Orchard Hill Rehabilitation And Healthcare Center

Review of Resident #11's medical record revealed Resident #11 had a history that included dementia, failure to thrive, and multiple contractures. On 7/15/25 on the 3:00 PM to 11:00 PM shift, Resident #11 complained about right foot pain. Resident #11 was also observed with right foot swelling.

The physician was notified and ordered for the right leg to be elevated on a pillow.

On 7/16/25 the physician ordered an x-ray and doppler study. On 7/16/2025 at 11:12 PM, Resident #11's X-ray result of the right hip showed that there was a displaced fracture laterally.

The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in

• The MDS is a set of assessment screening items employed as part of a standardized,

reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.

Review of Resident #11's MDS assessment with an assessment reference date of 7/16/25, Section GG, mobility, documented that Resident #11 was dependent on staff for all mobility.

Review of the facility's investigation into the injury of unknown origin documented that the initial report was not sent to OHCQ until 7/18/25 at 6:25 PM. On 10/16/25 at 9:46 AM an interview was conducted with the Director of Nursing (DON).

The DON confirmed the finding and stated that Staff #14 was written up by the prior DON for failing to notify administration timely.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

Review of Resident #11's medical record revealed a 7/16/25 physician's order for an x-ray and doppler study. On 7/16/2025 at 11:12 PM, Resident #11's X-ray result of the right hip documented there was a displaced fracture laterally. Resident #11 was sent to the emergency room for further evaluation.

Review of Resident #11's July 2025 Medication Administration Record (MAR) documented the resident received Tramadol 50 mg. for pain management on 7/13/25 at 18:31 for a pain level of 6 and on 7/10/25 at 13:50 for a pain level of 7.

Review of Resident #11's MDS with an assessment reference date of 7/16/25 failed to capture the fracture in Section I diagnoses and failed to capture the use of Tramadol, which is an opioid medication, in Section N, medications. On 10/16/25 at 2:00 PM an interview was conducted with the Regional Director of Case Management, Staff #16 who stated the facility was currently without an MDS coordinator, however they just hired 2 people that were coming on board.

Reviewed with Staff #16 that the fracture was not captured on the 7/16/25 MDS, Section I and the opioid was not captured in Section N. On 10/16/25 at 2:55 PM, Staff #16 confirmed the errors.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

During interview with Resident #3's representative (RP) on 10/14/25 at 9:06 AM, the RP stated he/she was never given a baseline care plan or had a meeting with the facility staff to discuss admission to the facility within the first 48 hours of admission.

Review of Resident #3's medical record on 10/14/25 revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation services.

Further review of Resident #3's medical record revealed there was no evidence in the medical record of a baseline care plan that was reviewed and given to the Resident's RP.

The medical record review failed to reveal evidence that the facility offered the Resident's representative a summary of the baseline care plan that included initial goals, physician orders, therapy services, dietary services, and social services within 48 hours of the resident's admission to the facility.

Interview with the Director of Nursing on 10/16/25 at 9:40 AM stated the process is on for baseline care plans is on admission the facility staff assess the Resident and generate a baseline care plan and social work staff review with the Resident in a navigation meeting within the first 48 hours of admission.

The DON was asked if the baseline care plan is reviewed with the Resident's representative also.

The DON stated it is reviewed with the Resident if they are their own RP and with the RP if they are not.

Interview with the Director of Nursing on 10/16/25 at 11:20 AM confirmed the facility staff failed to review the baseline care plans with the Resident's RP on 5/2/25.

During interview with Resident #3 on 10/16/25 at 11:28 AM, the Resident stated he/she would have wanted his/her RP involved in the navigation meeting on 5/2/25 to review his/her baseline care plans.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

Review of Resident #5's medical record on 10/14/25 revealed the Resident was admitted to the facility in September 2024 with a diagnosis to include end stage renal disease and dependence on renal dialysis.

The facility staff assessed the Resident on 7/13/25 to have a BIMS (Brief Interview for Mental Status) of 15 out of 15 indicating the Resident's cognition is intact.Review of facility documentation on 10/15/25 revealed a written statement from Staff #22 on 8/7/25 that stated: 8/5/25 1st day without a preceptor as night shift supervisor.

Had a nurse call out and I had to be on cart.

Was not trained on the cart. I never thought about passing meds and it was too late it would have been too close because next doses were going to be due. A statement from Staff #23 on 8/5/25 stated: During med pass it was observed prior Nurse (Staff #22) has signed off on multiple medications as being pass for Resident #5.

Upon investigation Resident #5 stated to not have been medicated during the overnight shift.Review of Resident #5's August 2025 Medication Administration Record revealed Staff #22 signed off she administered the following medications on 8/5/25: Dasatinib 50 mg, Duloxetine 60 mg, Fenofibrate 145 mg, Ferrous Sulfate 325 mg, Folic Acid 1 mg, Pantoprazole 40 mg, [NAME]-Vite 1 tablet, Apixaban 2.5 mg and Midodrine 5 mg.Review of an Employee Performance Improvement Notification for Staff #22 on 8/18/25 revealed it stated it was a written notice for Omission of medications signed in medical record.

Interview with Director of Nursing on 10/16/25 at 9:40 AM confirmed Staff #22 signed off he/she administered medications on 8/5/25 to Resident #5 that were not administered.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

Saturday 9/13/25.

reviewed the shower logs with the surveyor and confirmed the findings.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

GG, mobility, documented that Resident #11 was dependent on staff for all mobility.

swelling and the physician's order to elevate the leg on 7/15/25 at 21:56 until a change in condition

of the swelling.

There was no specific pain assessment of the leg/ankle region.

There was documentation on the July 2025 Treatment Administration Record (TAR) that pain was assessed every shift, but nothing about the status of the resident related to the swelling, and the conversation with the physician when the physician ordered the x-ray.

On 10/16/25 at 9:46 AM the Director of Nursing was interviewed, and she confirmed the surveyor's findings that there was no other documentation or assessment of the resident.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

treatment/services to prevent/heal pressures ulcers.

This was evident for 1 (#12) of 3 residents

known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue.

Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). On 10/14/25 at 9:30 AM a review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE] from an acute care facility with diagnoses that included bilateral lower extremity wounds with lymphedema, systemic lupus erythematosus, chronic kidney disease, stage 4 (severe), and acute embolism and thrombosis of deep veins of lower extremity. A 7/26/26 at 0:58 AM admission summary note documented that Resident #12 was admitted from the hospital after being admitted to the hospital for, foul smelling wounds.

The note documented that Resident #12 was bed bound, had lymphedema, and right thigh chronic wounds.

The note also documented that the resident had a pressure wound at sacrum and right outer thigh.

Lymphedema is a chronic condition that causes swelling the body's tissues due to a buildup of lymph fluid.On 7/28/25 a physician's history and physical note documented that Resident #12 had an infected sacral wound while in the hospital and received IV (intravenous) medication to treat the wound.

The note documented a right ischial wound, chronic lymphedema complicated by lower extremity cellulitis and worsening discharge from the wound with foul-smelling discharge.

The plan was to continue with local wound care for the decubitus ulcer which was a Stage III.Review of a 7/30/25 skin/wound note documented, resident has a stage 2 pressure ulcer located on the sacrum.

Resident has a stage 3 pressure ulcer located on the right thigh.An 8/1/25 progress note documented Resident #12, was seen by wound therapy on July 30th, 2025.

Patient was found to have multiple wounds.

Wound #1 is a right thigh wound, measurements 7.5 x 2.0 x 5.0 centimeters.

Stage 3.

Second wound is a sacral wound, measurement 2.2 x 0.6 x zero centimeters.

Wounds Stage 2.The next wound assessment found in Resident #12's medical record was dated 9/5/25.

The nurses signed off that weekly skin assessments were done, but there were no weekly skin assessments that had measurements, the characteristics of the wound, and if the treatment was working and if the wounds were improving or not improving.Further review of the medical record revealed an August 2025 Treatment Administration Record (TAR) for Resident #12 with an order, Cleanse stage 3 pressure ulcer located on the right thigh with wet to dry kerlix packing, cover with foam dressing daily.

This order was for one time a day for wound care with a start date of 8/1/25 to 9/4/25.

The TAR was blank on 8/9/25, 8/19/25, and 8/26/25. It was unknown if the treatment to the wounds was performed.On 10/14/25 at 11:00 AM an interview was conducted with the Director of Nursing (DON) who stated, the wound nurse does the wounds every day and Fridays are her documentation dates to make current.

The DON stated, we have had 3 wound nurses from March until current.

Documentation has been an area we have been working on for some time and with 3 different wound teams from the outside, it has been a challenge, so we have had some turnover.On 10/14/25 at 11:50 AM the DON brought her computer in with the surveyor, and she could not find wound assessments or measurements for August 2025 for Resident #12.

The DON gave the surveyor a 7/30/25 skin evaluation but there was no documentation provided for the entire month of August of wound measurements and evaluations.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

with wound care, even when we are short staffed.

Unit managers do not help, they only nitpick.

We are supposed to clock out at 3 PM and sometimes I don't get out until 5 PM.

Today I had 14

On 10/17/25 at 9:55 AM Staff #33 was interviewed and said, yes, we are short staffed.

Showers can't get done and they are late on water pass.

Therapy and dialysis patients take priority.

Trays come up and trays are on the floor but can't get passed.

On 10/17/25 at 9:57 AM Staff #34 was interviewed and said, we are short staffed and can't get showers done.

Nail care isn't getting done and some days beds are not made. We do not turn and reposition every 2 hours.

The residents do lay wet, unfortunately. We have expressed concerns at town halls.

The first day I oriented someone, and we had 18 patients.

After that the new orientee did not come back because it is too much. 4) Review of facility documentation revealed: a) Staffing sheets were reviewed from 7/25/25 to 7/30/25 that confirmed the staff findings of GNA to patient ratios. On 7/25/25 on day and evening shift on Unit 1, the census was 35 and there were 2 GNAs which made it a 1 to 17 ratio. On Unit 3 the census was 37 and there were 2 GNAs which made it a 1 to 18/19 ratio. On Station 2 the census was 27 and there were 2 GNAs and on Unit 4 the Census was 28 and there were 2 GNAs.

This pattern was repeated with 2 GNAs on day and evening shift for 7/26/25 to 7/29/25. On 7/30/25 there were 2 GNAs on each unit on day shift, however on the evening shift there were 3 GNAs on unit 1. b) Review of facility documentation on 10/15/25 revealed a written statement from Staff #22 on 8/7/25 that stated: 8/5/25 1st day without a preceptor as night shift supervisor.

Had a nurse call out and I had to be on cart.

Was not trained on the cart. I never thought about passing meds and it was too late it would have been too close because next doses were going to be due. A statement from Staff #23 on 8/5/25 stated: During med pass it was observed prior Nurse (Staff #22) has signed off on multiple medications as being pass for Resident #5.

Upon investigation Resident #5 stated to not have been medicated during the overnight shift. 5) On 10/17/25 the staffing boards were observed in the 4 units of the facility. On Unit 1 the census was 34.

There were 2 GNAs for a 1:17 ratio, 1 RN, and 1 LPN. On Unit 2 the census was 27.

There were 2 GNAs for a ratio of 1:13/14, and 2 RNs. On Unit 3 the census was 36 and there were 3 GNAs, however 1 GNA was split between unit 3 and unit 4. On Unit 4 the census was 27 and there were 2 GNAs (with 1 split between unit 3 and unit 4) and 2 LPNs.

On 10/17/25 at 10:00 AM an interview was conducted with the Director of Nursing (DON).

The DON was informed of all staffing concerns.

The DON stated, I figured all of the staff complained about staffing.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

minimal harm maintain accurate nursing staffing data.

This was evident during a complaint survey and was evident for 18 of 18 days reviewed.The findings include: On 10/14/25 at 9:30 AM the surveyor requested the

while reviewing a complaint, the surveyor was looking at the actual worked nursing schedules that were given from the Director of Nursing (DON). It was found that the schedules did not match up with statements from an investigation of who worked on a particular day. At that time the surveyor requested time punches to correlate with the nursing schedules. On 10/16/25 at 11:30 AM an interview was conducted with Staff #15, the Human Resources Director.

Staff #15 stated that she was going through time punches, and she confirmed that the schedule that was given to the surveyor as the actual worked schedule was not correct.

Staff #15 stated, we have had 2 schedulers during this time period.

They were not updating the On-shift scheduling and by the time I got involved in it, late into August, is when I found out about it.

From that point on we got a staffing person here.

Staff #15 stated, the schedules at the time were schedules that should have been printed from the On-Shift, and they were the old schedules, and they were pulled.

There was a book that she pulled from; however, the ones that were in the actual system is what was posted, and they still were not accurate.

Review of the schedules with the time punches revealed every day there were people that should not have been on the schedule that were listed as worked and people that had to be added on the schedule that were not initially on the schedule.On 10/17/25 at 11:20 AM the DON was informed of the concerns with not keeping an accurate account of who actually worked in the building and assignment on any given day and shift.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

The surveyor informed Staff #5 that the medication cart was left unlocked and unattended and that she could not be visualized from the hallway.The surveyor opened the top drawer of the medication cart and observed an opened 20 ml. vial of sterile water.

There was no date opened on the bottle of sterile water.

Also observed in the top right section of the first drawer was an insulin pen for Resident #14.

The insulin was opened on [DATE].

There was a second Insulin, Lispro, that was opened with no date opened. A third insulin, Aspart for Resident #14 did not have a date opened on the insulin pen and the seal was broken.

There was also an opened Lispro insulin for Resident #3 that was opened on [DATE] and an opened insulin Aspart that did not have a name and the seal was broken.According to the National Institute of Health, once the sterile water vial has been punctured and fluid has been removed, the container should be discarded no later than 4 hours after initial closure puncture.According to the manufacturer's instructions, the insulin should be dated when opened and should be discarded 28 days after opening.On [DATE] at 12:22 PM the Director of Nursing (DON) was informed of the observation.

The DON stated that the staff had received education about locking medication carts.

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Orchard Hill Rehabilitation and Healthcare Center 111 West Road Towson, MD 21204

and 8/31/25. Resident #12's medical record was incomplete related to wounds.