Every finding on record at Wilson Health Care Center

Based on record reviews and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, track, analyze, and implement effective performance improvement plans to address a pervasive, year-long rodent infestation that directly impacted environmental quality, sanitation, and resident well-being. Specifically, despite documented pest sightings that surged to fifty-two in a single month and required repeated facility-wide extermination clean-outs over a twelve-month period, the QAPI committee failed to recognize the ongoing pest infestation as a critical systemic failure that required formal committee review, tracking, and root-cause analysis until the issue was brought to their attention by the survey team.Findings include:On 8/20/26 at 8:03 a.m., a review of the facility policy titled Pest Management Policy (effective February 11, 2026) revealed that pest control activities were required to be monitored through the facility's Quality Assurance and Performance Improvement (QAPI) program. The policy stated that the facility was required to review the number and type of pest complaints, recurring locations, treatment effectiveness, and environmental causes, and that repeated or significant pest activity was required to trigger a formal QAPI assessment and corrective action.On 8/20/26 at 2:37 p.m., a review of the facility's QAPI committee meeting minutes, Ad Hoc incident reviews, and performance improvement documentation from August 2025 through August 2026 revealed a total absence of structured QAPI oversight regarding the facility-wide mouse infestation. Although internal documentation showed that the facility experienced escalating rodent activity which included forty-two sightings in December 2025 and fifty-two sightings in April 2026, along with four separate emergency exterminator clean outs, the QAPI committee did not establish a performance improvement plan, monitor staff reporting compliance, or evaluate the failure of implemented environmental interventions.On 8/20/26 at 4:11 p.m., a review of the facility's pest sighting logs demonstrated that data presented to facility leadership was fundamentally flawed due to missing entries, incomplete details, and a total absence of recorded sightings between August 8, 2026, and August 21, 2026, despite concurrent staff confirmation of daily mouse activity. The QAPI committee failed to audit the pest control logging system or identify that frontline nursing staff received zero training on reporting procedures.During an interview on August 20, 2026, at 9:17 a.m., the Director of Nursing and the Nursing Home Administrator confirmed that the QAPI committee did not formally track the mouse infestation as a quality measure or systemic performance deficit prior to the state complaint survey. The administration acknowledged that the QAPI committee failed to conduct a root-cause analysis regarding why pest control measures were ineffective and why staff did not log sightings, and conceded that formal committee action was only initiated after the survey team raised the issue.

Based on observations, record reviews, residents and staff interviews, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests and rodents. This was evidenced by a widespread, and continuous mouse infestation throughout the four-floor facility spanning from August 2025 through August 2026, which peaked at fifty-two documented sightings in a single month. The facility failed to enforce consistent logging and reporting mechanisms, failed to ensure effective environmental and structural vector controls were executed, failed to train frontline nursing and direct care staff on reporting protocols, and allowed severe pest activity to persist in resident living areas, common dining areas, and food service spaces, which directly impacted resident well-being and environmental sanitation. Findings include:On 8/20/26 at 8:03 a.m., a review of the facility pest control policy titled Pest Management Policy (effective 2/1/26) documented that the facility was required to maintain a safe, sanitary, and comfortable environment by taking prompt action to prevent, identify, control, and eliminate pest activity through an Integrated Pest Management approach. The policy outlined that all staff were responsible for immediately reporting pest sightings, keeping work areas clean, and following reporting procedures. The policy further dictated that the facility was required to maintain accurate recordkeeping, including pest sighting reports, locations, and corrective actions, and that staff were required to receive appropriate education regarding the identification and logging of pest activity.On 8/19/26 at 6:45 p.m., a review of the facility's internal document titled Review of Pest Control Efforts covering August 2025 through July 2026 revealed documented monthly mouse sightings, which included three sightings in August 2025, ten in September 2025, sixteen in October 2025, thirty in November 2025, forty-two in December 2025, twenty-nine in January 2026, seventeen in February 2026, twenty in March 2026, fifty-two in April 2026, fourteen in May 2026, twenty in June 2026, and eleven in July 2026. The records demonstrated that multiple clean out extermination events were required in November 2025, December 2025, and April 2026 due to uncontrolled activity. Furthermore, despite structural modifications such as caulking, the replacement of door sweeps, and the installation of ultrasonic deterrence devices, pest activity remained active and unresolved.On 8/19/26 at 5:31 p.m., a review of the facility's active pest sighting logs revealed a breakdown in monitoring. The logs lacked specific details such as the precise time of sightings, specific location details, and follow-up entries. Moreover, the pest log for August 2026 contained entries recorded only from August 1 through August 7, 2026, and completely omitted numerous pest sightings confirmed by staff to have occurred between August 8 and August 21 2026 (the time pertinent to the survey).On 8/21/26 at 10:27 a.m., a review of the facility's Resident Council minutes from six (6) months preceding the complaint survey revealed that concerns regarding mice activity at the facility was consistently brought up with no resolution.Observations during a facility tour on 8/17/26, at 10:59 a.m., revealed that the four-story building was equipped with exterior rodent bait stations around the perimeter, while the interior corridors across all units featured ultrasonic anti-rodent devices plugged into wall outlets. At 1:00 p.m. on 8/17/26, an inspection of a resident's room (room [ROOM NUMBER]) on the 100 unit revealed an active glue trap positioned behind a three-compartment chest of drawers. Subsequent random inspections of resident rooms across all floors revealed glue traps strategically placed in corners and hidden areas throughout active resident living spaces.During an interview on 8/18/26, at 11:58 a.m., Resident #11 stated that the presence of mice in the facility was a horrific experience and explained that they were often afraid to set their feet down on the floor out of fear that a mouse would run over them.During an interview on 8/18/26, at 12:13 p.m., Resident #12 conveyed that rodent activity was a frequent occurrence. Resident #12 noted that they observed mice scurrying along the baseboards of their room during the late evening hours, which caused them significant anxiety and rendered it difficult to sleep peacefully.During an interview on 8/18/26, at 12:29 p.m., Resident #13 reported that they personally saw mice near their bedside table on multiple occasions. Resident #13 added that despite notification to facility personnel, the rodents continued to appear regularly.During an interview on 8/18/26, at 12:47 p.m., Resident #14 stated that the rodent situation was intolerable. Resident #14 expressed frustration and stated that the sight of rodents across the floor disrupted their sense of personal dignity and comfort.During an interview on 8/18/26, at 12:50 p.m., Geriatric Nursing Assistant (GNA) #1 stated that while daytime sightings of mouse were less frequent, night-shift personnel continuously reported active mice sightings during shift change. GNA #1 confirmed that leadership never provided them with instructions or formal direction on how to log the specific times or locations of mice sightings.During an interview on 8/19/26, at 12:28 p.m., the Dining Manager stated that during late evening shifts, they regularly heard mice inside the walls and above the ceiling tiles of the dining areas. The Dining Manager acknowledged that while administration attempted to resolve the problem, the rodent infestation persisted, and conceded that they did not document these sightings in the official maintenance tracking log.During an interview on 8/20/26, at 6:12 a.m., GNA #6 stated that night shifts were characterized by constant pest activity. GNA #6 explained that mice were regularly seen as they darted across hallway corridors once ambient noise decreased, and that they never documented the sightings because the issue felt continuous and unmanaged.During an interview on 8/20/26, at 6:15 a.m., Licensed Practical Nurse (LPN) #2 reported observations of rodents near the nurse's station and inside utility closets on the overnight shift. LPN #2 explained that staff members frequently warned one another about mouse activity verbally rather than through the completion of official paper tracking entries.During an interview on 8/20/26, at 6:19 a.m., LPN #3 stated that rodents were a predictable element of the night shift. LPN #3 noted that mice routinely entered resident rooms through gap clearances under doors and behind heating units, but acknowledged a complete lack of familiarity with an official logging protocol.During an interview on 8/20/26, at 6:20 a.m., LPN #1 stated that mice were encountered frequently in the facility corridors during overnight hours, and reported that they sighted a mice from the preceding night shift on August 19, 2026. LPN #1 emphasized that the rodent infestation was a long-standing, unresolved issue and stated they received no formal training on the proper procedure for the logging of pest sightings.During an interview on 8/20/26, at 6:21 a.m., GNA #7 stated that overnight staff frequently encountered mice in resident's rooms, near linen carts, and corridors across the facility. GNA #7 explained that personnel became desensitized to the problem and did not record every event because facility leadership was already well aware of the infestation.During an interview on 8/20/26, at 6:25 a.m., Registered Nurse (RN) #4 stated that mouse sightings escalated substantially over the past year. RN #4 expressed a personal belief that the pest activity was seasonal, with emphasis that they expected an uptick in mouse activities at the facility during the coming winter season. RN #4 stated that the facility management did not conduct education regarding the maintenance of a pest log, and confirmed that the majority of pest encounters went unrecorded.During an interview on 8/20/26, at 6:27 a.m., RN #5 reported that overnight rounds frequently involved the startle of mice in resident rooms and common areas. RN #5 added that the mice were especially noticeable when staff turned on the light in resident's rooms at night when they attempted to provide nightly care. RN #5 confirmed that nursing staff lacked structured guidance on how to submit formal pest reports.During an interview on 8/20/26, at 6:29 a.m., GNA #8 stated that rodents were routinely seen beneath door frames along the second and third-floor residential halls during the late nights and early morning hours. GNA #8 added that they were never in-serviced on documentation of sightings in a centralized binder.During an interview on 8/20/26, at 6:32 a.m., LPN #4 stated that night-shift personnel regularly saw mice as they ran across floor spaces across the facility. LPN #4 confirmed that logging procedures were neither stressed by administration nor consistently executed by floor staff.During an interview on 8/20/26, at 6:35 a.m., GNA #4, an employee of six years, stated that mice were seen habitually in the middle of the night and scattered whenever room lights were switched on. GNA #4 stated they did not document these encounters because management was fully aware of the ongoing pest presence.During an interview on 8/20/26, at 6:38 a.m., GNA #9 stated that mice were observed along hallway baseboards during overnight bed checks. GNA #9 stated that staff lacked clarity on where the pest log was located or who was responsible for its maintenance.During an interview on August 20, 2026, at 8:25 a.m., the Assistant Director of Nursing (ADON)/Staff Educator acknowledged awareness of the facility's extensive rodent problem. The ADON confirmed that no educational training or inservices were provided to nursing staff regarding the mandatory operational protocol for the record and log of pest sightings. The ADON confirmed that the nursing education curriculum lacked pest reporting procedures.During an interview on August 20, 2026, at 9:17 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) acknowledged that the facility battled a major rodent infestation. The NHA and DON conceded that staff were not systematically trained or educated on the maintenance of pest sighting logs, which led to significant gaps in data collection. They further acknowledged that reliance on ultrasonic devices, glue traps, and exterminator clean-outs did not successfully eradicate the infestation.

Based on record review, staff interview, and facility policy review, it was determined that the facility failed to ensure that a resident's right to formulate an advance directive and to have a properly identified and authorized representative make healthcare decisions was maintained for 1 (Resident #15) of 4 residents reviewed for advanced directives during the annual survey. Findings include: On 04/28/2026 at 9:32 AM, an initial review of Resident #15's medical record revealed the resident had two incapacity certifications dated 6/28/24 and 7/10/24. There were 2 individuals noted to be making decisions for the resident, one was a niece of the resident, and the other was a friend who had Financial Power of Attorney. The medical record failed to contain documentation identifying a legally authorized representative or copies of a financial power of attorney (POA) documentation. On 04/29/2026 at 12:50 PM, further review of the Resident's medical records revealed multiple consent forms, including vaccine consents dated 8/7/24 and 7/7/25, that identified an individual as POA; however, no supporting legal documentation was present in the medical record to verify this authority. Additionally, a telephone consent for psychoactive medication dated 5/23/24 identified a different individual as POA, further contributing to inconsistency regarding the resident's decision-maker. On 04/29/2026 at 12:55PM, review of the social worker progress notes failed to reveal documented evidence that the resident or representative was offered the opportunity to complete an advance directive upon admission, nor was there social services documentation to support that education regarding advance directives was provided. During interview on 04/29/2026 at 1:46 PM, the Social Work Director confirmed that the facility did not have a copy of the Financial POA documentation on file, had not verified the scope of authority, and acknowledged that the individual signing consents should not have been permitted to do so without such verification. She further stated that neither the niece or the resident's friend have a legal surrogate decision maker form filled out, as required by the state of Maryland Surrogate Decision hierarchy, to make medical decisions on behalf of the resident. At this time the Social Work Director was made aware of the concerns. On 04/29/2026 at 2:04 PM, a review of the facility policy titled Health Care Decision Making - Advanced Directives - Maryland stated that residents will be informed of their rights regarding advance directives and that the facility will ensure a healthcare decision-maker is identified in the absence of an advance directive. It also stated that an existing advanced directive will be reviewed by the Social Worker and special care should be taken to clearly understand what rights are conferred by an advance directive that establishes health care agent (scope of decision making authority) and when the advanced directive becomes effective.

Based on record review, facility investigative materials, and staff interview, the facility failed to ensure the confidentiality and protection of a resident's medical record from unauthorized disclosure. This deficient practice was identified for 1 of 2 residents (Resident #138) reviewed as part of facility-reported incident investigations during the recertification/complaint survey.The facility implemented corrective actions prior to the start of the survey. Surveyor verification of the facility's corrective measures determined that the deficient practice had been corrected. Therefore, this deficiency is cited as past noncompliance with a compliance date of 07/03/2025. The findings include:HIPAA stands for the Health Insurance Portability and Accountability Act of 1996, a U.S. federal law designed to protect sensitive patient health information from being disclosed without consent. It establishes national standards for privacy, security, and electronic transactions of, or related to, Protected Health Information.On 04/29/2026 at 7:29 AM, review of facility investigation report #2692537 revealed that on 12/12/2025 at 9:16 AM, the facility Social Worker (Staff #31) received an email from the daughter of Resident #138 alleging a potential HIPAA violation, indicating that another resident's medical record had been provided during a medical appointment.On 04/29/2026 at 7:35 AM, review of Resident #138's electronic health record revealed that the resident's Minimum Data Set (MDS), dated [DATE], Section C, reflected a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severe cognitive impairment at the time of the incident.On 04/29/2026 at 8:04 AM, further review of the facility's investigative documentation revealed the followingA concern and resolution tracking form dated 07/02/2025, which indicated that Resident #138's daughter reported receiving an incorrect medical chart during a dental appointment. Documentation indicated that Licensed Practical Nurse (LPN #4) inadvertently provided another resident's chart, reportedly due to being rushed.Additional documentation indicated that Nurse Supervisor/Manager (Staff #5) confirmed that on 07/02/2025, during an in-house dental consultation with Staff #30, the incorrect chart was provided in error.In a written statement dated 07/04/2025, LPN #4 acknowledged that she mistakenly handed another resident's chart to Resident #138's daughter while the resident was being transported to an in-house dental appointment. The statement indicated that the daughter later returned the chart after identifying it as incorrect, and LPN #4 apologized for the error.04/29/2026 9:11 AM, The investigation packet also included an in-service education given to the staff members on 07/03/2025 stating the necessary actions to be taken by staff members during dental consultations.On 04/29/2026 at 9:54 AM, In an interview with the Director of Nursing (DON), when asked about the incident, she stated that Resident #138's documents had been prepared for the appointment and that the resident's daughter arrived early to accompany the resident. The DON stated that a nurse inadvertently selected and provided the incorrect chart to the daughter. The DON further stated that upon return from the appointment, the daughter reported noticing that the chart did not belong to her family member and expressed concern that treatment may have been based on incorrect information. The DON confirmed that the incorrect chart had been issued.The DON reported that the consulting dentist (Staff #30) did not rely on the paper chart during the visit, as electronic access to the resident's medical record was available. The DON further indicated that, at the time of the incident, it was the facility's practice to send paper charts with residents to appointments.The DON added that, following the incident, the facility provided in-service education to nursing staff, including charge nurses, geriatric nursing assistants (GNAs), and unit clerks, regarding verification of resident identity and medical records during transfers. The DON also reported that the facility revised its process and discontinued the use of paper charts for appointments, transitioning to a fully electronic system.Based on the facility's investigation, staff statements, and corrective actions, the facility failed to ensure the confidentiality and protection of a resident's medical record. Surveyor verification confirmed that the facility implemented corrective measures, including staff education and process changes, which prevented recurrence. Therefore, this deficiency is cited as past noncompliance with a compliance date of 07/03/2025.

Based on resident interview, record review, and staff interview, the facility failed to ensure that a resident received necessary services and equipment to maintain or enhance independence in activities of daily living, specifically related to bed mobility. This deficient practice was identified for 1 (Resident #65) of 2 residents reviewed for accommodation of needs. The findings include: On 4/27/2026 at 11:31 AM, an interview was conducted with Resident #65, who reported that the facility removed the bed rails from their bed due to concerns regarding entrapment risk. The resident expressed that without the bed rails, they experienced decreased independence with repositioning in bed and voiced fear of rolling out of bed during care. On 4/28/2026 at 12:36 PM, a review of physician orders revealed an order dated 9/27/2024 for Bilateral upper bedrails for bed mobility and promotion of independence per resident request, which was discontinued on 3/31/2026. On 4/28/2026 at 12:38 PM, Resident #65's Health Status Note from 3/31/2026 was reviewed. The note stated the resident was notified again that due to the risk of entrapment, the facility has decided to remove all bedside rails. He expressed understanding and his bedrails were removed. On 4/28/2026 at 12:43 PM, review of the most recent Bed Rail Evaluation dated 1/7/2026 indicated that bilateral side rails/assist bars were assessed as appropriate and necessary, serving as an enabler to promote independence. On 4/28/2026 at 1:25 PM, an interview was conducted with the Rehabilitation Director (Staff #32) and Director of Nursing (DON). Staff #32 stated that the resident's need or preference for bed rails had not been brought to the attention of the rehabilitation team prior to that day. The DON stated that the facility implemented a house-wide removal of bed rails due to entrapment risk, regardless of individual resident need. The DON confirmed that no individualized reassessment was completed prior to removal but stated that residents and their representatives were notified. The DON further stated that wider beds were provided as an alternative intervention. On 4/29/2026 at 8:52 AM, Resident #65 stated that they had informed the Nurse Manager (Staff #5) and other management staff of their desire to have bed rails reinstated. On 4/29/2026 at 9:47 AM, an interview with Staff #5 revealed that reevaluation of bed rail use should occur when there is a decline in ADLs and therapy should be involved to assess risks versus benefits. Staff #5 confirmed that they were not aware of Resident #65's concerns and could not recall whether a reevaluation was conducted prior to removal of the bed rails.

Based on interviews and record reviews, it was determined that the facility failed to provide dependent residents with showers. This was evident for 1 (Resident #18) out of 11 reviewed for activities of daily living during the recertification survey.The findings include:On 04/27/2026 at 1:58 PM, an interview with Resident #18's representative was conducted. They reported that Resident #18 preferred showers over bed baths, but the facility had not showered the resident in a long time.On 04/29/2026 at 11:54 AM, a review of Resident #18's medical record was conducted. The review revealed that the resident was scheduled to be showered every Mondays and Thursdays 3pm-11pm shift.Review of the Resident #18's preference evaluation indicated that the resident preferred showers in the morning.Review of the care plan and progress notes, failed to indicate that the resident refused showers.On 04/29/2026 at 1:05 PM, further review of the records revealed that Staff #9 had showered Resident #18 on 4/6/26, 4/10/26, 4/13/26, 4/16/26 and 4/20/26. No showers were documented for 4/2/26, 4/3/26, 4/9/26, 4/17/26, 4/23/26, 4/24/26 and 4/27/26.On 04/29/2026 at 2:55 PM, an interview with Staff #9 was conducted. She reported that she had not showered Resident #18 the entire month of April. She further clarified that she had provided the resident with bed baths only and documented the task under showers.On 04/29/2026 at 4:30 PM, an interview with the Director of Nursing (DON) was conducted. She confirmed that residents should receive showers twice a week unless the resident refused, and that the staff were expected to document refusals. On 04/30/2026 at 9:23 AM, a brief follow up interview with the DON was conducted. She reported that she had followed up with Resident #18 and staff and had identified that Resident #18 had not been showered as records indicated. She confirmed that the documentation was for bed baths and not showers. At this time DON was notified of the concerns.

Based on observations and interviews, it was determined that the facility failed to ensure that residents had call bells within reach. This was evident for 2 residents (Resident #122 and #181) out of 10 randomly selected residents observed on the unit during the recertification survey. The findings include:On 04/29/2026 at 3:05 PM, Surveyor observed Resident #122's call bell on the floor. When asked where the call bell was, Resident #122 looked around their bed and reported they didn't see it.On 04/29/2026 at 3:07 PM, an interview was conducted with Staff #14. Staff #14 stated that it is the facility staff's responsibility to ensure that resident call bells are within reach at all times. During an observation of the resident's room with Staff #14, she indicated that the call bell should have been clipped to the resident's bed to ensure accessibility. On 04/29/2026 at 3:15 PM, Surveyor observed Resident #181's call bell on the floor. On 04/29/2026 at 3:20 PM, an interview was conducted with Staff #15. Staff #15 stated that the resident was in therapy and reported that she was unsure why the call bell had not been returned to within the resident's reach.On 04/29/2026 at 3:30 PM, the Director of Nursing was made aware of the observations and concerns.

Based on record review and interview, it was determined that the facility failed to maintain the accuracy of the content of R14's EMR (electronic medical record). This was evident for three residents (R14, R179, and R180) as R14's EMR contained medical documents for R179 and R180. The findings include:A review of R14's EMR was performed on 4/28/26 at 11:30 AM. During the review, it was found that medical documents for two other residents had been added to R14's EMR. The surveyor note that on 4/22/26 at 1:45 AM, RN33 uploaded into R14's EMR under the Documents tab, a hospital discharge summary for R179 and the baseline care plan for R180.During an interview on 4/30/26 at 8:35 AM, DON2 stated, Anyone can upload documents into the resident's EMR under the Documents tab but usually the clerks do it. DON2 also confirmed that RN33 was a staff nurse at the facility. During an interview on 5/1/26 at 10:54 AM, NHA1 confirmed that there were two wrong documents uploaded into R14's EMR.

Based on medical record review and interviews with facility staff, it was determined the facility failed to ensure that: 1) staff accurately documented if a resident exhibited side effects while receiving anti anxiety medications; 2) staff accurately documented a resident's Treatment Administration Record; 3) staff accurately documented side effects of antipsychotic and anticoagulant medications; 4) antipsychotic medication monitoring on the treatment administration record (TAR) was documented to reflect resident status; 5) resident medical records accurately reflect a resident's status; and 6) resident's medical records were complete and accurately reflects the residents advance directive status. This was found to be evident for 5 (Resident #7, # 27, #55, #91, and #367) of 6 residents reviewed for unnecessary medications, 1 (Resident #49) of 3 residents reviewed for hospitalization , and 1 (Resident #121) of 4 residents reviewed for advance directives. The findings include: 1) Resident #7's medical record was reviewed on 4/10/25 at 10:58 AM and it revealed the resident had the following but not limited diagnosis: Dementia, Anxiety, and Depressive Disorder. The resident medication administration record for March 2025 and April 2025 was reviewed on the same date and indicated to observe the residents closely for significant side effects of anti-anxiety medication; including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior every shift and document (Y) if monitored and none of the above is observed, and (N) if monitored and any of the above was observed. Documentation by staff revealed a check mark above the staff initials for each shift. During a meeting with the DON on the same date she was asked to explain how she would verify if the resident had any of the above side effects and she stated that staff should document a yes (Y) when side effects are present with a note and no (N) when there are no side effects observed. She stated that re-education will be provided for her staff. All concerns were discussed with the Administration team at the exit conference on 4/10/25 at 2:00 PM. 48167 2) Review of Resident #27's medical record on 04/09/2025 at 09:38 AM the Treatment Administration Record (TAR) for the month of April 2025 revealed a physician order dated 08/01/2024 at 2300 PM, states Observe closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. Further review of the TAR revealed that Staff #23 documented No on 4/2/25 and N on 4/3/25-Night shift; Staff #24 documented N on 4/4/25-Day shift; and Staff #22 documented N on 4/3/25 and 4/8/25-Day shift and no progress note findings were found. During an interview on 04/09/2025 at 09:43 AM the Surveyor conducted a staff interview with Nurse Manager, staff #5 while reviewing Resident #27's April 2025 TAR. The surveyor asked Staff #5 are progress notes required when indicated. Staff #5 stated, yes progress notes are needed if staff members answer No or N. Staff #5 stated there were no progress notes completed for staff members who documented No or N and staff should have completed a progress note. 3) Review of resident #367 medical record on 04/09/2025 at 09:40 AM the Treatment Administration Record (TAR) for the month April 2025 revealed a physician order dated 08/01/2024 at 2300 PM, states Observe closely for significant side effects of Antidepressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift for Monitoring Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. Staff #23 documented No on 4/1/25, 4/2/25 and documented N on 4/3/25-Night shift; staff #22 documented N on 4/3/25 and 4/8/25-Day Shift, and no progress note findings were found. During an interview on 04/09/2025 at 09:45 AM the Surveyor conducted a staff interview with Nurse Manager, staff #5 while reviewing resident #367 April 2025 TAR. The surveyor asked staff #5 are progress notes required when indicated. Staff #5 stated yes progress notes are needed if a staff member answers No or N. Staff #5 stated there were no progress notes completed for staff members who documented No or N and staff should have completed a progress note. 49148 4) Antipsychotic drugs are prescription medications used to treat symptoms of psychotic disorders. Anticoagulants drugs are prescription medications that increase the time it takes the blot to clot. On 4/9/2025 at 9:15AM during a review of Resident #91's electronic medical record, the Surveyor discovered an order for Eliquis oral tablet 2.5MG, an anticoagulant, and Quetiapine Fumarate oral tablet 25MG, an antipsychotic. An additional review of the resident's electronic medical record revealed that the medications had been received according to the Medication Administration Record (MAR). Further review revealed orders located in the Treatment Administration Record (TAR) for the months of March 2025 and April 2025 to Observe closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation, or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) every shift. Document: 'Y' if monitored and none of the above was observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings and Observe closely for significant side effects of Anticoagulant medication including discolored urine, bleeding, bleeding gums, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nosebleeds every shift for Bleeding Precautions Document: 'Y' if monitored and none of the above was observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. According to the residents' TAR, the nursing staff was documenting 'N' for the antipsychotic and anticoagulant observation of side effects. A review of Resident #91's nursing progress notes for March 2025 and April 2025 failed to reveal a nurses note to coincide with all 'N' documented in the resident's TAR. 50573 5) On 04/09/25 at 07:34 AM, review of Resident #49's medical record revealed an active order for antipsychotic medication monitoring that indicated for staff to document Y as the resident was observed with no side effects, and N as the resident was observed with side effects. Antipsychotic medications are used to treat psychological (mental) signs and symptoms. Further review of the order revealed the indication that if staff were to document an N, then an additional step would be indicated on the resident's medical record about the observation. On 04/09/25 at 12:51 PM, review of Resident #49's TAR in March and April 2025 revealed a check mark for each shift but failed to reveal indication that Y or N was documented to reflect the observation based on the orders indication. 6) On 04/08/25 at 11:05 AM, review of Resident #55's medical record revealed a progress note titled, Fall Risk Evaluation dated 3/29/25 at 10:48 PM completed by Unit Coordinator (Staff 15), that indicated the resident had been hospitalized in the last 30 days of the progress note date. On 04/09/25 at 12:51 PM, the Director of Nursing informed the surveyor with Resident #55's last hospitalization date, which was 4/19/24. On 04/09/25 at 07:22 AM, the surveyor reviewed the concern with the Director of Nursing regarding the progress note dated 3/29/25 versus the last hospitalization date provided. She indicated that it was an error. 50457 7) Review of Resident #121's advance directive (AD) in the paper medical chart on 04/08/25 at 10:43 AM, revealed that the documents were missing dates, witness signatures, and other information. Review of Social Worker (SW) #19 progress note for Resident #121 dated 08/15/24 at 12:55 PM, revealed a note; Resident provided completed AD. Documents uploaded to the electronic medical records, and a copy was placed in the resident's chart. During an interview with SW #19 on 04/09/25 at 10:44 AM, the surveyor presented Resident #121's AD and informed SW #19 that the documents were missing dates and witness signatures. SW #19 acknowledged that the document was incomplete. On 04/10/25 at 09:38 AM, a review SW #19 progress note dated 04/09/25 at 2:17pm, revealed that she met with Resident #121 to review their AD. The social worker mentioned that the resident's AD was missing a date and witness signatures. The SW provided the residents with a copy and requested that they sign and have the AD witnessed. The social worker also helped in finding two witnesses.

Based on record reviews and interviews, it was determined that facility staff failed to ensure that a resident's Advance Directive (AD) was completed. This deficient practice was evident for 1 (#121) of 3 residents reviewed for AD during the survey. The findings include: Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. On 04/08/25 at 10:43 AM, a review of Resident #121's AD in the paper chart revealed several oversights. There was no indication of when the designated health agent's power would become effective--immediately or whenever the resident was unable to make informed healthcare decisions. The resident did sign the AD, but the form was not dated, and the signature and date for two witnesses were left blank. Additionally, part one of the organ donation section was incomplete, and the witness signature and dates were left blank. On 04/09/25 at 10:39 AM, the surveyor presented a copy of Resident #121's AD and informed the Administrator #1 that the documents were missing dates and witness signatures. The Administrator #1 stated that she expects all AD to be fully completed and noted that the resident's medical orders for life sustaining treatment (MOLST) form are used in the event of a code. During an interview with the Social Worker (SW) #19 on 04/09/25 10:44 AM, the surveyor presented Resident #121's AD. The SW #19 acknowledged that the document was incomplete. On 04/10/25 at 09:38 AM, a review SW #19 progress note dated 04/09/25 at 2:17 PM, revealed that she met with Resident #121 to review their AD. The resident's AD was missing a date and witness signatures. The SW provided the resident with a copy to review and requested that they sign and have the AD witnessed. The social worker also offered assistance in finding two witnesses should they need it. The resident agreed to review the documents and follow-up with the social worker.

Based on record review and interview with staff, it was determined that the facility failed to ensure a resident was free from misappropriation of resident property. This was evident for 1 facility reported incident (MD00214164) out of 5 facility reported incidents reviewed during the survey. The findings include: On 4/10/2025 at 7:30AM, a review of Resident #19's investigative file for the facility reported incident (FRI) MD00214164 revealed that on 1/24/2025 at 8:10AM, the resident notified the Nursing Home Administrator (NHA) that his/her credit card was missing, and that his/her credit card had been used four times on the evening of 1/23/2025 between 6:46PM and 8:41PM. An additional review of the investigative file revealed that after a thorough investigation, the facility was able to verify the allegation of misappropriation of resident property due to theft and use of the resident's credit card at various stores. On 4/10/2025 at approximately 1:20PM, the Surveyor conducted an interview with the NHA which confirmed the allegation of misappropriation of Resident #19's credit card.

Based on record review and staff interview, it was determined that the facility failed to include the resident comprehensive care plan goals with the required documentation during a transfer. This was evident for 1 (Resident #55) of 3 residents reviewed for hospitalization. The findings include: On 04/08/25 at 11:05 AM, review of Resident #55's medical record revealed he/she was hospitalized on [DATE]. On 04/09/25 at 10:24 AM, an interview with Charge Nurse/ Licensed Practical Nurse (Staff #20) revealed that comprehensive care plan goals were not sent with a resident upon a transfer. On 04/09/25 at 11:10 AM, an interview with Registered Nurse (Staff #21) revealed that comprehensive care plan goals were not sent with a resident upon a transfer. On 04/10/25 at 06:53 AM, the surveyor reviewed the concern with the Director of Nursing.

Based on record review and staff interviews, it was determined that facility staff failed to ensure that the resident and resident representative were notified in writing of a transfer and reason for transfer to the hospital. This was evident for 2 (Residents #55 and #54) of 3 residents reviewed for hospitalization. The findings include: 1. On 04/08/25 at 11:05 AM, review of Resident #55's medical record revealed he/she was hospitalized on [DATE]. On 04/10/25 at 06:53 AM, an interview with the Director of Nursing revealed that the resident and responsible representatives were verbally notified, but that there was not a written notice with reason for transfer provided. The surveyor reviewed the concern. 2. On 4/8 2025 at 12:40PM, a review of Resident #54's electronic medical record revealed that the resident was transferred to the hospital on 1/28/2025 after sustaining a fall. On 4/10/2025 at 10:45AM, an additional review of Resident #54's medical record failed to reveal documentation to indicate the resident and resident representative had been notified in writing of transfer and the reason for transfer to the hospital on 1/28/2025. During an interview conducted on 4/10/2025 at 11:55AM with the Director of Nursing (DON), the Surveyor expressed the concern that Resident #54's electronic and paper medical record failed to reveal documentation that the resident and their resident representative had been notified in writing of the transfer and the reason for transfer to the hospital on 1/28/2025. The DON was unable to provide further documentation. On 04/10/25 at 06:53 AM, an interview with the Director of Nursing revealed that the resident and responsible representatives were verbally notified, but that there was not a written notice with reason for transfer provided.

Based on record reviews and interviews, it was determined that facility staff failed to update a resident's care plan to address falls involving equipment. This deficient practice was evident for 1 (#121) of resident review for care plan revision during the survey. The findings include: During an interview with Resident #121 on 04/08/25 at 10:15 AM, they reported that the break lever on their wheelchair was broken. As a result of the broken lever, they had multiple falls while attempting to stand up or sit down using the wheelchair. Review of communication form and progress note revealed that Resident #121 had a fall on 10/07/24, 12/12/24, 12/27/24, 03/19/25, 04/09/25. On 04/09/25 at 1:05 PM, a review of the residents' post fall evaluation progress note dated 10/07/24 indicates that Resident #121 had an unwitnessed fall in their room while attempting to get into bed, and the wheelchair was involved in the fall. A review of physical therapy treatment note dated 12/30/24 revealed that physical therapy was informed of a fall the resident had in the bathroom. The resident reported that they did not lock the wheelchair brake and when they reached back to sit down the wheelchair moved. Review of Resident #121 care plan on 04/09/25 at 2:07 PM, revealed that on 09/17/24 the resident was identified as a high fall risk due to balance issues and a history of falls. Further review indicates that the resident's care plan was not updated to address the residents use of a wheelchair and compliance with locking the wheelchair brake until 3/19/25. During an interview with the Director of Nursing (DON) #2 on 04/09/25 at 11:00 AM the surveyor informed the DON #2 of the above findings. The DON #2 stated that the wheelchair involved was the resident's personal equipment. She further stated that the resident should have behavioral care plan addressing noncompliance with locking the wheelchair breaks. When asked whey the resident's care plan was not updated following the resident's fall on 10/07/24 and 12/27/24, the DON #2 was unable to provide an explanation.

Based on interviews, observations, and record reviews, it was determined that facility staff failed to ensure that a resident's wheelchair was safe for use. This deficient practice was evident for 1 (#121) resident review safety hazards during the survey. The findings include: During an interview with Resident #121 on 04/08/25 at 10:15 AM, they reported that the break lever on their wheelchair was broken. As a result of the broken break lever, they had multiple falls while attempting to stand up or sit down using the wheelchair. Review of communication form and progress note revealed that Resident #121 had a fall on 10/07/24, 12/12/24, 12/27/24, 03/19/25, and 04/09/25. On 04/09/25 at 8:57AM, the surveyor observed Resident #121 sitting in a wheelchair in their room, watching television. With permission from the resident, the surveyor assessed the wheelchair's brakes. Upon unlocking and locking the right break lever, it was noted that the lever did not fully lock the wheel, allowing movement with activity. The left brake lever locked the wheel preventing movement. After exiting the resident's room, the surveyor observed an unoccupied wheelchair in the seating area in front of the nurse's station. While assessing this wheelchair break levers, it was noted that the right brake lever did not fully lock the wheel, allowing for movement. The left break lever locked the wheel preventing movement. There were no tickets or signs indicating that the wheelchair needed repairing. On 04/09/25 at 9:18 AM, the surveyor informed nurse unit manager #5 about the malfunctioning brake levers on both wheelchairs and inquired about the process of addressing faulty resident equipment. The nurse UM #5 stated that nursing staff are responsible for reporting equipment concerns to the front desk secretary who will submit a work order through a platform called TELS. On 04/09/25 at 9:36 AM, during an interview with maintenance tech #25, he stated that nursing staff is responsible for immediately reporting equipment concerns. The surveyor asked if he regularly checks equipment including wheelchairs on the units to ensure they are functioning properly. Maintenance Tech #25 explained that he is the only technician for the building, and he does not proactively check equipment, but instead addresses issues based on reports submitted through the TELS system. The surveyor asked if a work order was submitted for Resident #121 in October and December 2024, and he stated that he was uncertain about gathering records from those months. During an interview with the Director of Nursing (DON) #2 on 04/09/25 at 11:00 AM the surveyor shared findings regarding Resident #121's wheelchair. The DON #2 reports that the wheelchair was the resident's personal property. When asked whether the wheelchair had been assessed for safety hazards upon the resident's admission or prior to its use within the facility, the DON #2 was unable to provide documentation confirming that an assessment had been conducted prior to use in the facility.

Based on observations and interviews with the facility staff, it was determined that the facility staff failed to ensure that a resident's call bell was within reach. This was evident for 1 resident (Resident #1) out of 4 residents observed during the survey. The findings include: On 4/08/25 at 10:24 AM, the resident was observed lying in bed comfortably. The call bell was noted to be hanging behind the bookcase at the foot of the resident's bed against the wall. The surveyor interviewed the resident and asked he/r, how they would call for assistance. They stated that they uses the call bell. The resident started to look for the call bell and then said, I don't know what I did with it. Then the surveyor asked, How would you ask for assistance if you can't find the call bell? The resident responded that s/he would wait until someone came to check in on them. On 4/09/25 at 1:17 PM, the resident was observed lying in bed, watching TV. The call bell was hanging from the wall on the left side of the bed on the floor. The surveyor went to the nursing station and to interview the Charge Nurse (CN) #15. The surveyor asked the CN #15 to walk with them to see a resident. After entering the resident's room, and the surveyor asked him where the call bell was. CN #15 stated that he had observed the call bell behind the bookcase the day before and had given it back to the resident. The CN #15 continued to say that he had started to educate his employees on the policy for call bells on the evening of 4/8/2025. Then, the CN #15 picked the call bell up off the floor and handed it to the resident.

Based on record review and interview, it was determined the facility failed to develop and implement abuse prevention policies to ensure the safety of their residents. This was evident for 1 of 1 facility abuse prevention policies and procedures reviewed. The findings include: During the investigation of facility reported incident #MD00178929, a review of the facility abuse prevention policies and procedures were reviewed on 1/21/25 at 2:15 PM. A review of the facility's Resident Rights - Abuse and Crimes against policy dated 11/13/24, failed to reveal procedures for the implementation of training of new and existing staff, those with contractual agreements, and volunteers to include their expected roles. Further review revealed there was no policy or procedure to establish the coordination with the quality assurance performance improvement [QAPI] program. On 1/22/25 at 11:53 AM, the NHA confirmed that she had provided all the abuse prevention policies and procedures and had confirmed this with the corporate office. The concerns were reviewed with the NHA who responded by stating she needed to write down the concerns so she could let the corporate office know. She offered no rationale as to why the information had not been included.

Based on record review and interview, it was determined that facility staff failed to recognize and report an injury of unknown within the required time frame. This was evident for 1 (#23) of 1 resident reviewed for injury of unknown origin. The findings include: A medical record review for Resident #23 on 1/22/25, at 2:49 PM revealed under the census tab, that the resident had been a long-term resident of the facility. The resident had a care plan initiated on 10/25/23, for the risk of falls related to dementia, lack of safety awareness, and the tendency to constantly reposition themselves to lay sideways or across in the bed. A review of the minimum data set (MDS), with an assessment reference date of 4/16/24, revealed the resident was severely cognitive (the ability to think and process information) impaired. A review of the progress notes revealed that Licensed Practical Nurse (LPN) #40 wrote a note on 6/25/24, at 11:49 AM that she found the resident lying with his/her left leg hanging on the left side of the bed, the resident was repositioned in bed and it was noted that their left lower leg was discolored with swelling, a blister on the left great toe, and was warm to touch. Further noting the resident was evaluated by the Nurse Practitioner (NP) #41and x-rays were ordered. Further review revealed on 6/25/24, at 10:17 PM LPN #25 wrote a note that the x-ray results were received and the resident had a fractured foot. On 1/22/25, at 3:39 PM, a review of the facility's investigation file for self-reported incident #MD00207069 was conducted. The initial self-report form documented the facility became aware of the injury of unknown origin on 6/25/24, at 5:30 PM upon receipt of the x-ray showing the resident had sustained a fracture. Further review revealed there was no evidence of how this injury occurred. However, a review of the email confirmation for sending the report to the State Agency revealed they failed to report the injury of unknown origin until 6/26/24, at 11:08 AM. Telephone numbers for LPN #25, who was the nurse on duty when the x-ray report was received and Unit Manager #44, who was the staff person who conducted the investigation, were requested. However, the Nursing Home Administrator (NHA) reported that both employees were out on leave and unavailable for interview. An interview with geriatric nursing assistant (GNA) #26, who was the GNA assigned to the resident on the day the incident occurred, was conducted on 1/23/25, at 10:50 AM. GNA #26 reported she remembered the resident but not the specific incident on 6/25/24. When asked about Resident #23, she stated that the resident was totally dependent on staff for care, but somehow the resident would scoot themselves around in bed to lay sideways on the bed. When asked if the resident would flail his/her arms and legs around, the GNA reported she did not recall the resident doing that. An interview with the Director of Nursing (DON) on 1/22/25 at 3:28 PM, revealed she agreed that LPN #25 should have reported this to a supervisor as an injury of unknown origin. The DON stated that LPN #25 received disciplinary action and 1:1 education regarding the expectations of reporting injuries of unknown origin. She stated she educated most of the other nurses and geriatric nursing assistance about injuries of unknown origin and reporting requirements. On 1/29/25, at 1:15 PM, this was reviewed with the NHA with the DON present.

Based on record review and interview, it was determined that the facility failed to ensure that an allegation of abuse was thoroughly investigated. This was evident for 1 (#8) of 21 residents reviewed for abuse. The findings include: The 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. A medical record review for Resident #8, on 1/22/25 at 10:30 AM, revealed a minimum data set (MDS) with an assessment reference date of 10/3/22, revealed the resident was not cognitively impaired and relied on staff for activities of daily living (such as toileting, getting in and out of bed, dressing, bathing, and personal care). On 1/22/25 at 10:00 AM, a review of the facility's procedure titled Resident Abuse Reporting and Investigation Guidelines (there was no date on the procedure) revealed in #9 the individual conducting the investigation should: #9a review all the documentation and evidence, #9e interview all witnesses, and #9h interview all staff members (on all shifts) who may have had contact with the resident during the period of the alleged event. A review of the facility's investigation file for the facility reported incident #MD00178929 on 1/21/25, at 2:41 PM revealed an email sent from Resident #8's family on 5/13/22, at 4:13 PM reporting that a staff member came into the resident's room around 5:00 AM on 5/13/22, slapped the resident's hand, took the call bell from them, placing it out of reach, and left the room. Another staff member came in later that morning with medications and gave the call bell back to the resident. A review of the call bell response time audit revealed the resident had not used the call bell between 4:30 AM and 8:46 AM. Further, review failed to reveal that the facility conducted the investigation to verify with the nursing staff who had brought medications to the resident that morning. A review of the staffing schedules revealed Licensed Practical Nursing (LPN) #45 was assigned to the resident on night shift 7/12/22 going into 7/13/22. Review of LPN #45's interview questions and answers with Unit Manager #44 revealed she was not asked if she had went into the room with medications that morning and if so, was the call light within the resident's reach or not. Furthermore, there was no interview with the nurse who was assigned to the resident on 5/13/22, dayshift, as they would have given the resident medications that morning. An interview with LPN #45 on 1/23/25 at 7:30 AM revealed she could not recall the incident or the interview that was conducted by Unit Manager #44. The Nursing Home Administrator (NHA) was interviewed on 1/22/25 at 12:18 PM. She reviewed the self-report form. When asked what she does to investigate an allegation of abuse, she stated that she would interview the alleged perpetrator to establish if they were in the room, provided care, and anything unusual or complain about abuse. She would interview all staff who were working around the time of the incident. When asked why staff were asked specific questions during this investigation and not asked about the events that were reported, she stated that she had not conducted the interviews. They were conducted by Unit Manager #44 who was out on leave and unavailable for an interview. She stated that she would review the investigation and report back with additional information. However, there was no additional information provided by the end of the survey.

Based on record review, interview, and facility policy review, the facility failed to administer a physician ordered medication for 1 (Resident #22) of 3 residents reviewed for medication administration. Specifically, the facility failed to administer a Rocephin (an antibiotic medication) injection to Resident #22 on 02/28/2024. Findings included: A facility policy titled, Medication Administration-General Guideline, revised 12/09/2024, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after the have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The policy revealed, B. Administration 2. Medications are administered in accordance with written orders of the prescriber. Per the policy, D. Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the resident's MAR/eMAR [Medication Administration Record/electronic Medication Administration Record] directly after the medication is given. Resident #22's Face Sheet indicated the facility admitted the resident on 02/19/2024. According to the Face Sheet, the resident had a medical history that included diagnoses of sepsis, urinary tract infection (UTI), and metabolic encephalopathy. A hospital Discharge/Transfer Summary, dated 02/19/2024, revealed Resident #22 came to the hospital from home for altered mental status and acute encephalopathy, and was found to have sepsis secondary to a UTI. The Discharge/Transfer Summary revealed the hospital treated the resident for the UTI and sepsis, which was resolved at the time of discharge after four doses of intravenous (IV) Rocephin. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/21/2024, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS revealed that Resident #22 had a UTI in the last 30 days and had not received any IV antibiotic medications during the last three days of the assessment look-back period. Resident #22's Care Plan Report, included a problem statement created on 02/28/2024, that indicated Resident #22 had an IV line for antibiotics. Interventions directed staff to administer antibiotics as ordered (effective 02/28/2024 through 03/06/2024). Resident #22's Telephone Orders, dated 02/27/2024 revealed an order for a urinalysis with a culture and sensitivity test. Resident #22's urinalysis laboratory report dated 02/28/2024 revealed the resident's urine contained a moderate amount of blood (reference range was negative amount), a large number of leukocytes (reference range was negative amount), red and white blood cells were too numerous to count per high power field (HPF) (reference range was zero to two), Many bacteria (reference range was none), and a moderate amount of crystals (reference range was none). Resident #22's Telephone Orders, dated 02/28/2024 revealed an order for Rocephin 1 gram IV every 24 hours for seven days for a diagnosis of UTI. Per the order, the first dose was required to be given STAT [immediately]. Resident #22's Telephone Orders dated 02/28/2024 revealed an order for one dose of Rocephin 1 gram to be administered intramuscular (IM) today for a UTI. Resident #22's February 2024 Medications record revealed a transcription of the order for Rocephin 1 gram IM with an order date of 02/28/2024. However, the medication record revealed the order was not assigned administration times in the date range and there was no documented evidence the medication was administered as ordered by the provider. The February 2024 Medication record revealed that staff documented that the first dose of IV Rocephin was administered on 02/29/2024. Resident #22's laboratory report dated 03/01/2024 revealed there was no bacterial growth on the resident's final urine culture. During an interview on 01/27/2025 at 11:23 AM, Licensed Practical Nurse (LPN) #21 stated he was the nurse who took the physician's order for an IV line for Resident #22 because the nurse practitioner's first order for Rocephin was for the medication to be administered IV. He stated the resident required a PICC (peripherally inserted central catheter) line to give the medication, which was why the order was re-written for the first dose of Rocephin to be given IM. LPN #21 stated if the nurse practitioner wrote an order for IM Rocephin, it should have been administered as ordered. During a telephone interview on 01/27/2025 at 11:14 AM, Pharmacist #34 stated there were no charges for Rocephin for Resident #22 on 02/28/2024 from the facility's Pyxis system (a computerized system that stored and dispensed medications). He stated there would have been a charge had the medication been removed from the system. He stated that no charge indicated Rocephin was not dispensed. During an interview on 01/27/2025 at 3:04 PM, LPN #24 stated she gave the IM mediation to Resident #22 on the day she took off the order. She stated she got the medication out of the Pyxis system, mixed it, and gave the medication. She stated she did not know why the resident's medication administration record did not reflect that the medication was administered. After notification that the pharmacy had no record that the medication was taken out of the Pyxis system, LPN #24 again stated that she took the medication out of the Pyxis system, reconstituted the medication, and gave the medication. During an interview on 01/27/2025 at 5:05 PM, the Director of Nursing (DON) stated she had spoken with LPN #24, and LPN #24 stated she did not give Resident #22's IM Rocephin. The DON stated she did not know why LPN #24 stated that she removed the medication from the Pyxis system because it was not given. The DON then stated her expectation was for any medication ordered by the physician or nurse practitioner to be given as ordered. During an interview on 01/24/2025 at 2:41 PM, Nurse Practitioner (NP) #38 stated if she wrote an order for Rocephin IM, she intended for the medication to be given. Per NP #38, the resident received a PICC line and then received six days of IV Rocephin. The Physician was interviewed on 01/23/2025 at 3:55 PM. Per the Physician, Resident #22 received six days of antibiotics. According to the Physician, six versus seven days of the medication would not have made any difference as the resident's prognosis was poor. The Physician stated they treated the resident's dehydration and infection, and the resident continued to decline. During an interview on 01/28/2025 at 1:49 PM, the Administrator stated any medication ordered by the physician or nurse practitioner was expected to be given as ordered.

Based on observation, staff interviews, and review of the clinical record and other pertinent facility documentation, it was determined that the facility staff failed to accurately assess resident #1 for elopement risk. As a result, the facility staff failed to develop and implement adequate safety interventions to address the needs of resident #1, who is cognitively impaired and has a history of wandering. These deficient practices, placed residents at risk for elopement and the potential for serious harm. Review of the facility's plan of correction implemented immediately after the facility gained knowledge of the incident result in the citation being cited as past non-compliance. The findings include: Corrective Action includes: 1. Resident#1 was placed on the locked dementia neighborhood on 6/26/18. 2. An elopement assessment was completed on 6/25/18 by the charge nurse, and the resident ' s careplan was updated. 3. The code to the kitchen elevator was changed by Maintenance on the morning of 6/26/18, and was distributed only to dietary staff and the Administrator to prevent non-dietary staff from entering the elevator. 4. The Food Service Manager conducted an inservice with dietary staff prior to the start of meal service on 6/26/18 on protecting residents and the use of elevator codes. The inservice covered the following: a. Not allowing visitors or residents on the dietary- they should be redirected to nursing staff b. Being mindful of 3rd floor residents (south and north) of getting on the elevator c. Not giving out elevator code to any residents/family/staff other than dietary staff. 5. The Director of Nursing conducted an inservice with staff members on 6/27/18 that covered the following: a. Only dietary staff are allowed to use the service elevator b. In the event that a resident/visitor requests to use the service elevator, he/she will be directed to the nurses station for further assistance. c. The dining staff will also inform the nursing staff that the visitor/resident has requested to use the elevator and assist with re-directing him/her to the appropriate individuals d. In the event that a resident enters the elevator with the dining staff member, the staff member will exit the elevator and escort the visitor/resident to the nurses station for further assistance. e. Residents or visitors seeking to exit the building on the third floor (north and south) should be directed to the nurse for assistance with leaving the building. 6. A visitor badge process was implemented on 6/27/18, requiring all visitors to the building to sign-in at the front desk and obtain a badge marked visitor. Monitoring: 1. The Director of Social Services or Assistant Director of Social Services will audit admission MDS ' s weekly for four weeks and then monthly for three months to evaluate if the resident was coded appropriately for wandering in Section E. During and at the conclusion of the audit and reporting period, the QAPI committee will re-evaluate and initiate any necessary action or extend the review period. The Nursing Home Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. 2. The Nurse Managers and House Supervisors will audit new admission records daily for four weeks to evaluate if the resident has a history of elopement/wandering prior to admission, that the elopement assessment was completed accurately, if an elopement careplan was initiated if appropriate, whether or not the resident is located on the appropriate neighborhood, and actions taken to remedy any discrepancies. During and at the conclusion of the audit and reporting period, the QAPI committee will re-evaluate and initiate any necessary action or extend the review period. The Nursing Home Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. This finding was identified during the investigation of facility reported incident MD 380. The findings include: 1. On 08-01-18, review of the facility investigation report revealed that staff #7 observed resident #1 standing in the loading dock area outside of the building on 06-25-18 at 6:15 PM without supervision. Staff #7 called staff #8 for assistance to escort resident #1 back to the 3 North unit. Further review of the investigation revealed that resident #1 left the unit by riding on a service elevator with kitchen staff. Resident #1 told the kitchen staff that he/she was a visitor and wanted to go home. Therefore, the kitchen staff allowed resident #1 to ride on the services elevator. The resident proceeded to get off the service elevator on the ground level and walked out of the building. The resident followed a pathway and went to the loading dock area alone. On 08-01-18 at 4 PM, interview of staff #8 revealed the third floor is secured. The nursing staff control the access of the visitor elevator. The service elevator is only used by kitchen staff. Interview of the facility administrator, on 08-01-18 at 5 PM, revealed that kitchen staff received an in-services on 06-26-18 related to protecting residents and the use of the service elevator. In addition, resident #1 was transferred to 3 South on 06-26-18. The Director of Nursing provided in-services on 06-27-18 to all facility staff related to assisting residents/visitors to exit the building and the service elevator use. In addition, all visitors were asked to wear badges starting on 06-27-18. On 08-01-18 and 08-02-18, review of the clinical record revealed that resident #1 was admitted to the facility on [DATE] from an assisted living facility. Based on the client summary, which was written by adult protective services (APS), resident #1 had dementia and wandered out of his/her own home in (MONTH) (YEAR). Since resident #1's family could not take care of him/her in the community, the resident was placed in an assisted living facility for safety concerns due to continued wandering in the community. Review of the health care practitioner physical assessment form, which was completed in (MONTH) (YEAR), resident #1 exhibited unsafe behaviors, which was referred to as wandering on a regular basis. While the resident was residing in the assisted living, he/she occasionally packed his/her belongings and attempted to leave. In (MONTH) (YEAR), staff documented that resident #1 wandered several times a day based on the [NAME]land Medical Assistance Medical Eligibility Review. Dementia is one of the resident's medical diagnoses. On 08-03-18 at 9 AM, telephone interview of staff #4 revealed that resident #1 was admitted to the facility for long term care placement. Resident #1 was placed on 3 North because of dementia. On 06-12-18, resident #1 was accompanied by an APS worker to 3 North on admission. Telephone interview of staff #6 on 08-03-18 at 9:45 AM revealed the APS client summary was provided to the facility upon admission. Staff #6 documented on 06-12-18 that resident #1 had a history of [REDACTED]. Based on the elopement risk assessment, which was completed by staff #6 on 06-12-18, resident #1 was not at risk to elope at the time of admission and no elopement risk protocol was indicated. Therefore, no plan of care related to wandering or elopement was developed. See F 636. The next day after admission, a care plan related to dementia and cognitive impairment was developed. One of the interventions was to monitor the resident's whereabouts in the facility to ensure safe environment by all staff. However, it was unknown how often the resident should be monitored and who was assigned to monitor resident #1. Review of the activity care plan revealed activity staff would provide favorite activities including talking, walking around and getting fresh air, one on one visits and social groups. The social services coordinator would provide room visit 2-3 times a week to resident #1. However, review of the resident participation log revealed no outdoor walking was offered to resident #1 since admission. Only one one on one visit was offered on 6-25-18 to resident #1. On 08-02-18 at 12:30 PM, interview of the facility administrator revealed no additional information. On 08-02-18, review of the nursing notes between 06-13-18 and 06-19-18 revealed that resident #1 was up wandering around the unit on 06-13-18 at 12 midnight and stated he/she wanted to go home. On 06-13-18, on the 7-3 shift, the resident was wandering around the unit and stated he/she was waiting for a train to go home. On 06-13-18, on the 3-11 shift, the resident wandered in the hallway and kept wanting to go home to his/her spouse. On 06-14-18, on the 7-3 shift, resident #1 was wandering in the hallway with an unsteady gait and stated that he/she wanted to catch a train or a bus to go home. Further review revealed that nursing staff documented resident #1 wandered on the unit or hallway daily between 06-15-18 and 06-18-18. However, review of the admission Minimum Data Status (MDS) assessment, a tool that reflects an individual's physical and functional status, revealed that staff #5 coded resident #1 as not exhibiting any wandering behaviors despite documentation by nursing staff that resident #1 wandered daily and wanted to go home between 06-13-18 and 06-19-18. See F 641. On 08-03-18 at 9:30 AM, telephone interview of staff #5 revealed he/she explained that resident #1 did not have any exit seeking behaviors on admission. Therefore, no elopement preventions were needed. Further review of the nurses notes revealed that resident #1 was observed wandering into another resident's bed and required assistance to return to his/her own bed in the evening on 06-20-18 and 06-21-18. However, the resident became agitated in the evening on 06-21-18 when nursing staff redirected him/her. On 06-24-18, resident #1 was reported wandering in the hallway and into other resident's rooms in the evening and at night. On 06-25-18 at 6:15 PM, resident #1 was observed in the loading dock area outside of the building without supervision. On 08-02-18 at 12 noon and 08-03-18 at 10 AM, interview of the facility administrator revealed no additional information. The facility's compliance date was 06-27-18. 2. Based on surveyor observation, review of the clinical record and interview of family and the facility staff, it was determined that the facility staff failed to transfer resident #4 with a sling to the left shoulder. This finding was identified during the investigation of a facility reported incident provided at the time of the survey. The findings include: On 08-01-18 at 12 noon, interview of resident #4 revealed the resident was alert, but oriented to name only. The resident was observed lying in bed with his/her eyes closed most of the time. On 08-01-18 at 12 noon, interview of resident #4's family member revealed that the resident could not engage in a conversation or communicate needs to the facility staff. Due to the resident's physical limitation, the resident required total assistance with activities of daily living. The family member stated that the nursing staff does not always transfer or turn resident #4 properly. On 08-01-18, review of the hospital discharge summary revealed that resident #4 had left [MEDICAL CONDITION] and bilateral shoulder pain due to subluxation (a partial dislocation). Further review of the initial occupational therapy assessment, dated 06-28-18 revealed that staff #4 recommended a sling for subluxation of the left upper extremity. Interview of staff #4 on 08-02-18 at 10:45 AM revealed that the sling was given to resident #4 and the nursing staff for use during transfers due to left [MEDICAL CONDITION] (paralysis of one side of the body). However, there was no evidence that a plan of care was developed for resident #4 to address the use of the sling for transfers. On 08-02-18 at 12:30 PM, interview of the facility administrator and the Director of Quality Assurance revealed no additional information.

Based on surveyor observation, review of the closed clinical records and administrative records, it was determined that the facility staff failed to prevent a resident from sustaining a fall with resulting injury. This finding was identified during the investigation of facility self report MD 409. This finding was evident in 1 of 11 residents selected in the survey sample. Review of the facility's plan of correction implemented immediately after the incident resulted in the citation being cited as past non-compliance. The findings include: On 06-19-17, a review of the closed clinical record revealed that resident #2 sustained a fall from a raised bed during the provision of care by a Geriatric Nursing Assistant (GNA), on 05-24-17, requiring transport to an acute care hospital. The resident was diagnosed with [REDACTED]. Further review of the clinical record revealed that resident #2 had a care plan which instructed facility staff that the resident required 2 staff members for transfer, as well as 2 staff members, for turning and repositioning. This care plan was located in the clinical record, with a copy posted in the resident's room inside the closet door. On 06-19-17, a review of administrative records revealed that a family member approached the nurses station to request assistance for resident #2. Two GNA's transferred resident #2 from the wheelchair to the bed, however, one GNA exited the room prior to the provision of care, leaving only 1 GNA to turn and reposition the resident during incontinence care. On 06-19-17 at 11:00 AM, interview with the Director of Nursing revealed that administrative records accurately depicted the events resulting in resident #2's fall on 05-24-17. The Director of Nursing stated that care plans are placed in each resident's closet to allow direct caregivers ready access to information regarding the provision of care. The Director of Nursing stated that the GNA did not follow the facility's protocol to check the closet care plan prior to providing care to resident #2 on 05-24-17. On 06-20-17 at 1:40 PM, interview with GNA staff member #1 revealed that he/she failed to look at the care plan in the closet prior to turning and repositioning resident #2. He/she acknowledged awareness that the resident required two people for turning and positioning, and normally had assistance to perform this task. GNA staff member #1 stated that, on 05-24-17, as he/she turned the resident to apply an incontinence brief, resident #2 reached for something and fell off the opposite side of the bed landing on the floor. Further review of administrative records revealed that the facility had identified and implemented immediate corrective action on 05-26-17. The corrective action included: acknowledgement by the facility that all residents had the potential to be affected by the deficient practice of failing to follow the plan of care. As a result, a review of all current physicians orders, care plans in the clinical records, and closet care plans was conducted to ensure consistency and accuracy of the information utilized by the direct caregivers in the provision of care. 100 % of all clinical records were reviewed for compliance. Discrepancies were immediately corrected. This was completed on 05-26-17. The DON provided evidence of the reviews by presenting completed audit tools for surveyor verification. The audit tool also reflected the changes made when inaccuracies were discovered. The surveyor also verified that resident #2 was included in the audit, and that corrective action had been taken to revise his/her care plan to reflect the current physicians orders for transfer. Surveyor observation of random rooms on each nursing unit, on 06-20-17, verified that the information reflected in the closet care plan was consistent with the plan of care in the clinical record and the physician order [REDACTED]. 90% of the nursing staff had been inserviced on the importance of adhering to the information provided in the plan of care, with particular attention given to safe transfer of residents, by 06-05-17. The remaining staff had been scheduled to receive the inservice education on the next scheduled day of their return to work, with a plan to have the remaining 10% completed by 07-05-17. A review of the signature sheets by the surveyor reflected both licensed and non-licensed signatures for staff members on all three shifts. The agenda for the training included turning and repositioning, transferring, and adherence to the number of staff members required for each, as reflected in the plan of care. The Unit Managers were assigned the responsibility to audit the clinical record of all new admissions to verify consistency and accuracy between physician orders, care plans, and closet care plans, to prevent recurrence. Additionally, the Unit Managers were responsible for random observation of the direct caregivers compliance with the instructions reflected on the closet care plans on a monthly basis. The surveyor requested, and received for review, the audits that had been conducted prior to the complaint survey. Additionally, the surveyor verified (by interview of the Unit Managers) that the audits were based on observation of care, and comparison of care, as per the physicians order sheet and plan of care. The Director of Nursing stressed that the audits were unscheduled, random observations. The Director of Nursing also informed the surveyor that the evening and weekend supervisors had also been instructed to conduct the same audits on off shifts. Results of the audits and compliance rates are to be presented to the Quality Assurance Committee. Surveyor review of the May 2017 Quality Assurance Minutes reflected the fall and injury of resident #2 and the corrective action taken immediately and plan for additional corrective action and ongoing monitoring. The corrective action also included ongoing compliance monitoring during their Nurse Manager meeting (held twice weekly) once consistent compliance has been achieved to prevent recurrence.

Based on surveyor review of the clinical record, interview with staff, and review of the facility investigation, it was determined that the facility staff failed to identity the correct family of resident #3 in an emergency and failed to react to the emergency situation as requested by the resident's power of attorney and as stated on the Maryland MOLST form. In addition, staff failed to follow the physician order [REDACTED]. This finding was evident on a facility reported incident reported to the surveyor on the day of an unrelated complaint investigation. The findings include: The Maryland Medical orders for life-sustaining treatment (MOLST) is a form completed by the physician after consulting with the resident or decision maker. This form is required by the state to alert staff in hospitals, facilities and emergency personnel in the event of a [MEDICAL CONDITION] or deterioration in health status, as to the wishes of a resident for advanced care including CPR. Resident #3 was certified as incompetent to make medical decisions, so her daughter who was her acting power of attorney, (POA) was consulted to determine her wishes. On [DATE], it was reported that resident #3 had been found deceased that morning. Based on the information provided to the surveyor on site, the resident did not receive CPR as requested, because the resident was misidentified. The surveyor was informed that an investigation was just beginning into the circumstances. Based on clinical record review, this was a [AGE] year old resident admitted for rehab services following a stroke. Her progress in rehab was limited due to her response and progress. Based on record review, on [DATE] at 12:55 AM, the Geriatric Nursing assistant (GNA) alerted the nurse that resident #3 was having difficulty breathing. She was observed with a large amount of coffee ground emesis and assessed with [REDACTED]. Oxygen was started but the resident was combative and did not keep the oxygen on consistently. Her blood pressure was documented as ,[DATE] mm/Hg, pulse was 104/ minute and respirations were 24/minute. Her oxygen saturation then varied between ,[DATE]%. Nursing notes stated the physician was notified at 1:10 AM. Resident #3's pulse ox reading was ,[DATE]% at 1:53 AM with oxygen on and off. At 2:45 AM, the resident was noted to be without a pulse or respirations. Her pupils were noted to be fixed and dilated. No attempt at CPR was attempted. A pulse oximeter is a medical device that measures levels of blood oxygen saturation, monitors pulse rate and calculates heart rate. A normal range is between ,[DATE] but is affected by age and condition of the resident. On [DATE], a final report of the facility's investigation for resident #3 was received. On [DATE], based on review of the investigation, resident #3's physician had signed the MOLST form on [DATE]. Based on the MOLST form, the POA directed staff to perform CPR, as well as the choice for artificial ventilation, blood transfusion, hospital transfer, medical workup and antibiotics. The documentation by the physician revealed that she received a phone call from the charge nurse at 12:10AM on [DATE]. The nurse told the physician that resident #3s blood pressure was in the 70s She further documented I quickly interrupted the nurse and said - send resident to ER as I remember her code status being FULL CODE. I also asked the nurse to notify the family about the transfer. The physician noted that she received another call from the nurse about 1 AM stating that the POA did not want resident #3 to go the the ER. She asked the nurse to document what the POA had said, since it was contrary to the what the MOLST stated. She asked to speak with the nurse supervisor, who was in agreement with the charge nurse. Based on nursing notes, both nurses verified the changes with the daughter via phone. The physician stated that she was called again, was informed that the family was electing hospice, that the daughter was on her way and that the resident was agitated, not keeping oxygen on. Because of the desire for comfort care, she ordered a one time dose of [MEDICATION NAME] to be administered for the restlessness and agitation. Documentation revealed that the resident refused the [MEDICATION NAME] about 2 AM. The physician documented that she received a call about 2:30 AM notifying her that resident #3 had expired. Based on the nursing documentation, the nurse interpreted the physician order [REDACTED].#3 to the hospital. Based on the facility documentation, the family of another resident, who had a DNR (do not resuscitate) status, was mistakenly called and that that family indicated the resident would be admitted to hospice. However, the name of the resident was not verified with the family member when they were called by either the charge nurse or nurse supervisor, despite the fact that the family gave the nurses their name which was not part of the members listed on resident #3's record as a contact. Resident #3's daughter was notified after the resident had died and the error was identified.