Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interviews with the staff and resident, it was determined that the facility failed to ensure the Comprehensive Minimum Data Set (MDS) assessments accurately reflected the resident's oral/dental status. This was found to be evident in 1 (Resident # 269) of 4 residents reviewed for the MDS assessment during the recertification/complaint survey. The findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the appropriate care they need. On 01/31/25 at 10:59 AM, Resident # 269's medical record was reviewed. The resident was initially admitted in February 2024 to the facility after undergoing abdominal surgery. Around mid-April 2024, the resident was hospitalized due to high ostomy output and re-admitted to the facility on [DATE]. On 1/31/2024 at 11:30 AM, a review of the MDS(Minimum Data Set) Comprehensive Assessment Section L - Oral/Dental Status dated 3/31/2024 and 4/26/2024 respectively was coded to have no oral or dental concern. On 1/31/2024 at 11:45 AM, a review of the Nursing admission assessment dated [DATE] revealed that it was documented the presence of own teeth, and the re-admission nursing assessment dated [DATE] documented the presence of a lower denture. On 1/31/2024 at noon, a review of the physician order identified an order created on 4/23/2024 that showed Patient admitted with partial lower denture please assist to apply in the morning and remove at bedtime every day and night shift. During an interview with Resident #269 on 01/31/25 at 01:03 PM, the resident stated he/she used to have both upper and lower dentures, however, before his/her initial admission to this facility, his/her upper denture was broken during a hospital procedure. The resident said, During my re-admission to this facility, I had my lower denture, but now the lower denture was broken and I have missing upper and lower teeth. On 1/31/2024 at 1:10 PM, the surveyor observed Resident #269 and verified that he/she did not have upper or lower dentures, with broken and missing upper and lower teeth. On 02/05/25 at 1:27 PM, the MDS manager (Staff # 48) was interviewed, and she explained the process of doing the MDS (Minimum Data Set) Comprehensive Assessment. She stated that the first step was to open the assessment and plot the date for the ARD (Assessment Reference Date) then for each section of the assessment, a record review will be done, then a resident interview and physical assessment related to pain, vision, hearing and oral condition will be conducted. Staff # 48 stated that she performed a record review, an interview, and a physical assessment of Resident #269 on both scheduled MDS Comprehensive Assessments dated 3/1/2024 and 4/26/2024 respectively. Staff # 48 acknowledged the presence of lower dentures based on the Nursing admission assessment dated [DATE]. Staff # 48 also confirmed that in section L of both Comprehensive assessments with ARD 3/1/2024 and 4/26/2024, no oral or dental issue was coded. On 02/07/25 at 12:30 PM, during the exit conference, the MDS concern was discussed with the Administrator and the Director of Nursing.

Based on record review and interviews, it was determined that the facility failed to thoroughly develop and implement a comprehensive person-centered care plan that addresses resident's medical, nursing, and mental and psychosocial needs that was identified in the admission comprehensive assessment. This was evident for 1 (Resident #89) of 4 residents care plans reviewed during the recertification/complaint survey process. The findings include: On 01/28/25 at 09:54 AM, in an interview with the resident's (Resident #89) representative, it was expressed to the surveyor that on 1/27/25 the resident had an episode of incontinence, the resident representative stated that the staff was notified of the resident's incontinence; however, incontinence care was not provided until a couple of hours later. On 01/29/25 at 11:23 AM, a review of the Geriatric Nursing Assistant (GNA) task list for Resident #89 in the month of January 2025 revealed that incontinence care was documented once on 1/27/25 at 1:36 AM. On 01/29/25 at 11:23 AM, review of the medical record revealed that the resident was a readmission in January 2025. A review of Resident #89's comprehensive care plan revealed that the care plan was not person-centered and it failed to identify and address all the services and interventions needed to attain or maintain the resident's highest practicable physical, mental, and psychosocial health. On 01/29/25 at 11:41 AM, in an interview with RN #55, she stated that the GNAs provide scheduled incontinent care and GNA usually does the incontinent care in the morning, after the start of shift, in the afternoon and as needed on day shift. She confirmed that the GNA was expected to document incontinent care on the GNA task list. RN #55 was also asked who was responsible for updating the care plan and she stated that every nurse can update the care plan as needed. RN#55 was then shown Resident #89's care plan and the surveyor expressed the concern that it did not reflect the care needs of the resident and she stated the care plan needs to be updated. On 01/30/25 at 09:45 AM, in an interview with RN #70, unit manager was asked who was responsible for updating the care plan and she stated the floor nurses and the nurse managers were responsible for updating the care plan. She stated that care plans were updated initially within 30 days, as needed with any change and 90 days with the admission assessment. Resident #89's care plan was reviewed with RN#70 and she was informed that the care plan does not reflect the resident's personal care needs nor all active diagnoses and interventions/treatments that will be provided to meet the care needs of the resident. On 01/30/25 at 12:35 PM, in an interview with the Director of Nursing (DON #1), she was informed of the above-mentioned findings and she stated that the comprehensive care plan was initiated; however; the unit manager was responsible for the care plan review and it was missed.

Based on review of resident medical records and interviews with resident and facility staff, it was determined that the facility failed 1) to involve/invite a resident who had the capacity, to attend his/her own care plan meetings, and 2) to revise the resident's care plan after the resident developed a stage 2 sacral pressure ulcer. This was evident for 2 residents (Resident #96 and #963) out of 4 residents reviewed for care plan during the Medicaid/Medicare recertification/complaint survey. The findings include: 1) On 01/28/25 at 10:47 AM, during the initial screening of Resident #96, when he/she was asked if he/she or someone that he/she had appointed, had been to meetings where his/her own plan of care care was discussed, he/she stated that he/she has never attended one because nobody ever told him/her about any meeting. On 01/29/25 at 09:32 AM, the surveyor reviewed the electronic health records of the resident revealed that Resident #96's Brief Interview for Mental Status (BIMS) score for all quarters in 2024 was 15.0 out 0f 15.0. It also revealed that Resident #96 did not attend the care plan meetings for the last 3 quarters in 2024, and there was no documentation showing that the resident had attended the meeting or the reason why the resident did not attend the care plan meetings. On 01/29/25 at 11:07 AM, in an interview with the Director of Social Work #5 when she was asked why Resident #96 was not included in his/her care plan meetings, she stated that the resident had his/her own issues and most times he/she declined to go to the meeting. She also added that there was always a note in the progress note to indicate resident's attendance and refusals. Director of Social Work #5 also informed the surveyor that she spoke with one of the social workers covering the building (via the phone) and stated that the person had told her that Resident #96 was agitated and could not attend the care plan meetings. 01/29/25 11:26 AM, the surveyor reviewed Resident #96's electronic health record with the Director of Social Work #5, there was no documentation seen. The Director of Social Work #5 also confirmed that there was neither documentation stating if the resident was invited to the care plan meetings nor documentation of the resident's reason for not attending the care plan meetings in the record. On 01/29/25 at 11:38 AM, the Director of Social Work informed the surveyor that she wanted to check in with the social worker in charge of the building to see if there was any other documentation somewhere. At 11:58 AM, she informed the surveyor that there was no further documentation as it was not documented and that going forward, they would always document the residents' participation and reasons if the resident was not available. 01/29/25 02:07 PM, The Nursing Home Administrator was informed about the findings. 2) On 2/4/2025, at 11:01 AM, a record review of Resident #963 noted that a care plan was initiated on 08/20/2024 on admission to the facility with a revision date of 9/15/2024, and a target date of 11/19/2024. A further record check revealed Staff #32 wrote a progress note on 8/20/2024 at 7:55 PM, stating that Resident #963, Condition of skin is normal with no pressure injury identified on admission.Additional record review on 2/4/2025 at 11:15 revealed a change in condition note dated 8/25/2024 at 11:42 by staff # 68 that stated, While doing morning care, the patient was noted with a stage 2 pressure ulcer on his sacrum area. The dressing was done using solosite gel, the resident denied any pain, and the provider was notified. On 2/4/2025 at 12:43 PM, an interview was conducted with staff # 32, who stated that care plans should be updated by the nurse or unit manager when there was a change in condition such as a wound. In an interview with the Director of Nursing (DON #1) on 2/4/2025 at 1:43 PM, the surveyor reviewed Resident #963's care plan with the DON #1. She verified that the care plan was not updated after the discovery of the stage 2 sacral pressure ulcer on 8/25/2024.

Deficiency Text Not Available

Based on facility reported incident and complaint, medical record review and interview, it was determined the facility failed 1) to provide care to meet the needs of a resident's physical, mental, and psychosocial health, 2) to ensure that residents receive treatment and care to promote the highest practicable wellbeing as evidenced by failures to consistently assess a resident for pain and failures to follow physician orders timely, and 3) to acquire a patient's medication to be administered thereby causing a delay in treatment. This was evident for 3 (Resident #131, #614, and #913) of 108 residents reviewed during a recertification/complaint survey. The findings include: 1) The facility staff failed to properly perform neuro checks after a fall for Resident #614. 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 the facility's 72 hour assessment protocol provided by DON #1 revealed the facility staff are to complete neuro checks at initial assessment, every 15 minutes X 4, then every hour X 3, then every 2 hours X 4, then every 4 hours X 3, then every shift for 48 hours. Review of Resident #614's medical record on 1/31/25 revealed the Resident had 2 falls on 8/4/24. The first fall was at 3:15 PM and the second fall was at 6:30 PM. Review of a nurse's note on 8/4/24 at 3:15 PM revealed the facility staff documented, Staff heard a loud bang noise turned around and observed resident on the floor by the bench in the hallway rubbing the right side of his/her head. Further review of Resident #614's medical record revealed after the first fall on 8/4/24 the facility staff did the initial assessment 8/4/24 at 3:15 PM, then neuro checks at 3:30 PM, 3:45 PM, 4:00 PM and then not again until 6:10 PM. The facility staff failed to do the last 15 minute neuro check at 4:15 PM and the hourly neuro check at 5:15 PM. Review of a nurse's note on 8/4/24 at 6:30 PM revealed the facility staff documented, Resident had another fall at 6:30 PM while ambulating with his/her walker. Further review of Resident #614's medical record revealed after the second fall on 8/4/24 the facility staff did the initial assessment 8/4/24 at 6:30 PM and not again until 7:30 PM. The facility staff failed to restart the 72 hour assessment protocol after the 2nd fall and do neuro checks every 15 minutes at 6:45 PM, 7:00 PM and 7:15 PM. The facility staff failed to do the hourly neuro checks at 8:30 PM, 9:30 PM and 10:30 PM. Interview with the Director of Nursing #1 on 1/31/25 at 9:35 AM confirmed the facility staff failed to complete neuro checks for Resident #614 on 8/4/24 per facility protocol. 2) On 2/3/2025 at 11:04 AM, a review of the investigation report of Facility Reported Incident (FRI) MD00212905, revealed that on 12/15/2024 around 20:00 (8:00 PM) Resident #131's daughter spoke to the charge nurse and requested to have Certified Registered Nurse Practitioner (CRNP)/MD (Medical Doctor) assess the resident's left hand due to soreness. The charge nurse assessed Resident #131's left hand and there were no bruises, discoloration nor swelling noted per documentation. Pain medication was administered as Resident #131 was on routine pain medication and pain scale was at 0/10. Charge nurse sent a secure message on 12/16/2024 at 7:12 AM and again at 7:16 AM to the clinical team regarding Resident #131's daughter's request. Per the report, on 12/16/2024 at 11:00, CRNP visited with Resident #131 regarding the report of left hand soreness and gave an order for Occupational therapy (OT) evaluation as no soreness was noted. However, OT did not see the resident until 12/21/2024, as reflected in an Occupational Therapy (OT) Treatment Encounter Notes dated 12/21/2024: Pt is a LTC (long term care) resident here at SK. Pt. was referred to OT skilled services secondary to discomfort on left hand and decreased ROM (range of motion). Patient referred to OT due to exacerbation of decrease in range of motion indicating the need for OT to improve motor control/tone in UE (upper extremity) and facilitate tone in UE. Medical chart reviewed and OT evaluation was completed Thus, OT failed to see and evaluate Resident #131 in a timely manner and failed to address Resident #131's left arm fracture revealed by XRAY done that morning of 12/21/2024. Further review of the report revealed that On 12/20/2024 at 17:30 (5:30 PM), Geriatric Nursing Assistant (GNA) reported to charge nurse that Resident #131was screaming for pain when their left arm was lifted. Charge nurse conducted an assessment of Resident #131 and confirmed that the resident screamed when their arm was lifted. Charge nurse notified CRNP who gave an order for a stat XRAY of the resident's left arm and wrist to rule out fracture. The XRAY was done on 12/21/2024 at 5:00 AM and on 12/21/2024 at 7:50 AM, facility staff received the XRAY results that revealed Acute fracture at the greater tuberosity with lateral displacement. Diffused Osteopenia. Mild DJD at the left shoulder without discoloration. 0n 12/21/2024 at 8:36 AM, CRNP was made aware of the XRAY report and new orders given for pain med x two days, orthopedic consult for left humerus fracture, and immobilize left arm. However, a review of Resident #131's medical records revealed that the resident did not have the orthopedic consult done until 12/23/2024 when the resident was sent to the ER via 911 where they further confirmed an acute left arm fracture. On 2/04/2025 at 9:57 AM, in an interview with the Director of Nursing (DON #2), surveyor reviewed the timeline of events, staff assessment of pain, and delay in scheduling/providing ordered consults/treatment. DON #2 stated that the Charge Nurse heard left hand soreness and focused her assessment on the resident's left hand. DON #2 confirmed that staff assessment was not consistent and stated that the staff should have assessed Resident #131's entire arm when the resident's daughter requested it, as that was an opportunity to do a full assessment of the resident. Regarding the gap between when Resident #131's daughter requested an assessment (12/15/2024) to when an XRAY was ordered/done (12/21/2024), DON #2 stated that the Nurse Manager had requested on 12/16/2024 via secured message that an XRAY of the left arm be done but the CRNP requested that staff continue to assess and OT to see and evaluate Resident #131. On 2/4/2025 at 12:18 PM, an interview was conducted with the 3 East Clinical Team Manager (CTM #31). CTM #31 confirmed that Resident #131's daughter had told staff during care conference on 12/16/2024 that the resident had left arm pain. CTM #31 stated that she did an assessment of the resident and found out that Resident #131was in pain when the left arm was lifted (resident made a sound) but she (CTM #31) did not observe any swelling and/or discoloration to the resident's arm. CTM #131 stated that she then asked Resident #131's assigned Licensed Practical Nurse (LPN #11) to send a secure message and request an order for an XRAY. However, CTM #31 stated that the request was made but the CRNP (Certified Registered Nurse Practitioner) did not want to do an XRAY and ordered OT to see Resident #131. Regarding resident assessments, CTM #31 stated that the expectation was that when a nurse goes to do an assessment of a resident, it should be thorough (head-to-toe). CTM #131 confirmed that the assessment done by the Charge Nurse on 12/15/2024 when Resident #131's daughter first requested an assessment of the resident's pain was not thorough. On 2/4/2025 at 1:26 PM, in an interview with the Program Director for Rehab (Staff #7), he confirmed that Resident #131 had an OT evaluation completed on 12/21/2024 at 3:48 PM by a part time (PRN) Occupational Therapist (OT #37), five (5) days after the CRNP gave the order for OT to see and evaluate the resident. On 2/4/2025 at 1:32 PM, a phone interview was conducted with Occupational Therapist (OT #37). Regarding the delay in seeing Resident #131 for OT evaluation as ordered, OT #37 stated that she got an order to see Resident #131 on 12/18/2024 but their system was down and so the resident was rescheduled to be seen on 12/21/2024 by the Therapy Scheduler. OT #37 stated that the referral was for left arm pain. She further stated that when she went in to see Resident #131on 12/21/2024, the resident was lying in bed comfortable and had bilateral hand contractures. OT #37 stated that she did not see the XRAY results that indicated the resident had a left arm fracture prior to going in to evaluate the resident: OT #37 stated that her evaluation of Resident #131 comprised of assessing both hands for range of motion (ROM) and contracture management. On 2/7/2025 at 8:29 AM, in a follow up interview with DON #2, she was made aware of surveyor's concerns regarding staff assessment of Resident #131's pain not being consistent, OT not seeing the resident in a timely manner, and delay in sending the resident out for orthopedic evaluation and proper management of the resident's left arm fracture. Based on when Resident #131 first began experiencing pain, it was determined that the facility staff failed to properly assess the resident, delayed in obtaining an X-ray of the resident's left arm and sending the resident out for orthopedic management of their left arm fracture. DON #2 confirmed surveyor's findings and stated they identified opportunities for improvement and have re-educated staff on those areas. 3) On 02/03/2025 at 12:53 PM, the surveyor reviewed intake number MD00198273, and it showed that the complainant had alleged the facility failed to acquire Resident #913's antibiotic medication to be administered upon his/her admission and he/she went for 2 days without receiving them. At 1:12 PM, the surveyor reviewed the electronic health record of Resident #913, and it revealed the following: a) The Nursing Progress note on 7/15/2023 at 09:00 PM showed- Resident #913 is a new admit to facility from the hospital. The resident is alert and oriented X 3, able to make his/her needs known. The resident is admitted for rehab to continue with his/her antibiotics (ABT) therapy for endocarditis. b) The Electronic Medication Administration record note on 7/15/2023 at 11:52 PM showed -Daptomycin Intravenous Solution Reconstituted 500 MG. Use 500 mg intravenously every 48 hours for endocarditis until 08/23/2023 at 11:59 PM. Daptomycin start date 7/16/23 at 6:00 PM, last administered at the hospital 7/14/23. c) The Electronic Medication Administration record note on 7/16/2023 at 7:15 PM showed- Daptomycin Intravenous Solution Reconstituted 500 MG. Use 500 mg intravenously every 48 hours for endocarditis until 08/23/2023 11:59 PM. IV Pharmacy called and stated they are reconstituting the solution and will be delivered. The oncoming nurse was made aware. d) On 07/17/2023 at 00:25 AM, RN #59 sent a secured message to the Physician, Staff #60 stating Good morning Doctor. Patient #913 is a new admit yesterday, he/she was supposed to have his/her IV Daptomycin 500mg yesterday at 6pm, the order states after every 48 hours and yesterday it was due. But unfortunately, it was not delivered by the pharmacy. Just got to them now and they say it will be delivered today at 2:30 AM. Could we reschedule the administration for today at 6pm. At 07:48 AM, the physician responded positively. e) The Electronic Medication Administration record note on 7/15/2023 at 11:52 PM showed that Daptomycin Intravenous Solution Reconstituted 500 MG was given on 07/17/2023 at 2:54PM. On 02/04/2025 at 7:30 AM, in an interview with the Clinical Team Manager of 2 West, Staff #19, when she was asked about the antibiotic treatment for Resident #913, she stated that the resident came in from admission on a Saturday evening (07/15/2023) and was supposed to get two antibiotics (Cefepime and Daptomycin). She stated that the resident was to commence Daptomycin Intravenous Solution Reconstituted 500 MG on 07/16/23 at 6:00 PM and every 48 hours. She stated that multiple calls were made to the pharmacy on 07/16/2023 but the medication was not sent to the facility, but the other antibiotic (cefepime) was given as scheduled because it was available in the facility. She also added that Daptomycin Intravenous Solution Reconstituted 500 MG was eventually sent on 07/17/2023 and a one-time dose was given at around noon per the Doctor's recommendation. On 02/04/2025 at 8:17 AM, Director of Nursing (DON #2) and Clinical Team Manager of 2 West, Staff #19 were both informed about the time Daptomycin Intravenous Solution Reconstituted 500 MG was ordered and the time it was given and they both agreed that the treatment was delayed.

Deficiency Text Not Available

Deficiency Text Not Available

Based on record reviews and interviews, it was determined that the facility failed to conduct the annual performance review for the Geriatric Nursing Assistants (GNA). This was identified for 1 of 3 GNA employee record (GNA #71) reviewed during the recertification/complaint survey process. The findings include: On 02/04/25 at 10:00 AM, during the staffing facility task the surveyor reviewed 3 GNAs' employee records. The record review revealed that the facility failed to provide signed documented evidence to support that GNA #71's performance review and in-service education based on the performance review results was completed in the year 2023 and 2024 as required. On 02/06/25 12:53 PM, in a telephone Interview with the Director of Nursing (DON #1), the DON #1 stated that GNA #71's performance review and competency assessment was missed in the year 2023. The 2024 performance review was documented; however, it was not signed because GNA #71 works on a PRN (as needed) schedule. On 02/07/25 at 10:24 AM, in an interview with the DON #1, she was asked if there was a competency assessment done in the year 2024 for GNA #71, she stated no, the competency assessment was usually done at the time of the performance review. The DON #1 stated that the performance review and competency assessment will be completed next week.

Based on observation, record review and interview it was determined the facility failed to ensure the monitoring for side effects for a psychotropic medication for Resident #25. This was evident for 1 out of 5 residents reviewed for unnecessary medications during the facility's recertification/complaint survey. The findings include: On 1/29/25 at 8:30AM the surveyor conducted a review of the medical record of Resident #25 and observed the following medical order dated as beginning on 1/4/25 for the following medication that they were receiving: Escitalopram Oxalate Oral Tablet 20 MG, Give 1 tablet by mouth one time a day for depression. Further review by the surveyor of the medical record for Resident #25 revealed side effect monitoring had not been instituted for the use of this psychotropic medication. On 1/29/25 at 9:27AM the surveyor conducted an interview with Licensed Practical Nurse #35 who reported to the surveyor that the process the facility uses for monitoring of side effects for residents receiving psychotropic medications is that a separate order is instituted on the medication administration record (MAR) for the resident in which alerts the nurses to complete and document assessment for side effect monitoring. On 1/29/25 at 9:36AM the surveyor conducted an interview with Clinical Team Manager (CTM) #33 who reported to the surveyor that the way side effects of psychotropic medications were monitored for residents was via the separate order on the MAR. When the surveyor inquired as to why Resident #25 did not have side effect monitoring for the use of the escitalopram medication, CTM #35 responded to the surveyor: yes, it would be on the medication administration record, but for some reason, I am not seeing it, for some reason it was dropped on 12/23/24. The surveyor shared their concerns with CTM #35 who acknowledged and confirmed understanding of the concerns and stated the following information to the surveyor: Yes, this should be in place for the resident, I'm putting it in as of today. On 1/29/25 at 10:18AM the surveyor conducted an interview and shared the concern with the facility's Director of Nursing (DON #1) who reported that the medications had been reviewed for the resident, however, it was just missed. At this time, the DON #1 acknowledged and confirmed understanding of the surveyor's concern. On 2/6/25 at 12:20PM the surveyor reviewed the medical record for Resident #25 and observed that after surveyor intervention, the medical order for side effect monitoring for psychotropic medication was instituted on 1/29/25 at 9:42AM. On 2/7/25 at 12:30PM the concern was shared with the facility's Administrator and DON #1 during the facility's exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with staff and the resident, observation, and medical record review, it was determined that the facility failed to provide appropriate dental care. This was evidenced by the resident's dental status not being accurately monitored and failing to have follow-up dental service. This was evident for 1 (Resident # 269) of 1 resident reviewed for dental care during this recertification/complaint survey. The findings include: On 1/31/2025 at 10:59 AM, a medical record review for Resident # 269 was conducted. The review revealed that the resident was admitted to this facility in February 2024 after undergoing abdominal surgery. Around mid-April 2024, the resident was hospitalized due to high ostomy output and re-admitted to the facility on [DATE]. On 1/31/2024 at 11:45 AM, a review of the Nursing admission assessment dated [DATE] revealed that it was documented the presence of own teeth, and the re-admission nursing assessment dated [DATE] documented the presence of partial lower dentures. Furthermore, the Brief Oral Health Status Form dated 3/4/2024, 4/29/2024, and 10/29/2024, documented in question # 6 Condition of Natural Teeth was coded 4 or more decayed or broken teeth/roots; fewer than 4 teeth in either jaw while in question # 7 Conditions of Artificial Teeth were unremarkable for all 3 oral assessments. In addition, upon further review of the Brief Oral Health Status dated 3/4/2024, 4/29/2024, and 10/29/2024 they were documented in item #12, additional Comments stated: Oral assessment completed, the patient has no upper teeth and few teeth in the lower part. Further review of Resident #269's order revealed that 4/23/2024 a physician order was created as Patient admitted with partial lower denture please assist to apply in the morning and remove at bedtime. On 1/31/2025 at 12:10 PM, the electronic medical record review of Resident #269 in the Treatment Administration Record from April 2024 until January 31, 2025, showed that nursing staff documented they were assisting with applying the partial lower dentures daily, put on in the morning and to remove at bedtime. On 1/31/2025 at 12:30 PM, the electronic medical record review for Resident # 269 revealed that a copy of the referral to Health Drive (the facility's referral system to contact dental, vision, and podiatry services) dated 8/15/2024 for dental consultation due to decayed, loose teeth, and dental check. Upon further record review, no follow-up documentation related to this referral was found. Furthermore, a referral to Health Drive was done dated 10/8/2024 for dental consultation due to loose, ill-fitting, or broken dentures and teeth check-ups. No follow-up documentation was found in his medical record if Resident # 269 was seen or not. During an interview with Resident #269 on 1/31/2025 at 1:00 PM, the surveyor asked if he/she had a denture. Resident # 269 stated I used to have both upper and lower dentures, however, before his/her initial admission to this facility, his/her upper denture was broken during a hospital procedure. The resident said, During my re-admission to this facility, I had my lower denture, but now the lower denture was broken and I have missing upper and lower teeth. On 1/31/2025 at 1:10 PM, the surveyor verified that Resident # 269 had no upper and lower dentures, with missing upper and lower teeth. On 01/31/25 at 1:20 PM, an interview was conducted with Staff # 15 (Licensed Practical Nurse). The surveyor asked if a resident had a denture, and who was assisting to apply the appliance to the resident. Staff # 15 stated that the nurse usually helped. A follow-up question was asked to Staff #15 if Resident # 269 had a denture. Staff # 15 stated that Resident # 269 had no dentures. On 1/31/2025 at 1:30 PM, a review of the progress notes in the medical record revealed a note from the Social Worker (Staff # 69) dated 12/16/2024 stating Resident requested assistance with determining if the resident's insurance covers obtaining new dentures. The Unit Social Worker contacted the resident's dental insurance and confirmed that the resident's dental insurance does not cover new dentures. On 01/31/25 at 1:35 PM, an interview was conducted with the Director of Social Services (Staff # 5). She verified the documentation from Staff # 69 and stated that no further action was required from the social work department. She also added that the nursing department was responsible for any dental services. During an interview with the Director of Nursing (DON #1) on 01/31/25 at 01:55 PM, the surveyor reviewed Resident #269's medical record with her. The DON #1 validated that there was no documentation from the nursing admission assessment and the brief oral assessment of any dentures, however, there was an order created on 4/23/2024 for the denture to be applied in the morning and removed at bedtime by the staff. The DON #1 acknowledged, that Resident #269 had a dental referral and there was no follow-up with the dental appointment until 1/31/2025.

Deficiency Text Not Available

Based on review of facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 9 (#629, #638, #640, #366, #625, #5, #622, #87, and #619) residents of 60 facility reported incidents reviewed during a recertification/complaint survey. The findings include: The Minimum Dats Set (MDS) is a standardized and comprehensive assessment screening tool used to identify resident's individual needs and areas of concern. BIMS stands for Brief Interview for Mental Status. It is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. 1) On 1/28/25 at 11:30 AM a review of facility reported incident MD00167904 was conducted and revealed a Clinical Team Manager received an email on 5/31/21 that stated on 5/30/21 around 2pm, Resident #629 complained to a musical therapist that he/she was raped 3 weeks ago. Review of the facility's investigation revealed that 36 staff were interviewed, however there were no resident interviews from the unit where Resident #629 resided. On 2/3/25 at 2:15 PM an interview was conducted with the DON #1. The DON confirmed that there was no resident interviews found in the investigative packet given to the surveyor. 2) On 1/29/25 at 8:10 AM a review of facility reported incident MD00195669 was conducted and revealed Resident #638 alleged that someone had punched the resident 3 times in the face the night before. Review of the facility's investigative packet that was given to the surveyor on 1/29/25 revealed there were (9) staff members that had worked with the resident that were interviewed. There were no resident interviews from residents that resided on the same unit to ask if they felt safe or had any abuse concerns with staff members. On 1/29/25 at 12:11 PM an interview was conducted with the Director of Nursing (DON #1). The DON #1 checked to see if the social worker had emailed resident interviews for the intake and confirmed that she did not have any resident interviews. 3) On 1/29/25 at 11:00 AM a review of facility reported incident MD00194021 was conducted and revealed Resident #640 alleged that a GNA was very rough when cleaning the resident during incontinence care. A review of the facility's investigation revealed an interview with the accused GNA along with a background check from the agency that the GNA was contracted from. There were no resident interviews from the agency GNA's assignment included in the investigation. On 1/29/25 at 12:11 PM an interview was conducted with the DON #1. The DON #1 checked to see if the social worker had emailed resident interviews for the intake and confirmed that she did not have any resident interviews. The DON confirmed it was an incomplete investigation. 4) On 1/29/25 at 11:49 AM a review of facility reported incident MD00206126 was conducted and revealed during the night shift on 5/26/24 Resident #366 alleged that a tall man came into the resident's room and changed the resident's diaper, and the resident stated he/she did not wear a diaper. Review of the facility's investigation revealed a written statement from the agency geriatric nursing assistant (GNA) and (7) resident interviews, however there were no other staff interviews included in the investigation. On 2/3/25 at 8:11 AM an interview was conducted with the DON #1. The DON #1 confirmed that there were no other staff interviews. The DON #1 stated, the agency GNA was interviewed and another GNA from our staff. The Social Worker stated that she interviewed others but there was no documentation. 5) On 2/3/25 at 10:15 AM a review of facility reported incident was conducted and revealed Resident #625's family member alleged that Resident #625 had been slapped on 3/2/23 and 3/3/23 by staff. Review of the facility's investigation revealed that 16 staff members were interviewed, however there were no other residents on the unit that were interviewed. On 2/4/25 at 7:45 AM the DON #1 was interviewed and confirmed there were no other resident interviews from the GNA's assignment. 6) On 2/3/25 at 11:20 AM a review of facility reported incident MD00194070 was conducted and revealed Resident #5 alleged to his/her son that Resident #5 had been hit on the back and arm by staff during care. Review of the facility's investigation revealed a statement from the GNA that was taking care of Resident #5, however there were no other staff interviews included in the investigation. On 2/4/25 at 9:57 AM an interview was conducted with the DON #1. The DON #1 confirmed that they did not have any other documented interviews of staff. 7) On 2/4/25 at 8:50 AM a report of facility reported incident MD00182370 was conducted and revealed Resident #622 alleged that he/she was sexually assaulted the previous evening on 2/10/22. A review of the facility's investigation revealed staff were interviewed but there were no other residents on the unit that were interviewed. On 2/4/25 at 9:57 AM an interview was conducted with the DON #1. The DON #1 confirmed that they did not have any other documented interviews of residents on the unit. 8) During an investigation of the facility self-reported incident, MD00206059, on 1/28/25 at 8:25 AM, it revealed that Resident #87 reported on 5/26/24 that a Geriatric Nursing Aide ( GNA #57) who was assigned to him/her violated the resident's rights, including turning off the call light, leaving the room, and not asking what the resident needed when they provided care to Resident #87. Further review of the facility's investigation regarding this report showed that the facility conducted a phone interview with GNA #57 and resident interviews, including Resident #87 and other residents. However, the facility did not have interviews with other staff to support their thorough investigation. In an interview with the Director of Nursing (DON #1) on 1/28/25 at 11:04 AM, she stated that the facility interviewed residents, perpetrators, and other staff while they were investigating the resident's abuse case. The surveyor reviewed Resident #87's abuse case with the DON. She said, I will search for other staff interviews for this case. On 1/30/25 at 2:41 PM, the DON #1 confirmed that the facility could not find other staff interviews for this reported incident. She validated the surveyor's concern that this investigation was not thoroughly performed. 9) On 2/4/25 at 9:00 AM, review of incident #MD00181518 had that Resident #619 told a family member who reported to the charge nurse, that, a male Geriatric Nursing Assistant (GNA) who gave resident a bath in the morning fondled their breast. The charge nurse reported the incident to the Clinical Team Manager. Review of Resident #619's MDS Section C (Cognition) on 2/4/25 at 9:15 AM with Assessment Reference Date (ARD) of 7/8/22 documented a BIMS score of 99 indicating that resident was unable to complete the interview. Review of the mental status assessment form, Section C1000 dated 7/7/22 documented that resident was severely impaired. The Resident also has a care plan for impaired cognitive function. Review of the investigative report done by the facility on 2/4/25 at 9:30 AM revealed that a thorough investigation was not conducted. The resident was assessed and no issues found except for old bruises from prior falls. The alleged staff member was immediately suspended and investigation started. The police, ombudsmen and the office of Health Care Quality (OHCQ) immediately notified. The resident, staff, and witness interviews were also obtained however, other resident's interviews could not be found. On 2/4/25 at 9:50 AM in an Interviews with the Director of Nursing (DON #1) she was made aware that other resident interviews could not be found and asked to verify. She checked the investigative report folder but could not find the missing document. She stated that if it's not in the folder, then it was not done. She was made aware that this was a concern.

Based on observation, interview and record review it was determined the facility failed to: 1.) ensure the labeling, dating, and expiration of nourishment items, 2.) ensure a sanitary environment in the nourishment refrigerator and 3.) ensure dishwashing machines met the minimum required manufacturer temperatures recommended for sanitization. This was evident for: 1.) 1 reach-in refrigerator in 1 out of 2 of the facility's kitchens, 2.) 1 nourishment refrigerator in 1 out of 2 of the facility's kitchens, and 3.) 3 out of 4 dishwashing machines, during the facility's recertification/complaint survey. The findings include: 1.) On 1/27/25 at 8:11AM during the surveyor's initial tour of the facility's kitchens, the surveyor observed the reach-in refrigerator located in the main kitchen which contained trays containing the following items which had no labeling or dates present to indicate preparation or expiration dates: plates of orange slices, cold salad sandwiches, approximately 14 individual containers of fruit with cream base, approximately 27 individual containers of cottage cheese, a metal pan of cold meat type salad with a plastic scoop cup located within the salad. On 1/27/25 at 8:27AM the surveyor requested a dual observation and shared concerns with Senior Dining Director, Certified Dietary Manager (CDM) #61 who observed the concerns. At this time the surveyor conducted an interview with CDM #61 who stated the following information to the surveyor: Items should be labeled and dated prior to storing in the refrigerator. At this time, they were unable to confirm with the surveyor as to when the foods had been prepared or were to expire. During the dual observation on 1/27/25 at 8:30AM a tray of cheese sandwiches was additionally observed in the reach-in refrigerator with the following label which read: prepared food, reheated, nourishment, prepared 1/13/25 11:56AM, discard by 1/16/25 11:56AM. When the surveyor inquired as to the labeling and expiration of this tray of sandwiches, CDM #61 proceeded to throw the items away into the trash can. 2.) On 1/27/25 at 8:14AM the surveyor observed the main kitchen's nourishment refrigerator which was found to contain a cardboard box in which various condiment packets including sugar and sugar substitute packets, tea bags etc. were observed sticking out of the box with visible circular spots of black, brown, and green matter. A container of soymilk was observed within the same nourishment refrigerator with the following labeling affixed to it: prepared 1/16/25 11:47AM, discard by 1/19/25 11:47AM. On 1/27/25 at 8:20AM the surveyor conducted an interview with Project Manager (PM) #63 who confirmed they were the interim person overseeing the kitchen at the present time until a new person was to begin employment. At this time, the surveyor requested a dual observation of the nourishment refrigerator with PM #63, who observed, confirmed, and acknowledged the surveyor's concerns. When the surveyor inquired as to what would be done with the items, PM #63 stated the following information: I'm going to throw them away. At this time, the surveyor observed them throw the items into the trash can. On 1/27/25 at 8:27AM the surveyor requested a dual observation and shared concerns with Senior Dining Director, Certified Dietary Manager (CDM) #61 who observed the concerning contents within the trash can. At this time, CDM #61 acknowledged and confirmed understanding of the surveyor's concerns. 3.) On 1/29/25 at 11:40AM the surveyor conducted an observation of the main kitchen's dishwashing machines. It was observed at this time that the meat dishwashing machine was under repair. On 1/29/25 at 1:39PM the surveyor conducted an observation of the main kitchen's dairy dishwashing machine while in operation and observed 3 out of 3 dials failed to be in working order as dishes were put through the machine, the needle was not moving to display the machine's temperatures. At this time, the surveyor conducted an interview of Maintenance Associate (MA) #64 to understand why the dials were not moving during the continued operation of the machine while it was actively washing dishes. At this time, MA #64 observed the dials which were not moving, and then they were observed pushing on the sliding door of the dishwasher with their hand. MA #64 then showed the surveyor that the pressure gauge was rising and the dials were now moving. Continued observation of the dials revealed the final rinse temperature did not meet the minimum required temperature of 180 degrees Fahrenheit as observed on the machine's manufacturer recommendations located on the machine's plackard and labeling and was labeled for being . The highest the dial was observed to read for the final rinse temperature in response to MA #64 having pushed on the door to the machine during operation of the dishwasher was 164 degrees on 1/29/25 at 1:39PM. When the surveyor further inquired as to why the machine could not sustain temperatures to MA #64, they stated the following information to the surveyor: There is a censor issue. MA #64 opened the door they had pushed on and showed the surveyor the censor that was located within it which they confirmed was malfunctioning and needed replacement. At this time, the surveyor shared their concerns. On 1/29/25 at 2:00PM the surveyor requested a dual observation with Director of Dining Services #65 who observed and confirmed that the dials for the dairy dishwashing machine were not moving unless MA #64 pushed on the door of the machine. On 1/29/25 at 2:00PM the surveyor conducted an interview with DODS #65 who stated the following information to the surveyor: The dishwashers constantly have repairs because of the equipment and kitchen's age. On 1/29/25 at 2:12PM the surveyor was approached by the Director of Building Services (DOBS) #66 who observed the dishwasher in operation and confirmed with the surveyor that the machine was not reaching the minimum required temperatures for wash (160F) or final rinse (180F) at this time. The wash temperature was observed to be at 158F and the final rinse temperature was observed to be at 148F. On 1/29/25 at 2:16PM MA #64 showed CDM #61, DOBS #66, DODS #65, and the surveyor that the censor was not working, and unless they pressed on the door of the machine which then caused the pressure gauge to raise and temperatures to increase, the required temperatures could not be met. On 1/29/25 at 2:19PM CDM #61 reported to the surveyor that they would not be utilizing the dishware at this time and would hold the dishware to re- run through the dishwasher after the repairs have been completed. On 1/29/25 at 2:26PM the surveyor conducted a dual observation with CDM #61 in the facility's additional kitchen located in a separate building. At this time, the dairy dishwasher machine in the additional kitchen was observed to not be meeting the minimum required manufacturer temperatures for wash and final rinse. During the machine's operation the temperature gauges were observed to be at 150F for the wash and 151F for the final rinse. Observation of the machine's plackard indicated the following manufacturer recommendations for minimum temperatures: 160F for wash, and 180F for final rinse. On 1/29/25 at 2:30PM CDM #61 the meat dishwasher located in the additional kitchen was put into operation by CDM #61 and it was observed that the wash temperature gauge was not consistently moving above 150F while dishes were being put through the machine, and the final rinse temperature was 176F. The machine was observed to not be able to consistently meet required temperature requirements. During an interview of CDM #61 on 1/30/25 at 11:40AM, after surveyor intervention, they reported to the surveyor that two fuses were found to be blown in the additional kitchen's dairy dishwasher booster which were repaired. The surveyor observed the dishwasher temperatures which were found to be meeting the required temperatures, and CDM #61 reported they were now resuming use of the dishwasher. On 1/30/25 at 11:44AM the surveyor observed the additional kitchen's meat dishwasher with CDM #61 while it was in operation and observed the wash temperature to be 140F which was not meeting the machine's manufacturer recommendation on the plackard for a minimum required temperature of 160F. On 1/30/25 at 11:44AM CDM #61 stated the following to the surveyor: It wasn't apparent that there was an issue with this one. On 1/30/25 at 11:49AM the surveyor continued to interview CDM #61 who reported to the surveyor that the main kitchen's dairy dishwasher was still being worked on and that there was no solution yet. On 1/30/25 at 11:49AM the surveyor observed CDM #61 shut the run button off for the meat dishwasher in the additional facility kitchen off, which then increased the wash temperature to 158F. At this time, the surveyor shared all dishwashing concerns with CDM #61 and confirmed that all dishwashers within the two buildings were using heat mode of sanitization. CDM #61 confirmed understanding and acknowledged the surveyor's concerns at this time. On 2/7/25 at 12:30PM the concern was shared with the facility's Administrator and Director of Nursing during the facility's exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 9 (Resident #366, #63, #367, #615, #626, #628, #644, #649, and #650) resident of 108 residents reviewed during the recertification/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) On 1/29/25 at 11:49 AM a review was conducted of Resident #366's medical record. Review of the miscellaneous section of the medical record revealed a Hospital Transfer summary for another resident, Resident #367 dated 5/16/24. There were 2 transfer summary entries. There were 22 pages of medical information on the first transfer summary that included Resident #367's name, medical record number, date of birth , patient demographics, medical diagnoses, medications, laboratory results, past medical history, and current medical history. The second transfer summary consisted of 61 pages of medical information that included progress notes from the in hospital stay, summaries, and diagnostic results. On 2/3/25 at 8:11 AM an interview was conducted with the Director of Nursing (DON #1). The DON #1 was shown the electronic medical record where Resident #367's transfer summary was loaded into Resident #366's medical record. The DON asked who uploaded it into the medical record and she confirmed the unit secretary uploaded the transfer summary into the wrong medical record. 2) The facility staff failed to document the administration of narcotic medications on residents' Medication Administration Records for Resident #615, #626, #628, #644, #649 and #650. Review of facility provided documentation on 2/3/25 revealed on 4/29/24 the Director of Nursing #1 (DON) received report from the Assistant Director of Nursing (ADON) of RN #17's medical emergency on 4/10/24 at 2:00 PM and resignation on 4/12/24 via text message. On 4/29/24 the DON began a review of residents' Controlled Medication Utilization Record and medications documented on residents' MARs (Medication Administration Records) for narcotics. a) Review of Resident #615's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS (Brief Interview of Mental Status) of 15 of 15, cognitively intact. Further review of Resident #615's April 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 4/10/24 at 7:55 AM, 11:57 AM and 3:59 PM. Review of Resident #615's April 2024 MAR revealed the Oxycodone 5 mg on 4/10/24 at 7:55 AM, 11:57 AM and 3:59 PM were not documented as administered to the Resident. Further review of the facility investigation revealed the DON interviewed the Resident on 4/29/24 but the Resident could not recall how many doses he/she received of Oxycodone on 4/10/24. b) Review of Resident #644's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 8 of 15, moderate cognitive impairment. Further review of Resident #644's April 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 4/10/24 at 10:55 AM, 2:55 PM and 6:55 PM. Review of Resident #644's April 2024 MAR revealed the Oxycodone 5 mg on 4/10/24 at 10:55 AM, 2:55 PM and 6:55 PM were not documented as administered to the Resident. Further review of the facility investigation revealed the DON interviewed the Resident on 4/29/24 but the Resident could not recall how many doses he/she received of Oxycodone on 4/10/24. c) Review of Resident #650's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 15 of 15, cognitively intact. The Resident was then discharged from the facility on 3/9/24. Further review of Resident #650's March 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Tramadol 50 mg on 3/3/24 at 7:55 AM, 3/7/24 at 7:55 AM and 3/8/24 at 7:55 AM and 12:00 PM. Review of Resident #650's March 2024 MAR revealed the Tramadol 50 mg on 3/3/24 at 7:55 AM, 3/7/24 at 7:55 AM and 3/8/24 at 7:55 AM and 12:00 PM were not documented as administered to the Resident. d) Review of Resident #649's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 10 of 15, moderate cognitive impairment. The Resident was then discharged from the facility on 4/8/24. Further review of Resident #649's March and April 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 3/21/24 at 8:00 AM, 3/26/24 at 7:55 AM, 3/26/24 at 11:59 AM and 4/4/24 at 8:00 AM. Review of Resident #649's March and April 2024 MAR revealed the Oxycodone 5 mg on 3/21/24 at 8:00 AM, 3/26/24 at 7:55 AM, 3/26/24 at 11:59 AM and 4/4/24 at 8:00 AM were not documented as administered to the Resident. e) Review of Resident #628's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 14 of 15, cognitively intact. The Resident was then discharged from the facility on 3/13/24. Further review of Resident #628's March 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 3/2/24 at 12:10 PM, 3/3/24 at 11:57 AM and 3/7/24 at 11:55 AM. Review of Resident #628's March 2024 MAR revealed the Oxycodone 5 mg on 3/2/24 at 12:10 PM, 3/3/24 at 11:57 AM and 3/7/24 at 11:55 AM were not documented as administered to the Resident. f) Review of Resident #626's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 10 of 15, moderate cognitive impairment. The Resident was then discharged from the facility on 3/14/24. Further review of Resident #626's February and March 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 2/3/24 at 12:40 PM, 2/4/24 1:19 PM, 2/8/24 at 7:55 AM, 12:15 PM, 5:00 PM, 2/9/24 at 1:00 PM, 6:20 PM, 2/14/24 at 11:54 AM, 2/17/24 at 12:00 PM, 2/18/24 at 12:12 PM, 2/22/24 at 7:50 AM, 2/23/24 at 12:07 PM, 2/26/24 at 12:55 PM, 2/27/24 at 1:00 PM, 2/28/24 at 1:12 PM and 3/2/24 at 12:10 PM. Review of Resident #626's February and March 2024 MAR revealed the Oxycodone 5 mg on 2/3/24 at 12:40 PM, 2/4/24 1:19 PM, 2/8/24 at 7:55 AM, 12:15 PM, 5:00 PM, 2/9/24 at 1:00 PM, 6:20 PM, 2/14/24 at 11:54 AM, 2/17/24 at 12:00 PM, 2/18/24 at 12:12 PM, 2/22/24 at 7:50 AM, 2/23/24 at 12:07 PM, 2/26/24 at 12:55 PM, 2/27/24 at 1:00 PM, 2/28/24 at 1:12 PM and 3/2/24 at 12:10 PM were not documented as administered to the Resident. Interview with the Director of Nursing (DON) #1 on 2/4/25 at 12:00 PM confirmed Staff #17 failed to accurately document the administration on narcotic medications for Resident #615, #644, #650, #649, #628 and #626. 3) On 2/3/25 at 12:50PM the surveyor conducted a review of the medical record for Resident #63 which revealed the following two separate medical orders for medications which were incomplete without an indication for use specified: a.) Seroquel Oral Tablet 25 MG, give 0.5 tablet by mouth one time a day, and b.) Amlodipine Besylate Oral Tablet 5 MG, give 1 tablet by mouth one time a day. On 2/4/25 at 9:50AM the surveyor reviewed prior recommendations made by Pharmacist #49 on 9/16/24 and 1/14/25, which included the need for diagnoses and/or indications for use of medications needing to be present within medical orders. On 2/4/25 at 10:14AM the surveyor conducted an interview with Clinical Team Manager (CTM) #50 who confirmed with the surveyor that when creating a medical order for medications, they could utilize either the diagnoses box or the indication for use box in which either would populate the indication for use in the medication order. The surveyor observed the medication orders for Resident #63's Amlodipine and Seroquel with CTM #50 who confirmed with the surveyor that the medication order did not display the indication for use and the diagnosis they had selected for indication of use was not populating to show on the medical order. CTM #50 further confirmed with the surveyor that they enter medication orders in response to pharmacy recommendations after the physician or nurse practitioner has reviewed the recommendations and provided a response. At this time, the surveyor shared their concern that the medical orders did not display an indication for use. CTM #50 acknowledged understanding of the surveyor's concern. On 2/4/25 at 10:39AM the surveyor conducted an interview with the Director of Nursing (DON #1) who confirmed with the surveyor that staff can either select related diagnoses or complete the indication for use box when creating a medical order. The DON #1 reported the following information to the surveyor: I did not know this was not showing under the order, we need to make sure we have the indication for use, most people use the indication section, so we did not know it wasn't showing up on the medical order, I review these and did not see these missing the indications.

Deficiency Text Not Available

Based on the review of the clinical records, surveyor observations, and interviews with residents and facility staff, it was determined that the facility failed to ensure 1 of 7 residents selected for the Dignity review was treated with respect and dignity by staff (Resident #237). The findings include: On 12-17-19 at 11:00 AM surveyor interview with Resident #237 revealed concerns with attitudes from some of the Geriatric Nursing Assistants (GNAs) at the facility. Further interview revealed the resident stated that the facility needed to provide additional training's to the GNA staff on the caring for and speaking to residents. The resident declined to give specific information of individual GNA staff members. On 12-19-19 at 5:15 PM observation of staff interactions with Resident #237, in the resident's room, revealed GNA (Geriatric Nursing Assistant) #4 entered the resident's room without knocking on the door nor awaiting for a response to enter. Further observation revealed GNA #4 informed the resident that she had come to pick up the resident's dinner selection menu. The resident's friend was present in the room at this time. Then GNA #4 snatched the ticket off the resident's table. The resident's friend inquired about a dinner meal that had been requested. GNA #4 then harshly told the resident's friend, You need to go downstairs and get a ticket. The friend as well as the resident then informed GNA #4 that a meal ticket had already been purchased. GNA #4 then harshly stated, Then give it to me. GNA #4 yelled, I don't have time for this from you and remained in the room yelling at the resident's friend with the resident as well as the surveyor still present. After surveyor intervention, GNA #4 was asked to exit the resident's room. Further interview revealed both the resident and friend stated, This is the type of behavior that some staff have demonstrated toward the resident. On 12-19-19 at 5:30 PM interview with the 3 [NAME] Unit Manager revealed that GNA #4 would be removed from Resident #237 care for the remainder of the shift. On 12-19-19 at 5:40 PM interview with the Director of Nursing (DON) revealed GNA #4 was removed from duty at this time. Further interview at 6:00 PM with the facility administrator and the DON revealed GNA #4 had now been terminated at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations and staff interviews, it was determined that the facility staff failed to store food items correctly with use-by dates in the kitchen freezers and refrigerators, and failed to serve food in a sanitary manner to prevent potential contamination. This was evident for 2 of 2 kitchens observed for proper and safe food storage and and in 2 of 11 dining rooms that had steam table service. The findings include: 1. Surveyor observation of the kitchen determined that the facility staff failed to have use-by dates on open packages and containers of food items stored in the freezers and the refrigerators in the facility kitchens. a. On 12-16-18 at 8:38 AM, surveyor observation of the walk-in dairy freezer in the [NAME] building kitchen revealed open packages of cheese manicotti, sliced frozen peaches, and [NAME] pastry sweets were not labeled with use by dates. In the walk-in dairy refrigerator, surveyor found an open flounder fish fillet package, a container of French dressing, and a container of Thousand Island salad dressing not labeled with a use by date. b. On 12-16-19 at 09:40 AM, surveyor observation of the kitchen in the [NAME]-Kogod building revealed that in the walk-in dairy freezer, there were two boxes of cookie dough with open packages and an open package of pie shells that were not labeled with use-by dates. In addition, surveyor observed an open package of vegan meatballs in walk-in meat freezer with no use-by date on the package. On 12-16-19 at 11:00 AM surveyor interview with the facility administrator revealed no additional information. 2. Surveyor observations of kitchen service from the unit pantries and staff interviews, it was determined that the facility staff failed to serve food in a sanitary manner to prevent potential contamination. This finding was evident in 2 of 11 dining rooms that had steam table service. a. On 12-16-18 at 12:38 PM, surveyor observed nursing staff take bowls of soup from kitchen staff who were serving lunch from the first floor steamtable. GNA #10 took six (6) uncovered bowls of tomato soup and went into the dining area to pass them to residents seated at the tables. However, only three (3) residents requested the soup, and at 12:46, GNA #10 returned the remaining three (3) uncovered bowls of soup to the kitchen staff who placed them back on the steam table. On 12-16-18 at 1:00 PM, as more residents presented for the lunch meal, one resident requested the tomato soup, and the kitchen staff picked up one of the previously returned uncovered bowls of soup and gave it to the GNA #10 to serve to the resident as requested. The soups that were not served to residents should have been discarded as they had been circulated uncovered throughout the dining room to various tables 22 minutes earlier. Returning them to the steam table increased the potential for contamination. b. On 12-17-19 at 12:55 PM, when passing trays to residents who chose to dine in their individual rooms GNA #9 received four (4) trays from the kitchen staff serving from the second floor East pantry steamtable. GNA #9 then went into each room, set each resident's tray up (moved items off the overbed table to make room for the meal as needed, removed all covered items, opened milks/drinks, etc.), applied a clothing protector around the resident's neck, then returned the removed covered items from the resident's room back to the cart which had trays that had not been passed. Furthermore, GNA #9 was not observed washing hands after leaving each room or before serving another tray. The trays were not served in a manner to prevent potential cross contamination and GNA #9 was observed serving four (4) different residents without washing his/her hands between rooms. On 12-20-19 at 4:00 PM, surveyor interview with the kitchen manager and the director of nursing revealed no additional information.

Based on clinical record review and interviews with facility staff, it was determined that the facility failed to provide a resident's representative the right to request, refuse, and/or discontinue treatment outlined in the Maryland Medical Orders for Life-Sustaining Treatment (MOLST). This finding was evident for 1 of 48 (#449) residents selected for this survey. The findings include: The Maryland MOLST form is a two-page 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/patient representative's wishes about medical treatments and makes those treatment wishes known to health care professionals. Surveyor review of resident #449's medical record revealed that a court ordered guardian was appointed on 07-24-18 to make decisions for them. Review of staff member #5's progress note on 11-13-18 revealed that resident #449 was not capable of making an advanced directive and the resident's guardian was their primary contact. On 11-13-18, resident #449's attending physician completed page one and page two of the MOLST form. Review of the MOLST form completed in 2017 revealed that page 2 was not completed. On 12-06-18 at 10:30 AM, interview with resident #449's attending physician revealed that the resident's guardian was not contacted when the 11-13-18 MOLST form was completed. The physician based the MOLST on discussion with the resident and their previous MOLST form completed in 2017. On 12-06-18 at 10:35 AM, interview with staff member #3 revealed that page 1 of the MOLST was discussed with resident #449's guardian, but page 2 was not. There was no evidence that resident #449's guardian was given the opportunity to request or refuse certain life sustaining treatments on page 2. On 12-06-18 at 3:30 PM, interview with the Director of Nursing revealed no new information.

Based on surveyor observation, review of the clinical record, and staff interview, it was determined that the facility staff failed to identify an appropriate medical symptom for the use of a physical restraint. This finding was evident for 1 of 2 residents (#100) reviewed for the physical restraint care area. The findings include: On 12-05-18 at 1:41 PM, observation of resident #100 and review of the clinical record revealed the use of a seatbelt when up in the wheelchair. Review of the clinical record for resident #100 revealed a physicians order, dated 06-19-17, for facility staff to ensure the seat belt is applied when resident is in the wheelchair for safety. There was no evidence of any medical symptom that the seatbelt was being used to treat in the physicians order or in the clinical record. In addition, there was no evidence in the clinical record of any interventions for reducing or discontinuing the seatbelt, which had been utilized for almost 18 months at the time of survey. On 12-06-18 at 3:10 PM, interview with the Director of Nursing (DON) revealed that the facility staff considered the seatbelt a restraint because of the inconsistency of resident #100's ability to remove it. The DON was unable to provide additional information related to a medical symptom that the seatbelt was being used to treat resident #100.

2. On 12-06-18 at 8AM, surveyor observation revealed that staff member #4 held a diabetic medication for resident #441 as ordered, due to the resident having a blood sugar that was less than 100 milligrams per deciliter (mg/dL). Review of the MAR revealed nurse #1 documented that he/she administered the diabetic medication to resident #441 on 12-04-18, 12-05-18, and 12-06-18 despite the resident's blood sugar being less than 100 mg/dL. On 12-06-18 at 8:35 AM, surveyor interview with staff member #4 revealed that they incorrectly documented that the diabetic medication was given to resident #441 on 12-06-18. After surveyor intervention, staff member #4 wrote a nurse's progress note clarifying that the diabetic medication was held per the physician's order. On 12-10-18 at 1 PM, interview with the Director of Nursing revealed no new information. Based on surveyor review of the clinical record, observation of medication pass, and interview with facility staff, it was determined that the facility failed to ensure standards of nursing practice for residents. This finding was evident for 2 of 5 residents selected during observation of medication pass (#302, #441). The findings include: According to the Maryland Nurse Practice Act 10.27.10.03 D (1) (2) (3) (4), the implementation of the nursing plan of care shall include, but is not limited to: recognizing the rights of the client, the family and significant others and providing a safe and therapeutic environment; the competent performance of the acts required to carry out the nursing plan; collection of data and reporting of problems that arise in the carrying out of the nursing plan; assisting in revising the nursing plan and providing viable alternatives if possible. 1. On 12-07-17 at 4:15PM, surveyor observation of medication pass for resident #302 revealed that LPN (Licensed Practical Nurse) # 6 administered 4PM scheduled medications including a medication used in the treatment of gas and bloating. Record review revealed physician orders for the gas and bloating medication to be administered three times daily, after each meal, for resident #302. However, further surveyor observation, on 12-07-18 at 4:20PM, revealed that resident #302 took the medication cup that contained the gas and bloating medication, placed the cup into the resident's personal bag and zipped the bag closed and proceeded to the dining room. Then LPN # 6 was observed signing off the administration of all of the resident's 4PM medications on the December 2018 MAR (Medication Administration Record) as completed. Interview with LPN #6, on 12-07-18 at 4:30PM, revealed that resident # 302 takes the medication after the resident's dinner meal, which is served in the dining room at 5PM, and therefore, the medication is administered by the resident and not by the licensed nurse. No additional information was provided. Further record review revealed no documented evidence that facility staff assessed the resident for the capability of self administration, nor obtained physician clarification regarding self administration of the medication. Additionally, LPN #6 documented the administration of the gas and bloating medication prior to its actual administration. Interview with the Director of Nursing, on 12-10-18 at 10:30AM, revealed no additional information.

Based on surveyor observation, review of the clinical records, and staff interviews, it was determined that the facility staff failed to maintain a safe smoking environment. This finding was evident for 1 of 2 residents (#428) who smoke and were selected for review. The findings include: On 12-05-18 at 12:01 PM, interview of resident #428 revealed the resident independently smoked in a designated smoking area, which had no receptacle for cigarettes butts. On 12-05-18 at 12:26 PM, surveyor observation of resident #428 smoking revealed no receptacle for cigarette butts at the designated smoking area. Further observation revealed that the fire extinguisher and smoking apron for emergencies remained in the old designated smoking area, and had not been relocated when a new area was selected. On 12-05-18 at 12:40 PM, the Director of Nursing was made aware that there was no receptacle in the designated smoking area. On 12-05-18 at 2:25 PM, the Director of Nursing notified the surveyor that a receptacle had been placed in the designated smoking area. On 12-05-18 at 2:40 PM, surveyor observation revealed a receptacle in the designated smoking area, however the smoking apron and fire extinguisher had not been relocated. On 12-07-18 at 2:38 PM, the Director of Maintenance was notified that the smoking apron and fire extinguisher had not been relocated . On 12-07-18 at 3:00 PM, the smoking apron, fire extinguisher and receptacle were observed by surveyor in the designated smoking area.

2. On 12-06-18 at 2:00 PM, review of the clinical record for resident #228 revealed a Nurse Practitioners progress note, dated 11-28-18, increasing an antipsychotic medication. The progress note documented that the resident did not have paranoia or psychoses. There was no evidence in the facility staff progress notes or behavior monitoring sheets of behaviors for resident #228 to reflect the need to increase the antipsychotic. Further review of the clinical record for resident #228 revealed a monthly summary, dated 11-21-18, which documented the resident's mood as stable since the last monthly assessment in October. In addition, a Medication Management Assessment form completed by the Nurse Practitioner on 11-28-18 documented the absence of any delusions or hallucinations for resident #228 with the medication recommendation being no change in psychoactive medication orders, yet immediately below that entry was a medication order to increase the AM dosage of the antipsychotic. On 12-06-18 at 2:50 PM, interview with the Nurse Practitioner revealed that the increase in the antipsychotic medication for resident #228 was based on a conversation with a family member, and not the assessment and documentation of the facility staff. On 12-06-18 at 2:55 PM, interview with the Director of Nursing revealed no additional information. Based on surveyor review of the clinical record, and staff interview, it was determined that the facility staff failed to ensure that residents are free of potentially unnecessary psychotropic medication. This finding was evident for 2 of 5 residents selected for review of the unnecessary medication care area (#108, 228). The findings include: 1. On 12-07-18 at 11:10 AM, surveyor review of the clinical records revealed that resident #108 was receiving multiple psychotropic (any medication capable of affecting the mind, emotions or behavior) medications to treat his/her health conditions. The psychotropic medication included, but was not limited to, an anti-anxiety drug that was ordered as needed for anxious behavior. Further review of resident #108's physician order sheets and medication administration record (MAR) for the months of June through December 07, 2018 revealed that the anti-anxiety drug that was ordered as needed, was still being administered. There was no evidence in the clinical record by the attending physician or the prescribing practitioner documenting the rational for the extended use of this medication beyond the 14 days as required. On 12-07-18 at 11:40 AM, surveyor interview with the Director of Nursing (DON) revealed no additional information

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, review of the [NAME] building resident council minutes, interviews with residents, resident's family member and facility staff, it was determined that the facility failed to ensure palatable and appetizing temperatures of food served on the 5th floor [NAME] dining room. This finding was evident for 1 of 11 dining rooms within the facility. The findings include: On 12-04-18, surveyor review of the facility's posted dining room hours revealed that the following available hours that residents are served in the facility's dining rooms: breakfast 8 AM-9:30 AM, lunch 12 PM-1:30 PM and dinner 5 PM -6:30 PM. Surveyor observation, on 12-04-18 at 12:20 PM, of the 5th floor [NAME] dining room, revealed metal containers of food that were transported in a heated cart from the facility's kitchen and then the individual containers are placed in a steam table device located in the dining room. A kitchen staff member in the dining room then obtains food temperatures prior to serving, records the results in a temperature log book, and proceeds to plate the resident's selection directly from the steam table. On 12-05-18, surveyor review of the monthly Resident Council Meeting minutes for the [NAME] building revealed that, during the August 2018 meeting, a concern was raised of why staff could not heat up food in the microwave. The facility's response was there was a policy in place that staff are not allowed to heat food up for residents, but residents themselves are allowed to heat up food from a microwave within the staff lounge. Further review of the meeting minutes revealed that, in June 2018 a concern was reviewed from a previous meeting, that the food was not hot and that food seemed to be wasted. Surveyor interview with the 5th floor resident council members and a family member on 12-06-18 at 3:40 PM that some of the hot food is served cool and not appetizing. In addition, residents stated that, at times, they have to wait to be served and the food is then cool and/or the entree posted becomes no longer available. a. On 12-06-18 at 5:30 PM, observation of the dinner meal served on the 5th floor [NAME] dining room revealed that the posted dinner menu included chicken okra and squash stew, sweet potato latke, apricot glazed tilapia, beef [NAME], green beans and sweet peas with mushrooms. Temperatures that were recorded by staff in the log book: stew at 166 degree Fahrenheit (°F), tilapia 163°F, peas 180°F, and green beans 168°F. However, surveyor observation on 12-06-18 at 5:32 PM of a requested portion of the meal plated directly from the steam table located in the 5th floor dining room, revealed the following temperatures obtained by the surveyor: sweet potato latke 111°F tilapia 116°F peas with mushrooms 100°F green beans 106.9°F b. On 12-07-18 at 12:20 PM, review of the 5th floor dining room temperature log book revealed the following initial temperatures obtained by kitchen staff prior to the start of the 12 noon meal service: veggie burger 186°F, egg plant flatbread 150°F, broccoli medley 167°F, succotash 182°F, and onion soup 193°F. However, surveyor observation, on 12-07-18 at 12:49 PM, of a requested portion of the meal plated directly from the steam table revealed the following temperatures obtained by the surveyor: veggie burger 120°F eggplant flatbread 139°F broccoli medley 98°F succotash 128°F soup 157°F c. On 12-10-18 at 12:20 PM, surveyor observation of initial temperatures obtained by assigned dining staff member #7 and chef #8 revealed the following temperatures: grilled cheese sandwich 158°F, tomato soup 200°F, fish 183°F, vegetable frittata 186°F, spinach 181.4°F, and peas 186°F. However, surveyor observation on 12-10-18 at 12:45 PM of requested portion of meal plated directly from the steam table revealed the following temperatures obtained by the surveyor and the Director of Food Services: fish 159°F frittata 164°F spinach 168°F peas 131°F Interview on 12-10-18 at 1 PM and 4 PM, with the Director of Food Services and chef #8, revealed further observation of the 5th floor dining room steam table of some escape of the steam from the heat source under the larger pan and pans not fitting tightly in the heat source. On 12-10-18 at 4:30 PM, interview with the Director of Nursing revealed no additional information.