the attending physician fails to address the irregularity in a timely manner, the DON will escalate the concern to the Medical Director.

Based on observations, record review, and interviews, it was determined that the facility failed to serve residents meals that reflected their preferences. This was evident in one out of two kitchen observations during the survey.The findings include:During an observation of the facility's Lunch tray line service on 4/30/26 at 1.15 PM, the surveyor requested a test tray as the last tray was being prepared. The tray included a meal slip for Resident #75, indicating that the Resident was on a regular diet and was to receive double portions of the entree. The Resident was to be served Italian sausage, 1/2 cup of sauteed spinach with garlic, 1/2 cup of Parmesan noodles, 1 buttered dinner roll, margarine, spiced peaches, 4 oz yogurt, and 8 oz fruit punch.An inspection of the tray revealed Italian sausage, sauteed spinach, Parmesan noodles, buttered dinner roll, margarine, spiced peaches, and 8 oz of fruit punch. However, the kitchen failed to provide Resident #75 the 4-oz yogurt as indicated on the meal slip. A record review later that day for Resident #75 contained a dietitian's note dated 1/9/26 that stated that Resident #75 requested that [he/she] no longer receive double portions of entrees and breakfast meats. Change noted in diet order and noted in Meal Tracker. However, earlier observations of Resident #75's lunch meal slip noted that he/she continued to receive double portions of entree.The review also included another dietitian's note dated 1/15/26 that recorded that Resident #75's Food preferences updated per [patient] request. [He/she] wants yogurt with meals. Changes noted in Meal Tracker. However, earlier observation of Resident #75's lunch tray did not show that he/she received yogurt.In an interview on 4/30/26 at 2:24 PM, the surveyor asked the dietary manager about Resident #75's double-portion order on the meal slip and stated that his staff had grabbed the wrong tray for Resident #75.

Based on resident interviews, observation, and staff interviews, it was determined that the facility failed to serve residents meals that were appetizing in appearance and at the appropriate temperature. This was evident for 1 of 2 kitchen observations. The findings include:During the initial screening of the survey on 4/28/26, Residents #26, #37, #10, #82, and #84 reported that the facility's food was served cold and tasted bland and terrible.An observation of the kitchen on 4/30/26 at 11:54 AM revealed that Staff #11 (Cook) was preparing food for lunch. An inspection of the steam table revealed that the cook had begun adding items before the surveyor arrived. Sausage and dinner rolls were on the steam table, and during the observation, spinach and parmesan noodles were added. Before preparing the trays to be sent to the units, staff #36 failed to check the temperatures of the food items on the steam table to determine the holding temperatures of the hot foods.During continued observation on 4/30/26 at 1.15 PM, the surveyor requested a test tray as the last tray was being prepared. The tray had a meal slip for Resident #75. The slip read that the Resident was on a regular diet and was to have double portions of the entree. The Resident was to be served Italian sausage, 1/2 cup of sauteed spinach with garlic, 1/2 cup Parmesan noodles, 1 buttered dinner roll, margarine, spiced peaches, 4 oz yogurt, and 8 oz fruit punch.The surveyor tasted each food item on the plate: the Parmesan noodles were dry, and the sauteed spinach was bland and flavorless. The sausages were 83.4 degrees F, and the spinach was 114.6 degrees F. In a follow-up interview, the dietary manager indicated that the acceptable holding temperature for hot foods on the tray line should be 135degrees F and verbalized understanding of the concern.

Based on observations and record review, it was determined that the facility failed to store food in accordance with professional standards. This was evident in 1 of 2 observations of the facility's kitchen during the recertification survey.The findings include:An initial tour of the facility's kitchen with the staff #12, dietary manager, on 4/28/26 at 8:52 AM revealed the following:- An observation of the walk-in freezer noted 3 slices of chicken patty in a zip-lock bag, with no label of when it was opened or the use-by date. Staff said, I got you, and added, I will just trash it.- An Observation of the facility's walk-in refrigerator revealed the following:-3 slices of bologna in a zip-lock bag; it had no label indicating when it was opened or its use-by date.-chunks of pineapple in a container with a label that stated, use by 4/22. Staff indicated that the labeling was a mistake. He said the date on there was the date it was prepared; however, it lacked an expiration date.-Butter scotch pudding labeled use by 4/25. Staff said it was a mistake and that the date was the opening date, not the use-by date, but it lacked a use-by date.-Prepared brown Beans with a label that read use-by 4/18. Staff said it was not supposed to be a use-by date; it should have been the prepared date, and it should have still had a use-by date.-Pureed chicken with no label of the prepared date or use-by date, staff said, I'm going to dump it in the trash.In a follow-up interview with Staff #12, he verbalized understanding of the concern about not labeling food items. He said he would address the concerns.

Based on medical record review, observation and interview it was determined that the facility failed to ensure staff maintained physician ordered enhanced barrier precautions when providing care. This was found to be evident for one (Resident #7) out of one resident reviewed for tube feeding.The findings include: Review of Resident #7's medical record revealed the resident received medications and feedings via a feeding tube. A feeding tube refers to a medical device used to provide liquid nourishment, fluids and medications by bypassing oral (by mouth) intake. Feeding tubes can also be called enteral tubes, PEG tubes or g-tubes. Review of the facility's policy for Enhanced Barrier Precautions (EBP) revealed: EBP refers to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, as well as targeted gown and glove use during high contact resident care activities. These activities include, but are not limited to, accessing/use of a feeding tube.On 5/1/26 at 8:33 AM surveyor observed Nurse #13 access the resident's feeding tube to administer three separate medications. The nurse also provided water flushes before and after each medication administration. After the medication administration the nurse cleaned the tube entry site and applied a clean gauze dressing. The nurse did not wear a gown during either the medication administration or the tube site care.On 5/1/26 at 8:53 AM further review of the medical record revealed an order, in effect since 4/25/25, to Use enhanced barrier precautions when providing hands on care or accessing the enteral tube site.On 5/1/26 at 8:56 AM surveyor asked Nurse #13 what EBP means. The nurse responded: clean your hands and use gloves for the dressing. Surveyor then asked about gown usage, to which Nurse #13 responded: that is my bad. Surveyor then observed the sign about Enhanced Barrier Precautions, which was posted outside the resident's room, with Nurse #13. The sign indicated a gown was required when providing care. Nurse #13 reported she had asked if any residents were on precautions this morning and was told no. The nurse also pointed out that there was no supply of gowns outside the resident's room.On 5/1/26 at 9:06 AM surveyor reviewed the concern with the Director of Nursing (DON) regarding the staff's failure to wear a gown while accessing the feeding tube for medication administration and providing site care. The DON reported the gowns are located on the door inside the room.

Based on observation and interview, the facility failed to ensure that a resident call system was within reach and readily accessible to meet resident needs for 1 (Resident #47) of 1 resident reviewed for call bell accessibility.The findings include: On 4/28/26 at 11:05 AM, observation on the unit revealed Resident #47 motioned for the surveyor to enter their room from the hallway.Upon entering, the resident's call bell was not within reach and could not be located. Resident #47 stated they were in pain.Due to the absence of an accessible call bell, the surveyor activated the empty bed call bell to alert staff.On 4/28/26 at 11:18 AM, Staff #6, a Registered Nurse, entered the room in response to the call. The surveyor informed Staff #6 that Resident #47 had motioned for assistance, and the resident's call bell could not be located.On 4/28/26 at 11:20 AM, Staff #6 located the resident's call bell behind the head of the bed, retrieved it, and secured it to the resident's blanket, making it accessible. Staff #6 acknowledged the surveyor's concern related to Resident #47's call bell being inaccessible. On 4/30/26 at 12:30 PM, during an interview with the Director of Nursing, they acknowledged the concern regarding the resident's call bell being inaccessible.

Based on administrative record review and staff interview it was determined that the facility staff failed to ensure that a resident was free of abuse while in the care of a Geriatric Nursing Assistant (GNA). This was evident for 1 (#2) of 1 residents reviewed for abuse. The findings include: On 2/11/26 at 12:06 PM, a review of facility reported incident, #2618494, revealed the facility had substantiated physical abuse based on resident and staff interviews. The facility investigation revealed on 9/11/25 after dinner & before 11:00 PM, during incontinence care, Resident #2 was slapped on his/her buttocks 2 times by Staff #1, Geriatric Nursing Assistant (GNA). The facility investigation documented the allegation of physical abuse was verified by the victim's statements, the repeated interviews that produced a consistent recounting of the incident, and the police confirmed the witness, Staff #2, GNA was involved to the extent that matched the alleged victim's consistent statements. As a result of the facility's investigation, Resident #1, GNA was terminated for his/her actions and reported to the Maryland Board of Nursing (MBON). The above findings were discussed with the Director of Nurses (DON) on 2/11/26 at 4:34 PM. The DON acknowledged the concerns and stated that once their investigation substantiated the abuse, Staff #1, GNA was terminated and reported to the board of nursing.

Based on administrative record review and staff interviews, it was determined that the facility staff failed to immediately report allegations of abuse to the facility administration and the state agency and failed to report the results of their investigation of an alleged incident to the State Survey Agency within 5 working days of the incident. This was evident for 1 (#2) of 1 resident reviewed for abuse. The findings include: On 2/11/26 at 12:06 PM, a review of the facility's investigation documentation for facility reported incident, #2618494 was conducted and alleged on 9/11/25, sometime after dinner and before 11:00 PM, Resident #2 was abused by Staff #1, Geriatric Nursing Assistant (GNA), and the abuse was witnessed by GNA #2, GNA. Following the incident, GNA #1 did not report the abuse and GNA #2, failed to notify the facility's administration of the witnessed abuse. The facility's self-report documented the alleged abuse was reported by Resident #2 to GNA #6 on 9/13/25 between 2:30 PM and 3:00 PM and GNA #6 then reported the abuse allegation to the facility's administration. A written statement signed by Resident #2 on 9/15/25, documented that sometime between 9/10/25 and 9/13/25, the resident thought s/he had a bowel movement (BM) and rang the call bell. GNA #1 and GNA #2 came into the room. When GNA #1 checked him/her and found out the resident had not had a BM Staff #1 said no BM, you're just playing then slapped Resident #2's bare behind 2 times. A written statement signed by GNA #2, on 9/15/25, documented s/he remembered s/he oriented with GNA #1, GNA on Wednesday (9/10/25) during incontinence care after Resident #2 was checked and had not had a BM GNA #1 slapped Resident #2 on the buttocks and said why put your light on? You don't have a BM, The failure of GNA#2 to notify the administration of the witnessed abuse of Resident #2 by GNA #1 delayed the facility's reporting to the state agency. The incident, documented as occurring on 9/11/25, was sent to the State Survey Agency, The Office of Health Care Quality (OHCQ), on 9/13/25 6:05 PM, which was greater than 2 hours after the alleged abuse was witnessed by GNA #2. In addition, further review of the facility's documentation revealed that the facility's final self-report was submitted to the State Survey Agency on 9/22/25 at 2:57 PM, which was greater than 5 working days after the incident. On 2/11/26 at 4:34 PM, the Director of Nurses (DON) was made aware of the concern with facility staff failing to report witnessed abuse which delayed the facility's reporting to the state agency and the concern with the late submission of the facility's final self-report. The DON acknowledged the concerns and offered no further comments at that time.

Based on observation, medical record review, facility documentation review and interview, it was determined the facility staff failed to prevent intimidation of a resident after the resident alleged sexual abuse resulting in psychosocial harm (Resident #5). This was evident for 1 of 4 residents reviewed for abuse during a complaint survey.The findings include: Review of facility reported incident 326592 was conducted on 8/12/25 related to Resident #5 allegation of sexual abuse by Staff #4 on 6/4/25.Review of Resident #5's medical record on 8/12/25 revealed the facility staff assessed the Resident on 6/13/25 to have a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating the Resident's cognitive function was intact.Review of the facility reported incident documentation provided by the Administrator revealed the facility reported to OHCQ (Office of Health Care Quality) on 6/4/25 Resident #5 reported at approximately 9:00 PM Staff #4 was providing perineal care and inserted a finger into the Resident's private area and asked does it feel good.Further review of the facility documentation related to the incident revealed witness statements including from Staff #7 who was Resident #5's assigned nurse on 6/4/25. Staff #7 statement stated Resident #5 called the nurses station and said he/she wanted to talk to the nurse. Staff #7 stated she immediately went to his/her room and the Resident said he/she had been sexually assaulted by a male GNA (geriatric nursing assistant). Staff #7 stated she called assigned GNA (Staff #4) for the Resident to confirm if Staff #4 was the one. Resident stated Staff #4 put his finger into the Resident's private area during care and asked the Resident if he/she is feeling good. Staff #7 stated they left the Resident's room and she immediately called the ADON (Assistant Director of Nursing). During interview with the Director of Nursing (DON) on 8/12/25 at 9:45 AM, the DON stated she received a call from the ADON on 6/4/25 at 9:20 PM that Resident #5 reported he/she was sexually assaulted by an agency GNA (Staff #4). The DON stated she instructed the ADON to go to the facility and the ADON lives within 5 minutes from the facility. The DON stated she then left for the facility and while driving to the facility the DON called 911. The DON stated 911 told her to ensure the alleged perpetrator remained at the facility. The DON then called Staff #7 and told her to not allow Staff #4 into any resident rooms, have Staff #4 stay at the nurse's station and to keep an eye on him. The DON stated when she arrived she immediately went to check on Resident #5 to make sure he/she was okay and shortly after that the police arrived. The DON stated she went with the police when they interviewed Staff #4. The DON stated when the police were questioning Staff #4 he initially denied the allegation but refused to answer any questions, refused to write a statement and requested a lawyer. The DON stated the police then left the facility with Staff #4. The DON stated Staff #4 was an agency GNA working 3-11 PM on 6/4/25 and this was his first shift in the facility. The DON stated after the incident Staff #7 was written up for bringing Staff #4 back into Resident #5's room after an allegation of sexual abuse. The Surveyor requested the write-up of Staff #7.During interview with Staff #7 on 8/12/25 at 11:45 AM, Staff #7 stated Resident #5 called the nurse's station and asked to speak to the nurse. Staff #7 stated she went immediately to the Resident's room and the Resident alleged he/she was sexually abused by a male GNA but did not know the GNA's name. Staff #7 stated at that time Staff #4 was at doorway, so she brought Staff #4 into room for the Resident to identify if Staff #4 was the perpetrator. She asked Resident #5 if Staff #4 was the one and the Resident confirmed. Staff #4 said what? and Staff #7 told Staff #4 in front of Resident #5 that the Resident said you sexually assaulted him/her. Staff #7 stated she called and reported the incident to the ADON. Staff #7 stated she was written up for allowing Staff #4 back into Resident #5's room after the allegation.During interview with the DON on 8/12/25 at 12:17 PM the DON stated the ADON was currently out on leave and unavailable for interview. During interview with Resident #5 on 8/12/25 at 1:09 PM, Resident #5 stated he/she put on his/her call bell to be changed and when the GNA came in room he got a washcloth and was cleaning him/her up. The Resident stated he was taking a long time and said he/she never had someone wash me up like that before. The Resident stated I could feel him put a finger inside of me and he pushed my leg up and asked me if it felt good. I didn't know what to say or do. He eventually left and I immediately called the desk and asked for someone to come to my room. When the nurse (Staff #7) came in, I told her what happened. She brought in the GNA (Staff #4) and had me identify him and tell the whole thing over in front of him. Resident #5 said when he/she saw him (Staff #4) come in the room he/she said why is he here, I don't want him here, I covered my eyes, I did not want to see him again. At that time the Surveyor observed the Resident place both his/her hands over his/her eyes. The Resident stated Staff #4 was crying and telling Resident #5 he was going to lose his job. After the incident Resident #5 stated he/she was afraid he was going to do this to someone else. Resident #5 said they had me talk to the Counselor and she put me on medication (Clonazepam) twice a day to help with my anxiety. Resident #5 stated I do have anxiety but this incident increased my anxiety and is triggering it more. Resident #5 stated he/she had been seeing the Counselor often but would like to have more scheduled counseling. The Surveyor told the Resident that they would notify the DON of his/her request.During interview with the DON on 8/12/25 at 1:50 PM, the DON stated when she arrived at the facility the ADON was standing by the nurse's station and Staff #4 was sitting at the nurse's station.During a second interview with Staff #7 on 8/12/25 at 2:09 PM, Staff #7 was asked what the DON said when she called her on 6/4/25. Staff #7 stated she couldn't remember what the DON said to her. Staff #7 was asked again what was said to Resident #5 when Staff #4 was in the room. Staff #7 stated I asked the Resident was he the one, and the Resident said yes. I told Staff #4 the Resident says you sexually abused him/her. Staff #4 said, no. The Resident told us what Staff #4 did. Resident #5 said I don't want him in here. On 8/12/25 at 2:25 PM the DON provided the Surveyor with the write up of Staff #7. At that time the DON was advised the Resident was requesting more counseling. The DON stated she would advise the Counselor (Staff #12). Review of the Employee Corrective Action Form for Staff #7 revealed it stated Staff #7 took alleged perpetrator back into resident room, making resident feel threatened, vulnerable and compromising his/her safety. It was signed by Staff #7 and DON on 6/9/25. During a second interview with Resident #5 on 8/13/25 at 10:25 AM, the Resident was asked how he/she felt when Staff #4 was brought back into room. Resident #5 stated I was mad, upset and uncomfortable. She (Staff #7) made me tell the whole thing in front of him (Staff #4) while he is crying and begging me about his job. Review of Resident #5's medical record on 8/13/25 revealed the Resident was seen by Staff #12 on 6/5/25. Staff #12 documented: Facility requested consultation related to increased anxiety and fearfulness after an alleged incident. Resident is currently exhibiting symptoms of tearfulness, feelings of hopelessness and anxiety related to recent traumatic event and flashbacks. The symptoms are noted to be intermittent and have worsened since last visit. The Resident alleged the GNA inserted his finger into him/her during peri care. The Resident demonstrates tearfulness during later conversation and expressed feeling traumatized by his/her perception of the alleged event. The Resident requests short-term medication for anxiety. Further review of Resident #5's medical record revealed the Resident was ordered Clonazepam 0.5 mg twice daily for breakthrough anxiety on 6/5/25. Further review of the Resident's medical record revealed the Resident is currently receiving Clonazepam 0.5 mg twice daily. Interview with Staff #12 on 8/13/25 at 2:00 PM, Staff #12 was asked if the incident on 6/4/25 had any effect on Resident #5. Staff #12 stated yes, prior to the incident the Resident was working on goal setting, getting out of bed and therapy. Staff #2 stated I thought the Resident was in a good place. Staff #12 stated after incident the Resident had sadness, frustration and survivor's guilt and they had been working on getting the Resident's anxiety to a manageable level and ordered the Clonazepam to help manage anxiety since the Resident had a history of anxiety but since the incident it had triggered it more. The Resident did tell Staff #12 about the GNA coming back in the room and him pleading his case to the Resident. The Resident stated he/she replays that and him begging him/her. Review of the facility's Abuse, Neglect and Misappropriation Policy (#NS-1300-03) states on Page 8: An Employee who is alleged or accused of being a party to abuse, neglect, misappropriation of property will be immediately removed from the area of resident care. Interview with DON on 8/14/25 at 10:00 AM confirmed the intimidation of Resident #5 by Staff #7 bringing Staff #4 back into the Resident's room to identify the perpetrator and retell the events after an allegation of sexual abuse on 6/4/25 resulting in psychosocial harm to Resident #5. The DON confirmed after an allegation of abuse the alleged perpetrator should be removed from all residents' care.

Based on record review, observation, and staff interview, it was determined that the facility staff failed to put measures in place to safely provide care for a resident by failing to ensure that specialty bed mattresses were properly secured on bed frames and failing to follow the specified number of staff support needed when providing care for residents. This resulted in the resident falling out of the bed and sustaining a fractured shoulder. This was found to be true for 1 of 5 (Resident #5) residents reviewed for accident hazards during the survey. The findings include: A care plan is a guide that addresses the needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. A Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care. One of the sections of the MDS is Activities of Daily Living (ADLs) which are tasks related to everyday life, (eating, bathing, dressing, toileting and transferring). The ADL score reviews each ADLs, to assess the resident's self-performance and determine the amount of staff support needed to perform each task. On 9/14/21 at 12:15 PM, during a tour on the Station 3-Unit, a resident reported to surveyors that a staff member dropped Resident #5 off the bed and broke his/her arm. A review of Resident #5's medical record was conducted on 9/14/21 at 12:15 PM. The resident was admitted to the facility with diagnoses that included a history of a [CONDITION(S)] from a motor vehicle collision that left them paralyzed on the right side of their body. Review of section G of the quarterly MDS assessment, dated 5/11/21, revealed documentation that Resident #5 had upper and lower extremity impairments on one side that required total care (assistance of 2 or more staff) for their bed mobility and transfers. Further medical record review revealed that Resident #5 had a fall on 1/21/2020. A progress note, dated 1/21/20 at 5:15 AM, indicated that Resident #5 had rolled off the bed when a GNA turned the resident to provide care. The fall resulted in a medium size hematoma to the resident's right upper forehead. A progress note, dated 1/22/20 at 10:16 AM, stated the mattress was not supported by the bedframe. Related to this fall, the care plan interventions included: Maintenance to check Resident's bed daily, initiated on 1/22/2020 and Maintenance to evaluate Resident's bed, initiated on 1/21/2020. On 9/15/21 at 2:45 PM, review of the facility's Occurrence and Occurrence Follow-up Report, dated 6/24/21, revealed that Geriatric Nursing Assistant (GNA) #23 provided morning hygiene care for Resident #5 by him/herself on 6/24/21. During the care, the GNA asked the resident to assist by turning to their side. When the resident turned, the mattress slid from off the bed and the resident fell to the floor and hit their shoulder. Further review of the medical record revealed a Nurse Practitioner's (NP# 33) note, dated 6/24/21 at 10:09 AM that indicated the resident had a left fractured shoulder requiring the provision of pain management with medication. A review of Resident #5's care plan, on 9/16/21 at 1:52 PM, revealed that care plan interventions dated 4/28/21, for Activities of Daily Living (ADL) care stated that Resident was dependent on staff for getting out of bed early in the morning and for it to be performed by night shift (total dependence on 2 staff using a mechanical lift device for transfers). On 9/16/21 at 11:08 AM, an interview was conducted with Maintenance Supervisor (staff #27). He explained that Resident #5 was in a used Bariatric (extra wide) bed when the fall occurred. The bed had support extensions that held the bed in place. However, for an unknown reason, the support springs were not there, which caused the mattress to slip off the bed on 6/24/21. During an interview conducted with Staff #27 on 9/17/21 at 11:00 AM, he stated that although the maintenance team does routine bed inspections, he had not done daily bed checks for Resident #5. However, he was unable to provide evidence that any inspections of Resident #5's mattress was done by the maintenance team since the care plan intervention was initiated on 1/21/20. An interview was conducted with the Resident #5's nightshift GNA (#23) on 9/16/21 at 6:58 AM regarding the 6/24/21 fall. GNA #23 stated that Resident #5 required total care for bed mobility, ADL care, and hygiene. They added that there was a book at the nurse's station that described the care needed for each resident on the unit. Although GNA #23 was aware that the resident required 2 staff members for the resident's bed mobility, they turned the resident without assistance from another GNA because they were able to do it on their own. However, during interviews with Resident #5's Licensed Practical Nurses (LPN #22) and LPN #2 on 9/16/21 at 7:05 AM, they indicated that there was no book as described by GNA #23 on the unit, however, it was expected that the nursing staff refer to the residents' individual care plans and the residents' Treatment Administration Records (TARs) to inform them of the type and the number of staff assistance that was needed to provide daily ADL care for residents. On 9/22/21 at 09:15 AM, the Nursing Home Administrator (NHA) and Corporate Strike Team Member (Staff #30) requested an interview with the surveyor team. During the interview, Staff #30 stated that there was an additional ADL care plan, dated 12/29/19, for Resident #5. This care plan indicated the resident required one person assistance with ADL care, however, the quarterly MDS assessment for Resident #5 that was completed 5/11/21 had documentation that the resident required total care (assistance of two or more staff) for their bed mobility.

Based on interview, documentation, and video surveillance review, it was determined the facility failed to initiate the process to allow indoor visitation of family members to residents of the facility when the opportunity following the facility's removal from their COVID-19 outbreak status. The facility did allow outside visitors, unrelated to business with the facility or residents, into the facility for a vaccination clinic. Residents watched the visitors from their rooms and emotionally expressed their sadness as they were not allowed to have their own family come into the facility for visits over the past year. Failure of the facility to recognize the resident's isolation from loved ones and friends resulted in psychosocial harm as evidenced by sadness, negative feelings, and resentment. This was evident for 6 (#8, #9, #10, #11, #12, #16) of 7 residents interviewed during a complaint survey, however, the lack of indoor visitation had the potential to affect all resident of the facility. This deficiency was cited at a scope and severity of H for the psychosocial harm experienced by multiple residents as a result of the facilities failure to allow indoor visitation. The findings include: COVID-19 (Coronavirus Disease 2019) is a disease caused by the coronavirus [DIAGNOSES REDACTED] -CoV-2. COVID-19 spreads from person to person, mainly through respiratory droplets produced when an infected person coughs or sneezes. According to the Centers for Medicare and Medicaid (CMS) September 17, 2020 Memo Ref: QSO-20-39-NH nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting have required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes. Nursing home residents have had physical separation from family and other loved ones during the COVID-19 pandemic and it has taken a physical and emotional toll on the residents. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and other expressions of distress. A 9/17/2020 Memo Reference: QSO-20-39-NH from CMS stated, Facilities should accommodate and support indoor visitation, including visits for reasons beyond [MEDICATION NAME] care situations, based on the following guidelines: a) There has been no new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing; b) Visitors should be able to adhere to the core principles and staff should provide monitoring for those who may have difficulty adhering to core principles, such as children; c) Facilities should limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time (based on the size of the building and physical space). Facilities should consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; and d) Facilities should limit movement in the facility. The memo also stated, Facilities should use the COVID-19 county positivity rate, found on the COVID-19 Nursing Home Data site as additional information to determine how to facilitate indoor visitation. Medium (5% - 10%) = Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond [MEDICATION NAME] care visits). The memo stated, facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with §483.10(f)(4)(v). For example, if a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium, a nursing home must facilitate in-person visitation consistent with the regulations. Review of the county positivity rate that was obtained from the local health department website revealed documentation that, on 1/27/21, the positivity rate was 6.64% which was in the medium category. The facility had been out of outbreak status from 1/15/21 to 1/27/21. During that time, the facility had not begun the process of allowing indoor visitations for residents, however, allowed outside visitors, not associated with the residents, to enter the building for a vaccination clinic while the residents watched. 1) Review of complaint MD 934 on 1/28/21 at 8:15 AM alleged that the facility opened their doors to family and friends of corporate owner(s) to obtain COVID-19 testing and vaccination. Interview of Staff #8 on 1/28/21 at 11:20 AM revealed that friends and family of the owner came into the building to receive COVID vaccinations. Video footage was provided to the surveyors by the NHA. Video footage of the hallways where the visitors and staff lined up and waited to receive the COVID-19 vaccination and the video footage of the lobby/receptionist area was reviewed on 2/5/21 and 2/8/21 for the recording date of 1/27/21. The lobby video footage revealed that, on 1/27/21 at 11:47 AM, (2) men entered the building. One of the men was using a walker. The other man signed in on the sign-in sheet. From 11:49:33 to 13:03:02, there were several visitors that walked through the front door and stood or sat in the lobby area. From 13:40:00 to 14:36:00, there continued to be visitors in the lobby area while physical therapy was working with a resident who was wheeling his/herself down the hallway. On 1/29/21 at 8:13 AM, an interview of Staff #10 revealed that there had not been any family visitations since the end of last year. Only 1 family member was allowed to come in. We had visitation for 3 weeks and had to stop. When asked how residents felt about not seeing family, Staff #10 stated, terrible. It's been a year. It's tough that they can't see family, can't do activities like we used to. It's miserable. Staff #10 was asked about the vaccinations on 1/27/21 and stated, People were lined up in the hall. Some were social distanced, and some were not. Staff #10 stated, There were other people here, family and friends of corporate and they were also here when the first vaccination clinic happened. Staff #10 stated that the doors to the resident's rooms were open to the hallway at the time that the people were standing in the hallway. On 1/29/21 at 10:46 AM, the NHA was asked who told her to allow the extra people to come to the facility for the COVID-19 vaccination. The NHA stated it was the Divisional Vice President (VP) of the region for the corporation (Staff #11). The NHA stated that Staff #11 called to say that people were coming into the facility. When asked if she questioned why they were coming in, she said that she did not. Interviews were conducted with multiple facility residents to determine if the facility was currently allowing in door visitation. The interviews revealed the following: A. Review of the MDS assessment that was conducted with a reference date of 11/22/20 for/of Resident #8 revealed that the resident was fully cognitively intact with an assessment score of 15/15 (Brief Interview for Mental Status). On 2/3/21 at 9:16 AM, Resident #8 was asked if he/she noticed anyone in the hallway last Wednesday (1/27/21). Resident #8 stated, There was a long line in the hallway. Resident #8 stated a lot of people, a whole lot. Resident #8 continued, I was offended because we were told there may be a possibility they would run out of vaccines and we would have to be rescheduled. I was in the hospital the first time they were offered so I was very upset. We did end up getting our shots later in the day after some of the visitors. My main objection was that I was finally told that they had a rapid test, because I was very upset. They were just walking around, and I was told they had a rapid test and they were getting their shots. I was told they were either family or friends of (name of company) and most of them came from the Levindale area and I got to thinking about it and I got angry. Because if those people are allowed to come in here after a rapid test, why can't my family, who I haven't seen since March, come in and visit me and that really upset me, and I spoke my mind about it. Resident #8 stated his/her door was open the entire time and when asked if the people in the hallway were social distanced, Resident #8 replied, Oh my God no, no way, it was a crowd. I was ticked off. I sit here and can't get out of bed and I watched. B. Resident #16 was interviewed on 2/4/21 at 11:40 AM in his/her room. When asked about family visits, Resident #16 stated that his/her family visited at the window or at the door at the end of the hallway with an intercom and that the weather sometimes limited the family visits. Resident #16 explained that a visiting area was previously set up in the facility to allow for indoor visits, but they were not allowed at the present time and could not recall how long ago the indoor visits stopped. Resident #16 stated that a tent area was set up for outdoor visits, but the weather was too cold to visit outdoors now. Resident #16 commented that he/she really enjoyed family visits but because of COVID, could not hug or kiss his/her son/daughter. Resident #16 stated, you want to be able to hug your kids at least, grandkids too. When asked how he/she felt about that, he/she went on to say It makes me feel like (expletive). I feel bad that I can't do it. As the surveyor was saying goodbye, Resident #16 commented that it was nice to have someone to visit with. Resident #16 then pointed to a photo on the nightstand and became tearful and indicated that the photo was of his/her family. Resident #16 stated, I just cry sometimes because I miss my family. C. Resident #12 was interviewed on 2/3/21 at 9:34 AM and stated, I am very sad, and I'm so upset. My son dropped off stuff at the front door and I had to elbow him and couldn't give him a kiss. No visitors allowed. The resident was asked about the visitors in the hallway last week and Resident #12 stated, They have done that a couple of times. D) Resident #9 was interviewed on 2/3/21 at 9:25 AM and stated, We can't have visitors. I like when my family comes. I miss my family. We have been told they can't come in. E) Resident #10 was interviewed on 2/3/21 at 9:29 AM and stated, We haven't had visitors in a year. I feel bad about that. F) Resident #11 was interviewed on 2/3/21 at 9:31 AM and stated, We have had no visitors and I miss my son and grandson. They are the only 2 that visit me every weekend and they are not allowed in the building because of [MEDICAL CONDITION]. Staff #9 was interviewed on 2/4/21 at 8:00 AM and was asked about visitors in the building. Staff #9 stated, friends of (name of owner), they came to the first vaccination clinic on 1/6/21. There were about 25 to 30 people. I went into the dining room and it was just filled with them. Staff #17 was interviewed on 2/4/21 at 10:30 AM and stated, It has been so long since visitors have come in to see the residents. I can't remember, but it has been so long. Staff #17 stated, We have had residents tearful and sad about not being able to see their family. The first person to come to mind is Resident #8 who was definitely tearful and sad. Staff #17 said that Resident #1 is a resident that needs a hug and that Resident #16 has bawled and has told me it is very hard not to be able to see his/her son. Staff #8 stated that Resident #11, is very close to his/her son, very, very close and has face-timed, but he/she would really like to see him, and he did visit regularly before COVID. Staff #17 stated, at this point I have no knowledge of when visitation can resume indoors. It will be up to corporate or the Governor to decide and in the meantime, we will keep with the face-time calls. Staff #17 was asked if she recalled anything about the last vaccination day, on 1/27/21, and Staff #17 stated, on Wednesday I didn't get here until 11:30 AM and there were not a lot in line when I got here, but I did see several people, 4 people that I did not know. The first vaccination I saw quite a few, at least a dozen and that was early because I was one of the first people in that very long line. Then the residents started asking me who they were. Staff #17 stated, Resident #8 told me about it. When the surveyor asked if Resident #8 was reliable, Staff #17 stated, he/she is truthful. He/she would not bend the truth to serve his/her own needs. The DON stated on 2/3/21 at 4:11 PM that she was working with the health department to start visitation back up because it had been 2 weeks since an outbreak and that she was on the phone with the health department. An interview was conducted with a nurse from the local health department (LHD) on 2/4/21 at 11:32 AM. When asked about visitation, the nurse stated that it was dependent on the facility's outbreak status. The nurse stated that the facility's last outbreak was when a staff member tested positive for COVID-19 on 12/24/20. The final closure report, # 964 outbreak, was closed on 1/14/21 with a report date of 1/15/21. They came out of outbreak status on 1/15/21 and we have had no recent phone calls asking about visitation. A second interview was conducted, on 2/4/21 at 3:46 PM, with the nurse from the LHD. The LHD nurse stated that she checked with the other health department staff members and no one had been working with the facility regarding visitation. The facility was still considered in outbreak mode on 1/6/21, the date of the first vaccination clinic, per the nurse from the LHD, however, the facility allowed visitors from the community into the building on 1/27/21 to receive the COVID-19 vaccination while denying visits from resident's family and loved ones.

Based on review of facility documentation, which included written records and video surveillance, interviews and medical record review, it was determined that facility staff verbally and physically abused residents on several occasions. Furthermore, when the first allegation of abuse was made, the facility failed to identify it as abuse and, therefore, failed to prevent further incidents of abuse by 1 staff member. The failure of the administration to recognize abusive behavior placed all residents at risk for abuse and contributed to the determination that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 11:21 AM on 1/17/2020. The facility developed a plan sufficient enough to remove immediacy which was reviewed and accepted after 6 attempts at 6:39 PM on 1/17/2020 while surveyors remained onsite. The facility obtained compliance and the Immediate Jeopardy was abated on 1/22/2020 at 1:05 PM. This was evident for 2 (#2, #1) of 10 residents reviewed for abuse. The Plan to remove immediacy that was presented to surveyors included: - Resident #1 was interviewed by the social worker and Resident #2 was assessed by licensed staff. -Appropriate disciplinary action was taken for GNA #2 and was no longer employed at the facility and the facility DON (Director of Nursing) was reporting GNA #2 to the Board of Nursing. -Facility professional licensed nursing staff completed a full body assessment on non-interviewable residents for signs of abuse. -All residents who were interviewable were interviewed by licensed professional staff regarding their treatment in the facility by GNAs during care. -Regional Director of Clinical Operations (RDCO) and staff educator began in-service to all facility staff on documenting grievances verbatim by the resident or family member. -Staff education began auditing GNAS regarding competency for obtaining a resident's weight in the wheelchair. -Facility staff were in-serviced by Staff Educator on proper behavior management and de-escalation of behavior. -Staff educator began auditing competency to GNAs to ensure proper behavior management and de-escalation procedures. -Facility removed any staff not trained on behavior management and behavior de-escalation from the schedule until trained. -All facility staff were in-serviced on Abuse Prohibition and prevention procedures, i.e. physical, mental, verbal, psychological and misappropriation. -RDCO educated the administrative staff on identifying and preventing abuse, the entire abuse policy, and de-escalation of resident behavior to ensure a safe environment. -RDCO re-educated and provided 1 to 1 in-service to Nursing Home Administrator in recognizing and identifying abuse, investigation and thoroughly completing investigations. -All facility state reportable incidents and grievances will be reviewed by RDCO and QAPI committee members for completion of thorough investigation, including employee file review, to identify patterns of behavior before submission of the final investigation for analysis and determination if substantiated or unsubstantiated -Social Services will conduct weekly abuse questionnaire audits for 3 weeks and then monthly times 3 with the results of the audits forwarded to QAPI committee for review and recommendations -The grievance officer will track and trend all grievances and report to QAPI monthly x 3 months. -RDCO will track and trend all state reportable events and ensure a thorough investigation has been conducted via review of all available information with findings submitted to the Governing body for review and recommendations monthly x 3 months. -The RDCO will oversee QAPI meetings. The findings include: 1) On 1/13/2020 at 7:29 AM, the surveyor requested from the Nursing Home Administrator (NHA) a copy of a self-reported incident related to Resident #2 that occurred in August 2019. At 7:34 AM, the NHA provided self-reported incident MD 005. The incident report revealed documentation that. on 8/12/19 at 4 PM, Family Member #9 reported to the Nursing Home Administrator (NHA) that she witnessed Resident #2 having an altercation with a care giver (GNA #2). GNA #2 was suspended pending investigation and abuse education to facility staff was initiated. The investigation documentation that was provided to the surveyors consisted of a written statement from GNA #2, a written statement from LPN #12, a document with 41 staff signatures for review of the policy Abuse, Neglect and Misappropriation with the objective to reduce the incidence of abuse, neglect and misappropriation in the facility; a grid with the name of 5 residents on the first floor that were interviewed regarding abuse, a copy of 10 employee names who took a quiz regarding patient/resident's rights for abuse and neglect; the facility policy for abuse and an employee corrective action form for GNA #2. The corrective action form was a final written warning for conduct issues, improper de-escalation of resident behavior and failure to report to supervisor in timely manner, which was issued on 8/19/19. Review of the facility's investigation revealed there was no documentation as to what the conduct issues were, no description of the resident behavior and no documentation as to what the employee failed to report in a timely manner. The facility determined that the abuse was unsubstantiated due to witness statements and interviews. Interview of Family Member #9 on 1/16/2020 at 9:34 AM revealed that she witnessed verbal and physical abuse on 8/9/19 to Resident #2. She stated, Resident #2 was walking back and forth down the hallway, was disruptive, went into a room, came out and then tried to come in the dining room where everyone was eating and when Resident #2 tried to get in GNA #2 stopped him/her. GNA #2 put her back against Resident #2 and pushed Resident #2 up against the wall. GNA #2 leaned up against Resident #2, against the wall by the doorway, and kind of restrained Resident #2 there. Resident #2 was yelling and then fell , and I went into the hallway and GNA #2 was verbally abusing Resident #2. Family Member #9 continued, Resident #2 said you raped me, and GNA #2 said, I don't want nothing to do with you something horrible. Family Member #9 continued, GNA #2 was yelling back at Resident #2. Resident #2 was on the floor and had blood on him/her and I got the other nurse. GNA #2 was obnoxious and just nasty. Family Member #9 continued, GNA #2 didn't listen to the other nurse. The other nurse (LPN #12) came out, said it was on camera and then went back to the desk. GNA #2 just left Resident #2 there and GNA #2 was yelling back at him/her. Resident #2 has dementia. Family Member #9 stated, GNA #2 is just abrupt and not very friendly. I told the NHA that she shouldn't still be there. If she is still there, I don't feel like the NHA listened to my concerns. I told them about the verbal abuse. The other nurse (LPN #12) tried to get the GNA to stop and the GNA said, I didn't do nothing, I didn't do nothing, so the other nurse didn't want to get into a verbal altercation. LPN #12 did try to help but the GNA was yelling and not responding and said I'm handling it. Family Member #9 ended by stating, GNA #2 had Resident #2 pinned up against the wall until he/she fell . Resident #2 was struggling to get away. Review of the 8/23/19 written statement from GNA #2 documented that the resident was riled up and she tried to calm Resident #2 down and direct Resident #2 to his/her room. GNA #2 documented in her written statement that Resident #2 was entering a room that he/she should not have been in and GNA #2 re-directed Resident #2 back to the hallway. The GNA's statement continued that the resident became very agitated, trying to run in the hall, pushing his/her weight against me and yelling rape. As (resident) went to grab the wall (railing) I leaned against the dining room door where Resident #2 continued to push and lean against me. While standing there preventing (resident)from falling face first, I began calling out to the nurse for assistance. (resident) got tired and dropped to the floor scraping the back of his/her left arm. I just wanted to help Resident #2 find his/her shoes, keep him/her and other residents safe. During the investigation into the facility reported incident, the State agency was given a copy of the video recording of the incident of 8/9/19 from facility staff. The video displayed GNA #2 treating Resident #2 in a rough manner. Review of the video for the incident on 8/9/19 revealed the resident was ambulating in the middle of the hallway and GNA #2 grabbed the back of the resident's pants and was restraining the resident, reaching around and putting her hand on the resident's chest to push him/her back from going forward and the resident grabbed the soiled linen cart attempting to get away from the physical restraint of GNA #2. The resident was pushing the linen cart up the hallway and GNA #2 was attempting to prevent the resident from going up the hallway. The resident stood up against the right side of the wall, next to the linen cart. After several minutes of conversation between GNA #2 and the resident, GNA #2 turned her back and appeared to shut the dining room door and the resident ran across the hallway. GNA #2 grabbed the resident by the front of the resident's shirt and twirled the resident around to the wall and pushed her body into the resident against the wall. The GNA continued to struggle/hold the resident, holding both of his/her hands and pinning the resident up against the wall. The GNA and the resident struggled, and during the struggle, the GNA was observed pushing the resident away, causing the resident to fall. The resident was on the floor and began to crawl and the GNA was seen speaking with the resident. The resident remained on the floor, sitting, and the GNA stood against the wall. The GNA then walked across the hallway and leaned up against the wall, with the resident continuing to sit on the floor. Seven minutes passed until LPN #12 walked down the hall, spoke to the GNA, and at that time, Family Member #9 was seen coming out of the dining room demonstrating what she saw to LPN #12. LPN #12 looked down at the resident sitting on the floor and walked away. A nurse came to assist the resident off the floor one minute later. Interview of State Trooper #1 on [DATE]20 at 2:45 PM revealed that he viewed the video of the incident with the NHA. The facility failed to include their review of the video in their investigation. 2) A second facility reported incident of alleged abuse, MD [AGE]9, that occurred on 1/1/2020 involving GNA #2 and Resident #1, was reviewed on 1/10/19. The facility documented that the allegation of abuse was unsubstantiated. Review of the incident revealed that Staff #3, a housekeeping aide, reported that he witnessed GNA #2 wheel a resident in a wheelchair in a rough manner. Staff #3 was interviewed on 1/16/2020 at 9:43 AM and stated, GNA #2 was abusive. I was coming from dumping the trash 45 minutes before it was time to leave and I hear someone struggling and yelling get up get up from the right side when I entered the building. I saw GNA #2 yanking and pulling Resident #1 in the wheelchair and she tilted Resident #1 forward and Resident #1 caught him/herself because he/she was falling out. I saw that and I said, what the expletive is wrong with you. You don't do that to people. I kept myself calm and she got louder and said, expletive, you don't say that to me. GNA #2 was moving towards me and then another nurse got in between me and her. GNA #2 swung at me. I kept taking steps back. I took 3 steps back. I was not loud, violent or swinging. I proceeded. If it wasn't for the nurse getting in between us it would have been a bad situation. Hearing it and seeing it was 2 different things. GNA #2 was violently yanking Resident #1 in the wheelchair. Where the scale is behind the corner is not on video - it is a blind spot - still inappropriately pushing him. Front wheels are free movement, the wheel was pressed up flat against the bottom of the scale and GNA #2 was trying to push him/her. GNA #2 kept shoving. The patient can be a handful, but it is how you handle. Her actions worked him/her up. Resident #1 became angry at what GNA #2 was doing. Staff #3 stated, If I see something, I am responsible to help. If I see someone getting hurt, I am responsible to step in to help. On [DATE]20 at 8:16 AM, the surveyor began watching the video of 1/1/20 (beginning at 2:15 PM) in the presence of the Maintenance Director (MD) and observed GNA #2 forcibly and abruptly raising the front wheels of the wheelchair and resident's legs off the floor. The resident appeared to be upset, making a fist and shaking his/her hand, and could be seen vocalizing. There was no audio. The surveyor asked the MD who had viewed the video and he stated the NHA had viewed it with him on 1/1/2020. The MD pointed out to the NHA about the rough handling of the resident. The observation of the video was not included in the final report of the facility's investigation of alleged physical abuse that was reported to the state health department, The Office of Health Care Quality (OHCQ). The facility reported incident documented that law enforcement was notified on 1/1/2020. Interview of State Trooper #1 on [DATE]20 at 2:45 PM revealed that State Trooper #2 came to the facility in response to the incident and inquired if there was video footage of the incident. State trooper #2 was told by the NHA that there was no video of the incident. State Trooper #2 was called by State Trooper #1, on [DATE] at approximately 4:20 PM, with the surveyors present and confirmed that he was told by the NHA that there was no video footage of the incident. Additionally, State Trooper #1 stated that when he viewed the 8/9/19 video with the NHA, he had requested a copy of the footage. An interview was conducted with the NHA and the Director of Nursing (DON) on 1/14/2020 at 4:43 PM about the incident of 1/1/2020 and the NHA was asked if law enforcement was called and if law enforcement viewed the video camera footage with the NHA. The NHA stated, we don't typically do that. The camera is used for maybe safety and that's it. The cameras were installed before we were here. When asked if there was any video footage, the response was no. The NHA stated, I never have had any video from the cameras since I have been here. The NHA stated he had been at the facility since May 2019. Again, the NHA stated, we use cameras for safety. The surveyor asked, what would constitute that you would review the video and the response was, let's say the door is not working right. It would be an example of safety and if there is anything alarming, anyone that came into the building. I know they record but I don't how long they record. I don't know how many cameras I have. The surveyors asked, has there ever been an occasion where you have looked at video and the response from the NHA was, I can't recall it When asked who was in charge of the cameras, the response was, I am in charge of the cameras. I don't know how long the camera records. At that time, the surveyors asked if they could see the video from 1/1/2020 and the NHA stated, the maintenance guy told me you saw a video, so my presumption was you saw the video. The NHA denied having a copy of the video. At that time, the surveyors requested a copy of the video footage from 1/1/2020 and were told the facility would have to consult with the legal department. On 1/14/2020 at 5:38 PM, the surveyors were told that the video could be viewed on 1/15/2020 and could receive a copy then. On 1/15/2020 at 10:13 AM, the surveyors watched the video from 1/1/2020 with the NHA, the RDCO and the Maintenance Director. The video that was displayed for the surveyors was only 30 seconds in length and was only of 1 view of the incident. A surveyor had initially watched the video on [DATE]20 at 8:10 AM with Staff #8 that lasted approximately 15 minutes with multiple camera angles. The surveyors asked if there was another camera angle that could be viewed and the response from the NHA was no. The surveyors repeated the question and stated, so you are telling us there is no other camera angle and the response from the NHA was no. A third time the surveyor looked at Staff #8 and asked again, and Staff #8 stated, yes, there is another angle. The NHA attempted to impede the surveyors from viewing another angle of the incident. On 1/15/2020 from 12:06 PM to 12:26 PM, the NHA was interviewed with the RDCO present. The surveyor asked the NHA, has anyone ever asked if there was video of the 1/1/2020 incident and the NHA said no. The surveyor stated, so no one has ever asked if you had video footage and he said, no, you guys are the first. The surveyor asked, so did the state trooper ask if you had video footage and he replied, the trooper never asked. On 1/17/2020 at 10:18 AM, Staff #18 was interviewed and asked if she had concerns about abuse in the building. Staff #18 stated, well, I have a lot of concerns about things in general in this building. About abuse, when we are told there is an allegation, that is it. Then we have to do what we do. I don't think people are cared for properly here and I know staffing has been a challenge for months in this building and when you don't have enough people to care for the residents it is neglect, a form of abuse. Staff #18 was asked, have you ever heard of staff being rough and has it been brushed under the carpet and the response was, yes, sometimes. It depends on who you are. It depends if things come out to light or are pushed away. The NHA is part of the problem. I don't think the NHA really hears or sees the big picture. We are the complaint department, that is what we do, handle the grievances and there have been a lot of care concern with grievances, a lot and I think 90% are legit. Staff #18 was asked, have you received instruction on how you are supposed to document an abuse or grievance. Staff #18 stated, there are certain words we are told not to write. Don't use words like rough, but if that is what you are told by a family or resident that should be documented. I believe what I document is the truth, and this is what I should document. Whether you hold a license or not you should still be true to what you are told. Staff #18 was asked if videos are ever reviewed for abuse allegations. The response was, I know that they have the capability. When the first allegation of abuse was made, the facility failed to identify it as abuse and therefore failed to prevent further incidents of abuse by 1 staff member, GNA #2. The failure of the administration to recognize abusive behavior placed all residents at risk for abuse and contributed to the determination that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 11:21 AM on 1/17/2020. On 1/17/2020 at 2:59 PM, the 2 [LOCATION] Ombudsman came to the facility to meet with the surveyors. The Ombudsman had a complaint from a resident who wished to remain anonymous as the resident feared retaliation from staff. The resident told the Ombudsman about an incident over a year ago that the resident felt was too long ago to investigate but wanted the Ombudsman to know about it. He/she didn't like the way a caregiver had touched him/her in the shower. It was a female GNA and he/she was hesitant, he/she wanted to tell the Ombudsman, but he/she wanted to be anonymous, didn't want to report, afraid of retaliation. The name of GNA #2 was brought up by the Ombudsman. The Ombudsman stated GNA #2 made the resident feel uncomfortable related to the shower incident. On 1/21/2020 at 12:03 PM, Staff #26 (maintenance assistant) was interviewed and stated that he had viewed video of incidents which have happened in the facility. I did not view the video on 1/1/2020 until I made the flash drives for them. Would be last Wednesday and Thursday. If I had seen the incident I would have immediately reported to my supervisor. If I had been there, I would have immediately intervened to make sure the resident was safe and then reported it to my supervisor. I was given a time frame of the time period for which to record by the NHA. Meaning it should be a 30 second clip. Staff #26 continued, there was another video that I just viewed but cannot remember the date, it was last year. It was of an aide and a (resident). She tried to get him/her back to his/her room and she blocked him/her with her arms. Because she had grabbed him/her by the seat of the pants and was directing him/her because he/she was trying to get away from her. I only saw it on video. If it was my family member, I would have been angry. Had I seen it in person, it would have been reported immediately. Those incidents bother me from me being me. But if I am in that situation, I stop and protect the resident and report it immediately. On 1/21/2020 from 3:28 PM to 3:45 PM, the Regional Director of Operations and the RDCO came into the surveyor's room to inform that the NHA had been let go, that they did an investigation themselves and were deeply disturbed and an interim NHA would be there that afternoon.

Based on record review and staff and family interview, it was determined that the facility staff failed to protect a resident, who was totally dependent on staff for all aspects of activities of daily living, from an accident with injury. The failure of staff to develop and implement a person-centered care plan after the resident was determined to be a falls risk, resulted in harm to the resident as the resident fell and sustained 3 broken ribs. Additionally, facility staff failed to obtain a physician's orders [REDACTED]. This was evident for 2 (#3, #13) of 3 residents reviewed for accidents. This deficienct practice resulted in actual harm to Resident #3. The findings include: 1) Review of Resident #3's medical record on 10/22/19 revealed that the resident was admitted to the facility on [DATE] from an acute care facility with a history of stroke ([MEDICAL CONDITION]) with right [MEDICAL CONDITION] (muscle weakness or [DIAGNOSES REDACTED] on one side of the body) and dysarthria (weakness in the muscles used for speech, which often causes slowed or slurred speech). The resident was also on a blood thinner medication, [MEDICATION NAME]. The resident had right sided [MEDICAL CONDITION] (excess fluid build-up in the tissues) and was admitted to the facility for physical and occupational therapy due to debility. A fall risk observation tool was completed upon admission and documented that the resident had diminished safety awareness and was non-ambulatory. The tool also documented that the current falls interventions in place were every 2 hour checks and bed in lowest position. An Occupational Therapy (OT) Plan of Care was completed on 7/26/19 and documented the reason for the OT referral was that the patient was in a weakened condition and displayed increased lethargy and was not at baseline per the spouse. The precautions listed included fall risk. A Physician's Certifications related to medical condition, decision making, and treatment limitations was in the medical record. It was signed on 7/29/19 and the physician documented that the resident lacks adequate decision making capacity due to dementia and stroke. Continued review of Resident #3's medical record showed increased [MEDICAL CONDITION] (swelling) per the 7/29/19 physician's visit. The 8/1/9 physician's visit documented increased [MEDICAL CONDITION] along with abnormal lung sounds. A second fall risk observation tool was completed on 8/1/19 and documented the resident had poor recall and judgement and was a total mechanical lift for all transfers. The tool also documented that the current falls interventions in place were bed in low position when occupied and check and change every 2 hours. On 8/2/19, the physician saw the resident again due to decline in health and documented chest x-ray findings of bilateral lower lung infiltrates, pleural effusions and [MEDICAL CONDITIONS]. A diuretic that the resident was taking was increased and the resident was started on an antibiotic with an order for [REDACTED]. Review of an MDS assessment, with an assessment reference date of 8/8/19, revealed documentation that the resident had a BIMs of 6. (BI[CONDITION] stands for Brief Interview for Mental Status). The BI[CONDITION] test is used to get a quick snapshot of how well someone is functioning cognitively at the moment. The range is from 1 to 15 with 15 being cognitively intact. A score of 0 to 7 points indicates severe cognitive impairment. A third fall risk observation tool was completed on 8/8/19 and documented that the resident had diminished safety awareness and had potential fall interventions in place. The form had an area where the licensed nurse checked n/a (not applicable) to having any current fall interventions in place. Review of all care plans for Resident #3 failed to reveal a care plan for the resident being a fall risk, after 3 fall risk assessments (dated [DATE], 8/1/19 and 8/8/19) were completed. Review of an 8/15/19 at 8:33 AM nurses note revealed documentation that, Resident found on the floor by a staff member and was reported to the nurse. Resident found laying on his/her right side with Hoyer pad laying behind him/her on the floor and wheelchair located behind the patient. Resident stated he/she had lower back pain and was transferred to bed. The nurse notified the NP (nurse practitioner) and was told to call 911 to be transferred to the hospital for further evaluation. The nurse documented, Resident wife has stated to the staff previously her husband has had multiple falls at home. This note was written on 8/15/19, however the resident fell on [DATE]. It was not labeled as a late entry note. Review of the NP note, written on 8/14/19, revealed documentation, fall from w/c (wheelchair) with left sided head and chest wall pain and left shoulder pain. Patient was sitting up in a wheelchair in his/her room. He/she was found by the staff on the floor in front of the w/c. Returned to bed via Hoyer lift. Assessed. c/o left sided head pain and left lateral chest wall pain. On [MED] (blood thinner) for afib ([MEDICAL CONDITION]). Upon assessment from the NP, the NP documented that the pt. appeared uncomfortable and complained of head pain and left shoulder. The NP documented to send to the emergency room for head CT (cat scan) and x-rays of left shoulder and chest. An interview was conducted with the resident's spouse on 10/21/19 at 9:03 AM. The spouse stated that the resident needed a sitter, or to be by the nurse's station. The spouse stated, when he/she was admitted , I stressed to the admitting doctor, admitting nurse and occupational therapist that he/she was a great falls candidate and that all falls precautions needed to be taken. The spouse stated, when I visited, I noticed on occasion that the wheelchair did not have the brakes on and that he/she always had on socks and no shoes. The spouse stated the resident should not have been left alone in the room, that the resident hollered for someone, no one witnessed the fall and the resident waited 20-30 minutes after pressing the call bell. He/she was unmonitored, unsupervised. I talked to the doctor at the hospital and I heard this should have never happened. I told them from the beginning that he/she was a fall's risk. On [DATE] at 1:45 PM, one of the OT assistants was interviewed and stated that she saw the resident for bed mobility, upper body bathing, max assist for brief change and rest of body. It was noted that he was a fall risk in the initial evaluation. On [DATE] at 1:50 PM, Licensed Practical Nurse (LPN) #4 was interviewed and stated, I remember the day. I was in morning meeting and I came out and found out he/she fell . He/she was put back in his/her room after therapy and no one knew he/she was in the room. It appeared he/she slid out of the wheelchair because the Hoyer pad was behind him/her on the floor. He/she had a gown on and no-skid socks. He/she should have been brought out to the nurse's station or therapy should have alerted the staff that they put him/her back in the room. He/she was a fall risk and he/she was in a low bed with fall mats. The nurse that worked that day no longer works here. On 11/4/19 at 11:34 AM, an interview was conducted with Staff #15, the (OT) Occupational Therapist. She stated, I evaluated. I get them every 10th visit when they need a progress note. He/she was a fall risk. If in a wheelchair I would expect him/her to be within view of staff. He/she was [DIAGNOSES REDACTED] and didn't use a half lap tray. The OT continued, Typically, we put in hall in view of nursing staff. I don't remember him/her coming down to therapy. They were at bedside and they to try and get a nurse to help with the Hoyer to get him/her up. The few times we were able to coordinate, the therapy session was right there in the room. He/she was either set up outside the door or in his/her room. Sometimes he/she wasn't feeling well enough, feeling sick to his/her stomach, lethargic, so we would just do therapy in bed. Towards the end I remember him/her having a decline and I think he/she had pneumonia and had a decline in his/her abilities. He/she was pretty sick for a while there. The OT continued, the resident was sitting on a Hoyer pad. I don't like the Hoyer pads and they do slide. I think there is increased potential for sliding when the Hoyer pad is sitting in the wheelchair. If the Hoyer pad could be tucked behind them then that is a different story. It is because of the material of the Hoyer pad. On 11/4/19 at 11:50 PM, LPN #4 was asked to look at the Hoyer lift pads to determine which pad the resident was sitting on. LPN #4 pointed out the mesh sling. LPN #4 felt the mesh sling and stated that it was the one. The mesh sling was shiny/slick. When asked if the Hoyer pad should be left in the wheelchair with the resident sitting in it, she stated, no, it should not be left in the chair. There should be a policy about that. The resident was taken to the emergency room and admitted to the hospital on [DATE]. Hospital documentation was reviewed and the 8/14/19 emergency room discharge summary revealed documentation, CT of the chest/abdomen/pelvis showed [MEDICAL CONDITION] posterior 8, 9 and 10. Pt. was started on [MEDICATION NAME], [MEDICATION NAME] for pain management. 2) A complaint was received regarding a GNA who took a resident outside in a wheelchair without the resident's oxygen on to smoke a cigarette in the parking lot. Review of Resident #13's medical record on 11/4/19 revealed that the resident had a [DIAGNOSES REDACTED]. A 9/23/19 BI[CONDITION] assessment was done for cognition and the resident scored a 15, which meant the resident did not have any cognitive deficits, however, on 8/26/19 and 8/29/19 (2) physicians certified that the resident lacked medical decision making capacity related to [MEDICAL CONDITION] and cognitive deficits. On 11/4/19 at 9:25 AM, Resident #13 was interviewed while they were sitting in their room wearing oxygen via nasal cannula at 2 liters. The resident was asked if they went out of the building recently. The resident stated that they did go outside one day last week and that theyasked the GNA to take them outside. Resident #13 stated, I needed to get out. The resident was asked if oxygen was worn when they went out and the response was, no. When asked if the staff were smoking around them, the response was, yes and I had a cigarette. I needed one because I was upset. I smoked for [AGE] years. When asked if the resident was wearing oxygen around the smoking the resident stated, no, I am not that stupid. On 11/4/19 at 10:00 AM, LPN #4 was interviewed and confirmed that the incident happened and said the Assistant Director of Nursing (ADON) took care of the disciplinary with the GNA. The DON was interviewed at 10:10 AM and stated, I remember something happened but the ADON took care of it. The ADON is off today. Further review of the medical record revealed that the physician was not notified that the resident went outside to smoke and there was no smoking assessment done for Resident #13 nor was no smoking care plan in place. Discussed with the NHA on 11/4/19 at 2:58 PM. He stated that it was a non-smoking facility and that the GNA should not have taken the resident outside to smoke.

Based on reviews of facility reported incident MD 030 and complaint MD 875, reviews of a closed medical record and the facility investigation, and staff interview, it was determined that the facility failed to ensure that Resident #3 was free from staff neglect. This was evident for 1 of 9 (Resident #3) residents reviewed during a complaint survey. The findings include: Reviews of the facility investigation into facility reported incident #MD 030 and complaint MD 875 revealed an allegation that Resident #3 received a fractured left humerus during care on 09/12/2015. Resident #3 resides on the facility Alzheimer's Care Unit and is totally dependent upon the nursing staff for all aspects of his/her care. Resident #3 is cognitively impaired, has limited communication, and does not have full use of his/her left arm. Further reviews of the facility investigation revealed GNA #2 and GNA #3 used a SARA 3000 lift to perform incontinence care for Resident #3 on 09/12/2015 at approximately 2 PM. A review of the SARA 3000 lift handling instructions indicated the SARA 3000 is a mobile raising aide intended to be used for raising to standing position and short transfer of residents. Residents who can only hold on to the resider support grips with one hand, such as those who have suffered a stroke, may still be raised with the SARA 3000, but their disabled arm shall be held down in front of the body during the raising by the caregiver (or a second caregiver), while their functioning hand holds the resident support arm in the normal way. After GNA #2 and GNA #3 performed incontinence care for Resident #3 at approximately 2 PM on 09/12/2015, Resident #3 was observed with a skin tear injury to the right elbow. GNA #2 notified Resident #3's charge nurse of the right elbow skin tear only. The charge nurse applied a dressing to the right elbow at this time. Later in the evening, around 11 PM on 09/12/2015, LPN #1 observed swelling and bruising to Resident #3's left upper arm. Resident #3's physician was made aware and new orders for an x-ray and pain medication were given. Review of Resident #3's closed medical record revealed nursing documentation, dated 09/12/2015 at 11:48 PM, documenting LPN #1 observed a large dark discoloration with swelling to Resident #3's left upper arm. LPN #1 documented Resident #3 complained and grimaced when the left upper arm was palpated. LPN #1 also documented Resident #3 guarded the left arm during the nursing assessment. In an interview with LPN #1 on 11/24/2015 at 5:05 PM, LPN #1 stated that he/she found the bruising to Resident #3's left shoulder when the nursing staff were changing Resident #3's clothing in preparation for placing Resident #3 to bed on 09/12/2015. LPN #1 stated the nursing staff performs all aspects of care for Resident #3 and that there were no reports of an injury to Resident #3's left arm given to LPN #1 in report prior to the beginning of the shift on 09/12/2015. In an interview with the facility Alzheimer's Care Unit (ACU) director on 11/24/2015 at 1:35 PM, the ACU director stated Resident #3 was to be a No Lift and this means the nursing staff are not to lift Resident #3 with any of the facility mechanical lifts. The ACU director stated Resident #3 could stand with the assistance of 2 staff members and that Resident #3 had very limited use of his/her left arm due to it being contracted. A contracture is a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints. The ACU director stated that the use of the SARA 3000 lift, when caring for Resident #3 on 09/12/2015, was inappropriate because Resident #3 did not have the use of both of his/her hands to grab onto the hand grips and assist with raising him/her to a standing position. Further review of the facility investigation revealed a second administrative interview with GNA #3 that occurred on 09/15/2015. The follow up administrative interview with GNA #3 on 09/15/2015 gave a detailed description and indicated GNA #3 and GNA #2 were aware of what happened to Resident #3's left arm injury that was not indentified until later in the evening at 11 PM on 09/12/2015. GNA #3 gave details that when he/she and GNA #2 were using the SARA 3000 lift with Resident #3 on 09/12/2015 at 2 PM, GNA #3 indicted he/she was controlling the SARA 3000 remote and was in the process of raising Resident #3. At this point, GNA #3 stated this is when GNA #2 tried to physically lift Resident #3's left arm towards the black hand grip to help Resident #3 reach the black hand-gripper. This is when both GNA #2 and GNA #3 heard a snap. GNA #3 indicated that he/she and GNA #2 just looked at each other. GNA #3 indicated this is when GNA #2 stated I think I broke her arm. GNA #3 also indicated in the interview that GNA #2 asked if they should tell the charge nurse and GNA #3 stated to GNA #2 that it was up to him/her because Resident #3 was assigned to GNA #2. When asked, GNA #3 indicated that neither he/she nor GNA #2 informed the charge nurse that Resident #3 possibly incurred and injury to the left arm on 09/12/2015. When questioned, GNA #3 stated that he/she did not tell the truth when interviewed on 09/13/2015 because GNA #3 did not want to get anyone in trouble. The surveyor determine that GNA #2 and GNA #3 were aware that Resident #3 may have injured his/her left arm, when being raised in the SARA 3000 lift on 09/12/2015 at approximately 2 PM, but chose not to inform the charge nurse. It was not until later in the evening on 09/12/2015 the nursing staff observed swelling and bruising of Resident #3's left arm. An x-ray obtained on 09/13/2015 determined Resident #3 suffered a recent fractured proximal humerus. The use of the SARA 3000 lift was not part of Resident #3's plan of care. GNA #2 and GNA #3 neglected to inform the charge nurse of a possible injury to Resident #3's left arm. A further detailed review of the facility investigation, staff education records, and interviews with staff determined the facility had completed and acceptable plan of correction and determined this citation to be past non-compliance.

Based on reviews of the medical records and interviews of the facility staff, it was determined that the facility staff failed to have a resident's wound assessed by a wound care specialist for 13 days after the wound was noted to be worsening. This finding was determined during the investigation of complaint intake # MD 128. The findings include: Resident # 1 was admitted to the facility on [DATE]. On admission, the resident was assessed by the nursing staff as having a Stage I area on his sacrum. Other [DIAGNOSES REDACTED]. The admission orders [REDACTED]. Review of the medical records revealed an initial plan of care for "Pressure ulcer actual and at risk due to: Assistance required in bed mobility, bowel incontinence, pressure ulcer present". Interventions included but were not limited to: weekly skin inspection, pressure reducing wheelchair cushion and pressure reduction/relieving mattress. Review of the medical record revealed that on 10/24/2011, interventions were added to the treatment plan that included: incontinence management every shift and cleanse perineal area and apply barrier cream after each incontinence episode. On 10/25/2011, documentation on the wound evaluation flow sheet noted that the resident's sacrum ulcer was a Stage I and was described as slight red and 3 centimeters (cm) long by 3 cm wide by 0 cm deep. Review of the nurses' notes and physician's orders [REDACTED]. Santyl is a [MEDICATION NAME] agent that is uses an enzyme to help break up dead skin. On October 28, 2011, the physician's orders [REDACTED]. Review of the physician note for 10/29/2011 revealed some bruising in the assessment for " derm " (skin). Interview of the resident's doctor conducted on 3/6/2012 at 2:20 PM revealed that he does not recall seeing the resident's wound on the coccyx on 10/29/2011 during his visit but if he did, he would have written it in the resident's medical record. On 11/2/2011, the resident's wound was assessed by the nurse who documented on the wound evaluation flow sheet that the resident's wound was a DTI (deep tissue injury), was red with scant amount of odor, slough was present, and that the treatment order for the area had been changed on 10/27/2011 to Santyl, a [MEDICATION NAME] agent. Interview of Employee #1 on 3/7/2012 at 10:00 AM revealed that, on 10/27/2011 or 10/28/2011, she was approached by a floor nurse and informed that the resident's wound had deteriorated and was also informed that the physician changed the order to Santyl but that in later review of the medical record found that the floor nurse had not documented the change in the condition in wound that prompted the change in treatment. Employee # 1 stated that she observes the wounds during wound rounds on Wednesdays with the physician and did not observe the resident's wound until 11/9/2011. Employee # 1 further revealed that the medical record did not contain any documentation on 10/27/2011 to describe the change in the wound that required a change in treatment. Employee # 1 stated that she reviews the weekly wound notes on Thursdays from the wound rounds conducted on Wednesdays and that on 11/3/2011 when she reviewed the documentation from 11/2/2011, she assigned the resident to be seen the following week by the wound care physician. On 11/9/2011, the resident was seen for an initial evaluation by the wound care physician at the facility. Review of the wound care evaluation dated 11/9/2011, and interview of the wound care physician on 3/7/2012 at 12:00 PM, revealed that the resident's wound was seen and evaluated. At this time, the wound was reclassified as "unstageable necrosis" (unable to determine wound measurement underneath dead skin tissue). A surgical debridement was performed to the wound to remove the necrotic tissue. Review of the medical records further revealed that the wound care physician saw the resident on 11/16/2011 and the wound was again surgically debrided. Reviews of the medical records and interviews of the facility staff failed to reveal that upon identification of a change in the resident's wound resulting in the facility staff notifying the physician for a change in treatment on 10/27/2011, and reclassification of the wound to a deep tissue injury on 11/2/2011, the resident's wound was not evaluated by a physician or wound care specialist until 11/9/2011.