**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with facility staff, it was determined that the facility failed to maintain a homelike environment in resident rooms. This was evident for 7 of 7 resident rooms reviewed during the environmental survey. The findings include: On 3/4/25 at 9:20 AM, a tour was conducted of rooms 79, 10, 18, 17, 32, 33, and 16, all of which were being reviewed for an increase in occupancy. The tour was conducted with the Administrator and the Director of Maintenance. The tour revealed the following concerns: - room [ROOM NUMBER]: no towel hanger in the bathroom - room [ROOM NUMBER]: no towel hanger in the bathroom. Damage noted to the footboard of the bed - the protective outer layer of the footboard was damaged and peeling away, exposing the inner particle board. - room [ROOM NUMBER]: no towel hanger in the bathroom. Damage noted to the footboard of the bed nearer the door - the protective outer layer of the footboard was damaged and peeling away, exposing the inner particle board. - room [ROOM NUMBER]: damaged gasket inside the spud flange at the base of the flush connection of the toilet. Exposed bolt securing the toilet to the floor, requiring a cap for safety and rust prevention. - room [ROOM NUMBER]: pull cord too short for the overhead light of the bed nearer the window. Also, the night light over that bed did not work. Damage noted to the footboard of the bed nearer the window - the protective outer layer of the footboard was damaged and peeling away, exposing the inner particle board. The seat of the toilet was noted to be loose and off center, posing a safety risk for residents transferring onto and off the toilet. - room [ROOM NUMBER]: pull cord too short for the overhead light of the bed nearer the door. Damage noted to the footboard of the bed nearer the door - the protective outer layer of the footboard was damaged and peeling away, exposing the inner particle board. - room [ROOM NUMBER]: pull cord too short for the overhead light of the bed nearer the door. Damage noted to the footboard of the bed nearer the door - the protective outer layer of the footboard was damaged and peeling away, exposing the inner particle board. The wall plate of the overhead sprinkler was loose over the bed nearer the window. The Administrator and the Director of Maintenance were present throughout the tour and confirmed all of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with facility staff, it was determined that the facility failed to ensure that resident bathrooms had effective mechanical ventilation. This was evident for 5 of 7 resident rooms reviewed during the environmental survey. The findings include: On 3/4/25 at 9:20 AM, a tour was conducted of rooms 79, 10, 18, 17, 32, 33, and 16, all of which were being reviewed for an increase in occupancy. The tour was conducted with the Administrator and the Director of Maintenance. All rooms included a bathroom attached to the room that included a sink and a commode. As part of the tour, effective mechanical ventilation in the bathroom was tested by observing if a thin piece of paper was drawn towards and held against the ventilation intake on the ceiling. This test was performed by the Director of Maintenance. This test showed effective ventilation in the bathrooms of rooms [ROOM NUMBERS], but failed to show effective ventilation in the bathrooms of rooms 18, 17, 32, 33, and 16. The Director of Maintenance was interviewed during the tour and confirmed that ventilation was ineffective in the above five bathrooms. The Director stated that the rooms were all serviced by rooftop ventilation units. The Director of Maintenance stated that the motors of the units were likely nonfunctional and would require repair.

Based on record review, and interview it was determined that the facility failed to notify the Resident's health care Responsible Party (RP) of a change to the Resident's plan of care. This was found evident in 1 (Resident #290) of 4 Residents reviewed for care planning. The findings include: On 8/14/24 at 9:52 AM, the surveyor reviewed Resident #290's medical record. The review revealed that Resident #290 was admitted to the facility in mid 2013. Further review revealed admitting paperwork dated 6/24/23 for Resident #290 that has a spouse/friend listed first and next a Responsible Party (RP) with a comment (representative payee). Additionally in the paper record, there was a typed note from the spouse/friend RP that stated, this RP makes medical decision for Resident #290 and to please see Maryland Health Care Decision Act paper signed on 12/15/04. On further review the surveyor noted that the designated financial RP (representative payee) was in attendance at the care plan meeting dated 2/21/19 and 2/27/20. On review of all the other care plan meeting held for Resident #290 the medical Responsibility Party was in attendance. The surveyor reviewed a progress note dated 1/14/21 that described that the Financial RP for Resident #290 was contacted regarding the end date for Medicare covered services. No mention that the medical RP was notified as well. On 8/16/24 at 9:04 AM, the surveyor interviewed the Director of Nursing (DON). In the interview the DON stated that when Medicare covered services are stopped and not covered we would contact both the medical RP and financial RP because there is a medical and financial component. On 8/15/24 at 9:16 AM, the surveyor interviewed Social Worker #17. During the interview SW #17 stated when the facility is going over a decision that a Resident would need to make the facility first determines if the Resident themselves have the capacity to make the decision. If they are deemed incapable then the facility would determine who the RP is. The surveyor asked SW#17 who is contacted when a Resident has a different medical RP than financial RP. SW#17 stated the medical RP is notified and the financial RP is only notified in regards to financial concerns. She further stated that the paperwork for these designations should be in the residents medical record. On 8/16/24 at 9:26 AM, the surveyor conducted a follow up interview with the DON. In the interview the surveyor relayed the concern that Resident #290's medical RP was not contacted or updated on the plan of care on three occasions because the facility notified or involved the financial RP.

Based on record review, and interview it was determined that the facility failed to inform a Resident's Responsible Party (RP) in advance of a change in the residents' plan of care. This was found evident in 1 (Resident #285) of 10 residents reviewed for Resident Rights. The findings include: On 8/27/24 at 1 PM, the surveyor reviewed Resident #285's medical record. The review revealed that Resident #285 had a past medical history that included, but not limited to, muscle weakness, malnutrition, dementia and dysphagia (difficulty swallowing). On further review of the record on a progress note dated 9/21/23 written at 7:17 PM by Licensed Practical Nurse (LPN) #18 described an incident where LPN #18 found Resident #285 on the floor. No injuries were noted after assessment and Resident #285's Responsible Party (RP) was notified. The surveyor next reviewed Resident #285's orders. An order was placed on 9/21/23 for Resident #285 to be changed from mechanical soft diet to pureed texture and chopped meats. No where in the medical record was a reason given for the diet change or that the RP was notified prior to the change in plan of care. On 8/28/24 at 9:14 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor asked the DON if a Resident's RP should be notified for diet order changes and prior to the change, for a Resident. The DON stated that any change in the plan of care a RP should be notified. The surveyor asked if there was documentation that the RP was made aware about the diet change and if the rationale for the change was in the medical record. The DON stated she would follow up. On 8/28/24 at 9:31 AM, the surveyor conducted a follow-up interview with the DON. The DON stated that LPN #18 believed the diet change was due a dental need and would have the LPN #18 explain the reason. On 8/28/24 at 9:38 AM, the surveyor interviewed LPN #18. During the interview LPN #18 was asked why Resident #285's diet was changed on 9/21/23 and if the RP was notified. LPN #18 stated she believed the diet order change due Resident #285's dentures. LPN #18 stated the Resident refused to use denture cream and didn't want to get a new pair of dentures. The surveyor followed up by asking if the RP was notified of the concern and change in plan of care prior to the diet order being changed. LPN #18 stated when a diet is changed usually speech is involved and the RP would be aware. LPN #18 stated she couldn't remember the specifics with the diet change. At the time of exit no documentation was provided to the surveyor to support rationale for diet change or that the RP was notified.

Based on observation, interview with staff, and record review it was determined that the facility failed to: 1) ensure a resident has a call bell within reach and is able to use it if desired and, 2) provide reasonable accommodations for a resident to assist with mobility. This was evident for 1 (Resident #44) observed during a tour of the facility and 1 (Resident #300) out of 2 residents reviewed for accommodations. The findings include: 1) On 8/8/2024 at 8:14 AM, the Surveyor observed Resident #44 laying in their bed and the call bell on the floor at the foot of the bed. The Surveyor expressed this concern with Licensed Practical Nurse (LPN) #16, who stated she would take care of it. On 8/9/2024 at 8:00 AM, the Surveyor observed Resident #44 laying in their bed. The Surveyor asked Resident #44 where his/her call bell was in case he/she needed to call for assistance. The resident stated he/she did not know. The Surveyor observed the call bell on the floor at the foot of the bed. On 8/9/2024 at 8:10 AM, the Surveyor informed LPN #16 of the second observation. The Surveyor observed LPN#16 clean the call bell and place the call bell on the bed next to the resident. LPN #16 confirmed that Resident #44 should have a call bell within reach. 2) On 8/27/24 at 1 PM, the surveyor reviewed Resident #300's medical record. The review revealed that Resident #295 had a past medical history which included, but not limited to, surgical amputation, muscle weakness, unsteadiness on feet, and need for assistance with personal care. On further review a care plan was initiated for Resident #300 on 3/16/24 stating; Resident is a potential/actual rehabilitation candidate related to recent amputation. One of the interventions listed was to refer Resident to Physical Therapy (PT), Occupational Therapy (OT) and Speech to improve resident mobility, transfer, strengthening as recommended post evaluation. The surveyor review of Occupational Therapy (OT) notes from a session dated 3/16/24 in which the OT documented, patient completed rolling to both sides with maximum assistance of 2, no bed rail available, requiring total dependence to maintain side lying to decrease caregiver burden during Activities of Daily Living (ADL)s. On a note written on 3/21/24 the OT wrote, the daughter voiced concerns that the patient does not have bedrails to assist during bed mobility, ADLs and pressure relief. The note further stated that the OT notified the team and daughters that an order for maintenance for bilateral bedrails had been placed on 3/16/24. The OT's follows by writing that the maintenance team stated they did not have bedrails available and had ordered them with a pending order. On 3/28/24 at 11:22 AM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview the surveyor asked if a resident needed bedrails would they be available. The NHA stated the facility had recently ordered more. He recalled that all the rails were in use when Resident #300 needed them and that 10 more rails were ordered. He stated he would look for the invoice. Following the interview at 11:28 AM, the surveyor received an invoice for 10 bedrails dated 4/3/24. The surveyor voiced the concern to the NHA that the need for the bedrails was identified on 3/16/24 and the order was not placed until 4/3/24.

Based on interviews and family council meeting minutes, it was determined that the facility failed to demonstrate their prompt response and rationale on concerns from the family council group. This was evident for 5 of the 7 months of family council meeting minute notes reviewed. The findings include: The surveyor reviewed a complaint received at the Office of Health Care Quality (OHCQ) on 10/27/2023. The complaint stated that the Nursing Home Administrator did not respond to the family council group's (FCG) concerns for the months of July, August, and September of 2023. During an interview on 08/21/24 at 10:05 AM with the Nursing Home Administrator (NHA) the surveyor asked what the process in place regarding family council meetings is. The NHA stated the family council group meets monthly and then sends the meeting minute notes to him monthly by email. The NHA also stated that he responds to monthly meeting minutes every month before the next meeting occurs. The surveyor requested a copy of all monthly meeting minutes from April 2023 to October 2023. In an interview with the complainant on 8/14/2024 at 10:12 AM, it was revealed that meeting minutes were emailed to the NHA shortly at the end of the meeting. The complainant provided documented evidence of an email thread (time-stamped messages) that the meeting minute notes were sent to the NHA monthly. The surveyor reviewed the meeting minutes which revealed that the NHA did not respond promptly to the FCG's concerns for the months of April 2023, May 2023, July 2023, August 2023, September 2023. The NHA's response to April 2023 and May 2023's concerns were documented in the June 2023 meeting minutes. Further review of the meeting minutes also revealed that the response to concerns for July 2023, August 2023 and September 2023 were documented on the October 2023 meeting minute notes. The NHA and the DON were made aware of the findings throughout the survey and at exit conference.

Based on observations and interviews it was determined that the facility failed to ensure information related to the Resident's [NAME] of Rights, including but not limited to the name and contact information of the Maryland's Long-Term Care Ombudsman program and a statement informing residents that they may file a complaint with Maryland's Survey Agency concerning any suspected violation of state or federal nursing facility regulation, was posted in easily viewed and accessible locations. This was found to be evident on all units/halls with resident care areas. The findings include: On 08/20/24 at 12:05 PM the surveyor toured all units with resident care areas in the facility. Observation of the Chesapeake, Patuxent, The Lodge, and Rehab area revealed that there were no signs posted showing the Residents [NAME] of Rights, information on how to contact and/or make a complaint to the state survey agency and the ombudsman office at the Department of Aging. During an interview with Staff #10 on 08/20/24 01:10 PM, the surveyor asked Staff #10 if there were any Resident Rights or information on filing a complaint with the State Survey Agency posted on the unit/halls. Staff #10 responded, We had them up at one point but must have been taken down when renovations began a year ago. On 08/20/24 at 01:21 PM the Nursing Home Administrator (NHA) provided the notice of Resident Rights poster to the survey team and said that he just located it and will post it in the hallway between the two units- opposite the main dining area. During an environmental tour of the facility on 8/21/24 9:45 AM the surveyor observed the required postings located on the wall between the two units- opposite the main dining area.

Based on observation and interview, it was determined that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in 1 of 1 survey results book posted in the facility. The findings include: Surveyor observation of the lobby on 8/6/24 at 9 AM and 8/7/24 at 7:15 AM revealed no evidence of the survey inspection results in an open and readily accessible area for residents, staff, and visitors to review and a tour of the facility did not reveal any signs posted telling residents where the state survey results were located. On 8/7/24 at 7:30 AM an interview with the Director of Nursing (DON) revealed the Survey Results binder was located in the Nursing Home Administrator's (NHA) office. The DON confirmed the book would be provided to the survey team upon the NHA's arrival to the facility. On 8/7/24 at 8: 00 AM, the Nursing Home Administrator provided the survey team with the Survey Results binder. The NHA stated the book may have been removed from the reception area due to rennovations conducted at the facility. An interview with the DON on 8/7/24 9 AM revealed that staff failed to place the results of survey inspections in a place easily accessible to any persons to be reviewed. On 8/8/24 8 AM The surveyor observed the survey results in a binder on a table in the reception area with a sign that stated: Survey Results. Further inspection of the binder revealed the most recent survey results were the recertification survey on 9/13/2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #8 was admitted on [DATE] with diagnoses including Chronic Pain Syndrome, Altered Mental Status, Interstitial Pulmonary Disease and Atrial Fibrillation. Upon review of Resident #8's medical record on 08/12/24 at 09:47AM, the surveyor observed a copy of Resident #8's Maryland Medical Orders for Life-Sustaining Treatment (MOLST) dated 07/03/24. The surveyor did not observe a copy of the resident's Advance Directive in the medical record or documentation to show that an attempt was made to obtain the document. In an interview on 08/13/2024 at 11:31 AM to explain the facility's Advance Directive process, the Social Worker stated when a resident is admitted to the facility, during my initial assessment and the care plan meeting, I ask if they have an Advance Directive. If the resident has an Advance Directive, I get a copy and review it to make sure it matches the MOLST . If the resident has an Advance Directive, it will be found in the Electronic Health Record (EHR) and in the chart behind the Advance Directive tab. On 08/13/24 at 01:16 PM the surveyor reviewed Resident #8's Initial admission Assessment completed by the Social Worker on 07/08/22. Under Section B Health Care Decision, it was documented that Resident #8 had an Advance Directive. The surveyor notified the DON on 08/14/24 at 1:09 PM that Resident #8's Advance Directive was not located in the medical record. The DON provided the surveyor with a copy of the MOLST dated 07/03/24. The DON did not provide the surveyor with a copy of Resident #8's Advance Directive. Based on record review and interview with staff, it was determined that the facility failed to have a system in place to ensure that copies of the resident's Advanced Directives have been obtained and maintained in the resident's medical record. This was evident for 3 (Resident # 8, #70 and #291) out of 4 residents reviewed for Advanced Directives. The findings include: An Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. 1) On 8/8/2024 at 12:05 PM, a review of Resident #70's electronic and paper medical record, revealed no documents that indicated the resident's written Advanced Directive. On 8/13/2024 at 11:31 AM, the Surveyor conducted an interview with the Director of Social Services, Social Worker (SW) #17. SW #17 informed the Surveyor that she interviews the resident and/or resident representative and completes a Social Services admission assessment within the electronic medical record. SW #17 continued, if the resident has an Advanced Directive on admission, she will get a copy from the resident or resident representative and review it. Subsequently, a copy of the Advance Directive will be imported into the electronic medical record as well as the paper chart under the Advance Directive tab. Durable Power of Attorney (DPOA) is a document that allows a person to choose someone to make health care decisions for them when they cannot make health care decisions for themselves. On 8/14/2024 at 9:18 AM, a review of Resident #70's Social Services admission assessment filled out by SW #17, revealed that the resident had an Advance Directive and an appointed health care agent. During additional record review, the Surveyor identified a facility contract within the resident's electronic medical record which revealed that Resident #70 had a Durable Power of Attorney. On 8/15/2023 at 9:16 AM, during an interview with SW #17, the Surveyor was informed that she does not follow up with the resident or the resident representative when they do not provide the facility with a copy of the Advance Directive at admission or once an Advance Directive is executed. The Surveyor informed SW #17 that Resident #70 did not have a copy of his/her Advance Directive in his/her electronic or paper medical record even after the facility identified that the resident possessed one. On 8/15/2024 at 10:51 AM, the Director of Nursing (DON) confirmed that Resident #70 had a DPOA. The DON retrieved a copy from the resident representative, placed a copy in the resident's medical record, and provided the Surveyor with a copy. 3) On 8/20/24 at 12:18 PM, the surveyor reviewed Resident #291's medical record. The review revealed that Resident #291 was admitted in late January 2023. Further review revealed that Resident #291 had a past medical history that included, but not limited to, dysphagia (difficulty swallowing), dysphonia (disorder of the voice), muscle weakness, unsteadiness of feet and need for assistance with personal cares. On further review a physician certification related to medical condition, substitute decision making and treatment limitation form was filled out for Resident #291. The attending physician checked the box stating, based on this examination, I hereby certify that this resident is; Capable of making an informed decision. This certification was dated 1/25/23. Next the surveyor reviewed the speech therapy notes. The review revealed that Resident #291 started working with speech on 1/25/23 and had a goal of resuming the least restrictive diet. In several of the early speech notes the therapist wrote that a family member continued to bring in thin liquid for Resident #291 even though Resident #291 was ordered to have a nectar thick liquid consistency and at one point an even thicker honey consistency. The note described that the Speech Therapist explained the risks and danger of consuming a consistency too thin when a Resident, with a compromised swallow, consumes thin liquids. The risks were noted as the resident could aspirate (when something enters the airway or lungs by accident) liquids potentially causing pneumonia. On further review a note written on 3/1/23 by the Speech Therapist stated, the patient reported I want you to [tell] them not to thicken my drinks anymore. Again in the note the Speech Therapist described explaining the risks to the resident. On review of Resident #291's medical record there was no discussion or meeting with the resident's primary care physician or interdisciplinary team to address Residents #291's desire to discontinue the thickened liquid treatment. On review of the grievance note written by Social Worker #17, Resident #291 stated he/she wanted to sign a waiver so that he/she could have thin liquids. On 8/21/24 at 10:18 AM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview the NHA stated he was aware that Resident #291 did not want to continue the thickened liquid and that the family would bring him/her thin liquids in which he/she would drink with the family. The surveyor asked if a resident had the right to discontinue treatment he/she did not want. The NHA stated that a Resident has that right if they are deemed competent. He further stated he was unaware if this resident was competent however could recall that the Speech Therapist was very concerned about the resident aspirating and would not recommend thin liquids. He stated that Resident #291's desire to stop the thickened liquid was not discussed with Risk Management or the facility's Medical Director and no arrangement was made to address Resident #291's desire to discontinue thickened liquids.

**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 provide written transfer notice to the resident and/or the responsible representative. This was found to be evident for 2 (Resident #8 and #20) of 2 residents reviewed for Hospitalizations. The findings include: 1) On 08/15/24 at 10:00 AM a review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. On 01/06/24, Resident #8 was transferred to the hospital and returned 1/10/24, then transferred again to the hospital on [DATE] and returned on 06/28/24. On both occasions, there was no documentation and/or evidence in the medical record to indicate that the facility staff notified Resident#8 /Resident #8's representative (RP) in writing of the reason for the transfers to the hosptal. 08/16/24 at 11:25 AM the Administrator gave surveyor documents which revealed that the Ombudsman was notified of Resident #8's transfers to the hospital. No document was given to verify that the resident and/or the RP was notified in writing of the transfers. In an interview with the Director of Nursing (DON) on 8/16/24 at 11:52AM, the DON was informed of the surveyor's findings and asked about the written documentation for transfers /discharges. The DON responded. I do not know if it was being done. 2) On 8/21/2024 at 9:10 AM, a review of Resident #20's electronic medical record revealed that the resident was transferred to the hospital on 6/1/2024 at 8:38 AM after he/she became unresponsive while eating breakfast. Resident # 20 was admitted to the hospital due to low blood pressure and altered mental status and returned to the facility on 6/4/2024. Additional review of the electronic medical record and the physical chart revealed that there was no documentation to indicate that the resident nor his/her representative was notified in writing of the hospital transfer on 6/1/2024. The facility was unable to provide documentation that a written notice was given to Resident #20 and/or the residents representative for the hospitalization on 6/1/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The surveyor reviewed Resident # 8's medical record on 08/14/24 at10:38 AM. The review revealed that Resident #8 had a quarterly MDS assessment completed on 08/02/24 and an annual assessment completed 05/11/24. There was no evidence in the medical record that a care plan meeting was held with Resident# 8 or Resident#8's representative and the interdisciplinary team around the time of either the quarterly or the annual MDS assessments. A further review on 08/14/24 at 10:45 AM revealed the last careplan meeting was held on 12/5/23 at 11:30 AM and the resident's spouse and son attended. The surveyor interviewed the Director of Social Work, SW #17, on 08/15/24 at 9:15AM. During the interview, SW #17, stated I do not have a record to show that a careplan meeting was held for Resident #8 after 12/5/23. We keep a log of residents' care plan meetings. The surveyor asked the SW #17 for a copy of the log. The log was reviewed for the period January 2024 to July 2024. Resident #8's name or his/her RP did not appear on the log. 3) A review of Resident #72's medical record on 08/19/24 at 8:10AM revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Major Depressive Disorder. A careplan was developed on 8/12/24 for therapeutic activities. The goal stated The resident will express satisfaction with type of activities and level of activity involvement when asked through the review date. Date Initiated: 08/12/2024 Target Date: 08/20/2024. There were no interventions indicated on the care plan to achieve the goal. 08/19/24 at 08:32 AM the surveyor notified the DON of the findings and inquired as to the reason there were no interventions for therapeutic activities on Resident #72's careplan. The DON stated she did not know but would ask the Activities Director. Later on 08/19/24 at 4:30 PM, the surveyor observed that Resident #72's Careplan was updated with interventions for therapeutic activities. Based on record review, and interview it was determined that the facility failed to: 1) conduct care plan meetings after each Resident Assessment, 2) hold quarterly care plan meetings for residents, and 3) failed to include interventions for a resident's activity care plan. This was found evident in 3 (Resident #290, #8, and #72) out of 4 residents reviewed for care planning. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1) On 8/14/24 at 9:52 AM, the surveyor reviewed Resident #290's medical record. The review revealed that Resident #290 was admitted to the facility in mid 2013. Next the surveyor reviewed the MDS assessment for Resident #290 along with the care plan meeting notes and sign in sheets. Resident #290 had a quarterly MDS assessment on 8/16/20 and 11/16/20 however no care plan meeting notes were noted for these assessment dates. On 8/16/24 at 7:39 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON stated she was not the DON at the time of these assessments and could not find any additional documentation that the care plan meetings were done following the 8/16/20 MDS assessment and 11/16/20 assessment. On 8/16/24 at 9:08 AM, the surveyor interviewed the Social Worker #17. During the interview the SW#17 stated she started working at the facility in 2021 and when she started the process for scheduling care plan meetings was for the facility to mail a letter to the Responsible Party (RP) and have the RP call and make the care plan meeting. She followed by stating that meetings were not being done. She further stated that currently the MDS coordinator gives the list of Residents who had their MDS assessment to the front desk and they call to make the care plan meeting with the RP.

Based on record review, interview, and observation it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent Residents. This was found evident in 2 (#291 & #45) out of 8 Residents reviewed for Activity of Daily Living (ADL) cares. The findings include: 1a) On 8/20/24 at 12:18 PM, the surveyor reviewed Resident # 291's medical record. The review revealed that Resident #291 was admitted in late January 2023. Further review revealed that Resident #291 had a past medical history that included, but not limited to, dysphagia (difficulty swallowing), dysphonia (disorder of the voice), muscle weakness, unsteadiness of feet and need for assistance with personal cares. On further review a progress note written by Licensed Practical Nurse (LPN) #13 stated Resident #291 requires extensive assistance with ADLs and uses a wheelchair and walker while in the facility. On 8/21/24 at 12:20 the surveyor requested shower records for Resident #291 from the Director of Nursing (DON). On 8/22/24 at 7:16 AM, the surveyor reviewed the shower and skin sheets provided by the DON. The first date on the shower sheet was dated 2/21/23 and Resident #291 had no documentation that a shower was completed on that day. On 2/24/23, 3/3/24, 3/7/23, 3/10/23, and 3/14/23 Resident #291 had a shower documented as completed. No documentation for a shower on 3/17/23 and on 3/21/23 a bed bath was documented as given due to a refusal, Again no documentation of a shower was given on 3/24/23 or 4/7/23. The surveyor interviewed the DON after review of the records. The DON stated she was unable to find the shower sheets for the earlier part Resident #291's stay. She further stated that without documentation she would not be able to confirm that showers were done. The surveyor reviewed the facility's policy and procedure for shower and tub baths. In the policy it states, at a minimum, the resident will be offered at least 2 full baths or showers per week. The policy further states that the date and time of the shower or tub bath was performed should be documented as well as if the Resident refused with the intervention taken. 1b) On 8/27/24 at 6:13 AM, the surveyor observed from the hallway that Resident #45's call light was on and noted a staff member walk into the room. Shortly after the light was turned off and that same staff member left the room to attend to an alarm from the room next door. On 8/27/24 at 6:14 AM, the surveyor knocked and entered into Resident #45's room and observed that Resident #45 was the only resident in the room, The surveyor interviewed Resident #45 and asked if he/she had just put on the call light. Resident #45 responded yes and that he/she told the Geriatric Nursing Assistant (GNA) that he/she needed to go to the bathroom. He/she further stated because of the limitations he/she had he/she would probably have to use a bedpan and was waiting for physical therapy to get up. Following the interview the surveyor observed, from the hallway, the GNA who answered the light return into Resident #45's room, retrieve a paper and a phone, and walk out of the room and down the hallway. On 8/27/24 at 6:39 AM, the surveyor asked staff at the nurses station for the staffing assignments and was informed that GNA #21 was assigned to Resident #45. On 8/27/24 at 6:54 AM, the surveyor interviewed GNA # 21. During the interview the surveyor asks if the night shift GNA had given report and if she was aware that Resident #45 had requested to use the restroom. Staff #21 stated she was not aware and at this time looked up and stated that Resident #45's call light just went on and that she would go talk to Resident #45. The surveyor followed GNA #21 to Resident #45's room and heard Resident #21 report he/she needed to use the bathroom. On 8/27/24 at 6:56 AM, the surveyor interviewed the Registered Nurse (RN) Staff #27 the nurse assigned to Resident #45 on the night shift. She stated it was never reported to her that Resident #45 had to use the bathroom this morning. The surveyor reviewed Resident #45's care plans. A care plan was initiated stating, Resident #45 has Activities of Daily Living (ADL) limitations requiring staff assistance for bed mobility, locomotion, walking, bathing, hygiene/dressing, oral care, toileting, transferring related to activity intolerance. Additionally, Resident #45 had a care plan stating he/she was at risk for bladder/bowel incontinence related to impaired mobility. On 8/27/24 at 7:16 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor described the observation that Resident #45's request to use the bathroom was first addressed 52 minutes after the first request and only after putting on the call light again. The DON agreed that the resident's needs should have been addressed timely and after the first request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the Facility Reported Investigation (FRI) for MD00206729 revealed that Resident #29 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infraction affecting Right Dominant Side, Acquired Absence of Right Leg Above the Knee, Conductive hearing Loss and Chronic pain. On 08/22/24 at 12:15 PM an interview with Resident #29 revealed that he/she experienced pain in the left shoulder while being transferred by an aide. The resident could not remember the date of the incident. On 08/22/24 at 12:35PM a review of Resident's #29 medical record revealed the resident reported to Staff #24 that on that on 6/15/2024 at approximately 2030 the assigned GNA, transferred him/her in a rough manner from wheelchair to bed. The transfer caused the resident to injure the left shoulder causing him/her to yell out in pain. Resident #29 also reported the incident to Staff# 26 on 6/15/24 at 9:30 PM. On 06/17/24 an X-ray of Resident #29's left shoulder was done and the result was, There is no fracture or periosteal reaction Resident #29 Physician's Order stated, the resident requires 2-person assist for transfers. Start Date10/11/2023. Resident #29's Care Plan stated the resident has limited physical mobility relating to disease process arthritis and right AKA (Above the Knee Amputee). Intervention: I need the assistance of 2 caregivers for boosting up in bed. Date initiated: 02/07/24. On 08/27/24 at 07:21AM the surveyor informed the Director of Nursing of the findings and of the potential for injury related to Resident # 29's one-person transfer instead of a two person transfer. The DON responded I understand what happened. Based on record facility policy review, and interviews, it was determined that the facility failed to: 1) adequately document responses to treatment of skin conditions and 2) provide 2-person assistance to ensure resident safety during transfers. This was found evident for 2 (Resident #291 an #29) of 4 residents reviewed for wounds and resident- assisted transfers. The findings include: 1) On 8/20/24 at 12:18 PM, the surveyor reviewed Resident # 291's medical record. The review revealed that Resident #291 was admitted in late January 2023. Further review revealed that Resident #291 had a past medical history that included, but not limited to, dysphagia, dysphonia, muscle weakness, unsteadiness of feet and need for assistance with personal cares. The surveyor reviewed the progress notes for Resident #291 and discovered on 2/20/23 that Licensed Practical Nurse (LPN) #16 documented that Resident #291 had an open area to the coccyx and that the area was cleaned, a foam dressing was applied and the doctor and Responsible Party (RP) was made aware. On that same day Registered Nurse RN #3 documented on assessment there was no open area noted and that the sacrum had blanchable redness. The note further stated treatment was ordered, barrier cream applied and foam dressing placed. On 2/28/23 Staff #3 wrote a note again stating that Resident #291 has blanchable redness to the sacrum and that barrier cream and a foam dressing were applied. The note further stated Resident #291 had an order for daily dressing changes. On further review of the progress notes dated 3/1/23, 3/13/23, 3/15/23, 3/18/23 and on 3/19/23 treatment to the sacral area is documented as done, however no description of the skin integrity was documented. Licensed Practical Nurse (LPN) #24 documented the area as a sacral wound. On 8/28/24 at 1:27 PM, the surveyor interviews RN #3. During the interview RN #3 stated that she remembered that Resident #291 did not have an open wound and she recalls re-assessing Resident #291 after a nurse had written it was open. The surveyor asked RN #3 where the characteristics of the wound were documented. She stated that in her notes and it was documented as blanchable redness not open. The surveyor reviewed the Treatment Administration Records (TAR) for Resident #291 for March and April of 2023. On review an order was entered on 2/20/23 and stated to cleanse open area to sacrum with normal saline, dry, apply zinc and optifoam dressing daily and as needed for wound care. Review of the March TAR showed on 3/21/23, 3/23/23 and 3/29/21 no dressing change was documented as done. On review of the April 2023 TAR on 4/7/23 and 4/11/23 no dressing change was documented as done. On 4/24/23 a new order was written that stated, Apply barrier cream to Moister Associated Damage (MAD) to sacrum every shift and as needed for wound care. These orders were checked and completed for April 2023. The surveyor reviewed the facility's policy and procedure titled, Non-Pressure Ulcers/Injury Wound Management. The policy lists arterial ulcers, diabetic ulcers, Moisture-Associated Skin Damage (MASD), surgical wounds, venous or stasis ulcers as examples and gives the definitions. In the general guidelines it states, staff will be encouraged to promptly report any observations of change in the resident ' s skin integrity. It further states evaluation/assessment of non-pressure injury wounds will be completed weekly and with significant changes in condition of the ulcer/injury by the licensed nurse and/or practitioner. The documentation of the evaluations /assessment of the wound will be maintained in the resident's medical record and interventions to promote healing of the wound and to minimize recurrence of development will be incorporated in to the resident's care plan. Resident centered interventions and treatments will be prescribed by the physician/practitioner and administration of the treatments will be documented in the resident ' s medical record. Documentation may include; Location of wound, date the wound was acquired, Description of the wound to include measurements (length, width, depth), presence/absence of any tunneling or undermining, type of tissue (epithelial, granulation, sloth necrosis, ect), presence/absence and type of drainage, surrounding tissue description, and presence/absence of pain with the wound. On 8/29/24 at 7:40 AM, the surveyor conducted an interview with the Director of Nursing (DON). In the interview the surveyor asked where the weekly assessments of the skin condition were located. The DON stated weekly skin assessments are completed and checked on the TAR and the shower sheets. The surveyor asked about documentation of identified skin conditions or wounds and documentation of characteristics or measurements. The surveyor relayed the concern that if the skin condition/wound is not documented with characteristics or measurements weekly, then how can the facility measure or know if the treatment is working or appropriate. The surveyor also showed the DON the missing date of wound care documentation for Resident #291 for both March and April of 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, review of medical records and interview of facility staff, it was determined that the facility failed to provide appropriate treatment to maintain an individual's limited range of motion. This finding was evident for 1 (Resident# 6) of 1 resident reviewed for range of motion. The findings include: On 8/8/24 at 8:15 AM the surveyor observed Resident #6 sitting in a wheelchair in his/her room using the left hand to stabilize the right arm which was flaccid. On 8/13/24 at 9:31 AM while in the hallway, the surveyor again observed Resident #6 sitting in a wheelchair using her/his left hand to support the right arm which was pressed against the inside of the wheelchair. The surveyor enquired from Staff #18 whether Resident # 6 should have an arm support. Staff # 18 replied yes and proceeded to the resident's room, retrieved a splint and placed it on Resident #6's right arm. A review of Resident #6's medical record on 08/13/24 at 08:31AM revealed that the resident was admitted to the facility on [DATE] with diagnoses including Cerebrovascular Disease, Flaccid Hemiplegia Affecting Right Dominant Side and Muscle Weakness and Aphasia. Additional review also revealed: - A physician order dated 6/12/24 that stated - PT (Patient) to wear Comfy Grip Splint during the daytime every day related to Flaccid Hemiplegia Right Dominant side. Wash and dry splint as needed; -A careplan intervention initiated on 12/13/22 that stated - Apply splint to right hand for contracture management- assess skin prior to application and upon removal for skin breakdown. On 08/14/24 at 10:49 AM the surveyor notified the DON of the findings. The DON provided no additional information.

Based on review of the daily staffing sheets and interviews with staff, it was determined that the facility failed to have a Registered Nurse (RN) providing services for at least 8 consecutive hours a day, 7 days a week. This was found to be evident 4 out of 19 days reviewed for sufficient and competent nursing staff during the annual survey. The findings include: During the entrance conference on 8/6/24, the Director of Nursing (DON) confirmed that the facility did not have any Federal or State nursing staffing waivers. On 8/22/24 at 8:34 AM, the Surveyor reviewed the daily staffing sheets from 7/22/24 through 8/5/24. On 7/28/2024, there was no RN coverage for 24 hours. On 8/27/24 at 11:05 AM, the Surveyor conducted an interview with Staff Scheduler #30. During the interview, the Surveyor was informed that finding RN coverage for the weekend shifts are a challenge and that most of the time there is no RN coverage on the weekends. Staff Scheduler #30 also informed the Surveyor that there is a weekend supervisor that will start soon, and that person is an RN. During additional review of daily staffing sheets on 8/27/24 at 12:00 PM, the Surveyor discovered that on 8/10/24, 8/11/24, and 8/17/24, all weekend shifts, there was no RN coverage for 24 hours at the facility. On 8/27/2024 at 12:23 PM, an interview was conducted with the DON. The DON confirmed that there is a problem with weekend RN coverage and acknowledged a need for a RN for at least 8 consecutive hours a day. The Surveyor and DON established that on 7/28/24, 8/10/24, 8/11/24, and 8/17/24, there was no RN coverage those days for 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined that the facility failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection. This was evident for 2 (Resident #72 and Resident # 22) out of 56 residents observed for Infection Control. The findings include: Droplet precautions are a set of measures used to prevent the spread of infections caused by germs that spread through coughing, sneezing or talking. 1) Review of record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Major Depressive Disorder, Muscle Weakness, Unsteadiness on Feet. Resident #72 had a history of falls, and his/her plan of care included an intervention dated 08/05/24 which stated - during periods of significant restlessness and attempting to get out of chair without assistance, offer period of mats on the floor for (NAME) to rest on or engage in activities with supervision. On 7/27/24 Resident #72 tested Positive for Covid-19 and was placed on droplet precautions. During rounds on 08/07/24 at 11:AM the surveyor observed Resident #72 lying on a mat on the floor in the dayroom. The dayroom's door was open and there was no signage on the door to indicate that Resident #72 was on droplet precautions. Further, another Resident # 30 who was not diagnosed with Covid-19 was in the dayroom sitting on a wheelchair. Both Resident # 72 and Resident # 30 were not wearing masks. The surveyor's observation was brought to the attention of Staff #25 who immediately removed Resident # 30 from the dayroom, closed the door and placed the droplet precautions signage on the door. On 08/07/24 at 01:41PM the DON was notified of the surveyor's observation. The DON stated that the signage was usually on the door, and someone must have removed it. 2) Review of Record revealed Resident #22 was admitted on [DATE] with diagnoses including Dementia, Difficulty walking, Need for Assistance for Personal Care, Dysphagia and Chronic Diastolic (Congestive) Heart Failure. Resident #22's physician orders dated 02/01/20 included Oxygen via nasal cannula at 2 liters every 24 hours as needed for Shortness of Breath. On 08/07/24 at 03:27 PM upon entering Resident #22's room, the surveyor observed the resident's nasal cannula lying on the floor while the oxygen concentrator was in use. Resident#22 was not in respiratory distress. Further inspection revealed that the nasal canula was not dated and the humidifier bottle was not dated or labeled with the resident's name. Staff #13 confirmed the findings and removed the nasal canula and humidifier bottle from Resident #22's room stating, they would be replaced. Staff #13 stated that nasal cannulas and humidifier bottles are changed once a week on Fridays and should be dated and labelled with resident's name and the date changed. The Assistant Director of Nursing was notified of the findings on 08/09/24 at 08:05 AM and confirmed that it is the facility's policy for nasal cannulas and humidifier bottles to be changed weekly and labelled with resident's name and date changed.

Based on observation and interview with staff, it was determined that the facility failed to ensure that the walk-in freezer was in safe operating condition that prevented ice build-up including ice frozen to the floor. This was found to be evident for the walk-in freezer in the kitchen. The findings include: On 8/13/24 at 8:30 AM, the Surveyor conducted a follow up tour of the kitchen. During the tour, the Surveyor observed the walk-in freezer. Located at the back of the freezer, just below the ceiling, was a two-condenser fan unit. There were tiny mounds of ice on the ceiling of the freezer in front of the left condenser fan. Behind the right condenser fan, was a pipe with ice buildup and icicles. At the back of the freezer, directly below the condenser fan unit and the pipe, was several large mounds of ice across the floor which made that area slippery. On 8/13/24 at 9:45 AM, Certified Dietary Manager (CDM) #6 confirmed the Surveyors findings in the walk-in freezer. CDM #6 stated that, he has to remove the ice buildup a couple times a week. He informed the Surveyor that a repair man came out a year ago to assess the freezer and said that the freezer was working properly and that it was just condensation near the fans. The Surveyor reviewed the concern that if working properly, there should not be ice buildup in the walk-in freezer. On 8/14/24 at 12:08 PM, Administrator #1 informed the Surveyor that Southern Maryland Refrigeration is the vendor that the facility utilizes for repairs. The vendor came out to assess the freezer about a year ago. Surveyor requested documentation of the most recent maintenance company service call for the walk-in freezer and a copy of the workorder. As of 8/29/2024 at 1:40 PM, Administrator #1 did not provide any recent documentation of service calls or repairs to the walk-in freezer in the kitchen prior to 8/13/24. The Director of Maintenance, #31, informed the Surveyor that the workorder for the walk-in freezer had been submitted and being serviced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 8/22/24 at 9 AM, the surveyor reviewed Resident #291's grievances filed in the facility's grievance log. On 3/9/23 Social Worker #17 documented that Resident #291's family member complained about Resident #291's phone not working, therapy questions, and food concerns. The section for follow-up stated, Social Worker would refer the summary to the Director of Nursing, Unit Manager, Dietary and Maintenance. It further described that SW #17 spoke to maintenance and a new phone would be placed in Resident #291's room and that an email was sent to the rehabilitation départment explaining the family members' concerns. However, no follow up from dietary was documented. Next the surveyor reviewed a grievance statement from 4/12/23. In the statement Resident #291 stated he/she was handled roughly while being helped to reposition in a wheelchair during this interaction with a Geriatric Nursing Assistant (GNA). Resident #291 reported hitting his/her elbow on the wheelchair causing it to bleed. He/she further described the GNA as rude and wishes not to have the GNA take care of him/her again. He/she reported being left soaked in diapers for an extended period of time. Finally he/she discussed the desire to sign a waiver so he/she could drink thin liquids. No follow up was documented in regards to these three grievances. On 8/26/24 at 11:28 AM, the surveyor reviewed intake #MD00192593 sent to the Office of Health Care Quality (OHCQ). The intake described Resident #291 had made a request to switch from the A bed to B bed for accessibility reasons. It further stated the request was made several times and never was addressed. The intake also stated that clothes were missing and never returned or compensated for. On 8/28/24 at 10:36 AM, the surveyor interviewed the NHA. During the interview the NHA stated he remembered Resident #291's family member requested to switch beds to the window side but could not recall the rationale for why it did not happen. He further stated that the family reported missing clothes and were instructed to bring in receipts for reimbursement. He stated no receipts were ever brought in. The surveyor expressed the concern that those grievances were not recorded and that there was no way to see that follow through was done when the facility knew of the concerns. The NHA stated that education on the grievance procedure is currently happening with the facility staff. Based on record review, and interviews it was determined that the facility failed to make an effort to resolve residents' grievances. This was found to be true for 2 of 2 grievances for Resident #58, 1 of 1 grievance for Resident #18, and 6 out of 8 grievances for Resident #291. The findings include: 1a) Review of Resident #58's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses including a cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, conversion disorder with seizures or convulsions, heart failure, chronic obstructive kidney disease, and stage 3 chronic kidney disease. Additional review of Resident #58's medical record showed a care plan created on 1/11/23 that stated Resident #58 has activities of daily living (ADL) limitations/deficits requiring staff assistance of 1 person for toilet use and transfers between surfaces. On 8/19/23 12: 45 PM Surveyors reviewed the grievance logs from 2023 through 2024. During review of the 2023 grievance binder, the surveyor noted a grievance dated 5/18/2023 written by the Director of Social Work, (SW) #17, that stated: on 5/18/23 around noon, I was walking past the Patuxent nurse's station when I heard loud yelling. I looked over and saw GNA/CMA #19 beside the med cart and Resident #58 sitting in his/her wheelchair. GNA/CMA #19 was yelling at Resident #58 about something. I can't recall what she was saying because I was so shocked to hear her yelling so loud. Further review of grievances revealed another grievance dated 4/27/23, involving Resident #58. The person voicing the concern was Resident #58 which stated he felt that staff were always rushing when providing care for him/her. The resident said that when staff wake him up in the morning, they do it by hollering at him. 1b) Review into the grievance binder labelled 2024 revealed a grievance dated 4/10/24 and the person voicing the concern was Resident #18. The grievance stated: that during a care plan meeting on 4/9/24, the reason Resident #18 wanted to move to a different unit was to get away from GNA/CMA #19 because of GNA/CMA #19 was being rough with him/her, telling him/her what to do, like a child. The grievance goes on to note that there was an incident where GNA/CMA yelled down the hall to Resident #18 you're not going to eat that candy before mealtime there were other people around and Resident #18 felt embarrassed. Review of Resident #18's medical record revealed that he/she was admitted to the facility on [DATE] with diagnoses including hemiplegia affecting the right dominant side, dementia without behavioral /psychotic/mood disturbance, cerebrovascular disease and dysphagia. Resident #18's care plan showed that due to past cerebrovascular accidents, the resident has an ADL self-care deficit with right side weakness. The resident required one staff assistance to turn and reposition in bed and with toilet use. Surveyors held an interview with SW #17 on 8/22/24 at 11:15 AM. Surveyors reviewed the grievances dated 5/18/23 and 4/27/23 with SW #17. SW #17 confirmed that she witnessed and documented the incident of verbal abuse when GNA/CMA #19 yelled at Resident #58 on 5/18/23 and she documented Resident #58's concerns on 4/27/23 about staff hollering at him/her. When surveyors asked SW #17 to describe the facility's grievance filing process, she stated that she is the grievance officer and the process is to type the concerns, log them, then send the grievance document to the DON, the Nursing Home Administrator (NHA), then she assigns the grievance to appropriate department supervisor for review and action. When surveyors asked SW #17 what happens after the grievances have been assigned, she stated that she is not given any results or resolutions nor responsible for following up with the grievances. SW #17 went on to say that the grievances dated 5/18/23 and 4/27/23, was given to the Unit Manager (UM) at the time, Assistant Director of Nursing (ADON), Staff #3, with a copy to the prior DON, Staff #34, and the NHA. Review of the grievances dated 5/18/23 and 4/2723 showed that the DON/UM was denoted as the assigned department supervisors to address the grievance. Later during the interview, SW #17 confirmed that the witnessed verbal abuse (Resident #58) on 5/18/23, Resident #58's grievance on 4/27/23 about staff hollering at him/her, and the grievance by Resident #18 reporting rough treatment and embarrassment, were reportable incidents but could not recall if the incidents were reported to the state. An interview was held on 8/23/2024 at 9:20 AM with the NHA. The surveyors and the NHA reviewed the two grievances related to Resident #58 and the grievance from Resident #18. The surveyor asked the NHA what the process was for any grievance filed at the facility and he replied: SW #17 is the designated grievance officer, and she documents the grievances, determines which department addresses them, and forwards a copy of the grievance to myself, the DON and the appropriate department supervisor/head of which the concern/grievance addressed. The NHA went on to say that the assigned department supervisor is to follow up with the resident/complainant in concern to resolve the grievance. The surveyor asked the NHA whether the written statement by SW #17 on 5/18/23 meets the definition of abuse, and he replied, yes. The surveyor asked the NHA about the grievance filed by Resident #58 on 4/27/23 and whether the details would be considered an allegation of abuse to which he replied: yes, it is. In addition, the surveyor asked the NHA whether the grievance filed by Resident #18 on 4/10/24 would be considered as an allegation of abuse, to which he answered, I can see how it can be interpreted as abuse. The NHA went on to say that he could see there was a pattern showing that GNA/CMA #19 was mentioned in these grievances. The surveyor requested documentation to show that the grievances were addressed. The NHA confirmed that there was no documentation of resolution or follow-up for the reviewed grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview and staff interview it was determined that facility staff failed to: 1) ensure that residents' allegations of theft were reported to in a timely manner and 2) respond to and report allegations of abuse. This was evident for 5 (Resident #68, Resident #42 and Resident #291, Resident #58, and Resident #18) of 10 residents reviewed for timely reporting and abuse. The findings: 1a) On 08/19/24 at 10:27 AM the surveyor reviewed a facility reported incident (FRI), #MD00206250, sent to the Office of Health Care Quality (OHCQ) on 6/3/24 which stated that Resident #68 reported $100 was taken from his/her wallet. The surveyor observed that the report was submitted on 6/3/24 and the date of the incident documented as 6/26/24. The discrepancy was pointed out to the Director of Nursing (DON) who confirmed it was an error and that the incident was reported to the facility by the resident on 5/25/24 and not 6/26/24. Additional review of the FRI investigation revealed a statement written by Staff #27 confirming that on 5/25/24, Resident #68 reported to her that $100 was taken from her/his purse. The facility investigation also revealed that the facility submitted an initial report to OHCQ on 5/29/24. The facility was required to submit a report to OHCQ within 24 hours of the allegation. On 08/21/24 at 08:05 AM the surveyor notified the Director of Nursing (DON) of the findings. The DON provided no additional information. 1b) On 08/16/24 at 10:00AM the surveyor review of the FRI # MD00206646 revealed a written statement on 6/2/24 from Staff#15 which stated Resident #42 reported to her that $30-$50 was stolen from his/her wallet. Further review of the FRI revealed that the facility submitted the initial report to OHCQ on 6/7/24. The facility was required to report the incident within 24 hours of the allegation. On 08/21/24 at 08:05 AM the surveyor notified the Director of Nursing (DON) of the findings. The DON confirmed no additional information. 2) On 8/21/24 at 10:18 AM, the surveyor interviewed the Nursing Home Administrator (NHA) and asked if he was aware of any allegations that Resident #291 made in regards to abuse. The NHA stated he could not recall any allegations. On 8/22/24 at 9 AM, the surveyor reviewed the grievance log from 2023. A typed note dated 4/12/23 at 11 AM stated that this social worker spoke with Resident #291 regarding allegations that he/she was abused and neglected by staff. The statement described that a Geriatric Nursing Assistant (GNA) roughly grabbed Resident 291's by the arms and yanked him/her up in the wheelchair causing him/her to hit his/her elbow against the wheelchair. In the statement Resident #291 gave a description of the GNA and stated the GNA was very rough and rude while providing care. Resident #291 also stated he/she does not want this GNA to take care of him/her anymore. On 8/22/24 at 11:44 AM, the surveyor interviewed Social Worker #17. During the interview SW #17 stated that she recalls taking the statement from Resident #291 and was told by the nurse that prior to the interview that Resident #291 wanted to speak with her. After speaking with Resident #291 the GNA was identified as GNA #11. SW #17 further stated the GNA #11 no longer is employed at the facility related to another incident. The surveyor asked SW#17 if other interviews were conducted or if the allegation was reported to the NHA. SW #17 stated any time a grievance or allegation is obtained a copy of the statements is sent to the Director of Nursing (DON), Unit Manager, department head related to grievance, and the NHA. She further stated she could not recall that she was asked to follow up on this allegation. On 8/23/24 at 9:46 AM, the surveyor interviewed the NHA. During the interview the NHA confirmed Resident #291's abuse allegation was never reported to the police or the Office of Health Care Quality (OHCQ) or that an investigation was conducted to follow up on the allegation. On 8/23/24 the facility reported they reported the allegation to the police and OHCQ as well as started an investigation into the allegation. 3a) Review of Resident #58's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses including a cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, conversion disorder with seizures or convulsions, heart failure, chronic obstructive kidney disease, and stage 3 chronic kidney disease. Additional review of Resident #58's medical record showed a care plan created on 1/11/23 that stated Resident #58 has activities of daily living (ADL) limitations/deficits requiring staff assistance of 1 person for toilet use and transfers between surfaces. On 8/19/23 12: 45 PM Surveyors reviewed the grievance logs from 2023 through 2024. During review of the 2023 grievance binder, the surveyor noted a grievance dated 5/18/2023 written by the Director of Social Work, (SW) #17, that stated: on 5/18/23 around noon, I was walking past the Patuxent nurse's station when I heard loud yelling. I looked over and saw GNA/CMA #19 beside the med cart and Resident #58 sitting in his/her wheelchair. GNA/CMA #19 was yelling at Resident #58 about something. I can't recall what she was saying because I was so shocked to hear her yelling so loud. Further review of grievances revealed another grievance dated 4/27/23, involving Resident #58. The person voicing the concern was Resident #58 which stated he felt that staff were always rushing when providing care for him/her. The resident said that when staff wake him up in the morning, they do it by hollering at him. 3b) Review into the grievance binder labelled 2024 revealed a grievance dated 4/10/24 and the person voicing the concern was Resident #18. The grievance stated: that during a care plan meeting on 4/9/24, the reason Resident #18 wanted to move to a different unit was to get away from GNA/CMA #19 because of GNA/CMA #19 was being rough with him/her, telling him/her what to do, like a child. The grievance goes on to note that there was an incident where GNA/CMA yelled down the hall to Resident #18 you're not going to eat that candy before mealtime there were other people around and Resident #18 felt embarrassed. Review of Resident #18's medical record revealed that he/she was admitted to the facility on [DATE] with diagnoses including hemiplegia affecting the right dominant side, dementia without behavioral /psychotic/mood disturbance, cerebrovascular disease and dysphagia. Resident #18's care plan showed that due to past cerebrovascular accidents, the resident has an ADL self-care deficit with right side weakness. The resident required one staff assistance to turn and reposition in bed and with toilet use. Surveyors held an interview with SW #17 on 8/22/24 at 11:15 AM. Surveyors reviewed the grievances dated 5/18/23 and 4/27/23 with SW #17. SW #17 confirmed that she witnessed and documented the incident of verbal abuse when GNA/CMA #19 yelled at Resident #58 on 5/18/23 and she documented Resident #58's concerns on 4/27/23 about staff hollering at him/her. When surveyors asked SW #17 to describe the facility's grievance filing process, she stated that she is the grievance officer and the process is to type the concerns, log them, then send the grievance document to the DON, the Nursing Home Administrator (NHA), then she assigns the grievance to appropriate department supervisor for review and action. When surveyors asked SW #17 what happens after the grievances have been assigned, she stated that she is not given any results or resolutions nor responsible for following up with the grievances. SW #17 went on to say that the grievances dated 5/18/23 and 4/27/23, was given to the Unit Manager at the time, Assistant Director of Nursing (ADON), Staff #3, with a copy to the prior DON, Staff #34, and the NHA. Review of the grievances dated 5/18/23 and 4/2723 showed that the DON/UM was denoted as the assigned department supervisors to address the grievance. Later during the interview, SW #17 confirmed that the witnessed verbal abuse (Resident #58) on 5/18/23, Resident #58's grievance on 4/27/23 about staff hollering at him/her, and the grievance by Resident #18 reporting rough treatment and embarrassment, were reportable incidents but could not recall if the incidents were reported to the state. An interview was held on 8/23/2024 at 9:20 AM with the NHA. The surveyors and the NHA reviewed the two grievances related to Resident #58 and the grievance from Resident #18. The surveyor asked the NHA what the process is for any grievance filed at the facility and he replied: SW #17 is the designated grievance officer, and she documents the grievances, determines which department addresses them, and forwards a copy of the grievance to myself, the DON and the appropriate department supervisor/head of which the concern/grievance addressed. The NHA went on to say that the assigned department supervisor is to follow up with the resident/complainant in concern to resolve the grievance. The surveyor asked the NHA whether the written statement by SW #17 on 5/18/23 meets the definition of abuse, and he replied yes. The surveyor asked the NHA about the grievance filed by Resident #58 on 4/27/23 and whether the details would be considered an allegation of abuse to which he replied: yes, it is. In addition, the surveyor asked the NHA whether the grievance filed by Resident #18 on 4/10/24 would be considered an allegation of abuse, to which he answered, I can see how it can be interpreted as abuse. The NHA went on to say that he could see there was a pattern showing that GNA/CMA #19 was mentioned in these grievances. The surveyor requested documentation to show the grievances were addressed. The NHA confirmed that there was no documentation of resolution or follow-up for the reviewed grievances. On 8/23/24 at 4:15 PM the surveyors held an interview with the NHA and the DON. The surveyors discussed concern that there was a grievance showing witnessed staff to resident abuse on 5/18/23, additional grievances filed by Resident #58 on 4/27/23 and Resident #18 on 4/10/24 alleging abuse, all of which confirmed the facility failed to ensure residents were free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3a) On 8/22/2024 at 12:00PM, a review of the FRI investigation file revealed that on 12/8/2022 at approximately 1:15 PM, the Resident #28 reported that Geriatric Nursing Assistant (GNA) #11 was rough when providing cares, refused to get the resident out of bed multiple times, and did not leave the call bell in reach. Additional review of the FRI investigation file revealed that the incident was reported to the Office of Health Care Quality on 12/8/2022 at 2:00 PM and the facility concluded its investigation on 12/13/2022 at 2:00 PM. The investigation file did not include documentation of a head to toe assessment, staff interviews or statements, other resident interviews or statements, an interview with the GNA perpetrator, nor education provided to the GNA perpetrator regarding abuse, resident rights, or proper transfer technique. During further review of Resident #28's electronic and paper medical record, the Surveyor discovered that there was no documentation of the abuse incident occurring on 12/8/2022. On 8/23/2024 at approximately 4:00PM, the Director of Nursing (DON) #2 informed the Surveyors that she noticed most FRI investigations had not been thoroughly investigated prior to her employment with the facility in May of 2023. 3b) On 8/22/2024 at 12:30 PM, the Surveyor reviewed GNA #11's employee file and discovered a statement made by Staff Scheduler #30 on10/6/2023 regarding a conversation she had with Resident #38. The statement revealed that GNA #11 had hit Resident #38 and was mean to the resident on 10/6/2023 during the day shift. Staff Scheduler #30 stated that she immediately reported the information to the charge nurse during her shift and unit manager that same evening. On 8/23/2024 at approximately 11:30 AM, the Surveyor asked DON #2 for the Facility Reported Incident (FRI) investigation file regarding Resident #38's allegation of abuse from the accused the perpetrator, GNA #11. The DON #2 was unable to provide the Surveyor with the FRI investigation file and stated, We just can't find it. DON #2 was able to provide documentation that a facility submitted a self-report to the Office of Health Care Quality on 10/9/2023 at 5:16 PM, but unable to provide any other documentation. There was no other documentation in Resident #38's electronic or paper medical record regarding this FRI. Based on record review, review of the facility's investigation files, and interviews it was determined that the facility failed to complete a thorough investigation and maintain the records of their investigation. This was found evident for 6 (Resident #291, #283, #58, #18, #28 and #38) out of 10 residents investigated for abuse. The findings include: 1a) On 8/22/24 at 9 AM, the surveyor reviewed the investigation the facility conducted into the allegation that GNA #11 hit Resident #283 on the head three times while providing care. The summary of the investigation described that an interview was conducted with Resident #291 and Resident #291's roommate, a witness. It also described a statement was taken from GNA #11, the alleged perpetrator, who denied the allegation. The reports stated that 4 other Residents that GNA #11 was assigned to were interviewed, however it did not state the results of the interviews or have copies of the interviews that were conducted. No GNA assignment documentation was in the file to help identify the other Residents potentially affected. No actual interviews or statements were found in the investigation or evidence to show the steps reported were actually completed. No evidence was in the file to suggest that GNA #11 was placed on leave pending the investigation. Next the surveyor reviewed GNA#11's employee file. The surveyor noted a time card that noted GNA #11 was on leave while the investigation was being conducted. On 8/23/24 at 9:46 AM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview the surveyor reviewed the concerns that in the investigation file there was no evidence to support an investigation was completed. The only document in the file was a summary of an investigation. The NHA agreed the interviews and statements were missing and should be part of the record. 1b) On 8/22/24 at 9 AM, the surveyor reviewed the grievance log from 2023. A typed note dated 4/12/23 at 11 AM stated that this social worker spoke with Resident #290 regarding allegations that he/she was abused and neglected by staff. The statement described that a Geriatric Nursing Assistant (GNA) roughly grabbed Resident 2901's by the arms and yanked him/her up in the wheelchair causing him/her to hit his/her elbow against the wheelchair. In the statement Resident #291 gave a description of the GNA and stated the GNA was very rough and rude while providing cares. Resident #291 also stated he/she does not want this GNA to take care of him/her anymore. On 8/22/24 at 11:44 AM, the surveyor interviewed Social Worker #17. During the interview SW #17 stated that she recalls taking the statement from Resident #291 and was told by the nurse that Resident #291 wanted to speak with her. After speaking with Resident #291 the GNA was identified as GNA #11. SW #17 further stated the GNA #11 no longer is employed at the facility related to another incident. The surveyor asked SW#17 if other interviews were conducted or if the allegation was reported to the NHA. SW #17 stated any time a grievance or allegation is taken a copy of the statements is sent to the Director of Nursing (DON), Unit Manager, the department head involved and the NHA. She further stated she could not recall that she was asked to follow up on this allegation. She explained that she takes statements from Residents and does not get involved when it comes to statements or employee personnel matters. On 8/23/24 at 9:46 AM, the surveyor interviewed the NHA. During the interview the NHA confirmed Resident #291's abuse allegation was never reported to the police or the Office of Health Care Quality (OHCQ) or an investigation conducted to follow up on the allegation. He also confirmed that GNA #11 was able to continue to work after this allegation however was not currently employed. 2a) Review of Resident #58's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses including a cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, conversion disorder with seizures or convulsions, heart failure, chronic obstructive kidney disease, and stage 3 chronic kidney disease. Additional review of Resident #58's medical record showed a care plan created on 1/11/23 that stated Resident #58 has activities of daily living (ADL) limitations/deficits requiring staff assistance of 1 person for toilet use and transfers between surfaces. On 8/19/23 12: 45 PM Surveyors reviewed the grievance logs from 2023 through 2024. During review of the 2023 grievance binder, the surveyor noted a grievance dated 5/18/2023 written by the Director of Social Work, (SW) #17, that stated: on 5/18/23 around noon, I was walking past the Patuxent nurse's station when I heard loud yelling. I looked over and saw GNA/CMA #19 beside the med cart and Resident #58 sitting in his/her wheelchair. GNA/CMA #19 was yelling at Resident #58 about something. I can't recall what she was saying because I was so shocked to hear her yelling so loud. Further review of grievances revealed another grievance dated 4/27/23, involving Resident #58. The person voicing the concern was Resident #58 which stated he felt that staff were always rushing when providing care for him/her. The resident said that when staff wake him up in the morning, they do it by hollering at him. 2b) Review into the grievance binder labelled 2024 revealed a grievance dated 4/10/24 and the person voicing the concern was Resident #18. The grievance stated: that during a care plan meeting on 4/9/24, the reason Resident #18 wanted to move to a different unit was to get away from GNA/CMA #19 because of GNA/CMA #19 was being rough with him/her, telling him/her what to do, like a child. The grievance goes on to note that there was an incident where GNA/CMA (Certified Medication Assistant) yelled down the hall to Resident #18 you're not going to eat that candy before mealtime there were other people around and Resident #18 felt embarrassed. Review of Resident #18's medical record revealed that he/she was admitted to the facility on [DATE] with diagnoses including hemiplegia affecting the right dominant side, dementia without behavioral /psychotic/mood disturbance, cerebrovascular disease and dysphagia. Resident #18's care plan showed that due to past cerebrovascular accidents, the resident has an ADL self-care deficit with right side weakness. The resident required one staff assistance to turn and reposition in bed and with toilet use. Surveyors held an interview with SW #17 on 8/22/24 at 11:15 AM. Surveyors reviewed the grievances dated 5/18/23 and 4/27/23 with SW #17. SW #17 confirmed that she witnessed and documented the incident of verbal abuse when GNA/CMA #19 yelled at Resident #58 on 5/18/23 and she documented Resident #58's concerns on 4/27/23 about staff hollering at him/her. When surveyors asked SW #17 to describe the facility's grievance filing process, she stated that she is the grievance officer and the process is to type the concerns, log them, then send the grievance document to the DON, the Nursing Home Administrator (NHA), then she assigns the grievance to appropriate department supervisor for review and action. When surveyors asked SW #17 what happens after the grievances have been assigned, she stated that she is not given any results or resolutions nor responsible for following up with the grievances. SW #17 went on to say that the grievances dated 5/18/23 and 4/27/23, was given to the Unit Manager (UM) at the time, Assistant Director of Nursing (ADON), Staff #3, with a copy to the prior DON, Staff #34, and the NHA. Review of the grievances dated 5/18/23 and 4/2723 showed that the DON/UM was denoted as the assigned department supervisors to address the grievance. Later during the interview, SW #17 confirmed that the witnessed verbal abuse (Resident #58) on 5/18/23, Resident #58's grievance on 4/27/23 about staff hollering at him/her, and the grievance by Resident #18 reporting rough treatment and embarrassment, were reportable incidents but could not recall if the incidents were reported to the state. An interview was held on 8/23/2024 at 9:20 AM with the NHA. The surveyors and the NHA reviewed the two grievances related to Resident #58 and the grievance from Resident #18. The surveyor asked the NHA what the process is for any grievance filed at the facility and he replied: SW #17 is the designated grievance officer, and she documents the grievances, determines which department addresses them, and forwards a copy of the grievance to myself, the DON and the appropriate department supervisor/head of which the concern/grievance addressed. The NHA went on to say that the assigned department supervisor is to follow up with the resident/complainant in concern to resolve the grievance. The surveyor asked the NHA whether the written statement by SW #17 on 5/18/23 meets the definition of abuse, and he replied yes. The surveyor asked the NHA about the grievance filed by Resident #58 on 4/27/23 and whether the details would be considered an allegation of abuse to which he replied: yes, it is. In addition, the surveyor asked the NHA whether the grievance filed by Resident #18 on 4/10/24 would consider as an allegation of abuse, to which he answered, I can see how it can be interpreted as abuse. The NHA went on to say that he could see there was a pattern showing that GNA/CMA #19 was mentioned in these grievances. The surveyor requested documentation to show the grievances were addressed. The NHA confirmed that there was no documentation of resolution or follow-up for the reviewed grievances. On 8/23/24 at 4:15 PM the surveyors held an interview with the NHA and the DON. The surveyors discussed concern that there was a grievance showing witnessed staff to resident abuse on 5/18/23, additional grievances filed by residents on 4/27/23 and 4/10/24 alleging abuse, all of which confirmed the facility failed to ensure residents were free from abuse.

Based on record review and interviews it was determined that the facility failed to provide routine administration of medications timely. This was found evident in 1 (Resident # 298) of 5 residents reviewed for medication administration. The finding include: On 8/15/24 at 1:16 PM, the surveyor reviewed Resident #298's medical record. The review revealed that Resident #298 was admitted to the facility early April of 2021 with a past medical history that included, but is not limited to, type 2 diabetes, disorientation, epilepsy (a brain disorder that causes seizures), and acute cystitis (infection/inflammation of the urinary tract system). The surveyor reviewed a progress note written on 4/17/21 by Licensed Practical Nurse (LPN) #29 that stated at 10:40 AM, upon initial assessment, Resident #298 was found nearly unresponsive and per report from the aide was not responsive enough to eat breakfast this morning. The surveyor next reviewed the Medication Administration Record (MAR) for April of 2021. The record revealed that Resident # 289 was given a scheduled 6 AM medication at 6:18 AM on 4/17/21. The next medication due to be given was Glimepiride (a medication used to treat high blood sugars in diabetics) and was scheduled for 8:30 AM. The administration record for this medication stated see progress note. The surveyor reviewed the progress note written on 4/17/21 at 12:28 AM by LPN #29. The note stated, unable to administer due to altered mental status and Resident #298 was being transferred out via Emergency Medical Service. On 8/19/24 at 1:42 PM, the surveyor reviewed the MAR with the Director of Nursing (DON). The Director of Nursing stated it is policy to give medications 1 hour before or 1 hour after the medication is due to be given. The surveyor relayed the concern that LPN #29 appeared not to have attempted to give Resident #298 his/her scheduled medication until 10:40 AM, 2 hours after the scheduled time. The DON confirmed there was a delay in medication administration.

Based on observation and interview with residents and facility staff, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents who eat food prepared by the facility. The findings include: On 8/08/24 at 10:00 AM, the Surveyor conducted an interview with Resident #74. During the interview, the resident stated that the food is lukewarm and not palatable. In addition, the Surveyors received complaints from resident families stating that the food is cold by the time it reaches their loved one. On 8/15/24 at 11:40 AM, the Surveyor observed preparation for the lunch tray line. The Certified Dietary Manager (CDM) #6 was present during the Surveyor's observation of the tray line. The first tray was prepared at 12:00 PM. Trays were prepared accordingly, placed in a meal cart, and immediately taken to the appropriate unit. The Surveyor was informed that the meal trays are delivered to each specific unit in an order based on the hallway and room numbers. This pattern continued until every resident had a tray. A test tray was requested by the Surveyor to be included on the last meal cart. On 8/15/24 at 1:00 PM, the final tray was placed on the meal cart. CDM #6 retrieved a temperature gauge and rolled the meal cart directly to the nursing unit. The meal cart arrived to the unit at 1:05 PM and 3 staff members assisted with passing out the lunch trays. The test tray was the last tray on the cart. CDM #6 performed the temperature testing: chicken breast, 119 degrees Fahrenheit; rice 126 degrees Fahrenheit; potato 117 degrees Fahrenheit; and peas 120 degrees Fahrenheit. The Surveyor interviewed CDM #6 at the end of the test tray process, around 1:10 PM, who stated that his expectation is for meal trays to be delivered to units timely and hot foods to be maintained at a temperature palatable for the residents. CDM #6 informed the Surveyor that several changes have been made to make sure the hot food is palatable for the residents. The kitchen staff have been educated on setting steam table temps, getting additional plates for the induction heater and prewarm them, keeping the food covered while on the steam table, and maintain warm plate pellets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with facility staff, it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents who eat the food prepared in the facility's kitchen. The findings include: During a tour of the facility's kitchen conducted on 8/13/24 at 8:30 AM, the Surveyor inspected the main walk-in refrigerator. The Surveyor observed a shelf containing an opened and unlabeled 1-gallon tub of Sysco mayo, a 1-gallon tub of Sysco mustard with a received date of 3/1 on the lid, and 1 gallon tub of Kens Homestyle Ranch with a received date of 7/29. During a continued tour of the kitchen, the Surveyor observed the dry goods storage pantry. The Surveyor noted an opened and unlabeled 28 oz box of Quaker Cream Of Wheat with a use first label, Ralson Foods Quick oats with a use first label, tub of Goldmetal Chocolate Fudge icing with a use first label, 26 oz pack of Idahoan classic mashed potatoes wrapped in plastic wrap, 12 inch flour tortilla package (12ct), 24 oz of orange Jello wrapped in plastic wrap, and 24 oz pack of lime Jello with a use first label wrapped in plastic wrap. In addition, the Surveyor observed the main walk-in freezer. There was a box of Iced Crown Danish variety pack of 24 apple, 24 cherry, and 24 raspberry which were labeled opened on 6/5/24 with a use by date of 7/5/2024. There were personal items such as a grocery bag with personal food items and a bouquet of [NAME] on the shelf of the freezer alongside other frozen foods. Located in the back of the freezer, just below the ceiling, was a two-condenser fan unit. There were tiny mounds of ice on the ceiling of the freezer in front of the left condenser fan. Behind the right condenser fan, was a pipe with ice buildup and icicles. At the back of the freezer, directly below the condenser fan unit and the pipe, was several large mounds of ice going across the floor which made that area slippery. On 8/13/24 at approximately 9:30 AM, during a walk through the kitchen, the Surveyor reviewed the unlabeled and expired food items with Certified Dietary Manager (CDM) #6. CDM #6 immediately removed the unlabeled and expired food items. He removed the personal items from the freezer and stated, personal items should never be in here. CDM #6 confirmed the Surveyors findings of ice buildup in the walk-in freezer and stated that, he has to remove the ice buildup a couple times a week. Surveyor reviewed the concern that if working properly, there should not be ice buildup in the walk-in freezer. On 8/13/24 at 10:20 AM, CDM #6 provided the Surveyor with a copy of the Labeling and Dating Foods (Date Marking) procedure which stated that once a package is opened, it will be re-dated with the date the item was opened (all ready to eat, potentially hazardous food will be re-dated with the use by date) and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. CDM #6 stated that he will review the labeling and dating procedure with his staff through an education in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff, it was determined that the facility failed to maintain complete and accurate medical records in accordance with acceptable professional standards. This was evident for 3 (Resident #64, Resident #34, and Resident #44) out of 56 resident records reviewed during the annual survey. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Cardiopulmonary resuscitation (CPR) is a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped. Do Not Resuscitate (DNR) is an order placed in a person's medical record by a doctor informs the medical staff that CPR should not be attempted. Do Not Intubate (DNI) is an order placed in a person's medical record by a doctor informs the medical staff that chest compressions and cardiac drugs may be used, but no breathing tube will be placed. 1) On [DATE] at 10:40 AM, during a review of Resident #64's paper medical record, the Surveyor discovered two MOLST forms in the resident's chart. The first MOLST form was dated [DATE] with code status of Do Not Resuscitate (DNR). The second MOLST form was dated [DATE] with a code status of Cardiopulmonary Resuscitation (CPR). On [DATE] at 10:45 AM, during a review of Resident #34's paper medical record, the Surveyor discovered two MOLST forms in the resident's chart. The first MOLST form was dated [DATE] with code status of DNR. The second MOLST form was dated [DATE] with a code status of Do Not Intubate (DNI). On [DATE] at 10:15 AM, the Surveyor conducted an interview with Licensed Practical Nurse (LPN) #16. LPN #16 stated that the nursing staff go to the paper chart for the MOLST form and code status. There should be one MOLST form in the resident's paper medical record and the old MOLST should be voided out. The Surveyor and LPN #16 confirmed two MOLST forms in Resident #64's and Resident # 34's paper chart. During an interview conducted on [DATE] at 10:25 AM with the Director of Nursing (DON) #2, the Surveyor expressed the concern that there were two MOLST forms in Resident #64's and Resident #34's paper chart. The Surveyor was informed that the nursing staff should look at the MOLST form with the most recent date if two are in the resident's chart. However, it is best practice to void the old MOLST to avoid mistakes. On [DATE] at 9:00 AM, during an interview with Unit Manager #10, the Surveyor was informed that the process for updating a MOLST form is that once a new MOLST form is created and reviewed by the physician, the old MOLST form should be voided by writing VOID across the form and place it in the paper chart behind the new MOLST form. The new MOLST form should then be uploaded into the electronic medical record. 2) On [DATE] at 9:45 AM, a review of Resident #34's electronic medical record revealed a nursing note written by LPN #16 which stated that the resident sustained a fall on [DATE] at 5:15 AM. The Surveyor identified another nursing note with the effective date and time as [DATE] at 3:45 AM, created on [DATE] at 11:06 AM by Registered Nurse (RN) #33 stating that Resident #34 sustained a fall. Morse fall scale is a fall risk assessment tool that predicts the likelihood that a patient will fall. Additional review of Resident #34's electronic medical record revealed a fall incident report, a Morse fall scale, and a skin and wound total body assessment documented on [DATE] for the fall sustained on [DATE] at 5:15 AM. On [DATE] at 10:11 AM, during an interview with LPN #16, the Surveyor discovered that the Geriatric Nursing Assistant (GNA) from the night shift on [DATE] informed LPN #16 that Resident #34 sustained a fall on [DATE] at 5:15 AM. On [DATE] at 11:05 AM the Surveyor conducted an interview with DON #2. DON #2 informed the Surveyor that RN #33 was suspended for not completing the fall protocol for Resident #34 immediately after his/her fall on [DATE] at 5:15 AM. 3) On [DATE] at 12:17 PM, a review of Resident #44's electronic medical record revealed that the resident sustained a fall on [DATE]. Further review of Resident #44's electronic medical record revealed that Resident #44 complained of bilateral hip pain on [DATE] and was transferred to the local hospital emergency room (ER) for further management of a left femoral fracture. Subsequently, Resident #44 had surgery for a comminuted intertrochanteric fracture involving the left femur. On [DATE] at 9:11 AM, a review of Resident #44's electronic medical record revealed a consultant Pain Management note written by Certified Registered Nurse Practitioner (CRNP) #32 on [DATE] at 8:42 PM regarding a session with Resident #44 on [DATE], the day after Resident #44's fall. According to the assessment note, Resident #44 had no recent acute incidents, trauma, or reported injury. There was no documentation of pain, the left femur fracture, or the surgical procedure related to the fractured femur from the fall sustained on [DATE] in subsequent pain management encounters on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Assessment findings on these dates reported no recent acute incidents, trauma, or injury and no significant change since the last assessments. On [DATE] 07:45 AM, DON #2 was made aware of the concern regarding inaccurate pain management assessment documentation for the pain management notes written on [DATE]-[DATE] by CRNP #32.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that drug regimen reviews performed by a consulting pharmacist identified irregularities in residents' medication regimens. This was evidenced by a resident with an order for an as-needed psychotropic medication that was not time-limited being cleared without medication irregularities for the four reviews that took place since the psychotropic was prescribed. This was evident for 1 (Resident #56) of 5 residents reviewed for unnecessary medications. Psychotropic medications affect a person's mental state or mood, and include antipsychotics and antianxiety medication, as well as, other categories of medication. Because elders are particularly susceptible to the effects of psychotropic medicaiton, federal regulation prohibits the use of psychotropic medication in nursing homes that is deemed unnecessary. This includes the use of psychotropic medication used on an as-needed basis for longer than a 14-day trial period without due explanation for such use. The findings include: Resident #56's medical record was reviewed on 9/11/19 at 1:53 PM. During the review, it was noted that Resident #56 was written for an antianxiety medication with a start date of 5/6/2019. The text of the order read, Give 1 tablet by mouth every 8 hours as needed for anxiety. It was noted that the resident had previously been prescribed this same medication on 1/10/19 with the directions, administer 1 tablet by mouth one time a day at bedtime as needed. On 1/16/19, a pharmacy communication note from the consultant pharmacist was sent to the facility noting, This resident has been ordered an as-needed psychotropic medication, which per regulation should be limited to 14 days or less unless the prescriber documents . the duration for the as-needed order. A duration was added to the order following this pharmacy recommendation. No pharmacy recommendation could be found regarding the as-needed antianxiety medication with a start date of 5/6/19. This was evident from the Pharmacist's Chroniological Record of Medication Regimen Review that was found for Resident #56. This review had NI (short for No Irregularities) circled for all of the reviews that took place since the 5/6/19 order began: 5/16/19, 6/13/19, 7/11/19, and 8/19/19. The Director of Nursing (DON) and the Quality Assurance (QA) Coordinator were interviewed on 9/13/19 at 12:03 PM. During the interview, the DON stated that Resident #56's primary physician wanted to maintain the resident's as-needed order for this antianxiety medication because when [Resident #56] begins to aspirate, the first sign is psychiatric symptoms and obtaining an order at that point would take too long to help the resident. The surveyor requested evidence of the attending physician's intentions with this medication and none that explained this rationale was provided by the time of the survey exit.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents' drug regimens remained free of unnecessary psychotropic medication. This was evident for 1 (Resident #56) of 5 residents reviewed for unnecessary medications. Psychotropic medications affect a person's mental state or mood, and include antipsychotics and antianxiety medication, as well as other categories of medication. Because elders are particularly susceptible to the effects of psychotropic medicaiton, federal regulation prohibits the use of psychotropic medication in nursing homes that is deemed unnecessary. This includes the use of psychotropic medication used on an as-needed basis for longer than a 14-day trial period without due explanation for such use. The findings include: Resident #56's medical record was reviewed on 9/11/19 at 1:53 PM. During the review, it was noted that Resident #56 was written for an antianxiety medication with a start date of 5/6/2019. The text of the order read, Give 1 tablet by mouth every 8 hours as needed for anxiety. There was no end date associated with this order. Resident #56's medication administration record (MAR) was reviewed for the previous two months and it was found that the resident did not receive any doses of the antianxiety medication in either month. The Director of Nursing (DON) and the Quality Assurance (QA) Coordinator were interviewed on 9/13/19 at 12:03 PM. During the interview, the DON stated that Resident #56's primary physician wanted to maintain the resident's as-needed order for this antianxiety medication because when [Resident #56] begins to aspirate, the first sign is psychiatric symptoms and obtaining an order at that point would take too long to help the resident. The surveyor requested evidence of the attending physician's intentions with this medication and none that explained this rationale was provided by the time of the survey exit.

Based on staff interview and medical record review it was determined the facility failed to ensure that some laboratory tests were completed in a timely manner for Resident #43. This was evident for 1 of 31 residents reviewed during the investigative portion of the survey. The findings include: On 6/21/18 at 10:51 PM during a review of the medical record for Resident #43, a physician's order was noted which included a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Lipid panel and an HgA1C (a component of hemoglobin) to be drawn on 6/11/18. The order, also, said in parentheses that the labs were not done in May 2018. Further review of the medical record revealed an order written on 2/2/18 for a CBC, CMP, Lipid panel, and HGA1C to be drawn every 3 months in the morning on the 2nd in Feb, May, Aug, & November. No record was found documenting that the May blood tests were drawn. During an interview with the Director of Nursing on 6/21/18 at 2:00 PM, she confirmed the labs had been missed. The facility is responsible to ensure that laboratory services are completed in a timely manner.

Based on the initial tour of the kitchen, it was observed that the facility staff failed to store, prepare and serve food under sanitary conditions. Factors in these observations can lead to foodborne illnesses. The finding includes: On 6/19/2018 at 10:15 A.M., an initial tour of the kitchen was performed. The following deficient practices were identified: A. The sink used for handwashing dishes contained three basins. The last basin in the sink was used for sanitizing the dishes and contained a chemical called Multi Quat Sanitizer. To ensure that the sanitizer is effective, the prepared mixture of the chemical with the water must be tested each time the sink is filled and must be maintained in a range of 150 to 400 parts per million. The facility did not have any test strips to verify that the correct dilution of the sanitizer was mixed. The surveyor was told that the facility ran out of the test strips this morning. B. This surveyor observed that the filters above the stove and the steam area were heavily soiled creating an unsanitary environment. On 6/19/2018 during an interview of the Kitchen Manager, he/she agreed that the filters needed to be washed. C. This surveyor observed that the temperature gauge used on the dishwasher to measure the water temperature was not working correctly and the glass covering on the gauge was cracked. This surveyor observed the facility staff tapping on the gauge during the wash cycle to get the temperature gauge to move. The gauge was reading 150 degrees and did not increase in temperature during the wash cycle. When the gauge is working correctly during the wash cycle the temperature slightly increases from the baseline of 150 degrees. The facility's Maintenance Director agreed that the gauge was not working correctly. When he/she manually tested the temperature during the wash cycle, the temperature increased to 165 degrees indicating that the gauge was not functioning accurately. On 6/19/2018, the gauge was replaced by the dishwasher vendor. On 6/20/2018, further observation revealed that during the wash cycle the temperature reading from the gauge increased each time the dishwasher was in the wash cycle. Findings of the observations were brought to the attention of the Kitchen Manager and Dietary Manager.