Every finding on record at Autumn Lake Healthcare at Cherry Lane

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan that specified the level of assistance a resident required for transfers/mobility for 1 (Resident #2) of 10 sampled residents. Findings included:An admission Record revealed the facility admitted Resident #2 on 08/19/2024. According to the admission Record, the resident had a medical history that included diagnoses of anoxic brain injury, epilepsy, and cardiomyopathy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #2 was dependent on staff for transfers. Resident #2's Care Plan Report included a focus area initiated 08/19/2024, that indicated the resident needed assistance with activities of daily living related to decreased mobility and acute intracranial processes. Interventions directed staff the resident was dependent on staff for mobility/locomotion on and off the unit. Resident #2's Physical Therapy (PT) Discharge Summary dated 04/05/2026, indicated the resident required a minimum of one person for transfers and was able to perform 75% or more of the activity but required weight-bearing assistance from one caregiver to complete. During an interview on 04/07/2026 at 8:37 AM, Resident #2 stated after the staff bathed them, two girls would come in with a lift and get them out of bed. During an interview on 04/07/2026 at 8:40 AM, Licensed Practical Nurse (LPN) #6 stated Resident #2 did not transfer on their own or get out of bed by themself. LPN #6 stated two persons assisted Resident #2 using the lift to transfer out of bed. During an interview on 04/08/2026 at 10:06 AM, Resident #2's Attending Physician stated Resident #2 would be discharged soon; however, the resident's family needed to come in for training on use of the lift. During an interview on 04/09/2026 at 10:05 AM, the MDS Coordinator stated Resident #2admitted to the facility using a mechanical lift, but the resident improved and some days the resident would not do as much, and the staff would use a mechanical lift. The MDS Coordinator stated the facility was behind updating residents' care plans. During an interview on 04/09/2026 at 2:30 PM, the Director of Nursing (DON) stated that when a resident completed rehabilitation, the Interdisciplinary Team (IDT) discussed falls, changes in the resident's condition, treatments, upcoming discharges, and therapy. The DON stated the Rehabilitation Director would inform the IDT if a resident was a one-person, two-person, required a lift for transfer, or used a wheelchair or walker during the morning meetings, and that information was communicated from the unit managers to the floor staff. During an interview on 04/10/2026 at 12:36 PM, the Rehabilitation Director stated that once a resident was completed with therapy, she communicated to nursing, dietary, and the social services team during the morning meetings. The Rehabilitation Director stated she did not have anything to do with the care plans or Kardex (a summary of a resident's care plan). The Rehabilitation Director stated she was unaware the staff were still using the mechanical lift as Resident #2's therapy discharge summary read the resident required maximal assistance of one person. During an interview on 04/13/2026 at 10:35 AM, Geriatric Nursing Assistant #16 stated Resident #2 had always been transferred by way of a mechanical lift. During a follow-up interview on 04/13/2026 at 1:32 PM, the DON stated she would expect care plans to be current and for revisions and updates to be done timely and accurately so that all staff would be aware of the expected care to be given to a resident. During an interview on 04/13/2026 at 1:47 PM, the Administrator stated communication was key, and the staff needed to communicate so that a residents' care plans were updated and revised timely.

Based on interview, record review, and facility policy review, the facility failed to ensure staff revised a resident's comprehensive person-centered care plan to reflect the resident's current transfer needs for 1 (Resident #6) of 10 sampled residents. Findings included: An admission Record revealed the facility admitted Resident #6 on 09/12/2025. According to the admission Record, the resident had a medical history that included diagnoses of spinal stenosis and wedge compression fracture of the first lumbar vertebra. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #6 required partial/moderate assistance for transfers Resident #6's Care Plan Report included a focus area initiated 09/13/2025, that indicated the resident needed assistance with activities of daily living related to spinal compression fracture and dementia. Interventions directed staff the resident was dependent on two staff with a mechanical lift for transfers. Resident #6's Physical Therapy (PT) Discharge Summary dated 12/24/2025, indicated the resident required a minimum of one person for transfers and was able to perform 75% or more of the activity but required weight-bearing assistance from one caregiver to complete.During an interview on 04/07/2026 at 1:36 PM, Resident #6's spouse stated the resident could stand with the assistance of staff and transfer out of bed.During an interview on 04/09/2026 at 10:05 AM, the MDS Coordinator stated the facility was behind updating residents' care plans.During an interview on 04/13/2026 at 11:09 AM, Geriatric Nursing Assistant #15 stated Resident #6 did not require a mechanical lift for transfer.During a follow-up interview on 04/13/2026 at 11:45 AM, the MDS Coordinator stated she did not know why Resident #6's care plan was not updated, as the Interdisciplinary Team discussed transfers in the morning meetings. During an interview on 04/13/2026 at 1:32 PM, the Director of Nursing stated she would expect care plans to be current and for revisions and updates to be done timely and accurately so that all staff would be aware of the expected care to be given to a resident. During an interview on 04/13/2026 at 1:47 PM, the Administrator stated communication was key, and the staff needed to communicate so that a residents' care plans were updated and revised timely.

Based on observation, interviews and record review, it was determined that the facility failed to ensure appropriate infection control practices. This was evident for 1 (Resident #16) of 59 residents reviewed for infection control during the recertification survey.The findings include:On 07/30/25 at 11:39 AM during initial rounds the surveyor observed a pair of sneaker-like black shoes on the bedside table of Resident #16. The inner soles of the shoes were marked with the resident 's name. Next to the shoes, was an unopened 4oz container of apple juice.While the surveyor was in the room, GNA #10 came into the resident's room to provide care. The surveyor interviewed GNA #10 and enquired about the black shoes. GNA #10 stated that she received training on infection control and that she was not responsible for the shoes on the bedside table. GNA #10 in referring to the shoes stated, I did not put it there, I met it there. Later at 11:45 AM on 07/30/25, Charge Nurse #9 entered the room and was interviewed by the surveyor. Charge Nurse #9 stated that the shoes should have been placed in the closet. Charge Nurse #9 removed the shoes from the bedside table and placed the container of apple juice in the trash. On 07/31/25 at 12:30 PM a review of Resident #16's clinical record revealed that the resident has multiple diagnoses including Dementia and is dependent on the nursing staff for dressing, grooming and personal hygiene. On 08/05/25 at 8:44 AM the Director of Nursing was notified and did not comment on the surveyor's findings.

Based on record reviews and staff interviews it was determined that the facility failed to screen and offer vaccinations to residents. This was evident for 2 (Residents #20 and #138) out of 5 residents screened for immunizations.The Findings include: During a medical record review on 08/12/2025 at 3:46 PM it was discovered that Resident #20 had been admitted on [DATE] and was offered the Pneumonia Vaccination which he/she refused. Resident #20 was still a resident in the facility and there was no documentation that Resident #20 was reoffered the Pneumonia vaccine. During additional medical record review on 8/12/25 at 3:59 PM it was revealed that Resident #138 was offered and refused the pneumonia vaccine on 8/31/2018. Resident #138 was still a resident in the facility and had no documentation of additional Pneumonia vaccines being offered. During an interview with the Infection Preventionist (IP) on 8/13/2025 at 8:06 AM he reported we would offer it again this year if you refused last year. He reported vaccinations are reviewed when it's time for flu vaccinations and pneumonia vaccines would be offered again if they were previously refused. He confirmed the Electronic Medical Records (EMR) showed the last time Resident #20 was offered the pneumonia vaccine was 8/19/20 and Resident #138 was last offered on 8/31/18. He advised he would check the Resident's paper chart because it may be in there since it's not in the EMR. During an observation with the IP reviewing the Resident's Charts on 8/13/25 at 8:23 AM there was no documentation of additional pneumonia vaccinations being offered to Resident #138 and he reported, I don't see the one we offered last year. There was also no documentation of additional offerings of the pneumonia vaccine for Resident #20, he reported I don't have it after reviewing the Resident's Chart.During an interview with the Director of Nursing on 8/13/25 at 9:04 AM she confirmed that Resident's that refuse the pneumonia vaccination should be offered the vaccine again in the future.

Based on medical record reviews, interviews and observations it was determined that the facility failed to ensure medical records were complete, readily assessable and organized. This was evident for 2 (Resident #163 and #137) of 2 residents reviewed for medical record storage.The findings include:During an interview with the complainant for Complaint #337031 on 7/31/25 at 5:07 PM he/she reported that the facility had not obtained weights daily as had been ordered for Resident #163.During a review of the Electronic Medical Record (EMR) on 8/01/25 at 11:52 AM for Resident #163 it was discovered that there was a doctor's order from 1/30/25 to 2/12/25 for weights to be done daily which stated, Weigh at same time every day and call MD if increases more than 2 lbs/day or 5 lbs/5 days, every night shift. Further review of the medical records for Resident #163 revealed three weights were documented in the EMR, they were obtained on 1/30/25, 2/03/25 and 2/12/25. The Treatment Administration Record (TAR) showed the weight order was signed off as completed every day from 1/30/25 - 2/11/25 except for when the resident refused on 2/08 and 2/10.During a review of the Resident's Paper Chart (Hard copies) from Medical Records on 8/01/25 at 11:33 AM it revealed no additional weights were documented in the Paper Chart (hard copies).During an interview with the Director of Nursing (DON) on 8/01/25 at 12: 59 PM she advised weights are documented and kept in a binder on the nursing unit. During an observation of the 2A/B Nursing Unit on 8/01/25 at 1:07 PM it was found to contain a binder called 2A/2B Weight Binder. Resident #163 did not have a daily weight log inside the binder.During an interview with the Unit Manager/Staff Educator RN on 8/01/25 at 1:18 PM she reported Medical Records would store the weight log with the Resident's chart.During an interview with the Medical Records Coordinator on 8/01/25 at 1:22 PM she reported there were no additional records for Resident #163. Everything would have been in the paper chart already provided.During an interview with the Unit Manager/Staff Educator RN on 8/01/25 at 1:28 PM she provided the Daily Weight Log for Resident #163, the weight log was curled into a circle and unable to lie flat. She reported the Weight Log was found in the previous unit manager's office that was not currently being used.During an observation with the Unit Manager/Staff Educator RN on 8/01/25 at 1:32 PM she showed where the records for Resident #163 were found. The Weight Log for Resident #163 was found loose, not in a binder or folder, and was rolled up with weight logs for other Residents lying on top of a rolling rack for file folders.2. During an interview with Resident #137 on 8/12/25 at 2:05 PM he/she reported that when admitted to the facility staff members took pictures of him/her without consent.During an interview with the Director of Nursing on 8/13/25 at 9:24 AM she reported residents would be asked for photo consent when the admission Packet is completed upon admission. She advised the Admissions Office stores and would have the admission packet for Resident #137. During an interview with the Admissions Director on 8/13/25 at 2:43 PM she advised they had been adding the admission packets to the Electronic Medical Record, but reported that records that were not recent were being stored in a room across the hall from the Admissions Director. She reported she had already looked for the admission Packet for Resident #137 today at the request of the Administrator and was unable to locate it. During an interview with the Administrator on 8/13/25 at 2:51 PM he reported they were unable to find the admission Packet for Resident #137. He stated he/she probably refused to sign it. The Administrator agreed that if the Resident had refused to sign the admission Packet there would be some documentation of the refusal. He confirmed there was no additional forms found related to the missing admission Packet.

Based on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This was evident in the Kitchen and in 2 (2A/B and 1A/B) of 4 Nutrition Rooms in the facility. This practice had the potential to affect all residents that eat food prepared by the facility's kitchen and that store food in nutrition rooms. The findings include:1. During the initial tour of the Kitchen with [NAME] #1 on 7/30/25 at 8:43 AM there were food products found open in the walk-in freezer with no label showing opening or expiration dates. The following foods were identified as being opened and unlabeled: An opened bag of chocolate chip cookies An opened bag of Charbroil Pattie for Salisbury An opened Bag of Salisbury steaks An opened bag of Tilapia Fillets An additional bag of Salisbury steaks/burgers An opened bag of Frozen Cookie Dough During an interview with [NAME] #1 on 7/30/25 at 8:58 AM he reported the items found were supposed to be labeled after opening with dates showing an opening and expiration date. He removed the opened and unlabeled items from the freezer. During an interview with the Food Service Director on 7/30/25 at 9:27 AM she confirmed the items found open in the freezer should have been labeled and advised Everything is supposed to labeled after opening. During a review of the Food Receiving and Storage Policy on 7/30/25 at 12:23 PM it was revealed that All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). 2. During an observation of the refrigerator for residents in the 2A/2B Nutrition Room with the Unit Manager/Staff Educator on 7/30/25 at 11:31 AM it was discovered to have undated and unlabeled foods stored inside. The following items were identified:A plastic container with an unknown food stored inside for Resident #39 with no dates A tied-up plastic bag of food for Resident #43 with no dates A blue lunch bag with food stored inside with no Resident identification or datesDuring an interview with the Unit Manager/Staff Educator RN on 7/30/25 at 11:36 AM, she reported that the kitchen staff monitors the nourishment refrigerators. She confirmed the refrigerator was for the residents and the items inside should've been labeled with the name of the Resident and an expiration date.During an observation of the 1 A/1 B Nourishment room on 7/30/25 at 11:52 AM with the First Floor Unit Manager it was discovered to have expired and unlabeled food stored inside.The expired food items included:Great Value Original Vanilla Yogurt that expired June 14, 2025Fat Free skim milk for Resident #146 that expired July 08, 2025The unlabeled items included:A plastic bag tied closed with food containers inside and was not datedA black bag tied shut with food containers inside and it had no dates or Resident identificationA plastic storage container with food inside that had no dates or Resident identification.A brown bag of food from Chido's Tex-Mex Grill had no date labeledDuring an interview on 7/30/25 at 11:59 AM with the 1st floor Unit Manager, she confirmed the items in the refrigerator should've been labeled with the name of the Resident and an expiration date. She also reported the expired items should have been removed from the refrigerator.During an interview with the Food Service Director on 07/30/2025 at 12:11 PM she reported she checks the refrigerators and the nursing supervisor's help to monitor the refrigerators. She advised items are checked for labeling with expiration dates and the resident's name. She reported anything not labeled properly or expired should be thrown away. During a review of the Food Receiving and Storage Policy on 7/30/25 at 12:23 PM it was revealed, All foods belonging to residents must be labeled with the resident's name, the item and the use by date.During a review of the Use and Storage of Food Brought in by Family or Visitors Policy on 7/30/25 at 12:32 PM it revealed, All food items that are already prepared by the family or visitor brought in must be labeled with content and dated and must be consumed by the resident within 3 days. If not consumed within 3 days, food will be thrown away by facility staff.

Based on observation and staff interviews, it was determined that the facility failed to properly label and store drugs. This was found to be evident in 1 of 1 medication cart observed during the survey recertification process.The findings include:08/05/2025 at 7:39 AM during environmental rounds on the 1st Floor A wing, the surveyor observed a medication cart left open and unattended. Inside the cart, the following items were noted; one bottle of Acetaminophen 325 mg, one bottle of Acetaminophen 500 mg, and one bottle of Stool Softener 100 mg. All three bottles were opened and did not have documented dates indicating when they were initially opened. On 08/05/2025 at 7:42 AM, RN #5 was interviewed in the presence of the Director of Nursing (DON) regarding expectations for the medication cart and labeling of opened medications. RN #5 stated that the medication cart is expected to remain locked at all times and that opened medications must be labeled with the date they are opened. RN #5 confirmed, in the presence of the DON, that the medication cart had been left unlocked and that the above medications were not labeled with a date of opening. On 08/05/2025 at 8:10 AM, the surveyor informed the Director of Nursing (DON) of the concern, and the DON acknowledged receipt.

Based on record review and staff interview, it was determined that the facility failed to provide adequate monitoring of residents on psychotropic medications for side effects. This finding was evident for 1 (Resident #2) of 5 residents reviewed for unnecessary medications during the recertification survey.The findings include:Resident #2 was admitted to the facility in December 2022 with diagnoses which included Dementia, Major Depressive Disorder and Diabetes Mellitus. On 08/06/25 at 8:59 AM a review of Resident #2's clinical record revealed that the resident had been receiving Seroquel 125mg daily at bedtime for Dementia from 06/30/25. Further review of Resident #2's clinical record revealed that a care plan was initiated on 12/15/22 addressing the resident's mood problem relating to Dementia. In the care plan there was an intervention Administer medications as ordered. Monitor/document for side effects and effectiveness. A review of Resident #2's Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to reveal evidence that the resident was monitored for side effects of the medication, Seroquel. On 08/06/25 at 10:11AM in an interview the Unit Manager#3 stated that residents who are administered psychotropic medications are monitored for side effects, and the results are documented on the MAR or TAR. The surveyor asked the staff member to review Resident 2's clinical record to ascertain whether the resident was being monitored. Unit Manager#3 reviewed the clinical and confirmed that Resident #2 was not being monitored for side effects of Seroquel.After the surveyor's intervention, on 08/07/2025 at 7:01 AM a review of Resident #2's clinical record revealed that a physician order was initiated on 08/06/25 to monitor the resident for side effects of the medication Seroquel. The monitoring started on 08/06/25. 08/08/2025 at 7:26 AM the Director of Nursing was notified of the surveyor's findings.

Based on review of employee personnel files and staff interview, it was determined that the facility failed to complete annual performance reviews for the Geriatric Nursing Assistants (GNA). This was identified for 1 (#18) of 5 GNA staff members reviewed during the annual survey. The findings include: Performance appraisals are to be completed at least every 12 months to identify in-service education needed to address competencies of the geriatric nursing assistants. On 08/07/2025 at 1:47 PM, a review of GNA #18's employee file revealed that GNA #18 was hired on 06/18/2014. Further review of the employee file revealed that a performance appraisal for GNA #18 was completed on 06/18/2017, however there was no evidence that performance appraisals were completed before or after this date. An interview with the facility Administrator on 08/07/2025 at 2:35 PM confirmed that performance appraisals for GNA #18 had not been completed at least annually from the date of hire. At the time of exit, the facility did not provide any additional documentation to show that performance appraisals for GNA #18 were completed annually as required.

Based on record review and interview, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #115) of 7 residents reviewed for care planning.The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). Resident #115 was admitted to the facility in November 2023 with diagnoses including Hypertension and Diabetes Mellitus. The surveyor reviewed Resident #115's clinical record on 8/01/25 at 07:15 PM. The review revealed that Resident #115 had quarterly MDS assessments completed on 9/01/24 and 11/30/24. Review of the resident's care plans revealed that all care plan goals were revised on 12/13/24. There was no evidence in the clinical record that a care plan meeting was held with the resident and the interdisciplinary team around the time of either quarterly MDS assessment or at the time of the care plan revision. The surveyor interviewed Social Services (SS) Staff #7 on 8/05/25 at 10:30 AM. During the interview, SS Staff #7 indicated that social services staff were responsible for coordinating the care plan meetings with residents. Further, care plan meeting notes were documented in the resident's electronic records the same day or a day after the care plan meeting was held. The surveyor enquired whether care plan meetings were held for Resident #115 for the months of August 2024 and November 2024. SS Staff #7 reviewed the resident's electronic record and Hard Chart in the presence of the surveyor and confirmed that there was no documentation of care plan meetings for those months. SS Staff # stated I did not find any documentation. The surveyor requested SS Staff #7 to provide the survey team with any evidence that care plan meetings had taken place for Resident #115 around the time when the quarterly MDS assessments were completed on 9/01/24 and 11/30/24. On 8/06/25 at 6:58 AM the Director of Nursing was made aware of the surveyor's findings. At the time of exit no additional information was provided to the survey team

Based on observation and interviews it was determined that the facility failed to maintain a resident's right to privacy. This was evident for 1 (Resident #137) out of 1 residents observed for privacy.The findings include: During an observation of the room for Resident #137 on 8/12/25 at 2:08 PM, it was observed that he/she was in the window bed, the roommate, Resident #22 was near the door lying in the bed with his/her eyes closed. There were no staff members in the room.During an interview with Resident #137 on 8/12/25 at 2:10 PM he/she began to express concerns to the surveyor at that point the Resident was asked do you want me to shut the door? The Resident replied yes.During an observation on 8/12/25 at 2:10 PM upon stepping from behind the curtain Geriatric Nursing Assistant (GNA) #19 was observed leaving the room from the side of Resident #22 on the door bed side. Resident #22 was still lying in the bed with his/her eyes closed and the curtain was open. There was no notification provided of GNA #19 entering the room.During a continued interview of Resident #137 on 8/12/25 at 2:16 PM GNA #20 made a rapid knock on the closed door and quickly walked in without a pause or invite. She walked into the bathroom. She was observed washing her hands. There was no opportunity for the Residents to invite or give the GNA permission to enter the room.During an interview at on 8/12/25 at 2:18 PM with GNA #20 reported I went in there to wash my hands and advised she was coming back from taking trays into the kitchen. During an interview on 8/12/25 at 2:50 PM with GNA #19 she reported she was not assigned to the room with Residents #137 and #22. She advised she went into the room for Residents #137 and #22 because she was looking for towels. During an interview with the Director of Nursing (DON) on 8/12/25 at 3:20 PM she reported the expectation is to knock and wait before entering the Resident's room and close the curtains if providing care.

Based on medical record review and facility staff interviews, it was determined that the facility failed to initiate care plans. This was evident for 3 residents (#118, #156 and #161) out of 3 residents reviewed for care plan implementation during a recertification survey process.The findings include:A care plan is a comprehensive, individualized plan of care developed for each resident. It outlines the residents' medical, psychological, emotional, and social needs, as well as the goals, interventions, and services required to meet those needs. Care plans are created and maintained by the interdisciplinary care team.1) On 08/07/2025 at 10:18 AM, Resident #118's medical records and medication administration records (MAR) revealed physician's orders for Quetiapine Fumarate Oral Tablet 25 mg, to be given 1 tablet by mouth at bedtime for psychosis, and Sertraline HCl Oral Tablet 50 mg, to be given 1 tablet by mouth once daily for depression.Further review of the medical record revealed that on 08/07/2025 at 11:15 AM, the facility failed to initiate a care plan related to antidepressant and antipsychotic medications to reflect the plan of care for Resident #118.On 08/08/2025 at 8:58 AM, the surveyor interviewed the ADON regarding the process for initiating a care plan for a resident receiving antipsychotic and antidepressant medications. He stated that the process is to have a care plan in place. He confirmed that no care plan had been initiated for Resident #118's antipsychotic and antidepressant medications and stated, It was an oversight. The surveyor informed him of the concern, and he acknowledged receipt.Peripherally Inserted Central Catheter (PICC) is a long, thin, flexible tube inserted into a peripheral vein, usually in the arm, and advanced to a central vein near the heart, used for long-term intravenous therapy, including medications, fluids, or nutrition, and requires monitoring for potential infection.2) On 08/04/2025 at 7:15 AM, review of Resident #156's medical records revealed that the resident was admitted to the facility on [DATE] with physician's orders for a Peripherally Inserted Central Catheter for Intravenous therapy (PICC line) to the right upper arm for IV therapy.Further review of the medical record revealed that on 08/04/2025 at 9:15 AM, the facility failed to initiate a care plan related to PICC Line to reflect the plan of care for Resident #156.On 08/05/2025 at 1:11 PM, the surveyor interviewed Unit Manager/Educator #3 regarding the expectation for initiating care plans for residents receiving antibiotic therapy via Peripherally Inserted Central Catheter (PICC) line. She stated that the expectation is to initiate a care plan as per physician's orders. Unit Manager/Educator #3 confirmed that no PICC Line care plan was initiated for Resident #156 during antibiotic therapy. On 08/05/2025 at 1:30 PM, the surveyor notified Unit Manager/Educator #3 and the DON of the concern, and both acknowledged receipt. 3) On 08/11/2025 at 3:30 PM during a medical record review, it was revealed that Resident #161 experienced a fall on 04/21/2024. Review of Resident #161's care plan documented, Resident is at risk for falls related to poor balance. Date Initiated: 04/05/2024. Revision on 04/06/2024. Goal: Resident will remain free of falls through next review. Date Initiated: 04/06/2024. Target Date: 07/05/2024. Further review of the medical record revealed that on 08/11/25 at 3:40PM, the facility failed to initiate an actual fall care plan to reflect Resident #161's fall on 4/21/24.On 08/12/2025 at 9:56 AM, the surveyor interviewed the ADON regarding the process for updating a care plan after a resident fall. The ADON stated it is the expectation that the manager and supervisor ensure the care plan is updated and interventions are implemented whenever there is a change in condition. He acknowledged this expectation was not met. The surveyor informed him of the concern, and he acknowledged receipt

Based on clinical record review and staff interview it was determined that the facility staff failed to code a resident's discharge status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (#152) of 3 residents selected for closed record review during the annual survey.The findings include: On 08/06/2025 at 10:06 AM, a review of Resident #152's clinical record revealed that a discharge MDS was completed on 5/21/2025. The resident was coded under MDS Section A2105 (Discharge Status) as discharged to short term general hospital. However, a review of progress notes on 08/06/2025 at 10:37 AM revealed a Discharge summary dated [DATE] which stated Resident #152 passed away in the facility.On 8/13/2025 at 2:34 PM, an interview was conducted with the MDS Coordinator #13 who confirmed that Resident #152 was a death in the facility and that the discharge status for Resident #152 was coded inaccurately.

Based on two complaints of alleged witnessed allegations of abuse and interview with facility staff, it was determined that the facility failed to report to the State agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident for 2 of 2 allegations of abuse identified during a complaint survey for Residents # 158 and #72.The findings include:1. Review of complaints #MD337029 and #MD3370330 both submitted from separate visitors of residents both alleged observing staff GNA #2 forcefully and aggressively push Resident #158 back down into his/her chair in the dining room on 1/16/25 and then restrain him/her in their chair with a bedside table. Both individuals also independently reported that they reported their observations and concerns to nursing staff and Administration and continued to follow up with the outcome and they received no answers. Interview on 8/1/25 at 10:47 AM with complainant from MD337030 verbalized that they were afraid to have GNA #2 care for their family member and reported that too to administration with no response.On 8/1/25 at 12:30 PM this surveyor interviewed the NHA and DON facility regarding the concerns identified by the family and residents related to the nursing staff and reported interactions.Regarding the January incident, they were asked if they reported it to the state agency. They stated they didn't think it was a self-report as it wasn't reported to them as abuse. They were asked what they consider abuse. The DON stated that she just had a message about a concern about GNA and the way he spoke to the resident and that he was mean and rough. This was clarified and asked why again it was not reported. The DON stated that she interviewed the GNA and that he said it didn't happen the way it was reported. The facility was notified that this was a concern and would be cited. The Administrator asked how it could be cited if I did not review their investigation. This surveyor asked again if the allegation of abuse was reported and if the residents were kept safe during their investigation. The Administrator reported no. This surveyor stated that a review of the actual investigation has nothing to do with the reporting to the state, which they stated they did not do, and the state has no record of.2. Review of the resident council meeting minutes from the past 6 months revealed intermittent concerns related to staff responses. Specifically, on 3/26/25, Resident #72 verbalized a concern about how an aide had delivered the breakfast tray, the resident then requested for the aide not to be assigned to him/her and at one point the aide responded to Resident #72 by saying 'bring it on.' Review of this incident with the DON on 8/1/25 at 12:30 PM, she stated that the resident in question has behaviors. The Administrator then asked if they are supposed to put in a report for every allegation a resident with behaviors has. This surveyor stated that it is not up to another individual to tell someone what abuse is. This surveyor also referred the facility policy and regulations as to what the facility should follow and report. According to the Resident council concern form, the action taken was to talk to other residents-that were not listed or identified, and spoke to the GNA in question who stated that it did not happen the way the resident stated.Again, the concern that this abuse allegation was not reported to the state agency or interventions for the safety of the residents implemented during the investigation. The DON stated that Resident #72 has certain 'dynamics' and has issues with the staff. She said she spoke to the GNA, and he said that is not what happened, so she did not consider it a reportable, but they made a soft file for it. This surveyor then presented at what point and why are you believing staff and not investigating the concerns that your residents and families are bringing to you.The ongoing concern that the facility is not reporting allegations of abuse to the state agency was reviewed on 8/1/25 at 12:30 PM.

Based on a review of a complaint intake, medical record review, and staff interview it was determined that the facility failed to document the reason leading up to a transfer of a resident to the hospital in the medical record including a reason for the transfer. This was evident for 1 (Resident #160) of 6 residents reviewed for hospitalization . The findings include: On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room . A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. Review of the closed paper medical record on 7/25/23 revealed Hospital discharge instructions with the resident's name time stamped/prepared on 4/17/19 at 4:13 AM. The local hospital's discharge instructions indicated resident #160 had a fall from standing and a laceration to scalp. On 7/26/23 the assistant director of nursing (ADON) was shown the hospital discharge instructions and informed of the lack of documentation related to the resident's transfer and return to the facility on [DATE]. At 1:10 PM on 7/26/23 the ADON returned and confirmed the lack of documentation in the medical record indicating that the resident was transferred to the hospital and the lack of documentation of the resident's return to the facility. The ADON provided an internal document that was not part of the medical record indicating on 4/17/2019 the resident was observed on the floor with the resident's head towards the foot of the bed, laceration to the posterior head with blood, and transferred to the emergency room for evaluation.

Based on interviews and record review it was determined the facility failed to perform a thorough investigation of an allegation of abuse. This was evident for 4 (Resident #253, #1, #175, and #71) out of 6 residents reviewed for abuse. The findings include: 1) Resident #253 relayed to the surveyor on 7/11/23 at 12:02 PM an allegation of abuse in which they had reported that an Occupational Therapist was swinging the cane at me (approximately) last Thursday (7/6/23) and the facility reported to my family that I was threatening the staff. On 7/17/23 at 12:01 PM, PTA (Staff #28), stated in an interview with surveyors regarding the alleged incident on 7/7/23: We had to pull him/her back in the chair. We snugged him/her back in the chair by the gait belt. He/she wants to walk. On 7/21/23 at 12:00 PM, the facility ' s incident self report form was reviewed by surveyors. The report indicated that, on 7/14/23 at approximately 3:47 PM, the facility began investigating an allegation that Resident #253 had been abused during a therapy session on or around 7/6/23. The facility documented that Resident #253 reported the following information during a follow up visit on 7/14/23 done by the Assistant Director of Nursing, Administrator, and Social Worker: The resident did report to them that while working with the therapist on Thursday (7/6), the therapist pulled the resident ' s cane from him/her and tried to poke and hit him/her. The report further documented: When asked if he/she was actually hit with the cane, he/she said no, she tried to. The surveyor noted that Resident #253 had not made an allegation of being hit by a staff member. Further review of the facility reported incident provided the following information: The investigation revealed this incident was reported by the therapist to the RD (Director of Rehab) that the resident had swung at her with his/her cane, the cane was taken away and he/she attempted to hit her with his/her walker after refusing to sit in his/her chair to prevent a fall. In a statement from the investigation file with an email date of 7/14/23, Physical Therapy Assistant (PTA, Staff #28), wrote the following information: Pt (patient) got angry and replied No, I ' m not sitting down. PTA (Physical Therapy Assistant) had to pull pt (patient) back in chair to prevent pt (patient) from falling.The complete investigation file was reviewed and failed to address that Resident #253 had the right to say no to sitting back down. Review of the facility reported incident investigation revealed the following statement: Other staff interviewed stated he/she never mentioned any rehab staff hitting him/her, but he/she did complain about rehab services. No further information regarding the resident ' s complaints about rehab services was included in the facility ' s investigation file. Further review of the investigation file revealed that there was one question asked to twenty-two staff members documented on 7/17/23: Have you witnessed or experienced any abuse of resident or staff from (Staff #21), OT? The following items were not documented in the facility ' s complete investigation file: 1.) interview times, 2.) additional information that had been asked or reported, 3.) 19 out of 22 staff interviewed had no position title listed, 4.) there was no documentation of who had performed the interviews of staff and residents, 5.) there were no interview dates, times, notes, or questions asked by the facility to the three staff members who provided statements, 6.) there was no written statement obtained from the resident. Reference to F585 43096 2) A facility-reported incident, MD 00156247, was reviewed on 07/21/23 at 01:52 PM. The report review revealed that Resident #1's family member informed the Director of Nursing that an assigned nurse hit the resident's arm on 07/16/2020. The facility's investigation packet contained four staff interviews: the interview sheet had a written question, Have you witnessed or have knowledge of any staff members physically harming any residents specifically [XX: Resident #1's name]?. Four staff members checked yes or no on these sheets with signatures; however, no name, title, or details were documented. Also, the facility's investigation packet had nine residents' interview sheets (the headline of the page titled resident's interview) with a written question, Have you witnessed or have knowledge of any staff members physically harming any residents specifically [XX: Resident #1's name]. Four resident interview sheets had handwritten names with their credentials (RN-registered nurse, or their shift (ex. 3-11 PM), two of them had written names and room numbers, and three had only written names. There were no records for Resident #1's statement and alleged perpetrator staff status/evaluations. During an interview with the Director of Nursing (DON) on 07/21/23 at 2:15 PM, the surveyor reviewed the facility's investigation packet with the DON. The DON agreed the investigation was not thoroughly conducted. 3)The surveyor reviewed a facility-reported incident MD00188119 on 07/24/23 at 08:11 AM. The review revealed that Resident #175's family member reported that a GNA (Geriatric Nurse Aide) threw and swung his/her leg while they cared for the resident. Further review of the facility's investigated packet, the alleged perpetrator GNA had an interview via telephone on 01/23/23. The written statement showed, on 1/23/23 this writer called alleged perpetrator about working with resident in xxx[Resident #175 ' s room number] However, there was no additional information about who conducted this phone interview. Also, the investigated packet had three interviewed papers named Re: Investigation including six written questions: did you work on [specific unit] on 1/22/23 on 3-11 PM shift? Were you assigned to room [resident #175's room number]? At any time did you enter room [the resident's room]? If yes, what care did you provide to the resident(s)? Did you hear or witness any physical or verbal inappropriate behavior? And have you heard any concerns related to any GNA's or other coworkers? All three sheets did not include the name, date, and signatures who filled out these forms. Additionally, there were four sheets named Re: investigation, including four written questions: do you have any concerns? Is the staff providing care for you? Have you heard or witnessed physically or verbal inappropriate behavior from staff? And do you feel safe in the facility? These four sheets contained signatures; however, not able to identify who and when signed these. During an interview with the Director of Nursing (DON) on 08/04/23 at 09:30 AM, the surveyor shared the above concerns with the DON. 48168 4) On 8/1/23 at 10:00 AM, a review of the facility ' s documentation of their investigation into an alleged employee-to-resident abuse of Resident #71 revealed that the documents lacked details of the date, time, place of the incident, the date and time of the interviews, the name of the alleged perpetrator, and the name of the person conducting the investigation interviews. A form titled January 6, 2023, which was a written statement signed by the resident's, Social Worker (SW), lacked the time it was written, the date and time of the incident, and the name of the alleged perpetrator or victim. Another form was found entitled, Resident Interview that had two questions on it: 1. Did any staff shout at you during care on 1/6/23?, and 2. Did any staff slap you during care on 1/6/23? A sentence below the questions read The resident is unable to answer due to his/her cognitive deficits. The resident ' s name was handwritten on the top of the page. There was no notation of the date or time of the incident, date or time of the interview, or the author of the document. There were also 4 other forms titled Re: Investigation which listed 4 questions which appeared to be questions targeted for residents. There was also a set of 3 forms titled Re: Investigation which listed 6 questions and appeared to be targeted to staff. Each of these forms had handwritten one-word answers and illegible marks at the bottom of each form which appeared to be signatures. None of the forms had any name or identifier, any dates or times of when they were created, any date or time of the incident, or the name and title of the author/interviewer. On 08/04/23 at 08:30 AM, during an interview with Geriatric Nursing Assistant (GNA) #30 who was the alleged perpetrator, the GNA was asked if she made a written statement regarding the incident and she responded that she gave a verbal statement to the Director of Nursing (DON), who wrote it down, but the GNA did not write her own statement. On 08/04/23 at 11:55 AM, the folder of the facility ' s investigation documentation was reviewed with the Director of Nursing (DON). The DON was shown the contents of the folder which lacked sufficient details. The DON asked if she could add the missing elements to the form and confirmed that the facility ' s investigation documentation was not thorough.

Based on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (Residents #105, 119, 106, and 160) of 6 residents reviewed for Notice requirements before transfer/discharge. The findings include: 1) Review of the medical record for Resident #105 on 7/28/2023 at 10:07 AM revealed that Resident #105 was transferred to an acute care facility on the following dates: 2/8/2022 for left hip acute fracture, on 10/29/2022 for change in mental status, on 4/12/2023 for unwitnessed fall, and on 7/13/2023 for change in mental status and hypotension (low blood pressure). However, there was no documentation and/or evidence in the record indicating that the facility staff notified the resident/resident's representative (RP) in writing of the reason for the transfer/discharge to the acute care facility on the above dates/times the resident was transferred out. 2) Review of medical record for Resident #119 on 7/31/23 at 10:20 AM revealed that Resident #119 was transferred to an acute care facility on 10/18/2022 for altered mental status, hypotension, dehydration, and positive for COVID, and on 5/13/2023 for change in mental status, incoherent with slurred speech and SOB (shortness of breath). On 7/31/2023 at 10:34 AM, review of the facility's Bed Hold policy revealed the resident was given a written notification of the policy on 10/18/2022 and 5/13/2023 respectively (the two times he was sent to the hospital). However, there was no written documentation that the resident and/or resident representative was notified in writing of the reason for the transfer/discharge to the hospital. On 7/31/2023 at 11:00 AM, in an interview with the 2nd floor Unit Manager (UM #4), she stated that residents, their representatives (RP)/family members were notified verbally when a resident was transferred to the hospital by the transferring nurse. She confirmed that the notification was done verbally and not in writing. However, UM #4 added that they (facility staff) have started as recently as last week to send written notifications in addition to the bed hold policy to residents and their RP/family when a resident was transferred to the hospital. 44441 3) Review of the medical chart on 7/18/23 at 1:56 PM revealed a physician's order written on 5/9/23 to transferred resident to the hospital for medical treatment. Further review of the AUTM Change in condition/Concurrent review'' document dated 5/9/23 revealed that the transfer/discharge section was checked off to indicate that a notification for transfer was given to the resident's representative when resident was sent out to the hospital. On 7/19/23 at 9:48 AM Resident was asked in an interview if s/he was given a written notice prior to hospital transfer/discharge on 5/9/23. Resident stated that s/he did not and that it may have been given to his/her daughter who was the resident's representative. The resident's daughter on 7/19/23 at 2:43 PM was asked in an interview if she received a written notice of transfer when resident was sent out to the hospital on 5/9/23. Resident's daughter indicated that she did not. On 7/20/23 at 9:07 AM the unit manager Staff #4 was asked if a written notice before Transfer/Discharge was given to the resident, or their representatives and she responded that the resident or family members were notified verbally by phone and that written notices are not sent. The Director of Nursing (DON) was made aware on 7/20/23 at 9:34 AM that the document was checked off as given to the resident's representative when resident was sent out to the hospital on 5/9/23. She was asked to provide a copy. On 7/20/23 at 10:15 AM the DON confirmed that the facility did not have a written notice of Transfer/Discharge document that they mail out to resident's or their representatives on transfer to hospital/ discharge. 15701 4) On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room . A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. Review of the closed paper medical record on 7/25/23 revealed Hospital discharge instructions with the resident's name time stamped/prepared on 4/17/19 at 4:13 AM. The local hospital's discharge instructions indicated resident #160 had a fall from standing and a laceration to scalp. On 7/26/23 the assistant director of nursing (ADON) was shown the hospital discharge instructions and informed of the lack of documentation related to the resident's transfer and return to the facility on [DATE]. At 1:10 PM on 7/26/23 the ADON returned and confirmed the lack of documentation in the medical record indicating that the resident was transferred to the hospital and the lack of documentation of the resident's return to the facility. The ADON provided an internal document that was not part of the medical record indicating on 4/17/2019 the resident was observed on the floor with the resident's head towards the foot of the bed, laceration to the posterior head with blood, and transferred to the emergency room for evaluation. A follow-up conversation was held with the ADON on 8/3/23 at 2:40 PM to review additional regulatory non-compliance related to the lack of any documentation in resident #160's medical record of the 4/17/2019 transfer to the hospital. There was not any documentation of resident #160 or a family representative was provided written notification of the facility initiated transfer to the hospital.

Based on record review and interviews, it was determined that the facility failed to failed to develop and implement comprehensive, Resident-centered care plans for residents residing in the facility. This was evident for 5 (Resident #71, #252, #177, #93, and #399) of 33 resident care plans reviewed during the survey. The findings include: 1) A review of Resident #71's physicians orders on 7/18/23 at 1:51 PM revealed an order dated 6/23/23 for OT (Occupational Therapy) Clarification; RNP (Registered Nurse Practitioner) order; Resting hand splint to be worn on L [left] hand 8hrs [hours] on, during the day, assessing for redness, skin tears, and maintaining palmar hygiene and nail hygiene. This order was discontinued on 7/18/23. On 7/19/23 at 9:14 AM, the resident's care plan was reviewed and revealed that there was no focused care plan problem listed for the hand splint ordered on 6/23/23. In an interview with the Rehabilitation Director (Staff #27), on 7/24/23 at 12:56 PM, Staff #27 stated that when OT transitioned the resident's hand splint care to nursing, the Minimum Data Set (MDS) Nurse or the Unit Nurse Manager would update the care plan. On 8/04/23 at 9:26 AM, in an interview with the Director of Nursing (DON), the DON showed the surveyor a copy of Resident #71's care plan that included an intervention for a hand splint, but the Date Initiated was 4/12/19. When further questioned, the DON was not sure if the copy of the care plan was current. On 8/04/23 at 9:44 AM, the MDS Director was interviewed and the copy of the resident's care plan was reviewed. The MDS Director clarified that the 4/12/19 date was incorrect and was associated with a different problem, that the hand splint care plan was initiated on 7/18/23. When asked where the splint intervention on the plan of care for the transition from OT to Nursing on 6/23/23, the MDS Director stated that it was not entered on the care plan at that time, that it was missed. The new hand splint problem dated 7/18/23 was for a new order for the hand splint dated 7/18/23. The MDS Nurse said she informed the DON regarding the missing information. 43096 2) On 07/26/23 at 10:51 AM, the surveyor reviewed Resident #252's medical records. The review revealed that the resident was admitted to the facility in November 2022 with the diagnosis of old myocardial infarction, dementia, anemia, and spinal stenosis. Further review revealed that The facility staff monitored Resident #252's hemoglobin level from 04/04/23. On 04/07/23, the resident was transferred to an acute care facility to treat low hemoglobin (6.3 g/dl: normal range 12.1-15.1g/dl). Resident #252's discharge summary from the acute care facility dated 4/14/23 showed that the resident received the management of gastrointestinal (GI) bleeding during his/her hospitalization . However, no care plan was developed regarding Resident #252's GI bleeding after the resident's readmission on 4/14/23. On 7/26/23 at 12:50 PM, the surveyor shared the above concerns with the Director of Nursing (DON). The DON confirmed the deficiency. 3) 08/03/23 at 8:30 AM, a review of Resident #177 ' s medical record revealed that he/she had an actual fall on 04/08/21 without injury: the change in condition form documented that resident found on the floor in a sitting position between his/her bed and wheelchair with lap buddy pushed to the side. Another change in condition form dated 04/20/21 documented that an unwitnessed fall occurred on 4/20/21 at 10:40 AM: Resident was observed lying on the floor in a prone position bedside his/her bed and wheelchair with lap buddy on the floor. During an interview with the Assistant Director of Nursing (ADON) on 8/04/23 at 07:35 AM, he said, Resident #177 was very confused while he/she had resided in this facility and had no awareness about fall risk. He/she always tried to stand up or move. That's why we applied lap buddy for fall precaution. On 08/04/23 at 11:03 AM, an interview was conducted with Staff (#27, Director of Rehab). Staff #27 stated that Resident #177 had the lap buddy since 2014 per his/her family's request, and the evaluation for the lap buddy used was done prior to applying. However, a review of Resident #177's care plan (in the electronic medical record: PCC) on 08/04/11:45 AM revealed no evidence that a care plan was developed regarding the use of a lap buddy. On 08/04/23 at 3:25 PM, the ADON submitted a copy of the lap buddy care plan for Resident #177 dated 3/02/17, which was in paper format, not PCC. The care plan's approaches/interventions indicated that A. evaluate and assess for the use of the least restrictive device (s), B. assess no less than q 90 days for possible restraint reduction/elimination, C. refer to PT/OT for evaluation of positioning, safety and mobility needs, D. educate Resident and family related to device, consequences/alternatives, E. apply devices per MD's order: Type- lap buddy, Reason- prevent falls, F. provide exercise daily, and G. maintain dignity. However, there was no further evaluation and/or revised documentation for the lap buddy in Resident #177's medical record (including a paper chart or PCC). During an interview with the ADON on 08/04/23 at 3:40 PM, he confirmed that the facility currently uses PCC for residents' records. Also, he explained that since Resident #177 had resided in the facility for a long time, they used paper for the care plan in 2017. The surveyor asked how current Staff could follow the Resident's lap buddy care plan. The ADON could not provide an answer. On 08/04/23 at 04:10 PM, the DON and Nursing Home Administrator were made aware of this issue. 44441 4) On 7/11/23 at 10:15 AM observation of resident #93 revealed that resident was on oxygen via Nasal Canula (NC), an oxygen tubing with nose prongs. The NC was connected to a humidifier on the oxygen concentrator, a machine that concentrates oxygen from the air, at the bedside. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/8/23 on 7/26/23 at 2:20 PM documented that resident was on oxygen therapy. Further review of the physician's order revealed an order written on 7/22/23 for oxygen therapy at 2 liters via NC every shift related to mild intermittent asthma. On 7/27/23 at 11:12 AM Review of the most recent care plan with a completion date of 7/21/23 revealed that there was no care plan developed for the use of oxygen therapy. On 7/27/23 at 11:27 AM The unit manager was made aware of this concern and asked to provide a copy of the care plan. She confirmed that the care plan for oxygen therapy was not developed for resident #93. 5) On 7/10/23 at 09:00 AM observation of resident #399 in bed revealed that resident #399's bed was raised up high to the surveyor's hip level. The resident was nonverbal and could not answer the surveyor's questions. No one was in the room with the resident. On 7/11/23, and 7/12/23 at 0900, resident was observed again in bed with the bed elevated up to the surveyor's hip level. On 7/12/23 at 2:19 PM, the unit manager Staff #4 and the Respiratory Therapist Staff #54 were at the bedside. The unit manager was made aware of the concerns and indicated that Resident #399 's wife visits resident daily and would put the bed up to chat with resident. Review of the physician's order revealed an order written on 5/9/23 that reads Bed in low position while resident is in bed every shift for injury prevention. Review of the resident's care plan with target completion date of 6/15/23 has as focus. Resident is at risk for falls related to (r/t) dependent on transfers, recent surgery, Cardiovascular Accident (CVA) with hemiplegia a paralysis on one side of the body. The goal was that Resident will remain free of falls through next review and the interventions was to Keep bed in lowest position. On 7/24/23 at 09:00 AM -Resident #399's bed was observed again in the high position with resident lying on it. The unit manager staff #4 and the Assistant Director of Nursing (ADON) were brought into the room and the concern reviewed with them.

Based on medical record review, interviews, and observations it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 8 (Resident #69, #148, #43, #253, #31, #50, #71, #72) of 83 residents reviewed during the survey. The findings include: 1) On 7/24/2023 at 1:11 PM, Review of order summary report for Resident #69 revealed two separate medication orders for Bactroban: - Bactroban External Ointment 2 % (Mupirocin) Apply to face topically one time a day for wound care. Order date 6/26/2023 and discontinued on 7/19/2023. - Left Cheek/Face Wound- Apply Bactroban and leave open to air twice a day. every day and evening shift order date 6/6/2023 and discontinued on 7/19/2023. On 7/24/2023 at 2:15 PM, Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June and July 2023 was completed. Staff documentation revealed duplicate medication (Bactroban) application to the resident's face from 6/27/2023 through 7/19/2023: MAR application noted one time a day for wound care and TAR, twice a day every day and evening shift. On 7/26/2023 at 10:40 AM, Review of Resident #69's paper chart revealed dermatology follow up notes dated 7/18/2023 that indicated the Resident's left cheek wound was biopsied with new order for treatment with bacitracin twice a day (reason why the Bactroban was discontinued on 7/19/2023). On 7/26/2023 at 10:45 AM, Surveyor reviewed Resident #69's MAR and TAR for June 2023 and July 2023 with the resident's nurse, Licensed Practical Nurse (LPN #18) and the Assistant Director of Nursing (ADON). They both stated that the check mark on the MAR and TAR meant the medication was administered to the resident. LPN #18 confirmed that the order for Bactroban was a duplicate order. She stated that the medication came from the pharmacy and for pharmacy to send a refill she had to put in another order (reason for the Bactroban order of 6/26/2023 on the MAR). She acknowledged that her signature on both the MAR and TAR meant she was applying the same medication two different times on day shift. However, LPN #18 stated that she only did the treatment once during the dayshift and confirmed that her documentation on the MAR for Bactroban application was not accurate. The ADON stated that the order put in to get pharmacy to refill the Bactroban should have been discontinued once the medication was delivered. The ADON added that the order on 6/26/2023 was put in wrong and staff was just documenting on the MAR and TAR without paying attention to the duplicate order. On 7/26/2023 at 11:15 AM, Resident #69's MAR and TAR for June 2023 and July 2023 were reviewed with the Director of Nursing (DON) who confirmed the order for Bactroban was duplicated and staff documentation inaccurate. On 7/26/2023 at 11:31 AM, in a follow up interview with Resident #69, s/he stated that staff had been applying the Bactroban to his/her left cheek wound two times a day. On 7/27/2023 at 10:15 AM, in an interview with the 2nd floor Unit Manager (UM #4), a discussion was held regarding the lack of accurate documentation related to the order for Bactroban. UM #4 confirmed that the check mark on the MAR for Bactroban meant the medication was applied. She added that because the medication was already in the treatment section (TAR), the nurse should have called the pharmacy for a refill instead of writing it as a new order. UM #4 further stated that the nurses were not applying the medication three (3) times as reflected in their documentation. 43096 2) On 08/02/23 at 11:27 AM, the surveyor reviewed a complaint, MD00182706. The complainant reported that the facility provided paperwork for Resident #148, including incorrect date of birth (DOB) and age. Also, the complainant added there was wrong code status documented on the papers. On 08/02/23 at 11:45 AM, Resident #148's medical records, including electronic (PCC: electronic medical record cloud) and paper charts, were reviewed. On admission record and PCC recorded Resident #148's date of birth as [xx/xx/xx: specific date in the middle 1950s]. Also, Resident #148's code was updated as DNR (Do Not Resuscitation) on 07/16/22 from the full code. A review of the order for the resident revealed that he/she had active order for DNR. However, there were multiple patient orders (documentation for internal communication between facility staff to providers) documented as below: a. Resident #148's lab result from [XX: name of laboratory] dated 07/18/22 at 01:25 PM documented DOB as 11/19/1950 (not Resident #148's DOB per PCC). b. The patient's order form dated 07/18/22 at 02:14 PM for Resident #148's diet order from dietitian to physician contained the resident's DOB as 11/19/1950. c. The patient's order form dated 07/18/22 at 07:35 PM regarding Resident #148's lab result from the facility staff to the physician documented the resident's DOB as 11/19/1950, which was not his/her DOB on PCC. d. Resident #148's lab result from the XX [name of laboratory] dated 07/19/22 at 03:05 PM documented Resident #148's DOB as 11/19/1950. e. Resident #148's lab result from the XX [name of laboratory] dated 07/22/22 at 01:39 PM contained the resident's DOB as 11/19/1950. f. The patient's order form dated 07/31/22 at 10:01 PM for Resident #148's x-ray result from the facility nursing staff to the physician documented the resident code as full code. On 08/02/23 at 02:10 PM, the surveyor verified that no other resident had the same name as Resident #148 in the facility's system. During an interview with the Director of Nursing (DON) on 08/03/23 at 09:39 AM, the DON confirmed that patient orders were a part of residents' medical records. The surveyor reviewed the patient's order sheets, and lab result reports with Resident #148's incorrect information. The DON said, I will talk to the laboratory too. On 08/04/23 at 04:10 PM, the DON and Nursing Home Administrator were made aware of this issue. 44441 3) On 7/11/23 at 2:34 PM Resident #43 was observed in room with limited range of motion to the left upper extremities and a Left-hand contracture. Resident was observed without a splint to the left hand. Resident's daughter was at the bedside and on interview stated that the resident had an order for a left-hand splint to be worn every 4-6 hours daily. The daughter further stated that staff stopped applying the splint because it hurts resident's hands. Review of the quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/6/23 on 7/26/23 at 9:43 AM documented an impairment to the upper extremities on one side. Review of the physician's order written on 5/12/22 had Order for left hand roll splint on left hand. Wearing Schedule: 4-6 Hours daily one time a day for Contracture prevention/management. On 07/26/23 at 10:09 AM a review of Resident #43's care plan with an ARD of 5/12/22 revealed a care plan for pain related to Cardiovascular Accident (CVA) with hemiparesis (a weakness or paralysis on one side). Some of the interventions were splint: left hand roll splint on left hand. Wearing Schedule: 4-6 Hours daily. On 7/26/23 at 11:00 AM a second observation was made of the resident, there was no splint to the Left arm. On 7/26/23 at 11:05 AM review of the residents July 2023 Treatment Administration Record (TAR) revealed that nursing staff were signing off that resident wore the splint. Resident #43 was observed again on 7/27/23 at 9:20 AM, 10:15AM and at 12:30PM. Observation revealed that resident was not wearing a splint to the Left hand. Review of the TAR on 7/27/23 at 12:35 PM revealed that this intervention was signed off by nursing to indicate that the splint was placed On 7/27/23 at 12: 40 PM The residents nurse a License Practical Nurse (LPN) Staff #6 was called to Resident #43's room and asked to show the surveyor where the splint was. Staff #6 looked through the resident's bedside table draws and found the splint, tried to put it on the resident's wrist but could not. Staff #6 could not tell the surveyor when last the splint was placed. The Geriatric Nursing Assistant (GNA) Staff #45 came over and told Staff #6 and the surveyor that the resident stopped wearing the splint a while back because resident complained that it hurts when staff attempted to place it. On 7/27/23 at 2:00 PM the unit manager Staff #4 was made aware of the concern that staff were signing off to indicate that the splint was placed when it was not. 47200 4) On 7/18/23 at 8:22 AM the Assistant Director of Nursing (ADON) brought Staff #29, Psychiatric Certified Registered Nurse Practitioner to the surveyor. The ADON introduced Staff #29 as the Psychiatrist. Staff #29 was asked by the surveyor if they were the Psychiatrist, and they responded yes. The surveyor had previously reviewed medical records which referred to Staff #29 as a Nurse Practitioner. During medical record review for Resident #253 on 8/1/23 at 9:46 AM, psychiatric notes were reviewed which documented Staff #29's position as physician. It was also noted by surveyors that Staff # 29's notes were electronically signed as a Physician instead of a Certified Registered Nurse Practitioner. In a note with an effective date of 6/29/23, Staff #29 had electronically signed the evaluation of Resident #253 as a Physician. A note for a visit performed on 7/18/23 by Staff #29 was not created and available on the medical record until 7/21/23. The note for a visit performed on 7/14/23 by Staff #29 was not created and available on the medical record until 7/18/23. During an interview with the Director of Nursing on 8/1/23 at 9:00 AM, they reported there was no set facility process in place for oversight of psychiatric records to ensure they are documented, timely, and accurate. During an interview with the facility Administrator on 8/1/23 at 11:03 AM, they stated the facility was not aware of Staff #29 documenting and signing as a physician, and their user role in the computer system had now been corrected. At this time, they acknowledged the surveyor's concerns. 5) On 8/2/23 at 11:21 AM, the surveyor reviewed the prescription dated 7/21/23 for Resident #31 to receive Trulicity injectable medication located in the medical record which states the following information: Inject 0.5 mililiters (0.75 miligrams total) under the skin once a week. Further review of the medical record revealed an order beginning 7/21/23 that directed a different amount of Trulicity: Inject 0.75 mililiters subcutaneously (under the skin) one time a day every Fri for Diabetes Mellitus. On 8/2/23 at 2:30 PM, the surveyor asked to see the Trulicity for Resident #31 which revealed each pen contained 0.5ml/0.75mg and the prescription labeling of the pens matched the labeling of the box they were stored in. The facility administrator and Director of Nursing were subsequently notified by the surveyor of the concern and acknowledged the surveyor ' s concern. 48168 6) In an interview with Resident #50 on 7/12/23 at 10:48 AM, the resident explained that despite asking, he/she has not been allowed to reside in a room with his/her spouse who is also a resident at the facility. On 7/28/23 at 08:06 AM a record review revealed no documentation in the Social Worker notes regarding Resident #50 ' s request to reside with his/her spouse. In an interview with Staff #33, the first floor Social Worker (SW), and Staff #2, the Director of Social Work, on 7/28/23 at 9:45 AM, Staff #2 reported that neither the resident's, nor the resident ' s spouse ' s rooms were big enough to accommodate them both based on their care needs. Staff #2 confirmed that there was no documentation in the resident record regarding this concern. 7) A record review on 7/18/23 at 10:16 AM for Resident #71 revealed a document entitled Change in condition dated 6/25/23 which described finding a new blister on the resident's left hand. Further review of skin assessment documentation revealed 3 consecutive weekly skin evaluations dated 7/2/23, 7/9/23, and 7/16/23 and all described the resident's skin as intact. On 7/18/23 at 12:02 PM, during an observation of Resident #71, and an interview with Licensed Practical Nurse (LPN) #46, the LPN showed the surveyor the resident's left hand with a scabbed blister approximately 5 mm (millimeters) in diameter. In an interview with the Unit Manager for Resident #71's unit on 7/19/23 at 10:13 AM the Unit Manager described the facility process for documenting skin assessments, and said that any new or existing skin alteration, including scratch and abrasion, should be documented weekly. On 8/02/23 at 1:39 PM in an interview with the Director of Nursing (DON), the DON confirmed that Resident #71's skin records on 7/2/23, 7/9/23, and 7/16/23 failed to capture the blister first identified on 6/25/23 and still present at the time of the survey. 8) On 7/20/23 at 11:46 AM a review of a Psychiatric Progress Note dated 7/13/23 for Resident #72 revealed that the printed document incorrectly listed the author, Nurse Practitioner (NP #29), as a Physician. The printed electronic document did not contain an e-signature, and the text of the document did not include the author ' s name or credentials. In an interview with the Director of Nursing (DON) on 8/01/23 at 9:10 AM, the DON said that she indicated that she did not have information about the NP notes that were documented. On 8/01/23 at 11:03 AM an interview with the Nursing Home Administrator (NHA) was conducted. The NHA explained that there were issues with Staff #29's User Role when he was first set up at another facility. When asked what his correct role was, the NHA confirmed that Staff #29 is an NP and not a Medical Doctor. The NHA also confirmed that the medical record documentation incorrectly indicated that Staff #29 was a physician.

Based on surveyor observation and staff interview it was determined the facility staff failed to keep the building clean, neat, attractive and in good repair. This was evident on both floors of the facility. The findings include. An environmental tour was conducted with the maintenance director (staff #16) on 7/21/23 at 9 AM. The maintenance director was informed of the accumulated environmental concerns by multiple members of the survey team during the initial days of the survey beginning on 7/10/23. The following observations were confirmed by the Maintenance director. In room [ROOM NUMBER] bathroom, revealed vinyl cove/base molding separating from wall along the left wall, a browned stained ceiling tile near the ventilation fan and a rust stained metal suspended ceiling strip above the sink. In room [ROOM NUMBER] bathroom, revealed a hole in the bottom of the wall to the right of the sink area measured approximately 10 inches long, 3 to 4 inches deep extending down under the cove molding area and appeared larger than what was visible. The wall was spongy and moved to slight pressure. Near the baseboard/cove molding to the left of the toilet was damage to the wall approximately 4 inches long where the vinyl cove molding was separated from the wall. Behind the head of bed C was exposed plaster above the cove molding approximately 3 x 5 inches. In room [ROOM NUMBER] bathroom noted wall damage at the area above the cove molding and the cove molding was separating from the wall. The bathroom sink was loose from the wall and slightly separated from the wall with damage to the wall at the sink area. On the wall directly across from the B bed, there were multiple scraps in the drywall halfway up the wall exposing the base layer of the Throughout the tour the maintenance director confirmed the observed damage and incomplete repairs and indicated that when the bathroom floors were replaced there was damage to the walls that was not repaired at the time and the vinyl cove molding should have been taller. Additionally, he called his assistant a couple of times to report what needed to be fixed. In room [ROOM NUMBER], behind the head of the bed A, noted peeling paint approximately 2 by 4 feet long area on the wall. In room [ROOM NUMBER], behind the head of the bed C, observed damage/peeling paint in an area approximately 1 foot x 1 foot. A second environmental rounds was initiated with the maintenance director on 7/27/23 at 12:30 PM. The maintenance director confirmed the following observations: In room [ROOM NUMBER] bathroom, the base/cove vinyl cove molding was separating below the sink and along the wall left of the sink. The wall behind the toilet shown to have a foot long brown stain. In room [ROOM NUMBER] bathroom, the paint was noted to be peeling off the wall underneath the toilet paper dispenser and above the base/cove molding approximately 2.5 feet long. Multiple damage areas on the walls above the cove molding shown to have top layer of wall board torn with spots missing. In room [ROOM NUMBER] bathroom, along the left wall to the sink areas of peeling paint above the base/cove molding approximately 3 feet long with separation between the base molding and the walls. On the right bathroom wall noted 6-inch dark oval discoloration in the middle of the wall. In room [ROOM NUMBER] bathroom, a length of the base/cove molding approximately 8 inches long was unattached to the wall exposing rough unpainted section of the wall where the molding was previously attached. The wall behind the head of bed C appeared to have streaks of peeling paint approximately 5 x 12 inches long as if the wall was scrapped by a rake. In the hallway outside of the 2nd floor dining room was a 1-foot semicircle stain in a ceiling tile. Throughout the tour the maintenance director confirmed the observed damage and incomplete repairs and indicated that when the bathroom floors were replaced there was damage to the walls that was not repaired at the time and the vinyl cove molding should have been taller. Additionally, he called his assistant a couple of times to report what needed to be fixed.