Every finding on record at Wicomico Nursing Home

Based on review of facility documentation, medical record review and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff. This was evident for 1 (Resident #7) of 4 residents reviewed for abuse during a complaint survey. The findings include: Review of facility reported incident 3038684 was conducted on 8/25/26 regarding verbal abuse of Resident #7 on 6/8/26 by Staff #7. Review of Resident #7's medical record on 8/25/26 revealed the Resident was admitted to the facility in 2024. Review of the Facility Reported Incident Initial Report Form provided by the Administrator on 8/25/26 revealed on 6/9/26 Resident #7 reported to the Director of Nursing that Staff #7 told the Resident you need to shut your fat a** up. Review of the Facility Reported Incident Follow-Up Investigation Report Form revealed the Resident's roommate's (Resident #9) statement that he/she overhead the interaction and reported Resident #7 was using vulgar language to Staff #7 and in turn Staff #7 made a statement consistent with the accusation. Review of Resident #9's statement from 6/9/26 revealed Resident #9 stated Staff #7 said I am trying to help you if you keep your fat a** over'. Review of Staff #7's statement from 6/11/26 revealed Staff #7 stated after exited the room she did say you fat b**** under her breath. During interview with Resident #7 on 8/25/26 at 12:10 PM, Resident #7 was asked if he/she remembers an incident between him/her and Staff #7 in June and what was said. Resident #7 stated he/she did and Staff #7 told him/her to put him/her big a** down. During interview with Resident #9 on 8/25/26 at 12:15 PM, Resident #9 stated he/she heard Staff #7 call Resident #7 fat a**. Interview with the Administrator on 8/25/26 at 12:30 PM confirmed verbal abuse by Staff #7 to Resident #7 on 6/8/26.

Based on review of facility documentation, medical record review, and interviews, it was determined the facility failed to report an alleged abuse (Resident #3) and an injury of unknown origin (Resident #4) immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 2 of 8 residents reviewed for facility reported incidents during a complaint survey.The findings include: 1) Review of facility reported incident 3044037 was conducted on 8/25/26 revealed Resident #3 reported to Staff #27 on 6/11/26 that Staff #20 was rough and she throws me around like a bag of potatoes. Review of Resident #3's medical record on 8/25/26 revealed the Resident was admitted to the facility in May 2026 for rehabilitation services. Further review of Resident #3's medical record revealed a Treatment Encounter Note by Staff #27 on 6/11/26 that stated: Patient upset about how staff was handling him/her and stated: She throws me around like a bag of potatoes. Staff #27 then documented she notified Staff #26 and Staff #28 of what Resident #3 stated. During interview with Staff #27 on 8/27/26 at 9:50 AM, Staff #27 stated after the Resident reported Staff #20 was rough and threw him/her around like a bag of potatoes she immediately reported it to Staff #26 and Staff #28. During interview with Staff #26 on 8/27/26 at 10:00 AM, Staff #26 stated she had reported the allegation by Resident #3 to Staff #28 on 6/11/26 because the Director of Nursing was not in the building and Staff #28 was in charge of the building that day. During interview with Staff #28 on 8/27/26 at 10:05 AM, Staff #28 stated on 6/11/26 she went and spoke with Resident #3 about what he/she reported to Staff #27. Staff #28 stated the Resident told her that he/she didn't mean it like that. Staff #28 stated she didn't report it to the Director of Nursing until 6/12/26 during morning meeting. Further review of the Facility Reported Incident Initial Report Form revealed the facility did not report the allegation by Resident #3 until 6/12/26, the day after. Interview with the Administrator on 8/27/26 at 11:25 AM confirmed the facility staff did not report Resident #3's abuse allegation timely to the Office of Health Care Quality due to the Administrator not be informed of the allegation until the next day on 6/12/26. 2) Review of facility reported incident 3105616 was conducted on 8/25/26 revealed Resident #4 was found 7/16/26 on the floor in his/her room with a hematoma to the right forehead. Review of Resident #4's medical record on 8/25/26 was admitted to the facility in 2025 and has a diagnosis of vascular dementia. Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain. Further review of Resident #4's medical record revealed the Resident was assessed by the facility staff on 7/2/26 to have a BIMS of 3 out of 15, indicating severe cognitive impairment. Review of a 7/16/26 7:28 PM nursing note revealed it stated: Resident was found lying on the floor, unresponsive have involuntary jerking movements were observed, neurological assessment completed, slight facial droop noted vital signs obtained. Review of a 7/16/26 8:06 PM nursing note revealed it stated: Resident sustained a hematoma to his/her right frontal lobe from the fall. Further review of Resident #4's medical record revealed the Resident was sent to the emergency room on 7/16/26 and returned to the facility on 7/19/26. Review of the Facility Reported Incident Initial Report Form provided by the Administrator to the Surveyor on 8/25/26 revealed the incident was not reported to the Office of Health Care Quality until 7/19/26. During interview with Resident #4 on 8/26/26 at 7:18 AM, the Resident was asked if he/she remembered what happened on 7/16/26 when he/she was found on the ground. The Resident answered no. Interview with the Administrator on 8/26/26 at 11:00 AM confirmed the facility staff did not report an injury of unknown origin for Resident #4 timely to the Office of Healthcare Quality.

Based on review of facility reported incident investigations, medical record review and interviews, it was determined the facility failed to thoroughly investigate an injury of unknown origin for a resident. This was evident for 1 (Resident #4) of 8 residents reviewed for facility reported incidents during a complaint survey.The findings include: Review of facility reported incident 3105616 was conducted on 8/25/26 revealed Resident #4 was found 7/16/26 on the floor in his/her room with a hematoma to the right forehead. Review of Resident #4's medical record on 8/25/26 revealed the Resident was admitted to the facility in 2025 and has a diagnosis of vascular dementia. Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain. Review of the facility investigation revealed a statement from Staff #34 that stated she was exiting a resident room when she heard a resident yelling for help and as entered the room observed Resident #4 on the floor. Further review of the facility's investigation on 8/25/26 revealed it did not contain a statement from the Resident's assigned nurse (Staff #33) who assessed the Resident on 7/16/26. The investigation also did not include a statement from the Resident's roommate (Resident #10). Interview with the Administrator on 8/26/26 at 11:00 AM confirmed the investigation was incomplete for Resident #4's injury of unknown origin on 7/16/26.

Based on review of complaints, interviews, and medical record review, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (Residents #5, #6) of 8 residents reviewed for complaints during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 8/26/26 at 8:25 AM a review of complaint 3167646 and Resident #5's medical record was conducted and revealed Resident #5 was admitted to the facility in October 2025.On 8/25/26 at 10:50 AM an interview was conducted with Resident #5's resident representative (RP) who stated that Resident #5 did not receive prescribed glaucoma eye drops for several days in May 2026. The RP stated that the facility staff failed to reorder the glaucoma drops in a timely matter.Review of Resident #5's April 2026 and May 2026 Medication Administration Record (MAR)s confirmed that Resident #5 missed several days of eye drop administration. Resident #5 was prescribed Latanoprost Ophthalmic Solution 0.005%, instill 1 drop in both eyes at bedtime for glaucoma and Brimonidine Tartrate Ophthalmic Solution 0.2%, instill 1 drop in left eye two times a day for glaucoma.Review of Resident #5's MDS assessment with an assessment reference date of 5/6/26 and 7/23/26, Section I, Active Diagnoses, failed to capture glaucoma.On 8/28/26 at 10:49 AM the MDS coordinator, Staff #4 was interviewed and stated that she initially started as a consultant in the beginning of June 2026 and was asked to help out in July 2026. The surveyor reviewed the 2 MDS assessments and Staff #4 stated that she agreed that glaucoma should have been captured, especially since the resident was receiving 2 different prescription eye drops for glaucoma.2) On 8/25/26 at 3:52 PM a review of complaint 3169442 and Resident #6's medical record was conducted.Review of a 7/1/26 eye care note documented Resident #6 was seen for follow-up of glaucoma, pressure check in the right and left eye. The examination revealed open angle glaucoma in both eyes.Review of a 3/19/26 medical consultation note documented Resident #6 was seen for complaints of vision impairment and unable to see light. The resident was diagnosed with a macular scar in the left eye and hypertensive retinopathy in both eyes.Review of Resident #6's April 2026 and July 2026 MARs documented the resident received the medication Pantoprazole 40 mg. twice per day for a duodenal ulcer.Review of Resident #6's MDS assessments with assessment reference dates of 4/2/26 and 7/2/26, Section I, Diagnoses, failed to capture glaucoma, hypertensive retinopathy, and duodenal ulcer.On 8/28/26 at 11:36 AM the MDS coordinator was interviewed and confirmed the findings.On 8/28/26 at 11:50 AM the NHA was informed of the findings.

Based on a review of complaint 3167646, interviews, and medical record review, it was determined that facility staff failed to develop a comprehensive person-centered care plan for a resident with glaucoma. This was evident for 1 (Resident #5) of 8 residents during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.Glaucoma is a group of eye diseases that damage the optic nerve, often due to high fluid pressure inside the eye called the intraocular pressure. Glaucoma is not curable and lost vision cannot be restored.On 8/25/26 at 10:50 AM an interview was conducted with Resident #5's resident representative (RP) who stated that Resident #5 did not receive prescribed glaucoma eye drops for several days in May 2026. The RP stated that the facility staff failed to reorder the glaucoma drops in a timely matter.Review of Resident #5's medical record revealed the resident was admitted to the facility in October 2025.Review of Resident #5's April 2026 and May 2026 Medication Administration Record (MAR)s confirmed that Resident #5 missed several days of eye drop administration. Cross Reference F684.Review of Resident #5's medical record revealed a 12/3/25 eye doctor's note that documented the assessment, primary open-angle glaucoma, bilateral, indeterminate stage. Intraocular pressures well controlled on current meds. We will continue to monitor at regular intervals. Follow-up in 4 to 6 months for IOP (intraocular pressure) check.Review of Resident #5's care plans failed to produce a care plan for glaucoma from admission to the facility to current date. A care plan would have focused on lowering IOP, preventing further vision loss, managing medications, and ensuring safety with goals of ensuring one hundred percent adherence to prescribed eye drop therapy and fall prevention.On 8/26/26 at 10:00 AM the Director of Nursing (DON) was interviewed and asked who was responsible for creating and implementing care plans. The DON stated, I guess nursing. I have been trying to keep on top of them as far as updating them since the MDS nurse left. The MDS nurse left 7/18/26. We were starting to wean away from the MDS person doing them as the new work flow was created. The DON was asked if she ever attended care plan meetings and she stated, rarely. The DON was informed of the December 2025 eye doctor's note regarding glaucoma, and that Resident #5 was prescribed 2 glaucoma eye drops every day, therefore the care plan should have been created back in December 2025. The DON confirmed that the care plan should have been in place.On 8/28/26 at 10:34 AM the Nursing Home Administrator was informed of the findings.

Based on a review of complaint 3167646, interviews, and medical record review, it was determined that facility staff failed to update a person-centered care plan for a resident dependent on staff for assistance with activities of daily living. This was evident for 1 (Resident #5) of 8 residents during a complaint survey.The findings include: A care plan guides and addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. A care plan is to be updated at least quarterly, and more often when the condition changes.On 8/25/26 at 10:45 AM complaint 3167646 was reviewed and alleged that Resident #5 was not toileted prior to meals and that it was agreed upon in 2 of the resident's previous nursing care plan meetings that the resident was to be toileted before meals.On 8/25/26 at 10:50 AM an interview was conducted with Resident #5's resident representative (RP) who stated that Resident #5 required assistance with toileting. The RP stated, my [Resident #5] has fallen several times trying to put him/herself in a wheelchair to go to the bathroom and finally he/she accepted the fact that no one is coming and to wet him/herself. In the care plan meeting we ask them to take him/her to the bathroom before each meal. I sat in 2 care plan meetings and was told it was going to be on the care plan, and it is not happening in the evening. A family member comes in the evening, and we were seeing that it happened. So, we asked for help with that. It is not being done. Recently there have been new staff and they do not know his/her care plan. I frequently had to tell them to give him/her a bed cradle and don't wrap feet and don't put cover over feet. About 5 times a week I have to explain it, and I shared it with the nurses to share with the people that take care of my [Resident #5], and this has been going on for months.Review of Resident #5's medical record revealed the resident was admitted to the facility in October 2025.Resident 5's care plans were reviewed and revealed a care plan that the resident had mixed incontinence and to offer toileting every 2 hours. The care plan was initiated on 10/28/25. There have been no updates to the care plan regarding toileting the resident before meals.Further review of Resident #5's care plans failed to produce an update to the ADL (activities of daily living) care plan for the bed cradle. A bed cradle is a metal or plastic frame placed under a mattress that arches over a patient's lower legs or feet. It lifts the weight of heavy sheets and blankets off of the feet to prevent pain, skin damage, and pressure ulcers caused by bedding resting directly on sensitive skin.On 8/25/26 at 2:12 PM observation was made of Resident #5's room. There was a bed cradle at the end of the bed with blankets over top of the cradle.On 8/25/26 at 5:20 PM observation was made of Resident #5 eating dinner in bed. The cradle was on the end of the bed. The blankets and sheet were directly on the resident's feet. The resident stated, I want them on there. My feet are cold.On 8/25/26 at 5:22 PM Geriatric Nursing Assistant (GNA) #25 was asked what the bed cradle was used for. GNA #25 stated that the resident liked his/her feet bundled. I put the blankets on the cradle to keep the feet warm. On 8/25/26 at 5:25 PM Licensed Practical Nurse #24 stated she has worked at the facility full time since March 2026. LPN #24 was asked why the bed cradle was on the bed and she said, to keep his/her feet from getting cold, so the air doesn't get to the feet. The family says his/her feet are cold.On 8/26/26 at 10:00 AM the Director of Nursing (DON) was interviewed and asked who was responsible for updating and implementing care plans. The DON stated, I guess nursing. I have been trying to keep on top of them as far as updating them since the MDS nurse left on 7/18/26. We were starting to wean away from the MDS nurse doing them as the new work flow was created. The DON was asked if she ever attended care plan meetings and she stated, rarely. The DON was informed of the answers the nursing staff gave as to why the bed cradle was on Resident #5's bed. The DON stated that LPN #24 came to her yesterday and informed her of the answer given to the surveyor. The DON was also informed of the concern that the care plan was not updated to reflect toileting before meals and the use of the bed cradle per the family's requests and discussions in previous care plan meetings. The DON was informed that it was reported these issues had been going on for several months. The DON confirmed that the care plan should have been updated to reflect the family's wishes for the resident and she expressed concerns that the staff did not know what the bed cradle was used for.On 8/28/26 at 10:34 AM the Nursing Home Administrator was informed of the findings.

Based on a review of complaint 3167646, interviews, and medical record review, it was determined that facility staff failed to provide eye drops for a resident when ordered by the physician for glaucoma and failed to notify the physician when the eye drops were not available. This was evident for 1 (Resident #5) of 8 residents reviewed during a complaint survey.The findings include: Glaucoma is a group of eye diseases that damage the optic nerve, often due to high fluid pressure inside the eye called the intraocular pressure. Glaucoma is not curable and lost vision cannot be restored.On 8/25/26 at 10:50 AM an interview was conducted with Resident #5's resident representative (RP) who stated that Resident #5 did not receive prescribed glaucoma eye drops for several days in May 2026. The RP stated that the facility staff failed to reorder the glaucoma drops in a timely matter.Review of Resident #5's medical record revealed the resident was admitted to the facility in October 2025. Review of Resident #5's April 2026 Medication Administration Record (MAR) documented Resident #5 was to receive Latanoprost Ophthalmic Solution 0.005% drops, instill 1 drop in both eyes at bedtime for glaucoma. When reviewing the MAR there should be a check mark along with the nurse's initials that would indicate the medication was given. If there is a 9 then that would indicate the medication was not given and there would be a corresponding nurse's note. For Resident #5, there were 9 s documented on 4/18, 4/19, 4,20, 4,21, 4,22, 4/23, 4/24, 4/26, 4/27, 4/29, and 4/30. The documentation corresponding with the following dates were as follows:4/18 to 4/24, and 4/26 - waiting delivery (7) days4/27 - not available4/28 to 4/30 - waiting delivery (3) daysFurther review of the April 2026 MAR documented the resident was to receive a second eye drop, Brimonidine Tartrate Ophthalmic Solution 0.2% Instill 1 drop in the left eye 2 times a day for glaucoma. Resident #5 did not receive the Brimonidine eye drops on the evening of 4/29 and on the day and evening shift on 4/30/26.Review of Resident #5's May 2026 MAR documented the resident did not receive the Brimonidine eye drops on the evening of 5/1 and 5/2 and did not receive the drops at all during the day and evening shift on 5/3, 5/4, 5/5, and 5/6/26.Continued review of Resident #5's medical record failed to produce documentation that the pharmacy or the physician were notified .On 8/28/26 at 10:00 AM the Director of Nursing (DON) was interviewed and stated that nursing would call the pharmacy, and they were told it was too early to refill the drops. I would tell them to make sure the doctor knows. My expectation is if it is too soon to fill then we have to charge the facility for the medicine. They should have notified the physician.On 8/28/26 at 10:34 AM the Nursing Home Administrator was informed of the findings.

Based on observation, staff interviews, and documentation review, it was determined that facility staff failed to keep treatment carts locked when unattended and discard expired medications/biologicals. This was evident on 1 of 4 nursing hallways observed during random observations made during a complaint survey. The findings include: On 8/27/26 at 2:12 PM observation was made on the 500-hallway nursing unit of an unlocked and unattended treatment cart sitting in the hallway outside of room [ROOM NUMBER]. The surveyor was able to open the drawers in the treatment cart and observed scissors in the top drawer along with a 100 ml bottle of NSS (normal saline solution) 0.9%, Lot #251111093, that was one third of the way full. The bottle was not dated when opened. Observed prescription lotions and ointments in the second and third drawer of the treatment cart. In the fourth drawer was an opened 100 ml. bottle of NSS 0.9%, Lot #251111093 that was one third of the way full that was not dated when opened and in the fifth drawer was an opened 100 ml. bottle of NSS 0.9%, Lot #251111093 that was one half full and not dated when opened. An opened 100 ml 0.9% sodium chloride (normal saline) bottle without preservatives should be either discarded immediately or within 24 hours because it lacks antimicrobial agents to stop germ growth. Once the seal is broken, airborne bacteria and fungi can quickly multiply in the liquid at room temperature.The treatment cart was left unattended from 2:12 PM to 2:17 PM when Registered Nurse (RN) #28 walked up the hallway and the surveyor informed her of the concern. RN #28 did not say anything to the surveyor. RN #28 took the treatment cart, locked it, and walked up the hallway.On 8/27/26 at 3:39 PM the Nursing Home Administrator NHA was informed of the observation and stated that she told nursing one week ago that all medication and treatment carts were to be cleaned out and items dated when opened.On 8/28/26 at 9:02 AM a second observation was made of an unlocked and unattended treatment cart on the 500-hallway nursing unit that was sitting in the hallway across from the nurse's station. There were no staff in the area. There were residents in the hallway and a resident in a wheelchair that appeared confused. The surveyor was able to open the top drawer and observed scissors along with other treatment supplies. The surveyor stood at the unlocked cart until the Director of Nursing (DON) appeared in the hallway at 9:05 AM. At that time the surveyor showed the DON the concern. The DON was looking around in the hallway to find a nurse and ended up locking the cart herself. The DON stated that the treatment cart should have been locked.Review of the Policy for Locking Medication and Treatment Carts that was given to the surveyor by the NHA revealed, Policy: All medication and treatment carts will be locked if staff assigned to the cart is not within reach of the cart. Procedure #3 documented, Staff assigned to each treatment or medication cart will lock the cart before leaving it unattended (out of reach).On 8/28/26 at 10:54 AM the NHA was informed of the second observation.

Based on record review and staff interviews, it was determined that the facility failed to ensure that care and treatment decisions for a resident assessed to lack decision-making capacity were made by a legally authorized representative. This was evident for 1 (Resident #7) of 5 residents reviewed for advance directives during the annual survey. The findings include: On 02/02/2026 at 12:31 PM, a review of Resident #7's medical record revealed two signed Physician Certifications Related to Medical Conditions, Decision Making, and Treatment Limitations, which documented that the resident lacked adequate decision making capacity. However, there was no evidence in the medical record of a legally authorized representative to make decisions for the resident. On 02/03/2026 at 11:00 AM, during an interview, the Social Work Director confirmed that Resident #7 had two certifications of incapacity and stated that, because the resident's children were not involved, the resident's sister had been making decisions for the resident. The Social Work Director further stated that the facility did not obtain documentation establishing the sister as a legally authorized surrogate decision maker.

Based on interviews, record reviews, and observations it was determined that the facility failed to ensure that residents requiring assistance with turning and repositioning were turned and repositioned at least every two hours. This was evident for 2 (Resident #3 and #4) out of 2 residents observed for pressure ulcers during the annual survey. The findings include: 1) On 02/02/2026 at 11:56 AM, record review revealed that Resident #3 had an order to be turned and repositioned every two hours. On 02/04/2026 at 9:11 AM, an observation revealed that Resident #3 was lying on his/her back. On 02/04/2026 at 11:23 AM, an observation revealed that Resident #3 was lying on his/her back. On 02/04/2026 at 1:17 PM, record review revealed that the resident had been signed off that they were turned and repositioned. On 02/04/2026 at 1:20 PM, an interview with a Registered Nurse (Staff #11) revealed that the expectation was that residents who required the assistance should be turned and repositioned every two hours. On 02/04/2026 at 1:23 PM, an observation revealed that Resident #3 was lying on his/her back. On 02/04/2026 at 1:53 PM, an interview with Geriatric Nursing Assistant (Staff #12) revealed that the expectation was that residents who required the assistance should be turned and repositioned every two hours. 2) On 02/04/2026 at 9:00 AM, record review revealed that Resident #4 was care planned to be turned and repositioned every two hours. On 02/04/2026 at 9:12 AM, an observation revealed that Resident #4 was lying on his/her back. On 02/04/2026 at 11:24 AM, an observation revealed that Resident #4 was lying on his/her back. On 02/04/2026 at 1:24 PM, an observation revealed that Resident #4 was lying on his/her back. On 02/04/2026 at 3:59 PM, the concerns were brought up to the Director of Nursing and she indicated that she understood.

Based on observations and interviews, it was determined that the facility failed to discard expired medications and store medications properly. This was evident for 2 out of 3 medications carts observed as part of the medication storage task during the annual survey. The findings include:On 02/05/2026 at 9:49 AM, an observation of medication cart in the 100s unit was conducted by the surveyor and Staff #7. The surveyor observed 1 bottle of Aspirin 325mg with an expiration date of 12/2025.A brief interview was conducted with Staff #7. When asked who is responsible for ensuring expired medications are not in the medication cart, she replied that the cart belonged to nurses and therefore nurses were supposed to check for expired medications every shift.On 02/05/2026 at 10:11 AM, another medication cart was observed in the 500s unit. The observation was conducted by the Surveyor and Staff #15.The medication cart contained the following expired medications:1). A bottle of Aspirin 325 mg that had an expiration date of 12/2024.2). A bottle of Tylenol extra strength with an expiration date of 9/2025. 3). A bottle of Benadryl 25 mg with an expiration date of 11/2025. 4). Hemoccult solution had an expiration of 8/2025.5). A bottle of Bacteriostatic 0.9% sodium chloride which had an expiration of 11/1/2025. Additionally, there was a Bisacodyl Suppository that was found in the medication cart. This medication did not have an expiration date. When asked what the expiration date was, Staff #15 stated that the suppository was not supposed to be stored in the medication cart but rather it should be stored in the fridge. On 02/05/2026 at 10:22 AM, the Surveyor and Staff #15, observed the medications in the medication fridge. There were 20 expired Bisacodyl Suppositories, expiration date of 9/9/2025. On 02/05/2026 at 10:30 AM, a follow up interview with Staff #15 was conducted. When asked whose responsibility it was to ensure 1). Expired medications were removed from the cart and 2). Medications are stored properly, Staff #2 stated that it was everyone's responsibility to ensure that medications are stored properly and that any expired medications are removed and discarded. She further stated, no expired medication should be in the medication cart. On 02/05/2026 at 10:40 AM, the Director of Nursing and facility administrator were notified of the concerns.

Based on observations and interviews, it was determined that the facility failed to use appropriate infection control practices while handling laundry. This was evident during the observation of the laundry room as part of the infection control task during the annual survey.The findings include:Personal Protective Equipment (PPE) refers to specialized clothing and gear-gloves, gowns, masks, and face shields designed to protect workers and patients from infectious materials, contaminants, and bloodborne pathogens. It acts as a physical barrier, critical for infection control during procedures and in high-risk environments.On 02/04/2026 at 12:45 PM, a tour of the laundry room was conducted. In the dirty laundry room area, the Surveyor observed a laundry cart half-way filled with clothes that were not bagged. There was a cart near the wall that had 2 hospital gowns and gloves.A brief interview was conducted with Staff #2. When Staff #2 was asked if the clothes were dirty, she said yes and that the clothes belonged to different residents in the facility. She also stated that she needed to wait for more resident clothes to be brought in for laundry because the machine only allows a certain load weight to wash. Moreover, when asked what she wore for PPE, staff pointed at gloves and a resident hospital gown. When asked about the ventilation of the room, Staff #2 stated that the vent was off. She added that in the summertime they open the vents to get the air out, but right now the laundry staff had turned off the vents for the season because of how cold it was in the laundry area.On 02/04/2026 at 12:47 PM, a tour of the clean laundry area was conducted. The surveyor observed holes in the ceiling with loose, exposed insulation materials. Clean, folded clothes were observed directly below the affected area. On 02/04/2026 at 1:26 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. When asked what PPE staff members are expected to wear, the ADON stated that the staff are provided with gowns, gloves and eye shield. When asked what type of gowns are used, the staff stated that the facility had blue disposable gowns that are one-time use. Staff was asked if she considered hospital gowns as appropriate PPE. She stated No, because it's made of cloth and therefore not protective. On 02/04/2026 at 1:48 PM, another tour of the laundry room was conducted with the ADON and Director of Nursing (DON). When asked if the dirty clothes should be bagged, the ADON stated yes, she is unsure why the clothes in the cart are not in a bag. The Surveyor asked the ADON what PPE the laundry staff should use or be readily available for use, the ADON stated gloves, gown and face shields. The Surveyor pointed out the hospital gowns that were being used as PPE. Lastly, the surveyor also showed the ADON and DON the clean area ceilings with loose, exposed insulation materials.On 02/04/2026 at 2:27 PM, the ADON reported to the surveyor that the maintenance staff had turned on the ventilation switch and that they would fix the ceiling holes to prevent cross contamination. On 02/04/2026 at 2:30 PM, the DON and ADON were notified of the infection control concerns.

Based on surveyor reviews of a facility reported incident and facility staff interview, it was determined that the facility failed to report the final investigation of an incident of alleged abuse reported by a resident's family member to the Office of Health Care Quality. This finding was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey. This finding is related to the facility reported incident #MD00212903. The findings include: On 03/06/2025, an on-site review of the facility reported incident for Resident #3 revealed that, on 12/19/24, Resident #3 was observed by a staff member and the resident's family member with discoloration to her bilateral hands and left forearm. Resident #3 was unable to describe how the discoloration happened. Further review of the facility investigation revealed that the facility submitted the initial report to OHCQ (Office of Health Care Quality) on 12/19/24, within 24 hours of the allegation as required. However, the final investigation report was not submitted to OHCQ. The facility is required to complete the investigation and submit the final investigation report within 5 working days. On 03/10/25 at 11:40 AM, the nurse surveyor interviewed the Assistant Director of Nursing (ADON) who was unable to provide any additional information. The facility ADON confirmed that the staff were unable to locate any documentation that a 5 day conclusion was reported to the State Survey Agency for facility reported incident MD00212903.

Based on reviews of a complaint, interviews with staff, and reviews of a closed record, it was determined that the facility failed to ensure that a resident's medications were administered as ordered. This was evident for 1 (Resident #1) of 4 residents reviewed during a complaint survey. The findings include: Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles. Review of complaint MD00215237 on 03/06/25 revealed an allegation Resident #1 was administered the wrong dosage of medication that caused his/her death. The complaint allegation indicated Resident #1 was only to receive one dose of the medication daily but instead received the medication twice daily. A review of Resident #1's closed medical record on 03/06/25 revealed a physician's order, dated 01/30/25, instructing the nursing staff to insert a peripherally inserted central catheter (PICC) line and administer the antibiotic, Cefepime, 1 gram, intravenously, every 24 hours, for 7 days. A review of Resident #1's January 2025 and February 2025 medication administration records revealed that on January 31st, February 1st and 2nd, the nursing staff administered the antibiotic Cefepime, 1 gram, intravenously, twice on these days. In an interview with Resident #1's physician on 03/06/25 at 4:40 PM, Resident #1's physician stated that he was made aware of the medication error by the nurse regarding Resident #1. Resident #1's physician confirmed that Resident #1 was to receive a 1 gram dose of Cefepime daily. In an interview with the facility pharmacy on 03/10/25 at 1:33 PM, the facility pharmacy manager confirmed the facility pharmacy received a new order for the antibiotic Cefepime, 1 gram, IV, to be administered every 24 hours, for 7 days. The facility pharmacy manager stated the physician order was signed by Resident #1 physician on 01/30/25 at 3:45 PM.

Based on medical record review and staff interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 1 of (Resident #1) of 4 residents reviewed during a complaint survey in relation to advanced directives. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. resident records. A review of Resident #1's closed medical record revealed a completed physician certification related to medical condition, decision making, and treatment limitations form dated 03/29/24. The facility nurse practitioner completed the form, signed the form, that was found in Resident #1's closed medical record on 03/06/25. In an interview with the facility CRNP#1 on 03/06/25 at 5:23 PM, CRNP#1 stated that she did not know why the signed certification form found in Resident #1's closed medical record did not have Resident #1's printed on the form. CRNP#1 stated that she receives a new binder full of documents to be completed for all newly admitted residents. These findings were shared with the Administrator and Assistant Director of Nursing on 03/10/25 at 3:20 PM.

Based on a review of a facility reported incident, medical record review, facility documentation review, observation and staff interviews, it was determined the facility failed to keep a dependent resident free from injury while transporting to activities in a wheelchair, which resulted in actual harm to Resident (R) #28. The failure of facility staff to place leg rests on a wheelchair while transporting a resident resulted in a fracture in the lower leg. This was evident for 1 of 30 sampled residents. The facility failed to ensure a resident was free from accident hazards by not identifying new fall interventions for one of three residents (R51) reviewed for falls resulting in a head laceration and pubic fracture. The facility failed to provide leg rests for the residents identified as requiring leg rests for injury prevention for one of one residents (R57) reviewed for wheelchair safety of 30 sampled residents. The findings include: 1. On 8/26/24 at 2:22 PM facility reported incident MD00194543 was reviewed and revealed Resident #28 sustained an injury while being transported during activities. The facility documented in their report that Resident #28, who was non-ambulatory, was being transferred to an activity via a wheelchair by an activity's aide. Resident #28 was holding his/her legs up when they became too heavy for him/her to hold up. Resident #28 dropped his/her legs to the ground, and they were caught up in the wheelchair per the aide. Resident #28 yelled out and the aide pulled the wheelchair backwards and asked the resident what was wrong. Resident #28 stated that, [his/her] knee hurt. The wheelchair did not have leg rests on the wheelchair. On 8/26/24 at 2:22 PM AM a review of Resident #28's medical record was conducted and revealed Resident #28 was admitted to the facility in March 2023 with diagnoses that included unspecified dementia, age-related osteoporosis, and a history of a right tibial fracture in 2021. Review of a 7/17/23 nurse's note documented, patient was brought to the nurse ' s station at approximately 1515 (3:15 PM) with an injury to [his/her] RLE (right lower extremity) and right knee. Area is red and beginning to swell. Patient is complaining of 8/10 RLE pain. Stat (immediate) x-rays to RLE were ordered. Review of a 7/17/23 nurse's note documented, portable x-ray was completed at right extremity, noted to be positive tibia fx. (fracture). The physician ordered for Resident #28 to be sent to the emergency room . At 8:30 PM Resident #28 was sent to the emergency room via 911. The note documented that the resident was in extreme pain and had been given medication with no relief. Review of the 7/17/23 Orthopedic Surgery Consult performed at the hospital on 7/17/23 at 10:52 PM documented, PMH (past medical history) significant for dementia and conservatively managed right proximal tibia fracture in July 2021, nursing home resident, primarily wheelchair dependent who presents for evaluation of right lower leg pain after apparent twisting incident in wheelchair at NH (Nursing Home). Mild swelling proximal lower leg with hematoma. No breaks in skin. Obvious pain with any passive motion of right knee. CT right lower leg without contrast: findings: comminuted fracture of the proximal tibia with displacement and diffuse osteopenia. There is osteoarthritis with osteophytes and narrowing of the knee compartments. Proximal tibia fracture with mild displacement. An X-ray of the right lower leg due to leg pain, right leg pain had the results, Osteopenia (low bone loss) and fractures of the proximal tibia with osteoarthritis (Osteoarthritis is a degenerative joint disease, in which the tissues in the joint break down over time). The conclusion was, Acute appearing proximal tibia fracture. The plan from the physician at the hospital stated, recommend conservative management of above injury. Appears [he/she] re-fractured area of proximal tibia which is not entirely surprising given advanced osteoporosis. Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures (broken bones). Review of Activity Aide #1' s written statement documented, I was taking resident outside for an outdoor stroll when [he/she] hollered in pain. I stopped, looked down, noticed [his/her] legs gave out and went under wheelchair. I then backed up wheelchair. [He/she] then told me that [his/her] right knee hurt a lot. I then went inside to retrieve [his/her] leg rests, since [he/she] did not have any leg rests on wheelchair. Once leg rests were on, I took [him/her] straight to the nurse. On 8/26/24 at 3:05 PM an interview was conducted with the Director of Physical Therapy (DPT). The DPT was asked who was responsible for the maintenance or determination of leg rests for residents in wheelchairs. The DPT stated, If a resident is referred to rehab or noticed by us, we would do an assessment. Everyone gets leg rests unless they self-propel. It would go to nursing and be care planned. On 8/26/24 at 3:10 PM an interview was conducted with the Activities Director (AD) who stated Activity Aide #1 no longer worked at the facility. The AD stated the incident with Resident #28 and the wheelchair was an isolated incident. The AD stated that some residents can hold their feet up and let you know when they are tired. The AD stated the activity ' s aide was taking the resident outside. They were on the front sidewalk heading to the patio. I think the resident got tired of holding [his/her] feet up and just let them down. The feet went under the wheelchair. On 8/26/24 at 3:22 PM and 8/27/24 at 10:19 AM calls were placed to Activity Aide #1 with no answer. As of 8/29/24 at 4:45 PM the aide failed to return the surveyor's call. Continued review of the facility's investigation revealed a Clinical Huddle Review dated 7/21/23 that documented 10 items for discussion during the review. The last item on the huddle was, recent leg injury related to non-use of leg rests. New protocol being implemented next week. There were 23 signatures of staff that attended. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident #39's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #28's quarterly MDS with an assessment reference date of 5/11/23 documented Resident #28 was extensive assistance with 2 people for locomotion on and off the unit and total dependence with 2 people off the unit. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the Resident #28's care. Review of Resident #28's at risk for falls care plan related to gait/balance problems, psychoactive drug use, and unaware of safety needs, had 6 interventions; anticipate and meet the resident's needs. Be sure the resident's call light is within reach for assistance as needed. The resident needs prompt response to all requests for assistance. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening, and improved mobility. Ensure that the the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Educate resident/family/caregivers/IDT as to causes and the resident needs a safe environment. The interventions on the care plan were not resident centered for Resident #28 and the care plan was not updated after the incident to reflect the use of wheelchair leg rests. On 8/27/24 at 1:25 PM an interview was conducted with the Director of Nursing (DON) who stated, that day [he/she] was holding [his/her] legs up and then let them down. It was an activity assistant. Typically, [he/she] is taken out of the room to another area. That day [he/she] was taken outside and maybe it was too far. The DON and the surveyor went out the front door where the incident occurred. There was a silver transition strip approximately 5 inches wide where the sliding glass doors automatically open and close. Resident #28 was pushed over the transition strip onto a piece of brown outdoor rug that was sitting on top of the concrete. The DON stated it happened there and not at the point where the sidewalk slopes mildly downhill toward the sitting area where residents can sit by the trees. On 8/27/24 at 4:05 PM the Nursing Home Administrator (NHA) gave the surveyor a copy of the Resident transport while in facility or on Campus from the Nursing Procedure Manual. Procedure number 3 documented, all residents will be evaluated by the Rehabilitation Team to determine the safest mode of transportation to be used within the facility. Number 4 stated, all residents that require a wheelchair as their safest mode of transport will be further evaluated by the team to determine the need for foot pedals/leg rests during transport. On 8/29/24 at 12:00 PM an interview was conducted with the resident's attending physician. When asked about the leg rests the physician stated, the resident probably should have had leg rests on the wheelchair since [he/she] was going a distance and outside. The resident's legs may get tired so the leg rests should be on the chair. 40902 2. Review of a facility policy titled, Resident transport while in facility or on Campus, revision date July 2023, revealed, Objective: To ensure the safe transportation of a resident within the facility. To determine the least restrictive and safest mobility transport for the resident. To promote the highest level of independence for the resident with regards to mobility when out of bed .Wheelchairs, and leg rests . All wheelchairs will have matching leg rests/foot pedals labeled . The residents that are required to have foot pedals/leg rests on their wheelchair when they are in it, will have a sign designating this placed at the head of their bed. Review of R51's Face Sheet, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including difficulty in walking, muscle weakness, repeated fall, and dementia. Review of R51's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/24 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 99 out of 15 which indicated the resident was severely cognitively impaired. Review of R51's care plan located under the Care Plan tab of the EMR and dated 02/01/23, revealed The resident was at risk for falls related to gait and balance issues and poor safety awareness. Interventions in place were anticipate and meet resident's needs, be sure the residents call light was within reach and encourage resident to use it, educate the resident and family about safety reminders and what to do when a fall occurred, ensure the resident was wearing appropriate footwear, follow facility protocol, and the resident needs a safe environment. Further review revealed no updated fall interventions since it was implemented on 02/01/23. a. Review of a Nurse's Note located in the EMR under the ''Notes'' tab, written by Licensed Practical Nurse (LPN) 1 on 03/09/24 at 10:47 AM, revealed GNA [Geriatric Nurse Aide] reported to nurses' station that resident was noted on floor. The resident was last seen in her wheelchair 2 minutes before falling. Injury noted to left side of her face with large amount of bleeding coming from the site. Resident was not removed from the floor until EMTs arrived, but a nurse was applying pressure to stop the bleeding. 911 was called immediately, resident daughter and physician were notified. Review of Incident report, provided by the facility and dated 03/09/24 at 10:35 AM, revealed staff notified nurse that resident was on the floor bleeding. When the nurse arrived at resident's room resident was lying on right side of face and large amount of bleeding, called 911, resident's daughter and physician. No additional interventions were added to the care plan. Review of a Nurse's Note located in the EMR under the ''Notes'' tab, written by Registered Nurse (RN) 5 on 03/14/24 at 11:28 PM, revealed Resident returned via transport without incident. Resident returned with head Injury from fall left with a laceration to the left side of scalp and one stitch to repair laceration. b. Review of a Nurse's Note located in the EMR under the ''Notes'' tab, written by Registered Nurse (RN) 5 on 03/14/24 at 11:28 PM, revealed Called to resident's room by attending GNA at approximately 6:45pm. Found resident flat on their back and laying under the bedside table. Resident states they tried to put themselves to bed. Passive range of motion done to all extremities; no pain noted at this time. No marks noted either. Resident was calm and denied any pain. Lifted with staff assistance to bed. Review of Incident report, provided by the facility and dated 03/14/24 at 6:45 PM, revealed called to residents room, resident lying flat on back under the bedside table, states they were trying to transfer from wheelchair to bed. No additional interventions were added to the care plan. c. Review of a Nurse's Note, located in the EMR under the ''Notes'' tab, written by LPN2 on 03/17/24 at 6:54 AM, revealed, Approximately 2:15 AM while during rounds resident was noted sitting in an upright position on his/her bedside mat wrapped up in her blankets. When asked, the resident what happened they stated, I rolled to get up to go cook breakfast and this is where I landed. Full head to toe assessment with ROM complete. No injuries noted. Resident is Alert and pleasantly confused. Neuro assessment sheet started. The physician assistant and daughter made aware. Review of Incident report, provided by the facility and dated 03/17/24 at 2:15 AM, revealed, resident found lying on bedside mat during hourly rounds. Resident stated they was getting up to cook. No injury noted, range of motion completed. The physician assistant and daughter made aware. No additional interventions were added to the care plan. d. Review of a Nurse's Note located in the EMR under the ''Notes'' tab, written by RN2 on 03/27/24 at 9:41 PM, revealed Resident found sitting on floor mat at the bedside with back against the bed. Resident was assessed no injuries or open areas noted. Resident assisted in the bed with two assists. Resident was turned on their left side with pillow placed behind back to offload his/her bottom. Residents' daughter called and made aware. The physician has been notified. Review of Incident report, provided by the facility and dated 03/27/24 at 9:30 PM, revealed, resident found sitting on bottom on floor mat by staff, no injuries noted. Resident was assisted back into bed by staff. No additional interventions were added to the care plan. e. Review of a Nurse's Note, located in the EMR under the ''Notes'' tab, written by LPN1 on 06/08/24 at 10:21 PM, revealed 6:30 PM called to resident's room, resident noted to be lying on left side between wheelchair and cooling unit, small amount of blood noted at forehead, initially resident denied pain and was independently moving all extremities, resident was lifted from lying position to bed and then began complaining of pain at both hip and my groin, daughter notified and requested that resident be sent to emergency room , physician notified. Review of Incident report, provided by the facility and dated 06/08/24 at 6:30 PM, revealed, see progress note. No additional interventions were added to the care plan. Review of a Nurse's Note located in the EMR under the ''Notes'' tab, written by LPN1 on 06/08/24 at 10:28 PM revealed, called received from hospice nurse who was notified of emergency room visit. Resident does have pubic fracture. During an interview on 08/28/24 at 12:04 PM, GNA3 stated staff had access to the Kardex and could see interventions there. She said if there was an intervention on the care plan that was not on the Kardex they may be informed by staff. She said R51 was a high fall risk, and that staff tried to keep her up at the nurse's station. She also said there was a mirror in the room that helped staff to see if he/she was trying to get up when they were walking in the room. She said R51 did not like her brief wet and the resident would get up and try to go to the bathroom. She said the mirror was recently put in the resident's room but there was no additional supervision or toileting for R51 by staff. She said she was unable to remember the fall R51 had on 03/09/24 but knew R51 had a few falls. She said there were no huddles or discussion with GNA staff about falls, or patterns or identifying new interventions, but stated the staff that find the resident after they have fallen must write a statement. During an interview on 08/28/24 at 12:29 PM, GNA2 said interventions were posted up in the resident's room and when there were changes that would be verbally communicated during shift-to-shift report. R51 had a weighted blanket on resident's lap when she was in the wheelchair, and she had a low bed and floor mats. She said she would lay the weighted blanket on him/her at times when he/and would get up the minute he/she wanted to. R51 would not know what to do with the call light due to her impaired cognition. She said she had not experienced staff including GNA's about falls discussion/interventions or fall investigation. During an interview on 08/28/24 at 1:21 PM, RN1 said R51 had floor mats and a low bed in place for fall preventions and when the resident was in their wheelchair staff kept an eye on them. He/She said staff would peek in on them every couple of hours due to he/she being a high fall risk. She did not remember the fall that occurred on 03/27/24 but she said there was no discussion after the fall about new interventions. But she said R52 had poor safety awareness and would call out for various people or things, frequently took their legs out of the bed, moved a lot in the bed, and would slide out of the bed onto the mat. But she was unaware of any new interventions implemented after the fall on 03/27/24. During an interview on 08/28/24 at 3:16 PM, LPN1 said staff tried to keep R51 in line of vision when they was out of the room, and there was a mirror (placed after the fall on 06/08/24) and there was a sitter provided by the family. Staff would check on them every two hours. She said R51 would not know how to use the call light, and he/she would get up when he/she wanted to get up. On 06/08/24 she was called to R51 room by a GNA (unsure who) and she found R51 on the floor on their side and there was blood, and it appeared R51 had hit her head on the ac [air conditioning] unit. She said at that time R51 denied pian, and their range of motion was fine, and there were no visual signs of pain. Staff lifted him/her from her lying position, and at that time R51 started complaining of pain in their groin. She stated R51 did not have a low bed at the time and that they had a regular hospital bed. She said she would have documented if there was a mat was on the floor at the time of the fall and she did not. Unsure about new fall interventions. During an interview on 08/28/24 at 3:39 PM, RN5 stated she was also the 3:00 PM-11:00 PM supervisor. She said R51's family provided a sitter that came in between 4:00 PM-5:00 PM and stayed until after dinner or until bedtime sometimes. She stated staff also checked on her frequently and would peek into the room when they passed by. During an interview on 08/29/24 at 11:01 AM the MDS Coordinator (MDS) said they have identified an issue that identified interventions were not making it onto the care plan, but they were unsure why. She said that after a new intervention was identified that was communicated to staff during shift to shift, but she said it would be a problem for any new staff or staff not working that day because they would have no idea about the new intervention in place if it was not actually listed on the care plan. She said staff were trying to keep R51 out of their room in the wheelchair and involved with activities. She said there should have been new interventions identified after each fall. She was unsure why she never caught that there have not been any new fall interventions implemented since 2023 when she reviewed the care plans quarterly. She reviewed all the falls Incident reports and stated she was not aware of any new interventions that were implemented after each fall. She said was aware R51 was a fall risk and had falls with injuries. During an interview on 08/29/24 at 12:05 PM, the attending physician stated he was aware that R51 has had falls, but he couldn't remember the falls specifically. He said he was sure there was some discussion about the falls, and he would have expected the facility to have identified new interventions after the falls occurred to try and prevent the injuries that occurred. During an interview on 08/29/24 at 12:37 PM, the Director of Nursing (DON) stated there was lot of discussion about new fall interventions for R51 after their falls, but she said there was no documentation about those discussions. She said staff were supposed to check in on the R51 frequently but that was only verbally communicated to staff and there was no documentation of that. And she was unable to say for sure that all staff were made aware of this. But she agreed that if it was put on the care plan all staff would be aware and that would be best practice. She said the facility did need to do better with their documentation and she admitted that when she looked at the care plan after a fall, she was just looking that the date of the fall was listed on it. She said even though she reviewed the care plan after each fall she never realized that there had not been an update since February 2023. 26446 3. Review of the EMR admission MDS with an ARD of 07/11/24 revealed R57 was admitted to the facility on [DATE] with multiple diagnoses which included dementia and a cervical (neck) fracture. Further review of this MDS revealed R57 was totally dependent on staff for all Activities of Daily Living (ADLs) except for eating and scored three out of 15 on the BIMS indicating R57 was severely impaired cognitively. Observation on 08/27/24 at 10:10 AM revealed Activity Aide (AA) 1 wheeling R57 in his/her wheelchair down the hall and out the front door of the facility. There were no leg rests on the wheelchair and R57 was holding his/her legs up off the floor. Review of the facility floor plan and the lengths of the hallways, provided by the Maintenance Director (MD), revealed AA1 wheeled R57 down the 400 hall into and through the 300 hall and through the main lobby and out the front door for more than 200 feet. During an interview on 08/27/24 at 10:15 AM, AA1 verified that she had received training to use leg rests when wheeling residents regardless if the resident was able to self-propel with their feet. AA1 verified that she had wheeled R57 without using leg rests requiring R57 to keep her legs elevated during transport. During an interview on 08/27/24 at 10:15 AM, the Infection Control Nurse/Staff Development (ICN/SD) verified the observation and that the staff had been trained to use leg rests for all residents during transport in a wheelchair. During an interview on 08/28/24 10:07 AM, the Director of Rehabilitation (DOR) stated that all residents were provided leg rests, and all residents should have leg rests on their wheelchairs unless the resident was self-propelling the wheelchair. The DOR stated that the rehabilitation staff evaluated the residents for their ability to self-propel the wheelchair with their feet. The DOR stated R57 had been evaluated and was appropriate to self-propel their wheelchair with her feet. The DOR stated that the facility policy was that anytime a staff member was pushing a resident in a wheelchair there were to be leg rests for the resident to rest their feet instead of having to keep them elevated off the floor. The DOR stated that sometimes residents would ask staff to push them once the resident was self-propelling. The DOR stated that staff should return to the resident's room and retrieve the leg rests before pushing the resident. The DOR stated that the leg rests were stored in the resident's room usually in the closet or a drawer. During an observation on 08/28/24 at 11:00 AM, RN1 verified there were no leg rests in R57's room. During an interview on 08/28/24 at 11:38 AM, the Medical Director verified that the facility's policy was for leg rests to be used when pushing a resident in a wheelchair. During an interview on 08/29/24 at 11:59 AM, the Attending Physician for all the residents in the facility verified that leg rests were to be used when wheeling a resident in the event the resident lowers their legs and [the leg] would get caught and injured. Surveyor: [NAME], [NAME] 16177

Based on observations, resident and staff interviews, and record review, the facility failed to ensure routine and 24-hour emergency dental care was provided or obtained from an outside resource to meet the needs for one of one resident (Resident (R) 55) reviewed for dental care out of 30 sampled residents resulting in significant weight loss. The facility failed to provide prompt dental services to a resident with identified dental pain by ensuring dental services were properly and timely arranged and completed to ensure continuity of care was provided to the resident. Findings include: Review of R55's Face Sheet located in the resident's electronic medical record (EMR) Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included left and right hip contracture, right knee contracture, congestive heart failure, and adjustment disorder with anxiety. Review of R55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/24 located in the resident's EMR under the MDS tab indicated the facility assessed R4 to have a Brief Interview for Mental Status (BIMS) score was eight out of 15, indicating R55 was moderately cognitively impaired. The MDS also indicated R55 was on a regular textured diet and had no dental concerns. Review of R55's Care Plan, last revised 12/05/23, indicated the resident had the potential for acute pain related to a history of fractures. The interventions included to administer analgesia .as ordered, to monitor and document for probable cause of each pain episode, to monitor/record/report to nurse any signs or symptoms of non-verbal pain, loss of appetite, refusal to eat and weight loss, and to notify the physician if interventions were unsuccessful or if current complaint was a significant change from the resident's past experience of pain. The care plan failed to identify changes in dental pain. Review of R55's Care Plan, dated 02/22/24, without revision in the EMR under the Care Plan tab, indicated the resident had an unplanned/unexpected weight loss related to poor food intake. The interventions included alerting the dietitian if consumption was between 0-25% for more than 48 hours, monitoring and evaluating any weight loss. The care plan failed to identify a decline due to dental concerns. Review of R55's Nursing Progress Notes, dated 07/24/24, revealed the resident complained of tooth pain, upon assessment the resident was noted with decay at left molar/tooth chipped. The Nurse Practitioner was made aware, and a new order was made for Anbesol as needed and 360 dental consult. The family was notified. Review of R55's Physician's Order and Signature Sheet, dated 07/29/24, documented a dental consult-left lower tooth pain/decayed tooth. Anbesol every 2 hours as needed for tooth pain. Review of R55's Nursing Progress Notes, dated 07/30/24, [He/She] was medicated this afternoon for complaint of dental and LE [lower extremity] pain with prn [as needed] Norco with good effect. An additional note stated Anbesol was applied for tooth pain. Review of R55's Nursing Progress Notes, dated 07/30/24, revealed to follow-up with 360 dental related to dental pain and decay one time only on 07/31/24 .360 not here today. Review of R55's Physician Progress Note, dated 08/01/24, revealed Patient seen for follow-up today. Patient complaining of toothache. Has not been eating very well because of dental pain. Dental pain likely secondary to tooth infection. Will treat with a course of Augmentin. Review of R55's Nursing Progress Notes, dated 08/01/24, revealed the resident complained of left lower gum pain related to left lower molar and that resident was scheduled to see 360 dental group on 08/14/24. The resident was medicated with as needed Norco for pain and also topical analgesic for left molar gum pain. The resident stated he/she could not eat her lunch related to dental pain. He/She was given a soft sandwich and ordered a mechanical soft diet. Review of R55's Nursing Progress Notes, dated 08/02/24, revealed the resident had complained of .lower molar pain, to see a new order for Augmentin (antibiotic) and resident had a pending dental consult. Review of R55's Nursing Progress Notes, dated 08/03/24, revealed .left lower dental pain. He/She declined her lunch. He/She is due to see the 360 dental on August 14th. Review of R55's Dietitian Progress Notes, dated 08/07/24, revealed Resident has mouth pain due to dental issues. Her meal intake is 0-50% currently. He/She has not wanted to eat since the pain started. He/She is on an antibiotic for the tooth. HIs/Her diet was also downgraded to Soft with Ground Meat due to the dental pain. Will upgrade diet as soon as dental issue has been resolved. Review of R55's Nursing Progress Notes, dated 08/11/24, revealed the resident completed prescribed antibiotics on 08/10/24. Review of R55's Summary Report, dated 08/14/24, also documented that the 360 dental group had Not Seen Resident was not seen due to time constraint. Review of R55's Nursing Progress Notes, dated 08/20/24, revealed the resident was scheduled to be seen by 360 dental group on 08/14/24 but was not seen due to time constraints. Review of R55's Dietitian Progress Notes, dated 08/22/24, revealed [His/Her] diet is Soft with Ground Meat due to dental pain currently. Resident wants to continue with this diet. HE/She had also taken Augmentin for the dental discomfort . Annual Dietary Evaluation: Height 62 inches. Weight 138.2 # (pounds). July weight was 145 # (pounds). Resident has had a 5% weight loss in one month. Review of R55's Plan of Care Note, completed by the MDS Coordinator (MDS) on 08/23/24, revealed Then when this nurse performed an oral assessment she pointed to her bottom left tooth in the back and stated it hurts. He/She rated her worst pain as a 10 and stated it rarely affects her sleep or activities. Review of R55's Nursing Progress Notes, dated 08/27/24, revealed, pain to bilateral knees and tooth .medicated for c/o [complaint of] tooth pain .tooth pain to lower gumline. Review of R55's Nursing Progress Notes, dated 08/28/24, revealed .lower tooth pain .c/o pain and discomfort to left lower tooth. Review of R55's medical record failed to identify any ongoing communication or attempt by the facility to resolve the resident's dental concern after antibiotic medication was completed on 08/10/24, the resident was not seen by the 360 dental group on 08/14/24 and continued to be in documented pain without resolution. Review of R55's medical record failed to identify any follow-up or communication with the family or outside resources to provide dental care in the community to address the acute change in condition in a timely manner. During an observation and interview on 08/27/24 at 11:04 AM, R55 stated he/she had dental pain and was supposed to see the dentist at the facility on 08/30/24. He/She said they were receiving pain medication and gel for the dental pain. He/She was observed touching and rubbing the left side of her lower jaw, grimacing, during the interview. During an observation and interview on 08/28/24 at 12:40 PM, R55 was observed in his/her room with their lunch tray placed in front of them on their bedside table, untouched. His/Her meal ticket revealed they was on a Soft diet. He/She said that they were uncomfortable and did not want to eat because he/she had tooth pain. He/She stated that they did not understand why they had not seen the dentist yet. He/She was again observed holding and rubbing the lower left side of his/her jaw while they grimaced in pain. During an observation and interview on 08/29/24 at 11:25 AM, R55 stated they had pain in her tooth, especially when their tongue touched it. R55 said that they needed to be seen by a dentist, because they had enough wrong already without the tooth pain. He/She was again observed rubbing and holding their lower left jaw while grimacing. During an interview on 08/28/24 at 12:44 PM, the Admissions Coordinator (ADM) stated that the facility nursing staff would go to the Medical Records/Scheduling (MR) if a resident needed an appointment with dental. During an interview on 08/28/24 at 12:50 PM, the Medical Records/Social Services (MR/SS) said that the facility had been trying to get R55 seen by a dentist. She stated that the facility used a dental group called 360 that had been in to see residents recently, and that the dental group would have a list of residents they intended to see when they arrived. The MR/SS confirmed that R55 was not seen by the dental group on the most recent visit in August. She stated that if the dental group documented that they could not see a resident due to a time constraint it was because the dental group had other facilities to go to. She said that she had contacted the resident's family member during this current week to determine who R55 had seen for dental care in the community prior to admission, but still needed to contact that dental provider to see if they could see the resident. During a subsequent interview on 08/28/24 at 1:27 PM, the MR/SS stated that she had just spoken to Accounting (AC) and R55 would not qualify for dental services by the 360 dental group until September 2024, so there should not have been any documentation of 360 dental group coming in to see the resident. During an interview on 08/28/24 at 2:00 PM, Geriatric Medication Assistant (GMA) said that she was familiar with R55. She confirmed that the resident had been complaining of lower left tooth pain for a few weeks. She stated that the resident had a darkened tooth that appeared to be broken and decayed. The GMA said that the resident had been prescribed antibiotics for the tooth because they thought it might be an infection. He/She stated that the resident had finished their antibiotics a while ago and still had the pain. He/She said that the resident still had a problem, and not just an infection. He/She stated the resident had a tough time eating because of it, and that nurses often had to provide the resident pain medication for the problem. The GMA was not aware if the resident had been seen by a dentist yet or not. During an interview on 08/28/24 at 2:40 PM, the AC said that R55 did not have coverage with the 360 dental group, and that the resident's representative had come into the facility on [DATE] to sign the application so that they could be seen with the dental group. She said the resident would not be covered until the following month and would not have been qualified to be scheduled to be seen by 360 dental group in August 2024. The AC said that the Medical Records/Scheduling (MR) should have known that R55 could not been seen by the 360 dental group by the middle of August 2024. She was not aware of why documentation continued to show the R55 was going to be seen by this dental group. During an interview on 08/28/24 at 3:22 PM, the MR said that she handled scheduling and transportation for residents. She said that nurses let her know who needs an appointment. She stated that for dental needs, she would look on her list to see if the resident was on the 360 dental group list and if they were not, she would try to find out who the resident used to see in the community and try to connect them back to that old dentist. The MR stated that the 360 dental group usually contacted her with a list of residents they would be seeing on their next visit, which she would then place at the nurse stations to let staff know who is going to be seen. She said that the facility also had a wheelchair van and Medicare transportation that they could use to send residents out for dental appointments. She stated that if a resident had an acute dental need, she would let a dentist know as soon as possible so they can be seen but could not recall any residents recently having an acute situation. The MR said that she had not been working when R55's tooth became a problem, but when she returned on 08/12/24 she found out the resident had not qualified to be seen by the 360 dental group until 09/01/24. She stated that she had been told that sometimes the resident had pain and sometimes she did not, so she did not feel it was urgent to get her seen acutely. She said that in morning meetings she was told that the resident was not being seen by the dentist. The MR said that on 08/27/24 she found out that the delay in dental care needed to be pursued by communicating with the family. She confirmed that she was not aware that the resident was in that much pain. During an interview on 08/28/24 at 3:45 PM, the Director of Nursing (DON) said that the facility had 360 dental group come to the facility to see the Medicaid and private pay residents that wanted to be seen. She said they generated a list, and if a resident had complaints, they put them on the list, too. The Director of Nursing said that the Attending Physician was made aware of anything unusual. She said that if the resident was not on the 360 dental group list they would send the resident to the community for dental services. She said that R55's dental concern was a new problem and that she had been complaining about her pain. She confirmed that the resident had been on antibiotics and that they thought she was supposed to be seen by the 360 dental group when they came in recently, but they left the facility without seeing her. She stated that the resident had a cavity and needed to be seen. She said that the family was involved, and that the facility was giving the resident medication for tooth pain. The Director of Nursing confirmed that if a resident had dental pain the facility would try to get them in right away, and not hold off on treatment. During an interview on 08/28/24 at 4:05 PM, Licensed Practical Nurse (LPN) 1 said that R55 had told her that part of the resident's tooth had broken off a while ago, and that she had dental pain. LPN1 said that she had been under the impression that R55 was being seen by a dentist, and did not realize the resident still had not been seen. She said that R55 received Tylenol, Norco, and Tramadol as needed for the dental pain, including in the last few days. The LPN1 said that the resident had been prescribed antibiotics, which she assumed was to be administered so that he/she could be seen afterwards for a dental procedure. During an interview on 08/29/24 at 10:22 AM, the DON confirmed that the facility did not have a policy that addressed dental concerns. During an interview on 08/29/24 at 10:31 AM, the Registered Dietitian (RD) stated that R55 had a problem with their tooth. She said it was giving the resident pain. The RD said that she believed that the facility was trying to get the resident a dental appointment since they had not been qualified to see the 360 dental group. She said that the resident's diet had been downgraded because of the dental pain, and that the resident needed to be seen to address the tooth pain. The RD said R55 had regular pain concerns, but the tooth pain was a new concern. She said that she hoped that after the resident was seen by a dentist, she could get her back onto a regular diet so she could continue to eat. The RD confirmed that the resident had lost weight during this time. She confirmed that the confusion in getting the resident seen by a dentist for dental pain had delayed in R55 getting seen promptly. During an interview on 08/29/24 at 11:10 AM, the Minimum Data Set Coordinator (MDS) said that R55's bottom tooth was bothering them, and he/she was supposed to see the 360 dental group when they came in, but they did not get to see them. She stated that she had observed the tooth to be discolored, and that the resident had complained of tooth pain after she had looked in R55's mouth. During an interview on 08/29/24 at 11:56 AM, the Attending Physician stated that the facility had 360 dental group come into the facility to see residents, but that the dental group had not seen the resident in August 2024 due to an insurance or something. He stated that he had prescribed R55 antibiotics early on with the plan of then seeing the dentist. The Attending Physician confirmed that he would have expected the resident to have been seen by a dentist by now. During a phone interview on 08/29/24 at 12:17 PM, a resident representative for R55 said that the facility had contacted her this current week to see who the resident had seen for dental care in the past. She said that the resident had broken her tooth, and that it had been going on for over a month. She stated that she thought R55 was going to be seen by the '360 dental group approximately August 14. The resident representative stated that the dental concern should be addressed sooner rather than later. During an interview on 08/29/24 at 3:52 PM, the Administrator said that the facility used 360 dental group for residents. She said that if a resident needed to be seen by a dentist, MR and/or MR/SS did the paperwork. The Administrator stated that if a resident needed dental emergency services, they could get it done because they did not let anyone stay in pain.

Based on record review, observation, and staff interview it was determined that facility staff 1) failed to update care plans when there were changes in resident needs or preferences and 2) failed to thoroughly evaluate and revise resident plans of care after each assessment. This was evident for 6 (#40, #27, #34, #28, #504, #505) of 10 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) On 8/26/24 at 10:00 AM Resident #40's medical record was reviewed and revealed an August 2024 physician's order for, Geri sleeves to bilat arms at all times. May remove for care, then reapply, every shift for skin discoloration. Geri-sleeves protect the upper extremities from abrasions, bruises, snags, and skin tears. Review of Resident #40's care plan, has potential for impairment to skin integrity r/t fragile skin, urinary incontinence, impaired mobility had 5 interventions. The care plan was not updated to reflect the use of Geri-sleeves. On 8/20/24 at 12:52 PM an interview was conducted with the Assistant Director of Nursing (ADON) who stated the resident had extremely thin, fragile skin and they have tried the leg sleeves, and the resident keeps taking them off and the resident has Geri sleeves that he/she refuses or removes. 2) On 8/26/24 at 11:16 AM Resident #27's medical record was reviewed and revealed on the evening of 6/9/23 Resident #27 was found face down on floor in [his/her] private room with visible bleeding from a facial wound. Resident #27 was send to the emergency room and found to have a left orbital floor/rib fracture with left maxillary sinus fracture. Review of Resident #27's care plan, at risk for falls related to gait/balance problems had 6 interventions that were dated prior to the 6/9/23 fall. There were no new interventions after the fall. On 8/26/24 at 9:05 AM observation was made of the resident eating breakfast in bed. There was a fall mat on the floor to the right side of the bed. The care plan was not updated to reflect the use of fall mats. On 8/26/24 at 3:30 PM a second observation was made, and Resident #27 was observed being wheeled in a wheelchair by an activity's aide. The resident did not have leg rests on the wheelchair. The leg rests were observed on the floor in the resident's room, however there was no signage about if the leg rests should be on or off the wheelchair. The care plan was not updated to reflect the use of leg rests. 3) On 8/26/24 at 12:40 PM a review of facility reported incident MD00192657 documented Resident #34 sustained a fall on 5/19/23. The resident was found sitting upright on buttocks with knees flexed outward, in the 100 hallway near the bathroom. Later in the day Resident #34 complained of low back and buttock pain. X-rays were taken which revealed an age-indeterminate compression fracture. The resident was to begin physical therapy. Review of the facility's investigation documented that Resident #34 was last seen by the attending GNA lying in bed in fetal position asleep. [Resident #34] is one person assist however [he/she] is non-compliant and will transfer [him/herself] from bed to bathroom with walker. To prevent this incident from happening again GNA should round more on resident and offer frequent toileting. Review of Resident #34's care plan at risk for falls was not updated to reflect rounding more on the resident and the offer of frequent toileting. On 8/29/24 at 12:37 PM an interview was conducted with the DON (Director of Nursing) who was asked what was done when someone fell . The DON stated the staff was expected to do a full assessment to determine if the resident could be moved or sent out, fill out an incident report, notify family, notify physician, document a progress note and an incident report that is forwarded to the DON. The DON stated, when I get the incident report, I check to make sure the family and physician were notified and make sure it is care planned. I actually look at the care plan when there is a fall. We discuss the interventions, the MDS Coordinator updates the interventions and sometimes I update the interventions, but the nurses don't. The DON was informed of the care plans that were not updated. 4) On 8/26/24 at 2:22 PM facility reported incident MD00194543 was reviewed and revealed Resident #28 sustained an injury while being transported during activities. The facility documented in their report that Resident #28, who was non-ambulatory, was being transferred to an activity via a wheelchair by an activity's aide. Resident #28 was holding his/her legs up when they became too heavy for him/her to hold up. Resident #28 dropped his/her legs to the ground, and they were caught up in the wheelchair per the aide. Resident #28 yelled out and the aide pulled the wheelchair backwards and asked the resident what was wrong. Resident #28 stated that, [his/her] knee hurt. The wheelchair did not have leg rests on the wheelchair. Review of Resident #28's at risk for falls care plan related to gait/balance problems, psychoactive drug use, and unaware of safety needs, had 6 interventions; anticipate and meet the resident's needs.Be sure the resident's call light is within reach for assistance as needed. The resident needs prompt response to all requests for assistance. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening, and improved mobility. Ensure that the the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Educate resident/family/caregivers/IDT as to causes and the resident needs a safe environment. The interventions on the care plan were not resident centered for Resident #28 and the care plan was not updated after the incident to reflect the use of wheelchair leg rests. 5) On 8/27/24 at 7:55 AM Resident #504's medical record was reviewed and revealed on 6/10/23 between the hours of 1:00 PM and 3:30 PM Resident #504 became very agitated and was found on the floor twice. Resident #504 was aggressive and not easily redirected. Resident #504 would not allow a full neuro assessment to determine if the resident had hit his/her head and was possibly suffering with an acute head injury. Resident #504 was sent to the emergency room for evaluation. Resident #504 was also evaluated for a hip injury and change in mental status. The resident returned to the facility with no fracture and no acute head injury. Continued review of Resident #504's medical record revealed Resident #504 had 6 falls from 3/24/23 to 6/10/23. Review of Resident #504's at risk for falls care plan only had 4 interventions that were initiated on 3/9/23. There were no additional interventions added to the care plan to aid in the prevention of further falls. Further review of Resident #504's care plans revealed a care plan, The resident has Shortness of Breath r/t recent hospitalization with pneumonia and COPD that was initiated on 2/3/22. The care plan had 7 interventions, however, was not updated to reflect oxygen use and how much oxygen the resident was to receive. There were no interventions about oxygen equipment change, oxygen cord length for when mobilized in the wheelchair and nothing about the inhalers the resident received according to the physician's orders and Medication Administration Record (MAR). They documented the resident received the inhalers Albuterol Sulfate every 4 hours when needed for shortness of breath and Ipratropium-Albuterol Sol. Inhaler every 12 hours when needed for wheezing and shortness of breath. On 8/28/24 at 9:21 AM an interview was conducted with the MDS coordinator who stated that everyone can create and update the care plan. The MDS coordinator was informed of the concerns related to not updating the care plan and she stated, as far as care plans, we were doing things for distraction, we just did not document it in the care plan. 6) On 8/27/24 at 12:00 PM a review of facility reported incident MD00191985 documented Resident #505 sustained a fall from the wheelchair prior to going to dialysis. The resident attempted to transfer self out of the chair and was found on the floor. Initially the resident did not complain of pain and was able to move all extremities. Later in the day, while at dialysis, the resident complained of pain and was sent to the emergency room where x-rays confirmed a right femoral neck intertrochanteric fracture. Review of Resident #505's care plan at risk for falls r/t poor safety awareness was not updated after the fall for additional interventions to keep the resident safe from injury. On 8/29/24 at 7:10 AM GNA #7 was interviewed and stated Resident #505, wanted what [he/she] wanted. [He/she] was not cooperative with anything. On 8/29/24 at 8:00 AM an interview was conducted with the MDS coordinator about who updates the care plans. The MDS Coordinator stated, when the shift supervisor is here Monday through Friday, depending on how busy the night was or if she was working on the floor, she will leave a report. I go to IDT meeting every morning and if there were changes, we would update the care plan. The MDS Coordinator stated that the DON looks at falls and brings to IDT. The DON adds fall to care plan, and we talk about it in IDT.

Based on observations, interviews, and policy review, the facility failed to provide visual privacy during a bed bath for one of one resident (Resident (R) 56) reviewed for privacy of 30 sample residents. This failure increased the risk of residents feeling humiliated and embarrassed when being exposed to others during care. Findings include: Review of the Code of Maryland Regulations, dated 09/18/19 and provided as the facility's residents' rights policy, revealed A nursing facility shall provide care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, and in full recognition of the resident's individuality .personal privacy in personal care . Review of the Bed Bath procedure, dated 04/01/90, revealed Screen patient [pull curtains] .Remove clothing and cover with sheet, not exposing patient unnecessarily . Review of R56's electronic medical record (EMR) quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/02/24 revealed R56 was totally dependent on staff for bathing and R56 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. During the tour of the facility on 08/26/24 at 10:40 AM, this surveyor knocked on R56's room door when a staff member stated, yes? This surveyor announced herself and opened the previously closed door to see R56 lying on her bed completely naked and exposed while Geriatric Nurse Aide (GNA) 4 was providing a bed bath. R56 had no sheet or bed blanket covering her. The privacy curtain was not pulled and R56 was visible to the surveyor from the hallway. The window curtain was also not pulled exposing R56 to anyone walking outside (with no coverage) past her room. R56's room was ground level. During an interview on 08/26/24 at 11:00 AM, GNA4 verified that the curtains were not pulled nor was R56 covered while receiving a bed bath. During an interview on 08/26/24 at 11:05 AM, when asked if they were bothered by being exposed while receiving a bed bath, R56 stated, not so much unless a man saw [her/him] then no, no, no. During an interview on 08/29/24 at 10:20 AM, the Director of Nursing (DON) stated, Privacy and dignity during care is our expectation. Not only the privacy curtain but the window curtain should be pulled, and the resident should be covered during the bath.

Based on observations, interviews, record review, and policy review, the facility failed to maintain a restraint free environment for one of one resident (Resident (R) 51) reviewed for physical restraints out of 30 sample residents. This failure increased the potential for R51, if attempted, to not be able to leave her bed. The use of restraints increased the risk of negative outcomes such as decline in physical functioning, increased accident hazards and falls, a loss of autonomy, and increased withdrawal, depression, and/or reduced social contact. Findings include: Review of the Code of Maryland Regulations, dated 09/18/19 and provided as the facility's residents' rights policy, revealed a physical restraint means a device including material or equipment, attached or adjacent to a resident's body, that the resident cannot remove easily and that restricts the resident's freedom of movement .Physical restraints may be used only: as an integral part of the an individual medical treatment plan; if absolutely necessary to protect the resident or others from injury; if prescribed by a physician .if less restrictive alternatives were considered and appropriately ruled out by the physician . Review of the facility's undated policy titled, Restraint Appropriate Risks and Benefits revealed the facility is ultimately responsible for the appropriateness of and decision regarding restraint usage . Further review of this policy revealed lists of appropriate restrictive devices from least restrictive to most restrictive. A wheelchair against the bed was not listed as an appropriate restrictive device. Review of R51's electronic medical record (EMR) quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/24 revealed R51 was admitted to the facility on [DATE] with multiple diagnoses which included dementia. Further review of this MDS revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating R51 was severely cognitively impaired. Review of the EMR Care Plan tab revealed a care plan for falls, revised 07/24/24, for multiple falls from their wheelchair or bed, two falls resulted in major injuries. Cross Reference: F689 Free of Accident Hazards, Supervision for R51. The interventions for the fall care plan did not include using a physical restraint to prevent R51 from attempting to transfer in or out of bed. Observation on 08/29/24 at 6:45 AM revealed R51 sleeping in a low bed with a fall mat in place on the right side of the bed. Further observation revealed a quarter side rail up on the right side of the head of the bed (HOB) and the left side of the bed was against the wall. R51's wheelchair was observed against the quarter side rail at the HOB extending past the quarter side rail. The wheelchair was observed placed up against the HOB in such a way that R51 would not be able to get out of bed or into the chair. Observation on 08/29/24 at 6:47 AM revealed Geriatric Nurse Aide (GNA) 1 walking into the hall from the nurses' station, entering R51's room, and moving the wheelchair away from the bed, and placing the wheelchair near the window. During an interview at the same time of the observation, when asked about the placement of the wheelchair against the HOB, GNA1 stated she had placed the wheelchair against the HOB because she [R51] leans over too far in the bed and falls out. During an interview on 08/29/24 at 7:00 AM, Registered Nurse (RN) 3 verified she was the nurse on the 11-7 (11:00 PM- 7:00 AM) shift and made rounds to observe the residents. RN3 stated she did see the wheelchair against the HOB but did not ask the GNA about the wheelchair nor did she move the wheelchair away from the HOB. RN3 was asked if the wheelchair against the HOB was an intervention to keep R51 from falling out of the bed. RN3 stated, No, the wheelchair is stored near the window or near the wall across from the foot of the bed. During an interview on 08/29/24 at 7:05 AM, the Infection Control Nurse/Staff Development (ICN/SD) nurse was notified of the observations and interviews concerning R51's wheelchair. The ICN/SD nurse stated. [the wheelchair against the HOB] is still a barrier [from getting out of bed] regardless if it was to keep her from falling out of the bed. During an interview on 08/29/24 at 10:45 AM, the Director of Nursing (DON) verified that the wheelchair was not to be placed against the bed.

Based on resident interview, staff interview, clinical record review, and a review of the facility abuse investigation it was determined that the facility staff failed to ensure residents were free from abuse (#36). This was evident for 1 out of 2 residents reviewed for a reportable incident. The findings include: A review of Resident #36's clinical record and the facility investigation revealed that the resident alleged to the Assistant Director of Nursing (ADON) and to the Administrator that geriatric nursing assistant (GNA) #23 had used a dry towel to apply lotion to his/her face and nose. The resident complained during the facility investigation that the towel was rough, and it hurt. The resident further informed the facility during their investigation that GNA #23 then shoved the towel in the resident's mouth. The resident was quoted during the facility investigation stating: He hurt me. I thought a tooth had broke. A review of the facility clinical record revealed that the resident was assessed. A review of a nursing note written on 4/18/19 noted: Redness and scratch marks were on the resident's face. Redness and bumps on nose and left cheek. Redness under chin. No sign of a broken tooth. [MEDICATION NAME] (an [MEDICATION NAME]) was administered as a result. A review of the resident's clinical record revealed that the resident stated that he/she did not want any new medications as a result of the incident but did agree to receive [MEDICATION NAME] to treat facial pain. The Sheriff's office was called at 12:15 PM on 4/18/19 and a deputy responded by 1:40 PM. He talked with the resident who had made the allegation. The resident did not want charges against the employee filed. The ADON and the Administrator talked with the staff member. He did not deny what the resident had alleged. The employee was terminated immediately on 4/18/19. A mandatory in-service was held with other facility employees. The family was notified at 1:15 PM on 4/18/19, primary physician was notified at 1:30 PM on 4/18/19, and the Ombudsman was called at 1:50 PM on 4/18/19. The Administrator was interviewed on 6/12/19 at 9:04 AM. She confirmed the preceding information. Stated that the resident did not want to press charges. She said GNA #23 admitted to the incident and told her that his career would be over. Resident #36 was interviewed on 6/12/19 at 10:34 AM. The resident said, Well, he was giving me a bath, he then did his usual habit of getting a cold bottle of lotion and dripped it on my body, he got me a towel, I complained about it and asked why he does this. He replied something like 'I don't know why'. GNA then jumped on bed and rubbed towel on my face. He then shoved the towel down my mouth. I haven't seen him since. Whenever I look out the window I wonder if he is in the parking lot. GNA said in the past that he owns two pistols. Told him I can get him fired and he replied that he didn't care. 'I can get a job anywhere'. He was a nasty (expletive). He often left room with his shoes untied. GNA said he was too lazy to tie his shoes. Resident said he/she had a sore mouth and a sore on the tip of the nose as a result. GNA #10 was interviewed on 6/12/19 at 3:40 PM. She said a staff member told her that the resident was complaining about GNA #23 and she went in to see the resident. The resident's face was red and had scratch marks on it. She stated she asked the resident what happened, and he/she said GNA #23 rubbed his/her face real hard and felt like he/she was being pushed down. Resident then alleged that it felt like the towel was being pushed into his/her mouth. Prior to this incident the resident said GNA #23 would pour the shampoo directly on the resident rather than on a towel. She confirmed that the marks were not on the resident prior to the incident. GNA #10 said she reported it to the Administrator who interviewed the resident immediately and the story did not change. RN #11 was interviewed on 6/13/19 at 8:20 AM. She said she recognized the resident's face was red and the resident was out of bed in his/her chair. The resident's face was fine that morning. The resident had red bumps on his/her face. She went to the nurse and asked if she knew what happened. The nurse immediately went to the room. She could not remember who told the Administrator. The resident told her that GNA #23 was rough with him/her. It was just the two of them. No other staff was present. She said they did not get along. RN#11 indicated the resident stated he/she not care for GNA #23 but would not say why.

Based on a facility reported incident, review of a medical record, and staff interview, it was determined that a facility staff member failed to follow a resident's care plan to prevent the resident from sustaining a laceration to the leg which required laceration repair. This occurred for 1 (Resident #50) of 8 residents reviewed for accidents during an annual recertification survey. The findings include: Review of facility reported incident MD 122 on 06/10/19 revealed an allegation Resident #50 sustained a laceration to the right lower leg during a transfer on 11/25/18. Review of Resident #50's medical record on 06/10/19 revealed Resident #50 had a history of [REDACTED]. Resident #50 was also noted to be at risk for non-pressure related skin impairment (skin tears) related to poor safety awareness. On 11/01/18 at 8:10 AM, Resident #50 suffered a skin tear to the right lower leg while being transferred from the bed to his/her wheel chair. Resident #50's injury was cleansed with normal saline and steri strips were applied. A review of the facility investigation into Resident #50's 11/01/18 right lower leg skin tear revealed that two staff were present The facility staff also conducted a post incident care plan review on 11/01/18 and determined that the nursing staff should start using a mechanical lift along with the use of two staff members when transferring Resident #50 from the bed to the wheel chair. Medical record review on 6/10/19 verified that the nursing staff updated Resident #50's care plans to include this new intervention, and updated the geriatric nursing assistants care guide on 11/01/18. In an interview with geriatric nursing assistant GNA #13 on 06/12/19 at 5:37 PM, GNA #13 stated she recalled transferring Resident #50 from the bed to the wheel chair with GNA #14. GNA #13 stated that s/he and GNA #14 each lifted Resident #50 under his/her arms and pivoted Resident #50 into his/her wheel chair. GNA #13 stated that s/he was not aware that Resident #50 had a cut on his/her leg during the transfer. GNA #13 stated that s/he was aware Resident #50 had delicate skin and that Resident #50 must have scratched his/her leg on one of the wheel-chair leg rests during the transfer. Further review of Resident #50's medical record revealed that on 11/25/18 at 7:11 AM, Resident #50 sustained another skin tear to the right lower leg during a transfer. A review of the facility investigation indicated Resident #50 sustained a skin tear to the right lower leg when being transferred from the bed into the wheelchair by GNA #16 while using a stand pivot transfer. Resident #50 was subsequently sent to the local hospital emergency room and was diagnosed with [REDACTED]. Resident #50's right lower leg wound was also diagnosed with [REDACTED]. performed a laceration repair of the right lower extremity. The facility investigation indicated GNA #16 inappropriately transferred Resident #50 by himself/herself using a stand pivot transfer which resulted in Resident #50 sustaining the skin injury to his/her right lower leg. In an interview with GNA #16, on 06/12/19 at 4:22 PM, GNA #16 stated that s/he was not aware Resident #50 required the use of a mechanical lift and the use of two staff members when being transferred from the bed to the wheel chair. GNA #16 stated s/he was not aware of the policy change at the time. GNA #16 stated specifically, that s/he transferred Resident #50 using the stand pivot transfer when s/he worked with Resident #50 during the morning of 11/25/18. A review of GNA #16's training records on 06/11/19 failed to reveal that s/he received the education that Resident #50 was to be transferred, after 11/01/18, by two staff members using a mechanical Hoyer lift. The facility conducted an investigation and subsequently terminated GNA #16 for failure to follow a resident's plan of care.

Based on observation, interviews and review of the medical record, facility investigation and manufacturer guidelines on 2/23/17, it was determined that the facility failed to safely transfer a resident (#61) using a Hoyer sling/lift. The resident fell from the Hoyer sling when the left loops ripped; this resulted in the resident falling and suffering a fractured left hip. Prior to the fall/fracture which was a result of the condition of the Hoyer sling the facility failed to maintain a system to assure that the Hoyer slings in circulation were evaluated for wear and tear. In addition (refer to #2), the facility failed to ensure a medication cart was locked; this was found to be evident in one medication cart observed on one out of the six nursing wings. The findings included the following: During the annual quality indicator survey (QIS) complaint #MD 105 received by the office of health care and quality (OHCQ), on 10/14/16 was reviewed. (There was also a facility reported incident (FRI), per the intake, dated 10/12/16 with the same intake number). The complaint alleged that resident #61 had: fallen from the Hoyer sling/lift when the straps of the sling broke; been transported to the hospital and; diagnosed with [REDACTED]. On 2/23/17 the surveyor reviewed resident #61's medical record, the facility investigation, the Hoyer user instruction manual, as well as interviewed the geriatric nursing assistants (GNA #2 and #3) involved in the transfer, the environmental services (EVS) director, the assistant administrator (AA) and the quality assurance (QA) nurse. A Hoyer lift is used for transfers when a person requires assistance to safely get into and out of bed. A pad (sling) fits under the person's body in the bed/chair and connects with loops to the arms on the Hoyer lift frame. A hydraulic pump is used to lift the person off the /chair surface. The slings come in different sizes - half slings, full slings and lift to stand slings. The user instruction manual included the following: A warning: to check the sling and stitching before each use; using bleached, torn, cut, frayed or broken slings was unsafe and could result in serious injury and/or death to a resident and; slings that were worn should be destroyed and discarded. In addition, it was recommended that the slings were checked regularly and before each use, for fraying and/or damage. Washing instructions also included a warning that the slings could suffer damage during washing and drying and should be checked carefully before each use. By way of history resident #61 had [DIAGNOSES REDACTED]. On 10/10/16 at 5:02 pm resident #61 was being transferred from the chair with a Hoyer sling/lift. Both of the left side loops that attached the sling to the lift ripped, the resident fell to the floor, resulting in complaints of pain in the left hip. The resident was transferred to the hospital and subsequently diagnosed as a left hip fracture. The facility completed an investigation and concluded after interviews with GNA #2 and #3 that the loops that connected the sling to the Hoyer lift had ripped resulting in the resident falling from the sling and complaining of pain in the left hip. The nurse, #5 that was in the room also confirmed this recollection of the event. During the survey on 2/23/17 at 2:49 pm and 3:15 pm the surveyor also interviewed both GNAs and the recollection remained the same - at the time of the fall/fracture they failed to assess the Hoyer sling for wear and tear. On 2/23/17 during the complaint investigation the Assistant Administrator, environmental services (EVS) director and Quality Assurance nurse told the surveyors, during interview, that they had not had a system in place at the time of the fall/fracture for assessing the Hoyer slings for wear and tear. The facility failed to safely transfer a resident using a Hoyer sling/lift; this resulted in the resident falling and fracturing his/her left hip. 2. The facility failed to ensure a medication cart was locked. This was found to be evident in one medication cart observed on one out of the six nursing wings. The findings include the following: During a tour of the facility this surveyor observed an unlocked medication cart in the hallway of the 500 wing on 2/22/17 at 1:46 PM. Several Geriatric Nursing Assistants (GNA's), a physician, and other facility employees were observed to walk by the unlocked medication cart. Another surveyor was called at 1:49 PM and arrived to the wing at 1:55 PM who confirmed the observation. This surveyor opened the medication cart and observed several medications in the drawers. The medications were for Residents #24, # 78, and #130. Some of the medications found were Lovenox (anticoagulant), albuterol (treats respiratory conditions), guaifenesin dextromethorphan (cough medicine), and phenylephrine (eye medication). Also found were lancets which are used to draw blood. The nurse (staff #4) who was responsible for the medication cart was interviewed on 2/22/17 at 2:00 PM. This surveyor asked if the medication cart was normally locked. She stated it was normally locked but she must have forgotten when she left for lunch. This surveyor asked when did she go to lunch and she replied that she left 20 minutes ago. The results of the observation were brought to the attention of the administration on 2/22/17 at 2:07 PM and no further information was provided prior to exit. The facility failed to ensure a medication cart was locked; this was found to be evident in one medication cart observed on one out of the six nursing wings.

Based on medical record review and interviews with staff, it was determined the nursing staff failed to attempt Cardiopulmonary Resuscitation (CPR) for a resident who's code status was a full code in one of 35 residents reviewed in Stage 2. CPR is an emergency procedure consisting of external cardiac massage and artificial breathing. It is the first treatment for [REDACTED]. CPR attempts to restore circulation of the blood and prevent death or brain damage due to lack of oxygen. A full code is an order to perform any and all interventions in the event of cardiac or respiratory arrest. The findings included: Resident #110 was a [AGE] year old female admitted to the facility on [DATE] for rehabilitation following a hospitalization for pneumonia. Resident #110 was her own health care decision maker and wished to be a full code. Review of the medical record revealed a MOLST form completed by the physician and resident on [DATE] documenting the resident's wish for CPR in the event of cardiac and/or [MEDICAL CONDITION] arrest ( no pulse and/or no respirations). The MOLST (Maryland Medical Orders for Life-Sustaining Treatment) form is the recognized physician order [REDACTED]. Further review of the medical record revealed the following note at 5:05AM on [DATE]: "GNA (Geriatric Nursing Assistant) called nurses to room. When staff member first entered room to perform incontinence care, it was noted that resident was not breathing. Upon closer inspection, resident was pale & cool to touch. 2 nurses assessed resident & verified that there was no pulse or respirations noted. Unable to obtain blood pressure or pulse ox (oxygen level in blood). (Physician's name) notified of resident's passing & authorized release of body to funeral home...". During an interview via telephone at 12:30PM on [DATE], nurse #1 verified that neither nurse attempted CPR. Nurse #1 stated that "nothing could be done for the resident. She was lying in bed with no breathing or pulse. She was not in rigor but she was not as moveable as normal". Rigor is the stiffening of a dead body. Interview with physician #2 on [DATE] at 2:10PM revealed that his opinion was that CPR would be ineffective secondary to the resident's age and coronary status. Physician #2 verified that resident was capable of making health care decisions and the resident did want CPR in the event of cardiac and/or [MEDICAL CONDITION] arrest. The nursing staff failed to initiate CPR for a resident who wished to have CPR in an attempt to be resuscitated.

Based on medical record review, interviews with staff and review of the facility's investigation, it was determined the nursing staff failed to use a Hoyer lift to transfer a resident from her bed to wheelchair and back to bed resulting in a laceration to her right leg. This occurred in one of two medical record reviews. A Hoyer lift is a mechanical device that uses a sling to transfer an individual from one surface to another. The findings included: Resident #1 was admitted to the facility on [DATE] for rehabilitation following a fall and right hip fracture at home. The resident is [AGE] years old, alert and oriented but with confusion and is legally blind. Review of the medical record on 03/22/12 revealed that physical and occupational therapy, along with the nursing staff, had assessed this resident and determined that the resident requires a Hoyer lift to be used for transfers in and out of bed based on the resident's weakness, intermittent confusion, and blindness. Review of the medical record revealed an assessment note dated 02/14/12 stating, "Therapy is working with resident for transfers to wheelchair. Depending on the day and dementia status they (physical therapists) feel she is more safe in the Hoyer lift transfer to wheelchair by staff...". Physical therapists are trained and licensed healthcare professionals who evaluate and diagnose movement dysfunction and develop a treatment plan to restore movement, reduce pain, prevent disability and promote safety during activities of daily living. Further review of the medical record revealed a physician's orders [REDACTED]. Review of the medical record revealed a nurse's note dated 02/29/12 at 9:50PM stating, "Resident transferred from w/c (wheelchair) to bed x 2 assists and sustained a tear to the (right) front calf 14cm (equals approximately 5.5 inches) long and crescent shaped...". The physician was notified and ordered that the resident be transferred to the hospital for treatment. Review of the MD Chart Viewer on 03/22/12 revealed that the laceration of the right leg was surgically closed with 27 staples. Review of the facility's investigation and interview with the Director of Nursing on 03/22/12 at 10:50AM revealed that GNA #1 (Geriatric Nursing Assistant) on the morning shift of 02/29/12 failed to follow the plan of care when she transferred the resident by herself from the bed to the wheelchair. According to the DON and the facility's investigation, GNA #1 asked nurse #4 how to transfer the resident instead of looking at the GNA Care Plan Kardex which states the resident is to be transferred via Hoyer lift and assistance of two staff. Nurse #4 failed to follow the plan of care and instructed GNA #1 to transfer the resident with one assist. The DON stated during the interview on 03/22/12 that nurse #4 also failed to look at the GNA Care Plan Kardex to verify how the resident was to be safely transferred. Although the resident was not injured during the morning transfer, both GNA #1 and nurse #4 put the resident at risk for injury by not using the Hoyer lift which had been determined to be the safest means of transfer for this resident. Further review of the facility's investigation and interview with the Director of Nursing on 03/22/12 revealed that when GNA #2 and GNA #3 were ready to transfer the resident from her wheelchair to her bed on 02/29/12 both knew that the resident was to be transferred by a Hoyer lift but because the sling was not under the resident (because GNA #1 had not used the lift that morning) they did not use the lift. GNA #2 and GNA #3 proceeded to transfer the resident from the wheelchair to the bed. According to the facility's investigation, the resident immediately stated to GNA #2 and #3 that her skin "tore". The resident's pants and TED stockings were not torn but had blood on them. When the garments were removed the 14cm laceration was noted on the right leg. The facility's investigation surmised that the resident's right leg which is weak slid under the bed and the clothing caught on the metal bedframe causing the laceration to her leg. GNA #1 and nurse #4 failed to follow the plan of care when transferring this resident from the bed to the wheelchair the morning of 02/29/12 putting the resident at risk for injury. GNA #2 and #3 failed to follow the plan of care when transferring this resident from the wheelchair to the bed the evening of 02/29/12 causing a 14cm laceration to the right leg that required 27 staples to close.