Elkton Nursing and Rehabilitation Center

Inspectors wroteBased on record review and interview, it was determined that the facility failed to allow residents the right to choose their attending physician. This was evident for thirteen (Residents #2, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, and #24) of the fourteen residents interviewed regarding this change.

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by failing to arrange or schedule physician-ordered specialist consults, procedures, diagnostic tests, or labs. This was evident for 4 (Resident #2, #4, #3, and #26) of 4 residents reviewed for consults, diagnostic tests, and labs during the complaint survey.

Inspectors wroteBased on a review of facility documents and interviews, it was determined the facility failed to maintain an effective grievance system. This was evident for 3 of 3 months of grievance forms from the months of May through July of 2026 reviewed during the complaint survey.

Inspectors wroteBased on interview, and record review, it was determined the facility failed to ensure that residents were provided with necessary medical supplies timely. This was evident for 3 (Resident #2, #8, and #9) of 3 residents reviewed for colostomy care during the complaint survey.

Inspectors wroteBased on review of complaint IQIES #3067494, record review and interviews, it was determined that the facility failed to accurately assess the facility's nursing staff needs and nursing staff competency needs during the annual and/or update of the Facility Assessment. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to implement and maintain an effective training program regarding nephrostomy tube care. This was evident during staff interviews while reviewing complaint #3067494 regarding nephrostomy tube flushing.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide adequate nutrition, hydration, and life-sustaining medications. Consequently, Resident #10 continued to reside in the facility without receiving any nutrition, hydration, or medications from 7/31/2026 to 8/3/2026. This was evident for 1 (Resident #10) of 3 residents reviewed during the revisit survey. This failure resulted in immediate jeopardy.

Inspectors wroteBased on observation, interviews, review of facility documents, and record reviews, it was determined that the facility failed to provide interventions consistent with the resident's needs and professional standards of practice, causing an accident that led to severe pain and an emergency room (ER) transfer. This was evident for 1 (Resident #1) of 3 residents reviewed for falls during the complaint survey. This resulted in actual harm to Resident #1.

Inspectors wroteBased on interview, record review, and staff interview, it was determined that the facility failed to notify Resident #1's emergency contact representative and physician in a timely manner after a significant change in condition related to a fall. This was evident for 1 (Resident #1) of 1 residents reviewed for falls during the survey.

Inspectors wroteBased on record review, observations and interview, it was determined that the facility failed to have prevent involuntary seclusion. This was evident for three (Resident #2, Resident #7 and Resident #8 ) out of three residents reviewed during the survey.

Inspectors wroteBased on review of medical records, observation, and interviews with residents and staff, it was determined the facility failed to report an allegation of resident neglect. This was evident for 1 (Resident #1) of 1 residents reviewed for neglect during the survey.

Inspectors wroteBased on surveyor review of administrative records and interview, the facility failed to ensure the Infection Preventionist (IP) participated in the first quarter 2026 Quality Assurance Performance Improvement (QAPI) meeting.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician ordered parameters when administering blood pressure medications. This was evident for 3 (#300, #304, #303) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to administer medications as ordered by the physician (Resident #302). This was evident for 1 of 5 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers. This was evident for 1 (#300) of 3 residents reviewed for pressure ulcers during a complaint survey.

Inspectors wroteBased on record review, observation, and interview, it was determined the facility staff failed to ensure interventions for safety were in place for a resident with a history of falls. This was evident for 1 (#300) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to obtain laboratory tests as ordered by the physician for residents (#300 and #302). This was evident for 2 of 3 residents reviewed for laboratory services during a complaint survey.

Inspectors wroteBased on review of medical records, facility investigation and interviews, it was determined that the facility failed to ensure that a resident who required a Hoyer lift for transfer was transferred with a Hoyer lift which resulted in harm to Resident #156 who sustained a fracture of the distal femur. This was evident for 1 (Resident # 156) out of 11 residents reviewed during the annual survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the hospice pain management orders for Resident #179 were followed which resulted in harm to the Resident due to unmanaged pain. This was evident for 1 out of 9 residents reviewed for pain management during the facility's recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews with residents and staff, it was determined that the facility failed to maintain a system to ensure that resident council concerns were acknowledged and addressed timely, resolutions were communicated, and interventions were effective. This failure had the potential to affect all residents.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to: 1) ensure the resident right to manage his or her financial affairs; and, failed to obtain written authorization for facility to act as a fiduciary of the resident's funds. This was evident for 1 (#58) resident out of 2 residents investigated for personal funds management; and 2) have a system in place that allows residents to access their personal funds on an ongoing basis and be available to the residents when they request. This practice has the potential to affect all residents who have allowed the facility to manage their personal funds.

Inspectors wroteBased on observations, interviews and facility environmental rounds, it was determined that the facility failed to 1) provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable homelike environment. This was evident throughout the facility; and 2) protection from loss for a resident's belongings. This was evident for 2 (Resident #3) out of 2 residents reviewed for personal property during the annual survey.

Inspectors wroteBased on observations, interviews and review of resident medical records, it was determined that the facility failed to: 1) Ensure that residents received the correct prescribed diet orders and serve the correct diet listed on meal tray tickets; and 2) Ensure resident dietary preferences were honored. This was evident for 6 (#172, #52, #12, #170) residents out of 28 residents reviewed and 2 random observations made during the surveyor's tray line observation as part of the kitchen review and has the potential to affect all residents.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure the food service department followed the menu and failed to ensure the provided menu met the requirement for the serving size of protein specified for the lunchtime meal. This was evident during a random observation of the serving tray line in the facility's kitchen and during the surveyor's review of the kitchen. Based on observation, interview, and record review it was determined that the facility failed to: 1) ensure the food service department followed the menu and failed to ensure the provided menu met the requirement for the serving size of protein specified for the lunchtime meal and 2) ensure menus and food preferences were followed according to the resident's meal ticket. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure safe and appetizing food temperatures. This was evident during the surveyor's review of the kitchen during the facility's recertification survey.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to: 1) ensure sanitary practices were followed in accordance with professional standards for food service safety; 2) ensure the monitoring and oversight of food temperatures in accordance with professional standards for food service safety; 3) ensure food was stored in accordance with professional standards for food service safety; 4) ensure thorough environmental cleaning of the kitchen; 5) ensure food items were labeled and discarded appropriately, 6) ensure the transport of food in accordance with professional standards for food service safety; 7.) ensure the monitoring, oversight, sanitation and maintenance of kitchen 8.) ensure sanitary food prep surfaces were free from personal items. This was evident during observations of the kitchen and has the potential to affect all residents.

Inspectors wroteBased on review of the Facility Assessment and interviews it was determined the facility failed to ensure that all required individuals participate in the Facility Assessment. Additional the facility failed to document, complete and accurately reflect Facility Assessment processes regarding the facility's physical environment, equipment, and other physical plant needs that are necessary to care for its population as well as an evaluation of the facility building maintenance capital improvements, or structures.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the outside resources utilized for delivery of food and nutrition services to the facility's residents followed professional standards. This was evident for 2 out of 2 contracted companies utilized by the facility for the delivery of food and nutrition services during the facility's recertification survey and has the potential to affect all residents of the facility.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure the dishwashing system was maintained in safe operating condition. This was evident for 1 out of 1 dishwasher present within the facility's kitchen.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure residents' right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This was evident for 7 (Resident #58, #143, #78, #12, #142, #180, #147) residents out of 14 investigated during the the survey.

Inspectors wroteBased on observation, record review, and interview with residents and staff, it was determined that the facility failed to: 1) maintain all smoking paraphernalia for residents who require supervision with smoking and failed to ensure smoking assessments were reviewed and revised according to the residents' current condition; 2) provide an environment that is free from accident hazards over which the facility has control and provides supervision to each resident to prevent avoidable accidents; 3) adequately assess, monitor, and implement facility smoking policy and procedures for residents that smoke. This was evident for 8 (Resident #33, #119, #55, #4, #45, #42, #2, #37) out of 40 residents reviewed for smoking had the potential to affect all residents who smoke.

Inspectors wroteBased on observation and interview it was determined the facility failed to: 1) ensure secure storage of medications 2) appropriately label and store drugs and biologicals in accordance with currently accepted professional principles (within medication rooms, carts, boxes, refrigerators). This was evident for 2 out of 2 random observations of the facility's second floor supply room, 1 out of 1 shower room on Unit 1, second floor, 1 of 3 medication carts and 1 of 1 Medication refrigerators on Station 2 investigated during the facility's survey.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to ensure a resident receiving a therapeutic mechanically altered diet was given food in the correct consistency based on the physician's order. This was evident for 1 (Resident #100) out of 2 residents observed for accuracy of meal tickets during the revisit survey.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility staff failed to implement appropriate infection prevention and control practices. This was evident in observation by surveyors during the environmental tour of the facility including the laundry room, 2 out of 2 hand washing sinks observed by the surveyor on floor 2 of the facility and 5 (#27, #52, #142, and #104, #3) out of 38 residents reviewing during the survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a safe functional environment. This was evident during 1 out of 1 multi-surveyor observation conducted of the facility's exterior grounds.

Inspectors wroteBased on observations and interviews with staff and residents, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. This was evident for 2 out of 3 nursing units observed during the annual survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure reasonable clinical and safety restrictions of the facility's policies, procedures or practices that protect the health and security of all residents and staff by allowing an unvaccinated animal into the controlled environment. This was evident for 1 (#115) resident out of 9 residents investigated during the facility's annual survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure that a current copy of a resident's advance directive was in the resident's medical record. This was evident for 1 (#58) resident out of 9 residents investigated for Advance Directives during the facility's annual survey.

Inspectors wroteBased on the review of medical records, administrative records, interviews, and observations it was determined the facility failed to protect a resident from physical abuse perpetrated by a facility employee. This was evident for 1 (#143) out of 8 residents reviewed for abuse during the recertification survey.

Inspectors wroteBased on interviews and medical record reviews it was determined that the facility failed to: 1) provide the resident representative with written notification of transfer to the hospital and written notification of the facility's bed hold policy upon transfer to the hospital, and ensure the local Ombudsman was notified timely, on a monthly basis, of a facility-initiated transfer to the hospital; 2) ensure the documentation of the clinical circumstances related to the return of the resident to the hospital as part of the transfer process. This was evident for 3 (Resident #153, #5 and #174) out of 7 residents reviewed for hospitalization during the survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect a resident's status. This was evident for 1 (Resident #5) out of 5 residents investigated for falls during the annual survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to develop a resident centered activity care plan that addressed the resident's physical, mental, and psychosocial needs with personalized goals with measurable objectives and interventions. This was evident for 1 (Resident #9) out of 4 residents reviewed for activities during the annual survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure residents right to participate in the development, review and revision of his/her care plan. This was evident for 2 (58 & 14) residents out of 2 residents investigated for care planning.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure consultations were timely scheduled and wound care was consistently performed. This was evident for 1 (Resident #3) out of 1 resident reviewed for foot care during the facility's recertification survey.

Inspectors wroteBased on observations, interviews and resident medical record review it was determined the facility failed to provide a resident incontinent care and services. This was evident for 1 (Resident #16) out of 11 residents reviewed and observed during the survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure a resident received necessary respiratory care and services that were in accordance with professional standards of practice, the resident's care plan, physician's orders, and the resident's choice. This was evident for 1 (#77) resident out of 9 residents investigated during the facility's survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This was evident for 3 (#58, #117, and #65) residents out of 9 residents investigated for medically related Social Services.

Inspectors wroteBased on observation, record review, and interview with a resident and staff, it was determined that the facility failed to: 1.) establish a system of records of receipt of controlled drugs 2.) to ensure accurate reconciliation of a controlled medication, 3.) immediately document medication administration of a controlled drug in the accountability record and Medication Administration Record (MAR), and 4.) submit timely requests for a residents controlled drug before it runs out. This was evident for 1 (Resident #39) out of 12 residents review for medications.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure a medication error rate of less than 5 percent for 4 (#27, #52, #170, and #104) residents out of 5 residents observed during 33 medication administration opportunities which resulted in an error rate of 12.12% by 2 of 2 certified medicine LPNs observed during the survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to assist a resident in making transportation arrangements to and from the source of service, when the resident needs assistance. This was evident for 1 (#58) resident out of 1 residents investigated for missed appointments due to transportation services during the facility's survey.

Inspectors wroteBased on record review, observation, and interview it was determined the facility failed to ensure staff assigned the supervisory responsibilities for the facility's food and nutrition services was a qualified dietetic service supervisor. This was evident during the surveyor's review of the kitchen during the facility's recertification survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure each resident received and the facility provides food that accommodates resident allergies, intolerances, and preferences. This was evident for 3 (Resident #58, #117 and #14) residents out of 9 residents reviewed during the survey.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain accurate medical records for residents. This was evident for 5 of 38 residents (Resident #109, #3, #4 and #55, #105) reviewed.

Inspectors wroteBased on review of a complaint, observation of resident rooms, and interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, comfortable interior. This was evident on 2 of 3 nursing units observed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 8 (#11, #41, #19, #34, #17, #4, #9, #26) of 57 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on review of complaints, medical record review, and interviews, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This was evident for 5 (#20, #17, #3, #13, #38) of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor the blood pressure and heart rate prior to administering a blood pressure medication per physician's orders. This was evident for 3 (#40, #34, 17) of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on observations, interviews, and documentation review, it was determined the facility failed to have an effective pest control program as evidenced by numerous flies and gnats seen throughout the facility. This was evident on 2 of 3 nursing units, in resident rooms, the kitchen, the rehab gym, and the conference room during a complaint survey.

Inspectors wroteBased on observation and staff interview it was determined that facility staff failed to treat each resident in a dignified manner by 1) standing over a resident while feeding the resident, and 2) not placing a urinary catheter bag in a dignity bag. This was evident for 2 (#50, #45) of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to notify a resident's representative for a change in condition (Resident #28). This was evident for 1 of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interview, it was determined that facility staff failed to ensure that resident medical records remained private and confidential. This was evident for 1 of 3 nursing units observed during a complaint survey.

Inspectors wroteBased on review of a complaint and interview, it was determined the facility failed to provide the residents with an environment that was free of misappropriation of property. This was evident for 1 (Resident #10) of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a complaint and interview, it was determined the facility failed to report allegations of misappropriation of property to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #10) of 57 residents reviewed during the complaint survey.

Inspectors wroteBased on review of a complaint and interview, it was determined the facility failed to conduct a complete investigation for allegations of misappropriation of property and failed to provide an investigation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #10) of 57 residents reviewed during the complaint survey.

Inspectors wroteBased on complaint review, record review, and interview it was determined that the facility failed to provide residents and or resident's responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications. This was evident for 1 (Resident #6) of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint review, medical record review and interview, it was determined the facility staff failed to provide needed activities of daily living (ADL) for a resident totally dependent on bathing assistance (Resident #30). This was evident for 1 of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on observation, interview and medical record review, the facility staff failed to ensure a resident had glasses (Resident #12). This evident for 1 of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #32). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey.

Inspectors wroteBased on observation, interview and medical record review, the facility staff failed to ensure fall mats were properly in place for a resident with a history of a fall (Resident #38). This was evident for 1 of 4 residents reviewed for falls during a complaint survey.

Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to provide the appropriate care and services to prevent urinary tract infections. This was evident for 1 (Resident #45) of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to assess a resident at risk for malnutrition by the dietitian in a timely manner (Resident #38). This was evident for 1 of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on observation, interview and medical record review, the facility staff failed to provide respiratory care to meet the needs of a resident (Resident #12). This was evident for 1 of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on review of complaints, medical record review, and interview, it was determined the facility failed to provide timely medications to meet the needs of the residents. This was evident for 1 (Resident #16) of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on observation, staff interview, and documentation review it was determined that facility staff failed to 1) keep treatment and medication carts locked when unattended, 2) date medication/biologicals when opened and discard medications/biologicals when expired. This was evident on 2 of 3 nursing units observed during a complaint survey.

Inspectors wroteBased on review of a complaint, medical record review, and interview, it was determined the facility failed to file in the resident's medical record a signed and dated EKG. This was evident for 1 (Resident #34) of 57 residents reviewed during a complaint survey.

Inspectors wrote3) The facility failed to obtain a gynecology appointment as requested by the resident. On 6/30/25 at 12:17 PM a review of complaint MD00210037 was conducted. Review of the complaint alleged that the facility failed to arrange and assist Resident #22 to an appointment with the gynecologist. Review of Resident #22's medical record revealed a physician's visit dated 11/22/21 which documented under the diagnosis, assessment and plan, Female perineal bleeding. Suspect vaginal/postmenopausal bleeding from endometrial thickening. Pelvic ultrasound results reviewed. The note documented that the resident would like to follow up with her gynecologist at a specific gynecology clinic. The note concluded, Order to set up appointment with patient's gynecologist placed. [...]

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Resident #12, #35) of 57 residents reviewed during a complaint survey.

Inspectors wroteBased on observation, documentation review, and staff interview, it was determined that the facility failed to post the resident census and total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides at the beginning of the shift. This was evident upon entrance to the facility and on 1 of 1 nursing units observed during a complaint survey.

Inspectors wroteBased on documentation review, resident, family, and staff interviews, and review of Resident Council meeting minutes, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 2 of 13 complaints submitted to the Office of Health Care Quality (OHCQ), 2) and 9 of 12 interviewable residents (#316, #26, #61, #5, #58, #366, #417, #64, and #21), and 1 of 3 family interviews (Resident #50's family member) conducted and 5 staff interviews, as well as review of staffing schedules and employee time punches. This deficient practice had the potential to affect all residents.

Inspectors wroteBased on Record review and interview with staff it was determined the facility staff failed to have sufficient staff with appropriate training and supervision caring for residents with a history of trauma and/or post-traumatic stress disorder as identified in the facility assessment. This was evident for 1(#21) of 4 residents reviewed for Behavioral-Emotional care.

Inspectors wroteBased on interviews of facility staff, it was determined that the facility failed to ensure a full-time clinically qualified nutrition professional for the oversight of food preparation and the daily kitchen operation. All the residents in the facility have the potential to be affected by not having a qualified nutritional professional with the appropriate competencies and skill sets to carry out food and nutrition services.

Inspectors wroteBased on observation, interview, and documentation review it was determined that the facility staff failed to: 1) date label and discard expired perishable food products 2) protect food items, dinnerware and cooking utensils from contamination during storage 3) ensure the required sanitation levels of the facility's dishwashing machine, 4) keep vents and ceiling clean and in good repair, and 5) ensure kitchen staff utilized effective hair restraints This practice had the potential to affect all residents that consumed food that was prepared by the kitchen.

Inspectors wroteBased on surveyor observation, review of records, and interview with residents and staff it was determined the facility administration failed to employ enough qualified staff, establish systems and implement procedures and protocol to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident and failed to maintain documentation related to staff COVID-19 vaccination and failed to ensure an adequate water management plan. This was evident during review of the kitchen and the infection control and antibiotic stewardship programs, five staff (#25, #30, #33, #31, #32) reviewed for immunizations and 2 of 6 residents (#61 and #21) reviewed for Personal Property and has the potential to affect all residents in the facility.

Inspectors wroteBased on observations, review of medical records, facility documentation, and staff interviews, it was determined the facility failed to: 1.) have an effective system in place to ensure infection control precautions were appropriately instituted, maintained, and monitored to prevent potential transmission of infectious disease (Resident #111, #79, #84, #34, #63, #366) and 2.) ensure measures instituted to prevent further spread during a Covid outbreak were being followed by facility staff and monitored (Staff #37, #49, #25, #38 #37, #72, #73, #10) and 3) ensure ice was transported, and stored in a manner that precludes contamination (Staff #65). This was evident during the annual recertification survey and has the potential to impact all residents, staff and visitors.

Inspectors wroteBased on interviews and the review of the facility records and residents' medical records, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident by the duration of antibiotic use was not accurately completed, and the facility's antibiotic stewardship program failed to document essential elements for antibiotic use. This was found to be true on 1 (Resident #366) out of 3 residents reviewed for antibiotic use and the facility's antibiotic stewardship program review during the survey.

Inspectors wroteBased on interviews and a review of the facility records, it was determined that the facility failed to designate at least one Infection Preventionist responsible for effectively managing its Infection Prevention and Control Program. This was evident during the Infection Control portion of the recertification survey and impacted the facility's ability to accurately track a current COVID outbreak in the building during the survey and implement, develop, and monitor an antibiotic stewardship program. This deficient practice has the potential to impact all residents in the building.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document providing education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents, and failed to maintain documentation related to staff COVID-19 vaccination. This was evident for 3 (Resident #34, #90, and #133) of 5 residents and five staff (#25, #30, #33, #31, #32) reviewed during this survey.

Inspectors wroteBased on review of administrative documents, and interviews of residents and staff it was determined that the facility failed to ensure that concerns and suggestions from the resident group were reviewed, and responses provided to the group in writing. This was evident in review of 4 of 4 resident council meeting minutes.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to: 1) ensure the resident/responsible party was provided information in a manner easily understood by the resident or resident representative to formulate an advanced directive and offered the opportunity to develop an advanced directive, 2) document/file the resident's advanced directive on their medical record, and 3) failed to inform and document discussions with residents/representatives who did not have an advance directive. This was evident for 4 (Resident #100, #105, #61 and #265) of 6 residents reviewed for Advance Directives.

Inspectors wroteBased on surveyor observation, record review and interviews with residents and staff it was determined the facility staff failed to: 1) provide housekeeping and maintenance services necessary to maintain kitchen floors, walls and air vents in a manner to facilitate cleaning, sanitization and prevent harboring of pests and protect dishware 2) exercise reasonable care for the protection of the resident's property by failing to have a system in place to ensure resident's clothing was protected from loss or misplacement for 2 (#61 and #21) of 6 residents reviewed for Personal Property 3) keep the building clean, neat, attractive and in good repair on three nursing units on both floors of the facility, and 4) ensure a sufficient clean linen supply was consistent and readily available for use. The Findings Include: [...]

Inspectors wroteBased on review of resident and facility records and interviews with residents and staff it was determined the facility failed to have an effective process in place to address and ensure prompt resolution of resident grievances by failing to have a Grievance Official who was responsible for overseeing the grievance process. This was evident for 2 (#61 and #21) of 6 residents reviewed for Personal Property.

Inspectors wroteBased on review of facility records and interview with facility staff it was determined the facility staff failed to ensure that all allegations of abuse were thoroughly investigated. This was evident for 2 reports (MD00193602 and MD00193445) of 12 facility reported incidents investigated, and 2 (Resident #111, #11) of 11 residents reviewed for Abuse.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to have a process to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (Resident #221,#127, #157, #267) of 5 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 5 (#221, #127, #157, #26, #267) of 5 residents reviewed for hospitalization during the recertification/complaint survey.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined that the facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for 8 (Resident #154, #157, #10, #100, #58, #367, #108, #21 ) of 69 residents reviewed during the recertification survey.

Inspectors wroteBased on observation, record review, and staff interview, it was determined that the facility staff failed to revise and update a comprehensive care plan for a resident and have care plan meetings with residents and/or resident's representatives. This was evident for 6 (#127, #10, #100, #26, #64, #6) of 69 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on observations, interview with residents and staff and medical record reviews, it was determined the facility staff failed to administer medications to the residents in accordance with professional standards of practice by 1) failing to observe that medications were safely taken when administered (Resident #21), 2) follow a medical order and implement an intervention (Resident #108), 3) failed to follow a plan of care for transfer (Resident #50) and ensure residents received care and treatment (Resident #90). This was evident for 4 of 69 residents (#21, #108, #50, #90) during the facility's recertification survey.

Inspectors wrote3). Resident #5 was observed on 10/30/23 at 12:51 PM. He/she was receiving oxygen via a nasal cannula (tubing to the nose) from an oxygen concentrator (a machine that concentrates oxygen from the room air) at 3L/min (liters per minute). A humidification bottle connected to the nasal cannula tubing was hand dated 10/28/23. Handwritten numbers 10/(??)/23 were observed written in black marker directly on the cannula tubing. However, the date was illegible. Resident #5 stated sometimes the water runs out and it takes a while to get a refill. Review of Resident #5's medical record on 11/8/23 at 11:40 AM revealed a physician order for oxygen at 3L/min via nasal cannula. Additional physician orders were written on 4/22/21 for: Oxygen Equipment Change Tubing/Nasal Cannula/Mask/Humidifier Bottle and clean filter weekly (when in use) every night shift every Sat. [...]

Inspectors wroteBased on a review of employee files and interviews, it was determined that the facility failed to put a system in place to ensure Geriatric Nursing Assistant's (GNAs) were competent with their skill sets. This was found to be evident for 3 (#58, #70, and #71) out of 4 GNA employee files reviewed for competencies and skill sets.

Inspectors wroteBased on medical record review and interviews with residents and staff it was determined the facility failed to assure that sufficient and appropriate social services were provided to meet the residents needs. This was evident during review of 2 (#61 and #265) of 6 residents for Advance Directives and 1 (#21) of 4 residents reviewed for Behavioral-Emotional care.

Inspectors wroteBased on the review of the resident medical records and interview with facility staff, it was determined that the facility failed to: 1) ensure opioids removed from the resident's supply were administered to the resident, 2) provide medication to meet the needs of the residents timely, and 3) ensure that drug records were maintained in a manner that accounted for all controlled drugs and allowed for reconciliation of dispensed and administered medication. This was evident for 4 (Resident #66, #90, #143, and #366) out of 4 residents reviewed for administration of narcotic medication, and 4 (Resident #61, #84, #87, #100) out of 5 residents reviewed for medication administration during the survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to have a system to ensure that monthly Medication Regimen Reviews were completed for facility residents. This was evident for 3 residents (Resident #10, #66, and #90) of 6 residents reviewed for unnecessary medications during the survey.

Inspectors wroteBased on observation, interview with facility staff, and review of facility policies, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 4 of 31 medications administered during the observation resulting in a medication error rate of 12.9% for the survey.

Inspectors wroteBased on observation, staff interview, and record review it was determined that facility staff failed to 1) properly label medications, 2) remove expired medications and date medication and biologicals when opened, and 3) monitor medication room refrigerator temperatures. This was evident on 3 of 3 nursing units observed during medication storage reviews.

Inspectors wroteBased on resident interviews, and observations of the kitchen services, it was determined that the facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature. Food complaints and concerns were identified for 4 (#48, #139, #61, #316) of 32 residents selected in the final sample.

Inspectors wroteBased on medical record review and interview of facility staff it was determined the facility failed to: 1) ensure accuracy of medication side effect monitoring documentation (Resident #108, #32); 2) ensure accurate documentation of an indication of a medication (Resident #32), and 3) maintain complete and accurate medical records in accordance with accepted professional standards (Resident #316, #127, #100). This was evident during a review of unnecessary medications during the facility's recertification survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to document/restore residents' Influenza and Pneumococcal vaccination status, including their education regarding benefits and risk factors for the vaccines, in their medical records. This was evident for 4 (#34, #105, #133, and #366) out of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey.

Inspectors wroteBased on observation, staff interview and record reviews, it was determined the facility failed to: keep the tray line plate warmers in operating condition, and failed to ensure a process was in place to address preventative maintenance of Hoyer lift equipment and scales. This was evident during observation of the kitchen and nursing units during the recertification survey and the ability to impact residents receiving food with missing plate bottom insulators and residents who are weighed with facility hoyer lift scales.

Inspectors wroteBased on interviews with residents and facility staff and surveyor observation it was determined the facility failed to ensure all residents were treated with respect and dignity. This was evident for 1 (#61) of 3 residents reviewed for dignity.

Inspectors wroteBased on review of facility records and interviews with facility staff it was determined the facility staff failed to ensure that all allegations of abuse were reported immediately. This was evident for 1 (#11) of 11 residents reviewed for Abuse and 1 report (MD00193445) of 12 facility reported incidents investigated during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to document the basis for resident transfer in the medical record, and failed to ensure appropriate information was communicated to the receiving acute care facility to ensure a safe and effective transition of resident care. This was evident for 1 (#267) of 5 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#221, #267) of 5 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on interviews and medical record reviews, it was determined the facility staff failed to ensure that a resident received care consistent with professional standards of practice to promote the healing of a Pressure Ulcer (PU). This was evident for 1 (Resident #26) of 4 residents reviewed for pressure ulcers during a recertification survey.

Inspectors wroteBased on record review and interview of facility staff it was determined the facility failed to ensure a resident received assistance to maintain their mobility and range of motion. This was evident for 1 (Resident #108) out of 6 residents reviewed for mobility.

Inspectors wroteBased on observation, interviews, and record reviews, it was determined that the facility failed to provide appropriate care and sufficient services based on the current standard of care for a resident with an indwelling catheter. This was evident for 1 (Resident #26) of 4 residents reviewed for Urinary catheter/Urinary Tract Infection (UTI) during the recertification survey.

Inspectors wroteBased on record review and interview of facility staff it was determined the facility failed to have a system to monitor residents' baseline body weight and respond to changes in residents' weights when their weight loss/gain was identified. This was evident for 2 (Resident #108, #6) of 9 residents reviewed for nutrition during the facility's recertification survey.

Inspectors wroteBased on observations, records review, and interviews, it was determined that the facility staff failed to provide care for residents' PEG tube (Percutaneous Endoscopic Gastrostomy) and failed to evaluate for possible continuation or discontinuation of the PEG tube. This was evident for 1 (Resident #6) of 3 residents reviewed for tube feeding during the survey.

Inspectors wroteBased on the interview and records reviews, it was determined that the facility staff failed to ensure the resident's pain medication was administered when the resident requested for it. This was evident for 1 (Resident #366) of 5 residents reviewed for pain management during the survey.

Inspectors wroteBased on record review and interviews it was determined the facility staff failed to provide culturally competent, trauma-informed care in order to eliminate or mitigate triggers that may cause re-traumatization for a resident with Post Traumatic Stress Disorder (PTSD). This was evident for 1(#21) of 4 residents reviewed for Behavioral-Emotional care.

Inspectors wroteBased on review of the medical record and resident interview it was determine the facility staff failed to ensure correct use of bed rails by failing to properly assess the resident and bed for risk of entrapment and proper instillation, obtain the resident's informed consent and ensure a physician's order was in place prior to installation and use of bed rails. This was evident for 1 (#265) of 1 residents reviewed for Physical Restraints.

Inspectors wroteBased on record review, staff interview, and observation, it was determined that the facility failed to ensure a physician-supervised resident's care, as evidenced by the physician's failure to review a resident's weight loss. This was evident for 2 (#6 and #98) of 9 residents reviewed for nutrition during the survey.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure the service of a charge nurse who was responsible for supervision, emergency coordination, physician liaison, and direct resident care for each unit. This was evident for one unit (unit 3: capacity of 60 beds ) out of three units that had no unit manager (same role as charge nurse).

Inspectors wroteBased on the review of Geriatric Nursing Assistant (GNA) personnel files and staff interviews, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 2 out of 2 personnel files reviewed during the annual survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to ensure coordination of care for residents receiving hospice care in the facility. This was evident for 1 (Resident #10) of 1 residents reviewed for hospice care.

Inspectors wroteBased on facility staff interviews and medical record reviews, it was determined that the facility failed to Include in its policies and procedures how it obtains and uses feedbacks from residents, resident representatives, and staff to identify problem prone issues as well as opportunities for improvement. This was evident during a review of the facilities Quality Assurance/Performance Improvement (QAPI) policies and procedure documents during a recertification survey.

Inspectors wroteBased on the interview and documentation review, it was determined the facility failed to ensure that a training program was in place and provided to their staff related to abuse, neglect, exploitation, and misappropriation of resident property along with dementia management and resident abuse prevention. This was evident for 5 (#2, #47, #58, #70, #71) out of 7 employees' training records reviewed during the annual survey.

Inspectors wroteBased on the review of census and staffing posting and staff interviews it was determined that the facility failed to ensure posted nurse staffing data specified daily per each shift. This was evident in the facility lobby during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined the physician progress notes were not in the resident medical records the day the resident was seen. This was evident for 2 (#217, #219) of 49 residents reviewed investigated during the annual survey.

Inspectors wroteBased on review of resident medical record and interview with facility staff, it was determined that the facility failed to: 1) ensure that the multidisciplinary team met upon a resident's admission and at least quarterly thereafter to create and revise residents' care plans; 2) invite residents and their family members to participate in those meetings; 3) update a resident's skin care plan based on instructions from a wound care physician; 4) update a resident's respiratory care plan after they no longer required droplet isolation; and, 5) update a resident's fall care plan once interventions are no longer being used. This was evident for 5 (Residents #82, #90, #309, #215, and #94) of 63 residents reviewed during the survey.

Inspectors wroteBased on medical record review, observations and interview with facility staff, it was determined the facility staff failed to: 1) provide Resident #78 with any liquids at lunch and failed to initiate an antibiotic in a timely manner, 2) extend the administration date to receive medication for 7 days as ordered by the physician for Resident #94, 3) administer medications as ordered by the physicians for Residents #57, #89 and #259, 4) administer medication within a reasonable period of time from when the medication was ordered for Resident #309, and 5) to document the rationale for administering as-needed pain medication for Resident #315. This was evident for 7 Residents (57, 78, 89, 94, 259, 309, and 315) of 63 residents selected for review during the annual survey process.

Inspectors wrote2) Review of Resident #123's medical record on 08/12/21 revealed that Resident #123 had his/her medications reviewed by the facility pharmacy consultant on 08/08/21, 07/07/21 and 06/10/21. The recommendations that were addressed by the pharmacy consultant were not in Resident #123's electronic medical record for review. Resident #123 currently receives the antipsychotic medication Haldol orally for nausea and vomiting every 6 hours. In an interview with the facility pharmacy consultant on 08/12/21 at 11:51 AM, the pharmacy consultant stated that he/she works for a totally separate pharmacy then the facility pharmacy that delivers medications to the facility. The pharmacy consultant stated that the documentation program she/he uses to chart on each resident is incompatible with the facility electronic medical record. [...]

Inspectors wroteBased on complaint, surveyor observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order for 1 of 3 nursing units and 1 other resident room. This was evident for 58 of 160 resident call lights reviewed during an annual recertification survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to provide a resident with dignity and respect by improperly transporting a resident down the hall. This was evident during a random observation on the facility dementia care unit.

Inspectors wroteBased on review of resident medical record and interview with residents' representatives and facility staff, it was determined that the facility failed to ensure that, 1) laboratory test results were communicated to a resident's attending physician, and, 2) family members were notified of a worsening of a resident's wound. This was evident for 1 (Resident #215) of 3 residents reviewed for urinary catheter and UTI, and 1 (Resident #210) of 10 residents reviewed for pressure ulcers.

Inspectors wroteBased on of tour of the facility with the Maintenance Director (#38) and observations it was determined that the facility staff failed to provide a safe, clean, comfortable homelike environment and failed to provide Resident #102 with a dresser for his/her personal belongings. This was evident for 1 of 63 residents selected for review during the survey process.

Inspectors wroteBased on medical record review, observation and staff interview it was determined that the facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #72, #78 and #94). This was evident for 3 out of 63 residents selected for review during an annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to develop a baseline care plan that addressed all of a resident's stated goals and objectives for their stay. This was evidenced by Resident #310's baseline care plan failing to address the resident's pain for a newly amputated great toe, this affected 1 of 61 residents selected for review during an annual survey.

Inspectors wroteBased on record review and staff interview it was determined that facility staff failed to develop and implement comprehensive care plans for residents (Resident #94 and #215). This was evident for 2 of 7 residents reviewed for care plans and 2 of 61 residents selected for review during an annual survey.

Inspectors wroteBased on medical record review, observation and interview it was determined the facility staff failed to provide thorough grooming and personal hygiene services for (Residents #78). This is evident for 1 of 6 residents reviewed for Activities of Daily Living (ADL) care and 1 of 63 residents selected for review during the annual survey process.

Inspectors wroteBased on observation, review of resident medical records, and interviews with residents' representatives and facility staff, it was determined that the facility failed to: 1) implement recommendations made by the wound care team and the wound clinic regarding the care of residents' pressure ulcers were followed; and, 2) ensure that, when residents have orders to elevate their heels to prevent pressure ulcers, those orders were followed. This was evident for 2 (Residents #210 and #78) of 10 residents reviewed for pressure ulcers.

Inspectors wroteBased on medical record review, observation and interview it was determined the facility staff failed to ensure residents received proper foot care and treatment (Resident #29 and #72). This was evident for 2 of 63 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined, the facility staff failed to promote an environment free from potential accidents for Resident (#94) in failure to keep the bed in low position and failed to apply leg rest to the wheelchair for Resident (#123). This was evident for 2 of 63 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review, interview and observation it was determined the facility staff failed to apply a catheter strap for Resident #102's catheter and failed to address a coude catheter recommendations for Resident #211 in a timely manner. This was evident for 2 of 63 residents selected for review during the annual survey process.

Inspectors wroteBased on complaint and reviews of a closed and active medical record, it was determined that the facility staff failed to: 1) obtain orders for oxygen and parameters for a resident's BiPAP machine, and 2) document a resident's oxygen usage and treatment in the electronic medical record. This was found to be evident for 2 out of 6 residents (Residents #57 & #215) reviewed for respiratory care during an annual recertification survey.

Inspectors wroteBased on medical record review it was determined the facility staff failed to follow up with recommendations for individual psychotherapy for Resident #94. This was evident for 1 of 5 residents selected for unnecessary medication review and dementia care and 1 of 63 residents selected for review during the survey process.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to ensure the safe storage of medications. This was evident for 1 out of 3 nursing units' refrigerators used to store medications.

Inspectors wroteBased on clinical record review it was determined that the facility staff failed to obtain a dental consult for the Resident (#102). This was evident for 1 of 6 residents selected for review of dental services and 1 of 63 residents in the survey sample.

Inspectors wroteBased upon medical record review, observation and interview it was determined that facility staff failed to assist a resident in obtaining routine dental care (Resident #72). This was evident for 1 of 63 residents selected for review during the annual survey

Inspectors wroteBased on observation, record review, resident and staff interview, it was determined that the facility staff failed to ensure that residents were given the opportunity to choose meals from a menu in advance of the meal being served, and that the residents received the items of choice from the menu. This was evident for 2 (Resident # 310 and # 316) of 8 residents reviewed for menu choices during the survey.

Inspectors wroteBased on review of the tray ticket and observation, it was determined the facility staff failed to provide Resident #94 with food as ordered and failed to provide a liquid to mix a packet of cocoa in. This was evident for 1 of 6 residents selected for review of food and 1 of 63 residents selected for review during the survey process.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility kitchen.

Inspectors wroteBased on complaint, review of a closed medical record, and staff interview, it was determined that the facility failed to obtain an order from the primary care physician for a resident to be seen by an endocrinology consultant. This was evident for 1 (Resident #215) of 63 residents reviewed during an annual recertification survey.

Inspectors wroteBased on medical record review and interview, the facility failed to follow infection control standards related to the care of a resident (Resident #29). This was evident for 1 out 63 residents reviewed during an annual survey.