Pines Nursing and Rehab

Inspectors wroteBased on record review, staff and resident interviews, and facility documentation, the facility failed to ensure staff provided incontinent care using safe techniques for 1 (#22) of 1 residents reviewed for incontinent care. Specifically, staff failed to discontinue brief removal after the resident complained of pain and failed to remove the plastic fastening tabs before pulling the incontinent brief from beneath the resident. This deficient practice resulted in a deep laceration to the resident's left posterior thigh, uncontrolled hemorrhage requiring emergency medical services, hospitalization for approximately three weeks, and treatment including transfusion of four units of packed red blood cells and three units of platelets.

Inspectors wroteBased on observation, interviews, and documentation review, it was determined that facility staff failed to treat each resident in a dignified manner by failing to dress a resident in clothing that was suitable for the resident, failing to place a urinary catheter bag in a dignity bag for residents with a Foley catheter, and failing to allow residents to dine in the dining room for dinner daily. This was evident for 10 (#14, #10, #27, #24, #13, #5, #23, #25, #26, #28) of 28 residents reviewed during a complaint survey.

Inspectors wroteBased on observations, interview, and medical record review, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed from staff. This was evident for 7 (#16, #17, #18, #19, #14, #21, #22) of 9 residents observed on the Homestead unit during a complaint survey.

Inspectors wroteBased on complaint, observations, and staff interview, it was determined the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident in the common areas of the facility and in 1 of 4 nursing units observed 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 4 (#12, #8, #4 #5) of 28 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interview, the facility staff failed to have all washers and dryers in working order to meet the needs of the residents. This was evident for 1 of 3 washers and 2 of 4 dryers in the laundry room observed during the complaint survey.

Inspectors wroteBased on medical record review and interview, the facility failed to notify the Resident's representative of a resident's physician appointment. This was evident for 1 (Resident #5) of 11 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review, observation, and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#10, #27) of 2 residents reviewed for urinary catheters during a complaint survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined that the facility staff failed to develop and implement a care plan related to a resident's specific needs related to an indwelling foley catheter. This was evident for 1 (Resident #27) of 2 residents reviewed for an indwelling foley catheter.

Inspectors wroteBased on medical record review and interview, the facility staff failed to have a quarterly care plan meeting for a resident (Resident #13). This was evident for 1 of 5 residents reviewed for care plan meetings during a complaint survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility failed to provide respiratory services in accordance with professional standards of practice. This was evident for 1 (Resident #15) of 28 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interview, the facility staff failed to maintain the temperatures of the shower on the Wye Oak Unit. This was evident for 1 of 2 showers on the Wye Oak Unit and 1 of 4 nursing units observed during the 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 gnats seen in resident rooms and on the unit. This was evident on 1 (Homestead) of 4 nursing units during a complaint survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure food was stored and prepared in a sanitary manner. This was evidenced by: (1) undated and unlabeled food items in the facility's kitchen refrigerators and freezers; (2) kitchen staff not wearing proper protective gear while preparing food for residents; (3) failure to label and date food items and monitor temperatures in all unit pantry refrigerators; and (4) water nesting on insulated plates and lids used to serve residents, as well as improper sanitization of kitchen sanitization buckets. These deficiencies were observed during the survey of the kitchen and have the potential to affect all residents.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to use appropriate infection control practices such as 1) improper storage of clean linens 2) improper storage of urine specimen 3) improper storage of leftover pudding inside the medication cart and 4) failure to implement enhanced barrier precautions for residents with pressure ulcers. This was evident for 1) 1 of 1 linen cart 2) 1 of 4 medication storage refrigerators 3) 2 of 10 medication carts and 4) 2 of 2 (Residents #12 and #116) residents with wound sampled during the recertification survey.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to ensure there was an effective pest control program for the kitchen. This was evident during the survey of the kitchen. This deficiency has the potential to affect all residents.

Inspectors wroteBased on observations and interview it was determined that the facility failed to ensure Residents were provided a dignified existence. This was evident for 14 (Resident #116, #84, #12, #91, #107, #57, #36, #14, #31, #21, #61, #115, #155 & #40) out of 38 Residents observed for dining during the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure the residents and the residents' representatives were offered the opportunity to develop an advanced directive. This was evident for 4 (Residents #12, #8, #3 and #40) of 7 residents reviewed for advanced directives during the recertification survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to provide a clean, safe and homelike environment. This was found to be evident during multiple tours and random observations of the facility during the recertification survey.

Inspectors wroteBased on interviews, record reviews and observations, it was determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately. This was found to be evident for 3 (Resident #6 , #91 and #107) out of 3 Residents reviewed for reporting abuse allegations.

Inspectors wroteBased on interviews, record reviews and interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse are investigated. This was found to be evident for 3 (Resident #6, #91 and #107) out of 3 Residents reviewed for investigating abuse allegations.

Inspectors wroteBased on interviews and record reviews it was determined the facility failed to ensure Resident Care Plans were developed. This was found to be evident for 4 (Resident #92, #107, #12 and #8) out of 23 Residents reviewed for Care Plans during the recertification survey.

Inspectors wroteBased on review of medical records and interviews it was determined the facility failed to 1) have quarterly care plan meeting with the interdisciplinary team. This was found to be evident for 1 (Resident #116) out of 22 residents reviewed for Care Plan Meetings, 2) review and revise the care plans to meet resident's needs, This was evident for (Resident #8, #12 and #107) of 23 residents reviewed for care plan timing and revision during the recertification survey. 3) develop a comprehensive care plan within the required timeframe. This was evident for 1 (#11) of 23 residents reviewed for pressure injuries during the recertification survey.

Inspectors wroteBased on medical record reviews, interviews and observations it was determined that the facility failed to ensure medical records were accurate, complete and readily assessible. This was found to be evident for 3 (Resident #92, #116 and #84) out of 3 Residents reviewed for accurate, complete and readily accessible medical records during the recertification survey.

Inspectors wroteBased on observations, record reviews and interviews it was determined that the facility failed to 1) maintain the nurse call system in working order. This was evident for 2 (#19 and #11) of 6 residents reviewed for call systems and 2) ensure residents had access to call bells. This was evident of 4 residents (Resident#54, #5, #14 and #40) out of 4 residents review during recertification and compliant survey process.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to invite the resident to participate in the care planning process. This was evident for 1 (Resident #8) of 5 residents reviewed for care planning during the recertification survey.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide the right to self-determination. This was found evident in 1 (Resident #121) out of 1 Resident reviewed for Self-Determination.

Inspectors wroteBased on observations, interviews and record review it was determined that the facility failed to 1) provide a private meeting for the Resident Council, 2) address grievances in a timely manner for 6 (Resident# 81, #44, #92, #12, #66, and #54) out of 12 Residents, and 3) provide grievance feedback. This was found to be evident for 1 out 1 observation of the Resident Council Meeting (RCM) during the recertification survey.

Inspectors wroteBased on observation, interviews and record review it was determined that the facility failed to ensure Residents were notified of all the Resident [NAME] of Rights. This was found to be evident during the Resident Council meeting during the recertification survey.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to notify resident's representative of a change in condition. This was evident for 1(Resident #8) of 1 resident reviewed in a complaint investigation.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide adequate privacy to the resident by exposing their body parts. This was evident for 1 (Resident #42) of 1 resident sampled during the medication administration.

Inspectors wroteBased on interviews and a review of pertinent documentation it was determined that the facility failed to ensure grievances were addressed in a timely manner. This was found to be evident for 1 (Resident #122) out of 1 Resident reviewed for grievances during the recertification survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to ensure 1) a Resident received a bed hold notice and 2) the Ombudsman was notified of transfers and discharges. This was found to be evident for 1 (Resident #107) out of 1 Resident reviewed for hospitalization during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to complete an admission MDS (Minimum Data Set) assessment within the required timeframe. This was evident for 1 (Resident #102) of 1 resident reviewed for resident assessments during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to transmit a Minimum Data Set (MDS) assessment within 14 days of completion. This was evident for 1 (Resident #102) of 1 resident reviewed for resident assessments during the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to accurately code and assess the Minimum Data Set (MDS) assessment. This was evident for 2 (Resident #8 and #13) of 2 residents reviewed during the recertification survey.

Inspectors wroteBased on observations, medical record reviews, and staff interviews, it was determined that the facility failed to: 1) follow physician orders for turning and repositioning, 2) ensure physician orders were obtained for hospice or end-of-life care and 3) ensure the provision of sufficient supply of linens for residents. This was evident for 2 residents (#40 and #3) out of 2 residents reviewed for quality of care during the recertification and complaint survey process.

Inspectors wroteBased on observations, record reviews, and interviews it was determined that the facility failed to (1) implement recommendations made by the wound care team to treat pressure ulcers and (2) failed to initiate care upon admission for a resident with a pressure ulcer. This was evident for 2 (Residents #116 & #131) of 2 residents evaluated for pressure ulcer care during the survey.

Inspectors wroteBased on record reviews, observations and interviews it was determined that the facility failed to implement an intervention, determined to be necessary, for a resident who was identified as a fall risk. This was evident for 1 (Resident #84) of 6 residents reviewed for accidents during the recertification survey.

Inspectors wroteBased on medical record review, observation, and interviews with facility staff, it was determined that the facility staff failed to consult the resident's physician to clarify orders regarding the medication route, G-tube feeding residual parameters, and ensuring the resident received feedings as ordered. This was evident for 1 resident (#40) out of 1 resident reviewed during the recertification survey process. On 08/25/2025 at 10:22 AM, review of Resident #40's medical record revealed the following physician orders: Thiamine HCl Oral Tablet 100 mg: Give 1 tablet by mouth once daily for supplementation, ordered on 05/10/2025 and Melatonin Oral Tablet 3 mg, give 1 tablet by mouth at bedtime for insomnia, ordered on 05/09/2025. On 08/25/2025 at 1:30 AM, further review of Resident #40's medical record revealed a physician's order for diet texture: Nothing by Mouth (NPO). Check residual: [...]

Inspectors wroteBased on observations, record reviews, and interviews it was determined that the facility failed to maintain respiratory equipment in a sanitary manner for 3 (Resident #26, #118 and #69) out of 3 residents observed for respiratory care.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure staff postings were updated. This was found to be evident for 4 out of 4 staff assignment boards and 1 facility staff posting observed during the recertification survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations in a timely manner. This was evident for 1 (#7) of 5 residents reviewed for unnecessary medications during the annual survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that 1) oral nutritional supplements and medication were properly stored and labeled. This was evident for 1 storage closet and 1 of 3 medication storage rooms. and 2) medications were stored properly. This was found to be evident for 1 out of 4 medication carts observed during the initial tour of the facility during a recertification survey.

Inspectors wroteBased on resident and staff interviews and record review, it was determined that the facility failed to ensure timely provision of necessary or recommended dental services for 1 resident (#34) out of 1 resident reviewed for dental care during the recertification and complaint survey.

Inspectors wroteBased on review of medical records, observation and staff interviews, it was determined that the facility failed to provide liquids consistent with resident's needs. This finding was evident for 1 (#119) of 7 residents reviewed for hydration during the recertification survey.

Inspectors wroteBased on record reviews and interview, it was determined that the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) meetings had the required committee members. This was found to be evident for 2 out of 2 quarterly committee attendance sheets reviewed during the recertification survey.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility staff failed to screen and offer pneumococcal vaccines to eligible residents. This was evident for 1 (Resident #114) of 5 residents screened for immunizations.

Inspectors wroteBased on interviews and observation it was determined that the facility failed to ensure essential equipment was operational. This was found to be evident for 2 out 2 Laundry equipment and the facility's telephone system observed during the recertification survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to maintain 1) a safe environment. This was evident in 1 out of 2 rooms closed off for construction or repairs and 2) a sanitary environment in the laundry room. This was evident on all the floors throughout the laundry room.

Inspectors wroteBased on review of staff educational files and interviews it was determined that the facility failed to ensure Geriatric Nursing Assistant (GNA) completed a required annual education course. This was found to be evident for 5 (#17, #35, #39, #40, & #41) out of 5 GNA educational files reviewed during the recertification survey.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide supervision to a cognitively impaired resident with a history of a fall with fracture. This was evident for 1 (#16) of 35 residents in the [NAME] Unit during a complaint survey. As result of these findings an Immediate Jeopardy was called at 4:45 PM on 3/11/25. The facility submitted a plan to remove the Immediacy on 3/11/25 at 8:30PM. The survey team verified completion of the plan on 3/14/25 at 11:08 AM with a compliance date of 3/13/25.

Inspectors wroteBased on review of a facility-reported incident, medical record review, and interviews, it was determined that the facility failed to keep vulnerable residents on the dementia unit free from physical abuse, which resulted in harm to the residents. This was evident for 3 out of 44 residents (#14, #24, and #18) reviewed during a complaint survey.

Inspectors wrote2) On 3/18/25 at 7:00 AM a review of complaint MD00208729 alleged that in July and August 2024 there were no washcloths, and the staff were tearing up bed sheets to use as washcloths. Review of complaint MD00204843 alleged there were no linens for bathing or incontinence care in January 2025. A review of the 2/27/25 resident council meeting minutes documented that minutes of previous council meeting were: EVS (environmental services) not bringing residents clothes back to residents after they are washed. New business was, residents do not get wash towels when they ask aides for them. A review of the 11/22/24 resident council meeting minutes documented, clothes not being given back from laundry, clothes not being picked up from laundry. A review of the 9/26/24 resident council meeting minutes documented, Residents complained of not getting their laundry back for extended periods of time. [...]

Inspectors wroteBased on documentation review, resident council meeting minute reviews, staff and resident interviews, and observation, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 10 of 42 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, multiple staff interviews, 3 of the 4 resident council meeting minutes reviewed and review of staffing schedules and employee time punches. This deficient practice had the potential to affect all residents.

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 5 out of 5 personnel files (GNA #49, #52, #50, #51, #47) reviewed during a complaint survey.

Inspectors wroteBased on review of resident council meeting minutes and interview, it was determined the facility failed to employ a qualified social worker on a full time basis. Failure to have a qualified social worker has the potential to affect all the residents of the facility. This was evident during a complaint survey.

Inspectors wrote2) On 3/10/25 at 11:00 AM a review of complaint MD00213615 and complaint MD00210751 revealed an allegation that the facility had been having issues with the water being cold at night when it was time for showers. Review of complaint MD00208729 alleged that there was no hot water in August 2024 and residents had to get a bath with cold water. On 3/10/25 at 2:00 PM an interview was conducted with Resident #5 who stated that there have been on and off issues with the hot water for a couple of months and the problem has not been fixed. On 3/10/25 at 2:31 PM an interview was conducted with the Director of Maintenance, Staff #7. Staff #7 stated, it was going on and off which started in mid-January (2025) when it got real cold outside. The switch on the boiler clicks off and back on. [...]

Inspectors wroteBased on documentation review and interview, it was determined the facility failed to ensure nurse aide competency training occurred no less than 12 hours per year. This was evident for 1 (GNA #52) of 5 geriatric nursing assistant files reviewed and had the potential to affect all residents during the extended survey of a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to treat a resident with dignity (Resident #1). This was evident for 1 of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of facility reported incidents, record review and interview it was determined the facility failed to have documentation of when the final report was submitted to the regulatory agency, Office of Health Care Quality (OHCQ) and failed to report allegations of abuse within 2 hours of the allegation to OHCQ. This was evident for 3 (#17, #8, #29 ) residents reviewed for 5 of 18 facility reported incidents reviewed during a complaint survey.

Inspectors wroteBased on review of facility reported incidents, medical records, and staff interview, it was determined the facility failed to provide documentation that allegations of abuse, injuries of unknown origin, and a gas leak were thoroughly investigated. This was evident for 9 (#17, #8, #16, #29, #21, #24, #41, #39, #23) of 44 residents reviewed and for 1 facility reported incident that involved the kitchen during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to provide ADL (activities of daily living) care for residents who were dependant for all ADL care. This was evident for 4 (Resident #11, #8, #1, #36) out of 44 residents reviewed for complaints during a complaint survey.

Inspectors wrote3) Facility staff failed to follow-up on a medication for a specific medical condition. On [DATE] at 1:00 PM a review of Resident #8's medical record was conducted and revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included Ankylosing spondylitis (AS), which is a chronic inflammatory disease that primarily affects the spine, causing inflammation and potentially leading to the fusion of vertebrae, resulting in stiffness and reduced flexibility. Review of Resident #8's [DATE] Medication Administration Record (MAR) documented Resident #8 was to receive the medication Enbrel via injection from a prefilled syringe every Monday for Pain. A [DATE] and [DATE] nursing note documented that the medication Embrel was not available from the pharmacy. Enbrel is a prescription medication that belongs to a class of drugs called tumor necrosis factor (TNF) inhibitors. [...]

Inspectors wroteBased on review of complaint, medical record review, and staff interview, it was determined the facility's registered dietician failed to document assessments in the resident's medical record and the facility currently failed to have a registered dietician that came on site to see resident's to see and assess residents for their current nutritional needs. This was evident for 1 (Resident #8) of 44 residents reviewed during a complaint survey and had the ability to affect all residents that resided in the facility.

Inspectors wroteBased on review of complaints, interview, and medical record review, it was determined the facility failed to provide timely medication to meet the needs of the residents. This was evident for 3 (#18, #8, #5) of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on review of resident council minutes, observations and interviews, the facility staff failed to prepare and serve food that was palatable, attractive and at a safe and appetizing temperature. This was evident for 5 (#9, #41, #42, #43, #36) of 44 residents interviewed and during a test tray observation during a complaint survey.

Inspectors wroteBased on observations and interviews with staff it was determined that the facility failed to store food and monitor temperatures in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen.

Inspectors wrote3) On [DATE] at 11:15 AM a review of Resident #8's medical record revealed geriatric nursing assistant (GNA) tasks for bathing. Review of bathing records for Resident #8 documented that Resident #8 received a bed bath for 12 of 30 days in [DATE]. Review of the geriatric nursing assistant (GNA) bathing task for [DATE] revealed blank spaces for the 7-3 shift on 9/1, 9/4, 9/5, 9/6, 9/8, 9/9, 9/11, 9/16, 9/18, 9/19, 9/21, 9/22, 9/23, 9/24, 9/25, 9/27, and [DATE]. There were blank spaces for the 3-11 shift on 9/2, 9/8, 9/9, 9/11, 9/13, 9/17, 9/18, 9/20, 9/23, 9/26, and [DATE]. There were blank spaces for the 11-7 shift on 9/2, 9/11, 9/14, and [DATE]. Review of bathing records for Resident #8 documented that Resident #8 received a bed bath for 13 of 31 days in [DATE]. Review of the GNA bathing task for [DATE] revealed blank spaces for the 7-3 shift and there were 7 days of documented refusals. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the resident call bell system in working order. This was evident for 1 of 4 nursing units during a complaint survey.

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 in the kitchen and parts of the facility along with ants. This was evident on 2 of 2 days observed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview It was determined the facility staff 1) failed to inform the resident and/or resident representative when there was a change in the resident's treatment plan related to medication, and 2) failed to inform the resident/representative of the risks and benefits of the medication and obtain consent prior to initiating psychotropic medication. This was evident for 2 (#12, #3) of 44 residents reviewed for complaints.

Inspectors wroteBased on medical record review and interview, the facility staff failed to notify a resident's physician of a change in status and failed to notify the physician when a medication was not available. This was evident for 2 (#30, #3) of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on resident complaint, and interviews with facility staff, it was determined that the faciity failed to keep residents personal items safe. This was evident for 1 out of 1 resident (#2) with misappropriation of property.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to conduct a complete and accurate assessment by failing to assess a resident's cognition, mood, and behavior on a quarterly assessment. This was evident for 1 (#16) of 44 residents reviewed for during a complaint survey.

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 2 (#16, #17) of 44 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review, interviews, and observation, it was determined the facility failed to have regular care plan meetings and failed to update interventions on the care plan. This was evident for 3 (#21, #15, #16) out of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on review or pertinent documents, medical record review and interview, it was determined that 1) the practitioner failed to follow professional standards of clinical practice by prescribing end-of-life medication to a full code resident without ensuring the resident and/or resident representative were fully informed about the use of end-of-life medications, and 2) the facility nursing staff failed to follow professional standards of nursing practice when administering psychotropic medication by failing to document in the medication administration record when the medication was given to a resident. This was evident for 1 (#12) of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers. This is evident for 1 (#30) of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a complaint, medical record review, and interview, it was determined the facility staff failed to follow up and obtain a motorized wheelchair for a resident in a timely manner. This was evident for 1 (#5) of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to assess a resident for removal of a catheter. This was evident for 1 (#1) of 44 residents reviewed during a complaint survey.

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 blood pressure parameters for administering a blood pressure medication. This was evident for 1 (#3) of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. This was evident for 1 (#12) of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, interviews and review of pertinent documentation, it was determined the facility failed to keep residents free from a significant medication error by failing to ensure medication was available in a timely manner for the facility to administer, and failing to accurately document when medications were not given or not available. This was evident for 1 (#3) of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 3 nursing units observed during a complaint survey.

Inspectors wroteBased on resident complaint, record review, and staff interview, it was determined that the facility staff failed to provide a resident with a bedtime snack and 3 meals daily. This was evident for 2 (#8, #10) of 44 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and interviews with the administrator, the facility failed to make an appointment for a resident to have a sleep study done so a CPAP can be ordered for a diagnosis of sleep apnea. This is evident for 1 (#29) of 44 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility documentation, interview, and observation, it was determined the facility staff failed to maintain nursing staffing data. This was evident during a complaint survey.

Inspectors wroteBased on observation, medical record review, review of facility ' s policy and procedures, and interview with staff, it was determined the facility failed to ensure that they were able to provide Cardio-Pulmonary Resuscitation (CPR) in accordance with physician ' s orders and the residents ' wishes. This was evident for 5 of 84 residents (#50, #48, #52, 54 and #51) reviewed for code status accuracy during a follow-up survey. An immediate jeopardy regarding residents #50, #48, #52, #51, was identified on [DATE] at 3:00 PM and the facility was informed on [DATE] at 3:18 PM. The Findings Include: Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a patient ' s wishes about medical treatments. The Maryland MOLST order form: [...]

Inspectors wroteBased on a resident complaint, staff interviews, and clinical record reviews, it was determined that 1) the facility failed to ensure a totally dependent resident's tube feeding and hydration nutritional needs were met. This occurred when Resident #45's tube feeding orders were changed without instruction from Resident #45's physician or guidance from the facility nutritionist. These new tube feeding orders were also not monitored. This caused Resident #45 to lose a significant amount of weight (18%) in 2 months which caused Resident #45 harm. Additionally, the facility 2) failed to provide a resident a therapeutic diet, 3) failed to intervene in a timely manner when a weight loss was documented, and 4) failed to re-weigh a resident after a 6 day hospital admission and initiate a physician ordered nutritional supplement. [...]

Inspectors wroteBased on record review, resident, and staff interview, it was determined that the facility failed to have a process in place to ensure that concerns and suggestions from the resident group were reviewed and responses provided to the group in writing. This was evident for 3 of 3 months of Resident Council meeting minutes reviewed during an annual recertification survey.

Inspectors wroteBased on surveyor observation and staff interview it was determined the facility staff failed to have a process to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. This was evident throughout the survey and on all nursing units. Additionally, the facility failed to supply heated water between 100- and 120-degrees Fahrenheit.

Inspectors wrote8) On 9/12/22 at 2:14 PM, Resident #141 was not observed in his/her room and the GNA (Staff #51) revealed the resident was at dialysis. Resident #141's medical record was reviewed on 9/16/22 at 8:15 AM. Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's medical records revealed the resident was diagnosed to have acute renal failure and was receiving hemodialysis three times per week. Review of Resident #141's care plan revealed the plan of care was initiated on 9/7/22 by a Healthcare Virtual Assistant (Staff #78). Review of the resident's care plan did not address care and services related to acute renal failure and scheduled hemodialysis three times per week. On 09/16/22 at 9:03 AM an interview was conducted with the nursing home administrator. She provided information related to the Healthcare Virtual Assistant (HVA). [...]

Inspectors wroteBased on interview, observation, and medical record review, it was determined the facility failed to implement an ongoing program of activities based on the abilities, interests and treatment needs of residents that resided in the facility. This was evident for 5 (#34, #62, #36, #5, #45) of 7 residents reviewed for activities and 2 (#9, #63) of 17 residents observed on the Homestead Unit, however affected all residents in the facility. This was evident during the annual survey.

Inspectors wroteBased on interview and observation it was determined the facility failed to have an activities program that was directed by a qualified professional. This was evident during the 14 days the surveyors were onsite for the annual survey and had the potential to affect all residents.

Inspectors wrote7) A review of the Resident Council minutes from the past three meetings (08/30/22, 08/05/22, 07/26/22) on 09/13/22 at 10:18 AM revealed continued complaints of a lack of staffing in the facility. The Resident Council documented the following unresolved issues: 08/30/22 - Poor staffing is still an issue, but it is mainly an issue on the weekends. 08/05/22 - The social worker is too busy to be involved in the resident's needs. 07/26/22 - Poor staffing is still an ongoing issue. Residents are not bathed or getting showers. Obtaining assistance from nursing assistants is still an ongoing issue. During the Resident Council meeting held on 09/13/22 at 10:18 AM, the residents complained of still not getting showers, staff will answer a resident's call light and then leave the room and never come back to assist the resident. [...]

Inspectors wroteBased on review of employee files and interview, it was determined that the facility failed to put a system in place to ensure Geriatric Nursing Assistant's (GNA's) were competent with their skills sets. This was found to be evident for 3 out of 3 GNA (GNA #37, #44 and #45) employee files reviewed for competencies and skill sets.

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 3 out of 3 personnel files (GNA 337, #44, #45) reviewed during the annual survey.

Inspectors wroteBased on interview and reviews of administrative documents, it was determined that the facility failed to ensure that nursing staff received and completed minimum training for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. This had the potential to affect all residents.

Inspectors wroteBased on observation, staff interview, and documentation review it was determined that facility staff failed to 1) keep medication and treatment carts locked when unattended, 2) discard expired medications and patient supplies, 3) maintain medication room refrigerators and freezers and monitor temperatures, 4) date medication and biologicals when opened, and 5) maintain narcotic medication reconciliation records. This was evident on 4 of 4 nursing units observed during random observations made during the annual survey.

Inspectors wroteBased on resident interviews, and observations of the kitchen services with the testing of a food tray, it was determined that the facility failed to serve food at a preferable/palatable temperature. Food complaints and concerns were identified for 09 (#16, #19, #20, #23, #44, #58, #75, #87, #141) of 24 residents selected in the final sample and a failed test tray was identified on the unit that was served last. This had the potential to affect all residents.

Inspectors wrote2) An environmental kitchen food service inspection was conducted in the facility's kitchen on 09/16/22 at 2:15 PM. The lunchtime dishwashing service was concluding at the time of the observation. The certified dietary manager (staff #61) was asked to restart the dishwashing machine and run trays through the machine. Observations of the temperature gauge for the hot water wash temperature remained at 140 degrees Fahrenheit (F.) as she placed multiple trays to run through the machine. A sign on the wall above the dishwashing machine indicated the minimum hot water wash temp was 160 degrees F. and the minimum rinse temperature was 180 degrees. The signage was very concise, instructing staff to inform a manager if the minimum hot water temperatures were not archived. During the observation, the wash water temperature did not rise above 140 degrees F. [...]

Inspectors wroteBased on interview, observation and record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively in order to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by failing to 1) ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, and ensure the nursing staff had training which included dementia training and yearly in-service training; [...]

Inspectors wroteBased on review of facility records and interview with staff, it was determined the facility failed to conduct and document an accurate/current facility-wide assessment that was up to date. This was evident during the review of the sufficient and competent nurse staffing task of the annual survey and the extended survey. This had the potential to affect all residents within the facility.

Inspectors wroteBased on written and verbal complaints, reviews of medical health records and staff interview, it was determined the facility failed to obtain a full time social worker when the certified number of beds exceeded 120 in the facility. Currently the facility was licensed for 170 certified beds. This was evident for 1 out of 1 required personnel and had the potential to affect all residents.

Inspectors wroteBased on interviews, reviews of facility documentation, resident records, and current survey findings, it was determined that the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) plan to ensure care and services were maintained at acceptable levels of performance and continually improved. The annual survey process resulted in 77 Federal citations with areas of potential systematic concerns identified by the survey process. This had the potential to affect all residents within the facility.

Inspectors wroteBased on observation, review of resident medical records, review of facility documentation, and interview with facility staff, it was determined that the facility failed to ensure that they developed and maintained an effective infection control program. This was evidenced by 1.) failing to destroy a used COVID-19 kit in the laundry room, 2.) failing to place an order for COVID-19 care/treatment for residents with confirmed COVID-19 infection. This was evident in 1 (Resident #63, #348) of 5 Residents reviewed for the COVID-19 order, 3.) failing to have a system in place to report a positive test for COVID-19 to the local health department. This was evidenced by lack of documentation for COVID-19 line listing from January 2022 to April 2022, 4.) failing to develop a facility policy for Personal Protect Equipment (PPE) during an outbreak in the facility; [...]

Inspectors wroteBased on interview and review of the facility records, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident by facility staff failing to submit antibiotic stewardship records to the surveyor to verify the facility had an antibiotic stewardship program as part of the facility's overall infection prevention and control program. This was evident during the annual survey and had the potential to affect all residents.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to have an effective system in place to ensure staff who were not up to date with COVID-19 immunizations, including unvaccinated staff, were tested according to state and federal guidelines. This was found to be evident for 58 out of 92 staff (regardless of vaccination status) who were not tested for COVID-19 the week of 9/4/22 (the facility had a COVID-19 outbreak), and 27 out of 92 staff (regardless of vaccination status) that were not tested the week of 7/10/22 while the facility had a COVID-19 outbreak. This deficient practice had the potential to affect all residents, staff, and visitors in the facility.

Inspectors wroteBased on interview and documentation review, it was determined the facility failed to ensure a training program was set up and in place for their staff to be educated on abuse, neglect, exploitation, and misappropriation of resident property along with dementia management and resident abuse prevention. This was evident for current staff and had the potential to affect all residents.

Inspectors wroteBased on documentation review and interview, it was determined the facility failed to ensure nurse aide competency training occurred no less than 12 hours per year as determined in nurse aides' performance reviews. This was evident for 3 of 3 files reviewed and had the potential to affect all residents.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to treat each resident in a dignified manner by 1) not knocking on the resident's door before entering, 2) standing over a resident while feeding the resident, 3) not changing a resident's wet clothing before proceeding with assisting the resident with his/her meal, 4) serving the breakfast meal on disposable paper when the facility had glass plateware available, and 5) pulling a resident backward down the hallway. This was evident for 6 (Resident #44, #6, #1, #65, #24, #19) of 54 residents reviewed during the annual survey.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive for 3 (#10, #69, #27) of 3 sampled residents for advance directives.

Inspectors wrote4) A review of Resident #141's medical record related to nutritional concerns was conducted on 9/20/22 at 2:15 PM. A nutritional assessment was completed on 9/8/22 by the dialysis dietitian. The dietitian documented a weight of 200 pounds (Lbs.) that was taken on 9/6/22. The nutritional summary revealed, Resident is at nutrition risk related to inadequate oral intake with elevated nutritional needs for wound healing and likely inadequate nutrient intake. A review of the vital signs weight section of the electronic health record revealed a second weight was documented on 9/19/22 at 10:03 PM as 160.8 Lbs. by a nurse (staff #47). The electronic health record automatically documented a weight comparison noting a 19.6 % significant weight loss of 39.2 Lbs. Further review of the medical record did not reveal any type of physician or dietician notification. [...]

Inspectors wroteBased on medical record review and staff interview it was determined that the facility 1) failed to ensure the discharge of a resident was documented in the medical record to include, the resident's status at the time of discharge, any required discharge instructions, the reason for the discharge and 2) failed to document that information was provided to the acute care facility when a resident was transferred there emergently. This was identified for 3 (#148 #10, #27) of 9 residents reviewed for discharge during the annual survey.

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 (#10, #27) of 6 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to 1) conduct an accurate, comprehensive assessment by failing to accurately assess a resident's dental status, mood and cognitive status, bowel and bladder status, and dialysis on comprehensive (Minimum Data Set) assessments and failed to 2) complete an admission MDS assessment within 14 days of a resident's admission to the facility. This was evident for 4 (#27, #59, #103, #291) of 23 residents reviewed for 4 different care areas and 1 (#141) of 1 newly admitted resident reviewed for the annual survey.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide residents and or resident's responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications. This was evident for 9 (#62, #97, #103, #107, #450, #36, #88, #141, #96) of 54 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to 1) review and revise resident care plans to reflect accurate and current interventions, and 2) ensure the full interdisciplinary team including residents and/or their responsible parties were invited to the care plan meetings. This was evident for 10 (#55, #5, #34, #62, #92, #107, #106, #99, #141, #19) of 54 residents reviewed during the annual survey.

Inspectors wroteBased on complaints, reviews of medical records, and staff interviews, it was determined that the facility failed to 1) ensure residents received medications as ordered by the physician, 2) document care given to a resident prior to being transferred to the hospital, 3) follow physician's orders, implement interventions and document when resident had a fall and 4) change a resident's nebulizer tubing and documenting when changed. This was evident for 8 (#45, #27, #92, #34, #97, #38, #36, #19) of 54 residents reviewed during an annual survey.

Inspectors wroteBased on medical record review, observation, and interviews it was determined the facility staff failed to ensure wounds were accurately assessed on admission and failed to provide appropriate treatment and services to promote healing of pressure ulcers. This was evident for 4 (#141, #95, #55, #108) 5 residents reviewed for pressure ulcers. A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. [...]

Inspectors wroteBased on reviews of a medical record, interview, and observation it was determined that the facility failed to 1) ensure that a resident received nebulizer treatments as ordered by the physician, and 2) develop a resident-centered care plan for a resident with Chronic Obstructive Pulmonary Disease (COPD) and oxygen use with resident-centered and measurable goals and 3)have physician's orders for the administration of oxygen. This was evident for 2 (#23, #10) of 2 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on observation, record review, administrative policy review, and interviews, it was determined the facility failed to assess residents for risk of entrapment from bed rails, obtain informed consent, and ensure bed rails were properly installed prior to the utilization of side rails for any resident. This was evident for 3 (Resident #141, #34, #36) of 9 residents reviewed for accidents during the annual survey.

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 6 (#105, #94, #141, #10, #34, #450) of 54 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the physician failed to see a resident once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. This was evident for 4 (#62, #10, #102, #107) of 54 residents reviewed during the annual survey.

Inspectors wroteBased on review of medical records and interview with staff it was determined that the facility failed to 1) have an effective system in place to ensure that drug regimen reviews were done for all residents at least monthly and 2) develop policies and procedures related Medication Regimen Review to include time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This was evident for 6 (#5, #6, #20, #64, #450, #63) out of 10 residents reviewed for medications during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to reconcile and transcribe medication orders accurately to the medication administration record as evidenced by transcribing a medication twice. By failing to transcribe orders accurately the resident did not receive medications at the prescribed time of day and/or received up to twice the amount of medication ordered. This was identified for 1 (#141) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility failed to follow a physician's order to 1) administer the antihistamine medication Benadryl twice daily for 2 days and then discontinue and 2) follow physician ordered blood pressure parameters. This was evident in 3 (#26, #32, #24) out of 3 residents reviewed for significant medication errors during a follow-up survey.

Inspectors wroteBased on complaint, and resident and staff interviews, it was determined that the facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This was evident for all residents in the facility reviewed during the annual survey.

Inspectors wroteBased on complaint, and resident and staff interviews, it was determined that the facility failed to prepare and serve a resident's nutritional wishes and plan of care. This was evident for all residents that can eat and drink in the facility and suffer from diabetes.

Inspectors wroteBased on resident complaint, record review and staff interview, it was determined that the facility staff failed to provide a resident with a bedtime snack. This was evident for 1 (Resident #23) of 12 residents reviewed for nutrition during the annual survey.

Inspectors wroteBased on medical record review, interviews and observations it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. Furthermore, the facility failed to assure the completeness, and accuracy of documentation related to the use of Healthcare Virtual Assistant Transcription Support services. This was evidenced by review of resident's medical records with multiple examples of incomplete documentation initiated by HVAs and documentation of staff performing assessments and documented progress notes at times the staff were not in the facility. This practice was evident for 13 (#141, #45, #49, #69, #97, #93, #103, #34, #10, #291, #97, #38, #99) of 54 residents reviewed.

Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Party (RPs) were provided education regarding the benefits, risks, and potential side effects of Influenza and Pneumococcal vaccines before requesting consent. This was evident for 4 (Resident #49, #4, #58, #11) of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document that education was provided to residents and staff regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine. This was evident for 4 (Resident #49, #11, #58, and #37) of 5 residents and 1 (Staff # 85) of 5 facility staff members reviewed for COVID-19 vaccinations during the annual survey.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to keep a bathtub and ice machine in operating condition. This was evident during environmental rounds of the facility for 1 of 1 bathtub found out of 2 observed bathing areas of the facility and in 1 of 1 nourishment rooms observed.

Inspectors wroteBased on observation, medical record review, and staff interview it was determined the facility failed to have a process in place to conduct regular inspections of bed frames, mattresses, and bed rails. This was evident for 1 (#34) of 8 residents reviewed for accidents during the annual survey.

Inspectors wroteBased on complaint, observation, and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order and within reach. This was evident for 2 of 3 nursing units observed during the annual survey.

Inspectors wroteBased on staff collaborated observations of two restrooms utilized by staff and residents, a nursing station and a shower room, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff as identified in 2 of 2 staff bathrooms observed and for 1 (200 hall) of 4 nursing units observed during the annual survey.

Inspectors wroteBased on policy review, review of facility reported incident MD00180950 and complaint MD00176593, and resident and staff interviews, it was determined that the facility failed to ensure a resident was free from misappropriation of resident property and exploitation. This was evident for 1 (Resident #113) of 13 residents reviewed for abuse, neglect and exploitation during the annual survey.

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility staff failed to conduct a complete and accurate assessment by failing to assess a resident's oxygen use and failing to assess cognition and mood. This was evident for 1 (#10) of 2 residents reviewed for respiratory, 1 (#62) of 8 residents reviewed for accidents, and 1 (#59) of 9 residents reviewed for quality of care.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to ensure that a recapitulation of the resident's stay was completed following a resident's discharge from the facility. This was evident for 1 (#93) of 3 closed records reviewed during the annual survey.

Inspectors wroteBased on a resident complaint, medical record reviews, and staff interview, it was determined that the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in their range of motion. This was evident for 2 (Residents #5, #45) of 4 residents reviewed for range of motion.

Inspectors wroteBased on medical record review, staff interview, and facility administrative documents, it was determined that: 1) the facility staff failed to protect a resident, who was totally dependent upon staff for all aspects of care from continued falls, 2) investigate the root cause of the falls and initiate nursing interventions to prevent further falls, and 3) update the resident's fall prevention care plan. This was evident for 1 (Resident #55) of 8 residents reviewed for accidents during the annual survey.

Inspectors wroteBased on a complaint, reviews of a medical record, and staff interviews, it was determined the facility staff failed to ensure that a resident was provided pain medication when requested and that a resident had ordered pain medication on admission. This was evident for 2 (#5, #98) of 9 residents reviewed for pain management during the annual survey.

Inspectors wroteBased on record review, staff interview, and observation, it was determined that the facility failed to ensure a physician supervised the care of a resident, as evidenced by the physician failing to evaluate a resident upon admission to the facility and failure to review a resident's weight loss. This was evident for 2 (#99, #106) of 33 complaints reviewed and 1(#34) of 12 residents reviewed for nutrition during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to 1) obtain lab tests as instructed by the resident's physician, and 2) place the results in the resident's medical record. This was evident for 1 (Resident #55) of 6 residents reviewed for unnecessary medications during the annual survey.

Inspectors wroteBased on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (#27) of 1 residents reviewed for dental while admitted to the facility under Medicare.

Inspectors wroteBased on record review and interview, it was determined the facility failed to provide rehabilitation services, evidenced by failing to provide physical therapy as initially planned. This was evident for 1 (Resident #58) of 7 residents reviewed for rehabilitation during the annual survey.

Inspectors wroteBased on observation, documentation review, and staff interview it was determined the facility failed to have the results of the most recent annual survey posted in the survey binder that was accessible to residents, family members and legal representatives of residents. This was evident during the first 2 days of the revisit survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (#27, #10, #29, #91 ) of 6 residents reviewed for hospitalization.

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 4 (#27, #10, #29, #91) of 6 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the nurse staffing data at the beginning of each shift and failed to retain the posted daily nurse staffing data for a minimum of 18 months. This was evident on 3 of 3 nursing units and in the facility lobby during the annual survey.

Inspectors wroteBased on the interviews with eight members of the resident council and a review of resident council notes from the past 12 months it was determined that the facility staff had not been addressing the residents' concerns.

Inspectors wroteBased on the observation of resident rooms during the initial tour of the facility, it was determined that the facility staff failed to maintain a safe and clean environment as evidenced by unattended maintenance and/or housekeeping needs, and broken items (room [ROOM NUMBER] and 314).

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to notify the resident or the resident's responsible party in writing of transfer to the hospital. The facility also failed to send a copy of the written transfer notice to the Office of the State Long-Term Care Ombudsman. This was evident for 3 of 47 residents (#64, #122, #123) sampled for investigations.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to review and revise Resident #275's care plan to reflect accurate and current interventions and failed to ensure the full interdisciplinary team including residents and/or their responsible parties are invited to the quarterly care plan meetings (#76 and #92). This was evident for 3 of 47 residents selected for review during the annual survey.

Inspectors wroteBased on interviews with residents from the resident council it was determined that the facility staff failed to ensure sufficient staffing for the facility.

Inspectors wroteBased on observation during the initial tour of the main kitchen it was determined that the facility staff, failed to store, and prepare, food under sanitary conditions.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for Residents (#33, #43, #64, #65, #67 and #92). This was evident for 6 of 47 residents reviewed in the annual survey.

Inspectors wroteBased on observation, and interview with staff it was determined that the facility failed to maintain all essential mechanical, electrical, equipment in safe operating condition on the lower level of the facility.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify a resident/resident representative in writing of a room change. This was evident for 1 (Resident #38) of 47 residents reviewed during an annual recertification survey.

Inspectors wroteBased on a review of a facility reported incident, a resident clinical record, and staff interview it was determined that the facility staff failed to ensure a resident's right to move about the facility and to exit the facility was honored (#174). This was true for 1 out of the 5 residents reviewed for facility reported incidents as part of the survey process.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to address the initiation of a MOLST form with Resident #89 and failed to properly void an old MOLST form when a new one was created for Resident #275. This was evident for 2 (Resident #89 and #275) of 47 residents reviewed for advance directives during an annual recertification survey.

Inspectors wroteBased on review of a medical record review and staff interview, it was determined the facility staff failed to notify a resident's family member of a recommendation to lower a Resident's antipsychotic medication after a psychiatric consultation. This was evident for 1 (Resident #33) of 47 residents reviewed during an annual recertification survey.

Inspectors wroteBased on review of the facility's investigation of a facility reported incident and staff interview it was determined the facility failed to protect Resident (#29) from abuse. This was true for 1 out of 47 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to notify the resident or the resident's responsible party in writing of the facilities bed-hold policy (#64, #122) before transferring them to the hospital. This was evident for 2 of 47 residents sampled for investigations.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to document accurate assessments for Resident (#66) on the MDS. This was evident for 1 of 47 residents selected for review during the survey process.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #223) of 47 residents reviewed during an annual recertification survey.

Inspectors wroteBased on review of medical record and staff interview, it was determined the facility staff failed to follow an established comprehensive care plan addressing nutrition for a resident (#34). This was evident for 1 of 47 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to administer a medication as ordered to Residents #120 and #275 and the facility staff failed to clarify the accuracy of a medication order for Resident #275. This was evident for 2 of 47 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for residents with pressure ulcers (Residents #275). This was evident for 1 of 47 residents selected for review during the investigation stage of the survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain weights as ordered for Resident (#275). This was evident for 1 of 47 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to thoroughly intervene and offer alternative pain management for Resident #275. This was evident for 1 of 47 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the consultant pharmacist failed to identify and bring to the facility staff's attention for Resident #275 the irregularity of the ordering of Potassium. This was evident for 1 of 47 residents selected for review during the survey process.

Inspectors wroteBased on medical record review and reviews of a relevant medical resource, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication. This was evident for 2 (Resident #33 and #117) of 6 residents reviewed for unnecessary medications during an annual recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs. This was evident for 1 (Resident #33) of 6 residents reviewed for unnecessary medications during an annual recertification survey.

Inspectors wroteBased on observation, reviews of a medical record, and staff interview, it was determined that the facility staff failed to offer and obtain dental services for a resident. This was evident for 1 (Resident #27) of 7 residents reviewed for dental services.

Inspectors wroteBased on resident complaint and staff interview, it was determined that the facility staff failed to provide a resident (Resident #43) with a bedtime snack as requested. This was evident for 1 (Resident #43) of 47 residents reviewed during an annual recertification survey.

Inspectors wroteBased on observation and staff interview the facility staff failed to post an isolation sign on room [ROOM NUMBER]A door to alert visitors, residents, and staff to see the nurse before entering the room. This was true for 1 out of 47 residents selected for review during the annual survey process.

Inspectors wroteBased on surveyor observation, it was determined that the facility staff failed to maintain a resident's call bell within reach. This was evident for 2 (Residents #223, #35) of 47 residents observed during an annual recertification survey.