Harmony Suites Rehabilitation And Wellness Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that staff accurately documented medication administration in accordance with accepted professional standards for 3 of 4 residents reviewed. Resident #16, who had a BIMS score of 15 and diagnoses including hypertension, chronic kidney disease, and end stage renal disease with dialysis dependence, stated that medications were sometimes given and sometimes not given because staff said they were not available. Review of the MAR showed multiple shifts with missing documentation for scheduled medications, missing vital signs, missing finger stick results, and missing pain assessments on non-dialysis days, and staff interviews indicated that if medications were unavailable they would be obtained from the pharmacy or Omnicell and a progress note would be written. Resident #3 had an order for sliding-scale insulin lispro before meals and at bedtime, but the MAR contained entries such as comment #9 instead of clear documentation for some blood sugar readings and insulin doses, and one day had blank MAR documentation for blood sugar checks. The progress notes did not explain why the medication was not given as ordered. Resident #97 reported missing thyroid medication doses after a change in medication and administration time, and the MAR showed comment #9 for doses on two dates without documentation in the progress notes to explain why the medication was not administered as ordered. The DON later acknowledged that the missing documentation for this resident was related to communication issues and that the information should have been documented in the resident's record.

Penalty

Inspection fine: $12,740

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and implement appropriate interventions to prevent elopement for a resident with known exit-seeking behaviors. On nursing admission, the resident was documented as exhibiting exit-seeking behavior, and later assessments showed dementia with a low BIMS score of 5, impaired communication, unsteady gait, muscle weakness with difficulty walking, and dependence on staff for most ADLs while using a wheelchair for locomotion. Despite this, the resident’s care plan did not address wandering behaviors until more than two months after admission, and the facility’s elopement prevention policy called for interdisciplinary planning, environmental modifications, monitoring, and identification of at-risk residents, which were not effectively implemented for this resident prior to the incident. On the date of the elopement, the resident, who frequently moved up and down the hall in a wheelchair and often expressed a desire to go home, asked an Environmental Service Aide (ESA) to go outside. The ESA, who had been employed less than two weeks and had not been trained in elopement prevention, opened a door and allowed the resident to exit the building. The resident later reported calmly to the NP that they had waited at the back door until an opportunity arose and left when the person nearby stepped away, and also reported losing balance and falling while leaving the building. Staff interviews confirmed that the resident was able to self-propel in a wheelchair but could not walk long distances without it. Following the resident’s departure, facility staff were unaware that the resident had eloped and there was no documentation indicating that the resident was unaccounted for over an approximate eight-hour period between early afternoon and late evening. The resident ultimately ended up at a local police department after being found by a citizen near a busy street and was then sent to a hospital. The DON acknowledged that the last progress note for that day only documented the resident’s lunch and independent eating, with no entries reflecting the resident’s absence during the subsequent hours. Interviews with the Maintenance Director and other staff confirmed that the resident often tried to leave and wanted to go home, yet the supervision and interventions in place did not prevent the elopement event.

Removal Plan

• Implemented a 100% headcount immediately following the elopement incident.
• Assessed Resident #16 immediately upon return from the hospital.
• Placed Resident #16 on 1:1 supervision.
• Ordered labs for Resident #16.
• Completed a full-body skin assessment for Resident #16.
• Placed a wander guard on Resident #16's right wrist.
• Updated the order to reflect wander guard use for Resident #16.
• Updated Resident #16's care plan.
• Updated the elopement binder to include Resident #16.
• Reviewed and revised Resident #16's elopement risk assessment to ensure accuracy and appropriate interventions.
• Completed an elopement drill on each shift.
• Educated staff regarding elopement and obtained staff statements.
• Reviewed all residents for elopement risk.
• Completed and/or updated elopement assessments for current residents.
• For residents identified at risk: obtained wander guard orders, applied wander guards, updated care plans, and initiated behavior monitoring.
• Audited and updated the facility elopement binder to ensure all at-risk residents are accurately identified and tracked.
• Implemented system-wide interventions, including applying wander guards to identified at-risk residents.
• Implemented a Leave of Absence (LOA) pink form process requiring the front desk to be notified before a resident leaves the building.
• Re-educated staff on elopement prevention protocols and the LOA form process.
• Reviewed and reinforced elopement policies and procedures with all staff.
• Conducted ongoing audits of the elopement binder to ensure accuracy.
• Conducted ongoing reviews of LOA documentation for compliance.
• Conducted random resident audits to ensure elopement risk assessments and interventions were in place.
• Reviewed audit results in the QAPI program and addressed identified issues promptly with corrective action.

Penalty

Inspection fine: $12,740

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status and physician-documented care for two residents. For one resident with high-grade papillary urothelial carcinoma status post chemoradiation, chronic kidney disease stage 4, and chronic obstructive pulmonary disease, both the admission and quarterly MDS assessments documented that the resident had no IV access. However, hospital discharge records, the facility history and physical, and multiple provider progress notes consistently documented the presence of a Port-a-catheter/central IV line in the right upper chest used for chemotherapy. A GNA and a staff nurse both recalled that this resident was admitted with an IV line/port in the right chest, confirming that IV access was present despite being coded as absent on the MDS. For another resident admitted with diabetes, COPD, obstructive and reflux uropathy, chronic kidney disease, hypertension, and dementia, a significant change MDS assessment indicated that the resident was taking a hypoglycemic (including insulin) medication during the look-back period. Physician orders showed that the resident’s Glipizide ER 5 mg daily was placed on hold due to lethargy and later discontinued due to poor oral intake and risk of hypoglycemia. The MAR for the same period showed that Glipizide ER was on hold and not administered from early to mid-month, indicating that the medication was not given during the MDS look-back period. Despite this, the MDS was coded as if the hypoglycemic medication had been administered. The MDS nurse and the Administrator both acknowledged that the MDS should accurately reflect the medical record and plan of care, but the assessments for these two residents did not do so.

Penalty

Inspection fine: $12,740

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s central venous access device (port-a-catheter). The resident was admitted with multiple complex diagnoses, including high-grade papillary urothelial carcinoma status post chemoradiation, peripheral vascular disease, chronic kidney disease stage 4, COPD, respiratory failure with hypoxia, and the presence of a cardiac pacemaker, among others. The admission MDS showed the resident was moderately impaired, and the care plan initiated shortly after admission addressed impaired cognitive function and risk for abnormal bleeding due to anticoagulant/antiplatelet use. However, review of the care plan initiated on 11/22/25 revealed no evidence that the presence of a port-a-catheter was addressed. There were no interventions for site care or dressing changes, no interventions for flushing or maintenance of the line, and no monitoring for complications such as infection, occlusion, or dislodgement, and no staff guidance regarding management of the central IV access. Multiple clinical records documented the existence of the implanted port in the right upper chest, including the hospital discharge summary, nursing progress notes, and several provider progress notes by different physicians over multiple days, all confirming the presence of a port-a-catheter or central IV line. During interviews, a GNA recalled that the resident had an IV line in the right chest upon admission but did not know what type of line it was or how it was managed. A staff nurse confirmed that the resident had IV access via a port-a-catheter and stated that care related to the IV access, including dressing management, was unclear due to the absence of a care plan. The MDS nurse acknowledged that the resident had a significant clinical condition and treatment that should have been reflected in the care plan, and the Administrator stated that the care plan should address residents’ clinical needs and guide staff in delivering care.

Penalty

Inspection fine: $12,740

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to assess, monitor, and obtain treatment orders for an accessed implanted venous port for a resident from admission through several weeks of stay. The resident was admitted with multiple serious diagnoses, including high-grade papillary urothelial carcinoma status post chemoradiation, abdominal aortic aneurysm, atherosclerotic heart disease, peripheral vascular disease, chronic kidney disease stage 4, COPD, respiratory failure with hypoxia, duodenal ulcer, gastrointestinal hemorrhage, dysphagia, obsessive compulsive disorder, major depression, and presence of a cardiac pacemaker. The admission MDS showed the resident was moderately impaired. Nursing admission notes documented a central IV line on the right chest used for chemotherapy, but review of the medical record showed no physician orders for dressing changes, flushing protocols, or site maintenance from admission through mid-December, and no evidence of ongoing assessment or monitoring of the device during that period. On a later date, a nurse documented that the implanted port was present with a Huber needle in place and that there had been no prior orders for care. Physician orders for monthly flushing with saline followed by heparin were not entered until mid-December. In interviews, a staff nurse stated that the dressing on the IV access was not changed and the port was not flushed because no physician orders had been initiated. The NP confirmed being notified weeks after admission that there were no orders for port management, and the DON acknowledged that the facility did not maintain IV access or perform dressing changes and that physician-ordered interventions were not initiated on admission. The Administrator reported that the oncology provider stated the port had not been maintained appropriately and that the lumen remained in place.

Penalty

Inspection fine: $12,740

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program for the care and maintenance of an accessed central venous device (Port-a-catheter) for one resident. The resident was admitted with high-grade papillary urothelial carcinoma status post chemoradiation, chronic kidney disease stage 4, and COPD, and had documented impaired cognitive function and moderate cognitive impairment on the MDS. Facility policy for central venous catheters required dressing changes on admission, weekly, and as needed; assessment of the insertion site; use of aseptic technique during dressing changes; routine flushing protocols; and regular needleless connector changes. Record review showed that, despite multiple provider notes documenting the presence of a Port-a-catheter on the right upper chest, there were no physician orders on admission for port dressing changes, flush protocols, or site maintenance. Staff interviews and observations further demonstrated that the accessed port was not properly maintained. A GNA reported that the resident had a dressing with an IV line to the right chest upon admission and that the dressing remained unchanged while the GNA provided showers, with no instructions given regarding IV site care or bathing precautions. A staff nurse recalled seeing the resident with a Port-a-catheter and Huber needle in place with the dressing not changed weeks after admission. The NP stated they were notified weeks after admission that the port remained accessed with no dressing changes performed. The DON confirmed that the facility did not maintain IV access or perform dressing changes and acknowledged the resident was at high risk for infection, and the Administrator reported that the oncology provider indicated the port-a-catheter was not maintained appropriately and that the lumen remained in place.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to provide adequate supervision and protective devices for residents who smoked, resulting in a deficiency. Specifically, one resident was seen in the dining room with multiple burn holes in their sweatpants and wheelchair cushion, and confirmed these burns were from smoking. This resident was not wearing a protective apron while smoking, despite their care plan and smoking assessment indicating the need for supervision and a smoking apron. Additionally, two residents were observed outside in the designated smoking area unsupervised, with one actively smoking without a protective device and the other holding cigarettes and a lighter without an apron or supervision. Interviews with staff revealed a misunderstanding or lack of adherence to facility policy, as the Activities Director stated that only dependent residents required supervision, contrary to the care plans and assessments for the residents involved. Record reviews confirmed that several residents required supervision and/or protective devices while smoking, but these measures were not consistently implemented. The Director of Nursing confirmed that all smoking residents were expected to be supervised and to use protective devices as required by their care plans and assessments.

Removal Plan

• Educate staff on safety for residents that smoke, supervision, and protective devices.
• Replace burnt clothing, wheelchair equipment, and perform skin assessments for residents who were not provided with protective devices while smoking.
• Review all smoking assessments to determine the safety needs of each smoker and revise as needed.
• Create a list for staff to identify all residents that require supervision and/or a protective device.
• Create a schedule that assigns staff to supervise the smokers during designated smoking times.
• Audit smoking breaks to evaluate whether supervision is being provided as required and whether aprons are being provided as required.
• Address negative findings immediately.
• Report results of audits to the Quality Assurance/Performance Improvement Committee and consider for further action if needed.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During the initial tour of the kitchen, surveyors observed several instances where food items were not stored or prepared in accordance with professional standards and the facility's own food storage policy. Specifically, a clear bag of corn, a clear bag of garlic bread, and a clear bag of Salisbury steak were found opened and undated in the walk-in freezer. Additionally, the corn and garlic bread were stored inside a box labeled for a different food item (broccoli florets). The Certified Dietary Manager (CDM) confirmed that the facility's policy requires opened packages to be securely closed and labeled with the date they were opened, which was not followed in these cases. Further inspection of the food preparation area revealed multiple containers of dried herbs and seasonings that were opened and undated, including bottles of rubbed sage, black pepper, and garlic powder. Notably, the garlic powder bottle contained a red-colored powder, the contents of which the CDM could not identify. The CDM acknowledged that these items were not properly labeled and dated as required by facility policy.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to follow nursing standards of practice regarding the handling and security of controlled medications. During a review of a facility-reported incident, it was found that the backs of several narcotic blister cards for four residents were taped for unknown reasons, with a total of 17 spots on four cards showing clear tape. Nursing staff who conducted the narcotic count noticed the taped blister cards but did not report this irregularity to facility management as required by policy. The facility's policy and the Maryland Nurse Practice Act both require immediate reporting of any suspicion or evidence of tampering or substitution of controlled drug packaging. Additionally, during a shift change narcotic count, a discrepancy was observed between the number of Oxycodone tablets recorded on the controlled drug count sheet and the actual number present in the blister card for one resident. The count sheet indicated 29 tablets, but only 28 were present. The nurse on the outgoing shift stated that he had administered a tablet and documented it on the Medication Administration Record (MAR), but failed to document the administration on the controlled narcotic count sheet at the time of administration. The nurse then documented the administration on the count sheet in the presence of the surveyor and the incoming nurse. Interviews with nursing staff and review of facility policy confirmed that the expectation is for all narcotic administrations to be documented both on the MAR and the controlled narcotic count sheet at the time the medication is removed from the narcotic drawer. The failure to report suspected tampering and to properly document controlled drug administration and counts led to the deficiency cited in the report.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct routine care plan meetings for several residents, as required by CMS regulations. Multiple residents reported not being invited to or involved in care plan meetings, and record reviews confirmed the absence of documentation for these meetings. Specifically, residents had not received quarterly care plan meetings, and in some cases, had not had a care plan meeting since admission or for extended periods exceeding several months. Interviews with staff, including the Director of Nursing and social work personnel, confirmed that care plan meetings were not being held as scheduled, often due to staffing turnover and absences. For example, one resident had not had a care plan meeting since June of the previous year, and another had not received one since admission in October. Family members of residents also reported not being invited to care plan meetings, despite being designated as Power of Attorney and expressing concerns about the resident's care. Record reviews for additional residents revealed that care plan meetings were not held within the required timeframe following quarterly or annual MDS assessments, with the most recent meetings documented many months prior. Staff interviews further corroborated the deficiency, with admissions that care plan meetings were not up to date and that documentation was lacking. The facility's social work leadership acknowledged that care plan meetings typically follow the MDS schedule but had not occurred in a timely manner due to staffing issues. The absence of care plan meetings and documentation was confirmed for multiple residents, indicating a systemic failure to comply with regulatory requirements for care planning.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a medication error rate below 5%, as required, with surveyors observing 13 medication errors out of 28 opportunities, resulting in a 46.42% error rate. Errors were identified during medication administration to three residents, involving both oral and enteral routes. One LPN administered MiraLax without measuring the required amount of water, using only 120 mL (approximately 4 ounces) instead of the instructed 6-8 ounces. The same LPN also failed to assess a resident for pain before administering Tylenol and did not follow the correct procedure for mixing and administering Modular Protein, using less water than directed. Additional errors included administering the wrong dose of ascorbic acid (500 mg instead of the ordered 250 mg) and cholecalciferol (2000 units instead of 1000 units), as well as using medications prescribed for one resident to medicate another. There were also failures to clarify orders, such as administering magnesium oxide via an NG tube to a resident who did not have one, and not clarifying conflicting orders for tube flushes. The LPN also failed to administer a prescribed nebulization treatment, did not attempt to offer it to the resident, and did not follow the correct timing for administering Latanoprost eye drops, which were given in the morning instead of at bedtime. Surveyors observed improper medication administration techniques, such as crushing all medications together instead of one at a time, not following the facility's policy for water flushes between medications, and failing to administer MiraLax as ordered. The LPN also disposed of a significant portion of Peridex mouthwash instead of administering the full dose. These actions and inactions directly contributed to the high medication error rate and demonstrated non-compliance with both physician orders and facility policies.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to ensure that medical records were complete and accurate for five residents, as evidenced by multiple deficiencies observed during the recertification survey. During a review of a facility-reported incident, it was found that the backs of several narcotic blister cards for three residents were taped for unknown reasons, with a total of 17 spots on four cards showing clear tape. The facility's policy requires that any tampering or irregularities with narcotic packaging, such as taping, be reported immediately to the Director of Nursing, but nursing staff did not report these taped blister cards as required. Additionally, during a narcotic shift count, a discrepancy was observed between the number of Oxycodone tablets recorded on a controlled drug count sheet and the actual number present in a blister card for another resident. The nurse on the previous shift had administered a tablet and documented it on the Medication Administration Record (MAR) but failed to record it on the controlled narcotic count sheet at the time of administration, only doing so after being prompted during the count. This failure to document narcotic administration in real time is contrary to facility expectations and policy. A further deficiency was identified in the management of PASRR documentation for a resident who had a positive Level I screen for serious mental illness and was referred for a Level II evaluation. The required PASRR Level II documentation was not found in the resident's medical record, and facility staff were unable to produce it despite attempts to locate or obtain it from the agency responsible for the evaluation. This lack of follow-up and incomplete recordkeeping resulted in the absence of critical documentation in the resident's file.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent further abuse, neglect, exploitation, and mistreatment from occurring while an investigation into an alleged abuse incident was in progress. A resident with moderate cognitive impairment (BIMS score of 12/15) reported that after falling on the floor, an LPN and two GNAs picked the resident up and threw them back onto the floor. The resident identified the staff involved and repeated the allegation during interviews with both facility staff and local law enforcement. Despite the serious nature of the allegation, the facility did not remove the alleged perpetrators from the work schedule during the investigation, and there was no evidence that abuse in-service training was conducted after the incident. The LPN confirmed that they continued to work with the resident following the reported event. The DON acknowledged that the expectation was for staff accused of abuse to be suspended pending investigation, but this did not occur, as confirmed by staff schedules and interviews.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a Licensed Practical Nurse (LPN) administered medication to a resident without closing the entry door to the resident's room. The resident's bed was located near the entry door, and the lack of privacy during medication administration was observed by surveyors. The LPN confirmed that the door was not closed during the process, and acknowledged that the facility's expectation is to provide dignity and privacy during care. The Director of Nursing also confirmed that staff are expected to maintain resident dignity, which includes closing the entry door while providing care.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors determined that the facility failed to ensure a resident had access to the facility's communication system, specifically the call bell. During multiple observations, the resident's call bell was found on the floor behind the head of the bed, out of the resident's reach. The resident reported to surveyors that the call bell was always out of reach and that they typically had to yell for help when assistance was needed. This was confirmed during an interview and direct observation with an LPN, who found the call bell on the floor and placed it on the resident's bed. A review of the resident's Minimum Data Set (MDS) assessment revealed that the resident had lower extremity impairment on both sides and required substantial to maximum assistance, indicating a high level of dependency. Despite these needs, subsequent random observations continued to find the call bell on the floor and inaccessible to the resident, demonstrating a repeated failure to accommodate the resident's needs and preferences for communication and assistance.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was offered information regarding Advance Directives. During a review of the electronic medical record and paper chart for one resident, there was no evidence of an Advance Directive on file or documentation that information about Advance Directives had been provided to the resident. This review was conducted on two separate occasions, and both times, the required documentation was absent. An interview with a social worker revealed that the facility's process requires staff to attempt to obtain an Advance Directive within seven days of admission and, if the resident does not have one, to offer information and document this in the chart. The social worker confirmed that this process had not been completed consistently and verified that there was no documentation for the resident in question indicating that Advance Directive information had been offered.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide required Medicare beneficiary notices to a resident who remained in the facility after Medicare Part A benefits ended, despite the resident having benefit days remaining. Record review showed that the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) were not provided or documented for this resident. The SNF ABN is intended to notify residents that their services may no longer be covered by Medicare, while the NOMNC informs them of their right to appeal the decision and request an expedited review. Interviews with the Business Office Manager (BOM) and review of facility forms confirmed that the required notifications were not completed or could not be located for the resident in question. The BOM acknowledged the absence of documentation and was unable to find evidence that the resident had been informed about the end of Medicare A coverage. The deficiency was identified through review of both the resident's medical record and the facility's internal notification review forms.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple deficiencies observed in resident rooms. One resident was found with two non-functioning televisions, one of which was left on top of a portable closet, and the hot water to the sink was not working due to a previously broken pipe. The resident also had a protruding electrical socket behind the bed and dislodged ceiling tiles in the bathroom, all of which contributed to an unsafe and uncomfortable living space. The resident reported that staff were aware of the broken television and hot water issue, but these problems persisted. Another resident's portable closet was found collapsing, with the top shelf detached and the side wall pushed outward, creating a risk of further damage or injury. Additionally, a third resident, who was dependent and required substantial assistance due to lower extremity impairment, had more than 20 pieces of candy and a container on the floor next to the bed for several days. The resident was unable to pick up the items due to their medical condition and had previously notified an LPN, who acknowledged awareness but did not remove the items promptly. These findings demonstrate a lack of timely response to environmental hazards and maintenance needs, directly impacting residents' safety and comfort.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive care plans for two residents, specifically regarding a resident's refusal to use a palm protector and another resident's use of an anticoagulant. For the first resident, observations revealed a left hand contracture with long fingernails pressing into the palm, and no palm protector in use despite an active physician order. Nursing staff confirmed the resident had a history of refusing both nail care and the palm protector, but there was no documentation or care plan update addressing these refusals. The care plan only included the use of the palm protector and monitoring for skin breakdown, without any mention of the resident's non-compliance or alternative interventions. For the second resident, records showed ongoing use of an anticoagulant medication, but there was no care plan developed to address this therapy. Interviews with nursing staff and the DON confirmed that care plans should be updated with changes in condition or medication, but acknowledged that the care plan for anticoagulant use was missing. The deficiency was identified through observation, record review, and staff interviews, with facility leadership being made aware of the lack of appropriate care planning.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with paraplegia, seizures, adult failure to thrive, and major depressive disorder was observed to have long, thickened, and curled toenails on both feet while lying in bed. The resident's clinical record included a physician order for a podiatry consult as needed, but there was no evidence that podiatry services had been provided to address the overgrown toenails. Staff confirmed the resident's condition and described the process for arranging podiatry care, which involves faxing orders to the service provider and scheduling appointments as needed. However, at the time of the survey, the resident had not yet received podiatry care for the observed condition.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident reported ongoing vision concerns, including seeing black spots and experiencing headaches, to nursing staff and the primary attending physician. Despite these complaints, documentation showed that the resident had not received an ophthalmology appointment after reporting these symptoms. The resident had previously requested to see an ophthalmologist and was aware that such services were available in the facility, but did not receive the needed evaluation. Record review revealed that the resident had been placed on a 'Do Not Treat' (DNT) list for optometry services due to a requirement for new consent, and this status persisted across multiple months. Staff interviews confirmed that the resident's need for vision services was known, and that the DNT status was not addressed to facilitate the necessary appointment. The Director of Nursing acknowledged that the expectation was for residents to receive eye exams when requested, but this did not occur for the resident in question.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with a left hand contracture and limited range of motion was not provided with the prescribed palm protector device, as ordered by the physician. Observations on multiple occasions revealed that the resident's left hand was clenched, with long fingernails pressing into the palm, and no palm protector was in use. The resident's medical record included an active order for a left palm protector to be worn daily after ADL care and removed at bedtime. However, during the survey, the resident was repeatedly observed without the device, and staff were unable to locate it when asked. Nursing staff interviews indicated that the palm protector was documented as applied daily on the Treatment Administration Record, except for one date, but direct observation and the resident's own statement contradicted this documentation. Staff also reported that the resident had a history of refusing nail care and the palm protector, but there was no evidence of consistent application or appropriate documentation of refusals. The deficiency was brought to the attention of facility leadership after these findings.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain respiratory therapy equipment according to professional standards of practice for a resident receiving nebulizer treatments with Ipratropium-Albuterol for wheezing. During multiple observations, the resident's nebulizer face mask and tubing were found stored in a clear plastic zip lock bag on the bedside table without any labeling to indicate when the equipment was put into use or when it should be replaced. Clinical record review confirmed ongoing physician orders for nebulizer treatments every six hours. Staff interviews revealed inconsistent understanding of the facility's policy, with one LPN stating the equipment should be changed and labeled daily, while the Director of Nursing stated the expectation was every seven days. The lack of labeling and clear adherence to equipment change protocols led to the deficiency.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that pain medication was administered according to professional standards of practice for a resident requiring pain management. Specifically, a physician order directed that Oxycodone HCl 15 mg (2 tablets) be given orally every 6 hours as needed for pain levels rated 5-10, with instructions to hold the medication if the resident was sedated. However, review of the Medication Administration Record (MAR) showed that staff administered the medication on multiple occasions when the resident reported a pain level of 3, which was below the threshold specified in the physician's order. Interviews with nursing staff revealed that nurses followed a standard 0-10 pain scale, asking residents to rate their pain and documenting this prior to administering PRN pain medications. Despite this, the medication was given outside the prescribed parameters. The Director of Nursing, Executive Director, and Nursing Home Administrator were subsequently made aware of the issue.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct annual performance reviews for two geriatric nursing assistants within the required 12-month period. Personnel file reviews showed that one staff member's review was due in May 2024 and another's in August 2024, but neither review was completed for the calendar year 2024. This deficiency was confirmed through documentation provided by the Executive Director and acknowledged by the Director of Nursing. The lack of timely performance reviews prevented the identification of in-service education needs and assessment of competencies for these staff members.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to respond in a timely manner to a recommendation made by the consulting pharmacist regarding a resident's medication regimen. Specifically, a resident was receiving Dicyclomine HCl 20 mg every 8 hours for abdominal cramping, and the consulting pharmacist noted in the November 2024 Medication Regimen Review (MRR) that long-term use of this medication is not indicated unless the patient has a diagnosis of Inflammatory Bowel Disease. The pharmacist recommended reviewing the use of Dicyclomine and adding a potential stop date if possible. Upon review, the surveyor was unable to locate the MRR in the resident's electronic or paper medical record. Interviews with staff revealed that pharmacy recommendations were typically faxed to the DON, who then forwarded them to the attending physician for review and action, with nurses filing the MRR in the paper chart. However, it was confirmed that the November 2024 pharmacy recommendation for this resident was not addressed, resulting in a failure to follow up on the pharmacist's recommendation as required by facility policy.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that medications and biologicals were not consistently stored in accordance with professional standards. In one instance, a resident reported that a nurse left medications on the nightstand for the resident to take after breakfast, rather than returning them to the locked medication cart when the resident initially declined to take them. Observations confirmed that a medication cup with multiple medications was left unsecured in the resident's room. The LPN acknowledged that facility protocol required medications to be returned to the locked cart if not immediately administered. In another case, surveyors observed multiple loose tablets scattered on and under a resident's bed, as well as a medication cup with several medications left on a tray table. The LPN admitted to leaving the medications at the bedside after the resident declined them, instead of securing them as required. Additionally, a separate observation found an LPN leaving a bottle of Anbesol and a tablet of digoxin unattended on top of the medication cart while entering a resident's room. The LPN later confirmed that medications should not be left unsecured. These actions resulted in medications being left unattended and not properly secured as per facility policy.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident reported not having received a dental cleaning in three years, despite having requested a dental appointment. The resident's medical record showed a physician's order for dental and other specialty consults as needed, but there was no evidence that a dental appointment had been scheduled or provided. Interviews with staff revealed that the resident was listed as 'Do Not Treat' (DNT) for dental services by the contracted provider, HealthDrive, due to a need for new consent and a payer source. This DNT status had been in place for several years, as confirmed by multiple HealthDrive lists reviewed by the surveyor. Further interviews with nursing staff and the DON confirmed that the facility was aware of the DNT status and the reasons for it, which included insurance issues and the need for updated consent. The DON stated that the facility's expectation was to provide routine dental services every six months and to cover costs if insurance was unavailable. However, the DNT status for this resident was not resolved, and the resident did not receive routine dental care as required, resulting in a failure to provide necessary dental services.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper infection prevention and control practices in both the resident care and laundry departments. In one instance, a resident who required tube feeding was observed with a visibly dirty feeding pole at the bedside, with dark brown spots along its base and shaft. Staff acknowledged the unclean condition and indicated that both housekeeping and nursing staff were responsible for cleaning the pole, but there was no awareness of a specific cleaning schedule. The surveyor requested documentation of cleaning logs, but these were not provided by the time of survey exit. Additionally, the laundry department was found to have practices that allowed for potential cross-contamination between clean and soiled linens. Clean linen was folded and stored on tables and in cubicles located directly next to the stairway door, which served as both the entry point for soiled linen and the exit for clean linen. Staff interviews confirmed that this process resulted in clean and dirty linens being handled in close proximity, with no separation between the two, and that this was the established practice within the facility.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During the annual recertification survey, surveyors observed that the laundry department in the basement had four ceiling tiles that were grossly soiled with large brown stains, chipped, and missing. The laundry aide present during the tour confirmed the condition of the tiles. When interviewed, the Environmental Services (EVS) Director stated that the Maintenance Department was responsible for replacing the ceiling tiles and explained that the soiling was due to rain from outside. The Maintenance Assistant acknowledged the need for replacement of the tiles. The Maintenance Department is located adjacent to the laundry department. The Nursing Home Administrator was notified of the condition of the ceiling tiles in the laundry department.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective pest control program, as evidenced by multiple direct observations of roaches in and around the kitchen area during the annual survey. On several occasions, surveyors, along with the Administrator, Certified Dietary Manager (CDM), and District Manager (DM), observed live and dead roaches in the hallway outside the kitchen, under the steam table during meal preparation, and in the dietary office. Both the CDM and DM initially stated they had not seen roaches in the kitchen area prior to these observations. The pest control activity log confirmed that the sightings were documented and reported by staff on the same day they occurred.

Penalty

Inspection fine: $48,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During an annual survey, an observation was made of the facility's outdoor refuse area, where debris was found scattered around the dumpster. The debris included several pairs of used medical gloves and clear plastic bags on the ground, rather than being properly contained within the dumpster. In an interview, the District Manager confirmed that the facility's expectation is for all trash to be disposed of inside the dumpster and acknowledged that the scattered debris and trash would be disposed of immediately.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean, safe, comfortable, and homelike environment, as observed by surveyors during rounds. On the 2nd floor, a room was found with missing ceramic wall tiles, a hole in the wallboard, cracked floor tiles, and a shared bathroom with a broken shower head bracket and crumbling walls. The ceiling panels were not securely fitted, and a toilet plunger was left uncovered on the floor. Similar issues were noted in the hallway, with shoe molding pulled away from the wall, exposing gaps and scrapes on the walls. On the 1st floor, the surveyor observed splintered handrails, missing shoe molding, and exposed wall plaster. Several outlets had loose plates, and there were holes and scrapes in the walls. In one room, the bedside table was dirty, and there was a foul smell. The windowsill was cluttered and dirty, with bugs and cobwebs present. Mouse droppings were observed on the floor, and the bathroom tiles were disintegrating. The kitchen also had issues, including a door that did not fully close, peeling paint, and cobwebs in the dry storage room. Interviews with staff revealed a lack of awareness and action regarding these deficiencies. A maintenance technician indicated that there had been no maintenance director for several weeks, and the Culinary Director was unaware of a large hole in the kitchen wall. During a walkthrough with the Administrator and staff, they were shown the concerns, but issues such as non-functioning water in a sink persisted. These observations highlight the facility's failure to provide a safe and clean environment for its residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately and appropriately identify a resident's health status and representative to change the resident's code status. This deficiency was identified during a complaint survey involving a resident with chronic obstructive pulmonary disease and rheumatoid arthritis. The resident was initially admitted with a Maryland Orders for Life Sustaining Treatment (MOLST) form indicating full code status, as per the health care agent named in their advance directive. However, the MOLST was later changed to 'do not intubate' and subsequently to 'do not resuscitate' by a surrogate decision maker, identified as the resident's child, without proper documentation or authority. The medical record lacked any advanced directive documentation or certifications of medical ineffectiveness that would authorize a surrogate decision maker to alter the MOLST. The attending physician admitted to changing the MOLST without full awareness of the relevant policies, procedures, and legal requirements regarding who has the authority to make such changes. This oversight was discussed with the facility's nursing home administrator and regional nurse, highlighting the concern that the surrogate decision maker did not have the proper authority to change the resident's MOLST.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from physical abuse by staff members. In the first incident, a resident complained of painful activities of daily living (ADL) care due to an improper transfer by a Geriatric Nursing Assistant (GNA). The GNA did not use a gait belt, an assistive device necessary for safe transfers, which resulted in the resident experiencing neck pain. The facility's investigation confirmed that the GNA did not follow proper procedures, opting to complete the task quickly instead. In the second incident, a resident in a motorized wheelchair accidentally backed over an agency GNA's feet, pinning the GNA to the wall. In response, the agency GNA physically hit the resident. This event was witnessed by an RN Supervisor and reported by the resident to an LPN. The facility's investigation confirmed the physical abuse by the agency GNA.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility staff failed to implement measures and reasonable care to prevent the loss or theft of a resident's belongings, specifically for one resident. A complaint was made regarding the disappearance of three bags of clothing belonging to the resident. The complainant reported seeing a nurse taking bags of clothing to her car, and although two bags were retrieved by the administrative staff, the third bag was not returned, and reimbursement had not been received. The facility's policy required an inventory of personal items to be completed and updated, but the inventory for this resident had not been updated since admission, and there was no evidence of the missing items being recorded. Interviews with staff revealed inconsistencies in the process of labeling and inventorying residents' belongings. The laundry staff indicated that they label clothing based on the name on the laundry bag, while the laundry supervisor stated that nursing staff were responsible for inventorying belongings. The facility's policy required an inventory sheet to be completed at admission and updated with any changes, but the inventory for the resident in question was outdated and incomplete. The facility failed to ensure that staff consistently followed procedures to prevent the loss or theft of resident belongings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility staff failed to report an allegation of misappropriation of a resident's belongings to the State Agency. A complaint was reviewed regarding a resident whose clothing was reported missing. The complainant discovered that three bags of the resident's clothing were missing and reported it to a staff member at the front desk, who mentioned observing a nurse taking bags of clothing to her car. The administrative staff retrieved two of the three bags and promised reimbursement for the third. However, the complainant never received further communication from the facility, and the incident was reported to the police by the complainant. The Director of Nursing confirmed the lack of evidence that the facility reported the incident to the state agency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility staff failed to conduct thorough investigations following reports of abuse and misappropriation of resident property, affecting three residents. In the first case, a resident reported being hit by an agency GNA, but the facility did not interview other residents on the unit to determine if they also experienced abuse or felt unsafe. The Director of Nursing confirmed this oversight during an interview. In the second case, a complaint was made regarding missing clothing belonging to a resident. Although some of the clothing was retrieved, the facility did not conduct a formal investigation into the incident, and the complainant did not receive further communication from the administration. In the third case, a resident's roommate reported witnessing another resident stealing money, but the facility's investigation lacked interviews or written statements from involved parties, leading to an inconclusive result. The Regional Nurse confirmed the absence of additional investigation documentation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility nursing staff failed to adhere to professional standards of practice by not reporting a resident's injury to a provider. Specifically, a Licensed Practical Nurse (LPN) did not report the formation of a bruise on a resident's left knee to their supervisor or administration. This incident was discovered when a Nurse Practitioner (NP) assessed the resident and found the bruise. The facility conducted an investigation and confirmed that the LPN was aware of the bruise earlier in the day but did not report it, leading to a deficiency finding during a complaint survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate care to a resident who was dependent on staff for activities of daily living (ADL). The resident, diagnosed with cellulitis and lymphedema in the bilateral lower extremities, was bed-bound and required extensive assistance from two people for toileting. The complaint highlighted a lack of care during specific weekends in March 2022, where there was no documentation of bowel or bladder movements for the resident on several days. Despite improvements in care, the resident reiterated concerns about the lack of care and treatment during the reported period. The quarterly minimum data set completed in January 2022 confirmed the resident's frequent incontinence and need for extensive assistance, yet the necessary ADL care was not documented or provided during the specified times.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility staff failed to provide appropriate foot care for a resident, identified as Resident #34, who was admitted with diagnoses including Diabetes Mellitus and Dementia. During the resident's seven-month stay, there was a physician's order for a podiatry consult, which was part of the care plan addressing the resident's diabetes. The care plan included interventions such as podiatry consults and monitoring of skin integrity and foot care. However, a review of the medical records revealed no documentation that the resident was seen by a podiatrist, as required by the physician's order and the care plan. Interviews with facility staff, including the DON and an LPN, indicated that diabetic residents were supposed to receive foot care from a podiatrist, and new admissions were automatically placed on a list for podiatry visits. Despite this process, the Regional Nurse confirmed the absence of evidence that the resident received the necessary podiatry care. The facility's policy stated that diabetic residents should be treated by licensed professionals, yet this was not adhered to in the case of Resident #34, leading to the deficiency noted in the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to have a discharge summary on the medical record for a resident who was reviewed during a complaint survey. The deficiency was identified when the medical record for a resident was reviewed in response to a complaint related to timely discharge. It was found that there was no physician discharge summary on the chart, despite a request for it. A discharge summary was later provided to the survey team, dated the same day it was requested, and inaccurately stated that the resident was seen 'TODAY' in their room. However, records indicated that the resident had left the facility against medical advice nearly two years prior and had not returned. The attending physician admitted to completing the discharge summary without seeing the resident and acknowledged a need to become familiar with regulations regarding the timeliness of discharge notes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a functioning call system was available in each resident's bathroom and bathing area, as observed during a tour. In one instance, the call bell activation box in a shared bathroom was mounted approximately 6 feet above the floor, with a short red cord ending about 5 feet above the floor, making it inaccessible to residents sitting or lying on the shower floor or seated on a shower chair. In another bathroom, the call bell activation switches were located on the walls to the left and right of the toilet. The switch on the left was in the off position with no pull cord, preventing activation by a resident lying on the floor. The switch on the right was in the activated position, but the indicator light in the hallway was not lit, and there was no audible sound at the nurse's station. Further observations confirmed that the call bell switches remained in the same positions, and issues persisted with the indicator lights and audible tones. During a follow-up observation, the left switch illuminated a red indicator light and produced an audible tone in the hallway when flipped down, but the hallway ceiling light failed to illuminate. The right switch failed to activate any indicator light or tone when toggled. These deficiencies were confirmed by the Maintenance Director, a maintenance assistant, and the Administrator during walking rounds.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective pest control program, as evidenced by the presence of mouse droppings and cockroach activity observed by the survey team on the 1st and 2nd floors. The pest activity was noted in resident rooms over several days, and the facility's pest control records revealed a history of ongoing pest issues that were not adequately addressed. The Maintenance Director confirmed that a pest control company visited the facility every three months, but the facility did not follow the company's recommendations, leading to continuous pest activity. During a tour of the facility, live roaches were observed in a resident's room, where the resident was eating snacks with crumbs scattered around. The room was cluttered, with open dresser drawers and items in disarray, potentially contributing to the pest problem. The facility's pest control documentation system, TELS, indicated that the roach problem had been documented since February 2024, with repeated concerns in various areas, including the kitchen and nursing stations. In the kitchen, structural issues such as unsecured ceiling tiles and a hole in the wall were identified, which could attract pests. The Culinary Director was unaware of these issues and had not reported them in the maintenance system. Pest control logs showed previous sightings of roaches in the kitchen, but the Culinary Director did not provide recent updates. The facility's failure to address these environmental concerns and follow pest control recommendations resulted in ongoing pest issues, potentially affecting all residents.