Every finding on record at Autumn Lake Healthcare at Calvert Manor

Based on interviews and resident record review, it was determined that the facility failed to prevent an avoidable accident with injury to Resident #15 during a transfer from the wheelchair to the bed. The facility failed to implement interventions, including adequate supervision that was consistent with the resident's needs, care plan and current professional standards of practice to reduce the risk of an accident. As a result, Resident #15 suffered a fall with harm (femur fracture). This was evident for 1 (#15) of 3 residents reviewed for accidents during the recertification survey. The findings include:A sit-to-stand lift is a specialized mobility device designed to help individuals with limited leg strength safely transition from a seated position to a supported, standing posture. It allows caregivers to easily transfer a patient between two seated surfaces, such as moving from a bed to a wheelchair, or from a chair to a toilet.To ensure quality care and accurate reimbursement, Centers for Medicare and Medicaid Services (CMS) mandates the use of the Minimum Data Set (MDS), which is a comprehensive clinical assessment tool used for all residents. The Brief Interview for Mental Status (BIMS) is a specific cognitive screening test conducted within Section C of that broader MDS assessment. Based on the interview performance, residents receive a score where 13 to 15 points indicates they are cognitively intact, while 8 to 12 points signifies moderate impairment.On 5/18/2026 at 9:30 AM, Resident #15 was interviewed during the initial screening process of the recertification survey and stated they had a fall in January 2026. The fall resulted in them having to go to the hospital where they were told they had fractured their leg. Resident #15 stated that they believe their bed was too high and their legs were not secured in the sit-to-stand lift when transferring from their wheelchair to their bed. Resident #15 stated they had to wear a leg brace for a month and a half and cannot use their left leg as well as before fall. Resident #15 stated it was a Geriatric Nursing Assistant (GNA) using the sit-to-stand lift during the fall and named GNA #25. Resident #15's medical record was reviewed on 5/19/2026 at 10:19 AM. Resident #15 was admitted to the facility on [DATE] with a BIMS score of 14 on their MDS dated [DATE]. Per medical record documentation, the fall occurred on 1/19/2026. Review of Resident #15's care plan prior to the fall showed, Transfer-Stand-up Lift with 2 Assist was initiated on 12/6/2022 and revised on 9/2/2025. Review of the resident's Kardex dated 1/19/2026 showed Transferring: Transfer-Stand-up Lift with 2 Assist.A progress noted dated 1/19/2026 at 5:55 PM stated, status post fall with left limb shortened and externally rotated. Patient stating pain 10/10 on assessment. Transferred to Emergency Department for further evaluation. Care plan reviewed. All interventions current and appropriate, will continue. The discharge summary from the hospitalization was reviewed and showed Resident #15 was diagnosed with an acute left distal femoral fracture. On 5/19/2026 at 1:53 PM, the facility's Handling and Transfer policy was reviewed. Under Compliance guidelines section 4 it stated, Mechanical lifts may include equipment such as full body Hoyer lifts or sit to stand lifts. Under section 10 it stated, Two staff members must be utilized when transferring residents with a mechanical lift.On 5/20/2026 at 1:35 PM, the facility's internal incident report dated 1/19/2026 at 5:20 PM was reviewed. Under Nursing Description it stated, Witnessed fall in room during transfer with sit-to-stand device. Resident was in sit to stand device in standing position. [Resident #15] became unable to support [themselves] and began sliding downward. Nurse and GNA present lowered [them] to the floor, one staff supporting head. Noted to have shortened left limb with outward rotation. Additional review of the incident report did not identify staff members involved. Resident #15 and their roommate (Resident #45) were interviewed on 5/20/2026 at 9:46 AM. Resident #45 had a BIMS of 12 on their MDS with Assessment Referral Date (ARD) of 11/11/2025. Resident #15 stated there was only one staff member (GNA #25) in the room when they fell during transfer. Resident #45 confirmed that there was only one staff member in the room at the time of the fall. Both residents stated that a Registered Nurse (RN) came into the room after the fall. Resident #15 stated that the RN that came in was RN #23.On 5/20/2026 at 12:00 PM, the staffing assignment for 1/19/2026 was reviewed. GNA #25 and RN #23 were assigned to Residents #15 and #45 on 1/19/2026 for the 3-11 PM shift. During an interview on 5/21/2026 at 10:43 AM, GNA #25 stated that they were the GNA assigned to Resident #15 during the fall. The GNA stated they were assisting the resident using the sit-to-stand lift to transfer between Resident #15's wheelchair and their bed when the resident was unable to hold their stance and started to slide downward. GNA #25 stated that they initiated the lift transfer by themself and were the only staff member in the room prior to the resident starting to fall. On 5/22/2026 at 10:25 AM, the Director of Nursing (DON) was made aware of surveyor concerns regarding Resident #15's fall and lack of a 2 person assist during the transfer process using the sit-to-stand lift. The DON stated this is the first time they have heard that only one staff member started the transfer process, and stated that it's the facility's expectation that the transfer would be conducted by two staff members per facility policy.

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to maintain nutrition room refrigerators in a sanitary manner as evidenced by the facility failing to maintain safe cold-storage temperatures and failing to discard expired resident food. This was found to be evident in 1 (South Unit) of 2 unit nutrition rooms observed. This deficient practice created the potential for foodborne illness.The findings include:On 05/18/2026 at 1:38 PM, the South Unit nourishment room refrigerator was observed. The thermostat inside the refrigerator read 50 F. The May temperature log was observed not to be filled out on dates 5/8, 5/10, 5/13, and 5/17.On 05/19/2026 at 9:23 AM and 12:09 PM, consecutive follow-up observations confirmed the temperature remained at 50 F.On 05/19/2026 at 12:56 PM, an audit of the refrigerator contents revealed the following expired and unlabeled items:1) A To Go food container for room [ROOM NUMBER]B dated 5/9/2026 (10 days old).2) An egg salad sandwich for room [ROOM NUMBER]A dated 5/9/2026 (10 days old).3) A To Go container with food for room [ROOM NUMBER]-B dated 5/13/2026 (6 days old).4) [NAME] Callender's Macaroni and Cheese meal stored in the refrigerator instead of the freezer, which lacked a name and date label.On 05/19/2026 at 12:48 PM, a review of the facility's Outside Food Policy was conducted. The policy stated: The prepared food must be consumed by the residents within 3 days of the labeled date.On 05/19/2026 at 2:00 PM, the Director of Nursing (DON) joint-reviewed the South Unit nourishment refrigerator with the surveyor. The DON confirmed the thermometer read 50 F, the temperature log was incomplete, and items exceeded the 3-day storage policy. The DON stated staff would immediately discard the outdated food items and contact maintenance to service the refrigerator.

Based on observations and staff interviews, it was determined that the facility failed to ensure that the residents' call bell system was functioning properly as evidenced by the call bell system monitor being turned off at the nurses' station. This was evident for observations of the North 1 Unit environmental tours during the recertification survey. The findings include: On 05/19/26 at 10:20 AM, the surveyor activated a call bell and observed that there were no audible or visual notifications of the request viewable from the nurses' station. On 05/19/26 at 10:21 AM, LPN #16 was interviewed. She verified that the call bell system monitor by the nurses' station was not on. LPN #16 attempted to power on the call bell system monitor, however the monitor displayed an error message reading no signal. She revealed that the night shift staff regularly turned off the call bell system due to the high volume. On the morning of 05/20/26, the surveyor observed that the call bell system was still turned off.On 05/20/26 at 10:52 AM, the surveyor interviewed the Director of Facilities and Maintenance Aid #19. The Director of Facilities confirmed surveyor observations that the call bell system monitor was turned off and confirmed that the call bell system should be on at all times. The surveyor observed the Director of Facilities restart the call bell system monitor. Maintenance Aid #19 stated that the night shift staff have been turning the system off.

Based on observation and staff interviews, it was determined that the facility failed to maintain resident's right to a dignified existence as evidenced by clothing labeled with the resident's name visible from the outside. This was evident for 1 (Resident #84) of 2 residents investigated for dignity.The findings include:On 05/19/26 at 9:53 AM, the surveyor observed Resident #84 sitting in the hallway with their name labeled on the top surface of both socks. Geriatric Nursing Assistant (GNA) #26 was interviewed on 05/21/26 at 8:46 AM. During the interview, GNA #26 revealed that resident clothing is tagged for laundry. Interview with the DON on 05/21/26 at 9:05 AM confirmed that laundry services label residents' clothing with their names.

Based on observations and interviews, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean, sanitary, and safe environment. This was evident for 1 of 4 units (North 1) observed during environmental tours in the facility.The findings include:Emergency pull cord is a safety device that is triggered by pulling a cord to alert staff that a resident has fallen or needs immediate help. The cord should end near the floor ensuring a resident can reach it if they fall.A medicine cup with pink colored fluid was observed on the windowsill in the women's shower in North 1 on 05/18/26, 05/19/26, and 5/20/26. The Director of Facilities was made aware and the medicine cup was removed by Environmental Supervisor #18 on 05/20/26 approximately at 11:00 AM. On 05/18/26 surveyors also observed on unit North 1: There was no emergency pull cord by 1 of the women's toilets. The emergency pull cord in the women' s shower and men's toilet did not reach the floor.A wall-mounted hand sanitizer dispenser in the hallway was not coveredThe hallway walls were damaged with missing pain, cuts, dents, and scuff marks.The surveyor interviewed the Director of Facilities on 05/20/26 at 10:52 AM. During the interview the Director of Facilities acknowledged that the emergency pull cord in the women's shower and men's toilet could not be reached by a resident from the floor. He confirmed that the women's toilet did not have an emergency pull cord.On 05/20/26, the surveyor interviewed Environmental Supervisor #18 with the Director of Facilities present. Environmental Supervisor #18 stated that shared areas including the bathroom and showers were cleaned daily. Her statement was confirmed by the Director of Facilities.On 05/21/26 at 8:46 AM, the surveyor observed a brown stain on the privacy curtain in Resident #47's room. The DON was notified on 05/21/26 about the observed stain on the curtain. On 05/22/26, the DON confirmed that the stained curtain was replaced with a clean curtain.

Based on interviews, review of complaint #2719958, and medical record review, it was determined that the facility failed to ensure a grievance resolution was implemented and maintained as evidenced by the facility failing to enforce a resolution preventing Registered Nurse (RN) #23 from providing care to Resident #12 after a grievance resolution mandated RN #23 would not provide care to the resident. This was found to be evident in 1 (Resident #12) of 1 resident reviewed for grievances.The findings include:During telephone interview with Resident #12's family member on 5/20/2026 at 10:03 AM, the family member stated a grievance was filed with the facility in December 2025 regarding the care received by their family member (Resident #12) by RN #23. The family member stated that they had complained to the facility multiple times regarding RN #23 and stated that the resolution to the grievance filed in December 2025 was that RN #23 was not to provide care to Resident #12 in any capacity. On 5/20/2026 at 10:45 AM, review of the grievance showed it was initiated by the facility on 12/31/2025 at 4:30 PM. Under Corrective Action it stated, Nurse named in compliant is aware that he is to not treat resident per [daughter] request (routine care). The decision issued was dated 1/5/2026 on grievance form and was signed by the facility's Social Worker (SW) #22.On 5/22/2026 at 7:25 AM, Resident #12's medical record was reviewed. Under Resident #12's Medication Administration Record (MAR) and Treatment Administration Record (TAR), RN #23 had documented medication administration and/or assessments of Resident #12 on dates 1/9/2026, 1/19/2026, 2/8/2026, 2/12/2026, 4/23/2026, and 5/20/2026.Review of staffing assignment sheets on 5/22/2026 at 8:14 AM showed that RN #23 was assigned care of Resident #12 on 1/9/2026, 1/19/2026, 2/8/2026, 2/12/2026, 4/23/2026, and 5/20/2026. Additional review of Resident #12's medical record including the care plan did not show documentation that Resident #23 was not to provide care to Resident #12.On 5/22/2026 at 10:00 AM, the original copy of the grievance maintained by the facility filed on 12/31/2025 was reviewed and confirmed under Corrective Actions that RN #23 was not to provide care to Resident #12 and the decision was dated 1/5/2026.On 5/22/2026 at 10:15 AM, surveyor concerns were addressed with the Director of Nursing (DON) and SW #22. Both staff members confirmed that the grievance resolution was that RN #23 was not to provide care to Resident #12. The staff members stated they believe RN #23 was verbally made aware of not being allowed to care for the resident. The DON stated they were under the assumption that RN #23 was not providing care to Resident #12 since the date (1/5/2026) of the grievance resolution.

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP). This was evident for 1 (Resident #14) out of 50 residents reviewed during the facility's recertification survey.The findings include:A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and current medication list must be given to the resident and/or RP and there must be evidence in the medical record that it was provided. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission.On 5/21/26 at 8:56 AM in an interview with the Director of Nursing (DON) when asked about the facility's process for BLCP's she stated there was a BLCP assessment that was completed. During the interview, she stated, We print a copy of it and their med (medication) list and give to the resident and/or family. When asked where it was located, she stated, Evaluations tab and a progress note saying a copy was provided. On 5/19/26 at 9:11 AM review of Resident #14's medical record revealed he/she was admitted to the facility on [DATE]. Further review of the medical record revealed a BLCP; however, failed to reveal evidence from the medical record that a copy was given to the resident and/or RP. Continued review revealed the AUTM Baseline Care Plan - V 4 and on the final page was SECTION 7. BLCP Summary and Signatures. Review of this section failed to reveal a signature in the field titled Signature of Resident and Representative. Additionally, there was no progress note that mentioned providing a BLCP to the resident and/or RP. On 5/21/26 at 12:50 PM in an interview with the DON interview, the surveyor shared the concern that for Resident #14 there was no signature on the BLCP assessment or any other evidence from the medical record that the resident/RP received it. The DON stated she would check if there was a progress note documenting that the resident/RP received the BLCP. On 5/21/26 at 1:56 PM in an interview with the DON when asked about evidence from the medical record that Resident #14 and/or his/her RP received the BLCP, she stated, I cannot find that. The surveyor shared this was a concern. The DON acknowledged understanding of the concern.

Based on medical record review and resident and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 of 32 (#25) residents reviewed during the survey process. The findings include:The Minimum Data Set (MDS) is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.In an interview with Resident #25 on 05/19/2026 9:40 AM , when Resident #25 was asked about their care, they stated that the only concern they had was that theyd didn't get a shower on most Tuesdays. The resident stated they were scheduled for a shower on Tuesdays during day shift and Fridays during evening shift. The resident stated that they consistently got their shower on Friday but rarely got it on Tuesday.Review of Resident #25's most recent MDS completed on 5/19/26 revealed that s/he is totally dependent for bathing requiring extensive assistance for all Activities of Daily Living (ADL). The Brief Interview for Mental Status (BIMS) revealed a score of 15 indicating adequate cognitive ability. Further review of Resident #25's shower schedule which is every Tuesday and Friday, as well as the Geriatric Nursing Assistant (GNA) task documentation of Activity of Daily Living (ADL) revealed that for Resident #25 from 4/1/2026 until 5/20/2026, only received shower on 8 out of the 14 days they were to receive a shower. On 5/21/2026 at 9:40 AM, the Director of Nursing (DON) was made aware of this concern and was unable to explain why this had occurred.

Based on observations, record review, and staff interview, it was determined that the facility failed to follow a doctor's wound care order. This was evident for 1 (Resident #47) of 50 residents reviewed in the investigation phase of the survey.The findings include:ACE bandage: a stretchable cloth used to provide adjustable pressure and support for muscle sprains, strains, and swelling.On 05/18/26 at 8:32 AM, the surveyor observed Resident #47's left lower leg wrapped in an ACE bandage.Resident #47's medical record was reviewed on 05/20/26 at 9:38 AM. The review revealed a doctor's order to discontinue ACE bandage wrap to left leg for gentle compression effective 05/15/26. On 05/20/26 at 10:40 AM, the surveyor observed Resident #47's left lower leg wrapped in an ACE bandage.On 05/21/26 at 9:00AM, the Director of Nursing (DON) was interviewed. During the interview, the DON confirmed that there were no active ACE bandage wrap orders for Resident #47's left leg after 5/16/26.

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to monitor and follow physician orders to obtain a resident's weight. This was evident for 1 (Resident #14) of 4 residents reviewed for nutrition during the facility's recertification survey. The findings include:On 5/19/26 at 9:11 AM review of Resident #14's medical record revealed he/she was originally admitted to the facility on [DATE]. Further review revealed that on 4/27/26 he/she was identified as Malnourished on his/her admission nutritional assessment. Continued review revealed the following physician order, Weigh resident weekly x4 weeks, then monthly if stable which was ordered on his/her admission date, 4/27/26. Review of Resident #14's weights revealed he/she was weighed three times since admission. On 4/27/26, the resident weighed 166 pounds, 4/28/26 weighed 161 pounds, and on 5/1/26, the resident weighed 161.2 pounds, which is a 2.89% loss in less than a week. According to the State Operations Manual (2025), 5% weight loss in 1 months' time is considered Significant Loss with regards to a resident's weight.On 5/19/26 at 10:16 AM review of Resident #14's medical record revealed an assessment, AUTM Nutrition Evaluation - V 2 dated 5/4/26. Continued review revealed the following questions and responses documented by the Registered Dietician (RD #33):Is there an actual or potential Nutritional Problem? Yes= varied intakes, impaired skin integrityIs there an active Nutrition Problem identified? YesNutrition Interventions: Monitor wts (weights), intakes & labs as availableOn 5/22/26 at 8:51 AM in an interview with RD #33 when asked about her role in the facility regarding residents' weight loss, she stated she reviewed their weights to see who triggered for weight loss. During the interview she stated that nursing staff should reweigh a resident if there was a 5 pound weight change. Additionally, she stated, Sometimes I have to remind nursing to reweigh. When asked if she monitored residents' weights, she stated, Yes, I can't say daily, but weekly. It's an ongoing process. When asked how she monitored the residents' weights, she stated by going into PCC (Point Click Care, the electronic medical record) and reviewing their weights. When asked how she knew if a resident had lost weight, she stated by reviewing their weights and I have a weight log that I use because I know PCC looks for any in between weights (and clarified in between to mean not just monthly weight loss but in between each month). When asked to explain the weight log she stated it was an excel program she used to plug in and monitor residents' weights. During the interview when asked if when she logged into PCC there was a dashboard that notified her of residents who had lost weight she stated yes. When asked once PCC had triggered a resident with weight loss, what were her next steps, she stated, I will go in and do a review to assess their intakes, weights, diet, skin, and labs. Then I go visit the resident to see what was going on during the time frame they would have triggered. When asked if the facility held any meetings where weight loss was discussed, she stated, We have our weekly Risk meetings where weight loss is discussed and our morning clinical meeting where weight loss is also discussed. When asked if Resident #14 was at risk for impaired nutritional status, RD #33 stated, Well, we consider everyone at risk. When asked if Resident #14 was discussed in any of the risk or morning clinical meetings for weight loss, she stated, No, not specifically as a weight loss. When asked if she was monitoring Resident #14's weights weekly, she stated, I cannot say I looked specifically at them. The surveyor shared the concern that there were no weights obtained for Resident #14 past his/her first week of admission to the facility. The resident was not weighed on 5/4/26, 5/11/26, or 5/18/26 as per the physician order. RD #33 acknowledged understanding of the concern.The surveyor then shared the concern that on Resident #14's admission nutritional assessment he/she was identified as Malnourished, in less than one week he/she lost 2.9% of his/her body weight, that in her 5/4/26 nutrition evaluation she documented Resident #14 as malnourished, noting weight loss from his/her admission [DATE]) to 5/1/26 of 166 pounds to 161.2 pounds, documented there was an actual or potential nutritional problem, and in the nutrition interventions section documented that she would be monitoring the resident's weights; however, she failed to monitor the weights as confirmed and verified by her interview. RD #33 acknowledged understanding of the concern. The facility policy, Weight Monitoring, was reviewed on 5/22/26 at 11:37 AM. The review revealed, Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a) Identifying and assessing each resident's nutritional status and risk factors, b) Evaluating/analyzing the assessment information, c) Developing and consistently implementing pertinent approaches, d) Monitoring the effectiveness of interventions and revising them as necessary. Further review revealed, Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.On 5/22/26 at 9:24 AM in an interview with the Director of Nursing (DON) when asked about the process for new admissions regarding weight, she stated, that residents were weighed within the first 24 hours of admission and then they should be weighed weekly x 4 [weeks] as long as their weight was stable. When asked who was responsible for entering the weights into PCC, she stated typically the nurses. When asked if the nurses or whomever entered the weights into the system were immediately able to see if the resident had lost weight, she stated yes, it would be flagged. When asked what happened when weight loss was noted, she stated the resident would be reweighed, typically the same shift or sometimes the next day. When asked whose responsibility it was to monitor residents' weights, she stated, Historically it's always been the dietician who keeps an eye on weights and weight losses/gains, but everyone should be involved. The surveyor shared the concern that RD #33 was not monitoring Resident #14's weights as verified and confirmed in her interview nor was the resident being weighed as per the physician order. The DON acknowledged understanding of the concern.

Based on observations, medical record review, policy review, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards and facility policy related to oxygen administration and nebulizer care. This is evident for 2 (Residents #3 and #47) of 6 residents reviewed for respiratory care during the recertification survey.The findings include: Supplemental oxygen: a medical treatment that delivers concentrated oxygen to individuals who cannot get enough through normal breathing. Flow rate: the amount of supplemental oxygen delivered per minute, typically measured in Liters Per Minute (LPM). Humidifier bottle: a bottle of sterile, distilled water that adds moisture to continuous-flow oxygen therapy to prevent dry, irritated, and bleeding nasal passages. Nasal cannula: a thin, flexible plastic tube that delivers supplemental oxygen directly into the nose. A nebulizer is a medical device that transforms liquid medication into a fine, breathable mist. Patients inhale this mist through a mouthpiece or face mask to deliver treatment directly into their lungs and airways. 1. On 05/18/26 at 8:35 AM and 05/19/26 at 9:58 AM, the surveyor observed Resident #47 receiving supplemental oxygen through a nasal cannula at a flow rate of 3 liters per minute (LPM). The nasal cannula was not labeled or dated. The humidifier bottle was dated 05/14/26. On 05/20/26 at 8:38 AM, Resident #47's medical record was reviewed. The record revealed a physician order effective 01/28/26 directing staff to change oxygen tubing and humidification bottle every Wednesday during the 11-7 shift and to date and initial the equipment when changed. The medical record also revealed an active physician order for oxygen at 2 LPM via nasal cannula beginning 02/24/26. On 05/20/26, the facility policy titled Oxygen Administration dated 10/27/25 was reviewed. The policy stated, Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated, and Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Licensed Practical Nurse (LPN) #16 was interviewed on 05/20/26 at 10:37 AM. LPN #16 verified that facility policy required oxygen tubing and humidifier bottles to be changed weekly during the 11-7 shift and dated and initialed when changed. LPN #16 stated nursing staff were responsible for reviewing physician orders to determine the scheduled change day. During a joint observation with the surveyor, LPN #16 confirmed the oxygen tubing was not labeled, the humidifier bottle was dated 05/14/26, and the oxygen flow rate was set at 3 LPM. On 05/21/26 at 8:40 AM, the surveyor observed Resident #47's nasal cannula dated 05/21/26; however, the humidifier bottle remained unlabeled and the oxygen flow rate was set at 2.5 LPM. 2. On 05/18/26 at 12:34 PM, Resident #3's nebulizer machine was observed on the bedside table with an attached nebulizer face mask. No label with date or time was observed on the nebulizer machine or nebulizer mask to indicate when the equipment was last changed. The nebulizer mask was not stored in a clean bag and was laying directly on the bedside table. On 05/19/26 at 9:25 AM, the nebulizer mask was observed laying on Resident #3's pillow, not stored in a bag, and without a date or time label. On 05/19/26 at 12:08 PM, the nebulizer mask was observed hanging on the side of Resident #3's bed, not stored in a bag, and without a date or time label. On 05/18/26 at 1:42 PM, the facility's nebulizer policy was reviewed. The policy directed staff to change nebulizer tubing every seventy-two hours or per facility policy and to store the nebulizer cup and the mouthpiece in a zip lock bag. On 05/19/26 at 2:05 PM, the Director of Nursing (DON) toured Resident #3's room with the surveyor. The DON observed the nebulizer mask hanging on the side of the resident's bed without a date or label and not stored in a bag. The DON stated it was the facility's expectation that nebulizer tubing be changed weekly or when dirty and stored in a bag when not in use. These concerns were discussed with the DON on 05/21/26 and again on 05/22/26 at 11:50 AM.

Based on observation, interview, and record review, it was determined that the facility failed to ensure bed rails were used in accordance with facility policy and physician orders. This is evident for 2 (Residents #1 and #16) of 2 residents reviewed for bed rail use.The findings include:On 05/18/2026 at 10:36 AM, Resident #16 was observed in bed with bilateral upper bed rails in the raised position. At 12:45 PM, review of the electronic medical record (EMAR) for Resident #16 revealed no physician order for bed rail use.On 05/19/2026 at 8:30 AM, Resident #1 was observed in bed with bilateral upper bed rails in the raised position. At 8:57 AM, review of the EMAR for Resident #1 revealed no physician order for bed rail use.On 05/20/2026 at 9:38 AM, review of a bed rail assessment completed earlier that day at 6:25 AM for Resident #1 revealed the question, Does the resident request use of enabler bars for assistance with bed mobility? was marked No. The assessment further indicated No benefits noted at this time regarding bed rail use. At 9:48 AM, Resident #1 was again observed in bed with bilateral upper bed rails in the raised position.At 10:44 AM, the Director of Nursing (DON) was notified of Resident #1 being observed with bed rails in use despite the assessment documentation indicating no identified benefit.At 11:30 AM, during interview, the DON stated the nurse had completed the bed rail assessment incorrectly and had been re-educated. The surveyor identified that a previous bed rail assessment dated [DATE] also documented no identified benefit and indicated the bed rails were not recommended for use. The surveyor further informed the DON that Resident #1 had been observed with bed rails in use both prior to and after completion of the assessment.At 12:02 PM, the surveyor requested the facility's bed rail policy from the DON.At 12:22 PM, review of the facility's bed rail policy provided by the DON revealed, Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bedrail.At 12:25 PM, during interview regarding initiation of bed rail use, the DON did not indicate the need for a physician order. The DON was informed that Residents #1 and #16 had been observed using bed rails without physician orders in place, contrary to facility policy.

Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were stored in accordance with professional standards and manufacturer guidelines by failing to date an opened multidose medication vial. This is evident for 1 of 2 medication storage rooms reviewed.The findings include:On 05/21/2026 at 11:52 AM, a medication storage observation was conducted. An opened box containing an opened vial of Tuberculin Purified Protein Derivative, Diluted Aplisol 1 mL was observed without a date indicating when the vial had been opened. This vial was intended for multiple uses and was kept in a medication refrigerator among other medications. The directions on the side of the box stated that the vial was to be discarded 30 days after opening and no date was found on the box or the vial indicating when it had been opened.At 12:06 PM, the Director of Nursing (DON) was presented with the vial and box and notified of the findings.

Based on observation, interview, and record review, it was determined that the facility failed to assist a resident in obtaining routine and necessary dental services. This is evident for 1 (Resident #1) of 1 resident reviewed for dental services.The findings include:On 05/19/2026 at 8:47 AM, Resident #1 stated during interview that they had not seen a dentist.On 05/20/2026 at 8:29 AM, review of the current care plan for Resident #1 in the electronic medical record revealed the following, The resident has dental health problems r/t (related to) cavities and broken, chipped teeth. At 8:33 AM, review of dental/oral evaluation documentation revealed assessments completed on 03/29/2025, 09/21/2025, and 02/09/2026 identified concerns with Resident #1's teeth.On 05/20/2026 at 11:30 AM, the Director of Nursing (DON) stated the resident refused a dental appointment when asked that day. The surveyor shared the concern that the resident had resided in the facility since 2023, was identified as having dental concerns, and did not have documentation to show dental services had been provided or consistently offered.On 05/21/2026 at 12:06 PM, the DON provided documentation showing the resident declined a dental appointment on 04/01/2025. No additional evidence was provided to show the facility had arranged or attempted to obtain routine dental services despite ongoing identified dental concerns.

Based on observations and staff interviews it was determined that the facility failed to 1.) follow infection control policy and procedure by maintaining and storing the face mask and tubing for a resident's nebulizer in the manner that was consistent with the facility's policy and procedure, and 2.) ensure staff performed appropriate hand hygiene during medication administration and resident care to prevent the potential spread of infection This was evident for 1 out of 32 residents sampled and for 1 (Staff #34) of 3 staff observed during medication administration observations. The findings include: 1.) During initial observation on 05/18/2026 at 10:25 AM, Resident # 71's Nebulizer mask was seen on the bookshelf next to the resident's bed uncovered, and neither the tubing or the mask had a date on them. During an observation on 05/19/2026 at 9:45 AM the Nebulizer mask was observed appropriately covered and sitting on the nebulizer machine in a bag with the date, but the tubing was not connected and on the floor, slightly under the bed and was not dated. The policy and procedure for maintaining was requested and received from the DON. This policy stated that the mask should be rinsed with sterile or distilled water, then placed on a paper towel to dry before being returned to a plastic bag that has the date it was put in use. Employee # 18 regarding the cleaning and storage of the mask and tubing and they stated that the rinsed the mask with tap water and allowed it to dry on a paper towel. When asked if they were aware that distilled or sterile water was supposed to be used they said no and that they would review the policy. They also stated that they had repeatedly reminded their co-workers to date the mask and tubing. During follow-up observations on 05/22/2026 at 10:05 AM The Nebulizer mask was attached to tubing and sitting on the shelf next to the nebulizer uncovered. Again, neither the mask or the tubing were dated. 2.) On 05/21/2026 at 8:32 AM, Staff #34 was observed administering medications to Resident #157. After completing the medication administration, Staff #34 used bare hands to adjust the resident's leg in bed. Staff #34 then exited the resident's room without performing hand hygiene and began preparing equipment to enter the room of Resident #154. Surveyor intervention occurred when Staff #34 put on gloves and attempted to enter Resident #154's room without first performing hand hygiene. On 05/26/2026 at 11:12 AM, the Director of Nursing was informed of the infection control concern involving Staff #34 failing to perform hand hygiene between care provided to Residents #157 and #154 during medication administration.

Based on medical record review and interview, it was determined the facility staff failed to notify a Resident's responsible party for a change in condition (Resident #3). This was evident for 1 of 10 residents reviewed during a complaint survey. The findings include:Review of Resident #3's medical record on 12/9/25 revealed the Resident was admitted to the facility on [DATE] at 11:55 AM with a diagnosis to include Alzheimer's disease. Alzheimer's disease is a type of dementia that affects memory, thinking and behavior.The facility staff assessed the Resident on 9/11/25 at 1:19 PM to be a high risk for wandering/elopement.Further review of the Resident's medical record revealed a nurse's note on 9/11/25 at 6:07 PM that states several attempts to leave unit. Wander Guard placed on right ankle.Review of Resident #3's medical record revealed no notification to Resident #3's responsible party of placement of a Wander GuardDuring interview with Resident #3's responsible party (RP) on 12/10/25 at 11:06 AM, the RP stated no one called him/her on 9/11/25 to advise him/her the Resident was wandering, attempting to leave the unit and the facility staff placed a Wander Guard on the Resident.Interview with the Director of Nursing on 12/10/25 at 11:25 AM confirmed there is no documentation in Resident #3's medical record of notification to the RP of placement of the Wander Guard on 9/11/25.

Based on medical record review and interview, it was determined that the facility staff failed to administer medications, treatments and supplements as ordered in a timely manner (Resident #3 and #6). This was evident for 2 of 10 residents reviewed during a complaint survey.The findings include:1. The facility staff failed to administer medication as ordered for Resident #3.Review of Resident #3's medical record on 12/9/25 revealed the Resident was admitted to the facility on [DATE] at 11:55 AM with a diagnosis to include dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.Further review of Resident #3's medical record revealed on 9/11/25 the Resident was ordered Donepezil 5 mg at bedtime for dementia.Review of Resident #3's Medication Administration Record revealed on 9/11/25 at 8:00 PM the Donepezil 5 mg was not administered with a code of 9 (Other/see nurses note).Review of Resident #3's nursing notes revealed Donepezil 5 mg on order from pharmacy.Review of Omnicell Inventory listed provided by the Director of Nursing (DON) on 12/9/25 revealed the Omnicell contains Donepezil 5 mg.Interview with the Director of Nursing on 12/10/25 at 9:40 AM confirmed Resident #3 was not administered Donepezil 5 mg on 9/11/25 as ordered by the physician.2.The facility staff failed to order and administer supplements timely for Resident #6.Review of Resident #6's medical record on 12/9/25 revealed the Resident was admitted to the facility in September 2025 with diagnosis to include malnutrition.Further review of Resident #6's medical record revealed the Resident was assessed by the Registered Dietitian (RD) on 9/26/25 who documented Resident appears very thin and his/her overall intakes slowly improving. Will recommend add 8 oz house supplement shake every day.Review of Resident's Patient Orders revealed the RD communicated to the Nurse Practitioner (NP) on 9/26/25 at 12:51 PM: new admission with varied intakes, 116 pounds = well below ideal body weight = agreed to supplement = malnourished recommend add 8 oz house supplement every day On 9/26/25 at 12:56 PM the NP (Staff #9) documented Ok. Review of the Resident's physician orders revealed the house supplement shake was not ordered until 9/29/25. Review of the Resident's September 2025 Medication Administration Record revealed the Resident was not administered the supplement shake until 9/30/25, 4 days after it was ordered.Interview with the Director of Nursing on 12/10/25 at 9:21 AM confirmed the facility staff fail to order and administer supplement shakes for Resident #6 timely.3.The facility staff failed to administer wound treatments as ordered for Resident #6.Review of Resident #6's medical record on 12/9/25 revealed the Resident was admitted to the facility in September 2025 with a diagnosis to include diabetes and peripheral neuropathy.Further review of Resident #6's medical record revealed the Resident was assessed by the Wound Nurse Practitioner on 10/14/25 for a left foot wound and treatment ordered.Review of the physician orders revealed on 10/15/25 the left foot wound orders were changed to Apply Calcium Alginate between the toes and cover the top and bottom of left foot every shift.Review of Resident October 2025 Treatment Administration Record revealed there is no documentation of the administration of left foot wound treatments on 10/18/25 3-11 PM, 10/19/25 3-11 PM, 10/24/25 11 PM - 7 AM and 10/26/25 3-11 PM. Interview with the Director of Nursing on 12/10/25 at 9:25 AM confirmed there is no documentation the facility staff administered left foot wound treatments for Resident #6 on 10/18/25 3-11 PM, 10/19/25 3-11 PM, 10/24/25 11 PM - 7 AM and 10/26/25 3-11 PM.

Based on a facility reported incidents, record review, and interviews, it was determined the facility failed to timely report an incident of abuse to the Office of Health Care Quality (OHCQ). This was evident for 6 (#63, #52, #84, #24, #71, #64) of 10 residents reviewed for abuse during the recertification/complaint survey. The findings include: 1) An investigation into Facility Reported Incident (#MD00203162) on 3/26/25 revealed that Resident #63 told a staff person on 3/2/24 at 8:30 AM that a staff person approached them from behind, lifted them up then dropped them to the floor. The staff person who Resident #63 reported the incident to then informed the Director of Nursing (DON) on 3/2/24 at 8:50 AM. According to the facility's investigation file, the DON reported to the state agency (Office of Healthcare Quality - OHCQ) at 12:15 PM on 3/2/24. The Assistant Director of Nursing (ADON) was interviewed on 3/26/25 at 8:35 AM. When asked how long does a facility have to report allegations of abuse to the state agency she replied, we have two hours to report abuse. This surveyor interviewed the DON on 3/27/25 at 1:57 PM. Explained the timeline of events: Resident #63 told a staff member of alleged abuse, the charge nurse told the DON, and then the DON reported the incident to OHCQ four hours later. This surveyor said a resident telling a nurse that a staff member picked them up and then dropped them to the floor would be an accusation of abuse even if the word abuse was not used. She agreed. The DON was interviewed on 3/28/25 at 9:22 AM. She said she reviewed all of her notes and emails. She confirmed that the timeline was correct and said It's on me. 44441 2) On 3/28/25 at 9:20AM, review of a facility reported incident #MD00185488 documented that Resident #52 reported to a Geriatric Nurse Assistant (GNA) that another GNA allegedly screamed at her and was rough. Review of the facilities Investigation on 3/28/25 at 9:48 AM revealed that the incident happened on 11/7/22 at 6:30PM. The facility administrator was made aware on 11/8/11 at 3:00PM. The initial report was sent to OHCQ on 11/8/22 at 8:30 PM, which was more than 5 hours later On 3/28/25 at 11:20 AM the Director of Nursing (DON) in an interview was asked about the timeline for reporting abuse allegations. She stated that the facilities protocol is for staff to report any observed incident of abuse immediately to their supervisors or unit managers. This in turn gets reported to the DON who forwards it to the administrator. She stated that once the administrator gets it, they must report it immediately to OHCQ because they have 2 hours reporting time window to do so per regulation. She was shown the reporting time of this incident and asked if it was timely. She checked it out and asked for time to reconfirm. On 3/28/25 at12:43 PM, the DON came back to report that she could not find any other document to indicate that the report was sent to the office timely. She confirmed that the report was sent late. 45131 3) On 03/31/25 at 02:47PM, a review of the Facility Reported Incident (FRI) MD00197463 revealed that on 9/25/23 at 10:00 PM, Resident #84 reported to RN#51 that Geriatric Nursing Aide (GNA) #50 was rough while providing care. The initial report was submitted to the Office of Healthcare Quality (OHCQ) on 9/26/23 at 1:47 PM and therefore failed to meet the 2-hour time frame reporting requirement. On 04/02/25 at 02:10 PM, in an interview with the Director of Nursing (DON), she was asked about the late report time and she acknowledged and stated that she was aware of the 2-hour report requirements for abuse allegation, and she will look into the above-mentioned issues related to late reporting. 4) On 3/31/2025 at 06:06 PM a review of a FRI MD00202953 revealed that on 2/25/24, Resident #24 reported to the facility that an unidentified person threatened to physically assault the resident. On 2/25/24 at 1:00 pm Staff #22 was made aware of the alleged incident; however, the documented evidence provided by the facility revealed that the incident was reported to the OHCQ on 2/25/24 at 3:46 PM and therefore failed to meet the 2-hour time frame reporting requirement. On 04/01/25 at 10:29 AM, in a DON interview, the DON was made aware that the reporting time for this FRI was not verifiable and the receipt of the initial report to OHCQ was requested from DON. On 04/02/25 at 02:10 PM, in an interview with the DON, she was asked about the late report time, and she stated that she was aware of the 2-hour report requirements for abuse allegation, and she will look into the above-mentioned issues related to late reporting. 5a) On 4/1/2025 at 10:48 AM a review of the facility reported incident MD00202052 revealed that on 1/30/2024 at 3:00 PM Resident #71 reported to Staff #17 that he/she was sexually assaulted by an unidentified person; however, the documented evidence provided by the facility revealed that the incident was reported to the OHCQ on 1/30/24 at 5:10 PM and failed to meet the 2-hour reporting requirement. On 04/02/25 at 02:10 PM, in an interview with the DON, she was asked about the late report time and she stated that she was aware of the 2 hour report requirements for abuse allegation and she will look into the above-mentioned issues related to late reporting. 5b) On 4/1/2025 at 1230 PM a review of a facility reported incident MD00191298 revealed that on 4/11/23 Resident #71 reported to Staff #48 on 4/11/23 at 12:00 PM; that he/she was sexually assaulted/ touch inappropriately by an unidentifiable person; however, the documented evidence provided by the facility revealed that the incident was reported to OHCQ on 4/11/23 at 2:02 PM and therefore failed to meet the 2-hour reporting requirement. On 04/02/25 at 02:10 PM in an interview with the DON, she was asked about the late report time frame and she stated that she was aware of the 2 hour report requirements for abuse allegation and she will look into the above-mentioned issues related to late reporting. 51128 6) On 03/24/25 at 10:20 AM, during the survey screening, Resident #64 informed a surveyor that GNA#31 got a hold of my feet and legs and pull me on the side of the bed and since that day my legs have been hurting. The resident also stated that GNA #31 pinched her thighs while assisting with pulling up her pants and when the GNA assisted with rolling her over, the Resident hit her thigh on the rail. The Resident stated that the GNA seemed irritated. On 04/01/25 at 11:32 AM, on observation, Resident #64 was lying in bed in a hospital gown. This Surveyor conducted a follow up interview. The Resident stated that she informed the Unit Manager #17 that GNA#31 had pinched her thighs and rough handled her legs while assisting her back to bed three weeks ago. An interview was conducted on 04/01/25 11:47 AM with Unit Manager #17. The surveyor asked if there was an incident that was brought to her attention concerning resident #64. Unit Manager #17 stated that the resident complained about being pinched and that she had a sore sacral area. The Unit Manager stated that she and the Nurse Practitioner performed a skin assessment of the residents, and there were no open areas or redness noted. The Unit Manager also added that she asked the Resident to demonstrate how she was pinched and the Resident refused to demonstrate, so there was no further action taken. The interview with the Director of Nursing (DON) on 04/01/25 at 12:33 PM revealed that she was not notified of an alleged abuse of Resident #64. When the surveyor informed the DON of the Resident's complaint and asked if this was a reportable incident, DON stated yes, and that she would notify OHCQ.

Based on multiple complaint intakes, record review and staff interviews it was determined that the facility failed to 1) implement an intervention on a resident's care plan, 2) arrange for a resident with fractured arm to go for an orthopedic appointment, 3A/B) fail to timely administer prescribed medications to residents, 4) Promptly report a positive lab result to the physician and hold laxative for a resident with diarrhea. This was evident for 4 (#132, #140, #230 , #142) of 24 complaints reviewed during the recertification/complaint survey. The findings include: 1) On 3/25/25 at 11:00 AM review of a complaint intake #MD00202774 had that Resident #132 was admitted to the facility and was having multiple falls secondary to a medical condition and that the facility was not willing to use other measures to keep the resident safe while being rehabilitated. Review of the Change in Condition Concurrent Review Forms on 3/25/25 at 11:22 AM document that resident fell 5 times in February 2024 and 7 times in March 2024. Dates reviewed include 2/12, 24,18,19 x2, 3/6, 7,10,11, 22, 25, and 31. A review of the resident's care plan with initiation date of 2/13/24 documented a fall care plan with interventions that stated that hipsters and soft helmets would always be on to keep the resident safe. Further review of the Physicians order and the treatment administration Record (TAR) for the months of February and March 2024 on 3/26/25 at 9:00 AM did not reveal that the hipster or soft helmets were ordered for staff to implement and monitor. On 3/16/26 at 1:25 PM In an interview with staff #17 a unit manager, she was asked about the hipsters and soft helmets. She stated that for hipsters and soft helmets, the nurse would obtain a verbal order from the Physician which is reflected in the Treatment Administration Record (TAR) and the nurse aids Kardex. She confirmed that if there were no orders from the doctor for the soft helmet or the hipsters, then the nurse would not implement or monitor the interventions. 2) On 3/27/25 at 12:00 PM review of a complaint intake #MD00211341 had that Resident #140 fell and fractured their right elbow and the facility failed to initiate a follow up surgeon appointment as ordered by the physician. Review of the physician order on 10/26/25 at 11:10 AM found two orders in September and one in October 2024 related to the fracture and request for surgical appointment. It read: -8/26/24: F/U with ortho following ulna fracture x ray results. -8/27/24: F/U with ortho following ulna fracture x ray results everyday shift. Obtain name of ortho from family and schedule appt. -10/1/24: F/U with ortho following ulna fracture x ray results (Family requesting no f/u) every shift every shift, Splint for Arm/Elbow Edema & Stabilization Document every shift Further review of the health status note dated 10/26/24 had Right elbow x-ray results show an acute mildly displaced fracture coronary process of ulna without dislocation. Results sent to third eye. Orders are as follows. obtain elbow splint and apply, consult ortho as outpatient, PCP to assess patient today and f/u with ortho, Notify clinician of any further change in condition. On 3/27/25 at 3:57PM in an Interview with Staff #16 a unit manager, she was asked if resident went for their orthopedic appointment as ordered by the physician. Staff #16 stated that the facility was made aware of the doctors' order for Resident #140 to go for orthopedic appointment, but the resident ended up not going. The Director of nursing (DON) said, the facility called the resident's spouse to let them know about the appointment and to obtain the name of the surgeons they would prefer the resident to see. That when the appointment was finally made, the resident's spouse said they could not keep the appointment, and that the surgeon said to take the resident to the emergency room (ER). The DON was asked if they took the resident to the ER as recommended and she said they did not. She was made aware that this was a concern. 3A) On 3/27/25 at 3:57 PM a review of the same complaint Incident #MD00211341 also had that Resident #140 was sent to the hospital on 9/4/24 for agitation. The resident came back to the facility with no explanation of the cause of the agitation. The family believed that it was a medication issue as this happens often when residents' medications were not given accurately. On 3/27/25 at 3:15PM: Review of the actual medication administration time for the month of June 2024 from 6/26-6/30 revealed that Resident #140's morning medications scheduled to be given at 8:00 am were administered after 10:00AM and 11:00AM which was more than 2 -3 hours late. Review of the facilities medication administration policy, however, stated that meds are to be given an hour before and an hour after the administration time. 3B) Review of another complaint incident #MD00185809 On 4/1/25 at10:30AM had that resident #230 was hospitalized twice because the facility did not have enough staff to administer timely breathing medications including resident's regular medications. That the pulmonologist (Lung doctor) has stressed the importance of these treatments being on a timely schedule. Review of the physician's order on 4/1/24 at 11:50 AM reveal orders written on 11/17/22: Tobramycin Inhalation Nebulization Solution 300 MG/4ML (Tobramycin), 1 inhalation inhale orally every 12 hours 7 days on and 7 days off for recurrent respiratory infection pulmonology recommendation: long-term use, orders written on 11/29/22: Budesonide Suspension 0.5 MG/2ML 1 vial inhale orally two times a day related to UNSPECIFIED ASTHMA, may be co-administered with Formoterol, and orders written on 11/29/22: Formoterol Fumarate 20 MCG/2ML Nebulization solution, Give 1 vial by mouth two times a day related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA (J96.01) may be co-administered with Budesonide. On 4/1/25 at 12:15 PM review of the medication admission audit report revealed that the resident got their medications 2-3 hours late on the following days in November 2023: 11/13/22: Tobramycin inhalation solution was scheduled for 8am, given at 11:08 AM Budesonide suspension inhaler was scheduled for 8am, given at 11:07 11/12/22 the Formoterol fumarate nebulizer scheduled for 9am, given at 15:45 11/15/22 Tobramycin solution scheduled for 8am, given at 10:18 The inhalers were also late on 11/15,11/16, 11/18, given after 10AM On 11/17/22, and 11/20/22, residents 8am medications were given at 11:22 AM. On 4/1/25 at 12:30 PM Staff #1 the Assistant director of nursing (ADON) in an interview regarding late medication pass was asked if residents complain about getting their medications (Med) late and she said they do. She was asked if staff complain that they have too many residents and can't get to them timely during med. pass and she said, yes. She was asked the policy for medication pass and she said it's supposed to be given an hour before and an hour after the scheduled medication administration time. She was made aware of the late medication pass concerns and said she was not aware of medications given 2-3 hours late, that it could be due to poor time management and other emergency reasons. 4) On 3/28/25 at 1:48PM review of a complaint incident #MD00198278 had that the facility failed to take action to hold a laxative for Resident #142 who was having diarrhea stool for 5-6 days. That the facility only contacted the physician to have the stool tested after the family made the supervisor aware of it. Review of the Physician order on 3/28/125 at 1:48PM revealed an order that read: 9/6/23: Senokot S Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 2 tablet by mouth one time a day for Constipation'' Further review of the health status note revealed a note dated 9/13/23 at 17:23 that had: Residents emergency contact aware of STAT C. diff and stool sample order Related to (r/t) diarrhea. Stool sample collect. Diamond labs contacted, reported sample to be collected today. Continuing review of the laboratory test result dated 9/13/23 showed that Clostridium-difficile (C-diff), a bacterium that causes intestinal infections including diarrhea and colon inflammation testing was done and came back positive the same day. A review of September 2023 Medication Administration record (MAR) showed that the resident was given the laxative, Senna, two times a day from 9/7 -9/16 while still having diarrhea stool. On 3/28/25 at 2:15 PM further review of the health status note dated 9/18/24 at 22:00 documented that the physician was made aware of the positive C-diff. result on this date and he ordered Vancomycin, a medication for the treatment of C-diff. Vancomycin was started on the 19th of September 2023 which was 6 days later after the facility was made aware that resident was positive for c-diff. On 3/31/25 at 3:52 PM in an Interview with staff #1 the Assistant director of nursing (ADON), she was made aware that Senna was given when Resident #142 was still having diarrhea stool and that the positive stool sample was not communicated to the physician in a timely manner leading to a delay in starting the treatment. She was asked about their process. She stated that the laxative should have been held, and the physician notified when diarrhea was noted. She explained that positive results are communicated to the physician right away to initiate treatment per policy. She confirmed the delay in treatment with vancomycin and said it should not have taken one week after the diagnosis of a positive C-diff to initiate treatment. She was made aware that this was a concern. 47200

Based on clinical record reviews, Resident (R) and staff interviews, it was determined that the facility failed to have sufficient staff to meet the needs of the residents for 8 of 29 sampled residents (Residents #3, #110, #64, #14, #231, #116, #24, #51) and 15 complaints (MD00210759, MD00185809, MD00207746, MD00198916, MD00211341,MD00202774, MD00195025, MD00214748, MD00203187, MD00208031, MD00200792, MD00203145, MD00206608, MD00206731, MD00209653) that identified staffing issues and concerns reviewed during the recertification/complaint survey. The findings include: During resident and family interviews, the resident and or family were asked about sufficient nursing staff. An example of a question asked was: do you feel that there is enough staff to meet your needs and concerns without having to wait a long time? Is there a problem with staffing during the week or on weekends? In addition, based on a investigation of complaints there was evidence to support staffing issues. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well an individual is functioning cognitively at that moment. A BIMS score can range from 0 to 15, with lower scores indicating a decline in cognitive performance. During an interview on 03/24/25 at 10:09 AM, Resident (R) #64 stated, no one came to help me on Saturday, no body showed up. I am wearing my night gown from the previous day, mostly on the weekend from Thursday night until Monday morning. I have laid in body waste at times before they come and clean me up. They never have enough help, especially on weekends. Review of R#64 clinical record on 3/24/25 at 10:30 AM revealed that resident has a BIMS score of 14. On 04/01/25 at 11:32 AM the surveyor observed Resident #64 was lying in bed in hospital gown. On 03/24/25 at 10:46 AM during an interview with R#14, Resident stated, I don't get enough help here, staff don't have time to do you., if you press your call bell, you have to wait for 1hour to get help, and you don't change. They use a lot of Agency who don't want to do any work, they don't want to give you a shower, they give you a bath instead. On 03/24/25 at 12:43 PM a review of the investigative notes for #MD00202284, revealed that a family member for Resident #3 complained that when I went to the facility to feed my family member breakfast, I learned that there were so many call offs or no shows of Agency persons that there were only 2 people to take care of 4 halls of residents and people there for rehab. The people were the nurse director for that wing and 1other full time employee. That would be 29 patients for each, to get them up, dress, pass out breakfast trays and feed those dependent diners, of which my family member is one. On 03/24/25 at 01:17 PM R#110 stated during an interview that staffing varies and facility short staff most of the time. On 03/25/25 at 08:25 AM R #231 stated he/she had waited for about 40 minutes for staff to assist him/her to the bathroom: They say to me we are short staffed, and we have a lot of people to care for. On 03/25/25 at 09:32 AM R #116 stated not sure if there is enough staff all the time. On 03/25/25 at 11:56 AM R #24 stated, They usually have low staff on the day and evening shifts on weekends, it happens often. During an interview on 03/25/25 at 12:46 PM, family member of Resident #51 stated, staff never have time to help him/her get out of bed, I would like to have him/her dressed so we can have lunch in the dining room but today I don't know what happened. They never have enough help especially on weekends. On 04/01/25 at 08:49 AM, an interview was conducted with Staffing Coordinator, Staff #15 who agreed that there is an issue with call outs on the weekends and that facility have used Agency staff to fill in vacancies on the staff schedule. An interview of GNA #25, who has been employed at facility for [AGE] years. She/he stated that the facility is short staffed at times, and it is hard to complete daily tasks. When asked if facility use Agency staff, she/he stated that the facility used Agency staffing a lot in the past, but the facility has cut back and absorbed some of the agency staff so that they have more regular staff now. On 3/28/25 at 11:45 AM, an interview was conducted with GNA# 33, who has been employed at the facility for 3 yrs. When the surveyor asked about staffing, GNA #33 stated that low staffing at times can cause a ratio of 2 GNA's to 30 residents per GNA. She/he said they have 4-6 GNA's on the floors some days, but most days, its 4 GNA's which equals to 15 residents. When GNA #33 was asked how often the facility has 1 GNA to 30 residents, she/he stated it happened at least one day a month mostly on the weekends on the evening and night shifts. GNA #33 further added that she/he worked as the only GNA on the whole floor around the middle of 2023 and said this has happened to other GNA's on night shift. GNA #33 stated that she/he is not able to complete all the GNA tasks when the facility is not adequately staffed. On 4/2/2025 at 2:25 PM, the surveyor made the DON aware of the staffing concerns.