Every finding on record at Woodside Rehab & Nursing

Based on review of employee personnel files and staff interview, the facility failed to complete annual performance evaluations for Geriatric Nursing Assistants (GNAs). This deficient practice was identified for 3 (GNA #23, #24, and #25) of 3 GNAs reviewed during the annual survey. The findings include: On 06/01/2026 at 11:25 AM, 3 GNA employee files were reviewed. During the review, none of the three GNA personnel files contained documentation of a completed annual performance evaluation.On 06/01/2026 at 12:54 PM, an interview with the Director of Nursing was conducted. When asked if the 3 GNAs had annual performance evaluations she stated that they had not had them done.

Based on employee file reviews and interviews with staff, it was determined that the facility failed to ensure that a Geriatric Nursing Assistant maintained a current and active certification required for employment. This was evident for 1 (GNA #23) of 5 health care professionals reviewed during the annual survey. The findings include: The Maryland Board of Nursing's Look Up A License feature serves as the primary source verification system for certification status. All Geriatric Nursing Assistants are required to maintain an active certification to work. On [DATE] at 11:25 AM, 5 employee files were reviewed. During this review the surveyor was checking that the health care professionals maintained current credentials required for their position. The employees were entered into the Look Up A License feature on the MBON website to verify the status of their required credentials. It was found that Geriatric Nursing Assistant (GNA) #23 had an expired certification with an expiration date of [DATE]. On [DATE] at 12:43 PM, a review of GNA #23's timesheets from [DATE] through [DATE] revealed that she worked 11 shifts after her certification expired on [DATE].On [DATE] at 12:46 PM, Human Resource/ Staff Scheduler #26 was interviewed. During the interview she was asked how she kept track of employee certifications and expiration dates. She said that she kept a binder of all employee licenses/certifications and expirations and would send out reminders to staff when they were close to expiring. At this time she was made aware of the concerns related to GNA #23 working without an active certification. The Director of Nursing was also made aware of the concern on [DATE].

Based on observation, record review and interview, it was determined that the facility failed to have evidence in Resident #8's care plan regarding Resident #8's limited mobility and the usage, monitoring and supervision of the bedrails. This was evident for one out of one resident (Resident # 8) reviewed for bedrails during an annual survey.The findings include:During screening on 5/26/26 at 10:15 AM, the surveyor observed that Resident #8 had 1/4 length bedrails on her bed. A review of Resident #8's EMR (electronic medical record) on 5/26/26 at 11:35 AM revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including, but not limited to, adult failure to thrive, dependence on supplemental oxygen and muscle weakness.Further review on 5/26/26 of Resident #8's admission Side Rail Evaluation dated 1/8/26 at 7:41 PM documented that Resident #8 requested the use of side rails and currently had 1/4 rail bilaterally in use on his/her bed. The Conclusion on Resident #8's admission Side rail evaluation stated, The care plan will reflect the use of side rails and interventions to minimize injury and/or entrapment. A review of Resident #8's care plan on 5/26/26 at 12:10 PM revealed that there was no documentation of the bedrails in Resident #8's care plan under the focus of limited physical mobility or self-care performance deficit related to activity intolerance.On 5/29/26 at 10:38 AM during an interview, Licensed Practical Nurse (LPN) #12 stated that Resident #8 uses the bedrails as enablers to move around in the bed. They help him/her turn and move up in the bed.

Based on record reviews and interviews, it was determined that the facility to code the residents' status accurately on the Minimum Data Set (MDS) assessment. This was evident for 3 (Resident #10, #72 and #8) out of 4 reviewed for accuracy of assessment during the recertification survey. The findings include: 1. On 05/27/2026 at 9:38 AM, a review of Resident #10's medical records was conducted. The review revealed that the resident had an active order for Lovenox 30 mg at bedtime. Lovenox (generic name: enoxaparin sodium) is a prescription anticoagulant, commonly referred to as a blood thinner. The review of the Medication Administration Record (MAR) for April revealed that the resident received Lovenox daily. MDS with Assessment Reference Date (ARD) of 4/16/2026 failed to indicate that the resident was on anticoagulants. On 05/28/2026 at 10:34 AM, an interview with Staff #6, MDS Coordinator, was conducted. She reported that she missed coding the anticoagulant and acknowledged that the MDS was inaccurately coded. 2. On 05/26/2026 at 9:47 AM, an interview with Resident #72 was conducted. They reported that they did not have diabetes and had never received insulin while in the facility. On 05/27/2026 at 10:27 AM, a review of Resident #72's medical records was conducted. The review of orders and MAR failed to reveal insulin administration. Review of MDS with ARD date of 2/14/2026 indicated that the resident received insulin for 5 days. On 05/28/2026 at 10:34 AM, an interview with the MDS coordinator was conducted. She stated that insulin shouldn't have been coded and confirmed that the MDS was coded inaccurately. On 05/28/2026 at 11:18 AM, the Director of Nursing was notified of the findings. 3. During screening on 5/26/26 at 10:15 AM, the surveyor observed that Resident #8 had 1/4 length bedrails on her bed. A review of Resident #8's EMR (electronic medical record) on 5/26/26 at 11:35 AM revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including, but not limited to, adult failure to thrive, dependence on supplemental oxygen and muscle weakness. Further review on 5/26/26 of Resident 8's EMR revealed Resident #8 had an admission Side Rail Evaluation dated 1/8/26 at 7:41 PM and a Quarterly Side Rail Evaluation dated 4/8/2026 at 12:52 PM. The MDS with Assessment Reference Date (ARD) of 4/17/26 failed to indicate that the resident had bed rails on his/her bed The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.

Based on observation, record review it was determined that the facility failed to ensure that comprehensive care plans were developed and implemented. This was found to be evident for one (Resident #9) out of eighteen residents reviewed during an annual survey.The findings include: During screening on 5/26/26 at 8:43 AM, the surveyor noted that Resident #9 had an indwelling foley bag that was covered with a dignity bag. A review of Resident #9's electronic medical record (EMR) on 5/26/26 at 12:15 PM revealed that Resident #9 was admitted to the facility on [DATE] with diagnoses including but not limited to, prostate cancer with metastases to the bone. Further review disclosed an order for an indwelling catheter for obstructive uropathy was written on 4/18/26 by MD#27 (Medical Director). On 5/27/26 at 1:35 PM, a review of Resident #9's care plan lacked evidence of any focus or interventions regarding Resident #9's obstructive uropathy necessitating an indwelling foley catheter.

Based on observation, record review, and interview it was determined that the facility failed to maintain professional standards of practice related to oxygen orders. This was evident for 1 (Resident #82) out of 4 residents reviewed for respiratory orders. The findings include: On 5/26/2026 at 12:52 PM, an observation of Resident #82 revealed that the resident was receiving oxygen therapy. On 5/26/2026 at 12:53 PM, record review failed to reveal an active order for oxygen. On 5/28/2026 at 10:52 AM, concerns were brought up to the Director of Nursing and she indicated that she understood.

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 #31) out of 8 reviewed for activities of daily living during the recertification survey.The findings include:On 05/26/2026 at 11:07 AM, an interview with Resident #31 was conducted. They reported that they had not had a shower in a long time because their legs are weak and relied on a wheelchair. On 05/28/2026 at 11:46 AM, a review of Resident #31's medical records was conducted. The review revealed that the resident was to shower on Wednesdays and Saturdays on evening shift. Review of the shower task indicated that the resident had not had a shower for the last 30 days. On 05/28/2026 at 12:18 PM, an interview with Staff #8 was conducted. They reported that Resident #31 was dependent on staff for activities of daily living. They further reported that when residents are offered a shower, a shower sheet should be completed and placed in the unit's shower binder. Additionally, if a resident refused a shower, the refusal must be documented on the shower sheet and on the resident's electronic medical record.On 05/28/2026 at 12:20 PM, a review of the unit's shower binder was conducted with the surveyor and Staff #8. There were no shower sheets with the Resident #31's name for the month of May. On 05/28/2026 at 12:30 PM, an interview with Staff #5 was conducted. They reported that if a resident refused showers for several days, then the nurse would notify the unit manager who then updated the care plan to include refusal of care. On 05/28/2026 at 3:02 PM, the Surveyor received additional shower sheets from the facility. The review of these documents revealed that Resident #31 was offered showers 2 times in January, there were no other records for April or May. On 05/29/2026 at 1:55 PM, an interview with the Director of Nursing (DON) was conducted. She confirmed that there was no evidence that Resident #31 was offered a shower for the month of May.

Based on record review and interview, it was determined that the facility's failed to ensure Resident #2's hospice documents including the coordinated plan of care were available to facility staff. This was evident for one out of two residents reviewed for hospice services. The findings include:Facility 's Coordination of Hospice Services Policy - When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental and psychological well-being. Policy Explanation and Compliance Guidelines: 1. The facility maintains written agreements with hospice providers specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care . Revised 2025A review of Resident #2's electronic medical record (EMR) on 5/26/26 at 12:36 PM revealed that Resident #2 was admitted to the facility on [DATE] with diagnosis including but not limited to, dementia and on 2/11/26, Resident #2 was admitted to [hospice] services with a diagnosis of idiopathic normal pressure hydrocephalus.During an interview on 5/27/26 at 12:48 PM, the Director of Nursing (DON) stated that in addition to the facility's paper chart on Resident #2, there will be a hospice chart for that resident to ensure communication between the facility staff and the Hospice personnel. DON stated, The hospice binder is usually a blue binder. I will bring it to you.A review of Resident #2's hospice binder on 5/27/26 at 1:49 PM revealed that the Your Hospice Team document was not completed with the names and contact information for those professionals involved in Resident #2's hospice care. The binder also lacked evidence of the hospice care plan, the hospice orders, a copy of Resident #2's hospice election form as well as information regarding how to access the hospice on-call system. On 5/27/26 at 2:52 PM, the Nursing Home Administrator (NHA) brought copies of Resident #2's hospice documents to the surveyor stating that they were in his office. Upon review, these documents still did not include the list and contact information for Resident #2's responsible hospice providers. During an interview on 5/27/26 at 2:10 PM, the DON confirmed that Resident #2's hospice binder did not contain these documents and thus the coordinated plan of care for Resident #2 daily care was not available to facility staff from 2/11/26 until surveyor intervention on 5/27/26.

Based on observations and interviews it was determined that the facility failed to maintain infection prevention and control practices related to sanitary ice handling by storing a cup directly inside a communal ice cooler instead of utilizing a sanitary ice scoop, creating the potential for cross contamination for residents receiving ice from the cooler. This was evident for 1 (Jamestown) out of 4 units The findings include: On 5/26/2026 at 9:05 AM, an interview with Resident #62 revealed that ice was being handled in an unsanitary manner, the resident indicated that a cup was being stored inside the ice cooler and used as a scoop and that anyone in the building had access to the cooler. On 5/26/2026 at 9:10 AM, an observation revealed that there was no dedicated scooping device available at the ice cooler located between the Williamsburg and Jamestown units. On 5/27/2026 at 11:26 AM, an observation revealed that a cup was stored inside the ice cooler and that no designated scooping device was available near the cooler. At the same time, the Licensed Practical Nurse (Staff #5) removed the cup from the ice cooler. On 5/27/2026 at 12:00 PM, an interview with Staff #5 revealed that the expectation was for the cup to be stored outside of the ice cooler. On 5/27/2026 at 12:30 PM, the concerns were addressed with the Unit Manager (Staff #7) and she indicated that she understood, On 5/27/2026 at 2:05 PM, the concerns were addressed with the Director of Nursing and she indicated that she understood.

Based on observations, record review and interviews it was determined that the facility failed to ensure: 1) appropriate resident information was sent to the receiving facility and 2) a resident's bed hold policy was maintained and care planned in accordance with facility policy and resident rights requirements, placing the resident at risk for misunderstanding bed hold procedures and return to facility expectations following hospitalization. This was evident for 3 (Resident #17, #6 and #77) out of 3 residents reviewed for hospitalizations. The findings include: 1. On 05/27/2026 at 11:15 AM, during unit rounding, the surveyor observed Staff #5 preparing Resident #17 to be transferred to the hospital. On 05/27/2026 at 11:55 AM, an interview with Staff #5 was conducted. When asked what documents were provided to the Emergency Medical Technician (EMT) for hospital transfer, staff reported the Facesheet, MOLST(Medical Orders for Life-Sustaining Treatment) form, lab results, and orders. She reported that she was in a rush and did not provide SBAR (Situation, Background, Assessment, and Recommendation) and care plan goals. She also added that it was not the facility's process to include comprehensive care plan goals as part of the transfer documents. On 05/27/2026 at 12:18 PM, a review of the facility's internal transfer form indicated that no care plan goals or SBAR document was sent with the resident to the hospital. On 05/27/2026 at 1:37 PM, an interview with the Director of Nursing (DON) was conducted. She acknowledged that she was not aware that comprehensive care plan goals were part of the documents that needed to be sent with a resident during hospital transfers. 2. On 5/27/2026 at 11:18 AM, record review revealed that Resident #77 was transferred to the hospital on 2/28/2026. On 5/27/2026 at 11:23 AM, documents that were sent with Resident #77 during his/her transfer to the hospital were requested. On 5/27/2026 at 12:18 PM, review of the documents received revealed that the bed-hold policy and comprehensive care plan goals were not included. On 5/27/2026 at 1:37 PM, an interview with the Director of Nursing revealed that the bed-hold policy had not been sent with Resident #77 during his transfer. On 5/28/2026 at 10:50 AM, an interview with the Director of Nursing revealed that the comprehensive care plan goals had not been sent out with Resident #77 either. At the same time, the concerns were addressed with the DON and she indicated that she understood. 3. On 5/26/2026 at 12:31 PM, record review revealed that Resident #6 was transferred to the hospital on 2/16/2026. On 5/27/2026 at 11:23 AM, documents that were sent with Resident #6 during his/her transfer to the hospital were requested. On 5/28/2026 at 9:31AM, review of the documents received revealed that the comprehensive care plan goals were not included. On 5/28/2026 at 10:50 AM, an interview with the Director of Nursing revealed that the comprehensive care plan goals had not been sent out with Resident #6. At the same time, the concerns were addressed with the DON and she indicated that she understood.

Based on the complaint, medical record review, reviews of all pertinent records from a local hospital and emergency services provider, interviews with current staff, and an interview with the resident's attending physician, it was determined that the facility failed to 1) honor a resident's end of life wishes. This caused harm to Resident #2. The facility also failed to follow the physician's specific pulse and blood pressure parameters before administering a cardiac medications. This was evident for 2 (Resident #2, Resident #4) of 8 residents reviewed during a complaint survey.The findings include:The Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding CPR and other life-sustaining treatment options. It is valid in all healthcare facilities and programs throughout Maryland. Section 1 includes orders to Attempt CPR or No CPR. Within the No CPR section, there are three options: A-1 Intubate; A-2 Do Not Intubate but comprehensive efforts may include limited ventilatory support by CPAP or BiPAP; and Option B No CPR, Palliative and Supportive Care, do not intubate or use CPAP or BiPAP.On [DATE], the Office of Health Care Quality received a complaint regarding issues with notification of a change in condition and concerns about the quality of care provided to Resident #2.On [DATE], a review of Resident #2's electronic medical record revealed that Resident #2 was admitted to the facility on [DATE] with a MOLST form dated [DATE] indicating the resident was a full code and wished to receive all life-sustaining treatments. Resident #2 was readmitted to the facility on [DATE] after a hospitalization for pneumonia and electrolyte abnormalities. The resident's diagnoses included, but were not limited to, cerebrovascular accident with residual left-sided weakness, atrial fibrillation, diabetes, chronic anemia, gastrostomy tube, and metastatic prostate cancer to bone. On [DATE], the attending physician documented an extensive discussion with Resident #2 and the resident's power of attorney regarding the care plan and code status. It was decided that Resident #2 was to be DNR/DNI with other measures permitted but allowing natural death. The attending physician also documented that Resident #2 did not have the capacity to make medical decisions. A new MOLST form dated [DATE] was completed, indicating No CPR, Option A-2 Do Not Intubate (DNI).A review of Resident #2's Medicare 5 day readmission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], documented a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment.In an interview with LPN #1 on [DATE] at 3:01 p.m., LPN #1 confirmed that they were the nurse who sent Resident #2 to the hospital on the evening of [DATE]. LPN #1 stated that Resident #2 had a change in condition and was observed vomiting coffee ground like material. LPN #1 stated the on-call physician was notified and ordered Resident #2 to be transferred to the hospital via 911 ambulance. LPN #1 reported making copies of Resident #2's medical record, including medication orders and the MOLST form, but could not recall the specific contents of the MOLST form and stated only that the resident was a hospital transfer.During an interview on [DATE] at 4:00 p.m., Resident #2's attending physician stated that they were not aware of which MOLST form was sent to the hospital on [DATE] with Resident #2. The attending physician confirmed that on readmission to the facility on [DATE] they spoke with the resident's spouse, who stated that Resident #2 was to be DNR. The attending physician reported completing a new MOLST form and placing it in the resident's medical record.A review of Resident #2's hospital record on [DATE] revealed a MOLST form dated [DATE] indicating that Resident #2 was a full code and desired all life-sustaining measures. A hospital label dated [DATE] with Resident #2's medical record information was attached to the [DATE] MOLST form which arrived with Resident #2 in the hospital emergency room. The [DATE] MOLST had not been voided by the facility staff on [DATE] when the new MOLST was created.The facility staff failed to ensure the updated written wishes of Resident #2's end of life care by voiding the [DATE] MOLST when a new MOLST form was created on [DATE]. Resident #2 had a change in condition on [DATE] and was sent to the hospital. At that time, the facility staff failed to clearly communicate Resident #2's updated MOLST form dated [DATE] to the emergency services personnel (EMS staff) on [DATE]. This failure resulted in harm to Resident #2, who had a do not resuscitate (DNR) and do not intubate (DNI) order on the [DATE] MOLST form. Resident #2 received cardiopulmonary resuscitation (CPR) and intubation during the transport to the hospital from the EMS crew. Resident #2 was resuscitated in the ambulance and remained in the hospital ICU for 20 days.2) Resident #4 was admitted to the facility on [DATE]. Resident #4's physician wrote an order, dated [DATE] at 9 am, instructing the nursing staff to administer the blood pressure medication Lisinopril, 10 mg, by mouth, one time a day, for hypertension, hold for a systolic pressure of less than 100 mm/Hg. A review of Resident #4's January and February 2026 medication administration records (MAR) revealed the nursing staff withheld administering a dose of Lisinopril 10 mg orally to Resident #4 on the following days: [DATE] - blood pressure documented 106/58XXX[DATE] - blood pressure documented 106/58XXX[DATE] - blood pressure documented 107/63XXX[DATE] - blood pressure documented 109/61XXX[DATE] - blood pressure documented 109/64XXX[DATE] - blood pressure documented 108/56XXX[DATE] - blood pressure documented 108/69. In an interview with LPN#3 on [DATE] at 12:13 pm, LPN#3 reviewed Resident #4's January and February 2026 MARs in relation to the documented blood pressure for each dose of Lisinopril. LPN#3 confirmed that they were the nurse who withheld a dose of Lisinopril to Resident #4 on the days in question. LPN#3 stated that they should have administered the dose of Lisinopril after re-reading the physician prescribed blood pressure parameters.

Based on reviews of a medical record and all pertinent administrative records, and staff interview, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 1 (Residents #4) of 8 residents reviewed during a complaint survey.The findings include:1) Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in conditions that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles. In an interview with the facility director of nurses (DON) on 03/04/26 at 4:33 pm, the DON stated that none of the facility policies and procedures have dates when they were implemented. Review of the facility policy Medication Administration on 03/09/26 instructs the nursing staff to: #20 - Sign the resident's Medication Administration Record (MAR) after the medication has been administered and #21 - If the medication is a controlled substance, sign the narcotic book. It was also noted that the Medication Administration policy did not reveal a date when the policy was implemented, revised, or what staff member reviewed and revised the policy. Resident #4 was admitted to the facility on [DATE]. During a review of Resident #4's medical record on 03/05/26, the nurse surveyor requested the Director of Nurses to please ask the medical records staff to bring all of Resident #4's thinned paper documents and access to Resident #4's electronic medical record. On 02/04/26 at 11:15 am, Resident #4's physician wrote an order instructing the nursing staff to administer the schedule II pain medication, Oxycodone, 5 mg, orally, every 6 hours as needed for left arm pain greater than 5/10 for 30 days. During the review of Resident #4's controlled medication utilization record medical records on 03/09/26, it was discovered that the nursing staff had administered 18 doses of the medication Oxycodone, 5 mg, orally between 02/05/26 and 03/09/26 to Resident #4. A review of Resident #4's February and March medication administration records (MAR) revealed the nursing staff had signed out and administered only 6 doses to Resident #4 between 02/05/26 and 03/09/26. 3 of the Oxycodone 5 mg doses documented as being signed out and administered to Resident #4 indicated Resident #4 complained of the following pain scale number:02/08/26, 6:08 pm, 3/10 pain.02/09/26, 6:50 pm, 0/10 pain.02/21/26, 7:05 pm, 3/10 pain. Further review of Resident #4's controlled medication utilization record and the February and March 2026 MAR's on 03/09/26, revealed that the nursing staff failed to perform a pain assessment and initial Resident #4's MAR as having administered a dose of 5 mg Oxycodone to Resident #4 on the following days:02/07/26 at 7 pm.02/13/26 at 6 pm.02/16/26 at 7 pm.02/17/26 at 6 pm.02/20/26 at 7 pm.02/27/26 at 7 pm.03/02/26 at 7 pm.03/04/26 at 8 pm.03/06/26 at 7 pm.03/08/26 at 7 pm.

Based on complaint, reviews of medical records and all pertinent documents, and staff interview, it was determined that the facility failed to immediately notify a resident's physician with the results of a swallowing evaluation. This was evident for 1 (Resident #1) of 8 residents reviewed during a complaint survey. The findings include: On 02/26/26 the Office of Health Care Quality received a complaint #2789783, concerning the facility staff notifying Resident #1's physician regarding the results of a swallowing test. Review of Resident #1's closed clinical record on 03/03/26 revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but not limited to severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate. At the time of admission to the facility Resident #1 was noted to have cognitive issues. On 12/30/25, the facility staff conducted a BIMS assessment. A Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive status. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. On 12/30/25 Resident #1 was determined to have a BIMS score of 3/15 which indicates severe impairment. A Fiberoptic Endoscopic Evaluation of Swallowing (FEES procedure) is a 20-minute, in-office procedure used to assess swallowing safety and efficiency. A speech-language pathologist (SLP) passes a thin, flexible camera through the nose to view the throat directly on a screen while the patient eats and drinks, helping to detect aspiration or food residue. During the admission process, Resident #1 was evaluated by the facility Speech and Language Pathologist (SLP) on 12/30/25. A 12/30/25progress note indicated the facility SLP spoke to Resident #1's responsible party via the telephone regarding Resident #1's current diet and prognosis for an upgraded diet. The facility SLP indicated that Resident #1's responsible party indicated Resident #1 failed a swallowing test at hospital, but they would like Resident #1 to have another swallowing test, in hopes of upgrading the diet. The facility SLP obtained physician orders and scheduled a FEES exam for Resident #1 to be done at the facility on 01/09/26. On 01/09/26, the FEES procedure results for Resident #1 were available to the staff on the same day. Resident #1 FEES results indicated the following recommendations: Resident #1 should have a soft and bite sized/mechanical soft chopped diet with thin liquids. Compensatory strategies included sitting upright, no straws, single sips, small bites, with a slow rate of intake. The staff may consider obtaining a PROVALE drinking cup if patients do not complete single sips independently. A Provale Cup delivers small sips of thin liquids with every normal drinking motion. This may promote safer swallowing. In an interview with the facility director of nurses (DON) on 03/05/26 at 10:15 am, the DON stated that there were no nursing progress notes in Resident #1's chart indicating Resident #1's physician was made aware of the FEES procedure results on 01/09/26.

Based on reviews of facility reported incident and staff interview, it was determined the facility staff failed to immediately report an allegation of suspected resident abuse to the local police. This was evident for 1 (Resident #4) of 8 residents reviewed during a complaint survey. The findings include: On 02/03/26 the Office of Health Care Quality received a facility reported incident concerning allegations that Resident #4 was identified with a fractured left humerus. The incident was reported as an injury of unknown source on 02/03/2026. The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Allegations of abuse are to be reported to the Office of Healthcare Quality and the local police in a timely manner. A review of the facility investigation into the injury of unknown source on 03/03/26 revealed a 5-day follow-up investigation report that an x-rayed identified Resident #4's fractured left humerus. At the time, Resident #4 was unable to tell the staff how the injury may have occurred. The facility reported there were no witnesses to the incident. The facility concluded that the conclusion was inconclusive and abuse had been ruled out. In the investigation, the facility measured Resident #4's BIMS and determined the score to be 13/15 though that Resident #4's BIMS score does fluctuate. A review of the facility Abuse policy on 03/05/26 revealed that the facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with State law. Further review of the 5 day facility follow-up investigation indicated that the facility did not report this allegation of abuse to law enforcement. In an interview with the facility administrator and director of nurses (DON) on 03/11/26 at 3:45 pm during the exit conference, the facility administrator confirmed that law enforcement was not notified of the allegation of abuse of Resident #4 on 02/03/26.

Based on complaint, reviews of all pertinent documents and a closed medical record and facility staff interview, it was determined that the facility failed to revise care plans to meet a resident's needs. This was evident for 1 (Resident #1) of 8 residents reviewed during a complaint survey. The findings include: On 02/26/26 the Office of Health Care Quality received a complaint #2789783, concerning the facility staff notifying Resident #1's physician regarding the results of a swallowing test. Review of Resident #1's closed clinical record on 03/03/26 revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but not limited to severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate. At the time of admission to the facility Resident #1 was noted to have cognitive issues. On 12/30/25, the facility staff conducted a BIMS assessment. A Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive status. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. On 12/30/25 Resident #1 was determined to have a BIMS score of 3/15 which indicates severe impairment. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #1's care plans on 03/05/26 revealed the facility dietician identified and developed a nutritional risk care plan for Resident #1, dated 12/29/25, related to diagnoses that included: dementia, congestive heart failure, limited mobility, and possible food and medication interactions. Nutritional care plan goals included Resident #1 will tolerate a modified diet texture/consistency without difficulty and will maintain adequate nutritional status as evidenced by no significant weight change, no signs or symptoms of malnutrition, and will consume 50% of daily meals. Interventions to Resident #1's nutritional care plan included 1) administering medications as ordered and monitor and document any side effects and effectiveness. 2) Monitor, document, and report any signs and symptoms of dysphagia, pocketing food, choking, coughing, drooling, holding food in the mouth, several attempts at swallowing, refusing to eat, or appear concerned during a meal. 3) provide 1:1 assistance with meals as needed. 4) provide supplements as ordered. 5) Provide, serve diet as ordered and monitor intake and record every meal. 6) The dietician is to evaluate and make diet change recommendations as needed. During the admission process, Resident #1 was evaluated by the facility Speech and Language Pathologist (SLP) on 12/30/25. A 12/30/25progress note indicated the facility SLP spoke to Resident #1's responsible party via the telephone regarding Resident #1's current diet and prognosis for an upgraded diet. The facility SLP indicated that Resident #1's responsible party indicated Resident #1 failed a swallowing test at hospital, but they would like Resident #1 to have another swallowing test, in hopes of upgrading the diet. The facility SLP obtained physician orders and scheduled a FEES exam for Resident #1 to be done at the facility on 01/09/26. A Fiberoptic Endoscopic Evaluation of Swallowing (FEES procedure) is a 20-minute, in-office procedure used to assess swallowing safety and efficiency. A speech-language pathologist (SLP) passes a thin, flexible camera through the nose to view the throat directly on a screen while the patient eats and drinks, helping to detect aspiration or food residue. On 01/09/26, the FEES procedure results for Resident #1 were available to the staff on the same day. Resident #1 FEES results indicated the following recommendations: Resident #1 should have a soft and bite sized/mechanical soft chopped diet with thin liquids. Compensatory strategies included sitting upright, no straws, single sips, small bites, with a slow rate of intake. The staff may consider obtaining a PROVALE drinking cup if patients do not complete single sips independently. A Provale Cup delivers small sips of thin liquids with every normal drinking motion. This may promote safer swallowing. In an interview with RN#1 on 03/05/26 at 10:50 am, RN#1 stated that Resident #1's Nutritional Risk care plan was not updated with any new nursing interventions after the 01/09/26 FEES procedure.

Based on observation and interviews it was determined that the facility failed to ensure medications were kept in locked compartments. This was evident in 1 (100 hall) of 4 nursing units observed. The findings include: On 03/10/26 at 10:58 am surveyor observed a medication cart unlocked an unattended in the hallway outside room [ROOM NUMBER]. No staff were observed around the medication cart at the time of the observation. This observation was immediately brought to the attention of LPN#2 who closed and locked the medication cart. This observation was brought to the attention of the director of nurses on 03/11/26 at 3:45 pm.

Based on observation and staff interview, it was determined that facility staff failed to ensure a resident received mail. This was evident for 1 (#5) of 8 residents reviewed during a complaint survey. The findings include: During an observation of the facility activity area on the first floor on 03/04/26 at 2 pm, an unopened letter addressed to Resident #5 was observed in the activity area. The letter to Resident #5 was from the local county DHS program and was stamped 10/24/25. A review of Resident #5's closed record revealed that Resident #5 was admitted to the facility on [DATE] and was discharged home on [DATE]. In an interview with the facility director of nurses (DON) on 03/04/26 at 3:32 pm, the facility DON was handed Resident #5's letter and stated that Resident #5 was recently discharged from the facility and could not give any details why the resident did not receive the letter in October 2025.

Based on observation and interviews with facility staff, it was determined the facility failed to: 1) Remove outdated nourishment from the refrigerator, 2) ensure a sanitary environment in cleaning food items, and 3) ensure the labeling, dating, and expiration of food items. This was found to be evident during the facility's recertification/complaint Medicare/Medicaid survey and has the potential to affect all residents who consume food prepared in the facility's kitchen. The findings include: During the initial tour of the kitchen conducted on 04/09/2025 08:08 AM, a quarter jar of yellow mustard with open date of 12/05/2024 was seen in the refrigerator. At 08:13 AM of the same day, a dual observation with the dietary aide staff #10 was done and he stated that the jar should have been removed from the refrigerator, and he took it out. On the same day at 8:19 AM, a tray containing celery, onions, and two green peppers was observed in the manual rinse compartment of the three-compartment dishwasher sink. When Staff #11 was asked why the vegetables were in the sink, she stated that she was planning to rinse them. Upon further questioning whether vegetables are typically rinsed in that area, she admitted that she sometimes does so but acknowledged that she should have used the designated food preparation sink instead. She further stated that the vegetables should not have been placed in the rinse compartment and promptly removed them to be rinsed in the appropriate food prep sink. On 04/09/2025 at 08:25 AM, the surveyor informed the Director of Dietary (DoD) #9 of the concerns from the kitchen tour. In response to the issue of the vegetables being in the dishwasher rinse compartment, Director of Dietary (DoD)#9 stated that they should have been in the designated vegetable rinsing area. The surveyor also brought to her attention a quarter jar of yellow mustard found in the refrigerator. Staff #9 acknowledged this and stated that the mustard should have been discarded and not stored in the refrigerator. On 04/09/2025 at 08:38 AM, During a joint observation with the Director of Dietary (DoD) #9, the surveyor observed two and a half loaves of sliced bread in the refrigerator with an expiration date of 04/08/2025. She acknowledged that the bread should have been discarded as of that date and immediately removed it from the refrigerator. On 04/09/2025 at 8:41 AM, the surveyor observed an unlabeled and undated frozen meat item in the freezer, which Director of Dietary (DoD)#9 identified as rose pork loin. She stated that the meat should have been labeled and dated immediately after being removed from its original packaging. According to her, the meat had been delivered on 04/07/2025 and that there was no way the surveyor would have know the delivery date. She proceeded to remove the item and stated she would label and date it appropriately.

Based on medical record review and interview with complainant and facility staff, it was determined that the facility failed to notify the Medical Director, the physician, or the resident's responsible party in a timely manner 1) when medication was not available from the pharmacy, and 2) when the resident had an inability to provide a urine sample for testing. This was evident during the review of 2 (Resident #76 and #78) of 3 complaints reviewed during this recertfication/complaint survey. The findings include: 1) Review on 4/15/25 at 8:22 AM of complaint MD #200018 regarding Resident #76 revealed concerns related to the availability of medication. Record review on 4/16/25 at 7:50 AM revealed that on 11/25/23 Benadryl anti-itch cream was entered into the orders, and to start on 11/26/23 at 9am and be administered again at 5PM, two times a day for five days. However, review of the MAR noted that on 11/26, 11/27, 11/28 a '0' was entered. According to the progress notes, on 11/26/23 at 1:55 PM, a nursing note stated that the medication was unavailable from the pharmacy. Another progress note was not available regarding the medication until 11/27/23 at 11:20 PM over 24 hours later a response to the status of the medication. This stated that staff contacted the pharmacy, and they were notified that insurance would not pay for the medications. On 11/28/23, the physician was notified and ordered another anti-itch cream that was ordered and entered to start that day, 3 days after the initial request and concern came in that Resident #76 was having excessive itching with no noted relief. The complainant was interviewed on 4/16/25 at 9:16 AM and stated that he just didn't understand why they could not get the medication for Resident #76, so he personally went out and bought the Benadryl cream himself. He also stated that he was only aware that the Benadryl cream was not available because Resident #76 told him. This surveyor interviewed staff LPN #30 on 4/16/25 at 9:30 AM. She was confirmed as one of the staff caring for Resident #76 that coded '0' on the MAR. She was asked what '0' meant as there was no coding on the MAR for this. She stated that the medication was not available. She was asked of the process when medications are not available from the pharmacy, and she stated that they would have notified the physician. There was no notification to the physician in the medical record or change in medication until 3 days after the initial order for Benadryl. This concern was reviewed with the DON during exit on 4/17/2025. 50904 2) On 04/16/2025 7:58 AM, the surveyor reviewed a complaint intake MD#00192004. The complainant alleged that on 04/19/2023, he/she found out that an ordered urine test for Resident #78 was not done because the facility could not get urine sample and allegedly stated that he/she was not notified of the inability to get urine sample from Resident #78. On 04/16/2024 at 8:29 AM, review of the resident's electronic health record revealed that a change in condition was documented in the progress notes on 04/15/2023, indicating decreased food and/or fluid intake. In response, the primary care provider recommended the following interventions: administration of Acetaminophen 650 mg rectally as needed, nebulizer treatment, and new diagnostic test orders. Subsequently, on 04/16/2023, two orders were entered for a Urinalysis, Culture, and Sensitivity (UA, C&S)-a test used to identify bacteria or other microbes in a urine sample and determine the most effective antibiotics or medications for treatment-to be performed via in-and-out catheterization (also known as intermittent or self-catheterization, involves inserting a thin, flexible tube (a catheter) into the bladder through the urethra to drain urine, and then removing it once the bladder is empty. This procedure is typically performed several times a day, as prescribed by a healthcare professional) every shift for two days. On 04/16/2025 at 9:17 AM, upon further review of the electronic health record, the surveyor found no documentation indicating that an attempt was made to obtain a urine sample on 04/17/2023. Additionally, there was no documentation that the physician or the resident's responsible party (RP) had been notified of the missed urine collection and, consequently, that the test was not completed. On 04/19/2023, Resident #78 was transferred to the hospital after the physician and family were notified. On 04/16/2025 at 9:25 AM, during an interview, the Director of Nursing (DON) was asked whether the test ordered for Resident #78 on 04/16/2023 was completed. She stated that upon reviewing Resident #78's health record, she discovered the test was not performed. On 04/16/2025 at 11:15 AM, the DON was informed that there was no documentation of physician or responsible party (RP) notification between 04/16/2023 and 04/18/2023 regarding the unsuccessful attempts to obtain a urine sample and she acknowledged it and stated that both the physician and the responsible party (RP) should have been notified of the inability to obtain a urine specimen from the resident.

Based on medical record review and interview, it was determined that the facility failed to ensure that advance directives were discussed with and/or information regarding advance directives was provided to residents and/or their responsible representatives (RP). This was evident for 2 (Resident #8 and #41) of 4 selected residents reviewed for advance directives during the recertification/complaint survey. Findings included: 1) On [DATE] at 11:40 AM, a review of Resident's #41 record revealed that the resident had capacity to make one's own decision, however, there was no documented evidence to support that the facility provided education and/or obtained Resident #41's advance directive. On [DATE] at 08:52 AM, in an interview conducted with the Director of social services (Staff #8), She stated that residents were evaluated on admission and if capable, they were asked about their ADs and copies requested to be placed in their paper chart. If a resident was deemed incapable and incapacity certification signed by the doctor, then Social Services will reach out to RP and ask for a copy that is kept in the resident's paper chart. Those residents that are deemed capable but do not have ADs are offered the opportunity to formulate one. On [DATE] at 01:33 PM, in an interview with Staff #8, she was asked about Resident #41's Advance Directive, and she stated that she will need to check and get back to the surveyor. She also stated that based on the previous surveyor interview, she was aware that a plan of correction will be required to address the missing AD documentation moving forward. The surveyor requested that Staff #8 provided any AD documentation for Resident #41, if available. On [DATE] at 01:55 PM, Staff #8 stated that there were no AD found for this Resident #41. 42507 2) On [DATE] a review of Resident #8's medical record revealed the resident was admitted to the facility in [DATE]. A review of the resident's paper chart revealed a Maryland Order for Life Sustaining Treatment (MOLST) dated [DATE] which indicated Attempt CPR and a certificate of capacity that revealed the resident was capable of making his/her own decisions. However, there was no Advance Directives document found in both the paper chart and electronic medical record. Review of Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of [DATE] revealed Resident #8 had a BIMS (Brief Interview for Mental Status) of ,d+[DATE] indicating the resident was cognitively intact. Further review of the medical record failed to reveal documentation of advanced directives or that a discussion about advance directives had occurred with the resident. On [DATE] at 9:47 AM, surveyor reviewed the concern with the Director of Social Services (DSS), Staff #8, regarding the lack of documentation about advance directives in the medical record. Staff #8 stated she had a discussion with the resident and the resident's brother regarding the formulation of advance directives and referred the surveyor to the resident's admission notes. On [DATE] at 10:39 AM, a review of Admission assessment dated [DATE] had nothing checked under Advanced Directives. A review of social services progress notes on [DATE] at 10:50 AM failed to reveal documentation that advance directives were discussed with the resident and/or RP. On [DATE] at 11:09 AM, in a follow up interview with the Director of Social Services (Staff #8), surveyor reviewed resident's admission assessment dated [DATE] and social services progress notes that did not reveal any documentation that advance directives was addressed with the resident. Staff #8 verified and confirmed surveyor's findings. The concerns regarding the failure to ensure advance directives was discussed with the resident/responsible was addressed with the Director of Nursing on [DATE] at 8:34 AM. No further documentation was provided. On [DATE] at 11:59 AM, additional review of social services progress notes revealed the following documentation on [DATE] at 9:32 AM: Note Text: DSS, followed back up with resident and provided resident with information on advance directives. DSS will continue to follow up with resident. Social Services. However, This was done after surveyor's intervention.

Based on surveyor observations, review of the clinical records, review of facility policy and procedure and interviews with facility staff and residents, it was determined that the facility failed to ensure that residents were free from accident hazards when a resident was observed smoking in their room, and residents assessed as requiring supervision with smoking were left unsupervised. This deficient practice put all residents at increased risk for serious harm from fire. This finding was identified for 2 out of 3 residents who smoke in the facility. (#9, #34). On (MONTH) 11, (YEAR) at 2 PM, an Immediate Jeopardy for health and safety was determined by the State Office of Health Care Quality. The Immediate Jeopardy was abated on (MONTH) 11, (YEAR) at 10:15 PM, following the facility's implementation of corrective actions to ensure the health and safety of all residents who were at risk for serious harm from fire. The following is the facility's abatement plan developed on 04-11-18: a. Residents #9, #17 and #34 have had their care plans and assessments updated to address the dangers of unsafe smoking. Additionally, these residents have all been counseled on the requirements for smoking and received reinforcement of the facility's smoking policy as well as the requirement of facility staff supervision for resident #9 when smoking. Smoking assessments will be conducted with residents during the admission process, and during each quarterly or MDS (Minimum Data Set) assessment process. b. The facility has posted a smoking schedule at nursing stations to ensure that supervision is present in the smoking area for resident #9 who requires staff supervision when smoking. Additionally, the facility provided a smoking apron to resident #9, with spare aprons also located inside the smoking area at a common known location. Additional fire extinguishers were obtained on 04-12-18, and mounted in the designated smoking area. c. All smoking materials of residents who smoke were secured in the facility's medication carts. Both residents, as well as their family members, were notified to have all smoking articles to be secured with the nursing staff and not in their rooms. The Action Plan also included immediate staff education, including ancillary departments, regarding the facility's current and the revised smoking policy and procedures. d. All Nursing Leadership will monitor for compliance daily throughout daily rounds to ensure compliance by residents who smoke. The Administrator and/or Director of Nursing are responsible for ensuring compliance. All smoking activities will be reviewed at the Facility Safety Committee level and/QA&A (Quality Assurance) committees on monthly basis and interventions will be reviewed as deemed necessary. The findings include: 1. On 04-10-18 at 2:30 PM, surveyor observation of resident #9 revealed the resident smoking in the designated smoking area. There was no evidence that resident #9 was supervised by staff and no evidence of a smoking apron ((flame retardant apron for smokers) in use. The resident is a quadriplegic (unable to use all four limbs). Further observation revealed that resident #9 dropped the filter of the cigarette on the ground while it was lit. Further observation at 3:30 PM, revealed resident #9 smoking again in the designated smoking area with resident #34. Surveyor observed resident #34 putting a cigarette in resident #9's mouth and lighting the cigarette for him/her. There was no evidence of staff supervision and no use of a smoking apron by resident #9. A bath towel instead was observed wrapped around resident #9's chest directly underneath the lit cigarette, while the cigarette was secured only by the resident's lips On 04-10-18, surveyor review of the 03-01-17 facility's smoking policy and procedures revealed that smoking materials of residents requiring supervision whil9e smoking will be maintained by nursing staff in the medication cart. In addition, supervised smokers will require supervision by staff, and a smoking apron will be provided. Surveyor review of the clinical record revealed that resident #9 was a quadriplegic and unable to light or hold a cigarette while smoking. The resident was grandfathered in as a smoker when the facility became smoke free (on grounds of facility) on 03-01-17. Further review revealed a smoking assessment on 03-31-18, which revealed that resident #9 was assessed with [REDACTED]. The score determined that the resident was at high risk for injury and required supervision with smoking. Based on the smoking policy, staff should maintain all smoking materials for the resident, provide supervision and use of a smoking apron. In addition, surveyor review of the comprehensive plans of care for resident #9 revealed no evidence of a care plan with interventions addressing smoking practices that reflected the individualized smoking needs of resident #9, . (Refer to F656 for additional information) On 04-10-18 at 10:30 AM, surveyor interview with resident #9 revealed that his/her mother brings the resident's smoking materials, which are kept within the resident's room. Further interview revealed the resident goes to the designated smoking area outside and usually smokes with another resident who helps me smoke by lighting my cigarette and we smoke with no staff supervision. On 04-10-18 at 12:12 PM, surveyor interview with LPN (Licensed Practical Nurse) #9 revealed that all residents who smoke keep their own cigarettes and lighters. In addition, there is no designated time to smoke and residents can go out to the outside patio, (designated smoking area) and smoke without staff supervision. On 04-10-18 at 3:35 PM, surveyor interview with GNA (Geriatric Nursing Assistant) #10 revealed I do not supervise or assist residents to smoke, because I am not a smoker and do not want to inhale the second-hand smoke. On 04-10-18, surveyor interview at 1:30PM with the facility administrator revealed that residents assessed as requiring supervision for smoking are not to be left unsupervised while smoking. Other residents are not to provide supervision for residents deemed as requiring supervision by staff. In addition, the administrator revealed I think the facility has at least 2 smoking aprons, but I don't remember where they are kept, when asked about smoking aprons. On 04-10-18 at 4:15 PM, surveyor interview of the Director of Nursing provided no additional information. 2. On 04-10-18 at 2:30 and 3:30 PM, surveyor observations revealed resident #34 assisting resident #9 to smoke a cigarette in the designated smoking area. There was no evidence of facility staff supervision On 04-10-18, surveyor review of the clinical record revealed that resident #34 was admitted after the implementation of the no smoking policy last year, with multiple medical conditions including, but not limited to, [MEDICAL CONDITION] (complete paralysis of the lower half of the body including both legs) and acquired absence of unspecified fingers. In addition, further record review revealed 03-11-18 nursing documentation that resident #34 was caught smoking a cigarette in his/her room. There was a pack of cigarettes and a lighter found on the resident's bedside table. On 03-12-18, documentation by SW (social worker) #2 revealed that both SW #2 and the facility's administrator met with the resident to discuss concerns about smoking in the facility. On 03-26-18, SW #2's documentation revealed that resident #34 was observed burning receipts in his/her room. However, the resident denied burning receipts in the room but admitted to doing so in the designated smoking area. There was a meeting with the resident, as well as the resident's mother, regarding a warning for the second time and the mother agreed to take away the resident's smoking materials. On 03-28-18, SW #2's documentation revealed an observation of #34 smoking a cigarette in the designated smoking area. Further review revealed that the resident admitted to smoking due to being stressed. At this time, SW #2 reiterated the facility's No Smoking Policy, and provided an update of the progress on finding the resident another facility, per the resident's request. On 03-30-18, a smoking care plan was initiated for resident #34 that included interventions to instruct the resident about smoking risks and hazards of smoking in the room. On 04-09-18 at 11:35 AM, surveyor interview of resident #34 revealed I go outside to use my vaporizer (electronic cigarette). While outside, I help another resident to smoke by putting the cigarette in his/her mouth and lighting it since the resident is paralyzed from the neck down. Further interview revealed that there are only 3 smokers in the facility and they usually go to the designated area to smoke without staff supervision, and no designated smoking schedule. In addition, the resident's electronic cigarettes are kept in the resident's room, while the other smokers keep their materials in their rooms. On 04-10-18 at 12:12 PM, surveyor interview with LPN (Licensed Practical Nurse) #9 revealed that all residents who smoke keep their own cigarettes and lighters. In addition, there is no designated times to smoke and residents can go out to the outside patio, (designated smoking area) and smoke without staff supervision. On 04-10-18 at 4:30 PM, surveyor interview with the facility administrator revealed that resident #34 was aware of the facility's no smoking policy prior to admission. The resident agreed to stop smoking prior to admission. The resident was warned three times about smoking in the building and a meeting was held with the resident's mother, who agreed to remove all smoking materials from the resident.

Based on a complaint, review of a closed medical records [REDACTED]'s foot wound which ultimately lead to the decline and ultimate amputation of the resident's foot, 2) to take steps to discontinue a medication, in which the resident was known to have an allergy too, which lead to the resident experiencing symptoms of an allergic reaction for several days. This occurred for 1 of 8 residents reviewed during a complaint survey. The findings include: Review of complaint MD 095, on February 8, 2012, revealed an allegation that the facility staff failed to address an open wound on resident #1's right foot. Review of resident #1's closed medical records [REDACTED] May 2009, and a documented history of being allergic to the medications: [MEDICATION NAME], and [MEDICATION NAME]. Review of resident #1's closed medical record on February 8, 2012 revealed a physician's orders [REDACTED]. The April 23, 2011 physician's orders [REDACTED]. The Braden scale is used to help health professionals, (especially nurse's), assess a patient's risk of developing a pressure ulcer. Further review of resident #1's closed medical records [REDACTED]. The nursing staff documented resident #1's right lateral foot wound as: measurements of 1.5 cm (centimeters) long, 1.0 cm wide and 0.5 cm deep, necrotic in appearance, with no drainage, odor, or pain. The nursing staff documented resident #1's right lateral foot to be a Stage II wound. Pressure wound means an inflammation, sore, or breakdown of tissues overlying a bony prominence that has been subjected to pressure, friction or shear. The staging system presented below is one method of describing the extent of tissue damage in the pressure ulcer. Stage I - A persistent area of skin redness (without a break in the skin) that is nonblanchable. Stage II - A partial thickness loss of skin layers either dermis or epidermis that presents as an abrasion, blister, or shallow crater. Stage III - A full thickness of skin is lost, exposing the subcutaneous tissues - presents as a deep crater with or without undermining adjacent tissue. Stage IV - A full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone. On June 17, 2011 at 11:41 pm, (an end of shift note was written by) the nursing staff which documented that resident #1's physician was notified about the resident's right lateral foot wound. The nursing staff documented that resident #1's physician gave a new treatment order, on June 17, 2011 at 7 pm, instructing the nursing staff to cleanse the resident's wound with wound cleanser (apply hydrogel and to cover with a 4 x 4 gauze dressing every day until healed). A hydrogel wound dressing (which is highly absorptive), contours to a wound site and maintains the wound in a moist state to promote healing. Further review of resident #1's closed medical records [REDACTED]. The records also included the documentation of new orders regarding resident #1's care, by his physician on June 20, 2011. However, further review of the resident's closed medical records [REDACTED]. The June 20, 2011 physician orders [REDACTED].#1's anticoagulant treatment for 2 days, and to obtain laboratory tests within the next week. On June 23, 2011, the nursing staff completed another skin integrity report, for resident #1, and documented that the resident's foot wound was now a Stage III wound, measuring at 3 cm long, 2 cm wide, 0.5 cm deep, with no drainage, odor or pain noted to the right lateral foot wound area. The nursing staff documented that the resident's right lateral foot wound had deteriorated from a Stage II to a Stage III wound, from June 17, 2011 to June 23, 2011. Further review of resident #1's closed medical records [REDACTED]'s right lateral foot wound on June 23, 2011. Further review of resident #1's closed medical records [REDACTED]. Review of resident #1's June 27, 2011 and June 30, 2011 physician documentation did not reveal an assessment of resident #1's right lateral foot wound. The surveyor could not determine if resident #1's physician was aware of the current status of resident #1's wound on either June 27, 2011 or on June 30, 2011. The nursing staff documented on July 7, 2011 at 9:09 am that resident #1's right lateral foot diabetic wound had marked improvement. However, the nursing note failed to categorize the wound, measurements or details concerns the condition of the wound. Resident #1 was still receiving daily Hydrogel dressing to his right lateral foot wound. The next documented nursing skin integrity report was completed on July 11, 2011, which indicated that the resident's foot wound was now unstagable. The wound was measured at 3.0 cm long, 3.0 cm wide, and had no depth. The surrounding tissue of the wound was described as macerated in appearance. On July 11, 2011, resident #1's physician assessed and documented that resident #1 had a wound to his right foot. The resident's physician wrote an order instructing the nursing staff to remove resident #1's sock. Despite this, there were no other (July 11, 2011) physician documentation, regarding the condition of the resident's foot in the closed medical record. Further review of resident #1's closed medical records [REDACTED]'s right lateral foot wound with saline, apply a thin layer of [MEDICATION NAME] cream, apply a dry dressing daily. A thorough review of resident #1's closed medical records [REDACTED]. In an interview with the nursing unit manager, on February 14, 2011 at 12 noon, the nursing unit manager stated she could not find the July 25, 2011 physician's assessment. The nursing unit manager stated resident #1's wife made the appointment and took resident #1 to a Podiatrist outside of the facility for consultation. On February 17, 2012, the surveyor obtained a copy of resident #1's July 25, 2011 podiatry consult which indicated that resident #1 had peripheral arteriole disease and absent pulses to the right foot. The July 25, 2011 podiatry consultation documented a right foot ulceration measuring approximately 2 to 2.5 cm in diameter through the skin to the deep fascia. There was no odor present or active drainage to the right foot ulceration. The July 25, 2011 Podiatrist assessment noted that there was some slight serous fluid and moisture to resident #1's right foot wound. The July 25, 2011 Podiatrist documented that resident #1's right foot was debrided by the use of a scalpel blade and tissue knipper on July 25, 2011. The July 25, 2011 podiatrist noted that resident #1 was using his right foot to propel himself in his wheelchair and that this was causing undue stress to the right foot. On July 25, 2011 the Podiatrist wrote out instructions for the facility nursing staff that resident #1's wife was to deliver to the nursing staff at the facility. On July 25, 2011, the nursing staff contacted resident #1's physician regarding the new right foot wound treatment orders that were sent to the facility by the July 25, 2011 Podiatrist. On July 25, 2011 at 11:30 am resident #1's physician instructed the nursing staff to follow the July 25, 2011 Podiatrist's recommendations for the care of resident #1's right foot. The pharmacy was contacted regarding the medicated cream, [MEDICATION NAME], for the treatment for [REDACTED]. On July 27, 2011 at 3:45 pm, the facility pharmacy contacted the nursing staff regarding resident #1's allergy to the medication [MEDICATION NAME]. The medicated cream, [MEDICATION NAME], ordered by the Podiatrist on July 25, 2011 has the ingredient [MEDICATION NAME] in the mixture. Further review of resident #1's closed medical records [REDACTED]'s right foot wound as being a problem wound, 2 x 2 cm, right side metatarsal, with sloughing, and a 2 x 2 cm right sole wound with sloughing. Resident #1's physician documented that resident #1 has not had any evidence to a Sulfa allergy since being at the facility and the allergy to Sulfa should be removed from resident #1's medical record. On July 28, 30, 31, 2011, Resident #1 received care to his right foot wound which included the use of the [MEDICATION NAME] cream. On August 1, 2011, resident #1's physician documented that resident #1 had an allergic reaction, a swollen face on July 31, 2011 which required the initiation of a steroid therapy. Resident #1 was to receive the steroid [MEDICATION NAME] 20 mg orally, twice daily for three days due to the swollen face. Resident course of oral [MEDICATION NAME] was discontinued on August 3, 2011. Further review of resident #1's closed medical records [REDACTED]. The nursing documentation indicated the right lateral foot was unstagable, had slough, and was 2.0 x 2.5 cm with no depth. Review of nursing documentation, dated August 4, 2011, failed to reveal that resident #1's physician was updated about the new wound to resident #1's right lateral foot. The nursing staff also documented that resident #1's right lateral foot wound was unstageable, was 3.0 x 3.0 cm with no depth with the wound edges noted to be macerated. Further review of resident #1's closed medical records [REDACTED]. In an interview with resident #1's physician on February 17, 2012 at 3:16 pm, resident #1's physician stated resident #1 did have an allergy to the medicated cream, [MEDICATION NAME], which caused the facial swelling to resident #1 on July 31, 2011. Resident #1's physician stated that he had no recollection of the July 25, 2011 Podiatry consultation or what was documented in the July 25, 2011 Podiatry consultation. Resident #1's physician also stated that resident #1 had a history of [REDACTED]. Resident #1's physician stated resident #1 had a special shoe for his right foot and had used crutches to ambulate, in the past, due the right foot deformity. Resident #1's physician concluded by saying that resident #1 had a history of [REDACTED]. On August 9, 2011 at 3:11 pm, the nursing staff documented that resident #1's right foot ulcers now had a minimal odor and drainage present. This was new for resident #1's wounds to the right foot. Further review failed to reveal that the nursing staff notified resident #1's physician about resident #1's foot wounds having an odor and were draining. Also on August 9, 2011, the nursing staff contacted resident #1's physician at 7:20 pm due to a different change in resident #1's condition. Resident #1 was noted by the nursing staff to have a generalized facial and body [MEDICAL CONDITION]. Resident #1's physician wrote for a STAT (immediate) dose of [MEDICATION NAME] (a diuretic) and [MEDICATION NAME] (a steroid) due to [MEDICAL CONDITION] and swelling. Further review of resident #1's closed medical records [REDACTED]. Resident #1's physician related resident #1's [MEDICAL CONDITION] to resident #1's [DIAGNOSES REDACTED]. Resident #1's physician noted resident #1 to have an infected right foot wound and that resident #1 had a previous episode of osteo[DIAGNOSES REDACTED] (infection in the bone) of the foot. The physician also documented that the resident's type II diabetes was unstable. The physician wrote for a STAT dose of [MEDICATION NAME] (a diuretic) and [MEDICATION NAME] due to [MEDICAL CONDITION] and swelling. On August 11, 2011, resident #1 was seen by the facility wound care physician. The wound care physician documented 3 separate wounds on resident #1's right foot. The wound care physician listed the following wounds: #1 - Right Lateral Foot, a diabetic wound, 2.5 x 2.8 cm with no depth, there was an odor with surrounding deep tissue injury (purple / maroon), there was a moderate serous exudates, 60% of the wound was necrotic (Eschar) and 40% of the wound had devitalized tissue. The wound care physician surgically debrided this wound on August 11, 2011. #2 - Right Lateral Ankle, a diabetic wound, 1.8 x 1.8 cm with no depth, there was an odor with surrounding deep tissue injury (purple / maroon), there was a light amount of serous exudate, 100% of the tissue was devitalized. The wound care physician surgically debrided this wound on August 11, 2011. #3 - Right Heel Wound, a diabetic wound, 4.6 x 5.7 cm with no depth, there was no exudate. The wound care physician documented this wound was stable, non-infected heel necrosis. The wound care physician also noted resident #1 to have a groin area fungal infection. The wound care physician wrote care and treatment orders for the fungal infection. On August 15, 2011 at 3:51 pm, resident #1 was noted to be very lethargic and unable to respond verbally, and unable to move his extremities. The nursing staff also documented that resident #1 had unequal pupils and his speech was unclear. Resident #1's physician was contacted and resident #1 was sent to the hospital for evaluation. Review of resident #1's August 23, 2011 hospital record revealed resident #1 was diagnosed with [REDACTED]. Resident #1 was stabilized in the hospital and underwent an above the knee amputation of the right lower extremity during the hospitalization . In an interview with the nursing unit manager on February 14, 2012 at 2:18 pm, the nursing unit manager stated she was unable to locate any Braden scales completed by the nursing staff from April 2011 through July 2011. Review of resident #1's closed medical records [REDACTED]. In conclusion, the facility staff failed to 1) provide the necessary care to resident #1's right foot to prevent an infection and ultimately the amputation of the right foot, and 2) discontinue the medicated cream, [MEDICATION NAME], when it was confirmed resident #1 was allergic to the medication as evidenced by resident #1 actually having an allergic reaction which required physician intervention on July 31, 2011.