Every finding on record at Autumn Lake Healthcare at Alice Manor

Based on observation and interview it was determined the facility failed to properly label and store drugs and biologicals. This was evident in 4 of 4 medication carts and 2 of 2 medication rooms observed during the recertification/complaint survey. The findings include: On 04/15/2026 at 9:06 AM, observation of medication cart one on the 2nd floor accompanied by Staff #11 Med Tech revealed the following:An over-the-counter medication bottle of Ger-Kot 8.6 mg tablets with an expiration date of 10/2025; this was verified by Staff #11, who voiced during the observation that the medication should have not been in the medication cart as it has expired.On 04/15/2026 at 9:16 AM, during an observation of the 2nd floor short hall medication cart accompanied by Staff #10 Agency Licensed Practical Nurse (LPN), the following was revealed: An over-the-counter (OTC) medication bottle of Acidophilus Probiotic that had an expiration date of 02/2026.An OTC medication bottle of Ibuprofen 200 mg with an expiration date of 12/2025.A Toujeo SoloStar insulin pen with an expiration date of 04/01/2026.A Humalog insulin pen with an expiration date of 02/03/2026.On 04/15/2026 at approximately 9:20 AM, an interview with Staff #10 (LPN) verified the medications observed on the 2nd floor short hall medication cart were expired and should have been properly disposed of. On 04/15/2026 at 9:25 AM, during an observation of the 2nd floor medication room accompanied by Staff #10 (LPN), in the medication refrigerator was a Tuberculin 5 tU/0.1 mL vial that was opened with no date that indicated when the bottle had been opened. Staff #10 verified at this time and stated the bottle should have been dated when opened.On 04/15/2026 at 9:34 AM, during an observation on the 1st floor of the 2nd hall, the medication cart, accompanied by Staff #12 Agency Licensed Practical Nurse (LPN), revealed the following: multiple loose pills in the medication cart with storage of medication cards.An OTC bottle of iron 325/65 mg tablets with an expiration date of 12/2024.On 04/15/2026 at approximately 9:36 AM, an interview with Staff #12 verified the loose pills and the iron medication bottle had expired and should have been properly disposed of.On 04/15/2026 at 9:40 AM, during an observation of the 1st floor medication cart accompanied by Staff #14 (Unit Manager), there were multiple loose pills mixed with the OTC medication in the top drawer of the medication cart.On 04/15/2026 at 9:50 AM, during an observation of the 1st-floor medication room accompanied by Staff #14, the unit manager, there were 2 bins of IV supplies stored under the sink and a Tuberculin 5 tU/0.1 mL vial that was opened with no date that indicated when the bottle had been opened. On 04/15/2026 at approximately 9:55, an interview with Staff #14, the unit manager, confirmed there should not be loose pills stored in the medication carts, items should not be stored under the sink in the medication room, and the tuberculin vial should have been dated when opened.On 04/15/2026 at 10:57 AM, during an interview, the Director of Nursing (DON) stated her expectation was that expired medications must be properly disposed of, no loose pills should be in medication carts, items should not be stored under the medication room sink, and opened medications like tuberculin vials must be dated. The concern was shared with the DON at that time.

Based on observation and staff interview it was determined that the facility staff failed to ensure containers with soiled items in them were covered. This was evident for one of the two facility floors observed during the recertification/complaint survey. The findings include:During a tour of the facility on 4/14/26 at 10:46 AM a laundry cart was observed to be filled about 2/3 to the top with dirty clothes in it but with no cover over the cart. It was located outside of a locker room and across from the kitchen on the second floor of the nursing home. The cart was also located near rooms [ROOM NUMBERS]. The clothes were loose and not in bags. At 10:50 AM on 4/14/26 a black basket located in the hallway on the second floor near the elevator was filled with soiled/used Hoyer lift pads. The basket was not covered, and the pads were not bagged. On 4/14/26 at 2:28 PM the laundry cart observed earlier in the day was observed to have even more dirty clothes. The cart was now filled to the top with clothes not in bags and still no cover over the cart. This surveyor observed on 4/15/26 at 8:08 AM the laundry cart still with dirty clothes in it outside of the locker room. Some of the clothes were in plastic bags that were torn and not tied up. Some of the clothes were in the cart loose. There was no cover over the cart. This surveyor interviewed the Director of Nursing (DON) on 4/15/26 at 10:00 AM. The observations of the uncovered laundry cart and the uncovered Hoyer pad basket were discussed. It was imparted to the DON the infection control risk of having uncovered laundry baskets and uncovered baskets for Hoyer lift pads. She expressed an understanding of the risk. She said the laundry is sent to a laundry in New Jersey on a routine basis and the dirty clothes are supposed to be in bags that are tied and intact.This surveyor toured the second floor with the DON to show her the uncovered cart with clothes that were in plastic bags that were ripped and untied, as well as the basket for the Hoyer lift pads. She said she understood the need to cover them and said it would be addressed immediately.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that 1) residents were offered the opportunity to participate in the care planning process, 2) Interdisciplinary Team (IDT) care plan meetings were conducted. This was evident for 4 (Residents #13, #40, #35, and #2) of 28 residents reviewed for care planning during the recertification/complaint survey.The findings include:Care plans are essential guides for the care residents receive. Regulations require that care plans be developed within seven days of a resident's comprehensive admission Minimum Data Set (MDS) assessment and be revised at least quarterly, or more frequently if a change in condition occurs. The facility must ensure these meetings are conducted by an IDT—including the attending physician, a registered nurse, a nursing assistant, a dietary services representative, the resident, and the resident's representative—and that these meetings are formally documented. 1) On 4/13/2026 between 9:25 AM and 9:57 AM, Residents #13, #40, and #35 stated they had not been invited to, nor have attended a care plan meeting since admission. On 4/14/2026 at 10:19 AM, record review revealed: Resident #13 was admitted on [DATE]. Resident # 40 was admitted on [DATE]. Resident # 35 was admitted on [DATE]. Further review of the medical records for Residents #13, #40, and #35 confirmed no documented evidence of care plan meetings notes or documentation indicating that the residents and/or their representatives were invited to participate in the care planning process. On 4/15/2026 at 9:18 AM, the surveyor received care plan attendance sheets for Resident #13 (dated 3/3/26), Resident #40 (dated 2/6/26), and Resident #35 (dated 3/4/26). However, these documents lacked sufficient evidence to confirm that care plan meetings were held with IDT participation or that the residents were present or invited, as required. On 4/15/2026 at 11:08 AM, Social Worker #7 confirmed that the care plan meetings for Residents #13, #40 and #35 were not documented. On 4/17/2026 at 8:01 AM, the surveyor notified the Director of Nursing (DON) of these findings and acknowledged the concern. 2) A review of Resident #2's medical record on 4/14/26 at 9:16 AM confirmed the resident has resided in the facility since April 2024. While the resident's MDS assessments were conducted on 8/12/25, 11/12/25, and 2/09/26, there was no documentation to support that the facility conducted required IDT care plan meetings following the November 2025 and February 2026 assessments. In an interview on 4/14/26 at 12:13 PM, Social Worker #7 confirmed that all care plan meetings must be documented in the electronic medical record. She verified that there were no records supporting that these required meetings took place for the periods in question. On 4/17/26 at approximately 10:00 AM, the surveyor presented these findings to the Director of Nursing (DON), who validated the absence of the required documentation.

Based on record reviews and interview, it was determined that the facility failed to ensure a registered nurse (RN) was on duty for at least 8 consecutive hours, 7 days a week. This was evident for 12 of 30 days reviewed during the recertification survey. The findings include: On 4/17/2026 at 7:17 AM, a review of the facility's staffing sheets revealed that no RN was on duty for at least 8 consecutive hours in a 24-hour period on the following dates: 1/3/26, 1/4/26, 1/10/26, 1/11/26, 1/17/26, 1/24/26, 1/25/26, 1/31/26, 2/7/26, 2/8/26, 3/8/26, and 4/5/26. On 4/17/2026 at 8:06 AM, the Director of Nursing (DON) verified the findings and acknowledged the concern.

Based on observation and interviews with facility staff, it was determined that the facility failed to adhere to professional standards for food service safety. These deficiencies were observed in the facility's kitchen and floor nourishment rooms during the recertification/complaint survey.The findings include:During an initial tour of the kitchen on 4/13/26 at 7:45 AM, conducted with the Certified Dietary Manager (CDM) #6, the following sanitary issues were noted:-A reach-in freezer contained a partially opened ice cream cup and a container of pie that were not covered or dated.-A reach-in refrigerator contained rotten cabbage dated 3/26/26. CDM #6 acknowledged it was unusable. Additionally, a bag of diced cabbage was observed without a label or date.-Two containers of soup base (chicken and beef) were stored in the dry pantry without lids coverage. CDM #6 confirmed these should have been covered.-A walk-in freezer contained an open, undated 10-pound bag of chicken breast. Two bags of rolls with a best by date of 4/11/26 were present; while the CDM initially claimed they were acceptable, she verified the date upon review and discarded them. A plastic bin labeled miscellaneous contained various items (English muffins, French toast, etc.) that were entirely unlabeled.On 4/15/26 at 9:54 AM, the surveyor monitored the dishwashing process. During the cycle, the wash temperature reached only 130 F. Although the rinse cycle reached the required 180 F, a subsequent load also failed to exceed 130 F during the wash cycle. Corporate CDM #39 acknowledged that the wash cycle should reach at least 150 F. When questioned, Kitchen Aide #15 incorrectly identified the required temperatures as 180 F for wash and 150 F for rinse.On 4/15/26 at 10:19 AM, inspections of the floor nourishment rooms revealed further concerns:-1st Floor Nourishment Room: An ice scoop was stored in a bin on the sink that contained standing water and a whitish dust. LPN #42 observed this condition with the surveyor. The refrigerator contained multiple unlabeled/undated items, including a plate covered with foil, a grocery bag with a pizza box, and two plastic bags of food. Additionally, food temperature logs were not being documented daily.-2nd Floor Nourishment Room: The refrigerator contained an undated, unnamed plate of food and two tied plastic bags of food lacking identifying information. An open, half-gallon container of lactose-free milk was expired (3/27/26).On 4/17/26 at 10:00 AM, the surveyor discussed these findings with the Director of Nursing (DON), who validated the identified concerns.

Based on interviews and review of facility reported incidents, it was determined the facility failed to investigate an allegation of resident abuse. This was evident for 1 (Resident # 59) of 2 residents reviewed for abuse during the recertification/complaint survey. The findings include:On 04/15/2026 at approximately 1:00 PM, a review was conducted of the facility's Abuse, Neglect, and Exploitation policy. This policy was implemented on 11/13/2023 and revised on 10/17/2025. Specifically, Section V, Investigation of Alleged Abuse, Neglect, and Exploitation, Subsection A. An immediate investigation is warranted upon suspicion or reports of abuse, neglect, or exploitation.On 4/13/2026 at 10:09 AM, Resident #59 reported an incident from 6-7 months prior. An unidentified female GNA allegedly threatened, I will have my momma come up here and beat your ass. Resident #59 cried, stating they felt treated like a piece of dirt. Resident #59 stated he/she had reported the incident to a former employee and the social worker. Resident #59 remained tearful, stating, I pray every day, God, please let the people I have interaction with today treat me nicely.On 04/14/2026 at 2:19 PM, Social Worker (SW) #7 was interviewed, witnessed by another surveyor, about the process for residents reporting abuse. SW #7 stated all abuse allegations must be reported immediately to the administrator and/or Director of Nursing (DON). SW#7: admitted Resident #59 reported to her that a female GNA had threatened to have her mother beat Resident #59's ass and stated she had immediately reported the occurrence to the DON. Social Worker #7 continued to elaborate that the female GNA perpetrator was fired and escorted out of the facility the same day; she was not sure but stated it was around or about a year ago.On 04/14/2026 at 3:07 PM, during an interview with the Administrator, Administrator in training (AIT), Director of Nursing (DON), Social Worker #7, the abuse allegation process was discussed. At this time, the surveyor reported two residents' allegations of verbal abuse, including Resident #59's allegation made during the 04/13/2026 10:09 AM interview, to the Administrator, AIT, DON, and SW. The Administrator replied that this is the first time of hearing of the 2 residents' allegations of abuse.On 04/15/2026 at 12:41 PM, during an interview, the Administrator (abuse coordinator) expressed that staff should report all abuse allegations to him and/or the DON. He stated that the facility's policy includes suspending the alleged staff perpetrator, investigating the matter (interviewing staff and residents), and reporting to state agencies within two hours. The Administrator agreed that a staff member threatening a resident with having their mother beat their ass constitutes abuse. The administrator informed the surveyor that the facility was currently investigating the verbal abuse allegation concerning one of the two reported abuse allegations that surveyor had brought to the facility's attention. However, no mention was made of an investigation into Resident #59's second alleged verbal abuse regarding the statement beat Resident #59's ass.On 04/15/2026 at 2:25 PM, the surveyor was approached by the Corporate Nurse and the Director of Nursing (DON). They had provided the surveyor with a facility-reported incident from 11/13/2024 (Incident # 312640) regarding Resident # 59, stating an investigation had already occurred. However, this reported incident was about a staff member making an offensive gesture (flipped her the bird). The Corporate Nurse claimed the facility had been cited for this, but past surveys did not show the allegation, Momma beat your ass, was a concern. The surveyor informed the Corporate Nurse and the DON that the direct allegation of Resident #59 stated a Geriatric Nursing Assistant (GNA) threatened to have her mother come and beat her ass. The Corporate Nurse reported Resident #59's story changes often and insisted this had already been investigated, but there was no indication a specific investigation occurred related to Resident #59's alleged abuse.On 04/16/2026 at approximately 3:30 PM, the concern was shared with the Administrator and the DON.

Based on observation, interviews, and medical record review, the facility failed to maintain a nasal cannula in a sanitary manner and administer oxygen according to the prescribed physician order for oxygen. This was identified for 1 (Resident #88) of 1 resident reviewed for respiratory during the recertification/complaint survey.The findings include:On 04/13/2026 at 8:30 AM, during an observation of Resident #88's oxygen concentrator, the following issues were noted: the oxygen tubing was not dated, a red light was illuminated on the concentrator, and the device was emitting a beeping noise.On 04/13/2026 at 10:53 AM, an observation and interview with Staff #3, an agency Licensed Practical Nurse (LPN), revealed Resident #88's oxygen concentrator was actively alarming (displaying a red light and beeping). Staff #3 confirmed that this alarm indicated an issue with the concentrator. The device was incorrectly set to 0 liters per minute (L/min.) when the correct setting should have been 1 L/min. Staff #3 adjusted the setting to 1 L/min., which silenced the alarm. Additionally, Staff #3 noted that the oxygen tubing lacked a date, stating it should be dated, and committed to changing and dating the tubing after administering medications.On 04/14/2026 at 9:12 AM, a review of Resident #88's medical record revealed physician orders dated 02/27/2025. These orders indicated continuous oxygen (O2) at 1 liter via nasal cannula (NC) every shift. Additionally, the orders required the O2 tubing to be changed weekly every Sunday night shift and as needed.On 04/14/2026 at 9:16 AM, a continued review of Resident #88's medical record revealed a care plan (dated 02/28/2025, revised 06/07/2025) for altered respiratory status due to pulmonary edema, respiratory failure, obstructive sleep apnea, history of pleural effusion, left lower lobe atelectasis, and COVID-19. Intervention included providing oxygen as ordered.On 04/14/2026 at 12:51 PM, during an interview, the Director of Nursing (DON) outlined the oxygen administration process. The DON stated that residents receiving oxygen would have a physician's order and a corresponding care plan, and residents should receive oxygen according to the physician's order. Furthermore, the DON emphasized that oxygen tubing must be changed weekly and that the new tubing should be dated to reflect the change. The concern was shared with the DON at this time.

Based on a review of medical records and staff interviews, it was determined that the facility failed to provide necessary care and follow required clinical protocols for a resident with an indwelling urinary (Foley) catheter. This failure was identified in 1 (Resident #85) of 2 residents reviewed during the recertification/complaint survey.The findings include:On 4/13/26 at 10:18 AM, the surveyor observed that Resident #85's Foley catheter drainage bag was hanging from the bed rail.A review of Resident #85's medical records on 4/14/26 at 1:24 PM revealed that there was no physician's order for Foley catheter care documented in the Treatment Administration Record (TAR). Furthermore, no comprehensive care plan had been developed to address the maintenance and monitoring of the catheter.On 4/14/26 at 1:40 PM, Licensed Practical Nurse (LPN) #8 confirmed that facility protocol mandates a physician's order for catheter care for any resident with an indwelling catheter. LPN #8 verified that Resident #85 had an active catheter but acknowledged the absence of a corresponding care order in the electronic system.During an interview with Director of Nursing on 4/15/26 at 9:40 AM, she confirmed that while Resident #85 received the catheter on 3/24/26 per a valid physician's order for insertion, staff failed to enter the necessary follow-up orders for ongoing catheter care and maintenance. The DON acknowledged and validated the deficiency.

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure that residents received the necessary care to promote their well-being. This deficiency was identified regarding one (Resident #2) out of the five residents reviewed during this recertification/complaint survey.The findings include:During a complaint investigation on 4/14/26 at 10:08 AM, it was revealed that Resident #2 was unable to attend a specialist appointment because an escort was not provided.In an interview on 4/15/26 at 2:11 PM, Resident #2 stated that they were scheduled to attend an outside appointment with an escort, which had been discussed during a care plan meeting prior to the scheduled date. However, on 3/13/26, the resident was sent out without an escort; consequently, the resident was unable to navigate the facility's door. As a result, the appointment could not be completed.In an interview on 4/16/26 at 12:15 PM, Social Worker #7 recalled a care plan meeting held on 3/12/26, which was attended by an ombudsman. During this meeting, they discussed the resident's request for an escort. Social Worker #7 stated, In the care plan meeting (3/12/26), the ombudsman said she had already spoken with the Nursing Home Administrator (NHA) and confirmed that [Resident #2] would go out with an escort, and the facility staff would arrange this.A review of Resident #2's medical record on 4/16/26 at 1:00 PM revealed that no care plan had been initiated regarding the need for an escort for outside appointments. In a subsequent interview, the Director of Nursing (DON) was asked whether the resident had a care plan regarding escort needs. The DON stated, There was no need for a care plan regarding resident escorts. Whoever is scheduling, we knew which residents needed escorts. When asked to provide documentation of a list of residents requiring escorts, the DON confirmed that no such list existed. Additionally, the DON added, I did not attend the care plan meeting; how I know this?On 4/17/26 at 11:10 AM, the ombudsman was interviewed. She stated that Resident #2's concern regarding an escort for the outside appointment had been discussed in person with facility staff prior to the 3/12/26 care plan meeting.The surveyor discussed these findings with DON and the NHA on 4/17/26 at 12:00 PM, and they validated the information provided.

Based on observations, interviews, and a medical record review, it was determined that the facility failed to provide necessary personal hygiene services and ADL care related to urine incontinence to totally dependent residents. This failure was identified in 2 (Resident #85, Resident #22) of the five residents reviewed for activities of daily living (ADL) care during the recertification/complaint survey.The findings include:Minimum Data Set (MDS) is a standardized screening and assessment tool used to evaluate the health status of residents in Medicare/Medicaid-certified long-term care facilities. Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, toileting, and mobility. Brief Interview for Mental Status (BIMS) is a standardized tool measuring cognitive function, including orientation, learning, and memory. The score ranges from 0 to 15. A score between 13 and 15 indicates intact cognition, while a score of 12 or less may indicate mild to severe impairment. 1) During an initial tour on 4/13/26 at 8:55 AM, Resident #85 was observed to have notably long fingernails. A review of Resident #85's medical record on 4/14/26 at 10:16 AM identified a BIMS score of 0 out of 15 (dated 3/09/26), indicating the resident was rarely or never understood. Furthermore, the MDS assessment dated [DATE] documented that Resident #85 was totally dependent on staff for ADL care. During an interview on 4/14/26 at 1:45 PM, Licensed Practical Nurse (LPN) #8 confirmed that the resident required total assistance and was unable to perform nail care independently. LPN #8 stated that personal hygiene for dependent residents is typically provided by nurse aides, though nurses also provide care based on the resident's specific needs. Following this interview, LPN #8 and the surveyor jointly inspected Resident #85's nails and confirmed that they were overgrown. 2) On 04/13/2026 at 11:12 AM, during an interview, Resident #22 expressed a concern regarding the timeliness of incontinence care. Resident #22 elaborated, stating, I haven't been changed in 10 hours now. The resident further explained, I told the medicine lady at 10:40 AM, and I don't know if she told anyone yet. Resident #22 became emotional, crying during the interview, and added, I need the cream on my butt because they have me sit in [feces]. I haven't been changed since 2 AM. Me having to wait for incontinence care happens 3 to 4 times a week. On 04/13/2026 at 11:27 AM, Resident # 22 pressed the call light. Staff #4 (Medication Aide) entered the room and confirmed that Resident #22 had requested incontinence care approximately 30 minutes earlier and she had reported to the Geriatric Nursing Assistant at that time. On 04/13/2026 at 11:34 AM, Staff #5 Geriatric Nursing Aide (GNA), entered Resident #22's room, provided information that her shift starts at 7am and confirmed that she had not provided any incontinence care to Resident #22 today. On 04/14/2026 at 9:28 AM, review of the MDS admission dated 1/19/2026 showed the resident was assessed as 3. Always Incontinent for both urinary (H0300) and bowel continence (H0400). Section GG Self-care for toileting hygiene (maintaining perineal hygiene, adjusting clothes) was marked as 3. Dependent-Helper does ALL of the effort. On 04/14/2026 at 9:18 AM, in review of Resident #22's medical record task section for the documented ADL care section for bladder and bowel continence, a lapse in care documentation was shown. The last recorded instance of incontinence care was dated 04/12/2026 at 12:10 AM, noting the resident was incontinent of bowel and bladder. The subsequent entry for 1:18 PM on the same day was documented that indicated, Resident not available. This indicated no incontinence care for Resident #22 was provided, exceeding over 11 hours. On 04/14/2026 at 12:54 PM, during an interview, the Director of Nursing (DON) expressed that residents who are incontinent of bowel and bladder should receive incontinence care checks every two hours and that documentation would be completed after the care was provided. This concern was shared with the DON during the interview.

Based on medical record review and interview, the facility failed to coordinate care for a resident receiving hospice services. This was evident for 1 (Resident #14) out of 1 resident reviewed for Hospice during the recertification/complaint survey.The findings include: Hospice care is a specialized form of healthcare that provides comfort and support to terminally ill patients and their families. It focuses on managing pain, symptoms, and other physical, emotional, and spiritual needs during the end of life.On 04/14/2026 at 10:50 AM, a review of Resident #14 revealed a physician's order, dated 01/14/2026, for admission to Amedysis Hospice. However, a subsequent review of the medical record on 04/16/2026 at 8:51 AM revealed a lack of communication notes from the Hospice provider regarding nursing visits since 03/22/2026.On 04/16/2026 at 9:25 AM, continued review of Resident #14's medical record revealed medication discrepancies between the 4/7/2026 Hospice IDG list and the facility's current physician orders. The Hospice list included Doxazosin, Haloperidol, Hyoscyamine, Lorazepam, Mirtazapine, Morphine, and Senna Lax (1 tablet). The facility orders, however, lacked haloperidol, hyoscyamine, and lorazepam. Additionally, the facility orders included Anasept Gel, Ondansetron, Melatonin, and Acetaminophen, which were absent from the Hospice list, and specified 2 tablets of Senna versus the hospice's 1 tablet.On 04/16/2026 at 10:04 AM, further review of Resident #14's medical record noted a change in condition progress note (4/7/2026, 14:57): A boil on the left side of the back opened; that was becoming an open area. The facility's provider Nurse Practitioner (NP) ordered wound cleanser, silver sorb gel daily, and a wound consult. Resident #14's responsible party (RP) was notified. A general note (4/7/2026, 10:56 AM) showed facility provider NP ordered Doxycycline 100 mg x 7 days for prophylaxis due to the open boil, and RP was notified. However, there was no documentation that indicated the Hospice provider was notified of the boil or antibiotic.On 04/16/2026 at 10:54 AM, during an interview, the Director of Nursing (DON) described the hospice communication process. Hospice staff typically report to her office upon arrival, then inform unit managers/nurses of updates. Hospice nurses use paper facility progress notes for documenting their visit. The facility would notify hospice of any patient condition change, documenting the contact person's name in a progress note. Hospice would be notified, and documentation recorded, for condition changes like skin issues or new antibiotics. Facility and hospice medication orders should match. At this time the concern was shared with the DON.

Based on a review of facility records, interviews with staff, and interviews with residents, it was determined that the facility failed to follow its established grievance process. This failure was identified in 3 of the 22 cases reviewed (Residents #2, #51, and #91) during this recertification/complaint survey.The findings include:During an interview on 4/15/26 at 2:11 PM, Resident #2 stated, The facility sends laundry to another state, and it takes more than a week to return. Some of my clothes were missing, and the facility offered lower-quality replacements, which I refused. The items remain missing.On 4/16/26 at 10:00 AM, the surveyor reviewed the facility's grievance logs. Records indicated that while some reports of missing clothing were resolved via reimbursement, others remained unresolved despite being marked as addressed.A grievance form dated 10/30/25 documented Resident #91's report of missing clothing. The facility recorded the resolution on 11/03/25 as clothes replaced. However, during an interview on 4/16/26 at 10:48 AM, Resident #91 stated he/she had missing clothes several items. Summer T-shirt dresses, fleece pants, and regular pants remained missing from an incident that occurred several months ago.A grievance form dated 1/05/26 stated, Resident #51 said, Patient reported 2 pairs of bottoms are missing and two tee shirts are missing. In an interview on 4/16/26 at 10:43 AM, the resident noted that while missing items are typically replaced within 4-5 days, one recent instance took three weeks to resolve.In an interview with Social Worker #7 on 4/16/26 at 12:15 PM confirmed that many residents have ongoing concerns regarding missing or improperly laundered clothing.During an interview with EVS Director #24 on 4/16/26 at 1:23 PM, he explained that personal laundry is collected by an outside contractor on Tuesdays, Thursdays, and Saturdays. The director admitted that items are frequently returned behind schedule. While he stated that he contacts the vendor regarding missing items, he conceded that some cases remain unresolved, and items are not always properly tracked or returned. When asked about interventions following similar findings during the previous year's survey, the EVS director noted only that the Nursing Home Administrator has begun providing financial reimbursements for missing items.In an interview with Director of Nursing on 4/17/26 at 10:00 AM, the surveyor discussed these findings with the Director of Nursing, who acknowledged and validated the concerns.

Based on observation, interviews with facility staff, and investigation of Facility Report Incidents # 312639 and # 312644, it was determined the facility failed to provide an environment that promoted dignity and resident's rights. This was evident for 4 (Resident #14, Resident #35, Resident #24, and Resident #95) of 6 resident reviewed for dignity and resident rights during the recertification/complaint survey.The findings include: 1) On 04/13/2026 at 9:03 AM, an observation of Resident #14 lying in bed, a paper sign on the wall above bed, indicated this resident is a feeder !!!! On 04/15/2026 at 3:25 PM, during an interview with the Director of Nursing (DON) reported Resident #14's representative requested that a sign be placed in the room for assistance with feeding. On 04/16/2026 at 8:43 AM, during an observation/interview, the Director of Nursing (DON) was present and verified the sign above Resident #14's bed that read: this resident is a feeder!!!! The DON confirmed this sign was a dignity issue, stating it would be more appropriate to indicate that the resident requires assistance with meals. The DON stated the sign would be removed and the concern was shared with the DON at that time. 2) On 4/13/2026 at 9:57 AM, Resident #35 was observed lying in bed with a hospital gown crumpled on top of his/her upper torso. During the interview, the resident stated a preference for wearing a hospital gown; however, he/she expressed frustration that the facility had not provided a gown that properly fit. On 4/15/2026 at 8:21 AM, a review of medical record revealed Resident #35 was cognitively intact with a BIMS score of 15.0 (Brief Interview of Mental Status is screening tool used to assist with identifying a resident's current cognition). The admission MDS assessment with an Assessment Reference Date (ARD) of 3/4/26 indicated that Resident #35 required supervision or assistance with upper body dressing. The MDS (Minimum Data Set) assessment is a standardized tool used to evaluate the residents' functional, physical, and psychosocial status and to guide individualized care planning. On 4/15/2026 8:33 AM, during the follow-up visit, Resident #35 was again observed with a hospital gown placed loosely on the upper body and a blanket covering the lower body. The resident demonstrated to the surveyor that available gowns were too tight at the neckline, causing pressure against the neck and resulting in discomfort when worn. On 4/15/2026 at 8:41 AM, Licensed Practical Nurse/ Unit Manager (LPN/UM) #14 stated that the facility had multiple gown sizes but confirmed that none appropriately fit Resident #35. On 4/15/2026 at 9:25 AM, the surveyor informed the Director of Nursing (DON) of the concern. On 4/17/2026 at 7:51 AM, the DON confirmed the facility has obtained additional gowns that fit Resident #35 and that the resident had begun using them. 3) On 4/14/2026 at 08:45, during the investigation of Facility Reported Incidents (FRI) to the Office of Healthcare Quality on May 6, 2025, it was noted that the facility reported an incident involving 2 residents (Resident #24, incident # 312644) and (Resident #95, incident #312639). The report stated that Staff # 45 had posted a video of the residents to a social media platform without their consent. During the review of the investigation on 4/14/2026 at 08:45 AM, The surveyor noted the following evidence: -Written statement by Staff #43, on 5/6/2025 it was brought to nursing management attention of an employee recording residents on his/her social media platform. The writer observed a video with a resident lying in bed in a hospital gown, swinging a television remote at a staff member. I also identified another video, I did not see a resident in the video, but I heard Staff #45 asking the resident what did you just say repeatedly, she/he then stated she/he wants to grab my butt. Warmest regards, Staff #43. -Written statement by Staff #43, To whom it may concern: Regarding the incident with Staff #45, when I asked why she/he recorded 2 residents and put them on his/her social media, his/her response was, I recorded the resident, because I also has rights to protect myself. Warmest regards, Staff #43. -Written statement by Staff #44, On May 6, 2025, I, staff #44, received a message via Instagram asking if I was at work. I stated yes and she/he asked if I could facetime so they could share screens. Once on the call I watched a video of a staff member recording a resident in bed in a gown swinging a bed remote yelling. On the second clip of the video the same staff member recorded a resident seated in his/her wheelchair. -Written statement by The Nursing Home Administrator (NHA), the Staff #45 admitted that she/he took the video and posted it on Instagram. She/he said that she/he was afraid of the patient swinging the remote and wanted evidence that the patient was trying to hurt him/her. She/he also stated she/he took the video of the resident because he/she was saying nasty inappropriate things and said he/she wanted to eat his/her vagina. She/he said she/he took down the videos and deleted them. On 4/14/2026 at 09:00 AM Review of the FRI investigation noted that the allegation was substantiated based on the video evidence and Staff #45 was terminated. On 4/14/2026 at 09:25 AM during an interview with the Director Of Nursing (DON), she stated that a phone call came from a GNA who worked here before though agency staffing. The GNA follows GNA #45 on social media and recognized Resident #24, and Resident #95 in a video that was posted on Instagram. The video was reviewed by the leadership team and they recognized both residents in the video. The video was entitled, This is what we have to deal with. The facility reported the incident to the board of nursing, notified the families, and reported the incident to the State. The DON had nothing further to add. Further review of Medical Records on 4/16/2026 at 11:42 revealed the following: -Resident #24 – was admitted to the facility on [DATE] and have a history of Alzheimer's disease and anxiety with a current Brief Interview on Mental Status (BIMS) score of 0 and had no recollection of the incident. -Resident #95 – was admitted to the facility on [DATE] and has a history of schizoaffective disorder, unspecified dementia, unspecified severity with other behavioral disturbances, and parkinsonism. Resident's BIMS score was 0. On 4/17/2026 at 09:00 AM, the DON and the NHA were made aware that this incident was a concern because neither residents gave consent to be in a video in a gown in bed or in a wheelchair, thus violating their basic rights for dignity and respect.

Based on observations and interviews with residents and staff, it was determined that the facility failed to prepare and serve meals that reflect residents' requested nutritional preferences and orders. This deficiency affected five (Residents #2, #8, #10, #59, and #96) of 22 residents reviewed during the recertification/complaint survey.The findings included:On 4/13/26 at 10:00 AM, Resident #10 reported that the food served did not match the order, stating, I only got one sausage; I am still hungry.On 4/13/26 at 9:30 AM, Resident #59 stated, I am supposed to get a banana for breakfast, but I do not get it. I have to buy and order my own bananas.On 4/15/26 at 2:11 PM, Resident #2 provided photographic evidence of meals served, noting discrepancies between the menu and the actual food provided. Specifically, the resident noted an instance where baked chicken was served instead of the scheduled chicken cacciatore.On 4/15/26 at 12:31 PM, the surveyor observed meal tray preparation in the kitchen and identified discrepancies between meal tickets and the food tray contents: Resident #8's meal ticket indicated the resident should receive soup and a main dish; however, the tray provided contained only the main dish. Resident #96's meal ticket indicated the resident should receive two portions of pureed bread; however, the tray contained only one.In an interview on 4/15/26 at 12:35 PM, Staff #39 (Corporate Certified Dietary Manager) confirmed that kitchen staff are required to prepare meals exactly as listed on the resident's meal ticket. She validated the discrepancies observed by the surveyor.

Based on observation, medical record review, and interview with resident and staff, it was determined that the facility failed to provide and document nonpharmacological interventions used prior to administration of pain medication as ordered. This was evident for 1 (Resident # 10) of 1 Resident reviewed for pain management during the recertification/complaint survey. The findings include: On 04/13/2026 at 10:05 AM during the survey screening process, The surveyor observed Resident #10 lying in bed in a hunched over position. The surveyor asked resident if she/he have pain, resident stated, I get cortisone shots for pain in my back. Review of the residents medical record on 04/16/2026 at 7:45 AM revealed that the resident has diagnoses to include chronic pain syndrome, neuralgia and neuritis. a care plan was in place noting that resident has (chronic) pain r/t PVD and wounds to bilateral lower extremities, abdominal cramping, and chronic pain syndrome with interventions to anticipate the resident's need for pain relief and respond immediately to any complaint of pain and evaluate the effectiveness of pain interventions (every shift). A further review of the Resident's medical record on 4/16/2026 at 08:00 AM revealed an order written for Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours as needed for pain 1-5 -Order Date 01/19/2026 and give Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours as needed for Severe pain 6-10, Order Date 01/19/2026. There was no order written for cortisone injections. An additional order was written on 1/19/2026 for Nonpharmacological interventions attempted prior to Verbal administering any As Needed (PRN) pain med, every shift. On 4/16/2026 at 08:30 AM, a review of the Residents #10's Medication Administration Record (MAR) from 4/1/2026 to 4/15/2026 noted that the Resident was administered pain medication daily. However, there was no written order or documentation on the Treatment Administration Record (TAR) or nursing notes regarding the nonpharmacological intervention attempted prior to the administration of pain medication.During an interview with the DON on 04/16/2026 at10:00 AM, The DON stated that the resident does not have any documentation of the Nonpharmacological methods used. The DON agreed that this was a concern and stated that the Resident's record will be updated and in addition, she would discuss the cortisone injections for the resident with the pain management team.

Based on a review of medical records and interviews with facility staff, it was determined that the facility failed to ensure that the provider accurately documented residents' current code status and capacity to make informed decisions. This was evident for 1 (Resident #14) of 1 resident reviewed for Hospice during the recertification/complaint survey.The findings include:On [DATE] at 10:20 AM, a review of Resident #14's medical records revealed provider notes from [DATE], [DATE], and [DATE] that showed the following: CODE STATUS: [DATE]: Patient wishes full resuscitation measures except blood transfusion (he/she is Jehovah Witness), ok with chest compressions, intubation, hemodialysis, artificial nutrition, and any necessary medical evaluations and hospital transfers, in the event of a medical condition requiring a higher level of care. Capacity: [DATE]: After conducting a thorough assessment and considering the patients ability to understand their medical condition, risks and benefits of different treatment options, as well as the ability to communicate their decisions, I conclude that the patient has the capacity to make informed medical decisions.Further review of Resident #14's medical records on [DATE] at 10:42 AM indicated a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form dated [DATE] and signed by the provider. The form specified No CPR, Option B, Palliative Supportive Care, and indicated Do not use any artificial ventilation (no intubation, CPAP, or BiPAP); Do not provide artificially administered fluids or nutrition; and Do not provide acute or chronic dialysis. On [DATE] at 10:48 AM, a continued review of Resident #14's medical record revealed a Physician Certification form related to medical condition, substitute decision-making, and treatment limitations. This form, dated [DATE] and signed by the provider, indicated the resident's inability to comprehend information and make decisions, with Xs marked in all unable sections of the Certification of Ability to Comprehend Information and Make Decisions. Furthermore, the Scope of Decisions-Making Capacity section stated the resident was incapable of making informed decisions for all medical treatments.On [DATE] at 10:54 AM, during an interview with the Director of Nursing (DON) stated that a provider's progress notes should reflect the resident's current status regarding both code status and capacity. The concern was shared with the DON at that time.

Based on record review and staff interview, it was determined that the facility failed to implement a trauma-informed care process meeting professional standards, which could eliminate or mitigate resident re-traumatization triggers. This was evident for 1 (Resident #5) of 1 resident reviewed for trauma-informed care during the recertification/complaint survey. The findings include: Trauma-informed care is a method of providing services based on recognizing the widespread impact of trauma and understanding, acknowledging, and addressing its effects. This approach incorporates knowledge about trauma into all aspects of care delivery-including care plans, policies, procedures, and practices-to prevent residents from experiencing re-traumatization and to recognize the signs and symptoms of trauma. A trigger is a psychological stimulus that prompts the recall of a traumatic event, even if the stimulus itself isn't traumatic. For many trauma survivors, transitioning to an institutional setting and losing independence can be profoundly re-traumatizing. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 04/14/2026 at 11:22 AM, in review of Resident #5's diagnosis list included undifferentiated schizophrenia and post-traumatic stress disorder.On 04/14/2026 at 11:36 AM, a review of Resident #5's plans of care, including those for behavior problems (refusals) dated 10/05/2023 and revised 01/27/2026, and psychosocial well-being (schizophrenia, hallucinations, and insomnia) dated 04/17/2025. However, the comprehensive care plan lacked a trauma-informed care plan addressing Resident #5's history of trauma/PTSD, specifically to identify triggers that may cause re-traumatization or to implement interventions to minimize their effect.On 04/14/2026 at 11:51 AM, a review of Resident #5's medical record revealed psychiatric notes from 11/19/2025, 10/01/2025, and 09/24/2025, all citing excessive sleepiness and PTSD (one also noting aggression toward staff). The 10/01/2025 note also mentioned a night shift report indicating the resident often yells and doesn't sleep at night. However, the psychiatric notes for Resident #5 did not address Resident #5's trauma/PTSD. Nor were there any further psychiatric notes found between 11/19/2025 and the present. On 04/14/2026 at 12:15 PM, during an interview, Social Worker (SW) #7 explained the facility's trauma-informed care (TIC) process: access to a psychologist, psychiatrist, psychosocial therapy, and a psychosocial assessment. Triggers are identified from history, diagnosis, direct communication, or family if the resident cannot communicate. TIC is incorporated into the comprehensive care plan. SW #7 confirmed Resident #5 lacked a TIC plan identifying triggers, a psychosocial assessment, and a psychiatric consultation since November 2025. The concern was shared with the Social Worker at this time. On 04/16/2026 at 2:00 PM, the concern was shared with the Director of Nursing.

Based on observations and staff interviews, it was determined that the facility failed to properly store and dispose of refuse. This was evidenced by the state of the two dumpsters located in the outdoor storage area during the recertification/complaint survey.The findings include:During an inspection of the facility's outdoor garbage storage area on 4/15/26 at 12:20 PM, the surveyor observed two dumpsters located directly beneath the second-floor kitchen deck. Both dumpsters had their lids open and were filled with refuse bags.During an onsite inspection on 4/15/26 at 1:07 PM, Dietary Aide #18 confirmed that dietary staff frequently dispose of trash bags by throwing them from the second-floor kitchen deck into the dumpsters below. The aide further confirmed that the dumpsters remained uncovered at all times.In an interview with Corporate Certified Dietary Manager #39 on 4/15/26 at 1:09 PM, the surveyor presented these findings to her who validated the concerns regarding improper disposal methods and the failure to maintain closed, sanitary waste containers.

Based on observation and interview with facility staff it was determined that the facility staff failed to maintain a clean and homelike environment. This was evident for 1 out of 2 nursing units observed during the recertification/complaint survey. The findings include:During the initial tour of the facility on 4/13/26 at 1:13 PM room [ROOM NUMBER] was noted to have discolorations on each of the walls and had baseboards that were chipped with missing paint. The door frame was also chipped and had missing paint. The floor leading to the entrance of the bathroom was sticky with blackened areas. This surveyor then observed the bathroom which was shared with room [ROOM NUMBER]. The sink was two-thirds filled with a yellowish tinged liquid. The interior side of the bathroom door was stained black from floor to the lower door hinge. Baseboards in the bathroom were worn and had areas of missing paint. During the initial tour of the facility on 4/13/26 room [ROOM NUMBER] was noted to have two walls with chipped drywall, baseboards that were chipped and discolored, cracked floor tiles by the head of one of the beds, and a dirty floor. The door frame was also chipped and had missing paint. This surveyor toured again on 4/16/26 at 10:35 AM. The door to the dietary office was observed to have a small hole in the bottom left corner along the floor. The handrail by the entrance to the locker room across from the kitchen was missing an end cap which posed a risk to anyone who brushed up against it. This surveyor toured with the maintenance director #17 on 4/16/26 at 10:58 AM to show him the areas of concern. The bathroom sink shared by the residents of rooms [ROOM NUMBERS] was stopped up on Monday but clear of liquid on Thursday. It has a sign that said, do not use. Staff #17 said he was waiting for some necessary parts to be delivered in order for him to get the sink operational again. He was shown the dirty floor, and he took a picture for reference. He was then shown the doorway with the chipped paint and the door with 1/3 to 1/2 of the surface removed. He said the door used to have a laminate type of cover that kept getting bent by residents bumping into it at the point the laminate meets the edge of the door. He was then shown room [ROOM NUMBER]. Areas of the molding near the floors were chipped with missing paint and appeared dirty. A resident of room [ROOM NUMBER] complained that the floor seemed uneven. Staff #17 noted an area of the floor that seemed uneven. This surveyor showed Staff #17 the handrail and he said he would get that fixed ASAP. This surveyor then showed him some uneven areas of the flooring on both the first and second floor units between the nursing station and the day rooms. Staff #17 said he would get an outside contractor to assess the floor. The doorway to the maintenance room near the elevator had a section of the door frame that was missing. Staff #17 was interviewed on 4/16/26 at 11:12 AM. He said he would take care of the issues pointed out to him and said that he would continue looking for anymore signs of wear and tear.

Based on observations and staff interviews, it was determined that the facility failed to ensure the daily posting of accurate nurse staffing information. This was evident for 2 of 5 days during the recertification survey.The findings include: On 4/13/2026 at 7:40AM, the surveyor observed that the first-floor nursing staffing board displayed an incorrect date of April 10, 2026, indicating that it had not been updated for 3 days. On 4/14/2026 at 12:48 PM, in an interview with the Director of Nursing (DON), she stated that the Supervisor or Unit Manager is responsible for completing and updating the nursing staffing board daily. On 4/15/2026 at 8:39 AM, the surveyor again observed that the first-floor nursing staffing board displayed an incorrect date of April 13, 2026. At the time of observation, the Licensed Practical Nurse/ Unit Manager (LPN/UM) #14 immediately corrected the date to reflect the current date. On 4/17/2026 at 8:06 AM, the surveyor notified the DON of these concerns and acknowledged the findings.

Based on medical record review, review of pertinent facility documentation, hospital record review and staff interview, it was determined the facility failed to ensure that residents were free from significant med errors as evidenced by a resident being administered medication that was not prescribed resulting in the resident ' s hospitalization . This was evident for 1 (#16) of 3 residents reviewed for medication administration during a complaint survey. This failure resulted in actual harm to Resident #16. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 3/15/24. The findings include: Methadone (a synthetic opioid used medically to treat chronic pain and opioid use disorders). Naloxone (Narcan) is a medication that quickly reverses an overdose of opioids. On 11/15/24 at 9:00 AM, a review of complaint MD00203494 was conducted. In the complaint, the complainant reported Resident #16 was admitted to the hospital on 3/9/24 with acute encephalopathy (change in brain function due to injury or disease), bradycardia (slow heart rate), acute hypercapnic respiratory failure (condition with too much carbon dioxide (CO2) in the blood) and the resident tested positive for methadone. Resident #16, who had not been receiving methadone treatment at that time, was managed for opioid intoxication. The complainant reported that the facility was called, and the Director of Nurses (DON) confirmed Resident #16 was not on methadone treatment and the DON did not know anything about the methadone overdose. On 11/15/24 at 9:28 AM, during a phone interview, the complainant indicated s/he was a hospital case manager and that following Resident #16 ' s arrival to the hospital emergency room , a toxicology screen revealed the resident, who had not been on a methadone treatment program, The emergency department (ED) records for Resident #16 ' s 3/9/24 ED visit, and the hospital records for his/her 3/10/24 to 3/14/24 hospital stay were requested by the State Office, received and reviewed by the surveyor on 11/18/24. In an ED note on 3/9/24 at 3:22 PM, the physician documented Resident #16 that Resident #16 presented to the ED for altered mental status and it had been reported that the resident was at his/her baseline when initially seen at 9:00 AM, and the resident was typically ambulatory and alert and oriented x 2. The physician wrote that Resident #16 ' s nurse checked on the resident around 12:45 PM and found him/her obtunded (diminished responsiveness to stimuli), in bed and hypoxic (too little oxygen). Review of Resident #16 ' s hospital discharge documentation dated 3/15/24, revealed, in a hospitalization summary, the physician documented Resident #16 presented from the nursing facility after being found lethargic, that upon presentation to the emergency department, s/he was hypoxic (deprived of oxygen), bradycardic (slow heart rate), and hypertensive (high blood pressure. The physician wrote that Resident #16 was given naloxone empirically, s/he started to regain consciousness, and the resident was placed on naloxone drip. Resident #16 ' s urine toxicology test came back positive for methadone and the resident was admitted to the Intensive Care Unit (ICU). Further review of the ED documentation revealed a Toxicology report on 3/9/24 at 8:03 PM, documented Methadone was detected in Resident #16 ' s urine. Review of Resident #16 ' s electronic medical record (EMR) revealed, on 3/9/24 at 2:25 PM, in a change in condition note, Staff #33, RN (Registered Nurse), agency nurse, documented that during lunch, Resident #16 was observed with excess saliva, sweating profusely, and high blood pressure, and the physician and resident representative were made aware. Staff #33, RN further documented on 3/9/24 at 7:58 PM, in a general nurses note, that Resident #16 had a change in condition and was sent to the emergency room (ER) for further evaluation. The nurse wrote that at 12:45 PM, though alert and breathing normally, Resident #16 was noted to be very lethargic, sweating profusely, with excessive salivation, high blood pressure (BP) reading of 195/75 and a heart rate (HR) of 33; the physician was notified and ordered Resident #33 be transferred to the ER for further evaluation. Also, on 3/9/24 at 11:02 PM, in a general nurses note, Staff #33 documented that Resident #16 was admitted to the Intensive Care Unit (ICU) for trouble breathing and hypoxia and indicated the ER physician had called the facility to make an inquiry on the resident ' s baseline status. Review of Resident #16 ' s March 2024 Medication Administration Record (MAR) revealed on 3/9/24 at 9:00 AM, Resident #16 was administered Acetaminophen (Tylenol) 1000 milligrams (MG) and an inhaler, Breo Ellipta. There was no other documentation in the MAR, to indicate that while s/he was in the facility, Resident #16 received any other medication on that day. Continued review of Resident #16 ' s medical record revealed no evidence to indicate the resident was on a methadone treatment program. On 11/15/24 at 11:38 AM, during an interview, the Nursing Home Administrator stated that he was aware Resident #16 was sent to the hospital when s/he had a change in condition, and at some point, the resident had a toxicology screen that was positive. The NHA indicated that an investigation into this had occurred, and would see what he could find. On 11/15/24 at 1:58 PM, Staff #16, the previous Director of Nurses (DON) confirmed s/he was the DON at the time of the above incident. During an interview, Staff #16 stated s/he had received a call from the facility ' s night shift nurse who reported s/he received a call from the hospital, asking clinical questions about the resident who had been admitted to the intensive care unit (ICU), and the physician was asking questions about the medication Resident #16 was prescribed. Staff #16 reported that the next morning, s/he received a call from a case manager at the hospital, who reported that a lab test found methadone in Resident #16 ' s system, and asking similar questions about the resident in reference to the methadone. Staff #16 indicated that at that time, they had no other information, except what was reported to him/her by the hospital. Staff #16 stated that once s/he was aware of the report from the hospital that Resident #16, who was not prescribed methadone, had methadone in his/her system, an investigation into the incident was initiated. The DON stated she reviewed medical records and confirmed Resident #16 was not prescribed Methadone. The DON stated that statements were received from the nurses who worked on that date (3/9/24) and received a statement from the nurse, Staff #33, RN, who was assigned to Resident #16 on that date. Staff #16 stated that Staff #33, the nurse assigned to Resident #16 that day was an agency nurse and that was the only day s/he had worked at the facility. The DON stated that Staff #33 reported Resident #16 was baseline at the beginning of the shift, ambulating back and forth to the bathroom, and noted to have a change in condition around mid-shift and was then sent to the hospital. Staff #16 reported that during the investigation, s/he identified Resident #24, who was the roommate of Resident #16, had been prescribed methadone. Staff #16 stated s/he re-interviewed the nurse, Staff #33 and asked if s/he remembered administering methadone to any residents and asked him/her to describe the resident who received the methadone. Staff #33 recalled administering the methadone, and described Resident #24, who was in a Geri-chair at that time, as the resident who had been administered the methadone. Staff #16 stated s/he was not able to substantiate that Resident #16 was inadvertently administered methadone his/her assigned nurse, Staff #33, that morning. Staff #16 stated that statements were also obtained from the nurses who cared for the resident in the days prior to the incident. Staff #16 stated that at the time of the incident, there were 2 residents in the building who were prescribed methadone, one was the resident ' s roommate, and the other resident was on another floor. Staff #16 stated that the facility was unable to determine how Resident #16 had gotten the methadone, however the resident's nurse on that day, Staff #33 was suspended during the investigation, and because s/he was an agency nurse, it was requested Staff #33 not return to the facility. Staff #16 stated that along with the investigation, an abatement plan was implemented which included the medication administration training of all nurses, including agency nurses, looking at medication transcription, completing audits and forwarding audit results to the facility's Quality Assurance and Performance Improvement (QAPI). Following the interview, Staff #16 provided the surveyor with a binder labeled, Medication Error, and indicated the binder contained documentation of the facility ' s investigation, and actions implemented to correct the deficient practice. Review of the binder revealed evidence of the facility ' s investigation, and correction plan that included the following provisions: 1. An audit of all resident ' s identification to assure all residents were validated with 2 identifiers per protocol. Completed 3/12/24. 2. Actions to prevent occurrence/recurrence implement: - All applicable facility policies and procedures (medication administration) were reviewed. - Re-educated licensed nurses on facility policies regarding medication administration as well as medication administration identification and transcription order guidelines. All nurses were educated and validated by test. - Educated the admission team on the importance of having the resident identifiers in place upon admission. Completed date 3/12/24. - Educate all orientees as part of the new hire process on medication administration identification and transcription orders. - The DON implemented a QAPI AD-Hoc to gather and process information from the audit with findings reported at the monthly QAA meeting for a minimum of 3 months. - Inservice Training Guide for Regulation F760 reviewed. The facility asserted likelihood for serious harm no longer existed 3/15/24. Included in the binder were:: - audits of all residents for 2 identifiers. - audits of medication orders for transcription errors, - Evidence of Medication administration observation of staff. - Evidence of licensed nurse training on facility policies regarding medication administration, and medication administration identification and transcription order guidelines, validated by medication errors policy review tests. The facility staff failed to ensure that Resident #16 was free from a significant medication error when the resident was administered medication (Methadone) that had not been prescribed, which caused the resident harm, and resulted in the resident ' s hospitalization . Based on the above actions taken by the facility and verified by surveyors on site, it was determined that the facility's deficient practice was past-noncompliance with a compliance date of 3/15/24 On 11/20/21 at 1:50 PM, the Nursing Home Administrator (NHA), the Director of Nurses, and Staff #6, [NAME] President of Operations were made aware of the above concerns, that the deficient practice had the potential to rise to a level of harm, and the concerns would be brought to the State Office for review. The NHA and Staff #6 acknowledged the concerns with no further comments offered at that time.

Based on clinical record review, review of the facility's Final Report of Investigation dated 9-16-13 for the elopement incident, and staff interview, it was determined that the facility staff failed to provide an assistive device and provide proper supervision (Resident #2) and to ensure the safety of a resident who was a known elopement risk (Resident #1). This was true for 2 out of the 3 residents in survey sample. The findings include: 1). Facility staff failed to provide a resident an assistive device and proper supervision. On October 9 and 10, 2013,a review of Resident #2's clinical record revealed that on 7/19/13 the resident was being pushed in a wheelchair from in front of the resident's room towards the Dining Room. The resident lowered their feet to the floor which caused the wheelchair to come to a sudden stop. The resident fell to the floor causing a laceration to their head. Nursing staff called 911 and the resident was sent to the hospital. Review of the incident revealed that the resident's wheelchair did not have leg rests attached. The resident's most current Minimum Data Set was completed on 5/2/13. The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A review of Section G0110E Activities of Daily Living (ADL) Assistance--Locomotion on unit revealed that staff scored the resident as a 4/2. This scored indicates that the resident is totally dependent on staff and needs one person for assistance with locomotion. The failure to provide an assistive device, the leg rests, and failure to provide proper supervision while transporting the resident allowed the resident's feet to fall to the floor causing the resident to fall from the wheelchair. The Director of Nursing was interviewed on 10/10/13 at 4:00 PM, and expressed an understanding of the incident. 2). Facility staff failed to ensure the safety of a resident who was a known elopement risk. On September 9, 2013,a review of Resident #1's clinical record revealed that the resident was admitted to the facility with a recent history of elopement. A review of the facility's Final Report of Investigation dated September 16, 2013 revealed that the resident on 9/12/13 had a conversation with Speech Therapist #1 about wanting to leave the facility after the resident's bags were packed. Interview with the therapist on 10/9/13 at 11:37 AM, revealed she told the social worker "around lunchtime" that the resident was at the nurses' station with packed bags and that the resident had attempted to leave with her via the elevator. The social worker then went upstairs to look for the resident. A Geriatric Nursing Assistant stated she saw the resident about 10 minutes earlier. The social worker went to the resident's room but did not find the resident. The Social Worker then alerted the upstairs staff and a search of the building began. The resident did leave the building and was found by facility staff a short distance from the facility. However, an interview with Receptionist #1 on 10/9/13 at 12:03 PM, revealed that the receptionist was not informed that the resident may have come downstairs with the intent to elope. The receptionist had the means to secure the front door so that only she could open door until it was reset. This security measure was not implemented. Failing to contact the receptionist denied her the opportunity to implement this security procedure. The Director of Nursing was interviewed on 10/10/13 at 4:00 PM, and she expressed an understanding of the findings.