Ellicott City Healthcare Center

Inspectors wroteBased on facility investigative record review, medical record review, and staff interviews, it was determined that the facility failed to ensure a cognitively impaired resident remained free from sexual abuse. This was evident for 1 (Resident #22) of 7 residents reviewed for abuse during the complaint survey. This deficient practice resulted in Immediate Jeopardy. However, the facility developed, implemented, and completed corrective actions prior to the start of this survey. The facility's plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 4/10/2026.

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility staff failed to document in the residents' medical record if notification of a room change was made to residents and the residents' representative. This was evident for 4 (Resident #28, #29, #30 and #31) of 9 residents reviewed for room transfers during a complaint survey.

Inspectors wroteBased on review of medical records, facility documentation review and interviews, it was determined the facility failed to provide documentation that allegations of abuse, neglect and injury of unknown origin were thoroughly investigated. This was evident for 6 (Resident #1, #3, #4, #17, #8, #6) of 16 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on medical record review, observation and interviews, the facility staff failed to ensure a resident's call bell was in reach. This was evident for 1 (Resident #12) of 5 residents observed for call bells during a complaint survey.

Inspectors wroteBased on review of facility reported incident, documentation review, and interviews, it was determined the facility failed to report an alleged abuse immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #17) of 16 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on review of complaints, 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 3 (Residents #16, #24, #17) of 28 residents reviewed during a complaint survey.

Inspectors wroteBased on record review, observation, and interview, it was determined that facility staff failed to administer medications in accordance with nursing practice standards. This was evident for 1 (Resident #6) of 16 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on review of a complaint, medical record review, and interview, it was determined that the facility failed to ensure that residents requiring dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #21) of 28 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on complaint, 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 3 (Residents #21, #6, #35) of 34 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on observation, pertinent document review, and interview it was determined that the facility failed to maintain a safe, comfortable and homelike environment. This was evident for 7 (Resident #1, #8, #40, #66, #90, #127, #140) of 15 residents reviewed during the environmental task, in addition to multiple random observations of elevated hot water in resident rooms on both floors of the facility which put all residents at risk of being affected by this deficient practice.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure medication carts were kept secured and failed to ensure controlled medications were stored in an affixed lock box. This was found to be evident during one random observation; and for five of five medication storage refrigerators reviewed during the medication storage task.

Inspectors wroteBased on staff interviews, review of pertinent documentation, and survey findings, it was determined the facility failed to ensure that an effective Quality Assurance Performance and Improvement (QAPI) program was in place to identify Quality concerns and develop effective plans of correction. This has the potential to affect all residents.

Inspectors wroteBased on observations, interviews, and medical record review, it was determined that facility staff failed to follow infection control protocols of the laundry process, maintain laundry dryers in a sanitary and hazard-free condition, and retain a copy of the original manufacturer's instructions for the washer and dryer; failed to ensure staff donned personal protective equipment and prevented other residents from entering the rooms of residents on contact precautions; and failed to perform hand hygiene during medication administration.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to provide the resident, and the resident's representative, in writing of the required transfer documents when the resident was transferred/discharged from the facility to an acute care facility. This was evident for two (Resident #14 and #150) of four residents reviewed for hospitalization during the survey.

Inspectors wroteBased on interviews, observation, and record review, it was determined that the facility failed to ensure: consults were scheduled as ordered; and that medications and treatments were administered and documented as ordered. This was evident for one (Resident #2) of one reviewed for urinary catheter use; one (Resident #44) of one resident reviewed for non-pressure skin conditions; one (Resident #7) out of one reviewed for insulin use; one (Resident #8) of three reviewed for pain management and one (Resident #127) of seven reviewed for general investigations.

Inspectors wroteBased on review of staff records and a staff interview, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received annual performance evaluations. This was evident for two (GNAs #28 and #29) of two GNA employee records reviewed during the survey.

Inspectors wroteBased on staff and resident interviews, record review and observations, it was determined that the facility failed to have a process in place to separate the Arbitration Agreement from the admission Agreement and failed to ensure that the person signing the Arbitration Agreement was cognitively capable or had legal authority. This was evident for three (Residents #6, #41, #52) of six residents reviewed for arbitration agreements. An arbitration agreement is a legal document used in long-term care facilities. It requires that disputes or injuries be resolved through private arbitration instead of through the court system. By signing, a resident waives their constitutional right to have a judge or jury decide the case. The arbitrator's decision is usually final and cannot be appealed. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain the call light/bell system in working order to allow residents to request assistance when needed. This was evident during environmental observation on 2 of 2 nursing units.

Inspectors wroteBased on observation, record review and resident and staff interviews, it was determined that the facility failed to provide quality care that promotes resident respect and dignity. This was evident for one (Resident #67) out of five residents reviewed for dignity during the survey.

Inspectors wroteBased on resident and staff interviews, record review and observation, it was determined that the facility failed to demonstrate prompt action in response to residents' grievances; provide a written response to residents of the grievance outcome; ensure an anonymous means to submit grievances; and post the Grievance Official name and contact information. This was evident for six of six Activities Team's grievances that were reviewed during this survey.

Inspectors wroteBased on interview and medical record review it was determined that the facility failed to inform the resident's responsible party (RP) of a change in condition. This was found to be evident for one (Resident #12) out of one resident reviewed for notification of change.

Inspectors wroteBased on review of pertinent records and interview it was determined that the facility failed to ensure Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) were provided to residents prior to the end of skilled services. This was found to be evident for two (Resident #89 and #115) out of three residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification Review.

Inspectors wroteBased on interviews and pertinent document review, it was determined that the facility failed to promptly respond to and resolve a resident grievance. This was evident for one (Resident #100) of one resident reviewed for general concerns during the survey.

Inspectors wroteBased on record review, observations, and interviews, it was determined that the facility failed to protect residents from verbal abuse. This was evident for two (Residents #90 and #111) out of six residents reviewed for abuse allegations.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure discharge planning was updated and facilitated by staff. This was found to be evident for one out (Resident #12) of two resident's reviewed for disharge.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission to the facility. This was found to be evident for one (Resident #2) out of two residents reviewed for PASARR.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident. This was found to be evident for one (Resident #2) out of one reviewed for urinary catheter use; two (Resident #2 and #89) out of four reviewed for activities; and one (Resident #14) out of one reviewed for the use of side rails.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the interdisciplinary team, including the resident's responsible representatives, participated in care conferences to review and revise a resident's care plan following Minimum Data Set (MDS) assessments. This was found to be evident for one (Resident #12) out of four residents reviewed for care planning.

Inspectors wroteBased on observations, interviews, and medical record review, it was determined that the facility staff failed to adhere to professional standards of nursing practice for timely and accurate documentation of medication administration in the medical record. This deficient practice was identified for four of 32 medications reviewed during the medication administration task and affected two (Resident #122 and #129) of the five residents observed.

Inspectors wroteBased on interviews, observations, and record review, it was determined that the facility failed to provide ADL (activity of daily living) care to residents. This was evident for two (Resident #6 and Resident #10) out of three residents reviewed for ADL care.

Inspectors wroteBased on interview, observation and record review, it was determined that the facility failed to develop, or update, activity care plans to address and facilitate residents' activity interests. This was evident for 3 (Resident #12, #2 and #89) of 4 residents reviewed for activities during the survey.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to implement medical recommendations for a resident to wear a splint. This was evident for one (Resident #111) of two residents reviewed for rehabilitative services.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to accurately assess, plan and provide for a resident's urinary catheterization needs. This was found to be evident for one (Resident #2) out of one resident reviewed for urinary catheterization.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility staff failed to follow proper tube feed management; to secure a feeding tube free from pulling to prevent dislodgement. This was evident for 1 (Resident # 13) out of 2 residents reviewed for tube feed management during the annual survey.

Inspectors wroteBased on observation, interview and medical record review it was determined that the facility failed to ensure informed consent was obtained from a resident/responsible representative prior to the initiation of side rails; to obtain a physician order ; or develop a care plan related to side rail usage. This was found to be evident for one (Resident #14) out of one resident reviewed for use of side rails.

Inspectors wroteBased on interviews, observations, and record review, it was determined that the facility failed to ensure ordered medications were maintained in stock and available for administration as prescribed. This deficient practice was identified for one (Resident #8) of three residents reviewed for pain management and for one (Resident #129) of five residents observed during the medication administration task.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to acknowledge a pharmacist's recommendation with a physician signature and define timely manner by which the consulting pharmacist's recommendations must be reviewed. This was evident for one (Resident #150) of five residents reviewed for unnecessary medications during the survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure social service notes were completed in a timely manner and readily accessible. This was found to be evident for one (Resident #12) out of four residents reviewed for care planning.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that employees received the mandatory training for quality assurance and performance improvement. This was evident for one employee (LPN #35) out of five employee files reviewed during this survey. Quality Assurance and Performance Improvement (QAPI) is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical and creative problem solving.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure required staffing information was posted on a daily basis. This was found to be evident during a random observation made on the first day of the survey and has the potential to affect all residents.

Inspectors wroteBased on interview and failure of the facility to provided required documentation, it was determined that the facility failed to have a transfer agreement with a local hospital. This has the potential to affect all residents.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure medications were administered based on professional standards of practice. This was evident for 1 of 1 medication administration observed during a complaint survey.

Inspectors wroteBased on complaint #2593162, observation, interview, and record review, it was determined that the facility failed to provide nail care to dependent residents. This was evident for 1 out of 1 resident (Resident #2) reviewed for Activities of Daily Living (ADL) care during the survey process.

Inspectors wroteBased on complaint #2593162, observations 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 test tray temperature observations conducted during survey process. This deficient practice has the potential to affect all residents who receive meals prepared and delivered by the facility.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to immediately inform the resident's legal representative of an accident involving 1 (Resident #9) of 3 residents reviewed for notification of change in condition.

Inspectors wrote2. An admission Record revealed the facility admitted Resident #10 on November 2023. According to the admission Record, Resident #10 had a medical history that included a diagnosis of unspecified Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/19/2025, indicated Resident #10 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment for Mental Status (SAMS). Resident #10's Care Plan Report included a focus area, revised 02/19/2024, that indicated the resident had impaired cognitive function related to Alzheimer's dementia. [...]

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to thoroughly investigate an allegation of abuse for 1 (Resident #6) of 3 sampled residents reviewed for abuse.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide necessary care and services to maintain proper grooming and personal hygiene related to fingernail care and bathing for 1 (Resident #2) of 4 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on review of complaint MD00213109, observation of resident rooms and equipment, and resident and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 3 of 4 nursing units observed.

Inspectors wrote3. On 2/27/25 at 10:15 AM a review of complaint MD00213453 alleged that Resident #23 was admitted with a wound on the buttocks and now had acquired wounds on the legs. It was alleged that the bandage on the wound on the worst leg had not been changed since 1/10/25. The complaint also alleged that the barrier used for the wound was not being applied to the resident's wound on the buttocks. Review of the January 2025 Treatment administration record (TAR) had an order, cleanse sacrum with wound cleanser, pat dry, apply Medi honey and calcium, and cover with dry dressing every day shift, Left Lower Leg: Cleanse with 0.25% Dakin's solution, pat dry apply Santyl and calcium alginate and cover with Bordered Gauze. [...]

Inspectors wroteBased on interview and review of pertinent documentation, it was determined that the facility failed to treat residents with respect and dignity by attempting to restrict a resident access to a family member which was inconsistent with the resident's wishes. This was evident for 1 (#4) of 37 residents reviewed for complaints.

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 1 (#18) of 28 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to ensure a resident's plans of care included individual resident care needs and interventions to assist each resident in reaching their highest practicable level of wellbeing (Resident #8). This was evident for 1 of 35 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, medical record review and interview, it was determined that the facility staff failed to provide needed activities of daily living for a resident dependent on assistance with care (Resident #8, #18, #24). This was evident for 3 of 28 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to administer treatments as ordered by the physician (Resident #8, #16) and failed to accurately assess a resident who was admitted with a nephrostomy tube and failed to monitor the nephrostomy tube while the resident resided at the facility (Resident #18). This was evident for 3 of 35 residents reviewed during a complaint survey.

Inspectors wroteBased on review of complaint, medical record review, and staff interview it was determined the facility failed to provide timely treatment/services to prevent/heal pressures ulcers. This was evident for 2 (#23, #18) of 28 residents reviewed for complaints 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 ensure orders for a topical anesthetic patch included the duration of time the patch should be applied. This was evident for 1 (#1) of 37 residents reviewed for complaints.

Inspectors wroteBased on medical review and interview, the facility staff failed to ensure a resident receives dental services as recommended (Resident #16). This was evident for 1 of 28 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to assess a resident's need for rehabilitation services (Resident #7). This was evident for 1 of 28 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review, observation and interview, the facility staff failed to obtain outside services for residents in a timely manner (Resident #8). This was evident for 1 of 28 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on observation and interview it was determined that the facility staff failed to maintain infection control procedures while providing patient care. This was evident on 2 of 5 units observed during a complaint survey.

Inspectors wroteBased on medical record review secondary to a complaint, interview with representatives and facility staff, it was determined that the facility failed to notify the correct resident representative when there was a documented change in condition. This was evident during the review of 1 of 4 residents reviewed with pressure ulcers.

Inspectors wroteBased on medical record review, interviews and observation, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#27, #75) of 6 residents reviewed for unnecessary medications, 1 (#92) of 6 residents reviewed for limited range of motion (ROM), 1 (#563) of 7 residents reviewed for accidents, and 1 (#20) of 1 resident reviewed for dental.

Inspectors wroteBased on medical record review and interview, the facility staff failed to have quarterly care plan meetings for residents (#101 and #27) and failed to revise a resident's care plan (Resident #6 and #16). This was evident for 3 of 31 residents reviewed during an annual survey.

Inspectors wroteBased on a review of medical records, Controlled Medication Utilization Record sheets, Medication Administration Record (MAR), and interviews with staff, it was determined that the facility failed to consistently document the administration of an as-needed (PRN) pain medication on the electronic MAR and further monitor the resident's pain level and efficacy of the medication. This was evident for 3 of 3 residents (#151, #81 and #169) reviewed during an annual survey.

Inspectors wroteBased on observations, medical record reviews, and interviews, it was determined the facility failed to maintain a medication error rate of less than 5%. This was found to be evident based on 9 errors identified out of 26 opportunities for error.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to properly store medications, as evidenced by not labeling multi-dose medications when they were opened. This was evident for 2 of 2 medication rooms and 2 of 4 medication carts observed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure a resident went to scheduled out of the facility physician visits in a timely manner. This was evident for 3 (#81, #20 and #159) of 31 residents reviewed during a complaint survey.

Inspectors wroteBased on record review, observations, and interviews, it was determined that the facility failed to maintain residents' dignity by staff standing over residents while assisting them to eat. This was evident for 2 (#48, #140) of 2 residents reviewed for dignity.

Inspectors wroteBased 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 the 1 of 1 survey results book posted in the facility.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that Beneficiary Protection Notifications were issued to 1) a resident who was discharged from Medicare-covered Part A stay with benefit days remaining and was discharged from the facility to his/her home and 2) Residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 3 (#514, #147, #65) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification.

Inspectors wroteBased on review of a facility reported incident with investigation, medical record review, and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff. This was evident for 2 (#47, #54) of 8 residents reviewed for abuse during an annual and complaint survey.

Inspectors wroteBased on reviews of facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 3 (#165, #47, #42) of 8 residents reviewed during the annual and complaint survey.

Inspectors wroteBased on interviews and medical record review, it was determined that the facility failed to notify residents and/or their representatives in writing of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 2 (#126, #39) of 7 residents reviewed for hospitalization.

Inspectors wroteBased on record review and interview it was determined that the facility failed to have a process in place to ensure that a baseline care plan was provided to the resident and resident representative within 48 hours of admission to the facility (Resident #159 and #75). This was evident for 2 of 14 residents reviewed for baseline care plans during an annual survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to develop comprehensive care plans for residents (Resident #20 and #75). This was evident for 2 of 31 residents reviewed during an annual survey.

Inspectors wroteBased on observations, medical record review, and interviews, it was determined that the facility failed to 1) provide a resident with the amount of assistance needed during meals, 2) ensure that a resident who was unable to carry out activities of daily living (ADL) fingernails were trimmed. This was evident for 2 (#48, #92) out of 4 residents who were reviewed for activities of daily living (ADL).

Inspectors wroteBased on observations, medical record reviews, and staff interviews, it was determined that the facility failed to provide activities to meet the residents' needs and preferences. This was evident for 1 (#48) of 4 residents reviewed for Activity.

Inspectors wroteBased on review of complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health. This was evident for 1 (#166) of 4 residents reviewed for quality of care.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #263). This is evident for 1 of 4 residents reviewed for pressure ulcers during an annual survey.

Inspectors wroteBased on interview and observation, it was determined that the facility failed to change the oxygen tubing for a resident dependent on Oxygen per facility policy. This was evident during the observations of 1 of 3 (#20) residents dependent on oxygen.

Inspectors wroteBased on observation and interview with consultants and facility staff, it was determined that the facility consultants failed to appropriately assess a resident and their need for psychiatric services, this was evident during the review of 1 of 5 (#107) residents reviewed for outside consultant services.

Inspectors wroteBased on reviews of a facility reported incident and medical record and facility staff interview, it was determined that the facility failed to obtain a urinalysis and urine culture, and sensitivity as ordered by Resident #106's physician. This was evident in 1 of 86 resident complaints reviewed during an annual recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (#169, #166) of 93 residents reviewed during an annual and complaint survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to supply a staff restroom with soap for staff to wash their hands after use. The lack of soap in a staff restroom is an important step in the implementation of appropriate standard and transmission-based precautions to help prevent the spread of infections. This deficient practice has the potential to affect all residents, staff, and visitors in the facility.

Inspectors wroteBased on medical record review, observations, and interviews with facility staff and residents, it was determined that the facility failed to: 1.) protect Resident #32 and Resident #29 from Resident #144 who had a documented history of combative, verbal, and physically aggressive behavior towards staff and other residents. This failure led to physical abuse, emotional distress, and psychosocial harm to Resident (#32) and physical abuse to Resident (#29) and 2.) keep residents free from abuse by staff (Resident #9), (Resident # 259) and (Resident #308). This was evident for 3 of 15 residents reviewed for abuse.

Inspectors wroteBased on observations, administrative record reviews and interviews with facility staff it was determined the facility failed to ensure that an effective call system was in place so that residents could access staff for assistance when needed. This was found to be evident during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility staff failed to: 1) report allegations of abuse to the appropriate agency for (Resident #9, #31, #126), and 2.) notify the state agency no later than 5 days of the results of investigations for (Resident #301, #308, #309). This was found to be evident for 6 of 15 intakes reviewed for abuse during the facility's annual Medicare/ Medicaid survey.

Inspectors wroteBased on a medical record review and interviews with facility staff it was determined the facility failed to follow professional standards of practice by documenting that a healed wound was assessed, and that physician-ordered treatment was being done to the wound. This was found to be evident for 1 (Resident # 96) of 16 residents reviewed for pressure ulcers during the facility's annual Medicare/ Medicaid survey.

Inspectors wroteBased on medical record review and interview with residents and facility staff, it was determined the facility failed to follow a physician order for residents (#81, #201, #66, #361, #13, #355, #363). This was evident for 7 of 19 residents reviewed for physician orders during the annual survey.

Inspectors wroteBased on record review and staff interview, the facility failed to provide continuity of physician supervised care to a resident. This was evident for 1 of 96 (Resident #13) residents reviewed during a recertification survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to: 1.) ensure an accurate review of hospital discharge summary information and the application of a wound vac per the recommendation of the surgeon (Resident #66); 2.) provide review and follow-up on orders issued for Resident #13. This was found to be evident for 2 of 96 residents reviewed during the facility's annual Medicare/ Medicaid survey.

Inspectors wroteBased on observations, administrative record reviews, and facility staff interviews, the facility administration failed to: 1) provide an alternative means for communication with providers when the providers cannot reach facility staff by normal means. This was evident for 1 out of 96 (Resident #105) residents review during a recertification survey; and 2.) ensure that an effective facility call system was in place so that residents could access staff for assistance when needed. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to ensure that accurate records were maintained for residents. This was found to be evident for 6 (Residents #81, #252, #117, #96, #359 and #363) of the 96 residents reviewed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on staff interviews, review of pertinent documentation, and survey findings, it was determined the facility staff failed to ensure that effective Quality Assurance and Performance Improvement (QAPI) interventions were implemented to address identified quality deficiencies. This was found to be evident while conducting the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on staff interviews, review of pertinent documentation, and survey findings, it was determined the facility staff failed to ensure that an effective Quality Assurance Performance and Improvement (QAPI) program was in place to identify Quality concerns and have a system in place to correct identified concerns. This was found to be evident while conducting the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on staff interviews, review of pertinent documentation, and survey findings, it was determined the facility staff failed to ensure that an effective Quality Assurance Performance and Improvement (QAPI) committee was in place to correct identified concerns. This was found to be evident while conducting the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on surveyor observation and staff interviews, facility staff and visitors failed to complete the COVID-19 declaration/surveillance form and the facility. This deficient practice has the potential to affect all staff and visitors to the facility.

Inspectors wroteBased on observation and interview it was determined the facility staff failed to: 1.) provide a dignified environment while a Resident (#26) was being assisted with dining, and 2.) failed to honor a resident's private space (Resident #126). This was evident 2 of 3 residents observed during the annual survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to ensure that a resident phone was working properly. This was found to be evident for 1 (Resident # 93) of 79 complaints and facility reported incidents reviewed during the facility's annual Medicare/Medicaid survey. Findings Include: A review of MD00178081 on 9/7/22 at 4:00 AM revealed multiple concerns regarding Resident #93's phone allegedly being unplugged and that the resident family was unable to reach the resident for several days. An initial tour of the facility was conducted on 9/7/22 at 4:30 AM and an observation was made of resident #93's room. The resident phone was observed on the overbed table, and the phone cord was completely severed. [...]

Inspectors wroteBased on interview with facility staff and residents and record review, the facility staff failed to honor residents' preferences of how daily activities will be scheduled. This is evident for 1 of 96 (Resident #355) residents reviewed during a recertification survey.

Inspectors wroteBased on observations and interviews it was determined the facility staff failed to ensure residents received contact information to reach the state agency and the ombudsman assigned to the facility. This had the potential to affect all the residents within the facility.

Inspectors wroteBased on observation and interviews it was determined the facility failed to ensure the residents, family members, and legal representatives had access to the results of the most recent survey results. This practice had the potential to affect all the residents.

Inspectors wroteBased on review of facility records and interview with staff it was determined that the facility staff failed to provide residents/representatives with Advanced Beneficiary Notice of Non-coverage (SNFABN) in a timely manner. This was evident for 1 (#144) of 3 residents reviewed for Beneficiary Protection Notification.

Inspectors wroteBased on administrative record review and interviews with facility staff, resident and family member, it was determined the facility failed to ensure that a resident's personal property was replaced when lost in the laundry. This was found to be evident for 1 (Resident # 111) of 79 intakes that were reviewed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to: 1.) provide complete and thorough documentation of an investigation and 2.) properly screen a current employee that had a previous substantiated allegation of abuse by the facility. This was found to be evident for 1 (Resident # 259) of 79 intakes that were investigated during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interviews it was determined the facility failed to notify the state agency of allegations of abuse within the mandated 2-hour time frame. This was evident in 2 (Residents #301 and #308) of 8 intakes investigated for abuse.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to have a system in place to ensure that residents and/or resident representatives were notified in writing when a resident is transferred out of the facility to a hospital and the rationale for the transfer. This was found to be evident for 1(Resident # 111) of 3 residents reviewed for Minimum Data Set (MDS) Quarterly Assessments during the facility's revisit survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident responsible party (RP) are given written notification of the facility bed hold policy when they are being transferred out of the facility to a hospital. This was found to be evident for 1 (Resident # 111) of 3 residents reviewed for Minimum Data Set (MDS) Quarterly Assessments during the facility's revisit survey.

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to ensure that quarterly Minimum Data Set assessments were completed on time. This was evident for 1 of 96 residents reviewed for the facility's recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to ensure that resident assessments were transmitted to the Center for Medicare Services (CMS) timely This was evident for 3 of 96 (Resident # 147, #366 and #375) residents reviewed for the facility's recertification survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to: 1.) accurately assess a resident with a sacral wound resident (#96); and 2.) accurately assess a resident (#54) for bowel and bladder on the Minimum Data Set (MDS). This was found to be evident for 2 of 96 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to develop a Comprehensive Care Plan for residents to identify measurable goals, interventions, and approaches to address the resident's needs. This was evident for 3 out of 19 (#15, #81 #361) selected residents for review for care plans during the annual survey.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to: 1.) update resident care plans for residents (# 96, #15, #126, #363). This was evident for 4 of 96 residents reviewed during the annual survey; and 2) ensure a resident had an interdisciplinary care plan meeting while residing in the facility. This was evidenced in 1 (Resident #307) of 3 resident records reviewed for care plan timing.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to ensure that activities were being provided to meet the resident's needs. This was found to be evident for 1 (Resident #252) of 96 residents reviewed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on record review and facility staff interview, the facility failed to provide 24 hour emergency physician services for a resident (Resident #68). This was evident for 1 out of 96 residents review during a recertification survey.

Inspectors wroteBased on medical record review and interviews the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months as required. This was evident in 2 of 2 requested copies of nursing staffing sheets related to Facility Reported Incidents (FRI) for Resident #306 and #309 reviewed during the annual survey.

Inspectors wroteBased on observation and interviews it was determined the facility staff failed to secure and store medications in locked medication carts. This deficient practice has the potential to affect all the residents within the facility.

Inspectors wroteBased on observation and interview it was determined the facility failed to provide intact and securely anchored handrails on the Magnolia unit. This deficient practice has the potential to affect all the residents on the first floor.