Every finding on record at Autumn Lake Healthcare at Baltimore Washington

Based on observations and interviews it was determined that the facility failed to maintain a safe, clean, comfortable, homelike environment for residents. This finding was found to be evident in 13 (#4, #7, #9, #10, #20, #21, #23, #25, #26, #27, #36, #37 and #107) out of 25 resident rooms and other facility common areas reviewed for physical environment during the recertification survey. The findings include:1.On 02/08/26 at 9:50 AM, the surveyors observed room [ROOM NUMBER]'s trash can overflowing with trash on the floor surrounding it, accumulated dust in the window and blinds, deeply scuffed areas in the floor and a partially detached door panel that was hanging loose. On 02/08/26 at 9:57 AM, the surveyors discovered a commode seat that was stained with a brown substance, a missing toilet rod and wrapped toilet paper that was not within reach in room [ROOM NUMBER]'s bathroom. On 02/08/26 at 11:06 AM, the surveyors observed that room [ROOM NUMBER] had a dead spider, cobwebs, and dust on and around the window. On 02/13/26 at 11:40 AM, the Administrator acknowledged the environmental concerns found in the facility. 2.On tour of Resident rooms on nursing units 1 and 2 of the facility on 2/8/2026 at 8:15 am the surveyor observed several Resident rooms that were not in good repair and not clean. room [ROOM NUMBER] – cracked faucet and no rod for the toilet paper in the dispenser in shared bathroom, no trash bag in trashcan; room [ROOM NUMBER] and 27 – marred bathroom doors; room [ROOM NUMBER], 26 and 36 – marred walls; room [ROOM NUMBER] – trash can with crack and no trash bag in the trash can; room [ROOM NUMBER] – trash can overflow with trash on the floor and marred room door. During an interview with Resident #128 in room [ROOM NUMBER] on 2/8/2026, he/she stated that the toilet paper was placed on the grab bar in the bathroom because there was no rod for the toilet paper. On 2/13/2026 at 6:56 AM the Licensed Nursing Home Administrator (LNHA) was notified of the concerns with the facility regarding the physical environment. At the exit conference on 2/13/2026 the administrative staff was notified of the concerns with the facility regarding a safe, clean, comfortable, homelike environment. 3.On 2/10/2026 at 10 AM, a tour of the facility with the Maintenance Director revealed: The shower room on Station 3 had One non-working ceiling light in one of the shower stalls, one over-bed table, one shower chair with a brown stain on the seat, The shower lever in that stall was also missing. On 2/20/2026 at 10:18 AM further tour of the facility with the Maintenance Director revealed: A cracked window covered in dark gray tape in room [ROOM NUMBER], A white blanket on the window sill in room [ROOM NUMBER], the resident and their roommate stated that on cold days, there is a draft felt from that part of the window, room [ROOM NUMBER]-A the metal heated baseboard severely damaged and pulled away from the wall. A tour was conducted with the Director of Housekeeping on 2/10/2026 at 10:46 AM which revealed: The Larger shower room on Station 3 had a bag of resident gowns in a plastic bag on the shower floor of the first shower stall; the second shower stall contained a large white trash can, a visibly soiled dark blue chair cushion; and the third shower stall contained a linen cart for soiled linens. A room at the back end of the shower room that had 3 floating shelves stacked with folded gowns, blankets, sheets, and reusable bed pads-- all of which were uncovered; a black manual wheelchair with folded lines stacked on the seat. Station 1 shower room, with a brown stain on the shower curtain Rooms on Station 2 and on Station 1 were toured and the surveyor conveyed the the concern that the windows in several of the resident rooms that were observed had dirt/debris and cobwebs. At 11 AM on 2/10/2026 the Director of Housekeeping confirmed that all the concerns identified during the tour were addressed immediately. 4.On 2/8/26 at 7:07 AM, upon initial entrance into the facility, the surveyor walked down and observed the dining room. The surveyor noted napkins and wrappers around the garbage can located by the dining hall entrance doors. On further review, the surveyor observed items left on a table that appeared to have been left from a mealtime. They consisted of a butter knife, spoon, plastic top to a small container, a crumpled-up napkin and an empty cup on its side. Several other tables had napkins crumpled-up and under the tables. One tabletop had what appeared to be paint splattered on top. The surveyor was able to wipe some of the paint residue off. On 2/8/26 the surveyor walked down the hallway and noticed garbage cans next to the resident's beds that were filled to the top. This was observed as follows: 8:39 AM room [ROOM NUMBER] bed A- garbage full 9:04 AM room [ROOM NUMBER] bed A- garbage full 9:21 AM room [ROOM NUMBER] bed A -garbage full On 2/8/26 at 1:49 PM, the surveyor reviewed the observations with the Nursing Home Administrator (NHA). He stated that housekeeping services were on site the day before and he would have expected the trash on the floor and garbage addressed.

Based on observations, record reviews, and interviews it was determined that the facility failed to utilize professional standards during, 1) tube feeding administration, 2) pressure ulcers and 3) unnecessary medications. This was found to be evident in 4 (#1, #2, #5, and #75) out of 9 residents reviewed during the recertification survey. The findings include: Enteral nutrition, also known as tube feeding, is a way to deliver dietary needs directly to the stomach or small intestine. A gastrostomy tube or (g-tube) is used when nutrition is delivered to your stomach. A common g-tube placed is called a percutaneous endoscopic gastrostomy (PEG) tube. This is done by a surgical procedure. 1) On 2/8/26 at 8:25 AM, the surveyor observed Resident #1 had a container of tube feed on his/her table labeled and dated. No tubing was noted, however there was a syringe on the table. On 2/10/26 at 9:48 AM, the surveyor reviewed Resident #1's orders. The review revealed an order placed on 9/24/25 that stated, every night shift the enteral feeding tubing to be changed along with the syringe. An additional order stated, Resident #1 to receive tube feeding (Jevity 1.5) bolus (300ml) via gravity 4 times per day at midnight, 6am, noon, and 6pm. On 2/12/26 at 6:22 AM, the surveyor observed no tube feeding was infusing for Resident #1. A tube feeding container was again noted on the bedside with a syringe. The bottle was sealed closed and no tubbing was noted. On 2/12/26 at 6:57 AM, the surveyor interviewed Resident #1's nurse Licensed Practical Nurse (LPN) #25. During the interview the surveyor asked when Resident # 1's was scheduled for tube feeding administration during his shift. LPN #25 stated he administered Resident #1 his/her feeding at 4 or 5 AM. The surveyor asked how the tube feeding was administered. LPN #25 stated that he used a syringe. He further stated that he poured the correct volume from the bottle into a cup and then poured the tube feeding into the syringe and fed via gravity. The surveyor confirmed that no tubing was utilized for the gravity tube feeding. On 2/12/26 at 8:33 AM, the surveyor reviewed Resident #1's February Medication Administration Record (MAR) with the Director of Nursing (DON). The review revealed that both the midnight and 6am administration of tube feeding were not marked as administered even though LPN #25 stated that he administered the tube feeding to Resident #1 at either 4 or 5 am. The DON stated that if the tube feeding was given the MAR should record the administration. She stated that she would reach out to the nurse and find out why the administration was not documented. On 2/12/26 at 10:37 AM, the surveyor conducted a follow up interview with DON. During the interview the surveyor asked how tube feeding should be administered with the use of multidose containers. The DON stated per manufacture guidelines and resident orders. The surveyor reviewed the concern that staff were using multidose containers of tube feeding formula and administer the tube feeding via syringe (not the attend way of administration). The surveyor asked for the manufacturer's guidelines for Jevity 1.5 Cal multidose container, the formula that Resident #1 received. On 2/12/26 at 11:25 AM, the surveyor reviewed the guidelines for Jevity 1.5 Cal. The product description stated the formula could come in two forms, a 235 milliliter can or 1.5 liter ready-to-hang and container. The can instructions stated that once opened, the can should be covered, refrigerated and used within 48 hours. The ready-to-hang container, the one that was in Resident #1's room, noted failure to follow the instructions for use increase the potential for microbial contamination and may reduce hand times. The instructions stated for gravity feeding, to use a 12 French (a commonly used, moderate-sized medical catheter with an outer diameter of 4.0 mm) or larger tube. The precautions stated to follow directions for the use provided by the manufacture of feeding sets. (tubing) Following the review of the manufacturer's guidelines the surveyor reviewed the concerns with the Director of Nursing (DON) that the facility was not following the manufacturers guidelines and as the instructions stated, there was an increase risk of microbial growth and contamination. The surveyor also reviewed the concern that tube feeding administration was not benign documented after the tube feeding was administered. Cross reference F693 Medication and Treatment Administration Record (MAR/TAR) is a legal, essential document in healthcare used to track, schedule, and document the administration of medications and treatments to Resident. It ensures safety, accuracy and real time documentation that prevents errors, provides a clear, unbroken record of care, and supports medication monitoring. Stage 2 Pressure Ulcer is a partial-thickness skin loss involving damage to the epidermis and part of the dermis, appearing as a shallow, open, pink/red wound or an intact/ruptured serum-filled blister. These wounds are painful, involve no fat or deeper tissue exposure, and often occur over bony prominences. 2) The surveyor conducted a record review of Resident #5's medical record on 2/11/2026 at 3:15 PM. Record review revealed that Resident #5 had a Wound Assessment Report dated 12/24/2025 that the stage 2 pressure ulcer/injury was resolved to the left buttock and there was no treatment indicated. Review of the physician orders indicated that Resident #5 had an active order for treatment for the left buttock stage 2 pressure ulcer for the month of January and February 2026. Review of the medication/treatment administration records for January and February 2026 revealed that the nursing staff was signing that the treatment was being performed daily. The surveyor conveyed to the Director of Nursing (DON) at 7:10 AM on 2/12/2026 that Resident #5 had a resolved pressure ulcer on 12/24/2025 but there was an active physician order for treatment to the healed pressure ulcer, and the nursing staff was documenting on the medication/treatment administration record that the treatment was being performed daily for January and February 2026. The DON stated that she would review this. Antipsychotic medication is a psychoactive drug used to manage psychosis symptoms like hallucinations and delusions by altering brain neurotransmitter activity. They function by reducing dopamine levels in the brain. Hypnotic medication (sedative) is a central nervous system depressant designed to induce sleep, commonly used for treatment of insomnia. They function by initiating and maintaining sleep. 3) On 2/12/2026 at 7:45 AM the surveyor conducted a record review of Resident #75's medical record. Review of the medical record revealed that Resident #75 had an active physician order for monitor for behaviors, Resident is on an antipsychotic medication, Zolpidem. Further review of the medical record revealed that Resident #75 was not prescribed an antipsychotic medication. Resident #75 had a physician order for Zolpidem 5 mg at bedtime for insomnia. Zolpidem was a hypnotic medication, not an antipsychotic medication. The surveyor conveyed to the Director of Nursing (ADON) at 8:15 AM on 2/12/2026 that Resident had a physician order for Zolpidem for insomnia, and had a physician order to monitor for behaviors, Resident is on antipsychotic medication, Zolpidem, but Resident did not have a physician order for antipsychotic medication. The DON acknowledged the surveyor. The surveyor conducted a record review of the medical record for Resident #2 at 9:15 AM on 2/13/2026. Review of the medical record revealed that Resident #2 received Insulin for Diabetes Mellitus. Resident #2 had physician orders for insulin to be given before meals and at bedtime based on the results of the Resident's blood sugar levels. Further review of the medical record revealed that there was no physician order for how much insulin to administer when the blood sugar was above the level of 400 for Resident #2. At 1:15 PM on 2/13/2026 in an interview with the Director of Nursing (DON) the surveyor reviewed the physician order for insulin for Resident #2. The surveyor conveyed that there was no physician order to administer insulin for a blood sugar result above 400. The DON stated that there should be a physician order to address the high blood sugar result above 400 for Resident #2. No additional information was provided by the facility at the time of survey exit.

Based on facility staff and Resident interviews and surveyor record review, it was determined that the facility failed to update and revise Resident care plans and failed to conduct Resident care plan meetings for 4 (Resident #2, 5, 75, and 126) out of 7 Residents reviewed for care plan timing and revision.The findings include:Care Plan is a tailored document summarizing a person's health conditions, care needs, medications, and goals and interventions designed to ensure consistent, proactive care. The care plan acts as a roadmap improving communication between providers, fostering patient independence, and enhancing safety. The care plan is evaluated on a regular basis to assess effectiveness and update as needed.On 2/8/2026 at 8:41 AM in an interview with Resident #5, Resident stated that he/she was not aware of a care plan meeting.The surveyor conducted a record review on 2/10/2026 at 9:30 AM of Resident #5's medical record and review of the medical record revealed care plan meeting attendance reports for 10/10/2024, 1/17/2025 and 9/18/2025 that were in the misc. tab of the electronic medical record.In an interview with the Director of Nursing (DON) at 11:30 AM on 2/10/2026 regarding the care plan meetings for the past year, she stated that she would follow up and check Resident #5's chart.In a follow up interview with the DON on 2/10/2026 at 1:00 PM she provided the surveyor with copies of the care plan attendance reports for 10/10/2024, 1/17/2025 and 9/18/2025, and stated that these were the only care plan meeting attendance reports that were in Resident #5's chart. The DON confirmed that there were no care plan meeting attendance sheets for April 2025 and July 2025.On 2/8/2026 at 11:17 AM in an interview with Resident #2 at 11:17 AM Resident stated that he/she was not aware of care plan meeting.The surveyor conducted a record review on 2/10/2026 at 10:00 AM of Resident #2's medical record and review of the medical record revealed care plan meeting attendance reports for 12/19/2024, 6/12/2025, 9/11/2025, 11/4/2025, 11/14/2025 and 12/5/2025 that were in the misc. tab of the electronic medical record.In an interview with the Director of Nursing (DON) at 11:30 AM on 2/10/2026 regarding the care plan meetings for the past year, she stated that she would follow up and check Resident #2's chart.In a follow up interview with the DON on 2/10/2026 at 1:00 PM she provided the surveyor with copies of the care plan attendance reports for 6/12/2025,11/4/2025,11/14/2025 and 12/5/2025 and stated that these were the only care plan meeting attendance reports that were in Resident #2's chart. The DON confirmed that there was no care plan meeting attendance sheet for March 2025.The surveyor conducted a record review of Resident #126's medical record on 2/11/2026 at 8:37 AM. Record review revealed that Resident #126 had a care plan for antibiotic therapy (Cipro) for infection of the back. Review of the current active physician orders did not reveal that Resident #126 had an active antibiotic order for Cipro. Further review of the care plan indicated that the antibiotic therapy care plan for Cipro was initiated on 11/3/2025. Review of the discontinued/completed physician orders revealed that Resident #126 received the antibiotic - Nitrofurantoin) in November 2025 for 7 days but did not have an order for Cipro.In an interview with the Director of Nursing (DON) on 2/11/2026 at 9:45 AM the surveyor conveyed that Resident #126 had a care plan for antibiotic therapy (Cipro) that was initiated on 11/3/2025 and that the Resident does not have a current physician order for antibiotic therapy, Cipro. DON acknowledged the surveyor and stated that it was the clinical team's responsibility to update the care plans.On 2/12/2026 at 7:45 AM the surveyor conducted a record review of Resident #75's medical record. Review of the medical record revealed that Resident #75 had a care plan for antibiotic therapy related to infection/pneumonia. Review of the active/current physician orders did not reveal that Resident #75 was receiving an antibiotic for pneumonia. Further review of the care plan revealed that the care plan for antibiotic therapy was initiated on 8/6/2025. Review of the discontinued/completed physician orders for Resident #75 revealed that Resident received antibiotic therapy (Zithromax Z-pak - Azithromycin) in August of 2025 for 5 days for pneumonia.In an interview with the Director of Nursing (DON) on 2/12/2026 at 8:15 AM the surveyor conveyed that Resident #75 had a care plan for antibiotic therapy that was initiated on 8/6/2025 and that the Resident does not have a current physician order for an antibiotic. DON acknowledged the surveyor.No additional information was provided by the facility at the time of survey exit.

Based on interview and record review, it was determined that the facility failed to develop and implement comprehensive care plans for residents. This finding was found to be evident in 4 (Resident # 2, #19, #31 and #136) out of 44 residents reviewed for comprehensive care plans. The findings include: Care Plan is a tailored document summarizing a person's health conditions, care needs, medications, and goals with interventions to ensure consistent care and improve quality of life. It acts as a roadmap for caregivers and providers to organize, prioritize, and manage daily care. 1) During an interview at 9:14 AM on 2/8/2026 with Resident #136 the surveyor observed that Resident had an intravenous (IV) antibiotic mini bag on the IV stand in the Resident Room. On 2/10/2026 at 11:10 AM the surveyor conducted a record review of Resident #136's medical record. Review of the medical record revealed that Resident #136 did not have a comprehensive care plan for the intravenous antibiotic and care of the intravenous access site. Additionally, Resident #136 had an incomplete care plan that addressed a mid-back surgical site and dermatitis (inflammation of the skin) but did not have goals and interventions included in that care plan. In an interview with the Director of Nursing (DON) on 2/10/2026 at 12:58 PM the surveyor reviewed with the DON that there was not a care plan for the IV antibiotic medication and care of the intravenous access site, and the care plan for the surgical site and the dermatitis was incomplete without goals and interventions. The DON acknowledged the surveyor and stated that the care plan was not reactivated when Resident #136 returned from hospital on 1/24/2026. Anticoagulant medication, or blood thinners prevent dangerous blood clots in veins, arteries, and the heart, reducing stroke and heart attack risk. These medications work by inhibiting specific clotting factors in the blood, with major side effects including increased bleeding. Deep Vein Thrombosis is a serious condition where a blood clot forms in a deep vein, usually in the legs or pelvis, causing swelling, pain, warmth, and redness. Caused by reduced blood flow or vein injury, it can lead to fatal pulmonary embolism. Treatment includes blood-thinning medications. The surveyor conducted a record review of Resident #19's medical record on 2/10/2026 at 12:30 PM. Record review revealed that Resident #19 had a care plan with interventions for monitoring signs and symptoms abnormal bleeding and bruising related to anticoagulant use. Review of the active physician orders revealed that Resident #19 did not have an order for anticoagulant medication, and further review of the discontinued physician orders did not reveal that Resident ever received an anticoagulant medication while at the facility. Resident was admitted on [DATE]. Additionally, review of the discharge summary from the hospital in November 2025 indicated that Resident #19 had a history of a deep vein thrombosis (DVT) and was not anticoagulated. In an interview with the Director of Nursing (DON) at 2:20 PM on 2/10/2026 the surveyor conveyed to DON that Resident #19 did not have an order for anticoagulant medication but had a care plan for DVT with an intervention for monitoring abnormal bleeding and bruising related to anticoagulant use. DON stated that it was the responsibility of the clinical team to implement and update the care plans. An RN MDS Coordinator is a specialized Registered Nurse in skilled nursing facilities who manages the Minimum Data Set (MDS) assessment. The RN MDS Coordinator assesses, documents, and codes a patient's functional, medical, and psychosocial status for federal/state compliance, care planning, and reimbursement. Minimum Data Set (MDS) assessment is a federally mandated, standardized, comprehensive clinical assessment tool used in Medicare and Medicaid certified nursing homes. The MDS evaluates Residents' functional, cognitive, and physical health, guiding care plans to meet individual needs. Completed upon admission, quarterly, annually and whenever a significant change in condition occurs by trained clinicians. On 2/12/2026 at 9:30 AM the surveyor conducted a record review of Resident #2's medical record. Review of the medical record revealed that Resident #2 had a fall on 11/10/2024 and had a medical diagnosis of history of falling. Further review of the medical record revealed that Resident #2's comprehensive care plan did not have a problem, goal or interventions for at risk for falls or an actual fall. Additionally, Resident #2 had a physician order for Eliquis 5 mg 2 times daily for atrial fibrillation (cardiac arrhythmia) but Resident did not have a comprehensive care plan for the Eliquis (anticoagulant medication) or the atrial fibrillation. In an interview with the Director of Nursing (DON) at 7:00 AM on 2/13/2026 the surveyor conveyed to the DON that there was not a care plan for the cardiac condition or the anticoagulant medication. DON acknowledged the surveyor. In an interview with the RN MDS Coordinator at 8:50 AM on 2/13/2026 the surveyor conveyed that Resident #2 had a fall on 11/10/2024 in the facility and had a diagnosis of history of falling but did not have a care plan for falls or at risk for falls. RN MDS Coordinator acknowledged the surveyor. No additional information was provided by the facility at the time of survey exit. 2) On 2/8/2026 at 9:09 AM, the surveyor interviewed Resident #31 and during that interview the resident stated that they had been diagnosed with Rheumatoid Arthritis approximately 20 years ago and had been in constant pain since. They reported that they had reported their pain and the intensity to the staff and had not received any medication for relief most of the time. On 02/12/2026 9:12 AM During the medical record review, it was discovered that there was no care plan for pain management even though Rheumatoid Arthritis is the primary medical diagnosis and the resident is prescribed both standing order medication and as needed medication (PRN) for pain. The resident is prescribed Hydrocodone-Acetaminophen 7.5-325mg every 8 hours; Lyrica 100mg twice daily; and a Lidocaine External Patch applied once daily; and Capsaicin 0.075% every 6 hours. In addition to the standing orders the resident is also prescribed Extra Strength Tylenol 500mg every 8 hours as needed. There was no mention of the resident's pain or the measures the facility were taking to relieve there pain in the initial care plan update on 1/30/2026, 72 hours after the resident's admission. According to the progress note on 1/30/2026, there were no medical or nursing staff in attendance at the care plan meeting. On 02/12/2026 at 11:50 AM, Employee #18 was asked about why pain management wasn't included in the care plan and they said they didn't know.

Based on observations, and interviews with facility staff, it was determined that the facility failed to provide an environment that promotes resident respect and dignity. This finding was evident in 1 of 44 residents (Resident #81) selected for this survey. The findings include: On 2/08/2026 at 8:45 AM surveyor observation of Resident #81 revealed a Foley catheter drainage bag (a Foley catheter is flexible tube which passes through the urethra and into the bladder to drain urine) hanging from the right side of the bed with no dignity bag (a bag which covers the Foley catheter's urine collection bag from plain sight) present. On 2/09/2026 at 9:30 AM, surveyor brought the Unit Manager into the room and asked her to identify the condition of the catheter collection bag. The Unit Manager acknowledged that there was no dignity bag over the collection bag. On 2/09/2026 at 1PM a tour of Resident #81's room with LPN #7 revealed that there was no privacy cover on Resident #81's Foley catheter drainage bag. LPN #7 confirmed that he/she or another nurse will retrieve and place a privacy cover on the drainage bag immediately.

Based on observations, interviews and record reviews, it was determined that the facility failed to 1) maintain infection prevention control practices for the storage of linen and 2) have a process to identify residents who required transmission based precautions. This was found to be evident in 2 (27 and 112) out of 2 rooms and 1 out of 3 nursing units reviewed for infection prevention and control during the recertification survey. The findings include: 1) At 7:40 AM on 2/11/2026 the surveyor conducted a random observation of the nursing unit. Outside of room [ROOM NUMBER], the nursing unit's clean linen cart was uncovered with folded linen observed on the three shelves of the cart. Additionally, employee #9 was observed administering medications to Residents and 2 Geriatric Nursing Assistants (GNAs) observed removing linen from the clean linen cart but did not cover the linen cart with the plastic pink cover that was attached to the cart. In an interview with employee #24 at 7:50 AM on 2/11/2026, the surveyor showed employee #24 the uncovered linen cart outside of room [ROOM NUMBER]. The surveyor asked employee #24 what the expectation was for covering the linen cart with clean linen on the shelves of the cart. Employee #24 stated that the linen cart should be covered and proceeded to cover the linen cart with the attached pink cover. No additional information was provided by the facility at the time of survey exit. 2) On 02/12/2026 at 11:11 AM the surveyor observed a Contact Precautions sign on the door of room [ROOM NUMBER]. The surveyor asked RN #21 how they identified the resident on Contact Precautions. RN #21 responded that they learned about precautions during shift report and from the sign on the door, and that visitors typically ask them for information. The surveyor asked Staff #26 how they knew which resident was on contact precautions. Staff #26 stated, When a resident is on a contact precautions, the facility places the sign on the door. When the surveyor asked how Staff #26 could identify the resident was on contact precautions, Staff #26 stated they prepped for both and treated them like both were on contact precautions. On 02/13/2026 at 6:57 AM, the surveyor asked GNA #23 how they knew which resident in room [ROOM NUMBER] was on contact precautions. GNA #23 stated, I would talk to the nurse. The surveyor then asked LPN #24 which resident was on precautions. LPN #24 responded, That's a good question. I think it should be Enhanced Barrier Precautions. I will go check. LPN #24 returned moments later and stated, I cannot find a reason for Contact Precautions. I will change it to Enhanced Barrier Precautions (EBP). The surveyor conducted a record review of the facility's Matrix on 02/13/2026 at 8:19 AM, which did not reveal any residents on transmission-based precautions. On 02/13/2026 at 10:19 AM, the surveyor interviewed Infection Preventionist (IP) Staff #3. Staff #3 stated that room [ROOM NUMBER] should probably have EBP and room [ROOM NUMBER] was on Contact Precautions for a wound. The IP stated she performed rounds and assessed the signage on the door. The IP further explained that they did not identify which bed required precautions to protect resident privacy. On 02/13/2026 at 12:21 PM, the Director of Nursing acknowledged the concern during an interview and stated that room [ROOM NUMBER] should probably be on EBP and she would investigate the issue.

Based on facility staff interviews and surveyor record reviews it was determined that the facility failed to maintain Resident medical records that were accurate and reflective of the Residents' care. This finding was found to be evident in 2 (Resident #19 and #126) out of 7 Residents reviewed for Resident records - identifiable information.The findings include:Anticoagulant medication, or blood thinners prevent dangerous blood clots in veins, arteries, and the heart, reducing stroke and heart attack risk. These medications work by inhibiting specific clotting factors in the blood, with major side effects including increased bleeding.Antiplatelet medication is a drug that prevents blood cells called platelets from sticking together to form dangerous blood clots, reducing the risk of heart attacks, strokes, and cardiovascular events. These medications are crucial for patients with coronary artery disease, stent placement, or prior vascular events.Care Plan is a tailored document summarizing a person's health conditions, care needs, medications, and goals with interventions to ensure consistent care and improve quality of life. It acts as a roadmap for caregivers and providers to organize, prioritize, and manage daily care.The surveyor conducted a record review of Resident #19's medical record on 2/10/2026 at 12:15 PM. Review of the medical record revealed that Resident #19 had an active physician order for Clopidogrel 75 mg by mouth daily for anticoagulant, order date 11/22/2025. Clopidogrel was not an anticoagulant medication, but an antiplatelet medication. Additionally, there was a care plan for Resident #19 that addressed monitor signs and symptoms (s/sx) of complications, abnormal bleeding and bruising, related to anticoagulant use.The surveyor at 2:20 PM on 2/10/2026 conveyed to the Director of Nursing (DON) that Resident #19 had a care plan for monitoring s/sx of complications for anticoagulant medication use and was not currently on an anticoagulant. The surveyor asked the DON who was responsible for the implementation and revision of Resident care plans and the DON that it was the responsibility of the clinical team.An Ostomy is a surgically created opening (stoma) on the abdomen that redirects waste (stool or urine) outside the body into a wearable pouching system, used when digestive/urinary systems cannot function normally due to disease, injury, or cancer. Minimum Data Set (MDS) assessment is a federally mandated, standardized, comprehensive clinical assessment tool used in Medicare and Medicaid certified nursing homes. The MDS evaluates Residents' functional, cognitive, and physical health, guiding care plans to meet individual needs. Completed upon admission, quarterly, annually and whenever a significant change in condition occurs by trained clinicians.The surveyor conducted a record review of Resident #126's medical record at 8:37 AM on 2/11/2026. Review of the medical record revealed that Resident #126 had a care plan for bowel incontinence/ostomy and an intervention for observe and report any redness, inflammation, drainage at ostomy site. Further review of Resident #126's medical record, specifically the MDS assessments Section H revealed that the Resident did not have an ostomy and was incontinent of bowel. Additionally, there was no physician order for ostomy care.In an interview with the Director of Nursing (DON) on 2/11/2026 at 9:45 AM the surveyor conveyed that Resident #126 had a care plan with intervention for ostomy care. The DON confirmed that Resident #126 did not have an ostomy. No additional information was provided by the facility at the time of exit.

Based on observation, an interview and record review the facility failed to maintain proper infection control procedures, specifically regarding staff's use of beard nets in the kitchen. This was evident during the follow-up tour of the kitchen. The findings include: On 2/11/2026 at 12:32 PM Staff #16, the [NAME] entered the kitchen with a hair net, washed their hands and went to the walk-in refrigerator and removed lettuce, tomatoes and ham. Staff #16 put on gloves and began cutting tomatoes, lettuce and ham. On 02/11/2026 at 12:41 PM Staff # 15, the Kitchen Director in Training went over to Staff #16, the [NAME] and assisted them with putting on a beard net. On 2/11/2026 at 2:00 PM Staff #17, the Kitchen Director, was interviewed and asked if it was required for kitchen staff to wear hair and beard nets while in the kitchen. Staff #17 replied yes hair and beard nets are required in the kitchen. Then Staff #17 was informed that Staff #16, the [NAME] was not wearing a beard net to cover their beard while cutting, tomatoes, lettuce and ham. Staff #17 did acknowledge that Staff #16 should have had a beard net on before they began handling any food. On 2/11/2026 at 2:15 PM record review of the facility policy stated that all kitchen staff will have their hair off the shoulders, confined in a hair net or cap and facial hair properly restrained.

Based on interview, observation and record review it was determined that the facility failed to follow up on dental care recommendations. This was found to be evident for 1 (#131) of 1 residents reviewed during the recertification survey. The findings include:On 02/08/26 at 8:40 AM, the surveyor interviewed Resident #131. The resident stated they had no teeth or dentures and had experienced discomfort from chewing on their gums. The surveyor observed the resident had no teeth while they ate breakfast. On 02/10/26 at 8:15 AM, a review of Resident #131's notes revealed dental/oral evaluations from 10/19/25, 01/23/26, and 01/26/26. The evaluations or dental notes did not mention a pending consult. The resident's last appointment was on 08/19/24 for dental extractions. On 02/12/26 at 9:34 AM, a review of Resident #131's dental consultation recommendations from 03/18/2024 stated Please call the attached number (410- - ) to schedule dental surgery. The process to start making dentures (5 appointments total) can be done 1-2 months after surgery. On 02/13/26 at 8:11 AM, the Director of Nursing acknowledged the delay in dental care and stated the facility would arrange follow up care.

Based on observations and interviews with staff, it was determined that the facility failed to properly store a Resident's medication. This was found evident on 2 of 3 observations for Resident #8. The findings include: On 2/8/26 the surveyor observed that Resident #8 had an inhaler next to him/her. The surveyor asked Resident #8 when the last time he/she used the inhaler. Resident #8 stated that he/she had taken a dose in the night when his/her breathing felt tight. The surveyor noted the inhaler was albuterol (a rapid-acting bronchodilator often called a rescue inhaler, used to treat or prevent bronchospasms) On 2/12/26 at 11:28 AM, the surveyor along with Unit Manager (UM) #10 both observed Resident #8 with his/her albuterol inhaler next to the resident. After leaving the room the surveyor asked UM #10 if Resident #8 was supposed to have medication at the bedside. UM#10 stated Resident #8 did not have an order or assessment completed to ensure self-administration of the inhaler was appropriate. She further stated she would remove the inhaler and pursue the step needed to identify if Resident #8 was safe to self-administer his/her inhaler. Next the surveyor reviewed the policy Resident Self-Administration of Medications. The policy states, a resident may only self-administer medications after the facility's multidisciplinary team has determined which medications may be self-administered safety. The assessment should be recorded in the medication self-administration assessment and kept in the medical record.

Based on record reviews and interviews, it was determined that the facility staff failed to adequately monitor a resident's drug regimen which allowed unnecessary duplicate orders for medications. This finding was evident for 1 (Resident #8) of 5 residents reviewed for unnecessary medications during the survey. The findings include: On 2/11/26 at 9:30 AM, the surveyor reviewed Resident #8's medical record. The review revealed trazodone (an antidepressant) was ordered for Resident #8 on 3/19/25 and stated, give trazodone 50mg by mouth at bedtime for depression. On review of the August 2025 Medication administration this was last given on 8/6/25 (the order discontinued on 8/7/25). On further review an additional order for trazodone was written on 8/5/25 and stated, give trazodone 50mg (three tabs to equal 150mg) by mouth nightly for insomnia. On review of the MAR this dose was given on 8/6/25 and 8/7/25 then discontinued on 8/7/25. Trazadone was given twice on 8/6/25 due to duplicate order. The surveyor next reviewed Resident #8's current medication orders. The review revealed an order for Zofran (brand name) also known as Ondansetron. The order was written on 12/24/25 and stated to give 4mg by mouth every 8 hours as needed for nausea/vomiting. This was an active order for Resident #8. Additionally, Ondansetron was ordered on 2/6/26 with instructions to give 4 mg every 8 hours as needed for nausea/vomiting. Two orders were written for the same medications. On 2/11/26 at approximately 1:30 PM, the surveyor conducted an interview with the Assistant Director of Nursing (ADON). During the interview the surveyor reviewed the concerns that Resident #8 had duplicated orders for two medications. The ADON stated she would remove the current duplicate order.

Based on medical record review and interview, it was determined that the facility failed to address medication regimen review (MRR) recommendations made by the consulting pharmacist. This was found to be evident for 2 (#35 and #75) out of 5 residents reviewed during the recertification survey. The findings include:Medication Regimen Review (MRR) is a comprehensive, ongoing, or monthly evaluation of a patient's medication list by a pharmacist to identify, prevent, and resolve medication-related problems. It involves reviewing all prescribed and over the counter medications, nutritional supplements, and lab results for interactions, duplications, inappropriate doses, and adverse effects to improve patient safety. This process is critical in the long-term care settings to maintain safety and reduce the risk of harm related to medication mismanagement. 1) On 02/10/26 at 11:50 AM, the surveyors reviewed Resident #35's MRR, dated 05/28/2025, which stated: Please initiate albuterol MDI 2 puffs every 6 hours PRN for shortness of breath. Wait 1 minute between puffs. Although the MRR recommendation was acknowledged on 06/18/25, it was not implemented. On 02/11/26 at 1:23 PM, the surveyor interviewed the Director of Nursing (DON) regarding Resident #35's MRR. The DON stated that she was unable to find the MRR recommendation follow up for 05/28/2025, and acknowledged that the recommendations were not addressed. 2) The surveyor conducted a record review of Resident #75's medical record on 2/12/2026 at 7:45 AM. Record review revealed that Resident #75 had pharmacist recommendations that had not been acted on by the physician or Director of Nursing (DON). Resident #75 had a physician order for Midodrine 5 mg by mouth 2 times a day for hypotension. Midodrine is used for low blood pressure upon standing (orthostatic hypotension). On 4/23/2025, 5/29/2025 and 7/30/2025 the pharmacist recommended during the monthly MRR that Midodrine should not be given after 6 pm or after the evening meal or less than 4 hours before bedtime. Resident #75 was receiving Midodrine in the evening at 2100 (9:00 PM). This time of 2100 (9:00 PM) was not changed by the facility until 8/5/2025; approximately 3 1/2 months from the initial pharmacist recommendation. Additionally, the pharmacist MRRs on 8/28/2025 and 10/29/2025 revealed that there was not a ferritin, TIBC and TSAT lab documented in Resident #75's medical record. Resident #75 had a physician order for Ferrous Sulfate 325 mg by mouth daily, an iron supplement. The pharmacist made a recommendation on 8/28/2025 and 10/29/2025 that during iron therapy the ferritin, TIBC and TSAT levels should be monitored every 3 months. In an interview with the Director of Nursing (DON) at 11:50 AM on 2/12/2026, the surveyor reviewed the pharmacist DRRs for Resident #75. The DON acknowledged the surveyor regarding the delay in the time change for the Midodrine and the recommendation for lab work (ferritin, TIBC and TSAT) not addressed with a rationale. The DON stated that she would follow up regarding the recommended lab work. In a follow-up interview with the DON on 2/13/2026 at 10:55 AM, she stated that Resident #75 had the iron studies done this morning by Diamond Lab. On 2/13/2026 at 12:30 PM the surveyor reviewed the facility's policy and procedure for Addressing Medication Regimen Review Irregularities implementation date 3/1/2023 and revised date 10/27/2025. The policy indicated that the pharmacist reviews the medication regimen of each Resident at least monthly. Additionally, the policy indicated that if the pharmacist should identify a recommendation the physician shall address the recommendation and the response shall be documented in the Resident's medical record or on a form designated by the facility prior to the next scheduled review. On 2/13/2026 during the survey exit the facility administrative staff were notified of the concerns with the pharmacist drug regimen reviews. No additional information was provided by the facility at the time of exit.

Based on record review and interviews with facility staff and family, it was determined that the primary medical provider failed to review the total program of care when the plan when a code status changed. This was found evident for 1 (Resident #1) out of 44 residents selected for review during the survey. The findings include: On [DATE] at 8:19 AM, the surveyor reviewed Resident #1's paper medical record. The review revealed a MOLST dated [DATE] that indicated Resident #1 wanted CPR based on instructions in the patient's advanced directives. On [DATE] at 1:45 AM, the surveyor reviewed a newer MOLST dated [DATE] provided by the DON that indicated Resident #1's surrogate decision maker elected to not have CPR performed in the case of cardiac arrest. The declination was Do Not Intubate (DNI). (This still allows limited ventilatory support by CPPAP or BIPAP). On [DATE] at 8:22 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked for documentation that would reveal the rationale/informed decision conversation that Resident #1's Resident Representative (RP) and Resident #1's primary provider had regarding the change in code status for Resident #1. The DON stated Resident #1 was transferred to the hospital in February 2025 and suggested that the change in code status may have been done at the hospital. She further stated that Resident #1's primary care provider also provides care at the hospital Resident #1 was transferred to. She stated she would look for the provider note that discussed the decision to change in Resident #1's medical regimen. Next the surveyor reviewed Resident #1's progress notes. A note written on 2/2025 by Provider #27 that stated the reason for the progress note was due to a readmission evaluation visit. Nowhere in the note did it state any conversation about changing the code status with Resident #1's RP. The plan stated, continue with plan of care. Again on [DATE] Provider #27 saw Resident #1 and wrote a progress note for a follow-up visit. This was the same day Resident #1's MOLST was changed from a full code to a Do Not Intubate (DNI). No notation that the change in care was ordered. The plan stated multispecialty notes reviewed and laboratory date reviewed with no new medications. On [DATE] at 10:23 AM, the surveyor conducted a phone interview with Provider #28, Resident #1's primary care physician. During the interview the surveyor asked if he had discussions and reviewed the risks and benefits for the change in code status for Resident #1 with Resident #1's RP. Provider #28 stated that he had that discussion and would have to review his notes.Next the surveyor conducted a phone interview with Resident #8's RP. During the interview the RP stated that she agreed with the current MOLST order but could not recall having the provider speak with her about the MOLST on the February 2025 admission. At the time of exit no additional documents were provided to the surveyor.

Based on observations, record reviews, and staff interviews, it was determined that the facility failed to provide appropriate pain management medication for resident 31. This was evident for 1 of 1 residents reviewed for pain management during the recertification surveyOn 2/8/2026 at 9:09 AM, the surveyor interviewed Resident #31. During that interview the resident stated that they had been diagnosed with Rheumatoid Arthritis approximately 20 years ago and had been in constant pain since. The resident stated that they were not receiving their pain medication correctly. On 2/9/2026 at 10:45 AM , the surveyor reviewed Resident #31 's medical records. The review revealed that Resident #31 had a standing order for Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg to be given every 8 hours. Further review of the medical record on 2/12/2026 at 9:12 AM revealed that on the Medication Administration Record that on 2/11/2026 the 6:00 AM dose was not signed for indicating that the dose had not been given. Hydrocodone-Acetaminophen 7.5-325mg is a controlled regulated substance that each tablet is signed for when it is administered. The control substance record did not have a tablet signed out on 2/11/2026 at 6:00 AM and the count for Hydrocodone-Acetaminophen 7.5-325 mg was accurate further proving that the medication had not been given. The Assistant Director of Nursing (ADON) was notified of the medication error.

Based on observation, interviews, facility policy review, and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 1 (Resident #8) out of 2 residents reviewed for respiratory care during the survey. The findings include: Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels. On 2/8/26 at 9:11 AM, the surveyor observed that Resident #8 was utilizing oxygen via nasal cannula. The nasal cannula was attached to an oxygen concentrator (a machine that extracts and filters nitrogen from ambient air to deliver 85-95% pure oxygen). The surveyor noted that 3 liters of oxygen per minute were being delivered to the resident from the oxygen concentrator. Resident #8 stated that he/she was supposed to have 4 liters of oxygen however, the machine was unable to maintain 4 liters and could only be turned as high as 3. On 2/11/26 at 9:08 AM, the surveyor reviewed Resident #8's care plan. The review revealed a care plan was initiated on 12/31/25 that stated, Resident #8 has oxygen therapy related to respiratory illness. One of the interventions written was oxygen setting, Resident #8 has oxygen via nasal (cannula) at (X) liters continuously. No specific concentration of oxygen was noted in the intervention but instead a letter x. On 2/11/26 at 11:48 AM, the surveyor reviewed Resident #8's orders. On 11/5/25 an order was written for Resident #8 to have 4 liters/minute of oxygen via nasal cannula. On 2/12/26 at 11:28 AM the surveyor conducted an interview with Unit Manager (UM) #10. The surveyor showed UM #10 Resident #8's oxygen concentrator and noted it was at 3 liters/minute. When asked what the ordered dose of oxygen was for Resident #8 UM #10 stated she would look it up and follow-up. After returning she stated that the level should be 4 liters/min. UM #10 was not able to increase to 4 liters/min on the concentrator and stated that she would have to replace the machine and that there was a spare machine on site. Next the surveyor reviewed the oxygen administration policy. The policy stated that oxygen should be administered under orders of a physician. It further stated, Resident's receiving oxygen should have a care plan that identifies the intervention for oxygen therapy based on the resident's assessment and orders such as but not limited to the type of oxygen delivery system, continuous or intermittent, when to discontinue, flow rates and SPO2 levels as ordered. Per the facility policy, all elements were not part of Resident #'8s respiratory care plan.

Based on observations, interviews, record reviews, it was determined that the facility, staff failed to 1) ensure that the tube feeding container was labeled and 2) the facility failed to administer enteral tube feeding per manufacture's instructions. This was evident for 2 (#1 and #120) residents reviewed for tube feeding during the recertification survey. The findings include: Enteral nutrition, also known as tube feeding, is a way to deliver dietary needs directly to the stomach or small intestine. A gastrostomy tube or (g-tube) is used when nutrition is delivered to your stomach. A common g-tube placed is called a percutaneous endoscopic gastrostomy (PEG) tube. This is done by a surgical procedure. 1) On 2/8/26 at 8:25 AM, the surveyor observed Resident #1 had a tube feeding container on his/her table labeled and dated. No tubing was noted, however there was a syringe on the table. On 2/10/26 at 9:48 AM, the surveyor reviewed Resident #1's orders. The review revealed an order placed on 9/24/25 that stated, every night shift the enteral feeding tubing to be changed along with the syringe. An additional order was for Resident #1 to receive tube feeding (Jevity 1.5) bolus (300ml) via gravity 4 times per day at midnight, 6am, noon, and 6pm. On 2/12/26 at 6:22 AM, the surveyor observed no tube feeding was infusing for Resident #1. A tube feeding container was again noted on the bedside with a syringe. The bottle was sealed closed and no tubing was noted. On 2/12/26 at 6:57 AM, the surveyor interviewed Resident #1's nurse Licensed Practical Nurse (LPN) #25. During the interview the surveyor asked when Resident # 1's was scheduled for tube feeding administration during his shift. LPN #25 stated he administered Resident #1 his/her feeding at 4 or 5 AM. The surveyor asked how the tube feeding was administered. LPN #25 stated that he used a syringe. He further stated that he poured the correct volume from the bottle into a cup and then poured the tube feeding into the syringe and fed via gravity. The surveyor confirmed that no tubing was utilized for the gravity feeding. On 2/12/26 at 10:37 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked how tube feeding should be administered with the use of multidose containers. The DON stated per manufacture guidelines and per resident's orders. The surveyor reviewed the concern that staff were using multidose containers of tube feeding formula to administer tube feeding via syringe. The surveyor asked for the manufacturer's guidelines for Jevity 1.5 Cal, the formula that Resident #1 received. On 2/12/26 at 11:25 AM, the surveyor reviewed the guidelines for Jevity 1.5 Cal. The product description stated the formula could come in two forms, a 235 milliliter can or 1.5 liter ready-to-hang and containers. The can instructions stated that once opened, the can should be covered, refrigerated and used within 48 hours. The ready-to-hang container, the one that was in Resident #1's room, noted failure to follow the instructions for use increase the potential for microbial contamination and may reduce hand times. The instructions stated for gravity feeding, to use a 12 French (a commonly used, moderate-sized medical catheter with an outer diameter of 4.0 mm) or larger tube. The precautions stated to follow directions for the use provided by the manufacture of feeding sets. On review of the facility's policy for Care and Treatment of Feeding Tubes, the surveyor noted the staff was asked to ensure that the selection and use of enteral nutrition was consistent with manufacturer's recommendations. Following the review of the policy the surveyor reviewed the concerns with the Director of Nursing (DON) that the facility was not following the manufacturers guidelines and as the instructions stated, increased the risk of microbial growth and contamination. Cross reference F658 2) On 02/08/2026 9:19 AM during the initial pool assessment, it was observed that Resident # 120 had a full bottle of tube feeding formula that was not dated or timed for when the feeding was hung. The bottle did have the tubing attached and was connected to the pump. Next to the formula bottle there was bag of water to flush the tube feeding and it had the date of 02/07/2026. The resident had an order for the tube feeding, via a pump, to run over 12 hours from 6 pm to 6 am.

Based on record review and interviews it was determined that the facility failed to ensure that residents had only one Maryland Order for Life-Sustaining Treatment (MOLST) form in their paper medical record. This was evident for 1 (Residents #1) of all residents present in the sample. The findings include: The Maryland Orders for Life-Sustaining Treatment (MOLST) form is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. It was designed to ensure that healthcare providers throughout Maryland have a uniform system of communicating a resident's end-of-life wishes in the event of cardiac or respiratory arrest. Cardiopulmonary Resuscitation (CPR) is the act of attempting to revive someone if their heart or breathing have stopped. On [DATE] at 8:19 AM, the surveyor reviewed Resident #1's paper medical record. The review revealed a MOLST dated [DATE] that indicated Resident #1 wanted CPR based on instructions in the patient's advanced directives. On [DATE] at 1:15 PM, the surveyor requested a copy of Resident #1's advanced directives and MOLST. On [DATE] at 1:45 AM, the surveyor reviewed the MOLST the Director of Nursing (DON) provided. The MOLST was dated [DATE] and indicated that Resident #1's surrogate decision maker elected to not have CPR performed in the case of cardiac arrest. The declination was Do Not Intubate (DNI). (This still allows limited ventilatory support by CPPAP or BIPAP). Along with MOLST the DON provided the surrogate decision making documentation as well as certifications by two provided indicating that Resident #1 was incapable of making medical decisions. All of these documents were dated April of 2024. Next the surveyor conducted an interview with the DON. During the interview the surveyor asked where the MOLST dated [DATE] came from. The DON stated she had found it in Resident's #1 paper medical record. The surveyor asked about the MOLST that was dated [DATE] seen earlier that day. The DON stated she would look and follow-up on the February 2025 MOLST. On [DATE] at 8:22 AM, the surveyor conducted a follow-up interview with the DON. During the interview the DON stated that both MOLSTs were located in Resident #1' medical record. The DON stated only one active MOLST should have been in the chart. She further stated that if there are two MOLST in the chart with contraindicating orders the staff reviews the date on the MOLST and would utilize the most recent date. The DON stated she removed the older MOST dating [DATE].

Based on observation, interviews, and surveyor record reviews it was determined that the facility failed to complete assessments accurately for residents. This was found to be evident in 5 (Resident #2, #7, #10, #31 and #126) out of 44 residents reviewed for Minimum Data Set (MDS) assessments. The findings include:Minimum Data Set (MDS) assessment is a federally mandated, standardized, comprehensive clinical assessment tool used in Medicare and Medicaid certified nursing homes. The MDS evaluates Residents' functional, cognitive, and physical health, guiding care plans to meet individual needs. Completed upon admission, quarterly, annually and whenever a significant change in condition occurs by trained clinicians. Care Plan is a tailored document summarizing a person's health conditions, care needs, medications, and goals and interventions designed to ensure consistent, proactive care. The care plan acts as a roadmap improving communication between providers, fostering patient independence, and enhancing safety. The care plan is evaluated on a regular basis to assess effectiveness and update as needed. 1.On 2/8/2026 at 11:08 AM the surveyor observed Resident #2 in bed, in no distress. The surveyor conducted an interview with Resident #2 who was alert and oriented x3 to person, place and time. Resident #2 stated that during a transfer he/she was lowered to the floor by 2 staff members because he/she was unable to bear weight. The surveyor conducted a record review of Resident #2's medical record at 9:30 AM on 2/12/2026. The record review revealed that Resident #2 had a change in condition evaluation on 11/10/2024 for a witnessed fall – 2 GNAs (Geriatric Nursing Assistant) transferring Resident from bed to wheelchair, Resident's knees buckled and Resident was lowered to the floor. Further review of the medical record for Resident #2 revealed that the Discharge – Return Anticipated MDS assessment dated [DATE] Section J was not coded for Resident having had any falls. At 8:50 AM on 2/13/2026 in an interview with the RN MDS Coordinator the surveyor conveyed that Resident #2 had a fall (lowered to the floor) on 11/10/2024, but the Discharge MDS dated [DATE] was not coded that Resident had any falls. MDS Coordinator reviewed the change in condition evaluation and the Discharge MDS and stated that the 11/30/2024 Discharge MDS should have been coded that Resident had a fall due to Resident being lowered to the floor on 11/10/2024. The MDS Coordinator stated that she would make the correction to the 11/30/2024 Discharge MDS to reflect that Resident #2 had a fall. On 2/13/2026 at 12:36 PM the surveyor conveyed to the Director of Nursing (DON) that the fall for Resident #2 was not coded on the Discharge MDS assessment dated [DATE] and that the MDS Coordinator was making a modification to the MDS to code the fall. On 2/10/2026 at 3:15 PM the surveyor conducted a record review of Resident #126's medical record. Review of the medical record revealed that there was a physician order on 10/15/2024, Admit to Hospice for Resident #126. Further review of the medical record revealed that there was a care plan for Hospice care. Review of Resident #126's MDS Quarterly assessment dated [DATE] Section O was not coded for Hospice care. In an interview with the RN MDS Coordinator at 7:20 AM on 2/11/2026 the surveyor reviewed the MDS assessments for Resident #126. The MDS Coordinator confirmed that Resident #126 was admitted to Hospice services on 10/15/2024 and that the Quarterly MDS assessment dated [DATE] was not coded for Hospice care. The MDS Coordinator stated that she would make the correction to the 1/23/2025 Quarterly MDS to reflect Hospice care for Resident #126. At 7:35 AM on 2/11/2026 the Director of Nursing (DON) was notified of the inaccurate MDS assessment dated [DATE] for Resident #126 regarding Hospice care. 2. On 2/9/26 at 9:52 AM, the surveyor reviewed Resident #7's medical record. The review revealed that Resident #7 had received the influenza vaccine on 9/22/25. Next the surveyor reviewed the Minimum Data Set (MDS) assessment dated [DATE] for Resident #7. In section O the question is asked, did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? Resident #7's assessment documented no. A follow up question was, if influenza vaccine not received, state reason. The response to this question was, Not offered. On 2/9/26 at 1:50 PM, the surveyor conducted an interview with the MDS coordinator Staff #2. During the interview the MDS coordinator reviewed the assessment dated [DATE] and confirmed that Resident # 7 received the vaccination and the MDS assessment was inaccurate. She further stated she would correct the error. On 2/9/26 at 9:52 AM, the surveyor reviewed Resident #10's medical record. The review revealed that in Resident #10's immunization record it was recorded that Resident #10 had refused the influenza vaccine on 12/10/25. It was also documented he/she was educated on the risks and benefits of the vaccination. An additional drop down area in immunizations also documented the Resident #10 received the influenza vaccination during the current influenza season in historical data. Next the surveyor reviewed the Minimum Data Set (MDS) assessment dated [DATE] for Resident #10. In section O the question is asked, did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? Resident #10's assessment documented no. A follow up question was, if influenza vaccine not received, state reason. The response to this question was, Offered and declined. On 2/9/26 at 1:33 PM, the surveyor conducted an interview with Assistant Director of Nursing (ADON) #3. During the interview ADON #3 stated that the nurse offered the vaccine on admission to the Resident and it was documented as refused that day, however after checking the historical data the vaccine was already administered for the 2025-2026 flu season. On 2/9/26 at 1:50 PM, the surveyor conducted an interview with the MDS coordinator Staff #2. During the interview the MDS coordinator reviewed the assessment dated [DATE] and confirmed that Resident # 10 received the vaccination and the MDS assessment was inaccurate. Staff #2 stated that she was unaware of the drop down box when review of historical data captured vaccination status. She further stated she would correct the error. 3. On 2/8/2026 at 9:09 AM, the surveyor interviewed Resident #31 and during that interview the resident stated that they had been diagnosed with Rheumatoid Arthritis approximately 20 years ago and had been in constant pain since. They reported that they had reported their pain and the intensity to the staff and had not received any medication for relief most of the time. On 2/9/2026 at 10:45 AM , the surveyor reviewed Resident #31 's medical records. The review revealed that Resident #31 had a standing order for Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg to be given every 8 hours with the resident's pain level, on a 0 (no pain) to 9 (extreme pain), to be recorded on the Medication Administration Record (MAR). The pain level was inconsistently entered with a large number of 0 even though the resident stated that she is never without pain and that not all nurses that brought medication asked about how bad the pain was. There were also X's were the pain level was not recorded. The surveyor spoke with Employee #24 who stated that the nursing staff had been instructed to ask the resident about their pain and to record the level on the MAR. The employee stated they could not explain the inconsistency. The surveyor also noted that during the medical record review, the Skilled Nursing Charting PDPM also indicated that resident had stated they had no pain. Again the resident denied ever being without pain. Further review of Resident #31 's medical record revealed an as needed (PRN) order for Extra Strength Tylenol 500 mg, as needed for chronic pain. This medication was only given once during the first two weeks of February, 2026, though the resident reported having asked for pain medication almost daily.

Based on observation and interview it was determined that the facility failed to maintain privacy for a Resident during meal delivery on the nursing units. This finding was found to be evident for 1 (Resident #75) out of 7 Residents reviewed for privacy.The findings include:At 8:52 AM on 2/8/2026 the surveyor observed employee #22 entering Resident #75's room without knocking on the door prior to entry. Employee #22 was delivering meal trays to Residents on the nursing unit.In an interview with Resident #75 on 2/8/2026, he/she stated that the staff does not always knock on the door when entering the room and that he/she and his/her roommate prefers the door open.On 2/13/2026 at 2:30 PM during survey exit the administrative team was notified of the concern with Resident privacy.

Based on record review and interviews, it was determined that facility staff failed to get consent from a Resident's Responsible Party (RP) or representative related to vaccinations. This finding was evident for 2 (Resident #3 & 10) of 5 residents reviewed for vaccinations during the survey. The findings include: 1) On 2/9/26 at 9:52 AM, the surveyor reviewed Resident #3's medical record. The review revealed that Resident #3 had refused the influenza vaccine on 9/16/25 and was educated on the risks and benefits of the vaccination. This was noted in the immunization record. Next the surveyor reviewed a progress note written by Registered Nurse (RN) #3 dated 9/16/25 that stated, Resident #3 (self- RP) has declined the seasonal flu vaccination. On further review of the record the surveyor noted that Resident #3 had two certifications that stated Resident #3 lacked adequate decision making capacity both dated 3/25/25. Resident #3's family member was named active Power of Attorney (POA) for health care. On 2/9/26 at 1:33 PM, the surveyor conducted an interview with Assistant Director of Nursing (ADON) #3. During the interview ADON #3 stated she offered the vaccination to Resident #3 and knew the resident had a history of refusing. The surveyor relayed the concern that the consent was not obtained from Resident #3's established RP. 2) On 2/9/26 at 9:52 AM, the surveyor reviewed Resident #10's medical record. The review revealed that Resident #10 had refused the influenza vaccine on 12/10/25 and was educated on the risks and benefits of the vaccination. This was noted in the immunization record. On further review, hospital discharge records documented that Resident #10 was discharged to the facility after a recent fall. The hospital records stated that Resident #10's aide had stated that Resident #10 was having difficulty walking prior to the fall. It also noted that Resident #10 had a past medical history that included but not limited to, autism spectrum, mental retardation and hearing loss. The hospital records included a contact person for Resident #10. On 2/9/26 at 1:33 PM, the surveyor conducted an interview with Assistant Director of Nursing (ADON) #3. During the interview ADON #3 stated that the nurse offered the vaccine on admission to the Resident and it was documented as refused that day, however after checking the historical data the vaccine was already administered for the 2025-2026 flu season. The surveyor relayed the concern that Resident #10 had an RP established and that the Resident was asked to consent and not the RP.

Based on medical record review, an interview with a resident's family member, and interviews with facility staff, it was determined that the facility failed to restart an anticoagulant (medication to prevent blood clots) for a resident with a history of [CONDITION(S)] (DVT). This resident developed a DVT and subsequently required surgical placement of an inferior vena cava (IVC) filter. This was evident for 1 of 15 residents reviewed during the survey (Resident #6). A DVT occurs when a blood clot, thrombus, forms in one or more of the deep veins of the body, usually in the legs. The inferior vena cava is a large vein in the middle of a person's body. An IVC filter is a small device used to stop blood clots from traveling to the lungs. The findings include: On 7/20/2021 at 10:30 AM, a review of the Resident #6's medical record revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/7/2020, Resident #6's laboratory results showed the resident ' s hemoglobin dropped from 9.2%, the baseline from previous labs, to 7.5%. This indicated the resident had a low hemoglobin or [CONDITION(S)] (a condition in which the blood doesn't have enough healthy red blood cells). Resident #6's primary physician, Staff # 13, discontinued the resident's order for [MEDICATION(S)] on 12/07/2020. The primary physician's note from 12/7/2021 stated in the assessment/plan to check the resident's stool for fecal occult blood as a potential source for the noted decrease in the resident's hemoglobin (and hematocrit). A comprehensive chart review revealed the stool check was not completed. According to the situation, background, assessment, and request (SBAR) created on 12/9/2020, a blood transfusion was ordered and completed on 12/10/2020, as an intervention to initially [MEDICATION(S)] the Resident #6's low hemoglobin. The order also included instructions for follow-up lab work to monitor the resident ' s hemoglobin levels. On 7/20/2021 the continued review of Resident #6's medical record revealed the resident is documented as his/her own representative. There was no documentation in the medical record to show that Resident #6 was notified about the changes in care related to the medication. A review of the resident's situation, background, assessment, and request (SBAR) communication form completed by the licensed nursing staff, the facility's staff inconsistently notified Resident #6's family member, Family Member #1, about changes in the resident's status. On 7/21/21 at 11:03 AM Family Member #1 was interviewed. Family Member #1 expressed that he/she was notified on 1/7/2021 regarding the presence of the additional DVT in Resident #6. Family Member #1 reported being concerned about the further need for a surgical procedure and a lack of prior interventions for DVT-including the administration of an anticoagulant. Family Member #1 denied being aware that Resident #The physician had discontinued the resident's order for [MEDICATION(S)]. On 7/23/2021 at 8:41 AM a review of Resident #6's lab worked revealed the following hemoglobin levels: 12/11/2020 after the blood transfusion showed the resident's hemoglobin was at 9.2%, On 12/14/2020 -9.6% 12/14/2020- 9.6% 12/17/2020-8.6% 12/21/2020-9.0% 12/23/2020-9.1% 12/29/2020- 9.1% 12/30/2020- 9.6% On 7/23/2021 at 9:59 AM a review of Resident #6's nursing progress notes for the month of December 2020 revealed an initial concern of gastritis. Resident #6 was placed on [MEDICATION(S)]. After 12/10/2020, the physician notes no longer addressed [MEDICATION(S)] for as a plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Physician provider notes completed by staff #12, the covering physician, reviewed on 7/23/2021 at 10:30 AM noted that on 12/24/2020 Resident #6 had complaints of swelling in bilateral (both) legs with an assessment showing, positive [CONDITION(S)] bilateral lower extremities. A continued review of the physician provider notes for Resident #6 revealed that on 12/28/2021 Staff #12 documented Resident #6 had pain all over, and documented the assessment as, positive [CONDITION(S)] bilateral lower extremities. On 7/23/2021 the continued review of Resident #6's medical record revealed the following: On 12/31/2021 an SBAR was completed and documented that Resident #6 was edematous (observable swelling from fluid accumulation in body tissues) in upper and lower extremities. A venous doppler of the lower extremities was ordered by a physician. A 1/4/2021 provider note completed by Staff #12 continued to document Resident #6's bilateral upper and lower extremity [CONDITION(S)] and noted the doppler exam as pending. On 1/6/2021 at 6:21 AM, according to the nursing progress notes, Resident #6 had an elevated pulse, however nursing documented that the resident's breathing was stable. The physician was notified, and no further changes were made to the resident's care at that time. On 1/6/2021, the venous doppler exam was completed and reported for the bilateral lower extremities as, Abnormal bilateral study consistent with bilateral DVT, right greater than left. Close follow up recommended to assure resolution. Staff #12 reviewed the doppler results on 1/6/21 at 8:00 PM and ordered a vascular consult for an IVC filter placement. Staff #12 identified a general surgeon to be contacted. On 1/7/2021 Resident #6 was transferred to the hospital at the request of the resident ' s family. Transfer diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/21/2021 at 9:06 AM the facility's Director of Nursing (DON) was interviewed regarding the discontinuation of Resident #6 ' s the [MEDICATION(S)]. She stated that it was the standard practice of Staff #13 to discontinue any anticoagulant when there was a drop in a resident's hemoglobin and the resident was anemic (a condition in which the blood doesn't have enough healthy red blood cells). On 7/23/2021 at 7:59 AM an interview with the Medical Director, Staff #15 revealed after his comprehensive review that the [MEDICATION(S)] was appropriately stopped after the noted decrease in the resident ' s hemoglobin and hematocrit; however, the lack of follow up and monitoring and acknowledgment related to Resident #6's DVT status was a concern. Additionally, Staff #15 stated that Resident #6's hemoglobin had increased and stabilized so the [MEDICATION(S)] could have been restarted as there were no other documented contraindications to restarting it. Staff #13, Resident #6's primary physician, was interviewed on 7/23/2021 at 10:51 AM. The surveyor's concerns related to the discontinuation of the [MEDICATION(S)], the lack of monitoring of the residents DVT, and the further development of an additional DVT was discussed during this conversation in the presence of the DON. Staff #13 stated that he discontinued the [MEDICATION(S)] on 12/7/2021 initially because of the resident ' s identified [CONDITION(S)]. The physician stated the plan was to monitor the [CONDITION(S)] and to resume the [MEDICATION(S)] once the resident's labs were stable. Staff #13 agreed during this phone call that the medication was not restarted and that was an oversight. This interview confirmed that Staff #13 did not order for Resident #6 to resume [MEDICATION(S)]. The failure to restart the medication after the stabilization of the resident's [CONDITION(S)] potentially caused the development of an additional DVT in a resident already prone to DVT, was discussed at this time and again during exit from the facility on 7/23/2021 at 2:00 PM with the facility DON and Administrator.

Based on review of medical record and other documentation, it was determined that the facility failed to document assessment, planning, and treatment for 7 pressure ulcers that Resident #246 acquired during this facility admission. The related failure to meet nutritional needs of the resident contributed to the pressure ulcer risk for Resident #246. Resident #246 also complained of pain related to the pressure ulcers when they were discovered after transfer from the nursing home to a local hospital on [DATE]. This concern was evident for 1 out of 48 residents reviewed (#246) during survey.The findings include:On 11/17/15 medical records for Resident #246's were reviewed. This review revealed that Resident #246 was admitted to the nursing home from a local hospital after a surgical procedure to address a left [MEDICAL CONDITION]. The hospital documentation indicated that the resident went to the nursing home with dry and intact skin, and with surgical staples also intact. Review of the nursing home's 10/9/15 nursing admission assessment revealed that nursing completed a head to toe observation documenting that no pressure ulcers were present on admission.Nursing assessment documentation completed 10/12/15 revealed the left hip surgical incision dressing was dry and intact but did not reveal any pressure ulcer concerns at that time. The nutrition data collection documentation revealed a note written on 10/12/15 which corroborated that skin was intact at that time.Further review of the medical records revealed a 10/15/15 care plan note which revealed that the resident was seen during wound rounds by the medical doctor who noted the surgical wound left hip staples peri-wound was clean and noted to continue current treatment. No evaluation of other skin integrity was documented. The care plan for skin integrity of the left hip related to surgical wound was initiated on 10/15/15. This care plan did not reflect any pressure ulcers and this care plan was not updated thereafter.Poor nutritional status is a risk factor for developing pressure ulcers. Review of the speech language pathologist (SLP) evaluation and recommendation for the resident dated 10/12/15 revealed a mechanical soft diet and 1:1 feeding supervision for all meals and that the resident demonstrated poor oral intake. However, further review of the medical record revealed 10/12/15 physician orders [REDACTED]. The physician ordered a regular diet with regular texture and regular consistency and a nutrition consult. Throughout the admission documentation revealed poor intake and many times resident #246 refused meals. These clinical factors did not lead to reevaluation of the dietary orders that remained inconsistent with the documented needs of the resident. Regarding fluids, review of the nutrition assessment revealed that the resident required 1663 milliliter (ml) or 1.6 liter a day which is 11,641 ml a week, and staff added 4 ounces of health shakes (chocolate) three times a day and chocolate milk with all meals. However, the medical record also revealed that on 10/12/15 the family notified the facility that Resident #246 was lactose intolerant and could not drink the offered health shakes. On 10/12/15, the dietitian therefore indicated that the shakes would be discontinued. However the health shakes were never discontinued. Review of the physician orders [REDACTED]. On 10/13/15 at 8:23 AM staff documented that they offered the health shakes again and on 10/13/15 at 2:05 PM staff documented that for the second time the daughter reported to staff that the resident could not drink the shakes they were offering. The record indicated that the residents, daughter states that .they bring ENSURE nutritional supplements from home <and again> resident is lactose intolerant. Staff nonetheless continued to document offering health shakes on 10/14 at 9:44 AM, 10/15 at 9:02 AM, 10/17 at 8:15 AM, 10/17 at 12:11 PM, 10/18 at 9:04 AM, and 10/18 at 12:22 PM. The last entry indicated that the daughter told staff again that the resident was lactose intolerant. No indications were found documented that front line staff communicated to care planning staff or that they ever notified the physician that Resident #246 was not eating and was not able to drink the health shakes they continued to offer. No indication was found the SLP and dietary assessments ever led to any development of any plan that might have better met the individualized needs of Resident #246. No indication was found of any assessment looking at the relationship between risk for pressure ulcer development and nutritional status concerns.On 10/18/15 nursing staff documented that he/she was notified by RCS of a buttock pressure wound. Surveyor review of the communication form and progress note dated 10/18/15 revealed a pressure ulcer on the right buttock was measured at 4 cm X 2 cm X 0.1 cm but there was no indication that a head to toe skin assessment was conducted even then.On 10/18/15 at 8:00 PM, the resident was transferred to a local hospital after staff finally notified the physician the resident was weaker and was refusing to eat (refusals to eat some meals at all were noted beginning on 10/15/15). Review of the hospital record revealed that when the resident arrived at the Emergency Department on 10/18/15, patient arrives in disheveled stated position on <his/her> right side with pillows and rolled blankets. Eyes matted with yellow drainage, undigested food is dried to the roof of his mouth and the R side of his face, patient has a soiled diaper .There is also a dressing to his sacrum covering a Stage II pressure ulcer .The right lower extremity is swollen . The following six additional pressure ulcers were documented in the ED record as well: Stage I pressure ulcers to R elbow, R ear, and right cheek, and additional Stage II pressure ulcers to right hip, right calf, and right shoulder. Failure to meet Resident #246's nutritional needs even when assessed, and failure to assess Resident #246's skin even after the sacral ulcer was finally identified, contributed to harm where Resident #246 developed 7 preventable pressure ulcers (as defined by the Centers for Medicare and Medicaid Services). Additionally, the hospital record revealed that Resident #246 suffered pain from the pressure ulcers indicating that the resident winced and groaned with any movement or assessment to the right side where the pressure ulcers were located.

Based on review of medical records and other documentation, it was determined that the facility failed to document assessment, planning, and treatment for 7 pressure ulcers that Resident #246 acquired during this facility admission, failed to meet nutritional needs of the resident that contributed to the pressure ulcer risk for Resident #246, and failed to ensure basic ADLs needs of the resident were met when the resident was transferred to a local hospital with 7 facility acquired pressure ulcers, and with observed dried food in his/her mouth and on his/her face. Resident #246 also complained of pain related to the pressure ulcers when they were discovered after transfer from the nursing home to a local hospital on [DATE]. This concern was evident for 1 out of 48 residents reviewed (#246) during survey.The findings include:On 11/17/15 medical records for Resident #246 were reviewed. This review revealed that Resident #246 was admitted to the nursing home from a local hospital after a surgical procedure to address a left [MEDICAL CONDITION]. The hospital documentation indicated that the resident went to the nursing home with dry and intact skin, and with surgical staples also intact. Review of the nursing home's 10/9/15 nursing admission assessment revealed that nursing completed a head to toe observation documenting that no pressure ulcers were present on admission.Nursing assessment documentation completed 10/12/15 revealed the left hip surgical incision dressing was dry and intact but did not reveal any pressure ulcer concerns at that time. The nutrition data collection documentation revealed a note written on 10/12/15 which corroborated that skin was intact at that time.Further review of the medical records revealed a 10/15/15 care plan note which revealed that the resident was seen during wound rounds by medical doctor who noted the surgical wound left hip staples peri-wound was clean and noted to continue current treatment. No evaluation of other skin integrity was documented. The care plan for skin integrity of the left hip related to surgical wound was initiated on 10/15/15. This care plan did not reflect any pressure ulcers and this care plan was not updated thereafter.Poor nutritional status is a risk factor for developing pressure ulcers. Review of the speech language pathologist (SLP) evaluation and recommendation for the resident dated 10/12/15 revealed a mechanical soft diet and 1:1 feeding supervision for all meals and that the resident demonstrated poor oral intake. However, further review of the medical record revealed 10/12/15 physician orders [REDACTED]. The physician ordered a regular diet with regular texture and regular consistency and a nutrition consult. Throughout the admission documentation revealed poor intake and many times Resident #246 refused meals. These clinical factors did not lead to reevaluation of the dietary orders that remained inconsistent with the documented needs of the resident. Regarding fluids, review of the nutrition assessment revealed that the resident required 1663 milliliter (ml) or 1.6 liter a day which is 11,641 ml a week, and staff added 4 ounces of health shakes (chocolate) three times a day and chocolate milk with all meals. However, the medical record also revealed that on 10/12/15 the family notified the facility that Resident #246 was lactose intolerant and could not drink the offered health shakes. On 10/12/15, the dietitian therefore indicated that the shakes would be discontinued. However the health shakes were never discontinued. Review of the physician orders [REDACTED]. On 10/13/15 at 8:23 AM staff documented that they offered the health shakes again and on 10/13 at 2:05 PM staff documented that for the second time the daughter reported to staff that the resident could not drink the shakes they were offering. The record indicated that the resident, daughter states that .they bring ENSURE nutritional supplements from home <and again> resident is lactose intolerant. Staff nonetheless continued to document offering health shakes on 10/14 at 9:44 AM, 10/15 at 9:02 AM, 10/17 at 8:15 AM, 10/17 at 12:11 PM, 10/18 at 9:04 AM, and 10/18 at 12:22 PM. The last entry indicated that the daughter told staff again that the resident was lactose intolerant. No indications were found documented that front line staff communicated to care planning staff or that they ever notified the physician that Resident #246 was not eating and was not able to drink the health shakes they continued to offer. No indication was found that SLP and dietary assessments ever led to any development of any plan that might have better met the individualized needs of Resident #246. No indication was found of any assessment looking at the relationship between risk for pressure ulcer development and nutritional status concerns.On 10/18/15 nursing staff documented that he/she was notified by RCS of a buttock pressure wound. Surveyor review of the communication form and progress note dated 10/18/15 revealed a pressure ulcer on the right buttock was measured at 4 cm X 2 cm X 0.1 cm but there was no indication that a head to toe skin assessment was conducted even then.On 10/18/15 at 8:00 PM, the resident was transferred to a local hospital after staff notified the physician the resident was weaker and was refusing to eat (refusals to eat some meals at all were noted beginning on 10/15/15). Review of the hospital record revealed the following documentation of the resident's status when he/she arrived at the Emergency Department (ED) on 10/18/15: patient arrives in disheveled stated position on <his/her> right side with pillows and rolled blankets. Eyes matted with yellow drainage, undigested food is dried to the roof of his mouth and the R side of his face, patient has a soiled diaper . There is also a dressing to his sacrum covering a Stage II pressure ulcer . The right lower extremity is swollen . The following six additional pressure ulcers were documented in the ED record as well: Stage I pressure ulcers to R elbow, R ear, and right cheek, and additional Stage II pressure ulcers to right hip, right calf, and right shoulder. Failure to meet Resident #246's nutritional needs even when assessed, and failure to assess Resident #246's skin even after the sacral ulcer was finally identified contributed to harm where Resident #246 developed 7 preventable pressure ulcers (as defined by the Centers for Medicare and Medicaid Services) that were not assessed or treated, and constituted neglect.Additionally, the facility failed to ensure that basic activities of daily living care needs were met when the resident arrived in the ED with dried food observed both in his mouth and on his face. Last, the hospital record revealed that Resident #246 suffered pain from the pressure ulcers indicating that the resident winced and groaned with any movement or assessment to the right side where the pressure ulcers were located.

Based on medical record review and interview with administrative staff, it was determined that the nursing staff failed to follow procedures to process a STAT (immediately) order for a complete blood count. This failure led to an untimely delay of 17 hours in obtaining the blood work results. This was evident for 1 of 5 residents (#5) reviewed. The findings included: Complete blood count (CBC) is a series of laboratory tests obtained from a blood sample that provides clinical information about the hematologic (blood) system and many other organ systems. White blood count (WBC), a component of a CBC testing, can help to determine the presence of a blood-borne infection and can help in monitoring response(s) to treatment. A normal WBC range is 3.7 to 10.6 (x 1,000 microliters of blood). WBC counts that continue to rise out of normal range indicate a worsening infectious condition and WBCs returning to normal baseline indicate improvement. Medical record review revealed that Resident #5 was admitted to the facility with multiple [DIAGNOSES REDACTED]. On 12/22/2014 at 2:00 p.m., Resident #5 was assessed by the nursing staff with a change in condition ("very confused"). At 2:30 p.m. on 12/22/2014, a physician was notified of the resident's change in condition and ordered a urinalysis (UA) with a Culture and Sensitivity (C&S) to be obtained on the morning of 12/23/2014. A UA is a laboratory test performed on a urine sample. A C&S identifies the bacteria causing an infection and which antibiotics could be most effective in treatment. Further review of the medical record revealed that on 12/23/2014, the nursing staff attempted to obtain the UA C&S with use of a catheter. However, the nursing staff was unable to pass the catheter through the resident's urethra into the bladder for collection of urine. As a result, the resident had penial bleeding and the UA C&S was never obtained for testing. The medical record revealed that later on 12/23/2014 at 4:30 p.m., nursing staff observed Resident #5 with further deterioration in his clinical condition. The resident was "vomiting, lethargic and having small amount of bloody urine," had an elevated temperature of 101 degrees Fahrenheit, and poor blood oxygenation rate of 88 percent (normal oxygenation rate is 96% -100%). On 12/23/2014 at 4:45 p.m., the Nurse Practitioner (NP) was notified of the resident's continued change in status, and the NP assessed the resident. Based on this assessment, the NP ordered a variety of tests and interventions that included: 1. STAT Chest X-ray to rule out pneumonia; 2. STAT Peripheral intravenous line access and the administration of fluids; 3. STAT laboratory test, specifically including a CBC; 4. Oxygen therapy to manage the resident's shortness of breath; 5. [MEDICATION NAME] and [MEDICATION NAME] to manage the resident's nausea and vomiting; 6. Condom catheter to monitor urine output; and, 7. Nursing instructions to monitor for persistent penial bleeding. Continued review of the medical record revealed the chest X-ray was performed at 9:00 p.m. on 12/23/2014 but it revealed no clinical concerns. On 12/23/2014 at 9:30 p.m., a consultant infusion therapy nurse inserted an intravenous catheter for the administration of fluids and the fluid administration began; and at this same time, nearly four hours after the NP's assessment, blood samples were obtained for the STAT-ordered CBC. Nursing documentation revealed that the blood specimen was collected at 9:30 p.m. and that the lab was called to pick up the blood specimen. This note indicated that the, "writer was told that after 8 pm no STAT labs can be picked up, will have to wait for morning pick up." Although the off-hours back-up system was in place, the off-hour process was not followed. Staff also did not notify the DON, the NP or the resident's attending physician that the transport of the specimen would be delayed until the following morning. By 7:45 a.m. the next morning (12/24/2014) the resident's condition had worsened further. A clinical note at this time indicated that the resident was, "observed lying in bed unresponsive to verbal stimuli, sternal rub performed (with no) response from patient." As a result of this nursing assessment the physician was called and ordered the resident to be transferred to the hospital.The hospital record revealed that the resident arrived in an unresponsive state and was supported by mechanical ventilation. Numerous medical tests were ordered and performed including a WBC that was elevated at 18 and two sets of blood cultures which revealed a blood stream infection (with gram-positive cocci noted in one of the specimens). The resident was started on antibiotic treatment. On 01/09/2015 at 3:30 p.m., the DON and Nursing Home Administrator revealed that the facility's contracted laboratory provider ensures STAT specimen pick up and processing 7 days a week, 24 hours a day. However, in a subsequent telephone-interview on 01/16/2015, the DON and Nursing Home Administrator revealed that a back-up system was in place for off hours specimen pick up. Specifically, a secondary laboratory provider is contracted by the facility when STAT laboratory request are made between the hours of 8:00 p.m. to 5:00 a.m. seven days per week. During these off-hours, the nursing staff is to call the secondary laboratory provider and the specimen is collected and taken to a local hospital for processing. The DON indicated that under this arranged/contracted service, the lab provider is expected to pick up and complete STAT-ordered specimens, "as soon as possible and not longer than four hours."

Based on observation, interview of facility staff and temperature recordings of foods completed by the surveyor, it was determined that the facility failed to maintain potentially hazardous foods at safe refrigeration temperatures, to install and maintain equipment waste lines in a manner that ensures foods and dishes are not contaminated in case of a blockage in the sewer lines of the facility and maintain handwashing supplies in the facility kitchen. The findings include: 1. At 9:30 a.m. on August 19, 2013, the surveyor entered the kitchen for initial tour during the facility's annual QIS recertification survey. The temperature reading on the outside of the walk in refrigeration unit read 52 degrees Fahrenheit. The interior thermometer near the door for the unit read 50 degrees Fahrenheit. Potentially hazardous foods, which may grow pathogenic (disease causing) bacteria, must be maintained at 41 degrees Fahrenheit or less to ensure safe food storage. Foods stored in the unit included eggs, milk, protein shakes, packaged egg products, raw ground beef and ham. The surveyor reviewed the temperature log attached to the walk-in refrigeration unit from August 1 to August 18, 2013 and found that the facility staff had recorded temperatures ranging from 44 to 50 degrees Fahrenheit for twenty seven of thirty one readings during the month of August. Nineteen of these readings were 50 degrees Fahrenheit. These temperatures included morning and evening readings. The surveyor notified the Director of Nursing and dietary manager at 9:45 a.m. on August 19, 2013 that the refrigeration unit was too warm. The surveyor then returned to the kitchen. Facility staff were not measuring any food temperatures or otherwise assessing the foods contained in the walk in refrigerator. Accompanied by the dietary aid and cook, the surveyor calibrated her thermometer and determined that it was accurate, reading 32 degrees Fahrenheit in an ice water slurry. Interview of the cook and dietary aid revealed that potentially hazardous foods stored in the walk in refrigerator that were not part of the recent delivery included milk, protein shakes and cottage cheese. The internal temperature of these foods would indicate the temperature of the unit over the time since the foods were placed there, as it may take several hours or more for food temperatures to reach the temperature of the refrigeration unit. At 10:10 a.m. on August 19, 2013, interview of the cook and dietary manager indicated that the interventions when the unit first was noted to be too warm in early August included contacting maintenance and on advice of the refrigerator technician, opening the walk-in freezer door to cool the refrigeration unit. When asked by the surveyor, the cook and dietary manager stated that they had not taken any temperatures of the foods as a result of the high readings on the unit's thermometer. At 10:25 a.m., the surveyor, accompanied by the dietary aid and cook and dietary manager, and two facility Dieticians observed temperatures of pints of milk, packaged liquid eggs in quart and pint containers and five pound containers of unopened cottage cheese to be 50 degrees Fahrenheit. Based on review of the temperature log and recordings of temperatures of foods on August 19, 2013, potentially hazardous foods stored in the unit since August 1, 2013 were stored above 41 degrees Fahrenheit. Due to the duration of the deficient practice and facility staff lack of response in monitoring food temperatures, it was determined that this poses an immediate jeopardy to the residents consuming foods contained in this refrigeration unit. At 11:45 a.m., the Administrator and Director of Nursing were informed verbally and in writing that an immediate jeopardy situation existed in the facility kitchen. The surveyor returned to the kitchen at 12:00 p.m. to observe lunch service. The menu included spaghetti with meat sauce. When the surveyor asked the source of the meat used in the sauce the cook stated that it was from the walk in refrigerator and had been there since Saturday, August 17, 2013. On surveyor intervention the meat sauce was discarded. Pureed meat that had previously been stored in the unit was also discarded. Interviews with the facility dieticians at 12:10 p.m. revealed that they work as clinical staff only and do not supervise the food service of the facility. The surveyor then reviewed the temperatures of foods at the tray line, where foods are monitored just prior to service. The temperatures of milk, which would indicate the ambient temperature of the refrigeration unit, were recorded at 44-46 degrees Fahrenheit for all of the breakfast service and three of seventeen days of dinner service. A plan of correction was submitted that included employee education and actions taken to discard foods that had been compromised. The immediate jeopardy was abated at 4:10 p.m. 2. The paper towel dispenser for the hand sink near the two compartment sink was inoperable on Monday August 19, 2013 and was not repaired on August 21, 2013. 3. The facility two compartment sink, ice machine, three compartment sink and dishwasher were observed to be directly connected to the facility sewage system. Sinks and other equipment that contact food or dishes must be indirectly connected to the sewage system prevent possible contamination in case of sewage backup. This is a repeat deficiency, previously cited on October 12, 2012.

Based on complaint, reviews of a closed medical record, a hospital record, and staff interview, it was determined that the resident's physician failed to take action when it was discovered that a resident had a severely distended urinary bladder with bilateral hydro[DIAGNOSES REDACTED], on an MRI result, which led to the resident being sent to the emergency room and admitted , 20 days later, with a [DIAGNOSES REDACTED]. This occurred for 1 of 4 residents reviewed during a complaint survey. The findings include: Review of complaint MD 854, on [DATE], revealed an allegation that resident #2 died unexpectedly.Resident #2 is a [AGE] year old female who was admitted to the facility, on [DATE], after having a total right hip replacement surgery at a local hospital. Resident #2 also suffers from hypertension, severe [MEDICAL CONDITION], frequent falls, [MEDICAL CONDITIONS], obesity, and carotid [MEDICAL CONDITION]. Resident #2 is competent and completed a Life Sustaining Treatment Options (LSTO) form which documents the resident's wishes regarding goals and care instructions. Resident #2 chose to have all life sustaining interventions performed and her goal was to walk again and return home. The LSTO form was signed by the resident on [DATE]. Resident #2's attending physician signed resident #2'sLSTO form on [DATE]. On [DATE], resident #2 had some laboratory studies obtained which demonstrated that resident #2 ' s blood urea nitrogen (BUN) was 27 mg/dl (normal 7 - 17) and a Creatinine of 0.80 mg/dl (normal 0.52 - 1.04). Review of resident #2's closed medical record, on [DATE], revealed an MRI of the Lumbar Spine result dated [DATE], which indicated that resident #2 suffered from a 1) nonacute moderate compression fracture at T12 with mild posterior central disc bulge at T12 - L1. 2) Moderate compression fracture at L4 with faint residual [MEDICAL CONDITION] that is likely subacute and 3) severe distention of the urinary bladder with bilateral hydro[DIAGNOSES REDACTED]. Resident #2's physician was made aware of the [DATE] MRI results on [DATE] at 6:10 pm. Resident #2's physician instructed the nursing staff to obtain a urology consult for the indication of a severe distention of the urinary bladder with bilateral hydro[DIAGNOSES REDACTED]. A urologist was contacted and an appointment was made for [DATE] at 1 pm. On [DATE], the urologist's office called the facility and cancelled resident #2's [DATE] appointment due to an insurance matter. On [DATE], a second urologist was contacted, who accepted resident #2 ' s insurance, and a new appointment was scheduled for [DATE]. On [DATE], the nursing staff contacted resident #2's physician, regarding the cancellation of the initial urology consult, and informed resident #2's physician a second urologist appointment was made for [DATE]. Further review of resident #2's closed medical record revealed that resident #2's attending physician visited and assessed resident #2 at the facility on [DATE]. Resident #2's attending physician documented resident #2's MRI results in the doctor's progress note and also noted that resident #2 was suffering from bilateral hydro[DIAGNOSES REDACTED]. Resident #2's attending physician did not document a plan for evaluation regarding resident #2's bilateral hydro[DIAGNOSES REDACTED] in the [DATE] doctor's progress note. In an interview with resident #2 ' s attending physician, on [DATE] at 4:53 pm, resident #2's attending physician stated that he was aware of the MRI result, and the finding of severe bladder distention with bilateral hydro[DIAGNOSES REDACTED] was an incidental finding. Resident #2's attending physician stated that resident #2 was not having any symptoms and the only plan was to obtain a urologist consult. Resident #2 was seen by the facility wound care team, on [DATE], and the corticosteroid, [MEDICATION NAME], was ordered for the treatment of [REDACTED]. The [MEDICATION NAME] was to be administered for the next five days. Resident #2 developed nausea on [DATE] at 6:15 pm. Resident #2's physician was contacted and an order for [REDACTED]. Review of resident #2's fluid and meal intake records, for [DATE], revealed the following nursing documentation: On [DATE], resident #2 consumed 25% of breakfast, refused lunch, and did not consume anything for dinner or the evening snack. On [DATE], resident #2 received a total of 240 ccs of liquids. On [DATE], resident #2 refused her breakfast, consumed 50% of lunch and 25% of dinner. Resident #2 also refused the evening snack. On [DATE], resident #2 received a total of 480 ccs of liquids. Resident #2's closed medical record did not reveal that resident #2's physician was made aware of the low oral and fluid intake for [DATE] and [DATE]. On [DATE] at 11:35 am, nurse #1 documented that resident #2 developed "a large area of redness and swelling to the right inner thigh and vaginal area". Nurse #1 documented that resident #2 was also complaining of pain. Nurse #1 contacted resident #2's physician who instructed nurse #1 to administer the antibiotic, Bactrim DS, one tablet orally, every twelve hours for 14 days, for the indication of right thigh [MEDICAL CONDITION] and to obtain a urinalysis and urine culture by straight catheter, and thirdly, to obtain a psychiatric consult. In an interview with nurse #1, on [DATE] at 3:13 pm, nurse #1 stated that resident #2 was administered a dose of the antibiotic Bactrim DS orally on [DATE]. Nurse #1 also stated that she could not obtain the urinalysis and urine culture due to resident #2 complaining of pain and being uncooperative during the straight catheter procedure. Nurse #1 stated she passed the information, regarding not being able to obtain the urinalysis and urine culture, onto the next nursing shift. Nurse #1 stated she received a phone call from resident #2's daughter, on [DATE], who informed nurse #1 that her mother " did not sound right " . Nurse #1 stated she assessed resident #2 who " seemed fine to me but also seemed dry in appearance " . Nurse #1 stated that she offered fluids to resident #2 throughout the day. Nurse #1 stated that resident #2 was not complaining of shortness of breath, a cough, nausea, or vomiting on [DATE] during the day shift. Further review of resident #2's closed medical record revealed nursing documentation; dated [DATE] at 5:10 pm, documented resident #2 had a change in condition. Nurse #2 documented that resident #2 was observed with confusion, low blood sugar, and right leg [MEDICAL CONDITION] with redness at 5:10 pm.Nurse #2 also documented that the lab work and urinalysis and urine culture was obtained from resident #2. Nurse #2 obtained a finger stick glucose sample from resident #2 and the result was 27 mg/dl. This is a very low reading. Nurse #2, documented that resident #2 was given a dose of [MEDICATION NAME] 1 mg intramuscularly to reverse the effects of the [DIAGNOSES REDACTED] Nurse #2 also documented that resident #2 was observed unable to move her right foot and a right pedal pulse could not be felt. Nurse #2 notified resident #2's physician, and then called and 911 to transport resident #2 to the emergency room . In an interview with nurse #2, on [DATE] at 4:30 pm, nurse #2, stated that on [DATE] resident #2 was observed to be slow to respond at approximately 4:30 pm. Nurse #2 stated resident had a temperature of 96.8 axillary because she could not hold an oral thermometer under her tongue. Review of resident #2's [DATE] 3:59 pm laboratory results revealed the following: Glucose - 20 mg/dl (normal ,[DATE]) Blood urea nitrogen (BUN) - 66 mg/dl (normal ,[DATE]) Creatinine - 1.98 mg/dl (normal 0.52 - 1.04) Potassium - 5.2 mmol/L (normal 3.5 - 5.1) Sodium - 141 mmol/L (normal 137 -145) Chloride - 105 mmol/L (normal 98 - 107) Review of resident #2's hospital record, on [DATE], revealed that resident #2 was admitted to the local emergency roiagnom on [DATE] at 5:44 pm. Resident #2 was admitted to the hospital on [DATE] with acute mental status change, [MEDICAL CONDITION] and right leg [MEDICAL CONDITION]. Resident #2's hospital record indicated that resident #2's condition worsened in which resident #2 had to be placed on a ventilator due to significant metabolic acidosis. Resident #2 was made a No Code on [DATE] and died the same day. Resident #2 final [DIAGNOSES REDACTED]. In conclusion, resident #2 had an MRI result, dated [DATE], which identified resident #2 with severe distention of the urinary bladder with bilateral hydro[DIAGNOSES REDACTED]. Other than scheduling a urology evaluation, resident #2's attending physician and the facility staff failed to evaluate the severe distention of the urinary bladder with bilateral hydro[DIAGNOSES REDACTED] between [DATE] through [DATE] with palpation of the bladder, ultrasound of the bladder, ultrasound of the kidneys, blood work, BUN, Creatinine, urinalysis, urine culture, 24 hour urine, further imaging studies, or other tests. This led to resident #2 being sent to the emergency room and admitted , 20 days later, with a [DIAGNOSES REDACTED].