Every finding on record at Autumn Lake Healthcare at Bridgepark

Based on complaint, reviews of a medical record, and staff interview, it was determined that the nursing staff failed to: 1) follow a physicians orders for withholding a cardiovascular medication when the pulse rate was less than 100 and document the resident's pulse rate when administering the cardiovascular medication, and 2) correctly document the route the cardiovascular medication should be administered. This was evident for 1 of 2 residents (Resident #1) reviewed during the complaint survey.The findings include:Review of Complaint 2662089 on 11/13/25 at 6:30 AM revealed a an allegation Resident #1 was not receiving quality of care at the facility.Resident #1 was admitted to the facility on [DATE] with diagnoses that include but not limited to being totally ventilator dependent, tracheostomy, and using a feeding tube for nutrition and hydration. Resident #1 is totally dependent upon the nursing staff for all aspects of his/her care. Resident #1 was sent out to the hospital on [DATE] for facial/head swelling.Review of Resident #1's medical record on 11/13/25 at 6:30 AM revealed a physician order, dated 09/05/25, instructing the nursing staff to administer the cardiovascular medication, Propranolol Hydrochloride, 10 milligrams, by mouth, every 8 hours, for tachycardia (a fast heart rate). Hold the medication if Resident #1's heart rate is less than 100 beats per minute.A review of Resident #1's September and October 2025 Medication Administration Records (MAR) revealed the nursing staff were signing off as administering a dose of Propranolol to Resident #1 without documenting Resident #1's heart rate and confirming Resident #1's heart rate was less than 100.The nursing staff also failed to correct the route in Resident #1's medical record as administering the Propranolol as being administered through Resident #1's gastrostomy tube (feeding tube).In an interview with the Director of Nursing (DON) on 11/13/25 at 9:30 AM, the DON was not aware the nursing staff were not documenting a pulse rate when administering the cardiovascular medication Propranolol to Resident #1 nor that the route of administering was by mouth.

Based on observation during the initial tour of the facility on 11/13/2025 at 5:35 AM, it was determined that the facility nursing staff failed to maintain the medication carts locked and secure. This was evident for 3 of 4 nursing units observed during a complaint survey.The findings include:During the initial tour of the facility on 11/13/2025 at 5:35 AM, the second-floor nursing unit was observed with one medication cart unlocked. Observations also include a medicine cup, located on top of the unlocked medication cart, with 2 cherry-colored oval tablets in the cup. The medication cart was unattended by any of the nursing staff.During an observation of the fourth-floor nursing unit on 11/13/2025 at 5:45 AM, the nurse surveyor observed 2 medication carts unlocked and unattended by any of the nursing staff.During an observation of the third-floor nursing unit on 11/13/2025 at 5:55 AM, the nurse surveyor observed 2 medication carts unlocked and unattended by any of the nursing staff.

Based on record reviews, and interviews, it was determined that facility staff failed to 1.) provide adequate supervision of a resident identified with inappropriate sexual behavior towards residents and staff resulting in actual harm to Resident #11, and 2.) ensure two-person assistance was provided while providing care to a resident in bed, as required by the resident's care plan. This deficient practice was evident for 2 of 5 residents (#11 and #98) reviewed for accidents during the annual survey.The findings include: 1) On 6/4/25, the surveyor reviewed facility incident reports and medical records for Residents #27 and #11. Resident #27 was admitted to the facility on [DATE] with diagnoses including schizophrenia and cognitive impairment. The nursing assessment for Resident #27 dated 6/19/24 documented a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impairment. A review of the facility reported incident (FRI) MD00193881 revealed that the facility substantiated that Resident #27 inappropriately touched Resident #85 on 6/29/23. The resident’s care plan was revised on 6/30/23, to address sexually inappropriate behaviors toward residents and staff. Interventions included administering psychotropic medications as ordered, monitoring side effects, establishing limits for inappropriate behaviors, and explaining unacceptable behavior to the resident. There was no documentation indicating that the facility revised the care plan to include increased supervision to ensure safety for all residents. Following the incident from 6/29/23, a review of a psychiatric evaluation conducted on 1/30/24 indicated that Resident #27 has a history of inappropriate sexual behavior towards staff. Another psychiatric evaluation was completed on 2/5/24 to assess the resident for Gradual Dose Reduction (GDR) of Zyprexa. It was documented that the resident previously failed a GDR attempt, but a second attempt was made. A progress note from the psychiatrist indicates that Resident #27 continued to display inappropriate behavior. Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia. The nursing assessment for Resident #11 dated 7/22/24 documented a BIMS score of 0 indicating severe cognitive impairment. A review of FRI MD00208357 revealed that Resident #27 inappropriately touched Resident # 11 on 8/2/24. The facility substantiated allegations of sexual abuse based on a witness account provided by Geriatric Nursing Assistant (GNA) #18. According to the investigation, on 8/2/24 at 2:54 PM, GNA #18 reports walking into room [ROOM NUMBER] at 2:54 PM and noticed Resident #27 on his/her knees next to bed A. Resident #27 appeared to be touching Resident #11 in the genital area. The GNA saw that one side of Resident #11 brief was wide open, and she could see his/her genital area exposed. The GNA immediately told Resident #27 to leave the room, and she redressed Resident #11, observing that the non-verbal resident was “tearful and kicking their legs urgently.” The surveyor conducted an interview with GNA #18 regarding FRI MD00208357. The surveyor asked if she recalled the incident involving Resident #11 and Resident #27. GNA #18 stated that she did remember and witnessed tears streaming down Resident #11’s face, explaining that the resident typically does not cry. When asked whether she believed the resident understood what had happened, the GNA stated “yes”. Although the resident is nonverbal, she appears to understand at times. Following the incident on 8/2/24, the facility requested a psychiatric evaluation which was conducted on 8/5/24. A psychiatrist's progress notes documented that the resident was evaluated at the nurse’s station and is now under close supervision by staff. A review of Resident #27s care plan revealed that the care plan was revised on 8/7/24, to address inappropriate touching of others. Previous care plan updates were made on 2/25/24, 2/26/24, 5/29/24 & 8/7/24 including behavioral monitoring, redirecting, and maintaining the resident’s dignity and right to sexual expression. However, the intervention failed to include increased supervision to ensure the safety of other residents. On 6/5/2025 at 7:35 AM, during an interview with the Administrator regarding FRI MD00208357. The surveyor asked whether the incident had been reviewed during the facility’s Quality Assurance and Performance Improvement (QAPI) meeting and if a corrective plan had been developed. The Administrator stated that the incident was reviewed during the facility’s risk management meeting, but no plan was implemented following the incident on 8/2/24. The Administrator confirmed that no additional supervision was initiated for Resident #27 beyond general monitoring and staff rounding. Both the surveyor and the Administrator reviewed Resident #27 care plan and acknowledged that the care plan should have included supervision interventions following the 8/2/24 incident. She also stated that no additional incidents of sexually inappropriate behavior towards another resident occurred between June 2023 and August 2024, she did not believe higher supervision was necessary. On 6/5/25 at 3:49 PM, both the Administrator and Director on Nursing (DON) were informed that the facility’s failure to revise Resident #27 care plan interventions to include more supervision led to the harm that occurred on 8/2/24. Both the Administrator and DON acknowledged that information. Although Resident #11 did not have any documented emotional distress, behaviors, or other negative outcomes from the incident on 8/2/24, the resident was known to be unable to respond normally to situations, to communicate effectively with staff, or to express their feelings clearly. In situations where a resident is unable to express their feelings such as this, the Reasonable Person Concept can be used to approximate how a reasonable person in the resident's situation would have reacted for the purpose of determining the outcome of a deficient practice. Using this concept, it was determined that a reasonable person would have experienced humiliation, anger, shame, and intimidation in response to the actions of Resident #27. Therefore, it was determined that psychosocial harm occurred to Resident #11. 2.) On 06/11/2025 at 11:00 AM, a review of complaint MD#00212331 revealed a concern regarding an incident that occurred in March of 2024 when only one staff member was providing care for Resident #98 which resulted in the resident rolling out of bed and hitting their head on the floor sustaining a cut over their right eye. Review of Resident #98's medical records on 06/12/2025 at 9:14 AM, revealed a baseline care plan for the resident that was completed on 03/12/2024. In this baseline care plan, under section 2B titled, Functional Abilities and Goals- Mobility, Bed Mobility: support provided, the resident was designated as a Two+ persons physical assist.On 06/12/2025 at 11:21, Resident #98's care documentation was reviewed for bed mobility in March of 2024. There were a total of 52 documented tasks performed for bed mobility. Of those 52, there were 30 documented as using a one person physical assist. On March 14, 2024 at 2:00 PM, just prior to the fall, the bed mobility task was documented as using a one person physical assist. Review of a change in condition dated 03/14/2024 revealed that the Resident rolled/fell out of bed during care by the assigned aid at 4:45 PM, thus sustaining a 1.0 cm laceration over the right eyebrow. On 06/12/2025 at 12:49 PM, during an interview with the Director of Nursing (DON), she stated that if a resident is designated as a Two+ persons physical assist for bed mobility then it is expected that the aid or nurse ensures that there are two people present during care.

Based on record review and interviews, it was determined that the facility failed to ensure nursing staff were competent with their skills set. This was evident for 3 (Staff #14, Staff #29, and Staff # 30) of 5 nursing staff evaluated for competency and has the potential to affect all residents. The findings include: 1a) Nursing competence is defined by the American Nurses Association as an expected level of performance that integrates knowledge, skills, abilities, and judgment. On 06/09/25 at 08:08 AM, as part of the sufficient and competent nurse staffing task, the surveyor asked the Director of Nursing (DON) to provide employee files of 5 randomly selected nursing staff. On 06/09/25 at 09:10 AM, the DON provided for Staff #14's employee file, one of the facility's contracted/agency Registered Nurse. On 06/09/25 at 09:15 AM, a review of Staff #14's employee file did not reveal any nursing competencies. The DON reported that she had contacted the staffing agency to request Staff #14 nursing competencies completed. On 06/10/25 at 11:57 AM, an interview with the DON was conducted. The DON reported that the agency could not provide Staff #14 nursing competencies or skill tests. Additionally, the DON acknowledged that she had identified the lack of staff education as a concern. 1b) On 06/10/2025 at 10:00 AM, a review of confidential complaints reported to the state agency revealed complaint #MD00206301. On 06/11/2025 at 12:10 PM, an interview with the complainant was conducted. S/He alleged that nurses who cared for Resident #92 were not skilled in taking care of a tracheostomy. On 06/11/2025 at 2:00 PM, a review of Resident #92's medical record was conducted. The review revealed that Resident #92 became unresponsive and was sent to the hospital on 5/31/24. On 06/11/2025 at 3:00 PM, the facility administrator was asked to provide: (1) the names of the nursing staff that worked on 5/31/24, and (2) their tracheostomy care competencies. On 06/11/2025 at 3:40 PM, the facility provided the names of the nursing staff who worked on 5/31/24, Staff #29 and Staff #30. However, the administrator acknowledged Staff #29 and Staff #30 had no tracheostomy care competencies. On 06/11/2025 at 3:50 PM, the lack of nursing competencies concern was discussed with the facility administrator and the DON.

Based on record review and interviews, it was determined that the facility failed to provide 12 hours of in-service training to nurse aides yearly. This finding was evident for 2 Geriatric Nursing Assistants (GNA #15 and GNA #16) of 2 nurse aide employee files reviewed during the recertification survey. The findings include: On 06/09/25 at 08:08 AM, as part of the sufficient and competent nurse staffing task, the surveyor reviewed two Geriatric Nursing Assistants (GNA) employee files (GNA #15 and GNA #16). The review of these records failed to show that the two GNAs had 12 hours of in-service education for the year 2024. On 06/09/25 at 09:50 AM, the facility administrator was asked to provide any documentation that indicated that GNA #15 and GNA #16 received in-service education. On 06/10/25 at 11:57 AM, an interview with the DON was conducted. The DON confirmed that GNA #15 and GNA #16 did not have 12 hours of in-service training, and that she had identified the lack of staffing education as a concern in the facility.

Based on record review and staff interview, it was determined that the facility failed to provide reasonable accommodations of preferences by not honoring a resident's request for female only caregivers. This was found to be evident for Resident #105 during investigation of facility reported incident MD00186826. The findings include: On 06/11/2025 at 11:00 AM, facility reported incident MD00186826 was reviewed by surveyor. In the report, Resident #105 alleged that a male caregiver had sexually assaulted them while applying barrier cream during incontinence care on 12/15/2022. The facility initiated an investigation and found the alleged incident to be unsubstantiated. Further record review revealed that Resident #105 was admitted to the facility on [DATE] and transferred to another nursing facility on 2/17/2023. Additional review of facility reported incident MD00186826 on 06/11/2025 revealed that the facility had stated on the Comprehensive & Extended Care Facilities Self-Report Form that the resident, is to receive ADL care from females only going forward. Included in the facility investigation packet was an interview conducted by the Nursing Home Administrator (NHA) with Resident #105 on 12/19/2022, where it was documented that the resident, explained that they did not want any males to work with them. On 06/12/2025 at 10:13 AM, review of Resident #105's electronic health record (EHR) revealed a nurse progress note dated 12/17/2022 that stated, Resident is alert and stable, able to make her needs known. No complaints, cooperated with GNA and RN, due meds and treatment provided as ordered and well tolerated. Supervisor made RN aware that patient cannot have Male care giver. Resident #105's treatment administration record (TAR) for barrier cream application during incontinence care was reviewed on 6/12/2025 at 11:35 AM. It revealed that on dates 1/5/2023, 1/10/2023, 1/15/2023, 1/16/2023, 1/17/2023, 1/24/2023, 1/27/2023, 1/28/2023, 1/29/2023, and 2/7/2023, two presumed male staff members performed the care. Additionally, review of Resident #105's care plan did not show a revision that included their preference for female caregivers. The NHA was interviewed on 06/13/2025 at 9:20 AM and presented a copy of the January and February 2023 TAR. The NHA confirmed that a check mark with initials on the TAR means that staff member performed the care and confirmed that the two presumed male staff members were indeed male. The NHA further stated that the care plan should have been updated to reflect the resident's wishes for only female caregivers and acknowledged surveyor concerns.

Based on record reviews and interviews it was determined that facility staff failed to notify a resident's representative of a change in the resident's medical condition and failed to inform the resident's representative of the resident's transfer to the hospital. This deficient practice was evident for one (#89) resident reviewed for notification of changes during the annual survey. The term resident representative means the following: An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications. The findings include: Resident #89 was admitted to the facility August 2023 with medical history that includes aphasia ( language disorder that can affect a person's ability to speak, understand, read or write) among other conditions. A review of complaint intake MD00202589 on 06/10/25 at 7:33 AM reveals that the complainant reported not being notified by the facility about a change in Resident #89's medical condition. The complainant stated that they learned of the resident's hospitalization on 2/10/24; one day after the admission occurred. On 6/11/25 at 6:50 AM, a review of Resident #89's admission record revealed that the complainant is listed as the resident's representative. Further review of the baseline care plan confirmed that the complainant was listed as the resident representative. On 2/9/24, a facility staff documented on a change of condition template that Resident #89 became short of breath. Under Section L1, it was noted that the Certified Registered Nurse Practitioner was notified on 2/9/24 and recommended stat diagnostic testing and medication. Under section M which addresses resident representative notification, staff documented that the resident was their own representative and that the resident was notified on 2/9/24. Resident #89 was transported to the hospital on the same day. There was no documentation indicating that the resident's designated representative was notified of the change in the resident's medical condition or the hospital transfer. On 06/11/25 at 7:33 AM, during an interview with the Director of Nursing (DON) with the Administrator present, the surveyor asked about the facility's expectation for notifying resident representative when a resident is transferred to the hospital. The DON stated that staff are expected to notify the residents' representatives. The surveyor informed the DON of the concerns mentioned in intake MD00202589. The DON stated that if the resident can make their own decisions, staff are not required to notify the representative.

Based on observations and interviews, it was determined that facility staff failed to 1.) maintain the facility's floors and resident shower room in a clean and sanitary condition and 2.) failed to ensure privacy for male and female residents who share a joint bathroom. This deficient practice was evident for multiple areas observed for cleanliness and resident privacy during the annual survey. The findings include: 1.) A review of complaint intake MD00208739 on 06/4/25 for Resident #4, reveals that the complainant reported ongoing cleanliness issues at the facility. They described the facility as filthy with trash and toilet paper scattered on the floors. The elevator was noted to be so dirty that the complainant's shoes stuck to the floor. A review of complaint intake MD00202589 on 06/4/25 for Resident #89, reveals that the complainant expressed concerns about the facility's cleanliness and is unclear when the floors were last swept or mopped, or how often the bathroom is cleaned. On 6/4/25 at 7:30AM, upon entry into the facility, the surveyor observed cigarette ashes, and a brown colored substance scattered on the floor near the resident designated smoking exit area on the first floor. The surveyor team entered the elevator on the first floor and noted that the soles of their shoes were sticking to the floor. Upon exiting the elevator, a paper straw wrapper was stuck to the bottom of the surveyor's shoe, and facility staff had to assist in removing it. On 6/4/25 at 7:47AM, an observation of the stairwell revealed trash, leaves, a used glove on the steps, along with a brown colored substance on the wall.On 6/4/25 at 7:52 AM, an observation of the resident shower room on the third floor revealed a janitor's cart with cleaning supplies, a white washcloth, toothbrush, shaving cream, and razor placed on the windowsill. Five wheelchairs were lined up against the wall, one chair was noted with an oxygen tank and reuseable bag attached to the back of the seat.On 6/4/25 at 8:03 AM, an observation of a resident's bathroom on the third floor revealed trash and toilet paper on the floor. Directly outside the resident's room, a plastic string and a paper straw wrapper were also observed.On 06/09/25 at 08:42 AM, during an interview with Environmental Services (EVS) Director #31, he stated that a set of EVS staff begin their shift at 6:00 AM and are responsible for removing trash, delivering clean linen to the units, and collecting soiled linen. He explained that a second group of employees begins at 7:00 AM and is responsible for cleaning the facility floors and stairwells. From 2:00 PM to 6:00PM, another group of staff is responsible for maintaining the cleanliness of the facility. On 6/09/25 at 8:57 AM, the surveyor reviewed images of the facility's floors, shower room, and stairwell with the EVS Director #31 and Director of Nursing (DON) from 6/4/25. Both acknowledged the surveyor's observation. 2.) During the initial tour of the third-floor unit on 6/4/25 at 7:55AM, the surveyor entered room [ROOM NUMBER] that housed four males and observed a bathroom on the right side of the room that connected directly to room [ROOM NUMBER] that housed two female residents. The bathroom doors on both sides were open, and the surveyor was able to walk directly through the bathroom from room [ROOM NUMBER] into room [ROOM NUMBER]. On 06/05/25 at 07:35 AM, the surveyor informed Administrator that bathroom doors connecting room [ROOM NUMBER] and room [ROOM NUMBER] were both open, which allowed the surveyor unsupervised access between male and female rooms. The Administrator stated that the bathroom door on the female side should remain closed, especially since the female residents are not able to access the bathroom independently. On 06/05/25 at 8:16 AM, the Administrator reported that maintenance staff placed a lock on the bathroom door on the room [ROOM NUMBER] side preventing residents from room [ROOM NUMBER] from accessing the female room through the shared bathroom. 3.) A geri-chair, also known as a geriatric chair or medical recliner, is a specialized chair designed for individuals with mobility challenges, often seniors or those with disabilities. These chairs offer comfort and support for prolonged sitting and feature adjustable components like backrests, footrests, and armrests, as well as reclining capabilities.On 6/4/2025 at 8:12 AM, the 4th floor shower room was observed to have used wash cloths laying on the floor next to the soiled linen bin. Two geri-chairs were observed being stored in front of 1 of 2 shower stalls. A wound dressing with date and time on it was observed hanging over shower stall handle in the 4th floor shower room on 6/10/2025 at 8:27 AM. The shower room floor was visibly soiled, and a geri-chair was observed being stored in the 2nd shower room stall. A soiled clothing item was observed to be laying on the air-conditioning unit.On 6/10/2025 at 8:37 AM, the 3rd floor shower room was observed by surveyor. A geri-chair with two pillows and a foam fall mat on top of it was observed being stored in the shower room. Two janitor carts with mop buckets full of dirty water were also being stored in the 3rd floor shower room. A geri-chair and a wheelchair were observed being stored in 1 of 2 shower stalls. Licensed Practical Nurse (LPN) #13 was interviewed on 6/10/2025 at 8:42 AM. LPN #13 stated that both showers were functional but that only one stall is typically used.The 4th floor shower room was further observed on 6/11/2025 at 8:04 AM with noticeable black soiled areas on floor as well as trash debris. The sink was also observed to be soiled with human hair scattered in the sink basin. The 3rd floor shower room had visibly soiled floor as well as 2 geri-chairs and 3 wheelchairs being stored in the room when observed on 6/11/2025 at 8:10 AM.The Nursing Home Administrator (NHA) was interviewed on 6/11/2025 at 8:47 AM and acknowledged surveyor concerns about the 3rd and 4th floor shower rooms.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure that a resident remained free of abuse. This deficient practice was evident for one (#11) of five residents reviewed for abuse during the annual survey. The findings include: Review of the facility's investigation file related to the facility reported incident MD00208357 and compliant intake MD00208362 on 6/4/25 at 2:45 PM, revealed that the facility substantiated allegations of sexual abuse based on a witness account provided by Geriatric Nursing Assistant (GNA) #18. GNA #18 reported that while walking into room [ROOM NUMBER] on 8/2/24 as part of her initial shift rounding, GNA #18 witnessed Resident #27 who is cognitively impaired on their knees next to Resident #11's bed and was touching the resident's genital area. The GNA immediately intervened and redirected Resident #27 out of the room. The GNA reported the incident to her floor nurse as they attended to Resident #11. Resident #11 who is cognitively impaired, did not appear to have any injuries but did note that the resident's incontinence brief had been pulled to the side. Review of the investigation file revealed that the incident occurred on 8/2/24, at 2:54 PM. The Director of Nursing (DON) became aware of the incident at 3:15 PM and notified the Administrator at the same time. Further review indicated that the Baltimore City Police Department was notified at 3:57 PM, and the report was submitted to the state agency at 4:57 PM on the same day. On 06/05/25 at 11:39 AM, during an interview, the Administrator stated that she recalled the incident that occurred on 8/2/24. After the incident, Resident #11 was transported to the hospital for further evaluation and returned to the facility with no physical injuries. Upon returning, Resident #11 was placed on a different unit. Resident #27 was evaluated and placed on one-to-one supervision until medication adjustments were effective.

Based on review of facility reported incident investigation, review of record and interviews, it was determined the facility failed to 1) report an allegation of abuse in a timely manner to the state agency, immediately, but not later than two hours after the allegation was made, and 2) report an injury of an unknown source to the state agency as required. This was evident for 1 resident (Resident #106) of 17 residents reviewed for timely reporting an alleged violation, and 1 resident (#94) of 3 residents reviewed for an injury of unknown origin during an annual survey. The findings include:1) On 06/10/2025 at 8:41 AM, review of the investigation report of Facility Reported Incident (FRI), MD#00190620 revealed that on 03/28/2023 at 09:15 AM, Resident #110 reported to the administrator that Resident #106 might have been choked by Geriatric Nursing Assistant (GNA #21) on 03/27/2023 during the evening shift. On 06/10/2025 at 8:57 AM, further review of the investigation packet showed that on 03/27/2023, Certified Medicine Aide (CMA #32)'s in her statement stated that on that day at around 6:00PM to 6:30 PM, a resident informed her that Resident #106 had been hit and on the same day Resident #106's roommate had given her a note about Resident #106 being hit. On 06/10/2025 at 12:53 PM, in an interview with the Nursing Home Administrator (NHA), when she was asked about the reporting time of an alleged abuse violation, she stated that she typically reports such incidents within two hours or less. When she was informed that the alleged violation was not reported in a timely manner, she responded that she learned about the incident from another resident as she was arriving at the facility and added that this failure to report to the supervisor was a major factor in the termination of CMA #32's employment, noting that CMA #32 was aware of the incident but failed to notify a supervisor who would have informed her(NHA). She was informed that delay in reporting was a concern that would be brought to our office, and she acknowledged understanding of the concern. 2) Review of complaints #MD00210615 and #MD00210588 on 6/4/25 at 10:21 AM, revealed an allegation that Resident #94 sustained an ankle fracture of unknown origin on or about 10/5/24. The Resident's medical record revealed that Resident #94 was non-verbal, and was completely dependent on staff for all care and ADL (Activities of Daily Living) including but not limited to bed mobility, turning and repositioning, toileting, and hygiene; and that s/he had severe contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). A Change in Condition/Concurrent Review dated 10/4/24 12:53 (12:53 PM) noted that the resident's left lower extremity was swollen, and left ankle was red and warm to touch; the Physician was contacted and ordered a STAT (immediate) x-ray to rule out a fracture and an ultrasound to rule out a Deep Vein Thrombosis (blood clot). The X-ray report dated 10/5/24 revealed the resident had fractures of the distal metaphysis of the left tibia and fibula (ankle area) in satisfactory position and alignment. S/he also had severe deformities of the left foot. No documentation was found in Resident #94's record of an accident, incident or trauma associated with the injury.On 06/4/25 at 11:30 AM the Administrator was asked if the facility reported the injury of unknown origin related to Resident #94's fractured ankle to the State Agency. She initially indicated no but then indicated that she would look because there may be something in her office. At 1:10 PM on 06/4/25 the DON (Director of Nursing) and the Administrator confirmed that the facility did not report the resident's injury to the State Agency. The DON provided the surveyor with an investigation that was completed by the facility on 10/7/24 and indicated the injury was not reported because the medical director determined that it was a pathological fracture. The DON confirmed that the medical director's determination was made on 10/7/24, 2 days after the initial injury was identified. She also confirmed that Resident #94 was incapable of moving independently. Cross reference F 628 and F 842.

Based on review of a facility reported incident it was determined the facility failed to 1) ensure the thorough investigation of an allegation of abuse, and 2) provide residents with psychological evaluations and physician assessments following a substantiated incident of resident to resident sexual abuse. This was evident for 1 (Resident #106) out of 17 residents reviewed for allegations of abuse, and 1 (MD#00193881) of 17 Facility Reported Incidents (FRI) reviewed during the annual survey.The findings include:1) On 06/10/2025 at 8:41 AM, review of the investigation report of Facility Reported Incident (FRI), MD#00190620 revealed that on 03/28/2023 at 09:15 AM, Resident #110 reported to the administrator that Resident #106 might have been choked by Geriatric Nursing Assistant (GNA #21) on 03/27/2023 during the evening shift. On 06/10/2025 at 11:12 AM, when the surveyor requested copies of employee files/trainings for GNA #21 from the Nursing Home Administrator (NHA), she informed this surveyor that GNA #21 was from a nursing agency and added that the facility did not have his employee file and training. When asked how the facility ensured that nursing agency staff received the required training, she explained that the facility had a contract with the agency stipulating that all staff would be properly trained before being assigned to the facility. On 06/10/2025 at 11:24 AM, She was asked to provide a copy of the contract with the nursing agency.On 06/10/2025 at 1:52 PM, The NHA and Director of Nursing (DON) informed the surveyor that they do not have the contract from the nursing agency do not have any documentation of GNA #21's training. She stated that it seemed the agency did not exist any longer. When they were informed that the inability to maintain an employee training/file record was a concern, the NHA and DON verbalized understanding of it and the DON stated that they should have ensured that GNA #21 had the required training which should have been made available on request. 2) Based on record review and interview with staff, it was determined that the facility failed to provide residents with psychological evaluations and physician assessments following a substantiated incident of resident to resident sexual abuse. On 06/05/2025 at 9:24 AM, the surveyor reviewed an investigation into an incident of resident to resident sexual abuse that took place on 06/29/2023 at 9:23 AM. In the investigation documentation, the facility made several claims that the residents had been seen by psychiatric services and the facility physician for assessment and evaluation following the substantiated incident. On 06/05/2025 at 10:01 AM, a review of Resident #27's medical records failed to reveal that the resident was seen for a psychiatric evaluation following the incident regarding the sexual abuse.On 06/06/2025 at 10:18 AM, a review of Resident #85's medical records failed to reveal that the resident was seen by the facility physician in regards to the sexual abuse. On 06/12/2025 at 2:13 PM, during an interview with the Director Of Nursing (DON), she stated that it was normal practice following any allegation of resident to resident abuse that both residents would be seen by psychiatric services and the physician to be assessed and evaluated. She stated that both residents involved in this incident had not been seen by psych services or the facility physician regarding the sexual abuse. The DON was made aware of the concern on 06/12/2025 and again during the exit conference on 06/13/2025

Based on medical record review and interviews it was determined the facility staff failed to ensure that the required minimum information was provided to the receiving provider upon transfer from the facility. This was evident for 1 (#94) of 3 residents reviewed for an injury of unknown origin. The findings include: A review of Resident #94's medical record on 6/4/25 at 10:21 AM revealed a Change in Condition/Concurrent Review dated 10/4/24 12:53 (12:53 PM) which noted that the resident's left lower extremity was swollen, and left ankle was red and warm to touch. The Physician was contacted and ordered a STAT x-ray to rule out a fracture and an ultrasound to rule out a Deep Vein Thrombosis (blood clot). The Change in Condition form contained a section to document specific information in the event of a hospital transfer. The section was blank. The X-ray report dated 10/5/24 confirmed the resident had fractures of the ankle. A Nursing Note dated 10/6/24 03:13 (3:13 AM) noted that the on-call physician was notified of the results and ordered that the resident be sent to the hospital for evaluation. Another Nurses Note at 03:33 (3:33 AM) on 10/6/24 indicated the resident was sent to the hospital at that time. No documentation was found to indicate that the required information was provided to the receiving provider at the time of the transfer. During an interview on 6/4/25 at 11:30 AM the Administrator was made aware of this finding and indicated the required information should be documented in the Change in Condition form. She reviewed the form and confirmed it did not contain the required information. She indicated that she would check with the DON (Director of Nursing). At 1:10 PM on 6/4/24 the Administrator and DON confirmed that there was no documentation to indicate that the required hospital transfer information was sent to the receiving facility. Cross reference F 609 and F 842.

Based on record review and interviews, it was determined the facility failed to ensure comprehensive care plans were developed and implemented. This was evident for 1 resident (Resident#104) out of 17 facility reported investigations, and 2 (Resident #58 and Resident #92) out of 6 residents reviewed for care plans. The findings include:1) A care plan is an outline of nursing care showing all the residents' needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care.On 06/11/2025 6:33 AM, the surveyor reviewed the facility's reported incident investigation packet for intake MD#00181243 in which the facility reported an unexpected death of Resident #104 to the state agency.On 06/11/2025 at 8:44 AM, further review of the investigation packet revealed the resident's death certificate which was signed by the certifying physician and dated 07/22/2022 was seen which revealed the following as the cause of deathA)Septic shock with approximate interval between onset and death described as days.B)Necrotizing Fasciitis with approximate interval between onset and death described as weeks.C)History IV drug abuse with approximate interval between onset and death described as years.D)Polysubstance abuse with approximate interval between onset and death described as years.On 06/11/2025 9:04 AM, review of the resident's electronic health record (EHR) showed that Resident #104 had diagnosis of osteomyelitis and history of substance abuse amongst other diagnosis. On 06/12/2025 at 7:31 AM, review of the resident's care plans failed to reveal a plan to address the history of substance abuse and there was no documentation found regarding what intervention would be facilitated by staff to prevent such while the resident was at the facility.On 06/12/2025 at 8:13 AM, in an interview with the Nursing Home Administration (NHA), When asked if there was a care plan in place for Resident #104 which addressed the history of substance abuse, she stated that the facility did not put a care plan in place for history of substance abuse. When asked if there should have been a care plan in place for the history of substance abuse, she stated that there should have been one in place which would have helped to identify that she had the potential for illicit substance use and interventions would have been in place. She also added that she did not know if a post mortem was done or not. 2a) On 06/06/25 at 07:52 AM, a review of Resident #58's medical records was conducted. This review revealed that the resident was dependent on staff for personal hygiene and toileting. Further review of the resident's care plan indicated that Resident #58 needed 2-persons assist during the provision of personal care. On 06/06/25 at 08:00 AM, a review of the resident's Minimum Data Set (MDS) revealed that the resident was coded as dependent on staff. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. MDS defines dependent as when the caregiver does all of the effort, or, the assistance of 2 or more helpers is required for the resident to complete the activity.On 06/06/25 at 01:50 PM, a review of Resident #58's personal hygiene record for March and April 2025 revealed that the resident received only 1 person assist during various shifts every day in March and April 2025.On 06/06/25 at 02:00 PM, further review of the record revealed a nurse note dated 06/01/2025 that indicated the resident rolled out of the bed and was caught by the aide who assisted the resident to the floor.On 06/06/25 at 02:25 PM, an interview with the Director of Nursing (DON) was conducted. The DON confirmed that according to the facility's provided documentation, Resident #58's care was provided by 1 person instead of 2-persons as care planned. 2b) On 06/11/2025 at 09:06 AM, review of confidential complaints reported to the state agency revealed complaint #MD00206301 which was received on 6/4/2024. This complaint alleged that Resident #92 did not receive tracheostomy care.A tracheostomy is a surgical procedure that creates an opening in the neck, called a stoma, through which a tube is inserted into the trachea (windpipe) to provide an airway and facilitate breathing.On 06/11/2025 at 10:00 AM, further review of Resident #92's medical record was conducted. The review revealed that Resident #92 was admitted into the facility with a tracheostomy on 4/3/24 and was discharged to a hospital on 5/31/24. A review of the resident's care plan did not include tracheostomy care.On 06/11/2025 at 10:30 AM, an interview with the DON was conducted. During the interview, the surveyor and the DON reviewed Resident #92's care plan and the DON confirmed that the resident was never care planned for tracheostomy care.

Based on record review and interviews, it was determined that the facility failed to revise care plans for residents. This was evident for 1 (MD#00207171) out of 17 facility reported investigations, 2 (Resident #100, #27) out of 5 residents reviewed for care plans reviewed during an annual survey.The findings include:1) On 06/09/2025 at 9:48 AM, the surveyor reviewed the facility's reported investigation packet for intake MD#00207171 in which the facility had stated that on 06/28/2024, Resident #64 was seen naked with another resident.On 06/09/2025 at 10:30 AM, further review of the investigative packets showed that the facility stated in the final report sent to the state agency that the corrective action to be taken would be to update Resident #64's care plan to reflect his/her wish for companionship with other residents but that his/her interactions would be supervised by staff, that no sexual interactions would take place due to resident's cognitive deficits and provide assistance with resolution as needed.On 06/09/2025 at 10:51 AM, review of the resident's care plan in the electronic health record dated 07/02/2024 showed inappropriate exposure behaviors with another resident which care-planned underneath behaviors care plan and there was no goal or intervention for the care plan focus. The surveyor did not see a care plan update that addressed Resident #64's desire for companionship with other residents or care plan intervention for staff to supervise him/her so that there would not be sexual interactions.On 06/09/2025 at 12:04 PM, in an interview with the Director of Nursing (DON), when she was asked what measures were put in place after the incident. She stated that she had just started working at the facility 2 days after the incident and that the Nursing Home Administrator would know more about it.On 06/09/2025 at 12:11 PM, in an interview with the Nursing Home Administration (NHA), when asked what measures were put in place after the incident, she stated that the facility had planned to update Resident #64's care plan to reflect the desire for companionship and that he/she would be supervised by staff so that there would be no sexual interaction. When she was asked for the documentation of the care plans, she stated that she would provide it to the surveyor.On 06/09/2025 at 12:16 PM, the NHA informed the surveyor that she had checked the resident's electronic health record but did not find any care plan that addressed Resident #64's desire for companionship with other residents or care plan intervention for staff to supervise him/her so that there would be no sexual interaction. When she was informed that this was a concern that would be taken to the office, she stated that the care plan should have been specific just as it was noted in the final report sent to the state agency. 2) On 06/11/25 at 9:00 AM, a review of Complaint #MD00212923 was conducted. The complaint expressed concerns with how Resident #100 fell and the process after the fall. On 06/12/25 at 9:30 AM, Resident #100's Change of Condition documentation was reviewed. On 12/6/2024, the change of condition documentation stated the resident was found on the floor during rounds.On 06/12/25 at 10:12 AM, a review of Resident #100's care plan and orders was conducted. A care plan of Potential for falls was created on 11/9/24. No revisions made to the care plan's Focus, Goal, or Interventions after the fall on 12/6/24. There was no additional Fall care plan created after the fall on 12/6/24. A review of Resident #100's orders revealed that no orders for interventions were created after fall on 12/6/24.On 06/12/2025 at 12:30 PM, an Interview with the Director of Nursing (DON). The DON noted that there was no Care plan, orders, or interventions created or revised after Resident #100's fall on 12/6/2025. 3.) Monitoring and Modification-Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks.A review of the facility's investigation file related to the facility reported incident MD00208357 and complaint intake MD00208362 on 6/4/25 at 2:45 PM, revealed that the facility substantiated allegations of sexual abuse. The investigation indicates that Resident #27 sexually assaulted Resident #11 on 8/2/24.Further review of the investigation file revealed that the facility's corrective action for the incident included updating Resident #27 care plan to reflect the incident from 8/2/24, monitoring sexually inappropriate behaviors, and assessing the effects of medication changes.On 6/5/25 at 12:26 PM, a review Resident #27 care plan indicates that the facility failed to update care plan interventions to address monitoring and supervision in response to the resident's inappropriate sexual behaviors. 06/05/25 11:39 AM during an interview with the Administrator, the surveyor discussed the facility's investigation file and corrective action plan. The surveyor asked if Resident #27 inappropriate sexual behavior was monitored and supervised, since there was no indication of such on the care plan. The Administrator stated that the resident was receiving psychotropic medication behavioral monitoring, but no additional monitoring or supervision was in place for the inappropriate sexual behavior.

Based on record reviews and interviews, it was determined that facility staff failed to 1.) ensure that a tube feeding container was labeled 2.) follow professional standards when caring for a resident who had a change in condition. This deficient practice was evident for one resident (Resident #53) out of 9 residents reviewed for tube feedings during the annual survey and one (#87) resident reviewed for nursing standards during the annual survey.The findings include: 1.)Gastrostomy tube (G-tube) is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube.On 06/04/25 at 07:54 AM, during the initial tour of the facility, Resident #53 was seen sleeping, in bed, with a bottle of enteral feed running at 70 milliliters per hour(mL/hr). The surveyor observed that the enteral feed did not have a name or date on it. The surveyor also observed that the water flush that was up did not have a name or date as well.On 06/04/2025 at 8:12 AM, Registered Nurse #3 was invited for dual observation and confirmed that it was not dated or labeled. When she was asked if the enteral feed and the water flush should have had a name and a date, she stated that it should have been named and dated appropriately. She also added that it would be dated immediately.On 06/04/2025 at 1:15 PM, the surveyor went to observed Resident #53 and discovered that both the enteral feed and the water flush had been labeled.2.) According to the American Nurses Association, nursing documentation must be accurate, timely, and reflect the patient’s condition and care provided. A failure to document an assessment following a change in condition during a nursing shift is inconsistent with these professional standards. A review of complaint intake MD00186830 reveals that a family member reported finding Resident #87 unresponsive during a visit and called 911. The family member reported that staff told them the resident was like that all day. The resident was transported to the hospital for further evaluation. Review of medical records reveals that the resident was admitted to the facility on [DATE]. A baseline care plan was completed and indicated that the resident is alert, cognitively intact, and can make needs and preference know to staff. A review of the nurse’s progress note dated 12/12/22 at 5:31 PM indicated that the resident was alert and responsive to care. Another nurse’s progress note dated 12/13/22 at 12:23 AM also documented that the resident was alert and responsive. Further review of the nursing progress note reveals that the day shift nurse on 12/13/22 failed to document a nursing assessment of the resident. A Physician (MD) #35 progress note dated 12/13/22 at 1:36 PM stated that the resident was seen earlier that day lying on the bed with their feet dangling down and was noted to be confused and disoriented. Laboratory tests were reviewed, and the physician ordered repeat labs in two weeks. A review of the nursing progress note dated 12/13/22 at 3:30 PM indicated that the evening shift nurse entered Resident #87’s room and observed that the resident was unresponsive. The resident’s family who was at the bedside requested that the resident to be transferred to the hospital. The doctor was notified, however, the family member called 911 and the resident was transported to the hospital by paramedics. On 6/11/25 at 9:58 AM, during an interview with MD #35 the surveyor asked about the process for assessing new admission. The MD #35 stated that he reviews the resident's hospital discharge summary and receives a report from the nursing staff. He explained that he completes a physical examination and documents his findings and orders laboratory test and treatment as needed. The surveyor discussed Resident #87 and mentioned that at the time of admission, the resident was documented as alert and cognitively intact. On 06/23/2025 at 5:32 PM, a review of hospital admission notes dated 12/13/22 reveals that at the time of arrival, the resident was noted with altered mental status and was diagnosed with a urinary tract infection and tested positive COVID.

Based on record review and interviews, it was determined that the facility staff failed to provide a resident (Resident #92) with oral care. This was evident for 1 (MD#00206301) of 46 intakes reviewed during the recertification survey. The findings include: On 06/10/2025 at 10:00 AM, a review of confidential complaints reported to the state agency revealed complaint #MD00206301. This complaint alleged that Resident #92 did not receive oral care during their stay at the facility. On 06/10/2025 at 10:20 AM, a review of Resident #92's medical record was conducted. The review revealed that Resident #92 was admitted into the facility with a tracheostomy on 4/3/24 and was discharged to a hospital on 5/31/24. A tracheostomy is a surgical procedure that creates an opening in the neck, called a stoma, through which a tube is inserted into the trachea (windpipe) to provide an airway and facilitate breathing. The review of the care plan failed to mention any intervention for tracheostomy care or oral care. On 06/11/2025 at 9:49 AM, an interview with the Director of Respiratory Therapy (Staff #19) was conducted. When asked whose responsibility it was to provide dependent residents with oral care, Staff #19 stated that Respiratory Therapists (RTs) were responsible and that tracheostomy care also included oral care. Additionally, Staff #19 reported that RTs were required to document oral care provided under progress notes. On 06/11/2025 at 10:00 AM, a review of the respiratory therapist progress notes was conducted. The review of these notes revealed that some respiratory therapists had documented oral care provision while others had not. On 06/11/2025 at 10:20 AM, the Director of Nursing (DON) was asked to provide the facility's tracheostomy care policy. On 06/11/2025 at 11:30 AM, the facility's tracheostomy care policy was received. Review of this policy only revealed the care of the tracheostomy and did not include oral care. On 06/11/2025 at 12:00 PM, the DON was notified of the investigation findings and concerns with the lack of oral care provision to a dependent resident.

Based on record reviews, observation, and interviews, it was determined that the facility failed to have documented evidence to support that the facility provided an ongoing program to support residents in their choice of activities. This was evident for 1 (Resident #73) of 3 resident reviewed for activities during the Medicare/Medicaid recertification survey. The findings include: On 06/04/2025 at 10:12 AM, during a family interview with Resident #73's Responsible Party (RP), when she was asked about the resident's activities, she stated that Resident #73 liked listening to music, but the facility was not offering him/her any activity. On 06/04/25 01:59 PM, this surveyor reviewed Resident #73's care plan goal which showed that he/she would accept/participate in one-on-one visits at least 2 times per week and the care plan intervention showed that the facility would provide one-on-one visits 2-3 time a week gospel music, daily bread, television. On 06/05/25 at 07:32 AM, in an interview with the Activities Director (Staff #8), when she was asked about the activity process for the residents, she stated that she would have assessed the residents upon admission to know their interests. She added that she provided activities to all the residents in the facility and that a one-on-one visit was made for residents that cannot go out of their rooms. When asked how activities were carried out, she stated that activity was usually done for residents who do not get out of their room according to the residents' care plans. On the same day at 07:38 AM, when the Activities Director was asked for the type of activities done with Resident #73, she stated that she plays lots of gospel music for him/her. When asked how often the music was played, she stated that it was played about 2 to 3 times a week and the timing depends on how staff were assigned to the residents on the floor and added that each session was about 15 minutes long. On 06/05/25 at 07:46 AM, the surveyor asked Staff #8 to provide an activity assessment and a copy of the residents' activity log. The required documents were provided at 08:40 AM and upon review, it showed that the resident had only logs for May 2025, this surveyor did not see the activity logs from admission on [DATE]. When Staff 19 was asked about the other logs from the time of admission, she stated that her former assistant had spilled drinks on the logs and had trashed them instead of leaving them out to dry. On the same day at 08:49 AM, further review of May 2025 activity log showed that Resident #73 had only 5 visits in May of 2025 (7th, 15th and 27th) and two times in June (3rd and 5th) so far. When she was asked the reason for the inconsistency, she stated that it was due to her not having enough support staff. On 06/06/25 at 01:46 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were informed of the concerns and the NHA stated that the documents should have been kept even if they were soiled instead of trashing the activity logs.

Based on observations, record reviews, and interviews, it was determined that facility staff failed to ensure a resident wore an arm splint as ordered by the physician. This deficient practice was evident for one (# 11) resident reviewed for position and mobility and 1 (Resident #58) of 2 residents reviewed for range of motion during the annual survey. The findings include: A contracture is an abnormal shortening of muscle tissue causing the muscle to be resistant to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand.1.) On 06/04/25 at 10:21AM, the surveyor observed Resident #11 in bed with bilateral upper extremity contractures. No arm splints were observed on the resident or noted anywhere in the resident's room. On 06/04/25 at 02:00 PM, the surveyor made a second observation of Resident #11. No arm splints were observed on the resident or noted anywhere in the resident's room.A review of Resident #11's Treatment Administration Record (TAR) on 6/5/25 at 8:26 AM indicated a physician order for the resident to wear a right arm splint daily for 6 hours, from 10AM-4PM. Further review of the medical records failed to indicate a reason why the arm splint was not applied. 06/05/25 at 10:45 AM, the surveyor made a third observation of Resident #11. No arm splints were observed on the resident or noted anywhere in the resident's room.During an interview with the Director of Nursing on 06/05/25 at 12:09 PM, the surveyor reviewed Resident #11's TAR for June 2025. The DON confirmed that the resident has an order for right arm splint to be worn daily for 6 hours per day from 10:00 AM-4:00 PM as tolerated. The surveyor informed the DON of the observations. The DON stated that she expects nursing staff to follow the physician's orders. 2.) On 06/04/25 at 10:38 AM, Resident #58 was observed without any splint after morning care.On 06/04/25 at 01:30 PM, a record review of Resident #58's orders was conducted. The review revealed an order that the resident should wear a rolled cloth on the left hand for 10 hours or as tolerated after morning care. Additionally, there was a care plan intervention for usage of splint on the left hand to prevent contractures.On 06/04/25 at 02:17 PM, during an afternoon observation on the unit, the surveyor observed Resident #58 without a splint on the left hand. On 06/06/25 at 03:11 PM, Resident #58 was observed lying on the bed without a splint. This observation was confirmed by Staff #28 who was asked to come to Resident #58's room. When asked if the resident should have a splint on, Staff #28 responded yes. On 06/09/25 at 11:11 AM, the Director of Nursing (DON) was notified of the findings.

Based on record reviews and interviews, it was determined that facility staff failed to ensure a treatment order was in place for a resident with a suprapubic catheter, and 2.) failed to change a resident for extended periods following episodes of incontinence. This deficient practice was evident for two (#4, #47) of two residents reviewed for bowel and bladder incontinence during the annual survey. The findings include: 1.) On 6/4/25 at 11:00PM, during an interview with Resident #4's representative, they expressed concerns regarding the resident's catheter, questioning how often it should be replaced. On 6/6/25 at 8:43AM, a review of Resident #4's treatment administration record revealed a physician's order to change the suprapubic catheter every 28 days and as needed. This order was discontinued on 5/20/25. Further review of the medical record indicated that the resident was discharged to the hospital on 5/19/25 and returned to the facility on 5/22/25. There were no physician orders in place for the suprapubic catheter, although the hospital discharge summary noted the presence of the catheter and recommended it be changed in one month. During an interview with the Director of Nursing (DON) on 6/6/25 at 1:48 PM, the DON stated that it is the responsibility of the admitting nurse to ensure all orders are entered at the time of admission. The surveyor informed the DON that Resident #4 returned from the hospital with a suprapubic catheter, however, there were no orders in place for the catheter. After reviewing the medical records, the DON acknowledged that there were no current orders for the suprapubic catheter. 2.) On 6/4/25 at 8:00 AM, a review of complaint intake MD00210014 revealed the complainant reported that Resident #47 is being left soiled for extended periods of time. On 6/04/25 at 9:18 AM, during an interview with Resident #47, the surveyor discussed allegations noted in intake MD00210012. The resident confirmed that they are often left unchanged for extended periods following episodes of incontinence. The resident also stated that they were last changed on the night of 6/3/25 and as of this morning 6/4/25 they have not been changed. On 6/5/25 the surveyor requested Resident #47's bladder continence Kardex (a quick reference tool used to outline a resident's toileting schedule and incontinence care) for the past 30 days from the Director of Nursing (DON). On 6/6/25 at 6:39 AM, the DON provided the surveyor with Resident #47's bladder continence Kardex from 5/8/25 to 6/5/25. Review of the Kardex for 6/4/25 indicated that the resident had an incontinent episode at 3:34 AM and was changed. The next entry was not documented until 12:14 PM. Further review of the Kardex indicated that the resident experienced extended periods without being changed on the following dates: 5/12/25, 5/17/25, 5/19/25, 5/22/25, 5/23/25, 5/24/25, and 6/3/25. During an interview with the DON on 6/6/25 at 7:34 AM, she explained that incontinence care should be completed prior to the change of shift, and that the geriatric nursing assistants are expected to round on residents every two hours and provide care as needed. The surveyor reviewed Resident #47's bladder continence Kardex with the DON and informed her of dates where the resident had gone extended periods of time with being changed. The DON acknowledged that on the dates mentioned, the resident was not changed in a timely manner.

Based on surveyor observations, review of the medical record, and interview with facility staff, it was determined the facility staff failed to provide residents with respiratory care consistent with professional standards by failing to 1) properly date label oxygen tubing when changed and 2) Change the water in the humidifier. This was evident for 1 resident (Resident #10) out of 9 residents on oxygen reviewed during the Medicare/Medicaid recertification survey. The findings include: On 06/04/25 08:07 AM, during the initial tour of the facility, Resident #10 was seen in bed with nasal cannula and oxygen running at around 2 liters. The oxygen humidifier bottle was dated 04/21/2025 and the nasal cannula tubing had no dates. On 06/04/2025 at 8:10 AM, Licensed Practical Nurse LPN#4 was invited for a dual observation, and she confirmed that the nasal tubing was not dated, and the oxygen humidifier bottle was dated 04/21/2025. When she was asked what the process was after changing nasal tubing, she stated that the normal process should have been to date it. When asked how often the water in the humidifier should be changed, she stated that she did not know and added that the water should not have been left unchanged for that long period of time. 06/04/25 01:39 PM, The DON was informed about these concerns, and she stated that the oxygen humidifier bottle would be changed immediately, and the nasal tubing would also be changed and dated because the last time that it was changed was not known because it was not dated.

Based on medical record review, facility staff written statements and interviews, and review of the hospital x-ray report, it was determined that the facility failed to manage the pain of 1 of 4 residents selected for review. The findings included the following: On 10/3/13, the facility reported a fracture of unknown origin to the Office of Health Care Quality. Resident #4 was noted to have swelling, warmth and pain in her left knee. She was examined and an x-ray revealed a fracture to the distal femur. She was transferred to the hospital for treatment. The distal femur is the part of the thigh bone nearest to the knee. On 10/8/13, 10/9/13, 10/10/13, 10/11/13, 10/15/13, and 10/16/13, the surveyor reviewed the closed medical record, the facility investigation, facility staff written statements as well as interviewed the facility staff. By way of history resident #4 had been admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is the inability to move a group of muscles in one side of the body. Resident #4 was totally dependent on the facility staff with the support provided by one person for bathing, bed mobility, dressing, locomotion off and on the unit, personal hygiene, toileting, and transfers. The surveyor interviewed geriatric nursing assistant (GNA) #17 and nurse #16 on 10/9/13 at 9am and 8:30am, respectively. Their written statements dated 9/26/13 and 10/9/13, respectively, were also reviewed. On 9/25/13 at around 2am, according to GNA #17, the resident complained of pain in her left leg which worsened when she was repositioned or provided incontinent care. GNA #17 reported the complants of pain to nurse #16. The resident continued to receive care including turning, positioning, and incontinent care the remainder of the night shift (11pm-7am), per the medical record, interviews and statements. She continued to have pain in her left knee. The facility failed to provide pain management for the resident. The surveyor interviewed GNA #3 and nurse #7 on 10/8/13 at 2:30pm and 2:40pm, respectively. Their written statements dated 9/27/13 and 10/9/13, respectively, were also reviewed. On 9/25/13 at around 9am the resident had swelling, warmth and pain in her left knee, according to the medical record, written statements and interviews with GNA #3 and nurse #7. Sometime after 9am, the physician was notified, came to the facility, aspirated fluid from the resident ' s left knee, ordered an x-ray to rule out a fracture, and ordered pain medication. The pain medication ordered for the knee pain included [MEDICATION NAME] 500 milligrams (mg) twice per day for three days and [MEDICATION NAME] 5/325 mg every 8 hours as needed for pain for one week. The resident continued to receive care including turning, positioning, and incontinent care the remainder of the day shift (7am-3pm), per the medical record, interviews and statements. In addition she had fluid aspirated from her left knee. She continued to have pain in her left knee. The facility failed to provide pain management for the resident; they failed to administer the medications prescribed for her knee pain. The surveyor interviewed GNA #13 on 10/10/13 at 8:30am. Statements written by GNA #13 and nurse #10 written on 10/9/13 were also reviewed. On 9/25/13 during the evening shift (3pm-11pm) resident #4 was described to have pain in her left leg. The pain worsened with touching or movement. At around 4pm GNA #13 was told by nurse #10 not to shower the resident due to the pain in her left knee and the pending x-ray. The GNA described the resident having pain which worsened during her bed bath and incontinent care. GNA #13 stated that she reported resident #4's pain to nurse #10. At 7pm, nurse #10 noted in the medical record that the resident's left knee was x-rayed. The X-ray results noted that the study was limited due to the resident ' s " pain and immobility " . At 11:10pm, nurse #10 noted that the left knee was swollen and warm to the touch. The resident continued to receive care including turning, positioning, and incontinent care the remainder of the evening shift, per the medical record, interviews and statements. In addition her left knee was manipulated during an x-ray. She continued to have pain in her left knee. The facility failed to provide pain management for the resident; they failed to administer the medications prescribed for her knee pain. The surveyor interviewed GNA #17 and nurse #16 on 10/9/13 at 8:30am and 9am, respectively. Their written statements dated 10/9/13were also reviewed. During the night shift (11pm-7am) from 9/25/13-9/26/13 the resident was described to be in pain and distress when touched, and during turning, positioning and incontinent care, according to GNA #17. On 9/26/13 at 1:11am, according to the radiology report the resident had a distal left femoral diaphyseal fracture with moderate displacement. A diaphyseal fracture is a fracture along the shaft of the bone and displacement indicates that the fractured bones have separated. At 6am, nurse #16 noted on a pain evaluation that the resident had pain evidenced by facial grimacing and holding her left knee. He indicated that the knee was elevated and a warm pack was applied. However, the nurse failed to administer the pain medications ordered for resident #4's knee pain. At 7am, nurse #16 notified the physician of the diagnosed fracture and the resident was to be transferred to the hospital for treatment. The resident continued to receive care including turning, positioning, and incontinent care the remainder of the night shift, per the medical record, interviews and statements. She continued to have pain in her left knee as noted by facial grimacing and holding her knee. The facility failed to provide pain management for the resident; they failed to administer the medications prescribed for her knee pain. At 10:30am, the ambulance arrived, the resident's left leg was immobilized and she was transferred to the hospital. At 2:06pm, according to the hospital x-ray report, resident #4 had an oblique fracture through the shaft of the distal femur with significant angulations and displacement. An oblique fracture means the break is slanted. Angulation and displacement describe placement of the bones; they have separated and are at an angle to one another. The facility failed to manage the resident's pain.

Based on medical record review, interviews with facility staff and residents, it was determined that the facility failed to: 1. Consistently monitor pain management; 2. Maintain written orders for narcotics prior to administration; 3. Obtain narcotics ordered for severe pain from the pharmacy; 4. Document administration of pain medication as ordered and; 5. Maintain an accurate list of residents on pain management. This was evident for 6 of 10 residents selected for review. The findings included the following: 1. The facility failed to consistently monitor pain management a. Resident #1 had left leg pain as a result of a fracture and surgery. On 12/3/13 at 2:30 p.m., the surveyor and the director of nursing (DON) interviewed the resident. She held her right hand in a clenched fist and described pain in her left leg. The DON and the surveyor then interviewed the charge nurse, nurse #4. She stated that she had administered pain medication to the resident at about 12:30 p.m. The resident had an order for [REDACTED]. At 2:45 p.m., the resident received a onetime dose of [MEDICATION NAME] for pain in her left leg. The back of the MAR failed to note the effectiveness. The pain assessment tool for that day, 12/3/13, noted " 0 " on the day and evening shift for pain, although resident #1 had described having leg pain and received a onetime dose of [MEDICATION NAME]. On 12/5/13, per interview with the assisting administrator, the medical director had ordered a pain consult for resident #1 and the primary physician had ordered [MEDICATION NAME] 15 milligrams twice per day as well as [MEDICATION NAME] 5/325mgs every 6 hours as needed. The [MEDICATION NAME] was to be used for breakthrough pain. On 12/6/13, the pain consultant ordered an increase in the [MEDICATION NAME] to every 8 hours. Later that day there was a note on the physician order [REDACTED]. On 12/10/13, the surveyor interviewed the assisting administrator. She stated that the primary physician had decided he did not want the resident to receive the medication ordered by the pain consultant and that the facility staff was going to contact the Medical Director for clarification; this was 4 days after the consultant had recommended an increase in resident #1's pain medication. From 12/5/13 until 12/9/13 at 5 a.m., the time frame after the primary physician had changed he resident ' s pain regime to include [MEDICATION NAME], the resident had received [MEDICATION NAME] for breakthrough pain 8-9 times. An accurate number of times the medication was administered were unclear due to illegible/incomplete documentation on the front and back of the MAR indicated [REDACTED]. b. Resident #3 had orders to treat the pain in his lower limbs. On 12/3/13, the surveyor reviewed resident #3 ' s medical record and interviewed nurse #5 and the assisting administrator. Resident #3's December 2013 MAR indicated [REDACTED]. The facility failed to consistently reveal accurate times of administration, reason for administration, and effectiveness. On the front of the [DATE]/1/13 noted administration at 3 p.m., but no initial to identify the nurse. On 12/3/13 at an unknown time there was a nurse ' s initial in the box. On the back of the MAR indicated [REDACTED]. On 12/3/13 at 1:30 p.m., the surveyor and the assisting administrator interviewed the nurse, #5, about her initials on the MAR. She stated that she had given the resident [MEDICATION NAME] that morning at " about 10am " . She then pulled out a small crumpled receipt from the controlled box and held it up to show them. The controlled box contains narcotics that are not available for the resident in the identified medication cart. 2. The facility failed to have a written order for a narcotic prior to administration. Resident #3 was treated with [MEDICATION NAME] for limb pain by the facility staff without a written order. On 12/3/13, the surveyor reviewed resident #3's medical record, MAR, and the medication list from the pharmacy. The December 2013 MAR indicated [REDACTED]. Review of the POS [REDACTED] At 2 p.m. during surveyor interview, the DON stated that after she had reviewed the medical record and interviewed the staff she discovered that he nurse had not transcribed the [MEDICATION NAME] order on the POS. The staff administered the [MEDICATION NAME] to the resident without a written order; this was confirmed by the DON. 3. The facility failed to obtain a narcotic ordered for severe pain from the pharmacy. Resident #4 had orders for treatment of [REDACTED]. On 12/3/13, the surveyor reviewed the resident's medical record. On 11/26/13, the resident had orders to receive [MEDICATION NAME] immediate release (IR) 15 milligrams for severe back pain. She also had orders for [MEDICATION NAME] 10 mgs twice per day and [MEDICATION NAME] IR 10 mgs every 4 hours for mild pain. At 1:45 p.m., the surveyor along with the DON looked in the narcotic book and box for the prescribed medication. There was not a narcotic sheet for the [MEDICATION NAME] IR 15 milligrams and it was not in the narcotic box. Further review of the pain assessment sheet on 12/10/13 revealed that in December the resident was noted to have pain on a scale of 1 - 10 at a level of " 8 " on 12/6/13 on the day shift and on 12/1/13 and 12/2/13 on the evening shift. Review of the MAR indicated [REDACTED]. The facility failed to maintain a narcotic ordered for severe pain. 4. The facility failed to administer the resident ' s medication as ordered. a. Resident #8 was on medication for generalized pain. On 12/6/13, the resident was ordered to receive [MEDICATION NAME] 5 milligrams every 6 hours as needed for pain. Review of the back of the resident ' s MAR indicated [REDACTED]. 5. The facility failed to maintain an accurate list of residents on pain management. On 12/3/13, the surveyor requested a list of resident ' s on pain management for the follow up survey review. The DON provided a list of residents on pain management printed that day from the pharmacy. Residents #5 and #7 were on the list and had not been in the facility since 11/16/13 and 11/6/13, respectively. Resident #1 was on a narcotic regime for pain management and was not on the list. This was the only list of residents on pain management provided to the surveyor and it was inaccurate.

Based on medical record and facility investigation review, as well as interviews with facility staff, it was evident that the facility staff failed to adequately supervise the resident's placement in bed during direct care. This resulted in the resident rolling from the bed sustaining a laceration to the left eyebrow, receiving medication for pain, and being transferred to the hospital for evaluation. This was evident for 1 of 6 residents selected for review.The deficiency is past non-compliance and no plan of correction is required. The findings included the following. The standard of practice is to ensure that when a resident is turned the resident is positioned safely in the center of the bed. On [DATE], the Office of Health Care and Quality received a complaint from resident #3's responsible party. The complaint allegation was that on ,[DATE]/ 2010, a nursing assistant at the facility "pushed or dropped" the resident on the floor. The complainant went on to describe an injury which led to a hospitalization . The resident was no longer in the facility, so the surveyor could not observe or interview the resident. On [DATE], the surveyor reviewed the resident's closed medical record and the facility investigation information. The resident was admitted to the facility on [DATE] and expired on [DATE]. By way of history resident #3 had been in the hospital prior to facility admission, from [DATE]-[DATE]. Her final [DIAGNOSES REDACTED]. Her condition on discharge noted a left upper extremity contracture. On [DATE], her admission physician orders [REDACTED]. The complainant was listed as the responsible party in the medical record. Her minimum data set,MDS, noted that she was dependent on the facility staff for provision of activities of daily living. On [DATE], her physician orders [REDACTED]. The orders further noted that she was to be comfort care until evaluated by hospice. On [DATE] at 2:15 PM, the hospice nursing assessment noted that the resident had pain in the left shoulder. She was described to reach for her shoulder and sometimes "groan". Her pain medication regimen was for Tylenol 650 mg every 6 hours as needed. She was also noted to be "bed bound". She was admitted to hospice and her physician orders [REDACTED]. On [DATE] at 8:00 PM, according to the facility occurrence report, geriatric nursing assistant (GNA) #4 was bathing the resident and turned around to wet the towel and resident #3 fell and hit her head against the bedside table. The resident was "bleeding from her left eyebrow". The nurse noted that she applied a pressure dressing and called 911 and resident #3 was transferred to the hospital. At 8:42 PM, the physician orders [REDACTED]. The surveyor reviewed the 2 statements provided by the facility staff, written by the GNA that was rendering care at the time of resident #3's fall: 1. On [DATE], 3 PM-11 PM shift, GNA #4 wrote that he was cleaning the resident at 8:40 PM turned around to wet the towel and "saw" the resident "fallen" from the bed. He wrote that he supported her but she hit her head against the bed side table. He then called the nurse and informed him. 2. On [DATE], 3 PM-11 PM shift, GNA #4 wrote an addendum to his statement. The addendum noted that he tried to provide support to prevent the resident from falling. Howeve,r the resident's weight was too much and she was lowered to the floor and in the process hit her forehead against the bed side table. He then went to get the nurse. It should be noted that on [DATE], the acting director of nursing provided the surveyor with a copy of an in-service for GNA #4, dated [DATE]. It reviewed the use of proper body mechanics, procedures for turning and repositioning residents, and transfer techniques. The need to turn residents toward the staff and not to turn residents away from them while performing turning and repositioning care and that supplies were to be gathered prior to rendering care were reviewed in writing with the GNA. According to the medical record, the resident was hospitalized from [DATE]-[DATE] following the fall. The hospital discharge summary report noted that the resident was hospice on the day of admission. Her [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. The resident's hospital course noted that she was started on intravenous antibiotics, hydration and admitted - initially- to the Intensive Care Unit. She was treated with "aggressive" hydration. The closing paragraph of the discharge summary noted that in view of the residents current history of having been admitted to the nursing home and put on hospice, with correction of the initial electrolytes, it was deemed that she could return to the nursing home and the family would be contacted to decide about placing her 'back under hospice". On [DATE], the physician's orders [REDACTED]. On [DATE], her morphine was changed to routine every 4 hours instead of as needed. On [DATE], the resident passed away. The resident was noted to be totally dependent on the facility staff. The GNA failed to position the resident properly which resulted in a fall and laceration as well as a hospitalization during the last 2 weeks of end of life care.