Every finding on record at Autumn Lake Healthcare at Arcola

Based on observations, and interviews, it was determined that the facility failed to ensure separation between the clean and soiled area of the laundry room was maintained to prevent cross contamination. This deficient practice has the potential to affect all residents of the facility.The findings include: During the initial tour of the laundry room on 12/8/25 at 9:29 AM, a laundry aide (Staff #9) explained how she and other laundry aides process linens. Staff #9 also demonstrated how she processes dirty linens while 2 other laundry aides were in the clean side of the laundry room folding clean linens. During this time, it was observed that the laundry room was equipped with vinyl drapes that separated the dirty side from the clean side of the laundry room, acting as a doorway. However, it stayed open at about 50%, with the bottom part placed in a bin to prevent it from closing shut.The Housekeeping Manager (Staff #10) was interviewed on 12/11/25 at 2:25 PM. During the interview, the finding with the vinyl drapes was discussed, and was invited to inspect the laundry room. During the inspection, the vinyl drapes were observed in the same setup as the initial observation (held open at about 50% by keeping the bottom part of the drapes in a bin). The concern was discussed about cross contamination between the soiled and clean linens. Staff #10 proceeded to remove the drapes from the bin to form a barrier between the clean and soiled area. However, it was discovered that the drapes were missing a piece, about 6 inches, leaving an opening from top to bottom of the doorway. Staff #10 indicated that he would get it fixed.On 12/15/25 at 10:22 AM, Staff #10 reported that the vinyl drapes separating the clean from the soiled area of the laundry room had been fixed.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure potentially hazardous food items were cooled according to acceptable standards. These findings have the potential to affect all residents of the facility.The findings include: During the initial tour of the kitchen on 12/8/25 at 9:55 AM, an inspection of the stand-up refrigerator was conducted with dietary manager (Staff #20). Cooked food items were observed and dated in the refrigerator. The items were:a) Mac and cheese dated 12/6b) Turkey dated 12/7c) noodles dated 12/6 d) ground beef dated 12/7e) rice dated 12/7Staff #20 indicated that the food items were leftovers. She was asked if she had temperature logs for the leftovers and she reported that she had holding temp logs for when they were served. Staff #20 was asked specifically about the cool down process for the leftovers, and she reported that they don't monitor the temperature for leftovers because they were small amounts. She added, all meals are cooked and served on the same day and that it was not their practice to precook any meals.A subsequent interview with Staff #20 was conducted on 12/19/25 at 11:18 AM. During the interview, she denied that there was leftover ground beef in the refrigerator and reported that the other items listed above were prepared and served over the weekend (12/6/25 to 12/7/25), then the leftovers were dated and kept in the refrigerator for her to decide if they can/should be reused. She reported that all the leftovers were discarded on 12/8/25 after the observation with the surveyor.Staff #20 was again asked if the kitchen staff who prepared the food items listed above, go through the cool down process before storing it in the refrigerator. Staff answered Yes. then she was asked, was it documented. And she answered, No, we don't document that. The concern was discussed with Staff #20 that There was no credible evidence/documentation to indicate the kitchen staff had gone through the required cooldown process for potentially hazardous food items found in the refrigerator. Staff #20 verbalized understanding of the concern.

Based on observations, record reviews and interviews, it was determined that the facility failed to ensure residents at risk for developing pressure injuries received appropriate services for treatment and prevention. This was evident for 5 (Resident #23, #25, #15, #8, and #2) of 7 residents reviewed for pressure injuries. The findings include: During the initial pool phase, the following observations were made: a) On 12/8/25 at 12:53 PM, Resident #23 was observed sleeping in bed, equipped with an air mattress. The control box for the mattress was located at the foot of the bed and was observed to be set at max weight of 350 lbs.b) On 12/9/25 at 11:20 AM, Resident #25 was observed sleeping in bed, equipped with an air mattress. The control box for the mattress was laying on the floor by the foot of the bed and was observed to be set at weight of 280 lbs.c) On 12/9/25 at 11:40 AM, Resident #15 was observed sleeping in bed, equipped with an air mattress. The control box for the mattress was located at the foot of the bed and was observed to be set at weight of 320 lbs.d) On 12/9/25 at 11:46 AM, Resident #8 was observed sleeping in bed, equipped with an air mattress. The control box for the mattress was located at the foot of the bed and was observed to be set at max weight of 350 lbs. e) On 12/8/25 at 10:27 AM Resident #2's bed was observed unoccupied, equipped with a running low pressure air loss mattress. The control pump was hanging at the foot of the bed with a setting of 350lbs. A medical record review was conducted on 12/9/25 at 1:35 PM. The review revealed the current weight of the residents indicated above. Resident #23 weighed 146.8 lbs. on 12/4/25, Resident #25 weighed 178 lbs. on 12/3/25, Resident #15 weighed 129 lbs. on 6/28/25 (weight had been discontinued), Resident #8 weighed 125 lbs. on 12/3/25 and Resident #2 weighed 194.5lbs on 12/3/25. The review also revealed that the identified residents were all at risk in developing pressure injuries as they were assessed using the Braden Scale. The Braden Scale is a widely used healthcare tool to assess a patient's risk of developing pressure injuries/ulcers (bedsores) by evaluating six key factors: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear. Scores range from 6 (severe risk) to 23 (no risk), with lower scores indicating higher risk (e.g., 18 or less suggests at-risk status), guiding interventions for prevention. On 12/17/25 at 9:46 AM the Potomac Unit Manager (Staff #17) confirmed Resident #2's low air mattress was set at 350 lbs. and that it does not reflect the resident's current weight. On 12/17/25 from 9:53 AM to 9:58 AM, an inspection of the air mattress settings was conducted with the Director of Nursing (DON). The DON confirmed observations (a-d) listed above. On 12/17/25 at 11:05 AM during an interview, the DON explained the facility's process with the use of air mattresses and reported that it was the responsibility of the nursing staff to ensure that the settings were appropriate to the residents, including the weight setting. On 12/17/2025 at 11:05 AM the concern was discussed with the DON that an overinflated air mattress puts a resident at a greater risk for developing pressure injuries. The DON acknowledged the concern and reported that she would be conducting a facility-wide in-service to ensure all air mattress weight settings are appropriate to the residents.

Based on observation, record review and staff interviews it was determined that the facility failed to: 1) provide information to residents to formulate advanced directives, 2) identify a responsible party for an incapacitated resident, 3) document Advance Directive discussions in the medical record, and 4) ensure procedures for medical orders for life-sustaining treatment (MOLST). This was evident for 3 (Resident #67, Resident #6, #8) out of 4 residents reviewed for Advance Directives during the annual survey.The findings include: 1) Resident #67 was admitted into the facility in late 2025. A review of the resident's medical records on [DATE] at 10:36 AM revealed an admission evaluation for advanced directive dated [DATE] that indicated the resident did not have one in place but would like to receive information to formulate one. Also, the resident was certified as capable of understanding and making decisions by the facility's medical provider on [DATE]. A subsequent review of Resident #67's medical record on [DATE] at 12:10 PM, failed to indicate that an advanced directive had been formulated or that information was provided to the resident to formulate one. The Social Services Director (Staff #13) was interviewed on [DATE] at 12:50 PM. During the interview, she confirmed that she was responsible for providing capable residents with information to formulate advanced directives. A review of Resident #67's medical records was conducted with Staff #13 on [DATE] at 12:59 PM. She confirmed that an Advanced directive had not yet been formulated and reported that the information was provided to the resident who indicated that his/her children would help in filling out the forms. However, there was no documentation to indicate that Staff #13 had this discussion with the resident or followed up with the residents' children about completing the form. The concern was discussed with Staff #13 that there was no credible evidence or documentation to indicate that the information to formulate an advanced directive was provided to a capable resident. The social services Director verbalized understanding and acknowledged the concern. 2) On [DATE] at 7:19 AM a review of Resident #6's electronic health record revealed an initial admission date of [DATE] and a subsequent admission date of [DATE] with diagnosis of chronic atrial fibrillation, degenerative disc disease, hypertension, and hyperlipidemia. The Social Service assessment dated [DATE] documented Resident #6 to be oriented to time, person, place, and situation. On [DATE] at 9:09 AM a record review of the Advance Directive Assessment completed on [DATE] and [DATE] revealed that Resident #6 expressed interest in meeting with a member of the Social Service team to discuss steps to formulate an Advanced Directive. On [DATE] at 9:23 AM a record review of a Social Service progress note dated [DATE]: Advance Directive and resident rights were offered and reviewed. A review of the medical record did not reveal documentation of Advance Directive discussions. On [DATE] a review of Resident #6's paper chart revealed a physician certification of incapacity dated [DATE]. And, additional diagnoses of Dementia, Major Depression Disorder and Cognitive Impairment with a brief interview mental status of 8. On [DATE] at 10:05 AM in an interview, full-time Social Services Director, (Staff #13) confirmed it was Social Service responsibility to complete and document Advance Directives. She stated, If a resident has capacity, I give them the packet to complete and return it to me. I don't help them complete it. If a resident is deemed incapacitated, I provide the Surrogate Decision Making form to the designated person to complete and return it to me. On [DATE] a review of the electronic health record and the paper chart did not reveal a Surrogate Decision Making form or an Affidavit of Familiarity. On [DATE] at 10:35 AM in an interview, Staff #13 indicated that the person identified as the emergency contact verbally declined to make medical decisions and confirmed that Resident #6's record lacked documentation reflecting this discussion. Staff #13 further indicated that no follow-up arrangements for appropriate representation have occurred. The Nursing Home Administrator and Administrator in Training were made aware of this concern on [DATE]. 3) On [DATE] at 10:40 AM, Resident #8's record review of progress notes or care plan revealed no evidence that an Advance Directive was addressed or established. During and interview on [DATE], Staff #13 reported, If an Advance Directive is not in place, residents and families are provided with Advanced Directive information packets upon admission. If they decided to act on the information, we would place a copy in the medical record. Staff #13 acknowledged that there was no follow-up regarding Advance Directives. A review of Resident #8's medical record did not reflect any documentation of the delivery of Advance Directive information to the resident and/or their family or follow-up discussions. On [DATE] at 10:33 AM, a staff interview was conducted with Licensed Practical Nurse (LPN #4), employed at the facility for 3 months as a float to different nursing units. The surveyor inquired about the procedures to ensure residents' Code Status, Medical Order for Life-Sustaining Treatment (MOLST) forms, and Advance Directives. At 10:35 AM, LPN #4 abruptly stopped the interview and walked away to respond to a call light for room [ROOM NUMBER]. On [DATE] at 10:37 AM, an interview was conducted with Geriatric Nurse Assistant (GNA #23), an employee at the facility for 17 years. The surveyor proceeded to ask, Do you know how to determine a resident's code status in the event of an emergency? GNA #23 explained that GNAs do not perform cardio-pulmonary resuscitation (CPR). If a change in condition was observed, the GNA informs a nurse, who will run to the chart rack to review the resident's code status and call a code on the phone, and other nursing staff come running quickly. On [DATE] at 10:55 AM, Medication Aide (Staff #7), who has worked at the facility for more than 52 years, was interviewed. The surveyor asked Staff #7, What would you do if there was an emergency situation and you needed to determine their code status? Staff #7 told the surveyor, I need to get an order. At 11:02 AM, LPN #4 and Staff #7, were asked, Is there any way to determine a resident's code status at the computer you are standing at? Staff #7 stated, We can look in the chart or [the electronic record] to determine code status. When the surveyor asked Staff #7 to provide a demonstration, Staff #7 showed the surveyor the Medication Administration Record (MAR) screen and confirmed that it does not display a resident's code status. LPN #4 was unable to navigate out of the MAR to show the surveyor where a resident's code status could be determined. On [DATE] at 11:20 AM LPN #6 was asked, If there's an emergency, how would you verify a resident's code status or advanced directive? LPN #6 stated, if there is a change in a resident's condition, I will go to the hard chart or look under the 'misc.' tab in the electronic medical record. LPN #6 navigated out of the MAR, accessed and reviewed orders, and located the standing 'refer to MOLST' order. However, review of the MOLST revealed that it was for the District of Columbia, not Maryland and therefore not an active order for life-sustaining treatment. LPN #6 acknowledged that best practice is to check the paper chart. On [DATE] at 2:16 PM, during an interview, the Director of Nursing (DON) replied nursing staff can review the order on [the electronic record] but needs to review the resident's hard chart when describing their process for determining a resident's code status. On [DATE] at approximately 10:55 AM, in an interview, the Medical Director (Staff # 22) , acknowledged that scanning and keeping a resident's MOLST in the electronic record is dangerous. On [DATE] at approximately 11:00 AM, Staff #22 was made aware that four out of five staff could not clearly state the expected process or provide a demonstration that would have enabled a swift, efficient emergency response and acknowledged that current staff practice aligns with expected standards of professional care.

Based on observation and interviews, it was determined that the facility failed to ensure that medications and medical equipment available for resident use were within their expiration dates. This was evident in 3 out of 3 medication storage areas reviewed during the survey.The findings include: On [DATE] at 10:35 AM, an observation of the first-floor medication storage unit was conducted with the Charge Nurse (Staff #17). The Charge Nurse reported that all items in the storage room were available for resident use. Observation revealed a box of [NAME] and Nephew prep wipes that was approximately half full, having an expiration date of [DATE]. Further observation revealed a box of Refresh eye drops prescribed for Resident #115 with an expiration date of 10/2025. The expiration dates were confirmed by Staff #17. Staff #17 removed the expired item from the room.On [DATE] at 10:59 AM, an observation of the second medication storage unit was conducted with the Charge Nurse (Staff #18). Observation of the cabinet counter revealed one package of Safe Step needle 20 Gauge (G) x 0.75 inch (3/4) with an expiration date of [DATE] and a suction catheter with an expiration date of [DATE]. The expiration dates were confirmed by Staff #18. Staff #17 removed the items.On [DATE] at 11:07 AM, continued observation with Staff #18 of the second-floor wall cabinet located outside the medication storage room revealed seven boxes of Tender Gentle Calcium Alginate wound dressings. Further observation revealed that four of the boxes were open, with at least one individual dressing package opened and part of a dressing removed. Further observation failed to reveal that the opened individual packages were labeled with the date and time the package was opened. Staff #18 confirmed that once a wound dressing package was opened, it should be labeled with the date opened.On [DATE] at 11:28 AM, an observation of the basement medication and medical equipment storage room was conducted with GNA/medical records staff (Staff #19). Observation revealed ten Angiocath Shielded Catheter Infusion Sets with an expiration date of [DATE] and ten Entra Flo 1000 ml gravity feeding sets with an expiration date of [DATE]. Further observation revealed approximately eight tracheostomy clean and care kits with an expiration date of 2//31/22 and more than eight nebulizer adapters with an expiration date of [DATE]. All expiration dates were confirmed by staff. Staff #10 placed all expired items in a box and reported that the items were being removed from the storage room. On [DATE] at 9:32 AM, during an interview, the Administrator confirmed that medications and medical equipment should be used within their expiration dates.

Based on record reviews and interviews, it was determined that the facility failed to ensure that education was provided to the resident's representative regarding the benefits and potential side effects associated with the COVID-19 vaccine. This was evident in 1 (Resident #71) of 5 residents reviewed for immunizations.The findings include: A review of Resident #71's immunization records from the electronic health record (EHR) on 12/11/25 at 3:39 PM, revealed COVID-19 vaccine was refused:a) On 11/13/23 by the resident, education providedb) On 10/17/24 by the resident, no education was providedc) On 10/15/25 by the resident, education providedThe Infection Preventionist Nurse (Staff #20) was interviewed on 12/15/25 at 10:29 AM. During the interview, she explained the facility's process with vaccinations/immunization, and how they are documented in the resident's medical record. A review of Resident #71's immunization records in the EHR was conducted with Staff #20 on 12/15/25 at 10:53 AM. She confirmed the findings listed above and indicated that she would review the resident's medical record and report back to the surveyor.A review of Resident #71's hard chart on 12/15/25 at 12:38 PM, revealed the consent forms for the COVID-19 vaccines. The forms indicated that the resident had declined, signed, and had been educated on the dates listed above. The resident's hard chart also revealed that the resident was certified as incapable of understanding and making medical decisions by 2 providers on 5/8/23.The findings were discussed with the Administrator in Training (AIT) on 12/15/25 at 1:48 PM. The AIT confirmed the findings, and the concern was discussed that although the resident had signed the declination of the vaccines and had been educated, s/he was certified by 2 providers as not having the capacity to understand and make decisions him/herself. The AIT verbalized understanding and acknowledged the concern.

Based on interviews, observation and record review, it was determined that the facility failed to provide legible, timely and accurate facility documents as required per the Centers for Medicare and Medicaid Services (CMS) entrance conference worksheet. This was evident at the entrance conference for this survey period. On 12/8/25 at 9:20 AM the surveyor and Acting Director of Nursing DON) commenced the entrance conference. Surveyor provided and reviewed a copy of the CMS entrance conference worksheet and other applicable documents to the DON. The required documentation and timeline for compliance was reviewed. Documents that were due upon entrance and actual date and time received were: On 12/8/25 at 12:23 PM- Census On 12/9/25 at 9:45 AM- Complete matrix for new admissions Documents that were due within 4 hours of entrance and actual date and time received were: On 12/9/25 at 7:23 AM- Complete matrix for all other residents. A record review of this document revealed inaccurate documentation for a hospice resident (Resident #144) and it was illegible. On 12/9/25 at 9:45 AM, in an interview, the Administrator in Training (AIT) acknowledged that the matrix was illegible and the error related to Resident #144's hospice status. On 12/9/25 at 1:15 PM the AIT provided an updated resident matrix that still inaccurately reflected Resident #144's hospice status. At that time, AIT was made aware of the concern of timeliness, illegibility and accuracy of Matrix.

Based on record reviews and interviews, it was determined that the facility failed to ensure that education was provided to the resident's representative regarding the benefits and potential side effects of the influenza and pneumococcal immunizations. This was evident in 1 (Resident #71) of 5 residents reviewed for immunizations.The findings include: A review of Resident #71's immunization records from the electronic health record (EHR) on 12/11/25 at 3:39 PM, revealed influenza immunizations were refused and education was provided to the resident on 4/1/23, 10/6/23, and 9/23/25. There was no documentation in the EHR to indicate the resident received or declined the influenza immunization for the year 2024.The Infection Preventionist Nurse (Staff #20) was interviewed on 12/15/25 at 10:29 AM. During the interview, she explained the facility's process with vaccinations/immunization, and how they are documented in the resident's medical record. A review of Resident #71's immunization records in the EHR was conducted with Staff #20 on 12/15/25 at 10:53 AM. She confirmed the findings listed above and indicated that she would review the resident's medical record and report back to the surveyor.A review of Resident #71's hard chart on 12/15/25 at 12:38 PM, revealed a consent form for the influenza immunization was signed and education was provided to the resident representative on 9/12/24. The resident's hard chart also revealed that the resident was certified as incapable of understanding and making medical decisions by 2 providers on 5/8/23.The findings were discussed with the Administrator in Training (AIT) on 12/15/25 at 1:48 PM. The AIT confirmed the findings, and the concern was discussed that on 10/6/23 and 9/23/25, Resident #71 made the decision to refuse and receive education regarding the benefits and potential side effects of influenza immunization. However, the resident was certified by 2 providers as not having the capacity to understand and make decisions for him/herself. The AIT verbalized understanding and acknowledged the concern.

Based on interview and record review, the facility failed to provide quarterly financial statements to residents, as required. This deficiency was identified for 4 (# 114, # 133, #2, #138) out of 5 residents reviewed for personal funds.The findings include: On 12/8/25 at 1:45 PM, Resident #114, a long-term resident since March 2025, reported that the facility managed her/his personal funds. The resident stated that no financial statements had been received.On 12/17/2025 at 11:19 AM, Resident #133, admitted to the facility in February 2025, reported that the facility managed her/his personal funds and that no financial statements had been received since admission.On 12/17/2025 at 1:33 PM, Resident #2, without cognitive decline and admitted to the facility over one year ago, reported that the facility managed her/his personal funds and that only one financial statement had been received.On 12/17/2025 at 1:27 PM, Resident #138, a long-term resident without cognitive decline, reported that the facility managed personal funds and that quarterly financial statements had not been received.On 2/16/25 at 3:24 PM, an interview with the business manager (Staff #11), revealed that the facility's financial system automatically generated quarterly statements, which were placed in envelopes and delivered to the residents by the activities department. Staff #11 reported that residents were not required to sign for receipt of the statements and that the business office did not receive confirmation of delivery.On 12/17/25 at 9:23 AM, an interview with the activity's director (Staff #20), indicated that envelopes containing quarterly financial statements were delivered to residents as provided by the business office. Staff #20 reported that no documentation was maintained to verify resident receipt of the statements. On 12/16/25 at 3:24 PM, the business manager provided quarterly financial statements dated 7/01/2025 through 9/30/2025 for Residents 's114, 133, 2, and 138. Review of the records failed to show resident or resident representative signatures acknowledging receipt of the quarterly financial statements. On 12/18/25 at 9:32 AM, the administrator confirmed that the business office did not maintain documentation verifying that residents received quarterly financial statements.

Based on observation, record reviews and resident and staff interviews, it was determined that the facility failed to ensure that the Grievance policy and process were properly implemented. This was evident for 3 out of 3 units reviewed during the annual survey. On 12/9/25 at 12:50 PM, in an interview, a Potomac Unit resident (Resident #32) conveyed that s/he had reported a recent incident to the unit manager (Staff #17) and that nothing came of the concern. Upon intentional observation of the Potomac Unit, the surveyor did not observe the Grievance Officer's name and contact information, accessible grievance forms or anonymous grievance boxes. On 12/16/25 at 10:58 AM the Administrator in Training (AIT) reported that any staff member who received a grievance was expected to report it to the unit manager or charge nurse. The unit manager was expected to complete a concern form initiating the grievance process. He stated that concern forms are located at the nurses' station. On 12/16/2025 at 11:14 AM the Regional Director of Nursing (Staff #12) reported that the facility does not want Geriatric Nurse Assistants (GNAs) to initiate a concern form independently. The expectation was to report a concern to a charge nurse or unit manager. Anonymous concerns can be reported through the facility hotline and/or email. The hotline number goes to the Regional Office and then we contact the facility. She stated that the Grievance Officer and contact information was posted throughout the facility. She indicated that staff would provide a concern form to any resident, family member and visitor upon request. The Grievance Officer oversees the grievance process. On 12/16/2025 at 11:16 AM a second surveyor observed the Gateway and Chesapeake Units and reported that no notices for the Grievance Officer's name and contact information and did not observe accessible grievance forms or labeled and locked anonymous grievance boxes.On 12/16/25 at 11:28 AM the surveyor asked the AIT to show the location of the posting and Grievance Box on the Potomac Unit. We walked off of the Potomac Unit, down the long hallway, at the transition doorway where he pointed to a paper sign thumbtacked to a bulletin board that read Compliance hotline. Next to the bulletin board hung a non-labeled, non-locking empty plastic brown bin that he indicated as the Grievance Box. On 12/16/25 the Potomac Unit Manager (Staff #17) indicated that concern forms are not at the nurses' station; they are in my office. She also stated, I complete the concern form and place it in a folder labeled Inservice for agency nurses and in-house nurses. On 12/16/25 at 12:07 PM in an interview, the Social Service Director (Staff #13) identified herself as the Grievance Officer and reported that staff initiate a concern form and send it to her. She meets with the individual departments; they investigate it, and bring it back to her. She then puts it in the grievance log. On 12/16/25 at 12:20 PM a review of the grievance log did not reveal any concern that referenced Resident #32's concern. On 12/16/25 at 12:42 PM in an interview, the Nursing Home Administrator (NHA) stated that the concern forms are located at each unit's nurses' nation. He stated residents, visitors, and family can get the Grievance Officer's contact information at each unit's bulletin board. On the Potomac Unit's bulletin board, he pointed to a sign that read [NAME] Lake Healthcare at Arcola Abuse Coordinator: [NAME] Gbenle (301) [PHONE NUMBER] ext. 2756. He stated Abuse and Grievance are the same. On 12/16/25 at 1:08 PM a review of the Grievance Policy dated 12/23/22 revealed, in part, that the grievance notice with Grievance Officer information will be posted in prominent locations throughout the facility, written decisions will be provided and the ability to file anonymously. On 12/16/25 at 2:02 PM the surveyor and NHA reviewed previously submitted concern forms dated 10/6/25, 10/20/25, 11/13/25; he acknowledged that each example revealed improper implementation of the grievance policy and process.

Based on record reviews and interviews, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medication use and failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days. This was evident for 3 (Resident #144, #15, and #5 ) of 7 residents reviewed for unnecessary medications.The findings include: 1) Resident #144 had been a resident of the facility since late-2024. The resident was admitted with diagnoses that include dementia with psychotic disturbance. Dementia with psychotic disturbance, or dementia-related psychosis (DRP), involves hallucinations (seeing/hearing things) or delusions (fixed false beliefs, like theft or persecution) in people with dementia, significantly increasing distress and burden. Common in conditions like Alzheimer's and Dementia with Lewy Bodies (DLB), it's characterized by visual hallucinations and misidentification. Management focuses on non-drug approaches first, as antipsychotics carry risks, and aim to reassure rather than argue with the delusions. A review of Resident #144's medical records was conducted on 12/10/25 at 12:32 PM. The review revealed an order for psychotropic medication on a PRN schedule. The order had a start date of 7/25/25 with an indefinite end date. On 12/15/25 at 9:47 AM, a subsequent review of Resident #144's medical record was conducted. The review revealed the administration record for the PRN psychotropic medication and indicated that it was administered on 9/11/25 at 8:09 PM. However, no other documentation was found to indicate why the medication was administered or if any non-pharmacological interventions were administered/attempted prior to the PRN psychotropic medication. The facility's policy for the use of psychotropic medications was provided by the Administrator in Training (AIT) on 12/14/25 at 2:52 PM. Under Policy Explanation and Compliance Guidelines, item #6 indicated non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications; and item #16 indicated that PRN orders for psychotropic medications are limited to 14 days. In an interview with the AIT on 12/15/25 at 2:58 PM, the findings were reviewed that Resident #144's PRN psychotropic medication was not limited to 14 days, and that it was administered on 9/11/25, but there was no documentation to indicate why it was administered and if any non-pharmacological approach was attempted. The AIT reported that he would review the resident's medical record and report back to the surveyor. At the time of survey exit on 12/19/25 at 2:35 PM, the concerns were again reviewed, and no further documentation was provided by the facility staff. 2) Resident #15 had been residing in the facility since mid-2009. A review of the Resident's medical records was conducted on 12/10/25 at 12:59 PM. The review revealed an order for a psychotropic medication on a PRN schedule. The order had a start date of 8/22/25 with an indefinite end date. The facility's policy for the use of psychotropic medications was provided by the Administrator in Training (AIT) on 12/14/25 at 2:52 PM. Under Policy Explanation and Compliance Guidelines, item #16 indicated that PRN orders for psychotropic medications are limited to 14 days. In an interview with the AIT on 12/15/25 at 2:58 PM, the concern was discussed that Resident #15's order for PRN psychotropic medication was not limited to 14 days. The AIT reported that he would review the resident's medical record and report back to the surveyor. At the time of survey exit on 12/19/25 at 2:35 PM, the concern was again reviewed, and no further documentation was provided by the facility staff. 3.) On 12/16/2025 at 9:50 AM, a review of R# 5's medication orders revealed: Entry date of 7/27/2025:Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium). Give 1 tablet by mouth two times a day for mood swings.Entry date: 7/31/2025 Melatonin Oral Tablet 3 MG (Melatonin). Give 2 tablet by mouth at bedtime for insomnia 2 tabs= 6mg. On 12/16/2025 at 10:00 AM, R# 5's medical diagnoses were reviewed. On 12/16/2025 at 10:10 AM, the review of R #5's record revealed:Entry Date: 7/24/2025Monitor for Side Effects of Sedative / Hypnotic Medication (burning or tingling in hands/feet, changes in appetite, constipation, diarrhea, dizziness, drowsiness, dry mouth or throat, headache, stomach complaints, tremors, weakness).Uses Sedative/ Hypnotic Medication: [Melatonin] Entry Date: 7/27/2025Enter the number that coincides with the behavior: 0 - no behavior noted, 1-Agitation, 2-Restlessness, 3-Wandering, 4-Withdrawal,5-Combativeness, 6-Verbal outbursts, 7-Refusal of Care, 8-Tearfulness, 9-Anxiety, 10-Paranoia, 11-insomnia.Every shift for Psychotropic Medication Use. On 12/16/2025 at 10:35 AM, R# 5's Medication Administration Record (MAR) did not reveal that side effect monitoring was monitored and documented for 'psychotropic medication use' as indicated by the 7/24/2025 order entry date. R #5's MAR did reveal that side effect monitoring was in place for the 'use of sedative/hypnotic medication: [melatonin]' from 7/27/2025. At 10:50 AM, a review of R #' 5's physical chart revealed that the admission medication regimen review documentation, completed by Staff #21 on 7/24/2025, was marked 'No recommendations.' On 12/16/2025 at 11:25 AM, a review of R #5's electronic record revealed subsequent monthly medication regimen reviews completed by Staff #21 for August, September, October, November, and December 2025. Each entry stated, No recommendations. On 12/16/2025 at 11:55 AM, R #5's record revealed that behavioral health (psych) services provided a consultation on 7/27/2025. There were no recommendations from the provider regarding evidence that a gradual dose reduction (GDR) was contraindicated or recommended. On 12/19/2025 at 10:08 AM, during an interview with Staff #21, they were asked, If no recommendations were made, and there was no evidence of side effect monitoring, what documentation demonstrates continued use was clinically appropriate? Staff #21 stated to the surveyor, I tend just to review the chart. I don't type up notes – I determine as I review if there is a need to review. On 12/19/2025 at 10:50 AM, during an interview with Staff #22, they were asked by the surveyor, What specific symptoms prompted the use of Depakote for [R# 5]? Staff #22 stated, [R# 5] was not taking it for seizure disorder. R# 5 was taking it for a mood disorder, and the resident had a history of cognitive impairment. They are seen by psych services because 'sundowning' had been present in the resident. This medication has been known to manage symptoms best. The surveyor followed up with Where is that risk–benefit analysis documented? Staff #22 defers to the psych services provider and the consultative documentation that would have been provided. R #5's chart has an admission medication regimen review from the psychiatric services provider from July 2025. Staff #22 stated, Our psychiatrist confirms that a GDR should be attempted with Depakote after 3-6 months with no symptoms of agitation, combativeness, etc. On 12/19/2025 at 11:50 AM, There was no evidence provided by the end of the survey that R #5, who was receiving Depakote Delayed Release 125 MG two times a day for mood swings as a psychotropic medication, was monitored for adverse consequences, as evidenced by the absence of documented side effect monitoring, lack of gradual dose reduction attempts, or documented contraindications, and repeated medication regimen reviews documenting no recommendations without evidence of clinical analysis. Refer also to F756.

Based on interviews and record review, the facility failed to report an allegation of misappropriation of resident property to the appropriate state agency. This deficiency affected one of one resident reviewed for abuse (Resident #65).The findings include: On 12/17/2025, during an interview with Resident #65's personal representative, she reported that the resident's cell phone went missing while s/he resided at the facility. The representative reported she did not know what happened to the phone. The representative stated that the facility was in the process of providing funds to replace the missing phone.On 12/18/2025 at 12:00 PM, review of the grievance record revealed that the phone was not recovered and that the facility planned to reimburse the resident for the cost of the phone. The grievance documentation confirmed that the iPhone was listed as a personal item on the resident's original inventory sheetOn 12/18/2025 at 2:30 PM, an interview was conducted with the Administrator-in-Training (AIT). The AIT stated that the missing phone was not reported to the Office of Health Care Quality (OHCQ) as a possible misappropriation because the resident representative did not state that the phone was stolen and the resident reported that s/he misplaced it. The surveyor requested documentation related to the facility's investigation of the missing phone.On 12/19/2025 at 9:05 AM, the facility provided the investigation file. Review of the investigation revealed that ten (10) staff members were interviewed on 9/26/2025. Each staff member was asked one question: Did you in any way come across Resident #65's cell phone? All ten staff members responded no. Review of the investigation file revealed that Resident #65 was interviewed by a nurse (Staff #17). Documentation indicated that when asked about the missing phone, the resident stated, Yes, I think I misplaced the phone after using it today. Documentation showed that the phone was reported missing the day after it was discovered. Continued review failed to reveal that a police report was on file. On 12/19/2025 at 1:02 PM, Resident #65 was interviewed by the surveyor and stated, Someone took it, when asked what s/he believed happened to her/his iPhone. On 12/19/2025 at 1:10 PM, review of the resident's hard chart revealed that Resident #65 lacked capacity to make healthcare decisions. On 12/19/2025 at 1:12 PM, review of the Brief Interview for Mental Status dated 10/10/2025 revealed that Resident #65 had moderate cognitive impairment. On 12/19/2025 at 1:05 PM, during an interview, the Administrator confirmed that the facility only reported missing items when theft was confirmed. The Administrator acknowledged the resident's cognitive decline and stated that the resident representative was unsure what happened to the phone.

Based on records review and interviews, it was determined that the facility failed to complete a comprehensive assessment within the mandated timeframe. This was evident for 1 (Resident #8) of 3 residents reviewed for resident assessmentsThe findings include: Resident #8 was admitted into the facility in early 2025. A review of the resident's medical record was conducted on 12/11/25 at 9:26 AM. The review revealed that the most current comprehensive assessment with an assessment reference date (ARD) of 10/21/25 was currently still in progress.In an interview with the Registered Nurse (RN #8) on 12/11/25 at 10:11 AM, she confirmed that she was the facility's coordinator for comprehensive assessments. RN #8 reported her process in completing each section of the assessment, and that 2 corporate nurses go over her work and are responsible in signing the section (section Z) to indicate all sections have been completed.A review of Resident #8's medical record was conducted with RN #8 on 12/11/25 at 10:17 AM. She reported that the comprehensive assessment with an ARD of 10/21/25 had been completed but was still showing as in progress because it had not yet been submitted. RN #8 was asked to print the assessment report to reveal all the sections.In a subsequent interview with RN #8 on 12/11/25 at 12:21PM, Section Z of the printed copy of the assessment report for Resident #8, was reviewed. The review revealed that the assessment was completed on 11/28/25 (38 days from the ARD). RN #8 was asked how many days it should be completed. She indicated that it was completed timely but would ask the corporate nurses to verify and report back to the surveyor.On 12/11/25 at 12:59 PM, RN #8 reported that she had reviewed Resident #8's medical record, specifically the comprehensive assessment with ARD 10/21/25, with the corporate nurses and stated, we are late.

Based on record review and staff interviews, it was determined that the facility failed to ensure accuracy and timeliness of resident's comprehensive care plan. This was evident for 2 (Residents #2, #23) of 4 residents reviewed for care planning during this survey.The findings include: 1) A care plan is a resident-centered document, prepared by an interdisciplinary team (IDT), that reflects the individual and unique needs of each resident. It describes the plan of care, goals of care and effectiveness of care. A comprehensive care plan must be completed within 7 days of completing a comprehensive assessment. This assessment includes admission, annual or a change in the resident's condition. The Minimum Data Set (MDS) is a federally mandated assessment tool used to gather information on each resident's most current health status and care needs that are used to determine care planning decisions. The assessment reference date (ARD) is the specific date used to indicate the resident's most current health assessment data for MDS purposes. On 12/16/25 at 3:06 PM a record review of Resident #2's Annual assessment MDS revealed an ARD of 10/17/25 and a completed date of 11/5/25. Section Z- Assessment Administration was signed and dated 11/05/25. On 12/16/25 at 3:23 PM a record review of a Progress note dated 10/17/25 revealed that a Care plan meeting was held with IDT for Resident #2. On 12/16/25 at 3:44 PM in an interview, the Social Service Director (Staff #13) confirmed that Resident #2's last care plan meeting was on 10/17/25, before the MDS was completed and signed. She acknowledged that she was unaware that the regulation required a comprehensive care plan must be conducted within 7 days of completing a comprehensive assessment . 2) Resident #23 had been a resident of the facility since late 2022. A review of the resident's medical record on 12/9/25 at 2:28 PM revealed progress notes by the social services department indicating that the last 3 care plan meetings dated 5/2/25, 8/19/25, and 11/4/25 had been rescheduled. However, there was no documentation to indicate that these care plan meetings took place on a later date. The Social Services Director (Staff #13) was interviewed on 12/16/25 at 1:33 PM. During the interview, she explained the process in scheduling care plan meetings and confirmed that she and her assistant were responsible in coordinating and scheduling them. Also, during the interview, Resident #23's medical record was reviewed with Staff #13. She confirmed that the last care plan meeting was scheduled for 11/4/25 and reported that the resident's family member was called to join the meeting via phone. However, the family member did not pick up so they decided to reschedule the meeting. Staff #13 was asked when the care plan meeting was rescheduled. She reported that it had not yet been rescheduled but offered no explanation why. Furthermore, Staff #13 confirmed that the care plan meetings for Resident #23 that were scheduled for 5/2/25 and 8/19/25 did not take place as well because the family members were not able to join in person or answer their phone to join via teleconference. She stated, when you call the family member they are not picking up. The concern was discussed with Staff #13 that the regulation does not require family members to attend the care plan meetings. However, the facility is required to have the meeting and develop the comprehensive care plan within 7 days after the completion of the comprehensive assessment. On 12/16/25 at 3:22 PM, the findings were discussed with the Nursing Home Administrator (NHA) and the Administrator in Training (AIT). Both staff acknowledged that the care plan meetings still need to take place even if family members or residents cannot or refuse to attend them. The NHA and AIT verbalized understanding and acknowledged the concern.

Based on resident and staff interviews and record review, it was determined that the facility staff failed to ensure that a dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 (Resident #4) of 5 residents reviewed for activities of daily living during the survey process. On 12/9/25 at 12:02 PM, in an interview, Resident #4 stated that s/he does not get showers as often as s/he would like. The Brief Interview for Mental Status (BIMS) revealed a score of 14 indicating adequate cognitive ability. On 12/16/25 at 9:23 AM, a review of Treatment Administration Record (TAR) in the electronic health record: Point, Click, Care (PCC) revealed Resident #4 received only six showers in November. A review of the shower assignment book revealed Resident #4's shower days as Wednesday and Saturday.A review of the Annual Assessment for the Minimal Data Set (MDS) dated [DATE] Section F revealed that it was very important to choose between a bath, shower, bed bath, or sponge bath and the MDS dated [DATE] Section GG revealed Resident #4 was dependent. The MDS is a federally mandated assessment tool that reflects information regarding each resident's health status and care needs. On 12/16/2025 at 9:46 AM a review of Resident's #4 TAR lacked documentation that Resident #4 refused showers. On 12/16/2025 at 10:20 AM in an interview, Geriatric Nursing Assistant (GNA #16) reported that residents were scheduled for showers two days/week. If a resident refused a shower, staff should document refused and give a bed bath. On 12/16/25 at 10:51 AM GNA #16 was unable to provide documentation that Resident #4 refused showers. On 12/19/25 the Nursing Home Administrator was made aware of this concern.

Based on observations, record reviews, and interviews, it was determined that the facility failed to provide activities to residents based on their comprehensive assessment to support the physical, mental, and psychosocial well-being. This was evident for 1 (Resident #9) of 3 residents reviewed for activities.The findings include: Resident #3 was a long-term resident of the facility, admitted in late 2015. Current diagnosis includes but not limited to Cerebral infarction.Cerebral infarction, also known as an ischemic stroke, is the death of brain tissue (infarct) from a sudden blockage of a blood vessel supplying the brain, cutting off oxygen and nutrients, making it a medical emergency requiring immediate treatment like clot-busting drugs (tPA) or surgery to restore blood flow and prevent permanent damage, leading to symptoms like weakness, speech problems, and vision issues. On 12/8/235 at 1:01 PM, the resident was observed in bed, lying steady, awake with no activity being provided.A review of Resident #9's medical record on 12/16/25 at 9:42 AM revealed the last annual comprehensive assessment with an assessment reference date of 12/22/24, section C indicated severely impaired cognitive skills for daily decision making; section F indicated resident is rarely/never understood and family /significant other not available to interview for daily and activity preference, and staff assessment of daily and activity preference indicated that the resident prefers to spend time outdoors.The Director of Activities (Staff #20) was interviewed on 12/16/25 at 9:47 AM. During the interview, she explained her process with providing activities to all the residents and documentation. She also reported that she had enough activity aides to complete all necessary tasks for activities.Staff #20 elaborated on documentation and indicated that for residents who are rarely/never understood, she and her aides provide in-room and 1:1 activities. A specific binder for these residents was provided to the surveyor for review. A total of 24 residents, including Resident #3, were documented in the binder showing the in-room and 1:1 activity provided in a checklist form separated by days of each month.Staff #20 was asked about outdoor activities. She reported that outdoor activities are documented in the group activity binder and provided it to the surveyor for review. The documentation was somewhat in a chronological order and revealed a group activity titled Sunshine Club dated 9/15/25. Staff #20 explained that it was the facility's outdoor activity where residents spend time outdoors, socializing, and listening to music, when the weather permits. Residents who participated in the activity were listed on the document. Staff #20 was asked, did any of the residents listed in the 1:1 binder participate in the facility's outdoor activity. She answered, No and explained some of the residents listed in the 1:1 binder are taken out by their family (Staff named 3 residents) or if they have a sitter (Staff named 1 resident). However, Staff #20 reported that when family members or sitters take residents to spend time outdoors, it is not documented in the residents' medical records.Staff #20 was asked, how about the residents who don't have family members or sitters. She did not provide an answer and/or explanation. The concern was discussed with Staff #20 that residents who are fully dependent on staff, and are rarely/never understood, who don't have family members or sitters, are not given the opportunity to spend time outdoors. Staff #20 stated, I understand what you mean. In an interview with the Nursing Home Administrator and Administrator in Training on 12/19/25 at 12:30 PM, the concern with activities for residents who are fully dependent on staff and a rarely/never understood was discussed. Both staff acknowledged the concern.

Based on record review, observation, and interview, it was determined that the facility failed to provide pain management in accordance with the resident's physician orders and professional standards of practice. This was evidence for 1 (R #2) of 4 residents reviewed for pain management during the recertification survey. The findings include: On 12/18/2025 at 9:27 AM, during a review of R #2's medical record, it was evident that pain medication was being administered to the resident outside of the ordered parameters for that current month of December 2025 and the previous month of November 2025.A review of ordered pain medication and related interventions for R #2 is as follows:Order entry date 08/16/2025 for: Assess resident for Pain Q (every) shift. Document Y/N. Y = Yes; N = No. If yes, medicate as ordered for pain and notify MD (the physician or relevant provider) if pain is not controlled every shift for pain evaluation.Order entry date 08/17/2025 for: OxyCONTIN Oral Tablet ER 12 Hour Abuse-Deterrent 30 MG (Oxycodone HCl) - Give 1 tablet by mouth every 12 hours for Abuse deterrent, do not crush, chew, or split.Order entry date 08/19/2025 for: Acetaminophen (Tylenol) Oral Tablet 500 MG - Give 2 tablets by mouth every 8 hours as needed for pain 1-5 out of 10.Order entry date 08/19/2025 for: HYDROmorphone HCl (Dilaudid) Oral Tablet 2 MG - Give 3 tablets by mouth every 4 hours as needed for pain 6-10 out of 10.On 12/18/2025 at 10:35 AM, 7 documented administrations of as-needed hydromorphone were identified, administered to R #2 below the ordered parameters of 6-10.On R #2's Medication Administration Record ( MAR) for 12/5/2025, for the Pain Level documentation provided for HYDROmorphone HCl Oral Tablet 2 MG (Hydromorphone HCl) Give 3 tablet by mouth every 4 hours as needed for pain 6-10, the pain score was documented as '2' at 4:00 PM. On 12/8/2025, the pain score was documented as '4' at 4:15 PM. On 12/9/2025, the pain score was documented as '3' at 4:00 PM. On 12/11/2025, the pain score was documented as '2' at 12:11 AM. On 12/14/2025, the pain score was documented as '5' at 2:41 AM. On 12/15/2025, the score was documented as '5' at 2:25 AM. For 12/17/2025, the pain score was '3' at 5:00 PM.On 12/18/2025 at 11:10 PM, the surveyor concluded that there was no supporting evidence that the ordering physician approved the administration of R #2's hydromorphone at the corresponding pain documented pain scores. This prompted the surveyor to expand the review to include the administration of R #2's hydromorphone from 10/2025 to 12/2025.On 12/18/2025 at 11:15 PM, the surveyor reviewed 12 documented administrations on R #2's MAR for November 2025 of as-needed hydromorphone identified as administered to the resident below the ordered parameters of 6-10.On 12/18/2025 at 12:21 PM, the surveyor reviewed 5 documented administrations of as-needed hydromorphone on R #2's MAR for October 2025, identified as administered below the ordered parameters of 6-10 to R #2. On 10/1/2025, the score was '0' at 1:30 AM. On 10/1/2025, the score was '3' at 9:28 PM. On 10/12/2025, the score was '5' at 5:09 PM. On 10/13/2025, the score was '0' at 12:40 AM. On 10/31/2025, the score was '5' at 2:29 AM. There was no supporting evidence in R #2's record that the physician was notified and provided an order. On 12/18/2025 at 12:40 PM, during an interview with Nurse #17, who also stated they were the unit manager for the unit where R #2 resides in the facility, was asked to review the pain medication protocol ordered for the resident and to discuss the pain scale. Nurse #17 stated that most residents have a standing Tylenol order unless contraindicated for 0-5 level pain. Residents are reassessed 30 minutes to 1 hour after administration to determine if the medication was effective or whether a next PRN (as needed) is needed, or to obtain a different order.On 12/18/2025 at 12:45 PM, the surveyor asked Nurse #17 to review R #2's MAR together jointly. Nurse #17 could not demonstrate to the surveyor how to access the MAR on the electronic record. The surveyor prompted Nurse #17 to R #2's MAR in the facility's electronic medical record to review the dates in question. On 12/18/2025 at 12:57 PM, during the review of R #2's MAR where the resident was provided medication at a level below 6-10/10 on the pain scale, Nurse # 17 stated, R #2 is well known to be in chronic pain. However, the documentation does not reflect the need for the medication, as the resident is reporting pain scores below 6-10. Nurse #17 goes on to state that R #2's pain concerns have been addressed with the provider. However, there is no documented evidence in the medical record that nursing or medical staff have addressed the resident taking PRN medication outside of ordered parameters. On 12/18/2025 at 1:20 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if they were aware that R #2 was being administered pain medication outside of the ordered parameters. 12/18/2025 1:32 PM, the DON stated, The medical director is aware of PRN pain medication being administered outside of the parameters. During this interview, the DON further explained, R #2 will insist that staff give him his medication. He has been known to call 911 and have emergency personnel come to the facility if he has not received it. However, no evidence is documented in R #2's record that indicates this is a pattern of behavior or has occurred for the period being reviewed between 10/1/2025 and 12/18/2025. On 12/19/2025 at 10:08 AM, an interview was conducted with Staff #21 regarding gradual dose reductions (GDR) reviews for R#2. She states that she has provided consultation for a couple of years to AL Arcola and provides this level of service to a bunch of [NAME] Lake Healthcare buildings. The surveyor asked her if she was aware of PRN pain medication being given outside of the ordered parameters. Staff # 21 stated, That is an interesting thing. I think the nursing staff enters the pain scale incorrectly. If they are entering the initial pain score as a follow-up pain score. The surveyor proceeded to ask Staff #21, If PRN use exceeds ordered parameters, what is your expectation for provider follow-up or order revision? Staff #21 replied, I will only educate or inform the DON or nursing staff if they are not documenting pain scales appropriately according to the order. They will follow their internal communication process with the facility provider. On 12/19/2025 at 10:25 AM, Staff #21 was asked by the surveyor, You documented 'No Recommendations' for several consecutive months in relation to a medication regimen review. Can you explain the clinical analysis that leads to that conclusion? Staff #21 stated, I read a lot of notes and make the best conclusion I can when making a recommendation for a GDR. I look at MARs and the usage. There is not always a pain scale on pain medication orders entered by the provider. The surveyor followed up by asking, Do you document this anywhere in your own record or as part of the resident's record other than your progress note in the electronic medical record that states 'No Recommendations' - aside from new admission and readmission reviews you already provide? Staff #21 stated, I tend just to review the chart, I don't type up notes - I determine as I review if I need to review.On 12/19/2025 at 10:32 AM, the surveyor continued by asking Staff #21, If 'No Recommendations' were made, what documentation demonstrates that continued use was clinically appropriate? Staff #21 explained, I don't type up notes - I determine as I review. In this instance, I would send an email communication to the DON to address the pain scale and prevent a ton of paperwork for the facility. I did not tell the DON that pain scales were wrong for R #2, but I did not see anything clinically indicative for recommendations for R #2. On 12/19/2025 at 11:50 AM, an interview was conducted with the facility's medical director. The medical director has served at the facility since 2008, stating he attends weekly risk meetings and monthly quality assurance and performance improvement (QAPI) meetings conducted by the facility. On 12/19/2025 at 11:55 AM, the surveyor asked, Are you aware that PRN pain medication was administered outside of the ordered parameters for R #2's HYDROmorphone HCl (Dilaudid) Oral Tablet 2 MG - Give 3 tablets by mouth every 4 hours as needed for pain 6-10 out of 10? The medical director stated, No. I am not aware of that. He was informed of the 24 instances between 10/1/2025 and 12/18/2025 in which the medication was administered outside the ordered parameters. The surveyor asked, Did you authorize that practice? The medical director stated, No. When further asked, When should nursing staff notify you if PRN use exceeds the ordered parameters? The medical director stated, All orders are to be administered as written. PRN pain medication should be administered according to the pain scale to be the least sedating, the least addictive, and the least restrictive. These issues have been brought up in our QAPI and risk meetings related to proper pain scales and proper pain management documentation.

Based on record review, observation, and interviews, it was determined that the facility failed to 1) implement the physician's order 2) ensure that each resident's drug regimen was free from unnecessary medications, and 3) ensure appropriate medication regimen review, monitoring, and follow-up in accordance with physician orders and professional standards of practice. This was evident for 3 (Resident #3, Resident #2 and Resident #5) of 7 residents reviewed for unnecessary medications during the recertification survey.The findings include: 1) Resident #3 was admitted into the facility in early 2025. The resident's medical record was reviewed on 12/18/25 at 11:11 AM. The review revealed a progress note from the pharmacist indicating that the medication regimen review (MRR) was conducted on 9/20/25 with new recommendations. A separate report pertaining to the pharmacy recommendation was found in Resident #3's hard chart on 12/18/25 at 11:27 AM. The report listed 3 medications that the resident was taking for hyperlipidemia and the result of the resident's lipid panel taken on 8/27/25. The pharmacist recommended for the physician to review whether any of the medications listed may be reduced or discontinued based on the lipid panel result. The physician agreed with the recommendation and ordered the Ezetimibe to be discontinued. Ezetimibe (brand name Zetia) is a prescription medication in a class of drugs called cholesterol absorption inhibitors, used to lower high blood cholesterol levels. It works by reducing the amount of cholesterol absorbed by the small intestine from food and bile. Ezetimibe is primarily used to treat high cholesterol (hyperlipidemia) and certain other lipid abnormalities, often when diet and exercise alone are insufficient. A review of Resident #3's medical orders on 12/18/25 at 11:31 AM, revealed an active order for Ezetimibe with an order date of 4/2/25. The Nurse Unit Manager (RN #17) was interviewed on 12/18/25 at 11:32 AM. During the interview, RN #17 explained the facilities process with MRR noting that when the provider have new orders as a response to pharmacy recommendations, the charge nurse or the unit managers (whenever she helps with MRR) would implement the change/new order (for example: adding a new medication, ordering a lab test, changing a dose or discontinuing a medication) in the resident's electronic health record and then write a progress note about it. Resident #3's medical record was reviewed with RN #17 on 12/18/25 at 11:47 AM. RN #17 confirmed that the physician's response to the pharmacy recommendation on 9/20/25 was to discontinue the order for Ezetimibe. She also confirmed that the current order for Ezetimibe had not been changed since it was ordered on 4/2/25. RN #17 reported that it was usually the responsibility of the charge nurse to ensure physician orders are implemented. The Director of Nursing (DON) was interviewed on 12/18/25 at 1:34 PM, the concern was discussed that the physician had ordered a medication to be discontinued based on the pharmacy recommendation from the MRR. The DON reported that it was her expectation that the Unit Managers were responsible for ensuring the physician order was implemented. The DON acknowledged the concern and indicated that she would be reviewing the facility's process with MRR with the unit managers. 2) On 12/18/2025 at 9:27 AM, a review of Resident #2's medical record revealed physician orders that included: 08/16/2025: Assess resident for pain every shift; medicate as ordered and notify the physician if pain is not controlled. 08/17/2025: OxyCONTIN ER 30 mg every 12 hours. 08/19/2025: Acetaminophen 1,000 mg every 8 hours as needed for pain (PRN) rated 1–5/10. 08/19/2025: HYDROmorphone HCl (Dilaudid) 6 mg every 4 hours as needed for pain (PRN) rated 6–10/10. On 12/18/2025 at 10:35 AM, review of Resident #2's Medication Administration Records (MARs) identified multiple administrations of PRN hydromorphone that were inconsistent with the ordered pain scale parameters. December 2025 MAR revealed 7 administrations of hydromorphone, November 2025 MAR revealed 12 administrations and October 2025 MAR revealed 5 administrations in which hydromorphone was administered for pain scores equal to 5 or below. There was no documented evidence in the medical record that the physician was notified, authorized, or revised the PRN opioid administration. On 12/18/2025 at 12:57 PM, during a joint MAR review, Nurse #17, the unit manager, acknowledged that Resident #2 received PRN hydromorphone at pain levels below the ordered parameters. On 12/18/2025 at 1:32 PM, the Director of Nursing indicated that the medical director was aware of PRN opioid administration outside ordered parameters. However, during an interview on 12/19/2025 at 11:55 AM, the medical director reported that he was not aware of this practice, confirmed that he did not authorize administration outside the prescribed pain scale, and stated, all orders are to be administered as written. Resident #2's medical record lacked evidence of medication regimen review, provider follow-up, or clinical reassessment to determine whether continued use was appropriate, necessary, or posed risk of adverse consequences. On 12/19/2025 at 10:32 AM during an interview with Consultant Pharmacist (Staff #21) stated, I would send an email communication to [the Director of Nursing] to address the pain scale and prevent a ton of paperwork for the facility. I did not tell the Director of Nursing that Resident #2's pain scales were wrong. 3) On 12/16/2025 at 9:50 AM, review of Resident #5's medication orders revealed: Depakote Delayed Release 125 mg twice daily for mood swings (order date 7/27/2025). Melatonin 6 mg at bedtime for insomnia (order date 7/31/2025). Review of Resident #5's MAR on 12/16/2025 at 10:35 AM revealed orders dated 7/24/2025, that required monitoring for adverse effects related to psychotropic medication (Depakote) use. There was no evidence of documented monitoring for adverse effects related to Depakote use. Review of the electronic medical record revealed that Staff #21 conducted medication regimen reviews July through December 2025 that repeatedly documented No recommendations, despite a lack of documented side-effect monitoring, no evidence of gradual dose reduction attempts, and no documented contraindications to dose reduction. During an interview on 12/19/2025 at 10:08 AM, Staff #21 acknowledged that she tends to just review the chart when determining No recommendations, and that she does not document clinical analysis as to her rationale. On 12/19/2025, at 11:50 AM, by the end of the survey, Resident #5 psychotropic medication use was not supported by documented clinical monitoring, risk-benefit analysis, or evaluation for dose reduction. The facility failed to ensure that the drug regimen was free from unnecessary drugs.

Based on interviews and medical record review it was determined that the facility failed to: 1) revise a Resident's care plan and 2) provide an invitation and/or invite a resident for a care plan meeting . This was evident in 4 Residents (#65, #36 #143, & #57) and 2 Residents (#63 and #38) out of 10 residents reviewed for care planning. The findings include: 1a) On 6/13/24 at 12:40 PM a review of Resident's #65 medical record revealed that the resident was admitted to the facility on [DATE] with multiple diagnoses which included Dementia, ETOH (alcohol) abuse and Hypertension (high blood pressure). On 4/16/24 Resident #65 sustained a fall and was hospitalized for Hip Fracture. Resident #65 was readmitted to the facility on [DATE]. A review of Resident #65 medical record on 6/14/24 01:06 PM revealed that the resident was administered Lovenox (Enoxaparin) injections for the period 4/22/24 to 5/5/24 for Deep Vein Thrombosis prophylaxis and a care plan was initiated on 4/22/24. The resident's care plan for Lovenox remained active even though the medication was discontinued on 5/5/24. On 6/17/24 at 09:05 AM the surveyor informed Unit Manager, Staff #5 of the care plans findings for Resident # 65. Staff #5 confirmed the findings and stated that they would take care of them. Further review of the residents' medical record on 6/28/24 at 12:55 PM revealed that the care plans for Resident #65 for Lovenox discontinued on 6/17/24. On 6/20/24 10:30 AM The Assistant Director of Nursing (ADON) was made aware of the findings. 1b) A review on 6/17/24 at 8:12 AM of Resident #36's medical record revealed the following. The resident was admitted to the facility on [DATE] with multiple diagnoses including Hypertension (high blood pressure), Atrial Fibrillation (irregular heart rhythm), Diabetes Mellitus. Resident #36 was administered Vancomycin (an antibiotic) for the period 5/9/24 -5/19/24 for C-diff (a bacteria that causes infection in the colon). The resident's care plan for Vancomycin remained active even though the medication was discontinued on 5/19/24. On 6/17/24 at 9:05 AM the surveyor informed Unit Manager, Staff #5 of the care plans findings for Resident #36. Staff #5 confirmed the findings and stated that they would take care of them. Further review of the residents' medical record on 6/28/24 at 12:55 PM revealed that the care plans for Resident #36 for Vancomycin were discontinued on 6/17/24. On 6/20/24 10:30 AM the Assistant Director of Nursing (ADON) was made aware of the findings. 44440 1c) On 6/25/24 at 12:02 PM, the surveyor reviewed Resident #143's medical record. The review revealed that Resident #143 was first admitted to the facility in early 2018 and had a past medical history, which included but not limited to, bipolar disorder, dementia with behavioral disturbances and schizoaffective disorder. On further review the surveyor noted a care plan for Resident #143 initiated on 8/26/20 that stated, Resident #143 is to be on one-on-one monitoring. The goal stated Resident #143 will remain calm without hurting someone through the next review date. This goal was revised on 6/3/21 however, the intervention of, to monitor the resident as ordered that were initiated on 8/26/20 were not revised. An additional care plan stated, Resident #143 has the potential to be physically aggressive related to dementia and was initiated on 10/21/20. The goal for this care plan stated Resident #143 will not harm self or others through the review date and was last revised on 6/3/21. One intervention listed was for one on one and supervision ongoing for the resident's safety and the safety of others. This intervention was initiated on 8/25/20. This intervention was initiated before the care plan date and both the care plans and intervention were not revised and not updated when the goals were reviewed on 6/3/21. The surveyor noted a psychiatric progress note written on 9/10/20 that stated that Resident #143 was seen, and no behavior disturbance was reported or noted. If further recommended, discontinuing the one to one monitoring. Additionally, a progress note written by the Director of Nursing (DON) on 9/11/20 that stated, the Facility will continue One on One at this time as a plan of care not physician orders. On 7/2/24 at 12:16 PM, the surveyor conducted an interview with the DON and Nursing Home Administrator. During this interview the DON confirmed that the care plan was not up to date, that the resident did not need one to one monitoring, and the care plan was inaccurate. 49815 1d) On 6/21/2024 at 8:36 AM the surveyor reviewed Resident #57's medical record. There was a current care plan for Seroquel which is an antipsychotic medication. Further review of the medical record revealed that there was not a current physician order for the medication and that the Seroquel was discontinued by the physician on 5/23/2024. The surveyor interviewed the Director of Nursing on 6/24/2024 at 12:25 PM and reviewed Resident #57's current care plan for Seroquel and the physician orders for the discontinuation of Seroquel on 5/23/2024. The Director of Nursing stated that he would have to investigate this. No additional information was provided to the surveyor by the Director of Nursing at the time of exit. 2a) During an interview on 6/12/2024 at 9:14 AM Resident #63 stated to the surveyor that he/she does not get invited to care plan meetings. The surveyor reviewed Resident #63's medical record on 6/17/2024 at 8:00 AM. There was no documentation that a care plan invitation was provided to Resident #63 for the December 2023 care plan meeting. During an interview conducted on 6/17/24 at 1:30 PM, the Social Services Director #15 conveyed that the facility was unable to locate the care plan invitation letter for Resident #63 for the December 2023 care plan meeting. The Social Services Director #15 was able to provide to the surveyor a copy of the September 2023 Care Conference Invitation letter that was provided to Resident #63 and the Responsible Party which is the expectation of the facility. 45733 2b) During a floor rounding, on 6/12/24 at 2:43 PM, Resident #38 stated, No one had talked to me about what program that I was in since I got here. Record review, on 6/13/24 at 1:28 PM, revealed that Resident #38 was admitted to the facility, on 2/21/24, with diagnoses of percutaneous pinning of pelvis on 2/12/24, impaired vision, cardiac arrhythmia and dementia. The resident was authorized for skilled level nursing care upon admission. The resident was able to answer questions appropriately, making his/her own decisions about his/her care and making his/her needs known. Further review of the Social Worker Staff #16's notes, dated 2/28/24 at 16:18 PM and 5/24/24 at 9:40 AM, revealed that the interdisciplinary team had conducted care plan meetings telephonically with this resident's surrogate without inviting the resident. During the second care plan meeting on 5/24/24, the discharge plan was changed from going home to becoming a long-term care resident. Per facility staff that the surrogate had not visited this resident since 2/21/24 nor to explain the long-term care's decision. During interview, on 6/14/24 at 10:09 AM, Social Worker Staff #15 stated that the care plan meetings were conducted telephonically and because the surrogate had only very limited for each care plan meeting, Staff #16 excluded Resident #38 from the meeting. During interview, on 6/14/24 at 11:50 AM, the Director of Nursing (DON) stated he could not remember why this resident was not in his/hers care plan meetings. The surveyor informed the DON that this resident was excluded from his/her own care plan meetings which it was a concern.

Based on observations, interviews and record review, it was determined that the facility failed to ensure sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 6/11/24 at 9:01 AM during an initial tour of the kitchen, the surveyor observed two large white (approximately 4 gallon) containers quarter filled with yellow liquid in Refrigerator #2. The containers were unlabeled and undated. Staff #10 immediately removed the containers and stated that they contained leftover lemonade. On 6/25/24 at 08:08 AM the surveyor observed the following during a follow-up tour of the kitchen: - Six stacks of white saucers (approximately 20 saucers per stack), wet nesting (occurs when wet dishes or pots and pans are stacked together before they are completely dry, which can lead to bacterial growth) with surface up on the countertop next to the dishwasher. Air drying dishes is required to ensure adequate sanitization. Staff #29 stated that she would rewash them and proceeded to put them into the dishwashing basket. - Surveyors inspected a room at the back of the kitchen housing the ice machine. Surveyors observed one 32-ounce (oz) beige colored tumbler, half filled with a tan colored liquid along with a soiled paper towel sitting on the second shelf. - Sticky floors noted when the surveyors inspected a room used for storing chemicals and several types of kitchen equipment. Staff # 10 stated that some of the kitchen equipment were out of service. There were no signs posted identifying which equipment was out of service. - Two bags of cake mix powder with a labeled date showing stored 5/21/24 observed with no expiration or 'use by date. - On the floor next to door of the walk-in freezer, there was a build-up of ice in the size and shape of a doorstop. There was wetness and ice build-up on top of a cardboard box sitting on a shelf under the fan in the freezer. The surveyor observed the staff remove the ice and the cardboard box from the freezer and discard it. At the time of the observation Staff #10 informed the surveyor that the freezer was serviced the week before. The surveyor asked Staff #10 for a copy of the record verifying the maintenance service. The surveyors reviewed the record which did not verify service to the freezer. On 6/26/24 at 1:07 PM the surveyor conducted observations of the nourishment room on the Potomac Unit. The findings include: - One opened half-filled cranberry apple 64 oz bottle with no dates on bottle - One zip lock bag with half of a head of a withered green, leafy vegetable, no dates or name on the bag - One 32 oz cup with a tan colored liquid, half filled, no name or date on cup - One covered container with cooked food- one fried chicken drumstick, some short ribs, and loose corn kernels. Container was dated 6/10/24 - One banana in a cup in the overhead cupboard - One opened 8 oz vanilla boost carton, no name or date on the carton On 6/26/24 at 1:20 PM the surveyor interviewed Staff #17 who stated that it was the facility's policy to label and date food stored in the refrigerator and also to have food thrown out after two days. The surveyor observed Staff #17 trash the non-compliant items. The surveyors reviewed a facility policy titled, Food: Safe Handling for Foods from Visitors, last revised on July 2019, which stated: Section 4- Label food with resident name and the current date; Section 5- Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for 7 or more days. On 6/26/24 at 1:22 PM the surveyor observed a soiled mobile steam table in the large dining room on the first floor. The top shelf contained 4 open trays with white residue at the bottom of each tray along with one empty plastic container, a used napkin, a white poster and deflated balloons. On the bottom shelf there were rust-like brown spots and a white powdered substance scattered along the length of the shelf. The DON was in the area, and he approached the surveyors while they were observing the steam table. He stated that steam table was used during the COVID-19 epidemic to give residents a homelike dining experience and it was no longer in service. He confirmed the findings of the surveyors and stated that he would arrange for the table to be removed. He was also made aware of findings relating to the refrigerator in the 1st Floor nourishment room. On 6/28/24 at 8:25 AM the surveyor observed the steam table had been removed

Based on surveyor review of clinical records, facility policies and procedures, and resident and staff interview(s), it was determined that facility staff failed to ensure that residents who lacked decision making capacity had an identified decision maker that could act on the resident's behalf for the resident's best interest. In addition, the facility failed to notify the hospital of the determination that a resident being transferred for evaluation lacked decision making capacity. This finding was the result of investigation of complaint #MD 746, which was evident for 1 (#49) of 2 residents reviewed for hospitalization during the survey. On 08-22-19 at 7:00 PM, an immediate jeopardy (IJ) for resident rights/exercise of rights was determined. On 8-23-19 at 12:38 AM, the facility staff submitted an IJ removal plan to the Office of Health Care Quality (OHCQ) which was accepted, related to the refusal of a resident's readmission to the facility following evaluation at a community hospital. The IJ was removed on 8-27-19 at 3:30 PM after confirmation that the accepted plan had been fully executed. After removal of the immediacy, the deficient practice remained at a scope and severity of E. The findings include: Review of the clinical record for resident #49 revealed a [DIAGNOSES REDACTED]. This certification deemed the resident unable to make medical decisions. There was no evidence in the clinical record that the facility staff notified the responsible party and/or emergency contacts to inform them of the physicians' determination of resident #49's incapacity, or the need to establish a clear authorized decision maker as a result of the incapacity certification. Review of a 11-2-18 social services note revealed that resident #49 threatened to harm him/herself if not transferred out of this place by Christmas. The note also stated that the social services department was working on discharge/transfer plan for the resident. There was no indication in the clinical record that an authorized decision maker had been contacted. Review of a 2-1-19 social services note from a previous care conference revealed that resident #49 was offered a transfer to another facility at his/her request. According to the note, the social worker informed the resident that he/she had been accepted for transfer to the facility in another county. The note also stated that the resident declined the transfer. The was no indication in the clinical record that an authorized decision maker had been contacted regarding transfer of resident #49 to another nursing facility, and there was no indication that the two physicians who had certified the resident as incapacitated had later determined that the resident could make medical decisions related to transfer on 02-01-19. On 07-12-19, resident #49 was transferred to the hospital emergency room for evaluation. There was no evidence in the clinical record that the facility staff had notified the emergency department's staff that two physicians had certified resident #49 to be incapable of making medical decisions at the time of transfer. Resident #49 remained on a stretcher with the escort of ambulance attendants as facility staff informed them that the patient was no longer welcome in the nursing home according to the EMT Patient Care Report dated 07-12-19. The EMT Patient Care Report also stated that, while resident #49 remained on a stretcher, facility staff shouted that we were not permitted through the front door (Refer to F-626) Review of an emergency department note, dated 07-12-19 at 10:47 PM, revealed director of nursing facility arrived and spoke with patient. Patient stated that she does not want to go back The administrator/DON gave patient paperwork to sign out of the facility. The note also stated Patient was cursing at staff from the facility. There was no evidence in the hospital record that two physicians had evaluated resident #49 for decision making capacity in the emergency department prior to the administrator and director of nursing giving the resident paperwork to sign out of the facility. In addition, emergency department staff documented the resident as calm upon arrival with no documented behaviors until after the 10:00 PM visit with the administrator and DON which resulted in documentation of the resident cursing. There was no documentation in the clinical record that the facility staff had notified the authorized decision maker that they allowed resident #49 to sign the notification of transfer or discharge in the emergency department, or that the authorized decision maker was informed that the resident no longer resided in the facility. On 08-21-19 at 2:40 PM, interview with the director from the emergency department that resident #49 was transferred to on 07-12-19, and interview with the RN charge nurse who was on duty in the emergency department at the time of resident #49's transfer revealed that the facility staff failed to notify them verbally or in writing that the resident had been determined by two physicians to be incapable of making medical decisions. As a result, the charge nurse stated that they allowed resident #49 to make all decisions pertaining to his/her care in the emergency department. The facility staff's failure to notify the emergency department staff of resident #49's incapacity to make medical decisions put the resident at risk for serious harm. On 08-22-19 at 5:00 PM, interview with the individual listed as the first emergency contact in the clinical record of resident #49 revealed that he/she had informed the facility social worker last year that he/she could not be a medical decision maker for resident #49. In addition, emergency contact #1 stated that he/she had not been made aware by facility staff of any changes in resident #49's medical condition since he/she had that conversation with the social worker last year. When asked, the individual emphatically stated he/she had no contact with anyone from the facility from 01-01-19 to the present date 08-22-19. On 08-22-19, review of the clinical record for resident #49's medical record revealed that, although the physician's certification of incapacity to make medical decisions was signed on 09-24-18 by the psychiatrist, and 10-07-18 by the attending physician, clinical records dated 11-12-18, 11-23-18, 01-03-19, 02-07-19, 03-12-19, 04-01-19, 04-30-19, 05-03-19, and 07-09-19 revealed that the facility staff notified the resident of his/her change in status, instead of notifying the authorized decision maker. On 08-22-19 at 5:30 PM, an attempt to reach the second emergency contact listed for resident #49 revealed that the name of the individual listed in the clinical record did not match the name of the person who answered the telephone. After surveyor verified the telephone number, the person who answered the telephone stated he/she did not know the person named as the second contact. On 08-22-19 at 5:40 PM, interview with the social work director revealed that she had not been hired at the time of resident #49's transfer to the hospital on 07-21-19, and that the former social work director was no longer employed with the facility. On 08-22-19 at 6:00 PM, interview with the director of nursing (DON) revealed that resident #49 was returned back to the facility via ambulance on 07-12-19 at around 5:00 PM, however, facility staff did not allow the resident's readmission per the DON because the hospital staff had not informed the facility staff that the resident was no longer a danger to self or others. On 08-22-19 at 6:00 PM, interview with the DON also revealed that, on 07-12-19 at approximately 10:00 PM, the facility administrator and DON presented to the hospital and observed resident #49 on a stretcher in the emergency department. A Notice of Transfer or Discharge Form was signed by resident #49 during this visit. (over 4 hours after refusing to readmit the incapacitated resident back into the facility). The administrator/DON failed to recognize resident #49's inability to sign documents related to the provision, withholding, or transfer of care as a result of their obtaining certifications of incapacity to make medical decisions, when the resident was allowed to sign the Notice of Transfer or Discharge form on the night of 07-12-19. Because of the facility staff's failure to recognize the determination of resident #49's incapacity based on mental illness, and failure to notify hospital staff of that incapacity, on 08-22-19 at 7:00 PM, the facility staff were notified of the Immediate Jeopardy (IJ) citation. On 8-22-19 at 12:38 AM, the facility staff submitted the IJ removal plan which included the following measures taken: On 08-22-19, the facility staff identified 64 residents who lacked capacity. The current administrator and director of nursing (DON) evaluated all identified residents to ensure that a responsible party, power of attorney or guardian was listed to ensure staff would notify the authorized decision maker in the event of the resident's transfer to the hospital. On 08-23-19, the administrator educated the social services staff that all residents lacking capacity must have an established responsible party, power of attorney, or guardian in place to facilitate resident care. On 08-27-19, the staff educator had educated 94% of licensed nursing staff about updating POA/Guardian/identifiable decision maker regarding transition of care. On 08-27-19 surveyors verified that the 64 residents who lacked capacity had an established responsible party, power of attorney or guardian in place to facilitate resident care. The removal plan also stated that the Director of Nursing will perform random audits of residents' records to identify inaccurate and incomplete information establishing POA/Guardianship/ Surrogacy/identifiable decision maker. Social Services will work with identified residents and family to ensure that appropriate documentation is in place in the resident's record. These audits will be performed weekly, times 4 weeks and monthly, times 2 months. Results of these audits will be reported at the facility's Quality Assurance and Performance Improvement Committee (QAPI) for appropriate action to be taken. On 08-28-19 at 3:30 PM, the IJ related to resident rights/exercise of rights was removed. (Refer to F-580)

Based on review of clinical records, facility policies and procedures, hospital and ambulance company records, interviews with facility, hospital and ambulance company staff, it was determined that the facility failed to allow a resident to return to the facility after being transferred to the emergency room for evaluation. This was evident for 1 of 2 (#49) records reviewed for hospitalization during the survey, and was related to complaint #MD 746. These failures resulted in an immediate jeopardy (IJ) being identified on 8-22-19 at 7:00 PM related to the facility's refusal to readmit a resident to the facility following evaluation at a community hospital (Resident #49). On 8-23-19 at 12:38 AM, the facility staff submitted an IJ removal plan which was accepted. The IJ was removed on 8-27-19 at 3:30 PM after confirmation that the accepted plan had been fully executed. After removal of the immediacy, the deficient practice remained at a scope and severity of D. The findings include: On 7-17-19, surveyor review of the clinical record revealed that Resident #49 was a long-term care resident who had resided in the facility since (MONTH) (YEAR). The resident's [DIAGNOSES REDACTED]. Further review of the clinical record for Resident #49 revealed that two physicians had signed certifications of incapacity to make medical decisions on 9-24-18 and 10-07-18. Review of the clinical record did not reveal any documentation to indicate that the facility staff had made attempts to obtain guardianship or seek an outside entity to make decisions on the resident's behalf due to their lack of capacity. A staff member documented on 7-12-19 that the resident requested the facility to call 911 for complaint of right leg pain and the resident was making suicidal statements and gestures. On 7-17-19, review of the hospital record for Resident #49 revealed a nursing note for 7-12-19 at 7:13 PM indicating that the resident was sent back to the hospital by a private ambulance company who reported to the hospital staff that, once they arrived at the facility, staff members were yelling at them stating they could not bring Resident #49 there. Surveyor review of the ambulance patient care report for 7/12/19 revealed that the ambulance arrived at the facility at 5:13 PM, left the facility at 5:31 PM and arrived back at the discharging hospital at 5:51 PM. In addition, further review of the hospital record revealed that the ER nurse called the facility on 7/12/19 and spoke to the DON and stated that Resident #49 was cleared medically by the ER doctor and cleared psychiatrically by the psychiatric services for discharge from the hospital and was safe to return to the facility. Further review revealed a nursing note, written on 7-12-19 at 10:47 PM, that noted the DON arrived at the hospital and spoke with Resident #49 and gave the paperwork to resident to be discharged from the facility. Surveyor review of Resident #49's clinical record at the facility revealed no documentation that the facility staff or the primary physician assessed Resident #49 prior to the refusal to readmit the resident to the facility and sent back to the hospital. There was no documentation that the facility staff called the hospital to inquire about Resident #49's medical condition prior to refusing to allow the resident to return to the facility. Further review of the clinical record revealed no evidence that the facility had documented that they could not meet the needs of the resident, or that they would not permit the resident to return. There was a note, documented on 7-12-19 at 12:09 PM, that stated Resident #49 was provided with the bed hold policy and the reason for transfer in writing. The next note, documented on 7-12-19 at 11:09 PM, stated the director of nursing (DON) and Administrator #1 gave Resident #49 a notice of discharge while the resident was at the ER and the resident signed the acknowledgment of notice. However, the resident was unable to make medical decisions and did not have the capacity to sign discharge papers from the facility. Surveyor review of a letter dated 7-12-19, signed by administrator #1, revealed that that the nursing facility's stance was that they were not able to take care of Resident #49 and the facility declined to re-admit the resident. However, there was no documented evidence in the resident's clinical record from the facility or the hospital that facility staff had communicated with the hospital to determine the resident's condition after being seen at the hospital and that the facility was unable to meet the needs of Resident #49 prior to refusing to allow the resident to return to the facility. Further review of a nurse's note, written on 7-12-19 at 11:09 PM, revealed that the DON documented that the resident did not want to return to the facility. However, review of a nurse's note written on 7-12-19 at 9:56 AM revealed that Resident #49 had recurrent behaviors of attention seeking and saying he/she wanted to leave but never leaves but keeps screaming (she/he) wants to. The note further documented that the resident had been to hospitals numerous times, but always asked to return to the facility. Surveyor review of the hospital record revealed a nurse's note, written on 7-12-19 at 10:50 PM, that documented the facility Director of Nursing arrived and spoke with Resident #49. The resident was cursing at staff from the nursing facility, and stated that he/she did not want to go back and was given the paperwork by facility staff to sign out of the nursing facility. On 7-17-19 at 11:00 AM, during the surveyor interview with the social worker from the hospital, she/he reported that on 7-12-19, Resident #49 was evaluated for medical and psychiatric complaints. The resident was cleared medically by the ER doctor and cleared psychiatrically by the psychiatric services for discharge from the hospital and was safe to return to the facility. Resident #49 was transported by a private ambulance company at approximately 5:00 PM to the facility. The social worker further stated that Resident #49 was transported back to the hospital by the private ambulance company. The report the hospital staff received from the ambulance staff was that, upon arrival to the facility, Resident #49 was refused readmission. Therefore, Resident #49 was returned to the hospital at approximately 6:00 PM with all the resident's belongings. On 8-21-19 at 9:00 AM, surveyor interview with the DON revealed that, when the ambulance staff brought the resident to the facility from the ER, Resident #49 was screaming, shouting, asking for her/his belongings and stated that he/she did not want to return to the facility. Resident #49 was outside the front entrance of the facility on the stretcher and refused to come back into the building. The DON called the hospital to inquire what were the medical findings for Resident #49 because there was no discharge summary paperwork with the resident. The DON stated that he called the hospital and spoke with the charge nurse that informed him that Resident #49 was calm prior to discharge from the hospital. The DON stated that the charge nurse would not give him any information about the medical findings for Resident #49. The DON stated that Resident #49 had to wait approximately one hour for the facility staff to pack up his/her belongings and administrator #1 to give the resident a letter declining his/her readmission. The DON further stated that he never refused to allow Resident #49 to return to the facility. On 8-21-19 at 2:30 PM, surveyor interview with the emergency room charge nurse revealed that he spoke to the DON on 7-12-19 at 6:00 PM to inquire why Resident #49 was returned to the emergency room when he/she was cleared medically by the emergency room doctor and cleared psychiatrically by the psychiatric services for discharge from the hospital and was safe to return to the facility. On 8-21-19 at 4:00 PM, during interview with the chief operating office for the ambulance company, he stated that his staff called the dispatch on 7-12-19 at 5:13 PM after arrival to the facility, stating that the staff refused to let Resident #49 through the front door. The ambulance staff loaded Resident #49 back into the ambulance. The facility staff then gave the ambulance staff three large moving boxes of the resident's belongings and helped to load them onto the ambulance. The ambulance staff were also given a letter from administrator #1 to be given to the hospital staff that stated the facility refused to allow Resident #49 to return. The ambulance attendant stated that it was the DON that came to the front door and refused to allow the resident in the door and made the resident and crew wait outside the lobby doors while the administrator #1 typed up a letter to give to the hospital. On 8-22-19 at 10:00 AM, surveyor interview with the administrator at the nursing home where resident #49 resided previously, revealed that Resident #49 was in their facility and had not had any behavioral outbursts or issues. On 8-22-19 at 3:30 PM, during interview with Resident #49's primary physician, he reported that he was notified after Resident #49 left the faciity on [DATE]. He also stated that he called the emergency room and spoke to the charge nurse who stated that Resident #49 was there, but had not been evaluated yet. In addition, the physician stated that he did not receive a call that evening from the facility staff, so he thought Resident #49 had been admitted to the hospital. On 8-22-19 at 7:00 PM, an immediate jeopardy (IJ) was determined due to the facility's failure to readmit a resident after being transferred to a community hospital emergency room for evaluation. On 8-22-19 at 12:38 AM, the facility staff submitted the IJ removal plan which included the following: -On 7-16-19, discharge planning for Resident #49 was implemented by administrator #2 and hospital social worker to discharge the resident to a sister facility. -On 8-22-19, the facility identified 64 residents who lacked capacity who were evaluated by the DON and administrator #2 to ensure they have a responsible party, power of attorney or guardian listed to ensure staff may notify them in the event a hospital transfer should occur. -On 8-23-19, administrator #2 educated the social services staff that all residents lacking capacity must have an established responsible party, power of attorney or guardian in place to facilitate resident care. -On 8-27-19, the 64 residents who lacked capacity were verified to have an established responsible party, power of attorney or guardian in place to facilitate resident care. - The facility will ensure that residents who lack capacity and are sent to the hospital will be allowed to return after evaluation by DON or designee to ensure their needs can be met at the facility. -On 8-22-19, administrator #2 educated the DON regarding the return or readmission of residents lacking capacity after evaluation done by DON/designee. -On 8-23-19, the nursing supervisors were educated regarding the return or readmission of residents lacking capacity after evaluation done by DON/Nursing Supervisor. -The facility will ensure that residents determined to be a threat to self or others are treated with dignity and respect, provided an appropriate discharge notice if applicable, and when discharged are discharged in a safe, appropriate, orderly fashion. -On 8-22-19, the DON and administrator #2 educated the staff educator regarding treating residents who present with behaviors with dignity and respect, provide them with an appropriate discharge notice when applicable, and discharging such residents in a safe, appropriate and orderly fashion. The staff educator will provide the same education to nursing staff by 8-27-19. -94% of active licensed nurses were in-serviced by 8-27-19 to ensure that residentswho are determined to be a threat to self or others are treated with dignity and respect, provided an appropriate discharge notice if applicable, and when discharged , are discharged in a safe, appropriate, orderly fashion. The nurses that were not in-serviced due to being out of town and unreachable by phone, will not be allowed to return to duty until they have completed their in-service training. - Finally, the removal plan stated that the Director of Nursing will perform random audits of facility hospital transfers and resident therapeutic leaves of absence to ensure that federal regulations permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave'// were followed. These audits will be performed weekly times 4 weeks and monthly times 2 months. Results of these audits will be reported at the facility's Quality Assurance and Performance Improvement Committee (QAPI) for appropriate action to be taken. On 8-28-19 at 10:30 AM, administrator #2 and the DON were notified that the surveyors had verified that the removal plan had been fully implemented as of 8-27-19 at 3:30 PM, and the immediacy was removed. (Refer to F550)

Based on surveyor review of clinical and administrative records and staff interview, it was determined that the facility failed to maintain a safe environment for a cognitively impaired resident with a history of exit seeking behavior, and the facility failed to review and revise the plan of care and adequately supervise a resident with exit seeking behavior. This deficient practice placed the resident at risk for elopement and serious harm. This finding was evident for 1(#33) of 3 residents reviewed for elopement and was related to facility reported incident #MD 717. Therefore, an Immediate Jeopardy for health and safety was called on 08-29-18 at 2:30 PM. The findings include: On 08-29-18, surveyor review of the facility reported incident revealed that Patient found outside of the facility and was re-directed back to facility. Investigation initiated, findings will be made known. Resident was placed in locked Unit. Elopement protocol initiated for facility. Further review of the facility's written investigation revealed no detailed information of how resident #33 was located. In addition, it was unclear of the exact location where the resident was found. On 08-29-18 at 10:45 AM, surveyor interview of the Director of Nursing revealed that resident #33 had walked to a bus stop and boarded a bus. Someone at the Metro transit station called the facility after seeing the resident's name band. Then the weekend supervisor went to the station and picked up the resident. Surveyor review of bus routes from the bus stop closest to the facility revealed that the route resident #33 likely traveled was approximately 16 minutes long with 19 stops. On 08-29-18, surveyor review of the clinical record revealed that, on 07-26-18 at 7:23 PM, a nurse's note was written that stated resident #33 had a wander guard intact and was wandering around the floor with his/her things trying to leave the building saying he/she has worked his/her shift and is ready to leave to take care of his/her son. He/she was put on(NAME)(locked) unit until later this evening There were no additional details of how resident #33 would be monitored when not on the locked unit. In addition, a nurse's note written on 07-26-18 at 7:27 PM revealed that the resident was scheduled to see the psychiatrist for evaluation for agitation and elopement. A wander guard system is an alarm system used to alert staff if a resident who has been determined at risk for elopement is trying to leave the facility or wander into a restricted area. A transmitter is placed on the at-risk resident (typically on a band around the wrist or the ankle) and when the resident approaches the door way or area equipped with a wander guard sensor an alarm sounds to notify staff. On 08-29-18 at 1:15 PM, surveyor interview of the Director of Nursing revealed that the interdisciplinary team had discussed the resident #33's attempted elopement at grand rounds on 07-26-18. The plan was to take the resident to the locked unit for activities if the resident was noted to be out of their room in the hallway. This was the plan until a room became available on the locked unit. Further review of the clinical record revealed no documented evidence of any increase or change in monitoring of resident #33 after the attempted elopement on 07-26-18. In addition, there was no revision of the care plan on 07-26-18 after the attempted elopement. Surveyor review of the nurse's notes written on 07-29-18 revealed that resident #33 was observed on the unit refusing medications at 9:50 AM. At 10:50 AM, the resident was observed in the hallway of the unit. There was no evidence that resident #33 was redirected or taken to the locked unit for activities as the Director of Nursing had stated was the plan. On 07-29-18 at 12:10 PM, the nurse's note revealed that resident #33 was not observed in own room. Dining room, basement and other units checked, and resident not observed. Elopement protocol activated. On 07-29-18 at 1:50 PM, a nurse's note was written that documented resident #33 was found outside of the facility and was returned back inside the facility. Further review of the facility investigation of the elopement revealed evidence that, after the elopement of resident #33, the wander guard system and doors were checked, an audit was completed on all residents who were wanderers, signs were posted on the doors to let family members know not to allow residents to go out the door with them and written notifications stating the same, were sent to family members. In addition, the facility stated they would educate all staff on the importance of supervision of vulnerable residents and include the need for staff to look beyond the area of any beeping alarm. However, surveyor review of staff training revealed that, since 07-29-18, only 63 of 154 facility staff were trained on elopement protocol and adequate supervision and only 27 of 154 facility staff were trained on prompt response to all beeps and alarms. On 08-29-18 at 2:15 PM, surveyor interview with the Director of Nursing and Administrator provided no additional information. The facility presented allegation of correction for Elopement/Abuse & Neglect and Resident Supervision. An elopement drill/post event was completed on 07-29-18. This included checks of the exit doors, functioning of the wander managements system, and functioning of wander management devices. Resident wander management device was checked upon safe return to the facility and was functioning properly. Review of administrative documents revealed that the Director Of Nursing conducted an audit on all residents who are wanderers to ensure that the appropriate plan of care/supervision level was in place. Residents assessed as being at risk for elopement were placed on increased location monitoring until all interventions were in place to ensure resident safety. The Nursing Home Administrator placed signage on both doors leading to the courtyard where the resident exited the lobby door. The signage notifies all visitors to ensure that the door is closed securely behind them upon exiting as well as not allowing any person to go through the door that is not visiting with them. The Administrator notified all responsible parties, emergency contacts, and vendors via mail of the importance of ensuring that exit doors are securely locked upon entering or exiting the facility, and that they should not allow anyone out of the building unless that individual is their family member. Review of administrative documents revealed that some staff received in-service education on 7/29/18 regarding the need to look beyond the area of any beeping alarm if there was no trigger in site. On 8/1/18, some staff received in-service education regarding the additional intervention of increased location monitoring for residents identified as high risk until all interventions to ensure patient safety were in place. As of 8/29/18, no staff would be cleared to return to duty until receiving additional training on elopement policy and interventions for residents at high risk for elopement. The Director of Nursing will conduct an ongoing audit of 3 residents' records per week that are deemed to be elopement risks for documentation of appropriate supervision of these residents. This will include the newly added interventions of increased location monitoring (i.e. every 15mins). Findings of these audit results will be reviewed in the QAPI meeting monthly for 3 months to ensure compliance. The Nursing Home Administrator will conduct on-going daily rounds to ensure that exit signage remains in place and that visitors are in compliance with the signage instructions. Findings will be reviewed in the monthly QAPI meeting for 3 months to ensure compliance. The Immediate Jeopardy was abated at 6:30 PM on (MONTH) 29, (YEAR).