Does PINES NURSING AND REHAB have any serious inspection findings?

Yes, PINES NURSING AND REHAB has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 143 total deficiencies from recent inspections.

What are the staffing levels at PINES NURSING AND REHAB?

PINES NURSING AND REHAB has a two-star staffing rating from CMS with 0.63 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is PINES NURSING AND REHAB located?

PINES NURSING AND REHAB is located in EASTON, MD. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does PINES NURSING AND REHAB have?

PINES NURSING AND REHAB has 195 certified beds.

Who owns PINES NURSING AND REHAB?

PINES NURSING AND REHAB is a for profit - corporation facility and is part of the KEY HEALTH MANAGEMENT chain.

What questions should families ask when visiting PINES NURSING AND REHAB?

Families visiting PINES NURSING AND REHAB should ask about how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does PINES NURSING AND REHAB compare to other nursing homes?

PINES NURSING AND REHAB has a 1-star overall rating, which is below average compared to other nursing homes in MD. Families should carefully review inspection findings and consider alternatives.

PINES NURSING AND REHAB

Name: PINES NURSING AND REHAB
Address: 610 DUTCHMAN'S LANE, EASTON, MD, 21601, US
Telephone: (410) 822-4000
Rating: 1.0

610 DUTCHMAN'S LANE, EASTON, MD 21601 · (410) 822-4000

For profit - Corporation 195 Beds KEY HEALTH MANAGEMENT Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

0/100

#216 of 219 in MD

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Last Inspection: September 2022

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

Pines Nursing and Rehab has received a Trust Grade of F, indicating significant concerns about the care provided, which is among the lowest possible ratings. It ranks #216 out of 219 facilities in Maryland, placing it in the bottom half of all nursing homes in the state, and #2 out of 2 in Talbot County, meaning there is only one local option that is better. While the facility appears to be improving, reducing issues from 65 in 2022 to 43 in 2025, staffing remains a weakness with a turnover rate of 53%, which is concerning when compared to the state average of 40%. The facility has incurred $23,543 in fines, which is average in context but still suggests ongoing compliance problems. There are also serious incidents, such as failing to provide proper CPR training for staff concerning residents' wishes and inadequate supervision for a cognitively impaired resident with a history of falls, highlighting both critical and serious deficiencies in care. Overall, while there are some signs of improvement, the facility has significant weaknesses that families should consider carefully.

Trust Score: F
In Maryland: #216/219
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $23,543 in fines. Lower than most Maryland facilities. Relatively clean record.
Skilled Nurses: Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for Maryland. RNs are the most trained staff who monitor for health changes.
Violations: 143 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2022: 65 issues

2025: 43 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Maryland average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 53%

Near Maryland avg (46%)

Higher turnover may affect care consistency

Federal Fines: $23,543

Below median ($33,413)

Minor penalties assessed

Chain: KEY HEALTH MANAGEMENT

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 143 deficiencies on record

2 life-threatening 3 actual harm

Sept 2025 6 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interview and record review, it was determined that the facility failed to notify resident's representative of a change in condition. This was evident for 1(Resident #8) of 1 resident reviewed in a complaint investigation.The findings include: On 8/26/2025 at 11:57 AM, during a telephone interview, Resident #8's Representative expressed surprise that the Foley catheter was discontinued without notification, stating it was previously deemed necessary. The representative emphasized, the facility doesn't call me at all! On 08/26/2025 12:44 PM, a review of Resident #8's progress from 8/1/25, indicated Foley came out. Provider was made aware. Provider has ordered a voiding trial. However, the note did not include any mention of the Resident #8's Representative being notified. On 8/27/2025 at 9:46 AM, Licensed Practical Nurse (LPN #18) confirmed that the nurses were expected to notify both the Physician and the Resident's Representative about any change of condition or order changes, and to document these notifications in the medical record. On 8/27/2025 at 9:56 AM, the Director of Nursing (DON) confirmed the requirement for nurses to contact the physician and the resident's representative regarding any change in resident status. The DON acknowledged this concern and stated that an in-service training would be conducted immediately.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews it was determined that the facility failed to (1) implement recommendations made by the wound care team to treat pressure ulcers and (2) failed to initiate care upon admission for a resident with a pressure ulcer. This was evident for 2 (Residents #116 & #131) of 2 residents evaluated for pressure ulcer care during the survey.The findings include:1) A pressure ulcer, also known as a bed sore or decubitus ulcer, is a localized area of skin damage that develops when prolonged pressure or shear forces disrupt blood flow to the tissues resulting in damage to the underlying tissue. Pressure ulcers are staged based on their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon).A Deep tissue injury (DTI) is a type of pressure injury that occurs when prolonged pressure or shear forces damage the underlying tissues, such as muscles, bones, and tendons. During a medical record review for Resident #116 on 8/19/25 at 6:22 PM it was discovered that a Wound Care provider's Wound Note from 6/17/25 reported the resident had a Stage III pressure ulcer and made the recommendation for the resident to have an air mattress for pressure redistribution.A review of Resident #116's wound care notes conducted on 8/19/25 at 6:30 PM revealed a recommendation for an air mattress for pressure redistribution on 7/29/25, 8/05/25, 8/12/25 and 8/19/25.During additional medical record review for Resident #116 it revealed the order for an air mattress was not entered into the resident's Electronic Medical Record (EMR) until 8/05/25. During an observation of the bed for Resident #116 on 8/20/25 at 7:46 AM it was discovered that the resident did not have an air mattress. During a repeat observation with Registered Nurse #13 of Resident #116 on 8/21/25 at 8:33 AM she confirmed that the resident did not have an air mattress but should have one. During an interview with Unit Manager #4 on 8/21/25 at 1:03 PM she agreed that Resident #116 should have an air mattress but did not have one at this time. She advised Wound Care recommendations are put in as orders typically the next day after wound care sees the resident. She reported she had just checked with maintenance about the air mattress and was told they had been ordered because all the air mattresses had been utilized. During an interview with Maintenance on 8/21/25 at 1:34 pm he provided a work order request that was submitted on 8/05/25 for Resident #116 to have an Air Mattress. He reported they needed more air mattresses, and he had placed a request for air mattresses to be ordered with the purchasing department on 8/18/25. He denied making any orders for air mattresses prior to 8/18/25. During an observation of Resident #116 on 8/25/25 at 10:48 AM it was discovered that the resident now has an air mattress.During an interview with the DON on 8/25/25 at 11:17 AM she confirmed there was a delay in the order for the air mattress being placed for Resident #116 and is not sure what the delay may have been since she is new to the facility. She reported it appeared the process might not have been followed through.2. During a medical record review for Resident #131 on 9/02/25 at 7:58 AM it was discovered that the resident was admitted to the facility on [DATE] with a pressure injury. The transferring Hospital Discharge Summary reported, current inpatient wound care order - Wound care dressing 2 times daily: Pannus and Coccyx - keep clean and dry. Turn and reposition every 2 hours. Apply Zinc paste twice a day. When cleansing incontinence away. Do not attempt to remove all of the barrier cream. Reapply Zinc cream as needed to maintain a protective coating over the area. The Discharge paperwork identified the Coccyx wound as a Pressure injury that had started on 2/13/25.During continued medical record review for Resident #131 it was revealed that the pressure injury was not identified upon admission to the facility and that there were no treatment orders placed to care for the pressure injury in the resident's Electronic Medical Record (EMR). During additional medical record review, it was discovered that a Wound Assessment Report from the Wound Care Provider dated 2/28/25 reported several wounds. The wounds included: A Pressure Ulcer/Injury that was determined to be a Deep tissue Injury to the right buttock and was listed as Present on Admission.A Pressure Ulcer/Injury that was determined to be Stage 3 to the right gluteal fold and was listed as Present on Admission.A Pressure Ulcer/Injury that was determined to be Stage 3 to the left gluteal fold and was listed as Present on Admission.A Pressure Ulcer/Injury that was determined to be a Deep tissue Injury to the right heel and was listed as Present on Admission.A Pressure Ulcer/Injury that was determined to be a Deep tissue Injury to the left buttock and was listed as Present on admission The Wound Care Providers gave recommendations for treating each wound that included, Right buttock Pressure Ulcer/Injury - apply zinc oxide paste to base of wound, leave open to air and change daily.Right gluteal fold pressure ulcer/injury - Cleanse with normal saline, apply calcium alginate to base of the wound, secure with bordered foam and change daily.Left gluteal fold pressure ulcer/injury - Cleanse with normal saline, apply calcium alginate to base of the wound, secure with bordered foam and change daily.Right heel pressure ulcer/injury - apply skin prep to base of wound, leave open to air and apply twice a dayLeft buttock pressure ulcer/injury - Zinc oxide paste to base of the wound, leave open to air, apply twice a day.The Wound Care Provider also recommended an alternating air/low air loss mattress for pressure redistribution.Further medical record review of the orders for Resident #131 showed that no wound care orders were placed for the pressure ulcers/injuries until 3/06/25. The wound care orders that were initially placed included:Order placed on 3/06/25 stated Left and Right buttock: skin prep every shift for wound healing Order placed on 3/06/25 stated Left and Right Gluteal fold: Cleanse with wound cleanser, apply calcium alginate/medihoney and cover with bordered foam everyday shift for wound healing.Order placed on 3/06/25 stated Right heel: skin prep: everyday shift for wound healing.Order placed on 3/13/25 stated Air mattress to bed, check functioning each shift. During an interview with the Director of Nursing (DON) on 9/02/25 at 10:52 AM she reported Wound Care Providers would see new residents admitted with a wound on a weekly basis and would be expected to be seen within a week at the latest. She advised Wound Care Providers send their recommendations after seeing the resident via e-mail within 24 hours to the facility. The doctor would then approve the orders and then the MDS Coordinator would put the wound care orders into the resident's EMR. She confirmed that there was no evidence of wound care being completed prior to the orders being placed into the EMR for Resident #131. She reported she was not with the facility at the time that the resident was here so she was not sure what the delay was for the resident to receive wound care, see Wound Care Providers or for the Wound care orders to be placed into the EMR. During a review of the Pressure Injury Prevention and Management policy on 9/02/25 at 2:46 PM it was discovered that Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. During a review of the Documentation of Wound Treatments Policy on 9/02/25 at 2:48 PM it was revealed that Wound Assessments are documented upon admission, weekly and as needed if the resident or wound condition deteriorates and Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift. (i.e., clean, dry, intact).During an interview with the MDS Coordinator on 9/04/25 at 11:16 AM she agreed there was a delay in Resident #131 getting wound care and having wound care orders added into the EMR. She reported that she was not at the facility at the time that the resident was in the facility, so she is not sure what may have caused the delays. She reported that when she returned to the facility she recognized an issue with wound care orders not being added into the EMR, so she offered to help to ensure the orders were being placed in a timely manner.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on interviews and observation it was determined that the facility failed to ensure essential equipment was operational. This was found to be evident for 2 out 2 Laundry equipment and the facility's telephone system observed during the recertification survey.The findings include: 1) During an observation conducted on 08/29/2025 at approximately 9:30 AM the Surveyor observed 1 washer in operation in the laundry room. Laundry Aide #29 stood in front of a large grey bin which was half filled with wet white linen. The Aide stated that the linen was already washed and was waiting for the load to dry so that she could place another load in the dryer. During the observation of the laundry room, it was discovered that the facility had 1 operational washer machine and 1 operational dryer machine. During an interview conducted on 09/03/25 at 2:29 PM, the Maintenance/ EVS Director reported that the facility has had 1 dryer machine operational for close to 1 year and 1 washer machine. Recently a second washer machine was delivered however the washer machine that was operational stopped working so instead of having 2 washer machines the facility is currently only able to use the 1 new washer machine. He stated that a request for service had been submitted. This Surveyor expressed concern for the washed wet laundry that was observed sitting in a bin waiting to be dried. The Maintenance/ EVS Director stated he was aware that the staff does that, and he educated the staff to not wash ahead. When asked if Laundry can keep up with the daily volume of the soiled laundry the Maintenance/EVS Director stated unfortunately they cannot. This is due to having 1 washer machine and 1 dryer machine. He stated that he runs a second shift from 4pm – 10pm to try to address the volume of soiled laundry, however during that time housekeeping mop heads, slings, and other cleaning cloths are also washed and dried. When asked how many machines were needed to fully address the daily soiled volume of laundry, the Maintenance/ EVS Director stated when the facility had 3 washer machines and 4 dryer machines all laundry was able to be cleaned in a day. When asked when the facility had 3 washer machines and 4 dryer machines he responded that the machines broke one by one through the last couple of years and had not been replaced except for the 1 new washer machine that was recently delivered. During an interview with the Nursing Home Administrator (NHA) conducted on 09/04/25 at approximately 9:45 AM, the NHA stated that she was recently made aware that 1 of the washer machines was not operational and stated that a service call had been requested. This Surveyor expressed concern that facility with a bed capacity of 170 had 1 dryer machine that was operational for close to 1 year and had 1 washer machine that was operational which cannot address the daily volume of soiled laundry even with running a second shift. During the continued interview this Surveyor expressed concern that numerous Residents had reported during the Resident Council Meeting laundry concerns in October of 2024 and in December 2024 they had multiple grievances for missing clothing items that were sent to laundry but were not returned. This Surveyor also expressed concern of the observation that washed wet laundry was stored in a bin waiting to be dried. This Surveyor expressed concerned that wet laundry in a bin in the laundry room warm environment had a potential to breed microbes. 2) A review of a complaint for Resident #129 was conducted on 08/28/25 at 3:00 PM. The complaint dated 04/12/25 stated “I attempted to call the Director of Nursing this morning as I was told there was no one at the facility yesterday to talk to. The Director's voicemail is full, and you cannot leave a message. I was then transferred to the Social Worker whose voice mail is also full and cannot leave a message. I have asked for a return call which I have not received at this time.” During a telephone interview conducted on 09/02/25 at 5:30 PM, Resident #122's Representative stated that he/she had been unable to reach the Nursing Home Administrator (NHA) by telephone to discuss his/her concerns about missing clothing, missed medications administration, and a missed meal. The Representative reported that the NHA's voicemail is full, and he/she cannot leave a message. During an interview conducted on 09/03/25 at 8:35 AM, the Surveyor asked the NHA if there had been problems with the phone system. The NHA stated that the facility's phone system is outdated and unable to retrieve messages. She explained that front desk staff have been instructed to screen calls and take messages on her behalf. She stated, “I normally return my calls within 24 hours.” When asked how long this issue has been occurring, the Administrator stated, “This problem has been ongoing for almost a year.” The Surveyor expressed concern that Residents, Resident Representatives and Providers were unable to leave voice mail messages for facility administration with concerns for Resident care via telephone. 3. Dryer lint buildup creates a significant fire hazard because lint is highly flammable and can ignite from the dryer's heat, leading to fires. On 08/28/25 at 1:15 PM the surveyor did a walkthrough of the laundry room. The Maintenance/EVS Director and Staff # 29 were present. The surveyor observed one dryer in operation. The Maintenance/EVS Director stated that only one of the 3 dryers in the laundry room was in working condition. The surveyor asked how often the Lint screens were cleaned. He stated that Lint screens were cleaned daily and logged in a binder. Upon inspection of the log binder, there was no evidence that cleaning was being done according to the scheduled routine. There were entries for April 2025, none for May 2025 and 14 daily entries for June 2025. There were no entries for July 2025 and one entry on 8/2/25 for the month of August 2025. For the month of June, the year was documented as “202”. The Maintenance/EVS Director stated that the entry June 202 was meant to be June 2025 as the year was not completely written out. When asked for the facility's Dryer policy and cleaning schedule, the Maintenance/EVS Director pointed to an undated document in the binder with the title “Proper Equipment Care and Maintenance (Carts, Lint Trap Cleaning).” The document stated “Dryers - *Lint Screens to be cleaned every hour. *Dryer Tops are to be cleaned weekly/as needed to prevent fires. *Inspect Dryer baskets daily for foreign objects (Silverware, Trash, Etc.) The Maintenance/EVS Director confirmed the surveyor's findings and stated that he had not reviewed the logs recently and was unaware the logs were not maintained. Immediately after the interview, the surveyor observed Staff #29 removing a large amount of lint from the dryer. On 9/02/2025 at 10:14 AM in an interview, the Administrator stated that she was made aware of the surveyor's findings by the Maintenance/EVS Director and that she had already started corrective action by conducting an in-service with the laundry staff on 8/28/25.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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Based on interviews, record reviews and observations, it was determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately. This was found to be evident for 3 (Resident #6 , #91 and #107) out of 3 Residents reviewed for reporting abuse allegations. The findings include: 1. On 08/20/2025 at 8:30 AM, this surveyor conducted an interview with Resident #6 and #91. The Resident's both reported that approximately one week prior, an individual entered their room, pulled up the individual's gown, and exposed themselves, appearing to seek sexual contact. Resident #6 and Resident #91 provided descriptive information about the individual and reported that he/she believed the person to be another resident living on the unit. Resident #6 also reported that this individual had previously urinated in the hallway. On 08/20/2025 at approximately 10:30 AM, this surveyor conducted an interview with the Administrator and the Chief Nursing Officer. The surveyor made them aware of the statements provided by Resident #6 and Resident #91 regarding an allegation of sexual abuse. On 08/20/2025 at 2:15 PM, the Administrator provided documentation to this surveyor regarding Resident #6 and Resident #91. On 08/20/2025 at 2:16 PM, this surveyor reviewed the records provided. The documentation included statements from Resident #6 and Resident #91, an interview statement with the alleged individual, Resident #108. A sheet signed by Geriatric Nursing Assistant (GNA) #2 and GNA #28 which indicated “Employees in Incident Area Having No Knowledge of Incident.” The documentation also included a witness statement from Unit Manager #4 discussing the incident with Resident #6. On 08/20/2025 at approximately 2:20 PM, this surveyor conducted a follow-up interview with the Administrator. The Administrator confirmed that the documents provided represented all records related to the information collected for the sexual abuse allegation reported by the residents to the surveyor. She clarified that the facility was not conducting its own investigation at this time, and that the documentation was provided solely to assist the surveyor with the investigation. On 09/03/2025 at approximately 9:30 AM, this surveyor conducted an interview with the Administrator and inquired whether a report had been made to the Office of Health Care Quality (OHCQ) regarding the allegations of sexual abuse reported by Resident #6 and Resident #91. The Administrator reported that no such report had been made. The surveyor informed the Administrator that this concern would be brought back to the office for further review. 2. During a phone interview conducted on 08/22/2025 at 8:29 AM, Resident #107's Representative reported that the Resident's roommate verbally abuses the Resident with threats routinely. The Representative stated the threats have upset the Resident and that he/she had reported the threats to the facility in the Care Plan meetings however nothing had been done. During an interview conducted on 08/22/25 at 8:35 AM, this Surveyor reported to the Nursing Home Administrator (NHA) that Resident #107's Representative reported that the Resident's roommate had been threatening the Resident. The Resident's Representative had also reported that he/she reported the concern of the roommate threats in the Care plan meetings. During an observation conducted on 08/22/25 at 8:47 AM, Resident #107 stated “roommate mean, I don't know why.” The Resident was visibly upset when speaking about the roommate. On 08/22/25 at approximately 11:30 AM, the NHA returned and stated that she reviewed the Care Plan meetings notes and that there is no documentation of the threats. She also stated that she spoke with Unit Manager #4 who advised she was aware of a situation that upset Resident #107 because the Resident's roommate (Resident #115) pushed Resident #107 in a wheelchair. During an interview conducted on 09/03/25 at approximately 9:00 AM, this Surveyor asked the NHA had she reported the allegation of verbal abuse to the Office of Health Care Quality (OHCQ). The NHA responded no because she had discovered and reported to this Surveyor that the only incident that occurred was when the Resident #115 pushed Resident #107 in a wheelchair. This Surveyor asked if she had interviewed the Resident regarding the Surveyor reported allegation she stated no. This Surveyor advised that when Surveyors report to the NHA that they have been advised of an allegation of any form abuse, the facility is required to report the allegation to OHCQ, and a thorough investigation is conducted. The NHA stated that she would report the allegation now (09/03/25).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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Based on interviews, record reviews and interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse are investigated. This was found to be evident for 3 (Resident #6, #91 and #107) out of 3 Residents reviewed for investigating abuse allegations. The findings include: 1. On 08/20/2025 at 8:30 AM, this surveyor conducted an interview with Resident #6 and #91. The Resident's both reported that approximately one week prior, an individual entered their room, pulled up the individual's gown, and exposed themselves, appearing to seek sexual contact. Resident #6 and Resident #91 provided descriptive information about the individual and reported that he/she believed the person to be another resident living on the unit. Resident #6 also reported that this individual had previously urinated in the hallway. On 08/20/2025 at approximately 10:30 AM, this surveyor conducted an interview with the Administrator and the Chief Nursing Officer. The surveyor made them aware of the statements provided by Resident #6 and Resident #91 regarding an allegation of sexual abuse. On 08/20/2025 at 2:15 PM, the Administrator provided documentation to this surveyor regarding Resident #6 and Resident #91. On 08/20/2025 at 2:16 PM, this surveyor reviewed the records provided. The documentation included statements from Resident #6 and Resident #91, an interview statement with the alleged individual, Resident #108. A sheet signed by Geriatric Nursing Assistant (GNA) #2 and GNA #28 which indicated “Employees in Incident Area Having No Knowledge of Incident.” The documentation also included a witness statement from Unit Manager #4 discussing the incident with Resident #6. On 08/20/2025 at approximately 2:20 PM, this surveyor conducted a follow-up interview with the Administrator. The Administrator confirmed that the documents provided represented all records related to the information collected for the sexual abuse allegation reported by the residents to the surveyor. She clarified that the facility was not conducting its own investigation at this time, and that the documentation was provided solely to assist the surveyor with the investigation. On 09/03/2025 at approximately 9:30 AM, this surveyor conducted an interview with the Administrator and inquired whether the facility had reported the allegations of sexual abuse, as described by Resident #6 and Resident #91, to the Office of Health Care Quality (OHCQ). The Administrator confirmed that the facility had not initiated an official investigation or submitted a report to OHCQ. The surveyor informed the Administrator that this concern regarding lack of investigation, and would be referred to the OHCQ for further review. 2. During a phone interview conducted on 08/22/2025 at 8:29 AM, Resident #107's Representative reported that the Resident's roommate verbally abuses the Resident with threats routinely. The Representative stated the threats have upset the Resident and that he/she had reported the threats to the facility in the Care Plan meetings however nothing had been done. During an interview conducted on 08/22/25 at 8:35 AM, this Surveyor reported to the Nursing Home Administrator (NHA) that Resident #107's Representative reported that the Resident's roommate had been threatening the Resident. The Resident's Representative had also reported that he/she reported the concern of the roommate threats in the Care plan meetings. During an observation conducted on 08/22/25 at 8:47 AM, Resident #107 stated “roommate mean, I don't know why.” The Resident was visibly upset when speaking about the roommate. During an interview conducted on 08/22/25 at 8:52 AM, Geriatric Nursing Assistant (GNA) #5 was asked if she was aware of any conflicts with Resident #107. The GNA stated that Resident 107's roommate Resident #115 continuously threatens and upsets Resident #107. The GNA stated that the staff asked that the roommate, Resident #115 be moved out of the room however nothing had been done. On 08/22/25 at approximately 11:30 AM, the NHA returned and stated that she reviewed the Care Plan meetings notes and that there is no documentation of the threats. She also stated that she spoke with Unit Manager #4 who advised she was aware of a situation that upset Resident #107 because the Resident's roommate (Resident #115) pushed Resident #107 in a wheelchair. During an interview conducted on 09/03/25 at approximately 9:00 AM, this Surveyor asked the NHA had she reported the allegation of verbal abuse to the Office of Health Care Quality (OHCQ). The NHA responded no because she had discovered and reported to this Surveyor that the only incident that occurred was when the Resident #115 pushed Resident #107 in a wheelchair. This Surveyor asked if she had investigated the Surveyor reported allegation of abuse and interviewed the Resident, the NHA responded no. This Surveyor advised that when Surveyors report to the NHA that they have been advised of an allegation of any form abuse, the facility is required to report the allegation to OHCQ and conduct a thorough investigation. The NHA stated that she would report the allegation now (09/03/25) and investigate.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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Based on observations, record reviews and interviews it was determined that the facility failed to 1) maintain the nurse call system in working order. This was evident for 2 (#19 and #11) of 6 residents reviewed for call systems and 2) ensure residents had access to call bells. This was evident of 4 residents (Resident#54, #5, #14 and #40) out of 4 residents review during recertification and compliant survey process.The findings include: 1. During an initial tour of the facility on 8/19/25 at 6:27 AM, surveyors observed the call light outside of Resident #19's room flashing on and off with an audible beeping sound heard at the nurses station. At 9:54 AM, during a second random observation by this surveyor, the same call light was observed flashing in the corridor without an audible sound. In an interview on 8/19/25 at 9:40 AM, LPN #31 confirmed she was assigned to Resident #19 and stated, “the call light is broken.” In an interview on 8/20/25 at 10:28 AM, Resident #19 stated the call light had been broken for months and “the light just stays on.” Resident #19's family member also confirmed the call light had not been working for a long time and stated staff gave Resident #19 a manual bell, but the bell could not be heard from the nurses station. On 8/26/25 at 10:15 AM, this surveyor reviewed the facility's July and August 2025 work order requests in TELS, the facility's building management platform system, which showed at least 8 reports of the broken call light for the room shared by Residents #19 and #11 between 7/28/25 and 8/20/25. All work orders showed a status of “open” or “in progress,” with no evidence the repairs were completed. In an interview on 8/26/25 at 2:35 PM, the Administrator stated she became aware of the broken call light on 8/18/25 and had submitted a maintenance request in the TELS system that day. The administrator confirmed that Resident #19 was given a bell to call for staff help and that staff was expected to make hourly rounds. In an interview on 8/26/25 at 11:54 AM, the Maintenance Director confirmed that the facility was aware of the broken call light in the room shared by Residents #19 and #11. The Maintenance Director stated he had tried calling the outside vendor a few times in the weeks before but did not have documentation of those calls. On 8/27/25 at 1:00 PM, the surveyor requested documents from the facility related to Resident #19's call light system repair. At approximately 1:37 PM, the Maintenance Director provided the surveyor with an email that was sent to the outside vendor on 8/27/25 at 1:11 PM by the Administrator which showed the facility requesting a service call for the broken call light. In an interview on 8/28/25 at 12:17 PM, the Maintenance Director confirmed that the outside vendor completed the service call earlier that day and provided the surveyor with a copy of the work order report. The report was reviewed to reveal that the patient station [call system] on the wall in Resident #11's bed space was broken and needed to be replaced. Continued review of the report revealed that the technician temporarily disconnected the station to stop the corridor light from flashing and wrote, “We need to order a new one and return and replace.” On 9/3/25 at 10:06 AM, this surveyor saw the call light in the corridor on but not flashing, with no audible sound noted, confirming the call system for Resident #19 was still not working. At the time of exit conference, no additional documentation was provided to show that the repairs needed for the broken resident call system for Resident #19 were completed. 2. During an initial tour of the facility on 8/19/25 at 6:27 AM, surveyors observed the call light outside of Resident #11's room flashing on and off with an audible beeping sound at the nurse's station. At 9:54 AM, during a second random observation by this surveyor, the same call light was observed flashing in the corridor without an audible sound. On 8/26/25 at 10:15 AM, this surveyor reviewed the facility's July and August 2025 work order requests in TELS, the facility's building management platform system, which showed at least 8 reports of the broken call light for the room shared by Residents #19 and #11 between 7/28/25 and 8/20/25. All work orders showed a status of “open” or “in progress,” with no evidence the repairs were completed. In an interview on 8/26/25 at 2:35 PM, the Administrator stated she became aware of the broken call light on 8/18/25 and had submitted a maintenance request in the TELS system that day. The administrator confirmed that Resident #11 was given a bell to call for staff help and that staff was expected to make hourly rounds. .In an interview on 8/26/25 at 11:54 AM, the Maintenance Director confirmed that the facility was aware of the broken call light in the room shared by Residents #19 and #11. The Maintenance Director stated he had tried calling the outside vendor a few times in the weeks before but did not have documentation of those calls. On 8/27/25 at 1:00 PM, the surveyor requested documents from the facility related to Resident #11's call light system repair. At approximately 1:37 PM, the Maintenance Director provided the surveyor with an email that was sent to the outside vendor on 8/27/25 at 1:11 PM by the Administrator which showed the facility requesting a service call for the broken call light. In an interview on 8/28/25 at 12:17 PM, the Maintenance Director confirmed that the outside vendor completed the service call earlier that day and provided the surveyor with a copy of the work order report. The report was reviewed to reveal that the patient station [call system] on the wall in Resident #11's bed space was broken and needed to be replaced. Continued review of the report revealed that the technician temporarily disconnected the station to stop the corridor light from flashing and wrote, “We need to order a new one and return and replace.” In an interview on 9/2/25 at 10:16 AM, Resident #11 confirmed that staff had given him/her a manual bell to use. Resident #11 further stated, “I ring the bell, but they still don't come.” On 9/3/25 at 10:06 AM, this surveyor randomly observed the call light in the corridor on but not flashing, with no audible sound noted, confirming the call system for Resident #11 was still not working. At the time of exit conference, no additional documentation was provided to show that the repairs needed for the broken resident call system for Resident #11 were completed. 3. A call bell system in long-term care is a resident-initiated alert system, usually at the bedside or in bathrooms, that signals staff to provide assistance when needed. 1) On 08/19/2025 at 9:41 AM, Resident #54 was observed sitting in his wheelchair on the left side of the bed with the call bell on the right side, lying on the floor under the bed. The resident stated he could not reach the call bell. GNA #34 was notified and acknowledged the call bell was improperly placed. 2) On 08/19/2025 at 10:50 AM, the surveyor observed Resident #5 in bed with the call bell hanging on the head of the bed frame. The resident was unable to reach the call bell. During an interview, GNA #34 confirmed that the call bell is supposed to be within the resident's reach. 3) On 8/19/2025 at 11:59AM the surveyor accompanied LPN #14 to Resident #63 and observed resident's call bell hanging on the nightstand. LPN# 14 confirmed to the surveyor that the call bell is not within resident's reach. On 08/19/2025 at 12:05 PM, an interview was conducted with LPN #14 regarding the expectation for call bell placement. She stated that call bells are required to be within the resident's reach. LPN #14 then placed the call bell within Resident #63's reach. The surveyor made her aware of the concern, and she acknowledged receipt. 4) On 08/20/2025 at 7:45 AM during rounds on the Chesapeake Unit, Resident #40 was observed in bed with the call bell lying on the floor. The surveyor called the Director of Nursing (DON) and accompanied her to the resident's room. The DON confirmed that the call bell was not within the resident's reach. On 08/20/2025 at 10:30 AM an interview was conducted with the Director of Nursing (DON) regarding the expectation for call bell placement. She stated that “call bells are supposed to be within residents' reach.” The surveyor made her aware of the concerns, and she acknowledged receipt, stating that “staff will be educated.” On 08/21/2025 at 12:00 PM, the surveyor informed the Administrator of the above call bell concerns and Administrator acknowledged receipt.

Mar 2025 37 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to provide supervision to a cognitively impaired resident with a history of a fall with fracture. This was evident for 1 (#16) of 35 residents in the [NAME] Unit during a complaint survey. As result of these findings an Immediate Jeopardy was called at 4:45 PM on 3/11/25. The facility submitted a plan to remove the Immediacy on 3/11/25 at 8:30PM. The survey team verified completion of the plan on 3/14/25 at 11:08 AM with a compliance date of 3/13/25. The findings include: On 3/11/25 at 2:22 PM in the [NAME] Unit, which is a secured memory care unit, observation was made of Resident #16, who had a history of a fall out of Geri-chair on 8/1/24 at 4:30 PM, that resulted in an acute mildly displaced fracture of the tip of the nasal bones, trying to get out of a Geri-chair that was located in the back of the common area of the unit. There were no nursing staff visible on the unit. The only staff member was Housekeeper (HK) #25 who was sweeping the floors. HK #25 saw the resident and ran over to him/her and attempted to talk the resident into staying in the chair. The housekeeper then walked up to the nurse's station and was looking for staff. HK #25 walked down the opposite hallway calling for staff while the surveyor stood at an unlocked and unattended medication cart observing Resident #16. At that time Resident #16 had his/her legs half way out of the chair. The surveyor ran and stood in front of the Geri-chair and encouraged the resident to sit back in the chair. HK #25 continued to look for staff and could not find anyone. HK #25 returned to the common room and offered to watch Resident #16 until nursing staff came back to the area so the surveyor could stand by the unlocked medication cart until licensed staff could secure the cart. Cross Reference F761 On 3/11/25 at 2:29 PM the AIT (Administrator in Training) came back to the unit and walked up and saw the medication cart and attempted to lock it while the surveyor stood there. At that time the surveyor asked where the nurse on the unit was. The AIT said he would get the unit manager (UM). He was asked again where the nurse on the unit was, and he said I'll get the unit manager. At 2:30 PM the unit manager walked up to the surveyor and the surveyor asked where the nurse on the unit was. UM #28 stated the nurse on the unit left early and the UM was responsible for 2 units. It was revealed that UM #28 was doing patient care on another nursing unit at the time. The surveyor informed UM #28 about Resident #16 trying to get out of the Geri-chair. UM #28 asked where the nursing assistants were. At that time geriatric nursing assistant (GNA) #5 walked into the common area and was told to watch Resident #16. A second GNA, GNA #15 came up the hall and said she was in the middle of changing a resident while doing last rounds and had the bed in a high position and could not leave the resident. A third GNA, GNA #29 was in a resident room doing patient care. Review of Resident #16's medical record revealed the resident had diagnoses that included ataxia, bipolar disorder, unspecified dementia with agitation, and Wernicke's encephalopathy. According to the National Institute of Health (NIH), Wernicke's encephalopathy is traditionally associated with chronic alcohol abuse and characterized by some combination of ataxia (impaired coordination, balance, and movement), ophthalmoplegia (paralysis or weakness of eye muscles), and altered mental status. As stated above, Resident #16 had a fall on 8/1/24 that resulted in injury. Preceding nursing notes dated 7/27/24 documented that Resident #16 had ongoing behaviors that included trying to climb on the floor, sitting on floor, and scooting along on buttocks on the floor. A 7/31/24 health status note documented, increased behaviors, patient lowers self to the floor and constantly attempts to get out of [his/her] chair. An 8/1/24 at 4:50 PM note documented that the resident had a witnessed fall by staff. The resident was trying to get up from the chair and fell on the floor face down. A subsequent note from the Nurse Practitioner (NP) on 8/2/24 documented an acute mildly displaced fracture of the tip of the nasal bones. Nursing notes that lead up to the observation on 3/11/25 documented on 2/26/25 at 10:00 PM that Resident #16 had an episode of psychosis that was reported on 2/21/25 where the resident pulled a dresser down and at some point hit his/her nose which resulted in, slightly distal of the previous fracture without significant fracture fragment displacement. A 3/3/25 note written by the NP documented that the resident had agitation and restlessness and was sitting up in a chair in the common room, rocking back and forth and trying to climb out of the chair. The NP increased the medication Seroquel to 200 mg. twice a day. Seroquel is an antipsychotic medication. A 3/10/25 at 1:36 PM nurse's note and a 3/11/25 at 1:31 PM nurse's note documented that Resident #16 was combative with care and smearing feces on self and the bed. Observation was made in the morning on 3/11/25 at 9:45 AM of Resident #16 in his/her room wearing a hospital gown. Resident #16 had just flipped over the tray table that had a breakfast tray on top. There was fluid and food on the floor and the mattress on the floor. Resident #16 was sitting on the edge of the bed rocking back and forth. Resident #16 was seen by another surveyor smearing feces on the bed and wall. After this intervention the facility did not increase staff supervision of Resident #16. Review of Resident #16's care plan, at risk for falls r/t Gait/balance problems, Psychoactive drug use and impulsiveness, failed to have specific resident centered interventions in place, for this cognitively impaired resident, about monitoring the resident while in a geri-chair. Cross Reference F657 Surveyor and Housekeeper intervention prevented Resident #16 from getting out of the Geri chair without assistance and prevented the other cognitively impaired residents on the dementia unit from accessing the unlocked medication cart. After the Immediate Jeopardy was called the facility submitted a plan to remove the immediacy. The facility took the following actions to address the concerns and prevent any additional residents from suffering an adverse outcome: a) Resident #16 was provided one on one supervision until cleared by Behavioral Health and the medication cart was immediately locked on the unit. b) The staff educator conducted an audit on all falls residents who were cognitively impaired and at risk for falls to ensure that resident specific interventions were in place. Licensed nurses and CMAs were educated to ensure medication carts were secured on all units when unattended. c) The staff educator will educate all licensed nurses and CMAs on medication cart safety. d) Staff educator will educate all licensed staff to ensure common areas are supervised when residents are present in common area. e) Staff educator will educate all nurses, GNAs and CMAs to ensure that residents' specific interventions are in place for residents who are at risk for falls. f) Any licensed nurses, CMAs or GNAs who are currently on leave for medical, vacation, FMLA, or sickness will be educated prior to returning to work g) All med carts will be audited 2 times per day for 2 weeks and 10 times per month for 4 months h) All common areas will be audited to ensure supervision of residents is present 4 times per day for 2 weeks, then 10 times per month for 4 months. i) All cognitively impaired residents at risk for fall will be audited to ensure their resident specific interventions are in place 2 times a week for 4 weeks then monthly times 4. j) All residents will receive a falls evaluation on admission, quarterly and yearly by MDS. k) All results from the audits will be presented to the QAPI team monthly to be reviewed and revised monthly for 4 months.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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3) On 3/10/25 at 8:16 PM a review of facility reported incident MD00207981 was conducted, and it alleged that verbal abuse towards Resident #18 was overheard from a unit manager and a wound nurse on 7/23/24 at 10:30 AM. Licensed Practical Nurse (LPN) #23 was overheard telling Resident #18 that he/she needed to get up and also told Resident #18 not to dismiss her. A written statement from Nurse Practitioner (NP) #68 documented that LPN #23 stated to the resident, if you don't get out of this bed and move your arms and legs you will never walk again. Resident #18 responded, okay. LPN #23 responded by saying, you don't answer me like that; that's dismissing me, and I won't be dismissed. A written statement from the previous unit manager (UM) #31 documented, this writer observed [name of LPN #23] being verbally aggressive towards a resident. She was telling the resident [he/she] needed to do more for [him/herself]. When the resident said okay, nurse was very rude telling [him/her] that [he/she] does not get to dismiss her, saying okay is being dismissive to the nurse. I feel she was very rude to the resident. A written statement from Resident #18 documented, nurse came in and told me I needed to more for myself. When I said okay, she looked at me weird and told me not to dismiss her. The facility documented that LPN #23 admitted saying the word dismissive to Resident #18. Review of a psychiatric visit dated 7/23/24 documented Resident #18 had a history of insomnia, depression, and anxiety. The note documented that Resident #18 reported being upset due to an incident that happened with his/her nurse. Resident #18 reported feeling sad about how the nurse spoke to the resident, however Resident #18 was unable to remember the nurse's exact words or the name of the nurse. Resident #18 reported to the psychiatrist that the nurse's words affected his/her mood that day. Review of LPN #23's personnel file revealed the LPN was terminated from the facility on 7/23/24 and reported to the Board of Nursing. On 3/11/25 at 1:53 PM an interview was conducted with Staff #31. Staff #31 stated the nurse was telling Resident #18 that the resident needed to get up for their own good and the nurse was nasty about it, and it made the resident feel uncomfortable and really bad. Staff #31 stated the resident was in tears and that is why Staff #31 reported it to the Director of Nursing (DON). Staff #31 stated she did not say anything to LPN #23 because, she was not very people friendly. The Nursing Home Administrator was informed on 3/18/25 at 5:15 PM. Based on review of a facility-reported incident, medical record review, and interviews, it was determined that the facility failed to keep vulnerable residents on the dementia unit free from physical abuse, which resulted in harm to the residents. This was evident for 3 out of 44 residents (#14, #24, and #18) reviewed during a complaint survey. Findings include: 1a) On 3/11/25 at 10:22 AM, a review of the medical record was conducted for Resident #15. Resident #15 had a history of refusing medication except for seizure medications. He/She takes medications when he/she feels like it. Resident #15 resided in the dementia unit. His/her BIMs (Brief Interview for Mental Status) score was 11/15, indicating he/she had some memory loss. Resident #15 was able to communicate with staff. Resident #15 preferred to be by themselves and did not like other residents entering his/her room. Medical record review conducted for Resident #14 on 03/13/25 at 2:52 PM revealed Resident #14 was admitted to the facility with a diagnosis of dementia, restlessness, and agitation. Further review revealed a progress note that documented on 4/3/24 at approximately 2:30 AM the staff heard yelling and screaming down the hall. Staff observed Resident #14 being punched by Resident #15 in the hallway. The aide observed blood coming from Resident #14 ' s mouth. A red mark was on the face of Resident #14 and a scratch was observed behind Resident #14 ' s left ear. Police were called and responded; however, Resident #15 would not speak to the police. A psych evaluation was ordered for Resident #15. A psychiatric evaluation was conducted on 4/18/24. Resident #15 stated, I do not belong here. When the crazies leave me alone I am ok. He/she denied all altercations but refused to take medications. In addition, on 7/28/24, Nurse Staff #70 on the unit heard yelling and screaming and went to see what was going on. Resident #14 was hit by Resident #15 for going into his/her room. Police were called and responded. Resident #14 was taken to the hospital for evaluation, received stitches, and was sent back to the facility. 1b) On 3/14/25 at 10:00 AM, a medical record review was conducted for Resident #24. Resident #24 had a BIMs score of 99, meaning he/she rarely understands. On 4/13/24, staff saw Resident #24 leaving the room of Resident #15. Resident #24 had a red mark on his/her face after leaving the room. Police were contacted and responded. Resident #15 admitted to hitting all the residents, stating, They were in my room, and I don't like that. An interview was held with the Medical Director, Staff #9, and the Nursing Home Administrator on 3/13/25 at 9:27 AM. The Medical Director stated, I know him/her very well. He/she had a fall resulting in a head injury prior to coming to the facility. I am aware of at least three residents that he/she struck and I reviewed the incidents that happened at the facility. He/she didn't take his/her psych medicine, he/she only took his/her seizure medication. After the first incident I would have expected a psych eval, behavior medication. I would talk to him/her about their meds and do a meds evaluation. I would care plan his/her behaviors. After the second or third time, depending on the circumstances, I would look for alternative settings. Is this the right place for him/her? Looking in retrospect, he/she probably should have had interventions put in place and we could have looked at a more appropriate setting. It was discussed in a risk meeting. There should have been interventions put in place. On 3/13/25 at 9:47 AM, the Medical Director stated, On 4/3/24, we spoke to the Nurse Practitioner (NP) about alternative placement. There was another incident on 06/07/24 and the resident remained in the facility. On 7/30/24 another resident was struck and Resident #15 remained in the facility. The Advanced Practice Registered Nurse (APRN) who conducted the psych evaluation on 4/18/24 revealed, Resident is not a danger to self or others but would benefit from continued behavioral health. There was no incident report for this incident. 2) On 3/10/25 at 8:16 PM, a review of facility-reported incident MD00207981 was conducted, and it alleged that verbal abuse toward Resident #18 was overheard from a Unit Manager and a Wound Nurse on 7/23/24 at 10:30 AM. Licensed Practical Nurse (LPN) #23 was overheard telling Resident #18 that he/she needed to get up and also told Resident #18 not to dismiss her. A written statement from Nurse Practitioner (NP) #68 documented that LPN #23 stated to the resident, If you don't get out of this bed and move your arms and legs you will never walk again. Resident #18 responded, Okay. LPN #23 responded by saying, You don't answer me like that; that's dismissing me, and I won't be dismissed. A written statement from the previous Unit Manager (UM) #31 documented, This writer observed [name of LPN #23] being verbally aggressive towards a resident. She was telling the resident [he/she] needed to do more for [him/herself]. When the resident said okay, the nurse was very rude, telling [him/her] that [he/she] does not get to dismiss her. Saying okay is being dismissive to the nurse. I feel she was very rude to the resident. A written statement from Resident #18 documented, A nurse came in and told me I needed to do more for myself. When I said okay, she looked at me weird and told me not to dismiss her. The facility documented that LPN #23 admitted saying the word dismissive to Resident #18. Review of a psychiatric visit dated 7/23/24 documented Resident #18 had a history of insomnia, depression, and anxiety. The note documented that Resident #18 reported being upset due to an incident that happened with his/her nurse. Resident #18 reported feeling sad about how the nurse spoke to the resident; however, Resident #18 was unable to remember the nurse's exact words or the name of the nurse. Resident #18 reported to the psychiatrist that the nurse's words affected his/her mood that day. Review of LPN #23's personnel file revealed the LPN was terminated from the facility on 7/23/24 and reported to the Board of Nursing. On 3/11/25 at 1:53 PM, an interview was conducted with Staff #31. Staff #31 stated the nurse was telling Resident #18 that the resident needed to get up for their own good and the nurse was nasty about it, and it made the resident feel uncomfortable and really bad. Staff #31 stated the resident was in tears and that is why Staff #31 reported it to the Director of Nursing (DON). Staff #31 stated she did not say anything to LPN #23 because, She was not very people friendly. The Nursing Home Administrator was informed on 3/18/25 at 5:15 PM.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview It was determined the facility staff 1) failed to inform the resident and/or resident representative when there was a change in the resident's treatment plan related to medication, and 2) failed to inform the resident/representative of the risks and benefits of the medication and obtain consent prior to initiating psychotropic medication. This was evident for 2 (#12, #3) of 44 residents reviewed for complaints. The findings include: A psychotropic describes any drug that affects behavior, mood, thoughts, or perception Schedule II (C2) controlled drugs refer to drugs with a high potential for abuse and addiction that are regulated by the government and include anxiolytic (anti-anxiety) benzodiazepine medication and opioid (analgesic) (narcotic) medication. 1) On 3/11/25 at 9:00 AM, a review of complaint #MD00209003 alleged Resident #12, who was terminally ill, but not on hospice or receiving palliative care, was prescribed and administered Ativan (anxiolytic) and Morphine (Opioid) for end of life, without notifying the resident's representative, and obtaining consent. The complaint alleged that giving the medications together contributed to Resident #12's respiratory failure, and lead to the death of the resident. The complaint also alleged the facility staff failed to notify Resident #12's representative timely when the resident was transferred to the hospital. A review of Resident #12's electronic medical record (EMR) revealed Resident #12 was admitted to the facility in mid-August 2024 following a transfer from a sister facility and had multiple diagnoses, including hepatocellular carcinoma (liver cancer) and hepatic encephalopathy (brain disorder caused by liver dysfunction). The resident was discharged from the facility following his/her transfer to the hospital 3 days after admission. In a Nurse Practitioner (NP) Progress Note on 8/15/24 at 12:30 PM, Staff #64 NP documented Resident #12 was being transferred from another facility to the current facility on that day, and the NP was very familiar with Resident #12 because the NP provided care to him/her at the other facility. The NP wrote that Resident #12 was currently a full code, that resident's declining condition was discussed with the Director of Nurses (DON), and the DON would discuss end-of-life (EOL) care, which they believed was appropriate, with the resident's representative. The NP further wrote that s/he left C2 (controlled drugs) prescriptions for EOL medications with the DON because an NP on site [in the facility] tomorrow, with the stipulation that Resident #12's code status was changed to reflect this. A review of Resident #12's physician orders in the EMR revealed an 8/15/24 order for Lorazepam (Ativan) (anxiolytic) Oral Concentrate 2 MG (milligrams) /ML (milliliters) Give 0.5 ml orally every 2 hours as needed for restlessness; agitation for 14 Days related to end of life and an 8/15/24 order for Morphine Sulfate oral solution 100 MG/5ML, give 0.25 ml orally every 2 hours as needed for dyspnea (shortness of breath), end of life care. The EMR documented the orders for Lorazepam and Morphine were entered in the electronic record as active orders by the NP, Staff #64 on 8/15/24 at 12:15 pm. A review of Resident #12's August 2024 Medication Administration Record (MAR) revealed: - An 8/15/24 order for Lorazepam by mouth every 2 hours as needed for restlessness; agitation related to end of life for 14 days that was documented as given on 8/16/24 at 11:41 PM, and 8/18/24 at 1:00 AM - An 8/15/24 order for Morphine Sulfate oral solution by mouth every 2 hours as needed for dyspnea (shortness of breath) and end of life care with a start date of 8/15/24 at 12:15 PM was documented as given on 8/18/24 at 1:00 AM. Continued review of Resident #12's medical record failed to reveal documentation to that prior to initiating psychotropic medication for end-of-life care, the resident and/or resident representative was informed of the risks and benefits of the medication and consent was obtained On 3/18/25 at approximately 4:50 PM, the attending physician, Staff #66, was made aware of the above findings. At that time, Staff #66 reported s/he knew Resident #12 from the previous facility, that the resident had been diagnosed with liver cancer, and the physician felt for the family. Staff #66 stated that s/he became aware Resident #12 had been put on Ativan and Morphine when he saw the resident following his/her transfer to the facility, The physician stated s/he thought the NP wanted something more for the resident's pain and it never entered his/her head that the medications were for end-of-life, and Resident #12's family didn't want that. The physician stated that it was the providers job to talk to the families and s/he would never have left signed prescription for end-of-life care without first talking to the family. The above concerns were were discussed with the DON and Nursing Home Administrator (NHA) on 3/18/25 at 6:00 PM. The DON acknowledged the concerns at that time and offered no further comments. 2) On 3/14/25, at 9:00 AM, a review of complaint # MD00214414 alleged that Resident #3 and/or his/her representative were not notified when a new medication, Duloxetine (Cymbalta) (antidepressant), (treats neuropathic pain) was prescribed or consent obtained prior to the resident receiving the new medication. On 3/14/25 at 10:00 AM, a review of Resident #3's EMR revealed Resident #3 was admitted to the facility in late December 2024 following an acute hospitalization and discharged from the facility in late February 2025. The medical record documented that Resident #3 had multiple diagnoses including hypertension (high blood pressure (BP), cirrhosis of liver (scarring of liver), hepatic encephalopathy (brain disorder caused by liver dysfunction), kidney failure, and received hemodialysis (procedure to remove waste products and excess fluid from the body). Review of Resident #3's January 2025 MAR revealed a 1/23/25 order for Duloxetine by mouth one time a day for neuropathy that was documented as given in the AM on 6 (1/23, 1/24, 1/25, 1/26, 1/27, 1/28) occasions in January. The order was on hold from 1/29/25 to 1/31/25 then discontinued. In a NP Progress Note, on 1/22/25 at 10:05 PM, Staff #64, NP wrote that Resident #3 reported increased pain due to neuropathy and wrote that the resident was to start taking Duloxetine every day. In a physician visit progress note, on 1/29/25 at 2:55 AM, Staff #6, Physician, indicated Resident #3 requested to see the physician about his/her left shoulder pain, and the resident's spouse was concerned about the resident's mental status, The physician wrote the resident was on Oxycodone for pain and recently started on Cymbalta. The physician's assessment and plan indicated there were many factors with Resident #3's change in mental status from hepatic encephalopathy and medication and wrote that the Cymbalta would be held for now. Continued review of the medical record failed to reveal documentation that the resident and/or his/her representative had been informed when there was a change in the treatment plan, and new medication was prescribed. Continued review of Resident #3's medical record failed to reveal documentation to indicate the resident and/or the resident's representative had been informed that psychotropic medications had been ordered or the risks and benefits of psychotropic medication and failed to obtain consent prior to initiating the medication. On 3/18/25 at 4:44 PM, during an interview, Staff #66, Attending Physician, stated s/he spoken with Resident #3's spouse several times, and when the spouse was concerned with Resident #3 receiving the Cymbalta, the physician agreed with the spouse and put the Cymbalta on hold. Staff #66 also stated the Cymbalta was ordered by a different practitioner, and if the physician had ordered the medication, s/he would have notified the resident's representative right away. The DON and NHA were made aware of the above concerns on 3/18/25 at 6:35 PM. The DON and NHA acknowledged the concerns and offered no further comments at that time.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, the facility staff failed to notify a resident's physician of a change in status and failed to notify the physician when a medication was not available. This was evident for 2 (#30, #3) of 44 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #30's medical record on 3/12/25 revealed the Resident was admitted to the facility in May 2023 for rehabilitation. Further review of the Resident's record revealed a nurse's note on 5/27/23 at 2:49 PM stated, Resident reported during transfer back to bed from chair staff member accidentally stepped on his/her foot. Resident currently denying any pain on left foot. The existing bruise on right foot, xray done previously. Further review of Resident #30's medical record revealed no notification to the Resident's physician to determine if any further treatment should be ordered for the Resident's left foot. Interview with the Director of Nursing on 3/13/25 at 5:28 PM confirmed the facility staff failed to notify Resident #30's physician on 5/27/23 when the Resident had a change in condition.2) On 3/14/25, at 9:00 AM, a review of complaint # MD00214414 alleged the facility failed to inform and acquire consent from Resident #3 and his/her responsible party, when a medication was ordered for the resident, and prior to Resident #3 being given the medication. At 3/14/25 at 10:00 AM, a review Resident #3's electronic medical record) (EMR) revealed Resident #3 was admitted to the facility in late December 2024 following an acute hospitalization and discharged from the facility in late February 2025. The medical record documented that Resident #3 had multiple diagnoses including hypertension (high blood pressure (BP), cirrhosis of liver (scarring of liver), hepatic encephalopathy (brain disorder caused by liver dysfunction), kidney failure, and received hemodialysis (procedure to remove waste products and excess fluid from the body). Review of Resident #3's January 205 electronic Medication Administration Record (eMAR) revealed a 12/27/24 order for Rifaximin 500 MG tablet by mouth two times a day, at 8:00 AM and 8:00 PM for encephalopathy. The MAR was signed off with the code 9 (other/see nurses notes) 12 (1/3, 1/12, 1/13, 1/19, 1/21, 1/22, 1/23, 1/25, 1/28, 1/29, 1/20 1/31/25) of 31 administrations scheduled at 8:00 AM, and 7 (1/12, 1/23, 1/24, 1/27, 1/28, 1/20, 1/31/25) of 31 administration times scheduled at 8:00 PM in January, indicating 19 of 62 scheduled administration times in January, Resident #3 was not given Rifaximin as ordered. Review of Resident 3's order administration notes populated when the Rifaximin order was signed 9, revealed documentation indicating that Rifaximin was not available in the facility for the staff to administer to the resident. Continued review of Resident #3's EMR revealed, on 1/31/25 at 8:03 PM, in a Nurse Practitioner (NP) follow-up note, Staff #77, NP, wrote that Resident #3 continued with lethargy and low blood pressure, and the resident should be taking Rifaximin every day for hepatic encephalopathy. The NP wrote that, per the staff, the resident had not received Rifaximin because of expense and authorization was needed. The NP wrote s/he was told by with management that the medication was approved, and the resident would receive it, and that Resident #3's lethargy could be from not getting his/her prescribed Rifaximin. In an NP follow-up note on 2/3/25 at 11:17 PM, Staff #77, NP, wrote that Resident #3 was seen, that the resident appeared lethargic, and his/her lethargy could be hepatic encephalopathy. The NP wrote that s/he spoke with the nurse, and the resident was not getting Rifaximin because the medication was not available, however, staff had signed that Rifaximin had been given to the resident. A continued review of the medical record failed to find documentation to indicate the physician was notified when Resident #3 was not given Rifaximin as prescribed, or when the medication was unavailable. During an interview, on 3/18/25 at 4:44 PM, the above concerns were discussed with Resident #66's attending physician, Staff #66. At that time, Staff #66 stated he/she had not been notified that Resident #3 had not been getting Rifaximin as prescribed, and the physician had assumed the resident had been taking the medication. Staff #66 also stated that the physician should be called any time a resident was out of medication. The concerns with physician notification were discussed with the Director of Nurses (DON) and Nursing Home Administrator (NHA) on 3/18/25 at 6:35 PM. The DON and NHA acknowledged the concerns and offered no other comments at that time. Cross Reference F760

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident complaint, and interviews with facility staff, it was determined that the faciity failed to keep residents personal items safe. This was evident for 1 out of 1 resident (#2) with misappropriation of property. Findings include: On 2/4/25 Resident #2 entered the facility. Resident resided on the dementia unit in room [ROOM NUMBER] A. Resident had just been discharged from the hospital with the following diagnosis: Severe Sepsis with shock, Pneumonia, Autoimmune hepatitis, Pericardial effusion, anemia, volume overload, covid positive, hyponatremia, Folate deficiency, Hypomagnesemia, hypokalemia. Resident has a Bims score of 14/15 conductd on 2/13/25. (Bims is a mini mental score, indicating resident is alert and orriented.) On 3/12/25 at 4:31 pm, a review of Resident's #2's medical chart was reviewed. The complaint states resident's wallet was stolen. It had all her/his insurance cards, credit cards and debit card. On 2/12/24 nurses note states purse was locked up at nurses station because they put her/him in a room with a dementia patient and the other resident kept taking Resident #2 her/his things. Her/his purse was stripped bare. So they locked it up but it had mysteriously disappeared. The responsible party stated that the asst. social worker was suppose to contact the family, but that never happened. Resident also had a partial top plate in her/his mouth but when she/he fell out of bed one night. She/he said she/he lost it when the male nurse tossed her/him back in the bed. Resident #2 cannot identify male nurse. Also missing were 2 blankets, a pillow, a battery charger pact, kindle charger, phone charger her /his top partial teeth and some clothing items. 2/12/25 Resident's purse with $63 dollars in it was handed over to oncoming nurse to lock up in the nurse's med cart. On 3/12/25 Unit manager Staff # 28 looked for the purse on her unit and could not find. Purse was found at [NAME] facility with resident. Administrator found a Wallet when she came here to work in July of 2024. There was no name on the wallet and no one reported a missing wallet. The wallet had 36.00 cash inside but nothing else, Administrator sent a picture of the wallet to [NAME] where the resident currently lives to see if she can identy wallet. Other missing item will be looked for. The administrator also stated that this facility has not been filling out inventory sheets when residents are admitted .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the facility staff failed to conduct a complete and accurate assessment by failing to assess a resident's cognition, mood, and behavior on a quarterly assessment. This was evident for 1 (#16) of 44 residents reviewed for during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. On 3/12/25 at 10:24 AM a review of Resident #16's medical record was conducted. Resident #16 was admitted to the facility in October 2022 with diagnoses that included, but were not limited to, Bipolar disorder, dementia, and Wernicke's encephalopathy. Review of Resident #16's medical record revealed Resident #16 had behaviors while a resident at the facility. A 12/23/24 nurse practitioner note documented the resident had behavior disturbances and was prescribed Seroquel 75 mg. twice per day that had just been increased. Review of Resident #16's quarterly MDS assessments, Section C, Cognition and Section D, Mood, and Section E, behavior, with an assesment reference date of 1/15/25, were not assessed which made the assessments incomplete. On 3/18/25 at 5:20 PM an interview was conducted with LPN #8, MDS Coordinator. LPN #8 validated that the resident had behaviors and stated that the social worker typically completed that section of the MDS, however the social worker was out and no one assessed the resident's behavior.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#16, #17) of 44 residents reviewed for complaints during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 3/10/25 at 10:12 AM a review of Resident #16's medical record revealed a quarterly MDS assessment with an assessment reference date of 1/13/24. Review of Section E behaviors, E0200 coded behavior not exhibited. Behaviors that would be coded in Section E0200, A. would be physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) or E0200B, Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). A 1/7/24 at 5:04 AM behavioral note for Resident #16 documented, behavior: 5:04 AM, hitting, throwing things and cussing at staff. While shift change, resident runs into another resident chair with [his/her] wheel chair and continues to go backwards full force while staff tries to redirect [him/her] but [he/she] ignores them and starts to throw objects at staff. It was documented that the behavior was not redirectable at that time and interventions were not attempted due to the resident being too aggressive at that time. On 3/18/25 at 5:20 PM an interview was conducted with Staff #8, MDS coordinator who confirmed the error. 2) On 3/10/25 at 9:10 PM a review of facility reported incident MD00208337 was conducted and revealed Resident #17 was found to have a right hip fracture and was sent to the emergency room on 8/1/24 according to the census tab in the electronic medical record. Review of the discharge return anticipated MDS with an assessment reference date of 8/1/24, Section J1900, Number of falls since prior assessment, was coded 1 injury (except) major. This was inaccurate as it should have been coded for a major injury which included a bone fracture. On 3/11/25 at 8:37 AM an interview was conducted with the MDS Coordinator who confirmed that the MDS was coded incorrectly and should have been coded a hip fracture. The Nursing Home Administrator and Director of Nursing were informed on 3/18/25 at 5:15 PM.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. a) On 3/10/25 at 10:12 AM a review of Resident #16's medical record was conducted and revealed there were quarterly MDS assessments done on 1/15/25 and 10/15/24. Review of Resident #16's medical record failed to produce documentation that there was a care plan meeting held after the MDS assessments. On 3/12/25 at 11:51 AM Staff #27, the Social Work Assistant, was interviewed and stated that care plan meeting sign-in sheets were normally scanned and put in the miscellaneous section of the electronic medical record if a meeting was held. Staff #27 stated that they did not have a care plan meeting in January 2025 because Staff #27 was by herself and she had to do everything related to social services. Staff #27 also stated that she attempted to contact Resident #16's mother multiple times to have a care plan meeting in October 2024 and she could not get in touch with her. Staff #27 was asked if the IDT had a care plan meeting in October 2024 and the response was, no. b) Further review of Resident #16's medical record on 3/10/25 at 10:12 AM revealed on 8/1/24 Resident #16 had a fall. Resident #16 was getting up from a chair and fell face forward onto the floor and sustained an acute mildly displaced fracture of the tip of the nasal bones. On 3/11/25 at 2:22 PM, Resident #16, who had a fall, as stated above on 8/1/24 at 4:30 PM out of a geri-chair, was observed trying to get out of the geri-chair that was located in the back of the common area of the dementia unit. Review of care plans for Resident #16, at risk for falls r/t Gait/balance problems, Psychoactive drug use and impulsiveness, failed to have specific resident centered interventions in place, for this cognitively impaired resident, about monitoring the resident while in a geri-chair. On 3/11/25 at 4:45 PM the issue was discussed with the Nursing Home Administrator and Director of Nursing who confirmed the findings. Based on medical record review, interviews, and observation, it was determined the facility failed to have regular care plan meetings and failed to update interventions on the care plan. This was evident for 3 (#21, #15, #16) out of 44 residents reviewed during a complaint survey. The findings include: 1) The Stepmom of Resident #21 called to say, the patient was admitted to the facility in April in 2024 and has had only one care plan meeting on 8/19/24. On 8/19/24, the Interdisplinary Team met, including social services assistant and nursing to complete a quarterly care plan meeting. Resident was present and is alert and oriented. Family was present including his/her sister. Social services discussed MOLST - resident is a Full Code. BIMS is 15/15. Discharge plan is to continue long term care at facility - eventually resident would like to possible transfer to [NAME] to be closer to family. Therapy discussed - if resident experiences a fall or decline, therapy will reevaluate. Diet discussed - resident's diet is carb controlled, regular texture and thin liquids - NO PORK! Nursing discussed resident treatments and medications. Resident states they feel they are treated with dignity and respect. Resident and family were provided a copy of the resident's care plan and order summary. Concerns addressed included resident needed nails trimmed, he/she continues to receive pork despite kitchen being aware that he /she cannot have it, and activities needs to complete menu with him. It has been 7 months since last CP meeting was held. (last meeting 8/19/24). Social worker, staff # 27 was interviewed on 3/12/25 at 12:27 PM and asked why it has been so long since last Care Plan meeting and she did not have a responce other than saying a care plan meeting is scheduled in next few days. Administrator was asked the same question on the same day and stated she knew nothing about it. 2) Resident #15 entered into the facility on [DATE] and discharged [DATE]. He/She has a diagnosis of alchol abuse and substance abuse and attacking other residents who come into his/her room. On 4/3/24 and 4/13/24 Resident #15 hit Resident #24. There was no interventions or CP for Resident #15. On 6/7/24 resident hit Resident #16 who he/she hit for wandering into his/her room. No Care Plan or interventions. On 7/28/24 resident hit Resident #14 who wandered into his/her room. No care plan or interventions. On 7/21/24 and 8/26/24 Resident #15 hit Resident #41 for going into his/her room. On 8/12/24 new administrator wrote a care plan and put in place a doorbell to residents room and a stop sign on residents front door. These are the only 2 interventions on Resident #15 Care plan. Unit manager was interviewed but did not know these residents as she just joined the facility. An interview was held with the Medical Director, Staff # 9 on 3/13/25 at 9:27 AM: ' I know him very well. He/she is currently at Mannokin and that is the building I see the patient at. He/she had a fall resulting in a head injury prior to coming to the facility. I am aware of at least 3 residents that he/she struck and I reviewed the incidents that happen at the facility. He/she didn't take his/her psych medicine, he/she only took his seizure medication. After the first incident I would have expected psych eval, behavior medication. I would talk to him about his meds. Do a meds evaluation. I would care plan his behaviors. After the 2nd or 3rd time it depending on the circumstances I would look for alternative settings. Is this the right place for him?' 'Looking in retrospect he/she probably should have interventions put in place and we could have looked at a more appropriate setting. It was discussed in risk meeting. There should have been interventions put in place.'

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review or pertinent documents, medical record review and interview, it was determined that 1) the practitioner failed to follow professional standards of clinical practice by prescribing end-of-life medication to a full code resident without ensuring the resident and/or resident representative were fully informed about the use of end-of-life medications, and 2) the facility nursing staff failed to follow professional standards of nursing practice when administering psychotropic medication by failing to document in the medication administration record when the medication was given to a resident. This was evident for 1 (#12) of 44 residents reviewed during a complaint survey. The findings include: Schedule II (C2) controlled drugs refer to drugs with a high potential for abuse and addiction that are regulated by the government and include anxiolytic (anti-anxiety) benzodiazepine medication and opioid (analgesic) (narcotic) medication. A psychotropic describes any drug that affects behavior, mood, thoughts, or perception On [DATE] at 9:00 AM, a review of complaint #MD00209003 alleged Resident #12, who was terminally ill, but not on hospice or receiving palliative care, was prescribed and administered Ativan (anxiolytic) and Morphine (Opioid) for end of life , without notifying the resident's representative, and obtaining consent. The complaint alleged that giving the medications together contributed to Resident #12's respiratory failure, and lead to the death of the resident. The complaint also alleged the facility staff failed to notify Resident #12's representative timely when the resident was transferred to the hospital. A review of Resident #12's electronic medical record (EMR) revealed Resident #12 was admitted to the facility in mid-[DATE] following a transfer from a sister facility and had multiple diagnoses, including hepatocellular carcinoma (liver cancer) and hepatic encephalopathy (brain disorder caused by liver dysfunction), and a history of blood transfusions. The resident was discharged from the facility following his/her transfer to the hospital 3 days after admission. Resident #12 had a MOLST (Maryland Orders for Life Sustaining Treatment) form that was signed and dated [DATE] and documented Resident #12 elected to Attempt CPR, indicating the resident was a full code. In a Nurse Practitioner (NP) Progress Note on [DATE] at 12:30 PM, Staff #64 NP documented Resident #12 was being transferred from another facility to the current facility on that day, and the NP was very familiar with Resident #12 because the NP provided care to him/her at the other facility. The NP wrote that Resident #12 was currently a full code, that resident's declining condition was discussed with the Director of Nurses (DON) (Staff #78) and the DON would discuss end-of-life (EOL) care, which they believed was appropriate, with the resident's representative. The NP further wrote that s/he left C2 (controlled drugs) prescriptions for EOL medications with the DON because an NP on site [in the facility] tomorrow, with the stipulation that Resident #12's code status was changed to reflect this. On [DATE] at 6:41 PM, a review of Resident #12's [DATE] Medication Administration Record (MAR) revealed orders for 2 psychotropic medications to be administered as needed for symptoms related to end of life symptoms. Resident #12's [DATE] MAR documented: - An [DATE] order for Lorazepam (Ativan) (Anxiolytic) by mouth every 2 hours as needed for restlessness; agitation related to end of life for 14 days that was documented as given on [DATE] at 11:41 PM, and [DATE] at 1:00 AM - An [DATE] order for Morphine Sulfate (Opioid) (narcotic) oral solution by mouth every 2 hours as needed for dyspnea (shortness of breath) and end of life care with a start date of [DATE] at 12:15 PM was documented as given on [DATE] at 1:00 AM. Both the Lorazepam and Morphine orders had been entered into the EMR by the NP, Staff #64 Continued review of the medical record revealed on [DATE] at 3:30 AM, in a nurse's note, the nurse documented that Resident #12 was restless in bed, trying to get out of bed, and the nurse assisted the resident's personal caregiver to reposition the resident. The nurse documented Lorazepam was given per PRN (as needed) order for end-of-life care for comfort. On [DATE] at 10:03 AM, in a change in condition note, the nurse wrote Resident #12 was unresponsive to verbal stimuli or sternal rub; vital signs unstable, and 911, the physician and the DON were notified, and the resident was sent to the emergency room. Continued review of Resident #12's medical record failed to reveal documentation to that prior to initiating psychotropic medication, the resident and/or resident representative was informed of the risks and benefits of the medication and consent was obtained, and no documentation was found in the medical record to indicate end of life care for Resident #12 discussed with the resident's representative prior to initiating the medications. In addition, there was no further documentation in the medical record to indicate the NP, Staff #64, followed up with the resident, the resident's responsible party or the DON following the implementation of the orders. On [DATE] at 12:47 PM, an interview was conducted with the NP, Staff #64 who stated s/he knew Resident #12 from the previous facility, that the resident was very sick, that s/he had a liver tumor and required repeated blood transfusions. The NP indicated that at the previous facility, the NP had numerous discussions with the family about the residents health, and the NP had not seen Resident #12 at the present facility, Staff #64 stated s/he had a conversation with the DON, Staff #78, that the resident was nearing end of life, that the practitioner had attempted to talk to the family and the resident's MOLST was a full code. The NP stated s/he wrote the prescriptions for morphine and lorazepam for Resident #12 for the resident for palliative care and EOL for the resident's comfort and gave the physical prescriptions to the DON with the stipulation they would be available if the MOLST was changed, the resident was in a lot of pain, or something changed. The NP indicated that the DON said s/he would talk to the family about changing the resident's code status and the NP wanted the prescriptions available if his/her MOLST was changed to palliative care. The NP stated s/he had not yet had that conversation with the family and was concerned if the MOLST was changed, a provider would not be available to write the prescriptions. The NP confirmed that s/he entered the EOL orders in the EMR as active orders. On [DATE] at 2:45 PM, the above concerns were discussed with the Medical Director, Staff #9, Physician, who stated s/he remembered the resident very well. At that time, Staff #9 expressed concerns with Resident #12 being administered medications for end of life, and stated that the resident should have gotten Narcan (medication that reverses Opioid overdose). On [DATE] at 9:25 AM, Staff #9, Medical Director stated that s/he wanted the surveyor to know that s/he took the concerns with the practitioner who prescribed the medications end-of-life care to Resident #12 very seriously and removed the practitioner from the facility. Staff #9 stated that the practitioner would not be back, and the practitioner's practice would be reviewed. On [DATE] at approximately 4:50 PM, the attending physician, Staff #66, was made aware of the above findings. At that time, Staff #66 reported s/he knew Resident #12 from the previous facility, that the resident had been diagnosed with liver cancer, and the physician felt for the family. Staff #66 stated that s/he became aware Resident #12 had been put on Ativan and Morphine when he saw the resident following his/her transfer to the facility, The physician stated s/he thought the NP wanted something more for the resident's pain and it never entered his/her head that the medications were for end-of-life, and Resident #12's family didn't want that. The physician stated that it was the providers job to talk to the families and s/he would never have left signed prescription for end-of-life care without first talking to the family. The above concerns were discussed with the Director of Nurses (DON) and Nursing Home Administrator (NHA) on [DATE] at 6:00 PM. The DON acknowledged the concerns at that time and offered no further comments. 2) Following review of Resident #12's medical record, a concurrent review of the controlled substance count sheet for the resident's prescribed Lorazepam, and morphine, and Resident #12's August MAR was conducted and revealed facility nursing staff failed to follow professional standards of nursing practice when administering psychotropic medication by failing to document in the medication administration record when the medication was given to a resident. Resident #12's [DATE] MAR documented: 2a) An [DATE] order for Lorazepam by mouth every 2 hours as needed for restlessness; agitation related to end of life for 14 days that was documented as given to the resident on [DATE] at 11:41 PM, and on [DATE] at 1:00 AM. A review of a controlled substance count sheet for Lorazepam 2 mg/ml revealed documentation that a dose of Lorazepam was removed for Resident #12 on [DATE] at 11:43 PM, on [DATE] at 1:00 AM, and on [DATE] at 3:00 AM. A concurrent review of Resident #12's August MAR revealed the Lorazepam removed from the count sheet on [DATE] at 3:00 AM was not documented as given on the MAR, indicating the nursing staff failed to document when the Lorazepam was administered to the resident. 2b) An [DATE] order for Morphine Sulfate (narcotic) oral solution by mouth, give every 2 hours as needed for dyspnea (shortness of breath) and end of life care with a start date of [DATE] at 12:15 PM was documented as given on [DATE] at 1:00 AM. A review of a controlled substance count sheet for Morphine Sulfate 100 mg/ml documented a dose of morphine was removed for Resident #12 on [DATE] at 1:00 AM and a dose of morphine was removed for Resident #12 on [DATE] at 3:00 AM. A concurrent review of Resident #12's August MAR revealed the Morphine removed from the count sheet on [DATE] at 3:00 AM, was not documented as given on the MAR, indicating the nursing staff failed to document when the Morphine was administered to the resident. The above concerns were discussed with the Director of Nurses (DON) and Nursing Home Administrator (NHA) on [DATE] at 6:00 PM. The DON acknowledged the concerns at that time and offered no further comments.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers. This is evident for 1 (#30) of 44 residents reviewed during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. Review of Resident #30's medical record on 3/12/25 revealed the Resident was admitted to the facility in May 2023. Further review of Resident #30's medical record revealed the Resident was assessed by the Wound Nurse Practitioner (WNP) on 6/6/23 and determined to have a DTI to the left heel. Review of the weekly skin assessment revealed the facility staff failed to assess Resident #30's left heel DTI the week of July 3rd, 2023 to include measurements and the status of the pressure ulcer. Review of Resident #30's July 2023 Treatment Administration Records revealed no evidence the facility staff provided treatment to Resident left heel DTI on 7/7, 7/10, 7/16, and 7/18/23. Interview with the Director of Nursing on 3/13/25 at 5:28 PM confirmed the facility staff failed to assess Resident #30's left heel pressure ulcer on 7/3/23 and failed to provide treatments on 7/7, 7/10, 7/16, and 7/18/23.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on review of a complaint, medical record review, and interview, it was determined the facility staff failed to follow up and obtain a motorized wheelchair for a resident in a timely manner. This was evident for 1 (#5) of 44 residents reviewed during a complaint survey. The findings include: On 3/12/25 at 5:30 PM a review of complaint MD00213409 alleged that Resident #5 had a power wheelchair that was no longer working. Resident #5 was supposed to get a new power wheelchair, however still had not received the wheelchair and alleged that the facility was not going to pay for the wheelchair. Review of Resident #5's medical record revealed Resident #5 had been a resident at the facility since 2015 and had diagnoses that included, but were not limited to, multiple sclerosis, type 2 diabetes mellitus with hyperglycemia, arthritis, low back pain, peripheral vascular disease, chronic venous hypertension, and absence of the left toe. On 3/10/25 at 2:00 PM an interview was conducted with Resident #5 who stated he/she had been waiting on the facility to get his/her motorized wheelchair. Resident #5 stated that the facility ordered the wheelchair, and Medicaid had approved the wheelchair, but Resident #5 still didn't have the wheelchair, and it had been at least 4 months since it was ordered. On 3/13/25 at 11:00 AM an interview was conducted with the previous Director of Maintenance, Staff #33. Staff #33 stated that Resident #5's previous wheelchair stopped working and therapy was working with insurance to get a new wheelchair for the resident. On 3/13/25 at 11:05 AM an interview was conducted with the Director of Physical Therapy, Staff #35. Staff #35 stated the facility was applying for a new wheelchair and everything was submitted. The surveyor asked why it was taking so long to get the wheelchair. Staff #35 stated he did not know the status of the wheelchair or where the process fell off. On 3/13/25 at 3:44 PM an interview was conducted with the Regional Business Office Manager, Staff #13. Staff #13 stated the facility received prior authorization on 11/26/24 and the wheelchair was ordered. Staff #13 stated the previous business office manager was no longer the business office manager, so all of the information related to the wheelchair, including the invoice from the medical supply company was sent to an incorrect email. Staff #13 stated the previous business office manager worked at a sister facility and did not receive email that was directed to her from this facility. Staff #13 was asked if someone at this facility had access to receive the emails once the previous business office manager left. Staff #13 said there was some type of technical issues with emails. Staff #13 stated the wheelchair company reached out to someone new in the business office on 2/25/25 and informed them that the prior authorization was expiring on 2/25/25 and the invoice needed to be paid before the wheelchair could be delivered. That person failed to let anyone know that information. Staff #13 stated today was the first time she was hearing about the issue. Staff #13 stated, we usually receive updates prior to the authorization date ending. Several things fell through. She stated the only time she was involved was when they paid out of a resident's fund account. Staff #13 produced an email from the medical supply company dated 3/13/25 which stated, please see attached documentation for [name of Resident #5] for [his/her] power wheelchair. We will need payment from [name of facility] as soon as possible. Attached are the documents that you will need to submit to MA to get reimbursed. On 3/18/25 at 5:15 PM the Nursing Home Administrator and the Director of Nursing were informed of the delay in getting the resident's wheelchair.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the facility staff failed to assess a resident for removal of a catheter. This was evident for 1 (#1) of 44 residents reviewed during a complaint survey. The findings include: Review of Resident #1's medical record on 3/10/25 revealed the Resident was admitted to the facility in October 2024 with a diagnosis to include neuromuscular dysfunction of bladder. Further review of Resident #1's medical record revealed the Resident was admitted to the facility with an indwelling urinary catheter. During interview with Resident #1 on 3/11/25 at 2:00 PM, the Resident stated he/she feels like he/she is having more feeling, can tell when urinating and stated was told there would be a voiding trial but it has not happened. A voiding trial is a procedure used to assess a patient's ability to urinate without the need for a urinary catheter. It is typically performed after a period of catheterization, such as after surgery or hospitalization. During interview with the Medical Director on 3/12/25 at 10:44 AM, the Medical Director stated he doesn't think the Resident will regain physical function or bladder control based on the Resident's spinal injuries suffered but does think a voiding trial is not a bad idea and has ordered one. After Surveyor intervention, a voiding trial was ordered for Resident #1 on 3/12/25.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician ordered blood pressure parameters for administering a blood pressure medication. This was evident for 1 (#3) of 44 residents reviewed during a complaint survey. The findings include: On 3/14/25, at 9:00 AM, a review of complaint # MD00214414 alleged that Resident #3's representative was not notified when a new medication was prescribed for the resident or prior to the resident receiving the new medication. On 3/14/25 at 10:00 AM, a review Resident #3's electronic medical record) (EMR) revealed Resident #3 was admitted to the facility in late December 2024 following an acute hospitalization and discharged from the facility in late February 2025. The medical record documented that Resident #3 had multiple diagnoses including hypertension (high blood pressure (BP), cirrhosis of liver (scarring of liver), hepatic encephalopathy (brain disorder caused by liver dysfunction), kidney failure, and received hemodialysis (procedure to remove waste products and excess fluid from the body). 1) Review of Resident #3's January 2025's medication administration record (MAR) revealed a 1/25/25 order for Amlodipine (Norvasc) (treats high BP) by mouth 1 time a day for hypertension, hold for systolic (top number of a BP reading) less than 110, that was discontinued on 1/27/25. The January MAR documented that Resident #3 was given Amlodipine when the resident's systolic blood pressure was outside of parameters on 2 (1/25, 1/26) of 3 administrations days in January. The MAR documented on 1/25/25, at the hour of Day, Resident #3's BP was 101/66 and the medication was given and not held when the resident's systolic bp was outside of parameters, and the MAR documented on 1/26/25, at the hour of Day, Resident #3's BP was 102/76 and the medication was given and not held when the resident's systolic bp was outside of parameters. The facility failed to follow the physician's order by administering the medication when the resident's BP was outside of the ordered parameters 2) Review of Resident #3's February 2025 MAR revealed a 1/31/25 order for Midodrine (treats low BP) by mouth one time a day every day, Monday, Wednesday, Friday, for hypotension (low BP). Hold for systolic BP greater than 140, that was discontinued on 2/27/25. The February MAR documented that Resident #3 was given Midodrine on 11 (2/3, 2/5, 2/7, 2/10, 2/12, 2/14, 2/17, 2/19, 2/21, 2/24, 2/28) of 11 administration times in February, with no documentation found in the MAR to indicate the resident's blood pressure (BP) was monitored prior to the administration of Midodrine. 3) Further review of Resident #3's February 2025 MAR revealed a 1/31/25 order for Propranolol (Inderal) (treats high blood pressure) by mouth two times a day for hypertension, hold for systolic BP less than 110, that was discontinued on 2/27/25. The February MAR documented that Resident #3 was given Propranolol at 8:00 AM on 25 (2/1, 2/3, 2/4, 2/5, 2/6, 2/7, 2/8, 2/9, 2/10, 2/11, 2/12, 2/13, 2/14, 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/21, 2/22, 2/23, 2/24, 2/25, 2/26) of 26 administrations in February, with no documentation to indicate the resident's BP was monitored prior to the administration to Propranolol. The February MAR documented Resident #3 was given Propranolol at 5:30 PM on 22 (2/1, 2/2, , 2/4, 2/5, 2/6, 2/7, 2/8, 2/9, 2/11, 2/12, 2/13, 2/14, 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/22, 2/23, 2/24, 2/25, 2/26) of 25 administrations in February with no documentation to indicate the resident's BP was monitored prior to the administration to Propranolol. The facility failed to follow the physician's order by failing to monitor Resident 3's BP prior to administering the medication, then potentially holding the medication if the BP was outside of the ordered parameters. On 3/18/25 at 4:44 PM, the above concerns were discussed with the Director of Nurses (DON). The DON acknowledged the concerns and offered no further comments at that time.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. This was evident for 1 (#12) of 44 residents reviewed during a complaint survey. The findings include: Schedule II (C2) controlled drugs refer to drugs with a high potential for abuse and addiction that are regulated by the government and include anxiolytic (anti-anxiety) benzodiazepine medication and opioid (analgesic) (narcotic) medication. A psychotropic describes any drug that affects behavior, mood, thoughts, or perception On [DATE] at 9:00 AM, a review of complaint #MD00209003 alleged Resident #12, who was terminally ill, but not on hospice or receiving palliative care, was prescribed and administered Ativan (anxiolytic) and Morphine (Opioid) for end of life , without notifying the resident's representative, and obtaining consent. The complaint alleged that giving the medications together contributed to Resident #12's respiratory failure, and lead to the death of the resident. The complaint also alleged the facility staff failed to notify Resident #12's representative timely when the resident was transferred to the hospital. A review of Resident #12's electronic medical record (EMR) revealed Resident #12 was admitted to the facility in mid-[DATE] following a transfer from a sister facility and had multiple diagnoses, including hepatocellular carcinoma (liver cancer) and hepatic encephalopathy (brain disorder caused by liver dysfunction), and a history of blood transfusions. The resident was discharged from the facility following his/her transfer to the hospital 3 days after admission. Resident #12 had a MOLST (Maryland Orders for Life Sustaining Treatment) form that was signed and dated [DATE] and documented Resident #12 elected to Attempt CPR, indicating the resident was a full code. In a Nurse Practitioner (NP) Progress Note on [DATE] at 12:30 PM, Staff #64 NP documented Resident #12 was being transferred from another facility to the current facility on that day, and the NP was very familiar with Resident #12 because the NP provided care to him/her at the other facility. The NP wrote that Resident #12 was currently full code, that resident's declining condition was discussed with the Director of Nurses (DON) (Staff #78) and the DON would discuss end-of-life (EOL) care, which they believed was appropriate, with the resident's representative. The NP further wrote that s/he left C2 (controlled drugs) prescriptions for EOL medications with the DON because an NP on site [in the facility] tomorrow, with the stipulation that Resident #12's code status was changed to reflect this. On [DATE] at 6:41 PM, a review of Resident #12's [DATE] Medication Administration Record (MAR) revealed orders for 2 psychotropic medications to be administered as needed for symptoms related to end of life symptoms. Resident #12's [DATE] MAR documented: - An [DATE] order for Lorazepam (Ativan) (Anxiolytic) by mouth every 2 hours as needed for restlessness; agitation related to end of life for 14 days that was documented as given on [DATE] at 11:41 PM, and [DATE] at 1:00 AM - An [DATE] order for Morphine Sulfate (Opioid) (narcotic) oral solution by mouth every 2 hours as needed for dyspnea (shortness of breath) and end of life care with a start date of [DATE] at 12:15 PM was documented as given on [DATE] at 1:00 AM. Both the Lorazepam and Morphine orders had been entered into the EMR by the NP, Staff #64 Continued review of Resident #12's medical record failed to reveal documentation to that prior to initiating psychotropic medication, the resident and/or resident representative was informed of the risks and benefits of the medication and consent obtained, and no documentation was found in the medical record to indicate end of life care for Resident #12 discussed with the resident's representative prior to initiating the medications. In addition, there was no further documentation in the medical record to indicate the NP, Staff #64, followed up with the resident, the resident's responsible party or the DON following the implementation of the orders. On [DATE] at 12:47 PM, during an interview, Staff #64, NP stated s/he had not seen Resident #12 after s/he arrived to the current facility, however s/he knew him from the previous facility. Staff #64 stated Resident #12 was very sick, and the NP had numerous discussions with the family about the residents health. Staff #64 stated that the resident was nearing the end of life, that his/her MOLST was full code, and the NP had attempted to talk to the family. The NP stated s/he spoke with the DON who said s/he would talk family about changing Resident #12's code status and the NP wanted prescriptions available if the resident's MOLST was changed to palliative care and was concerned a provider would not be available to write the prescriptions. The NP stated s/he wrote the prescriptions for morphine and lorazepam for Resident #12 for palliative care and EOL and gave the physical prescriptions to the DON with the stipulation they would be available if the MOLST was changed, the resident was in a lot of pain, or something changed. The NP indicated s/he didn't think the prescriptions would be sent to the pharmacy until the resident's MOLST was changed and confirmed that s/he entered the orders for the in the EMR as active orders. On [DATE] at 2:45 PM, the above concerns were discussed with the Medical Director, Staff #9, Physician, who stated s/he remembered the resident very well. At that time, Staff #9 expressed concerns with Resident #12 being administered the lorazepam and morphine for end of life care while s/he was a full code, and indicated the EMT's should have given the resident Narcan (medication that reverses Opioid overdose). On [DATE] at approximately 4:50 PM, the attending physician, Staff #66, was made aware of the above findings. Staff #66 stated that s/he became aware Resident #12 had been put on Ativan and Morphine when he saw the resident following his/her transfer to the facility, The physician stated s/he thought the NP wanted something more for the resident's pain and it never entered his/her head that the medications were for end-of-life, and Resident #12's family didn't want that. The physician stated that it was the providers job to talk to the families and s/he would never have left signed prescription for end-of-life care without first talking to the family. The above concerns were discussed with the Director of Nurses (DON) and Nursing Home Administrator (NHA) on [DATE] at 6:00 PM. The DON acknowledged the concerns at that time and offered no further comments. Cross Reference F550, F658

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on medical record review, interviews and review of pertinent documentation, it was determined the facility failed to keep residents free from a significant medication error by failing to ensure medication was available in a timely manner for the facility to administer, and failing to accurately document when medications were not given or not available. This was evident for 1 (#3) of 44 residents reviewed during a complaint survey. The findings include: On 3/14/25, at 9:00 AM, a review of complaint # MD00214414 alleged the facility failed to inform and acquire consent from Resident #3 and his/her responsible party, when a medication was ordered for the resident, and prior to Resident #3 being given the medication. At 3/14/25 at 10:00 AM, a review Resident #3's electronic medical record) (EMR) revealed Resident #3 was admitted to the facility in late December 2024 following an acute hospitalization and discharged from the facility in late February 2025. The medical record documented that Resident #3 had multiple diagnoses including hypertension (high blood pressure (BP), cirrhosis of liver (scarring of liver), hepatic encephalopathy (brain disorder caused by liver dysfunction), kidney failure, and received hemodialysis (procedure to remove waste products and excess fluid from the body). Review of Resident #3's January 205 electronic Medication Administration Record (eMAR) revealed a 12/27/24 order for Rifaximin 500 MG tablet by mouth two times a day, at 8:00 AM and 8:00 PM for encephalopathy. The MAR was signed off with the code 9 (other/see nurses notes) 12 (1/3, 1/12, 1/13, 1/19, 1/21, 1/22, 1/23, 1/25, 1/28, 1/29, 1/20 1/31/25) of 31 administrations scheduled at 8:00 AM, and 7 (1/12, 1/23, 1/24, 1/27, 1/28, 1/20, 1/31/25) of 31 administration times scheduled at 8:00 PM in January, indicating 19 of 62 scheduled administration times in January, Resident #3 was not given Rifaximin as ordered. Resident #3's February 2025 MAR documented the Rifaximin 500 MG tablet by mouth two times a day, at 8:00 AM and 8:00 PM for encephalopathy that was signed with the code 9 on 4 (2/1, 2/3, 2/4, 2/5/25) of 5 administration times scheduled at 8:00 AM, and on 1 (2/3/25) of 5 administration times scheduled at 8:00 PM. When the medication administration is coded 9, the medication order populates in an administration note in the EMR for the practitioner to document pertinent information when medication was not given. Review of the Resident #3's order administration notes for when the Rifaximin order was signed 9, revealed Rifaximin was not available in the facility for the staff to administer to the resident. The Rifaximin order administration notes documented the following - on 1/3/25 at 8:04 AM, awaiting delivery, nurse made aware. - on 1/12/25 at 8:51 AM, reorder, nurse aware. - on 1/12/25 at 7:35 PM, medication on order. - on 1/13/25 at 9:05 AM not on hand, not in back up, med reordered from pharmacy. - on 1/19/25 at 9:12 AM, pending pharmacy delivery, nurse aware. - on 1/21/25 at 8:45 AM, medication has been ordered. waiting on pharmacy. - on 1/22/25 at 8:47 AM, reorder, nurse aware. - on 1/23/25 at 8:31 AM, waiting for approve, on 1/23/25 at 5:38 PM, the note documented, on order. - on 1/24/25 at 7:22 PM, medication on order - on 1/25/25 at 7:47 AM, medication on order, nurse aware. - on 1/27/25 at 7:42 PM, on order. - on 1/28/25 at 11:24 AM, not on hand, not in backup, waiting on payment authorization. - on 1/28/25 at 9:29 PM, medication has been ordered; waiting on pharmacy. - on 1/29/25 at 9:19 AM, waiting on payment authorization. - on 1/30/25 at 10:43 AM pharmacy is waiting on payment authorization. - on 1/31/25 at 2:29 AM, there was no provider documentation. - on 1/31/25 at 9:02 AM, on order. - on 2/1/25 at 12:51 PM, the medication was not given, the pharmacy was notified and stated they need a authorization form signed by our facility. The nurse is aware. - on 2/3/25 at 1:37 PM, not on hold, not in back up, awaiting authorization. - n 2/3/25 at 7:30 PM on order. - on 2/4/25 at 8:27 AM, med on order, and - on 2/5/25 at 8:31 AM, awaiting delivery, nurse aware. Continued review of Resident #3's EMR revealed, on 1/31/25 at 8:03 PM, in a Nurse Practitioner (NP) follow-up note, Staff #77, NP, wrote that Resident #3 was seen that day, the resident continued with lethargy and low blood pressure, the resident should be taking Rifaximin every day for hepatic encephalopathy. The NP wrote that, per the staff, the resident had not received Rifaximin, that authorization was needed because of the expense. The NP wrote s/he spoke with management and was told the medication was approved and the resident would receive it. The NP further wrote the resident's lethargy could be from not getting his/her prescribed Rifaximin. In a NP follow-up note on 2/3/25 at 11:17 PM, Staff #77, NP, wrote that Resident #3 was seen that day, the resident appeared lethargic, and his/her lethargy could be hepatic encephalopathy. The NP wrote that s/he spoke with the nurse, and the resident was not getting Rifaximin because the medication was not available, however staff had signed [in the MAR] that Rifaximin had been given to the resident. On 3/18/25 at 4:44 PM, during an interview, the above concerns were discussed with Staff #66, Attending Physician. At that time, Staff #66 stated he/she had not been aware that Resident #3 was not given Rifaximin as ordered, that s/he assumed the resident was taking the medication. Staff #66 also stated that the physician should be called any time a resident was out of medication, On 3/18/25 at 6:35 PM, the Director of Nurses (DON) and Nursing Home Administrator (NHA) were made aware of the concern that the facility failed to ensure prescribed medication was available to be administered, resulting in Resident #3 not receiving Rifaximin as prescribe. The DON & NHA acknowledged the concerns at that time, with no other comments offered. The surveyor then requested pharmacy documentation of when Rifaximin was dispensed and became available in the facility to give to Resident #3. On 3/19/25, the surveyor reviewed a pharmacy invoice that listed the medications the pharmacy dispensed to the facility for Resident #3 from 2/27/24 to 2/25/25. The pharmacy invoice documented the date Rifaximin 550 MG tablets were dispensed to the facility, the number of tablets dispensed on that date and the days the doses would cover as follows: - 6 tablets dispensed, for 3 days on 12/27/24. - 6 tablets dispensed for 3 days on12/30/24. - 6 tablets dispensed for 3 days on 1/3/25. - 8 tablets dispensed for 4 days on 1/7/25. - 8 tablets dispensed for 4 days on 1/13/25. - 28 tablets dispensed for 14 days on 2/5/25. - 28 tablets dispensed for 14 days on 2/20/25. The pharmacy invoice documented a total of 22 doses of Rifaximin were dispensed in January 2025, and Resident #3's January 2025 MAR, documented Rifaximin was given to the resident on 43 of 62 administration times scheduled in January. A concurrent review of the Rifaximin dispensing record and the resident's January MAR revealed staff documented Rifaximin was administered to the resident when the medication was unavailable in the facility on 18 of 43 scheduled administration times in January. Rifaximin was inacurately documented as given on 6 (1/7, 1/18, 1/20,1/24, 1/26, 1/27/25) administration times scheduled at 8:00 AM, and 12 (1/2, 1/6, 1/11, 1/17, 1/18, 1/19, 1/20, 1/21, 1/22, 1/25, 1/26, 1/29/25) administration times scheduled at 8:00 PM On 3/19/25 at approximately 1:00 PM, the DON was made aware of the concern with Resident #3 not being given Rifaximin as prescribed, and the concern with staff documenting the medication had been administered when there was no evidence the medication had been available to give. The DON acknowledged the concerns, and indicated she was aware of staff who may have falsely documented the medication administration in the MAR.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 3 nursing units observed during a complaint survey. The findings include: On 3/11/25 at 2:22 PM observation was made of an unlocked and unattended medication cart on the Homestead Unit, which is a locked memory care unit. The unattended medication cart was sitting next to the nurse's station which was adjacent to the dining/activity room. The top drawer of the medication cart was opened by the surveyor and observation was made of resident's medications and a pair of scissors on the left-hand side of the drawer. Subsequent drawers were opened by the surveyor and observation was made of anti-hypertensive, anti-psychotic, anti-depressants, and other varieties of medications. There were residents ambulating in the unit in the hallways and the dining/activity area. There was no nursing staff available in the unit. The surveyor stood at the medication cart until 2:29 PM when the AIT (Administrator in Training) came back to the unit and walked up and saw the medication cart and attempted to lock it while the surveyor stood there. At that time the surveyor asked where the nurse on the unit was. The AIT said he would get the unit manager (UM). He was asked again where the nurse on the unit was, and he said I'll get the unit manager. On 3/11/25 at 2:30 PM the unit manager walked up to the surveyor and the surveyor asked where the nurse on the unit was. UM #28 stated the nurse on the unit left early and the UM was responsible for 2 units. It was revealed that UM #28 was doing patient care on another nursing unit at the time. The surveyor informed UM #28 that the medication cart was left unlocked and unattended and the surveyor was able to open all the drawers. At that time UM #28 locked the medication cart. The Nursing Home Administrator and the Director of Nursing were informed on 3/11/25 at 4:45 PM.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected 1 resident

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Based on resident complaint, record review, and staff interview, it was determined that the facility staff failed to provide a resident with a bedtime snack and 3 meals daily. This was evident for 2 (#8, #10) of 44 residents reviewed for complaints during a complaint survey. The findings include: 1) On 3/10/25 at 9:30 AM an interview was conducted with Resident #8 who complained he/she was not always getting an evening snack. On 3/17/25 at 11:15 AM a review of complaint MD00204843 alleged Resident #8 had not been given any food the day before. Review of Resident #8's medical record revealed a physician's order for peanut butter crackers 3 times daily and as needed. On 3/18/25 at 11:06 AM Staff #30, the Dietary Director was interviewed and stated the resident received beer battered fish for breakfast, lunch, and dinner per his/her request along with peanut butter crackers. Staff #30 stated that there were a lot of times the resident would tell her that he/she didn't get fish, however the food cart would come back and the fish was in there. Staff #30 stated she would go back and warm it up and the resident would tell her that they don't give it to him/her but she couldn't prove that. Staff #30 stated there were a lot of times Resident #8 would call and ask for peanut butter crackers because the resident takes medication with the crackers. Staff #30 stated that the staff go down around 7 PM and take his/her snacks down. Staff #30 stated that she does hear that the snacks don't make it there and she will check the refrigerator and the snacks are still in the pantry on the floor. She stated, I am assuming they aren't passing them. My staff will bring back trays of nourishments. I have voiced my concerns about that to the administrator. She said this was happening in December 2024 and January 2025. On 3/18/25 at 5:15 PM the Nursing Home Administrator and Director of Nursing were informed of the issue with snacks being passed at night.2) On 3/11/25 at 2:14 PM, a review of complaint #MD00212207 alleged that on 2 days (11/24/23, 11/25/23) following Resident #10 admission to the facility, the resident was not provided with a meal. Following review of the complaint, a review of Resident #10's medical record revealed Resident #10 was admitted to the facility for rehab in November 2023 following an acute hospitalization for right knee patellar fracture and patellar tendon repair. The medical record documented Resident #10 had multiple diagnoses including hypertension, diabetes, COPD (chronic obstructive pulmonary disease). Review of Resident #10's November 2023 Documentation Survey Report revealed the intervention, Nutrition - amount Eaten which was followed by the times, 9:00 AM, Day (7-3), 1:00 PM, Day, (7-3) and 6:00 PM, Evening, (3-11) then followed by a space to document the percentage of the meal eaten by the resident during those times for each day of the month. The report documented that on 11/24/23 at 6:00 PM (evening, 3-11) Resident #10 consumed 75% of a meal. However, on 11/25/23, during 7 AM to 3:00 PM, there was no documentation to indicate the resident had eaten anything. On 11/25/24 at 9:00 AM Day, (7-3) and on 11/25/23. Day (7-3) the spaces to document the percentage of the meal eaten were blank, with no documentation to indicate Resident #10 consumed any portion of a meal, or beverage, with no documentation to indicate the resident had eaten a meal at those times. On 3/19/25 at approximately 8:30 AM, the surveyor asked Staff #30, Dietary manager for a copy of the meal tickets for any meals provided to Resident #10 on 11/24/23 and 11/24/23. On 3/19/25 at 9:00 AM, Staff #30 reported meal tickets for Resident #10 were not able to be printed for the resident for dates requested because the resident had been discharged from the facility. Staff #30 was made aware of the allegation that meals were not provided to Resident #10 on 11/25/23, and the concerns with no documentation to indicate the resident been provided breakfast or lunch on that day. Staff #30 acknowledged the concerns and indicated there was no evidence to indicate a meal had been provided to the resident on that date.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0840 (Tag F0840)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews with the administrator, the facility failed to make an appointment for a resident to have a sleep study done so a CPAP can be ordered for a diagnosis of sleep apnea. This is evident for 1 (#29) of 44 residents reviewed during a complaint survey. The findings include: On 3/10/25 at 11:18 AM a medical chart was reviewed for Resident #28. Resident was admitted [DATE] and discharged on 2/23/24. On 1/20/24 Doctor ordered a sleep study to be scheduled to rule out sleep apnea. The order was taken off by the former Director of Nursing, however the appt. was never made. I spoke to the current administrator who was not here during that time and has no information regarding Resident #28. The former DON is no longer here to discuss Resident #28 to see why apt. was not made. Resident was discharged to another facility on 2/23/24.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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Based on medical record review and interview, it was determined the facility staff failed to treat a resident with dignity (Resident #1). This was evident for 1 of 44 residents reviewed during a complaint survey. The findings include: Review of Resident #1's medical record on 3/10/25 revealed the Resident was admitted to the facility in October 2024 with a diagnosis to include disease of the spinal cord. Further review of Resident #1's medical record revealed the facility staff assessed the Resident on 12/17/24 to be dependent on care for showering/bathing. During interview with Resident #1 on 3/11/25 at 2:00 PM, Resident #1 stated recently he/she was left in the shower room naked and uncovered facing the door. Resident #1 went on to say he/she remembered 2 nursing assistants had placed him/her naked in a shower chair, turned on the water and left him/her uncovered when Nurse #22 needed them to help with a new admission. Resident #1 was not positive the names of the 2 nursing assistants but did remember GNA #71 is the staff member who discovered him/her. Resident #1 stated he/she did not like the way he/she was treated. During interview with GNA #71 on 3/12/25 at 3:04 PM, GNA #71 stated remembered Nurse #22 asking for her to help give Resident #1 a shower. GNA #71 stated when she went into the shower room the Resident was facing the door naked and uncovered. GNA #71 stated Resident #1 stated I don't know what happened but they left me like this but I am glad it was you that walked in. GNA #71 stated she proceeded to give the Resident a shower and afterwards told Nurse #22 they should have at least covered him/her up. GNA #71 then took the Surveyor to the shower room and showed how the shower chair and the placement of the shower chair were facing the door. During interview with Nurse #22 on 3/12/25 at 4:57 PM, he stated he remembered asking GNA #71 to assist Resident #1 in getting a shower due to getting a new admission. Nurse #22 also stated GNA #71 did tell him that the Resident was left in the shower uncovered. The findings were reviewed with the Administrator on 3/17/25 at 2:00 PM.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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Based on reviews of facility reported incidents, record review and interview it was determined the facility failed to have documentation of when the final report was submitted to the regulatory agency, Office of Health Care Quality (OHCQ) and failed to report allegations of abuse within 2 hours of the allegation to OHCQ. This was evident for 3 (#17, #8, #29 ) residents reviewed for 5 of 18 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 3/10/25 at 9:52 PM a review of facility reported incident MD00208337 was conducted and revealed Resident #17 was found to have a right hip fracture on 8/2/24. On 3/10/25 at 1:30 PM the NHA was interviewed and stated that she could only find the initial email confirmation of when the incident was sent to OHCQ which was on 8/2/24 at 9:07 AM. The NHA could not provide documentation as to when the final report was submitted to OHCQ. 2) On 3/10/25 at 10:10 AM a review of complaint MD00212393 was conducted and revealed a police officer came to the facility after being called by Resident #8. Resident #8 made an allegation to the police officer that he/she had been abused by staff on 11/1/24 at an unknown time. According to the police officer, the police officer notified RN #48 of the allegations. On 3/17/25 at 11:26 AM an interview was conducted with the NHA inquiring if a self-report had been sent to OHCQ regarding the incident. The NHA stated RN #48 did not notify her about the incident. 3) On 3/14/25 at 9:50 AM a review of facility reported incident MD00211056 was conducted and revealed Resident #8 alleged that he/she was assaulted by a GNA who handled him/her roughly on 10/16/24 at approximately 4:00 PM. Review of the investigative paperwork that was provided to the surveyor from the Nursing Home Administrator (NHA) revealed the NHA became aware of the incident on 10/20/24 at 3:43 PM via email and the former Director of Nursing (DON) became aware via email on 10/20/24 at 4:14 PM. Review of the email confirmation documented the initial report was submitted to OHCQ on 10/21/24 at 2:33 PM which was not within 2 hours of the alleged assault. On 3/14/25 at 10:15 AM an interview was conducted with the NHA. The NHA stated she reviewed the email when she and the former DON became aware of the incident. The NHA was informed that the report was not submitted to OHCQ within 2 hrs. The NHA stated she had been away for a couple of days and opened her email on a Sunday. The NHA was informed that the former DON responded to the email one half hour after being informed and she could have reported it to OHCQ if the NHA was off. 4) On 3/18/25 at 3:33 PM a review of facility reported incident MD00196064 was conducted and revealed Resident #29 was at the hospital for a medical condition and alleged to hospital staff that he/she was assaulted while sleeping on 8/21/23 while residing at the facility. On 3/10/25 at 12:10 PM the NHA stated she could not find the investigation file with the investigation, therefore it was unknown if the report was sent timely to OHCQ. The NHA stated she was not employed at the facility at the time. 5) A review of facility reported incident MD00187740 on 3/11/25 revealed on 1/1/23 GNA #75 reported she observed 2 unknown residents tied to chairs in the Homestead Unit. Futher review of the facility investigation revealed GNA #75 did not report this allegation to anyone until 1/8/23 when she reported to LPN #74 who encouraged the GNA to report to Administration. Further review of the facility investigation revealed GNA #75 did not report the incident and LPN #74 did not report the incident until 1/12/23 to the former Director of Nursing (Staff #76). Interview with the Administrator on 3/14/25 at 7:35 AM confirmed the facility staff failed to report an allegation of abuse to the Administration in a timely manner.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7) On 3/12/25 at 12:27 PM a chart review was conducted for Resident #21. According to facility report, resident reported , he/she was touched inappropriately on his/her butt by GNA a few days ago. Employee was suspended pending investigation, R.P. and Doctor notified, Ombudsman notified. Resident and staff interviews were obtained. A head to toe assessment was conducted and psyc services were contacted. Facility found that the reported incident did not occur as there was no evidence to prove this. On 3/12/25 at 1 PM this surveyor spoke with the administrator, who stated she has no incident report in regards to this. Resident stated during interview with him/her on 3/12/25 at 12:30 PM, this did not happen again as he/she has not seen the GNA since. 8) On 3/11/25 at 2:30 PM a record review was conducted for Resident #24. On 4/3/24, at approximately 2:30 AM the aide and nurse had heard yelling. They ran down the hallway and observed Resident #24 allegedly being punched in the face by another resident (#15). The residents were immediately separated. The aide observed blood coming from resident's mouth, a mark on the left side of his/her face and a scratch behind his/her left ear. There is no incident report , interviews or any other information connected to this. Administrator aware. 9) On 3/13/25 at 2:52 PM, a chart review was conducted for Resident #41. On 7/21/24, Resident # 39 had been wandering around the unit. Suddenly a nurse heard a screaming from outside room [ROOM NUMBER]B loudly telling resident to stay away from his/her room. Pt. was observed walking faster 2 rooms away from 321B room. 321B was also walking faster chasing the pt. and had tried to push her/him. Resident #15 in room [ROOM NUMBER]B was told to stop pushing her/him and needs to keep his/her hands off. Resident #15 in 321B screaming, stated pt. came into his/her room while he/she was watching TV. Resident #15 in 321B was told Resident #39 is confused that she/he did not know what she/he was doing but Resident #15 continued to screem to keep Resident #39 away from his/her room. No injury noted since nurse was able to de-escalated the situation. DON (Diecctor of Nursing) and Dr. was made aware of situation. Staff will continue to monitor Resident #39 and Resident #15 for the remaining of shift. Surveyor spoke to administrator on 3/13/25 at 3 PM, about incident report and administrator stated 'no incident report was done, and there are no interviews. 10) On 3/11/25 at 11:22 AM a medical chart review was conducted for Resident #39. On 7/21/24, Resident #39 went into Resident #15's room and got pushed out of the room by Resident #15. No injuries were noted to Resident #39. Resident #39's BIMS as of 7/2/24 was 10/15 which indicated moderate cognitive impairment. No incident report filed. Administrator was uaware of incident.11). Review of facility reported incident MD00184663 on 3/10/25 revealed on 10/7/22 the facility reported the smell of gas at the facility. Per the report the gas griddle was repaired and staff were educated. On 3/10/25 the Administrator was asked for any evidence of an investigation into the incident including interviews, repairs and education. Interview with the Administrator on 3/10/25 at 12:15 PM confirmed she began working at the facility in July 2024 and has no file or futher information of the incident. 12) Review of facility reported incident MD00206032 on 3/10/25 revealed on 5/24/24 the facility reported Resident #23 suffered a fall with injury. On 3/10/25 the Administrator was asked for any evidence of an investigation into the incident including interviews, audits and education. Interview with the Administrator on 3/10/25 at 12:15 PM confirmed she began working at the facility in July 2024 and has no file or futher information of the incident. Based on review of facility reported incidents, medical records, and staff interview, it was determined the facility failed to provide documentation that allegations of abuse, injuries of unknown origin, and a gas leak were thoroughly investigated. This was evident for 9 (#17, #8, #16, #29, #21, #24, #41, #39, #23) of 44 residents reviewed and for 1 facility reported incident that involved the kitchen during a complaint survey. The findings include: 1) On 3/10/25 at 9:52 AM a review of facility reported incident MD00208337 was conducted and revealed Resident #17 was found to have a right hip fracture on 8/2/24. On 3/10/25 at 1:30 PM the NHA (Nursing Home Administrator) was interviewed and stated that she could not find any paperwork regarding the incident. 2) On 3/10/25 at 10:10 AM a review of complaint MD00212393 was conducted and revealed a police officer came to the facility after being called by Resident #8. Resident #8 made an allegation to the police officer that he/she had been abused by staff on 11/1/24 at an unknown time. According to the police officer, the police officer notified RN #48 of the allegations. On 3/17/25 at 11:26 AM an interview was conducted with the NHA inquiring if a self-report had been sent to OHCQ regarding the incident. The NHA stated RN #48 did not notify her about the incident, therefore an investigation was not done. 3) On 3/10/25 at 10:12 AM a review of facility reported incident MD00208329 was conducted and revealed Resident #16 fell from a chair resulting in a fracture of the tip of the nasal bones. Review of the investigative packet that was given to the surveyor was void of an investigation. On 3/10/25 at 12:10: PM the NHA stated she could not find the investigation. She stated that she had just started at the facility and the previous Assistant Director of Nursing who handled the intake no longer worked at the facility. 4) On 3/10/25 at 11:16 AM a review of facility reported incident MD00204171 was conducted and revealed a Clinical Team Member received a text message on 4/1/24 at approximately 6:30 AM that stated Resident #8 had a bruise focal to the right wrist and the resident reported that the staff was rough during care on 3/30/24. Review of the facility's investigation revealed that 4 staff were interviewed, which included the accused geriatric nursing assistant (GNA) who did not work that day, a second GNA, and a licensed practical nurse (LPN). The 2 witnesses for the second GNA were not interviewed. There were no resident interviews from the unit where Resident #8 resided and no skin assessments from residents who were not interviewable. On 3/10/25 at 10:30 AM an interview was conducted with the NHA. The NHA confirmed that the investigation was incomplete and that she was not employed at the facility at that time. 5) On 3/14/25 at 9:50 AM a review of facility reported incident MD00211056 was conducted and revealed Resident #8 alleged that he/she was assaulted by a GNA who handled him/her roughly. Review of the facility's investigation revealed staff were interviewed about the incident, however there were no residents interviewed on the unit that would have been in the accused GNA's assignment. On 3/14/25 at 10:15 AM an interview was conducted with the NHA who confirmed there was no other documentation related to the incident. 6) On 3/18/25 at 3:33 PM a review of facility reported incident MD00196064 was conducted and revealed Resident #29 was at the hospital for a medical condition and alleged that he/she was assaulted while sleeping on 8/21/23. On 3/10/25 at 12:10 PM the NHA stated she could not find the investigative file with the investigation. The NHA stated she was not employed at the facility at the time and had looked through the office and files and could not find the paperwork.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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Based on medical record review and interview, it was determined the facility failed to provide ADL (activities of daily living) care for residents who were dependant for all ADL care. This was evident for 4 (Resident #11, #8, #1, #36) out of 44 residents reviewed for complaints during a complaint survey. The findings include : 1) On 3/10/25 at 10:30 AM a medical record review was conducted for Resident #11. Family made a complaint that resident had not been bathed or received showers. Resident #11 needs extensive assistance with all activities of daily living. On 6/15/24 Neurocognitive Health evaluated Resident #11. The resident was found he/she can be difficult with care. She/he cannot drink from a glass as she/he will spill into her/his food. She/he plays with toddler toys, and music keeps her/him calm. Resident #11 will independently lay on the floor. Resident behaviors are worse at night Resident #11 was Hallucinating during apt. with Neurocognitive health apt. on 6/15/24. According to care records, resident had 1 shower 8/13/24 am shift; Resident #11 did not have shower or bed bath on 8/10/24 , 8/11/24, 8/14/24, 8/15/24, 8/17/24, 8/18/24. There was no bathing recorded for eve or night shift. Turn and reposition was not done on the following dates: 8/9/24, 8/12/24, 8/16/24, 8/19/24 Night shift 8/12/24, and eve shift 8/9/24; 8/11/24; 8/15/24 Toileting not done on the following dates: 8/12/24; 8/16/24, 8/19/24 Eve 8/9/24, 8/11/24 and 8/15/24 Night shift 8/10/12 and 8/12/24 The administrator and the unit manager of the dementia unit were interviewed on 3/10/24 at 10 AM and asked if they knew anything about this and both stated they were unaware resident was not receiving care.4) On 3/13/25 at 8:30 AM, a review of complaint #MD00209282 alleged Resident #36 did not receive adequate care at the facility On 3/13/25 at 8:48 AM, during an Interview, Resident #36 reported that s/he was not always able to get a shower on his/her shower days, and that staff told him/her it was because there wasn't enough help. Resident #36 stated that s/he was able to wash him/herself, however, someone needed to put the resident in the shower, and they were supposed to stay in the room during his/her shower, in case the resident needed help. Resident #36 further stated that most of the time, the person who put him/her in the shower did not stay in the room during the resident's shower, and that once, when the aide didn't stay, the resident slipped in the shower and fell. On 3/13/25 at 3:30 PM, a review of Resident #36's medical record revealed Resident #36 resided in the facility for long term care since 2022, with diagnoses included muscle weakness and the resident used a wheelchair for mobility. A review of Resident #36's quarterly assessment with an assessment reference date of 12/22/24 documented that the resident had a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident was cognitively intact and the assessment documented Resident #36 required supervision or touching assistance to shower/bathe (wash, rinse, dry) self. Review of Resident #36's care plans, revealed a care plan, [Resident #36] has an ADL self-care performance deficit with the intervention, the resident requires set up assistance by 1 staff [for] bathing/showering On 3/13/25 at 3:40 PM, a review of Resident #36's March 2025 geriatric nursing assistant (GNA) Documentation Survey Report, the intervention ADL Shower, revealed Resident #36's shower days were Mondays and Thursdays, on dayshift, and documented that from 3/1/25 thru 3/13/25, Resident #36 had received only a shower on one (3/3/25) of 4 potential shower days. There was no documentation found to indicate Resident #36 received a shower on Thursday, 3/6/25, Monday 3/10/25 and Thursday, 3/13/24. The above concerns were discussed with the DON on 3/18/25 at approximately 6:45 PM. The DON acknowledged the concerns at that time with no further comments offered. 3) Review of Resident #1's medical record on 3/10/25 revealed the Resident was admitted to the facility in October 2024 with a diagnosis to include disease of the spinal cord. Further review of Resident #1's medical record revealed the facility staff assessed the Resident to be dependent on care for showering/bathing. During interview with Resident #1 on 3/11/25 at 2:00 PM, the Resident stated he/she is not receiving showers 2 days a week like he/she would like and can remember going 16 days straight in February without a shower. Review of Resident #1's Documentation Survey Report for showers on 3/12/25 for January, February and March 2025 revealed the facility staff has not documented any showers given to Resident #1. Interview with the Director of Nursing on 3/12/25 at 12:00 PM confirmed the facility staff has no documentation they provided showers twice weekly for Resident #1 in January, February and March 2025. 2) On 3/10/25 at 10:10 AM a review of complaint MD00212393 alleged that Resident #8 was not receiving bed baths as needed. A review of complaint MD00210139 alleged that Resident #8 was bed bound, and it was alleged that Resident #8, was filthy and receiving no care and that staff were refusing to give the resident bed baths. Review of Resident #8's medical record revealed the resident was admitted to the facility in March 2024 with diagnoses that included Ankylosing spondylitis (AS), which is a chronic inflammatory disease that primarily affects the spine, causing inflammation and potentially leading to the fusion of vertebrae, resulting in stiffness and reduced flexibility. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #8's 9/6/24 quarterly MDS assessment documented that Resident #8 was dependent on staff for all activitites of daily living care. Review of bathing records for Resident #8 documented that Resident #8 received a bed bath for 12 of 30 days in September 2024, 13 of 31 days in October 2024, 14 of 30 days in November 2024, and 12 of 31 days in December 2024. On 3/17/25 at 1:55 PM an interview was conducted with licensed practical nurse (LPN) #28. LPN stated that geriatric nursing assistants (GNA)s document if they give a shower or bed bath or if the resident refuses. LPN #28 stated that if a resident refuses a bed bath or shower then the GNAs were to tell the nurse, and the nurse was to document the refusal. On 3/18/25 at 7:05 AM an interview was conducted with the Director of Nursing (DON). The DON was asked if a resident was bedridden should a bed bath be offered or given every day. The DON stated that a bed bath should be given every day with AM care. If it is refused it should be documented. There should not be any blank spaces on the GNA documentation. Cross Reference F842 for all GNA documentation.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Facility staff failed to follow-up on a medication for a specific medical condition. On [DATE] at 1:00 PM a review of Resident #8's medical record was conducted and revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included Ankylosing spondylitis (AS), which is a chronic inflammatory disease that primarily affects the spine, causing inflammation and potentially leading to the fusion of vertebrae, resulting in stiffness and reduced flexibility. Review of Resident #8's [DATE] Medication Administration Record (MAR) documented Resident #8 was to receive the medication Enbrel via injection from a prefilled syringe every Monday for Pain. A [DATE] and [DATE] nursing note documented that the medication Embrel was not available from the pharmacy. Enbrel is a prescription medication that belongs to a class of drugs called tumor necrosis factor (TNF) inhibitors. It is used to treat autoimmune conditions such as Rheumatoid arthritis (RA), Psoriatic arthritis (PsA), Ankylosing spondylitis, and Plaque psoriasis. Enbrel works by blocking the action of TNF, a protein that plays a role in inflammation. By inhibiting TNF, Enbrel can reduce inflammation and improve symptoms in autoimmune conditions. A [DATE] progress note from the previous Director of Nursing (DON) documented that the previous Assistant Director of Nursing (ADON) contacted the pharmacy to find out when the Embrel was to arrive and the pharmacy indicated it was too soon to fill and denied by the resident's insurance. It was documented that upon investigation, it appeared that the last facility the resident was in filled it just prior to the resident going to the emergency room. The previous facility received 4 standard dose injections. The medication was placed on a hold due to the interaction the resident would have with being put on Amoxicillin, however the resident was to continue to take this medication as prescribed once discharged from the hospital. This is why insurance was denying it. The facility agreed to pick up the cost of one injection until the insurance was able to cover. Resident #8 received the Embrel injection on [DATE]. Continued review of Resident #8's medical record revealed he/she received the Embrel on [DATE], [DATE], and [DATE]. On [DATE] and [DATE] progress notes documented that the medication was not available and they were waiting for pharmacy. A [DATE] nurse practitioner (NP) note documented the Embrel was no longer authorized by insurance, therefore they had to prescribe a different medication. A [DATE] NP note documented that Naprosen was a first line medication that could be prescribed. The NP also offered to the resident to receive steroid shots and have consults with orthopedics. Resident #8 refused. On [DATE] the NP wrote a note which stated, I will order Enbrel 50 mg SC qwk (every week). I am unsure what the issue is/was with insurance approval. If need be, I am happy to provide documentation to the insurance company as to the necessity of this medication. After the [DATE] note there was no further documentation about trying to get the Embrel prescription filled and approved by insurance. There were physician progress notes that documented Resident #8 used to be on Embrel, however nothing about trying to get it covered for the resident. On [DATE] at 2:55 PM an interview was conducted with the Medical Director. The Medical Director stated he was still trying to figure out why Resident #8 has not been getting the Embrel. He said he would speak directly to the resident about it. The surveyor informed the Medical Director of the concern that there was no follow-up related to the medication and the Medical Director agree that there should have been follow-up. On [DATE] at 9:23 AM the Medical Director informed the surveyor that the Embrel was not preauthorized, and it dropped off and no one followed up on it. The Medical Director stated he would put the resident back in for the Embrel. The Medical Director stated, why [he/she] was not without it for the last year; I cannot say. It may prevent progression of hearing loss. [He/she] was on it for ankylosis to reduce the inflammation. There is nothing that stops it. The Embrel helps. On [DATE] at 5:15 PM the Nursing Home Administrator and the Director of Nursing were informed of the concern. Based on review of complaints, medical record review, and staff interview, it was determined the facility failed to properly perform neuro checks and document a change in condition for a resident following falls, failed to order oxygen for a resident, and failed to follow-up on medication for a specific medical condition. This was evident for 3 (#4,#26, #8) of 44 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #4's medical record on [DATE] revealed the Resident was admitted to the facility in [DATE] for rehabilitation following a 5 month hospitalization with a diagnosis to include delirium and respiratory failure. The facility staff failed to properly perform neuro checks after unwitnessed falls for Resident #4. A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. Review of Resident #4's medical record revealed the Resident had unwitnessed falls on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Further review of the Resident's medical record revealed after the initial assessment of the Resident there was no documented neuro checks of the Resident. Further review of Resident's medical record revealed no change of condition assessments were completed following the [DATE], [DATE], [DATE], [DATE], and [DATE] falls. A change of condition assessment would include the situation, vital sign evaluation, general background information, evaluations of mental status, functional, behavioral, neuro, skin and pain. It would also include a review of the findings and notification documentation to provider and representatives. Interview with the Director of Nursing on [DATE] at 2:45 PM confirmed the facility staff failed to complete neuro checks and changes of condition for Resident #4 from [DATE] until [DATE]. 2) The facility failed to obtain an order for oxygen on a regular basis or as need basis. On [DATE] at 10:40 AM a review of medical records was conducted. Resident #26 had a history of FX 2nd cervical vertebra, protein calorie malnutrition, MRSA and VRE resistant, Sepsis from complication of leg amputation done at the hospital [DATE], Disc degeneration, Chronic ulcer left stump, Dialysis, end stage renal disease, COPD (chronic obstructive pulmonary disease), HTN (hypertention), and is dependent for all ADLs (Activities of daily living). On [DATE] resident was brought to dialysis by aid. The aid stated to ombudsman that although resident wears 02 in his room she forgot to bring tank to dialysis. Nurse in dialysis noticed resident was slumped over in wheelchair and lips were blue. She placed 02 on resident and called 911 and resident was sent to the hospital. Dialysis nurse is no longer here to interview. There was no order for oxygen ongoing or PRN according to MDS staff #8. Resident also had severe sepsis related to MRSA and VRE infection resistant wound to the left amputated stump. Resident went to dialysis on [DATE] but did not go to dialysis [DATE] and [DATE] because he didn't feel well. On [DATE] resident had a pulse ox of 83% on room air. On [DATE], Resident passed away at the facility. The death certificates states resident died from cardiopulmonary arrest and end stage renal disease. Administrator is aware and stated ok.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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Based on review of complaint, medical record review, and staff interview, it was determined the facility's registered dietician failed to document assessments in the resident's medical record and the facility currently failed to have a registered dietician that came on site to see resident's to see and assess residents for their current nutritional needs. This was evident for 1 (Resident #8) of 44 residents reviewed during a complaint survey and had the ability to affect all residents that resided in the facility. The findings include: On 3/17/25 at 11:15 AM a review of complaint MD00204843 alleged Resident #8 had not been given dinner and that the resident weighed 79 pounds. Review of the weight section of Resident #8's electronic medical record documented the last weight recorded for Resident #8 was on admission to the facility, 3/1/24, and Resident #8 weighed 176 pounds. Resident #8 has refused weights since admission. Review of Resident #8's medical record revealed there have been no nutritional notes or nutritional assessments from 3/4/24 to 3/7/25. Further review of the medical record revealed Resident #8 only received fish for breakfast, lunch, and dinner per request and peanut butter crackers to be consumed when taking medication. On 3/17/25 at 3:01 PM an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated the previous dietician worked at the facility until September 2024 and that they only had a dietician that worked remotely. The NHA stated they were in the process of hiring a dietician that would come to the facility. The NHA stated the previous dietician resigned just after the NHA started working at the facility in July 2024. The NHA was informed there were no nutritional assessments documented in Resident #8's medical record from 3/4/24 to 3/7/25. On 3/18/25 at 7:30 AM an interview was conducted with the previous dietician, Staff #69. Staff #69 stated, I am surprised to know that there is no documentation. It is very surprising to me, and I cannot say one way or another. My practice, besides the initial assessment, is I would go and see them (the residents) and talk to them when they had an issue. [He/she] had a very specific diet that [he/she] followed, and I would do follow-ups every 3 months. If I had the time I did. I was full time until August. Staff #69 stated she did see Resident #8. Staff #69 was asked if she saw residents every 3 months and she said, I would say not always able to keep up with seeing residents every 3 months. I don't know if I did or not. There was a lot of turnovers. I tried to keep up. I left because I couldn't keep up and there wasn't enough time, and I felt I was not the best fit for that position. I couldn't get to all the documentation and see the residents as they needed to be seen. I was pulled into the kitchen countless times, working the tray line and managing the tray line. I would always go for what was immediately needed. On 3/18/25 at 5:15 PM the Nursing Home Administrator and the Director of Nursing were informed of the concern.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on review of complaints, interview, and medical record review, it was determined the facility failed to provide timely medication to meet the needs of the residents. This was evident for 3 (#18, #8, #5) of 44 residents reviewed during a complaint survey. The findings include: 1) On 3/10/25 at 8:16 PM a review of Resident #18's medical record revealed Resident #18 did not receive the medication Escitalopram 20 mg. on 3/9/25 and 3/10/25 for depression due to the medication being on order. On 11/27/24, 11/28/24, 11/29/24, and 11/30/24, Resident #18 did not receive the transdermal patch Nicotine for smoking cessation and the patch was on order. On 3/13/25 at 8:28 AM an interview was conducted with Licensed Practical Nurse (LPN) #36. LPN #36 was asked what she did if a medication was not available. LPN #36 stated she would call the provider and let them know that the medication was not available or to see if they wanted to order an alternative. First I check the cubex. If it is a medication that requires prior authorization the DON (Director of Nursing) will handle and fax over to pharmacy. On 3/13/25 at 8:30 AM an interview was conducted with Certified Medicine Aide (CMA) #37. CMA #37 stated she would let the nurse know and she would see if she could get the medicine out of PIXUS system and put it in for a reorder. CMA #37 stated, I normally do re-orders 5 days prior to running out. Some do 8 days, 5 days, or 2 days prior to running out. Depends on the medicine aide. On 3/13/25 at 8:35 AM an interview was conducted with CMA #38 who stated, I check the bottom of the cart, tell the nurse, call the pharmacy, and then put in a 9 and document. We have had issues with the pharmacy. I usually reorder 2 weeks out. 2) On 3/17/25 at 11:15 AM a review of complaints received from Resident #8 alleged that in February 2025 the resident's Naproxen (2) 250 mg. tablets for pain were not available. Review of emar (electronic medication administration record) notes documented the Naproxen was on order 2/7/25 at 10:00 PM and not available. A 2/8/25, 2/9/25, 2/11/25, 2/12/25, 2/13/25, 2/14/25, and 2/15/25 documented awaiting delivery. Further review of Resident #8's medical record revealed in April 2024, Zinc 50 mg. was not available on 4/17/24 as awaiting delivery from pharmacy along with Garlic 0.5 mg. On 4/19/24 Vitamin D3 and Garlic 0.5 mg were not available, and the nurse was following up with the medication. On 4/20/24 Vitamin D3 and Garlic 0.5 mg were being followed up by the nurse and not available. On 4/22/24, 4/23/24, and 4/25/24 the medication was on order and awaiting pharmacy. The 4/25/24 note documented, this medication will be in on 4/26/24 per the pharmacy. On 3/18/25 at 6:30 PM the concern was discussed with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) who stated they were working on the issue. 3) On 3/12/25 at 5:30 PM a review of complaint MD00213409 alleged that Resident #5 was having a hard time receiving medications that were prescribed. Review of Resident #5's medical record revealed a medication administration note dated 10/4/24 that documented the medication Gilenya 0.5 mg for multiple sclerosis was on order and not available. The pharmacy was called to confirm reorder. On 10/6/24 a note documented Oxycontin 10 mg. was not given as it was not available and awaiting pharmacy. A 10/7/24 documented Oxycontin 10 mg, medication not yet received by pharmacy. A 12/19, 12/20, 12/21, 12/22, 12/23, and 12/25/24 notes documented the medication Gilenya 0.5 mg was on order and the pharmacy was awaiting for prior authorization form from the facility. A 12/26/24 and 12/27/24 note documented, medication is currently not available. Confirmed with pharmacy that medication is on order but pending a prior authorization form from the facility. The situation has been communicated to the ADON and Unit Manager for further follow-up and resolution. A second note dated 12/27/24 documented, prior auth faxed for Fingolimod (Gilenya) sent today. A 12/29/24 note documented, medication on order. Pharmacy contacted; delay due to pending prior authorization form from the facility. A 12/31/24 note documented, Medication on order. Pharmacy contacted; delay due to pending prior authorization from the facility. ADON and NP made aware. The facility failed to have a process in place to ensure that medications that required preauthorization forms were followed up on timely. On 3/18/25 at 6:30 PM the concern was discussed with the DON and NHA.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on review of resident council minutes, observations and interviews, the facility staff failed to prepare and serve food that was palatable, attractive and at a safe and appetizing temperature. This was evident for 5 (#9, #41, #42, #43, #36) of 44 residents interviewed and during a test tray observation during a complaint survey. The findings include: 1) During interview with Resident #9 on 3/11/25 at 7:00 AM, Resident #9 complained the food was bad and not getting what is on the menu. The Surveyor noted the menu posted on the Chesapeake Unit stated lunch was salisbury steak, parsley potatoes, butter carrots, dinner roll and vanilla pudding. Observation of Resident #9's lunch meat tray ticket on 3/11/25 at 12:20 PM said diet: bite sized, double portion. Observation of Resident #9's lunch tray at that time revealed it contained ground up meat with gravy, diced hash browns and vanilla pudding. The tray did not contain carrots or any vegetable or a dinner roll. The Dietary Manger was brought to the Chesapeake Unit to observe Resident #9's lunch tray on 3/11/25 at 12:40 PM and confirmed the meat was ground and it did not contain a vegetable or roll. 2) Interview with Resident #42 on 3/11/25 at 12:30 PM, Resident #42 stated he/she does not get what he/she orders. The Surveyor returned on 3/11/25 for dinner service and the Resident stated he/she ordered Kielbassa and mashed potatoes but instead the Surveyor observed Resident #42 was served what appeared to be a piece of Salisbury steak with gravy and cabbage on the side. The Surveyor observed Resident #9 (Resident #42's roommate) was served Kielbassa and mashed potatoes. Interview with Resident #42 on 3/11/25 at 6:15 PM, Resident #42 stated when you are in a place like this you look forward to getting your meals but not here since I never get what I asked for. 3) Interview with Resident #43 on 3/14/25 at 11:25 AM, the Resident stated he/she is unhappy with the taste of the food and that is cold when it is supposed to be hot. 4) Interview with Resident #41 on 3/17/25 at 11:00 AM, the Resident stated he/she is tired of not getting what he/she orders and that the food is cold. 5) The Surveyor reviewed 4 recent Resident Council Meeting minutes provided by the Administrator. Review of the Resident Council Meeting minutes on 9/26/24 the residents complained the trays were brought out late, cold and sometimes the wrong food on trays. In the 11/22/24 Resident Council meeting residents discussed food being served cold and frozen on the weekends and that is not on the resident's menus. In the 1/16/25 Resident Council Meeting minutes the residents discussed proper food is not being put on the trays and they are not getting what they ask for on the menus. In the 2/27/25 Resident Council Meeting minutes the residents discussed cold food being served at meals and residents not getting the food they filled out on the menus. 6) On 3/17/25 at 12:58 PM the Surveyor did a temperature reading of a test tray with the Dietary Manager present. The Surveyor waited on the Chesapeake Unit and when the dining cart arrived the Surveyor immediately pulled a regular tray and checked the temperatures. Noodles with a beef gravy had a temperature of 119 degrees and mixed vegetables had a temperature of 104 degrees. Hot foods are to be served at 135 degrees. The Surveyor reviewed the findings with the Administrator on 3/17/25 at 2:00 PM. 7) On 3/13/25 at 8:48 AM, during an Interview, when asked if s/he had any concerns with the meals provided by the facility, Resident #36 stated the food provided by the facility tasted good, however what is on the tray is not always what you wanted, and the food was usually cold. Resident #36 stated that residents fill out daily menu papers and select the food they would like at each meal, and stated that most of the time, the food was what you ordered. Resident #36 stated that the food tasted good, however it was usually cold and it's not what you wanted. The above concerns were discussed with the Director of Nurses (DON) on 3/18/25 at approximately 6:45 PM. The DON acknowledged the concerns at that time with no further comments offered.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observations and interviews with staff it was determined that the facility failed to store food and monitor temperatures in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: Due to multiple complaints of food quality, the Surveyor began a kitchen tour with the Dietary Manager on 3/17/25 at 9:20 AM. At that time the Surveyor observed the following concerns and the Dietary Manager confirmed: In the dry storage area was a large bag of cornmeal on the bottom shelf. The bag had a ripped open area that was not sealed. 4 large containers of dry goods located on the floor labeled thick it, flour, panko and sugar. None of the 4 large containers were dated to be able to determine how long the dry goods had been in the bins. A plastic container of walnuts had a crack in it, not allowing it to be sealed. In the freezer was a tray of 16 individual plastic containers of sherbert that were not dated. The sink next to the food prep area did not contain soap. Review of the temperature logs revealed no daily temperatures recorded for the reach in refrigerator, walk in refrigerator and freezer daily from 3/1 through 3/17/25. During interview with the Dietary Manager at that time, the Dietary Manager stated I told staff they need to record the temperatures here daily. Follow up interview with the Dietary Manager on 3/17/25 at 9:35 AM, the Dietary Manager stated the cook recorded the temperatures in a notebook and accidentally took the notebook home yesterday. The findings were reviewed with the Administrator on 3/17/25 at 10:20 AM.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On [DATE] at 11:15 AM a review of Resident #8's medical record revealed geriatric nursing assistant (GNA) tasks for bathing. Review of bathing records for Resident #8 documented that Resident #8 received a bed bath for 12 of 30 days in [DATE]. Review of the geriatric nursing assistant (GNA) bathing task for [DATE] revealed blank spaces for the 7-3 shift on 9/1, 9/4, 9/5, 9/6, 9/8, 9/9, 9/11, 9/16, 9/18, 9/19, 9/21, 9/22, 9/23, 9/24, 9/25, 9/27, and [DATE]. There were blank spaces for the 3-11 shift on 9/2, 9/8, 9/9, 9/11, 9/13, 9/17, 9/18, 9/20, 9/23, 9/26, and [DATE]. There were blank spaces for the 11-7 shift on 9/2, 9/11, 9/14, and [DATE]. Review of bathing records for Resident #8 documented that Resident #8 received a bed bath for 13 of 31 days in [DATE]. Review of the GNA bathing task for [DATE] revealed blank spaces for the 7-3 shift and there were 7 days of documented refusals. There were no bed baths documetned on 10/1, 10/3, 10/4, 10/5, 10/10, 10/11, 10/12, 10/13, 10/14, 10/15, 10/16, 10/18, 10/19, 10/21, 10/22, 10/29, 10/30, and [DATE]. There were blank spaces for the 3-11 shift for 10/1, 10/4, 10/10, 10/14, 10/15, 10/18, 10/19, 10/21, 10/26, and [DATE]. There were blank spaces for the 11-7 shift for 10/3, 10/4, 10/5, 10/9, 10/10, 10/14, 10/16, 10/18, 10/23, and [DATE]. Review of bathing records for Resident #8 documented that Resident #8 received a bed bath for 14 of 30 days in [DATE]. Review of the geriatric nursing assistant (GNA) bathing task for [DATE], there were blank spaces for the 7-3 shift on 11/3, 11/8, 11/16, 11/17, 11/21, 11/22, 11/24, and [DATE]. There were blank spaces for the 3-11 shift for 11/1, 11/2 11/,3 11/6, 11/13, 11/14, 11/15, 11/16, 11/20, 11/21, 11/29, and [DATE]. There were blank spaces for the 11-7 shift for 11/16, 11/25, 11/26, 11/27, 11/28, 11/29, and [DATE]. Review of bathing records for Resident #8 documented that Resident #8 received a bed bath for 12 of 31 days in [DATE]. Review of the geriatric nursing assistant (GNA) bathing task for [DATE], there were blank spaces for the 7-3 shift on 12/4, 12/6, 12/12, 12/15, 12/24, 12/25, 12/26, 12/27, 12/29, and [DATE]. There were blank spaces for the 3-11 shift for 12/2, 12/4, 12/8, 12/10, 12/14, 12/15, 12/19, 12/21, 12/24, 12/25, 12/28, 12/29, 12/30, and [DATE]. There were blank spaces for the 11-7 shift for 12/1, 12/2, 12/4, 12/9, 12/11, 12/12, 12/13, 12/16, 12/19, 12/20, 12/21, 12/24, 12/27, 12/28, 12/29, 12/30, and [DATE]. On [DATE] at 1:55 PM an interview was conducted with LPN #28. LPN stated that GNAs document if they give a shower or bed bath or if the resident refuses. LPN #28 stated that if a resident refuses a bed bath or shower then the GNAs were to tell the nurse, and the nurse was to document. On [DATE] at 7:05 AM an interview was conducted with the Director of Nursing (DON). The DON was asked if a resident was bedridden should a bed bath be offered or given every day. The DON stated that a bed bath should be given every day with AM care. If it is refused it should be documented. There should not be any blank spaces on the GNA documentation. 4) On [DATE] at 9:52 PM a review of facility reported incident MD00208337 was conducted and revealed Resident #17 was found to have a right hip fracture on [DATE]. Resident #17 was sent to the hospital on [DATE] and according to the facility and the census tab of the electronic medical record, Resident #17 never returned to the facility. Review of Resident #17's progress note section of the medical record revealed a [DATE] at 6:43 AM administration note documented, sent to ER. Review of a [DATE] at 16:01 (4:01 PM) physician's progress note doumented the resident was seen on [DATE] and documented, chief complaint and documented that the resident was sent to the ER from the facility on [DATE] s/p fall and had a mildly displaced femoral neck fracture. The family preferred conservative management. The patient was without complaints. The note had a history, medications, review of systems, and assessment and plan. The document was signed by Physician #66. Review of a [DATE] at 9:24 AM physician's progress note documented a date of service [DATE] as a discharge note and that Resident #17 had expired at 2:26 PM. Death certificate completed. On [DATE] at 8:37 AM an interview was conducted with the MDS Coordinator and she was asked why she did not do a reentry on Resident #17 when the resident came back from the hospital. The MDS Coordinator reviewed Resident #17's medical record with the surveyor and confirmed the physician's note of [DATE] was not for the resident seen at the facility as the resident never returned from the hospital. The physician then wrote a note for [DATE] that said the resident had expired. The MDS Coordinator stated it was the wrong resident. On [DATE] at 4:10 PM an interview was conducted with Physician #66 and he was asked how he saw Resident #17 on [DATE] at the facility when the resident was never readmitted to the facility from the hospital. Physician #66 looked extensively in his phone and at first kept insisting that he saw the resident. Physician #66 continued to look at the electronic medical record system and said there must have been 2 people with a similar last name. Physician #66 was adamant that when he did the death certificate that he took that very seriously and put the note in the resident's chart. The surveyor asked Physician #66 if Resident #17 was admitted to the sister facility and he just documented in the wrong system. Physician #66 looked at the sister facility's electronic system from his phone and stated Resident #17 was not admitted there. There were no other facility's that Physician #66 went to. Physician #66 stated, the only explanation is that I put it in about another patient. It was an innocent mistake. It is not something I take lightly. The software we use there are names that are similar. I must have mixed up with another patient. On [DATE] at 4:48 PM the Nursing Home Administrator stated she found out Resident #17 was re-admitted to their sister facility and passed away there. Physician #66 was informed and stated he must have clicked on the wrong facility when he wrote the notes. Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 4 (#30, #4, #8, #17 ) of 44 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) Review of Resident #30's medical record on [DATE] revealed the Resident was admitted to the facility in [DATE] and left the faciity on [DATE]. Further review of the Resident's medical record revealed no note or assessment at discharge to include where the Resident was discharged to and Resident's status at discharge. Interview with the Director of Nursing on [DATE] at 5:28 PM confirmed the facility staff failed to document the discharge of Resident #30 on [DATE]. 2) Review of Resident #4's medical record on [DATE] revealed the Resident was admitted to the facility in [DATE] and left the faciity on [DATE]. Further review of the Resident's medical record revealed no note or assessment at discharge to include where the Resident was discharged to and Resident's status at discharge. Interview with the Director of Nursing on [DATE] at 2:45 PM confirmed the facility staff failed to document the discharge of Resident #4 on [DATE].

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the resident call bell system in working order. This was evident for 1 of 4 nursing units during a complaint survey. The findings include: During investigation of a complaint of non-working call bells on the Homestead Unit, the Surveyor began a tour with Staff #11 on 3/10/25 at 1:15 PM of the Homestead Unit. The following occupied rooms were observed to not have a functioning call bell: 300A, 300B, 301A, 301B, 302A, 302B, 303A, 303B, 304A, 305A, 305B, 306B, 307A, 307B, 310A, 310B, 312A, 312B, 313B, 315A, 315B, 316A, 316B, 317A, 317B, 318A, 318B, 319A, 319B, 320A, 320B, 321A, 321B, 322A and 322B. room [ROOM NUMBER]B had a manual call bell on top of a dresser but was not in reach of the Resident. No other rooms had manual bells at the residents' bedside. Interview with the Administrator on 3/10/25 at 1:30 PM confirmed the call bell system is not in working order on the Homestead Unit and no contractor is currently in the building working on the call bell system.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and documentation review, it was determined the facility failed to have an effective pest control program as evidenced by numerous flies and gnats seen in the kitchen and parts of the facility along with ants. This was evident on 2 of 2 days observed during a complaint survey. The findings include: On 6/16/25 at 9:30 AM observation was made of several gnats and a fly in the conference room. On 6/16/25 at 9:27 AM observation of the laundry room in the washer area and dryer area with Staff #9 present revealed multiple flies and gnats. At that time there was standing water on the ground between and behind the washing machines. On 6/16/25 at 1:25 PM observation was made of flies in the kitchen over the food preparation area. The flies were hanging on 2 black electric cords that were hanging down from the ceiling over the food serving station and there were flies flying over the food. There was a minimum of 12 flies seen at that time. The surveyor then went into the kitchen general storage area and the dry storage area where gnats were observed. Staff #26 stated the flies were bad and had been in the kitchen for a while and hoped that something would be done about it. On 6/16/25 at 1:30 PM the Dietary Manager was interviewed and said pest control was just out on 6/10/25 and treated. The Dietary Manager showed the surveyor a copy of the pest control log which documented the pest control company came out, however there were no reports of pests, so they treated the baseboards. According to the pest control log, the previous time the pest control company was in the kitchen was 5/13/25. On 6/16/25 at 2:07 PM observation was made of an ant in the hallway outside of the conference room door adjacent to the staffing office. The Nursing Home Administrator was shown the ant at that time. On 6/17/25 at 11:15 AM observation was made in the soiled section of the laundry room of an open trash can with a used yogurt container with at least 12 gnats and flies that were swarming around the container and the laundry area. At that time the Nursing Home Administrator (NHA) was present and said, why is a trash can in the middle of the laundry room? On 6/17/25 at 11:25 AM an interview was conducted with Staff #7 the Regional Maintenance Director. Staff #7 stated that there were pest control logs at the receptionist desk and at nurse's stations. Review of pest control log revealed the pest control company was coming to the facility every 2 weeks. Staff #7 confirmed that there was a pest control problem and that the pest control company should have been coming to the facility more frequently.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 3/18/25 at 7:00 AM a review of complaint MD00208729 alleged that in July and August 2024 there were no washcloths, and the staff were tearing up bed sheets to use as washcloths. Review of complaint MD00204843 alleged there were no linens for bathing or incontinence care in January 2025. A review of the 2/27/25 resident council meeting minutes documented that minutes of previous council meeting were: EVS (environmental services) not bringing residents clothes back to residents after they are washed. New business was, residents do not get wash towels when they ask aides for them. A review of the 11/22/24 resident council meeting minutes documented, clothes not being given back from laundry, clothes not being picked up from laundry. A review of the 9/26/24 resident council meeting minutes documented, Residents complained of not getting their laundry back for extended periods of time. On 3/18/25 at 7:20 AM an interview was conducted with the Environmental Services Manager, Staff #7. Staff #7 was asked if there was a linen shortage and he stated, yes, earlier this year. Being able to order enough linen due to rips and stains. We have a budget. We had enough but didn't have enough to keep up. We have linen based of off census. On 3/18/25 at 7:30 AM an interview with geriatric nursing assistant (GNA) #55 revealed, we are always short linen. On 3/18/25 at 9:12 AM an interview was conducted with GNA #19 and GNA #20 who stated, we have linen issues all the time. We come in and there is no linen until 10:00 AM. At least every other day it happens. We had to cut up towels sometimes to use as washcloths. We have complained to upper management. It has been going on for at least the last 6 months and longer. If a resident has a blowout you have to go to another unit to get linen. There are not enough washcloths. We get two washcloths every day per person. Once a shift is when we get linen, and it runs out quickly. On 3/18/25 at 9:15 AM an interview of GNA #57 revealed, linen is a struggle. In the morning there is none left. They are only working with 1 dryer and 1 washer. We run out a lot. We have to go down to laundry and get the linen. On 3/18/25 at 9:18 AM an interview with GNA #18 and GNA #15 was conducted. They stated, some days are better than others and then some days we barely get any linen. We are short washcloths, towels, and fitted sheets. We barely get 1 washcloth per person. We may get 6 washcloths each and then we have to use a towel, half as a washcloth and the other half to dry. This has been going on for the past 6 months to a year. On 3/18/25 at 9:45 AM an interview was conducted with Staff #58. Staff #58 stated, we only have 1 working washing machine and 1 working dryer. It is off and on. There are 4 washers and 4 dryers. Someone is here today working on them. This has been going on for at least 2 months. There are supposed to be 2 to 3 washcloths per patient. On 3/18/25 at 9:47 AM an interview was conducted with Staff #59. Staff #59 stated that the issue with linen, has been going on for a while now, greater than 6 months. There currently is 1 working washing machine and 1 working dryer. Someone came last week, when surveyors entered the building, and ordered a part and are back today to fix it. Staff does complain about being short on linen. It is a problem between being short linen and only 1 machine working at a time. The residents complain that their personal clothes are taking longer to get back. The turnover is supposed to be 72 hours, but it may take longer. We have to take turns using the machines. We have to have the linen carts ready by 3 for the next shift. The 11-7 shift is out of luck. Trying to get linen out but there is not enough for the 11-7 shift. On 3/18/25 at 9:48 AM observation was made of the washing machines in the laundry room. There was only 1 machine that was in use. There were repair men in the room working on the other machines. On 3/18/25 at 9:50 AM the surveyor asked Staff #7 and Staff #34 how long the problem with the washing machines and dryer had been going on and they both looked at the surveyor. The surveyor asked, a while and they both shook their heads yes. The Surveyor said, budget issues and both looked and shook their heads, yes, in agreement. On 3/18/25 at 5:15 PM the Nursing Home Administrator and the Director of Nursing were informed of the concern. Based on observation of resident rooms, staff interview, review of a complaint, and review of resident council meeting minutes, it was determined the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and provide necessary linens for the residents. This was evident on 4 of 4 nursing units observed during a complaint survey. The findings include: 1) During a tour with Staff #11 on 3/10/25 of the Homestead Unit, the Surveyor noted along with a non-working call bell system, the rooms also were in need of repairs. The Surveyor began a tour with Staff #11 on 3/11/25 at 10:30 AM of the Homestead Unit. The Surveyor with confirmation from Staff #11 noted the following observations: room [ROOM NUMBER]-ripped fall mats, wallpaper coming off the wall room [ROOM NUMBER]-ceiling tile cracked over the toilet room [ROOM NUMBER]-corner of heater vent loose exposing pipes and insulation room [ROOM NUMBER]-air conditioner had peeling electric tape around the system room [ROOM NUMBER]-no mirror above the sink, cracks in wall above heater, rusted ceiling vents room [ROOM NUMBER]-call bell out of the wall with wires exposed, heater vent cover loose room [ROOM NUMBER]-tile missing on floor, hole in drywall, light bulb out above toilet, fan rusted room [ROOM NUMBER]-hole in dry wall, wall in disrepair around sink leaving exposed wood room [ROOM NUMBER]-corner of heater vent loose, molding coming off wall, hole in ceiling tile room [ROOM NUMBER]-broken tile around bathroom sink, corner of heater vent loose room [ROOM NUMBER]-corner of heater vent loose, stained ceiling tiles room [ROOM NUMBER]-corner of heater vent loose room [ROOM NUMBER]-molding loose room [ROOM NUMBER]-corner of heater vent loose room [ROOM NUMBER]-holes in wall, air conditioner had peeling electric tape around the system, black colored markings noted around air conditioner, wall paper and ceiling/wall room [ROOM NUMBER]-corner of heater vent loose, paint chipping room [ROOM NUMBER]- air conditioner had peeling electric tape around the system, uncovered outlet room [ROOM NUMBER]-corner of heater vent loose, stains on ceilings Activities Room-cover to outlet off, molding in disrepair around sink Common Area in front of nursing station-noted black colored markings on ceiling tiles The findings were reviewed with the Administrator on 3/11/25 at 11:15 AM. At that time the Administrator stated Staff #11 had also confirmed the findings with the Administrator.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation review, resident council meeting minute reviews, staff and resident interviews, and observation, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 10 of 42 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, multiple staff interviews, 3 of the 4 resident council meeting minutes reviewed and review of staffing schedules and employee time punches. This deficient practice had the potential to affect all residents. The findings include: 1) Ten out of forty-two complaints that the Office of Health Care Quality (OHCQ) received and reviewed on this survey alleged the facility did not have sufficient nursing staff to provide essential care to the residents that resided at the facility. Complaints consisted of geriatric nursing assistants (GNAs) having 15 to 30 residents to take care of during any given shift. There were concerns that the residents were not receiving timely care, were not receiving showers and bed baths, call bells were not answered timely, and resident food was cold because staff did not pass out to residents in a timely manner. 2) Review of the Resident Census and Conditions CMS 672 form that was given to the surveyor from the Director of Nursing indicated that 97 of the 114 residents in the facility were either totally dependent on nursing staff for toileting or required the assistance of one or two nursing staff for assistance with toilet use. It was also documented that 100 of the 114 residents in the building were dependent on staff for bathing, 97 residents were totally dependent or required assistance of 1 to 2 staff for dressing, 102 residents required assistance for transferring, and 72 of the 114 residents were either totally dependent or required assistance of 1 or 2 staff members for eating. There were 61 residents documented with occasional or frequent incontinence of the bladder and bowel. There were 20 residents with a pressure ulcer greater than stage 1 and 7 of those were acquired in house with 81 residents receiving preventive skin care. There were 19 residents that had behavioral healthcare needs. 3) A review of Resident Council Meeting minutes dated 2/27/25 documented the concerns of GNAs not answering call bells as old news. A review of the 1/16/25 Resident Council Meetings documented old business as, nursing staff being short and the residents not getting proper care. New business for the month included, nursing staff being short, not enough nurses to care properly for the residents, nurses cutting off call bells without addressing the concern of the resident and putting double diapers on residents. A review of the 11/22/24 Resident Council Meeting Minutes documented old business as, call bells being on for extended amounts of time. A review of the 9/26/25 Resident Council Meeting Minutes documented old business as, lack of staff, nurses/aides lack of quality of care, and call bells going unanswered. New business documented, it has been reported and acknowledged by the department heads that on September 26th that there has been a shortage of GNA's and CNA's which led to residents not being got up out of bed as sufficiently as residents would like, soiled linen being left in the resident rooms and trays being left on the cart for extended amounts of time causing food to be cold, when resident eat and when residents ask the aides to warm the food up in the kitchen, the food is not being warmed up. 4) Staff interviews: a) On 3/10/25 at 9:08 AM Staff #4 stated, staffing is not good. Sometimes there is only 1 GNA. There are increased falls and increased fights with residents. b) On 3/10/25 at 9:10 AM an interview with Staff #5 stated, staffing is not great. Sometimes we can't even get started until after 7:30 AM. We have at least 12 to 15 residents. It is a lot. c) On 3/10/25 at 9:12 AM Staff #18 stated, a lot of the time we work short. Most of the time there are just 2 of us. We have 17 to 18 residents each on day shift. We can't do a full bath. It is usually a partial bath and then we have to document. There are a lot of behaviors, and we have to redirect the residents. d) On 3/10/25 at 9:44 AM observation was made of the breakfast cart sitting in the 200 hallway. Resident #8 had complained of not receiving breakfast yet. An interview was conducted with Staff #20. Staff #20 stated, there are only 2 aides, and we have to take residents to dialysis and there is no one else to pass trays to 30 some people. That is the norm. We can't get to everything. e) On 3/10/25 at 3:55 AM Staff #21 stated they work short, and it is a problem when they need 2 people when using the Hoyer lift and need to spot each other. Staff #21 stated they could have 10 to 15 residents depending on the unit. f) On 3/11/25 at 9:35 AM Staff #16 stated that staffing is sometimes good and sometimes bad. Staff #16 stated that on the rehab unit a GNA typically has 15 patients on day shift. Staff #16 stated, last week there was a call out and I was by myself on the floor for 30 patients with an orientee until lunch time. g) On 3/11/25 at 9:40 AM Staff #15 stated, staffing is terrible. We can't give showers and cannot get enough time to get the residents clean. We have between 16 and 17 residents each. The residents don't just have dementia. They have psych issues, behaviors, and it clashes with the dementia residents. When we are short we don't get a break and can't get to some of the people until after lunch. h) On 3/11/25 at 1:00 PM Staff #19 stated they work short staffed. We can't give adequate care. There are just 2 of us for 30 residents during the day so that is 15 residents each. If there are only 2 of us on dialysis days then showers can't get done. i) On 3/17/25 at 8:55 AM Staff #44 stated, staffing, it is horrible. You work short. Normally on Chesapeake 3-11 or 11-7 we have 2 aides or 1 ½ and 1 might have 19 people. I work on Chesapeake and Wye Oak. Realistically, residents do not get turned every 2 hours. j) On 3/17/25 at 12:30 PM, during an interview, Staff #46 stated that there wasn ' t always enough staff to get her work done. Staff #46 reported that today the GNA ' s had 15-16 residents each to care for, they had to get residents ready for therapy and it also was a dialysis day. Staff #46 stated that on dialysis days, there was supposed to be someone to transport the residents back and forth to dialysis, but today, and most of the time they didn ' t have anyone to do this, so the aides had to transport their own residents. Staff #46 stated that when there is not enough staff, she can ' t give her residents showers and can ' t finish documentation. Staff #46 reported she had worked other shifts, and she thought they needed more staff on dayshift. k) On 3/17/25 at 3:40 PM Staff #53 was interviewed and asked about the note of 2/20/25 in Resident #8's medical record where it was documented, b/p (blood pressure) not obtained due to staffing. Staff #53 stated, we didn't have enough GNAs on the floor and [he/she] was not in favor of me. When you make accusations - I'm not going in there. [He/she] tells me I am harassing [him/her]. I brought it up to the administration and they say they will find more staff that can go in there. How my day goes, there was not enough staffing on the floor between GNAs and nurses. It was lunch time when I documented that note. I have 1,000 things going on. l) On 3/17/25 at 3:45 PM Staff #49 was interview and stated, we are short staffed. We can't give showers, do our documentation, rounds, a lot of falls and safety concerns. Staff #24 confirmed what Staff #49 stated. 5) On 3/17/25 at 10:09 AM a review of the facility assessment documented staffing was adequate based off a PPD of 3.0. With staffing, PPD stands for per patient day and refers to the amount of nursing hours allotted per day per resident. Staffing goals were to maintain a 3.0 PPD. Our companies PPD allowed is 3.24. The aides run a 15:1 ratio. Department heads that are licensed GNA's periodically assist w/ADLs. Maryland CO[DATE].07.02.19 states, A nursing home shall employ supervisory personnel and a sufficient number of support personnel to provide a minimum of 3 hours of bedside care per occupied bed per day, 7 days per week. Review of actual worked nursing staffing schedules revealed the facility failed to provide a minimum of 3 hours of bedside care per occupied bed per day, 7 days per week. This was evident for 6 of 8 days reviewed for July 2024, 3 of 5 days reviewed for October 2024, 6 of 8 days reviewed for November 2024, 5 of 26 days reviewed for January 2025, and 10 out of 19 days reviewed for February 2025. On 3/11/25 at 1:47 PM an interview was conducted with Staff #24, the nursing scheduler. She stated she has been in the position for the past 2 weeks. When asked about scheduling she said it has to be 3.0 PPD and can't go over 3.2 PPD, not in this building. The minimum is 2.8 PPD. Cross Reference CO[DATE] 6) On 3/11/25 at 2:22 PM observation was made of an unlocked and unattended medication cart on the dementia unit. The top drawer was opened by the surveyor and observation was made of resident's medications and a pair of scissors. There were residents ambulating in the dementia unit in the hallways and common area while the surveyor stood at the unattended medication cart. During the observation, Resident #16, who had a history of a fall out of Geri-chair on 8/1/24 at 4:30 PM, that resulted in an acute mildly displaced fracture of the tip of the nasal bones, was observed trying to get out of the Geri-chair that was located in the back of the common area of the unit. There were no nursing staff visible on the unit. Housekeeper (HK) #25 was the only staff member visible on the unit. Surveyor and Housekeeper intervention prevented Resident #16 from getting out of the Geri chair without assistance and prevented the other cognitively impaired residents on the dementia unit from accessing the unlocked medication cart until nursing staff could be found. This resulted in an Immediate Jeopardy situation. On 3/13/25 from 4:00 PM to 4:30 PM the surveyors had an extensive conversation with the Chief Operating Officer (COO) of the facility. A discussion occurred concerning issues related to staffing, food, lack of resident showers, resident dissatisfaction related to cold food and staffing. The COO stated understanding. On 3/18/25 at 5:15 PM the Nursing Home Administrator and the Director of Nursing were informed of the concern.7) On 3/13/25 at 8:30 AM, a review of complaint #MD00209282 alleged Resident #36 did not receive adequate care at the facility On 3/13/25 at 8:48 AM, during an Interview, when asked if there was enough staff available to get the care s/he needed without having to wait a long time, Resident #36 indicated that there wasn't always enough staff and sometimes it took 20 to 25 minutes for them to answer the call light. When asked what staff could not get done for him/her, Resident #36 stated that they never make his/her bed and only strip it about once a month. Resident #36 also stated that s/he did not always get a shower on his/her shower days, and staff had told him/her it was because they did not have enough help. The concerns with staffing were discussed with the Nursing Home Administrator (NHA) and Director of Nurses (DON) on 3/18/25 at 6:40 PM. The NHA and DON acknowledged the that concerns with inadequate staffing had been identified. Cross Reference F689

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected most or all residents

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CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Social Worker (Tag F0850)

Could have caused harm · This affected most or all residents

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Based on review of resident council meeting minutes and interview, it was determined the facility failed to employ a qualified social worker on a full time basis. Failure to have a qualified social worker has the potential to affect all the residents of the facility. This was evident during a complaint survey. The findings include: Review of Resident Council Meeting minutes from January and February 2025 provided by the Administrator revealed the residents discussed not being able to see social workers to address concerns about their case. Interview with the Social Work Assistant (SWA) on 3/12/25 at 11:06 AM, the SWA stated she works at the facility part time 3 days a week and the other 2 days the Regional Social Worker comes to the facility. The SWA stated she is currently pursing her Associate's degree in nursing and does not have a Bachelor's degree in social work or a human services field. The SWA stated she was unable to hold any care plan meetings in January because she was by herself until the 3rd week or so in January 2025 when the Regional Social Worker starting coming to the building 2 days per week. Interview with the Administrator on 3/12/25 at 4:30 PM confirmed the facility does not have a qualified social worker on a full-time basis.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected most or all residents

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2) On 3/10/25 at 11:00 AM a review of complaint MD00213615 and complaint MD00210751 revealed an allegation that the facility had been having issues with the water being cold at night when it was time for showers. Review of complaint MD00208729 alleged that there was no hot water in August 2024 and residents had to get a bath with cold water. On 3/10/25 at 2:00 PM an interview was conducted with Resident #5 who stated that there have been on and off issues with the hot water for a couple of months and the problem has not been fixed. On 3/10/25 at 2:31 PM an interview was conducted with the Director of Maintenance, Staff #7. Staff #7 stated, it was going on and off which started in mid-January (2025) when it got real cold outside. The switch on the boiler clicks off and back on. I went over to the unit, and I looked at the boiler and it was reading the code, and we got someone to service it. They are here today. They came last Thursday. It has been going on since January. First it happened in the Chesapeake area and then it happened in the Wye Oak area. It went out and I would reset the boiler, and it was fine. In February it was just the Wye Oak unit. Staff #7 was asked by the surveyor, so it happened in January. Did it every happen prior to January? Staff #7 stated, no. At that time the surveyor asked if he had informed anyone about having someone come to fix the unit. Staff #7 said he didn't because he would flip the switch, and the hot water would come back on. On 3/10/25 at 2:43 PM an interview was conducted with the Regional Director of Maintenance, Staff #34. Staff #34 was asked when he became aware of this issue. Staff #34 stated, this morning about the boiler issue. Staff #34 was asked why he was just made aware of the issue. Staff #34 stated, because you guys walked in the door. Staff #34 stated that he needs to be kept in the loop. I would have had someone come out right away and verify the patient care areas had hot water and would have contacted the vendor as it seemed to be some kind of issue. On 3/10/25 at 3:25 PM a review of the work order report for 8/1/24 to 8/30/24 revealed on 8/15/24 there was no hot water on the Chesapeake unit. The timeline was created on 8/15/24 by the previous Assistant Director of Nursing (ADON) and closed out by Staff #34. The comments stated, staff complaining there is no hot water on the unit. Duplicated w/o (without) removing this one. Waiting on parts to come in. A second work order was created on 8/19/24 with the notes, we push the button to reset the hot water, and it doesn't get hot anymore. The work order was set to completed on 8/21/24. On 3/18/25 at 5:15 PM the issue was discussed with the Nursing Home Administrator and the Director of Nursing. 2) On 3/18/25 at 7:00 AM a review of complaint MD00208729 alleged that in July and August 2024 there were no washcloths, and the staff were tearing up bed sheets to use as washcloths. On 3/18/25 at 9:15 AM an interview GNA #57 revealed, linen is a struggle. In the morning there is none left. They are only working with 1 dryer and 1 washer. We run out a lot. We have to go down to laundry and get the linen. On 3/18/25 at 9:18 AM an interview with GNA #18 and GNA #15 was conducted. They stated, some days are better than others and then some days we barely get any linen. We are short washcloths, towels, and fitted sheets. We barely get 1 washcloth per person. We may get 6 washcloths each and then we have to use a towel, half as a washcloth and the other half to dry. This has been going on for the past 6 months to a year. On 3/18/25 at 9:45 AM an interview was conducted with Staff #58. Staff #58 stated, we only have 1 working washing machine and 1 working dryer. It is off and on. There are 4 washers and 4 dryers. Someone is here today working on them. This has been going on for at least 2 months. There are supposed to be 2 to 3 washcloths per patient. On 3/18/25 at 9:47 AM an interview was conducted with Staff #59. Staff #59 stated that the issue with linen, has been going on for a while now, greater than 6 months. There currently is 1 working washing machine and 1 working dryer. Someone came last week, when surveyors entered the building, and ordered a part and are back today to fix it. Staff does complain about being short on linen. It is a problem between short linen and only 1 machine working at a time. The residents complaint that their personal clothes are taking longer to get back. The turnover is supposed to be 72 hours, but it may take longer. We have to take turns using the machines. We have to have the linen carts ready by 3 for the next shift. The 11-7 shift is out of luck. Trying to get linen out but there is not enough for the 11-7 shift. On 3/18/25 at 9:48 AM observation was made of the washing machines in the laundry room. There was only 1 machine that was in use. There were repair men in the room working on other machines. On 3/18/25 at 9:50 AM the surveyor asked Staff #7 and Staff #34 how long the problem with the washing machines and dryer had been going on and they both looked at the surveyor. The surveyor asked, a while and they both shook their heads yes. The Surveyor said, budget issues and both looked and shook their heads, yes, in agreement. On 3/18/25 at 5:15 PM the Nursing Home Administrator and the Director of Nursing were informed of the concern. Cross Reference F584 Based on observation and interview, the facility failed to ensure the kitchen's dishwasher, boiler, laundry washer and dryer were in working order. This had the potential to affect all residents. This was evident during a complaint survey. The findings include: 1) During observation of the facility's kitchen on 3/17/25 at 9:45 AM with the Dietary Manager, the Surveyor noted the gauges on the dishwasher rinse temperature and wash temperature were not rising and both noted on 110 degrees. At the time 3 staff (Staff #61, #62 and #63) were manually cleaning dishes of debri and running dishes through the dishwasher. At that time the Surveyor asked Staff #61 if the gauges were moving this morning above 120 degrees. Staff #61 stated no and staff continued to run dishes through the dishwasher. The Dietary Manager stated she worked last night and at that time the dishwasher was working properly. The Surveyor asked the Dietary Manager if the dishwasher was hot water sanitizing or chemical sanitizing. The Dietary Manager stated chemical and showed the Surveyor the chemicals feeding into the dishwasher. On the dishwasher is posted for chemical sanitizing dishwasher the final rinse and wash tank minimum temperature is 120 degrees. The Dietary Manager confirmed the dishwasher was currently running at 110 degrees and stated she would contact Maintenance and the manufacturer. On 3/17/25 at 10:05 AM, the Surveyor was informed the dishwasher was working, the Surveyor returned to the kitchen and was met by Corporate Director of Maintenance. At that time the dishwasher's rinse temperature and wash temperature was again observed to be 110 degrees. The Corporate Director stated he saw the temperatures go to 115 degrees and confirmed the temperature did not meet the dishwasher's manufactures guidelines. The Corporate Director of Maintenance stated a contractor has been contacted. The findings were shared with the Administrator on 3/17/25 at 11:05 AM who stated the facility has converted to using paper products until the dishwasher is in working order.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected most or all residents

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Based on documentation review and interview, it was determined the facility failed to ensure nurse aide competency training occurred no less than 12 hours per year. This was evident for 1 (GNA #52) of 5 geriatric nursing assistant files reviewed and had the potential to affect all residents during the extended survey of a complaint survey. The findings include: On 3/17/25 a review was conducted of geriatric nursing assistant (GNA) personnel files. A review of GNA #52's personnel file revealed GNA #52 was hired on 7/12/22. There was no formal way to validate the yearly training and number of hours GNA #52 received by reviewing the personnel file. Review of a binder that contained in-service signature sheets for various topics throughout the year was reviewed to validate education and give credit for education received. The binder contained 9 in-service sheets that GNA #52 had signed as attended throughout the year. It was not known the amount of time credited for each in-service. On 3/17/25 at 5:13 PM an interview was conducted with Staff #67, staff educator, who had just started on 2/24/25. Staff #67 stated she just started and was just putting a training program together. Staff #67 stated, I am getting my binder together and getting my stuff together for it. All of what is currently in the binder is prior to when I started. We do not have anything formal as far as keeping track of the number of hours of education. On 3/17/25 at 5:23 PM an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated, we cannot validate the number of hours of GNA training. There are signatures next to topics only. The NHA stated, we are a little behind with our education. As of this June we are starting yearly competencies and reviews for the GNAs.

MINOR (C) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

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2) On 3/10/25 at 8:10 AM observation was made in the lobby of the posted nursing schedule for the day. The schedule on the table to the right of the door entrance documented the Staffing projected hours for 3/6/25. The form documented the census was 113 and the projected HPPD was 2.9. The posting had documented all 3 shifts. The staffing sheet had not been updated for 4 days. The Nursing Home Administrator and Director of Nursing were informed on 3/18/25 at 5:15 PM. Based on review of facility documentation, interview, and observation, it was determined the facility staff failed to maintain nursing staffing data. This was evident during a complaint survey. The findings include: 1) During review of complaints and facility reported incidents from January 2023 until January 2025 the Survey team asked the Administrator and Director of Nursing for daily nursing staffing sheets that include staff assignments, census and actual hours worked. Interview with the Administrator on 3/12/25 at 10:44 AM, the Administrator stated we do not have daily nursing staffing sheets until February 2025. The Administrator stated that is when we started to maintain the data.

Sept 2022 65 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0678 (Tag F0678)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility ' s policy and procedures, and interview with staff, it was determined the facility failed to ensure that they were able to provide Cardio-Pulmonary Resuscitation (CPR) in accordance with physician ' s orders and the residents ' wishes. This was evident for 5 of 84 residents (#50, #48, #52, 54 and #51) reviewed for code status accuracy during a follow-up survey. An immediate jeopardy regarding residents #50, #48, #52, #51, was identified on [DATE] at 3:00 PM and the facility was informed on [DATE] at 3:18 PM. The Findings Include: Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a patient ' s wishes about medical treatments. The Maryland MOLST order form: Consolidates important information into orders that are valid across the continuum of care Standardizes definitions, reminds patients and clinicians of available treatment options, Increases the likelihood that a patient ' s wishes regarding life-sustaining treatments are honored throughout the health care system 1. On [DATE] at 1:25 PM, during a tour of the Homestead unit, two paper charts with Resident #50 ' s name on the spine of the charts were observed. Both charts were next to each other in the nurse ' s station. Although both charts had Resident #50 ' s name on it, they were labeled with different bed locations. On [DATE] at 1:26 PM, during an interview with Geriatric Nursing Assistant (GNA) #6 indicated that both paper charts were for the same resident and stated there was only one resident by that name on the unit. On [DATE] at 1:30 PM, the surveyor reviewed both paper charts for Resident #50. The review of the one of the paper charts revealed a MOLST physician order form dated [DATE] that indicated Resident #50 requested Cardio-Pulmonary Resuscitation (CPR) be performed. This was the only MOLST order form found in this chart. The second paper chart for Resident #50 revealed two MOLST physician order forms. One MOLST order form was dated [DATE] indicating CPR to be performed, however this MOLST order form had been stricken through with the word void written on it. The second MOLST order form was dated [DATE] and indicated that Resident #50 requested to be a Do Not Resuscitate (DNR), and additionally, do not intubate. On [DATE] at 1:35 PM, the surveyor interviewed the charge nurse on the Homestead unit, Registered Nurse (RN) #7. During this interview, RN #7 could not recall what the code status for Resident #50 was but indicated she would pull the paper chart to find the code status. RN #7 proceeded to grab both of Resident #50 ' s paper charts. RN #7 then opened one of Residents # 50 ' s paper charts and reviewed the MOLST order form. RN #7 stated she would perform CPR. The surveyor confirmed with RN #7 that there were two paper charts for Resident #50. The surveyor asked RN #7 why she checked that specific chart when there were two paper charts for Resident #50 and RN #7 stated, because that chart was on top. RN #7 indicated the admission staff must have put together an additional paper chart when Resident #50 was readmitted . The surveyor requested RN # 7 review the second paper chart. RN #7 confirmed there were additional MOLST forms in the second paper chart and that the most up-to-date code status for Resident #50 was a DNR. On [DATE] at 1:40 PM, the surveyor observed the Assistant Director of Nursing (ADON) walk over to the nurse ' s station on the Homestead unit. The ADON was updated of the duplicate paper charts with multiple MOLST order forms for Resident #50 by RN#7. The ADON then took both of Resident #50 ' s paper charts and consolidated them into one paper chart. On [DATE] at 2:49 PM, the surveyor interviewed RN #8. During the interview RN #8 described the process for what she would do when finding a resident in cardiac arrest. RN #8 indicated she would call for help and check the MOLST form in the resident ' s paper chart. RN #8 demonstrated where she would find the MOLST order form. She also indicated if there were two MOLST order forms in the resident ' s paper chart she would check the date and would proceed with the most current order. RN #8 stated she could also check the electronic record and look for the MOLST order form that is scanned and placed in the miscellaneous section. On [DATE] at 3:45 PM, the surveyor reviewed Resident #50 medical records. During a review of a physician ' s history and physical for Resident #50 dated [DATE], the surveyor discovered that Resident #50 was readmitted to the facility in October of 2022 from an acute care facility. Further review of Resident #50 ' s medical record revealed an active order written in the electronic medical record on [DATE], for Resident #50 to be a full code. On [DATE] at 3:50 PM, the surveyor conducted an interview with Social Worker (SW) #21. During the interview SW #21 stated she is not involved with the MOLST form process. She stated she does not review resident ' s MOLST order forms with the residents and indicated this responsibility was for the physicians. They surveyor asked SW #21 to describe the process when there are multiple MOLST order forms for a resident. SW #21 stated when a doctor voids a MOLST it should be taken out of the resident ' s paper chart. She also indicated the previously scanned MOLST order form in the resident ' s electronic medical record cannot physically have void written on the document, but the word void should be edited in the title of the document. Review of the facility ' s Advanced Directives policy states in section 10, The plan of care for each resident will be consistent with his or her documented treatment preferences and or advanced directive. Review of the facility ' s policy entitled, Do Not Resuscitate Order states in section 6, The Interdisciplinary Care Planning Team will review advanced directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. On [DATE] at 4:08 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated it was her expectation that staff would refer to the paper chart and check the MOLST order form to obtain a resident ' s code status. She also indicated that the social worker should be reviewing resident ' s MOLST order forms on admission and during care plan meetings with the residents. When asked what the process would be if there were conflicting MOLST order forms or conflicting code status orders in the electronic medical record the DON stated, she would get clarification on the MOLST order form and she would expect the order in the electronic medical record to state, See MOLST for code status. The DON stated she was aware that Resident # 50 had a MOLST order form in the paper chart stating wishes for a DNR as well as an active order in the electronic medical record for a full code, indicating that CPR would be initiated if warranted. The DON confirmed this would need to be corrected. The failure to have one accurate MOLST form in place for a resident #50, and the failure of staff to identify the most up-date MOLST form had the potential for Resident 50 to receive CPR against his/her wishes expressed in the MOLST form (a physician ' s order) in the event Resident #50 had a cardiac arrest. On [DATE] at 6:25 PM the DON submitted a plan to remove the immediate jeopardy. The plan included: Removing all duplicate charts with multiple MOLSTs and having one active chart with one active MOLST. Educating all licensed nurses on the process of locating the most current and active MOLST for residents that had MOLST orders. Only licensed nurses who received the education would be permitted to work. All residents who were noted to have duplicate MOLST within their electronic medical record, that does not correspond with their MOLST in the paper chart, will have electronic MOLST removed. Residents that have orders within their record that do not match with their active MOLST will have their orders changed so they both correspond. Residents with multiple MOLSTs have had their voided MOLST removed from the record and have one active MOLST on file. 3) The surveyor reviewed residents' electronic medical records (PCC) and paper charts on [DATE] at 10:30 AM. A review of Resident #48's medical records revealed that a scanned MOLST form as Full code dated [DATE] was filed under PCC miscellaneous. However, the paper chart of Resident #48 had a MOLST form dated [DATE] as No CPR option A-2, Do Not Intubate. 4) A review of Resident #52's medical record on [DATE] at 10:40 AM revealed that Resident #52 had a scanned MOLST form as Full code dated [DATE] on his/her electronic medical records. However, the paper chart of Resident #52 had a MOLST form dated [DATE] as No CPR option A-2, Do not Intubate. During an interview with Licensed Practical Nurse (LPN #25) on [DATE] at 10:45 AM, LPN #25 stated she would look at residents' PCC to ensure resident's code status. LPN #25 also added if a resident's electronic medical record did not contain code status, she/he would look up the resident's paper chart. LPN #25 also stated that she did not receive any orientation before working in this facility. 5) On [DATE] at 11:00 AM, a follow up review of the paper charts and electronic medical records (PCC) for residents on the Homestead unit was conducted. Resident # 54 had a MOLST form in her paper chart dated [DATE] that checked No CPR, Option B, Palliative, and supportive Care (Prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use CPAP or BIPAP. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. However, a review of the Electronic Medical Record for Resident #54 revealed a MOLST form dated [DATE] that checked No CPR, Option A-2, Do Not Intubate (DNI): Comprehensive efforts may include limited ventilatory support by CPAP or BiPAP, but do not intubate. On [DATE] at 12:46 PM, in an interview with RN #7, she stated that if a resident went into cardiac arrest or became unconscious, she would immediately start CPR, call for help and ask someone to get the resident's paper chart. They would look at the MOLST form for the resident's code status and would continue CPR if the resident was a full code. If the resident was a DNR (do not resuscitate), RN #7 stated she would stop the CPR. RN #7 further stated that if the MOLST was not in the paper chart, they would look for it in PCC under the miscellaneous section. When asked about Resident #54 having two different MOLST forms, RN #7 stated that based on the dates on the MOLST forms, the one in PCC should have been voided because the MOLST form in the paper chart was the most current. On [DATE] at 6:25 PM the DON submitted a plan to remove the immediate jeopardy. The plan included: Removing all duplicate charts with multiple MOLSTs and having one active chart with one active MOLST. Educating all licensed nurses on the process of locating the most current and active MOLST for resident's that had MOLST orders. Only licensed nurses who received the education would be permitted to work. All residents who were noted to have duplicate MOLST within their electronic record that did not correspond with their MOLST in the paper chart, will have electronic MOLST removed. Residents that have orders within their record that do not match with their active MOLST will have their orders changed so they both correspond. Residents with multiple MOLSTs have had their voided MOLST removed form the record and have one active MOLST on file. The facility submitted a plan of removal on [DATE] at 5:03 PM that was not accepted. On [DATE] at 6:55 PM the facility submitted a third plan of removal that was accepted on [DATE] at 6:55 PM After determination of Immediate Jeopardy concerns, an extended survey was conducted. The Immediate Jeopardy was removed on [DATE] at 2:50 PM after validation that the plan had been implemented. 2) A review of Resident #51's medical record on [DATE] revealed that Resident #51 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paraplegia, chronic cystitis, adult failure to thrive, hypertension, and gastric reflux. Further review of Resident #51's medical record on [DATE] revealed 2 different MOLST forms and a physician's order that were not congruent. The first MOLST form was completed by the resident's physician on [DATE] which indicated Resident #51 decided that s/he did not want to have CPR performed and did not want to be intubated (option A-2). Resident #51's physician also indicated, under section 2c artificial ventilation, that Resident #51 decided that staff could use only CPAP or BiPAP for artificial ventilation. In a review of section 7c, artificially administered fluids and nutrition, Resident #51 wanted to receive artificial hydration as a therapeutic trial, but do not give artificially administered nutrition. A second MOLST form was completed by Resident #51's physician on [DATE] which indicated Resident #51, as a trial, decided that s/he did not want to have CPR performed and did not want to be intubated (option A-2). Resident #51's physician also indicated, under section 2d artificial ventilation, that Resident #51 decided that s/he did not want to use any artificial ventilation (no intubation, CPAP, or BiPAP). Under section 7b, artificially administered fluids and nutrition, Resident #51 now wanted to receive artificial hydration and nutrition, if medically indicated, as a trial, for 1 week. Resident #51's first MOLST form, dated [DATE], had not been voided prior to being scanned into Resident #51's electronic medical record after the creation of the second MOLST form on [DATE]. Further review of Resident #51's electronic medical record physician's orders on [DATE], revealed that Resident #51's physician indicated that upon admission, on [DATE], Resident #51 was to be a Full Code. The [DATE] physician's FULL CODE order for Resident #51 had not been updated, month to month, to reflect Resident #51's current Life-Sustaining Treatment from [DATE] thru [DATE] and changes in the MOLST forms. In an interview with the facility administrator, on [DATE] at 12:08 PM, the nurse surveyor reviewed the concerns with Resident #51's 2 - incongruent MOLST forms and the incongruent FULL CODE order found in Resident #51's electronic physician's orders. A request for all thinned records for Resident #51 was issued. The facility administrator stated that there were no other thinned records for Resident #51 in the medical records department.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 9/21/22 at 1:30 PM, Resident #63's medical records were reviewed for a portion of complaint investigation MD00179202. The review revealed that Resident #63 was initially admitted to this facility in June 2021 with the diagnosis of end-stage renal disease and needed hemodialysis three times a week. Resident #63 was transferred to the hospital due to a condition change on 1/20/22 and readmitted to the facility on [DATE]. Further review of Resident #63's weights and vitals summary revealed that the resident's body weight was 171.16 pounds, post-dialysis on 12/11/21 and 157.08 pounds post-dialysis on 2/4/22. However, no documentation (notification to physician, notification to responsible party, care plan, interventions, dietician note, and skilled nursing note) was found in Resident #63's medical record regarding a 14.08-pound weight loss (12.15%) within 57 days. During an interview with the Medical Director (Staff # 34) and the Interim DON on 9/21/22 at 1:51 PM, the surveyor asked what the acceptable weight loss for dialysis residents was. Staff #34 stated that even though the acceptable weight loss would be variable depending on each status, less than 5% loss would be acceptable. The surveyor shared Resident #63's case: staying in the hospital for 16 days, weight checked 9 days later after being readmitted , and 12% weight loss recorded. Staff #34 confirmed that the weight change was not usual and stated he expected to be notified. The facility policy, Weight Monitoring with a revised date of 7/8/21 was reviewed on 9/23/22. The policy review revealed: residents are to be weighed upon admission and/or re-admission as well as monthly and/or on as-needed basis. Dietician assessment and follow-up needs to be documented in resident's clinical record. MD (Doctor of Medicine) /RP (Responsible Party) / RD (Registered Dietician) notification of weight gain/loss trends need to be documented by a licensed nurse in the clinical record. The above concern was discussed with the Interim DON on 9/28/22 at 1:30 PM. 4) On 9/15/22 at 2:21 PM a medical record review was conducted for Resident #27. Resident #27 was admitted to the facility in July 2022 with diagnoses that included, but were not limited to, repeated falls, atherosclerotic heart disease, chronic kidney disease and major depressive disorder, recurrent. The resident was hospitalized for 5 days in August 2022 and returned to the facility after being treated for bacteremia and a urinary tract infection. Resident #27 contracted COVID-19 on 8/30/22. Review of the weight section of Resident #27's medical record revealed the resident weighed 130 lbs. (pounds) upon admission on [DATE], 130.8 lbs on 7/5/22, 133.6 lbs. on 7/13/22 and 135.6 lbs. on 7/27/22. Review of hospital notes dated 8/19/22 documented the resident's weight at 130 lbs. Review of the nursing readmission evaluation dated 8/23/22 at 17:10 (5:10 PM) documented the weight of 135.6 lbs. that was taken on 7/27/22, prior to hospitalization. As noted above, the resident lost 5.6 lbs while hospitalized . The nursing staff failed to re-weigh the resident upon re-admission. A nutritional assessment was done on 8/26/22 by the previous dietician and the weight of 135.6 lbs. on 7/27/22 was also used. The dietician did not order any nutritional supplements. Review of the hospital discharge instructions dated 8/23/22 documented, will need continued nutritional supplement. Review of the weight monitoring policy that was given to the surveyor by the Interim Director of Nursing (DON) on 9/16/22 at 12:30 PM revealed the second paragraph which stated, residents are to be weighed upon admission and/or re-admission, as well as monthly and/or on as needed basis. Under the weight process guidelines, #2 documented, A comprehensive nutritional assessment will be completed by the Registered dietician upon or post admission or re-admission. Assessments should include the following information, b. weight. There was no documentation found in the medical record that the previous dietician requested a more recent weight due to the resident being hospitalized for 6 days. On 9/16/22 at 1:38 PM an interview was conducted with Registered dietician, Staff #25 who stated she has only been at the facility since August 15, 2022 and that she has been training and another dietician was filling in. Staff #25 stated she was officially starting Monday, 9/19/22. Staff #25 stated, I would expect the resident to be weighed when they come back from the hospital. If greater than 3 days I would see the resident. I have not seen [him/her] prior to today. The surveyor showed Staff #25 the nutritional assessment dated [DATE] and that the other dietician used the weight from 7/27/22. Staff #25 stated she would have expected Resident #27 to be weighed and should have used the new weight for the assessment. Staff #25 was also shown the discharge summary from the hospital that stated to continue on a nutritional supplement. On 9/19/22 at 9:03 AM a review of medical record revealed Resident #27 still had not been weighed and the nutritional supplement still had not been addressed. Discussed with the Interim DON on 9/28/22 at 12:15 PM. 5) On 9/21/22 at 9:53 AM a record review was conducted for Resident #34 and revealed the resident was admitted to the facility in January 2022 with diagnoses that included, but were not limited to, Parkinson's disease, unspecified dementia, mood disturbance, and anxiety. Resident #34's medical record revealed the resident weighed 156.6 lbs. (pounds) on 6/21/22 and 145 lbs. on 7/13/22, which was a 7.4% weight loss in 1 month. There was no weight obtained in August 2022. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #34's quarterly MDS with an assessment reference date of 7/20/22 coded a 7.4% weight loss in 1 month. Review of a nutritional assessment dated [DATE] documented, Patient has significant weight loss of 7.4% within 1 month with weight history 6/21/2022 156.6#, 7/13/2022 145# BMI 22 (normal). RD (Registered Dietician) does not believe recent weight is accurate. RD requested reweight but this has not been obtained. This was documented from the previous RD who was no longer employed at the facility. Further review of Resident #34's medical record failed to produce documentation that the physician or the responsible party were notified of the weight loss. Review of physician's orders for Resident #34 revealed the order, pt. to utilize [NAME] cup during meals daily as tolerated and staff assist with all meals. The physician's order was written on 1/28/22. The [NAME] Cup is a lightweight, easy-to-grip adapted drinking cup designed to prevent spills. On 9/21/22 at 9:20 AM observation was made of Resident #34 in bed with the tray table in front of him/her with a breakfast tray on top. There was scrapple with scrambled egg on top of toast. The butter and jelly containers were not opened. There was a regular plastic cup on the tray with no lid. The plastic cup was sideways and empty. The silverware was still in the plastic wrapper. The resident was pointing to something that the surveyor could not understand. At that time the surveyor went into the hallway and asked Geriatric Nursing Assistant (GNA) #57 if she was assigned to the resident. GNA #57 stated she was not, however she asked what she could do for Resident #34. The surveyor asked if the resident used utensils and GNA #57 said yes. The surveyor showed GNA #57 that the utensils were still in the plastic wrapper. GNA #57 got the utensils out of the package and cut the resident's food into bite size pieces. Resident #34 started picking up the bite size pieces and put them in his/her mouth. The facility staff failed to follow physician's orders for a [NAME] Cup. Furthermore, review of Resident #34's Treatment Administration Record (TAR) documented on 9/21/22 that the nurse signed off that Resident #34 utilized a [NAME] Cup at breakfast (8:00 AM) and lunch (12:00 PM) which was inaccurate. On 9/21/22 at 11:16 AM an interview was conducted with Physician #77 who stated, I was not notified of the weight loss. I would have expected to be notified. Since July many nurses have quit their positions. Notifying me and making sure vitals are done and orders are carried out is what we rely on. It is not feasible to check weights myself. We rely on staff. It is an issue as I rely on staff. The time we have to backtrack to see if these things are getting done, we get paranoid. On 9/21/22 at 1:06 PM an interview was conducted with Dietician #25 who stated she had just started at the facility and was in the process of seeing all residents. Dietician #25 stated she saw the resident yesterday and put Resident #34 on weekly weights. Staff #25 stated she cut up the resident's sandwich and saw the resident get the top of the bread off. I cut it up and [he/she] automatically took the food. I went to the kitchen to go over what finger foods are. [She/He] needs to have wedge like pieces and I wanted to make sure everyone was aware of that. Staff #25 continued, Visually, [he/she] looked like someone I wanted to check in on. On 9/21/22 at 1:43 PM a discussion was conducted with the Medical Director about Resident #34's weight loss. The Medical Director stated, the physician should have been notified of the weight loss. 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 the dietary care plan for Resident #34 documented, is at potential nutritional risk r/t need for modified texture diet that was initiated on 1/24/22 and revised on 2/10/22. The interventions on the care plan were, Encourage good hydration by providing fluids with meals and med pass, Encourage good meal intake according to diet order (allow double portions), RD to evaluate per protocol or PRN to provide updated recommendations, and Diet, weights as ordered. There was no evidence in the medical record that the care plan was evaluated and updated to reflect weight loss. Based on a resident complaint, staff interviews, and clinical record reviews, it was determined that 1) the facility failed to ensure a totally dependent resident's tube feeding and hydration nutritional needs were met. This occurred when Resident #45's tube feeding orders were changed without instruction from Resident #45's physician or guidance from the facility nutritionist. These new tube feeding orders were also not monitored. This caused Resident #45 to lose a significant amount of weight (18%) in 2 months which caused Resident #45 harm. Additionally, the facility 2) failed to provide a resident a therapeutic diet, 3) failed to intervene in a timely manner when a weight loss was documented, and 4) failed to re-weigh a resident after a 6 day hospital admission and initiate a physician ordered nutritional supplement. This was evident for 5 (#45, #141, #27, #34, #63) of 12 residents reviewed for nutrition during the annual survey. The findings include: 1) In an interview with Resident #45 on 09/13/22 at 2:43 PM, Resident #45 informed the surveyor that he/she lost weight since the nursing staff was administering Resident #45's tube feeding at a slower rate and was only receiving the tube feeding for 12 hours a day. Resident #45 was admitted to the facility in December 2011 with diagnoses that include but are not limited to traumatic brain injury, quadriplegia, peg tube insertion, seizures, suprapubic catheter, dysphagia, and contractures in the extremities. Resident #45 was totally dependent upon the facility staff for all aspects of his/her care. Resident #45 had a Brief Interview for Mental Status (BIMS) assessment, conducted by a facility staff member, on 05/11/22 and 07/28/22 during the quarterly review process. Resident #45 was assessed to have a 15/15 score during both quarterly assessments. A score of 13 to 15 suggests the resident is cognitively intact. A review of Resident #45's clinical health record on 09/13/22 revealed that on 04/18/22 at 1:13 PM, the nursing staff documented that Resident #45 weighed 133.7 pounds. On 06/21/22 at 3:36 PM, the nursing staff documented that Resident #45 weighed 109.6 pounds. Resident #45 lost 24.1 pounds (18%) from 04/18 thru 06/21/22. A review of Resident #45's previously recorded weights revealed the following: 12/04/21 - 137.7 pounds 02/02/22 - 135.4 pounds 03/01/22 - 131.3 pounds A review of the facility weight monitoring policy, (that was initiated on 09/28/2020 and reviewed/revised on 07/08/21) on 09/16/22 at 2 PM, revealed the following initial statement: The facility is committed to maintaining quality care by implementing below weight practice guidelines to maintain adequate nutritional status and assure the standard of practice is met for residents served. Under the weight process guidelines, #4 revealed the following: Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. Resident #45's weight had been stable on the current physician-prescribed tube feeding and hydration orders which were initiated on 11/10/21. A review of Resident #45's 02/21/22 nutritional assessment documented that Resident #45's calculated nutrient needs are being met with tube feeding. Resident #45 has a usual body weight of 130 pounds, a BMI of 20.6, and an ideal body weight of 154 pounds, with a height of 68 inches. On 02/21/22 the facility dietician noted the physician-prescribed tube feeding orders were as follows: 1) Nothing by Mouth (NPO) 2) Product and Rate - Jevity 1.5, to run at 105 ml/hour, over a 12-hour infusion. 3) Volume 1260 ml. 4) Flush - 150 ml water, every 4 hours 5) Total flush over 24 hours (ml) - 900 ml 6) Total volume infused over 24 hours (ml) - 2160 ml 7) Total calories - 1890. 8) Total protein - 80 grams. 9) Total Free Water - 1858 ml On 04/22/22, RN #31 documented a new physician's order to lower Resident #45's tube feeding to the following: Infuse Jevity 1.5, for Nutrition related to gastrostomy status, Formula: Jevity 1.5 Rate: 75 ml/hr., Duration: 12 hours, Volume: 900 ml. In an interview with the former facility dietician, staff member #63, on 09/20/22 at 12:28 PM, the former facility dietician stated that he/she worked at the facility from February 2022 thru the first week in August 2022 and became aware of Resident #45's significant weight loss that was identified in June 2022. The former facility dietician stated that Resident #45 lost a significant amount of weight in a short period of time with no interventions. The former facility dietician stated that he/she was not made aware when a nurse changed Resident #45's tube feeding orders on 04/22/22. No one contacted me. The former facility dietician stated that there was no communication between nursing and him/her. The former facility dietician stated that the nursing staff also missed obtaining a May 22 weight on Resident #45 which allowed Resident #45's weight to continue to drop. The former facility dietician stated that he/she sent an email to the nursing administration about Resident #45's significant weight loss. The former facility dietician stated, Resident #45 fell through the cracks. After Resident #45's significant weight loss was identified, the former facility dietician stated that the corporate dietician had a meeting with the facility's clinical staff. The former facility dietician stated that he/she would have increased the length of time (duration) of Resident #45's tube feeding and not lowered the rate. Further review of Resident #45's 06/29/22 physician orders, revealed that new tube feeding orders were put into place that instructed the nursing staff to administer Resident #45's tube feeding, Jevity 1.5, one time a day, to infuse at 65 ml/hour over 16 hours from 4 PM to 8 AM. A review of Resident #45's care plans on 09/15/22 revealed a 01/19/2021 focused care plan that indicated Resident #45 needed to gain some weight while receiving tube feeding and flushes. This care plan was revised on 02/14/22 by the facility's Healthcare Virtual Assistant. On 05/10/22, the revised goal for Resident #45 is to tolerate his/her tube feeding and flushes so that he/she is able to gain and maintain weight with a BMI in the range of 22- 25 during the review period. Nursing interventions included: weighing Resident #45 as ordered, monitoring tolerance to TF and flushes, monitoring the need for other nutrition interventions, monitoring and evaluating any weight loss to determine percentage lost, following the facility protocol for weight loss, and if weight decline persists, contact physician and dietician immediately. In an interview with the facility's corporate dietician, staff member #53, the facility dietician stated that he/she recalled having a conversation with the former facility dietician, staff member #63, when Resident #45's significant weight loss was identified at the end of June 2022. The corporate dietician recalled that the former dietician #63 did not recall being informed when Resident #45's tube feeding rate was lowered and that the facility dietician was having difficulty getting answers from staff. The corporate dietician stated that he/she reviewed Resident #45's significant weight loss with the facility clinical team and thought that Resident #45's 06/21/22 weight of 109.6 may have been inaccurate. The corporate dietician stated that he/she was not able to find anything in Resident #45's clinical record as to why Resident #45's tube feeding rate was changed on 04/22/22. The corporate dietician stated that he/she was aware that Resident #45 did have episodes of vomiting and diarrhea and considered that Resident #45 may have had a malabsorption intestinal issue. The corporate dietician stated that she/she had taken Resident #45's significant weight loss to the monthly weight committee (QAPI) in July 2022. Body mass index, BMI, according to CDC.GOV is a value derived from the mass and height of a person. A healthy range is between 18.5 to 24. If your BMI is 18.5-20, you're a bit underweight and can't afford to lose more. In an interview with the current facility dietician, staff member #25, on 09/20/22 at 9:56 AM, the current facility dietician stated that Resident #45's BMI in February 2022 was documented at 20.5 which was within the normal range for Resident #45. The current facility dietician stated that Resident #45's current BMI, as of the 09/14/22 nutritional assessment, is 17.3. The goal now for Resident #45 is to get his/her BMI above 19. In an interview with Resident #45's physician on 09/20/22 at 9:44 AM, Resident #45's physician stated that he/she was unaware why Resident #45's tube feeding orders were changed on 04/22/22. Resident #45's physician stated that he/she recalled having conversations with staff about Resident #45's weight loss and muscle atrophy in June 2022. Resident #45's physician also stated that Resident #45's family was aware of the weight loss. In an interview with the facility interim Director of Nurses (DON) on 09/28/22 at 6 PM, the interim DON stated that she/he looked into Resident #45's significant weight loss and discovered that RN #31 had discussed Resident #45's diarrhea issue with the former facility dietician, staff member #48, in February 2022 before staff member #48 stopped working in the facility. The interim DON stated that RN #31 had taken it upon himself/herself to change Resident #45's tube feeding orders on 04/22/2022 to help Resident #45's issues with diarrhea without notifying Resident #45's physician. 2) The facility staff failed to intervene in a timely manner when a weight loss was documented for Resident #141. A review of Resident #141's medical record related to nutritional concerns on 9/20/22 at 2:15 PM revealed the resident was admitted to the facility on [DATE]. A nutritional assessment was completed on 9/8/22 by the dialysis dietitian. The dietitian documented weight of 200 pounds (Lbs.) that was taken on 9/6/22. The nutritional summary revealed, Resident is at nutrition risk related to inadequate oral intake with elevated nutritional needs for wound healing and likely inadequate nutrient intake. A review of the vital signs weight section of the electronic health record revealed a second weight was documented on 9/19/22 at 10:03 PM as 160.8 Lbs. by a nurse (staff #47). The electronic health record automatically documented a weight comparison noting a 19.6 % significant weight loss of 39.2 Lbs. Further review of the medical record did not reveal any type of physician or dietician notification. A review of the facility's Weight Monitoring policy dated 9/28/20 with a Reviewed/Revised date of 2/11/21 revealed Weight Analysis: The newly recorded weight should be compared to the previous recorded weight and it further defined significant weight change percentages. All weights are to be entered into the Point Click Care (PCC), under the weights and vital signs portal. Unit Managers and/or ADON to validate prior to PCC entry, with a further indication of physician, dietician, and resident's responsible party notifications of weight gain/loss trends need to be documented by a licensed nurse in the clinical record. Multiple care area concerns were shared with the Interim DON on 9/22/22 at 4:29 PM including the documentation of a 39 Lbs. weight loss without further documentation or physician notification. On 9/26/22 at 12:51 PM the Interim DON had a follow-up discussion and had Staff #47 involved. Staff #47 indicated that she entered a post dialysis weight and apologized for not recognizing Resident #141's significant weight loss.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of facility reported incident MD00180950 and complaint MD00176593, and resident and staff interviews, it was determined that the facility failed to ensure a resident was free from misappropriation of resident property and exploitation. This was evident for 1 (Resident #113) of 13 residents reviewed for abuse, neglect and exploitation during the annual survey. The findings include: A review of the facility Abuse, Neglect and Exploitation policy, on 09/26/22, revealed that the policy was last reviewed/revised and implemented on 10/12/20 and defined Misappropriation of Resident Property as: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent, Reviews of Facility Reported Incident MD00180950 and Complaint MD00176593 on 09/26/2022 revealed an allegation that Resident #113 went to retrieve his/her $2500.00 in cash, credit cards, and gift cards from the administrator on 04/29/2022 at 2:30 PM and discovered that someone had stolen Resident #113's cash, credit cards, and gift cards. A review of the facility investigation revealed that Resident #113 was admitted from the hospital on [DATE]. At that time, staff members documented and photocopied Resident #113's cash, credit cards, and gift cards. The staff provided Resident #113 with a photocopy of the credit cards and gift cards and a receipt for the $2547.00. The items were then secured in the facility safe. On 04/29/2022 at 5:00 PM, the facility investigation indicated that Resident #113 requested the return of his/her cash, credit cards, and gift cards. At that time, the staff were unable to locate Resident #113's $2547.00 cash, credit cards, or gift cards. The facility administrator initiated an investigation and notified the local police. In an interview with Resident #113 on 09/26/2022 at 2:47 PM, Resident #113 stated that someone at the facility took my money. I had to cancel all my credit cards. I had gift cards that I received during Christmas, but I was unable to determine how much was on each of the gift cards. When it happened, a staff person told me that the police would want to speak with me, but no police officer ever interviewed me. I kept my receipt the staff gave me when I was admitted from the hospital. The facility did reimburse me with a check for the amount of cash only. In an interview with the former facility administrator that was working at the facility on 04/29/2022, the former administrator stated that the facility usually does not hold a resident's money and that a resident is usually requested to place their belongings in a locked drawer or open a resident funds account. The former administrator stated that Resident #113's sister was supposed to pick up the money. The facility has a safe but the safe was unlocked. We were unable to determine when Resident #113's cash, credit cards, and gift cards were lost.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected 1 resident

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Based on observation, medical record review and interview, it was determined the facility staff failed to conduct a complete and accurate assessment by failing to assess a resident's oxygen use and failing to assess cognition and mood. This was evident for 1 (#10) of 2 residents reviewed for respiratory, 1 (#62) of 8 residents reviewed for accidents, and 1 (#59) of 9 residents reviewed for quality of care. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 9/11/22 at 9:26 AM observation was made of a portable oxygen tank on the back of Resident #10's wheelchair in the resident's room. On 9/14/22 at 2:10 PM Registered Nurse (RN) #14 was asked about the oxygen and the response was, I don't know why [he/she] has the oxygen; maybe it is because dialysis might put it on [him/her] if the sats (oxygen saturation level) drops. On 9/15/22 10:30 AM a medical record review was done for Resident #10. The vital sign section of the medical record documented Resident #10 received oxygen on 1/31/22. Review of Resident #10's quarterly MDS assessment with an assessment reference date of 2/10/22 failed to capture oxygen use in section O0100, in the previous 14 days. The oxygen use of 1/31/22 should have been captured, therefore made the assessment inaccurate. 2) On 9/15/22 at 9:21 AM a review of Resident #62's medical record was conducted. Resident #62 was admitted to the facility in April 2022 with diagnoses that included, but were not limited to, Alzheimer's disease, unspecified dementia with behavioral disturbance and senile degeneration of the brain. Review of the quarterly 6/15/22 and 8/5/22 MDS assessments, Section C, Cognition and Section D, Mood, were not assessed which made the assessments incomplete. 3) On 9/26/22 at 4:25 PM a review of Resident #59's medical record was conducted. Resident #59 was admitted to the facility in June 2020 with diagnoses including, but not limited to, unstable angina, diabetes mellitus with diabetic neuropathy, COPD, and end stage renal disease. Review of the quarterly MDS assessment with an assessment reference date of 1/7/22, Section C, Cognitive Patterns, was not assessed, which made the assessment incomplete. On 9/14/22 at 11:25 AM an interview was conducted with Staff #24, the MDS Resource Coordinator who stated, My hire date was June 2022. There was someone else here doing MDS assessments. Resource MDS means I am a floater. I personally have not done a lot of the MDS. Staff #24 stated that she was helping social work doing Sections C and D. Staff #24 stated that Social Work should be doing sections C and D. She should have time. She comes on Tuesdays and Fridays, so I now started doing a check to ensure that the MDS sections are done. Discussed with the Interim Director of Nursing on 9/28/22 at 12:15 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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Based on record review and interview with facility staff, it was determined that the facility failed to ensure that a recapitulation of the resident's stay was completed following a resident's discharge from the facility. This was evident for 1 (#93) of 3 closed records reviewed during the annual survey. The findings include: On 9/22/22 at 10:51 PM a record review was conducted for Resident #93 that revealed Resident #93 was admitted to the facility in June 2022 due to a fractured ankle. A 7/7/22 at 11:41 AM care conference note documented that Resident #93 wanted to go home. A 7/11/22 at 14:20 (2:20 PM) nursing progress note documented, this nurse, accompanied by the head of Therapy and the ADON (assistant director of nursing) spoke to patient about the risks and dangers associated with leaving AMA (against medical advice). Resident acknowledged teachings and warnings. The note continued, not satisfied with night shift care which was the main reason for [his/her] decision to leave AMA. PT (physical therapy) advised of dangers associated with leaving AMA due to physical weakness and changes to weight bearing status and requested additional time for PT. ADON also spoke to resident regarding limitations after leaving AMA and patient continued to be firm in leaving AMA. Resident signed AMA form and was witnessed by sister and myself. Resident was released under [his/her] sister's cognizance. A 7/12/22 at 16:47 (4:47 PM) Nurse Practitioner Progress Note documented, pt. discharged from this facility. There was no discharge summary found in the electronic or paper medical record. On 9/23/22 at 11:02 AM an interview was conducted with the Social Work Director who stated, we are having issues with physician's doing discharge summaries. Discussed with the Interim Director of Nursing on 9/28/22 at 12:15 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident complaint, medical record reviews, and staff interview, it was determined that the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in their range of motion. This was evident for 2 (Residents #5, #45) of 4 residents reviewed for range of motion. The findings include: 1) In an interview with Resident #5 on 09/12/22 at 1:59 PM, Resident #5 stated that he/she has some movement in his/her left leg but needs more therapy to walk again. In an interview with Resident #5's family member on 09/12/22 at 2:02 PM, Resident #5's family member stated that Resident #5 was only receiving 30 minutes of therapy a day due to his/her health insurance policy when he/she was admitted to the facility, but that was 3 years ago. Resident #5's family member stated that the hospital physician informed Resident #5 that he/she should be able to walk again with continued therapy. A review of Resident #5's medical record on 09/14/22 revealed that Resident #5 was admitted to the facility on [DATE] and suffers from a stroke with left-sided weakness, diabetes, neuropathy, obesity, Atrial fibrillation, and a valve replacement. Resident #5 is dependent upon the facility staff for several aspects of his/her care including transfers, bed mobility, toilet use/incontinence care, and personal hygiene. A review of Resident #5's occupational therapy documentation on 09/13/22 revealed that a physician's order was written on 06/28/22 at 3 PM, instructing the nursing staff to get Resident #5 out of bed at 2 PM for 3 hours and then place Resident #5 back in bed around 5 PM. A second order was written on 08/16/22 instructing the nursing staff to assist Resident #5 into his/her wheelchair to maximize out-of-bed activity performance and ensure the progression of function skills. Reviews of Resident #5's August and September 2022 Treatment Administration Records thru 09/13/22, revealed that the nursing staff documented assisting Resident #5 into his/her wheelchair 8 times. A review of Resident #5's MDS [NAME] Report on 09/14/22 at 12:12 PM, failed to list any nursing restorative program interventions to perform with Resident #5. This part of the form was left blank. A further review of Resident #5's medical record revealed a physician's order, dated 07/13/22, instructing the nursing staff to add Resident #5 to the Restorative Nursing Program indefinitely. In an interview with the facility nursing restorative GNA, staff member #67, on 09/20/22 at 7:26 PM, staff member #67 stated and confirmed that Resident #5 was not receiving any restorative nursing services. In an interview with a former facility occupational therapist (staff member #55) on 09/27/22 at 8:44 PM, staff member #55 stated that he/she recalled Resident #5 and that upon discharge from therapy services, staff member #55 wrote an order to get Resident #5 out of bed. Staff member #55 stated that the facility did not have a nursing restorative program when he/she stopped working at the facility. 2) In an interview with Resident #45 on 09/13/22 at 2:53 PM, Resident #45 stated that he/she needs more therapy. Resident #45 stated that he/she has a contracture and uses a splint on the left wrist. Resident #45 was admitted to the facility in December 2011 with diagnoses that include but are not limited to traumatic brain injury, quadriplegia, peg tube insertion, seizures, suprapubic catheter, dysphagia, and contractures in the extremities. Resident #45 was totally dependent upon the facility staff for all aspects of his/her care. Resident #45 had a Brief Interview for Mental Status (BIMS) assessment, conducted by a facility staff member, on 05/11/22 and 07/28/22 during the quarterly review process. Resident #45 was assessed to have a 15/15 score during both quarterly assessments. A score of 13 to 15 suggests the resident was cognitively intact. A review of Resident #45's care plans on 09/13/22 revealed a limited physical mobility care plan related to quadriplegia that was initiated on 06/22/20 and revised by the facility's Healthcare Virtual Assistant on 05/19/22. The goal was to keep resident #45 free of complications related to immobility, including contractures, thrombus formation, and skin breakdown, through the next review date. Further review of Resident #45's medical record on 09/13/22 revealed that on 06/22/20, the nursing staff initiated a nursing intervention onto Resident #45's limited physical mobility care plan instructing staff to provide gentle range of motion as tolerated with daily care. Further review of Resident #45's September 2022 treatment administration record (TAR) and the GNA documentation failed to reveal any documentation that facility staff were following the limited physical mobility care plan and providing Resident #45 with a gentle range of motion with daily care. In an interview with Resident #45 on 09/13/22 at 2:35 PM, Resident #45 stated that S/he has not had a care plan meeting in over a year. A review of Resident #45's clinical health record on 09/13/22 revealed that the last time the facility staff held a care plan meeting for Resident #45 was on 11/19/21. In an interview with the facility social worker on 09/23/22 at 10:37 AM, the facility social worker stated that S/he was still looking for any other documentation that Resident #45 had a care plan meeting in the year 2022. In an interview with the facility's restorative nursing assistant (staff member #67) on 09/20/22 at 2:05 PM, staff member #67 stated and confirmed that Resident #45 was not currently receiving restorative nursing services. In an interview with a former facility occupational therapist (staff member #55) on 09/27/22 at 8:44 PM, staff member #55 stated that he/she recalled Resident #45 and that upon discharge from therapy services, staff member #55 wrote an order to get Resident #45 out of bed and for positioning. Staff member #55 stated that the facility did not have a nursing restorative program when he/she stopped working at the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility administrative documents, it was determined that: 1) the facility staff failed to protect a resident, who was totally dependent upon staff for all aspects of care from continued falls, 2) investigate the root cause of the falls and initiate nursing interventions to prevent further falls, and 3) update the resident's fall prevention care plan. This was evident for 1 (Resident #55) of 8 residents reviewed for accidents during the annual survey. The findings include: A review of Resident #55's medical record on 09/26/22 revealed that Resident #55 was admitted to the facility on [DATE] with diagnoses that include but were not limited to diabetes, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, and bilateral above the knee amputation of the right and left leg. Resident #55 has been assessed as being dependent upon the facility staff for many aspects of his/her care. Resident #55 had a Brief Interview for Mental Status (BIMS) assessment, conducted by a facility staff member, on 08/21/22 during the annual assessment process. Resident #55 was assessed to have a 04/15 score during the annual assessments. A score of 0/15 to 7/15 suggests the resident has severe cognitive impairment. On 08/18/22 a baseline care plan was developed and indicated that Resident #55 was at risk for falls related to gait and balance problems. The goal of the care plan was to: 1) minimize the risks of falls through the review date, and 2) that Resident #55 will not sustain a serious injury through the review. Nursing interventions included: 1) anticipating and meeting the resident's needs, 2) ensuring the bed is in the lowest position, 3) physical therapy to evaluate and treat as ordered and as needed (PRN), 4) The resident needs a safe environment with: keep floors free from spills and/or clutter, adequate glare-free light, a working, and reachable call light, the bed in a low position at night, side rails as ordered, handrails on walls, personal items within reach. On 08/23/22, the nursing staff initiated an Actual Fall care plan for Resident #55 related to poor safety awareness. The actual fall care plan was revised on 09/06/22 with the following revisions by the healthcare virtual assistant: 1) Resident #55 will resume usual activities without further incident through the review date, 2) Ensure that commonly used items are placed within reach, 3) Ensure the chair is locked when the resident is sitting position, and 4) Reinforce to call for assistance. Further review of Resident #55's medical record revealed that on 08/18/22 at 6:17 AM, resident #55's nurse documented a change in condition review sheet that indicated Resident #55 was found on the floor by staff members. In the statement, Resident #55 indicated that he/she rolled off the bed. Resident #55 was assessed by the nurse and there were no complaints of pain or injury. A review of the fall incident report only listed one Predisposing Situation Factor as being admitted within 72 hours of the fall. Further review of nursing documentation dated 09/10/22 at 4:19 PM, Resident #55's nurse documented that staff observed Resident #55 sitting on the floor. Resident #55 informed the nurse that he/she was trying to walk. Resident #55 denied any pain, injury, or hitting her head. Later that evening on 09/10/22 at 8:15 PM, Resident #55's nurse was again made aware by an aide that Resident #55 was again observed on the floor. Resident #55 denied any pain, injury, or hitting her head. Resident #55's physician and the facility administrator were made aware of Resident #55's falls at this time. Resident #55's physician instructed the nurse to obtain some laboratory tests. Further review of Resident #55's medical record revealed a nursing note, dated 09/22/22 at 10:33 AM, indicating that staff observed Resident #55 on the floor again on 09/18/22 around dinner time. Resident #55 stated that he/she had rolled off the bed. Resident #55 complained of his/her left hip hurting at this time. Resident #55 was administered Tylenol at this time. In an interview with the facility Interim Director of Nurses (DON) on 09/22/22 at 11 AM, the interim DON stated that there were no facility investigations or root cause analyses of Resident #55's falls that occurred on 09/10/22 at 4:19 PM, 09/10/22 at 10:47 PM, or 09/18/22 at dinner time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 9/19/22 at 09:50 AM Resident #98's closed medical record review revealed that the resident was admitted to the facility on [DATE] at approximately 5:30 PM after neck surgery. The resident also has a history of chronic pain and used narcotics (a drug that relieves pain) at home. A review of the new admission order revealed an order written on 8/26/21 for Oxycodone 30 mg. Immediate release (fast acting) for pain every 4 hours as needed (PRN). A review of the medical record revealed that upon Resident #98's arrival at the facility, s/he requested pain medication, but the facility could not guarantee when the pain medication would be available for the resident. A review of the progress note written by the former administrator on 8/27/21 at 1:33 PM stated that He called 911 early AM to go to the hospital since his pain meds were not in the facility. The Director of Nursing (DON) was made aware that there was a complaint allegation that a resident was in the facility and did not get his/her pain medication as ordered, the resident called 911 and was taken back to the hospital. The DON was asked about the process for obtaining medications not available in the facility. S/he explained that medications not available could take up to 4-6 hours for delivery from the pharmacy. Upon request, she provided a list of narcotic medications stocked by the facility on 9/20/22 at 3:10 PM. A review of the list of narcotic medications stocked by the facility for the month of September 2021 revealed that oxycodone 30 mg. Immediate release was not listed. Based on a complaint, reviews of a medical record, and staff interviews, it was determined the facility staff failed to ensure that a resident was provided pain medication when requested and that a resident had ordered pain medication on admission. This was evident for 2 (#5, #98) of 9 residents reviewed for pain management during the annual survey. The findings include: 1) A review of complaint MD00181990 on 09/11/22 revealed an allegation that residents in the facility were not receiving their medications. In an interview with Resident #5 on 09/12/22 at 2 PM, Resident #5 stated that he/she did not receive any pain medication for 3 days, due to being unavailable, after being readmitted to the facility on [DATE]. A review of Resident #5's medical record on 09/14/22 revealed that Resident #5 suffers from a stroke, left-sided weakness, diabetes, neuropathy, obesity, Atrial fibrillation, chronic pain, and a cardiac valve replacement. Resident #5 is dependent upon the facility staff for several aspects of care including transfers, bed mobility, toilet use/incontinence care, and personal hygiene. Resident #5 was sent to the hospital on [DATE] for complaints of chest pain. Review of Resident #5's hospital discharge summary revealed the hospital physician instructed Resident #5 to continue taking the following medications: 1) Tylenol, 1000 mg, orally, every 8 hours as needed for pain. 2) Oxycontin ER, 10 mg, orally, twice daily. 3) Oxycodone, 5 mg, orally, every 6 hours as needed for pain. A review of Resident #5's September 2022 Medication Administration Record (MAR) on 09/14/22 revealed that Resident #5 did not receive a dose of Oxycontin or Oxycodone from 09/01/22 until 09/05/22. In an interview with the facility pharmacy manager on 09/15/22 at 2:05 PM, the pharmacy manager stated that the nursing staff failed to obtain a signed controlled substance form, C-II form, from Resident #5's physician. The pharmacy received a physician-signed C-II form on 09/04/22, for Resident #5's Oxycontin and Oxycodone. In an interview with RN #16 on 09/20/22 at 1:58 PM, RN #16 stated that Resident #5 ran out of his/her Oxycontin and Oxycodone again. RN #16 stated he/she was able to obtain a physician-signed C-II form for both medications and faxed them to the pharmacy. In an interview with Resident #5 on 09/20/22 at 3:35 PM, Resident #5 stated that the facility ran out of his/her pain medication again. Resident #5 stated that the nurses gave him/her Tylenol, but the Tylenol does not relieve his/her pain and that currently his/her pain is a 9/10.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, it was determined that the facility failed to ensure a physician supervised the care of a resident, as evidenced by the physician failing to evaluate a resident upon admission to the facility and failure to review a resident's weight loss. This was evident for 2 (#99, #106) of 33 complaints reviewed and 1(#34) of 12 residents reviewed for nutrition during the annual survey. The findings include: 1) On 9/26/22 at 10:54 AM, a review of the complaint MD00166828 revealed that Resident #99 was admitted to the facility on [DATE] for ambulatory dysfunction s/p (status post) fall. Further review of the medical record identified that a telehealth provider wrote the initial patient and medication assessment on the admission date with detail; patient has just arrived at this facility today and is awaiting full initial evaluation by primary team. [agency company name] is consulted today to check on patient status and to review medications and orders. However, there was no attending physician's assessment record about Resident #99 in the paper chart or electronic medical record until the resident was discharged from the facility on February 2021. During an interview with the interim Director of Nursing (DON) on 9/26/22 at 12:20 PM, she explained that the telehealth was an on-call coverage provider who worked holidays or weekends while the attending providers were off. The surveyor asked the interim DON whether the telehealth note was considered a primary physician's assessment or not. The interim DON confirmed, no, the on-call staff is just on call. The attending physician needs to assess residents. 2) On 9/26/22 at 1:55 PM, a portion of investigating complaint MD00172868 revealed Resident #106 was admitted to this facility on 2/6/21 for a subacute therapy-related recent fall. Further review of the medical record showed that a telehealth provider wrote a brief note for Resident #106's admission on the same day. Also, the admission note was written by an attending Nurse Practitioner (NP #49) on 2/11/21. However, there was no physician's history and physical assessment note related to Resident #106 in a paper chart or electronic medical record. The interim DON was advised of the concern on 9/28/22 at 1:30 PM regarding the attending physician's initial assessment/documentation was not recorded for newly admitted residents. The interim DON confirmed that physician's records were not found in the resident's medical records. 3) On 9/21/22 at 9:53 AM a record review was conducted for Resident #34 and revealed the resident was admitted to the facility in January 2022 with diagnoses that included, but were not limited to, Parkinson's disease, unspecified dementia, mood disturbance, and anxiety. Resident #34's medical record revealed the resident weighed 156.6 lbs. (pounds) on 6/21/22 and 145 lbs. on 7/13/22, which was a 7.4% weight loss in 1 month. Further review of Resident #34's medical record failed to produce documentation that the physician or the responsible party were notified of the weight loss. Review of physician's visits in the medical record failed to document that the resident had been seen by a physician since 6/23/22. On 9/21/22 at 11:16 AM an interview was conducted with Physician #77. Physician #77 looked in his tablet and stated he saw Resident #34 on 7/20/22. The surveyor informed Physician #77 his progress notes were not in the medical record. Physician #77 said that the notes should be there and he would have his office send them over. Cross Reference F711. The weight taken on 7/13/22 was documented in the medical record under the vital sign section. Physician #77 stated, since July many nurses have quit their positions, notifying us and making sure vitals are done and orders carried out is what we rely on. It is not feasible to check weights myself. I came here to put my time in and I have added [name of facility] and we rely on staff. It is an issue. I rely on staff. We were not notified of that weight. The time we have to backtrack to see if these things are getting done, we get paranoid. Review of Physician #77's 7/20/22 visit for Resident #34 documented, follow-up of chronic medical conditions and to establish care. Under the vital sign section of his note, height and weight were blank. The physician's plan documented, reviewed care with staff. I came to establish care with the patient. I see no changes at this time. The patient is stable and appears comfortable and in no distress. Physician #77 failed to thoroughly review Resident #34's medical record and failed to recognize the 7.4% weight loss in 1 month. The concerns were reviewed with the Interim Director of Nursing on 9/28/22 at 12:15 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0775 (Tag F0775)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility staff failed to 1) obtain lab tests as instructed by the resident's physician, and 2) place the results in the resident's medical record. This was evident for 1 (Resident #55) of 6 residents reviewed for unnecessary medications during the annual survey. The findings include: Review of Resident #55's medical record on 09/19/22 revealed physician orders, dated 08/21/22, 08/25/22, 08/26/22, 09/11/22, and 09/12/22 instructing the nursing staff to obtain laboratory specimens for the following: 1) 08/21/22 at 11:59 PM - obtain a CBC (complete blood count) and a CMP (comprehensive metabolic profile) on 08/26/22, one time only for type II diabetes and hallucinations for 1 day. 2) 08/25/22 at 12:45 AM - obtain a CBC (complete blood count) and a CMP (comprehensive metabolic profile) on 08/26/22, one time only, for hallucinations, agitation, and anxiety for 7 days. 3) 08/26/22 at 12:01 AM - obtain a CBC, CMP, and urine sample for urinalysis and culture and sensitivity for one day. Resident #55 was placed on the antibiotic Keflex, 1 capsule two times a day for hallucinations, agitation, and anxiety for a suspected urinary tract infection (UTI) for 7 days. 4) 09/08/22 - repeat a CBC and CMP to be collected on 09/09/22. There were no specific reasons documented in Resident #55's medical record to obtain the CBC and CMP on 09/09/22. A review of Resident #55's nursing progress notes on 09/19/22 revealed a nursing progress note dated, 09/09/22 at 2:10 PM that indicated Resident #55 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER]. In an interview with the facility laboratory spokesperson, staff #86, on 09/22/22 at 12:58 PM, staff #86 stated that the lab has been processing laboratory samples for the facility since December 2021. Staff #86 stated that the lab did not process any lab specimens for Resident #55 in August 2022. Staff #86 also stated that on 09/09/22, the laboratory staff attempted to call a panic lab value for Resident #55, a glucose reading of 48 mg/dl, but was unsuccessful. Staff #86 stated the laboratory staff called to speak with the nurse for Resident #55 on 09/09/22 at 7:49 PM, 8:04 PM, and 8:14 PM. Staff #86 stated that the lab has a policy that after 3 unsuccessful attempts to notify the facility nursing staff of a critical lab value, the laboratory staff is to release/send the lab results to the facility. Staff #86 then stated that there was a urine for analysis ordered for Resident #55 from 09/12/22 that the lab has not received. The 09/12/22 urinalysis was ordered to evaluate Resident #55 for confusion and falls.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (#27) of 1 residents reviewed for dental while admitted to the facility under Medicare. The findings include: On 9/12/22 at 1:08 PM an interview was conducted with Resident #27. Resident #27 was asked if he/she had natural teeth or dentures. Resident #27 stated, I have dentures but they got lost when I went to the hospital. On 9/15/22 at 2:45 PM Resident #27's spouse was in the room and expressed concern to the surveyor about the missing dentures that got lost the evening that Resident #27 fell and was sent to the hospital. Resident #27 stated the dentures were on the floor and they haven't seen them yet. The spouse stated she told the administrator and was told they were being looked for. On 9/16/22 at 8:44 AM a medical record review was conducted for Resident #27. A 8/23/22 nursing admission assessment documented, no teeth - lost dentures at the hospital. The resident was ordered a regular diet, mechanical soft - chopped meat texture, dental soft diet with additional portions. On 9/16/22 at 9:15 AM an interview was conducted with the Nursing Home Administrator (NHA) who stated, I think they fell on the floor after EMS was working on [him/her.] I told the staff to look for them and I spoke to the [spouse] to see if they were lost in transport. The NHA was informed that there was no documentation in the medical record about what was being done related to the dentures and that the resident was not aware of what the facility was doing about the missing dentures. The NHA stated, of course we will pay for it. On 9/16/22 at 12:43 PM the NHA wrote a progress note in Resident #27's medical record that stated, Residents [spouse] called this writer on 8/19/2022 regarding missing dentures. Referred to DON (Director of Nursing). will check [name of dental] services if they received a referral for this patient. The aide stated that the dentures fell on the floor at the time of pt. being taken to the hospital by the 911. The aide stated that she sent the dentures with pt. Unable to find in room. A 9/16/22 at 12:45 PM progress note that was written by the NHA documented, this writer called the dental office to follow up. A 9/16/22 at 16:30 (4:30 PM) progress note documented by the NHA stated, dental office was contacted [name] and message was left . Will follow up on Monday . [spouse name] was informed about the same that dentist notified to assess for [name] lower dentures. As of of 9/27/22 at 5:00 PM there was no further documentation regarding the dental follow-up. The concern was discussed with the Interim Director of Nursing on 9/28/22 at 12:15 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility failed to provide rehabilitation services, evidenced by failing to provide physical therapy as initially planned. This was evident for 1 (Resident #58) of 7 residents reviewed for rehabilitation during the annual survey. The findings include: 1) During an interview with Resident #58 on 9/11/22 at 9:37 AM, the resident stated he/she received rehabilitation therapy six months later after admission. The resident also reported, since the facility did not offer the therapies, I had to learn myself. If they helped me on time, I might not need this wheelchair now. On 9/20/22 at 12:39 PM, the surveyor reviewed Resident #58's medical record. Resident #58 was admitted to the facility in January 2021 and needed rehabilitation therapy due to general weakness. Further medical record review revealed that Resident #58's physician ordered, evaluate and treat in skilled Physical/Occupational Therapy on 1/25/21. On 9/27/22, the surveyor requested a copy of therapy documentation for Resident #58. The Director of Therapy (Staff #54) confirmed that since the current Therapy team had been working for this facility since November 2021, some documentation could not be seen. Staff #54 stated she would ask for help from the facility management staff. On 9/28/22 at 8:14 AM, Staff #54 submitted a review of the medical record for Resident #58. The resident's physical therapy evaluation and treatment plan revealed that Resident #58's treatment plan was, frequency- 5 to 6 times per week, duration- 4 weeks, intensity- daily, and period - 1/26/21 to 2/24/21. However, the physical therapy Discharge summary dated [DATE] showed Resident #58's physical therapy was discontinued due to a change in payer source. Also, the same documentation under discharge recommendations indicated, continue therapy services, a restorative program established/trained: not indicated at this time. Resident #58's physical therapy restarted on 3/5/21. During an interview with the Interim Director of Nursing (DON) on 9/28/22 at 1:30 PM, the surveyor informed her about concerns related to the therapy stopping due to payer changes. The Interim DON was also informed that the surveyor was waiting for the former therapy company's phone call. The surveyor received a call from the former Rehab company's [NAME] Present of Operation (Staff #82) on 9/29/22 at 3:55 PM. Staff #82 explained the general procedure for nursing home resident's discharge plan from the therapy program and added that discharge for the payer change was not expected. Also, Staff #82 added, since we had many buildings, I'm unable to recall each case. But if it was discontinued due to payer change, it was not our standard procedure. It needed to be re-evaluated as soon as possible to continue the therapy.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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7) On 9/12/22 at 8:33 AM observation was made of the breakfast cart arriving to the Mill Landing nursing unit. GNA #12 was observed carrying a breakfast tray to Resident #19's room. GNA #12 failed to knock on the resident's door before entering the room. On 9/12/22 at 8:37 AM, upon exit of Resident #19's room, GNA #12 was asked if she realized that she failed to knock on the resident's door prior to entering. GNA #12 stated, I didn't notice. On 9/12/22 at 8:41 AM Resident #19 was asked if the GNA who brought breakfast knocked on the door before entering. Resident #19 stated, No. When asked how often it happened that the staff failed to knock on the door the resident replied sometimes. The Director of Nursing was made aware on 9/27/22 of the concerns prior to survey exit. 6) During an observation of the Wye Oak unit on 9/15/22 at 10:59 AM, two surveyors observed GNA #23 pulling Resident #24's Geri chair backward with one hand in the activity area of the unit. The surveyor interviewed GNA #23 right after the observation. GNA #23 said, since the Geri chair's wheel is not going straight forward, I pushed the chair backward. GNA #23 also stated that she has been using the chair and pushing it backwards and never asked for it to be repaired. This concern was reviewed with the Interim Director of Nursing (DON) on 9/28/22 at 1:15 PM. The Interim DON confirmed that she never received a report regarding the geri chair, and stated that she would provide education to staff. Based on observation and staff interview, it was determined that the facility staff failed to treat each resident in a dignified manner by 1) not knocking on the resident's door before entering, 2) standing over a resident while feeding the resident, 3) not changing a resident's wet clothing before proceeding with assisting the resident with his/her meal, 4) serving the breakfast meal on disposable paper when the facility had glass plateware available, and 5) pulling a resident backward down the hallway. This was evident for 6 (Resident #44, #6, #1, #65, #24, #19) of 54 residents reviewed during the annual survey. The findings include: 1) During an observation of Resident #44 on 09/11/22 at 8:30 AM, the surveyor observed Geriatric Nursing Assistant (GNA) #12 failing to knock on the residents door before entering Resident #44's room. 2) During an observation of Resident #6 on 09/11/22 at 8:35 AM, the surveyor observed GNA #12 failing to knock on the resident's door before entering Resident #6's room. 3) During an observation of Resident #1 on 09/21/22 at 1:10 PM, the surveyor observed GNA #57 bring Resident #1 his/her lunch meal tray and set the tray down on the table in front of Resident #1. GNA #57 stepped away to continue to pass out other residents' meal trays and that is when Resident #1 grabbed the cup of iced tea off the lunch meal tray and spilled the cup of iced tea all down the front of his/her clothing. GNA #67 was observed assisting Resident #1 with attempting to dry off Resident #1's clothing with a towel. Moments later, GNA #57 returned to Resident #1 who was seated in his/her Geri chair at the 200 hall dining area which was located at the nurses' station. GNA #57 was observed proceeding to feed Resident #1 while standing next to Resident #1. In an interview with GNA #57 on 09/21/22 at 1:16 PM, GNA #57 stated that Resident #1 was still wet from spilling his/her iced tea on himself/herself and that he/she was going to change Resident #1's wet clothing when he/she takes Resident #1 back to his/her room to put him/her to bed. 4) During an observation of Resident #6 on 09/28/22 at 11:23 AM, the surveyor observed GNA #72 pulling Resident #6 backward from his/her room, while seated in his/her wheelchair, to the 200 hall dining area near the nurses' station. 5) During the observation and interview with Resident #65 on 09/11/22 at 8:56 AM, Resident #65 complained to the surveyor about eating on disposable paper plates. Resident #65 stated that this was the first time this had happened since being admitted to the facility. In an interview with the facility assistant kitchen manager (staff #58) on 09/11/22 at 12:25 PM, the facility kitchen manager stated that there was not enough kitchen staff available to prepare the breakfast meal this morning and that is why I decided to serve the residents in the facility on paper and plastic plates. The assistant kitchen manager stated that the lunch meal would be served on regular plate ware for lunch.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive for 3 (#10, #69, #27) of 3 sampled residents for advance directives. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. 1) On [DATE] at 9:49 AM a chart review for Resident #10 revealed the resident was admitted to the facility in [DATE] with a past medical history that included, but was not limited to, type 2 diabetes mellitus, vascular and Alzheimer's dementia, diabetic neuropathy and nephropathy, and end stage renal disease with hemodialysis therapy. During a review of the clinical record on [DATE], the resident's MOLST was located, but there was no information indicating that an opportunity to formulate an advance directive was recently provided to the resident and/or the resident representative. 2) On [DATE] at 10:22 AM a chart review for Resident #69 revealed the resident was admitted to the facility in [DATE] with a past medical history that included, but was not limited to, dementia, cerebrovascular accident, hypertension, seizures, anxiety, and peripheral vascular disease. During a review of the clinical record on [DATE], the resident's MOLST was located, but there was no information indicating that an opportunity to formulate an advance directive was recently provided to the resident and/or the resident representative. 3) On [DATE] at 1:50 PM a chart review for Resident #27 revealed the resident was admitted to the facility in [DATE] with a past medical history that included, but was not limited to, AICD (automatic implantable cardioverter-defibrillator), coronary artery disease, basal cell carcinoma and hypertension. During a review of the clinical record on [DATE], the resident's MOLST was located, but there was no information indicating that an opportunity to formulate an advance directive was recently provided to the resident and/or the resident representative. On [DATE] at 12:51 PM an interview was conducted with the social worker regarding advance directives. The social worker was asked if she discussed living wills, power of attorney, or anything involving advance directives or health care options. The social worker stated, I don't. If they ask I can. I usually do not have a discussion about advance directives. I don't do that, health care options. On [DATE] at 2:45 PM Resident #27's spouse was in the resident's room and was asked if facility staff ever approached him/her about advance directives besides the MOLST. Resident #27's spouse stated, no. I have a living will at the house, but they never asked for it. Discussed with the interim Director of Nursing on [DATE] at 12:15 PM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8) A medical record review of Resident #29 was conducted on 9/22/22 at 1:20 PM. A progress note, a part of the medical record, written by Registered Nurse (RN) #79 on 9/21/22 at 6: 44 AM, stated, Resident was yelling out loud. Resident was found to be sweating profusely. Resident blood sugar checked at was 48. Resident given glucose, Blood sugar went up to 64. Resident continued to yell out. Resident wanted to go the hospital. Resident assessed by supervisor. Resident sent to ER for evaluation. An interview was conducted with RN #79 via phone on 9/22/22 at 3:11 PM. RN #79 stated that she assumed the supervisor called 911, the physician, and family members. Further review of the medical record did not reveal documentation that the physician ws notified of Resident #79's health status. On 9/23/22 at 10:23 AM, the NHA was interviewed and revealed that there was no credible evidence that the physician was notified of the resident's status. The concern was shared with the Interim DON on 9/28/22 at 1:30 PM. 5) On 9/21/22 at 9:53 AM a review of Resident #34's medical record revealed the resident weighed 156.6 lbs. (pounds) on 6/21/22 and 145 lbs. on 7/13/22, which was a 7.4% weight loss in 1 month. There was no weight obtained in August 2022. Review of a nutritional assessment dated [DATE] documented, Patient has significant weight loss of 7.4% within 1 month with weight history 6/21/2022 156.6#, 7/13/2022 145# BMI 22 (normal). RD (Registered Dietician) does not believe recent weight is accurate. RD requested reweight but this has not been obtained. Further review of Resident #34's medical record failed to produce documentation that the physician or the responsible party were notified of the weight loss. On 9/21/22 at 11:16 AM an interview was conducted with Physician #77 who stated, I was not notified of the weight loss. I would have expected to be notified. Since July many nurses have quit their positions. Notifying me and making sure vitals are done and orders are carried out is what we rely on. It is not feasible to check weights myself. We rely on staff. It is an issue as I rely on staff. On 9/21/22 at 1:06 PM an interview was conducted with Dietician #25 who stated she had just started at the facility and was in the process of seeing all residents. Dietician #25 stated she saw the resident yesterday and put Resident #34 on weekly weights. On 9/21/22 at 1:43 PM a discussion was conducted with the Medical Director who stated, the physician should have been notified. 6) On 9/12/22 at 10:59 AM an interview was conducted with Resident #62's responsible party (RP). During the interview the RP was asked if she was notified by the facility of changes in Resident #62's care. Resident #62's RP stated she was not notified of a change in medication. On 9/19/22 at 10:08 AM a review of Resident #62's medical record revealed the resident was admitted with a diagnosis of dementia. The resident was previously hospitalized for aggressive behavior and behavioral disturbances and was started on anti-psychotic medication. The resident was admitted to the facility's dementia unit for care. On 9/19/22 at 10:08 AM a review of Resident #62's medical record revealed the antipsychotic medication Seroquel was changed from 75 mg. twice per day to 100 mg. twice per day on 8/3/22 and the antidepressant medication Zoloft 25 mg. was initiated on 8/18/22. There was no documentation that the RP was notified at that time. 7) On 8/4/22 at 7:30 AM a review of the medical record for Resident #450 revealed the resident was admitted to the facility in the beginning of December 2021 from an acute care hospital with diagnoses that included, but were not limited to, type 2 diabetes mellitus, non-pressure chronic ulcer of the right lower leg, sepsis and endometrial cancer. Review of Resident #450's December 2021 physician's orders revealed the order for the diabetes medication Jardiance 25 mg. to be taken every day. Review of Resident #450's Medication Administration Record (MAR) for December 2021 documented the Jardiance was not available to be administered on 12/19, 12/20, 12/21 and 12/22/21. Review of Resident #450's MAR for January 2022 documented the Jardiance was not available to be administered on 1/5, 1/6, 1/7, 1/8, and 1/9/22. There was no documentation that the physician was notified of the delay in the administration of the medication. Review of a 1/4/22 physician's visit documented the plan was to start Resident #450 back on his/her home dose of Ozempic. (Ozempic is an injection medication used to help control high blood sugar for people with type 2 diabetes). Will be started back on Megestrol for appetite stiumlant given history of cancer as recommended by oncologist. (Megestrol is similar to a natural substance made by the body called progesterone. It treats breast cancer and endometrial cancer by affecting female hormones involved in cancer growth). The physician also wrote to continue the Jardiance treatment. Continued review of Resident #450's MAR for January 2022 documented the Megestrol was not available on 1/5, 1/6, 1/7, 1/8, 1/9, and 1/10/22. The Ozempic, which was only to be given on Fridays, was not available on 1/7, 1/14, 1/21 and 1/28/22. The medication Semglee 80 units every day was not available on 1/15/22, and not signed off on 1/21/22 and 1/29/22. Semglee is a prescription long-acting man-made-insulin used to control high blood sugar in adults and children with type 1 diabetes and in adults with type 2 diabetes. The notations were either pending delivery or on order. There was no documentation that the physician was notified of the delay in the administration of the medication. A 2/10/22 physician's note documented, fingersticks has been fluctuant, reaching mid 200s. [He/she] is on high-dose Lantus 80 units. Also, [he/she] is on Ozempic. Continue the same. The resident had not received the Ozempic and the physician was unaware. Discussed with the Interim DON on 9/28/22 at 12:15 PM and again on 9/28/22 at 5:00 PM along with the Medical Director. The Medical Director stated, nursing was educated for the physician notification and it had improved. Not sure about the training for the agency staff. Both the Interim DON and Medical Director were informed of the findings. Based on a complaint, review of medical records, and staff interview, it was determined that facility staff failed to notify a resident's representative and physician when, 1) a resident developed a Stage II pressure wound, 2) a critical lab value was reported by the lab, 3) a resident was observed having a choking episode, 4) a resident had an unplanned weight loss, 5) a resident had a medication change, and 6) a resident was sent to the hospital emergently. This was evident for 7 (Resident #55, #6, #141, #34, #62, #450, #29) of 54 residents reviewed during the annual survey. The findings include: 1) A pressure ulcer, also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III ( full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full-thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). Review of Resident #55's medical record revealed a Nurse Practitioner Wound Consultant note, dated 08/23/22 at 11:15 AM, that indicated Resident #55 was now observed with a Stage II pressure ulcer on the sacrum. The pressure ulcer measured 3.33 cm x 2.68 cm x 8.92 cm. The depth was noted to be 0.10 cm. No odor was noted. The edges were attached. The Nurse Practitioner Wound Consultant indicated the wound was present prior to admission to the facility. Treatment for the pressure wound included: a dressing change to the wound three times a day, a wedge/foam cushion for offloading, and a wheelchair cushion, pressure reduction, and turning precautions were discussed with the staff at the time of the visit, recommended heel protection and pressure reduction to bony prominences, and the staff was educated on all aspects of care. The Nurse Practitioner Wound Consultant requested to keep the wound site covered and avoid contamination with feces at all times. No documentation was found in the medical record that indicated Resident #55's responsible party was notified at this time. In an interview with Resident #55's responsible party on 09/23/22 at 4:44 PM, Resident #55's responsible party stated that he/she has only been contacted by the nursing staff for a couple of falls and nothing regarding a pressure wound. Resident #55's responsible party also stated that there has not been a care plan meeting since admission and that the last phone call he/she received from the nursing staff was yesterday, 09/22/22, for a fall. The staff told me Resident #55 had a fall and was okay. Cross-reference F 686 2) In an interview with the facility-contracted laboratory administrator (staff member #86) on 09/22/22 at 12:58 PM, the laboratory administrator stated that on 09/09/22, Resident #55 was identified with a glucose of 44 mg/dl. The lab administrator stated that a glucose result of 44 mg/dl was a critical lab value. The lab director indicated the lab staff documented an attempt to call Resident #55's nurse 3 times (7:49 PM, 8:04 PM, 8:14 PM) on 09/09/22 without success. A review of Resident #55's medical record on 09/26/22 failed to reveal lab results being placed in Resident #55's medical record or electronic medical record. A review of Resident #55's medical and electronic record failed to reveal that Resident #55's responsible party or physician were made aware of the critical glucose result of 44 mg/dl on 09/09/22. Cross-reference F 775 3) A review of Resident #6's medical record on 09/14/22 at 10:20 AM, revealed in a nursing progress note dated 09/11/22 at 11:51 PM that a GNA staff member reported to the nurse that Resident #6 was gagging while swallowing and then started spitting the food. The 09/11/22 at 11:51 PM progress note did not indicate what meal this episode occurred on. There was no documentation that Resident #6's physician or the responsible party was made aware of this episode. Further review of Resident #6's medical record revealed a nutritional assessment note dated 06/17/22 at 1:06 PM that indicated Resident #6 was at an increased risk for aspiration due to his/her diagnosis of a history of a stroke with dysphagia. A review of Resident #6's care plans revealed that Resident #6 was at risk for altered nutrition/hydration and weight change related to dysphagia. Goal #2 on the care plan indicated Resident #6 will have no choking episodes through the review date. This goal was initiated on 08/05/20 and revised on 01/13/22. The fourth nursing intervention for Resident #6's care plan was to alert Resident #6's physician and the facility dietician of significant changes. In an interview with the facility speech language pathologist (SLP-staff member #66), on 09/14/22 at 10:35 AM, the SLP stated that he/she had not been notified of Resident #6's choking episode on 09/11/22 and confirmed that Resident #6 was not receiving SLP services at that time. The facility SLP stated that nursing was responsible for notifying therapy services for any type of acute issue. The facility SLP also stated and confirmed Resident #6 was on the least restrictive diet possible, with regular textured foods with mechanical ground meat. The facility SLP was aware that Resident #6 had a history of needing artificial nutrition and hydration and that Resident #6 did have the feeding tube removed. These findings were shared with the facility Administrator and Interim Director of Nurses (DON) at the exit conference on 09/28/22 at 6:00 PM. 4) A review of Resident #141's medical record related to nutritional concerns was conducted on 9/20/22 at 2:15 PM. A nutritional assessment was completed on 9/8/22 by the dialysis dietitian. The dietitian documented a weight of 200 pounds (Lbs.) that was taken on 9/6/22. The nutritional summary revealed, Resident is at nutrition risk related to inadequate oral intake with elevated nutritional needs for wound healing and likely inadequate nutrient intake. A review of the vital signs weight section of the electronic health record revealed a second weight was documented on 9/19/22 at 10:03 PM as 160.8 Lbs. by a nurse (staff #47). The electronic health record automatically documented a weight comparison noting a 19.6 % significant weight loss of 39.2 Lbs. Further review of the medical record did not reveal any type of physician or dietician notification. A review of the facility's Weight Monitoring policy dated 9/28/20 with a Reviewed/Revised date of 2/11/21 revealed Weight Analysis: The newly recorded weight should be compared to the previous recorded weight and it further defined significant weight change percentages. All weights are to be entered into the Point Click Care (PCC), under the weights and vital signs portal. Unit Managers and/or ADON to validate prior to PCC entry, with a further indication of physician, dietician, and resident's responsible party notifications of weight gain/loss trends need to be documented by a licensed nurse in the clinical record. Multiple care area concerns were shared with the Interim DON on 9/22/22 at 4:29 PM including the documentation of a 39 Lbs. weight loss without further documentation or physician notification. On 9/26/22 at 12:51 PM the Interim DON had a follow up discussion with the surveyor, and she involved Staff #47 in the post discussion. Staff #47 indicated that she entered a post dialysis weight and apologized for not recognizing Resident #141's significant weight loss and therefore she did not notify a physician.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 9/21/22 at 7:44 AM observation was made of Resident #10's room, and it was noted the resident was not in the room. Registered Nurse (RN) #14 was asked where Resident #10 was and RN #14 stated Resident #10 was sent out to the hospital on 9/16/22 due to the resident's toe, looked bad. Review of Resident #10's medical record on 09/21/22 at 08:05 AM revealed a 9/16/22 at 13:10 (1:10 PM) nurse practitioner progress note which documented the chief complaint was, recurring right great toe trauma that has now developed into an arterial ulcer. The plan documented, wound significant worse, suspected fasciitis. Pt. started on PO (by mouth) ABX (antibiotics) day prior. Recommend transfer to ED (emergency department) for evaluation. Review of Resident #10's 9/16/22 change in condition note was incomplete. There was no documentation that the receiving facility was notified of the transfer. 3) On 9/11/22 at 11:11 AM Resident #27's medical record was reviewed and revealed a MDS assessment for a discharge return not anticipated dated 8/18/22. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Further review of the medical record revealed there were not any progress notes between the dates of 8/18/22 and 8/23/22 when the resident was re-admitted . On 9/16/22 at 8:44 AM continued medical record review revealed a hospital Discharge summary dated [DATE] which documented Resident #27 was admitted to the hospital for a urinary tract infection and bacteremia and was being discharged back to the facility. On 9/16/22 at 9:15 AM the Nursing Home Administrator (NHA) was informed that there was no documentation about the transfer to the hospital. The surveyor informed the NHA that it initially could not be determined if the resident was discharged home or elsewhere. The NHA stated Resident #27 was transferred to the hospital. Based on medical record review and staff interview it was determined that the facility 1) failed to ensure the discharge of a resident was documented in the medical record to include, the resident's status at the time of discharge, any required discharge instructions, the reason for the discharge and 2) failed to document that information was provided to the acute care facility when a resident was transferred there emergently. This was identified for 3 (#148 #10, #27) of 9 residents reviewed for discharge during the annual survey. The findings include. 1) On 09/22/22 at 4 PM, Resident #148's closed medical record was reviewed in relation to complaint intake MD00177030. Resident #148 was discharged on 5/13/22. Progress notes indicating the resident discharge were not found. Documentation related to the resident's status at the time of discharge, discharge instructions, a discharge plan, or the reason for the discharge was not found in Resident #148's medical record. On an electronic Transfer/Discharge Report under the miscellaneous information section, there was a Transfer/Discharge to Private home/apartment without a forwarding address or how or by whom the resident left the facility. On 9/23/22 at 8:33 AM the medical records coordinator (staff #5) was informed of the electronic records' lack of discharge documentation. She was asked to provide the hard (paper) chart and any information she could find related to Resident #148's discharge. She returned with the resident's closed hard chart indicating she reviewed the resident's electronic medical record and reported she did not find information related to the resident's discharge on [DATE]. A review of the hard chart did not reveal any additional information related to the resident's discharge from the facility. At approximately 11:30 AM on 9/23/22 the nursing home administrator was informed of the documentation that was not found by the medical records person. No other documentation was provided related to Resident #148's discharge.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#10, #27) of 6 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 9/21/22 at 7:44 AM observation was made of Resident #10's room, and it was noted the resident was not in the room. Registered Nurse (RN) #14 was asked where Resident #10 was and RN #14 stated Resident #10 was sent out to the hospital on 9/16/22 due to the resident's toe, looked bad. Review of Resident #10's medical record on 09/21/22 at 08:05 AM revealed a 9/16/22 at 13:10 (1:10 PM) nurse practitioner progress note which documented the chief complaint was, recurring right great toe trauma that has now developed into an arterial ulcer. The plan documented, wound significant worse, suspected fasciitis. Pt. started on PO (by mouth) ABX (antibiotics) day prior. Recommend transfer to ED (emergency department) for evaluation. Review of Resident #10's 9/16/22 change in condition note was incomplete. There was no documentation in Resident #10's medical record that the resident was informed of the transfer and was prepared in a manner that the resident understood. 2) On 9/11/22 at 11:11 AM Resident #27's medical record was reviewed and revealed a MDS assessment for a discharge return not anticipated dated 8/18/22. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Further review of the medical record revealed there were not any progress notes between the dates of 8/18/22 and 8/23/22 when the resident was re-admitted . On 9/16/22 at 8:44 AM continued medical record review revealed a hospital Discharge summary dated [DATE] which documented Resident #27 was admitted to the hospital for a urinary tract infection and bacteremia and was being discharged back to the facility. On 9/16/22 at 9:15 AM the Nursing Home Administrator (NHA) was informed that there was no documentation about the transfer to the hospital. The surveyor informed the NHA that it initially could not be determined if the resident was discharged home or elsewhere. The NHA stated Resident #27 was transferred to the hospital. There was no documentation in the medical record that Resident #27 was informed of being sent to the hospital and was prepared in a manner that the resident understood. On 9/28/22 at 12:15 PM reviewed the concerns with the Interim Director of Nursing.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was determined the facility staff failed to 1) conduct an accurate, comprehensive assessment by failing to accurately assess a resident's dental status, mood and cognitive status, bowel and bladder status, and dialysis on comprehensive (Minimum Data Set) assessments and failed to 2) complete an admission MDS assessment within 14 days of a resident's admission to the facility. This was evident for 4 (#27, #59, #103, #291) of 23 residents reviewed for 4 different care areas and 1 (#141) of 1 newly admitted resident reviewed for the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 9/12/22 at 1:08 PM an interview was conducted with Resident #27 who stated his/her dentures got lost when he/she was transferred to the hospital. On 9/15/22 at 2:45 PM Resident #27's spouse expressed concern to the surveyor about Resident #27's missing dentures that fell on the floor the evening that the resident was sent to the hospital and have not been found. Resident #27 was transferred to the hospital on 8/18/22. On 9/16/22 at 8:44 AM a medical record review for Resident #27 was conducted and revealed a 7/8/22 admission MDS assessment that documented in section L0200, Dental, B. no natural teeth or tooth fragments (edentulous). The 8/28/22 admission MDS assessment documented no issues (not edentulous) in section L0200. Review of the 8/23/22 nursing admission assessment documented, no teeth - lost dentures at the hospital. The 8/28/22 admission MDS was incorrect as the resident was edentulous and was missing his/her dentures. 2) On 9/26/22 at 4:25 PM a review of Resident #59's medical record was conducted. Resident #59 was admitted to the facility in June 2020 with diagnoses including, but not limited to, unstable angina, diabetes mellitus with diabetic neuropathy, COPD, and end stage renal disease. Review of the comprehensive MDS assessment with an assessment reference date of 1/28/22, Section C, Cognitive Patterns, and section D, Mood was not assessed. On 9/13/22 at 12:51 PM an interview was conducted with the Director of Social Work who stated she does Section C and D of the MDS assessments but if she doesn't get to them the MDS coordinator will do them. The Director of Social Work stated that she was only in the building 2 days per week, and she said, I try to hit the important stuff, try to get my MDS done, talk to families. I probably miss a good portion of what I am supposed to do. She continued, the MDS coordinator left last week due to frustrations and corporate is doing the MDS now. 3) On 9/23/22 at 8:00 AM a review of Resident #103's medical record was conducted. Resident #103 was admitted to the facility in January 2022 with diagnoses that included, but were not limited to, contusion of the right hip and repeated falls. Review of hospital notes dated 1/24/22 documented that a urinary catheter was inserted on 1/24/22 at 23:56 (11:56 PM). Indication: immobilization required (trauma/surgery). Review of a 1/25/22 nursing admission assessment documented in Section J, Bladder/Bowel, comment section, resident has a foley catheter in place. A Foley catheter is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag. A 1/26/22 bowel and bladder assessment documented, Indwelling catheter, Does the resident have an indwelling catheter? YES. Review of the admission MDS with an assessment reference date of 1/31/22, Section H Bladder and Bowel, H0100 Appliances, coded, none of the above. Further review of the admission MDS, section C, Cognition and Section D, Mood, was not assessed. 4) On 9/26/22 at 2:00 PM a review of Resident #291's medical record was conducted. Resident #291 was admitted to the facility in August 2021 with diagnoses including, but not limited to, dependence on renal dialysis, diverticulitis of intestine, and chronic atrial fibrillation. Review of the admission MDS with an Assessment Reference Date of 8/31/21, Section O0100, Special Treatment, Procedures, and Programs failed to capture Dialysis. Review of Resident #291's August 2021 physician's orders documented, Dialysis M-W-F. Review of Resident #291's August 2021 Medication Administration Record (MAR) documented that staff obtained post dialysis weights every Monday, Wednesday, and Friday. For August 2021 it was signed off on Friday, 8/27/21 and Monday, 8/30/21. On 9/14/22 at 11:25 AM an interview was conducted with Staff #24, the MDS Resource Coordinator who stated, I work remotely sometimes and sometimes I am in the building. As of lately I have been here daily. Usually, 3 days here and 2 days remote. My hire date was June 2022. There was someone else here doing MDS. Resource MDS means I am a floater. I personally have not done a lot of the MDS. Staff #24 stated that she was helping social work doing the BIMS and PHQs now to make sure they were not having that problem. Staff #24 stated that Social Work should be doing sections C and D. She should have time. She comes on Tuesdays and Fridays, so I now started doing a check to ensure that the MDS sections are done. On 9/27/22 at 11:06 AM with the Interim Director of Nursing (DON) a discussion was held regarding the MDS errors. 5) Resident #141 was admitted to the facility on [DATE]. A review of Resident #141's medical record on 9/26/22 revealed the comprehensive 5-day admission assessment dated [DATE] was still in progress and was not completed within 14 days of the resident's admission to the facility. On 9/26/22 at 1 PM the Interim DON was informed of the overdue admission assessment. She summoned the MDS assessment coordinator (staff #24), so she could be informed of the MDS assessment that was still in progress. Staff #24 responded that she was working on the assessment. On 9/26/22 the assessment was overdue by 6 days as it was day 20 of Resident #141's admission to the facility.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9) A review of Resident #96's medical records on 9/22/2022 at 9:29 AM revealed that the resident was admitted to the facility on [DATE] for rehabilitation after neck surgery with a sacral ulcer and a foley catheter (A flexible plastic tube inserted into the bladder to provide continuous urine drainage). A continuous review of the medical record revealed that there was no Peak baseline care plan put in place for this resident. A review of the comprehensive care plan dated (2/1/2021) showed there were no baseline care plans put in place within 48 hours for the sacral ulcer or the foley catheter. The medical record was reviewed with the interim DON on 9/22/2022 at 1:30 PM. The surveyor made her aware that there was only one intervention initiated on 2/1/2021 which did not include interventions for the Foley catheter or sacral wound. Upon request, a copy of the care plan was provided by the DON showing only one care area initiated on 2/1/2021. 6) On 9/11/22 at 10:39 AM, an interview was conducted with Resident #36's spouse. The spouse stated he/she did not receive any documentation related to Resident #36's care plan on admission, and Resident #36's family stated they did not know his/her plan for treatment. On 9/14/22 at 11:05 AM an interview was conducted with LPN #30. LPN #30 stated, for the new admit assessment, I do full screening, head to toe assessment, verify vaccinations status. I do not give a copy of baseline care plan and copy of medication. Only given when the family member requests it. On 9/16/22 at 1:00 PM, a review of Resident #36 's electronic and paper medical record revealed the baseline care plan of the resident was completed on 7/21/22 without the staff member's name and title. Further review of the medical records showed no evidence to support Resident #36's care plan was reviewed and informed to the resident or resident's responsible party. The concern was shared with the interim DON on 9/28/22 at 1:30 PM. No additional supportive documentation was submitted by the interim DON. Based on interview and record review, it was determined that the facility failed to provide residents and or resident's responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications. This was evident for 9 (#62, #97, #103, #107, #450, #36, #88, #141, #96) of 54 residents reviewed during the annual survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1) On 9/12/22 at 10:48 AM an interview was conducted with the responsible party (RP) for Resident #62. The RP was asked about care plan meetings, and she stated, they called me when [he/she] was admitted in April of this year. I had 1 care plan meeting since then. The RP stated she did not get anything in writing when Resident #62 was admitted . She stated she did not get a copy of the care plan and the only papers she received was a bill and a notice of when the next care plan meeting would be. On 9/15/22 at 7:37 AM a record review for Resident #62 was conducted. Both the paper and electronic medical record failed to produce a signed copy of the baseline care plan. There was a baseline care plan that was completed in the electronic medical record dated 4/4/22, but it was not signed. There was no documentation that it was reviewed with the RP. 2) On 9/26/22 at 9:07 AM a record review was conducted for Resident #97. Resident #97 was admitted to the facility in January 2021 with diagnoses including Sepsis due to Methicillin susceptible staphylococcus Aureus, acute exacerbation of COPD, end stage renal disease requiring renal dialysis and type 2 diabetes mellitus with a foot ulcer. Further review of Resident #97's medical record failed to produce a baseline care plan. On 9/26/22 at 11:35 AM the NHA confirmed there was no baseline care plan. On 9/26/22 at 12:15 PM discussed with the Interim Director of Nursing (DON). 3) On 9/23/22 at 8:00 AM a record review was conducted for Resident #103. Resident #103 was admitted to the facility in January 2022 with diagnoses including but not limited to contusion of right hip and repeated falls. Further review of the medical record failed to produce a baseline care plan. On 9/27/22 at 11:06 AM discussed with the Interim DON. 4) On 9/26/22 at 11:15 AM a record review was conducted for Resident #107. Resident #107 was admitted to the facility in May 2021 with diagnoses that included nontraumatic subarachnoid hemorrhage, acute respiratory failure, and cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery. Further review of the medical record revealed a baseline care plan was completed in the electronic medical record, however there was no signature on the care plan and no documentation that the care plan was given to the resident or RP for review along with a list of the medications the resident was receiving at that time. 5) On 9/22/22 at 3:43 PM a record review was conducted for Resident #450. Resident #450 was admitted to the facility in December 2021 with diagnoses that included sepsis, type 2 diabetes mellitus and non-pressure chronic ulcer of right lower leg. Further review of the medical record revealed a baseline care plan that was initiated on 12/1/21, however the care plan was not signed by the staff completing the care plan or the resident. There was no documentation that the baseline care plan had been given to the resident along with a list of medications the resident was receiving at that time. On 9/28/22 at 12:15 PM the issue was discussed with the Interim Director of Nursing. 7) Resident #88 was admitted to the facility on [DATE]. Interview of Resident #88 on 9/11/22 revealed he/she recently had a care plan meeting. Resident #88 denied receiving a care plan summary nor a list of medications. Resident #88's medical record was reviewed on 9/12/22. Review of the Peak Baseline Care Plans revealed there was no date that that baseline care plan was reviewed with the resident or a signature that the resident received a copy of the care plan or medication list. A Care Conference Note dated 9/9/22 did not include an acknowledgement of the resident being provided a care plan summary or medication list. 8) On 9/14/22 at 11:30 AM, a review of Resident #141's electronic and paper medical records revealed the resident was admitted to the facility on [DATE]. Review of the Peak Baseline Care Plan failed to have the staff member's name, title, and date of completion of the care plan. There was no date that that baseline care plan was reviewed with the resident or a signature that the resident received a copy of the care plan or medication list. The Peak baseline care plan was incomplete and listed as in progress. Further review of medical records revealed no documentation about the facility staff providing information to the resident for the baseline care plan.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10) A review Resident #19's medical record on 09/14/22 at 12:30 PM revealed that Resident #19 was admitted to the facility on [DATE] for rehabilitation. Review of the resident's medical records showed that there was no documentation of care plan meetings with the resident and /or the resident's representatives and progress notes could not be found. Resident #19 in an interview on 9/14/22 at 1:02 PM stated that s/he never participated in his/her care plan meeting, was never invited, and was never involved in the development of his/her care plan. On 09/27/22 at 10:35 AM the Social Worker (staff #3) was interviewed and confirmed that the resident never had a care plan meeting with the interdisciplinary team and was never invited to a care plan meeting since his/her admission to the facility. Staff #3 stated that s/he only worked two days a week (Tuesdays and Fridays) and held care plan meetings on Fridays. 7) The surveyor reviewed Resident #106's medical record for the investigation MD00172868 on 9/26/22 at 1:55 PM. The review revealed that Resident #106 had quarterly MDS assessments completed on 4/9/21, 5/16/21, 8/16/21, 11/15/21, and 2/8/22. However, the review revealed that care plan revisions were not documented on each quarterly MDS assessment. There was no evidence in the medical record that a care plan meeting had been held with the resident and the interdisciplinary team around the time of either quarterly MDS. The Director of Social Services (SS Director) was interviewed on 9/23/22 around 11:00 AM. During the interview, the SS Director stated that the social work department was responsible for scheduling and arranging the care plan meetings. The SS Director further confirmed that there was no evidence of a care plan meeting. 8) A review of a complaint MD00166828 on 9/26/22 at 10:54 AM revealed that Resident #99 was admitted to the facility on [DATE] for ambulatory dysfunction s/p (status post) fall and transferred to the hospital in February 2021. Also, the complaint report stated that Resident #99 failed to follow the neurologist, no precautions were placed for the fall, and the facility staff did not manage the resident's pain. A further review of Resident #99's medical record revealed that Resident #99 had fall incidents on 1/30/21 and 1/31/21. Resident #99's care plan related to high risk for falls was initiated on 1/8/21, including interventions; anticipate and meet the resident's needs, educate the resident/ family/caregivers about safety reminders and what to do if a fall occurs., and treat as ordered or PRN (as needed). However, no care plan revision was documented after the fall incidents occurred. During an interview with the Interim DON on 9/28/22 at 1:30 PM, the Interim DON confirmed that there was no documentation to support that the care plan was revised for Resident #99 related to fall incidents. 3a) On 9/14/22 at 10:44 AM an interview was conducted with the responsible party (RP) for Resident #34. The RP stated she was very disappointed in the care at the facility and she was trying to get the resident moved out of the facility. The RP stated the facility, is not responsive at all. Have never scheduled a care plan meeting and [he/she] has been at the facility since January. On 9/20/22 at 12:51 PM a medical record review was conducted for Resident #34. There was no evidence that a care plan meeting had been held with the interdisciplinary team. Furthermore, there was no evidence that the care plans that were created for Resident #34 were evaluated. On 9/20/22 at 2:42 PM an interview was conducted with the Social Worker, Staff #3. Staff #3 stated she had a care plan meeting with the RP and yes, it was probably just me on the call. Staff #3 admitted that the IDT did not have a care plan meeting with the RP. 3b) Review of the dietary care plan for Resident #34 documented, is at potential nutritional risk r/t need for modified texture diet that was initiated on 1/24/22 and revised on 2/10/22. The interventions on the care plan were, Encourage good hydration by providing fluids with meals and med pass, Encourage good meal intake according to diet order (allow double portions), RD to evaluate per protocol or PRN to provide updated recommendations, and Diet, weights as ordered. There was no evidence in the medical record that the care plan was evaluated and updated to reflect weight loss. 4) On 9/14/22 at 11:06 AM a review of Resident #62's medical record was conducted and revealed Resident #62 had the diagnosis of Alzheimer's disease, senile degeneration of the brain and unspecified dementia with behavioral disturbance. Further review of Resident #62's medical record revealed care plans were in place, however there were no care plan evaluations. 09/13/22 at 12:51 PM an interview was conducted with Staff #3 who stated, I have not been doing written evaluations of care plans. 5) On 9/19/22 at 11:13 AM a review of Resident #92's medical record revealed care plans were in place but there was no evidence that the care plans were evaluated. 6) On 9/26/22 at 11:15 AM a review of complaint MD00170005 documented that it was very difficult to reach staff to coordinate the resident's (Resident #107) plan of care and that there had not been any care plan meetings held for the resident. A review of Resident #107's medical record was void of any care plan meeting notes or documentation that a care plan meeting was held. On 9/26/22 at 2:54 PM the Nursing Home Administrator (NHA) confirmed there were no care plan meeting notes and no evidence of care plan meetings held. On 9/26/22 at 4:57 PM an interview was conducted with Resident #107's responsible party (RP) who stated, there was no care plan meeting. No one was available. Discussed with the Interim Director of Nursing on 9/28/22 at 12:15 PM. Based on medical record review and interview, it was determined the facility staff failed to 1) review and revise resident care plans to reflect accurate and current interventions, and 2) ensure the full interdisciplinary team including residents and/or their responsible parties were invited to the care plan meetings. This was evident for 10 (#55, #5, #34, #62, #92, #107, #106, #99, #141, #19) of 54 residents reviewed during the annual survey. The findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents (regardless of payer) of long-term care facilities certified to participate in Medicare or Medicaid. Each care plan provides a framework for guiding the review of trigger areas and clarifying a resident's functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. These thorough assessments provide the interdisciplinary team additional information to help them develop a comprehensive plan of care. By modifying the care plans provided in this resource, you'll fit the individual needs of your residents while satisfying the requirements of the new assessment process. 1) A review of Resident #55's medical record on 09/26/22 revealed that Resident #55 was admitted to the facility on [DATE] with diagnoses that include but are not limited to diabetes, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, and bilateral above the knee amputation of the right and left leg. Resident #55 had been assessed as being dependent upon the facility staff for many aspects of his/her care. Resident #55 had a Brief Interview for Mental Status (BIMS) assessment, conducted by a facility staff member, on 08/21/22 during the annual assessment process. Resident #55 was assessed to have a 04/15 score during the annual assessments. A score of 0/15 to 7/15 suggests the resident had severe cognitive impairment. On 08/18/22 a baseline care plan was developed and indicated that Resident #55 was at risk for falls related to gait and balance problems. The goal of the care plan was to: 1) minimize the risks of falls through the review date, and 2) that Resident #55 will not sustain a serious injury through the review. Nursing interventions included: 1) anticipating and meeting the resident's needs, 2) ensuring the bed is in the lowest position, 3) physical therapy to evaluate and treat as ordered and as needed (PRN), 4) The resident needs a safe environment with: keep floors free from spills and/or clutter, adequate glare-free light, a working, and reachable call light, the bed in a low position at night, side rails as ordered, handrails on walls, personal items within reach. On 08/23/22, the nursing staff initiated an Actual Fall care plan for Resident #55 related to poor safety awareness. The actual fall care plan was revised on 09/06/22 with the following revisions by the healthcare virtual assistant: 1) Resident #55 will resume usual activities without further incident through the review date, 2) ensure that commonly used items are placed within reach, 3) ensure the chair is locked when the resident is in sitting position, and 4) reinforce to call for assistance. Further review of Resident #55's medical record revealed that on 08/18/22 at 6:17 AM, resident #55's nurse documented a change in condition review sheet that indicated Resident #55 was found on the floor by staff members. In the statement, Resident #55 indicated that he/she rolled off the bed. Resident #55 was assessed by the nurse and there were no complaints of pain or injury. A review of the fall incident report only listed one Predisposing Situation Factor as being admitted within 72 hours of the fall. Further review of nursing documentation, dated 09/10/22 at 4:19 PM, revealed Resident #55's nurse documented that staff observed Resident #55 sitting on the floor. Resident #55 informed the nurse that he/she was trying to walk. Resident #55 denied any pain, injury, or hitting her head. Later that evening on 09/10/22 at 8:15 PM, Resident #55's nurse was again made aware by an aide that Resident #55 was again observed on the floor. Resident #55 denied any pain, injury, or hitting her head. Resident #55's physician and the facility administrator were made aware of Resident #55's falls at this time. Resident #55's physician instructed the nurse to obtain some laboratory tests. Further review of Resident #55's medical record revealed a nursing note, dated 09/22/22 at 10:33 AM, indicating that staff observed Resident #55 on the floor again on 09/18/22 around dinner time. Resident #55 stated that he/she had rolled off the bed. Resident #55 complained of his/her left hip hurting at this time. Resident #55 was administered Tylenol at this time. In an interview with the facility interim Director of Nurses (DON) on 09/22/22 at 11 AM, the interim DON stated that there were no facility investigations or root cause analyses of Resident #55's falls that occurred on 09/10/22 at 4:19 PM, 09/10/22 at 10:47 PM, or 09/18/22 at dinner time. Reviews of Resident #55's fall prevention care plan failed to reveal any updates or revisions to prevent Resident #55 from continued falls. 2) In an interview with Resident #5 on 09/12/22 at 2:06 PM, Resident #5 stated that S/he has not attended any care plan meetings in year 2022. A review of Resident #5's medical record on 09/12/22 failed to reveal any documentation that Resident #5 or his/her family had been invited to a quarterly care plan meeting in the year 2022. In an interview with the facility social worker on 09/23/22 at 10:37 AM, the facility social worker stated and confirmed that Resident #5 had not had a care plan meeting in the year 2022. 9) Resident #141's medical record was reviewed on 9/16/22 at 8:15 AM. Resident #141 was admitted the facility on 9/6/22. Review of Resident #141's medical records revealed the resident was diagnosed to have acute renal failure and was receiving hemodialysis three times per week. Review of Resident #141's medical record on 9/22/22 revealed a care plan meeting was attended by the social worker and the director of rehabilitation along with the resident and resident's family on 9/20/22. Review of the care plan signature sheet failed to indicate that a nurse and a nursing assistant were involved in the meeting. Review of the resident's care plan on 9/22/22 failed to show care planning related to the resident receiving care and services related to receiving hemodialysis three times per week. During an interview with the interim DON on 9/22/22 at 4:29 PM several care area concerns were discussed with review of the medical record. Discussed the documented care plan meeting for Resident #141 on 9/20/22. Review of the care plan with the interim DON shown that there was not a care area related to care and services for hemodialysis. Review of the medical record on 9/26/22 revealed, the nursing home administrator had created a care area related to the resident receiving hemodialysis and interventions related to care.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10) A nebulizer is a small machine that turns liquid medication into a mist. A nasal cannula is a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, the device has 2 prongs and sits below the nose. On 09/12/22 at 08:03 AM, Resident #19 was observed in his/her room receiving oxygen therapy via a nasal cannula connected to an oxygen concentrator machine. S/he also had a nebulizer machine at his/her bedside table. The tubing on the nebulizer machine was dated 6/12. as the date it was last changed. A review of the resident's medical records revealed that Resident #19 was admitted on [DATE]. S/he was ordered oxygen continuous at 2 Liters/min via nasal cannula (NC) and Ipratropium-Albuterol solution, 1 vial orally via nebulizer every 4 hours as needed for shortness of breath. Further review of the orders revealed an order placed on 6/5/22 at 09:42 AM for Nebulizer tubing, change weekly every evening and night shift every Sat, date and initial tubing, place in a plastic bag at bedside''. A review of the Treatment Administration Record (TAR) on 9/12/22 showed that the order was placed on 06/05/22 and was noted that the evening and night shift staff signed off on the (TAR) every week, for the months of June, July, August, and September of 2022 indicating that they change the tubing 25 times since the initiation of the order. The tubing at the bedside table attached to the nebulizer machine was dated 6/12 as confirmed by 2 surveyors on 9/14/22. On 09/20/22 at 11:00 AM, the Licensed Practical Nurse (LPN) staff #30 was taken to the resident's room and shown the nebulizer tubing still with the date of 6/12 and asked how often the tubing was ordered to be changed. Staff #30 said that the night shift was responsible for changing the tubing once a week, nightly. S/he took the nebulizer tubing away and trashed it. 8) During an interview with Resident #38 on 9/11/22 at 9:50 AM, Resident #38 stated she/he fell from the wheelchair last Wednesday (9/7/22) and hit back and neck. The Resident added she/he had not received treatment or assessment by nursing staff. On 9/14/22 at 10:58 AM, a review of medical record for Resident #38 was conducted. Resident #38 was alert and oriented, and the BIMS (Brief Interview for Mental Status: a screen used to identify a resident's current cognition and to help determine if any interventions need to occur. 13-15 score means intact cognitive response) score was 15/15 on 7/20/22. Further review of the medical record revealed a written note by Staff #1. Staff #1 wrote a progress note on 9/9/22 at 10:38 AM; Resident stated he/she was ambulating by him/herself using rolling walker to the Bathroom, got dizzy and lost balance and fell to the floor. He/she stated, picked him/herself up, did not hit anywhere, and failed to report the incident to the nurse. However, there was no other documentation for Resident #38's assessment or interventions related to the fall in the electronic medical records. An interview was conducted with Staff #1 on 9/16/22 at 10:10 AM. During the interview, Staff #1 stated Resident #38 reported the fall to the rehab director on 9/9/22, and the fall incident was shared at the facility's risk meeting. Since Staff #1 had ordered the nurse staff to do head to toe assessment, the assessment dated [DATE] was not mentioned as fall evaluation. During an interview with the Rehab director (Staff #54) on 9/19/22 at 8:32 AM, she explained that the therapy team (physical, occupational, and speech therapy) received all of the residents' fall reports and evaluated residents who had a fall. The therapy team identified staff # 54, stated Resident #38's 9/8/22 fall via risk management documentation, and fall assessments were completed in the Rehab's documentation system. Staff #54 submitted a copy of treatment encounter note(s) dated 9/8/22 at 12:38 PM for Resident #38. The form stated, Pt reported having an unwitnessed fall yesterday, 9/7/22 The surveyor reviewed Resident #38's care plan on 9/14/22 at 11:27 AM. The care plan was revised on 9/9/22 under risk for fall-related left foot, and right foot wound/swelling as, Resident #38 had an actual fall related to poor balance on 9/7. On 9/28/22 at 1:30 PM, an interview was conducted with the interim Director of Nursing (DON). Since the Resident's medical record and staff interview had some discrepancies between the fall incident occurred to date and the facility's assessments, the surveyor asked the interim DON about Resident #38's fall. The interim DON stated the assessments and interventions were not applied timely. 9) On 9/20/22 around 11 AM, the surveyor observed Resident #36 was sitting in the wheelchair at the activity area in front of Wye Oak nursing station with the Resident's spouse. Resident #36 had 2x2 gauze dressing above his/her Right temple. Since the Resident had not had the dressing on previous observation (during the week of 9/11/22), the surveyor asked the Resident's spouse about it. The spouse replied the Resident had a fall last week. On 9/21/22 at 8:10 AM, a review of Resident #36's medical record was conducted. There was no written documentation found related to the Resident's fall from the week of 9/11/22 to 9/21/22 in the electronic medical records (PCC). During an interview with Licensed Practice Nurse (LPN #7) on 9/21/22 at 8:38 AM, LPN #7 showed the shift-to-shift report binder, used for nurse's handover notes, which included Resident #36's fall on 9/16/22 at 5:45 PM. The note indicated Resident #36 had a small bruise on the Right temple with this fall. LPN #7 also showed a risk manager screen on PCC. *Risk Manager is a part of the facility's medical record which was able to sort on PCC. On 9/21/22 at 9:20 AM, the interim DON confirmed that the data under the risk manager tab was a part of residents' medical records. However, details under the risk manager were not placed under each Resident's chart, and it would be able to activate with a special request. Also, the form named fall report, printed and submitted by LPN #7 on 9/21/22 at 8:38 AM, was marked privileged and confidential- not part of the medical record- do not copy test. The fall report, a part of risk manager documentation, written date 9/16/22 at 5:52 PM, showed Resident #36 was found on the Resident's room floor in a prone position with a face skin tear. Additionally, the skilled nursing evaluation dated 9/16/22 at 7:42 PM and the Pain evaluation dated 9/17/22 at 00:55 AM were linked in risk manager documentation. However, none of them mentioned Resident #36's fall on 9/16/22. During an interview with the interim DON on 9/21/22 at 9:21 AM, the interim DON was asked how to verify Skilled Nursing Evaluation dated 9/16/22 at 7:43 PM and Pain Evaluation dated 9/17/22 at 00:55 AM were related to Resident #36's fall on 9/16/22 or nursing staff's routine assessment. No answer replied from the interim DON. 2) On 9/15/22 at 2:21 PM a medical record review was conducted for Resident #27. Resident #27 was admitted to the facility in July 2022 with diagnoses that included, but were not limited to, repeated falls, atherosclerotic heart disease, chronic kidney disease and major depressive disorder, recurrent. Review of the medical record revealed a void in documentation from 8/18/22 to 8/23/22. Review of the MDS section of the medical record revealed a discharge return not anticipated assessment that was done on 8/18/22 and then an entry assessment on 8/23/22. A 8/15/22 at 16:08 (4 PM) progress note documented Resident #27 complained of pain and nausea after self transferring between chairs. Tylenol was administered. The next progress note was dated 8/16/22 at 14:01 (2:01 PM) which documented, Change in Condition which had nothing in the note. A Change in Condition Assessment was in the assessment section which documented a fall without injury. A 8/18/22 at 11:13 AM nursing progress note documented a call from the resident's spouse related to a fall. The next progress note in the system was dated 8/24/22. Review of the hospital discharge (d/c) summary dated 8/23/22 documented Resident #27 was admitted to the hospital on [DATE] with a chief complaint of fever and malaise. The d/c summary documented the resident had been having falls and had been generally weak. There was no documentation of the care that Resident #27 received leading up to the hospitalization. There was no documentaton in the medical record as to what the signs and symptoms were that made the facility staff call 911 to send the resident out. On 9/16/22 at 9:15 AM the Nursing Home Administrator (NHA) was informed there was no documentation about Resident #27's transfer out of the facility. The surveyor expressed to the NHA that it was unknown if the resident was transferred home or sent to the hospital. The NHA stated the resident was transferred to the hospital. Discussed with the Interim Director of Nursing (DON) on 9/28/22 at 12:15 PM. 5) On 9/20/22 at 10:18 AM a review of Resident #92's medical record was conducted. Resident #92 was admitted to the facility in June 2021 with diagnoses that included, but were not limited to, end stage renal disease secondary to vasculitis, on dialysis 3 times per week, chronic anemia, and mesonephric adenoma of the bladder. Review of Resident #92's paper medical record revealed an Advanced Dialysis Center Physicians Order Sheet dated 7/8/22 that documented the order, Change Calcium Acetate to one with breakfast and two with dinner. Calcium acetate is used to treat hyperphosphatemia (too much phosphate in the blood) in patients with end stage kidney disease who are on dialysis. Calcium acetate works by binding with the phosphate in the food you eat, so that it is eliminated from the body without being absorbed. Facility staff noted the order on 7/12/20 which was (4) days later. Facility staff failed to timely follow physician's orders. 6) On 9/20/22 at 4:20 PM observation was made of Resident #34 and his/her room. There was a television on a table that was flipped over on its face/screen. On top of the back of the television was a French fry and a pair of TED stockings. TED (Thrombo-Embolus Deterrent) stockings are also known as compression stockings, anti-embolism stockings, or support hose. They help reduce the risk of developing a deep vein thrombosis (DVT) or blood clot and help reduce the risk of swelling (edema). On 9/21/22 at 7:39 AM observation was made of the TED stockings lying on top of the television. Further observations on 9/21/22 at 12:09 PM revealed the TED stockings were still on top of the television. At 12:53 PM on 9/21/22 the resident was observed out of bed wearing gray slipper socks without TED stockings. Review of physician's orders for Resident #34 documented, Support hose. On in the morning and remove at bedtime. The order was written on 1/18/22. Review of Resident #34's Treatment Administration Record (TAR) for September 2022 documented on 9/20/22 and 9/21/22 that Resident #34 wore TED stockings. On 9/21/22 at 5:00 PM the NHA toured with the surveyor and observed Resident #34. The NHA was asked to note what the resident was wearing on his/her feet. Resident #34 was wearing gray slipper socks and not TED stockings. At that time the NHA was informed that the past 2 days the TED stockings were signed off as worn, when they were not worn. The physician's orders were not followed. 7) On 9/26/22 at 9:07 AM a review of Resident #97's medical record was conducted. Resident #97 was admitted to the facility on [DATE] with a medical history that included, but was not limited to, end stage renal disease that required hemodialysis, sepsis secondary to a right leg lower extremity ulcer that required to be treated with the medication Vancomycin via IV (Intravenous) which means within a vein. This allows the medicine or fluid to enter the bloodstream right away, diabetes mellitus, COPD (Chronic Obstructive Pulmonary Disease), atrial fibrillation and peripheral vascular disease. Review of the discharge summary from the acute care facility dated 1/19/21 documented, patient will need to follow-up with podiatry within 1 week of discharge and after follow-up with them, they can decide whether patient needs to be on prolonged antibiotic course. Podiatry is a branch of medicine devoted to the study, diagnosis, and medical and surgical treatment of disorders of the foot, ankle, and lower extremity. The discharge summary also documented, please check CBC, BMP, CRP and Vanco trough level on 1/25/21. Further review of the medical record failed to produce a consultation or follow-up visit from podiatry and failed to produce blood tests results for 1/25/22. On 9/26/22 at 11:35 AM the Nursing Home Administrator stated that no labs were found. Cross Reference F770 and F687. 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. Continued review of the medical record revealed the facility failed to create and implement a baseline care plan that would have directed care until the IDT (interdisciplinary team) met and discussed the care requirements with the resident to create interventions to meet the resident's goals. Furthermore, the facility failed to create and implement care plans for Resident #97's wound care for the vascular diabetic ulcer on the right lower leg, dialysis for Resident #97's end stage renal disease along with nutrition, pain, activities of daily living, heart disease and a respiratory care plan for COPD. Cross Reference F655 and F656. On 9/28/22 at 12:15 PM reviewed the medical record with the Interim Director of Nursing who confirmed the findings. Based on complaints, reviews of medical records, and staff interviews, it was determined that the facility failed to 1) ensure residents received medications as ordered by the physician, 2) document care given to a resident prior to being transferred to the hospital, 3) follow physician's orders, implement interventions and document when resident had a fall and 4) change a resident's nebulizer tubing and documenting when changed. This was evident for 8 (#45, #27, #92, #34, #97, #38, #36, #19) of 54 residents reviewed during an annual survey. The findings include: 1) In an interview with Resident #45 on 09/13/22 at 2:48 PM, Resident #45 complained that he/she does not receive his/her medications on time. Resident #45 stated that he/she currently has a supra-pubic catheter to urinate because he/she cannot just urinate. Resident #45 stated that he/she needs to make sure the nursing staff administers the bladder antispasmodics on time. Resident #45 stated that he/she is scheduled for another bladder procedure to help relieve the bladder spasms. A review of Resident #45's medical record on 09/15/22 revealed that he/she was admitted to the facility in December 2011 with diagnoses that include but are not limited to traumatic brain injury, quadriplegia, peg tube insertion, seizures, suprapubic catheter, dysphagia, aphasic, and contractures in the extremities. Resident #45 was totally dependent upon the facility staff for all aspects of his/her care. Resident #45 had a Brief Interview for Mental Status (BIMS) assessment, conducted by a facility staff member, on 05/11/22 and 07/28/22 during the quarterly review process. Resident #45 was assessed to have a 15/15 score during both quarterly assessments. A score of 13/15 to 15/15 suggests the resident is cognitively intact. While conducting survey process tasks on the 200 nursing unit on 09/15/22 at 11:41 AM, this surveyor observed Resident #45's family member walked onto the unit and proceed to enter Resident #45's room. Moments later, Resident #45's family member exited the room and walked swiftly to the 200-hall nurses' station. In an interview with Resident #45's family member at this time, Resident #45's family member stated that Resident #45 had not received any of his/her 9 AM medications. In an interview with GNA #67 on 09/15/22 at 11:45 AM, who was also standing at the nurses station, GNA #67 stated that he/she had just answered Resident #45's call bell and informed Resident #45's charge nurse that Resident #45 had not received his/her morning medications. A review of Resident #45's September 2022 medication administration record (MAR) on 09/15/22 at 11:46 AM revealed that Resident #45 failed to receive the following medications timely as instructed by Resident #45's physician: 1) Omeprazole, 20 mg, via G-tube, at 9 AM, for a gastric ulcer. 2) Banatrol, 1 packet, via G-tube, at 9 AM, for loose stools. 3) Carboxymethylcellulose eye gel 1%, to both eyes, at 9 AM, for dry eyes. 4) Clonazepam 0.5 mg, via G-tube, at 8 AM, for seizures. 5) Famotidine, 20 mg, via G-tube, at 8 AM, for gastric reflux. 6) Levetiracetam, 1000 mg, via G-tube, at 9 AM, for seizures. 7) Methscopolamine Bromide, 2.5 mg, via G-tube, at 9 AM, for bladder spasms. 8) Metoclopramide, 5 mg, via G-tube, at 8 AM, for bowel regimen. 9) Metoprolol Tartrate, 25 mg, via G-tube, at 8 AM, for hypertension. 10) Polyethylene Glycol, 17 grams, via G-tube, at 8 AM, for constipation. In an interview with Resident #45's charge nurse (staff member #30) on 09/15/22 at 11:56 AM, Staff member #30 stated and confirmed that he/she had not administered Resident #45's 09/15/22 morning medications to him/her. Staff member #30 stated that he/she usually does not work on the 200 unit and stated that there are many residents on the 200 hall that are heavy and require blood pressures and many medications. Staff member #30 stated that as soon as he/she was done changing another resident's dressing, that he/she would administer Resident #45 his/her medications. An observation of staff member #30 on 09/15/22 at 12:12 PM, staff member #30 entered Resident #45's room with a tray full medications to administer.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 9/21/22 at 11:00 AM Resident #108's medical record was reviewed and revealed Resident #108 was admitted in September 2014, with a diagnosis that included Multiple Sclerosis, Neuromuscular dysfunction of bladder, Quadriplegia (paralysis all 4 limbs), Contractures of Bilateral elbows, ankles, and left hand, and Seizures. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of progress notes documented Resident #108 was sent to an acute care facility on 12/18/20. Review of the discharge MDS with an assessment reference date of 12/18/20 documented in Section M, Skin, that there were no pressure ulcers. Review of progress notes dated 12/23/20 documented that Resident #108 was received back at the facility at 5:30 PM. The note documented that the resident had a pressure ulcer that was a stage 2 on the sacrum and areas on the heels and ankle. Resident #108 was sent back out to the acute care facility on 1/18/21 and returned on 1/22/21. The re-admission assessment documented, 2 skin openings to the left buttocks. opening to left heel. abration to left calf. The physician ordered waffle boots intact to both feet while in bed every shift for skin protection. The physician also ordered for the resident to be turned and repositioned every 2 hours while in bed and weekly skin checks. Further review of the medical record revealed the resident was followed by the wound care nurse practitioner (NP). There were notes from the NP regarding measurements and the status of the wounds dated 1/5/21, 1/12/21, 3/16/21, 3/23/21, 3/30/21, and 4/13/21. Facility staff documented that weekly skin checks were done on 1/6/21, 1/29/21, 3/9/21, 3/11/21, 3/16/21, 3/23/21, 3/30/21, 4/6/21, and 4/13/21. Facility staff failed to do skin checks every week which would have included a description of the wound along with measurements. Review of the Treatment Administration Record (TAR) for March 2021 revealed blanks for floating heals every shift to prevent skin breakdown and waffle boots intact to both feet while in bed on 3/2, 3/8, 3/18, 3/19, 3/21, 3/25 and 3/29/21 during day shift, and on 3/7/21 night shift. Review of the care plan, the resident has actual for pressure ulcer development r/t MS and Immobility had only 2 interventions: monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size, stage and teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. The care plan for pressure ulcer was not comprehensive for Resident #108. It did not describe the treatments and interventions to promote healing. On 9/23/21 at 12:00 PM an interview was conducted with Staff #62 (nurse practitioner) and she was asked if she remembered Resident #108. After the surveyor showed her photos of the resident's pressure ulcer with a picture of the resident she replied No, I do not remember that resident. On 9/23/21 at 12:30 PM the NHA was informed of the findings. 2) A review of complaint MD00178416 on 9/23/22 at 7:50 AM revealed that the facility staff did not address Resident #95's wound. An interview with Resident #95's son on 9/23/22 at 8:50 AM revealed the resident had back surgery before being admitted to this facility, and the resident had some bed sore on his/her back which treatment had been started during hospitalization. A review of Resident #95's medical record on 9/23/22 at 9:00 AM revealed that the resident was admitted to this facility on 5/10/22, and an initial wound assessment was done by [name of company] (contracted wound care team) Nurse Practitioner (NP #91) on 5/16/22. The review of the initial wound assessment revealed Resident #95 had a pressure ulcer on the left buttock, dressing change frequency noted twice a day, and dressing noted as other: see note. Further review of Resident #95's progress notes revealed a progress note written by a different NP (Staff #62) on 5/16/22; wound plan of care: see [name of company] documentation for full wound description and recommended nursing plan of care. Plan of care assessment & plan - patient, has a pressure injury; pressure reduction and turning precautions discussed with staff at the time of visit recommended, including heel protection and pressure reduction to bony prominences. The surveyor reviewed Resident #95's medical records (Treatment Administration Record, skin assessment, order summary, and care plan) on 9/23/22 at 9:46 AM. The review of the Treatment Administration Record (TAR) for May 2022 to July 2022 revealed that skin assessment daily was checked off by nursing staff daily starting on 5/11/22. The review of skin assessment revealed there were 3 assessments documented; an assessment dated [DATE] recorded as, skin intact- no, if no, are areas new no and an assessment dated [DATE] recorded as, skin intact-yes, and an assessment dated [DATE] recorded as skin intact- no, if no are areas new- no. Additionally, the review of the order summary for Resident #95 revealed the order of cleanse bilateral buttock/sacral area with normal saline, pat dry, and cover with zinc oxide with no covering was initiated on 6/29/22. There was no order before 6/29/22. A review of Resident #95's care plan revealed no care plan for the resident related to his/her wound care. In an interview with Staff #62 on 9/23/22 at 11:04 AM, Staff #62 stated the facility had had a wound nurse 1 to 2 months ago who did rounds with her, put the order in, and educated nursing staff for the wound care. Staff #62 added that since all the wound nurses left, she communicated directly to the nurses as needed but usually put orders on her note (progress note). Staff #62 stated she expected the nurses to follow the order from her note. Also, Staff #62 confirmed that the facility had a wound nurse in May 2022. During an interview with the Nursing Home Administrator (NHA) on 9/26/22 at 9:11 AM, the NHA was informed of the above concerns. 3) A review of Resident #55's medical record on 09/26/22 revealed that Resident #55 was admitted to the facility on [DATE] with diagnoses that include but are not limited to diabetes, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, and bilateral above the knee amputation of the right and left leg. Resident #55 was assessed by the nursing staff on 08/17/22 at 10:18 PM and was only noted with a scar to the groin area (site #24). The rest of Resident #55's skin was noted to be intact. The nursing staff completed a Braden Scale for Predicting Pressure Sore Risk assessment on 08/17/22 at 10:18 PM and assessed Resident #55 to be at a Moderate Risk for developing a pressure wound with a score of 13/18. On 08/19/22 a baseline care plan was developed and indicated that Resident #55 is at risk for skin breakdown related to limited mobility. The goal for Resident #55 will be to maintain or develop clean and intact skin by the review date. Nursing interventions included: encouraging good nutrition and hydration in order to promote healthier skin, to follow facility protocols for treatment of injury, to identify/document potential causative factors and eliminate/resolve where possible, Pad side rails, wheelchair arms or any other source of potential injury if possible, pressure redistributing mattress to bed and a cushion to the wheelchair, to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. In a review of the facility's Skin Assessment policy on 09/26/22 which had an implementation date of 10/01/21 and no revision date, revealed under the heading, Policy: It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. The facility policy also listed: Explanation and Compliance Guidelines: A full body, or head-to-toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. A review of Resident #55's admission orders revealed a physician's order, dated 08/18/22 at 12:29 AM, instructing the nursing staff to perform a skin assessment daily. Further review of Resident #55's medical record revealed a Nurse Practitioner Wound Consultant note, dated 08/23/22 at 11:15 AM, that indicated Resident #55 was now observed with a Stage II pressure ulcer on the sacrum. The pressure ulcer measured 3.33 cm x 2.68 cm x 8.92 cm. The depth was noted to be 0.10 cm. No odor was noted. The edges were attached. The Nurse Practitioner Wound Consultant indicated the wound was present prior to admission to the facility. Treatment for the pressure wound included: a dressing change to the wound three times a day, a wedge/foam cushion for offloading, and a wheelchair cushion, pressure reduction, and turning precautions were discussed with the staff at the time of the visit, recommended heel protection and pressure reduction to bony prominence's, and the staff was educated on all aspects of care. The Nurse Practitioner Wound Consultant requested to keep the wound site covered and avoid contamination with feces at all times. No documentation was found in the medical record that indicated Resident #55's physician or responsible party was notified at this time. A review of Resident #55's physician assessments, dated 08/18/22 at 3:08 PM, and 08/18/22 at 1:49 AM failed to reveal any documentation that Resident #55 was admitted with a pressure wound. The facility physicians failed to document a skin assessment for Resident #55 on 08/18/22 at 1:49 AM or 3:08 PM. In an interview with Resident #55's responsible party on 09/23/22 at 4:44 PM, Resident #55's responsible party stated that he/she had only been contacted by the nursing staff for a couple of falls. The last phone call from the nursing staff was from yesterday, 09/22/22 for a fall. The staff told me Resident #55 had a fall and was okay. A review of Resident #55's hospital discharge record on 09/26/22 failed to reveal any hospital staff documentation that Resident #55 had a sacral wound upon discharge to the facility on [DATE]. A review of Resident #55 admission MDS assessment, with an ARD date of 08/21/22, revealed section M, Skin Conditions, indicated Resident #55 was admitted without any existing pressure ulcers. A review of Resident #55's August 2022 nursing staff documentation, regarding turning and repositioning every 2 hours, failed to reveal any documentation the nursing staff performed turning and repositioning for Resident #55 on the following days: Friday, 08/19/22 - day and evening shifts. Saturday, 08/20/22 - day shift. Sunday, 08/21/22 - day and evening shifts. A review of Resident #55's August 2022 nursing staff documentation, regarding the percentage of meals eaten, failed to reveal any documentation of the nursing staff had documented percentage of meals consumed for Resident #55 on the following days: Friday, 08/19/22 - breakfast and lunch meals. Saturday, 08/20/22 - breakfast and lunch meals. Sunday, 08/21/22 - breakfast, lunch, and dinner meals. Tuesday, 08/23/22 - dinner meal. In an interview with the facility Nurse Practitioner Wound Consultant (CRNP) on 09/23/22 at 12:40 PM, the facility CRNP stated that he/she is alerted by staff when a resident develops a wound. The facility CRNP also stated that he/she does not write wound orders and that it is the nursing unit managers who do this. Further review of Resident #55's medical record failed to reveal any documented physician order as to what dressing type the nursing staff should apply to Resident #55's Stage II wound after the wound was assessed by the Wound CRNP on 08/23/22 at 11:15 AM. In an interview with Resident #55's physician on 09/28/22 at 10:45 AM, he stated that the facility wound consultant is the practitioner who documents on resident's wounds. The nursing staff is to follow up by contacting the Wound CRNP for any wounds. Based on medical record review, observation, and interviews it was determined the facility staff failed to ensure wounds were accurately assessed on admission and failed to provide appropriate treatment and services to promote healing of pressure ulcers. This was evident for 4 (#141, #95, #55, #108) 5 residents reviewed for pressure ulcers. A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). 1) On 9/14/22 Resident #141 was asked about his/her sacral wound and if the wound received treatments. The resident indicated not often enough. Resident #141's medical record was reviewed on 9/14/22. Review of the Peak admission /readmission Evaluation Section C, Skin condition revealed Right buttock pressure. Review of a nutritional assessment completed on 9/8/22 revealed the resident had one stage 2 pressure wound. There was not any documentation to reveal wound measurements and/or the status of wounds. Review of the treatment administration record (TAR) on 9/14/22 revealed a prescribed daily cleansing treatment to bilateral buttocks, application of Medi honey, and covered with a border foam dressing. There were daily initials by nursing staff to indicate treatment to the buttock wounds except for 9/9 and 9/13/22. On both days there was a code of #9 that = other/see nurses note. Review of the progress note section did not reveal any notes written on 9/9 or 9/13/22. A baseline care plan in the assessment section of the medical record was shown to be In Progress and not completed. There was not any documentation related to the resident having a wound. Review of the care plan revealed that the care plan was created by a Healthcare Virtual Assistant on 9/7/22. There was a plan of care related to the resident having multiple bruising and scabs on upper and lower extremities but there was not any care plan documentation of the resident having a stage 2 pressure ulcers on the bilateral buttocks. There was a documented goal of the resident's bruises to heal by review date. There was not any documentation in the medical record to indicate the resident was evaluated by a physician since admission. Review of nursing progress note did not reveal any status condition or measurements of buttock wounds. On 9/15/22 at 10:18 AM an interview was conducted with a Certified Registered Nurse Practitioner (Staff #62). She revealed that she was at the facility on Tuesdays and Thursdays to analyze wounds. She revealed that she had not seen Resident #141 to evaluate his/her wounds. Review of the medical record on 9/16/22 revealed a 9/15/22 note by the wound nurse practitioner with a documented evaluation of the resident's wounds. This evaluation was 9 days after the resident's admission to the facility. The wound nurse documented the wounds were assessed to be bilateral stage 3 wounds on the buttocks. The nurse practitioner documented a prescribed order of, Apply thin layer of Venelex and cover with border gauze BID (2 times per day). Wound care concerns along with other care concerns for Resident #141 was shared with the interim Director of Nursing (DON) on 4/22/22 at 4:29 PM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 9/11/22 at 9:26 AM observation was made of a portable oxygen tank on the back of the wheelchair for Resident #10. There was a nasal cannula attached to the oxygen tank. A nasal cannula consists of a flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils to deliver oxygen. On 9/14/22 at 2:10 PM an interview was conducted with RN #3. RN #3 stated she did not know why the resident had oxygen. The surveyor said, even with the nasal cannula wrapped around the back of [his/her] chair. RN #3 said, don't know, maybe because dialysis might put it on [him/her] if [his/her] sats (oxygen saturation) drop. On 9/15/22 at 10:30 AM a review was conducted of Resident #10's electronic and paper medical record. Resident #10 was admitted to the facility in January 2021 with diagnoses that include vascular and Alzheimer's dementia, hypertension, diabetes mellitus type 2 with diabetic neuropathy and nephropathy, and end stage renal disease with hemodialysis therapy. There were no physician's orders for the administration of oxygen. Review of the vital sign section of Resident #10's electronic medical record revealed documentation that oxygen was used on 1/23/21, 2/12/21 and 1/31/22. There were no nursing notes that documented the use of oxygen. Further review of Resident #10's medical record failed to produce evidence that a respiratory care plan was developed for when needed oxygen therapy. Discussed with the interim Director of Nursing on 9/28/22 at 12:15 PM. Based on reviews of a medical record, interview, and observation it was determined that the facility failed to 1) ensure that a resident received nebulizer treatments as ordered by the physician, and 2) develop a resident-centered care plan for a resident with Chronic Obstructive Pulmonary Disease (COPD) and oxygen use with resident-centered and measurable goals and 3)have physician's orders for the administration of oxygen. This was evident for 2 (#23, #10) of 2 residents reviewed for respiratory care during the annual survey. The findings include: 1) In an interview with Resident #23 on 09/11/22 at 1:20 PM, Resident #23 stated that he/she wass supposed to be receiving Nebulizer treatments for COPD. A review of Resident #23's medical record on 09/13/22 at 9 AM, revealed that Resident #23 was admitted to the facility on [DATE] with diagnoses that include but are not limited to insulin-dependent diabetes, end-stage renal disease on hemodialysis, Parkinson's disease, hypertension and chronic obstructive pulmonary disease (COPD). On 08/23/22 at 3:51 PM, Resident #23 complained of a cough. The nursing staff documented that Resident #23's physician started Resident #23 on an antibiotic, daily, for four days, Prednisone taper, and instructed the staff to administer nebulizer treatments due to his/her cough and history of COPD. A review of Resident #23's September 2022 medication administration record (MAR) on 09/13/22 revealed that between 09/02/22 and 09/09/22 the nursing staff documented that at 13 possible medication administration times, Resident #23's nebulizer medication was not available to administer. A review of Resident #23's nursing progress notes documented that on 09/02/22 at 12:34 AM, 09/05/22 at 3:05 PM, 09/06/22 at 12:40 AM, 09/07/22 at 10:55 PM, and 09/08/22 at 11:15 PM, the nurses documented that they were awaiting delivery from the pharmacy. A review of Resident #23's care plan on 09/23/22 failed to reveal that the nursing staff implemented a care plan for respiratory problems with measurable goals and nursing interventions/evaluations.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 09/19/22 at 7:56 AM, a review of Resident #36's medical record was conducted. Resident #36's medical record revealed that the resident was admitted to the facility in July 2022 for rehabilitation after a bone fracture. Further review revealed Resident #36 had an order of side rails/guard rails ordered by attending Physician #76. The [spouse] is requesting side rails for safety purposes. Order date 7/25/22. However, further review of Resident #36's medical record revealed there was no assessment for side rail use, no consent for bed rail use, and no evaluation related to bed rail use. On 9/19/22, around 10:00 AM, the surveyor observed Resident #36 lying in bed with quarter bed rails up on both sides. During an interview with Licensed Practice Nurse (LPN) #49 on 09/19/22 at 12:30 PM, she stated that a consent form, resident assessment, and Physical & Occupational therapy consult were required for bed rail use. On 9/19/22 at 12:40 PM, the surveyor requested a copy of the policy for the bed rails. At 12:48 PM on 9/19/22, the Nursing Home Administrator (NHA) submitted the bed rail policy and stated, I knew that we did have an issue with bed rail use. Nothing was done for that. The surveyor shared concerns regarding Resident #36's bed rail use. During an interview with the Medical Director and the Interim Director of Nursing (DON) on 9/28/22 at 5:00 PM, the medical director confirmed that bed rails should be considered as a physical restriction. Also, he stated that Resident assessment, consent, and rails functioning tests are required. 2) On 9/21/22 at 7:39 AM observation was made of Resident #34 lying in bed with bilateral 1/2 side rails in the raised position. On 9/21/22 at 4:30 PM a medical record review was conducted for Resident #34 and revealed a recent side rail assessment had not been done. The last side rail assessment was done on 4/15/22. The 4/16/22 bed safety review documented the resident had behavioral symptoms that may place them at risk for accident hazards. The hazard was cognitively impaired. The resident's level of consciousness/cognition was disoriented x 3 at all times. It was documented that the resident was not able to communicate their needs due to cognitively impaired. It was documented that the resident did not have a fall within the last 6 months. This was an inaccurate assessment as further review of the medical record revealed the resident had a fall on 2/18/22 on the floor beside the bed and on 3/27/22 had a fall from the wheelchair. Additionally, on 4/20/22 the resident was found on the floor on [his/her] backside trying to get off floor. On 7/8/22 the resident had a fall on the floor in front of the bed. A side rail consent dated 1/21/22 checked off 1/4 partial rail to the left and right upper and were recommended at all times when the resident was in bed. Checked off was a release schedule of during meals, during activities and during supervised visits. There was a bullet point for consent that documented, I do consent to the use of side rail(s) recommended above. I understand that I have the right to refuse the use of side rail(s) or can revoke this consent at any time. It was signed by a nurse on 1/21/22. It was not signed by the responsible party (RP). It was noted the nurse no longer worked at the facility. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of the MDS assessment with an assessment reference date (ARD) of 7/20/22 documented the resident was extensive assistance with 2 people for bed mobility, however, was extensive assistance with 1 person on the 6/25/22 assessment. On 9/22/22 at 7:40 AM an interview of geriatric nursing assistant (GNA) #12 was conducted and she was asked if Resident #34 always had bed rails up when in bed. GNA #12 stated, yes, because [he/she] is a fall's risk and they are always up. On 9/22/22 at 7:42 AM a review of the electronic and paper medical record revealed a blank form for consent for use of bed rails. There was no physician's order for the side rails and no care plan for the side rails. There was no documentation in the medical record of an evaluation of the alternatives that were attempted prior to the use of the side rails. There was no signed consent from the resident representative prior to the use of side rails. There was no assessment of the bed, the mattress, or the risk of entrapment. On 9/27/22 at 11:13 AM an interview was conducted in Resident #34's room with the Director of EVS (environmental services) and Maintenance, Staff #19, and the Regional Director of Plant Operations. Staff #19 was asked if he had a process in place to check side rails. Staff #19 stated he would have to check. He has only been in the position for the past 2 weeks. Based on observation, record review, administrative policy review, and interviews, it was determined the facility failed to assess residents for risk of entrapment from bed rails, obtain informed consent, and ensure bed rails were properly installed prior to the utilization of side rails for any resident. This was evident for 3 (Resident #141, #34, #36) of 9 residents reviewed for accidents during the annual survey. The findings include 1) Resident #141 was admitted to the facility on [DATE]. Upon initiation of the survey on 9/11/22 Resident #141 was observed daily lying-in bed with bilateral half-side rails in the up position. A review of the medical record on 9/22/22 revealed that the Peak Side Rail Evaluation was initiated by a Healthcare Virtual Assistant (Staff #78) and was not completed and was not signed by a nurse in the facility. The Peak Fall Risk Assessment was listed as In progress and was not completed. Informed consent for use of the side rails was not obtained. There was not a physician's order for use of side rails. A review of the resident's plan of care did not reveal a plan of care for the use of side rails. The medical record did not reveal documentation for utilization and/or purpose for the use of side rails. Review of the facility's policy, Proper use of bed rails which was reviewed and revised on 7/25/22 by Clinical Services documented the following: -Resident assessment must include an eval of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. -The resident assessment must also assess the resident's risk from using bed rails. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. -The facility will attempt to use appropriate alternatives prior to installing or using bed rails. -If no appropriate alternatives are identified, the medical record should include evidence of the following: -Purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful -Assessment of the resident, the bed, the mattress, and the rail for entrapment risk. The facility failed to follow its own policy related to the use of bedside rails.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 9/15/22 at 10:30 AM a review of Resident #10's medical record was conducted and revealed that the attending physician's notes were not in the electronic medical record on the day the resident was seen. There were physician visit notes dated 1/6/22 and 4/19/22, however there were no other notes in the electronic or paper medical record. 5) On 9/20/22 at 12:51 PM a review of Resident #34's medical record was conducted and revealed that the attending physician's notes were not in the electronic medical record on the day the resident was seen. A physician's progress note with an effective date of 1/17/22 had a created date of 1/21/22. A physician's progress note with an effective date of 1/20/22 had a created date of 2/2/22. A physician's progress note with an effective date of 2/14/22 had a created date of 2/21/22. A physician's progress note with an effective date of 2/21/22 had a created date of 2/24/22. A physician's progress note with an effective date of 3/2/22 had a created date of 3/8/22. A physician's progress note with an effective date of 3/14/22 had a created date of 3/21/22. A physician's progress note with an effective date of 6/23/22 had a created date of 6/30/22. On 9/21/22 at 11:16 AM an interview was conducted with physician #77. Physician #77 was asked why he had not seen the resident since 6/23/22 and he looked in his tablet and stated that he saw the resident on 7/20/22 and the nurse practitioner saw the resident on 8/28/22. Physician #77 was informed that his physician's visit was not in the medical and he said it should be and his office staff could send the note over. Physician #77 stated that the notes are entered into an electronic medical record and were sent from his office to the facility to be uploaded. On 9/21/22 at 1:43 PM the Medical Director was informed of the failure to get the physician's notes into the resident's electronic medical record. 6) On 9/22/22 at 3:43 PM a review of Resident #450's medical record was conducted and revealed that the attending physician's notes were not in the electronic medical record on the day the resident was seen. A physician's progress note with an effective date of 12/2/21 had a created date of 12/8/21. A physician's progress note with an effective date of 2/10/22 had a created date of 2/16/22. A physician's progress note with an effective date of 3/3/22 had a created date of 3/9/22. A physician's progress note with an effective date of 12/7/21, 12/23/21 and 1/4/22 was not in the medical record. Upon surveyor request on 9/28/22 at 9:54 AM, the NHA returned the request paper and documented that the Medical Director was getting the physician visit notes for the surveyor. Once the physician visit notes were received it was noted that the 3 physician's visits were printed on 9/28/22 at 11:00 AM and given to the surveyor. They were not in the medical record. On 9/28/22 at 12:30 PM the concerns were discussed with the Interim Director of Nursing. Based on medical record review and staff interview it was determined the physician progress notes were not in the resident medical records the day the resident was seen. This was evident for 6 (#105, #94, #141, #10, #34, #450) of 54 residents reviewed during the annual survey. The findings include: 1) Resident #105 was admitted to the facility on [DATE]. Resident #105's closed medical record was initially reviewed on 9/26/22 in relation to complaint MD00173347. A review of the resident's attending physician (staff #76) documentation revealed a History and Physical Note with a Visit date of 4/27/21 that was electronically signed on 5/2/21 and uploaded to the electronic medical record on 5/5/21. Continued review of Resident #105's medical record for the attending physician's notes revealed one SOAP Note with a visit date of 8/5/21, signed on 8/8/21 and uploaded to the electronic medical record on 8/11/21. On 9/27/22 an interview of the Nursing Home Administrator (NHA) was conducted at 1:13 PM. She was informed of an approximately 3-month gap of the lack of Resident #105's attending physician notes in the medical record. On 9/27/22 at 5:25 PM 7 printed physician notes electronically signed by Staff #76 were received. Additional interview of the NHA on 09/28/22 at 9:30 AM revealed that the attending physician's 7 notes were never in the resident's medical record. 2. Resident #94 was admitted to the facility on [DATE]. Resident #94's closed medical record was initially reviewed on 9/26/22 in relation to complaint MD00175387. A review of the medical record revealed that the attending physician's notes were not in the electronic medical record on the day the resident was seen. The following note examples were documented by Resident #94's attending physician (staff #76) A physician's progress note with an effective date of 2/24/22 at 10:23 AM had a created date of 3/2/22 at 13:48 [1:48 PM]. A physician's progress note with an effective date of 3/10/22 at 16:01 had a created date of 3/18/22 at 11:00 AM A physician's progress note with an effective date of 3/15/22 at 18:49 had a created date of 3/24/22 at 12:46 PM. A physician's progress note with an effective date of 4/5/22 at 19:21 had a created date of 4/12/22 at 23:30. A physician's progress note with an effective date of 4/26/22 at 4:19 AM had a created date of 5/2/22 at 18:08. 3) Resident #141 was admitted to the facility on [DATE]. Resident #141's medical record was initially reviewed on 9/11/22. On 9/12/22 at 10:00 AM Resident #141 was observed to receive a visit from a physician (staff #77). The doctor was interviewed at 10:16 AM. He revealed that he was an independent contractor and began resident visits a few times per week beginning at the end of July 2022. Review of Resident #141's medical record on 9/14/22 did not reveal any physician notes. On 9/15/22 at 9:50 AM Staff #77 was re-interviewed. The doctor indicated that he had seen/visited the resident on 9/7, 9/8, and 9/12/22. The doctor was informed that his notes were not found in the resident's medical record. Review of the resident's medical record on 9/20/22 revealed that a note was created by the doctor (staff #76) that was listed as the resident attending physician on 9/16/22 at 13:56 for an effective date of visit as 9/14/22 at 18:14. It was documented in the progress note that staff #77 was the writer, as the note was electronically signed on 9/16/22 at 12:05 AM. An interview was conducted with the Nursing Home Administrator at 1:40 PM on 9/20/22. She reviewed the attending physician's note and called the physician (Staff #76) at 1:45 PM. The call was on speaker and the attending physician indicated that he did not write the note. He acknowledged that the writer's name (staff #77) was documented in the body of the progress note. The doctor was informed of the new doctor's visit notes were not documented in the medical record for the three visits prior to 9/14/22. On 9/21/22 paper copies of the new doctor's visits were provided and placed on the hard chart (paper). A physician's History and Physical note with a documented visit date of 9/7/22 at 4:10 AM was electronically signed on 9/9/22 at 11:04 AM. A physician Soap note with a documented date of visit on 9/12/22 at 10:00 AM was electronically signed on 9/12/22 at 11:10 PM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was determined the physician failed to see a resident once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. This was evident for 4 (#62, #10, #102, #107) of 54 residents reviewed during the annual survey. The findings include: 1) On 9/15/22 at 9:21 AM a review of Resident #62's medical record was conducted. Resident #62 was admitted to the facility in April 2022. There were physician visits dated 4/5/22, 4/21/22, 5/17/22, and 8/31/22. The resident was not seen in June 2022 or July 2022 as there were no physician visits found in the electronic or paper medical record. 2) On 9/15/22 at 10:30 AM a review of Resident #10's medical record was conducted. Review of physician visits revealed visits dated 1/6/22 and 4/19/22. There were no other physician visit notes in the electronic or paper medical record. 3) On 9/23/22 at 7:30 AM a review of Resident #102's medical record was conducted. Resident #102 was admitted to the facility on [DATE]. There was no physician's history and physical or any type of physician's visit within the first 30 days of admission. On 9/23/22 at 12:36 PM the Nursing Home Administrator (NHA) brought information to the surveyor and confirmed there was no physician's history and physical or any type of physician's note within the first 30 days of admission. 4) On 9/26/22 at 11:15 AM a review of Resident #107's medical record was conducted. Resident #107 was admitted to the facility on [DATE]. There was no physician's history and physical or any type of physician's visit within the first 30 days of admission. On 9/26/22 at 2:54 PM the NHA gave the surveyor copies of items requested and there were no physician's visits. On 9/28/22 at 12:15 PM the concern was discussed with the Interim Director of Nursing.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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7) On 9/19/22 at 10:54 AM, a review of Resident #63's medical record revealed that the consultant pharmacist reviewed the resident's drug regimen every month and documented them under the facility's electronic medical record (PCC) since the resident's admission. Further review of the Monthly Drug Regimen revealed that the consultant pharmacist documented on the form, No irregularities present: Yes, Please see the note. However, the surveyor could not find any written note from the consultant pharmacist on Resident #63's PCC or paper chart on 9/19/22 at 10:50 AM. During an interview with the Nursing Home Administrator (NHA) on 9/19/22 at 11:00 AM, the NHA confirmed that the facility did not have a consultant pharmacist's note about residents' Monthly Drug Regiment Review. 5) Review of the medical record for Resident #450 on 9/22/2022 at 3:43 PM revealed the resident was admitted to the facility in the beginning of December 2021 from an acute care hospital with diagnoses that included, but were not limited to, type 2 diabetes mellitus, non-pressure chronic ulcer of the right lower leg, sepsis and endometrial cancer. Further review of the electronic and paper medical record failed to produce documentation that the pharmacist had performed a monthly medication review of Resident #450's medications. On 9/15/22 at 9:12 AM an interview was conducted with the NHA regarding pharmacy reviews. She stated there was no process in place related to the staff reviewing and following up on pharmacy reviews. She stated, I have a nurse going through the stack of papers now to see if any were addressed. In addition, when asked for the pharmacy review policy she said she was waiting for pharmacy to send it over. When asked if they had a policy at the facility that they were going by she stated, not that I can find. Based on review of medical records and interview with staff it was determined that the facility failed to 1) have an effective system in place to ensure that drug regimen reviews were done for all residents at least monthly and 2) develop policies and procedures related Medication Regimen Review to include time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This was evident for 6 (#5, #6, #20, #64, #450, #63) out of 10 residents reviewed for medications during the annual survey. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough monthly evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. 1) A review of Resident #5's medical record on 09/12/22 failed to reveal any monthly pharmacy review and recommendation evaluations in the medical record or the electronic medical record. The surveyor was unable to determine whether monthly pharmacy medication consultation reviews were being done. Resident #5 was currently prescribed the following medications: Warfarin, Sertraline, and Metoprolol Succinate. 2) A review of Resident #6's medical record on 09/14/22 failed to reveal any monthly pharmacy review and recommendation evaluations in the medical record or the electronic medical record. The surveyor was unable to determine whether monthly pharmacy medication consultation reviews were being done. Resident #6 was currently prescribed the following medications: Depakote, Risperdal, and Clonazepam. In an interview with the facility Interim Director of Nurses (DON) on 09/14/22 at 1:25 PM, the interim DON stated that there were no monthly pharmacy consult notes in any of the residents charts or electronic medical records. In an interview with the facility Administrator on 09/15/22 at 09:01 AM , the facility Administrator confirmed that there were no monthly pharmacy consult reports in any resident chart. The facility Administrator went on to state that none of the current staff printout the monthly pharmacy consult reports and place them in the residents charts, not for any resident. 3) A review of Resident #20's medical record on 09/27/22 failed to reveal any monthly pharmacy review and recommendation evaluations in the medical record or the electronic medical record. The surveyor was unable to determine whether monthly pharmacy medication consultation reviews were being done. Resident #20 is currently prescribed the following medications: Warfarin, Sertraline, Clonazepam, Buspirone, and Remeron. In an interview with Resident #20's charge nurse #31 on 09/27/22 at 10:47 AM, Nurse #31 stated that she/he was unable to locate and monthly pharmacy consultation notes in Resident #20's medical record or electronic medical record. 4) A review of Resident #64's medical record on 09/27/22 failed to reveal any monthly pharmacy review and recommendation evaluations in the medical record or the electronic medical record. The surveyor was unable to determine whether monthly pharmacy medication consultation reviews were being done. Resident #5 was currently prescribed the following medications: Lexapro, Potassium Chloride, Tramadol, and Metoprolol Tartrate. In an interview with Resident #64's charge nurse #31 on 09/27/22 at 10:47 AM, Nurse #31 stated that she/he was unable to locate and monthly pharmacy consultation notes in Resident #64's medical record or electronic medical record. 6) On 9/14/22, a copy of the facility's MRR policy was requested from the Nursing Home Administrator (NHA). Interview of the NHA on 9/15/22 at 9:12 AM revealed that she could not find a facility MRR policy. The NHA provided a policy from the pharmacy that delivers medication to the facility, that was titled Addressing Pharmacy Recommendations. Review of the pharmacy's policy on 9/15/22 did not include time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. During an interview with the NHA on 9/20/22 at 1:45 PM, it was reviewed that the facility failed to have an MMR policy.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility failed to reconcile and transcribe medication orders accurately to the medication administration record as evidenced by transcribing a medication twice. By failing to transcribe orders accurately the resident did not receive medications at the prescribed time of day and/or received up to twice the amount of medication ordered. This was identified for 1 (#141) of 5 residents reviewed for unnecessary medications. The findings include: Resident #141 was admitted to the facility on [DATE]. A review of Resident #141's medical record revealed admitting diagnosis that included Diabetes, high blood pressure, and acute renal failure requiring hemodialysis. The medication administration record (MAR) was initially reviewed on 9/19/22 and revealed a duplicate transcribed medication order for Insulin Glargine. The insulin Glargine was ordered as inject 5 units subcutaneously (under the skin) one time a day for DM (diabetes mellitus) into the skin nightly. The order was transcribed to the MAR twice and showed documentation of the staff administering the medication at 9:30 AM and at 9:00 PM beginning on 9/7/22. A review of the medication list on the 9/6/22 hospital discharge summary revealed the order as Basaglar Kwikpen 100 units/ML (milliliter) solution pen-injector Generic drug insulin glargine Inject 5 units into the skin nightly. The orders were found to be transcribed by two different nurses. The order that was transcribed to be administered at 9:30 AM was discontinued on 9/17/22. The nurse that transcribed the order to the MAR for administration at 9:30 AM was the Nursing Home Administrator. An interview was conducted with the NHA on 9/20/22 at 1:40 PM and she was questioned about the Insulin Glargine duplicated order on the medication administration record. She avoided answering the question and did not validate that she had transcribed the order. At 3:30 PM on 9/20/22 the charge nurse (staff #30) reviewed the electronic physician's order page with the duplicate insulin Glargine order showing the Created by name was the NHA, and she confirmed that the person identified as the Creator was the nurse who transcribes the order to the medication administration record. Further review of the medical record revealed a progress note written by the NHA on 9/16/22 Spoke to Dr. [name of attending(staff#76)] about two heparin orders and he stated to d/c the one time a day and continue three times day heparin. He will evaluate next week. A review of the hospital discharge summary documented/instructed to administer Heparin 5000 units/ml into the skin 3 times daily. (Heparin is an anticoagulant used to prevent the blood from clotting) A review of the two orders on the MAR revealed one order dated 9/6/22, matched the hospital discharge summary, and was transcribed to the MAR as Heparin Sodium Solution 5000 Unit/ml inject 1 ML subcutaneously three times a day for clot prevention. This order was transcribed to administer the medication at 6:00 AM, 2:00 PM (1400), and 10:00 PM (2200). The heparin order dated 9/7/22 and discontinued on 9/16/22 was transcribed to the MAR as Heparin Sodium injection solution 5000 UNIT/ML inject 5000 unit subcutaneously one time a day for DVT (deep vein thromboses) for 14 days inject 1 ML into the skin 3 times daily. This order was transcribed to be administered 1 time per day at 9:30 AM. This order was Created by the Nursing Home Administrator. Another identified medication duplicate on the medication administration record was documented on the hospital discharge summary as Calcium Acetate (Phos Binder) 667 MG (milligram) capsule Take 1 capsule by mouth 3 times daily with meals. A review of the MAR revealed the order of 9/6/22 for Calcium Acetate was documented as administered at corresponding mealtimes of 8:00 AM, 12:00 Noon, and 5:00 PM. The duplicate order of 9/7/22 and discontinued on 9/13/22 documented that staff administered the duplication of Calcium Acetate at non-mealtimes of 6:00 AM, 2:00 PM (1400), and 10:00 PM (2200) for 6 days. A meeting was held with the Interim Director of Nursing (DON) on 9/22/22 at 4:29 PM with collaborated review of Resident #141's medication administration review. Concerns related to reconciliation of Resident #141's medications on admission to include duplication of insulin, and heparin medication orders, and the antidepressant medication Celexa was transcribed to the MAR without an indication of use or why was the medication changed from 20 mg. to 40 mg. daily. A follow-up interview was conducted with the Interim DON per her request on 9/26/22 at 12:51 PM. She presented educational documentation and reprimand write-up to a nurse related to the concerns reviewed on 9/22/22.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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2) On 1/5/22 at 1:15 PM a review of the medical record for Resident #32 was conducted and revealed Resident #32 was admitted to the facility in August 2022 with diagnoses that included, but were not limited to, repeated falls, muscle wasting and atrophy, atherosclerotic heart disease, weakness and hypertension. Review of Resident #32's December 2022 physician's orders revealed an order for hydralazine 10 mg. twice per day for high blood pressure. The order stated to hold the medication if the SBP (systolic blood pressure) was below 120. The top number of the blood pressure refers to the amount of pressure in the arteries during the contraction of the heart muscle. This is called systolic pressure. The bottom number refers to the blood pressure when the heart muscle is between beats. This is called diastolic pressure. Review of Resident #32's December 2022 Medication Administration Record (MAR) revealed the hydralazine was given when the SBP was below 120. The medication was given on the following days: 12/1 118/78 8 PM 12/3 116/70 8 AM 12/4 118/69 8 AM 12/7 116/68 8 PM 12/8 111/66 8 AM and 118/64 8 PM 12/12 119/68 8 PM 12/13 119/68 8AM and 117/63 8 PM 12/14 119/67 8AM 12/16 118/65 8 AM and 114/66 8PM It was also noted that Resident #32 was prescribed 3 additional antihypertensive medications, Amlodipine 10 mg. once per day, Lisinopril 10 mg. once per day, and Metoprolol 25 mg. once per day. Those antihypertensives had hold parameters for SBP less than 110 and the Metoprolol 25 mg. also had a heart rate (pulse) hold for less than 60. The metoprolol was given on 12/3 with a heart rate of 59 and on 12/16 with a heart rate of 58. 3) On 1/4/23 at 12:30 PM a review of Resident #24's medical record was conducted and revealed an order for the antihypertensive medication, Lisinopril 5 mg. hold if Systolic Blood Pressure (SBP) was less than 110 and the HR (heart rate) was less than 60. Review of Resident #24's December 2022 and January 2023 Medication Administration Record (MAR) revealed the medication was given on 12/30/22 when the SBP was 100/66 and the heart rate was 60. Further review revealed a second antihypertensive medication, Metoprolol 25 mg. to be given twice per day, Hold if SBP less than 110 and HR less than 60. Review of Resident #24's December 2022 and January 2023 Medication Administration Record (MAR) revealed the medication was given on 12/30/22 at 9:AM when the SBP was 100 and the heart rate was 60 and again on 1/3/23 at 9 PM when the blood pressure was 102/66 with a heart rate of 68. It was noted that the medication was held on 12/20/22 when the b/p was 150/44 and the heart rate was 56. On 1/4/23 at 2:05 PM an interview was conducted with Nurse Practitioner #35 regarding the order. Staff #35 was asked if she meant for the order to read for both the SBP and the HR to be out of parameters in order to hold the medicine or if either one, SBP or HR were out of parameters, should the medication be held. Staff #35 stated, If one not correct don't give. The surveyor informed Staff #35 that the nursing staff was interpreting the order in different ways and were not consistent. Staff #35 stated, it is just symantics the way the order was written. The surveyor expressed to Staff #35 that the way the order was written, and the way some of the staff were interpreting the order, it read to hold if SBP below 110 and the HR below 60, not OR the heart rate below 60. An interview of the DON on 1/4/23 at 2:00 PM was conducted and she confirmed the concern related to the parameters and the word and versus or in the order. On 1/4/23 at 2:37 PM an interview was conducted with Certified Medicine Aide #9 who stated, I would get clarification from the nurse and then document that the nurse was aware. On 1/4/23 at 2:42 PM an interview was conducted with RN #7 who stated, both should be out of parameter. RN #7 then stated that when looking at the order she was looking at the SBP being below 100 and not 110. She said the order was, cut and dry looking at below 100 for the SBP. On 1/4/23 at 3:40 PM the DON and ADON were made aware of RN #7's response and how the medication was given outside of parameters. On 1/11/23 at 3:00 PM during the exit conference the Medical Director informed the surveyor that he was concerned about the statement by Staff #5 and he was going to address the situation and he also stated that the way the order was written was confusing and going to be changed. Based on medical record review and interview with staff, it was determined that the facility failed to follow a physician's order to 1) administer the antihistamine medication Benadryl twice daily for 2 days and then discontinue and 2) follow physician ordered blood pressure parameters. This was evident in 3 (#26, #32, #24) out of 3 residents reviewed for significant medication errors during a follow-up survey. The findings include: Benadryl (diphenhydramine) is a brand-name medication that's classified as an antihistamine. It's used to help relieve symptoms of hay fever (seasonal allergies), other allergies, and the common cold, as well as itchy skin due to insect bites, hives, and other causes. Benadryl is effective for decreasing itchy skin from hives. It's often considered a first-choice treatment for hives. But although it's effective for decreasing symptoms of seasonal allergies, Benadryl isn't often used for this purpose. This is due to side effects such as sleepiness. 1) A review of Resident #26's medical record on 01/05/23 revealed a physician's order instructing the nursing staff to administer the antihistamine medication, Benadryl, 25 mg, by mouth, every 12 hours for an allergic reaction, administer the medication times 2 days and then discontinue. A review of Resident #26's January 2023 Medication Administration Record (MAR) revealed that Resident #26 had been receiving Benadryl, twice daily since November 2022. The January 2025 MAR instructed the nursing staff to administer Benadryl 25 mg orally, times 2 days, and then discontinue. In an interview with Resident #26's attending physician on 01/05/23 at 12:15 PM, the nurse surveyor asked Resident #26's physician if the nursing staff should continue to administer Benadryl twice a day. Resident #26's physician stated that Resident #26 was placed on Benadryl and Prednisone for the short term due to the possibility of having an allergic reaction to an antibiotic. These findings were brought to the Director of Nursing on 01/05/23 at 12:45 PM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on complaint, and resident and staff interviews, it was determined that the facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This was evident for all residents in the facility reviewed during the annual survey. The findings include: In an interview with Resident #23 on 09/11/22 at 10:06 AM, Resident #23 stated that he/she does not receive diabetic beverages to drink (unsweetened drinks). Resident #23 stated there was no other choice of beverages for resident's who are diabetic, except water and unsweetened tea. All of the beverages coming from the kitchen were some forms of juice that had sugar added. In an interview with Resident #5 on 09/11/22 at 10:40 AM, Resident #5 stated that he/she does not receive daily meal menus. Resident #5 also stated that you get whatever the kitchen sends out. Residents do not have any choice of meals. In an interview with the facility dietician on 09/23/22 at 11:35 AM, the dietician confirmed that the facility kitchen does not serve sugar free beverages for the residents that have diabetes, and that the kitchen only has water and unsweetened tea to serve diabetic residents. The facility dietician also confirmed that the residents do not receive daily meal menus due to the fact that the facility has a lack of activity staff.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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Based on complaint, and resident and staff interviews, it was determined that the facility failed to prepare and serve a resident's nutritional wishes and plan of care. This was evident for all residents that can eat and drink in the facility and suffer from diabetes. The findings include: In an interview with Resident #23 on 09/11/22 at 10:06 AM, Resident #23 complained that he/she does not receive diabetic beverages to drink (unsweetened drinks). Resident #23 stated there was no other choice of beverages for resident's who are diabetic, except water and unsweetened tea. All of the beverages coming from the kitchen were some forms of juice that had sugar added. In an interview with the facility dietician on 09/23/22 at 11:35 AM, the dietician confirmed that the facility kitchen does not serve sugar free beverages for the residents that have diabetes, and that the kitchen only has water and unsweetened tea to serve diabetic residents.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident complaint, record review and staff interview, it was determined that the facility staff failed to provide a resident with a bedtime snack. This was evident for 1 (Resident #23) of 12 residents reviewed for nutrition during the annual survey. The findings include: In an interview with Resident #23 on 09/11/22 at 1:20 PM, Resident #23 complained that the facility dietician does not follow the diabetics in the facility and the kitchen does not know how to prepare food for diabetics and that this has concerned him/her since admission. Resident #23 stated that he/she suffers from insulin dependent diabetes and end stage renal disease for which he/she receives hemodialysis. Resident #23 stated that his/her meals consist of carrots, greens, and potatoes. Resident #23 stated that I am not served any dietary protein and served some type of juice that has sugar added. A review of Resident #23's 09/11/22 lunch meal ticket at 1:20 PM revealed that the kitchen prepared and sent a: carbohydrate controlled, liberal renal, regular meal with nectar thick liquids. At the top of Resident #23's meal ticket indicated in bold lettering DO NOT USE!! A review of Resident #23's medical record on 09/11/22 revealed that Resident #23 was admitted to the facility on [DATE]. Resident #23's current physician directed dietary orders revealed that on 07/11/22, Resident #23 was to receive a Renal diet, Regular texture, with thin regular consistency liquids and in the evening, Resident #23 was to receive a diabetic snack. In a follow-up interview with Resident #23 on 09/13/22 at 9:10 AM, Resident #23 stated that he/she did not receive a snack last night and that his/her finger stick glucose reading was 75 mg/dl. In a follow-up interview with Resident #23 on 09/21/22 at 4:30 PM, Resident #23 stated that he/she did not receive his/her nighttime snack last evening on 09/20/22. Resident #23 stated that he/she requested a peanut butter and jelly sandwich from the kitchen and the sandwich could not be found when he/she asked the staff. Resident #23 again stated that he/she suffers from diabetes and receives dialysis services in the facility. Resident #23 stated that he/she did receive a frozen supplement last evening. In an interview with the facility dietician on 09/23/22 at 11:35 AM, the dietician confirmed that the facility kitchen does not serve sugar free beverages for the residents that have diabetes, and that the kitchen only has water and unsweetened tea to serve the diabetic residents.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13) On 9/11/22 at 09:42 AM the surveyor observed Resident #38 had a gauze dressing with pink oozing mark on his/her left foot, and end of the gauze (at least 30 cm long) was hanging on the bed. Immediately an interview was conducted with Resident #38. The dressing change was ordered every day, but wound nurse did it twice a week. The resident also said that the current dressing was applied on last Thursday (11/8/22). The second observation for Resident #38's wound was conducted on 9/12/22 at 11:53 AM. The resident had the same dressing as on 9/11/22. Also, the surveyor found a bug flying in the resident's room. Another observation was done on 9/14/22 around 10 AM. Resident #38 had a new dressing with a handwritten date of 9/13/22. During an interview with Resident #38 on 9/15/22 at 1:53 PM, the resident said, wound nurse changed the foot dressing on 9/13/22 and this morning (9/15/22). They didn't change the dressing yesterday. On 9/15/22 at 1:56 PM a review of Resident #38's medical record revealed that the resident had an order of, Left foot near 3rd toe: Cleanse with wound cleanser onstream setting, pat dry. Apply a thin layer of medihoney f/b (foreign body) cut a piece of Calcium alginate AG and cover with DCD (dry clean dressing). Every day shift for wound care monitor daily for s/sx (sign/symptom) of pain, infection & healing - order initiated on 7/26/22, discontinued on 9/15/22. Additionally, Resident #38's Treatment Administration Record (TAR) showed the facility nurses checked off the resident's foot wound dressing was done daily from 9/8/22 to 9/15/22 (except 9/11/22). On 9/16/22 at 10:10 AM, the surveyor shared concerns regarding Resident #38's wound dressing which was not changed daily but recorded as done daily with the NHA. The NHA stated, I will talk to nurses. 14) A review of complaint MD00166828 on 9/26/22 at 10:54 AM revealed that Resident #99 was admitted to the facility on [DATE] for ambulatory dysfunction s/p (status post) fall and transferred to the hospital on February 2021. The complaint report contained that Resident #99 failed to follow the neurologist, no precautions were placed for the fall, and the facility staff did not manage the resident's pain. For more information regarding Resident #99's care, the surveyor requested a closed record for the resident on 9/26/22 at 11:00 AM. The facility staff did not provide the resident's closed record until 3:30 PM on 9/26/22. On 9/26/22 at 3:45 PM, an interview was conducted with the NHA. The surveyor asked about Resident #99's closed record. The NHA replied, we do not have Resident #99's closed record. We can't find the folder. In an interview with the interim DON on 9/28/22 at 1:30 PM, the surveyor informed the concern related to the discharged resident's closed record. The interim DON stated that some documentation was missing since the facility had re-arranged rooms several times. 4) On 9/15/22 at 11:02 AM a review of Resident #49's medical record was conducted. Resident #49 was admitted to Hospice on 8/27/21. There were Hospice visit notes in the paper medical record up to 7/7/22. There were no recent visits documented. RN #14 confirmed the findings and stated they are usually pretty good at getting their notes in the record. 5) On 9/14/22 at 10:15 AM a review of Resident of Resident #69's medical record was conducted. Resident #117's laboratory results of a Hemoglobin A1C dated 1/6/20 was found in the Advanced Directives section of Resident #69's electronic medical record. Hemoglobin A1C or HbA1c test is a simple blood test that measures the average blood sugar levels in the blood over the past 3 months. The interim DON was informed on 9/14/22 at 10:24 AM. 6) On 9/26/22 at 9:07 AM the medical record of Resident #97 was reviewed. Resident #118's signed death certificate dated 5/6/22 was in the front of Resident #97's closed paper medical record. Resident #97 was discharged from the facility on 3/2/21. 7) On 9/23/22 at 11:11 AM the medical record of Resident #93 was reviewed. Review of the progress note section of the electronic medical record revealed a care conference note for a date of service of 7/1/22 that was not written and put into the electronic medical record until 7/27/22 at 10:48 AM. Resident #93 was discharged from the facility on 7/11/22. On 9/23/22 at 11:02 AM the social work director was asked why the note was entered 26 days after the meeting. The social worker stated, I could not get the note into the system timely due to the volume of work. 8) On 9/23/22 at 8:00 AM the medical record of Resident #103 was reviewed. Review of the 1/25/22 nursing admission assessment documented the resident had a foley catheter. A foley catheter is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag. A 1/26/22 bowel and bladder assessment documented, Indwelling catheter, Does the resident have an indwelling catheter? YES; If the resident has an indwelling catheter is there a plan for removal? No. Bladder status was documented as yes, has an indwelling catheter. A 1/27/22 physician's H&P (history and physical) did not mention about GU (genitourinary) status. Review of hospital notes dated 1/24/22 documented urinary catheter was inserted 1/24/22 at 23:56 (11:56 PM). Indication: immobilization required (trauma/surgery). Review of the entire medical record failed to indicate if Resident #103 had a foley catheter or had urinary incontinence. There was no physician's order for a foley catheter. GNA (geriatric nursing assistant) documentation documented bladder incontinence even though documentation was spotty and not thorough. Review of GNA documentation for January 2022 from 1/25/22 to 1/31/22, all 3 shifts (day, evening, night) revealed there were only 3 times that there was documentation. On 1/26, 1/27 and 1/31 evening shift. All of the other days and shifts were blank. For February 2022 for 2/1/22 to 2/4/22 there were blanks on day shift 2/1, 2/2, 2/3, evening shift 2/4 and night shift 2/1/22. On 9/27/22 at 11:06 AM with the Interim DON, a discussion was held regarding the lack of accurate documentation related to the foley catheter and the resident's urinary continence status. 9a) On 9/20/22 at 4:20 PM observation was made of Resident #34 and his/her room. There was a television on a table that was flipped over on its face/screen. On top of the back of the television was a French fry and a pair of ted stockings. TED (Thrombo-Embolus Deterrent) stockings are also known as compression stockings, anti-embolism stockings, or support hose. They help reduce the risk of developing a deep vein thrombosis (DVT) or blood clot and help reduce the risk of swelling (edema). On 9/21/22 at 7:39 AM observation was made of the TED stockings lying on top of the television. Further observations on 9/21/22 at 12:09 PM revealed the TED stockings were still on top of the television. At 12:53 PM on 9/21/22 the resident was observed out of bed wearing gray slipper socks without TED stockings. Review of physician's orders for Resident #34 documented, Support hose. On in the morning and remove at bedtime. The order was written on 1/18/22. Review of Resident #34's Treatment Administration Record (TAR) for September 2022 documented on 9/20/22 and 9/21/22 that Resident #34 wore TED stockings. This was inaccurate documentation. On 9/21/22 at 5:00 PM the NHA toured with the surveyor and observed Resident #34. The NHA was asked to note what the resident was wearing on his/her feet. Resident #34 was wearing gray slipper socks and not TED stockings. At that time the NHA was informed that the past 2 days the TEDS were signed off as worn, when they were not worn. 9b) Review of physician's orders for Resident #34 revealed the order, pt. to utilize [NAME] cup during meals daily as tolerated and staff assist with all meals. The physician's order was written on 1/28/22. The [NAME] Cup is a lightweight, easy-to-grip adapted drinking cup designed to prevent spills. On 9/21/22 at 9:20 AM observation was made of Resident #34 in bed with the tray table in front of him/her with a breakfast tray on top. There was a regular plastic cup on the tray with no lid. The plastic cup was sideways and empty. Review of Resident #34's TAR documented that the nurse signed off on 9/21/22 that Resident #34 utilized a [NAME] Cup at breakfast (8:00 AM) and lunch (12:00 PM) which was inaccurate. 10) On 9/21/22 at 8:05 AM the medical record of Resident #10 was reviewed and revealed on Friday, 9/16/22, Resident #10 was transferred to the hospital for a change in medical condition. Review of assessments for Resident #10 revealed a COVID-19 assessment was conducted on Sunday, 9/18/22 even though Resident #10 was admitted to the hospital and not in the facility. Further review of Resident #10's medical record revealed the Change in Condition/Concurrent review dated 9/16/22 was incomplete. 11) On 9/26/22 at 2:00 PM a review of Resident #291's medical record was conducted. Resident #291 was admitted to the facility in August 2021 with diagnoses including, but not limited to, dependence on renal dialysis, diverticulitis of intestine and chronic atrial fibrillation. Review of a discharge planning tool that was initiated 9/2/21 at 16:09 (4:09 PM), documented that Resident #291 was going to be discharged to another facility on 9/3/21. There was no documentation in the medical record on 9/3/22 that the resident was in fact discharged , where to, with whom, and the condition of the resident upon discharge. 12) On 9/26/22 at 9:07 AM a review of Resident #97's medical record was conducted. Resident #97 was admitted to the facility on [DATE] with a medical history that included, but was not limited to, end stage renal disease that required hemodialysis, sepsis secondary to a diabetic right leg lower extremity ulcer, diabetes mellitus, COPD (Chronic Obstructive Pulmonary Disease), atrial fibrillation and Atherosclerotic heart disease. Further review of the medical record revealed the facility only created care plans for activities, safe discharge and actual fall. Resident #97 was discharged from the facility on 3/2/21, however the care plan, at risk for limited meaningful engagement due to COVID-19 restrictions was initiated on 9/26/22 and created on 1/29/21 and revised on 9/26/22 with the current NHA's name. The NHA's name was on the interventions and goal with create and revised dates of 9/26/22. The NHA's name and create and revised dates of 9/26/22 also documented on the safe discharge and actual fall care plan, even though the resident was discharged from the facility on 3/2/21. 3) On 09/15/22 at 3:10 PM a review was conducted of Resident #45's electronic medical record. During the review, while looking for information regarding the Resident's responsible party, it was noted that a different Resident's activity care plan had been entered into Resident #45's care plan. The other resident's activity care plan indicated it was created on 08/18/2021. Based on medical record review, interviews and observations it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. Furthermore, the facility failed to assure the completeness, and accuracy of documentation related to the use of Healthcare Virtual Assistant Transcription Support services. This was evidenced by review of resident's medical records with multiple examples of incomplete documentation initiated by HVAs and documentation of staff performing assessments and documented progress notes at times the staff were not in the facility. This practice was evident for 13 (#141, #45, #49, #69, #97, #93, #103, #34, #10, #291, #97, #38, #99) of 54 residents reviewed. The findings include: 1) Review of electronic medical records revealed documentation by Healthcare Virtual Assistants (HVA). The nursing home administrator (NHA) and the director of nursing (DON) provided explanations to the survey team as the role of the HVAs and how the facility staff utilize the assistance of the HVAs. Healthcare Virtual Assistant Transcription Support Services Guidelines were provided to the survey team with an implemented dated of 3/4/22 and a reviewed/revised dated of 4/1/22. The service contract indicated that the service began in November 2021 and the Corporate Chief Nursing Officer stated that the service started in November 2021. The facility failed to assure the completeness, and accuracy of documentation related to the use of Healthcare Virtual Assistant Transcription Support services. Resident #141's medical record was reviewed repeatedly during the survey. Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's medical record on 9/22/22 at 10:10 AM revealed a Peak COVID-19 Evaluation dated 9/21/22, time stamped for 18:42 (6:42 PM) and a Lock Date 9/21/22 20:18 (8:18 PM). The assessment was created by a HVA (staff #78). The nurse who completed the assessment worked day shift 7 AM to 3:30 PM on 9/21/22. An interview was conducted with the nurse (Staff #7) at 10:19 AM on 9/22/22. She stated that she was not at the facility at the times recorded on the assessment. She indicated that when she was locking the assessments for the resident under her care on 9/21/22 she noticed the time discrepancy. She stated that she added a time next to her name. She confirmed that this evaluation/assessment for Resident #141 did not have a time by her name, and she was not in the facility at the times recorded on the assessment form. Review of the electronic medical record for Resident #141 on 9/26/22, under the Assessment tab, revealed 6, In Progress assessments dated 9/6/22. The assessments were titled Peak Braden, Peak Fall Risk Evaluation, Peak Lift Transfer Evaluation, Peak Side Rail Evaluation, Peak Elopement Risk Assessment, and Peak Baseline Care Plans. The screen view indicated the 6 assessments were Created by and Revised by a HVA (staff #78). Review of each assessment shown to have incomplete documented assessment data. Other In Progress in completed assessments that were Created by and revised by a HVA included: Peak COVID-19 Evaluation dated 9/7/22 Peak PDPM/Skilled Nursing Evaluation, 2 evaluations dated 9/10/22 Peak PDPM/Skilled Nursing Evaluation dated 9/11/22 Peak PDPM/Skilled Nursing Evaluation dated 9/13/22 Continued random review of assessments revealed documented completion of assessments by a nurse that was not in the facility for the Effective Date of the assessments. Review of Peak COVID-19 Evaluation with an effective date of 9/11/22 was Created by a HVA and was signed by a registered nurse (staff #92) on 9/23/22. COVID-19 Evaluation with an effective date of 9/14/22 was Created by a HVA and was signed by a registered nurse (staff #92) on 9/22/22. A Peak PDPM/Skilled Nursing Evaluation with an Effective Date of 9/14/22 was created by an HVA and signed by staff #92 on 9/23/22 and a Peak PDPM/Skilled Nursing Evaluation with an Effective Date of 9/21/22 was created by an HVA and signed by staff #92 on 9/23/22. It was also noted that a Daily Nursing Charting note was created on the progress note section of the electronic medical record for each of the PDPM/Skilled Nursing Evaluations. Copies were requested and received of the identified Peak Evaluations and progress notes. On 9/26/22 at 1:00 PM the interim DON was asked about the identity of Staff #92. She revealed, staff #92 was a DON at another Peak facility. A phone interview was conducted with the DON of the other Peak facility on 9/28/22 at 2:38 PM. She stated that she did not perform any of the assessments. She indicated that she had locked the assessments and the name of the nurse was on the document. She was informed that the printed documents were shown to be signed by her without any additional names on each of the documents. The printed documentation did not indicate that the document was locked. The concern was expressed to her, that her signature on the document was a false representation of an evaluation that was not performed on the resident. On 9/28/22 at 6:15 PM, the medical director and the interim DON were shown the copies of the Evaluations that were signed by a nurse that did not perform the assessment, and the assessment documented at a time when the nurse was not in the facility. 2) Resident #141's medical record was reviewed on 9/16/22. Review of the Certified Registered Nurse Practitioner wound consultant (staff #62) note was electronically signed on 9/15/22 at 1:56 PM and revealed inaccurate/false documentation in the note. The note was written after she assessed Resident #141's wounds. The nurse practitioners note stated, Wound rounds completed and reconciled with wound nurse today. All questions and concerns answered for staff and patient as applicable. The nurse practitioner was interviewed on 9/22/22 at 9:44 AM. She was asked who the wound nurse was that she reconciled with as documented in her note. She acknowledged that the facility does not have a wound nurse, further replied that the bulk of her notes were prepopulated, and she did not know how to change the prepopulated data. On 9/23/22 review of the Nurse practitioner's note, that was electronically signed on 09/22/2022 1:43 PM revealed the same inaccurate information referencing wound rounds was, reconciled with the wound nurse today. The facility did not have a wound nurse on 9/22/22.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Party (RPs) were provided education regarding the benefits, risks, and potential side effects of Influenza and Pneumococcal vaccines before requesting consent. This was evident for 4 (Resident #49, #4, #58, #11) of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey. The findings include: Pneumococcal vaccine helps prevent pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications. Influenza (Flu) vaccines can prevent influenza. (Centers for Disease Control and Prevention- vaccines and preventable disease) PCC (Point Click Care) is a cloud-based healthcare software provider helping long-term care. The PCC has an immunization tab which shows vaccination status (immunization name, date given, and consent status). 1) On 9/15/22 at 8:47 AM, a medical record review was conducted for Resident #49. Resident #49 had resided in the facility since December 2019, and the electronic medical record (PCC) immunization section showed the resident received the Flu vaccine in 2020 and 2021. However, there was no documentation for Resident #49's consent form or education related to the Flu vaccine, despite the resident receiving the vaccine in 2021. 2) The medical record of Resident #4, who was admitted in May 2022, was reviewed on 9/15/22 at 9:00 AM. There was no documentation related to Pneumonia vaccine status in Resident #4's paper chart or in PCC. 3) On 9/15/22 at 9:05 AM, the medical record was reviewed for Resident #58, who was admitted in January 2021. The PCC immunization tab showed the resident refused the Flu vaccine and there was no data for the pneumonia vaccine. Further record review revealed that there was no consent and education documentation to support that Resident #58 received education regarding the benefits, risks, and potential side effects of Influenza and Pneumococcal vaccines before requesting consent. 4) On 9/15/22 at 9:10 AM, medical records were reviewed for Resident #11, who had resided in the facility since September 2020. The PCC immunization tab showed influenza -consent required and no documentation for the pneumonia vaccine. During an interview with the Interim Director of Nursing (DON) on 9/15/22 at 11:55 AM, the Interim DON confirmed that consent required meant the vaccine was not given and needed to update immunization with consent, education, and administration. The Interim DON was aware of the above concern on 9/28/22 at 1:30 PM. No additional documentation was submitted to the survey team until the exit conference held on 9/28/22 around 7:00 PM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected multiple residents

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Based on medical record review and staff interview, it was determined the facility failed to document that education was provided to residents and staff regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine. This was evident for 4 (Resident #49, #11, #58, and #37) of 5 residents and 1 (Staff # 85) of 5 facility staff members reviewed for COVID-19 vaccinations during the annual survey. The findings include: On 09/15/22 at 08:47 AM, five residents were randomly selected for review of the COVID-19 vaccination. A review was conducted of paper and electronic medical records. 1) A review of Resident #49's medical record revealed Resident #49 had resided in the facility since December 2019 and received COVID-19 vaccines at the facility. However, there was no documentation Resident #49 received education regarding the benefits, risks, and potential side effects of the second dose of COVID-19 vaccine (administrated on 1/19/21). 2) A review of medical records revealed that Resident #11 had resided in the facility since September 2020. Resident #11 received the first dose of COVID-19 vaccine on 1/24/21, however, there was no documentation Resident #11 received education regarding the COVID-19 vaccine. Additionally, the cloud-based healthcare software (also known as PCC) immunization section showed Resident #11 refused consent for the second dose of COVID-19 vaccine. There was no documentation to support the facility provided education to the resident regarding the vaccine. 3) On 9/15/22 at 9:20 AM, a review of Resident #58's medical record revealed that Resident #58 had resided at the facility since January 2021. Resident #58 refused the COVID-19 vaccine on 8/16/22, however there was no documentation Resident #58 received education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine. 4) On 9/15/22 at 9:30 AM, a review of Resident #37's medical records revealed Resident #37 was admitted to this facility in July 2022. However, there was no documentation related to the COVID-19 vaccination status in the paper chart or under PCC immunization section. During an interview with the Interim Director of Nursing (DON) and Nursing Home Administrator (NHA) on 9/15/22 at 12:06 PM, the surveyor shared concerns related to COVID-19 vaccination documentation. The Interim DON and NHA confirmed that there was no documentation to support COVID-19 vaccination education provided to the residents. The COVID-19 staff vaccination status form was submitted by the NHA on 9/14/22 at 12:09 PM. Also, the NHA confirmed that the facility had one staff (Staff #85) who was not vaccinated for COVID-19 due to a religious exemption. However, there was no documentation to support Staff 85's education on the benefits, risks, and potential side effects of receiving COVID-19. The Interim DON was aware of the above issues on 9/28/22 at 1:30 PM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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2) Observation was made on 9/13/22 at 12:01 PM in the Homestead unit pantry/nourishment room of the ice machine. The ice machine was empty. Staff #26 walked into the nourishment room and stated, the ice machine has been broken for a while and we have to go to the kitchen to get ice for the unit and it is very inconvenient when we are short staffed. The broken ice machine was discussed with the Interim Director of Nursing on 9/28/22 at 12:15 PM. Based on observation and staff interview it was determined the facility failed to keep a bathtub and ice machine in operating condition. This was evident during environmental rounds of the facility for 1 of 1 bathtub found out of 2 observed bathing areas of the facility and in 1 of 1 nourishment rooms observed. The findings include. 1) On 9/28/22 beginning at 1:30 PM, an environmental tour of the facility was conducted with the director of EVS and maintenance (staff #19). In the Wye Oak unit's bathing suite, an out-of-commission bathtub was identified. The drainpipe of the tub was noted to be cut from the wall and the tub was moved against the wall. Upon interview with the EVS/maintenance director, he did not know how long the tub had been out of commission. The bathtub was not in operating condition.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected multiple residents

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Based on observation, medical record review, and staff interview it was determined the facility failed to have a process in place to conduct regular inspections of bed frames, mattresses, and bed rails. This was evident for 1 (#34) of 8 residents reviewed for accidents during the annual survey. The findings include: On 9/21/22 at 7:39 AM observation was made of Resident #34 lying in bed with bilateral 1/2 side rails in the raised position. On 9/21/22 at 4:30 PM a medical record review was conducted for Resident #34 and revealed a recent side rail assessment had not been done. There were no physician's orders for side rails and there was not a care plan for side rail use. On 9/27/22 at 11:13 AM an interview was conducted in Resident #34's room with the Director of EVS (environmental services) and Maintenance, Staff #19, and the Regional Director of Plant Operations. Staff #19 was asked if he had a process in place to check side rails along with the beds and mattresses. Staff #19 stated he would have to check. He has only been in the position for the past 2 weeks. The surveyor showed Staff #19 the loose side rail and the Regional Director confirmed the side rail was loose and should have been reported in the TELS system (electronic system for repairs), however they have so many agency staff working at the facility and things don't get reported. Cross Reference F700 The side rails issue was discussed with the Interim Director of Nursing on 9/28/22 at 12:15 PM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 9/13/22 at 8:39 AM an interview was conducted with Staff #88 who stated, the call bells have been an issue since July 2022 and people act like they don't know the call bells are broken. 3) Observation was made on 9/15/22 at 10:44 AM of the call bell ringing in room [ROOM NUMBER]. The call bell was audible at the nurse's station but was not lighting up outside of room [ROOM NUMBER] in the hallway. 4) Observation was made on 9/20/22 at 4:20 PM of Resident #34 lying in bed. Resident #34's call light cord was on the right side of the bed. The surveyor pushed the button on the call bell several times and and the call bell was not audible and did not illuminate. Observation was made of a hand held bell on the night stand table in front of the closet. The bell was approximately 5 ft. away from the resident. On 9/21/22 at 5:00 PM the surveyor took the Nursing Home Administrator (NHA) in Resident #34's room. The surveyor showed the NHA that the hand held call bell was on the night stand which was on the other wall that was not next to the bed. The NHA stated, I thought they fixed the call bell. The NHA tried the call bell and acknowledged that it did not work. On 9/28/22 at 5:30 PM an interview about QA (quality assurance) activities was discussed with the Medical Director and the Interim Director of Nursing (DON). They were asked if the issue with broken call bells had been brought up in the QA meetings. The Medical Director replied, the call bells not working has not been brought up in QA. Based on complaint, observation, and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order and within reach. This was evident for 2 of 3 nursing units observed during the annual survey. The findings include: 1) A review of complaint MD00178416 on 09/11/22 at 7:30 AM, revealed an allegation that resident call bells have been broken for months. During an initial observation of the 200-hall nursing unit on 09/11/22 at 8:15 AM, the nurse surveyor observed the following: An observation of Resident #70 on 09/11/22 at 8:30 AM, revealed a call bell wall receptacle in disrepair. An observation of Resident #6 on 09/11/22 at 8:35 AM, revealed a call bell wall receptacle in disrepair. An observation of Resident #34 on 09/11/22 at 8:56 AM, revealed a call bell wall receptacle in disrepair. Resident #34 was supplied with a handheld call bell that was located on his/her bedside table. When asked, Resident #34 was unable to demonstrate how to use the handheld call bell to call for assistance from the nursing staff, An observation of Resident #1 on 09/11/22 at 9:50 AM, revealed Resident #1's call bell lying on the floor behind Resident #1's bed. Resident #1, when asked, was unable to locate his/her call bell. In an interview with the facility assistant maintenance man, Staff #11 on 09/11/22 at 8:50 AM, Staff #11 stated that there were many call bell units that were broken in resident rooms. Staff #11 stated that he does not have parts to fix all the broken call bell units and that the call bells break every day. Staff #11 stated that he will use call bell unit parts from other resident rooms that are not occupied. Staff #11 stated that the facility administrator is aware of the broken resident rooms call bell issue and that there was no current plan or contract to fix the call bell system at this time that he was aware of. In an interview with Staff #27 on 09/12/22 at 10:17 AM, Staff #27 stated that he was instructed to pass out handheld call bells to residents on the morning of 09/11/22 when the State Survey team entered the building. During an observation and interview with Resident #5 on 09/11/22 at 10:40 AM, Resident #5 stated that his/her call bell had been broken now for four days and that the staff had supplied him/her with a cowbell to request for assistance.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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2) On 09/12/22 at 10:55 AM, surveyor observation at the 200 hall nurses' station revealed a red-colored sharps container underneath the 200 hall nurses' station desk. The locked sharps container was observed sitting on the floor behind the medical record shredding container. Alongside the locked sharps container was a brand new sharps container lid. The surveyor lifted the locked sharps container onto the desk. Observations of the locked sharps container revealed what appeared to be whole, round pills and capsules throughout the container. The whole, round pills and capsules appeared to be in a retrievable condition. At this time, the facility corporate clinical nurse #32 was passing by the 200 hall nurses' station. The nurse surveyor made the corporate clinical nurse aware of the findings and the surveyor handed the locked sharps container to the corporate clinical nurse. In an interview with the facility Administrator on 09/12/22 at 11:05 AM, the facility Administrator asked the nurse surveyor questions about the discovery of the locked sharps container. The facility Administrator stated that the locked sharps container should have been placed in the soiled holding room for trash removal. During the interview, the Administrator also removed two single gallon-sized drug buster containers from the 200 hall nurses' desk and had them placed in the soiled holding room for trash removal. 3) During an observation of the 200 hall on 09/21/22 at 1:35 PM, surveyor identified malodors emitting from the 200 hall shower room. A closer observation of the 200 hall shower room revealed an approximate 5-inch hole, an uncovered shower drain on the floor of the right shower stall. The surveyor identified the malodors emitting from the uncovered shower drain. Based on staff collaborated observations of two restrooms utilized by staff and residents, a nursing station and a shower room, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff as identified in 2 of 2 staff bathrooms observed and for 1 (200 hall) of 4 nursing units observed during the annual survey. The findings include. 1) An observational environmental tour of the facility was conducted on 9/28/22 with the environmental services director/maintenance director #19 beginning at 1:30 PM. Observation of the staff restroom that was shared with residents on the Chesapeake unit did not have a paper towel dispenser and the paper towels were kept on the back of the toilet. The environmental services director was informed that a hand-washing sink for the staff is required to be equipped with a goose-neck spout, with a separate soap dispenser, and a disposable paper towel dispenser. Observation of the staff restroom that was shared with the residents on the Wye Oak unit did not have a staff hand washing sink that was equipped with a goose-neck spout.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected most or all residents

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Based on record review, resident, and staff interview, it was determined that the facility failed to have a process in place to ensure that concerns and suggestions from the resident group were reviewed and responses provided to the group in writing. This was evident for 3 of 3 months of Resident Council meeting minutes reviewed during an annual recertification survey. The findings include: A review was conducted of the 2 PM Resident Council meeting minutes from 07/26/22 on 09/12/22. The following concerns were noted: Staffing on Saturday 07/23/22, there was a shortage of GNA's and RNs in the building which led to a resident walking around the building naked. Staffing has been an issue on the weekends with a lack of care shown towards the residents and leading them to receive the wrong medications or no medications at all. The issues with the aides refusing to help the residents is an ongoing issue, it has been discussed in prior meetings with no improvements. The lack of bathing and showers is still an ongoing problem. The residents have voiced concern over the number of meetings that are being held daily and it also causes a lack of support to the rest of the facility. There has been no improvement or changes after the meetings. The administrator tried to address the staffing issue only on the weekends. It is a constant staffing issue on the weekends. It was brought up again the issues with the water the residents are drinking. The water is still brown with debris coming from the sinks. The issue with the residents and families not being able to speak with the social worker has been brought up again. The residents feel there is no one to speak to in the facility. The residents believe that the new administration does not care to get to know the residents. There was no evidence provided that these issues were addressed by facility staff. A review of the Resident Council meeting minutes dated 08/05/22 at 3:30 PM, revealed the following concerns: residents are still being given the wrong medications. There still is a lack of bathing and showers for the residents. The water is still coming out brown in color. The staff do not walk around and introduce themselves to the residents. The dining room may be reopened. Aides are arguing amongst themselves. The facility needs improved activities. A concern that when the food carts arrived, the aides are not quickly bringing the food to the residents. There was a request to bring in vending machines. There was no evidence provided that these issues were addressed by facility staff. A review of the Resident Council meeting minutes dated 08/30/22 at 2:05 PM, revealed the following same concerns: The staff are now delivering water in gallon jugs for the residents and staff. The local utility company has worked on the plumbing and the water should be clean to use. Poor staffing is still an issue mainly on the weekends. A new staffing coordinator is working on the weekend staffing to ensure that back-up help is in the building when staff call out. Residents' ability to choose their meals and receive their choices had continued to be an issue. Residents complain there is no help with discharges. The residents were still complaining about being denied help from the nursing staff. The nursing staff were saying to the residents that there was a lack of help. On 09/12/22 at 10:17 AM, an interview with the Activities Aide revealed that he/she was assigned to supervise and assist residents with Resident Council meetings and had taken minutes at those meetings. He/she reported that after the meeting, the facility administrator would review and remove items from the meeting minutes before the minutes would be distributed. The Activities Aide stated that there was no money in the budget for activities. We do not have parties, birthday parties, raffles, coffee, or donuts. There are no records to be found of the resident council meetings before June 2022. During an interview with the Resident Council President on 09/13/22 at 11:45 AM, the resident Council President stated that the staff had not provided the residents with a list of foods available to the residents 24/7, policies that were requested, and had not addressed the lack of hot water in part of the building.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 9/11/22 at 9:13 AM observation was made of holes in the corners of the fitted bed sheet in room [ROOM NUMBER]A. The left corner hole exposed 6 inches by 6 inches of the bed mattress. On 9/11/22 at 9:20 AM observation was made of 2 ceiling tiles that had 2 circle shaped brown stains that were over the bed in room [ROOM NUMBER]B. The bottom of the over the bed tray table was rusted and the vinyl on the bilateral wheelchair armrests were cracked down the inside and outside of the armrests. On 9/12/22 at 10:31 AM observation was made of Resident #67 sitting in a wheelchair in the front dining room. The left wheelchair armrest was missing vinyl over half of the armrest and the underneath padding was exposed. The right wheelchair armrest also had cracked vinyl throughout the armrest. On 9/13/22 at 7:59 AM the vinyl on Resident #115's right wheelchair armrest was torn and the padding was exposed. On 9/13/22 at 12:25 PM employees on the Homestead nursing unit showed the surveyor the courtyard off the Homestead unit where the residents used to go outside for fresh air. The employees stated the fence was down, therefore the residents could not go outside. It was also observed that there was high grass and weeds. The employees stated, they just don't take care of the place. While on the unit there was black debris noted on the ceiling grates. On 9/14/22 at 7 AM in the Homestead nursing unit nourishment room there were 3 floor tiles missing by the refrigerator. Under the sink were dead and active bugs. The back wall under the sink appeared to be busted through to the foundation with concrete rocks as the back wall. There were plastic wrappers on the floor and under the sink along with cobwebs. Observation was made on 9/15/22 at 11:12 AM of the over the bed light in room [ROOM NUMBER]. The string from the over the bed light was not attached, therefore the resident was unable to turn the light on and off. An observation of Resident #25's room on 09/11/22 at 8:56 AM revealed a set of bed side drawers that appeared to be in disrepair/non-functioning. In an interview with Resident #25 on 09/11/22 at 8:56 AM, Resident #25 indicated that he/she had been asking the staff for awhile to fix the drawers. An observation of Resident #45's room on 09/11/22 at 9:10 AM, revealed that Resident #45's window was obscured by a large buildup of dirt and cobwebs. An observation of the 200 nursing unit dining area located next to the nurses' station, on 09/11/22 at 10:50 AM, revealed that the large bay window was obscured by dirt and cobwebs. Based on surveyor observation and staff interview it was determined the facility staff failed to have a process to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. This was evident throughout the survey and on all nursing units. Additionally, the facility failed to supply heated water between 100- and 120-degrees Fahrenheit. The findings include: On 9/28/22 at 12:48 the Environmental Services (EVS) Director (staff #19) indicated that in addition to his title as the EVS Director he assumed the role of the Maintenance Director. A tour of the environment of care was conducted on 9/28/22, in response to team discussions of prior findings during the survey. The following limited observations were collaborated with the Director of EVS and Maintenance beginning at 1:30 PM on 9/28/22. On the Homestead unit in room [ROOM NUMBER] the EVS Director was informed of the initial observations of this room occurred on 9/12/22 at 8:45 AM. A shower curtain and rod remained on the floor in the left-hand corner of the room by the window. The over the bed tray table base was rusted. The wall to the left of the window was observed with two areas of wall board missing on the ledge exposing a silver (metal) bead approximately 4 inches and 6 inches in each area. The light over the sink was not fully lit. The ceiling vent above the toilet appeared encrusted with dirt. The EVS director stated, it looks terrible. An 8-foot section of cove molding at the end of the hallway was noted to be separating from the wall exposing cavities in the brown wood behind it. Outside of room [ROOM NUMBER] the heating element appeared to be separating off the wall as it was sloped downward. The wall handrail across from the nursing station was missing the end cap. On the Chesapeake unit in room [ROOM NUMBER] the air conditioner vent was shown to have black mold like discolorations. In room [ROOM NUMBER] there was not a privacy curtain for the toilet. In 217 B a handle to the bed side drawer was broken. In room [ROOM NUMBER] the air conditioning unit in the wall did not have a filter and there was built up accumulations of lint like particles on the vents. In the unit's shower room malodors were detected upon entering the room. There was a 5-inch uncovered drainage hole in the floor of the left shower stall. Cracks were noted in the cove molding and on the floor covering close to the entrance to the room. The windows to the common area by the nurse's station were observed to be dirty, with cobwebs and spider webs on the outside. The EVS Director was informed of observations made to room [ROOM NUMBER] at the initiation of the survey on 9/11/22 of a large roll of brown paper towel was noted on the floor of the resident's toilet/ bathroom. The square paper towel dispenser on the wall was empty. It was reported that the square paper towel dispenser was replaced on 9/29/22. Rooms on the Mills Landing unit that were occupied during the initiation of the survey and not utilized now were observed. In room [ROOM NUMBER] and 403 the window screens were bent and ill fitted with cobwebs and dead bugs entrapped between the screen and window. In room [ROOM NUMBER] there was a series of quarter sized bumps and/or holes in the ceiling wall board along the long wall. The plastic light cover in the fixture above the bed was noted to be dislodged. The bathroom had discoloration in the floor tiles around the parameter of the room. In room [ROOM NUMBER], the door to the bathroom had two quarter sized ill repaired filled holes but remained indented and not repainted. In room [ROOM NUMBER] the sink in the bathroom was not level as it was noted with a tilt to the right. An incomplete wall repair was noted as there was white dry jagged spackle with unsmoothed edges above the cove molding. On 9/15/22 at 4 PM Resident #2 reported having cold water from the hand sink in the room. The hot water temperatures were checked in rooms #102, 104, and 106. The hot water temperatures were tested to be less than 80 degrees Fahrenheit in all three rooms. The staff was informed of the lack of hot water. An interview was held with the nursing home administrator at 4:50 PM on 9/15/22. She revealed that the maintenance man was so busy that he failed to check the water temperatures for the day. On the morning of 9/16/22, the EVS/Maintenance Director informed the survey team that by the end of the day a new hot water heater would be installed. A review of hot water logs on 9/27/22 revealed some room locations that were not reaching the minimum hot water temp of 100 degrees Fahrenheit. room [ROOM NUMBER] was tested to be 91 degrees on 9/24/22 and room [ROOM NUMBER] was tested to be 98 degrees on 9/24/22. During the environmental tour at approximately 2:45 PM, maintenance tested the hot water in room [ROOM NUMBER] at 80 degrees and tested the hot water in room [ROOM NUMBER] at less than 80 degrees.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10) An observation for Resident #38 on 9/11/22 at 9:11 AM and a review of the resident's medical record on 9/15/22 at 2:23 PM revealed that Resident #38 had a left foot wound since his/her admission in July 2022. However, a review of Resident #38's medical record on 9/15/22 at 2:30 PM revealed that there was no care plan related to the resident's left foot wound care. 11) The medical record of Resident #63 was reviewed on 9/21/22 at 11:40 AM. The review of the change in condition report dated 1/10/22 written by a nursing staff revealed that Resident #63 was diagnosed COVID-19 positive on 1/10/22. However, a further review of Resident #63's medical record revealed that there was no care plan related to COVID-19 care. 12a) Review of complaint MD00178416 on 9/23/22 at 7:50 AM revealed that Resident #95 had chronic issues with urinary catheter care and urinary tract infections since June 2022. Further review of Resident #95's medical record documented that Resident #95 was admitted to the facility in May 2022, and a urinary catheter had been in place before the admission due to urine retention. However, further review of Resident #95's medical record revealed that there was no care plan for the urinary catheter. 12b) A review of Resident #95's medical record on 9/23/22 at 9:00 AM revealed that an initial wound assessment was done by [name of company] (contracted wound care team) Nurse Practitioner (NP #91) on 5/16/22. The review of the initial wound assessment revealed that Resident #95 had a pressure ulcer on the left buttock. However, a further review of Resident #95's medical record revealed that there was no care plan related to wound care. 13) A review of complaint MD00166828 on 9/26/22 at 10:30 AM revealed that Resident #99 was admitted to the facility in January 2021 for ambulatory dysfunction s/p (status post) fall and transferred to the hospital in February 2021. Also, the complaint report documented that Resident #99 failed to follow the neurologist, no precautions were placed for the fall, and the facility staff did not manage the resident's pain (headache). Resident #99 had pain. Further review of Resident #99's discharge summary from the hospital dated 12/31/20, before being admitted to the facility, revealed that Resident #99 received a VP shunt (a small plastic tube that helps drain extra cerebrospinal fluid from the brain) due to a post-traumatic fall with an accompanying headache. Also, a written note dated 1/1/21 by a telehealth provider (on-call agency provider) that the discharge summary was reviewed and approved. An MDS (Minimum Data Set: a powerful tool for implementing standardized assessment and facilitating care management in nursing homes) assessment dated [DATE] coded pain under J0300. During an interview with Resident #99's Responsible Party (RP) on 9/26/22 at 10:38 AM, the RP stated that Resident #99 had a severe headache since his/her admission. The RP also stated that the facility only ordered Ibuprofen for the resident's headache, and no other intervention was applied. However, a review of Resident #99's care plan on 9/26/22 at 1:00 PM revealed no care plan related to the resident's headache. The surveyor reviewed the resident's care plans with the Interim DON during an interview on 9/28/22 at 1:30 PM. The Interim DON confirmed there was no care plan related to the resident's specific health conditions that needed nursing staff care. Based on observation, medical record review, and staff interview it was determined that facility staff failed to develop and initiate comprehensive, resident centered care plans for residents residing in the facility. This was evident for 13 (#10, #27, #97, #34, #49, #62, #107, #141, #1, #38, #63, #95, #99) of 54 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 9/11/22 at 9:26 AM observation was made of a portable oxygen tank on the back of the wheelchair for Resident #10. There was a nasal cannula attached to the oxygen tank. A nasal cannula consists of a flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils to deliver oxygen. On 9/14/22 at 2:10 PM an interview was conducted of Registered Nurse (RN) #3. RN #3 stated she did not know why the resident had oxygen. The surveyor said, even with the nasal cannula wrapped around the back of his chair. RN #3 said, don't know, maybe because dialysis might put it on [him/her] if [his/her] sats (oxygen saturation) drop. On 9/15/22 at 10:30 AM a record review of the vital sign section of Resident #10's electronic medical record revealed documentation that oxygen was used on 1/23/21, 2/12/21 and 1/31/22. Further review of the medical record failed to produce a care plan for oxygen therapy. 2a) On 9/12/22 at 1:08 PM an interview was conducted with Resident #27. Resident #27 was asked if he/she had natural teeth or dentures. Resident #27 stated, I have dentures but they got lost when I went to the hospital. On 9/15/22 at 2:45 PM Resident #27's spouse was in the room and expressed concern to the surveyor about the missing dentures that got lost the evening that Resident #27 fell and was sent to the hospital. Resident #27 stated the dentures were on the floor and they haven't seen them yet. The spouse stated she told the administrator and was told they were being looked for. On 9/16/22 at 8:44 AM a medical record review was conducted for Resident #27. A 8/23/22 nursing admission assessment documented, no teeth - lost dentures at the hospital. The resident was ordered a regular diet, mechanical soft - chopped meat texture, dental soft diet with additional portions. Continued review of the medical record failed to produce an individualized care plan for dentures and what to do for the resident until the dentures were replaced. 2b) On 9/15/22 at 2:21 PM a medical record review was conducted for Resident #27. Resident #27 was admitted to the facility in July 2022 with diagnoses that included, but were not limited to, repeated falls, atherosclerotic heart disease, chronic kidney disease and major depressive disorder, recurrent. The resident was hospitalized for 5 days in August 2022 and returned to the facility after being treated for bacteremia and a urinary tract infection. Resident #27 contracted COVID-19 on 8/30/22. Review of the weight section of Resident #27's medical record revealed the resident weighed 130 lbs. (pounds) upon admission on [DATE], 130.8 lbs on 7/5/22, 133.6 lbs. on 7/13/22 and 135.6 lbs. on 7/27/22. Review of hospital notes dated 8/19/22 documented the resident's weight at 130 lbs. Review of the nutritional care plan, has potential nutritional problem r/t GERD (related to Gastroesophageal reflux disease) was created by the Healthcare Virtual Assistant on 8/31/22 and revised by the MDS Coordinator on 9/12/22. There were 3 interventions on the care plan; administer medications as ordered. monitor/document for side effects and effectiveness provide, serve diet as ordered. Monitor intake and record q (every) meal and RD to evaluate and make diet change recommendations PRN (when necessary). The care plan was not individualized for Resident #27. There was nothing about a nutritional supplement, nothing about taking weights and how often, nothing about specific foods the resident liked and should be offered and there was nothing about a specific diet. There was no evidence that the resident was involved in the creation of the care plan. The nutrtional problem was documented as related to GERD. There were no interventions related to GERD. 3) On 9/26/22 at 9:07 AM a review of Resident #97's medical record was conducted. Resident #97 was admitted to the facility on [DATE] with a medical history that included, but was not limited to, end stage renal disease that required hemodialysis, sepsis secondary to a diabetic right leg lower extremity ulcer, diabetes mellitus, COPD (Chronic Obstructive Pulmonary Disease), atrial fibrillation and Atherosclerotic heart disease. Further review of the medical record revealed the facility failed to create and implement a care plan for dialysis, wound care, diabetes, COPD, heart disease, pain, activities of daily living, and nutrition. The only care plans created were for activities, safe discharge and actual fall. On 9/26/22 at 11:35 AM the Nursing Home Administrator (NHA) gave the surveyor a paper back that had requested items from the surveyor from the medical record. Care plans were not checked off as provided to the surveyor. On 9/28/22 at 12:15 PM reviewed the concern with the Interim Director of Nursing (DON) who confirmed the finding. 4a) On 9/21/22 at 4:30 PM a review of Resident #34's medical record revealed an activities assessment that was done on 1/20/22. The assessment documented Resident #34 preferred 1:1 activity/visit, liked to watch tv/movies, and liked to watch football. The assessment documented it was somewhat important to go outside to get fresh air when the weather was good; do favorite activities; keep up with the news; listen to music the resident likes and have snacks available between meals. An activities comprehensive assessment dated [DATE] documented the same likes with the changes, do my favorite activities; go outside to get fresh air when the weather is good; somewhat important to have snacks available between meals; choose bedtime; listen to music that likes; keep up with the news. Review of Resident #34's care plan, independent/dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t (if dependent) Physical Limitations that was created on 1/21/22 by an activities aide and revised on 2/10/22 by the healthcare virtual assistant (HVA) documented a goal, will participate in activities of choice 1-3 times weekly. Interventions included, Encourage verbalization and socialization during one to one in room visits 1-3 times week and Follow infection control procedures in coordination with nursing. The care plan was not resident centered as it did not correlate with the likes on the activities assessment. Cross Reference F679 4b) On 9/21/22 at 7:39 AM observation was made of Resident #34 lying in bed with bilateral 1/2 side rails up. Review of the medical revealed there was not a care plan for side rails. On 9/22/22 at 7:40 AM GNA #27 was interviewed and asked if the side rails were always up when in Resident #34 was in bed and she said, yes, because [he/she] is a fall's risk and they are always up. Cross Reference F700 4c) On 9/21/22 at 9:20 AM observation was made of Resident #34 in a 45-degree angle in bed with the over the bed tray table in front of the resident. There was scrapple with scrambled egg on top of toast. The butter was not opened and the jelly was not opened. There was a regular plastic cup on the tray, no lid that was sideways and empty. The silverware was still in the plastic sleeve. The resident was pointing to something that the surveyor did not understand. At that time the surveyor asked GNA #57 if she was assigned to the resident. GNA #57 stated she wasn't but she asked what she could do for the resident. The surveyor asked if the resident used utensils and she said yes. She came in the room and got the utensils out of the package and cut the resident's food up. A second observation was made of Resident #34 on 9/21/22 at 10:49 AM. Resident #34 was still in bed, was not wearing TED stockings (support hose as ordered by physician) and was in a hospital gown. The resident's hair was desheveled and the resident had overgrown facial hair. The resident's fingernails were also long. Review of Resident #34's care plan, has an ADL (activities of daily living) self-care performance deficit r/t Dementia, Impaired balance, Limited Mobility had the interventions, check nail length and trim and clean on bath day and as necessary. The care plan was not followed. The care plan was not resident centered as it did not state how often the resident should be shaved. The care plan did not state the feeding assistance required or anything about cuting food up for the resident. Review of physician's orders documented, pt. to utilize [NAME] cup during meals daily as tolerated that was written on 1/28/22 and Staff assist with all meals. The [NAME] Cup is a lightweight, easy-to-grip adapted drinking cup designed to prevent spills. Use of the Kennedy cup and staff assist with all meals was not included in the care plan. 5) On 9/11/22 at 10:03 AM Resident #49's medical record was reviewed and revealed Resident #49 started Hospice care on 8/7/21. A hospice care plan was created on 9/13/22, which was 13 months after entering hospice. There were only 2 interventions, Assist [name] with any ADL needed and notify [name] of any changes to condition. 6a) On 9/14/22 at 11:06 AM a review of Resident #62's medical record was conducted and revealed Resident #62 had the diagnosis of Alzheimer's disease, senile degeneration of the brain and unspecified dementia with behavioral disturbance. Further review of the medical record revealed Resident #62 wore a wanderguard for wandering beginning in April 2022. A 8/29/22 nursing progress note documented, resident had episodes of wandering. Review of care plans for Resident #62 failed to produce a care plan for wandering. 6b) On 9/12/22 at 10:40 AM an interview was conducted with Resident #62's responsible party (RP). The RP stated, we go once a week each to visit. When I come [he/she] is usually sitting in a chair by the nurse's station. [He/She] is either in [his/her] room asleep in a chair or by the nurse's station. The residents are bored to death. [He/she] worked [his/her] whole life and to do nothing just drives [him/her] crazy. Review of Resident #62's care plans failed to produce evidence that an activities care plan was created for Resident #62. 6c) On 9/12/22 at 10:40 AM Resident #62's responsible party (RP) stated she has been requesting Resident #62 to be seen by dental since admission because his/her dentures did not fit right. A 6/3/22 communication with family note documented, eats well even without [his/her] dentures. A 9/9/22 at 14:37 (2:37 PM) nursing progress note documented, Daughter in to visit during lunch time. Daughter asked for resident to be seen by a dentist due to [his/her] dentures not fitting well and resident unable to eat [his/her] lunch with them in. [name] is aware and gave order for resident to have a dental consult done. Review of care plans for Resident #62 failed to produce a care plan related to dentures. 6d) Continued review of Resident #62's care plans revealed the care plan, has a nutritional problem r/t significant weight change, poor PO intake, in the setting of Alzheimers/dementia with the intervention, provide, serve diet as ordered. Monitor intake and record q (every) meal. Review of GNA tasks for the amount eaten for September 2022 was blank for day/breakfast shift and day/lunch shift on 9/1, 9/2, 9/3, 9/5-9/11, 9/13-9/17, 9/19, 9/20, 9/25 and 9/26/22. For the evening/dinner shift the tasks were blank for 9/1, 9/2, 9/10, 9/11, 9/16, 9/17 and 9/24/22. The care plan was not followed. 7) On 9/26/22 at 11:15 AM a record review was conducted for Resident #107. Resident #107 was admitted in May 2021 with diagnoses that included, but were not limited to, nontraumatic subarachnoid hemorrhage from intracranial artery, cerebral infarction due to occlusion or stenosis of left middle cerebral artery and acute respiratory failure. On 9/26/22 at 11:15 AM a review of complaint MD00170005 for Resident #107 was conducted. The complainant alleged the staff were not providing appropriate care for Resident #107 and that the resident only had 1 shower since admission to the facility in May of 2021. The resident was discharged from the facility on 9/23/21. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #107's admission MDS with an assessment reference date of 5/29/21, Section G, documented the resident was totally dependent on staff for personal hygiene, bathing, dressing and toileting. Review of Resident #107's activities of daily living (ADL) care plan documented the problem as, the resident has an ADL self-care performance deficit that was initiated on 7/14/21 with 1 intervention, requires mechanical lift with assistance of 2 staff for transfers that was initiated on 7/29/21. The care plan failed to include all ADL care that staff would have a need to know in order to properly take care of Resident #107. Furthermore, the care plan was initiated 8 weeks after admission and the intervention was added 10 weeks after admission. 9) Depakote is one of the first generation of a class of medications called antiepileptic drugs. Depakote is used to treat complex partial seizures, simple and complex absence seizures, as well as acute manic symptoms in patients with bipolar disorder. During an observation of Resident #1 on 09/11/22 at 9:50 AM, Resident #1 was observed lying in bed apparently talking with someone. Resident #1 was cursing, yelling, and pulling off his/her clothing. There were no family or staff members present in the room. A review of Resident #1's medical record on 09/11/22 revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: diabetes, abnormal posture, macular degeneration, hypertension and dysphagia oral phase. A review of Resident #1's medical record on 09/21/22 revealed Resident #1 was receiving the following antiseizure medication, Depakote, 125 mg., orally, twice daily, for the indication of dementia with behaviors. Further review of Resident #1's medical record failed to reveal a care plan to address a plan, goals, and nursing interventions to address Resident #1's behaviors and possible side effects of the medication. 8) On 9/12/22 at 2:14 PM, Resident #141 was not observed in his/her room and the GNA (Staff #51) revealed the resident was at dialysis. Resident #141's medical record was reviewed on 9/16/22 at 8:15 AM. Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's medical records revealed the resident was diagnosed to have acute renal failure and was receiving hemodialysis three times per week. Review of Resident #141's care plan revealed the plan of care was initiated on 9/7/22 by a Healthcare Virtual Assistant (Staff #78). Review of the resident's care plan did not address care and services related to acute renal failure and scheduled hemodialysis three times per week. On 09/16/22 at 9:03 AM an interview was conducted with the nursing home administrator. She provided information related to the Healthcare Virtual Assistant (HVA). She indicated that the HVA does not meet with the resident or family and the HVA is utilized for paper compliance. She was informed, the resident's care plan was not developed to reflect a resident person-centered care plan due to the omission of care and services for acute renal failure and scheduled hemodialysis.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8) During an interview with Resident #36's spouse on 9/11/22 at 10:39 AM, the spouse stated Resident #36 was lying on the bed all day without any interactions. The spouse also mentioned, there was no television either. A review of Resident #36's medical record revealed that Resident #36 was admitted to the facility in July 2022 for s/p (status post) recent fall. Also, the resident had a diagnosis of dementia. On 9/13/22 around 10:00 AM, the surveyor observed that Resident #36 was sitting in the wheelchair by his/herself in the room. A second observation on 9/14/22 around 11:00 AM, the resident was sitting in the wheelchair with the spouse at the activity area near the Wye Oak nursing station watching television. On 9/16/22 at 12:45 PM, the surveyor reviewed Resident #36's medical record related to the resident's activities. The review revealed no documentation regarding Resident #36's activities. The surveyor tried to interview activity staff. However, two other surveyors confirmed that activity assist (staff #27) left the parking lot at 10:30 AM on 9/16/22. On 9/16/22 at 1:40 PM, Resident #58 reported his/her concerns related to the lack of activities staff. Resident #58 stated that Staff #27 resigned this morning (9/16/22). During an interview with the Interim Director of Nursing (DON) on 9/28/22 at 1:30 PM, the surveyor asked about Resident #36's activities. The Interim DON confirmed that the facility did not have any supportive evidence that the facility provided individual or group activities for the resident. Based on interview, observation, and medical record review, it was determined the facility failed to implement an ongoing program of activities based on the abilities, interests and treatment needs of residents that resided in the facility. This was evident for 5 (#34, #62, #36, #5, #45) of 7 residents reviewed for activities and 2 (#9, #63) of 17 residents observed on the Homestead Unit, however affected all residents in the facility. This was evident during the annual survey. The findings include: 1) On 9/13/22 at 12:51 PM an interview was conducted with Staff #3. Staff #3 was asked about activities at the facility. Staff #3 stated, [name], who was the activities director just left 2 weeks ago. He was trying but now there are only 2 activity aides here. He was trying to do things with them, doing crafts and movies. The issue was being given money. There is no budget to do things with the residents. 2) On 9/16/22 at 9:30 AM Staff #27, (activities assistant) was interviewed and stated she had been employed at the facility since June 2022. Staff #27 stated, we do not have a director and the other full timer is suspended pending investigation. Staff #27 stated, no activities happened yesterday. We don't have a budget to do things, like to buy arts and crafts supplies. At the end of the month if there is money left over we get it. The most we spent in a month was $100. We don't have money to have parties like we used to. We can do birthdays and we will go out and buy things with our own money, but we aren't supposed to spend our own money, but if we don't then who will. We try to have activities on the dementia unit. I will go back there to see how it is going and because they are understaffed they can't get people out of bed and they turn me away. If there are people back there we will paint, have bingo, and make bracelets. I have tried to do movies but the DVD player is broke. I'll hand out candy and I paint their nails. I will do 1:1 visits with people but can't do a 1:1 activity. Activities really don't start until 10:30 AM. I don't do logs for 1:1 visits. 3) Observation was made on 9/20/22 at 4:20 PM of Resident #34 lying in bed. In the resident's room to the right of the bed was a television (tv) that was flipped over and lying on its face, the screen. On top of the back of the tv was a French fry and TED stockings (supportive hose). There was a soiled diaper on the floor in front of the closet. There also was a spoon on plastic lying on the floor next to 1 french fry. The curtain was pulled so the resident did not have anything to look at, no activities, no tv on, no radio, just lying in bed staring at the privacy curtain that was pulled in front of the bed and the side walls. A second observation was made on 9/21/22 at 7:39 AM of Resident #34 sleeping in bed. There was a bottle of cleaner spray on the floor. The tv was face down on the table and there was a cup, plate, spoon, and TED stockings lying on the top of the tv. The privacy curtain was pulled in the front of the bed so the resident could not see his/her roommate. At 10:49 AM Resident #34 was in bed and at 12:09 PM Resident #34 was in bed. The tv was not on, there was no radio and there were no books or magazines. At 12:53 PM the resident was out of bed, dressed and sitting in a wheelchair in the dining area with other residents. On 9/21/22 at 4:30 PM a review of Resident #34's medical record revealed an activities assessment that was done on 1/20/22. The assessment documented Resident #34 preferred 1:1 activity/visit, liked to watch tv/movies, and liked to watch football. The assessment documented it was somewhat important to go outside to get fresh air when the weather was good; do favorite activities; keep up with the news; listen to music the resident likes and have snacks available between meals. An activities comprehensive assessment dated [DATE] documented the same likes with the changes, do my favorite activities; go outside to get fresh air when the weather is good; somewhat important to have snacks available between meals; choose bedtime; listen to music that likes; keep up with the news. 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 #34's care plan, independent/dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t (if dependent) Physical Limitations that was created on 1/21/22 by an activities aide and revised on 2/10/22 by the healthcare virtual assistant (HVA) documented a goal, will participate in activities of choice 1-3 times weekly. Interventions included, Encourage verbalization and socialization during one to one in room visits 1-3 times week and Follow infection control procedures in coordination with nursing. The care plan was not resident centered as it did not correlate with the likes on the activities assessment. On 9/21/22 at 5:00 PM the surveyor requested the Nursing Home Administrator (NHA) to accompany the surveyor to visit Resident #34. The surveyor showed the NHA the resident's room along with observing the resident. The NHA was shown the overturned TV with the items on top and how the screen was lying flat on the table. The NHA stated, I told maintenance to take care of that. At that time the surveyor informed the NHA about the resident not having any activities and being in the room in silence. 4) On 9/12/22 at 10:40 AM an interview was conducted with Resident #62's responsible party (RP). The RP stated, we go once a week each to visit. When I come [he/she] is usually sitting in a chair by the nurse's station. [He/She] is either in [his/her] room asleep in a chair or by the nurse's station. The residents are bored to death. [He/she] worked [his/her] whole life and to do nothing just drives [him/her] crazy. On 9/14/22 at 11:55 AM a medical record review was conducted for Resident #62 who was admitted to the facility in April 2022 with diagnoses that included, but were not limited to, Alzheimer's disease, senile degeneration of the brain, and unspecified dementia with behavioral disturbance. On 9/14/22 at 1:48 PM observation was made of Resident #62 wandering around the locked dementia unit. Resident #62 was following the aide into the nourishment room. In addition to Resident #62, other residents were also wandering around the unit. There were no activities occurring in the unit. Further observations of Resident #62 revealed nurses had the resident sit at the nurse's station or in a chair in front of the nurse's station. Review of Resident #62's care plans failed to produce evidence that an activities care plan was created for Resident #62. There were no activity notes documented in Resident #62's medical record. 5) On 9/14/22 at 2:03 PM Resident #9 went into another resident's room and was going through the resident's closet while the resident was yelling at Resident #9 telling him/her that he/she was rude. The nurse and the GNA were on the COVID unit at that time. The resident was yelling at Resident #9, what are you doing? Resident #9 wheeled him/herself out of the room and went into rooms #320, #322, and across the hall. There were still no activities happening in the unit and no staff to intervene in the behaviors. 6) On 9/15/22 at 10:45 AM one the of GNAs was trying to find an activity for Resident #63 because the resident kept attempting to stand from the wheelchair. There were no formal activities for any of the residents in the Homestead unit. 7) On 9/15/22 at 10:46 AM GNA #12 was interviewed and stated it was probably her fourth time on the Homestead (dementia) unit. GNA #12 was from an agency. She stated, there are no organized activities back here. They used to but they don't do much back here anymore. I do feel bad for the residents because they are on the lockdown unit and these people should be able to do a lot more activities because it is only these hallways. Like [name] is very OCD and it would be nice to give him a big board and something to help calm his behavior. I have worked in a lot of other facilities where there are activities and there really is nothing happening here. 9) Activities refer to any endeavor, other than routine ADL's, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. In an interview with Resident #5 on 09/12/22 at 1:58 PM, Resident #5 stated that the activities in the facility do not meet his/her needs. Resident #5 stated that she/he is young. A review of Resident #5's medical record on 09/14/22 revealed that Resident #5 was admitted to the facility on [DATE] and suffers from a stroke with left-sided weakness, diabetes, neuropathy, obesity, Atrial fibrillation, and a valve replacement. Resident #5 is dependent upon the facility staff for several aspects of his/her care including transfers, bed mobility, toilet use/incontinence care, and personal hygiene. A review of Resident #5's medical record on 09/20/22 revealed a 08/23/21 initiated care plan indicating Resident #5 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physician limitations. The goal of the care plan was that Resident #5 will attend/participate in activities of choice 3 times monthly by the next review date (09/20/22). Staff interventions included: Activity staff will offer 1:1 room activities if Resident #5 is unable to attend out of room events, Activity staff will remind Resident #5 of upcoming activity events and provide him with a monthly activity calendar, ensure that the activities Resident #5 is participating in are compatible with physical and mental capabilities, follow infection control procedures in coordination with nursing, It is important for me to have family or a close friend involved in discussion about my care, Resident #5 needs assistance to activity functions, Resident #5's preferred activities are talking on his cell phone and using it to search the web, reading articles, watching TV, tempt your taste buds, coffee cart, in room visits and special events. Further review of Resident #5's medical record failed to reveal any activity staff progress notes/documentation since 2021. In an interview with staff member #28 on 09/19/22 at 12:09 PM, staff member #28 stated that the activity staff do not know where to document 1:1 visits that the activity staff held with a resident. The activity staff do not have access to a resident's electronic medical record and the activity staff do not write any type of activity progress notes on paper. 2) In an interview with Resident #45 on 09/13/22 at 2:33 PM, Resident #45 stated that he/she would like to do more activities, especially outside of the room activities Resident #45 was admitted to the facility in December 2011 with diagnoses that include but are not limited to traumatic brain injury, quadriplegia, peg tube insertion, seizures, suprapubic catheter, dysphagia, and contractures in the extremities. Resident #45 is totally dependent upon the facility staff for all aspects of his/her care. Resident #45 had a Brief Interview for Mental Status (BIMS) assessment, conducted by a facility staff member, on 05/11/22 and 07/28/22 during the quarterly review process. Resident #45 was assessed to have a 15/15 score during both quarterly assessments. A score of 13 to 15 suggests the resident is cognitively intact. A review of Resident #45's care plans on 09/13/22 revealed a 08/18/21 initiated care plan indicating Resident #45 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physician limitations. The goal of the care plan was that Resident #45 will attend/participate in activities of choice 1-3 times weekly by the next review date (11/26/22). Staff interventions included: Activity staff will offer 1:1 room activities if Resident #5 is unable to attend out of room events, Activity staff will remind Resident #45 of upcoming activity events and provide him with a monthly calendar, ensure that the activities Resident #45 is participating in are compatible with physical capabilities, follow infection control procedures in coordination with nursing, Resident #45 needs assistance/escort to activity functions, Resident #45's preferred activities are listening to music, communicating with friends and family via IPAD, watching TV, reminiscing, and playing games on his tablet. Further review of Resident #45's medical record failed to reveal any activity staff progress notes/documentation. Further review of Resident #45's medical record failed to reveal any activity staff progress notes/documentation since August 2021. In an interview with staff member #28 on 09/19/22 at 12:09 PM, staff member #28 stated that the activity staff do not know where to document 1:1 visits that the activity staff held with a resident. The activity staff do not have access to a resident's electronic medical record and the activity staff do not write any type of activity progress notes on paper.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0680 (Tag F0680)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation it was determined the facility failed to have an activities program that was directed by a qualified professional. This was evident during the 14 days the surveyors were onsite for the annual survey and had the potential to affect all residents. The findings include: On 9/13/22 at 12:51 PM an interview was conducted with Staff #3 who stated the facility was without an activity's director. Staff #3 stated the activities director had left and the replacement just left 2 weeks ago. He was trying to do things with them, doing crafts and movies. The issue was being given money to do things with the residents. There is no budget. Now there are only 2 activity aides here. On 9/16/22 at 9:30 AM an interview was conducted with Staff #27, an activities assistant, who stated she had been employed at the facility since June 2022. Staff #27 stated, we do not have a director and the other full timer is suspended pending investigation. Staff #27 stated, no activities happened yesterday. Staff #27 stated, When I came, I didn't have a director so there was no direction, and I haven't been trained. I have asked to go to other facilities to be trained and I don't get any help. When [name] was here there was a calendar, and I am going off that, but he is gone. He has been gone about 3 weeks. When I came there was 1 activity a day if that. Staff #27 stated that the Nursing Home Administrator (NHA) knew but didn't have time to talk to the activity staff. Staff #27 stated, I am being thrown out there, I don't know anything, and they are giving me all of these responsibilities. Observations were made throughout the survey, from 9/11/22 to 9/28/22 that there were no organized activities. On a few occasions there were approximately 2 to 4 residents that met in the dining area and did a small activity. There were no organized activities on the Homestead unit (secure dementia unit). Cross reference F679 Discussed with the Interim Director of Nursing on 9/28/22 at 12:15 PM.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9) During an investigation of complaint MD00175354, it was revealed that Resident #58 submitted concerns to OHCQ about low staffing. The submitted complaint included the resident's brief had not been changed from 1/15/22 till the evening shift on 1/16/22. On 9/23/22 at 9:00 AM, the surveyor requested a copy of the actual working staff and employee punch report from 1/15/22 to 1/17/22. At 12:30 PM on 9/23/22, the Nursing Home Administrator (NHA) brought a copy of the employee punch report and stated the facility did not have an actual nursing staff list for January 2022 . Also, she confirmed that the facility used employee punch reports for the agency nursing staff's attendance. On 9/23/22 at 12:42 PM, the NHA reported the facility census: 110 on 1/15/22, 109 on 1/16/22, and 109 on 1/17/22. On 9/23/22 at 3:30 PM, the surveyor reviewed the GNAs task report on January 2022 for Resident #58. The report included data for Resident #58's Activities of Daily Living (dressing, eating, locomotion off unit, locomotion on unit, personal hygiene, toilet use, incontinence bowel, transferring, bathing, ambulation, bed mobility, walk in room, walk in corridor, and incontinence bladder). However, there was no documentation on Resident #58's GNA task report from 1/13/22 to 1/18/22 to support the facility GNA's provided care to the resident. During an interview with the interim Director of Nursing (DON) on 9/28/22 at 1:30 PM, the surveyor discussed the low staffing issue in January 2022. Based on documentation review, resident, family and staff interview, observation, and review of Resident Council meeting minutes, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 9 of 22 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, 10 (#30, #65, #64, #38, #20, #58, #19, #88, #44, #45) of 10 interviewable residents, 2 (#62, #34) of 3 family interviews conducted, multiple observations, 3 of 3 resident council meeting minutes reviewed and review of staffing schedules and employee time punches. This deficient practice had the potential to affect all residents. The findings include: 1) Nine out of twenty-two complaints that the Office of Health Care Quality (OHCQ) received and reviewed on this survey alleged the facility did not having sufficient nursing staff to provide essential care to the residents that resided at the facility. Complaints consisted of geriatric nursing assistants (GNAs) having 20 to 30 residents to take care of during any given shift. There were concerns that the residents were not receiving timely care and not receiving showers, that residents on the dementia unit (Homestead) were placed in double diapers. 2) Review of the Resident Census and Conditions CMS 672 form that was completed by the Interim Director of Nursing during the annual survey indicated that 82 of the 88 residents in the facility were either totally dependent on nursing staff for toileting or required the assistance of one or two nursing staff for assistance with toilet use. It was also documented that 85 of the 88 residents in the building were dependent on staff for bathing, 83 residents were totally dependent or required assistance of 1 to 2 staff for dressing, 78 residents required assistance for transferring and 58 of the 88 residents were either totally dependent or required assistance of 1 or 2 staff members for eating. There were 77 residents documented with occasional or frequent incontinence of the bladder and 70 residents documented with occasional or frequent incontinence of the bowel. 3) Resident interviews: 3a) On 9/11/22 at 8:40 AM Resident #58 was interviewed and stated, there is low staff especially on Fridays and Monday mornings. One nurse worked 3 days straight, never went home. 3b) On 9/11/22 08:56 AM an interview was conducted with Resident #65 who stated, they are short staffed. There are long wait times when you call for staff. 3c) On 9/11/22 at 9:50 AM Resident #38 stated that it takes a long time to get help. 3d) On 9/11/22 at 10:02 AM Resident #64 complained of long call bell wait times to the surveyor. Resident #64 stated, I am miserable all the time. I need something for anxiety. 3e) On 9/11/22 Resident #20 stated there was a lack of help/staffing. Medications are not given on time. The resident stated that yesterday, he/she got their 8 AM medications at 3:15 PM. Resident #20 stated that call bell wait times were 3 to 4 hours long. Resident #20 stated, I need assistance getting up. There is no staff to help me. 3f) On 9/11/22 at 11:16 AM Resident #88 stated, one woman was here for 24 hrs. Resident #88 did not know her name. Resident #88 stated, the staffing shortage is ridiculous. Resident #88 stated that he/she had not gotten his/her medications on occasion and repeated that staff were at the facility for a long time and another person was there for 18 hours. Resident #88 stated, the biggest problem is staffing. 3g) On 9/11/22 at 11:19 AM Resident #19 stated, staff do not show up for work. They come and don't do any work. We put call bells on, but they don't come. Sometimes it may take up to 4 hours. I need to go home to a different Rehab. 3h) On 9/12/22 an interview was conducted with Resident #30. Resident #30 complained, always low staff, took forever to receive care. They (staff), not doing their job, nobody cared about residents, blame game each other (staff). 3i) On 9/12/22 at 12:42 PM Resident #44 stated, they are overworked and underpaid. Not enough staff. 3j) On 9/13/22 02:30 PM Resident #45 stated, it takes staff a long time to answer my call bell. 4) Staff Interviews: 4a) On 9/13/22 at 7:40 AM an interview was conducted with Staff #18 who worked part time. When asked about staffing Staff #18 stated, when we have 2 Geriatric Nursing Assistants (GNAs) on the 11:00 PM to 7:00 AM shift it is doable. When we have 1 GNA it is hard because we have to watch Resident #62, one resident defecates on sheets and smears it all over all night long and when the aide is in there cleaning up and I have a resident out here who falls, and I need help getting them up or someone else needs something. Staff #18 stated, I also have to go on the COVID unit with 5 people and I have an IV back there. On the 3:00 PM to 11:00 PM shift we always need 2 GNAs. We have had 1. I was told to watch Resident #62. I have to be creative with Resident #62 to keep [him/her] in my sight while I do things. Staff #18 stated, there are no activities on 3-11. Sometimes when we come on duty there are 5 people up and the rest are in bed for their nap. What is the point in getting everyone else up when you have to watch Resident #62. We also have another resident that attempts to go in the pantry, so you have to watch him. 4b) On 9/13/22 at 7:50 AM Staff #14 stated, I have the COVID unit. I pass my meds over here, watch Resident #62, the door buzzer, answer the phones, and feeders. On the COVID unit they feel isolated, so you have to spend extra time over there. Activities is sporadic during the day. Staff #14 stated, it is a lot because yesterday in the corner of the dining room Resident #62 pulled his/her pants down and had a BM, there were feeders, and taking care of COVID residents who are isolated. Staff #14 stated that Resident #62 was on 1:1 observation while awake due to behaviors yesterday, however the resident was sitting on the side of the bed eating breakfast and there was no one else in his room. Staff #14 stated, I am keeping an eye on [him/her] because they have not sent /anyone back to sit with [him/her], and I do not have a med aide today, so I have to pass all the meds today. 4c) On 9/13/22 at 8:24 AM an interview was conducted with Staff #17 (agency staff). Staff #17 was asked about staffing and stated, treatments don't get done, patients are not getting the proper care. The GNA's not doing rounds effectively. On my shift 11-7, the GNA's tell me about the dates on the dressings. There are 1 to 2 GNAs at night. Two is doable, but 1 GNA for 29 patients is not and that happens 3 out of 4 nights per week. On 9/13/22 at 8:39 AM an interview was conducted with Staff #88 who stated there was a common complaint that residents were desperate for a shower or therapy. They have gone through several administrators. The wait to get changed is a common complaint. 4d) On 9/13/22 at 12:00 PM Staff #26 also stated that there were no activities, nothing for the residents to do. She stated, we are short staffed, and I worked by myself 2 Sundays ago and had 18 residents. We don't have supplies and the nurses are doing 2 wings on 3-11 and 11-7. 4e) On 9/13/22 at 12:51 PM an interview was conducted with Staff #3 who stated, Yes, I have staffing concerns in the facility, lack of staff nursing, GNA's. Basic care not getting done. Getting a lot of complaints from staff and residents and I send to administration and the response is will look into it. When asked if she feels they will look into it she stated, no. She said, there is no guidance for nursing. Staff #3 stated the current interim DON was the regional nurse and was not full time. I don't know who is heading the nursing department. They do work with 1 GNA on the unit. I have not helped with bedside care, maybe meal trays. I hear call bells ringing a long time. 4f) On 9/13/22 at 2:20 PM an interview was conducted with Staff #49, the nursing scheduler. Staff #49 went through the schedule on the computer with the surveyor to show how to tell who actually worked. Staff #49 had only been at the facility for 1 month. Staff #49 stated that prior to her coming a lot of nursing supervisors left and it has been a struggle to keep the schedule full. She did confirm that a nurse worked 24 hours straight because another nurse failed to show up and she didn't have anyone to give her keys to. 4g) On 9/15/22 at 1:50 PM Staff #12 stated, I have 4 residents on the COVID unit and 6 residents on the Homestead unit. It is a lot because the 6 residents on the Homestead unit are total care and 2 residents on the COVID are total care. I still have to get to the COVID unit to do the 2 residents over there. It is hard because I have to help pass trays, watch the resident that keeps trying to stand out of the wheelchair and the one resident that keeps peeing on the floor and the man in the wheelchair keeps yelling help. We got him up today because his bottom was sore. Someone also called out over here today. 4h) On 9/16/22 at 9:15 AM a conversation was held with the Nursing Home Administrator (NHA). Staffing on the Homestead unit was discussed and the NHA was informed of all the observations the surveyor had made. The NHA stated they were meeting the 3.0 Patient Per Day hours (a state requirement for staffing levels). The surveyor informed the NHA that the federal staffing regulation was not being met because the needs of the residents were not being met. 4i) On 9/27/22 at 1:17 PM an interview was conducted with Staff #7. I have seen double diapering because day shift brought it to my attention. This was back in March 2022. Staffing was awful 3-11, 11-7 throughout. GNA's were doing double shifts. There were 1 or 2 nurses for the whole building. The schedules don't reflect that. There were times there was only had 1 aide. One night there were multiple callouts. We all came together to help for 3-11 shift. The med pass was late and routine meds were not given. Staffing is a little better because Mill Landing is closed and there are not as many on Homestead. 5) Family and Resident Responsible Party (RP) Interviews: 5a) On 9/12/22 at 10:44 AM Resident #62's RP was asked if she had any staffing concerns. The RP stated, if there is 1 person at the front desk of the Homestead unit it is a good day. If there are 2 it is shocking. There is always someone new there. [Resident #62] is never changed out of [his/her] clothes. We will know what [Resident #62] is wearing when we leave and in the same outfit when we come back. They don't bathe, encourage to brush teeth, and don't put [him/her] in pjs. My brother will when he visits. 5b) On 9/14/22 at 10:44 AM Resident #34's responsible party (RP) stated, I am very disappointed in the facility. We are attempting to get [Resident #34] moved. [Facility name] is not responsive at all. Have never scheduled a care plan meeting and [Resident #34 has been there since January. The RP stated that Resident #34 should be clean shaven. There is always food on [him/her]. 6) Observations: On 9/13/22 at 12:00 PM observation was made in the Homestead nursing unit, which housed residents with cognitive impairments that required a secure, safe unit. Resident #9 was in a wheelchair and was trying to push the doors open to the COVID unit. GNA #26 was passing lunch trays and could not answer the call bell that was going off in the COVID unit. On 9/14/22 at 12:09 PM a male resident walked into the nourishment room on the Homestead unit that was not locked. He came out at 12:12 PM. Meanwhile, Resident #9 was trying to get into the covid unit via wheelchair. The male resident drank an ensure that he got out of the nourishment room and then was looking through the food cart that was delivered on the unit and still sitting in the hallway. On 9/14/22 at 12:24 PM Resident #9 went through the double doors onto the COVID unit and in the hallway. Staff had to get the resident out of the unit. At 12:27 PM Resident #9 opened the COVID unit doors again and got in the unit, and the doors closed behind him/her. Resident #9 made it down the hallway until staff could get him/her out. There were 2 GNAs on the unit, 1 for a 1:1 for Resident #62. The nurse was walking a family member to the door and working with the physician, and the other GNA was attempting to pass lunch trays. Resident #9 was constantly moving around the unit via wheelchair by self-propelling with his/her feet. In addition, the phone was ringing while the surveyor was sitting at the nurse's station observing activity on the unit. While sitting at the nurse's station observing the unit, the call bell was ringing in room [ROOM NUMBER], the room of a new admission, from 12:35 PM to 12:52 PM, which was 17 minutes. Resident #9, at 12:36 PM came out of the COVID unit. The surveyor missed seeing the resident enter the unit. At 12:43 PM Resident #9 opened the COVID unit doors again but turned around. At 12:54 PM Resident #9 opened the COVID unit doors. At 12:57 PM Resident #9 was eating a roll and managed to go through the doors of the COVID unit and made it halfway down the hall. The doors were closed to resident rooms on the unit. Resident #9 was in the hallway for 2 minutes until staff got him/her out of the unit. At 12:59 PM a resident was coughing in the dining area. There were no staff in the dining area at that time. At 1:48 PM there were residents wandering on the unit. Resident #62 followed an aide into the pantry while Resident #9 was grabbing gloves off a medication cart. The phone was ringing, and a visitor wanted to be let out of the unit via the secure door. A code was needed to get off the unit, therefore staff had to open the door. The unit had just received a new admission. There were no activities at that time on the unit. On 9/14/22 at 2:03 PM Resident #9 went into another resident's room and was going through the resident's closet while the resident was yelling at Resident #9 telling him/her that he/she was rude. The nurse and the GNA were on the COVID unit at that time. The resident was yelling at Resident #9, what are you doing? Resident #9 wheeled him/herself out of the room and into room [ROOM NUMBER], #322, and across the hall. There were still no activities happening in the unit and no staff to intervene in the behaviors. On 9/15/22 from 10:10 AM until 10:41 AM (31 minutes) the call bell was ringing in room [ROOM NUMBER] in the Homestead unit. There were only 3 residents up and there were no activities. At 10:28 AM a male resident helped himself to apple juice from the drink cart. From 10:44 AM to 11:15 AM (31 minutes) the call bell was ringing in room [ROOM NUMBER]. At 10:45 AM one the of GNAs was trying to find an activity for Resident #62 because the resident kept attempting to stand from the wheelchair. On 9/15/22 at 11:48 AM on the Homestead unit the lunch trays were delivered in the food truck. There was 1 GNA on break and there were 2 call bells ringing, of which (1) was on the COVID unit. The secured doorbell was also ringing at the same time. Staff started passing lunch trays at 12:01 PM. On 9/21/22 at 12:11 PM observation was made in the Homestead unit of Resident #11 sitting on other side of dining room table adjacent to where his/her breakfast tray was still sitting on the table. Resident #11 was still in a hospital gown. The meal cart was in the unit. There were only 3 residents up. The Admissions Director was on the unit helping to pass lunch trays at 12:15 PM. The resident census was 17 and there was no one on the COVID unit since Friday 9/16/22. 7) A review of the Resident Council minutes from the past three meetings (08/30/22, 08/05/22, 07/26/22) on 09/13/22 at 10:18 AM revealed continued complaints of a lack of staffing in the facility. The Resident Council documented the following unresolved issues: 08/30/22 - Poor staffing is still an issue, but it is mainly an issue on the weekends. 08/05/22 - The social worker is too busy to be involved in the resident's needs. 07/26/22 - Poor staffing is still an ongoing issue. Residents are not bathed or getting showers. Obtaining assistance from nursing assistants is still an ongoing issue. During the Resident Council meeting held on 09/13/22 at 10:18 AM, the residents complained of still not getting showers, staff will answer a resident's call light and then leave the room and never come back to assist the resident. 8) In an interview with Resident #5 on 09/11/22 at 10:40 AM, Resident #5 stated that the facility is short-staffed. During the week you may have 1 to 2 staff members between 30 residents, but on the weekends it is worse. Resident #5 stated that he/she has not received a shower in 2 months and that the administrator is not willing to listen to the residents. A review of Resident #5's medical record on 09/14/22 revealed that Resident #5 suffers from a stroke, left-sided weakness, diabetes, neuropathy, obesity, Atrial fibrillation, and a valve replacement. Resident #5 is dependent upon the facility staff for several aspects of care including transfers, bed mobility, toilet use/incontinence care, and personal hygiene. In a follow-up interview with Resident #5 on 09/23/22 at 4:10 PM, Resident #5 stated that he/she called for his nursing assistant for assistance at 10 AM this morning due to needing incontinence care. Resident #5 stated that she/he did not receive incontinence care until just before noon. Cross reference F 684

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected most or all residents

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Based on review of employee files and interview, it was determined that the facility failed to put a system in place to ensure Geriatric Nursing Assistant's (GNA's) were competent with their skills sets. This was found to be evident for 3 out of 3 GNA (GNA #37, #44 and #45) employee files reviewed for competencies and skill sets. The findings include: On 9/20/22 at 9:32 AM a review of GNA employee files were conducted for GNA #37, #44 and #45. The review of employee files did not reveal documentation that indicated the GNA's had completed their competency skills and techniques to safely provide care to the residents. During an interview conducted on 9/20/220 at 11:26 AM, Staff #20, (Director of Human Resources) stated, I have not seen any yearly reviews since I have been here. I have not seen evidence of yearly evaluations or training. They did not have anything in place. On 9/20/22 at 11:38 AM an interview was conducted with the Nursing Home Administrator (NHA), the Interim Director of Nursing (DON) and Staff #7. The Interim DON stated, we do not have a Staff Developer. We had a DON and ADON and 2 managers. She stated they had a DON from June 6, 2022 to August 31, 2022 and they hired an ADON in the middle of August 2022 that only lasted for 2 weeks. She said she knew everything about what to do and then she quit. Now we have hired a new DON that is starting in 2 weeks and we are in the process for interviewing and recruiting for an ADON. The Interim DON stated, with the nursing shortage most of the GNAs are all agency. All GNAs are certified. Yearly performance reviews are supposed to be done but they are not being done. We don't have a lot of regular staff. The interim DON confirmed that competency skills and techniques were not done.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected most or all residents

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Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 3 out of 3 personnel files (GNA 337, #44, #45) reviewed during the annual survey. The findings include: A review was conducted of GNA personnel files on 9/20/22 at 9:32 AM. A review of GNA #37's personnel file revealed GNA #37 was hired on 8/4/21. A review of GNA #44's personnel file revealed GNA #44 was hired on 9/14/20. A review of GNA #45's personnel file revealed GNA #45 was hired on 4/21/20. On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources and the Business Office Manager. Staff #20 stated, I have not seen any yearly reviews since I have been here. I have not seen any evidence of yearly evaluations. They did not have anything in place. On 9/20/22 at 11:38 AM an interview was conducted with the Nursing Home Administrator (NHA), the Interim Director of Nursing (DON) and Staff #7. The Interim DON stated, we do not have a Staff Developer. We had a DON and ADON and 2 managers. She stated they had a DON from June 6, 2022 to August 31, 2022 and they hired an ADON in the middle of August 2022 that only lasted for 2 weeks. She said she knew everything about what to do and then she quit. Now we have hired a new DON that is starting in 2 weeks and we are in the process for interviewing and recruiting for an ADON. The Interim DON stated, with the nursing shortage most of the GNAs are all agency. All GNAs are certified. Yearly performance reviews are supposed to be done but they are not being done. We don't have a lot of regular staff.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0741 (Tag F0741)

Could have caused harm · This affected most or all residents

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Based on interview and reviews of administrative documents, it was determined that the facility failed to ensure that nursing staff received and completed minimum training for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. This had the potential to affect all residents. The findings include: On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources and the Business Office Manager. Staff #20 stated, So right now there is nothing for existing staff on yearly training related to dementia management. Staff #20 stated that Corporate should have a training program and different modules for training throughout the year. I have not set it up yet. I just did my yearly set-up at [name of sister facility]. It is in modules, and I know how I want to set it up. They did not have anything in place here. Staff #20 stated, when hiring nursing assistants and nurses, I have a check off list that I have. They get a new hire packet and they turn in the tests before they start. Included in the new hire packet was abuse prevention and reporting, resident rights and facility responsibilities, HIPAA security and compliance and ethics. There was nothing about dementia training or caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. On 9/20/22 at 11:38 AM an interview was conducted with the Nursing Home Administrator (NHA), the Interim Director of Nursing (DON) and Staff #7. The Interim DON stated, we do not have a Staff Developer.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility staff failed to discard expired medications and biologicals: 6) On 9/11/22 at 7:28AM observation was made of the medication room located on the Mill Landing Way nursing unit. The following items were found to be expired: (64) Curad Oil Emulsion Dressings, Lot #01978, expired on 1/2022 (5) EZ Swab Collection (BD), Lot# 211196600128E20, expired on 8/31/2022 (11) Foam Heel Dressings ([NAME]), Lot #170721, expired on 8/2022 (10) CVP Dressing Trays (Medline), Lot #2020070990, expired on 6/30/2022 Dressing Change Kit (Wolf-Pak) Lot # 200353910, expired on 10/31/2021 Coenzyme Q-10 200mg Lot # 358799, expired on 10/2021 Opsite dressing 10 x14 cm ([NAME]/Nephew) Lot # 1429, expired on 7/2019 Ocular Vitamins (Geri-Care) Lot #357896631062, expired on 7/2022 Acetaminophen (MHL) 650 mg. Lot #359204, expired on 3/2022 (2) Centrum Silver MVI, Lot # DY7573, expired on 5/2022 Assure Control Solution (Glucometer) Lot#021621A, expired on 5/6/22 AD&E Ointment Lot #2312220, expired on 5/2022 3% Hydrogen Peroxide 16 fl. oz. Lot #0468463, expired on 3/20/22 Dakin's Solution 16 fl. oz. Lot #6722, expired on 7/2022 Milk of Magnesia Lot #XMR038, expired on 4/2022 On 9/11/22 at 8:45 AM an interview was conducted with RN #4 who confirmed the findings. 7) On 9/11/22 at 8:49 AM observation was made in the Wye Oak nursing unit medication room of the medication room refrigerator. There were no temperatures documented on the temperature log, the thermometer was broken, and it was written on the temperature log thermometer broke. There was a large amount of ice build-up observed in the freezer. The following medications and supplies were observed expired: Flucticasone Propionate Nasal Spray (Health A2Z) Lot # RR6978, expired on 4/2022 Assure Dose Control Solution (Glucometer) Lot# 021621A, expired on 6/5/2022 AD&E Cream (Gentell) Lot # 231220, expired on 5/2022 Opened Foley Catheter Insertion Trays (Medline) Lot # 96920030002(Unsterile due to being open on shelf) Sodium Bicarbonate 325 mg. (Graxell) Lot # 0820011, expired on 8/2022 Opened Ureteral Catheter Tray (AMSINO) Lot # 156304KS, expired on 9/20/2023 (Unsterile due to container open on shelf) (2) Ocular Vitamins (Geri Care), Lot #631T01, expired on 7/2022 (24) Lemon Glycerin swabs, (Medline) Lot # 61219070024 expired on 7/2022 Acetaminophen 650 mg. Lot # 359204, expired on 3/2022 Thiamin B-1 100mg (Geri Care) Lot #851S09, expired on 8/2022 Calcium 600 +D 5mcg (Geri Care) Lot #747S02, expired on 5/2022 Dakin's Solution 16fl oz. Lot # 6722, expired on 7/2022 Magnesium Citrate 10fl oz. Lot # CJ12339, expired on 6/2022 Povidone Iodine 8fl oz. Lot # MDGK02-01, expired on 8/2022 On 9/11/22 at 9:40 AM an interview was conducted with Certified Medication Assistant (CMA) #6 and LPN# 7. Both staff members verified the findings. 8) On 9/11/22 at 9:44 AM observation was made of the medication room located on the Chesapeake nursing unit: The medication room door was observed ajar and unlocked. The following medications and biologicals were observed expired: Dakin's Solution 16fl oz. (Century Pharmaceuticals) Lot # 6722, expired on 7/2022 Dakin's Solution 16fl oz. (Century Pharmaceuticals) Lot # 6601, expired on 2/2022 Povidone Solution 8fl oz. (Medline) Lot # 196JA138, expired on 6/2021 (2) Povidone Solution 8fl oz. ([NAME]) Lot # MDGK02-01, expired on 8/2022 Pro-Stat AWC (Nutricia) 30 fl. oz. Lot # B211557, expired on 7/15/2022 Pro-Stat AWC (Nutricia) 30 fl. oz. Lot # B212427, expired on 8/27/2022 Pro-Stat AWC (Nutricia) 30 fl. oz. Lot # B211591, expired on 8/19/2022 Sentry Senior MVI Lot # 14360400, expired on 6/2022 Aspirin 325 mg. bottle opened by staff and dated 1/18/2021, Lot # P120438, expired on 5/2022. On 09/11/22 at 10:27 AM an interview was conducted with CMA #8 who confirmed the findings. 9) On 9/11/22 at 11:30 AM observation was made of the medication cart #1 on the Mill Landing nursing Unit located in the alcove across from the nurse's station. The following was observed: Albuterol Sulfate 90 mcg., with no date that the container was opened by staff. Moxifloxacin Ophthalmic 0.5%, no date when staff opened. Timolol Maleate eye drops for glaucoma, opened on 7/30/2022 (per manufacturer Discard the eye drops 4 weeks after opening). Resident #35 was discharged from the facility on 9/8/2022 and the medications were still in the cart. Nitroglycerin 0.4 mg. Lot # FA7774, expired on 2/2024, but contained no open date by staff on vial. According to the National Library of Medicine, Nitroglycerin is a volatile substance which evaporates from tablets if strict precautions are not taken. The tablets kept in small, amber, tightly capped glass bottles in a refrigerator maintain their potency for three to five months if bottles are opened once a week. After five months the unused tablets should be discarded. Fluphenazine 125mg./5ml., Lot #2102145.1, vial opened 7/27/2022. Per the manufacturer's storage instructions, the vial should be dated and discarded within 28 days of opening. Nitroglycerin 0.4 mg. Lot# 410726, vial opened with no date when opened by staff. Tuberculin Purified Lot # C5994AA, not refrigerated (open vial with no date when opened by staff, per package it stated should remain refrigerated. The vial was not refrigerated.) Pro-Stat Lot # B210020 expired 4/6/2022 (Dated opened by staff on 8/30/2022). 10) On 9/11/22 at 10:30 AM an inspection of the medication cart #2 located on the [NAME] nursing Unit that was in the alcove across from the nurse's station revealed the following: Novolog Flex Pen noted in top drawer of cart labeled opened on 8/3/22 with an expiration date of 9/3/22. Pro-Stat Liquid Lot# 212427, expired on 8/2022 On 9/11/22 at 10:44 AM, expired medications were reviewed with RN #14 who confirmed the findings. 11) On 9/12/22 at 8:45 AM an inspection of Medication Cart #3 on the Chesapeake nursing unit revealed the following expired and/or non-dated medications: Pro-Stat Lot # B212454, expires 9/24/2022, No date opened by staff on container noted. Citroma (Mag Citrate) Lot # 0546395, expires 9/20/2023, current Resident #45, still receiving medication, 30 ml. every 2 days. No date opened by staff noted on bottle. According to NIH (National Institute of Health), mag citrate should be discarded within 24 hours of being opened. Ellipta S/N # 0173-0873-10 Expiration date unable to view due to sticker covering box. No date when box was opened. Per manufacturer Ellipta the medication should be thrown away 6 weeks after opening the foil tray. 12) On 9/11/22 at 11:21 AM observation was made of an unlocked and unattended medication cart located outside of room [ROOM NUMBER]. The resident's door was closed. Upon exiting the room, RN #7, was asked if s/he knew the medication cart was unlocked. RN #7 stated I was just in the room, I left the door open, the GNA (Geriatric Nursing Assistant) shut the door. 13) On 9/12/22 at 10:15 AM observation was made of an unlocked and unattended medication cart sitting in the alcove area with 2 residents observed sitting directly adjacent to the unlocked cart. The surveyor remained at the cart until the nurse returned. CMA #22 was asked if she knew the medication cart was unlocked. CMA #22 stated I thought I locked it, I'm agency and today is my first day I'm sorry. 14) On 9/13/22 at 7:27 AM, (2) Surveyors reviewed the narcotic section and the narcotic logbook that was in the medication cart located on the Mill Landing unit. There was a new narcotic signature sheet that revealed only one (1) nurse signed the shift change narcotic count for the 11PM-7AM shift (night shift). Interview with LPN #15 was asked by surveyors why the count sheet only documented one (1) signature for the 11PM-7 AM shift narcotic count. LPN #15 replied The on-coming nurse counted with me but was pulled off the unit to staff another area and refused to sign the narcotic count sheet because she was moved to another unit (Chesapeake Unit). I signed in the 3 PM-11PM shift then, and since I also worked the 11PM to 7 AM night shift, I double signed the record because there is no other nurse to sign with me, then in the morning I will sign off with the day shift nurse on 7 AM-3 PM. The Administrator was informed of concerns on 9/13/22. Based on observation, staff interview, and documentation review it was determined that facility staff failed to 1) keep medication and treatment carts locked when unattended, 2) discard expired medications and patient supplies, 3) maintain medication room refrigerators and freezers and monitor temperatures, 4) date medication and biologicals when opened, and 5) maintain narcotic medication reconciliation records. This was evident on 4 of 4 nursing units observed during random observations made during the annual survey. The findings include: Facility staff failed to lock medication and treatment carts when unattended: This was a repeat citation from a complaint survey that ended on 3/9/22. 1) On 9/11/22 at 7:15 AM, upon entry to the facility, observation was made of an unlocked medication and treatment cart in the 200 hallway, and an unlocked medication cart in the 100 hallway. By the time the surveyor walked back through the hallways, after finding someone who could assist the surveyors, the carts had been locked. 2) On 9/13/22 at 7:59 AM observation was made on the Homestead unit of the medication cart that was sitting next to the nursing station. The cart was unlocked and unattended. The surveyor opened the top drawer and observed scissors, insulin pens, a glucometer, and 25 capsules of piroxicam 10 mg. Registered Nurse (RN) #14 walked over and the surveyor informed her the cart was unlocked and asked her if the night shift left it unlocked. RN #14 stated, no, we did narcotic count. I forgot to lock it. There were no residents in the area at that time. 3) On 9/13/22 at 12:00 PM observation was made of an unlocked medication cart sitting in front of the COVID unit. Staff #26 was in the vicinity and as the surveyor approached, RN #14 walked over and locked the cart. 4) On 9/14/22 at 2:12 PM to 2:19 PM Medication cart 2 was left unlocked while RN #14 went back to the COVID unit. A resident walked over to the med cart and then walked away. The surveyor walked over to medication cart and opened the top drawer and observed 3 insulin pens and Tylenol. The second, third and fourth drawers were opened and displayed resident medications. RN #14 was informed at 2:20 PM of the unlocked medication cart and she said, I can't believe I did that. During the observation there was an aide sitting at the nurse's station with the surveyor. 5) On 9/14/22 at 2:40 PM a request was made for the medication storage policy from the Nursing Home Administrator (NHA). The surveyor received the medication storage policy from the NHA on 9/15/22 at 9:10 AM. Number 1, General Guidelines, documented, a. all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). b. only authorized personnel will have access to the keys to locked compartments. On 9/16/22 at 9:15 AM the NHA was informed of the observations of the unlocked medication carts. On 9/28/22 at 5:30 PM an interview was conducted with the Medical Director and the interim Director of Nursing (DON) regard quality assurance (QA) activities related to the repeat deficiency of unlocked medication carts. The Medical Director and interim DON stated, it is reported on by pharmacist, when regional visits. We had an Adhoc QA meeting and the NHA and I completed the audits. The other NHA did not print the audits and put in the binder and I have not monitored. That was brought up with other surveys, follow-up audits were supposed to be done and I do not know if they were brought back to QA.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of complaint MD00177291 on 09/11/22 at 7 AM, revealed an allegation that the morning breakfast meals were cold and not palatable. In an interview with Resident #20 on 09/11/22 at 9:50 AM, Resident #20 stated that the food quality was poor. In an interview with Resident #23 on 09/11/22 at 10:06 AM, Resident #23 stated that the food was fair and that there are good and bad days. Resident #23 stated that facility does not serve enough different types of sugar free beverages for residents that have diabetes. In an interview with Resident #44 at 09/12/22 at 12:46 PM, Resident #44 stated that he/she does not like the food. Resident #44 went on to say that the food is to brittle to eat, over salted, hard to chew, and not nourishing. In an interview with the facility Resident Council on 09/13/22 at 10:18 AM, the residents complained that they do not receive water/pitchers of ice water at the bedside unless you ask for it. The residents also complained that they have not been given a list of foods and beverages available to them on a 24/7 basis. A review of 3 previous Resident Council minutes, 08/30/22, 08/05/22, and 07/26/22, revealed that resident food complaints were a common monthly issue. In a breakfast test tray observation on 09/23/22 at 9:09 AM, the breakfast meal was determined to be cold and did not hold temperature. Based on resident interviews, and observations of the kitchen services with the testing of a food tray, it was determined that the facility failed to serve food at a preferable/palatable temperature. Food complaints and concerns were identified for 09 (#16, #19, #20, #23, #44, #58, #75, #87, #141) of 24 residents selected in the final sample and a failed test tray was identified on the unit that was served last. This had the potential to affect all residents. The findings included: Upon initiation of the survey on 9/11/22 random food complaints from residents included: Interview of Resident #58 at 8:28 AM was asked about the food and responded, the milk tastes sour, some days the food is cold and somedays it's hot. At 10:05 AM Resident #43 stated the food is terrible; not enough food to eat. At 10:06 AM Resident #23 indicated the food, is fair some days it's bad. At 10:45 AM Resident #16 indicated food is bad and Resident #75 indicated the meals were bad and not hot with cold eggs and toast. At 11:15 AM, during an interview with Resident #19, revealed food is served cold and the portions are small. Introduction interviews continued on 9/12/22. Resident #141 was interviewed at 9:20 AM with indication, the food is served cold. Resident # 20 responded at 11:44 AM, Food is poor. Resident #44 at 12:46 PM revealed, I do not like the food, brittle to eat, over salted, hard to chew, not nourishing. Review of the resident council meeting minutes for a meeting held on 7/26/22 revealed old business concerns of poor food quality (primarily lack of consistent schedule and food temperature. The minutes did not reveal an administrative response to the poor food quality concern. On 9/13/22 at 10:00 AM an interview with 4 resident council members revealed, food quality had not improved. On 9/23/22 at 7:15 AM breakfast meal service observations were initiated in the kitchen. Per a handwritten note that was posted near the kitchen tray line indicated, the breakfast tray line was to begin at 7:20 AM. At 7:30 AM dietary staff began to take and record food temperatures and had to place some pans of food back into a steamer/oven to raise the temperature of the food. The tray line began at 7:40 AM. Review of the breakfast menu revealed 2 ounces (oz) of scrambled egg, 2 oz. turkey sausage patty, 1 slice of toast, and cereal of choice. The bread did not look toasted as the bread was white. A [NAME] brand thermometer was calibrated in an ice water bath at 8:05 AM. A test tray was requested to the Certified Dietary Manger (staff #61) and was placed on the food cart at 8:20 AM. The cart arrived on the Chesapeake unit at 8:25 AM. Initially only one nursing assistant passed out food trays. It was noted that a separate, open aired cart had an assortment of juices in clear plastic pitchers without any ice and insulated carafes of coffee with plastic coffee mugs and plastic juice cups. The orange juice appeared to have settled and some staff assisting with the delivery of breakfast and beverage would try to swirl the pitcher prior to pouring. The surveyor waited until the last resident tray was delivered prior to temperature check of the test tray. The test tray was removed from the cart at 9:11 AM. The meal was tested with the dietary manager (staff #61). The scrambled egg temperature was 100 degrees Fahrenheit (F.), turkey sausage was 98 degrees F., and the requested cup of apple juice was tempted at 60 degrees and a cup of coffee was checked to be 82 degrees. The eggs and sausage were tasted and were cold on the palate. The dietary manager acknowledged that the white piece of bread did not look like toast. At 9:15 AM Resident #43 was eating breakfast at the table closest to the nursing station and was asked about his/her breakfast. Resident #43 stated it was not good, it was cold, but the girls can heat it up if I ask. Resident #43 indicated that he/she did not want it heated as the food would be rubbery after heating in the microwave. Additionally, Resident #87 was also eating breakfast and indicated his/her breakfast was cold, including the coffee.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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3) On 9/13/22 at 12:01 PM observation was made in the pantry/nourishment room of the Homestead unit of the ice machine. The ice machine was empty. Staff #26 was in the nourishment room at the time and the, the ice machine is broke and we have to leave the unit to go to the kitchen to get ice and bring it back to the unit. The machine has been broken for a while. It was also noted that the front of the refrigerator in the nourishment room was rusted. Based on observation, interviews of facility staff, and documentation review, it was determined that food service employees failed to ensure that sanitary practices were followed, equipment was maintained, and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice had the potential to affect all residents. This was evident during the initial tour of the facility kitchen and nourishment rooms while conducting the annual survey. The findings include: 1) On 09/11/22 at 7:30 AM a tour of the facility's main kitchen was conducted with the facility's Assistant Food Service Manager (Staff #58). Upon entering the kitchen, observations of the kitchen floor revealed free standing water that covered the kitchen entrance and was observed leaking under the door of the storage room located near the front door. The kitchen floor lacked signage notifying staff and vendors that the floor was wet. No staff members were actively attempting to dry the floor or wipe up the water. In an interview with Staff #58 on 09/11/22 at 7:35 AM, Staff #58 stated that 2 of the kitchen sinks were currently clogged and backup onto the kitchen floor if the water was allowed to run into the drain. Observations of the general kitchen ice machine revealed a heavy buildup of dirt and mold on the ice machine lid. The ice machine was functioning and making ice cubes. Observations of the large kitchen refrigerator revealed 12 sandwiches that lacked a date when they were created, 4 pitchers of what appeared to be juice also lacked a date they were created, and 6 bowls of pudding were observed on a tray that also lacked a date when they were created. A wheelchair armrest was also observed under one of the kitchen sinks. A wheelchair was not observed in the kitchen area. In an interview with the facility assistant maintenance director staff #11 on 09/11/22 at 8:50 AM, staff #11 stated that she/he was aware that 2 of the kitchen sink drains were clogged. Staff #11 stated that the local plumbing vendor was coming back on Monday to fix the 2 kitchen sink drains. Staff #11 stated that there was also a water leak behind the 3 compartment sink in the dish room. Staff #11 also stated that the plumbing vendor was here last week to fix the clogged kitchen grease trap. Staff #11 stated that the facility has a monthly plumbing contract that services the building. The assistant maintenance director #11 stated that she/he reports to the facility administrator. In an interview with the facility administrator on 09/11/22 at 9:05 AM, the facility administrator confirmed that he/she was the facility person who authorizes repair work in the facility. The facility administrator stated that he/she was not aware of a problem with a grease trap or an issue with flooding in the kitchen. The facility administrator also stated that the Local Health Department was not currently aware of an issue in the facility kitchen, nor has he/she seen any flooding in the kitchen. The facility administrator stated that he/she saw some water on the floor and confirmed the facility dish washer system was functioning. 2) An environmental kitchen food service inspection was conducted in the facility's kitchen on 09/16/22 at 2:15 PM. The lunchtime dishwashing service was concluding at the time of the observation. The certified dietary manager (staff #61) was asked to restart the dishwashing machine and run trays through the machine. Observations of the temperature gauge for the hot water wash temperature remained at 140 degrees Fahrenheit (F.) as she placed multiple trays to run through the machine. A sign on the wall above the dishwashing machine indicated the minimum hot water wash temp was 160 degrees F. and the minimum rinse temperature was 180 degrees. The signage was very concise, instructing staff to inform a manager if the minimum hot water temperatures were not archived. During the observation, the wash water temperature did not rise above 140 degrees F. The Dietary Manager revealed that the repair vendor for the dishwashing machine (Ecolab) was at the facility earlier in the day to service the dishwasher. The certified dietary manager was asked to show the dishwashing machine temperature logs. The log was kept in her office. The log shown was a daily sheet for all temperatures titled Food temp logs, 3 Comp sink, and Walk-in Temps. There was a place to record dishwasher temperatures for the water temperature of the wash and sanitize for Breakfast, Lunch, and Dinner. The wash temperature for the breakfast service was documented as 180 and the Sanitize(rinse) level was 189. There was not any documentation for the wash and rinse temperatures for the lunchtime service. A review of the log for 9/15/22 showed that the wash and sanitize water temperatures for breakfast were both 140 degrees F. The lunchtime hot water temperatures were both documented as 140 degrees F. There was not any documentation for the dinner time wash and sanitize water temperatures. A review of the log for 9/14/22 did not reveal any dishwashing machine water temperatures for all three mealtimes. The dietary manager made copies of the documents per request. The facility failed to ensure that minimum dishwashing water temperatures were maintained for proper sanitation of the dishware.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected most or all residents

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Based on interview, observation and record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively in order to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by failing to 1) ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, and ensure the nursing staff had training which included dementia training and yearly in-service training; 2) ensure the food served to residents was palatable and served at the correct temperatures, 3) ensure there was an ongoing program to support residents in their choice of activities along with having an activities director to lead the program, and 4) ensure that the facility had a qualified social worker who was available to meet the individual needs of the residents. This was evident during the annual survey and had the potential to affect all residents. The findings include: 1) Facility administration failed to ensure there was enough staff available to ensure that the residents that were currently residing in the facility had their needs met daily. Surveyors entered the facility unannounced on Sunday, 9/11/22 at 7:00 AM. During the screening process at the beginning of the survey 10 of 10 residents that were interviewed complained about lack of nursing staff. Two of 3 family interviews conducted revealed staffing concerns, and review of 3 of 3 resident council meeting minutes revealed staffing concerns. Some of the concerns expressed by residents were long wait times once the call bell was activated and that it took a long time to get help. Some resident complaints stated wait times could be 3 to 4 hours long. Resident complaints included not receiving medications on time and taking forever to receive care. There were several complaints from residents stating that the call bells were not working, and in some cases hand call bells were given to residents. On 9/13/22 at 8:39 AM an interview was conducted with Staff #88 who stated, call bells have been an issue since July. People act like they don't know the call bells are broken. In an interview with the facility assistant maintenance man, Staff #11 on 09/11/22 at 8:50 AM, Staff #11 stated that there were many call bell units that were broken in resident rooms. Staff #11 stated that he does not have parts to fix all the broken call bell units and that the call bells break every day. Staff #11 stated that he will use call bell unit parts from other resident rooms that are not occupied. Staff #11 stated that the facility administrator is aware of the broken resident rooms call bell issue and that there was no current plan or contract to fix the call bell system at this time that he was aware of. Staff at the facility verbalized staffing concerns stating that basic care was not being done. Staff stated that resident behaviors on the Homestead unit were time consuming and when they had to deal with the increased behaviors with limited staff, it was hard. In addition, the staff on the Homestead unit also were responsible for the residents on the COVID-19 unit. Staff stated that since those residents were on isolation, when staff went on that unit it took longer due to isolation precautions and the residents wanted someone to talk to since they were in isolation. Staff stated that treatments were not being done and the residents were not getting the proper care. Staff stated that 1 GNA for 29 patients was not doable and, that happens 3 out of 4 nights per week. A common complaint was that residents were desperate for a shower or therapy. Staff stated the facility has gone through several administrators and had a staff walkout a couple of months ago that was in the paper. The wait to get changed is a common complaint. Staff #3 stated she received a lot of complaints from staff and residents and that the Nursing Home Administrator was informed, and the response was, will look into it. When asked if she feels they will look into it, she stated, no. On 9/16/22 at 9:15 AM a conversation was held with the Nursing Home Administrator (NHA). Staffing on the Homestead unit was discussed and the NHA was informed of all the observations the surveyor had made. The NHA stated they were meeting the 3.0 PPD hours. The surveyor informed the NHA that the federal staffing regulation was not being met because the needs of the residents were not being met. The 3.0 PPD hours was a minimum standard for the state requirement, not the federal requirement. Cross Reference F725 2) The facility failed to ensure nursing staff competencies, yearly training, and new employee orientation were being done. On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources, and the Business Office Manager. Staff #20 stated, I have not seen any yearly reviews since I have been here. I have not seen any evidence of yearly evaluations. They did not have anything in place. Staff #20 was asked about in-service training and she stated, only for new hires is there abuse training. Right now, there is nothing for existing staff on yearly training related to abuse and dementia management. Staff #20 stated, Corporate should have a training program. Different modules for abuse training throughout the year. I have not set it up yet. I just did my yearly set-up at [name of sister facility]. It is in modules, and I know how I want to set it up. They did not have anything in place here. On 9/20/22 at 11:38 AM an interview was conducted with the Nursing Home Administrator (NHA), Interim Director of Nursing (DON), and Staff #7. They said, we do not have a Staff Developer. They stated the process of training and competencies, never evolved because the ADON was only at the facility for a week. We do not have any competencies on nurses and GNAs. The Interim DON stated, yearly performance reviews are supposed to be done. We don't have a lot of regular staff. I have not tracked making sure everyone is getting the 12 hours of training. On 9/28/22 at 5:30 PM, during a quality assurance interview, the interim DON and Medical Director stated, training has not been discussed in QA. The DON stated, I identified the lack of training and new employee orientation. As of 9/28/22 nothing had been put in place to correct the deficient practice. Cross Reference F943 and F947 3) Concerns were expressed to the surveyors from residents that the food was served cold and was not good. The interim DON and MD stated that they did QA the food and, it is much better than what it was, but it isn't where it should be. The MD stated that the previous Nursing Home Administrator (NHA) brought in test trays every week to sample. The previous NHA has not been at the facility since May 31, 2022. There has not been any more documented follow up related to the food. Review of the resident council meeting minutes for a meeting held on 7/26/22 revealed old business concerns of poor food quality (primarily lack of consistent schedule and food temperature). The minutes did not reveal an administrative response to the poor food quality concern. On 9/13/22 at 10:00 AM an interview with 4 resident council members revealed, food quality had not improved. Facility administration knew about the food quality and failed to develop an action plan to address the concerns. Cross Reference F804 4) The facility failed to have an activities program that was directed by a qualified professional. On 9/16/22 at 9:30 AM Staff #27, (activities assistant) was interviewed and stated she had been employed at the facility since June 2022. There was no activity director at that time. On 9/13/22 at 12:51 PM an interview was conducted with Staff #3 who stated the facility was without an activity's director. Staff #3 stated the activities director had left and the replacement just left 2 weeks ago. He was trying to do things with them, doing crafts and movies. The issue was being given money to do things with the residents. There is no budget. Now there are only 2 activity aides here. Several observations were made on the Homestead (dementia) unit. No activities occurred on the unit and was corroborated by staff. Administration was aware of the lack of activities, however an action plan was not in place. Cross Reference F679, F680 and F725 5) Facility administration failed to provide needed social work: During the Resident Council interview that occurred on 09/13/2022 at 10:18 AM, the active Resident Council members complained that there was not a fulltime social worker in the facility and that the current social worker did nothing for the residents and did not answer resident or family member phone calls. On 9/13/22 at 12:51 PM an interview was conducted with Staff #3, Social work Director, who stated, I am here 2 days a week. Staff #3 was asked if she was able to get all the social service assessments done. Her response was, I try, I try to do 50%. I am here Tuesdays and Fridays. Staff #3 stated she was also providing social services at another (sister) facility. Staff #3 stated, I thought I could handle both places. When Staff #3 was asked if she attended Quality Assurance meetings she stated, I do not attend because they are not held on days that I am here. Staff #3 was asked, what kind of interaction do you have with resident-to-resident interactions? Staff #3 stated, I have not been involved with any of that. I would think I should be, but I don't know if it is because I am not here every day. Staff #3 stated, I try to hit the important stuff. I probably miss a good portion of what I am supposed to do. Facility Administration was aware that the Social Worker was splitting her time between 2 of the same corporately owned buildings. Administration was aware as the social worker could not attend monthly quality assurance meetings, however the practice continued of only having part time social work at the facility. Concerns discussed with Administration during the Quality Assurance interview and at the exit conference on 9/28/22 at 8:15 PM.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

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Based on review of facility records and interview with staff, it was determined the facility failed to conduct and document an accurate/current facility-wide assessment that was up to date. This was evident during the review of the sufficient and competent nurse staffing task of the annual survey and the extended survey. This had the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. A copy of the Facility Assessment was provided at the initiation of the survey. The Date of the assessment or Update was Change of Leadership 9/20/21. Date assessment reviewed with QAA/QAPI (Quality Assessment and Assurance/ Quality Assurance and Performance Improvement committee) was documented 10/2021. On 9/28/22 at 5:30 PM an interview was conducted with the QA Director, which was the Interim Director of Nursing and the Medical Director. The Medical Director stated, it was reviewed at least 2 years ago. I brought a copy from the other facility, and I told administration to please prepare and send to me and we would review as a group. When I came back a month later, [name of previous NHA] showed me the most updated plan. I think I would have recalled that it was reviewed. There was a discussion about a plan. I would remember if it was reviewed. It was not reviewed last year. Review of the Facility Assessment (FA) revealed out of the 17 people that completed the assessment, only 2 remained at the facility along with the governing body. On page 5 of the assessment there was nothing about possible elopements from the facility or the use of a secured unit and wander guards for elopement risk residents. On page 6 of the assessment under infectious diseases, it did not list COVID-19. On page 7 of the assessment under special treatments and conditions, there was nothing about the quarantine of new admissions for COVID-19 surveillance and anyone with symptoms along with the need for constant screening and testing for COVID-19. The special treatments and conditions documented on pages 7 and 8 was compared to the Resident Census and Conditions that was provided to the surveyors upon admission to the facility on 9/11/22. There was an increase in oxygen therapy, IV medications, injections, dialysis, ostomy care and isolation or quarantine for active infectious disease. Assistance with activities of daily living (ADL) had increased in all categories such as dressing, bathing, transfer, eating, toileting, and mobility. Continued review of the Facility Assessment revealed the staffing plan was documented on page 12. The staffing plan did not mention Certified Medicine Aides (CMA) which the facility currently used. The staffing plan did not mention the overwhelming use of agency staff. The staffing plan documented a need for 1 RN supervisor for evenings and nights 7 days a week and for an Assistant Director of Nursing (ADON) and (3) Unit managers. The facility was currently without those staff. On page 13 of the Facility Assessment the plan documented, describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any given time. Consider if and how the degree of fluctuation in the census and acuity levels impact staffing needs. The facility documented (1) full time DON - currently had an interim DON, (1) ADON - currently did not have, (3) unit managers - currently did not have. For other departments in the facility the plan documented, recreation department has (3) FT (full time) staff to coordinate programs, activities and entertainment. The recreation department did not have (3) FT staff. (Cross reference F679 and F680). On page 14 of the Facility Assessment the plan documented under staff training/education and competencies, Additional training in 2020 is ongoing for CDC, CMS and MDDH guidelines regarding COVID. This was not up to date. The facility documented the staff training/education and competencies that were necessary to provide the level and types of support and care needed for the resident population, however, the facility was not doing staff competencies, yearly evaluations, or the minimum of 12 hours of geriatric nursing assistant (GNA) education required per year. The facility assessment did not address the high quantity of agency staff that were utilized daily and the components to provide education/training and/or competencies for all the agency/contractual staffing. The facility did not have a staff developer. Cross Reference F726, F730, F741, F943, F947

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Social Worker (Tag F0850)

Could have caused harm · This affected most or all residents

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Based on written and verbal complaints, reviews of medical health records and staff interview, it was determined the facility failed to obtain a full time social worker when the certified number of beds exceeded 120 in the facility. Currently the facility was licensed for 170 certified beds. This was evident for 1 out of 1 required personnel and had the potential to affect all residents. The findings include: Review of complaint MD00181590 on 09/11/22 revealed an allegation that there was not a full time Social Worker in the facility. During the Resident Council interview that occurred on 09/13/2022 at 10:18 AM, the active Resident Council members complained that there was not a full time social worker in the facility and that the current social worker does nothing for the residents and will not answer resident or family member phone calls. In an interview with the facility social worker on 09/13/22 at 12:51 PM, the facility social worker stated that S/he is the only social worker in the facility and works twice a week on Tuesdays and Fridays. The facility social worker stated that S/he also works full time at another company facility and stated I try to complete 50% of the social history assessments on newly admitted residents. Fridays are completely taken up by care plan meetings. On Fridays, I may have up to 10 scheduled care plan meetings. This only leaves me Tuesdays to assess residents and attend utilization review meetings. There are many times I don't leave the facility until 8 PM. I try to speak with families and accomplish the important stuff like completing MDS assessments. I complete sections C, D, E, Q, and S, on Resident MDS assessments. The facility social worker also stated that S/he was not involved in resident to resident incidents but would make referrals to the facility psych services. The facility social worker also stated that S/he does not have discussions about advance directive, obtaining a powers of attorney, or creating living wills with residents unless asked by staff or residents.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, reviews of facility documentation, resident records, and current survey findings, it was determined that the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) plan to ensure care and services were maintained at acceptable levels of performance and continually improved. The annual survey process resulted in 77 Federal citations with areas of potential systematic concerns identified by the survey process. This had the potential to affect all residents within the facility. The findings include: On 9/28/22 at 5:30 PM an interview was conducted with the Medical Director (MD) and the Interim Director of Nursing (DON) regarding Quality Assurance (QA) activities. The interim DON was responsible for maintaining the QA notes and binder. During the interview the entire survey team was present. The survey team brought up the following concerns to determine if the QA committee was aware of the concerns and if so, what interventions were put into place. 1) Food Concerns were expressed to the surveyors from residents that the food was served cold and was not good. The interim DON and MD stated that they did QA the food and, it is much better than what it was, but it isn't where it should be. The MD stated that the previous Nursing Home Administrator (NHA) brought in test trays every week to sample. The previous NHA has not been at the facility since May 31, 2022. There had not been any more documented follow-up related to the food. Review of the resident council meeting minutes for a meeting held on 7/26/22 revealed old business concerns of poor food quality (primarily lack of consistent schedule and food temperature). The minutes did not reveal an administrative response to the poor food quality concern. On 9/13/22 at 10:00 AM an interview with 4 resident council members revealed, food quality had not improved. A test tray was removed from the food delivery cart on 9/23/22 at 9:11 AM. The meal was tested with the dietary manager #61. The scrambled egg temperature was 100 degrees Fahrenheit (F.), turkey sausage was 98 degrees F., and the requested cup of apple juice was tempted at 60 degrees and a cup of coffee was checked to be 82 degrees. The eggs and sausage were tasted and were cold on the palate. The dietary manager acknowledged that the white piece of bread did not look like toast. Cross Reference F804 The QA committee failed to develop an action plan related to continued food concerns. 2) Environment As the survey progressed there was evidence that non-compliance existed with the environment. The facility staff failed to have a process to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. Observations were made in resident rooms and common living areas of incomplete repairs, rusted table bases, cobwebs, dirt and insects in between window screens and windows. There were stains on ceiling tiles, issues with base molding, lighting, cracked and missing vinyl on resident wheelchair armrest and dirty ceiling vents among other issues and findings. Cross Reference F584 and F921 The interim DON stated, I am so embarrassed. I am just going through the documentation, and I cannot find the QA reports and there is no proof to show that we did QA the environment. EVS (environmental services) typically reports on environmental issues, but there was no specific project. 3) Call bell system not working There were several complaints from residents stating that the call bells were not working, and in some cases hand call bells were given to residents. On 9/13/22 at 8:39 AM an interview was conducted with Staff #88 who stated, call bells have been an issue since July. People act like they don't know the call bells are broken. In an interview with the facility assistant maintenance man, Staff #11 on 09/11/22 at 8:50 AM, Staff #11 stated that there were many call bell units that were broken in resident rooms. Staff #11 stated that he does not have parts to fix all the broken call bell units and that the call bells break every day. Staff #11 stated that he will use call bell unit parts from other resident rooms that are not occupied. Staff #11 stated that the facility administrator is aware of the broken resident rooms call bell issue and that there was no current plan or contract to fix the call bell system at this time that he was aware of. The interim DON and MD stated that call bells had not gone through QA. 4) Physician Notification During the survey it was found that there were issues with facility staff failing to notify the physician of weight loss, pressure ulcer development, a critical lab value, a choking episode with a resident and unplanned weight loss. Cross reference F580 The MD and interim DON stated it was brought up in QA about physician notification, and that nursing was given education and it was felt it improved significantly. The surveyors asked how agency staff were included in the education. The MD stated, that was pushed on to the unit managers, however, we have not had unit managers for a couple of months. We did it once but no people to continue through with it. The MD and interim DON were informed of the continued evidence of noncompliance. 5) Abuse reporting and investigation The facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) and failed to submit the results of the investigation within 5 days. This was evident for 7 of 13 residents reviewed and the facility failed to thoroughly investigate allegations of abuse and neglect. This was evident for 10 of 13 residents reviewed for abuse and neglect. Cross reference F609 and F610 The MD stated, the process has not gone through QA. We always make recommendations to do this and do that and unfortunately, you know. 6) Care plan development, implementation, and evaluation Widespread noncompliance was found by surveyors related to the development and implementation of resident centered care plans. The MD stated, care plans have been an ongoing review when we review charts. Not having a consistent Director of Nursing, Assistant Director of Nursing and unit managers has been an issue. We are aware of the issue with care plans. The QA committee failed to develop an action plan to address the noncompliance related to care plans. 7) Documentation related to activities of daily living and nursing notes Review of resident medical records which included Geriatric Nursing Assistant (GNA) tasks, resident treatment administration records (TAR), and resident assessments, revealed the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. Furthermore, the facility failed to assure the completeness, and accuracy of documentation related to activities of daily living. The GNA's failed to sign off showers, bathing, toileting, turning and repositioning, bed mobility, feeding and dressing. The nurses either failed to sign off treatments were done or signed off those treatments were done when they were observed not done. The MD and interim DON stated that the MDS coordinator would complain about the documentation and the facility would go back to the agency and try to hold their staff accountable. The MD stated, I have noticed, and we have not done a QA process. On a weekly basis I will ask a resident if their needs are being taken care of. It has gotten better with an informal look. We have never done quality assurance on nursing notes. It has been brought up in QA in the midst of the pandemic and the difficulty in getting notes completed. It was not an active QA discussion. Further review of medical records revealed the facility enlisted the services of Healthcare Virtual Assistant Transcription Support services, (HVA) in November 2021. During reviews of resident medical records, it was found that HVA would initiate comprehensive nursing assessments and care plans and there were instances where there was no documentation that the nurses were validating the assessments. The QA committee failed to look at the issue formally and put a plan in place for improvement. Cross Reference F842. 8) Activities The facility failed to have an activities program that was directed by a qualified professional. On 9/16/22 at 9:30 AM Staff #27, (activities assistant) was interviewed and stated she had been employed at the facility since June 2022. There was no activity director at that time. On 9/13/22 at 12:51 PM an interview was conducted with Staff #3 who stated the facility was without an activity's director. Staff #3 stated the activities director had left and the replacement just left 2 weeks ago. He was trying to do things with them, doing crafts and movies. The issue was being given money to do things with the residents. There is no budget. Now there are only 2 activity aides here. Several observations were made on the Homestead (dementia) unit. No activities occurred on the unit which was corroborated by staff. Cross Reference F679, F680 and F725 The MD stated activities had not been addressed in QA and activities for residents with cognitive impairment have not been addressed in QA, even though the facility has been without a qualified activity director for several months. 9) Staffing Based on documentation review, resident, family and staff interview, observation, and review of Resident Council meeting minutes, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 9 of 22 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, 10 of 10 resident interviews, 2 of 3 family interviews conducted, 3 of 3 resident council meeting minutes reviewed and multiple observations. The facility has been dependent on agency staff to fill vacancies in the nursing schedule. Cross Reference F725 The MD and interim DON stated, it has been a topic of discussion. There was no QA plan put in place to address staffing that was presented to surveyors. 10) Staff training and new employee orientation On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources, and the Business Office Manager. Staff #20 stated, I have not seen any yearly reviews since I have been here. I have not seen any evidence of yearly evaluations. They did not have anything in place. Staff #20 was asked about in-service training and she stated, only for new hires is there abuse training. Right now, there is nothing for existing staff on yearly training related to abuse and dementia management. Staff #20 stated, Corporate should have a training program. Different modules for like abuse training throughout the year. I have not set it up yet. I just did my yearly set-up at [name of sister facility]. It is in modules, and I know how I want to set it up. They did not have anything in place here. On 9/20/22 at 11:38 AM an interview was conducted with the Nursing Home Administrator (NHA), Interim Director of Nursing (DON), and Staff #7. They said, we do not have a Staff Developer. They stated the process of training and competencies, never evolved because the ADON was only at the facility for a week. In April [name] was here as ADON and she resigned the first week of August. We do not have any competencies on nurses and GNA's. The Interim DON stated, with the nursing shortage most of them are all agency. Yearly performance reviews are supposed to be done. We don't have a lot of regular staff. I have not tracked making sure everyone is getting the 12 hours of training. The MD and interim DON stated, training has not been discussed in QA. The DON stated, I identified the lack of training and new employee orientation. As of 9/28/22 nothing had been put in place to correct the deficient practice. On 9/28/22 at 8:10 PM during exit interview with the Administrative staff, the surveyors informed the staff there was concern with the QA program.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of resident medical records, review of facility documentation, and interview with facility staff, it was determined that the facility failed to ensure that they developed and maintained an effective infection control program. This was evidenced by 1.) failing to destroy a used COVID-19 kit in the laundry room, 2.) failing to place an order for COVID-19 care/treatment for residents with confirmed COVID-19 infection. This was evident in 1 (Resident #63, #348) of 5 Residents reviewed for the COVID-19 order, 3.) failing to have a system in place to report a positive test for COVID-19 to the local health department. This was evidenced by lack of documentation for COVID-19 line listing from January 2022 to April 2022, 4.) failing to develop a facility policy for Personal Protect Equipment (PPE) during an outbreak in the facility; 5.) failing to ensure the facility provide updated COVID-19 education to staff, 6.) failing to maintain Alcohol Base Hand Rub dispensers and supplies. This was evidenced by 9 out of 41 ABHR dispensers observed without ABHR present, 7.) failed to ensure COVID-19 screening was performed for staff and visitors to entered the facility, 8.) failed to have a system in place to ensure that each resident was evaluated daily to check for COVID-19 symptoms. This was evident for 7 (#29, #36, #38, #58, #63, #141 and #10) of 7 residents reviewed for daily COVID-19 screening, 9.) failing to assess a resident for tuberculosis evidenced by failure to document the results of a two-step tuberculin skin test within 10 days of admission to the nursing home. This was evident for 1 (Resident #141) of 1 new admissions reviewed for tuberculosis and failed to follow infection prevention and control to prevent the spread of infection. These practices had the potential to affect all residents; 10.) failing to date and/or change/discontinued resident oxygen tubing (Resident #10); 11.) failing to store personal items separately from patient items evidence by observation of staff belongings on the clean linen laundry table and in a linen closet; 12.) staff failed to appropriately wear face masks, evident for 3 staff observed during the survey (Staff #41, #93, #94); 13.) failing to date and/or discard Sterile Water used for Inhalation (Resident #78). The findings include: A COVID-19 line listing is a tool that enables a facility to track and monitor residents and staff with COVID-19. It identifies positive tested individuals' names, dates of birth, test results, symptoms, outcomes, and vaccination information. The line listing can also be used to identify outbreaks of COVID-19 in a facility. Alcohol-based hand rub (ABHR) is the preferred approach to prevent healthcare-associated infections in most routine patient encounters, except when handwashing with soap and water is advised. Inappropriate utilization of ABHR could have detrimental effects, most importantly during the coronavirus disease (COVID-19) pandemic, which includes exposure of healthcare professionals to healthcare-associated infections and the development of resistant microorganisms. (National Library of Medicine: National Center for Biotechnology Information) 1) Two surveyors observed the facility laundry room on 9/13/22 at 10:01 AM. There was a stainless stationary shelf on the left side of the folding table. The surveyors observed some curtains, linens, a gallon water bottle with 1/5 remaining water, and an opened allergy medication bottle. Also, a surveyor found a used COVID-19 test kit on the shelf. On 9/13/22 at 10: 05 AM, an interview was conducted with the EVS director (Staff #19) in the laundry room. The surveyor asked about the used COVID-19 test kit on the shelf. Staff #19 immediately threw it away, and he stated it had been left by a staff member who did their self-test and left the kit on the shelf. Staff #19 stated all things on the shelf were not in use and said, we will discard the shelf soon. The Interim Director of Nursing (DON) was informed of the concern on 9/28/22 at 1:30 PM. 2a) The surveyor reviewed a medical record of Resident #63 on 9/21/22 at 11:40 AM. The review of the change in condition report dated 1/10/22 written by a nursing staff member revealed that Resident #63 was diagnosed as COVID-19 positive on 1/10/22. Also, the report included a note under the interventions section, The client is on droplet precaution. Mask will be worn when leaving the room. Aseptic education was given to the client. However, no physician's order was found for Resident #63 regarding COVID-19 care. 2b) The surveyor reviewed the medical records of Resident #348 for a portion of investigating complaint MD00178201, on 9/22/22 at 4:00 PM. The record review revealed that Resident #348 was admitted to the facility in March 2022 and tested positive for COVID-19 on 5/13/22. Further review of the medical records revealed the Change in Condition form completed by nursing staff on 5/13/22 that showed Resident #348 tested positive for COVID-19 on the same day, the physician was notified, and isolation precautions were updated on 5/13/22. Also, the facility's daily COVID-19 evaluation documented the resident tested positive from 5/13/22 to 5/19/22. However, a review of Resident #348's order showed no order for COVID-19 care/treatment. 3) Review of complaint MD00176851 on 9/13/22 at 9:00 AM revealed that the facility had not reported positive COVID-19 cases to the local health department at the beginning of May 2022. On 9/13/22 at 11:00 AM, surveyor requested a copy of COVID-19 line listing from January 2022 to May 2022. The Interim (DON) submitted an electronic version of the COVID-19 line listing files dated 5/11/22, 5/13/22, 5/16/22, 5/19/22, 5/23/22, 5/26/22, 6/7/22, 6/9/22, 7/1/22, 7/7/22, 8/30/22, and 9/11/22 via email on 9/14/22 at 9:57 AM. On 9/14/22 at 10:30 AM, a review of the COVID-19 line listing dated 5/11/22 revealed that the facility had five residents test positive for COVID-19 on 4/30/22, and one resident tested positive on 5/9/22. During a phone interview with an employee at the local health department (Staff #90) on 9/15/22 at 10:07 AM, Staff #90 confirmed the previous facility ADON (Assistant Director of Nursing) called on 5/2/22 and reported the facility had 4 residents test positive for COVID-19 on 4/30/22. Staff #86 stated that even though the local health department discussed testing, infection control, staffing, and guidance to fill out the line listing, the facility had not submitted the COVID-19 line listing until the middle of May 2022. On 9/16/22 at 1:28 PM, the surveyor reviewed randomly selected residents' medical records to verify whether the facility had a COVID-19 outbreak from January 2022 till May 2022. The record review revealed a written progress note, [family member] letting know one of our staff members has tested positive for COVID-19, dated 3/11/22 under Resident #2's and #24's records. Also, further review of Resident #63's medical record revealed that the resident was diagnosed as COVID-19 positive on 1/10/22. The surveyor interviewed the Interim DON on 9/16/22 at 2:07 PM. The interim DON stated since so many DONs and ADONs stayed a short time and left, there was technical difficulty in handing over all COVID-19-related documentation, including line listing and documentation of the COVID-19 outbreak report. She confirmed that there was no documentation for the COVID-19 line listing from January 2022 to May 2022. Also, the interim DON stated that the facility did not have evidence they reported to the local health department related to the COVID-19 outbreak. The surveyor shared concerns about the facility's failure to develop a system of reporting/tracking COVID-19 to the local health department on 9/28/22 at 1:30 PM. 4) During an initial facility tour on 9/11/22 at 7:54 AM, a Geriatric Nurse Aide (GNA) #84 handed an N-95 masks to surveyors at the Wye Oak unit nurse station. GNA #84 explained to surveyors since the facility had an outbreak of COVID-19, all staff needed to wear N-95 masks. Also, GNA #84 confirmed that staff did have surgical masks when they entered the building this morning. On 9/12/22 at 7:07 AM, the surveyor observed GNA #51 wearing a surgical mask at the Mill Landing unit. During an interview with GNA #51 at the time, she stated, we had COVID-19 positive residents last week. They moved to the Homestead unit. I'm not sure they are still in this facility or not. On 9/12/22 at 7:10 AM, the surveyor observed Licensed Practice Nurse (LPN) #30 and Registered Nurse (RN) #16 had surgical masks on while at the Wye Oak nurse station. On 9/12/22 at 9:05 AM, LPN #15 was wearing a surgical mask. An interview was conducted with LPN #15 at that time. LPN #15 said, I understood there is COVID-19 resident in this building. But we have a choice to wear an N-95 or a Surgical mask. We must change the mask to N-95 when we enter the COVID-19 unit. The surveyor requested all the facility's policies for COVID-19 on 9/12/22 at 1:30 PM. The interim DON brought policies: Infection Prevention and Control Program- revised date 7/14/21, COVID-19 testing Guidelines - revised 6/9/22, Antibiotic Stewardship Program - implemented date 7/30/21, and COVID-19 vaccination - revised date 1/10/22. However, none of these policies indicated PPE use during an outbreak of COVID-19 in the facility. This concern was informed to the interim DON on 9/28/22 at 1:30 PM. 5) During an interview with the interim DON (who also had the role of Infection Control Preventionist) on 9/14/22 at 1:55 PM, the interim DON stated the basic infection control education (such as hand hygiene and PPE use) was provided to the newly hired employees during training. Also, the interim DON said the updated COVID-19 Information was sent to all staff via the message system. During the interview, the interim DON confirmed that the messaging system was not trackable. On 9/20/22 at 3:25 PM, the surveyor reviewed the facility's COVID-19 education binder, which the interim DON provided. The review of the education binder showed a training record for the COVID-19 vaccination dated 8/22/21 containing 36 staff signatures who attended. No other training records were found in the binder. At 3:50 PM on 9/20/22, the surveyor interviewed the interim DON and asked how many staff worked in August 2021. The interim DON said, I need to verify it, but more than 36. On 9/28/22 at 1:30 PM, the surveyor informed the interim DON regarding concerns that there was no evidence to support the facility provided updated COVID-19 education to all staff. 6) During the initial tour of the facility on 9/11/22 at 7:30 AM, the surveyor found an Alcohol Based Hand Rub (ABHR) dispenser was broken near the washroom in the Wye Oak unit and three empty ABHR dispensers on the Wye Oak Hall (between room [ROOM NUMBER]-106). Additionally, during the facility tour on 9/13/22 at 8:40 AM, the surveyor found the facility had a total of 41 ABHR dispensers placed on the wall between residents' rooms; 6 were broken, and 3 were empty. During an interview with the EVS director (Staff #19) on 9/14/22 at 8:09 AM, Staff #19 stated that the central supply team ordered the ABHR supplies, and the housekeeper refilled them. The maintenance team would fix the broken dispenser. On 9/14/22 at 11:20 AM, during an interview with GNA #5, also the general supply manager, GNA #5 stated she did not order the ABHR gels, but the EVS team did. On 9/27/22 at 11:29 AM, the surveyor shared the concerns with the interim DON regarding the ABHR issues (broken and/or empty). The DON was unable to identify the person responsible for managing the ABHR supplies but consulted the interim DON. The interim DON stated, EVS would manage the ABHR dispenser and refill. Now Staff #19 also had a maintenance director role. Every ABHR dispenser was fixed. On 9/28/22 around 9 AM, the surveyor found 2 empty ABHR dispensers in the Wye Oak 100 hallway. 7a) When the surveyor team initially entered the building for the survey on 9/11/22 at 7:00 AM, there was no announcement posted for the COVID-19 screening required for any visitors or staff at the main entrance. During the survey period from 9/11/22 to 9/12/22, no announcement was posted for the COVID-19 screening necessary in the facility. On 9/12/22 at 7:40 AM, a surveyor entered the facility without COVID-19 screening through the KIOSK (a tablet for COVID screening questions and temperature check). The surveyor pushed a bell for the door to be opened, the door was opened remotely, allowing access to the conference room without completing the COVID-19 screening. During her entry process, no one reminded or monitored surveyor for COVID-19 screening. During an interview with the interim DON on 9/13/22 at 11:17 AM, the interim DON confirmed that whoever entered the building, regardless of entering time, needed to be screened by the Kiosk. The COVID-19 screening included a temperature check and three yes-no questions: Any signs/symptoms of illness including cough, body aches, chills, fatigue, sore throat, congestion, runny nose, shortness of breath, headaches, loss of taste/smell, nausea/vomiting, diarrhea, Have you been identified as a close contact to someone with COVID-19 or had contact with someone with COVID-19 within the last 14 days, and Have you been fully vaccinated? The interim DON also explained that if anyone entered the facility off hours (8 PM-8 AM: no receptionist attending hours), a shift supervisor would open the door (directly or remotely) for visitors, and the supervisor would require the visitors to do the COVID-19 screening. The surveyor asked how the visitor would know to do COVID-19 screening if the entrance door opened remotely and no announcement was posted for the screening. The interim DON did not add any comments. 7b) During an interview with the Nursing Home Administrator (NHA) on 9/15/22 at 8:39, the NHA stated that the employee punch report was the most accurate documentation to verify who worked on a certain day and time. The NHA explained that the punch report also recorded agency nursing staff's clock-in time. On 9/21/22 at 11:24 AM, the surveyor reviewed the facility's punch report and KIOSK screening report for 9/11/22, 9/12/22, and 9/15/22. On 9/11/22: a total of 34 staff names were listed on the punch report. Among the listed 34 staff, 17 staff screened for COVID-19 via the KIOSK system. On 9/12/22: a total of 40 staff names were listed on the punch report. Among the listed 40 staff, 12 staff had COVID-19 screening records in the KIOSK. On 9/15/22: a total of 37 staff names were listed on the punch report. Among the listed 37 staff, 14 staff were screened for COVID-19 via KIOSK. During an interview with the interim DON on 9/28/22 at 1:30 PM, the surveyor informed the interim DON of concerns that staff were not screened for COVID-19 when entering the facility. 8) On 8/26/22, the State of Maryland Health Secretary issued an Amended Directive and order Regarding Nursing Home Matters (No. 2022-08-26-01). The Amended Directive continues to instruct, Each nursing home resident shall be evaluated daily to check for COVID-19 by the nursing home's clinical staff. 8a) The surveyor reviewed daily COVID-19 evaluations from 9/11/22 to 9/27/22 during the ongoing survey period for randomly selected Residents (#29, #36, #38, #58, #63, and #141) on 9/28/22 at 10:00 AM. The review of records revealed that 6 out of 6 Residents' daily COVID-19 evaluations were not documented under electronic medical record (PCC). i) Resident #29's COVID-19 daily evaluation was not documented on 9/11/22 ii) Resident #36's COVID -19 daily evaluations were not documented on 9/11/22, 9/13/22, 9/14/22, 9/15/22, 9/19/22, 9/23/22, 9/25/22, and 9/27/22. iii) Resident #38's COVID-19 daily evaluations were not documented on 9/11/22, 9/13/22, 9/14/22, 9/15/22, 9/21/22, 9/23/22, and 9/25/22. iv) Resident #58's COVID-19 daily evaluations were not documented on 9/11/22, 9/13/22, 9/14/22, 9/15/22, 9/17/22, 9/18/22, 9/19/22, 9/25/22, and 9/26/22. v) Resident #63's COVID -19 daily evaluations were not documented on 9/11/22, 9/13/22, 9/14/22, 9/15/22, 9/18/22, 9/19/22, and 9/25/22. vi) Resident #141 was admitted to the facility on [DATE]. Resident #141's medical record was reviewed on 9/27/22 for daily COVID-19 evaluations. A Peak COVID-19 evaluation dated 9/7/22 was found not completed as it was labeled in progress by a Healthcare Virtual Assistant. The evaluation was not signed by a facility nurse to show completion of the COVID-19 evaluation. There was no documented COVID-19 evaluations on 9/15, 9/17, 9/18, 9/19, and 9/26/22 for resident #141. 10) On 9/11/22 at 9:26 AM observation was made of a portable oxygen tank on the back of the wheelchair for Resident #10. There was a nasal cannula attached to the oxygen tank. There was no date indicated on the nasal cannula as to when the nasal cannula was attached and/or changed. A nasal cannula consists of a flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils to deliver oxygen. On 9/14/22 at 2:10 PM an interview was conducted with RN #3. RN #3 stated she did not know why the resident had oxygen. The surveyor said, even with the nasal cannula wrapped around the back of his chair. RN #3 said, don't know. On 9/15/22 at 10:30 AM a record review of the vital sign section of Resident #10's electronic medical record revealed the last time the resident used oxygen was 1/31/22, which was at least 8 months that the nasal cannula has been attached to the oxygen without being changed, as there was no date known. 11) On 9/21/22 at 8:05 AM a review of Resident #10's medical record was conducted and revealed daily COVID-19 evaluations were not done on 9/10/22, 9/9/22, 9/6/22, 8/27/22, 8/26/22, 8/20/22, 8/16/22, 8/13/22, 8/12/22, 8/6/22, 8/5/22, 8/4/22, 7/27/22, 7/25/22, 7/9/22, and 7/2/22. 11) Facility staff failed to store personal items separately from patient items: On 9/11/22 at 7:56 AM observation was made in the laundry room. There was clean laundry in a bin next to the folding table and clean laundry at the end of the table. On the clean folding table was a pocketbook, drink bottle, shaker bottle and a cell phone. On 9/12/22 at 8:41 AM observation was made of the linen closet at the end of the 200 hallway. There were 3 backpacks hanging on the inside of the door: 1 flowered backpack that had Puerto Rico embroidered on the front, 1 black cloth backpack and 1 orange/pink cloth backpack. 12) Facility staff failed to appropriately wear face masks: On 9/13/22 at 3:35 PM an agency GNA was in the Homestead unit with her mask below her nose. She was wearing a surgical mask under a sparkly mask. On 9/20/22 at 12:58 PM and 3:25 PM observation was made of Staff #41 come out of Nursing Home Administrator's office, walk into the hallway past a resident and back to the receptionist desk. Staff #41 was wearing a mask under her chin. On 9/23/22 at 9:07 AM observation was made in the kitchen of Staff #93 and Staff #94 wearing their masks below their chins while they were standing at the food steam table. 13) On 9/16/22 at 12:59 PM observation was made of Resident #78's nightstand. There were (2) 550 ml. bottles of Sterile Water for Inhalation. The first one was opened, one fourth used with a date opened written on the bottle in pen of 11/10/21, Reference # AS0552. The second bottle was opened with one fifth of the contents remaining. There was no date opened on the bottle. According to an email response from the manufacturer, The product is sterile saline for inhalation packaged in plastic container. Once opened, it is no longer considered sterile. There are no studies on how long it is good for after opening. Saline is mostly water. Evaporation will (slowly) change the salinity level. Different environmental conditions (temperature, humidity) have effects on evaporation. There is also potential for contamination after the container is opened. On 9/28/22 at 12:15 PM discussed all concerns with the Interim DON. 9) The facility failed to assess a resident for tuberculosis within 10 days of a resident's admission to the facility. Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's medication administration record (MAR) on 9/20/22 revealed the resident was administered the tuberculin skin test (TST) intradermally on 9/7/22 and 9/13/22. There was no documentation of the results of both tests. The interim DON was interviewed on 9/20/22 at 4 PM. She was asked, where do the staff document the reading/results of a Tuberculin skin Test? The interim DON indicated that the results would be recorded on medication administration record. She was informed that the results of two administered tuberculin skin test were not documented in the record.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

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Based on interview and review of the facility records, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident by facility staff failing to submit antibiotic stewardship records to the surveyor to verify the facility had an antibiotic stewardship program as part of the facility's overall infection prevention and control program. This was evident during the annual survey and had the potential to affect all residents. The findings include: On 9/14/22 at 1:55 PM, an interview was conducted with the Interim Director of Nursing (DON), who also had responsibility for the Infection Control Preventionist (ICP) in this facility. The Interim DON stated that the facility had an antibiotic stewardship program for monitoring and tracking resident's antibiotic use, and she explained that, all documentation was filed in the Infection control binder. The surveyor asked the Interim DON to bring the antibiotic stewardship documentation in for surveyor review. The surveyor re-requested the Interim DON to bring the facility antibiotic stewardship documentation binder on 9/20/22 at 3:25 PM. On 9/21/22 at 9:14 AM, the Interim DON submitted a facility policy of the Antibiotic Stewardship Program with a date implemented on 7/30/21. Meanwhile, the surveyor asked about documentation for antibiotic stewardship. The Interim DON said, still looking for the binder. A review of the antibiotic stewardship program policy revealed that antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy): Policy #4. B.iv. and at least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data: Policy #4. b. v. However, no documentation was submitted to support the facility implementing an Antibiotic Stewardship Program to monitor the use of antibiotics until an interview with the Interim DON on 9/28/22 at 1:30 PM. During the interview, the DON confirmed, Unfortunately, I was not able to find the antibiotic stewardship binder.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0886 (Tag F0886)

Could have caused harm · This affected most or all residents

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Based on interview and record review, it was determined that the facility failed to have an effective system in place to ensure staff who were not up to date with COVID-19 immunizations, including unvaccinated staff, were tested according to state and federal guidelines. This was found to be evident for 58 out of 92 staff (regardless of vaccination status) who were not tested for COVID-19 the week of 9/4/22 (the facility had a COVID-19 outbreak), and 27 out of 92 staff (regardless of vaccination status) that were not tested the week of 7/10/22 while the facility had a COVID-19 outbreak. This deficient practice had the potential to affect all residents, staff, and visitors in the facility. The finding includes: The line listing is one type of epidemiologic database and is organized like a spreadsheet with rows and columns. Typically, each row is called a record or observation and represents one person or case of disease. (Center for Disease Control and Prevention) On 9/11/22 at 8:16 AM, an entrance conference was conducted with the Nursing Home Administrator (NHA), and she confirmed the facility was on COVID-19 outbreak status since 9/1/22. During an interview with the Interim Director of Nursing (DON), also Infection Control Preventionist, on 9/14/22 at 1:06 PM, the Interim DON confirmed that COVID-19 tests should be done twice a week for all staff regardless during the outbreak period. At the same time, the surveyor reviewed COVID-19 testing documentation for staff for the week of 9/4/22-9/10/22. That week, 34 sheets of paper, each including a staff's name, date, and COVID-19 test results, were filed in the facility documentation binder. Since the NHA confirmed on 9/14/22 at 12:09 PM that the facility had 92 staff, 34 sheets of COVID-19 testing for staff provided did not meet the testing requirement during the outbreak that all staff were tested twice a week regardless of vaccination status. Additionally, the surveyor reviewed COVID-19 testing records for the week of 7/10/22-7/16/22. The COVID-19 line listing, submitted by the Interim DON on 9/14/22 at 9:57 AM via email, revealed the week of 7/10/22-7/16/22 was during the COVID-19 outbreak period. 65 of COVID-19 testing result papers were filed in the facility testing binder. On 9/14/22 around 2:00 PM, the DON stated similar numbers of staff (92)worked in the facility in July 2022. The 65 sheets of COVID-19 testing for staff did not meet the testing requirement during the outbreak that all staff were tested twice a week regardless of vaccination status. During an interview with the Interim DON on 9/28/22 at 1:30 PM, the surveyor shared concerns regarding COVID-19 testing for all staff were not documented while the facility had a COVID-19 outbreak. No further evidence was provided to support all staff were tested during the outbreak until the survey team exited. 2) On 9/14/22 at 12:09 PM, the NHA submitted a form of COVID-19 Staff Vaccination Status to the survey team. The review of the form revealed there was one staff (Staff #85) who was not vaccinated for COVID-19 due to religious exemption. On 9/15/22 at 8:50 AM, the NHA submitted a copy of the religious exemption for Staff #85 dated 1/28/22 with the religious leader's signature. Also, the attached Determination form stated Staff #85's religious accommodation from the COVID-19 Vaccine was granted by Human Resource staff on 2/10/22 with alternative safety precautions required which were, COVID-19 screening completed prior to entry in the facility, COVID-19 testing completed biweekly at the facility or as per facility protocol and maintain social distancing with all Staff and residents unless required in the provision of care. On 9/15/22 at 1:30 PM review of the facility policy for COVID-19 vaccination, with a revised date of 1/10/22 revealed, if approved for either religious and/or medical reason/s the employee agrees to continue wearing a mask and complete a COVID-19 rapid test weekly under Policy Explanation and Compliance Guidelines #31. The surveyor requested documentation for Staff #85's COVID-19 weekly test on 9/15/22 at 3:00 PM. However, the facility did not submit testing records for Staff #85 until the end of the survey. On 9/28/22 at 1:30 PM, the Interim DON said, Staff #85 did COVID-19 test sometimes, but not weekly. I was not able to find weekly test records.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected most or all residents

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Based on interview and documentation review, it was determined the facility failed to ensure a training program was set up and in place for their staff to be educated on abuse, neglect, exploitation, and misappropriation of resident property along with dementia management and resident abuse prevention. This was evident for current staff and had the potential to affect all residents. The findings include: On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources and the Business Office Manager. Staff #20 was asked about in-service training and she stated, only for new hires is there abuse training. Right now there is nothing for existing staff on yearly training related to abuse and dementia management. Review of the packet for new hire training revealed printed papers for self study on Resident Abuse Prevention and Reporting, Resident Rights and Facility Responsibilities, Compliance and Ethics Program, and HIPAA Security. Each stapled packet had a Pre/Post Test. Staff #20 explained that a new hire would receive the packet and then have to return the post test prior to working. Staff #20 stated, Corporate should have a training program. Different modules for like abuse training throughout the year. I have not set it up yet. I just did my yearly set-up at [name of sister facility]. It is in modules, and I know how I want to set it up. They did not have anything in place here.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation review and interview, it was determined the facility failed to ensure nurse aide competency training occurred no less than 12 hours per year as determined in nurse aides' performance reviews. This was evident for 3 of 3 files reviewed and had the potential to affect all residents. The findings include: A review was conducted of GNA personnel files on 9/20/22 at 9:32 AM. A review of GNA #37's personnel file revealed GNA #37 was hired on 8/4/21. A review of GNA #44's personnel file revealed GNA #44 was hired on 9/14/20. A review of GNA #45's personnel file revealed GNA #45 was hired on 4/21/20. There was no evidence that 12 hours of training occurred for the three GNA's. On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources and the Business Office Manager. Staff #20 stated, I have not seen any yearly reviews since I have been here. I have not seen any evidence of yearly evaluations. They did not have anything in place. Staff #20 was asked about in-service training and she stated, only for new hires is there abuse training. Right now there is nothing for existing staff on yearly training related to abuse and dementia management. Staff #20 stated, Corporate should have a training program. Different modules for like abuse training throughout the year. I have not set it up yet. I just did my yearly set-up at [name of sister facility]. It is in modules, and I know how I want to set it up. They did not have anything in place here. On 9/20/22 at 11:38 AM an interview was conducted with the Nursing Home Administrator (NHA), Interim Director of Nursing (DON), and Staff #7. They said, we do not have a Staff Developer. We had a DON and (Assistant) DON and 2 managers. It was divided between the ADON and managers. They stated, it kind of fell apart. They said they had a DON from June 6 to August 31, 2022. They hired an ADON in the middle of August 2022 and she did not last for 2 weeks. She said she knew everything about what to do and then she quit. They stated the process of training and competencies, never evolved because the ADON was only at the facility for a week. In April [name] was here as ADON and she resigned the first week of August. We do not have any competencies on nurses and GNAs. The Interim DON stated, so far I have not had any GNAs without experience. With the nursing shortage most of them are all agency. All GNAs are certified. Yearly performance reviews are supposed to be done. We don't have a lot of regular staff. I have not tracked making sure everyone is getting the 12 hours of training.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected most or all residents

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Based on observation, documentation review, and staff interview it was determined the facility failed to have the results of the most recent annual survey posted in the survey binder that was accessible to residents, family members and legal representatives of residents. This was evident during the first 2 days of the revisit survey. The findings include: On 1/3/23 at 9:10 AM (1) white binder that was labeled survey results was observed in the lobby of the facility sitting on a table. On 1/4/23 at 10:56 AM observation was made of (1) white survey binder labeled survey results in the lobby of the facility sitting on a table. In the binder was a 3-page letter from the Office of Health Care Quality (OHCQ), the regulatory agency, that informed the facility of the survey results from the annual survey that ended on 9/28/22. The Statement of Deficiencies (Form CMS-2567) which documented deficiencies resulting from the annual survey was not attached to the letter and was not found in the survey binder. On 1/4/23 at 10:58 AM an interview was conducted with the Nursing Home Administrator (NHA) who stated that he was responsible for putting the results of the survey in the binder. The NHA stated, we were trying to figure out what to do with it because there were so many pages. On 1/4/23 at 3:00 PM (3) white binders were observed on the table in the facility lobby that housed the Statement of Deficiencies from the annual survey that ended on 9/28/22.

MINOR (C)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 9/22/22 at 12:40 PM, Resident #58 verbally reported his/her concern related to Resident #29's transfer which occurred on 9/21/22. Resident #58 stated Resident #29 transferred to the hospital on 9/21/22, and family members of Resident #29 visited the facility to see the Resident without knowing Resident #29's status. A medical record review of Resident #29 was conducted on 9/22/22 at 1:20 PM. A progress note, a part of the medical record, written by RN #79 on 9/21/22 at 6:44 AM, stated, Resident was yelling out loud. Resident was found to be sweating profusely. Resident blood sugar checked was 48. Resident given glucose; Blood sugar went up to 64. Resident continued to yell out. Resident wanted to go the hospital. Resident assessed by supervisor. Resident sent to ER for evaluation. An interview was conducted with RN #79 via phone on 9/22/22 at 3:11 PM. RN #79 recalled the incident occurred around 9/20/22 at midnight. Also, RN #79 stated that she assumed the supervisor called 911, the physician, and family members. She said, All I did was stay with the resident at the bedside. My supervisor brought papers (current order and face sheet), and I handed them to EMT. Further review of the medical record did not reveal documentation that the Resident or Responsible Party (RP) was informed in writing related to the transfer to the hospital. On 9/23/22 at 10:23 AM, the NHA was interviewed and revealed that there was no creditable evidence related to the resident or RP receiving notification in writing of the transfer. 4) On 9/27/22 at 8:08 AM, a review of Resident #91's electronic and paper medical records revealed Resident #91 was transferred to the hospital on 8/6/22 for a change in medical condition. Further review of Resident #91's medical record documentation revealed the responsible party was notified. However, there was no written documentation that the responsible party was notified in writing of the hospital transfer. The Interim Director of Nursing was informed on 9/28/22 at 1:30 PM. Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (#27, #10, #29, #91 ) of 6 residents reviewed for hospitalization. The findings include: 1) On 9/12/22 at 1:37 PM a review of Resident #27's medical record was conducted. It appeared that Resident #27 was sent to the hospital on 8/18/22 as there was an MDS Discharge Return Not Anticipated assessment listed under the MDS section of the medical record. There was no documentation in the medical record about Resident #27's discharge to the hospital on 8/18/22. A hospital Discharge summary dated [DATE] confirmed that Resident #27 was admitted to the hospital on [DATE]. There was no written documentation in the medical record that the responsible party and/or resident was notified in writing of the hospital transfer. 2) On 9/21/22 at 7:44 AM observation was made of Resident #10's room. Resident #10 was not in the room. At that time Registered Nurse (RN) #14 was asked where the resident was and RN #14 stated, Oh, [he/she] got sent out on the 16th because [his/her] toes was looking bad. Review of Resident #10's electronic and paper medical record on 9/21/22 at 8:05 AM revealed on 9/16/22, Resident #10 was transferred to the hospital for a change in medical condition. Further review of Resident #10's medical record revealed there was no written documentation that the responsible party and/or resident was notified in writing of the hospital transfer. On 9/16/22 at 9:15 AM an interview was conducted with the Nursing Home Administrator (NHA) who confirmed there was no documentation in the medical record related to written notification of transfer to the hospital.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0625 (Tag F0625)

Minor procedural issue · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) A medical record review of Resident #29 was conducted on 9/22/22 at 1:20 PM. A progress note, a part of the medical record, written by RN #79 on 9/21/22 at 6:44 AM, revealed the resident was transferred to the hospital due to low glucose. Further review of the medical record did not show copies of the bed hold policy to be provided to the resident at the time of transfer. On 9/23/22 at 10:23 AM, an interview with the NHA revealed no credible evidence related to the resident receiving written bed-hold policy notification at the time of each transfer. 2) On 9/27/22 at 8:08 AM, a review of Resident #91's electronic and paper medical records revealed Resident #91 was transferred to the hospital on 8/6/22 for a change in medical condition. Further review of the medical record did not show copies of the bed hold policy to be provided to the resident at the time of transfer. The Interim Director of Nursing was informed on 9/28/22 at 1:30 PM. Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 4 (#27, #10, #29, #91) of 6 residents reviewed for hospitalization during the annual survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. The findings include: 1) On 9/12/22 at 1:37 PM a review of Resident #27's medical was conducted. It appeared that Resident #27 was sent to the hospital on 8/18/22 as there was an MDS Discharge Return Not Anticipated assessment listed under the MDS section of the medical record. There was no documentation in the medical record about Resident #27's discharge to the hospital on 8/18/22. A hospital Discharge summary dated [DATE] confirmed that Resident #27 was admitted to the hospital on [DATE]. There was no written documentation in the medical record that the responsible party and/or resident was notified in writing of the bed hold policy. On 9/16/22 at 9:15 AM an interview was conducted with the Nursing Home Administrator (NHA) who confirmed there was no documentation in the medical record related to written notification of the bed hold policy. On 9/27/22 at 5:00 PM it was noted in the medical record of Resident #27 that the NHA signed a bed hold for 8/18/22 that was uploaded into the system on 9/19/22. 2) On 9/21/22 at 7:44 AM observation was made of Resident #10's room. Resident #10 was not in the room. At that time RN #14 was asked where the resident was and RN #14 stated, Oh, [he/she] got sent out on the 16th because [his/her] toes was looking bad. Review of Resident #10's electronic and paper medical record on 9/21/22 at 8:05 AM revealed on 9/16/22, Resident #10 was transferred to the hospital for a change in medical condition. Further review of Resident #10's medical record revealed there was no written documentation that the responsible party and/or resident was notified in writing of the bed hold policy.

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

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Based on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the nurse staffing data at the beginning of each shift and failed to retain the posted daily nurse staffing data for a minimum of 18 months. This was evident on 3 of 3 nursing units and in the facility lobby during the annual survey. The findings include. On 9/11/22 at 7:10 AM, upon entry to the facility's lobby, the daily nursing staffing form was posted on the receptionist counter and was dated 9/9/22. There was no nursing staffing form for 9/11/22 displayed. On 9/13/22 at 7:15 AM the daily nursing staffing form that was posted in the lobby for display was dated 9/11/22. On 9/13/22 at 7:25 AM the nursing assignment on the Wye Oak nursing unit had day shift displayed in paper form that was dated 9/12/22. On 9/13/22 at 7:40 AM on the Homestead nursing unit, on the white staffing board, was the 9/12/22 assignment. Per LPN #18, yesterday's schedule is still up there. On 9/13/22 at 3:35 PM observation was made of the staffing board in the Homestead nursing unit. The census was 21. There were 2 GNA names on the board. The day shift nurse's name was still on the board. On 9/22/22 at 4:08 PM in the Homestead nursing unit, the day shift nurse's name was still on the dry erase board with 1 GNA. There was no 3-11 staffing data. There was a paper taped to the nursing station that had the 9/21/22 11:00 PM to 7:00 AM staff assignment. At 4:11 PM RN #14 stated that someone called out and she was now staying with 2 GNAs. The Interim Director of Nursing was informed of the observations on 9/28/22 at 12:15 PM. On 9/23/22 at 11:45 AM the surveyor requested from the Nursing Home Administrator (NHA) the actual worked nursing schedules for Sept. 2021 for 9/3, 9/4, 9/5, 9/10, 9/11, 9/12, 9/17, 9/18, 9/19, 9/24, 9/25, and 9/26. The NHA was unable to provide any staffing information. The NHA stated, we don't have them. The NHA was also unable to provide actual worked nursing schedules along with staffing assignments prior to April 2022.

Oct 2018 28 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0559 (Tag F0559)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility failed to notify a resident/resident representative in writing of a room change. This was evident for 1 (Resident #38) of 47 residents reviewed during an annual recertification survey. The findings include: Review of Resident #223's medical record on 10/23/18 revealed that Resident #223 was transferred to room [ROOM NUMBER] A on 10/09/18. In an interview with the facility Nursing Unit Manager on 10/24/18 at 11:19 AM, the Unit Manager stated that Resident #223's room change on 10/09/18 was staff initiated and that Resident #223 and Resident #223's family did not receive written notification of the room change.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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Based on a review of a facility reported incident, a resident clinical record, and staff interview it was determined that the facility staff failed to ensure a resident's right to move about the facility and to exit the facility was honored (#174). This was true for 1 out of the 5 residents reviewed for facility reported incidents as part of the survey process. The findings include: A review of Resident #174's clinical record revealed the resident had an elopement risk assessment completed on 12/29/17. The elopement risk assessment determined the resident was not a risk for elopement. The facility nursing staff put a WanderGuard bracelet (device that alerts facility staff that a resident is leaving a safe area) on the resident on 12/29/17 to alert them if the resident attempted to leave the facility. Record review did not reveal that resident was informed of the reason for the WanderGuard or the right to refuse to wear it. The resident cut off the WanderGuard bracelet on 1/7/18 and left the facility to get fresh air sometime between 3:30 PM and 3:40 PM. The resident was returned to the facility at 3:55 PM. Nursing staff had the resident sign an agreement on 1/7/18 to wear the WanderGuard bracelet and another one was applied. The Director of Nursing was informed of the findings on 10/25/18 at 8:50 AM and no evidence was provided to refute the finding prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined the facility staff failed to address the initiation of a MOLST form with Resident #89 and failed to properly void an old MOLST form when a new one was created for Resident #275. This was evident for 2 (Resident #89 and #275) of 47 residents reviewed for advance directives during an annual recertification survey. The findings include: A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must be accurately and legibly complete the form and then sign and date it. Voiding the Form: to void this medical order form, a physician or nurse practitioner shall draw a line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician or nurse practitioner to void the MOLST order from. Keep the voided order form in the patient's active or archived medical record. 1. Medical record review revealed on [DATE] the physician assessed Resident #89 and documented: the resident has adequate decision-making capacity (including decisions about life-sustaining treatments). On [DATE] the Certified Registered Nurse Practitioner completed a MOLST form. Review of the form revealed the facility staff documented the MOLST was completed by the resident's health care agent as named in the resident's advance directive. Advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. Further record review revealed on [DATE] the facility staff assessed the resident and determined the BIMS (Brief Interview for Mental Status). Further interview revealed the facility staff failed to address the initiation of the MOLST with Resident #89 to include his/her wishes for end of life care. Interview with the Director of Nursing on [DATE] at 1:00 PM confirmed the facility staff failed to include Resident #89 in the completion of the MOLST to determine the choices were his/hers. 2. Review of Resident #275's medical record on [DATE] at 2:30 PM revealed Resident #275 had 2 active MOLST forms in his/her medical record that were incongruent. The first MOLST form was dated [DATE] and indicated Resident #275 had completed the MOLST form and wanted to be a Full Code/Attempt CPR. The second MOLST was dated [DATE] and was also created by Resident #275. The second MOLST form indicated Resident #275 wanted to be a No CPR, Option A-1, Intubate: Comprehensive efforts may include intubation and artificial ventilation, May use intubation and artificial ventilation for a limited period of time (until family arrives), Do not give blood products, Do not transfer to the hospital but treat with options available outside the hospital, Do not perform any medical tests to diagnose and/or treat a medical condition, Do not use antibiotics, Do not give provide artificially administered fluids or nutrition and Do not provide acute or chronic dialysis. Interview with the Director of Nursing on [DATE] at 1:00 PM revealed the facility staff failed to void a MOLST dated [DATE] when Resident #275 completed a new MOLST on [DATE].

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on review of a medical record review and staff interview, it was determined the facility staff failed to notify a resident's family member of a recommendation to lower a Resident's antipsychotic medication after a psychiatric consultation. This was evident for 1 (Resident #33) of 47 residents reviewed during an annual recertification survey. The findings include: Reviews of Resident #33's medical record on 10/23/18 revealed that the facility psychiatrist assessed Resident #33 on 10/04/18 and recommended reducing Resident #33's antipsychotic medication, Olanzapine, from 7.5 milligrams (mg) to 5 mg orally every evening. Review of Resident #33's October 2018 medication administration record revealed that Resident #33 was still currently receiving the same dose of 7.5 mg every evening. In an interview with the facility Social Worker on 10/23/18 at 4:45 PM, the facility Social Worker stated that the facility did not receive a copy of the 10/04/18's psychiatrist's assessment with recommendations until 10/11/18. The facility Social Worker stated that the psychiatric consultants do not have access to the facility electronic medical record system and the psychiatric staff have to email their assessments over to the facility. Further review of Resident #33's medical record revealed that the facility nurse practitioner assessed Resident #33 on 10/22/18 and documented an assessment at that time. The nurse practitioner failed to document that the 10/04/18 psychiatric recommendations had been reviewed and spoke to Resident #33's responsible party regarding the recommended changes to Resident #33's dose of Olanzapine.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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Based on review of the facility's investigation of a facility reported incident and staff interview it was determined the facility failed to protect Resident (#29) from abuse. This was true for 1 out of 47 residents selected for review during the annual survey process. The findings include: A review of the facility staff's investigation (MD00125458) revealed on 4/11/18 Resident #29 reported to the facility staff GNA (Geriatric Nursing Assistant) #1 told him/her they were disgusting for laying in stool for several hours and should have put the call light on. The resident explained the call light was put on, another GNA answered the light and reportedly stated that they would relay the message to the appropriate care giver. At the time of allegation, GNA#1 was placed on administrative leave and not allowed to finish her shift. The resident was assessed, and no injuries were noted. The Ombudsman and responsible party for the resident was notified. At the end of the investigation and witness statements, the GNA#1 was terminated. Surveyor interview with Resident #29 on 10/24/18 at 10:45 AM revealed the resident stated he/she felt safe and revealed no further incidents of verbal abuse by any facility staff. Interview with the Director of Nursing also revealed the GNA was referred to the Maryland Board of Nursing. Prior to hire, GNA#1 had a background check and no records were noted related to abuse to the elderly. The GNA received Abuse, Resident Rights and Dignity on admission. Further review revealed the facility staff conducted in-services: Preventing, Recognizing, and Reporting Abuse for all direct care givers about the compliance date of 5/10/18. The Director of Nursing was interviewed on 10/24/18 at 1:00 PM. She confirmed the results of the facility investigation and confirmed the results of the investigation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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2. Review of the medical record for Resident #122 revealed the resident was transferred to an acute care facility on 5/24/18, 7/7/18 and 8/24/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 10/23/18 at 1:50 PM, the Director of Nurses confirmed that Resident #122 and the Resident's responsible party did not receive the facility bed hold policy when Resident #122 was transferred to the hospital. Based on medical record review and interview, it was determined that the facility failed to notify the resident or the resident's responsible party in writing of the facilities bed-hold policy (#64, #122) before transferring them to the hospital. This was evident for 2 of 47 residents sampled for investigations. The findings include: 1. Resident #64 was transferred to the hospital on 5/24/18, 7/7/18 and 8/24/18. An interview with the Regional Corporate Nurse on 10/23/18 at 1:50 AM confirmed the facility did not give Resident #64 a copy of the facilities bed hold policy with each of these hospitalizations.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview it was determined the facility staff failed to document accurate assessments for Resident (#66) on the MDS. This was evident for 1 of 47 residents selected for review during the survey process. The findings include the following: The minimum data set (MDS) is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Review of Resident #66 MDS, with an ARD of 05/30/18, revealed it was inaccurate. Section L Dental (D), was coded that the resident did not have broken natural teeth or cavity. Review of Resident #66 medical record revealed that the resident had a Dental Consult on 2/15/18 and 9/12/18 that revealed 4 retained roots and fracture tooth. On 10/25/18 at 10:00 AM, an interview with the MDS Coordinator confirmed not documenting the broken teeth.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #223) of 47 residents reviewed during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #223's medical record on 10/24/18 revealed Resident #223 was readmitted to the facility on [DATE]. Review of the medical record failed to reveal documentation that a copy of the baseline care plan was provided to Resident #223 or Resident #223's responsible party within 48 hours after admission. In an interview with the facility Social Worker on 10/24/18 at 10:49 AM the facility Social Worker confirmed the facility staff did not supply Resident #223 nor his/her responsible party with a copy of the baseline care plan after being admitted to the facility on [DATE].

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on review of medical record and staff interview, it was determined the facility staff failed to follow an established comprehensive care plan addressing nutrition for a resident (#34). This was evident for 1 of 47 residents selected for review during the annual survey. The findings include: On 10/22/18 at 1:00 PM Resident #34's care plan review revealed that he/she was to be setup for feeding, supervised, cued, and assisted with feeding as needed and to be sat up for meals. On 10/22/18 at 1:45 PM resident #34 was found in his/her room lying flat in bed with lunch plate on overbed table. The lunch meal was cold. The Director of Nursing(DON) confirmed the finding at 1:50 PM. The DON then got a nurse and resident #34 had incontinent brief changed and food warmed and assisted with lunch. The DON confirmed the care plan was not followed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation and interview, it was determined the facility staff failed to administer a medication as ordered to Residents #120 and #275 and the facility staff failed to clarify the accuracy of a medication order for Resident #275. This was evident for 2 of 47 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to administer a medication to Resident #120 as ordered by the physician. Medical record revealed on 9/23/18 the physician ordered: Exemestane 25 milligrams by mouth 1 time a day with a meal. Exemestane is indicated for the treatment of advanced breast cancer. Review of the Medication Administration Record revealed the facility staff documented the administration of the Exemestane from 9/24/18 to 9/30/18 and 10/1/18-10/23/18 at 8:00 AM. Observation of medication pass on 10/24/18 at 8:00 AM revealed the Certified Medication Aide (CMA #1) failed to administer the Exemestane as ordered. It was further noted the medication was not in the facility. It is the expectation the facility nursing staff re-order routine medications in a timely to prevent the resident from missing a dose of the medication. Interview with the Director of Nursing on 10/24/18 at 1:00 PM confirmed the facility staff failed to administer a medication to Resident #120 as ordered by the physician. 2A. Medical record review revealed on 9/12/18 the physician ordered: Humulin NPH insulin, 40 units subcutaneously at bed time. Humulin NPH insulin is used to help lower blood glucose levels in people with diabetes. Further record review revealed the facility staff failed to obtain and administer the insulin on 10/22/18 at hour of sleep as ordered by the physician. 2B. Medical record review revealed for Resident #275 revealed the resident was admitted to the facility with the discharge summary of medication ordered on 9/11/18: Potassium 95 milligrams by mouth every day. Potassium is a mineral that is found in many foods and is needed for several functions of the body, especially the beating of your heart. Further record review revealed the facility staff failed to administer the medication from 9/11/18-9/19/18. It was also noted the facility staff failed to thoroughly clarify with the physician. Potassium is not a medication ordered or administered in milligrams but in the ordering system of milliequivalent (mEq). Interview with the Director of Nursing on 10/24/18 at 1:00 PM confirmed the facility staff failed to obtain and administer NPH insulin to Resident #275 and failed to clarify the dosing order for Potassium for Resident #275.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation and interview, it was determined the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for residents with pressure ulcers (Residents #275). This was evident for 1 of 47 residents selected for review during the investigation stage of the survey process. The findings include: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Medical record review for Resident #275 revealed on 9/24/18 the physician ordered: make sure heels are off loaded. When it comes to wound care, the term float the heels means that a resident's heel should be positioned in such a way as to remove all contact between the heel and the bed. Surveyor interview with Resident #275 on 10/23/18 at 11:00 AM revealed the resident stated he/she was moved to another room; however, the facility staff failed to take the pillows with her/him and the feet had not been elevated since last night. Medical record review revealed on 10/22/18 at 5:37 PM the facility staff documented: transferred to new room. Surveyor observation of the resident on 10/23/18 at 11:00 AM revealed the resident resting in bed; however, the facility staff failed to elevate the resident's feet as ordered by the physician. Interview with the Director of Nursing on 10/24/18 at 1:00 PM confirmed the facility staff failed to elevate Resident #275's heels off the bed as ordered by the physician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the facility staff failed to obtain weights as ordered for Resident (#275). This was evident for 1 of 47 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #275 revealed on 9/11/18 the physician ordered: weights every week, Tuesday, 3-11 shift. Review of the medical record revealed the facility staff failed to obtain weights on: -9/18/18-- the resident refused and indicated he/she was in pain and would be weighed in morning; however, there is no evidence the facility staff attempted to obtain that weight; -9/25/18-- the resident refused and indicated he/she was in pain and would be weighed in the morning; however, there is no evidence the facility staff attempted to obtain that weight; -10/2/18 -- no evidence weight was obtained. Interview with the Director of Nursing on 10/24/18 at 1:00 PM confirmed the facility staff failed to obtain weights as ordered on Resident #275.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the facility staff failed to thoroughly intervene and offer alternative pain management for Resident #275. This was evident for 1 of 47 residents selected for review during the annual survey process. The finding includes: Medical record review for Resident #275 revealed on 9/18/18 the physician ordered: Oxycodone 10 milligrams by mouth every 6 hours as needed for moderate to severe pain. Oxycodone is intended for the management of moderate to severe pain in patients who require treatment with an oral opioid analgesic and Oxycodone tablets are an immediate-release formula. Further medical record review revealed the facility staff documented the administration of the Oxycodone on: -9/18/18 at 7:35 PM and re-evaluation of pain at 9:37 PM with verbalized pain level of 10, -9/20/18 at 6:40 AM and re-evaluation of pain at 8:34 AM with verbalized pain level of 10, -9/20/18 at 12:30 PM and re-evaluation of pain at 5:35 PM with verbalized pain level of 10, -9/21/18 at 9:00 AM and re-evaluation of pain at 9:23 AM with verbalized pain level of 10 -9/29/18 at 8:18 PM and re-evaluation of pain at 11:12 PM with verbalized pain level of 10, -9/30/18 at 8:38 AM and re-evaluation of pain at 4:16 PM with verbalized pain level of 10, -10/4/18 at 11:18 AM and a re-evaluation of pain at 12:29 with verbalized pain level of 10 and -10/22/18 at 11:35 AM and re-evaluation of pain at 1:16 PM with verbalized pain level of 10. As noted above, Resident #275 verbalized the pain level remained a 10 after the administration of Oxycodone. Interview with the Director of Nursing on 10/24/18 at 1:00 PM confirmed the facility staff failed to intervene when Resident #275 verbalized the oral medication was not effective pain management.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the consultant pharmacist failed to identify and bring to the facility staff's attention for Resident #275 the irregularity of the ordering of Potassium. This was evident for 1 of 47 residents selected for review during the survey process. The findings include: Medical record review revealed for Resident #275 revealed the facility was admitted to the facility with the discharge summary of medication ordered on 9/11/18: Potassium 95 milligrams by mouth every day. Potassium is a mineral that is found in many foods and is needed for several functions of the body, especially the beating of your heart. Further record review revealed the consultant pharmacist failed to identify and notify the facility staff of the irregularity in the ordering of the Potassium. Potassium is not a medication ordered or administered in milligrams but in the ordering system of milliequivalent (mEq). Interview with the Director of Nursing on 10/23/18 at 2:00 PM revealed the consultant pharmacist will immediately notify the facility of an irregularity and correct that error with the physician. Interview with the Director of Nursing on 10/24/18 at 1:00 PM confirmed the consultant pharmacist failed to identify and notify the facility staff of the irregularity of Potassium ordering for Resident #275.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on medical record review and reviews of a relevant medical resource, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication. This was evident for 2 (Resident #33 and #117) of 6 residents reviewed for unnecessary medications during an annual recertification survey. The findings include: 1. Review of Resident #33's medical record on 10/23/18 revealed a physician order, dated 05/11/18, instructing the nursing staff to administer the medication, Divalproex (Valproate) sprinkles, 250 mg, orally, twice a day for the indication of dementia with behavioral disturbance. Valproate preparations are given to treat residents who suffer from seizures and bipolar disorder. A review of the National Institute for Health Care Excellence, 10 March 2015 article, Management of Aggression, agitation and behavioral disturbance in dementia: Valproate preparations determine that evidence from randomized controlled trials (RCT's) suggest that valproate preparations (including sodium valproate and valproate semisodium) are no more effective than placebo for treating agitation or behavioral disturbances in people with dementia. The surveyor determined that the facility staff failed to take steps and eliminate the administration of the medication, Divalproex sprinkles, in a resident that suffer from of dementia with behavioral disturbance. 2. A review of Resident #117's clinical record revealed that the resident's primary physician wrote an order indicating that if the resident's blood sugar was below 70 then the nursing staff are to call the healthcare provider and initiate the hypoglycemic protocol. A review of the resident's Medication Administration Record (MAR) revealed that on 10/23/18 the resident had a blood sugar of 60. There was no evidence that the physician or a nurse practitioner was called. A review of the hypoglycemic protocol revealed that the nurse is supposed to administer 4 ounces of juice or 5-6 oz of soda unless meal time then have resident eat. The nurse is supposed to check the blood sugar again 15 minutes later. The Director of Nursing was interviewed on 10/24/18 and she said she understood the findings. No further evidence was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview it was determined that the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs. This was evident for 1 (Resident #33) of 6 residents reviewed for unnecessary medications during an annual recertification survey. The findings include: Reviews of Resident #33's medical record on 10/23/18 revealed that the facility psychiatrist assessed Resident #33 on 10/04/18 and recommended reducing Resident #33's antipsychotic medication, Olanzapine, from 7.5 milligrams (mg) to 5 mg orally every evening. The facility psychiatrist recommended a gradual dose reduction (GDR) for Resident #33 at this time. Review of Resident #33's October 2018 medication administration record, on 10/23/18, revealed that Resident #33 was still currently receiving the same dose of 7.5 mg every evening. A review of Resident #33 medical record also revealed a care plan titled: Resident is at risk for complications related to the use of psychotropic drugs, mood stabilizers, and insomnia medications. Nursing interventions included: obtain a psychiatric evaluation as ordered, complete a behavior monitoring flow sheet, and do a gradual dose reduction as ordered. In an interview with the facility Social Worker on 10/23/18 at 4:45 PM, the facility Social Worker stated that the facility did not receive a copy of the 10/04/18's psychiatrist's assessment with a GDR recommendation until 10/11/18. The facility Social Worker stated that the psychiatric consultants do not have access to the facility electronic medical record system and the psychiatric consultants have to email their assessments over to the facility. Further review of Resident #33's medical record revealed that the facility nurse practitioner assessed Resident #33 on 10/22/18 and documented an assessment at that time. The nurse practitioner failed to document that the 10/04/18 psychiatric recommendations had been reviewed and spoke to Resident #33's responsible party regarding the recommended changes to Resident #33's dose of Olanzapine.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, reviews of a medical record, and staff interview, it was determined that the facility staff failed to offer and obtain dental services for a resident. This was evident for 1 (Resident #27) of 7 residents reviewed for dental services. The findings include: During an observation of Resident #27 on 10/22/18 at 1:25 PM, Resident #27 was observed with missing teeth. Review of Resident #27's medical record revealed a physician order, dated 08/02/17, instructing the nursing staff to obtain a dental consult for patient health and comfort. Further review of Resident #27's medical record failed to reveal any documentation a dental consult had been offered or obtained since Resident #27 was admitted to the facility on [DATE]. In an interview with the facility nursing unit manager on 10/24/18 at 10:26 AM, the nursing unit manager stated that Resident #27 had never been referred to a dentist since being admitted . The nursing unit manager also stated the facility had a dentist that came to the facility to provide dental services on site. The facility staff must take steps to minimally offer dental services to each resident and document each resident's response in the medical record.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected 1 resident

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Based on resident complaint and staff interview, it was determined that the facility staff failed to provide a resident (Resident #43) with a bedtime snack as requested. This was evident for 1 (Resident #43) of 47 residents reviewed during an annual recertification survey. The findings include: During an interview with Resident #43 during the annual recertification survey, Resident #43 stated that s/he did not receive a bedtime snack, a peanut butter and jelly (PBJ) sandwich, that s/he had requested. In an interview with the facility dietitian on 10/25/18 at 10:20 AM, the facility dietitian confirmed that Resident #43 did not receive his/her bedtime sandwich last evening. The facility dietitian stated that the dietary staff failed to deliver the bedtime snacks to Resident #43.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility staff failed to post an isolation sign on room [ROOM NUMBER]A door to alert visitors, residents, and staff to see the nurse before entering the room. This was true for 1 out of 47 residents selected for review during the annual survey process. The findings include: The facility staff failed to post a sign on a resident door indicating isolation. On 10/22/18, an observation outside resident's room [ROOM NUMBER]A was a box. When opened contained items necessary for respiratory isolation, gowns, masks, and gloves. The box had no signage indicating the items needed to be worn before entering the room or to see the nurse before entering. The resident had an infection requiring isolation. No one entering without previous knowledge would be alerted that the box meant isolation was expected. On 10/22/18 the Director of Nursing confirmed there was not signage to indicate to stop and see a nurse before entering room [ROOM NUMBER]A.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on surveyor observation, it was determined that the facility staff failed to maintain a resident's call bell within reach. This was evident for 2 (Residents #223, #35) of 47 residents observed during an annual recertification survey. The findings include: 1) During an observation of Resident #35 with the unit charge nurse on 10/23/18 at 9:55 AM, the surveyor observed Resident #35's call bell to have been placed on top of Resident #35's over bed light away from Resident #35's reach. 2) In a second observation with the unit charge nurse of Resident #223 on 10/23/18 at 10:05 AM, the surveyor observed that Resident #223's call bell was on lying the floor away from Resident #223's reach.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

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Based on the interviews with eight members of the resident council and a review of resident council notes from the past 12 months it was determined that the facility staff had not been addressing the residents' concerns. The findings include: This surveyor met with members of the resident council on 10/24/18 at 2:00 PM. The residents brought up concerns that they said they had brought up many times and on an almost monthly basis. The issues included: -quality of the food and the fact that the kitchen often runs out of one of the entree choices prior to all the residents having the opportunity to request it; -they also said that pie is often on the menu but is rarely available and is most often substituted with green Jell-O and that the former Dietary Manager told the resident council via the Recreation staff person that the issue is the facility budget. There was no indication that any adjustments to either the budget or how the kitchen staff prepare food was presented to the resident council. A review of the resident council meeting notes revealed the following: -10/31/17: residents complained of cold food, running out of food, and lack of choice; -11/28/17: residents had same concerns -- not addressed by dining services; -12/26/17: same concerns noted; -1/30/18: same concerns noted; -2/27/18: staffing shortage issues were mentioned; -5/29/18: residents still complaining of running out of food and lack of choices; -6/26/18: aides won't help during meal time, food issues, staff answer call lights by saying I'll get someone but then they don't; -8/28/18: food cold is cold; -9/25/18: Dinner is often late. The resident council's concerns were shared with the facility staff at the exit conference on 10/25/18.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation of resident rooms during the initial tour of the facility, it was determined that the facility staff failed to maintain a safe and clean environment as evidenced by unattended maintenance and/or housekeeping needs, and broken items (room [ROOM NUMBER] and 314). The findings include: During the initial tour of the facility on October 25, 2018 the survey team observed the following evidence of unattended maintenance and/or housekeeping concerns: 1. room [ROOM NUMBER] was found with a dirty Tube Feeding pump and pole with old dried tube feeding solution, cob webs from the ceiling, smell of urine, and a suction canister with an open and used suction catheter on the end table. In an interview on 10/25/18 the Director of Nursing was made aware of these concerns. 2. During an observation of the Homestead Unit on 10/22/18 at 10:30 AM, the surveyor observed a broken glass picture frame on the sink in room [ROOM NUMBER].

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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3. A medical record review for Resident #122 was conducted on 10/22/18. Review of the physician order written on 5/24/18, 7/7/2018, and 8/24/2018 revealed that Resident #122 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman. On 10/23/18 01:50 PM, an interview with the Administrator revealed that a written notice for emergency transfers and bed hold notices to the resident and/or the resident representative, was not initiated. Based on medical record review and interview, it was determined that the facility failed to notify the resident or the resident's responsible party in writing of transfer to the hospital. The facility also failed to send a copy of the written transfer notice to the Office of the State Long-Term Care Ombudsman. This was evident for 3 of 47 residents (#64, #122, #123) sampled for investigations. The findings include: 1. Resident #64 was sent to the hospital on 5/24/18, 7/7/18, and 8/24/18. An interview with the Corporate Regional Nurse on 10/23/18 at 10:50 AM revealed the facility had not notified Resident #64 in writing of the transfers nor the reason for the transfers. The facility did not send the Ombudsman a copy of the transfer notice. 2. A review of Resident #123's clinical record on 10/23/18 at 3:00 PM revealed that the resident was discharged to the hospital on 7/27/18. A review of the reasons for the hospitalization revealed that there was an incident that resulted in the need for observation and/or treatment at the hospital. There was no evidence that the ombudsman was contacted. The Director of Nursing was interviewed on 10/25/18 at 8:00 AM. No evidence was provided prior to exit that the ombudsman had been notified. The Administrator confirmed at the exit conference that the facility had not been notifying the ombudsman.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #76's clinical record revealed that the resident's last care plan meeting was on 2/7/17. The Interdisciplinary Care Plan attendance sheet showed that the Social worker, Recreation Director, Director of Nursing and Dietitian attended the meeting. The resident and the resident's family representative did not attend this meeting. It was not clear if an attempt was made to schedule the meetings to accommodate the family or primary physician so that they could attend. 3. A review of Resident # 92's clinical record revealed that the resident was admitted to the facility on [DATE] and had the first care plan meetings was on 8/15/2018. The Interdisciplinary Care Plan attendance sheet showed that only the Social Worker, Director of Nursing, Physical therapist and the responsible party (RP) attended the 8/15/18 meeting, neither the primary physician nor dietary staff attended the meeting. Interview with the Social Worker on 10/23/18 at 3:00 PM confirmed the facility staff failed to review and revise the care plan for Resident #92 and 76 to reveal accurate interventions. Based on medical record review and interview, it was determined the facility staff failed to review and revise Resident #275's care plan to reflect accurate and current interventions and failed to ensure the full interdisciplinary team including residents and/or their responsible parties are invited to the quarterly care plan meetings (#76 and #92). This was evident for 3 of 47 residents selected for review during the annual survey. The findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. 1. Medical record review for Resident #275 revealed the resident was admitted the facility with diagnosis that included but not limited to: retention of urine and had an indwelling urinary catheter. Urinary retention is an inability to completely empty the bladder. A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Because it can be left in place in the bladder for a period, it is also called an indwelling catheter. Medical record review revealed the facility staff assessed the resident on 9/17/18 and 9/24/18- Section H-Bowel and Bladder-A. Indwelling catheter and responded that Resident #275 had an indwelling catheter. On 9/11/18, the facility staff initiated a care plan: resident requires indwelling Foley catheter due to retention. Further record review revealed the facility staff assessed the resident and documented on 10/8/18 that Resident #275 no longer had a Foley catheter. Surveyor observation of the resident's care plans on 10/23/18 revealed the facility staff failed to review and revise the indwelling catheter care plan to reflect current and accurate interventions related to the removal of the indwelling catheter. Interview with the Director of Nursing on 10/24/18 at 1:00 PM revealed the facility staff failed to review and revise the indwelling care plan for Resident #275 to reflect accurate and up to date interventions.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on interviews with residents from the resident council it was determined that the facility staff failed to ensure sufficient staffing for the facility. The findings include: This surveyor interviewed residents from the resident council on 10/24/18 at 2:00 PM. Residents stated that food is often delivered late and they are told the reason is that they are short staffed. They said staff will often not answer call lights during lunch because they don't have enough staff to serve trays, feed residents, and to clear the trays while still providing nursing care. Nursing staff refuses to provide any assistance with going to the bathroom or provide incontinence care during meal time. The residents said staff are so busy that they often forget to tell residents that they have mail and it is up to the residents to ask if they received any mail. A review of the resident council meeting notes revealed that staffing issues were raised on 2/27/18, 6/26/18, and 9/25/18. The facility staff were informed of these concerns at the exit conference.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation during the initial tour of the main kitchen it was determined that the facility staff, failed to store, and prepare, food under sanitary conditions. The findings include: On 10/22/18 10:33 AM, during the initial tour and observation of the main kitchen with the Food Service Director, it was found that: 1. The dry storage room door was propped open and it was noted to have cereal spilled on the floor and shelves, crackers and sugar packets was noted on the floor. 2. The storage room floor was dirty. 3. The storage room walls had chipping paint. 3. The main kitchen floor was wet and very slippery. 4. The handwashing sink next to the prep table was leaking and had standing water on the floor. The wall behind the sink had chipping paint. Flies were seen in the area of the standing water. 5. The floor drains noted to have food pieces. 6. The walk-in refrigerators/freezer had black specks on the ceiling and the floor was dirty with black marks and food debris. 7. Greased was noted behind the stove, grill and oven on the floor, walls and pipes. 8. The refrigerator had a ham stored on the shelf partially uncovered and expose to the elements. 9. Open dried beef that was undated. 10. Air vents in the ceiling dirty. 11. Standing water by the prep table and in the dishwasher area. 12. The wall behind the dishwasher was black. 13. A broken refrigerator with a sign on it that stated broken to be removed on 2/10/18. The weekly cleaning schedules were requested during the initial tour. After, review of the cleaning schedule several the items listed above were not cleaned at all. The Food Service Director was made aware and acknowledged surveyor's concerns. These deficiencies were confirmed with the Food Service Director on 10/22/18.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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3. Medical record review for Resident #92 revealed on 6/20/18, the facility staff completed a MOLST and indicated the MOLST was reviewed and completed. The top section of the MOLST has an area to be checked by the resident or as per the authority granted by the Health Care Decisions Act. The facility staff failed to indicate who gave the informed consent and who the MOLST was discuss with. Interview with the Director of Nursing on 10/22/18 at 2:00 PM confirmed the facility staff failed to maintain the medical record for Resident #92 in the most accurate form. Based on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for Residents (#33, #43, #64, #65, #67 and #92). This was evident for 6 of 47 residents reviewed in the annual survey. The findings include: 1. Review of Residents #43, #64, #65 and #67's medical record revealed no current physician orders for medications or treatments. On 10/23/18 at 1:40 PM, the Regional Corporate Nurse stated the physician had signed the current orders for October, but the medical records staff had not filed in the current orders in each resident's chart. The current orders were with the medical records staff and not in the record. 2. Reviews of Resident #33's medical record on 10/23/18 revealed that the facility psychiatrist assessed Resident #33 on 10/04/18 and recommended reducing Resident #33's antipsychotic medication, Olanzapine, from 7.5 milligrams (mg) to 5 mg orally every evening. The facility psychiatrist recommended a gradual dose reduction (GDR) for Resident #33 at this time. Review of Resident #33's October 2018 medication administration record, on 10/23/18, revealed that Resident #33 was still currently receiving the same dose of 7.5 mg every evening. In an interview with the facility Social Worker on 10/23/18 at 4:45 PM, the facility Social Worker stated that the facility did not receive a copy of the 10/04/18's psychiatrist's assessment with a GDR recommendation until 10/11/18. The facility Social Worker stated that the psychiatric consultants do not have access to the facility electronic medical record system and the psychiatric consultants have to email their assessments over to the facility. The facility staff must take steps to place all consultant recommendations in the medical record timely. This delay prevented the facility staff from possibly initiating a gradual dose reduction sooner with a resident receiving the antipsychotic medication Olanzapine.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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Based on observation, and interview with staff it was determined that the facility failed to maintain all essential mechanical, electrical, equipment in safe operating condition on the lower level of the facility. The findings include: 10/23/2018 at 3:45 PM, during the tour of the lower level of the facility with the Maintenance Director the following observation was made: 1. The tour of the lower Unit level revealed Power strips in the patient's rooms. Six of the patient's rooms had portable air conditioners/heater units connected to a powder strip. The portable air conditioner displayed a tag on the cord that revealed safety precautions that read do not use an adapter or an extension cord and a warning that read Following theses basic precautions will reduce the risk of fire, electrical shock, injury or death when using your air conditioners. At that time the power cords were removed from the power strip, and the portable air conditioners/Heaters were connected to the electrical supply as required by the manufactory's recommendations. 2. On 10/24/18 at 7:59 AM, a tour of the kitchen revealed a leaking handwashing sink near the prep table. Standing water was observe on the floors, below the sink. 3. On 10/24/18 the Maintenance Director revealed that the Residents medical equipment is inspected once a year by an outside vendor. The report dated 5/15/2018, from the vendor reflected that the nebulizer machine needed a filter or new filters. The Maintenance Director stated that he was unaware of the facility policy to change the nebulizer machine filters monthly and it was not done.

Jul 2017 7 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0323 (Tag F0323)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) During an interview with Resident #125 that took place on [DATE] at 1:26 PM, the resident stated that s/he had been transferred that morning with a sit-to-stand lift with the assistance of only one nursing assistant. The resident idenified Geriatric Nursing Assistant (GNA) #17 as the staff member who assisted him/her with the sit-to-stand lift this morning. A review of the facility's policy of resident transfers with Hoyer Lifts and Sit-to-Stand Lifts reveals that the facility requires two personnel to assist with all transfers. An interview with the Director of Nursing (DON) that took place at 2:00 PM on the same day confirmed this expectation. GNA #17 was interviewed at 2:30 PM and confirmed that s/he transferred Resident #125 that morning all by himself/herself. GNA #17 stated that s/he has had to do it alone other times before, and that the usual reason is not enough staff to help. The GNA stated that was also the reason this morning. These concerns were reviewed with the Administrator during survey exit. 3) The facility failed to maintain the safety of resident (#81) during transfer, resulting in a laceration to the forehead and cheek, bruising to the left shoulder and knee - requiring steri-strips and pain medication. Steri Strips are sterile pieces of medical tape used to close wounds. A Hoyer Lift is an assistive device that allows patient/patients to be transferred between a bed and a chair or other similar resting places. By way of history, according to the medical record, (resident #81) has End stage Dementia and is totally dependent on staff for care. An investigation was performed of facility reported incident # MD00113747, which included review of the medical record, review of the facility's investigation, and interviews with the DON (Director of Nursing) on [DATE] at 1 pm, GNA (Geriatric Nursing Assistant) #1 on [DATE] at 2 pm, and GNA #2 on [DATE] at 11 am. The investigation reavealed that, on [DATE] at approximately 9:40 am, GNA #1 and GNA #2 were transferring the resident from the bed to the chair using a Hoyer Lift. During the transfer, the sling strap came off the Hoyer Lift's hook and the resident fell to the floor. GNA #1 stated GNA #2 failed to properly secure the straps to the Hoyer Lift, causing the resident to fall out. GNA#2 stated s/he was unsure as to why the strap came off, but verified the allegation that the strap came off during transfer. The resident sustained a laceration to the forehead and cheek (requiring steri strips) and bruising to the left shoulder and knee (requiring pain management). The resident was given PRN (when needed) Tylenol 650 mg by mouth and steri strips were applied to the forehead at the time of the incident. Further review of the medical record revealed the resident was seen and assessed by the physician on [DATE] at 9:45 am, who rendered the following orders: Morphine Sulfate Concentrate (MSIR) 20mg/cc liquid. Give (0.25 cc) 5 mg (milligrams) po (by mouth) every hour PRN for mild pain or distress. Morphine Sulfate Concentrate (MSIR) 20mg/cc liquid. Give (0.5 cc) 10mg (milligrams) po (by mouth) every hour PRN for moderate pain or distress. Morphine Sulfate Concentrate (MSIR) is used to treat moderate to severe pain. On [DATE], the resident received the following doses of pain medication. 10:45 am 5 mg MSIR, 1:02 pm 10 mg MSIR, 2:45 pm 10 mg MSIR and 8:23 pm 10 mg MSIR. On [DATE], at 2:45 pm the resident was seen by the NP (Nurse Practitioner). New order to administer Morphine Sulfate Concentrate (MSIR) 20mg/cc liquid. Give (0.25 cc) 5 mg (milligrams) sublingual (under the tongue) every 12 hours at 6 am and 6 pm for pain. Continue PRN dosing. The resident received the scheduled MSIR (5 mg) at 6 pm on [DATE]. On [DATE], the resident received the following doses of pain medication. 6 am 5 mg MSIR (routine), 8:23 am 10mg MSIR (PRN), 12:30 pm 10 mg MSIR (PRN). On [DATE] at 12:30, a new order was given for Morphine Sulfate Concentrate (MSIR) 20 mg/cc. Give (0.25 cc) 5 mg sublingual every 8 hours for pain. Hold if respirations 14 or below per minute. The resident received MSIR at 6pm (routine) and the MSIR 5 mg (PRN) at 10:10 pm. On [DATE], the resident received the following doses of pain medication: 12 am, MSIR 5mg (routine) 8 am, MSIR 5mg (routine) 9:51 am MSIR 5mg (PRN) 12:31 pm MSIR 5mg (PRN) 4 pm MSIR 5 mg (held) - held respirations 10. 11:58 pm Tylenol Suppository 650 mg for elevated temp (temperature) of 102. On [DATE], the resident received the following pain medications: 12am MSIR 5 mg (routine) and MSIR 10 mg (PRN) 6 a m, MSIR 5mg (routine) 6:48 am Tylenol Suppository 650 mg for elevated temp of 101.8 8 am MSIR 5mg (routine) 12:28 pm MSIR 5mg (PRN) 4 pm MSIR 5 mg (routine) 10:35 pm Tylenol Suppository 650 mg for elevated temp of 100.2 10:37 pm MSIR 10 mg (PRN) On [DATE], the resident received the following pain medication: 12:00 AM: MSIR 5mg (routine) 5:19 AM: Tylenol Suppository 650 mg for elevated temp (temperature) of 102. 8:00 AM: MSIR 5mg (routine) 11:12 AM: MSIR 10mg (PRN) 4:00 PM: MSIR 5mg (routine) The resident expired on [DATE] at 8:40 PM. Review of the medical record revealed a (MOLST) Maryland medical Orders for Life-Sustaining Treatment. According to the document the resident was a do not transfer, but treat with options available outside of the hospital. At the time of the incident, the resident was on hospice care for end stage dementia and had been for greater than a year. During interview with the Director of Nursing on [DATE] at 1 pm, he/she stated that GNA #1 and GNA #2 had been in-serviced on the proper use of the Hoyer Lift, pad and straps. Based on review of MD00109991, MD00108061, medical records and interviews it was determined that the facility failed to 1) ensure that a resident's environment remained as free from accident hazards as possible as evidenced by the presence of side rails for a resident who had been assessed as not requiring side rails which resulted in bruising to the resident's forehead and eye (Resident #58) ; 2) & 3) ensure staff provided adequate supervision and assistance when utilizing a mechanical lift to prevent accidents as evidenced by two residents falling from the lift while being transferred resulting in a fractured hip for one resident and a head laceration for the second resident (Residents #257 and #81); 4) ensure that residents were transferred in a sit-to-stand lift by two staff members as required by the facility's procedures and nursing standard of care. The findings include: 1) On [DATE] review of Resident #58's medical record revealed the resident had resided at the facility for several years and whose diagnosis included dementia. On [DATE], a Bed Rails Eval was completed. This evaluation revealed the resident did not need bed rails for positioning/support and/or rising from supine to sitting/standing position as a mobility enabler and that Bed Rails were not indicated as a mobility enabler at this time. Nor were the bed rails a patient or resident representative preference. Review of nursing notes revealed a skin assessment was completed on [DATE] with no skin injury/wounds were noted. Further review of the nursing notes revealed that on [DATE] at 10:42 AM, the nurse documented: new onset/change in skin integrity as evidenced by bruise. Location: Resident noted to have bruise on right forehead as well as right outer eye. On [DATE] at 1:14 PM, nurse documented: [name of resident] has hand tremors and involuntary head movement (baseline) Has used top 1/4 rail to aide in independent bed mobility. Staff feels that [name of resident] may have bumped [his/her] head on the rail. Side rails have been removed. Skin is intact. No swelling. No signs of any distress. On [DATE] at 8:20 AM, interview with the Dementia Unit program manager revealed that if side rails were assessed as not being indicated they would either secure the rails in the down position or remove them from the bed. The Director of Nursing (DON) then reported that if the someone had snipped the tie down [securing device] then they would remove the rails from the bed and that if the resident can't use the rails they try to get rid of them. Surveyor then reviewed the concern that the resident had been assessed in December as not needing side rails but investigation into the bruising on the face in January determined it was a result of the side rails. On [DATE], the DON confirmed that side rails were on the resident's bed at the time of the injury and she had them removed from the bed after the injury was noted. 2) On [DATE] review of Resident #257's medical record revealed diagnosis which included: stroke with right sided weakness; and heart disease. The [DATE] Minimum Data Set assessment revealed that the resident was totally dependant for transfers with the assist of at least two staff persons. Review of the nursing notes revealed that on [DATE] Resident fell off hoyer lift while being transferred from the wheel chair to the shower chair with assist of 2 CNAs [certified nursing assistants]. One of the sling straps slid out the hook, and resident fell on the floor hitting [his/her] fore head, sustaining a hematoma [bruise]. Resident also complained of right knee pain Ice applied to hematoma. Patient sent to ED [emergency department] via 911. On [DATE], a Change in Condition Followup note revealed staff contacted the hospital and was informed that the resident had been admitted with a right hip fracture. On [DATE] at 3:10 PM, interview with GNA Staff #22 revealed that on [DATE] another GNA [Staff #23] had come to assist her with the transfer of the resident; she hooked her side and the other GNA hooked the other side; during the transfer the other GNA's side came loose. When asked if anything could of been done differently she replied: double check; if someone doesn't want to participate the right way get someone else to participate. Review of the employee file for the GNA Staff #23 revealed that on [DATE] an Individual Performance Improvement Plan was put in place regarding the incident on [DATE]. Review of this form revealed Resident [ID number] was being lifted via a mechanical lift when [s/he] slipped out of the sling causing [him/her] to fall to the floor. Patient received a fracture which necessitated transfer to the hospital. Upon investigation, it was determined that 1. the sling was not fastened correctly to the lift and 2. [Staff #23] failed to wait for the second GNA to assist with swinging patient over to the shower chair. On [DATE] at 5:00 PM, surveyor reviewed the concern with the DON and the Administrator regarding the resident's fall during the mechanical lift transfer which resulted in harm to the resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0246 (Tag F0246)

Could have caused harm · This affected 1 resident

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Based on interviews and observation, it was determined that the facility staff failed to honor the choices of Resident #57. This was evident for 1 of 36 residents selected for review during Stage 2 of the survey process. The findings include: On 7/28/17, a review of Resident #57's medical record was initiated. The concern exists that the Resident verbalized on 7/25/17 at 12:30 PM that facility staff is not getting him/her out of bed since the chair being used has been taken away. According to the Resident, it has been several months since the chair was removed. This Resident requires a bariatric sized chair, which is used for patients who require larger chairs to sit comfortably. In an interview with the DON (Director of Nursing), the reason given for the chair's removal was frequent refusals to get out of bed and the specialty chair, which was being rented, was returned. A review of medical record documentation doesn't reveal that the Resident refused to get out of bed. The Director of Nursing stated since the chair's return to the supplier, a dialysis chair had been set aside for the resident's use. But in an interview with the nurse in the dialysis center on 7/28/17 at 10:30 AM, it was stated that the center prefers their chairs not be used in the nursing center because they come back in bad condition and there are no available extra chairs in the dialysis center. In an intervew with employee #32 on 7/28/17 at 10:17 AM, it was revealed the Resident #57 has asked to get out of bed frequently, as recently as 2 weeks ago. When the nurse was made aware of the last request, the staff person was told that there were no chairs available. In a second interview with the Resident on 7/28/17 at 10 AM, he/she wanted to be able to get out of bed to relieve the pressure on his/her back and legs. The concern exists that the facility has not been meeting the needs of the Resident. The Director of Nursing and the Administrator were made aware at the exit conference.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0329 (Tag F0329)

Could have caused harm · This affected 1 resident

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The facility staff failed to provide adequate indication for administering of an antipsychotic medication for resident (#255). This occurred in 1 of 36 resident in the stage 2 sample. The findings include: Quetiapine Fumarate (Seroquel) is a medication used treat schizophrenia, bipolar disorder and depression. Review of resident (#255) medical record on 7/26/17 at 11 am revealed a physician order dated 7/6/17, to administer Quetiapine Fumarate (Seroquel) 150 mg (milligrams) by mouth at bedtime for depression. Further review of the medical record revealed the resident did not have a diagnosis of depression; however did have a diagnosis of schizophrenia. During interview with the Director of Nursing on 7/26/17 at 1 pm, it was revealed the resident is ordered the medication for schizophrenia and not depression. Not having the adequate indication for this medication could result in behaviors not being monitored to determine if the medication is needed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0514 (Tag F0514)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical record and interview with facility staff, it was determined that the facility failed to have a resident's death certificate on file in the closed record at the time of the survey. This was true for 1 of 6 residents (Resident #81) reviewed that had had expired in the facility. The findings include: During a review of Resident #81's closed record that took place on [DATE] at 9:40 AM, it was found that, although the resident had expired in the facility, no death certificate could be found in the closed record. When this concern was brought up with Medical Records personnel #18 at 11:00 AM on the same day, the survey team was told that the death certificate had been misfiled. It was produced for the survey team at 10:00 AM on [DATE] and was placed into the resident's closed medical record. These findings were reviewed with the facility's Administrator and Director of Nursing during the exit conference.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0253 (Tag F0253)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During an obsevation of the facility's external environment that took place on 7/27/2017 at 11:45 AM, it was found that the facility had a large hole in the brick exterior wall. The hole was located on the building's southern wall outside of the rehabilitation suite, according to the Director of Maintenance. The hole measured 11 inches in diameter at the widest measurement and was found to be filled with loose dirty rags. A tour of the exterior facility was completed with the Director of Maintenance on 7/28/2017 at 9:30 AM. The Director of Maintenance confirmed the hole, removed the towels and identified that water piping could be found inside the hole. The piping segment had been filled with fiberglass but a small gap in the fiberglass was large enough to allow access to rodents and other vermin. There were no obvious signs of pests. The findings were reviewed with the Director of Nursing and Administrator during exit. Based on observation and staff interview, while conducting facility tours, it was determined that the facility staff failed to maintain residents' physical environment in a clean, orderly and safe manner. The findings include: 1) On 7/27/17 at 12:00 PM, during a tour of the facility with the Administrator, it was determined that the carpeting throughout the facility was stained, worn and unsightly. 2) During the 7/27/17 tour of resident areas with the facility's Administrator, it was determined that the three food service carts, three drink carts and three used dishes carts had debris and stains. Each cart had a buildup of debris around the base and wheel areas and sides. The food service cart outside room [ROOM NUMBER] also had a torn front panel. The food service cart in the Homestead Unit lacked sides around the dish storage area. The Administrator confirmed the findings on 7/27/17 at 12:00 PM that the facility failed to maintain food service carts and carpeting in a sanitary manner.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0371 (Tag F0371)

Could have caused harm · This affected multiple residents

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Based on staff interviews, observation, and review of temperature logs and other pertinent documentation, it was determined that the facility 1) failed to take food temperature readings at critical control points during cooling of meats; 2) failed to ensure the reach in refrigerator in the kitchen was in good working order; and 3) failed to ensure the ceiling of the dry storage area was intact. Each of these unsafe practices placed all residents who consume food from the kitchen at increased risk for food borne illness. The findings include: 1) On 7/24/17 at approximately 10:30 AM, the Certified Dietary Manager (CDM Staff #25) reported that they do sometimes cook large pieces of meat that are then cooled down for later use. S/he went on to report that the cooks do monitor the cooling process but stated that they do not document the temperatures during the cooling process. Confirmed that there were no cooling logs. On 7/24/17 at 12:45 PM, the CDM presented the surveyor with a blank [name of corporation] Cooling Chart and reported that s/he was in the process of inservicing staff in the use of this form. Review of this form revealed the following instructions: Start recording temperature once the food reaches 135 F. Cool from 135 F to 70 F in 2 hours, then 70 F to 41 F or below for the remaining 4 hours. If product does not achieve cooling from 135 F to 70 F in 2 hours , it must be thrown out or reheated and then cooled again. The form also had columns to document the: Date; Food name of Roast Meat/Food item; [NAME] temperature and time, Time Begins (with 135 pre-printed in the temperature row); 1st hour, 2nd hour, 4th hour and 6th hour with rows for time and temperature for these reading. On 7/27/17 at approximately 1:00 PM, surveyor observed a Cooling Chart posted in the kitchen which had documentation of a temperature of 190 at 12:30 in the [NAME] column; 1:30 in the Times Begins column; 170 at the 1st hour, and 140 at 2nd hour. There was no documentation found on this posted chart as to the date, the name of the food item or any temperatures below 140. When the surveyor asked the cook (Staff #27), if a roast is at 135 degrees at 11:00 am and two hours later the temperature is at 80 degrees what would you do? The cook's response was to cut the meat down [into smaller pieces] to get it cooled down some more. After reviewing the Cooling Chart instructions with the cook, she stated she had answered the question wrong. The cook denied having received any recent inservices regarding the cooling process of meats. The concern regarding the failure of kitchen staff to document cooling temperatures and the cook's inability to verbalize the appropriate action if food had not cooled to the proper temperature was reviewed on 7/27/17 with the acting food service director (Staff #26). This concern was also reviewed with the Administrator on 7/27/17 at 5:00 PM. 2) On 7/24/17 at approximately 10:15 AM during the kitchen tour the surveyor observed, in the presence of the CDM (Staff #25), the temperature of the reach in refrigerator (#2) to be 50 degrees. The CDM reported they had been using the refrigerator a lot that morning. At 12:45 PM, the CDM reported to the surveyor that the temperature of the reach in refrigerator was now down to 40 degrees. Review of the facility's HACCP [Hazardous Analysis Critical Control Point] Food Flow Chart for Cold Ready to Eat Foods revealed that items should be stored in a refrigerator at 40 F or less. On 7/27/17 at approximately 12:15 PM during a re-visit to the kitchen the surveyor observed, in the presence of the acting food service director (Staff #26), that the temperature of the reach in refrigerator was above 45 degrees. At 4:40 PM surveyor observed that all of the items had been removed from the reach in refrigerator and a sign had been posted to not use the refrigerator. Staff #26 reported that there was an issue with the refrigerator not getting to temperature, that he had thrown out all the items that had been stored in that refrigerator and had contacted a repair company. Surveyor then reviewed the July 2017 Refrigerator temperature log identified by staff as being for the reach in refrigerator. This log revealed that the temperature was documented every day at 6:00. On the following dates the temperature was documented above 40 degrees: 7/5: 46 degrees 7/6: 42 degrees 7/13: 46 degrees 7/14: 44 degrees 7/19: 42 degrees 7/21: 42 degrees No documentation was provided to indicate these elevated refrigerator temperatures had been addressed by staff prior to 7/27/17. The concern regarding the refrigerator temperatures was addressed with the Administrator on 7/27/17 at 5:00 PM. The Administrator reported they expected the repairmen that evening. 3) On 7/24/17 at 10:05 AM during tour of the dry storage area of the kitchen it was observed that approximately a 6 inch x 18 inch section of a ceiling tile was missing, pipes were noted going up into the ceiling and insulation was exposed. At 12:45 PM the Certified Dietary Manager (Staff #25) reported that maintenance was addressing the open area in the ceiling today. On 7/27/17 surveyor observed, in the presence of the acting food service director (Staff #26) that part of the open area had been repaired; however, there remained open areas of approximately 1 inch by 2 inches from the wall to one of the pipes; and an open area of approximately 1.5 x 1 inch around the second pipe. Surveyor discussed the concern with the food service director that these open areas can be a point of access for insects or mice. The concern regarding the open areas in the ceiling of the dry storage area was addressed with the Administrator on 7/27/17 at 5:00 PM.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0498 (Tag F0498)

Could have caused harm · This affected most or all residents

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Based on review of MD00108061, medical records and employee files and interviews with staff it was determined that the facility failed to have a system in place to ensure all geriatric nursing assistants (GNA) received training and demonstrated competency in mechanical lift transfers after an incident in which a resident fell during a transfer; and failed to have an effective system in place to document that newly hired GNAs have demonstrated skills competency. These failures put all residents in the facility at risk of injury. The findings include: Cross reference to F 323. 1) On 7/26/17, review of the facility reported incident MD00108061 revealed that on 10/31/16 a resident had fallen during a mechanical lift transfer and that the facility was providing staff education on Safe Resident Handling which would include verbal and visual competencies and include a post test. On 7/26/17, the credible evidence that the GNAs had been observed using proper technique and were competent to perform transfers safely was reviewed. This review failed to reveal documentation that all of the GNAs that had been employed in November 2016 had been observed and deemed competent to perform transfers safely. On 7/26/17, the Nurse Practice Educator reported that she was not positive that every GNA that worked in the building as of 10/31/16 had received the training. She went on to report that she had not done all the trainings herself. On 7/27/16 after further review of the documentation with the surveyor, the Nurse Practice Educator confirmed that several GNAs missed the training/competency observation in November 2016. Surveyor then discussed the concern with the Nurse Practice Educator (NPE) that, when a training need is identified, there was no system in place to ensure all GNAs would receive the training. 2) On 7/27/17 at approximately 9:00 AM, the Director of Nursing reported that newly hired Geriatric Nursing Assistants (GNA) are assigned to work with a mentor and that there is a skills check off that should be completed and put in their employee files. On 7/27/17 review 5 GNAs hired since February 2017, who according to staffing sheets worked in July 2017, revealed that 4 (Staff #28, #29, #30 and #31) out of the 5 GNAs failed to have any documentation of skills competency prior to being allowed to work independently. This information was reviewed with the NPE who confirmed there was no new hire skills documentation for these employees. The NPE reported that she had identified this as a problem and had instituted a form that the new hires had to sign indicating they had to return the skills sheet prior to coming off orientation but was unable to state when she began using the form. On 7/27/17 at 5:00 PM, surveyor reviewed the concern regarding the failure to complete the mechanical lift training with all of the GNAs after the October 2016 incident; and the failure to have a system in place to ensure newly hired GNAs have demonstrated skills competencies prior to working independently with the DON and the Administrator.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), Special Focus Facility, 3 harm violation(s). Review inspection reports carefully.
• 143 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $23,543 in fines. Higher than 94% of Maryland facilities, suggesting repeated compliance issues.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Pines Nursing And Rehab's CMS Rating?

CMS assigns PINES NURSING AND REHAB an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Pines Nursing And Rehab Staffed?

CMS rates PINES NURSING AND REHAB's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 53%, compared to the Maryland average of 46%.

What Have Inspectors Found at Pines Nursing And Rehab?

State health inspectors documented 143 deficiencies at PINES NURSING AND REHAB during 2017 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 133 with potential for harm, and 5 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Pines Nursing And Rehab?

PINES NURSING AND REHAB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by KEY HEALTH MANAGEMENT, a chain that manages multiple nursing homes. With 195 certified beds and approximately 120 residents (about 62% occupancy), it is a mid-sized facility located in EASTON, Maryland.

How Does Pines Nursing And Rehab Compare to Other Maryland Nursing Homes?

Compared to the 100 nursing homes in Maryland, PINES NURSING AND REHAB's overall rating (1 stars) is below the state average of 3.0, staff turnover (53%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Pines Nursing And Rehab?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.

Is Pines Nursing And Rehab Safe?

Based on CMS inspection data, PINES NURSING AND REHAB has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Maryland. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Pines Nursing And Rehab Stick Around?

PINES NURSING AND REHAB has a staff turnover rate of 53%, which is 7 percentage points above the Maryland average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Pines Nursing And Rehab Ever Fined?

PINES NURSING AND REHAB has been fined $23,543 across 1 penalty action. This is below the Maryland average of $33,314. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Pines Nursing And Rehab on Any Federal Watch List?

PINES NURSING AND REHAB is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.

Facility Details

Beds: 195
Avg. Residents: 120
Occupancy: 61.6%
Ownership: For profit - Corporation
Chain: KEY HEALTH MANAGEMENT
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
2 Immediate Jeopardy citations: -24
3 Actual Harm citations: -15
143 Deficiencies: -10
Fines ($23,543): -2
Abuse Finding: -15
Special Focus Facility: -20
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 215010