Every finding on record at Autumn Lake Healthcare at Arlington West

Based on interview, and record review, it was determined that the facility failed to assist a Resident to receive proper treatment to maintain vision. This was found evident of 1 (Resident #15) out of 1 Residents reviewed for hearing and vision during an annual survey. The findings include:On 6/29/26 at 7:45 AM, the surveyor reviewed complaint #2705270 submitted in December of 2025. The complaint alleged that the facility failed to administer Resident #15's eye drops according to instructions.On 6/29/26 at 9:30 AM the surveyor conducted an interview with Resident #15 and during the interview Resident #15 stated that he/she continued to have concerns that the facility was not providing his/her eye drops as prescribed. On 6/30/26 at 7:27 AM, the surveyor reviewed Resident #15's ophthalmology notes. On 10/29/25 a 1 week post operative note from Resident #15's left eye surgery documented significant inflammation due to inconsistency receiving eyedrops. The note further states that Resident #15 reported not receiving eye drops consistently. On 6/30/26 at 8:01 AM, the surveyor reviewed Resident #15's Medication Administration Records (MARs). The review revealed in October of 2025 on 12/25/25 prednisolone acetate ophthalmic suspension was left blank for the 6 am dose and coded 7 (sleeping) on 12/28/25 for the 9PM dose and on 12/28/26 latanoprost ophthalmic solution was coded 7 (sleeping ) for the 9PM dose. No where in the instructions did is say hold the medication if sleeping and on further review it was noted that Resident #15 received his/her other scheduled medications, atorvastatin and gabapentin, at 9 PM on 12/28/25. On review of Resident #15's January 2026 MAR it was noted on 1/1/26 the 9 AM dose of dorzolamide solution was coded 9 (see progress notes); medication not available. However, this medication was not a new medication and was started on 3/29/25. On further review it was noted that on 1/3/26 on the 6 AM dose difluprednate ophthalmic drop was left blank. The instructions were to administer 1 drop into the right eye 4 times per day and was written to start on 1/2/26. A duplicate order was written to start that same day for difluprednate ophthalmic, however, the instructions stated to instill 1 drop into the right eye every 2 hours while awake. This medication was signed out as given twice at 6AM, noon, 6PM and Midnight until the order for every two hours was discontinued on 1/9/26. On review of the June 2026 MAR the prednisolone acetate ophthalmic suspension was left blank on 6/26/26 on the 6 AM dose as well as the difluprednate ophthalmic drop scheduled for the same time. On 7/1/26 at 7:36 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated he was aware that Resident #15 made the accusations that he/she was not getting his/her eye drops as ordered. He further stated that Resident #15 had refused care and had a history of making false statements about cares. The surveyor reviewed the missed documentations of not receiving the eye drops that validated Resident #15's concerns.

Based on observations, review of medical records, facility investigative file, and interviews it was determined that the facility failed to implement interventions, determined to be necessary, for residents who were dependent and identified as fall risks. This was evident for 3 (Resident #9, #8 and #48) out of 4 residents reviewed for accidents. The findings include:A Hoyer lift is a mechanical lift that transfers residents with limited mobility. It operates using a supportive sling under the Resident. The sling attaches to the lift, allowing the Resident to be raised in the air and transferred between surfaces. 1) On 6/29/26 at 9:17 AM, the surveyor conducted an interview with Resident #9. During the Resident #9 stated that he/she had recently been transferred by two staff without the use of a hoyer lift even though he/she was supposed to utilize the lift for transfers. Next the surveyor requested any investigation into the incorrect transfer for Resident #9 from the Nursing Home Administrator. On 6/30/26 at 12:38 PM, the surveyor reviewed a grievance form dated 6/19/26. The grievance investigation confirmed that Resident #9 was transferred by the Certified Nursing Assistant (CNA) without the use of a hoyer lift and she was educated on the need to adhere to the mode of transfers in the Resident's plan of care. The surveyor next reviewed Resident #9's care plan and noted a care plan that stated Resident #9 was at risk for falls related to increased need for assistance with transfers. Additionally, a care plan stated Resident #9 had an Activities of Daily Living performance deficit with an intervention requiring 2 staff participation with transfers using Hoyer lift. On 7/1/26 at 6:53 AM, the surveyor conducted an interview with the NHA. During the interview the NHA confirmed that Resident #9 was not transferred using the hoyer lift as he/she should have been and that the CNA was educated. The surveyor reviewed the allegation that Resident #9 stated that there were two people involved in the transfer but only one was educated in the grievance report. The NHA confirmed that there was also a physical therapy assistant also involved. The surveyor reviewed the concern that two staff in different departments both transferred the resident not according to his/her care plan putting the resident at risk for a fall or injury. 2) On 6/29/26 at 8:57 AM, the surveyor observed Resident #8 resting in bed and noted his/her call bell on the floor. At this time Certified Nursing Assistant (CNA )#14 came into the room. The surveyor asked her if Resident #8 should have the call bell in reach. CAN #14 stated the Resident #9 was resistant to care and would throw the call light on the floor at times. On 6/30/2026 at 8:30 AM, the surveyor reviewed Resident #8's change of condition as were as follows:3/9/26- Unwitnessed fall in dining room with bump to forehead3/21/26- Found sitting on the floor in room4/11/26-Unwitnessed fall with right eyebrow laceration Next the surveyor reviewed Resident #8's orders. The review revealed on 3/10/26 an order was placed for Resident #8 to wear hipsters as tolerated, an additional order was written on 4/13/26 for Resident #8 to wear a soft helmet at all times as tolerated and on 4/15/26 and order was written for Resident #8 to wear a brace to the left arm at all times as tolerated. On 6/30/26 at 8:49 AM, the surveyor reviewed Resident #8's care plan and noted Resident #8 had an actual fall care plan with injury with an intervention to keep Resident #8's call light in reach and encourage resident to use it as well as an intervention that stated Resident #8 had impaired cognition and was not able to comprehend how to use a call bell and that staff needed to anticipate his/her needs and wants. Both of these care plans conflict each other. On 7/1/26 at 9:17 AM, the surveyor observed Resident #8 up in a wheelchair in the dining area. Resident #8 did not have a soft helmet on or an arm brace. He/she also appeared not to be wearing hipsters. On 7/1/26 at 9:18 AM, the surveyor conducted an interview with the Assistant Director of Nursing (ADON) and asked if Resident #8 was supposed to have the helmet, splint and hipsters. The ADON confirmed she was supposed to and applied Resident #8s' helmet and directed a staff to apply the hipsters and arm brace. The surveyor related the concerns that the fall prevention interventions were not being utilized or updated if not appropriate. 3) On 7/2/26 at 8:03 AM the surveyor reviewed intake #2635777. The intake alleged that Resident #48 was improperly put into a wheelchair and had fallen. Next the surveyor reviewed Resident #48's medical record. The review revealed a note written on 9/27/26 that stated that while resident #48 was being lifted out of the wheelchair and onto the shower bed the hoyer lift pad was noted not to be correctly positioned under the resident and the resident began to slide out the wheelchair. If further stated that the Resident was then lowered to the ground by staff. On further review it was noted that Resident #48 had risk for falls care plan with actual fall with one of the reasons indicated was the increased need for assistance with transfers. One of the interventions was updated on 9/29/25 and stated nursing staff were educated on safety awareness and the proper way of positioning the Hoyer pad underneath the resident correctly. On 7/2/26 at 11:09 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that a staff member described the reason that Resident #48 fell on 9/27/25 was due to the misplacement of the hoyer lift pad even with Resident #48 being a fall risk Resident. The DON confirmed that the pad was misplaced.

Based on observations, interviews, and record review, it was determined that the facility failed to obtain and administer medications according to a Resident's medication regimen and ensure that pharmaceutical services included the removal of expired medications and the safe handling of medications. This was evident for 1 resident (Resident #48) out of 7 reviewed for medications and 2 (2nd floor) of 4 medication carts during medication administration facility task observation.The findings included: 1) On 7/1/2026 at 9:04 AM, surveyors observed Staff #8 administer scheduled AM medications and inspected the medication cart drawers. Surveyors observed 5 unidentified loose medications at the bottom of the second drawer of the medication cart. On 7/1/2026 at 9:56 AM, surveyors observed Staff #9 administer scheduled AM medications and inspected the medication cart drawers. Surveyors observed 1 bottle of Acetaminophen 500 milligrams (mg)/15 milliliters (mL) with an expiration date in 2025. The specific month was not legible, and the lot number and expiration date were not clearly readable. Surveyors also observed 2 bottles of Chlorhexidine Gluconate Oral Rinse without an expiration date. In addition, surveyors observed at least 22 unidentified loose medications at the bottom of the medication cart drawers. On 7/1/2026 at 10:02 AM, surveyors notified Staff #3, who was passing by the medication cart area, of the unidentified loose medications and expired/undated medication bottles. Staff #3 acknowledged the concerns, stating the expectation was for staff members to pick up medications if they fell in the medication cart. On 7/1/2026 at 10:45 AM, surveyors informed the Director of Nursing (DON) regarding the findings related to unidentified loose medications in medication carts and expired/undated medications. The DON acknowledged the concerns. 2) On 7/2/26 at 8:03 AM the surveyor reviewed intake #2635777. The intake alleged that Resident #48 asked for his/her Zanaflex and was told that the medication was not available. Next the surveyor reviewed Resident #48's September 2025 Medication Administration Record (MAR). Zanaflex was ordered on 8/18/25 and written to give 4mg every 6 hours as needed for muscle spasms. It was discontinued on 9/26/25 and reordered the same day with the same administration instructions. A progress notes written on 9/27/25 at 8:15 PM documented that the staff called the pharmacy regarding Resident #48's Zanaflex and was told the medication was on back order. The note further stated the Resident's Responsible Party (RP) and provider were updated. However, no substitute or change in plan was made after finding out the medication was not available. The surveyor noted Resident #48 had a self-care deficit care plan for performing Activities of Daily Living (ADLs) related to chronic spastic tetraplegia (also known as spastic quadriplegia), a severe neurological condition that paralyzes all four limbs and the trunk while causing severe, chronic muscle stiffness and involuntary spasms. On 7/2/26 at 11:09 AM the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor confirmed that if a resident had a medication prescribed that the medication should be available. The DON stated that he would look into the order. At the time of exit no additional information was provided.

Based on record review, observations, interview with resident and staff, the facility failed to ensure a clean, comfortable and homelike environment. This is evident for 1 (resident #66 ) out of 1 resident reviewed during the survey. The findings include: On 6/13/25 at 2:30 PM in an interview of Resident #66 in reference to his/her comfort, Resident #66 stated that their curtain/drapes have not been cleaned and there were stains on it. Surveyor looked at the curtain/drape and saw one large spot/stain on it roughly about 4 inches in circumference. On 6/17/25 at 8:36 AM surveyor interviewed the Director of Nursing (DON #2 ) about how often are the curtains changed in the resident's rooms. DON #2 was unsure and brought in the Environmental Service Director (EVS #4). The surveryor interviewed EVS #4 and asked how often the curtains are changed in the residents' rooms. She replied they change the curtains when they do deep cleaning to the rooms, after a discharge, after a resident was on Isolation, and when it is visibly soiled. The DON #2 and EVS #4 were then advised of the observation of the curtain/drape in Resident #66's room with the visible stains on it. The EVS #4 stated that she will have the curtain changed today.

Based on interview and record review it was determined the facility failed to ensure a resident was free from abuse. This was evident for 1 (Resident #74) out of 5 residents reviewed for abuse during the facility's recertification survey. The findings include: On 6/12/25 at 8:48AM in response to the surveyor's request, the facility's Administrator provided the complete investigative file for the self reported facility incident MD00195518 involving Resident #74 in which abuse of the resident was investigated by the facility. Review of the investigative file revealed Resident #74 reported that Geriatric Nursing Assistant (GNA) #6: entered his room and forcibly turned and positioned him, yelled at him, and put a pillow over his face. Further review of the complete investigative file for MD#00195518 on 6/17/25 at 12:47PM by the surveyor revealed documentation by the facility on a follow up self report form made to the Office of Health Care Quality that on 8/12/23 Resident #74 reported the allegation of abuse by GNA #6 to facility staff, and after investigation into the allegation, including an interview of the resident's roommate, the result of the investigation was found to be substantiated by the facility and a report was documented as made to the Maryland Board of Nursing (MBON) regarding GNA #6 as well as the facility placing them on a do not return staffing list. On 6/17/25 at 2:06PM the surveyor reviewed the facility's documentation of the August 2023 complaint form in which the facility had documented their complaint and concern regarding GNA #6 to the MBON and also a letter from August 2023 in which there was a response made from the MBON indicating they received a complaint. On 6/17/25 at 3:13PM the surveyor conducted an interview with the facility's Administrator who confirmed that Resident #74's allegation of abuse was substantiated by the facility. At this time the surveyor shared the concern with the Administrator who acknowledged the concern.

Based on record review and interview it was determined the facility failed to ensure the timeliness of reporting of an allegation of abuse. This was evident for 1 (Resident #17) out of 5 residents reviewed for abuse (MD00205138) during the facility's recertification survey. The findings include: On 6/16/25 at 12:52PM the surveyor reviewed the facility's complete investigation file for MD00205138 which documented the facility's initial self report made to the Office of Health Care Quality (OHCQ) of an allegation of staff to resident physical abuse documented as having been submitted on 4/28/24 at 12:55PM by the facility Administrator in which an allegation of physical abuse was reported by Resident #17 to Geriatric Nursing Assistant (GNA) #7 on 4/28/24 at approximately 8:00AM. Further review of the facility's initial self report stated the following information: documented under the section on the self report form used to indicate the date and time that the Administrator was notified of the incident and by whom, was observed to be 4/28/24, 11 am. On 6/16/25 at 1:18PM the surveyor reviewed the written statement within the facility's complete investigative file dated 4/28/24 in which Registered Nurse #8 documented that the allegation was reported by Resident #17 to a GNA during breakfast time about 7:55AM. On 6/16/25 at 1:18PM the surveyor additionally reviewed the written statement within the facility's complete investigative file in which GNA #7 documented the resident's allegation as having been reported to him/her at about 7:55AM on 4/28/24. On 6/16/25 at 3:18PM the surveyor conducted an interview with the facility's Administrator who confirmed with the surveyor that the initial self report made to OHCQ was not submitted within the two hour time frame and they responded: Yes, because it (the allegation) was slow to get to me.

Based on observation, interview, and record review it was determined the facility failed to ensure that a resident's medication preparation was in accordance with the physician's order for the prescribed dosage amount. This was evident for 1 out of 25 medication administrations observed by the surveyor during the review for medication administration during the facility's recertification survey. The findings include: On 6/13/25 at 8:12AM the surveyor conducted a medication administration observation of Licensed Practical Nurse (LPN) #9 who was preparing to administer medications to Resident #25. The surveyor observed LPN #9 retrieve a pill package from the medication cart which read the following information on the labeling of it: Keppra Oral Tablet 250MG (Levetiracetam), Give 250 mg by mouth in the evening for seizure. At this time, the surveyor observed LPN #9 pop one single 250mg pill from the package into the medication cup for the resident and LPN #9 then handed the surveyor the pill pack, as they were finished with it, for the surveyor to review and write down the medication information, and LPN #9 moved on to pop the next medication from the next pill package. This surveyor recorded Keppra 250mg, 1 tab, in the surveyor notes, and then this surveyor observed the point click care (PCC) system on the computer which read the following physician order for 9:00AM medication administration of Keppra for the resident: Keppra Oral Tablet 250MG (Levetiracetam), Give 500 mg by mouth one time a day for seizure disorder. At this time, the surveyor conducted an interview of LPN #9 and inquired as to why the resident was being administered only 1 tablet ([NAME] dose of 250mg) instead of 2 tablets (total dose of 500mg), and further inquired as to why it was being administered from the evening pill pack instead of a morning pack. At this time, LPN #9 was observed comparing the evening pill pack label to the physician's medication administration order in PCC and confirmed with the surveyor that the dose prepared for the resident was incorrect, and after surveyor intervention, LPN #9 was observed searching the medication cart for the morning dosage pack of Keppra. LPN #9 reported to the surveyor that they did not see any morning Keppra pill pack within the medication cart, and after surveyor intervention, proceeded to pop a second Keppra 250mg pill from the evening pill pack into the medication administration cup. On 6/13/25 at 8:50AM the surveyor conducted an interview with Director of Nursing (DON) #2 and shared the concern with them. DON #2 confirmed understanding of the concern and stated the following to the surveyor: I will educate the nurse. On 6/13/25 at 9:06AM the surveyor observed the morning Keppra pill pack which was brought to the surveyor by DON #2. DON #2 stated to the surveyor that they had found the pack in the back of the medication cart and stated to the surveyor: As you can see, they have been taking from the other evening pack. Review of the medical record of Resident #25 on 6/13/25 at 11:17AM by the surveyor revealed the following active medication order on the June 2025 Medication Administration Record: Keppra Oral Tablet 250 MG (Levetiracetam), Give 500 mg by mouth one time a day for seizure disorder.

Based on observation, interview, and documentation review it was determined that the facility staff failed to store, prepare, and maintain a sanitary environment in accordance with professional standards for food service safety by failing to ensure dishwasher hot water temperatures are frequently checked to ensure cleanliness and sanitation of dishware, failing to ensure safe refrigerator temperatures and failing to dispose of outdated food items. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. The findings include: 1) An initial environmental kitchen food services inspection was conducted on 4/19/22 at 8:46 AM. The dishwasher temperature log was found near the dishwasher hanging on a clipboard. A review of the Dishwasher Temperature log revealed that the staff was not consistently monitoring the temperatures of the dishwasher. The entire log was observed to have missing temperature monitor checks on each day of the month when dishware and utensils are washed. Most of the April 2022 Dishwater Temperature Log was blank. There was not any documentation of the dishwasher wash and sanitation water temperatures for 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, 4/12, 4/17, 4/18, and 4/19/22. The Certified Dietary Manager (CDM) was asked to provide a copy of the current Dishwater Temperature Log for April 2022. On 4/26/22 at 8:20 AM an interview was conducted with the CDM. A review of the current dishwasher temperature log revealed that all the previous blank dates 4/4/22 to 4/12/22 were filled in by one staff member for 10 days straight. The dishwasher temperature log shown that the temperature sanitation level was not monitored for the dinner mea The documented times checked by the dietary staff were recorded as 7 or 7:30 AM, 10:30 or 11:30 AM, and 1 PM. The minimal requirement for the wash temperature of the facility's dishwasher is 150 degrees Fahrenheit (F) and the minimum rinse temperature is 180 degrees F. Most of the temperatures for April 2022 were recorded as the minimum of 150 degrees F. wash temperature and 180 degrees F. rinse temperature. The CDM turned on the dishwasher and ran the machine through 3 cycles and the dishwater wash temperature did not meet the requirement of 150 degrees F. Observation of the dietary staff dishwasher lunchtime service was observed at 2:10 PM on 4/26/22. Observations of the dishwasher through 3 complete wash and rinse cycles did not reveal a wash temperature greater than 146 degrees F. The rinse temperature rose above the minimum temperature to 184 degrees F on the third observed cycle. The CDM was made aware, and she ran the dishwasher to observe that the wash cycle was below 150 degrees F. The facility called in a dishwasher service technician as the nursing home administrator requested the surveyors to meet with him at approximately 3 PM on 4/26/22. The service technician ran the dishwasher with surveyors observing and the wash temperature only reached 149 degrees. The service technician returned to the surveyors within the hour to share that he found a malfunction of the dishwasher and had repaired the malfunction and reported wash temperatures around 160 degrees F. 2) During an initial kitchen tour conducted on 4/19/22 at 8:46 AM, a half-filled box with pasteurized eggs (103 of 180 eggs) was found on the bottom shelf of a refrigerator. There was a handwritten date marked as 01/18 and a printed date was left on the side of the box that read best before/sell by 2/18/22. On 04/19/22 at 09:01 AM an interview was conducted with the Certified Dietary Manager (CDM). She stated, the facility kept the eggs for 6 months, and the eggs were given only to residents who wanted pasteurized eggs. On 4/26/22 at 2:12 PM, an interview was conducted with the Registered Dietitian (RD #21). RD #21 stated since the nursing home has a population at high risk for foodborne illnesses, the pasteurized eggs should not be used after the marked date on the package which was 2/18/22. Surveyors informed RD #21 that 103 of 180 eggs had remained in the box in the refrigerator. RD #21 said, it needs to be thrown away. The Nursing Home Administrator and Director of Nursing were made aware of the above concerns on 5/6/22 at 3:10 PM.

Based on observation and staff interview, it was determined that the facility staff failed to provide residents with dignity and respect by improperly transporting residents down the hall (Resident #70, Resident #173 Resident #21 and assisting a resident to eat (Resident #65). These events were evident during 5 random observations on the facility nursing units during the survey. The findings include: 1) During an observation of the 3rd-floor nursing unit on 04/20/2022 at 11:11 AM, therapy staff member #14 was observed pulling Resident #70 backwards in a wheelchair down the hallway towards the main dining area. A review of Resident #70's medical record revealed that Resident #70 was measured to be 72 inches tall during the admission process on 04/01/2022. In an interview with Resident #70 in the resident's room on 04/20/2022 at 12:25 PM, Resident #70 stated that he/she was currently receiving therapy services for standing and balance. The surveyor observed Resident #70's wheelchair sitting against the wall at the end of his/her bed. The surveyor asked Resident #70, do you have footrests that go to your wheelchair? Resident #70 stated no, I cannot find them. The surveyor then asked Resident #70, does it bother you that staff pull you backwards down the hall instead of facing forward when ambulating you in your wheelchair? Resident #70 stated that his/her feet get tangled underneath the wheelchair because of the lack footrests. 2) During an observation of the 3rd-floor nursing unit on 04/22/2022 at 1:36 PM, the surveyor observed a Geriatric Nursing Assistant (GNA) #36 pulling Resident #173 backwards in a geri chair (a medical chair that can recline) down the hallway towards Resident #173's room. During a second observation of the 3rd-floor nursing unit on 04/22/2022 at 1:45 PM, the surveyor observed GNA #36 again pulling Resident #173 backwards in a geri chair down the hallway towards the main dining area. In an interview with Resident #173 on 04/22/2022 at 1:45 PM, the surveyor asked Resident #173 if it bothered him/her that staff members pull him/her backwards while ambulating down the hallway. Resident #173 stated, no. In an interview with GNA #36 on 04/22/2022 at 1:45 PM, GNA #36 stated that s/he was bringing Resident #173 back to his/her room to see if Resident #173 was wet (incontinent). These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM and again reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference. 3) During an observation of the 2nd-floor nursing unit on 04/25/22 at 12:30 PM, GNA #22 was observed pulling Resident #21 backwards down the hallway towards the main dining area while the resident was seated in a Geri chair. This concern was reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference. 4) During an observation of the 3rd-floor nursing unit on 4/26/22 at 12:53 PM, GNA #34 was observed assisting Resident #65 eating in the resident's room. Resident #65 was sitting on his/her bed and GNA #34 was standing over the resident. This concern was reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference. These concerns were discussed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.

Based on interview and review of facility reported incident (FRI) investigation documentation it was determined the facility staff failed to thoroughly investigate incidents of alleged verbal and physical abuse. This was evident for 5 of 6 residents (Resident #9, #225, #226, #275, #276) reviewed for abuse. The findings include: 1) On 4/28/2022 at 2:00 PM, review of the facility reported incident MD 599 revealed that Resident #9 had alleged that GNA #33 slapped him/her. The facility administrative staff investigated and substantiated the allegation of physical abuse and terminated GNA #33. Resident #9's roommate was noted as not a reliable witness and was not interviewed. However, other residents to whom the accused employee provided care or services were not interviewed. On 5/4/2022 at 10:36 AM, in an interview with the Administrator, she/he was made aware that no other residents on GNA #33's assignment had been interviewed. The Administrator stated she/he had no further information to give the surveyor. 2) On 4/29/2022 at 2:15 PM, review of the facility reported incident MD 102 revealed that on 12/16/19 at 2pm, Resident #226 reported to the unit manger that GNA #34 who was taking care of him/her on 12/15/19 hit them in the back of their neck. Further review of the facility investigation revealed the facility was not able to substantiate the allegation of abuse, however the facility failed to do a thorough investigation. The facility failed to interview other staff members or residents during the investigation. On 5/2/2022 at 9:53 AM, the Administrator and the DON were asked for copies of the written statements by the other residents to whom the accused employee provided care or services that were interviewed. The Administrator stated that she/he could not find any additional documents pertaining to the above allegation. She/he further stated that she/he was not working in the facility at the time of the incident and did not have access to the records. 3) Review of facility reported incident MD 279 on 5/2/2022 revealed that Resident #225 reported on 4/15/2021 that GNA #35 was rough, loud and would not let them sit back down when they requested to because of leg pain. Verbal abuse was substantiated by the facility and GNA #35 was terminated, however a thorough investigation was not done. There was no statement from the perpetrator and/or record of interviews of other residents to whom the accused employee provided care or services. The Director of Nursing (DON) was interviewed on 5/2/2022 at 1:19 PM and could not provide any further documentation and stated that the former DON who completed the investigation no longer worked in the facility. On 5/4/2022 at 10:36 AM, in an interview with the Administrator, she/he was made aware that the facility staff did not conduct a thorough investigation of the above allegation. 4) On 5/2/22 at 9:14 AM, a review of the facility reported incident MD 139 revealed that Resident #275 reported that GNA #53 used foul language when Resident #275 requested care on 2/22/22. Verbal abuse was substantiated by the facility and GNA #53 was terminated. The facility's self-report form indicated the resident was assessed for injury or pain. However, there was no documentation to support Resident #275's assessment such as a progress note, change of condition, head-to-toe assessment, or evidence a psych consult was ordered. Also, there was no statement from the perpetrator and/or record of interviews of other residents to whom the accused employee provided care or services. 5) On 5/2/22 at 1:17 PM , a review of the record of the facility reported incident MD 245 revealed that Resident #276 reported that GNA #56 hit the resident on 10/17/21. Further review of the facility investigation revealed the facility was not able to substantiate the abuse based on the resident statements and witness statements. According to the facility investigation record, upon interview of the resident, Resident #276 stated, nobody hit me, it's too hard to turn in the bed cause it hurts. The facility obtained 3 witness statements from the staff. All three staff denied the abuse incident on Resident #276. However, the facility failed to document Resident #276's assessment regarding the abuse report. Also, there was no statement from the perpetrator and/or record of interviews of another resident to whom the accused employee provided care or services.

Based on record reviews, observation, and staff interview, it was determined that the facility failed to: 1) develop and implement comprehensive person-centered care that were resident specific with measurable objectives and goals (Resident #26, #66, #57, #273) and 2) develop a care plan to address the use of an anticoagulant (Resident#58). This was evident for 5 out of 55 residents reviewed during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) Resident #66's medical record was initially reviewed on 4/20/22 and revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record indicated that rehab therapy ended on 6/12/20 and the resident was to continue with a restorative nursing program. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3 orders were written as nursing to don (AFO) ankle-foot orthosis and knee brace on LLE (left lower extremity) before ambulation, doff after ambulation 2) Nursing to assist patient ambulate using front wheeled walker with CGA, Gait belt on, with ankle-foot orthosis and knee brace on left lower extremity for 25-50 as tolerated by the patient 3) Nursing to assist patient with functional transfers from bed to/from wheel chair, wheel chair to/from toilet with CGA-min assist, with gait belt on. All three-orders indicated every day shift. Review of the resident's care plans on 5/4/22 did not reveal any care planning related to a nursing restorative program. There was not an intervention to ambulate the resident with assistance. A plan of care was written for a focus area of potential for fall related to impaired mobility, incontinence. The goal was written as [Resident #66] will have decreased risk of falls with intervention through the review date. The goal is not measurable as it did not quantify what are the risk factors for this resident. Concerns of care planning and lack of evaluations were discussed with the DON on 5/4/22 at 11:39 AM. 2) Review of Resident #26's medical record on 4/20/22 at 10:43 AM revealed 2 orders written on 10/28/21 for Restorative program. 1) Nursing will assist patient with ambulation (walk to dine) 100-150 feet using hemi-walker as tolerated with gait belt with contact guard assist. This task will take at least 15 minutes to complete. one time a day, 2) Nursing will assist patient with functional transfers from bed <>w/c <> commode with contact guard assist as tolerated. This task will take at least 15 minutes to complete one time a day. Review of Resident #26's care plan on 5/4/22 revealed there was a focus area that the resident had an actual fall related to poor balance and poor safety awareness initiated on 10/18/21 and revised on 4/21/22. The goal was written that the resident will be free of injuries related to fall through the review period. The interventions were written as: Bed in low position, non-skid socks and shoes, and PT consult /screen for transferring. There were not any written interventions to assist the resident with ambulation. The care plan was not resident centered as there was not any documentation of restorative care and the interventions that were to be provided. 3) An observation was made on 4/20/22 at 10:13 AM of Resident #57 who was in a semi-sitting position (30-45 degrees) in bed. A second observation was made on 4/20/22 at 11:52 AM, the resident was in the same position (semi-sitting position). A third observation was made on 4/20/22 at 1:18 PM, the resident was in the same position. A review of Resident #57's medical record on 4/20/22 at 08:30 AM revealed the resident was readmitted to the facility on [DATE] from an acute care facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This weakness and diminished mobility can be temporary or permanent), pulmonary embolism, and pressure wound on the sacrum and Left lateral heel, and vascular wound on Right lateral lower leg. A review of the order summary for Resident #57 on 4/26/22 at 10:31 AM revealed that the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #57's treatments administration record documented that the facility staff did the resident's turn and reposition every shift. An interview was conducted with a Geriatric Nursing Assistant (GNA) #38 on 4/26/22 at 11:25 AM. GNA #38 stated that she did not turn and reposition Resident #57 since the resident had not requested it. During an interview with Resident #57 on 4/27/22 at 1:20 PM, the resident said, I'm comfortable in this position, want to keep it. The resident denied that changing positions was performed by staff, the resident stated that he/she wanted to stay in the same position. A review of the care plan for Resident #57 was conducted on 4/27/22 at 2:30 PM. There was no care plan related to the refusal of turning and repositioning. The Director of Nursing was made aware of this on 4/27/22 at 3:05 PM. 4) On 4/29/22 at 10:30 AM, a review of the facility reported incident MD 245 revealed that Resident #273 had alleged unknown discoloration on the left upper back and back of the left hand on 11/30/2021. Further review of the facility injury report indicated, Patient has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, a review of the care plan for Resident #273 on 4/29/22 at 11:36 AM revealed that there was no care plan or intervention initiated regarding the high risk of bruising. During an interview with the Director of Nursing (DON) on 4/29/22 at 1:34 PM, she was asked to provide a care plan related to Resident #273 being at high risk for bruising due to a medical diagnosis. The DON confirmed that the care plan was not updated regarding this unknown bruise and injury of unknown origin. 5) A review of Resident #58's clinical record on 04/29/2022 at 3:30 PM revealed Resident #58 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon admission, Resident #58 was placed on the anticoagulant, [MEDICATION(S)], 5 mg, orally, twice daily, for bilateral pulmonary embolisms. Taking this medication may increase the risk of bleeding. A care plan to address the risk of bleeding was not developed. These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM. These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.

Based on observation, medical record review and staff interview it was determined the facility failed to have a process to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 3 of 4 residents (Resident #21, #26, #66) reviewed for limited range of motion during the survey. The findings include. 1) Resident #21's medical record was reviewed on 4/20/22 at 1:15 PM. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was found to indicate staff sign off daily to show compliance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observations of Resident #21 on 4/25/22 at 12:37 PM and 2:36 PM revealed that the resident was not wearing a knee brace. The Licensed Practical Nurse (LPN) #19assigned to Resident #21 was interviewed at 2:36 PM on 4/25/22. She was asked about the resident's knee brace, and she responded that she has not seen the brace since she started working at the facility. When asked, she indicated that she started working at the facility in January 2022. At 3:05 PM on 4/25/22, a GNA #22 was observed to apply a knee brace on Resident #21's right leg. An interview was conducted with the nursing home administrator (NHA) and the director of nursing (DON) at 3:00 PM on 4/26/22. The DON stated that they do not have a restorative program here at the facility. She indicated that the order to don and doff the knee brace daily for Resident #21 was not put into the EHR system correctly. Showing a printed copy of the order she revealed that the Order Type was incorrectly identified as Restorative. The order did not transfer to the Treatment administration record (TAR). She indicated that there was not any place in the EHR to document daily compliance for application of the right knee brace. Review of Resident #21's care plans on 5/2/22 at 9 AM revealed an identified Focus area initiated on 3/14/21 related to the resident having an activity of daily living self-care performance deficit. The goal was written as the resident will improve current level of function with the intervention of rehab services. The interventions indicated that the resident was totally dependent on staff for personal hygiene, oral care, dressing, and transfers. On 4/19/22, right knee brace on 4-6 hours during the day was added. 2) Resident #66 was interviewed on 4/20/22 at 11:22 AM. Resident #66 revealed he/she has limited extent of movement of joints. Resident #66 indicted that he/she is to be walked daily, and he/she was informed that there is not enough staff to be walked daily. Resident #66's EHR orders were reviewed during the interview and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Three orders were written on 6/12/20 were labeled as Restorative Nursing Program, 1) nursing to don (AFO) ankle-foot orthosis and knee brace on LLE (left lower extremity) before ambulation, doff after ambulation 2) Nursing to assist patient ambulate using front wheeled walker with CGA, Gait belt on, with ankle-foot orthosis and knee brace on left lower extremity for 25-50 as tolerated by the patient 3) Nursing to assist patient with functional transfers from bed to/from wheel chair, wheel chair to/from toilet with CGA-min assist, with gait belt on. All three-orders indicated every day shift. The DON acknowledged that there was not a place for staff to sign off daily as the three orders were not transcribed correctly and the orders did not transfer to the treatment administration record. Review of the medical record on 5/4/22 revealed that all three restorative orders were discontinued. The order to assist resident to ambulate was discontinued on 4/20/22 and the other 2 Restorative Nursing program orders were discontinued on 4/26/22. No documentation was found as to a reason that the orders were discontinued. Further EHR review of the resident's care plans revealed that there were no interventions documented to assist the resident with functional transfers, don a AFO and knee brace prior to ambulating, or assist resident with a gait belt on for functional transfers. 3) Review of resident #26's medical record on 4/20/22 at 10:43 AM revealed 2 orders written on 10/28/21 for Restorative program. 1) Nursing will assist patient with ambulation (walk to dine) 100-150 feet using hemi-walker as tolerated with gait belt with contact guard assist. This task will take at least 15 minutes to complete. one time a day, 2) Nursing will assist patient with functional transfers from bed <> w/c <> commode with contact guard assist as tolerated. This task will take at least 15 minutes to complete. one time a day. Both restorative orders were documented on the treatment administrative record (TAR) for 9:00 AM. Nurses consistently sign the TAR as task completed. During the survey the resident was not observed ambulating to dine and was always observed in a wheelchair. On 5/4/22 at 10:30 AM review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was evaluated by rehab and rehab physical therapy was initiated for new onset reduced dynamic balance, decreased strength, decreased functional mobility, increased need for assistance from others and decreased neuromotor control. As of 4/26/22 rehab staff assessed the resident's baseline for safe ambulation using a hemi-walker was 10 feet. The nurses were signing off that the resident ambulated 100 - 150 feet daily without any notes that the resident was unable to perform ambulation for the restorative program. The director of rehabilitation was interviewed on 5/4/22 at 11:53 AM. She showed and demonstrated the hemi-walker that was kept in the nursing station. She was informed that the nurses were documenting daily that the resident was ambulating a greater distance than the rehab assessed baseline of 10 feet. Review of the TAR at 1:05 PM on 5/4/22 revealed that the restorative order for ambulating Resident #26 was signed off by the licensed practical nurse #42 assigned to the resident. The nurse was interviewed at this time and was asked how far did the resident ambulate today? She asked what the resident's room number was, reviewed a sheet of paper and stated that she did not see the resident ambulate today. The resident's care plan was reviewed after the interaction with the resident's nurse. Review of the care plan revealed there was a focus area that the resident had an actual fall related to poor balance and poor safety awareness initiated on 10/18/21 and revised on 4/21/22. The goal was written that the resident will be free of injuries related to fall through the review period. The interventions were written as; Bed in low position, non-skid socks and shoes, and PT consult /screen for transferring. There were not any written interventions to assist the resident with ambulation. The DON was interviewed on 5/6/22 at 10:16 AM and was informed that the nurse had signed off on an order that was not performed with the resident. She indicated that the resident does walk and discussed that the resident was recently picked up by physical therapy and the evaluated ambulation baseline was only 10 ft and there was no supporting documentation by the nurses as to the resident's progress related to assisted ambulation. She was informed of the lack of care planning. She was shown were a nurse indicated the resident had refuse ambulation on 5/1/22 and there was not any additional documentation related to the resident's refusal.

Based on observations, staff interviews, and record review, it was determined that the facility failed to obtain accurate weights and verify weights as needed. This was found to be evident for 4 residents out of 4 residents (Resident #3, #57, #176, #178) reviewed for nutrition and hydration during an annual recertification survey. The findings include: Mechanical lifts are devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone. They include floor lifts, sit-stand lifts, and ceiling track lift systems. Some of these lifts can obtain weights on residents. A Hoyer lift is a kind of mechanical lift. (New York State of Opportunity- Health and Safety Alert) 1) An electronic medical record review of Resident #57 was conducted on 4/26/22 at 11:11 AM. The resident's body weight was recorded as: 3/22/22 - 255 lbs. (lift scale) 3/24/22 - 256 lbs. (Hoyer #1) 3/25/22 - 257.7 lbs. (Mechanical Lift) However, these recorded body weights were crossed out by the facility Dietitian #52. Further medical record review revealed that Dietitian #52 wrote a nutrition note under the resident's progress note on 4/21/22; Weights gathered from 3/22-3/25/ inaccurate, weights then verified for correct weights on April 6, April 19th, and April 20th. Will strikeout weights that were inaccurate. Some variance was noted in Hoyer lifts but verified for accuracy with the most recent weights. BMI still indicates obese I at 30.9 Further medical record review for Resident #57 revealed that Resident #57's initial body weight was 225 lbs. via Hoyer lift on admitted [DATE]. The resident was transferred to a hospital for lethargy and respiratory distress on 3/29/22. Resident #57 was readmitted to this facility on 4/5/22. The resident bodyweight was 228 lbs. via Hoyer lift on 4/6/22. An interview was conducted with the maintenance director on 4/26/22 at 1:20 PM. He stated the facility had 3 Hoyer lifts; one for just lifting, and two for lifting and measuring weight. An interview was conducted with the director of nursing (DON) on 4/27/22 at 9:44 AM. The DON confirmed that Dietitian #52 had worked remotely and had never been in the facility building. The surveyor asked the DON how Dietitian #52 had recognized Resident #57's weight record was inaccurate and that there was an issue with the Hoyer lift scale. The DON stated Dietitian #52's progress note was unreliable. The surveyor requested any documentation to support how the facility verified weight measurements when Resident #57's weight was changed and reassessed interventions. No other documentation was submitted prior to survey exit. 2) A review of Resident #3's documented weights for the past month, on 05/05/2022 at 2:30 PM, revealed the following: 04/05/2022 - 192.8 pounds 04/06/2022 - 191.2 pounds 04/11/2022 - 193.2 pounds 04/18/2022 - 191.7 pounds 05/05/2022 at 12:25 PM - 158.2 pounds The weight difference between the 04/05/2022 weight of 192.8 pounds and the 05/05/2022 weight of 158.2 pounds is 34.6 pounds (17.9%). A review of Resident #3's April 2022 documented amount of meals consumed revealed that Resident #3 consistently consumed 76-100 % of his/her breakfast, lunch and dinner. A review of the facility weight monitoring policy revealed the following: 6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant weight change is defined as: a. 5% change in 1 month (30 days) b. 7.5 % change in 3 month (90 days) c. 10% change in weight in 6 months (120 days) 7. Documentation: a. The physician should be informed of a significant weight change in weight and may order nutritional intervention. h. Notification to the resident and/or representative of any significant weight change. Further review of Resident #3's medical record on 05/05/2022 at 2:30 PM revealed a 05/05/2022 12:25 PM recorded weight of 158.2 pounds. In an interview with the third-floor charge nurse Staff #44 on 05/05/2022 at 2:50 PM, the third-floor charge nurse stated that Resident #3's weight was documented correctly and that s/he oversaw the staff weigh Resident #3 in his/her wheelchair on the third-floor hallway scale. The third-floor charge nurse stated that s/he was not aware of Resident #3's previously recorded weights. Medical record review did not reveal any documentation Resident #3's physician or representative were notified of the significant weight change. On 04/04/2022, the facility dietician documented Resident #3 has alterations in nutrition/hydration related to medical issues and that Resident #3 frequently chooses not to follow diet recommendations. The facility dietician noted Resident #3 had weight gain on 04/06/2022. In an interview with the facility director of nurses (DON) on 05/05/2022 at 3:15 PM, the DON was made aware of Resident #3's current documented weight of 158.2 pounds as recorded by the facility staff on 05/05/2022. The facility DON stated that s/he just got off the phone with staff #44 regarding another resident's documented weight regarding significant weight loss. The DON stated that s/he would investigate Resident #3's newly charted weight and get back with the surveyor. The DON was asked if the difference documented in Resident #3's weight could have been user error or a mechanical scale error? The facility DON did not produce any type of quality assurance assessment regarding documented resident weight issues since being hired at the facility in July 2021. In a follow-up interview with the facility DON on 05/06/2022 at 11:33 AM, the facility DON stated that s/he weighed herself/himself on her/his scale at home and then compared the weight to the third-floor scales. The DON stated that as of 05/06/2022, the weight scales on the third floor are inaccurate. The DON stated that s/he contacted the facility maintenance director to obtain a company to calibrate the facility scales. 3) Review of complaint MD 930 on 04/25/2022 revealed an allegation Resident #178 had a significant weight loss that was not identified by the facility nursing staff. On 08/20/2021, Resident #178's admission weight at the receiving long-term care facility was 81.6 pounds. A review of Resident #178's closed medical record revealed documentation, dated 08/20/2021 at 11:26 AM revealed that Resident #178 was transferred to another long-term care facility. Resident #178's family initiated this transfer. In an interview with the receiving facility administrator on 05/04/2022 at 11:50 AM, the receiving facility administrator stated that Resident #178's admission weight was 81.6 pounds. Additional weights were also obtained from the administrator. In an interview with the facility DON on 05/04/2022, 11:50 AM, the DON stated, I believe the admission weight at the receiving facility was incorrect when Resident #178 was admitted . I called the facility in August 2021 and spoke to the facility ADON, it may have been over a weekend, and the receiving facility ADON stated that Resident #178's admission weight had been wrong and subsequent weights were in the 120's. In a second phone call to the receiving facility, the facility administrator indicated the following August/September 2021 weights were recorded for Resident #178 after the 08/20/2021 admission as: 08/20/2021: 81.6 pounds 08/21/2021: 81.4 pounds 08/24/2021: 84.8 pounds 08/27/2021: 81.9 pounds 08/31/2021: 86.4 pounds 09/03/2021: 86.5 pounds 4) Review of complaint MD 144 on 05/04/2022 revealed an allegation Resident #176 had a significant weight loss and that the communication from the facility staff was poor. In an interview with the MD 144 complainant on 05/04/2022 at 9:55 AM, the complainant stated that s/he was not made aware of Resident #176's weight loss in November 2021 and that communication from the facility was poor. A review of Resident #176's closed medical record revealed nursing documentation that on 10/05/2021 at 12:04 PM, Resident #176's standing weight was 139.6 pounds. On 11/03/2021 at 3:29 PM, the nursing staff documented Resident #176's weight via wheelchair to be 110.6 pounds. On 11/08/2021 at 11:37 PM, the nursing staff documented Resident #176's weight via wheelchair to be 110.8 pounds. Between 10/05/2021 and 11/03/2021, the nursing staff documented a 29-pound (20.7%) weight loss. The 11/08/2021 documented reweigh of 110.8 pounds for Resident #176 also shows a significant weight loss of 28.8 pounds (20.6%). Further review of Resident #176's closed medical record failed to reveal Resident #176's physician or representative were immediately made aware of the significant weight loss on 11/02/2021 or 11/08/2021. Further review of Resident #176's closed medical record revealed that the facility dietician #53, erroneously crossed through Resident #176's documented weights (11/03/21 of 110.6 and 11/08/21 of 110.8) and on 11/17/2021 at 1:34 PM noting Resident #176's documented weight on 11/16/2021 at 2:57 PM of 111.6 pounds was valid. Dietician #53 documented that Resident #176 had a significant weight loss on 11/17/2021 at 3:53 PM. There was no indication why Dietician #53 struck out weights on 11/03/2021 and 11/08/2021. These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM. These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.

Based on medical record review and staff interview it was determined the facility staff failed to have a process to ensure that medication regimen reviews occur monthly for all residents and pharmacist recommendations were timely acted upon and documented in the resident's medical record. This was evident for 6 of 6 residents (Resident #24, #28, #31, #41, #67, #180) reviewed for unnecessary medications. Additionally, the facility failed to develop policies and procedures related to time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. 1) Resident #28's medical record was reviewed on 4/21/22 at 2:52 PM. Resident #28 was admitted to the facility on [DATE]. Monthly Medication regimen reviews were not readily found in Resident #28's medical record. At 3:00 PM on 4/21/22 the nursing home administrator was asked to provide a copy of the facility's Monthly medication regimen review policy. On 4/22/22 at 9:30 AM the director of nursing (DON) revealed that the pharmacist documents the monthly medication reviews in the Electronic Health Record (EHR) under the progress note tab. Review of Resident #28's EHR at 9:35 AM on 4/22/22 revealed one generic progress note written by the consultant pharmacist. The note was written as a late entry note for 3/13/2022 and the note was created on 3/31/2022. The pharmacist identified a medication irregularity as he wrote Please evaluate [MEDICATION(S)] and Aspirin usage together. There was not any documentation of a pharmacy medication review in the month of February 2022. On 4/22/22 at 10:30 AM the director of nursing provided a copy of the facility's Drug Regimen Review policy. She indicated that the pharmacist emails a list of residents that were found by the pharmacist with a medication irregularity at least once a month. The policy was reviewed and shared with the DON that the policy was vague and did not provide time frames for the different steps in the process and the steps the pharmacist must take when an identified medication irregularity requires urgent action. The DON was asked if the medication irregularity identified by the pharmacist in March 2022 was evaluated by the resident's attending physician. On 4/22/22 at 11:10 AM a re-interview with the DON revealed that she had reviewed Resident #28's paper chart and did not find any documentation of the resident's attending physician responding to the pharmacist's late entry recommendation for 3/13/22. Further review of Resident #28's medical record revealed the pharmacist had created a late entry note at 9:51 AM on 4/22/2022. The effective date of the note was 2/8/2022. The identified medication irregularity was written as Please evaluate [MEDICATION(S)] and Aspirin usage together. At 11:35 AM on 4/22/22, a meeting was held with the Nursing Home Administrator and the DON. The newly identified pharmacist late entry note from February was added on 4/22/22. The DON indicated that the pharmacist does his reviews off-site. The DON was asked to provide a copy of the Consultant Pharmacist Report from 2/8/22. The DON returned at 12:01 PM with a blank report. There was not any indication of the resident's attending physician's evaluation for the 2/8/22 identified medication irregularity. Further review of Resident #28's EHR on 4/25/22 at 8:40 AM, revealed that the consulting pharmacist wrote a late entry progress note with an effective date of 4/13/22 and the note was created on Sunday 4/24/22 at 1:19 PM. The consulting pharmacist identified additional medication irregularities as well as the same identified irregularity from 2/8/22. The pharmacist wrote, please evaluate the benefit/risk of use for sliding scale insulin order, should [MEDICATION(S)] order include a length of therapy? Please evaluate [MEDICATION(S)] and Aspirin usage together, Aspirin and [MEDICATION(S)] suggested for dosing with food. Ongoing review of the medical record did not reveal that any of the identified medication irregularities were evaluated by the resident's attending physician. The medical director was interviewed on 5/5/22 at 11:25 AM. The concern of the late entry pharmacist medication regimen and lack of physician follow-up and lack of a clear policy related to timelines of reviews was shared. The medical director was asked if he receives emails from the consulting pharmacist identified medication irregularities and he responded that he had not received any recent emails from the pharmacist. He was asked what is the time frame that a physician should respond to the pharmacist's monthly review and he indicated within 24 hours. 2) On 4/27/22 at 12:36 PM, medical record review revealed that Resident #31 was admitted to the facility on [DATE] with a diagnoses that included Dementia, Depression, and chronic [CONDITION(S)]. On 4/27/22 at 2:12 PM, review of the Pharmacist monthly medication review progress notes from December 2021 through April 2022 revealed late entry notes with suggest PRN (as needed) Acetaminophen order indicates not to exceed 3 gm/day and No recommendation indicated for 1/10/22, 2/8/22, 3/13/22, and 4/13/22. On 4/27/22 at 2:35 PM, in an interview with the DON, she/he stated that the Drug Regimen Review policy given to the other surveyor was the only policy they have. That policy was reviewed and did not address time frames for steps in the MRR process and steps the Pharmacist must take when an irregularity requires urgent action. 3) On 4/27/22 at 2:30 PM, medical record review revealed that Resident #24 was admitted to the facility on [DATE] with diagnoses that included Dementia and Depression. On 4/27/22 at 2:40 PM, review of pharmacy progress notes revealed late entry monthly medication regimen review notes for 11/8/21, 12/8/21, 2/22/22, and 3/13/22 with No recommendations indicated. For 1/10/22 the following was noted; Please evaluate if [MEDICATION(S)] and/or [MEDICATION(S)] dosage reductions could be attempted at this time. For 4/13/22 the note was: Please clarify [MEDICATION(S)] diagnosis of [CONDITION(S)]. On 4/28/22 at 11:00 AM, review of the Medication Administration Record for the month of April 2022 was completed. Ongoing review of the medical record did not reveal that the identified medication irregularity for 4/13/22 was evaluated by the resident's attending physician. On 5/5/22 at 11:20 AM, in an interview with the Medical Director, he/she stated that the Pharmacist's recommendations were flagged for the attending physician to review every 24 hours to 48 hours. However, physicians should review residents' charts every 24 hours. The Medical Director further stated that the recommendations moving forward was for the pharmacist to attend the Quality Assurance Performance Improvement meetings to discuss medication issues. On 5/6/22 at 3:15 PM, all concerns were addressed with the Administrator and the Director of Nursing prior and during the survey exit conference. 4) On 4/22/22 at 9:50 AM review of the electronic and paper record for Resident #41 revealed the resident was admitted to the facility on [DATE]. Further review of the resident's electronic medical record revealed a generic progress note written by the consultant pharmacist. The note was a late entry written on 3/31/2022, for a review completed on 3/13/2022. The pharmacist identified a medication irregularity and wrote should [MEDICATION(S)] order include a length of therapy? Please evaluate the benefit/risk of using [MEDICATION(S)]. Are [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] all needed for spasms? Another note was created on 4/22/22 as a late entry from a review completed on 4/13/2022. The pharmacist wrote, Are [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] all needed for Muscle spasms? Are [MEDICATION(S)] and [MEDICATION(S)] both needed for [CONDITION(S)]? Please evaluate the benefit/risk for [MEDICATION(S)]. An interview conducted with the DON on 4/22/22 at 10:30 AM revealed the DON was asked if the medication irregularity identified by the pharmacist in March 2022 and April 2022 was evaluated by the resident's attending physician. The DON returned at 11:55 AM and confirmed that there was no documentation regarding the attending physician's evaluation for March 2022 and April 2022 addressing the medications in question. 5) On 4/22/22 at 10:30 AM review of the electronic and paper record for Resident #67 revealed a generic progress note written by the consultant pharmacist. The note was a late entry written on 3/31/2022, for a review completed on 3/13/2022. The pharmacist identified a medication irregularity and wrote Is [MEDICATION(S)] for [CONDITION(S)] still needed? If so, please evaluate if a dosage reduction could be attempted at this time. Is a sliding scale insulin order still needed? Please evaluate if a [MEDICATION(S)] dosage reduction could be attempted at this time. Another note was created on 4/22/22 as a late entry from a review completed on 4/13/2022. The pharmacist wrote, Please evaluate potential [MEDICATION(S)] and [MEDICATION(S)] effect on [MEDICATION(S)]. Sevelamer suggested for dosing with meals. An interview conducted with the DON on 4/22/22 at 10:30 AM revealed the DON was asked if the medication irregularity identified by the pharmacist in March 2022 and April 2022 was evaluated by the resident's attending physician. The DON returned at 11:55 AM and confirmed that there was no documentation regarding the attending physician's evaluation for March 2022 and April 2022 addressing the medications in question. 6) A review of complaint MD 719 on 05/06/2022 revealed allegations Resident #180 was not provided with a quality of care while s/he resided in the facility. A review of Resident #180's closed medical record initially failed to reveal any monthly pharmacy reports. In an interview with the facility director of nurses (DON) on 05/06/2022 at 11:20 AM, the DON stated that the current pharmacist consultant started working for the facility in February 2020. After obtaining a copy of the pharmacist consultant's review of Resident #180's medication on 03/11/2021 from the DON, the pharmacy consultant suggested adding not to exceed 3 gm/day to Resident #180's order for Tylenol. The 03/11/2021 pharmacy consultants report was not initially located in the closed record. There was no indication that Resident #180's physician reviewed the recommendation and signed off as accepting or declining the recommendation. A review of the facility policy Drug Regimen Review on 05/06/2022 at 11 AM revealed under #5) Documentation shall include whether any clinical significant medication issues were identified, and how the issues were addressed. Documentation to support follow-up on identified issues shall include: a. Two-way communication (in person, by telephone, voice mail, electronic means, facsimile, or other) between the clinician(s) and the physician by midnight of the next calendar day, AND b. All-physician-prescribed/recommended actions were completed within a reasonable time. These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM. These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.

Based on the review of the medical record review, observations, and interviews, it was determined the facility staff failed to: 1) maintain medical records in the most accurate form as the facility failed to completely identify the positions of staff in the electronic health record. All resident records are affected by this lack of staff identification; 2) maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident for 3 out of 8 residents (Residents #25 and #32 and #180) reviewed for medical records during the survey, The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. While conducting medical record reviews during the survey it was discovered that progress notes would have a name of the clinician, but the note did not include a title, or the staff position. This is most evident in review of the staff administration legend on each monthly medication administration record (MAR) or the treatment administration record (TAR). The legend on each MAR of TAR lists the staff's initials, long username (full name), username, followed by the last column designation. The designation was blank for most staff documenting in the medical records. The NHA and the DON were informed of the concern related to lack of identification of the clinicians on 4/26/22 at 3:45 PM. 2) On 4/25/22 at 2:20 PM, review of Resident #25's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2022 revealed several blanks for the evening shift on 4/23/22 and no corresponding progress notes to explain if the medication was given and/or treatment done by the evening shift nurse. For example, IV [MEDICATION(S)] (antibiotics) had no staff initials on the 9:00 PM slot and a notation of 9 with staff initials in the 9:00 AM slot. On 4/25/22 at 2:37 PM, Surveyor conducted an interview with the Assistant Director of Nursing (ADON). The ADON confirmed that the blanks on the MAR and TAR meant the medication was not given and treatment not done. She/he stated that the 9 noted on the 9:00 AM slot meant Other/See Nurse Notes based on the facility's chart codes. The ADON further stated that the evening nurse should have written a progress note to explain why the med was not given/treatment not done. the ADON identified the evening nurse for 4/23/2022 to be a part time nurse that had worked a double shift on 4/23/2022. Further review of Resident #25's medical record on 4/26/22 at 10:46 AM revealed that the nurse wrote a late entry progress note with an effective date of 4/23/22 that read: 4/23/2022 21:18 eMAR- Medication Administration Note Late Entry: Note Text: [MEDICATION(S)] not given spoke with pharmacy, states next dose to be delivered on next delivery dose to be given once arrival oncoming nurse made aware 3) On 4/22/22 at 10:10 AM, in an interview with the surveyor, Resident #32 stated that she/he was not picked up for [CONDITION(S)] on Wednesday 4/20/22. On 4/22/22 at 10:25 AM, in an interview with the resident's attending physician #25 who was on the 3rd floor unit at the time, he/she stated that Resident #32 usually refused to go to [CONDITION(S)], and it was not new that the resident did not go on Wednesday 4/20/2022. On 4/22/22 at 10:28 AM, in an interview with Licensed Practical Nurse (LPN #7), she/he stated that transport was running late, and Resident #32 got inpatient and refused to go for [CONDITION(S)]. When asked if transport did make it to the unit, LPN #7 stated no because she/he had called and canceled the transportation and notified the [CONDITION(S)] center. LPN #7 further stated that was not the first time the resident had refused to go to [CONDITION(S)]. When asked were that incident was documented, LPN #7 stated she/he had forgotten to document about it and proceeded to put in a late entry note. On 4/22/22 at 11:55 AM, in an interview with the surveyor, the Assistant Director of Nursing (ADON) confirmed that Resident #32 refused to go to [CONDITION(S)] on Wednesday 4/20/22, however it was not documented. On 5/6/22 at 3:15 PM all concerns were discussed in detail with the Administrator and the Director of Nursing during the survey exit conference. 4) Review of complaint MD 719 on 05/05/2022 revealed an allegation Resident #180 had a significant weight loss. A review of Resident #180's closed medical record on 04/25/2022 revealed a dietician #20 progress note, dated 01/12/2021 at 6:37 PM that indicated Resident #180's oral intake was good with 0-26% of meals being ingested. The facility dietician's progress note was reviewed because Resident #180 was noted with a significant weight loss at this time. Facility staff documented that Resident #180 weighed 231 pounds on 12/29/2020 and 203 pounds, 28 pounds (12.1%) weight loss on 01/08/2021, and 202 pounds, 29 pounds (12.5%) weight loss on 01/11/2021. In an interview with the facility dietician #20 on 05/05/2022 at 8:28 AM, dietician #20 stated that the dietary progress notes on 01/12/2021 at 6:37 PM were incorrect regarding the 0-26% intake being good. Dietician #20 stated that the progress note in Resident #180's chart should have indicated Resident #180's oral intake was poor on 01/12/2021. These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM. These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.

Based on observation, record review, and staff interview, it was determined that the facility failed to maintain strict infection control processes evidenced by: 1) staff failing to keep a urinary catheter bag off the floor. This was evident for 1 of 4 residents (#57) reviewed for a foley catheter and 2) failed to provide education and convey updates to staff on COVID-19. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The findings include: A urinary catheter (also known as foley catheter) is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag. (Foley Catheter definition on Merriam-webster) Germs can travel along the catheter and cause an infection in the bladder or kidney that could cause a catheter-associated urinary tract infection if proper infection control practices are not put in place and followed. (Centers for Disease Control guideline) 1) Observation was made on 4/25/22 at 11:50 AM of Resident #57 lying in bed. Resident #57's foley catheter bag was lying on the floor wedged under the frame of the over the bed tray table. A second observation was made on 4/25/22 at 2:50 PM and the bag was still in the same position. On 4/25/22 at 2:50 PM, the Director of Nursing (DON) was present at the resident's bedside and saw the foley bag. The DON stated that the foley bag should not be lying on the floor and should be away from the entrance room door. A third observation was made on 4/27/22 at 10:38 AM, the foley bag was full of urine (about 800cc) and lying on the floor. On 4/25/22 at 3: 00 PM on review of the hospital discharge summary dated 4/16/22 revealed that Resident #57 had an indwelling foley for chronic urinary retention. The DON was made aware of the findings on 4/27/22 at 11:10 AM. 2) An interview with an Infection preventionist and the DON was conducted on 4/28/22 at 1:10 PM. During the interview the DON stated previous assistant director of nursing (ADON) who resigned from the position in July 2021 provided all COVID-19 education to all staff. Also, she stated since the previous ADON resigned, the current staff did not have access to the training documentation records. On 5/5/22 at 9:22 AM, the DON provided some documentation related to COVID-19 education provided to the facility staff. From 2/7/2020 to 1/29/2021, education was provided a total of 10 times to the facility staff. On 2/7/21 hand hygiene/ hand washing/ABHR competency education was provided, and 25 staff signed on the attendance list. On 3/24/20 COVID-19 education was provided, and one staff signed on the attendance list. On 3/24/20, 71 staff signed the attendance list for COVID-19 preparedness education. On 9/18/20, a COVID-19 outbreak protocol education was held, and 34 staff signed on the attendance list. On /5/5/22 at 10:00 AM the DON confirmed the facility's average staff number was higher than 80 facility staff. However, the training records provided did not include all the staff employed by the facility. The DON and the Nursing Home Administrator were made aware of this finding on 5/5/22 at 2:57 PM.

Based on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Parties (RPs) were provided education on Influenza and Pneumococcal vaccines before requesting consent. This was evident for 5 (Resident #25, #26, #32, #53, and #67) of 5 residents reviewed for Immunizations during the survey. The findings include: Pneumococcal vaccine help prevents pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people [AGE] years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications. Influenza (Flu) vaccines can prevent influenza. (Centers for Disease Control and Prevention- vaccines and preventable disease) On 4/27/22 at 2:50 PM, a medical record review was conducted for Resident #25. A facility's consent form dated 9/24/21 was filed in the resident's paper chart. The resident consented for the Flu vaccine and refused the Pneumococcal vaccine. However, no other documentation was found in the record that the resident received education regarding the benefits or risks of receiving the Flu and Pneumococcal vaccine. A review of the electronic medical chart under the immunization tab for Resident #26 was conducted on 4/28/22 at 08:50 AM. The review revealed the resident refused the Flu and Pneumococcal vaccine without a date recorded. A consent form was filed on the resident's paper chart marked as refused Flu and Pneumococcal vaccine dated 9/24/21. However, there was no supportive documentation regarding the resident receiving education regarding the risks or benefits of receiving the vaccines. Further review of the electronic medical chart under the immunization tab revealed Resident #32 refused the Pneumococcal vaccine without the date recorded and received the Flu vaccine on 11/15/21. Neither the consent form nor documentation of education was filed on the resident's paper chart or electronic medical chart. A medical record review of Resident #53 on 4/28/22 at 10:10 AM revealed under the electronic medical chart, the immunization tab recorded the resident refused Flu and Pneumococcal vaccines without a date recorded. There was no consent or education documented found on the resident's paper chart or electronic chart. Further electronic and paper medical record review for Resident # 67 revealed that the resident received a Flu vaccine on 10/7/21 and a Pneumococcal vaccine on 11/5/21. However, no documentation was found for the consent form or evidence of education provided to the resident. During an interview with the Director of Nursing (DON) and Infection Control Preventionist (ICP) on 4/28/22 at 10:40 AM, the DON explained that the facility assessed a new resident's vaccination eligibility upon their admission. If the resident is a candidate for the vaccine, a consent form will be signed by the resident self or RPs, and the signed consent will be filed in the resident's paper chart. Also, the DON stated the facility did not separately document regarding providing education to residents. The consent form of vaccination status for the facility was reviewed with the DON during the interview. The form did not include education regarding the benefits and potential side effects of the Flu and Pneumococcal vaccine. The Nursing Home Administrator was made aware of the above concern on 5/5/22 at 2:50 PM.

Based on the staff interview, review of facility policies, and facility's tracking record, it was determined the facility failed to provide COVID-19 testing for the unvaccinated staff. This was evident for 3 of 50 staff (Licensed Practical Nurse (LPN) #39, Registered Nurse (RN) #40, and Geriatric Nursing Assistant (GNA) #41) reviewed for COVID-19 testing during the survey. The finding includes: During the entrance conference with the Nursing Home Administrator (NHA) on 4/19/22 at 8:35 AM, she stated that the facility currently had three unvaccinated staff (LPN #39, RN #40, and GNA #41). On 4/28/22 at 1:40 PM during an interview with the Infection Control Preventionist (ICP), she stated that since the county COVID-19 rate was elevated, the facility had started to do the COVID-19 testing twice a week from the week of 4/18/22 for the unvaccinated staff. Before the week of 4/18/22, the facility performed a COVID-19 test once a week for the unvaccinated staff. The ICP also submitted the staff COVID-19 testing log. On 4/28/22 at 1:44 PM a review of the testing log revealed that for the week of 4/25/22, GNA #41 missed the COVID-19 testing one time, and the week of 4/18/22 RN #40 and GNA #41 missed the COVID-19 testing one time, and the week of 4/4/22 no test was done for GNA #41 and RN #40. On 4/28/22 at 2:00 PM a review of the facility policy, Employee COVID-19 Vaccination Mandate and Staffing Contingency Plan, was conducted. The policy indicates that the facility will implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19 to include: requiring at least weekly testing for exempted staff, and staff who have not completed their primary vaccination series until the regulatory requirement is met, regardless of whether the facility or service site is located in a county with low to moderate community transmission, in addition to following CDC recommendation for testing unvaccinated staff in facilities located in counties with substantial to high community transmission. During an interview with the DON and the ICP on 4/29/22 at 8:48 AM, they were made aware of the above concerns and no other documentation was provided.

Based on medical record review and staff interview, it was determined the facility failed to: 1) document education provided regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents and staff, and 2)maintain a consent form in the residents' medical record. This was evident for 1 of 5 residents (Resident #67) and 8 facility staff members reviewed for COVID-19 vaccinations during the survey. The findings include: 1) On 4/27/22 at 2:30 PM, Resident #67's medical record review was conducted. The electronic medical record under the immunization tab revealed Resident #67 received the COVID-19 vaccine on 1/7/21, 1/29/21, and 10/20/21. However, no documentation was found for the consent form and evidence of education was provided under the resident's paper chart or electronic medical record. During an interview with the Director of Nursing (DON) on 4/28/22 at 9:00 AM, she stated Resident #67 received the COVID-19 vaccine from a pharmacy vendor. Since the vendor pharmacy received consent and provided a factsheet before the vaccines were given and took all documentation back, there was no signed consent in the resident's paper chart. She added she would try to get it from the vendor pharmacy. No further supportive documentation was submitted to the surveyor team until the exit meeting. Also, the DON stated the facility did not document the benefit and potential risks of the COVID-19 vaccine. 2) Review of COVID-19 vaccination records for facility staff members was conducted on 4/28/22 at 10:30 AM. A review of Staff #17, #22, #29, #37, and #38's COVID-19 vaccination records failed to show that they received education regarding COVID-19 vaccination benefits, risks, and potential side effects. An interview was conducted with DON and Infection Control Preventionist (ICP) on 4/28/22 at 10:40 AM. The ICP stated that the former assistant director of nursing (ADON, #45) had provided COVID-19 vaccine education to all staff. The ICP and DON also stated since ADON #45 resigned, current staff was unable to find education and/or training documentation. On 5/5/22 at 9:22 AM, the DON submitted staff training records from 2/7/20 to 3/27/21. However, the records did not include the benefits and potential risks associated with the COVID-19 vaccine. The nursing home administrator was made aware of the above concerns on 5/5/22 at 2:50 PM.

Based on complaints, reviews of an active and closed medical records [MEDICAL RECORD OR PHYSICIAN ORDER] #176). This was evident for 2 of 9 complaints reviewed during an annual recertification survey. The findings include: 1) Reviews of complaint MD 030 on 04/20/2022 at 9 AM revealed an allegation that Resident #65 was observed by a family member with a wound that was not identified by the nursing staff. In an interview with the complainant, on 04/21/2022 at 2:25 PM, the complainant stated that Resident #65 had just been observed by him/her to be unresponsive, sweaty, hot to touch, and unable to finish the therapy session this morning. The complainant stated that Resident #65 did not respond to his/her name when being called. The complainant stated that s/he was concerned that the nursing staff was unable to recognize a hypoglycemic event and take steps to correct the [CONDITION(S)] in Resident #65. The complainant stated that Resident #65's glucose level by finger stick was 68 mg/dl and that s/he was worried about the amount of insulin Resident #65 was receiving. A review of Resident #65's medical record on 04/22/2022 revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #65's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 03/24/2022 at 7:30 AM, Resident #65's physician ordered the nursing staff to administer [MEDICATION(S)] Insulin, inject 2 units subcutaneously before meals for diabetes and hold for blood glucose less than 120 On 03/24/2022 at 7:30 AM, Resident #65's physician ordered the nursing staff to administer, [MEDICATION(S)] [MEDICATION(S)] insulin, Inject as per sliding scale: if 151 - 200 = 1 unit; 201 - 250 = 2 unit; 251 - 300 = 3 units; 301 - 350 = 4 units IF > 350 GIVE 5 UNITS CALL MD/NP, subcutaneously before meals and at bedtime for diabetes. On 04/15/2022 at 6 PM, Resident #65's physician ordered the nursing staff to administer [MEDICATION(S)] insulin, inject 9 units subcutaneously two times a day for diabetes and hold for blood glucose less than 120. On 04/22/2022 at 4:45 PM, Resident #65's physician ordered the nursing staff to Inject [MEDICATION(S)], 1 syringe subcutaneously as needed for diabetes, Administer for blood glucose less than 60 or symptomatic and repeat blood glucose 15 minutes after administration. If blood glucose is still less than 70 and the patient is unable to swallow, repeat the dose and notify MD. A review of Resident #65's documented finger stick glucose readings for April 2022 revealed Resident #65's glucose readings had not dropped below 110 mg/dl. In an interview was conducted on 04/22/2022 at 3:58 PM with Resident #65's 04/21/2022 day shift charge nurse (Employee #8). Employee #8 stated that Resident #65 did have a hypoglycemic event on 04/21/2022 just after his/her therapy session and before lunchtime. Employee #8 stated Resident #65's fingerstick glucose reading was 63 mg/dl at that time. Employee #8 stated that s/he was alerted to Resident #65's change in condition by Resident #65's family member. Employee #65 stated that s/he notified the facility director of nurses (DON) at this time also. Employee #8 stated that s/he did administer a dose of [MEDICATION(S)] to Resident #65 that was obtained from the DON. When questioned, Employee #8 stated that s/he had not documented anything about Resident #65's 04/21/2022 hypoglycemic event in Resident #65's medical record including a progress note that indicated Resident #65's glucose was 63 mg/dl, the administration of a dose of [MEDICATION(S)], or notification of the incident to Resident #65's physician. Employee #8 stated that she did not notify Resident #65's physician. A review of the facility Hypoglycemic Management policy, implemented, reviewed and revised on 05/01/2021, revealed the following guidelines: #3) a resident that has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . #5) If the blood glucose level is 70 mg/dl or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucose's as indicated, and notify the practitioner of the results as ordered. 2) Review of complaint MD 144 on 05/04/2022 revealed an allegation Resident #176 had a significant weight loss and that the responsible party was not informed by the facility nursing staff. A review of Resident #176's closed medical record revealed nursing documentation that on 10/05/2021 at 12:04 PM, Resident #176's standing weight was 139.6 pounds. On 11/03/2021 at 3:29 PM, the nursing staff documented Resident #176's wheelchair weight to be 110.6 pounds. On 11/08/2021 at 11:37 PM, the nursing staff documented Resident #176's wheelchair weight (weight obtained while resident seated in a wheelchair) to be 110.8 pounds. Between 10/05/2021 and 11/03/2021, the nursing staff documented a 29-pound (20.7%) weight loss. The 11/08/2021 documented reweigh of 110.8 pounds for Resident #176 also shows a significant weight loss of 28.8 pounds (20.6%). Further review of Resident #176's closed medical record failed to reveal Resident #176's physician or representative was immediately made aware of the significant weight loss on 11/03/2021 or 11/08/2021. A review of the facility weight monitoring policy, dated 07/21/2021, revealed the following: 6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant weight change is defined as: a. 5% change in 1 month (30 days) b. 7.5 % change in 3 month (90 days) c. 10% change in weight in 6 months (120 days) 7. Documentation: a. The physician should be informed of a significant weight change in weight and may order nutritional intervention. h. Notification to the resident and/or representative of any significant weight change. These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM. These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.

Based on medical record review, facility investigation review, and facility staff interviews it was evident that the facility failed to honor the resident's wishes for cardio [MEDICAL CONDITION] resuscitation (CPR). This was evident for 1 of 7 residents selected for review. On [DATE] and [DATE], the surveyor reviewed the information surrounding the death of resident # 1. She was admitted on [DATE] with [DIAGNOSES REDACTED]. Her care included coverage by respiratory therapy services, nebulizer treatments, antibiotics, and 2 liters of Oxygen. Her physician order [REDACTED]. On [DATE], according to the progress notes, the resident was alert, oriented, and able to make her own health care decisions and wished to be a full code. Her Maryland medical orders for life-sustaining treatment (MOLST) form was completed and noted that per the patient she wanted to have CPR attempted. On [DATE] at 6 AM GNA #8, assigned to the resident, found her to be unresponsive. GNA #8 yelled for Nurse #4 - the nurse assigned to the resident. According to the director of nursing's (DON ' s) interviews with the GNA and nurse, the nurse looked at the resident and stated that she was dead and walked out of the room; she did not initiate CPR. The GNA proceeded to bathe the resident's body. The DON stated that when she asked the GNA if the resident ' s body was cold she told her it was warm but getting cool. At approximately 6:45 AM Nurse #4 spoke to a nurse from another floor and called the certified registered nurse practitioner (CRNP). The CRNP told the nurse the resident was a full code and to call 911 and start CPR. The nurse did not start CPR. At 8:45 AM her body was released to the funeral home. The facility staff failed to perform CPR as the resident had chosen. The resident died without receiving CPR.

Based on medical record and facility investigation reviews and interviews with the facility staff, it was evident that the facility failed to transfer a resident as ordered. This resulted in a fracture of the resident's leg. This was evident for 1 of 7 residents selected for review. The findings included the following: On 12/12/12 and 12/13/12, the surveyor reviewed the medical record and facility investigation for Resident # 3. In addition, the director of nursing (DON) and geriatric nursing assistant (GNA) #7 were interviewed by the surveyor on 12/13/12. The investigation by the facility revealed that GNA #7 had transferred Resident #3 prior to the injury by herself instead of with another person as ordered for the resident 's safety. Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED].#7 revealed that the resident was not able to use her lower extremities to stand or move. The GNA kardex and Care plan at the time of the transfer noted that the resident required 2 persons for safe transfers. On 10/28/12 at 6 PM, GNA #7 transferred Resident #3 from her wheel chair to her bed by herself. During surveyor interview GNA #7 described placing her hands beneath the resident's arms and transferring her from the wheel chair to the bed. At the end of her shift, at 6 AM, she reported that the resident had changes to her left leg and notified the nurse. The nurse assigned to Resident #3 documented that the resident had a large dark red discolored area on the left lower extremity from mid thigh to mid shin. The range of motion to the leg was not within normal limits and she complained of pain during the assessment. The physician ordered an X-ray of the left femur/knee/tibia and fibula to rule out a fracture. The X-ray revealed an oblique fracture of the distal femur. The resident was medicated for pain and transferred to the hospital where she underwent surgical repair of the fracture. An oblique fracture is when the break/ crack is diagonal to the axis of the bone. An oblique fracture of the distal femur is generally caused when the foot is caught in position and the upper leg is rotated, such as may occur during the transfer of this resident as described above. On 12/13/12, the surveyor interviewed the DON and reviewed the events with her. She stated that she thought the injury occurred during the transfer. In summary, GNA #7 transferred Resident #3 alone at 6 PM; at that time the resident's leg was as it had always been. At 6 AM the resident had discoloration and pain on movement. The physician ordered an X-ray and a fracture was diagnosed . The facility staff failed to transfer the resident with the assistance of 2 persons; this resulted in a fractured left leg.