Every finding on record at Williamsport Health and Rehabilitation Center

Based on review of pertinent documentation and interviews it was determined that the facility failed to ensure a registered nurse (RN) was on duty in the facility for 5 consecutive 8 hour shifts in a row. This deficient practice has the potential to affect all residents. The findings include:Maryland state regulations require RN coverage 24 hours a day 7 days a week.On 8/19/26 at 2:17 PM the Schedule Coordinator (Staff #17) was interviewed in regard to staffing goals. When asked if a goal was to have a RN on duty every shift, Scheduler #17 responded: I try, I feel for the most part we are reaching that goal. Surveyor and Scheduler #17 then reviewed the weekend assignment sheets for the month prior to the start of the survey (7/18-8/16/26). Scheduler #17 confirmed there was no RN coverage on 9 of the 30 shifts reviewed.On 8/20/26 review of the 6/28/26 Daily Nurse Staffing Summary revealed 0 registered nurses were working on the day, evening and night shift. Review of the 6/29/26 Daily Nurse Staffing Summary failed to reveal documentation for the staffing on the day or evening shift; and 0 registered nurses were working on the night shift.On 8/20/26 at 12:45 PM surveyor reviewed the Daily Nurse Staffing Summary information found for 6/28 and 6/29/26 with the Nursing Home Administrator (NHA). And reviewed the concern with the NHA that it appeared there was no RN working for two days in a row. Surveyor requested payroll documentation to support if an RN was working on 6/28 or 6/29.On 8/20/26 at 2:51 PM surveyor reviewed additional documentation provided by the NHA that revealed two RNs were working on 6/29/26 starting at 10:52 PM and 10:58 PM (night shift). No documentation was provided to indicate an RN was working on the day, evening or night shift on 6/28 or on the day or evening shift on 6/29/26.During an interview with the NHA on 8/26/26, surveyor reviewed the concern regarding no RN for 5 consecutive shift. The NHA reported during this interview that the evening supervisor had recently left employment with the facility.As of time of survey exit on 8/26/26 at 3:40 PM no additional documentation was provided to indicate an RN was on duty during the five consecutive shifts from 6/28 day shift through evening shift on 6/29/26.

Based on observations, record reviews, and interviews, it was determined that the facility failed to establish and implement a comprehensive grievance policy and procedure, failed to make required grievance information available to residents and their representatives, and failed to provide a complainant with a written grievance decision. This was evident for one (Resident #128) of four residents investigated for complaints (Complaint #305273), and this deficient practice has the potential to impact all residents. The findings include: 1) On 6/23/26 at 1:29 PM, the Maryland Office of Health Care Quality (OHCQ) received a complaint (#305273) from a family member of Resident #128 regarding medication administration. The complaint alleged that on 6/14/26, Nurse #3 initially administered five medications and, when Resident #128 questioned whether all prescribed medications had been provided, the nurse stated she was looking for [their] Eliquis [a blood thinner] and later returned with the additional medication. The complaint further alleged that during the first several days of the resident's stay, the medications administered appeared to vary from day to day, prompting the family to request a printed medication list for verification. The resident reportedly began counting medications during administration due to concerns that all prescribed medications were not consistently provided. The complaint also alleged that Resident #128 received Dulera (an inhaled medication) twice daily and repeatedly needed to remind nursing staff that the inhaler had not been administered, including on 6/22/26, when family members witnessed the resident remind staff about the missed inhaler. The family stated that their concern was not simply delayed medications, but the repeated need for the resident to remind staff about prescribed and scheduled medications. On 8/19/26 at 1:32 PM, the surveyor interviewed the complainant, a family member of Resident #128. The complainant reported that they kept extensive notes during the resident's stay at the facility due to concerns regarding the resident's care. The complainant also reported that they contacted the Nursing Home Administrator (NHA) regarding their concerns and that it took the NHA approximately one week to respond to the email. On 8/25/26 at 1:49 PM, the surveyor asked the NHA if she recalled receiving an email from Resident #128's family member. The NHA stated that she recalled an email regarding the resident's care plan meeting. The surveyor requested a copy of the email. On 8/25/26 at approximately 2:00 PM, the NHA provided the surveyor with an email dated 7/8/26 in which Resident #128's family member requested a telephone call to discuss medication administration concerns. The NHA also provided a grievance form dated 7/15/26, seven days after the initial email, which stated, Resident's [#128] family member voiced concerns that they feel when the nurse is giving medication to the resident that she does not communicate if something is being held or if something has changed. Further review of grievance form #16261 revealed the following: The Summary of Investigation stated that a review of notes was conducted. There was no evidence that the staff member who conducted the investigation observed medication administration or interviewed other residents or staff to determine whether similar complaints or concerns existed. The Summary of Findings and Summary of Actions Taken contained identical statements: I have reviewed all notes. Resident has been updated every time a medication has been held or changed. Providers have also seen [Resident #128] regarding medications s/he no longer wants to take and time adjustment to medications have been made. The Resolved Note section was blank, and the Resolved By section stated, 7/17/26 by the NHA. The grievance form did not identify the individual who conducted the investigation. On 8/25/26 at 3:06 PM, the surveyor interviewed the NHA, who identified herself as the facility's grievance official. When asked about her role in closing grievances, the NHA stated that she conducts the final review of all grievances. When asked what the final review includes, she stated that she will review it for better understanding and then close it. When asked what she meant by close it, she stated, I just click a button [in the electronic program] and it closes that grievance. The surveyor asked whether she notifies complainants of the findings following an investigation. The NHA stated, I try to, and explained that the individual who conducted the interview sometimes notifies the complainant of the findings. The surveyor asked the NHA if she was aware that the regulation requires the complainant to be notified in writing of the findings. The NHA stated, Yes, I do know it is supposed to be in writing, and added, We are not doing that right now but are aware that we are supposed to be doing that and going forward the new program will allow us to document that we notified the complainant. The NHA confirmed that the facility did not have documentation demonstrating that the complainant was notified in writing of the findings of the investigation. Under federal regulation 42 CFR 483.10(j), Medicare- and Medicaid-certified nursing facilities are required to establish a comprehensive grievance policy and provide the resident or resident representative with a written decision regarding the grievance. Subsequent review of the facility's policy and procedure titled Grievances, policy number 401, dated 11/1/23, revealed that the policy states that, per request, the facility will provide written notice of the grievance findings. The policy does not meet federal requirements, which require the facility to notify the complainant in writing of the results of the grievance investigation. 2) On 8/24/26 at 12:41 PM, observations of resident units and common areas were conducted to determine whether information regarding the facility's grievance process was available to residents, staff members, families, and visitors. No facility grievance information was observed on the C Down, A Wing, or B Wing resident care units. On 8/24/26 at 12:49 PM, a posting was observed on the 1200 Unit, also identified as Terrace, that provided contact information for the Rytes Company. The posting stated that the service was available to employees, residents, and families and that operators unrelated to the company accepted anonymous calls. The posting did not identify the facility's designated grievance official or provide a facility grievance official's business address, email address, and business telephone number. The posting did not inform residents of their right to submit grievances orally or in writing, identify the expected time frame for completing a grievance review, or inform residents of their right to receive a written grievance decision. On 8/24/26 at 12:55 PM, a posting containing the facility's logo and a Quick Response (QR) code was observed in the elevator between the Terrace and Heights units. A QR code is a two-dimensional barcode that stores digital data, such as website or document links, and can be scanned with a smartphone camera or electronic device to provide immediate access to electronic information. Additional postings containing the QR code were observed near the Canal-Side Heights and Canal-Side Skylight elevators. The postings stated that residents, family members, staff members, and visitors could voice concerns, ask questions, and submit grievances without fear of reprisal. The QR code postings did not identify the facility's designated grievance official or provide the grievance official's business address, email address, and business telephone number. The postings did not inform residents of their right to submit grievances orally, in writing, and anonymously. The posting further did not identify the expected time frame for completing a grievance review or inform residents of their right to receive a written grievance decision. On 8/24/26 at 12:59 PM, a locked deposit box labeled Confidential Resident/Family Concerns was observed near the 2R elevator off the Terrace Unit. No information was posted at or near the box explaining how a written grievance could be submitted, including anonymously. No information was observed identifying the person responsible for retrieving and processing submissions, or identifying the designated grievance official at the facility. No observation explained the facility's grievance review and written-decision process near the submission box. On 8/25/26 at 9:05 AM, during an interview with the Nursing Home Administrator (NHA) they identified themselves as the facility's designated grievance official. The NHA stated that an individual who did not wish to provide a name or contact information could submit a grievance through the QR code system and that the submission would be routed to the NHA on a portal via internet access. On 8/25/26 at 9:20 AM, during the interview and review of the facility's grievance process, the NHA acknowledged that the facility did not have a written policy or process that identified the designated grievance official. The NHA further acknowledged that the facility did not have a written internal process describing how written grievances, including those submitted anonymously, would be received, routed, tracked, and handled. The NHA acknowledged that facility postings did not inform residents that grievances could be submitted orally or in writing and did not disclose who the designated grievance official was.

Based on interviews and record reviews, it was determined that the facility failed to ensure that a Registered Nurse (RN) was in the building to provide direct supervision to a Licensed Practical Nurse (LPN) while the LPN was administering medication through a peripherally inserted central catheter (PICC) line. This was evident for one (Complaint #3052373) of four complaints reviewed during the annual recertification survey.The findings include:On 6/23/26 at 1:29 PM, the Office of Healthcare Quality (OHCQ) received Complaint #3052373 from a family member of Resident #128. The complaint alleged that Licensed Practical Nurse (LPN) #3 administered antibiotics through the resident's PICC line. The complainant reported that while replacing the cap, LPN #3 turned or twisted the PICC line, causing the resident immediate pain.On 8/19/26 at 1:32 PM, the surveyor interviewed the complainant. The complainant stated that they kept detailed notes on their phone due to concerns about the care Resident #128 was receiving. When asked whether another nurse was present when LPN #3 provided PICC line care, the complainant stated that she (LPN #3) was the only person present. The surveyor asked whether another nurse returned to assess the PICC line following the reported incident. The complainant stated that no one returned to the room to assess the PICC line and that LPN #3 was the only nurse who provided the care.On 8/20/26 at 12:24 PM, the surveyor reviewed the June 2026 staffing sheets. The review revealed that there was no RN on duty for the evening shift (3:00 PM-11:00 PM) or night shift (11:00 PM-7:00 AM) on 6/14/26. The Unit Assignment Sheet indicated that LPN #3 was assigned to B-wing for both the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts on 6/14/26. Review of the unit assignments confirmed that there was no RN on the unit on 6/14/26.On 8/25/26 at 10:45 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding the administration of medications through a PICC line. When asked who was permitted to provide PICC line care, the ADON stated that both RNs and LPNs were permitted to provide care. When asked whether both RNs and LPNs were permitted to administer medications through a PICC line, the ADON stated that both were permitted to administer medications. The surveyor clarified whether RN supervision was required when an LPN administered medications through a PICC line. The ADON initially stated, No, they do not need supervision. The surveyor then asked whether, according to the Nurse Practice Act, an LPN could administer medications through a PICC line when an RN was not present in the building. The ADON stated, No they are not.The surveyor asked whether the ADON was aware that there was no RN on the unit on 6/14/26 while an LPN was administering medications through a PICC line. The ADON stated that the issue came to the facility's attention when the surveyor requested the staffing sheets for 6/14/26. The ADON acknowledged that she was aware there had been shifts when no RN was on duty and an LPN administered medications through a PICC line. She confirmed that an RN must be present on the unit while medications were administered through a PICC line for an LPN to administer the medication.The surveyor asked whether the facility educated LPNs regarding their scope of practice. The ADON stated that LPNs were educated regarding their scope of practice and that she was also educated regarding scope of practice. When asked whether the facility had a policy addressing what an LPN should do if asked to perform a task outside their scope of practice, the ADON stated, I would have to look. When asked what the facility's process was when there was no RN in the building and a resident had medications due through a PICC line, the ADON stated, They should reach out to management.The surveyor asked whether anyone monitored the schedule to ensure appropriate RN coverage. The ADON initially stated, I will check to get back to you, but the Director of Nursing (DON) and I are always on call. The ADON subsequently stated that administration reviews the schedule but acknowledged that call offs happen and that there are times when call-offs are not brought to her attention. She further stated, The scheduler looks over the schedule but doesn't always report it to us if there was a call out.On 8/25/26, the facility provided a policy and procedure titled IV Therapy, policy number 1102, effective 1/29/24. The policy states, Licensed Practical Nurses (LPNs) may not push any IV medications in Maryland. The policy did not address whether LPNs may hang antibiotics through a PICC line or require RN supervision for medication administration through a PICC line.Additionally, the facility provided a copy of the Maryland Board of Nursing regulations, which state that an LPN may perform the following act under the direct supervision of an RN following a comprehensive patient assessment: Administer medications by PICC by hanging prepared pharmacy solutions.The Maryland Board of Nursing, under CO[DATE].27.20.05(C), states that an LPN may perform additional infusion therapy acts under the direct supervision of an RN following a comprehensive patient assessment. Specifically, CO[DATE].27.20.05(C)(2) states that an LPN may, Administer medications by midclavicular, PICC, CVC, and implanted ports by hanging pharmacy prepared solutions.CO[DATE].27.20.02(9) defines direct supervision as oversight exercised by a registered nurse who is present on the unit of care during the infusion therapy process. Direct supervision includes observation, assessment, evaluation, and direction.On 8/25/26 at 2:15 PM, the surveyor reviewed Resident #128's Medication Administration Record (MAR). The review revealed that LPN #3 administered Ceftriaxone, an antibiotic, via the resident's PICC line on 6/14/26, the date on which there was no RN on the unit. Further review of a progress note written by LPN #3 dated 6/14/26 stated, Continues on IV Ceftriaxone no adverse effects observed. The progress note did not document the resident's reported complaint of pain in the PICC line during the treatment.On 8/25/26 at 11:12 AM, the surveyor interviewed the Nursing Home Administrator (NHA) and asked whether she was aware that there was no RN on the B-wing unit on 6/14/26 while LPN #3 provided PICC line care without RN supervision. The NHA stated that she was aware of the breakdown between scheduling and ensuring appropriate staff were scheduled. The surveyor expressed concern that LPN #3 was administering medication via a PICC line without RN supervision. The NHA confirmed that she understood the facility had placed the LPN in a difficult position by not having an RN on duty and stated that she understood the concern.On 8/26/26 at 10:06 AM, the surveyor conducted a follow-up interview with the NHA. The NHA stated that the facility did not have a policy and procedure specifically addressing a nurse's scope of practice. She stated that the corporate office was responsible for developing the facility's policies and procedures and that, because the policies were used across multiple states, they were blanket policies that did not necessarily address Maryland-specific scope-of-practice requirements. The NHA stated that the facility would work on updating its policies and procedures and developing a solution to ensure that LPNs do not administer medications via a PICC line without an RN present for supervision. She further confirmed that the Director of Nursing and ADON were expected to be on call at all times to provide coverage when needed.

Based on interviews, record reviews, and observations, it was determined that the facility failed to ensure the implementation of its infection prevention and control program, including the appropriate use of transmission-based precautions (TBP), environmental cleaning and disinfection, proper handling of linens, and hand hygiene. This was evident for one (Complaint #3052373) of four complaints reviewed and through findings identified during the infection control task.The findings include:A PICC line (peripherally inserted central catheter) is a long, thin, flexible tube placed in a vein in the upper arm and threaded into a large vein near the heart for long-term medical treatments. 1) On 6/23/26 at 1:29 PM, the Office of Health Care Quality (OHCQ) received complaint #3052373 from the family of Resident #128 alleging infection control concerns. The complainant reported that Resident #128 was admitted with a bacterial bloodstream infection and a PICC line and was initially assigned a roommate with an active C. difficile infection. The complainant alleged that, on multiple occasions, a Geriatric Nursing Assistant (GNA) bathed the roommate using a basin and emptied the bath water into the shared bathroom toilet. The complainant reported that, when Resident #128 expressed concern about the infection risk, the GNA stated that the water had not splashed and later reported being unable to locate disinfecting wipes. The complainant reported that a family member subsequently purchased disinfecting wipes and cleaned the bathroom. On 8/19/26 at 1:32 PM, the surveyor conducted an interview with the complainant, who reported that the family was very concerned that Resident #128 would contract C. diff and had requested a room change. On 8/20/26 at 4:18 PM, the surveyor reviewed the facility's infection control policy and procedure (P&P) #1601, dated 2/6/20, which stated the following regarding C. difficile: Transmission Prevention: Place in a room (cohort) with another patient with C. difficile-associated diarrhea. If a private room or cohorting is not available, the individual patient's clinical situation and the Center's resources will be considered in deciding patient placement with collaboration from the physician and infection preventionist. Measures to be taken include extensive housekeeping measures to prevent cross-contamination. Cohorting patients with the same illnesses with the same staff. On 8/25/26 at 12:59 PM, the surveyor conducted an interview with the facility Infection Prevention (IP) expert, Registered Nurse (RN-IP #2), and asked how room assignments are handled when a resident has C. diff. RN-IP #2 explained that a resident with C. diff is placed under Contact Precautions, which are specialized infection control measures used to prevent the spread of infection through direct or indirect contact with an infected person or their contaminated environment. RN-IP #2 further explained that a resident would be cohorted with another resident with C. diff, if possible. She stated that, if it was not possible to prevent a shared room, the medical condition of the resident who would be asked to share a room would be considered. She added, We are obliged to find another room if we can. RN-IP #2 explained that residents with C. diff should not share a bathroom with another resident. She stated, if the resident is incontinent, we would put a red waste bin inside the room with a red bag for disposal and the other resident (roommate) can still use the rest room. She stated that necessary precautions would be posted outside the room and both roommates would be educated about the potential for exposure. The surveyor then asked if the facility would ever consider placing a resident with a PICC line in a room with a resident with C. diff. RN-IP #2 replied, We would never put someone in a room with a PICC line with a C. diff resident and explained that because the residents would be on two different types of precautions, Enhanced Barrier Precautions (EBP) for the PICC line and Contact Precautions for C. diff, it would be inappropriate to place them together. She added, You can't have them in the same room. The surveyor then asked if RN-IP #2 was familiar with Resident #128. RN-IP #2 responded, I was on vacation when [they] were admitted and would never have put them in a room with someone with C. diff. The surveyor asked if other nurses were aware that they should not cohort residents on these two types of precautions. RN-IP #2 replied, Yes, they should know that. The surveyor asked RN-IP #2 to confirm who Resident #128's roommate was and whether the roommate had C. diff. RN-IP #2 checked the computer and confirmed that the roommate was Resident #18 and had C. diff at the time Resident #128 was housed with them. The surveyor asked if RN-IP #2 was aware of the family's concern that a basin was being emptied into the shared bathroom toilet and that disinfecting wipes were not available. RN-IP #2 replied, I was unaware since I was on vacation, but this is a concern. She explained that it was necessary to select the correct cleaning wipe because not all wipes are able to kill C. diff. The surveyor asked if it was ever appropriate to empty a basin of a resident with C. diff into the toilet of a resident's bathroom when the resident did not have C. difficile. RN-IP #2 stated that it would not be appropriate and that the residents should not have shared the bathroom. On 8/25/26 at 1:29 PM, the surveyor conducted an interview with the District Manager of Environmental Services (DM #6) and asked if the facility had special protocols for cleaning resident rooms when a resident had C. difficile. DM #6 showed the surveyor pages 54-56 of the EVS policy manual, which outlined specific cleaning procedures for Contact Precautions related to C. difficile. The surveyor asked if the cleaning was documented. DM #6 replied that the facility EVS account managers were responsible for ensuring that staff documented cleaning on a quality control log. The surveyor requested those records, and DM #6 stated that, due to a breakdown in processes, the current manager had not been maintaining the cleaning records. On 8/25/26 at 1:36 PM, the surveyor conducted an interview with the facility Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA) and asked who makes decisions regarding resident room assignments. The NHA replied that the facility nurse liaison works with admissions staff to identify a preliminary room assignment for the resident. Per the NHA, the liaison will contact the Director of Nursing (DON), ADON, and typically RN-IP #2 when there are infection control concerns. When asked specifically about placing a resident in a room with another resident who has C. diff, the ADON replied that they look at bed availability and whether the residents are continent or incontinent because they cannot share a bathroom. She added that they would sometimes place a resident in the same room as a person with C. diff. The surveyor then asked, If a person with a PICC line was admitted would you put them with another resident with C.diff and is it okay to intermingle EBP and Contact precautions? The ADON replied, Sometimes we have to and would consider the clinical situation of both residents. On 8/25/26 at 2:07 PM, the NHA stated that the facility was at full capacity when Resident #128 was admitted and therefore had to place the residents together. The surveyor requested a copy of the census for the date of Resident #128's admission. Shortly after the meeting, the NHA provided the surveyor with the census report, which revealed that there were 118 total residents and that the facility was at 92.9 percent capacity. The NHA confirmed that based on the census, the facility could have placed Resident #128 in a different room and stated that it would have been the correct thing to do. On 8/26/26 at 9:26 AM, the surveyor conducted a record review and confirmed that Resident #18 had a diagnosis of enterocolitis due to Clostridium difficile while Resident #128 was housed with them. At the time of survey exit on 8/26/26 at 3:40 PM, no additional cleaning documentation had been provided to the surveyor. 2) On 6/23/26 at 1:29 PM, the Office of Health Care Quality (OHCQ) received a complaint (#3052373) from the family of Resident #128 that included infection control concerns. The complainant reported that their family member, Resident #128, was admitted with a bacterial bloodstream infection requiring careful infection prevention measures. The complaint alleged that the bathroom in Resident #128's room was not cleaned from the date of admission, 6/11/26, until housekeeping serviced the room on 6/16/26, despite Resident #128 being housed with a resident who had a contagious illness. The complaint further alleged that, after Resident #128 was moved to a different room on 6/17/26, no housekeeping services had been provided in the new room as of 6/23/26. The complainant reported that the floors had not been swept or mopped, the bathroom had not been cleaned, and the sinks and other surfaces had not been sanitized. On 8/19/26 at 1:32 PM, the surveyor conducted an interview with the complainant, who reported that the family was very concerned that Resident #128 would contract an illness due to being placed in a room with a resident who had a contagious illness and because the room was not being cleaned. On 8/25/26 at 11:26 AM, the surveyor interviewed the District Manager (DM #6) of Environmental Services (EVS) and asked how the facility documented cleaning of the facility. DM #6 explained that each day, housekeeping staff are assigned one deep cleaning in addition to routine maintenance cleaning. The surveyor asked if cleaning checklists were maintained. DM #6 replied that the facility EVS account managers, who manage the housekeeping and laundry departments, are responsible for requiring staff to complete cleaning checklists. The EVS managers are then responsible for randomly selecting two rooms each day for a quality inspection. DM #6 also stated that he visits the facility monthly to conduct a quality check. DM #6 stated that the facility had recently discovered that the previous account manager had not been maintaining the cleaning records and that the facility would be unable to provide evidence of room cleaning schedules. The surveyor discussed the complainant's cleaning concerns with DM #6. DM #6 stated that a new manager-in-training had recently started and that they were working to ensure completion of the checklists and audits. 3) On 8/21/26 at 1:22 PM, the surveyor toured the laundry area and interviewed a woman who identified herself as the EVS account manager (Staff #7) regarding the process for maintaining cleanliness in the laundry area. Staff #7 stated, We clean the washers and dryers daily, mop the floors, and clean the lint screens between loads. The surveyor then asked Staff #7 if cleaning checklists were maintained. Staff #7 stated that she had a binder with the checklists, but someone had quit and she was unsure what had happened to the checklists. Staff #7 retrieved a binder from a shelf that contained a document titled Dryer Lint Trap Log, which included checklists from January 2025 through April 2025, and a blank document dated May 2025. The surveyor asked if there were any current logs. Staff #7 stated that the logs were usually kept on the dryers for staff to complete daily but that they might be in her office. The surveyor asked Staff #7 to locate the current cleaning checklists. Staff #7 was away for approximately 15 minutes. The surveyor then observed Staff #7 walk to a dryer, place a document on a magnetic clip attached to the dryer, and walk away. The surveyor asked another laundry worker, identified as Staff #33, about the checklist. Staff #33 stated that Staff #7 had placed the document on the dryer. The surveyor reviewed the document, which was titled Lint Trap Cleaning Log. The document was dated August 2026 and contained multiple entries for each day of August, with signatures indicating completion at 3:00 PM for the 6:00 AM to 3:00 PM shift. The surveyor observed that the entries contained different initials and signatures; however, the initials and signatures appeared to be written in the same handwriting and with the same ink. The entry corresponding to 8/21/26 contained initials in each designated box. Staff #7 returned to the area, and the surveyor asked where the document had been located. Staff #7 stated that it had been in her office. The surveyor asked if the handwriting on the document was hers. Staff #7 replied, Yes because I fill it out for my staff 'if they forget'. The surveyor asked if she had just completed the document. Staff #7 replied, Like I said I fill it out if my staff forgets. The surveyor then asked if she located any other cleaning checklists. Staff #7 stated that she would have to look. The surveyor then asked Staff #33 if she completed any checklists daily. Staff #33 stated that she completed only Load tracking, which she described as a document indicating the time a laundry load was started. Staff #33 stated that Staff #7 should have the records in her office because only the current week was available on the clipboard. On 8/21/26 at 1:59 PM, the surveyor interviewed the Nursing Home Administrator (NHA) and expressed concerns regarding the lack of cleaning documentation in the laundry area. The surveyor showed the NHA the document provided as evidence of the August 2026 lint trap cleaning. The surveyor pointed out that the entries appeared to be written with the same pen and handwriting despite containing different signatures. The NHA replied, This isn't how we do business and we do not condone creating documents for the purpose of the survey. She stated that she would speak with the staff and follow up with the surveyor. On 8/21/26 at 3:15 PM, the District Manager (DM #6) of EVS and the NHA met with the surveyor regarding the cleaning documentation. DM #6 apologized and stated that the facility was embarrassed by the situation. He stated that the facility would address the situation and take appropriate action. On 8/24/26 at 10:30 AM, the NHA provided the surveyor with the facility's Laundry Policy and Procedure #026, dated 2/1/25. The policy stated: -The lip of the washer door should be disinfected prior to closing the door and starting the cycle. -Lint traps cleanings should be documented on the Lint Trap cleaning log. Lint traps should be checked, brushed, and cleaned at least every hour unless state/local requirements prescribe more frequent attention. -The laundry area and equipment should be routinely cleaned and disinfected utilizing the 5-step method. At the time of survey exit on 8/26/26 at 3:40 PM, no additional cleaning documentation had been provided to the surveyor. 4) On 8/21/26 at 1:39 PM, the surveyor toured the facility laundry room. The surveyor was standing on the soiled side of the laundry room and observed Staff #33 complete work on the soiled side and then walk directly to the clean side and begin folding towels. The surveyor approached Staff #33 and asked if she had the ability to perform hand hygiene. Staff #33 stated, Oh I'm so sorry, I got sidetracked with you asking questions. Staff #33 then performed hand hygiene but did not remove the linens that she had touched with her hands prior to sanitizing. On 8/21/26 at 1:59 PM, during an interview with the Nursing Home Administrator (NHA), the surveyor expressed concerns that hand hygiene had not been performed by Staff #33 after leaving the soiled side of the laundry area. The NHA stated that she would address the concern with staff. On 8/21/26 at 2:24 PM, the surveyor conducted an interview with the facility Infection Prevention Registered Nurse (RN-IP #2) and asked if she monitored the laundry room. RN-IP #2 stated that she monitored the laundry room and had recently provided education to staff regarding hand hygiene. On 8/24/26 at 10:30 AM, the NHA provided the surveyor with the facility's Laundry Policy and Procedure #026, dated 2/1/25. The policy stated, Employees must remove gloves, doff [take off] PPE, and wash hands prior to exiting the soiled side of the laundry area.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure a resident with pressure injuries receive appropriate services for treatment and prevention. This was evident for 1 (Resident #1) of 1 resident reviewed during the complaint survey. The findings include:Resident #1 was a newly admitted resident of the facility. The care for the resident's pressure injuries was indicated in the report related to complaint3023604. On 6/16/26 at 11:22 AM, Resident #1 was observed sleeping in bed. The resident's bed was equipped with an air mattress with the control box located at the foot of the bed. The firmness setting was a dial with different weight selections that go up to 350 then max firmness. The Dial was observed to be turn all the way to max firmness. A review of Resident #1's medical record was conducted on 6/16/26 at 11:29 AM. The review revealed an order for the nurses to check the resident's air mattress indicated for wound healing, for placement, function and comfort each shift. Also, the resident's most recent weight was 178.5 lbs. taken on 5/22/26. A nursing aide (Staff #5) was interviewed on 6/16/26 at 11:41 AM. Staff #5 reported that nursing aides are not allowed by the facility to make any changes to a resident's air mattress setting but do check that they are inflated and not beeping for any alerts. She also reported that when there is any concern identified with a resident's air mattress, she reports it to the nurse and/or maintenance staff. The nurse (Nurse #4) who was currently assigned to Resident #1 was interviewed on 6/16/26 at 11:44 AM. During the interview, she was asked to explain the order: Resident is to have a low loss air mattress for wound healing Check placement and function and comfort every shift for Wound care. Nurse #4 enumerated the things that she checks on the air mattress including the firmness setting and explained that the resident's weight should match the weight setting on the control. Nurse #4 was invited to accompany the surveyor in Resident #1's room on 6/16/26 at 11:51 AM. Nurse #4 confirmed that the resident's air mattress was set to max firmness and reported that she had identified this when she went into the resident's room around 9 AM. However, she had not had a chance to report it to her unit manager and added that the resident had chronic pain and was not sure if the mattress firmness setting had something to do with pain management. Nurse #4 then indicated that she would talk to her manager to find out. A subsequent review of Resident #1's medical record was conducted on 6/16/26 at 11:56 AM. The care plan for the resident's pressure injuries indicated interventions that included the use of the air mattress. However, there was no documentation to indicate that the firmness setting should be set to max firmness. The Nurse Unit Manager (Staff #3) was interviewed on 6/16/26 at 12:08 PM. During the interview, Staff #3 was asked about Resident #1's air mattress setting and she reported that it was set to max firmness due to the resident's complaint of pain. Staff #3 was asked if there was any documentation to indicate that setting the firmness to max promotes comfort to the resident and/or if there had been any report to indicate that setting the air mattress to the appropriate weight had caused pain or discomfort for the resident. Staff #3 answered No to both questions. During an interview with the Director of Nursing (DON) on 6/16/26 at 2:09 PM, the concern was discussed that a resident's low loss air mattress indicated for wound healing was not set up appropriately for treatment and prevention. The DON indicated that the concern was already reported to her, verbalized understanding and acknowledged the concern.

Based on record review and interview, it was determined that facility staff failed to provide quality of care to their residents. This was evident for 1 (#1) of 1 resident reviewed for falls.The finding include:Neurological Assessments (neurochecks): an assessment conducted by nurses that includes a full set of vital signs (blood pressure, pulse, respirations, and temperature), check pupils for size and reaction to light, weakness on one or both sides, and level of consciousness. The purpose of the neurochecks is to monitor the resident for symptoms to indicate a brain injury following a fall in which the resident is known to have hit their head or if it is unknown.A medical record review for Resident #1 on 5/8/26 at 9:02 AM revealed a post fall assessment dated [DATE] that documented the resident had a fall, but the time of the fall was unclear. A review of the neurocheck assessment revealed that the nurse completed one for the required timeframes but failed to include a full set of vital signs for each neurocheck. Further review revealed a post fall assessment that documented the resident had a fall on 11/25/25 at 5:20 AM. Review of the neurocheck assessments revealed one assessment had been entered around 8:30 AM by LPN #6, but the rest were blank. Review of the vital signs tab revealed that this was the only vital sign entered for 11/25/25. On 5/8/26 at 2:18 PM Licensed Practical Nurse (LPN) #2, who was the nurse who cared for the resident on 11/21/25 reported that she writes the neurochecks on a sheet of paper at the time she conducts the assessment then later transcribes them to the computer. She stated that she could recall exactly what occurred on 11/21/25 but thought she may have forgotten to change the date and time for all the vital signs (because they auto populate to the last set of vital signs taken) for each assessment. However, she was unable to provide evidence that a full set of vital signs were obtained. An interview with LPN #6 on 5/8/26 at 12:34 PM, who was the nurse assigned to Resident #1 on 11/25/25, revealed she was unable to recall what had happened that day. She stated she normally writes the neurochecks on a cheat sheet and then entered them in the computer later. She stated she had not retained a copy of the neurocheck cheat sheet. On 5/8/26 at 2:18 PM an interview with LPN #5, the unit manager for the unit that Resident #1 resided on, was conducted. She reported that she would review all the post falls forms the next day that she was on duty to ensure that they were completed. However, she was unable to provide a rationale for the reason she had not reviewed this resident's falls. The concerns were reviewed with the Director of Nursing on 5/8/26 at 2:31 PM.

Based on record review and staff interview, it was determined that facility staff failed to document a resident's discharge as required. This was evident for 2 (#3 and #4) of 4 residents reviewed for discharge. The findings include:1) A medical record review for Resident #3 on 5/6/26 at 10:08 AM revealed a discharge summary on 4/23/26 written by Nurse Practitioner (NP) #10 which noted the resident was discharged on 4/23/26. Further review revealed no discharge note was written by nursing to indicate how the facility staff provided a safe and orderly discharge. A review of the discharge instructions in the assessment tab revealed they had been completed by the Assistant Director of Nursing (ADON). A review of the document tab (documents that were uploaded into the computer) revealed discharge instructions were uploaded and had a handwritten note on them that they were given via telephone. There was no date/time or signature of who provided them over the phone. An interview with the ADON conducted on 5/7/26 at 10:25 AM revealed on the day of discharge staff were to print the discharge instructions, review them with the resident and the person taking the resident home, and have them sign the discharge instructions. She stated that the nurse should write a progress note about the discharge. When asked about Resident #3's discharge she stated that she completed the discharge instructions but had not discharged the resident that day. When asked who had, she stated she would find out and report back to the surveyor. She reported back that it was Licensed Practical Nurse (LPN) #11. LPN #11 was called and a message left to call back for an interview, but he failed to do so. The concerns were reviewed with the Director of Nursing on 5/8/26 at 2:31 PM. 2) On 5/6/26 at 11:56 AM a medical record review for Resident #4 revealed a progress note dated 4/21/26 that was written by Social Services Staff #8. The note read that she was asked to provide a 30-day discharge notice to the resident. However, she failed to document the reason for the discharge. Further review of the progress notes failed to reveal the reason the resident had been issued a 30-day notice. A review of the uploaded documents failed to reveal a copy of the 30-day discharge notice. An interview on 5/6/26 at 1:09 PM with Social Services Staff #8 revealed the resident was issued a 30-day discharge notice due to the failure to pay the facility for their services. When asked where the discharge notice was located in the medical chart she stated she was not sure. She reported she was not sure what she was required to document in the medical record regarding a discharge. The Regional Social Worker Staff #9 was interviewed on 5/7/26 at 1:58 PM. She stated that Staff #8 had appropriately documented the discharge because she noted the discharge notice was given. She stated that the reason for the discharge was on the 30-day discharge notice that was supposed to be uploaded into the medical record. However, it was not uploaded in the medical record until 5/6/26 after surveyor intervention. The concerns were reviewed with the Director of Nursing and Nursing Home Administrator on 5/8/26 at 3:05 PM.

Based on record review and staff interview, it was determined that the facility discharged their residents inappropriately. This was evident for 1 (#3) of 4 residents reviewed for discharge. The findings include:MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. On 5/6/26 at 10:00 AM a review of intake #2991200, revealed the complainant felt Resident #3 was inappropriately discharged home. A medical record review for Resident #3 on 5/6/26 at 10:08 AM a medical record review revealed an MDS with ARD of 4/8/26 that documented the resident had no cognitive impairment. On 4/20/26 a Notice of Medicare Noncoverage (NOMNC) signed by the resident documented the resident's last covered day was 4/22/26. A progress note written by Social Services Staff #8 on 4/21/26 revealed the resident appealed the decision, but the decision was upheld. She wrote another progress note on 4/22/26 that the resident appealed again and they were awaiting the results. The discharge MDS with ARD of 4/23/26 revealed the resident was a substantial to maximum assist for some ADLs and dependent on staff for mobility in and out of bed and for transfers between surfaces. On 4/23/26 Nurse Practitioner (NP) #10 documented a discharge summary that read the resident needed moderate to maximal assistance per the therapy note. He noted that they were offered a mechanical lift, but the family declined due to limited space in the home. He wrote that the resident had wounds that required wound care. He wrote that the resident needed to establish a primary care doctor in the community and that they were going home with home health services. The resident was discharged home on 4/23/26. However, there was no evidence in the record that home health services had been set up prior to the resident being discharged . On 5/6/26 at 10:41 AM an interview with the resident and a family member revealed they had no home health services, to include therapy services, set up prior to discharge. They reported it was a planned discharge because the resident's insurance was ending. They reported the resident was unable to move from one surface to another, it was difficult to bath and care for the resident. An interview with Social Services Staff #8 on 5/6/26 at 1:09 PM revealed that she had been working with the resident for a discharge because the insurance coverage was ending and they were unwilling to pay privately. She reported she faxed information on 4/23/26 to 2 home health agencies. She stated that the first one was unable to take the resident due to insurance. She then reached out to another agency but had not followed up to ensure that services were set up. She failed to ensure that the resident had the post-discharge services that they needed prior to their discharge date . On 5/7/26 at 10:08 AM an interview with Licensed Practical Nurse (LPN) #13 revealed she was aware Resident #3 was planning to go home on 4/23/26 because the resident told her goodbye on 4/22/26. Geriatric nursing assistant (GNA) #12, who worked on Resident #3's unit, was interviewed on 5/7/26 at 10:41. She reported that she knew the resident was going home on 4/23/26. She stated the resident was saying his/her goodbyes to the staff on 4/22/26. On 5/8/26 at 2:10 PM an interview with the home health agency revealed that they received the referral for Resident #3 on 4/23/26, however they had not provided services for the resident. She stated that they cannot provide services for a resident without a primary care doctor in the community which was the case with this resident. An interview with the Regional Social Worker Staff #9 on 5/7/26 at 1:58 PM revealed she was providing oversight of the Social Services Staff. The concerns were reviewed with her and she was asked if this was an appropriate discharge. She stated that she had no concerns with how Social Services Staff #8 set up Resident #3's discharge.During an interview with the Nursing Home Administrator on 5/6/26 at 3:02 PM she reported that the discharge was resident initiated. However, there was no evidence in the medical record or during interviews that this was the case.

Based on record review and interview, it was determined that the facility failed to ensure that their residents were free of accidents/hazards. This was evident for 1 (#1) of 1 resident reviewed for falls. The finding include:A medical record review for Resident #1 on 5/8/26 at 9:02 AM revealed a care plan for the resident's risk of falls that was initiated on 11/17/25. The goal was that the resident would not have an injury from a fall with 2 interventions in place; to keep commonly used items nearby and remind the resident to use the call light. The attending physician documented during a resident visit on 11/18/26 that the resident had dementia and abnormality with their walking. Review of the assessments revealed a post fall assessment was completed for the resident on 11/21/25. Facility staff documented that the resident was found on the floor near their bed. A review of the care plan for resident's risk of falls revealed staff updated it to read the resident had an actual fall on 11/24/25, 4 days after the resident's fall. The goal was not changed and the intervention added was to offer the resident to go back to bed after visitors leave. Further review of the assessment tab revealed the resident was found on the floor on 11/25/25. Further review of the care plan revealed facility staff added an intervention to keep the bed in the lowest position. A progress note written by Social Services Department read that the family wanted the resident discharged home on [DATE]. An interview with Resident #1's family member on 5/8/26 at 1:26 PM revealed that s/he was notified on 11/21/25 that the resident had fallen out of his/her wheelchair and then on 11/25/25 that the resident had fallen out of his/her bed. The family member reported that they felt facility staff had not checked on Resident #1 enough to prevent the falls. This was why the family decided to take the resident home on [DATE]. On 5/8/26 at 2:18 PM Licensed Practical Nurse (LPN) #5, who was the unit manager, revealed that she had no rationale why they failed to include the level of supervision needed to prevent the resident from falling. The concerns were reviewed with the Director of Nursing on 5/8/26 at 2:31 PM.

Based on record review and interview it was determined that the facility failed to have a process in place to ensure that residents' choice to not have cardiopulmonary resuscitation (CPR) was honored. This was evident for 2 (#8 and #7) of 2 residents reviewed for advanced directives. As a result of these findings, a state of immediate jeopardy (IJ) was declared on [DATE] at 3:20 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on [DATE] at 4:43 PM and it was not accepted. The facility submitted a second draft at 5:35 PM, and it was not accepted. The third draft was submitted on [DATE] at 6:16 PM and the facility's written plan to remove the immediacy was accepted on [DATE] at 6:31 PM with an alleged date of compliance of [DATE]. After removal of the immediacy, the noncompliance was determined to continue with a scope and severity of F. The findings include:On [DATE] at 9:55 AM an interview with Unit Manager (UM) #13 revealed, the facility had no procedure in place to inform staff where they were to look for residents' Maryland Orders for Life-Sustaining Treatment (MOLST) forms in the medical record.An interview with LPN #5 on [DATE] at 9:49 AM revealed that the code status was on the information bar in the resident's record, the MOLST forms uploaded in the documents in the miscellaneous tab, and it was on the daily assignment sheets used by the nurses. He stated he preferred to look at the actual MOLST.An interview with Registered Nurse (RN) #6 on [DATE] at 9:52 AM revealed that the code status was on the information bar in the resident's record or she looked at the MOLST form that was uploaded in the documents under the miscellaneous tab. RN #6 stated that it took a little while to retrieve the information since it was only on the computer.1. A medical record review for Resident # 8 revealed in the miscellaneous tab two active MOLST had been uploaded. The MOLST dated [DATE] documented the resident wished to be a full code and it was not voided and the title did not indicate voided. On [DATE] Medical Record (MR) #14 uploaded a new MOLST dated [DATE] that documented the resident did not want CPR to be performed. Also she uploaded a copy of the [DATE] MOLST which had been voided. However, she failed to remove the active [DATE] MOLST. Further review of the medical record revealed a progress note dated [DATE], that documented the resident was found unresponsive and CPR was initiated. Staff failed to document the time CPR was initiated. On [DATE] at 8:43 AM, Emergency Medical System (EMS) staff arrived and the resident was pronounced dead at 8:44 AM.On [DATE] at 4:26 PM an interview with LPN #1, who was assigned to the resident that day, revealed she had no memory of the incident.During an interview with Licensed Practical Nurse (LPN) #3 she confirmed that R8 received CPR until EMS staff arrived. She stated that when the paperwork was brought to EMS to take the resident to the hospital it was discovered the resident's wish was no CPR and the code was stopped. She stated that she called the previous Director of Nursing (DON) #2 and they did a whole house audit to ensure only one active MOLST was in the residents' medical record.An interview with the previous DON #2 on [DATE] at 4:41 PM revealed she investigated the incident. She reported there were 2 active MOLST in the document section of the medical record and there were 2 physician orders that populated to the code status on the information bar on the resident's medical record.One order stated the resident was a full code and the other stated no CPR.She reported that she asked LPN #3 to conduct a whole house audit that day, she wrote a performance improvement plan (PIP), and education was provided to staff.On [DATE] at 12:10 PM a review of the audit report revealed there were other residents identified who had more than one active MOLST on their record and conflicting code status orders. Review of the Performance Improvement Plan revealed that they reiterated the MOLST process and clearly outlined whose role and what their responsibilities were. A review of the process revealed the provider was responsible for changing the orders in the computer when the MOLST was updated and to void the previous order. The provider was to give the new MOLST and the voided MOLST to medical records during the week and to the Supervisor on the weekend, and they were responsible to upload the documents in the medical record. Nurses on the unit were responsible for a second check that both matched and for alerting the DON or ADON to delete the previous active MOLST from the medical record. A review of the education provided revealed that not all nursing staff were educated regarding the process. On [DATE] at 12:49 PM the concerns were discussed with the current DON and the Nursing Home Administrator (NHA).A subsequent interview with the previous DON #2 on [DATE] at 2:37 PM confirmed that all nursing staff, including agency staff, received education regarding how to determine the code status of a resident. They had not addressed the issue of 2 active MOLST on the record, and the fact that the providers were not ensuring that the correct code order was in place and all others were discontinued.However, this plan of correction failed to prevent this incident from recurring as evidenced by another incident with R7 on [DATE]. 2. A medical record review for R7 on [DATE] at 5:24 PM revealed that the resident had an active MOLST dated [DATE] that read the resident's wishes were, no CPR. This document was not uploaded into the documents section until [DATE]. Review of the physician orders revealed on [DATE] agency Registered Nurse (RN) #11 entered an order for DNI (Do Not Intubate) which matched the MOLST completed on [DATE]. On [DATE] an order was entered by the previous DON #2 for a full code and verified by the attending physician. This order did not coincide with the resident's MOLST and was active until [DATE], the day the resident coded. A progress note written on [DATE] by RN #12 revealed that the resident coded on [DATE] and CPR was initiated at 6:37 AM, EMS continued CPR when they arrived at 6:49 AM and then at 6:59 AM the resident was pronounced dead.Surveyor attempted to contact RN #12 on [DATE] at 10:45 AM, on [DATE] at 4:40 PM, and then on [DATE] at 4:41 PM the previous DON #2 texted her and asked her to call the surveyor. However, RN #12 failed to call back. An interview with LPN #15 on [DATE] at 11:07 AM revealed she arrived after the code for R7. She reported that she, along with RN #12 were looking at the resident's record and found that there were 2 active MOLST in the record.The previous DON #2 reported during an interview on [DATE] at 4:41 PM that she collected statements from staff who were involved in the code for R7. She stated she was unable to recall where RN #12 had looked for the code status of the resident before initiating CPR on [DATE], but that the nurse was not technically savvy.On [DATE] at 12:15 PM a review of the statement written by RN #12 failed to reveal where she looked for the resident's code status. She wrote what occurred during the code, however failed to reveal the events leading up to the code to determine the reason a resident was given CPR against their wishes. As a result of these findings, a state of immediate jeopardy (IJ) was declared on [DATE] at 3:20 PM. The facility's written plan to remove the immediacy was accepted on [DATE] at 6:31 PM with an alleged date of compliance of [DATE]. The provisions of the plan to remove the immediacy included the following:Resident #8 and Resident #7 were affected by this practice and no longer reside in the facility.On [DATE] the facility completed 100% audit of all MOLST forms and code status orders to ensure they matched. Any discrepancies identified were corrected upon discovery. The audit was completed by the Assistant Director of Nursing.Starting on [DATE] all clinical nursing staff in the facility, including agency staff, were educated on ensuring that when a code event occurs, they are to look in Point Click Care [the electronic medical record system] under documents and filter for category MOLST for the active MOLST.Any staff not available will be educated prior to beginning their next scheduled shift to include active agency staff.Date of Compliance: [DATE]On [DATE] at 8:00 AM, an onsite visit was conducted. After validation on [DATE] of the implementation of the facility's plan of removal, which included staff interviews and record reviews, it was determined the facility's removal plan was completed and the Immediate Jeopardy removed on [DATE].

Based on record review and interview it was determined that the facility failed to implement corrective action when they determined that staff had inaccurate and inconsistent code status information on residents' medical records which resulted in residents receiving unwanted Cardiopulmonary Resuscitation (CPR). This failure led to another resident receiving unwanted CPR for the same reason. This was evident for 11 of 11 months of QAPI meeting minutes reviewed. The findings include:1. On [DATE] at 3:23 PM a medical record review for Resident (R)8 revealed in the miscellaneous tab there were 2 active Maryland Orders for Life Sustaining Treatment (MOLST) forms uploaded. The MOLST dated [DATE] documented the resident wished to be a full code and the one dated [DATE] documented the resident wished not to have CPR, but to die naturally. Further review of the medical record revealed a progress note dated [DATE], that documented the resident was found unresponsive and CPR was initiated. Staff failed to document the time CPR was initiated. On [DATE] at 8:43 AM EMS arrived and the resident was pronounced dead at 8:44 AM. An interview with the previous Director of Nursing (DON) #2 on [DATE] at 4:41 PM revealed she was the DON at the time of the incident and investigated it. She confirmed that when she reviewed R8's medical record that there were 2 active MOLST with conflicting code statuses. She stated that the resident had 2 code status physician orders on the medical record that populated to the code status on the information bar at the top of the medical record. One order stated the resident was a full code and the other stated no CPR. She reported that she asked Licensed Practical Nurse (LPN) #3 to conduct a whole house audit that day to ensure other residents had the appropriate MOLST and code status orders, she wrote a performance improvement plan (PIP), and education was provided to staff. She reported that she emailed the PIP to the Nursing Home Administrator (NHA) to approve and add to the agenda for Quality Assurance Performance Improvement (QAPI) committee meeting. On [DATE] at 12:10 PM a review of the audit report dated [DATE] revealed there were other residents identified who had more than one active MOLST on their record and conflicting code status physician orders. Review of the Performance Improvement Plan revealed that she planned for them to reiterate the MOLST process and clearly outline each person's role and responsibility. A review of the process revealed the provider was responsible for changing the orders in the computer when the MOLST was updated and void the previous order. The provider was to give the new MOLST and the voided MOLST to medical record staff during the week and to the supervisor on the weekend, and they were responsible for uploading the documents in the medical record. Nurses on the unit were responsible for a second check that both matched and to let the DON or ADON know there was an active MOLST that needed deleted from the medical record. A review of the education provided revealed that not all nursing staff were educated regarding the process. However, this PIP was not discussed in the QAPI meetings. A review of the QAPI committee meeting minutes on [DATE] at 1:39 PM revealed that the meeting minutes for [DATE] - [DATE] failed to mention the MOLST PIP that was created by the DON. 2. A medical record review for R7 on [DATE] at 5:24 PM revealed that the resident had an active MOLST dated [DATE] that read the resident's wishes were no CPR. This document was not uploaded into the documents section until [DATE]. Review of the physician orders revealed on [DATE] agency Registered Nurse (RN) #11 entered an order for DNI (Do Not Intubate) which matched the MOLST completed on [DATE]. However, on [DATE] an order was entered by the previous DON #2 for a full code and verified by the attending physician. This order did not coincide with the resident's MOLST and was active until [DATE], the day the resident coded. This created 2 conflicting code statuses on the medical record. A progress note written on [DATE] by RN #12 revealed that the resident coded on [DATE] and CPR was initiated at 6:37 AM, EMS continued CPR when they arrived at 6:49 AM and then at 6:59 AM the resident was pronounced dead. The resident received 12 minutes of CPR that was unwanted. The previous DON #2 reported during an interview on [DATE] at 4:41 PM that she collected statements from staff who were involved in the code for R7. She stated she was unable to recall where RN #12 looked for the code status of the resident before initiating CPR on [DATE], but that the nurse was not technically savvy.On [DATE] at 12:15 PM a review of the statement written by RN #12 failed to reveal where she looked for the resident's code status. She wrote what occurred during the code, however failed to reveal the events leading up to the code to determine the reason a resident was given CPR against their wishes. DON #2 failed to investigate the incident to determine the cause, so the facility could implement corrective action to prevent future occurrences. A subsequent interview with the previous DON #2 on [DATE] at 1:42 PM revealed the facility failed to have evidence of actions taken to prevent this incident from occurring in the future. On [DATE] at 1:39 PM a review of the QAPI committee meeting notes [DATE] - [DATE] revealed that after the second incident on [DATE] the facility failed to review this system breakdown in their QAPI meetings to implement corrective action to prevent it from occurring again. An interview with the Nursing Home Administration on [DATE] at 1:00 PM revealed she remembered receiving the PIP and discussing it with staff, however had no rationale as to why it was not included in the QAPI meeting minutes. She stated that had not followed through with the PIP in subsequent meetings. She stated she recalled being told about the second incident, however, was not sure what happened in that incident. She confirmed it was not discussed in the QAPI meetings. Cross Reference: F678

Based on observations, record review, and interview, it was determined that the facility failed to have adequate staff to ensure that residents were bathed, dressed, and out of bed in a timely manner. This was evident for 1 of 2 units observed.The findings include:On 2/11/26 at 11:00 AM Geriatric Nursing Assistant (GNA) #2 was overheard asking 2 different people if they could assist with getting a resident out of bed. A subsequent observation revealed they were going into Resident #1's room to get the resident out of bed and a mechanical lift was in the room. (Mechanical lift transfers required staff members to safely transfer a resident).On 2/12/26 at 12:56 PM Resident #1 and Resident #2 were still in bed and eating their lunch. At 2/12/26 at 1:24 PM GNA #2 was observed getting Resident #2 out of bed. A subsequent interview with GNA #2 when she was coming out of the room revealed this was the first time she had time to get Resident #2 out of bed. A medical record review for Resident #1 on 0/11/26 at 10:41 AM failed to reveal a preference to get out of bed after lunch. On 2/12/26 at 11:35 AM a medical record review for Resident #2 revealed in the resident's care plan that the resident was to be out of bed for breakfast. A review of the facility assessment on 2/13/26 at 11:00 AM revealed that it was signed by the Nursing Home Administrator (NHA) on 1/6/25 and reviewed by the quality assurance committee on 2/21/25. In the document it noted that they needed 32 geriatric nursing assistants (GNA) each day to provide care for the residents.A review of the staffing schedules and census for 1/31/26, 2/1/26, and 2/4/26 revealed they were consistently below the required amount of GNAs. On 1/31/26 their census was 125 out of 127 and they had 27 GNAs scheduled that day; 5 less GNAs than noted as needed in the facility assessment. On 2/1/26 their census was at full capacity of 127 and they had 29 GNAs scheduled that day; 3 less GNAs than noted as needed in the facility assessment. On 2/4/26 they had 123 residents and they had 27 GNAs scheduled that day; 5 less GNAsthan noted as needed in the facility assessmentA review of the schedule for 2/11/26 revealed there was 1 nurse assigned to the upstairs and downstairs C wing units with 1 GNA assigned upstairs with 13 residents (who is required to stay on that unit unless there was someone to relieve them) and 1 GNA assigned to the 16 residents downstairs.A review of the census and condition of the C-wing down unit revealed that at the time of the observation they had 16 residents on the unit. There were 7 residents who need 2 staff to assist them to move around in the bed and to get out of bed, 8 were dependent on bathing, 6 were dependent on dressing, and 9 were dependent on toileting. Staff passed the trays out and assisted with set up as needed for 16 residents. There was 1 resident who needed to be fed and 1 resident who needed staff to cue them to eat or continue to eat.An interview with GNA #2 on 2/11/26 at 11:08 AM revealed she bathed Resident #1 then at 10:30 AM she was trying to find another person to assist with getting the resident out of bed because she required a mechanical lift to transfer. She stated that every day that the unit did not have a float nurse assigned it was difficult to get residents out of bed who required 2-person assistance. She stated that she and a nurse were assigned to the unit, but the nurse also covered upstairs too.During an interview with the assigned nurse Licensed Practical Nurse (LPN) #5 on 2/11/26 at 11:30 AM she reported that she was upstairs for about 40 minutes this morning, at the time that GNA #2 needed assistance, to care for the residents upstairs and give the GNA on the second floor a 10-minute break. She stated that sometimes the unit manager would help when she was upstairs in her office, but that was not often. She reported that in the afternoon she had to be on the second floor again in the afternoon for about 40 minutes to give afternoon medications and give the GNA a 1/2 hour break.An interview with GNA #3, who was assigned to the 2nd floor, revealed she had previously covered the first floor at times. She stated that it was difficult to get residents bathed and out of bed in the mornings especially when they required 2-person assistance. She stated that even though there was a nurse assigned to help, they had their own duties to do in the morning. She reported that she was unable to leave her unit to assist the other GNA unless she had coverage.An interview with the NHA and DON on 2/12/26 at 3:10 PM revealed that their staffing levels were based on the required staffing per day per resident. The DON reported that she does not look at the acuity and needs of the residents to ensure there were enough staff that residents were not left in bed until after lunch unless it was their preference. Neither of them referred to the facility assessment as a tool to assist with determining staffing levels. Reviewed the observations and asked why the float nurse had not been assigned to the unit as indicated on the schedules. The NHA reported that she thought a float nurse was being assigned to the unit. A subsequent interview with the DON on 2/13/26 at 3:00 PM revealed she had not used the facility assessment to determine staffing levels. She acknowledged that the staffing levels were not enough to allow staff to bath and get resident's out of bed in a timely manner. The NHA was unavailable for a subsequent interview.

Based on record review and interview, it was determined that the facility failed to provide incontinent care for a resident in need of these services. This was evident for 1 (#5) of 2 residents reviewed for incontinent care. The findings include: On 9/18/25 the State Agency (SA) received a complaint that the Resident (R)5 did not receive incontinent care on 9/16/25 and on 9/17/25. The complainant noted that there was a strong smell of urine in the resident's room and that the brief and bed were saturated with urine on both days. On 12/10/25 at 10:00 AM a review of the facility's assignment sheets for the unit where R5 resided were reviewed. On 9/16/25 on night shift there was 1 nurse and 1 geriatric nursing assistant (GNA) scheduled to care for 35 residents. On 9/16/25, during the day shift there was 1 nurse and 2 GNAs scheduled to care for 34 residents. On 9/16/25, during the evening shift there was 1 nurse and 3 GNAs scheduled to care for 32 residents. On 9/17/25, there were 32 residents and during night shift there was 1 nurse and 1.5 GNAs (because 1 GNA was split between 2 units), on day shift there was 1 nurse and 3 GNAs, and on evening shift there was 1 nurse and 3 GNAs. A medical record review for Resident (R)5 on 12/10/25 at 12:35 PM revealed a progress note written by Nurse Practitioner (NP) #17, who treated R5's wounds, documented the resident needed assistance with personal care. The recommendation was to provide thorough skin care for each incontinent episode. A review of the GNA's documentation for incontinent care for 9/15/25 night shift revealed the GNA documented that this activity did not occur for the resident and n/a for bladder incontinence care. On 9/16/25 there was no documentation to indicate that staff provided incontinence care for the resident on day shift. On evening shift the GNA documented the resident refused care, however, there were no progress notes to indicate that the nurse was made aware and provided education to the resident. On night shift, 9/16/25 into 9/17/25 there was no documentation that staff provided the care. The same on 9/17/25 day shift and evening shift. The days that the complainant indicated the resident had not been changed and the urine was soaked through to the bedding. An interview with the Director of Nursing (DON) with the Nursing Home Administrator (NHA) present on 12/10/25 at 10:25 AM revealed that they agreed there was a concern that incontinent care was provided since it was not signed off or documented that the activity had not occurred or n/a. The DON stated that if staff did not sign off the task, then it was not done.

Based on observation, record review, and interview, it was determined that facility staff failed to maintain a clean and homelike environment for their residents. This was evident for 1 (Unit A) of 2 units observed for cleanliness. The findings include: An observation on 12/1/25 at 12:04 PM of the A unit revealed in rooms [ROOM NUMBERS] the floor was carpeted and visibly soiled near the doorway. There was debris on the floor. A second observation on 12/9/25 at 2:29 PM revealed several rooms had crumbs and debris on the floor and in the hallway. room [ROOM NUMBER] A, 214 A and B, 216 A and B had crumbs and debris under the beds. In the hallway outside room [ROOM NUMBER] and 219 there was debris scattered. The door to the room with the ice chest had a cup lid laying in the corner to the left of the door. On 12/8/25 at 10:25 AM an interview with Environmental Director (ED) revealed that housekeeping staff were responsible for ensuring that the residents' room floors and unit hallways were free of debris. She reported that through her weekly quality checks she had identified that the housekeeper responsible for unit A had not been keeping the floors clean on the unit. The employee was disciplined, but there continued to be an issue. When asked what she determined was the issue, she reported that it was a lack of time management skills. The concerns were reviewed with the Nursing Home Administrator at the time of exit on 12/10/25 at 2:30 PM.

Based on record review and interview, it was determined that facility staff failed to provide residents with their right to privacy of personal information by holding care plan meetings in their rooms with roommates present. This was evident for 1 (#3) of 1 resident reviewed for privacy concerns. The findings include: On 12/3/25 at 9:52 AM a review of a complaint received by the state agency (SA) on 8/15/25 revealed that Resident (R)3 had a care plan meeting that was held in his/her room with the roommate present. The complainant reported that the roommate made a comment during the meeting to indicate that they were listening. The complainant reported that when it was brought to the attention of the staff holding the meeting, they were informed that this was how they conducted the meetings since COVID 19 pandemic. On 12/8/25 at 3:59 PM a review of the letter sent to R3's representative regarding the care plan meeting revealed that it specifically stated that the meeting was to be held in the resident's room. In addition, it was noted that the meetings were 20 minutes in length. An interview with the Director of Social Services on 12/8/25 at 3:23 PM revealed that care conferences for residents in the short-term rehab units were held in their rooms. She stated the way the rooms were laid out it afforded them more privacy than the residents on the long-term care units (LTC). After discussing the layout of the rooms in the rehab unit she agreed that it may not be private enough to hold a care plan meeting. She agreed that the rooms on the LTC were not private enough, especially if there was a roommate present. She stated that they just started placing rehab residents on the LTC unit. An interview on 12/8/25 at 3:59 PM with Social Services Staff #16 confirmed that R3's care plan meeting was held in his/her room on the LTC unit. She stated the roommate was present and they had pulled the curtain for privacy. She stated she was accustomed to holding short-term rehab resident's care plan meetings in their rooms that she had not considered the lack of privacy for R3. She reported that the family brought it up but it was at the end of the meeting. On 12/10/25 at 2:31 PM the concerns were discussed with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) who agreed that the residents' rooms were not the appropriate location to hold a care plan meeting unless the roommate was out of the room.

Based on interviews with facility staff and review of the dietary supervisor credentials, it was determined the facility staff failed to ensure a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation.The findings include:On 7/15/25 at 8:10AM an observation of the facility kitchen was made. During the interview the kitchen manager (Staff #13) reported that her highest level of credentials were in serv safe. She reported that she was in the process of taking the Certified Dietary Manager (CDM) class. She reported that she received consultation from the Regional Dietary Manager. On 7/18/25 at 10:17 AM an interview was conducted with the Regional Dietary Manager (Staff #31). He reported that he was just filing in with the regular dietary manager. Dietary Manager (Staff #31) reported he was not sure he reviewed his certificated dietician certification (CDM), but he would look for it and provided it to the survey team. No CDM certification was provided prior to the end of the survey.On 7/21/2025 9:32 AM during an interview with the Regional Dietary Manager (Staff #7), she reported that she is responsible for oversight of the Kitchen for the facility. She reported she was not a CDM. On 7/18/2025 at 11:37 AM during a brief Interview the Administrator reported that she wanted to take responsibility for not having a CDM. She thought the current kitchen manager was a CDM. On 7/23/2025 at 8:59 AM during an interview with Registered Dietician (RD) (Staff #18) reported she provided services to the facility on site, 2 days a week and remotely. The RD (Staff # 18) reported that she does not provide oversite of the kitchen but does collaborate with the dietary manager on resident's diets. On 7/24/2025 at 11:31 AM during an interview with Registered Dietician (Staff #32) he reported that he works on site at the facility one day a week and has remote hours. He reported he is certified as a CMD but had not had any oversight responsibilities of the facilities kitchen.On 7/24/2025 at 1:11 PM the above concerns were shared with the Director of Nursing. No additional information was provided prior to the end of the survey.

Based on interviews and a review of pertinent documents, the facility failed to follow the required procedure for addressing residents' grievances. This was evident for 1 (Resident #6) out of 3 residents reviewed for personal property during a survey.The findings include:On 7/15/2025 at 10:09 AM, Resident #6, who was admitted to the facility for rehabilitation, reported that one of her/his long pants was missing. S/he stated that this had been reported to a facility staff member.On 7/17/2025 at 11:20 AM, the Director of Social Services and Discharge Planning (Staff #3) was interviewed. She confirmed that she did not have a grievance form regarding the resident's missing pants.On 7/17/2025 at 11:24 AM, the Director of Social Work & Discharge Planning (Staff #3) was interviewed. She reported that a resident or family member can report grievance either electronically or verbally to a staff member. A staff member who receives a grievance is expected to document it online. The grievance is then sent to the appropriate department, and the actions taken to resolve the grievance are documented on the electronic form.On 7/17/2025 at 11:52 AM, a follow-up interview was conducted with the Director of Social Work & Discharge Planning Director(SSD) (Staff #3). During the interview, she confirmed that the facility's grievance procedure does not require the person filing the grievance to sign that they received the resolution. Additionally, the person does not receive a written copy unless they specifically request one. She also confirmed that she had never provided a written copy of the grievance form to the person filing the grievance during her tenure at the facility. In a second interview with the SSD, she confirmed that there is no place on the document for the residents to sign.On 7/17/25 the Director of Social Work & Discharge Planning Director (Staff #3) provided 8 completed grievance forms from 4/7/25 to 7/3/25. Review of the grievance forms failed to reveal a space on the form for the residents to sign that they reviewed and or received a copy of the completed grievance form. On 7/17/2025 at 12:15 PM, the Administrator was interviewed. During the interview, she reported that she reviews and approves all grievance resolutions. The Administrator confirmed that their grievance process does not include having the person filing the grievance sign to indicate agreement with the resolution, nor do they receive a written copy of the resolution.On 7/17/2025 at 3:38 PM, the Director of Nursing provided a policy titled Service Concerns/Grievances with an effective date of 3/1/25.On 7/17/2025 at 3:41 PM, a review of the Service Concerns/Grievances policy revealed that it does not include a requirement for the residents to sign or receive a copy of their grievance.On 7/24/2025 at 1:11 PM, the concern that there was no documentation showing that the resident received a written copy of the grievance resolution was shared with the Director of Nursing. She reported that she was unaware a written copy was required to be provided to the person filing the grievance. She stated that she would review the requirements and discuss them with her management team.

Based on observation, interview, and record review, it was determined that the facility failed to ensure the proper storage of medications. This was evident for 1) three of five medication storage areas reviewed, 2) one unsecured storage room (C-Wing), 3) inappropriate temperature control and ice buildup in two refrigerators (C-Wing and A-Wing), and 4) the presence of food items in a medication refrigerator (West View Heights).The findings include: Based on observation, interview, and record review, it was determined that the facility failed to ensure the proper storage of medications. This was evident for 1) one medication room that was unable to be secured (C-Wing) of three medication rooms reviewed, 2) two medication refrigerators kept at inappropriate temperatures in two of three medication storage rooms (C-Wing and A-Wing), 3) one medication refrigerator that contained food on one (West View Heights) of three medication rooms observed, 4) one unlocked medication cart of two medication carts reviewed on canal side terrace B unit, and 5) one unlocked treatment cart of one treatment cart observed on A wing. The findings include: 1). On 7/17/25 at approximately 8:50AM, the surveyor observed that the C-Wing Medication Storage room didn't have a lock. Nurse #15 confirmed that there was no lock on the door. On 7/17/2025 at approximately 10:00 AM, the surveyor toured the facility's medication storage areas in the A-Wing, C-Wing, and [NAME] View Heights, accompanied by the Director of Nursing (DON). At 10:09 AM, the surveyor entered the C-Wing medication storage room and observed that the room was not secured, as the door handle did not lock. Inside the room, neither the medication refrigerator nor the cabinets were secured with locks. When questioned, the DON stated, they are just over-the-counter medications in the cabinets. However, the surveyor observed several medications and needle-type devices stored in the cabinets. On 7/17/25 around noon, the surveyor interviewed the Nurse Unit Manager (Nurse #22), who confirmed that the door to the medication room on the C-Wing is unable to be locked and stated that she had told someone before that they needed a lock for the medication refrigerator as well. She confirmed that the cabinets do not lock. On 7/17/2025 at 1:04 PM, the surveyor and the survey team leader conducted a second inspection of the C-Wing medication storage area and confirmed that the door to the room was unable to be locked and that the refrigerator remained unlocked (a pad lock was now in place but not secured). The surveyors were able to enter the room and access cabinets which contained multiple bottles of over-the-counter medications, lancets, needles (syringes), alcohol pads, and medical grade disinfectant wipes, wound care cleaner and an unsecured plastic storage container on the floor, which was full of resident prescription medications in blister packs. On 7/17/2025 at 3:37 PM, the surveyor addressed concerns with the DON regarding the unlocked C-Wing door, cabinet, and medication refrigerator. The DON confirmed the issue, stated that the medications would be relocated until the room could be secured, and acknowledged that replacing the lock was not in her toolbox of duties, but assured it would be addressed. 2a). When looking at the medication refrigerator/freezer in the C Wing medication room the surveyor observed significant ice buildup, the DON confirmed this finding. The surveyor asked how often the facility defrosts the refrigerator and she stated it is to be done during monthly cleaning. She pointed to the temperature log on the refrigerator which had a place to write the cleaning date (nothing written) but failed to include any type of documentation about defrosting the refrigerator. When the surveyor asked what temperature range the medications were to be kept, she stated I think it is 34-42 degrees, but I need to check the manufactures directions. 2b.) On 7/17/2025 at 10:21 AM, the surveyor, accompanied by the Director of Nursing (DON), observed the A-Wing medication room. The surveyor again noted a buildup of ice within the medication refrigerator/freezer. Additionally, the surveyor observed that the refrigerator temperature was not recorded on 7/3/25 or 7/4/25. The temperature log posted on the refrigerator indicated that the internal temperature should be 40 degrees or less. When asked about the procedure for addressing temperature deviations, the DON stated that staff are expected to close the refrigerator and retake the temperature. If the temperature is still off after an hour, they should try adjusting the temperature. If it remains out of range, they are to notify maintenance. 3). On 7/17/2025 at 10:32 AM, the surveyor, accompanied by the DON observed the medication storage area on the [NAME] View Height (WVH-Wing). The DON opened the medication refrigerator/freezer and noted that raspberry sherbet and chocolate ice cream were being stored with medications. The DON stated that she was aware that food was not to be stored with medications and immediately threw the items away. The Manufacturer's for Use (MFU) instructions are the official guidelines provided by the drug manufacturer outlining how a medication must be stored, handled, and administered to maintain its safety, stability, and effectiveness. On 7/18/2025 at 9:13 AM, the DON provided the surveyor with the facility MFU's for the medications within the facility that requiring refrigeration. The findings are as follows: All the following medications should be stored between 36-46 degrees. Latanoprost Ophthalmic Solution Aformeoterol Tartrate Inhalation Solution Veltessa The following medication storage instructions state: Do not freeze, do not thaw and use, and discard if frozen: Novolog, Humalog, Humalog, Novolin, Humulin, Lantus, Levemir, Insulin Epogen Cyletzo Vancomycin On 7/18/2025 at 9:22 AM, the DON provided the surveyor with the medication refrigerator cleaning and temperature logs. Below is a summary of findings for Units A and C from January through May 2025: Unit A (Jan–May 2025): Missing Temperature Documentation: 1/2, 1/7, 1/15–1/18, 1/21–1/22, 1/26, 1/30, 2/4, 2/8, 2/13–2/14, 2/18, 2/22–2/23, 2/27–2/28, 3/4, 3/8, 3/13, 3/18, 3/22–3/23, 3/27–3/28. (No logs were provided for April or May.) Out-of-Range Temperature: 1/6 recorded at 32°F. No documentation for cleaning or defrosting. Unit C: Missing Temperature Documentation: 5/21–5/23, 5/27–5/28. (No logs were provided for January through April.) Out-of-Range Temperatures: 5/5: 35°F 5/12: 28°F (adjusted but not rechecked) No documentation for cleaning or defrosting. On 7/24/2025 at 10:03 AM, the surveyor performed a review of facility policies and procedures as follows: Administration Procedures for all Medications effective date 9-2018 and revised on 8-2020 (Policy 9.1) which states: Security- All Medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide. Medication Room Temperature Log (policy #1016) effective date 1/29/24 :The medication room refrigerator temperature will be recorded twice daily and will ensure that the temperature is between 36-46 degrees. Out of range temperatures are to have the temperature adjusted and rechecked within one hour to verify the effectiveness of the temp adjustment. Maintenance should be notified if the temp remains out of range. Medications should be stored in a separate refrigerator until the unit has been repaired. Medication Rooms (policy #506) effective date 2/6/20: The refrigerators in the medication rooms are to be cleaned every night and defrosted weekly unless frost free. Storage of Medications (policy 4.1) effective 9/2018: The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Refrigerated medications should be stored between 36-46 degrees Refrigerated medications are kept in closed and labeled containers with internal and external medications separated from each other and from fruit juices, applesauce, and other foods used in administering medications. On 7/18/2025 at 12:13 PM, the surveyor discussed medication storage and temperature monitoring concerns with the DON. The DON confirmed that medication refrigerators were not being properly monitored, with no documentation of corrective actions when temperatures dropped below 36°F, including instances near or at freezing. She acknowledged that some medications should not be exposed to freezing temperatures. The DON also confirmed that two refrigerators observed on 7/17/25 had visible ice buildup and had not been defrosted per facility policy. Temperature logs were not consistently completed, and staff failed to follow protocols for rechecking or escalating temperature issues. Additionally, the DON confirmed that food items were stored alongside medications, and that the C-Wing medication room door had previously been unable to be locked but was repaired the night before following surveyor feedback. 4). A medication storage observation at the canal side terrace B unit was conducted on 7/17/25 at 12:57 PM. During the observation, 1 of the 2 medication carts were unattended and unlocked. Also, there were residents wandering on the unit passing the identified medication cart. The Certified Medication Aide (Staff #6) who was working with the other medication cart at approximately 30 feet away, was interviewed about medication storage on 7/17/25 at 1 PM. She reported that the Canal side terrace B unit had 2 medication carts and 1 medication storage room. Staff #6 agreed to show the surveyor the unit's medication room. Staff #6 locked her medication cart and proceeded to walk to the medication room passing the unlocked medication cart. After showing the medication room to the surveyor, Staff #6 then proceeded to walk back to her medication cart and in process, she locked the other medication cart as she walked by it. The surveyor asked Staff #6 if that was her medication cart and she reported that it was the Licensed Practical Nurse's (LPN #5). Staff #6 also reported that LPN #5 had stepped out of the unit and stated, my practice is to always check the medication cart before walking away, I don't know why she (referring to LPN #5) left it like that. On 7/17/25 at 1:02 PM, LPN #5 returned to the unit and joined the discussion about the unlocked medication cart. LPN #5 confirmed that the identified medication cart was hers, thanked Staff #6 for locking it, and verbalized understanding that medication carts should always be locked when unattended, noting special importance in her unit with wandering residents with dementia. On 7/21/25 at 3:24 PM, the finding was discussed with Director of Nursing, and she verbalized understanding and acknowledged the concern. 5). On 7/23/25 at 7:31 AM a treatment cart was observed to be unlocked. The cart was located on the A Wing, at the end of the hall. On 7/23/25 continued observation of the treatment cart revealed the cart remained unlocked from 7:31 AM to 7:47 AM. On 7/23/25 at 7:47 AM the surveyor brought the unlocked treatment cart to the attention of Nurse (Staff #13). Nurse (Staff #13) immediately locked the cart. She confirmed that the treatment cart should be locked. On 7/23/25 at 8:48 AM a review of the treatment cart in the presence of nurse (Staff #13) revealed (but were not limited to) the following items: First drawer: Triamcinolone acetonide, cream, Second drawer: Hydrocortisone percent cream Betadine solution Third drawer: blood drawl tube and supplies Bottom drawer IV catheters (needles used to start an IV). On 7/23/2025 at 8:52 AM during an Interview with the Director of Nursing she confirmed that the treatment cart should be locked. On 7/24/2025 at 11:17 AM the regional director of Clinical (Staff # 9) provided the facility policy titled Storage of Medications with the effective date of 9/2018. On 7/24/2025 11:25 AM a review of the above policy revealed that only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aids) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by people with authorized access.

Based on observations and interviews, the facility failed to maintain a clean and comfortable homelike environment. This was evident for eight of eight days of environmental observations.The findings include: On 7/15/2025 at 8:20 a.m., the surveyor noted a strong odor of urine in the C-wing and observed stains on the carpeting throughout the C-wing.On 7/15/2025 at 10:20 a.m., the surveyor interviewed Resident #33 and their family member. Both expressed concerns about the facility's cleanliness. The family member pointed to the carpet near the resident's bed and stated that it was filthy. The surveyor observed heavy staining on the carpet in that area.On 7/15/2025 at 3:37 p.m., Resident #33's family member called the surveyor to express continued concerns, stating that the facility had drastically gone downhill, especially regarding cleanliness. They commented, We knew something was going on because there was more cleaning and staff here today than ever, referring to the presence of surveyors in the building.On 7/16/2025 at 9:56 a.m., the surveyor noted that the strong urine smell observed the previous day remained present in the C-wing.On 7/17/2025 at 8:05 a.m., the surveyor again observed a strong urine odor in the C-wing, accompanied by a stale, wet smell. Others on the survey team agreed that they had noticed a strong urine smell.On 7/22/2025 at 8:45 a.m., the surveyor noted a very strong urine odor in the C-wing and observed intermittent stains throughout the first-floor carpeting. Stains on the C-wing carpeting remained visible.On 7/23/2025 at 2:18 p.m., the surveyor continued to observe a strong urine odor in the C-wing. Dirt-stained carpets were also noted intermittently throughout the 1st, 2nd, and 3rd floors, as well as in the elevator. Resident #33's room continued to have heavily stained carpet on both sides of the bed.On 7/24/2025 at 9:34 a.m., the surveyor observed a strong urine odor in hallways A and C. Continued staining was noted on the carpet from the administrative offices through to the elevator on the main floor, as well as on the 2nd floor outside the elevator and in the C hallway.On 7/24/2025 at 9:43 a.m., the surveyor observed stains on the 3rd-floor carpeting just off the elevator and before the transition to laminate flooring. Resident #33's room remained unchanged, with heavily soiled, worn carpet on both sides of the bed. The C-wing hallway carpeting also remained soiled and worn.On 7/24/2025 at 9:50 a.m., the surveyor interviewed the Regional Director of Clinical Operations. When asked about the urine odors in A and C hallways, she confirmed awareness. When asked about the carpet condition, she stated that the facility was aware of the staining and wear.On 7/24/2025 around noon, the surveyor conducted a facility walkthrough to observe the condition of the carpets. The surveyor noted multiple areas with visible staining on the carpeting. The Maintenance Director confirmed that there are areas of the facility with stained carpet.

Based on record reviews and interviews, it was determined that the facility failed to honor the resident's/resident representative's right to access personal and medical records. This was evident for 1 (Resident #133) of 2 residents reviewed for neglect. The findings include:A review of the intake information related to MD00217274 indicated that Resident #133's representative had requested medical records after the resident's death and was wrongfully denied the request.In an interview with the resident representative on 7/17/25 at 12:31 PM, s/he reported filling out a medical records request form at the front desk of the facility. Then after some time, had received a phone call from a facility staff informing him/her that the request was denied and no further explanation was provided.The Director of Nursing (DON) was interviewed on 7/23/25 at 2:16 PM. During the interview, she reported the process to request medical records and indicated that a record request form is filled out and submitted to the medical records coordinator (Staff #44) to be processed.On 7/23/25 at 2:45 PM, Staff #44 was interviewed. During the interview, she reported that she had been with the facility since February of 2025. She also provided a copy of the records request form to the surveyor and reported that she kept the filled-out forms for her records.When Staff #44 was asked about resident #133, she immediately pulled out the record request form that was filled out by the resident representative dated 4/28/25 and indicated that the DON had already informed her of what the surveyor was looking for. Staff #44 reported that the medical records request was denied because the representative only had a financial Power of Attorney (POA) and was ultimately decided by a third-party company (Rytes company) that the representative lacked the clearance to obtain the medical records.Staff #44 further explained the process for records request, indicating that once the form is filled out, she sends them to Rytes company via email for determination, then after Rytes company reviews the request and the resident's medical record, they would inform Staff #44, via email, if the records can be released.Staff #44 provided the surveyor with a copy of the email received on 4/29/25 from Rytes company, addressed only to her, stating records could not be released due to: The request lacks supporting documents demonstrating that the person signing the authorization and/or making the request is the personal representative of the resident and has the authority to request/release medical records. Qualifying documents could include a power of attorney for healthcare, health care surrogacy or proxy, guardianship document or advanced directive. Instructions on the email stated, In the event that you have additional relevant documents in your file, please provide to Rytes by responding to this email with the additional documents.Subsequently, Resident #133's medical records were reviewed with Staff #44 on 7/23/25 at 2:58 PM. The review revealed the resident's advanced directive with an upload date of 3/19/25, that stated the representative's name as appointed POA for healthcare in the event that the resident cannot make healthcare decisions him/herself. Staff #44 reported that she did not see the advanced directive because she does not review resident records. She indicated that she solely relies on Rytes company to figure that out.On 7/23/25 at 3:41 PM, the findings were discussed with the Regional Director of Clinical (Staff #9). Staff #9 confirmed that both Rytes company and Staff #44 had complete access to Resident #133's medical record that included the advanced directive.Staff #9 agreed that based on the advanced directive, the representative should have been deemed eligible for the medical records request by Rytes company. Also, the medical records coordinator should have reviewed Resident #133's medical record and provided the advanced directive document to Rytes company, as instructed in the email and inform the Director of Nursing and Nursing Home Administrator. Staff #9 verbalized understanding of the concern and stated, I will contact Rytes and find out what happened.On 7/24/25 at 8:56 AM, Staff #9 reported that she had talked to staff from Rytes company and investigated the concern. They indicated that they had made a mistake and were looking at the wrong resident. Staff #9 indicated that she had instructed Staff #44 to contact Resident #133's representative about providing the medical records as initially requested.

Based on surveyor observation, record review, and interviews with residents and staff, it was determined that the facility staff failed to ensure that care and services were provided to assist all residents in achieving their highest practicable level of wellbeing. This was evidenced by: 1) facility staff's failure to ensure that each resident received treatment and care in accordance with professional standards of practice as evidenced by a nurse providing a treatment without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #74, #59) out of 7 residents selected for unnecessary medication review, 3) the facility staff's failure to ensure that arm protectors were provided as prescribed by the physician for 1 (#35) of 13 residents reviewed for Abuse, 4) the facility staff failure to identify and follow up when a resident had a change in physical status for 1 (#26) of 28 residents observed during initial resident observations, and 5) the facility staff failure to arrange and provide a follow-up appointment as per a consulting specialist's recommendation for 1 (#38) of 4 residents reviewed for Urinary Catheter or [CONDITION(S)]. The findings include: 1) Based on review of complaint #MD 339, medical record review and complainant and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional standards of practice as evidenced by a nurse providing a treatment without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evident for 1 (#250) of 12 residents reviewed for abuse. The findings include: On 6/10/22 at 3:41 PM, review of complaint #MD 339 was conducted. In the complaint , the complainant reported that, while Resident #250 resided in the facility, the complainant received a phone call from the facility and was told that Resident #250 had a cut on the ear that was bleeding, and the resident was sent to the emergency room . The complainant stated that he/she was told that a staff person scratched Resident #250's ear while using a tool to clean the resident's ear. On 6/10/22 at 3:45 PM, a review of Resident #250's medical record revealed that Resident #250 was admitted to the facility in January 2021 for rehab following an acute hemorrhagic stroke (bleeding in brain) resulting in right sided [CONDITION(S)] (paralysis) and [CONDITION(S)] (difficulty with language or speech, usually caused by brain damage), and indicated that the resident was vulnerable, immobile and had difficulty communicating. On 1/8/21 at 3:09 PM, in an Admission Summary note, the nurse documented that Resident #250's right arm was flaccid (limp), his/her right leg was weak, and the resident was aphasic, with garbled or whispered speech and difficult to understand. A review of Resident #250's medical record was continued on 6/13/22 at 9:00 AM. In a nurse's note written on 3/4/21 at 10:19 PM, it was documented that Resident #250 was having steady bleeding with clots from his/her right ear that started at 7:00 PM, and the CRNP (certified registered nurse practitioner) was notified. In a later note, on 3/5/21 at 12:00 AM, the nurse wrote that the bleeding had continued with clots of blood noted at the ear canal, the NP (nurse practitioner) was notified, an order was given to send Resident #250 to the ER (emergency room ) for evaluation, and the resident was transferred to the hospital. In an ED (emergency department) Provider note, with a discharge date of [DATE] at 2:09 AM, the PA (physician's assistant) wrote that Resident #252 was sent to the ER for bleeding from the right ear, and that per report, the resident had bleeding from right ear canal after nursing home staff tried to clean the ear. In the summary statement, the PA wrote that the nursing report stated the bleeding began after the ear was being cleaned and there was evidence of an abrasion within the ear canal. The PA also indicated the resident was being discharged back to the facility with instructions that included no foreign objects within the ear canal. In an incident note, on 3/5/21 at 7:10 AM, the nurse indicated that he/she received in report that Resident #250's ears had been cleaned on dayshift, and the 3-11 shift nurse reported the resident had been bleeding from the right ear. The nurse wrote that when he/she came on shift, the bleeding continued with clots of blood noted at ear canal, the NP was notified, and the resident was sent to the ER for evaluation. The nurse wrote that, on 3/5/21 at 3:52 AM, when the ER was called for an update, he/she was notified Resident #250 had a laceration in the ear canal and was on his/her way back to the facility. In a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician wrote that yesterday [3/4/21], the resident's ears were cleaned out by a nurse (RN Staff #3) after which the resident's ear started to bleed with clots. Resident #250 was sent to the emergency department and was found to have an abrasion of the ear canal and the ear was packed. The physician wrote that when he/she removed the resident's ear pack, there was a gelatinous clot. Resident #250's medical record indicated that a facility nurse provided a treatment to Resident #250's right ear which resulted in a resulting in an injury (abrasion) to the resident's right ear canal, however, continued review of the medical record failed to reveal a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the nurse who provided the treatment to Resident #250's ears failed to document the reason for the treatment, the treatment performed or the resident's response to the ear treatment. On 6/13/22 at 1:37 PM, during an interview, when asked about Resident #250's right ear canal abrasion, Staff #5, PA indicated that an RN had cleaned Resident #250's ear and caused trauma. Staff #5 stated that a nurse took a curette (ear cleaning tool) and took it upon him/herself to clean the ear. Staff #5 stated that he/she had not instructed the nurse to clean out the resident's ears and to his/her knowledge, no one gave the nurse an order to clean out the resident's ears, and that he/she would never advise a nurse to use a curette to clean out a resident's ears. Staff #5 stated that the nurse who cleaned out Resident #250's ears said he/she saw the ear wax and wanted to get it. Staff #5 identified the nurse as an RN, Staff #3. On 6/13/22 at 3:40 PM, during an interview, the DON (Director of Nurses) stated that nurses were not to clean resident ears with a curette. The DON stated that Staff #3, the person implicated as the staff nurse who cleaned the Resident #250's ears with a curette without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time, the DON indicated that he/she had not been the DON at the time of the incident. On 6/15/22 at 10:29 AM, a phone interview was conducted with Staff #3. At that time, Staff #3 stated he/she could not recall the incident related to cleaning Resident #250's ears which resulted in a right ear canal abrasion. Staff #3 stated he/she did not believe he/she would do that or go off a shift had there been a problem. When asked if he/she cleaned resident ears, Staff #3 stated he/she would clean a resident's ear if needed and would use an otoscope (tool used to visualize and examine the ear canal) to assess the situation. If the ear needed to be cleaned, Staff #3 stated he/she would use an otoscope & curette to clean the ear. Staff #3 indicated he/she had provided the treatment weekly at a different out of state facility. When asked if the treatment required a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked again if he/she recalled the situation, Staff #3 did not recall the situation and did not believe he/she would do that and would have remembered if he/she had notified the physician. Staff #3 stated he/she was never made aware of the incident, or received education about the incident, and would have remembered if he/she had been. On 6/15/22 at 11:31 AM, during a second interview, Staff #5, PA stated he/she had not talked directly to Staff #3 about the incident. Staff #5 stated that Staff 7, who was the DON at that time, called the PA and asked if he/she had given Staff #3 a curette to clean the resident's ear, which he/she had not. Staff #5 stated that he/she knew Staff #7, was addressing it and the PA had never given an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/22 at 12:47 PM, during a phone interview, Staff #7, RN stated that he/she was the DON at the time of the incident. Staff #7 stated that one of the nurses had cleaned out the Resident #250's ear with a curette and caused the bleeding. Staff #7 stated he/she was told about the incident by the nursing staff the next day and did speak with Staff #3 about the incident. Staff #7 indicated that at that time, it was realized there was no policy, so a facility policy was created to have nurses clean out resident ears by flushing and that he/she would expect a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/22 at 1:00 PM, the facility's policy for ear irrigation, dated 3/10/21 and evidence of the staff education provided following the above incident was reviewed. The policy was designed to address the needs of the residents at the facility when cerumen build up is evident in the ear canal and requires intervention. Ear irrigation is the only approved procedure to remove cerumen from the ear canal. The policy indicated that an order from a medical provider would be needed for ear irrigation and included the statement Do not insert an object into the ear canal, such as Q-tip or plastic curette. Review of the facility's On the Spot Education, dated 3/5/21, stated staff nurses, GNA (geriatric nursing assistant), CMA (certified medication aide) or any other staff member are not to clean resident's ears with anything other than soap and water, do not place Q-tip or any other device and attempt to remove ear wax/debris. If there is a concern of wax build up/debris or any other inner ear concern report this issue/concern with the providers. Do not attempt to remove wax/debris or anything else manually. The sign-in sheet was signed by 3 nurses and 6 GNAs and did not include Staff #3's signature. On 6/15/22 at 2:28 PM, the DON & ADON (assistant director of nurses) were made aware of the above findings and confirmed there was no further evidence to indicate that the all the clinical nursing staff, including Staff #3, had been educated on the facility's policy and the process to follow when a resident needs his/her ears cleaned. 2a) On 6/9/22, review of Resident #74's medical record revealed that the resident had resided at the facility for several years. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had been receiving the antipsychotic medication [MEDICATION(S)] for more than one year. Further review of the medical record revealed an order, dated 8/8/21, for an EKG (electrocardiogram) annually in May to assess for QT prolongation due to [MEDICATION(S)] usage. An EKG is a diagnostic medical test that records the electrical signal from the heart to check for different heart conditions. QT prolongation may indicate a heart signaling disorder than can cause irregular heartbeats. Further review of the medical record failed to reveal documentation to indicate that an EKG had been completed when due in May 2022. On 6/13/22, surveyor reviewed with the Assistant Director of Nursing (ADON) that no results for the EKG could be found in the medical record. On 6/14/22 at 2:54 PM, the ADON confirmed that no EKG had been completed as ordered. 2) Further review of the medical record revealed a physician order, dated 3/10/22, for an AIMS (Abnormal Involuntary Movement Scale) assessment to be completed every four months. The order included a notation that the resident is on [MEDICATION(S)]. AIMS is a rating scale used to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder than can develop as a side effect of antipsychotic medication usage. On 6/13/22, further review of the medical record failed to reveal documentation of an AIMS assessment. The ADON was informed that no AIMS assessment was found in the medical record. On 6/15/22 at 2:26 PM, the DON confirmed that there were no AIMS assessments for the resident. On 6/24/22 at 12:30 PM, surveyor reviewed the concern with the DON and ADON regarding the failure to complete the ordered EKG and AIMS testing. 2b) On 6/21/22, review of Resident #59's medical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The insulin orders also included instructions to hold (not administer) if the fingerstick blood sugar level was below 120. Further review of the medical record revealed an order, with a start date of 5/11/22, for Fingerstick Blood Sugar levels four times a day and to contact the provider if the level was less than 70 or greater than 400. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record failed to reveal documentation to indicate that the blood sugar levels were being obtained more than twice a day. On 6/22/22, the surveyor reviewed the concern with the DON and ADON regarding the failure to obtain the blood sugar levels four times a day as ordered by the provider. As of time of exit on 6/24/22 at 2:45 PM, no additional documentation was provided to indicate that the blood sugars were being obtained as ordered. (Cross reference F757) 3) Resident #35 was observed on 6/6/22 at 2:31 PM. He/She was lying in bed and had several small dark spots and small scabbed spots over the backs of his/her hands and forearms. His/her skin appeared thin. A small piece of white elastic mesh stockinette approximately 4-5 inches long covered a dressing on the resident's left forearm approximately midway between his/her wrist and elbow. The resident indicated that he/she did not wish to speak to the surveyor. Resident #35's medical record was reviewed on 6/14/22 at 9:59 AM. The record included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] is an anticoagulant (blood thinner) medication used to treat and prevent blood clots and stroke. The side effects of [MEDICATION(S)] include easy bruising and bleeding. The record also included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May remove for bathing. Please document if resident declines application. The reason for the order was indicated as For fragile skin. The record contained a Plan of Care for: Skin tear to left forearm and potential for further tissue impairment. The interventions included but were not limited to: Geri-sleeves (arm protectors) to be worn daily; May remove for bathing. This intervention was initiated 4/13/22. A review of the 6/2022 Treatment Administration Record (TAR) revealed the order for arm protectors,with spaces labeled Day Eve and Night, for the nurse to sign off that they completed this order each shift. The TAR was not signed for dayshift at that time. However, a review of Resident #35's nursing progress notes failed to reveal documentation as to why the resident was not wearing his/her arm protectors on 6/6/22 when observed by the surveyor. Additional observations of Resident #35 were made on 6/14/22 at 2:32 PM and 6/15/22 at 11:47 AM. During each of these observations, Resident #35 was lying in bed without arm protectors in place, the elastic mesh stockinette was in place on his/her left forearm. Further review of the 6/2022 TAR on 6/15/22 at 12:32 PM revealed that the order for arm protectors was signed off every shift from 6/1/22 - 6/15/22 including day shift on 6/6/22, 6/14/22 and 6/15/22 when the surveyor observed the resident without the arm protectors. No documentation was found in the record to indicate that the resident was not wearing them and why. During an interview on 6/15/22 at 1:28 PM, Staff #56 reviewed and confirmed that she signed off Resident #35's arm protectors for the current shift. She then observed Resident #35 with the surveyor and confirmed that the resident was not wearing arm protectors. When asked who was responsible for putting the arm protectors on Resident #35, she stated technically if I'm signing them off, I should be putting them on but usually the girls will put them on. When asked how she verifies that they are on the resident she stated, it would be by sight. In an interview on 6/15/22 at 1:36 PM, Staff #50 a GNA (Geriatric Nursing Assistant), reviewed Qshift (the GNA's electronic documentation tool) with the surveyor and Staff #56. Staff #50 indicated that Resident #35's arm protectors were not listed for the GNA's to apply. The Director of Nursing and Assistant Director of Nursing were made aware of these findings on 6/15/22 at 1:44 PM. 4) Resident #26 was observed on 6/6/22 at 11:54 AM with a brown area on his/her lower left cheek. The area was approximately 1.5 long x .5 cm wide, and the edges appeared slightly pink-red. When asked, the resident did not seem to be aware of the area and indicated that he/she was not sure what it was. Resident #26's medical record was reviewed on 6/22/22 at 10:30 AM. A physicians order was written on 7/12/18 for: Concurrent Review: Appraise and observe resident daily for changes in physical or mental status every shift. Document yes or no if changes are observed. If a change has occurred, the change should be documented in the form of a nurses note. No documentation was found in the record to indicate that the area on the resident's left cheek was identified and addressed by staff. Review of Hospice documentation revealed a Hospice Nurse progress note dated 6/16/22. Under Wound(s) identified NO was noted. Resident #26 was observed again on 6/22/22 at 3:55 PM. The area was still present on his/her left cheek and appeared to be unchanged since first observed on 6/6/22. Further review of the medical record, on 6/22/22 at 4:00 PM, again failed to reveal documentation indicating that staff identified and addressed the area. Staff #1, a Licensed Practical Nurse, was present and when asked if she was aware of a scratch or abrasion on Resident #26's left cheek area she stated No and confirmed there was no treatment ordered. She was made aware of the surveyor observations and that it was first observed by the surveyor on 6/6/22. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware of the above findings on 6/22/22 at 4:53 PM and indicated that they would look for additional information. On 6/23/22 at 8:39 AM, the DON & ADON confirmed that they were unable to find documentation that staff identified and addressed the area on Resident #26's left cheek. 5) During an interview on 6/7/22 at 11:50 AM, Resident #38 stated that he/she had a [CONDITION(S)] (Urinary Tract Infection) that I can't seem to get rid of. Resident #38's medical record was reviewed on 6/21/22 at 9:28 AM. The record revealed that Resident #38 was seen by an Infectious Disease specialist for a consult related to his/her recurrent [CONDITION(S)]'s on 2/10/22 at 9:00 AM. The consultants' findings indicated: Recurrent [CONDITION(S)], urinary incontinence, and chronic dysuria (painful or difficult urination). The Recommendations included: 1) Start [MEDICATION(S)] (an antibiotic) 250 mg (milligrams) at bedtime. 2) Start [MEDICATION(S)] 10 mg once daily to prevent rash. 3) if no improvement of dysuria, then d/c (discontinue) [MEDICATION(S)]. 4) if dysuria improves then continue [MEDICATION(S)] long term & f/u (follow up) 3 months. Review of the physicians' orders revealed an order which started on 2/11/22 for [MEDICATION(S)] Capsule 250 mg by mouth at bedtime for Prophylactic [CONDITION(S)]. The order was active and ongoing. Further review of the medical record revealed that sident #38 had a Cystoscopy and a Urologist consult on 4/12/22. The recommendations from the Urologist included, but were not limited to, Prophylactic ABX (antibiotics) daily. However, no consultation report was found for a 3 month follow up visit with the Infectious Disease Physician in 5/22 as per their recommendations on 2/10/22. Staff #1, a charge nurse, was interviewed on 6/21/22 at 10:38 AM. She was asked where the surveyor could find the consultation report for Resident #38's 3-month Infectious Disease follow up appointment. She indicated that it would be in the record. Upon looking, she was not able to find it. She indicated that transportation schedules the appointments. In an interview on 6/21/22 at 10:56 AM, the ADON was asked to explain the process for scheduling follow up appointments when recommended by a consulting provider. She indicated that the staff receiving the consultation report initiates a transportation request form, the provider signs off on the form and it is given to transportation to schedule. She was made aware that the surveyor was unable to find a report of the follow up visit and indicated she would look for the report. Staff #58, the transportation director, was interviewed on 6/21/22 at 10:59 AM. She was unable to confirm that the resident had a follow up appointment with the infectious disease practitioner as recommended. In another interview, on 6/21/22 at 1:55 PM, the ADON was asked if she was able to find documentation of a follow up Infectious Disease visit for Resident #38 in 5/22. She indicated that it was not done, that when the resident returned from the appointment on 2/10/22 the nurse took the orders off for the medications, but did not complete the transportation request form, so transportation did not schedule an appointment and it was not done.

Based on medical and administrative record review, staff and family member interviews, it was determined the facility failed to include the method of transport in Resident #2's discharge plan, which resulted in the resident sustaining an injury during an attempted transfer into a vehicle and delayed discharge. This was evident for 1 of 4 residents reviewed during this complaint survey. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The MDS assessment directs the facility staff on issues that may need to be addressed. 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. ADLs (Activities of Daily Living) refer to daily self-care activities such as bathing, grooming and dressing. The findings include: Surveyor review of complaint MD 352 revealed a concern that, on the day that Resident #2 was to be discharged , facility staff failed to aid the resident's family member in transferring the resident into the car. Medical record review revealed Resident #2 was admitted to the facility for rehabilitation services with [DIAGNOSES REDACTED]. Review of the 30-day Medicare MDS assessment, dated 2/15/18, revealed that staff coded the resident in Section G Functional Status B- Transfers as a 3/3 (requires the extensive assistance of 2 staff). The resident was coded in the End of PPS Part A MDS assessment, dated 3/12/18, as requiring substantial/maximum assistance for movement from a sitting to standing position, chair/bed-to-chair transfer. It was noted in the assessment that the resident did not walk and used a wheelchair or scooter. The medical record contained a care plan, with an initiation date of 2/8/18, that addressed an ADL self-care performance deficit related to impaired balance, limited mobility, limited range of motion, and musculoskeletal impairment. A Social Services Progress Note, dated 3/7/18, reported the resident had a discharge date from therapy. The therapy department recommended long-term care, but the resident's family member wanted the resident to go home and have home health services. A Nurses' Note, dated 3/13/18, reported the resident's family member attempted to transfer the resident to car that afternoon, that the resident was unable to do so, and was lowered to the ground by the family member. During the transfer, the resident's left leg twisted under her/him and under the car. Facility staff assisted the resident to the wheelchair and she/he was brought back into the facility and assessed by the nurse practitioner. An x-ray of the left knee and ankle revealed a fracture at the base of the 5th metatarsal (the metatarsal bones are the long bones in the middle of the foot). A Social Services Note, dated 3/13/18, reported the resident was to discharge this date. Following the incident, the resident's family member spoke to the Administrator who agreed to pay for the resident to stay overnight and for transportation home the next day. During an interview with the surveyor, on 5/4/18 at 11:55 AM, the Director of Nursing (DON) was asked if staff would normally assist in transferring a resident into the car during discharge. The DON stated that if the discharge was planned, they would provide assistance, but not if it was against medical advice. Medical record review did not reveal documentation that the discharge was against medical advice. In interview with the surveyor. on 5/4/18 at 12:32 PM. the Administrator stated that he/she was present on 3/13/18 and noted that the resident's family member approached RN #2 to ask for assistance getting the resident into her/his car. The Administrator stated the family member then asked if RN #2 could ask therapy staff for assistance. The administrator stated that the Rehabilitation Services Director reported that, because the resident had been discharged from therapy, his/her employer would not allow him/her to assist with the transfer. The Rehabilitation Services Director also stated that he/she had not practiced transfers to the car during the resident's therapy sessions. During an interview with the surveyor, on 5/4/18 at 2:13 PM, RN #2 stated she/he had never transferred anyone into a car. He/she went to Rehabilitation Services Director to ask for assistance and he/she declined. RN #2 stated that he/she tried to help a little but really did not know what to. RN #2 stated he/she observed that the resident could not pivot and could not make it into the seat. In interview with the surveyor, on 5/4/18 at 2:23 PM, the Social Services Associate stated that the physical therapist recommended that the resident stay in the facility. She/he stated that, although discharge to home was not recommended by the physical therapist, it was a planned discharge. The Social Services Associate stated that therapy staff generally work with residents and family members on safe transfer into a car, but since the Rehabilitation Department was recommending long-term care that training was not provided. The resident was discharged from therapy the day before she/he went home. Based on medical and administrative record review, staff and family member interviews, it was determined the facility failed to include transportation needs in Resident #2's discharge plan and failed to provide assistance during this planned discharge, which resulted in the resident sustaining an injury during an attempted transfer into a vehicle.

Based on complaint, review of a medical record and staff interview, it was determined that the facility staff failed follow a physician's order and failed to take steps to prevent a resident from falling and receiving an injury. This was evident for 1 of 13 residents (Resident #5) reviewed during a complaint survey. The findings include: Review of complaint MD 912 on 07/01/2015 revealed an allegation that Resident #5 fell backwards in the shower room and sustained lacerations to the left hand and was diagnosed with [REDACTED]. Review of Resident #5's medical record revealed a physician's order, dated 01/29/2015, which instructed the nursing staff not to leave Resident #5 alone during care or while in bathroom, and that care must be completed and Resident #5's safety ensured, before leaving the room. Review of the GNA (geriatric nursing assistant) care guide for resident #5 on 07/01/2015 also revealed the physician order instructing the nursing staff not to leave Resident #5 alone during care or while in bathroom, and that care must be completed and Resident #5's safety ensured, before leaving the room. Review of Resident #5's medical record on 07/01/2015 revealed a physician note, dated 04/26/2015 at 3:28 PM, which indicated that Resident #5 had fallen in the bathroom on 04/24/2015 and sustained skin tears of the back of the left hand. Resident #5's physician also documented that Resident #5 was uncooperative with a physical examination and was transferred to the emergency room . In the emergency room , it was discovered that Resident #5 had suffered compression fractures in the lumbar spine. Review of Resident #5's, 04/24/2015, post fall investigation revealed that Resident #5 had fallen in the bathroom on 04/24/2015 at 4:10 PM and was in a highly agitated state, hitting staff, and yelling at staff prior to the fall and after the fall. The 04/24/2015 post fall investigation also documented that Resident #5 had thrown his/her walker into the shower twice. In an interview on 07/02/2015 at 2:58 PM, GNA #3 stated that he/she was attending to Resident #5 on 04/24/2015 just before Resident #5 fell in the bathroom. GNA #3 stated that Resident #5 did not want to get dressed in the bathroom and that Resident #5 was hitting and cursing at GNA #3. GNA #3 stated that he/she left Resident #5 in the bathroom and walked down the hall to get the charge nurse. GNA #3 stated that he/she returned to find Resident #5 throwing his/her walker around the room. GNA #3 stated that he/she closed Resident #5's bathroom door at this time and then he/she heard a loud boom. GNA #3 stated that he/she then opened Resident #5's bathroom door and that is when he/she observed that Resident #5 had fallen to the floor. GNA #3 stated Resident #5 was complaining of pain in his/her head and hip area after the incident. GNA #3 failed to follow the physician order instructing the nursing staff not to leave Resident #5 alone during care or while in bathroom, and that care must be completed and Resident #5's safety ensured before leaving the room. This lead to Resident #5 being unsupervised in the bathroom, on 04/24/2015 at 4:10 PM, when Resident #5 fell and sustained skin tears to his/her hands, and compression fractures to the lumbar spine.

Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to follow a resident's plan of care by using 2 staff members to transfer or move between surfaces,failed to assess changes in a resident (pain) and failed to notify the physician of the changes. Resident #3 demonstrated signs and symptoms of moderate to sever pain for a full week (from 4/23/15 through 5/1/15) without adequate or effective assessment or treatment. This was evident for 1 of 13 residents (Resident #3) reviewed during a complaint survey. The findings include: Review of complaint MD 281, on 06/30/2015, revealed an allegation that Resident #3 was found to have bilateral leg fractures. Review of Resident #3's closed medical record revealed an activities of daily living (ADL) care plan, that was initiated on 10/17/2014, which required the nursing staff to use 2 staff members to transfer Resident #3 between surfaces. The ADL care plan was developed due to Resident #3's cognitive deficits, history of bilateral femur fractures, and weakness. Review of Resident #3's closed medical record on 06/30/3015 revealed nursing documentation, dated 04/23/2015 at 9:34 PM, indicating that Resident #3 was resistive, hit at staff during transfers and PM care, and complained of his/her legs hurting. In an interview with GNA #4, on 07/01/2015 at 4:30 PM, GNA #4 stated that he/she recalled that Resident #3 required 2 staff members to transfer him/her in and out of bed. GNA #4 stated that he/she recalled the nurse telling him/her that Resident #3 had to be up for dinner. GNA #4 stated that he/she was unable to recall how Resident #3 got out of bed into a chair on the evening of 04/23/2015. GNA #4 stated that he/she did transfer Resident #3 by himself/herself back to bed later in the evening. GNA #4 stated that he/she has transferred Resident #3 in and out of bed by himself/herself in the past. GNA #4 also stated that Resident #3 started crying out in pain later in the evening, and GNA #4 stated that he/she informed the nurse of Resident #3's complaints of pain. In an interview on 07/16/2015 at 3 PM, LPN #6 stated that he/she did recall seeing Resident #3 out of his/her and seated in his/her chair during the evening shift on 04/23/2015. LPN #6 stated that he/she did not assist, nor did he/she know how Resident #3 was transferred to the wheelchair or back to bed that evening. In an interview 07/01/2015 at 3:18 PM, GNA #5 stated that he/she worked the evening shift on 04/23/2015 but was not assigned to Resident #3. GNA #5 stated that he/she was never asked by GNA #4 to assist with transferring Resident #3 into his/her wheelchair or bed during the evening shift on 04/23/2015. GNA #5 stated that Resident #3's family did not come into the facility to visit that evening, and that he/she did not see Resident #3 in the dining room for dinner either. GNA #5 stated that he/she did go to Resident #3's room, after 7 PM on 04/23/2015, to help assist GNA #4 with Resident #3's care, but Resident #3 was already back in bed. GNA #5 stated that he/she heard Resident #3 screaming at approximately 7:20 PM on 04/23/2015 and thought GNA #4 was in the room with Resident #3 at that time. Later that evening on 04/23/2015, GNA #5 stated that he/she did go back to Resident #3's room and observed Resident #3 smack GNA #4 on the arm. Further review of Resident #3's closed medical record on 06/30/3015 revealed nursing documentation, dated 04/23/2015 at 9:34 PM, indicating that Resident #3 was resistive, hitting at staff during transfers and PM care, and complained of legs hurting. In an interview on 07/10/2015 at 1:06 PM, LPN #6 stated that he/she did not assess or report Resident #3's complaints of his/her legs hurting because Resident #3 had a history of [REDACTED]. LPN #6 stated that Resident #3 spit out his/her evening medications on 04/23/2015. Further review of Resident #3's closed medical record revealed nursing documentation, dated 04/24/2015 at 10:22 AM, indicating Resident #3 was complaining of his/her knees hurting, was hitting at staff and not wanting his/her pants or TED hose put on, and told the nursing staff no when asked if he/she wanted to get out of bed. In an interview on 07/13/2015 at 12:56 PM, LPN #5 stated that there was no report from the night shift nurse, on 04/24/2015, that Resident #3 was complaining of his/her knees hurting. LPN #5 stated that Resident #3's complaint of knee pain was old, as was the behavior of not wanting to get out of bed. Review of Resident #3's therapy notes, dated 04/24/2015 at 4:47 PM, revealed documentation that Resident #3 was very agitated and combative this date and refused to participate. The therapy note also indicated, per nursing, that Resident #3 had been complaining of bilateral lower extremity leg pain all day. In an interview on 07/20/2015 at 11:25 PM, COTA #1 stated that a nurse told me Resident #3 had bilateral leg pain, but could not recall which nurse informed him/her of this. COTA #1 stated that he/she was not able to give Resident #3 any care on 04/24/2015, and that he/she informed his/her supervisor. Further review of Resident #3's closed medical record revealed nursing documentation, dated 04/25/2015 at 6:15 AM, indicating that Resident #3 was complaining of bilateral leg pain. Resident #3 was also observed to be clammy, had vomited, and refused to take any pain medication. The on-call physician was notified of the vomiting by LPN #2 in an email at 6:38 AM, and the on-call physician responded back to LPN #2 by email at 7:16 AM asking LPN #2 about Resident #3's bowel movement status. In an interview on 07/13/2015 at 1:23 PM, the 04/25/2015 on-call physician stated that he/she did not recall the nurse reporting that Resident #3 complained of bilateral leg pain. The 04/25/2015 on-call physician stated that he/she was worried about pneumonia or a urinary tract infection in Resident #3, so he/she called the facility later in the day and gave verbal orders that included a chest x-ray, laboratory tests, and medication orders. Review of Resident #3's closed medical record revealed nursing documentation, dated 04/25/2015 at 6:59 PM, indicating that Resident #3 was showing signs and symptoms of pain when staff attempted to get Resident #3 out of bed or move Resident #3's legs. Resident #3 yelled out in pain and stated stop. In an interview on 07/13/2015 at 3:35 PM, RN #1 stated that he/she informed the on-call physician about Resident #3's leg pain on 04/25/2015 when he/she spoke to the 04/25/2015 on-call physician. On 04/25/2015 at 10:39 PM, RN #1 also documented that Resident #3 continued to complain of leg pain when staff did care or touched Resident #3's legs. RN #1 stated that he/she did not know why he/she did not contact the physician about the continued complaints of leg pain in Resident #3. RN #1 stated that he/she could have called the nursing supervisor on call, and that there was not a nursing supervisor in the building during the evening shift on 04/25/2015. Review of nursing documentation, dated 04/27/2015 at 5:48 AM, revealed that Resident #3 cried out with care whether it was taking a temperature, giving medications or changing him/her. Later, on 04/27/2015 at 10:53 AM, LPN #5 contacted and spoke to Resident #3's physician specifically about Resident #3's complaint of increasing pain in the left leg when care is performed. PA #1 assessed Resident #3 complaints of left leg pain on 04/27/2015 at 11:00 AM, and identified an old bruise behind Resident #3's left knee. An x-ray performed later in the day on 04/27/2015 revealed a comminuted impacted [MEDICAL CONDITION] distal femur at the total knee prosthesis with moderate angulation and [MEDICAL CONDITION]. On 05/01/2015 at 6:26 AM, the nursing staff notified the facility on-call physician about Resident #3's complaint of moderate to severe pain the other (right) upper leg with swelling. An order to x-ray Resident #3's right hip and knee was obtained on 05/01/2015. Later on 05/01/2015, an x-ray result of the right knee revealed an impacted comminuted [MEDICAL CONDITION] femur at the knee prosthesis that seemed to be similar to the fracture described on the left. Cross reference F 157

Based on a review of the resident's medical record, review of the facility's investigation and interview with staff, it was determined that a staff member failed to perform cardiopulmonary resuscitation (CPR) as ordered by the physician per the resident's request when her heart ceased to beat. The findings include: Resident # 1 had [DIAGNOSES REDACTED]. Based on the medical record, the resident was capable of making her own decisions regarding her health care needs. By way of history, the resident was hospitalized for [REDACTED]. A dictated note by the resident's physician (who is also her physician in the nursing home) stated, "I discussed her code status with the patient and she has agreed to change the code status to Do Not Resuscitate (DNR)." This note indicated that if her heart would cease to beat she would not want to be revived. After a course in the hospital, the resident returned to the facility. Initial physician orders [REDACTED]. On [DATE], the following nurse's note reveals, " 7 p.m. Dr. ... updated about resident's desire to be a full code. New order received, daughter at bedside and updated." Physician order [REDACTED]. T.O.(telephone order)." The order was faxed to the physician and signed. On [DATE], the resident was in the process of being evaluated by a hospice agency as her condition was declining. Based on the facility investigation, the resident's daughter, a facility LPN#1, and hospice nurse were in the resident's room. The resident's status began to decline rapidly and at 1 p.m. she ceased to breathe. The facility staff failed to perform CPR per the resident's directive and physician order. Based on the facility investigation that began [DATE], it was determined that LPN#1 indicated to the resident's physician that she did not feel it (CPR) would help. Surveyor interview with LPN#1 on [DATE] revealed the same information. She did not perform CPR as she felt it would not help. LPN# 1 also stated to the surveyor that she was aware that the resident had an order for [REDACTED]. The facility staff failed to honor Resident #1's wish to remain a full code.