Every finding on record at Autumn Lake Healthcare at Chesapeake Woods

Based on record review and interviews it was determined that the facility staff failed to supervise a cognately impaired resident who was at high risk for elopement as evidenced by the resident leaving the facility unattended without the staff's knowledge. This deficient practice was evidenced in 1(#40) of 1 resident investigations reviewed for elopement during the recertification survey.The BIMS (Brief Interview for Mental Status) assessment is a quick standardized cognitive screening tool used in long-term care facilities to gauge a resident's orientation, attention and memory recall through simple questions about the date and repeating three words. Scored from 0-15, it helps staff track changes in cognitive function, identify potential delirium or dementia, and determine if further specialized assessment is needed. Scores are categorized: 13-15 (intact), 8-12 (moderate impairment), 0-7 (severe impairment).The findings include:On 12/15/25 at 10:09 AM a review of the facility's investigation related to the elopement of Resident #40 revealed on the afternoon of 12/21/24 a visitor was in their truck in the parking lot of the facility and heard Resident #40 attempted to open the door to their vehicle. The visitor realized Resident #40 was a resident from the facility. He & his wife brought the resident back to the facility. Prior to the incident Resident #40 was residing on the Dementia Unit Choptank which was a locked unit. It was documented that the residents' Brief Interview for Mental Status (BIMS) score at the time of the incident was 5/15. On 12/15/25 at 10:40 AM a review of the Investigation Summary revealed the secured door leading out of the Dementia Unit (Choptank) malfunctioned and was not securely locking. The surveyor reviewed the Wandering/Elopement assessment completed on 05/12/23 when Resident #40 was admitted and revealed the resident was deemed a high risk to wander.On 12/15/25 at 1:18 PM during an interview with Regional Director of Maintenance #10 the surveyor asked when there is a maintenance issue that needs to be addressed, how does the staff communicate the problem to the maintenance department. Regional Director of Maintenance verbalized the staff puts a work order request in TELS. The surveyor asked what checks and balance system was in place to ensure that maintenance issues are addressed. He/she verbalized they go out and fix what needs to be fixed. On 12/15/25 at 2:11 PM during an interview with Regional Director of Maintenance #10 the surveyor asked for documentation to verify the door to the secured Dementia Unit, Choptank was repaired. The Regional Director of Maintenance #10 verbalized a work order was not completed for the door to be repaired on 12/21; when the resident got out of the facility, he/she came in and fixed the door. When he/she comes in on emergency calls he/she doesn't create a work order. The surveyor asked how they could verify if the door was repaired and what was wrong with the door. Regional Director of maintenance #10 verbalized the plate that grabs the mag lock would not close. The plate got stuck and it wouldn't move. He/she adjusted the plate and the speed of the closer. He/she kept adjusting it long enough for it to close. The Administrator reported he/she had the staff checking the doors every shift after the incident occurred for 4 days afterwards. On 12/16/25 at 9:18 AM a review of the Performance Improvement Plan (PIP) dated 01/03/25 indicated the door was repaired and the staff were instructed to check the doors every shift x 5 days then weekly by the maintenance department for three months. A note on 12/27/24 indicated every shift door checks were completed. In-service education was to be provided to all staff to check the doors after entering and exiting the unit. A note on 12/26/24 indicated all staff were in-serviced on checking the door after entering and exiting the unit. The surveyor reviewed the documentation to verify the staff checked the doors every shift x 5 days as indicated on the PIP. The surveyor reviewed an invoice from the security company dated 02/26/25. A description of the services to be provided: Install 4 Single Door Mag locks with Bond Sensors, 2 Timer Modules, 2 Piezo Buzzer, 2 Audio/Visual Sirens, and 1 Power Supply. A note was written on the invoice that stated, replacement Choptank Buzzer, mag lock alarms with timer. The Administrator was made aware the invoice did not indicate a fee was paid for the services on the invoice. The Administrator provided an email from the security company indicating the work was started on 02/20/25 and completed on 02/26/25.On 12/16/25 at 11:14 AM the surveyor reviewed the days and times when there was no documentation to verify the staff checked the doors after the resident eloped. The Administrator confirmed the dates and times.On 12/17/25 at 9:01 AM during an interview with the Administrator the surveyor reported all the staff were not in-serviced concerning elopement and the surveyor confirmed the doors were not checked for 5 days as indicated on the PIP. The Administrator reported there was no further information about the training and the doors being checked. The surveyor reported that after reviewing all the documentation from the investigation, there is no documentation to support the door to the locked Dementia Unit Choptank was repaired prior to 02/26/25. The compliance date was determined to be 02/26/25.

Number of residents sampled: Number of residents cited: Based on observations, record review, and interviews with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the initial tour of the kitchen.The findings include:Cross-contamination refers to the transference of harmful substances or pathogenic microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils that have not been properly cleaned after contacting raw food and then touching ready-to-eat foods. Cross-contamination may also arise from inadequate dishwashing procedures that fail to effectively wash, rinse, sanitize, and air-dry all food equipment.On 12/10/2025 at 7:45 AM, The surveyor conducted a kitchen tour with the Healthcare Services Group (HCSG) Regional Manager after calibrating stem thermometers in a cup of ice water, and the following non-compliance issues were identified:Front Entrance AreaHandwashing Facility Absence: A hand sink was missing near the ice machine and the drink station. Employees must walk across the kitchen to the walk-in cooler or warewashing areas for handwashing after each tasks such as donning hair/beard nets, serving ice, dispensing fountain sodas, and coffee/tea.Ice Machine Condition: The interior and exterior of the ice machine were unclean.Improper Ice Storage: The ice bucket and scoop were stored incorrectly on top of the ice machine.Mop Sink/Chemical Storage Area 4. Handwashing Facility Absence: A hand sink was not present in the mop sink/chemical storage area. 5. Clutter: The mop sink area was cluttered. 6. Ventilation Verification: the mechanical exhaust ventilation operability could not be verified due to insufficient lighting by the mop sink area.Warewashing Area 7. Hand Sink Integrity: The hand sink and faucet were not securely fastened to the wall and sink basin. 8. Mechanical Dishwasher Condition: The interior and exterior of the high-temperature mechanical dishwasher were unclean, showing excessive accumulation of dust, dirt, debris, and food particles. (Final rinse temperature measured 173 F with a DishTemp thermometer). 9. Type 2 [NAME] Design: The Type 2 Local Exhaust Ventilation ([NAME]) for the high-temperature mechanical dishwasher was improperly designed and calibrated, failing to sufficiently remove heat, steam, and vapors. Steam was observed dissipating into the kitchen instead of being drawn into the [NAME] directly above the dishwasher. 10. Structural Cleanliness: Walls and floors underneath the equipment were soiled. 11. Sanitizer Concentration: The sanitizer level in the 3-compartment sink was measured above 400 ppm from the dispensing unit. 12. 3-Compartment Sink Faucet: The faucet at the 3-compartment sink was loose. 13. Sink Sealant Condition: The sealant around the edges of the 3-compartment sink was unclean and/or missing. 14. 3-Compartment Sink Drainage Failure: A dump test on the 3-compartment sink failed, with the drain line splashing gray water onto the kitchen floor. 15. Floor Condition: Pools of standing gray water were observed in cracked floor tiles around the 3-compartment floor sink.Food Preparation Area 16. Can Opener Cleanliness: The prep table-mounted commercial can opener was unclean. 17. Utensil Storage: Wall-mounted cooking utensils were improperly hung. All food contact surfaces and kitchen equipment must be smooth, non-porous, and easily cleanable and sanitized. 18. Prep Sink Drainage Failure: A dump test on the in-counter food prep sink failed, with drain lines discharging gray water directly onto the kitchen floor. 19. Bulk Food Storage Cleanliness: Bulk food bins stored beneath a food prep table were unclean. 20. Equipment Integrity: The food prep table legs were replaced with makeshift, painted wooden legs that are now bent and no longer perpendicular to the floor. 21. Storage Height: The bottom shelves of clean dish racks require elevation to 18 inches off the floor.Cooking AreaH 22. Hand Sink Integrity: The hand sink was not securely fastened to the wall. 23. Equipment Cleanliness: All cooking equipment beneath the Type 1 canopy hood was unclean, exhibiting excessive buildup of grease, dirt, dust, debris, and food particles. 24. Structural Cleanliness: Walls and floors underneath the cooking equipment were unclean. 25. Exhaust Obstruction: The overshelf over the 6-burner gas range obstructed the exhaust of grease, steam, odor, and latent vapors from the cookline. Excessive buildup of grease, dirt, and debris were observed beneath the overshelf. 26. Equipment Placement: The commercial convection oven and steamer protruded beyond the canopy hood overhang, allowing grease, steam, and latent vapors to escape into the kitchen. 27. Canopy Hood Condition/Documentation: The canopy hood baffles were unclean. Unable to verify the last hood service report or the date on the service plate during the survey. 28. Equipment Repair: The inoperable steam table must be repaired or replaced to prevent the harborage of dust, dirt, debris, bacteria, and pests. 29. Personal Items: Personal belongings were observed near the cookline. 30. Clean Storage Height: Clean sheet pans were stored under the in-counter prep sink, next to the drain line, less than 18 inches above the floor. 31. Equipment Repair and Cleanliness: The interior and exterior of the hot warming cabinet were unclean. The door gaskets of the unit were warped. Walk-in Refrigerator 32. Door Gaskets: The walk-in refrigerator door gaskets were unclean. 33. Threshold Plate: The threshold plate was loose and unstable. 34. Evaporator Coils: Ice buildup was observed behind the condensate fans around the evaporator coils. 35. Storage Practices: Milk crates were stored directly on the floor. 36. Shelving Cleanliness: Shelving units were unclean.Walk-in Freezer 37. Conditions of Walk-in freezer/Potential Cross-contamination: Walls, floor, ceiling, and shelving units were covered with excessive frost, ice buildup, and ice dam. Ice buildup was present inside open food boxes, excessive frost on ice cream cartons, icicles formed around the condensate fans reaching the bags of ice in the back corners of the unit, and on top of frozen sheet pans. All unopened/sealed food boxes delivered that morning were stored on the floors. A freezer truck was reserved to relocate the items. 38. Door Gaskets: Repair or replace torn walk-in freezer door gaskets.Throughout the Kitchen Area 39. Backflow Prevention: Backflow prevention devices must be provided on all water lines and/or replaced every three years. 40. Drainage Air Gap: Rusted floor sink grate covers must be removed, and an air gap equal to two times the diameter of the drainpipe must be provided on all drainpipes to prevent siphonage. 41. Cracked, Chipped, Pitted, and Unsealed Wood: Repair or replace broken floor tiles and cove base. Replace all cracked/chipped/pitted plate covers, food containers, and utensils. Seal porous materials with food-grade sealant to prevent/eliminate absorption and bacterial proliferation. 42. Wall and Ceiling Penetrations: Seal open penetrations on the walls and ceilings throughout the kitchen to prevent pests/insect infestations. 43. Odor Control and Cleanliness: All floor sinks, trench drains, drainpipes, p-traps, and drain hubs must be cleaned to eliminate foul odors.Food Storage Area 44. Structural Damage: Water damage was observed on the ceiling. 45. Equipment Storage: Mixer attachments were stored improperly.Unit Ice Chest and 5-gallon Water Dispenser 46. Non-Commercial Equipment and Sanitation: Two push carts holding a non-commercial grade ice chest and 5-gallon water dispenser were in front of the kitchen double doors. The surveyor asked the HCSG Regional Manager to open the ice chest lid and verified standing water with floating black, unknown particles. In addition, the bottom shelves of the push carts were heavily soiled, potentially from juice spillage from the 5-gallon water dispenser. The surveyor could not verify the location in the kitchen where the ice chest coolers and water dispenser were washed, rinsed, sanitized, and air-dried.At 9:23 AM, the Regional Maintenance Director, Maintenance Director, HCSG Regional Director, and the Administrator toured the kitchen to go over the list of findings listed above. At 11:10 AM, the surveyor observed the HCSG Regional Manager discarding open boxes of biscuits, pizza dough, health shakes, pie shells, pancakes, and frozen pie. The walk-in freezer floor was very slippery with layers of ice buildup on the floor. The walk-in freezer conditions were noted to be hazardous for employees to remove additional contaminated food items safely. All sealed and unopened boxes were to be removed upon the freezer truck's arrival. The surveyor requested to be present when the freezer was shut off, and ice buildup have been melted to witness the discard of the remaining contaminated food items from the unit. Cross reference to F880

Number of residents sampled: Number of residents cited: Based on observations and interviews with facility staff, it was determined that the facility failed to maintain clean and effective ventilation systems, thereby impeding proper airflow throughout the premises. This was evident in 13 out of 16 ventilation systems reviewed during the annual survey.The findings include:Local Exhaust Ventilation ([NAME]) systems are designed/engineered to capture and remove contaminants such as excessive heat, steam, condensation, vapor, smoke, and fumes. This is achieved by calibrating the total pressure, which is determined by the sum of the static pressure exiting and entering the system, minus the velocity pressure entering the system. In addition, the fan speed, pressure, and power must be adjusted to account for the specific gravity of the contaminant being captured and removed by the [NAME] system, considering the specific size and air changes of the room.Type 1 hood systems are designed and installed primarily over cooking equipment to exhaust grease, heat, steam, condensation, vapor, smoke and fumes from the kitchen. Type 2 hood systems are designed and installed primarily over high-temperature mechanical dishwashers and other commercial kitchen equipment that produce excessive steam, condensation, and vapor.On 12/10/2025 at 8:20 AM, the surveyor utilized a smoke stick to assess the laminar airflow of the [NAME] systems in the kitchen, and the following deficiencies were noted:The Type 2 hood situated above the high-temperature mechanical dishwasher was found to be inadequately designed and calibrated, resulting in insufficient removal of heat, steam, and vapors. Steam was observed dissipating into the kitchen rather than being effectively captured by the [NAME] directly above the dishwasher.The Type 1 canopy hood serving the commercial convection oven and steamer was positioned such that the appliance protruded beyond the canopy hood's overhang. This configuration allowed grease, steam, heat, condensation, and latent vapors [NAME] out into the kitchen.On 12/17/2025, at 2:25 PM, the Regional Maintenance Director assisted the surveyor in the physical verification of the following ventilation systems' functionality by placing a sheet of tissue paper on the exhaust fan covers:Dirty laundry room - inoperableClean laundry room - inoperableChoptank janitor's closet - inoperableSoiled utility closet - inoperableSpa Room - sufficientroom [ROOM NUMBER] bathroom - inoperableBathroom in E hallway - sufficientroom [ROOM NUMBER] bathroom - sufficientB-wing soiled utility room - inoperableB-wing janitor's closet - inoperableroom [ROOM NUMBER] bathroom - insufficientroom [ROOM NUMBER] bathroom - inoperableroom [ROOM NUMBER] bathroom - inoperableOxygen tank storage room - positive pressureAt 3:55 PM, the surveyor presented the findings to the Administrator, who confirmed that the Regional Maintenance Director had also shared the information.

Based on observations and interview it was determined that the facility staff failed to ensure residents had access to their calls bells if assistance was needed. This deficient practice was evidenced in 7 (#10, #28, #44, #59, #72, #83, & #85) out of 36 residents who resided on Choptank during the recertification survey.The findings include:On 12/10/25 at 7:44 am during observation rounds the surveyor observed multiple residents on the unit Choptank who did not have access to their call bells. At 7:46 am the surveyor observed Resident # 44 call bell on top of the fall mat next to the bed. At 7:53 am the surveyor observed Resident #85 & Resident #28 call bells on the floor. At 7:55 am the surveyor observed Resident #10 call bell hanging off the side of the bed. At 8:04 am the surveyor was unable to locate Resident #72 call bell. Geriatric Nursing Assistant #15 found the resident's call bell inside the top drawer of the bedside table. At 8:11 am the surveyor observed Resident #59 call bell on the floor near the head of the bed close to the wheel and Resident #83 call bell was clipped to the privacy curtain. On 12/16/25 at 3:00 pm the surveyor reported there were several residents who did not have access to their call bell during observation rounds. The Director of Nursing verbalized whenever the staff goes into a residents room the staff is to ensure the residents have their call bell.On 12/17/25 at 10:57 am during an interview with Registered Nurse Unit Manager #15 the surveyor asked how they ensure the residents have their call bells. He/she verbalized that the staff should ensure the residents have their call bells as much as possible.

Based on observations and interviews, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment sufficient to minimize or eliminate the risk of cross-contamination as evidenced by residents who shared a bathroom personal items were not labeled and failed to implement proper hand hygiene practices to help prevent the spread of pathogenic diseases. This was evident in 13 areas within the facility that were assessed during the recertification survey. The findings include: Infection control practices include indications for the use of gloves, masks, and other personal protective equipment (PPE); methods for hand hygiene; procedures for vascular access and dressing changes; and protocols for cleaning and disinfecting equipment and the environment following spills and splashes of blood or effluent. Infection control measures include implementation of care, handling, cleaning, storage, and disposal of equipment, supplies, biohazardous waste and including proper ventilation. Hand hygiene refers to a general term that includes hand washing with soap and water, antiseptic handwash, and the use of alcohol-based hand rub (ABHR). 1). On 12/10/25 at 7:44 am during observation rounds on the unit Choptank, the surveyor observed the residents personal care items in their bathrooms were not labeled. The residents who reside in room [ROOM NUMBER] personal care items in the bathroom were not labeled. At 7:53 am while in room [ROOM NUMBER] the surveyor observed the residents' personal care items in the bathroom were not labeled. At 7:58 am the surveyor observed the residents in room [ROOM NUMBER] personal care items in the bathroom were not labeled. At 8:03 am while in room [ROOM NUMBER] the surveyor observed the residents' personal care items in the bathroom were not labeled. At 8:11 am the surveyor observed the residents in room [ROOM NUMBER] personal care items in the bathroom were not labeled. On 12/17/25 at 10:59 am the surveyor reported several residents had personal care items that were not labeled in a shared bathroom. The Director of Nursing verbalized the staff were made aware to label the residents' personal care items. 2). 1) On 12/10/2025 at 7:30 AM, the surveyor observed that employees, after donning a hairnet, were required to walk across the kitchen near the walk-in coolers and/or the hand washing area, in order to wash their hands. This indicated the absence of a readily accessible handwashing sink near the front entrance. At 7:45 AM, the surveyor asked the Healthcare Services Group (HCSG) Regional Manager for the location where employees would perform hand hygiene after putting on a hair net, or prior to dispensing ice from the ice machine and/or serving beverages at the drink station near the front entrance doors. The HCSG Regional Manager confirmed the lack of a hand sink by the kitchen entrance doors, noting that the two available hand sinks are situated near the walk-in coolers and the hand-washing area on the opposite side of the kitchen. 2) On 12/10/2025 at 8:55 AM, the surveyor observed two push carts containing a non-commercial grade ice chest and a 5-gallon water dispenser positioned in front of the kitchen double doors. The surveyor requested the HCSG Regional Manager to open the ice chest lid and verified the presence of standing melted ice water containing floating black, unidentified particles. The surveyor was unable to verify the location within the kitchen where the ice chests and water dispensers were washed, rinsed, sanitized, and air-dried. At 1:35 PM, the surveyor confirmed that the ice/water station was situated in front of the nurses' stations. However, no open sinks were located nearby for nursing staff to properly wash their hands with soap and water before dispensing ice to residents. 3) On 12/10/2025 at 1:40 PM, the surveyor noted that the over-the-toilet commodes in rooms [ROOM NUMBERS] exhibited rusted and damaged components. These parts included bolts holding the handles to the frames that could potentially contact residents' hands, as well as components at the front of the frame. The rust on these bolts and joints made these areas difficult to sanitize effectively between uses. On 12/11/2025 at 10:08 AM, the surveyor observed a rusted commode within the resident restroom in room [ROOM NUMBER]. At 1:10 PM, the surveyor provided the Director of Nursing (DON) with room numbers and photographic evidence of the rusted, chipped, and/or cracked commodes. 4) On 12/11/2025 at 10:34 AM, the surveyor conducted an interview with Resident #8 and observed a full portable urinal placed on top of the bedside dresser drawer, situated in front of a box of Riz crackers. At 11:19 AM, the surveyor asked the Assistant Director of Nursing (ADON) whether the placement of the full urinal by the resident's bedside dresser conformed to the facility's standard practice. The ADON confirmed that this placement did not adhere to the proper standard procedures for handling a full portable urinal. 5) On 12/16/2025 at 7:46 AM, the surveyor observed Staff #21 and Staff #23 encountering difficulty while pushing two carts, which contained exposed plates, dome plate covers, and milk, in addition to one steam table, out of the kitchen double doors and the unit double doors. At 7:51 AM, after setting up the steam table and two push carts in the B-wing hallway, the surveyor asked the dietary service employees where they would wash their hands with soap and water after touching high-contact surfaces during the transport of the food carts and prior to serving food to the residents. Staff #21 and Staff #23 responded that they do not wash their hands before donning and after doffing gloves to serve food. Then further explained that they were not permitted to have a bottle of ABHR. 6) On 12/16/2025 at 8:00 AM, the surveyor noted wet nesting on top of the dome plate covers stacked on one of the push carts, which caused by improper warewashing procedures. The surveyor observed Geriatric Nursing Assistants (GNAs) shaking moisture from the dome plate covers before placing them on plates or placing the covers directly onto the plates to serve residents, potentially causing cross-contamination. 7) On 12/16/2025 at 8:38 AM, Resident #6 approached the steam table in a wheelchair and informed Staff #21 and Staff #23 that the green beans from the previous evening's dinner were very delicious. Resident #6 also expressed disappointment regarding being denied second servings while grasping the white cutting board on the steam table for assistance in the hallway. The surveyor advised Resident #6 not to touch the steam table due to potential heat hazards. At 8:39 AM, the surveyor did not observe dietary service employees sanitizing the cutting board. Then when asked, the dietary service employees confirmed that similar situations had occurred previously where residents would approach the hot steam table, and exposed food carts. At 8:40 AM, the surveyor observed dietary service employees touching a keypad and then touching double doors to enter the Choptank unit. Therefore, the surveyor instructed the dietary service employees to properly wash their hands with soap and water in the bathroom while keeping the door open to avoid contact with the doorknob. 8) On 12/16/2025 at 8:43 AM, the surveyor observed and confirmed with Staff #15 that no residents seated at the dining room tables had performed hand hygiene. 9) On 12/17/2025 at 1:12 PM, the surveyor observed Staff #21 wearing a winter scarf around her neck while working in the kitchen. The surveyor asked the HCSG Regional Manager to increase the kitchen thermostat, as wearing street clothes were prohibited while working in the kitchen. The Regional Nursing Home Administrator confirmed that the thermostat was set to 53 degrees Fahrenheit in the kitchen. 10) On 12/17/2025 at 1:17 PM, the surveyor toured the laundry room with the Environmental Services (EVS) Director and the Administrator. The following instances of non-compliance were observed: Soiled Laundry Room Damaged surfaces: The drywalls situated behind the two laundry washers, the mop sink, and the two-basin utility sink (which had been converted into a hand sink) were significantly damaged. The floors and cove base exhibited cracks, chips, and tears. Unsanitary sink: The hand washing sink was heavily stained, and the water faucet and turning knobs were soiled with an excessive accumulation of dirt, dust, and debris. Unclean mop sink: The mop sink was unclean and heavily stained. Soiled chemical storage: The chemical storage dunnage racks were heavily soiled with an excessive buildup of cleaning solutions, dust, dirt, and debris. Improper storage: Cleaning supplies, including mops and mop buckets, were improperly stored between the two commercial washing machines. Mechanical ventilation: The mechanical ventilation system was noisy, with stains observed around the vent cover on the ceiling. Clean Laundry Room Ventilation/ Open window: The ventilation system was inoperable; thus, a window was open to facilitate air circulation within the room. Stained floor: Stained floor tiles were observed adjacent to the dryer unit. Lack of hand hygiene: Laundry must be processed and handled in a manner that prevents the spread of infections. 11) On 12/17/ 2025 at 2:25 PM, the surveyor observed an oxygen tube remaining attached to an oxygen cylinder while assessing the oxygen storage room with the Region Maintenance Director. The Regional Maintenance Director confirmed that the oxygen tubing was attached to the full oxygen cylinder. 12) On 12/18/2025 at 9:00 AM, the surveyor observed Staff #24 wearing a mask positioned under her chin in the kitchen before promptly pulling it up to cover her nose. She then approached the surveyor without performing hand hygiene with soap and water. The surveyor asked Staff #24 about the purpose of wearing a mask in the kitchen. She stated that four additional employees from the Healthcare Service Group were required to wear masks due to declining the influenza vaccine based on allergies or personal reasons. 13) On 12/18/2025 at 9:20 AM, the surveyor requested the EVS Director to provide the policy and procedures for cleaning/disinfecting soiled IV poles and to identify the storage location for clean IV poles. The EVS Director stated that soiled poles are stored in the utility closets, and once cleaned, the IV poles are placed in front of the Central Supply Room doors, adjacent to the kitchen. The surveyor requested access to the Central Supply Room, but the EVS Director did not possess the room key. At 9:45 AM, the surveyor interviewed Staff #37, Medical Records Coordinator, who is also responsible for the Central Supply Room, regarding the three IV poles stored in the room. One of the IV poles exhibited dirt/spills on the bottom, and all three poles were uncovered. Staff #37 stated that the IV poles are placed in front of the room doors, and she places them back in the locked Central Supply Room without receiving confirmation from EVS that they have been cleaned and disinfected. At 11:32 AM, the surveyor conducted an interview with the Infection Preventionist (IP) to communicate the findings. The IP confirmed that the infection control issues have been shared by the staff throughout the survey period.

Based on observations and interviews it was determined that the facility staff failed to provide a clean homelike environment as evidenced by soiled and unlined waste baskets and stained wash sinks in residents' rooms. This deficient practice was observed on the Unit Choptank during the recertification survey.The findings include:On 12/10/25 at 7:50 am while in room [ROOM NUMBER] the surveyor observed stains in the sinks of the resident's bathroom. At 7:56 am while in room [ROOM NUMBER] the surveyor observed a soiled unlined waster basket next to a resident's wheelchair. At 7:58 am while in room [ROOM NUMBER] the surveyor observed pink stains in the sink, a soiled unlined waste basket, and stains on the bathroom floor. At 8:04 am the surveyor observed a soiled unlined waste basket in room [ROOM NUMBER]. At 8:06 am the waste basket in room [ROOM NUMBER] was soiled and unlined. At 8:11 am the waste basket in room [ROOM NUMBER] near bed B was soiled and unlined. On 12/17/25 at 11:32 am the surveyor informed EVS Director #30 the environmental concerns observed during observation rounds. EVS Director #30 verbalized doing rounds the previous day and there were multiple trash cans that didn't have bags, and the situation was rectified. Rounds are usually done 2-3 times daily. The trash cans will be cleaned when they do their rounds. They leave waste bags in the linen closet for the staff to use when they are not present. The commodes and sinks are cleaned while they are in the building.

Number of residents sampled: Number of residents cited: Based on observations, record review, and interviews, it was determined that the facility failed to ensure that resident meals were palatable, sufficiently portioned, and the foods were maintained outside of the food danger zone. This was evident for 2 (Resident #82 and Resident #5) of 2 residents interviewed and 2 of 2 foodservice operation days observed during the annual survey. The findings include: The Food Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. On 12/11/2025 at 1:15 PM, a telephone interview with Resident #82's Power of Attorney (POA) revealed that the resident was not receiving adequate food portions. On 12/11/2025 at 1:37 PM, Resident #5 voiced complaints regarding the taste and texture of the food. The resident further explained that the roast beef served for dinner on 12/10/2025 was tough, resembling rubber, and could not be cut with a butter knife. On 12/16/2025 at 9:15 AM, the surveyor observed Staff #21 requesting Staff #23 to retrieve an additional batch of scrambled eggs with cheese from the kitchen while scraping the bottom of the food pan in front of the Choptank unit. Staff #23 informed Staff #21 that the AM [NAME] had placed an additional sheet pan of scrambled eggs in the steam table. However, Staff #21 pointed out that the scrambled eggs in the steam table were without cheese. Residents who had previously ordered scrambled eggs with cheese had been served without the cheese. On 12/17/2025 at 1:05 PM, both the surveyor and the Healthcare Services Group (HCSG) Regional Manager took internal food temperatures of the last test plate at the Choptank unit. The internal food temperatures recorded were as follows:Sliced roast pork sandwich on the test plate: 97 degrees F.Sliced roast pork in the steam table pan: 121 degrees F.Mashed potatoes on the test plate: 117 degrees F.Mixed vegetables on the test plate: 112 degrees F.Apple sauce on the pushcart (individually pre-portioned the previous night and stored in the walk-in refrigerator): 57 degrees F.On 12/19/2025 at 2:45 PM, the surveyor also shared the final test tray temperatures to the Regional Nursing Home Administrator and the HCSG Regional Training Manager. Cross reference to F880

Number of residents sampled: Number of residents cited: Based on review of medical records and interview with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1of 5 residents (Residents #4) reviewed during the investigation phase of the survey for unnecessary medications. The findings include: On 12/15/2025 at 11:40 AM Resident #4's Medical Management Review (MMR) and the Medication Administration Record (MAR) were reviewed. The MMR had 2 recommendations for Resident #4. The first recommendation was addressed by Staff # 32, Physician Assistant (PA) as evidence by the written order, signature and date on the MMR. However, the second recommendation by the consulting pharmacist was not addressed. The consulting pharmacist stated that Resident #4 has an order for Midodrine 5mg three times a day for hypotension, low blood pressure (BP). Midodrine should be administered no later than 6pm (3-4 hours before bedtime) to avoid supine hypertension, high BP. Currently evening administration is at 9:00 PM. Please review the administration times for Midodrine for Resident #4 and consider changing the time so that the evening dose is not given past 6:00 PM. Review of the MAR revealed that Resident #4 is still receiving Midodrine 5mg three times a day at 9:00AM, 1:00PM and 9:00PM. The date the consulting pharmacist gave the recommendation was 11/7/2025 and today's date is 12/15/2025. On 12/16/2025 at 12:45 PM Staff #32, PA was interviewed and asked if this was her signature on the MMR dated 11/7/2025 for Resident #4 and they confirmed that yes this is my signature. Staff #32 was then asked if a note had been written with a rational stating why the pharmacy recommendations from the MMR were not addressed. Staff #30 stated that the order was missed, stating that the first recommendation was addressed but not the second recommendation for Midodrine. Staff #32 acknowledged that the second recommendation should have been addressed.

Based on review of Geriatric Nursing Assistant, (GNA) personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews at least every 12 months on 1 out of 2 GNA files reviewed during the recertification survey.The findings include: On 12/18/2025 at 10:13 AM Staff #8, GNA record review revealed that their 12-month performance review was last completed 5/17/2024. On 12/18/2025 at 10:30 AM the Director of Nursing (DON) was interviewed and asked if they had any more documentation related to Staff #8, GNA's 12-month performance evaluation. The DON stated they do not have Staff #8's performance evaluation for 2025. The DON verbalized understanding that GNA's performance evaluation should be done annually.

Based on medical record review and interview it was determined that the facility staff failed to adhere to professional nursing standards as evidenced by the nursing staff failure to document why a resident did not receive their enteral nutrition. This deficient practice was evidenced in 1 (#10) of 1 resident record reviewed for enteral nutrition during the recertification survey.The Maryland Nurse Practice Act guide and governs nursing practice in the state of Maryland. Registered Nurses, Licensed Practical Nurses, and certificate holders are expected to practice within the established regulations defined by the Nurse Practice Act. According to 10.27.10.02 B (3) (c) (i) The LPN contributes to the nursing assessment by recording data in a manner which is complete, timely, and accurate.The findings include:On 12/17/25 at 9:59 am a review of Resident #10 enteral nutrition order was dated 11/30/25 at 12:47 pm read Enteral Feed Order two times a day for dysphagia Jevity 1.5 at 55 ml hour x 20 hours (Total Volume 1100ml). Up at 5:00 pm, down at 1:00 pm: total volume for 24hrs 1100 ml. The volume of tube feeding the resident received was documented on 12/2, 12/3, and 12/4 was zero. 12/10 had an x in the column and a 9 which indicated see note. There was not a note in Point Click Care (PCC) from the nurse indicating why the resident did not receive their feeding. On 12/11/25 at 9:11 am while the surveyor was in Resident #10 room the TF was not infusing for at least 10 minutes. Licensed Practical Nurse (LPN) #17 went into the room and verbalized the pump was beeping. LPN #17 attempted to restart the tube feeding pump but there was a lot of air in the tubing. He/she verbalized they would get another bag to restart the tube feeding. At least 30-45 minutes passed without the resident receiving their enteral nutrition. On 12/17/25 at 10:57 am during an interview with Registered Nurse Unit Manager #15 the surveyor reported after reviewing Resident #10 treatment administration record, several nurses documented the resident did not receive their enteral nutrition and there was no documentation to indicate why. RN Unit Manager #15 verbalized if the resident did not receive their nutrition, the physician should have been notified and a note should have been written.

Based on record review and interviews it was determined that the facility staff failed to initiate a person-centered care plan for a resident who was high risk for wandering, required assistance with oral hygiene, and a resident who frequently refused ADL care. This deficient practice was evidenced in 2 (#11 & #40) of 11 resident records reviewed for person centered care plans during the recertification survey.The findings include:1) On 12/10/25 at 12:47 pm during observation rounds the surveyor noticed Resident #40 had several missing teeth and the remaining teeth were discolored and decayed. On 12/12/25 at 9:31 am during an interview with the RN Unit Manager of Choptank #15 the surveyor asked how the facility ensures the residents receive dental care. He/she verbalized they don't ask if the residents had recent vision, dental, or audiology care when they are admitted . Routine dental assessments are done quarterly; he/she gets them enrolled into Health Drive. They usually don't care plan for all services for Health Drive. The surveyor received a copy of Resident #40 dental assessment that was provided on 11/13/25 by Health Drive. A review of the assessment revealed Resident #40 could not perform oral hygiene independently. On 12/12/25 at 10:23 am during an interview with the Director of Nursing (DON) he/she verbalized RN Unit Manager of Choptank #1 oversees Health Drive and the ADL care plan for Resident #40 indicated the GNA sets the resident up for teeth brushing. The surveyor reported setting the resident up for teeth brushing and brushing his/her teeth was not the same. The care plan was not patient specific and did not indicate the staff brushed Resident #40 teeth. The Health Drive form said the resident could not perform oral hygiene independently. On 12/15/25 at 11:53 am a review of Resident #40 care plans; the resident had a care plan for wandering/elopement that was initiated on 12/21/24, but the care plan was not person centered. A review of the elopement assessment dated [DATE] when the resident was admitted to the facility revealed the resident was deemed high risk for wandering/elopement. A person-centered care plan was not initiated when the resident was deemed high risk for wandering/elopement. 2) On 12/16/25 at 7:46 am reviewing the Task section in PCC to see if there is documentation to verify Resident #11 received showers. Per PCC the resident was scheduled to receive a shower on Wednesday & Saturday during the 3 pm-11pm shift. It was documented that the resident had a shower on 12/03/25 at 8:41 pm and 12/10/25 at 8:56 pm. It was documented he/she did not have a shower on 12/06 and 12/13. A review of the progress notes, there was no documentation to indicate why he/she did not receive a shower. During an interview with the DON on 12/16/25 at 11:45 am, he/she verbalized the resident refused showers. The surveyor asked for a copy of the care plan for the resident refusing ADL care. Prior to the end of the survey, the surveyor did not receive the requested care plan for resident #11 refusing ADL care.

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 1 (resident # 2) of 3 residents reviewed that were transferred to an acute care facility. The findings include: Review of the medical records for Resident #2 on 12/15/2025 at 3:52 PM revealed on 8/24/2025 the resident was sent to an acute care facility for a change in his/her medical condition. Further review of the medical record failed to produce written evidence that the resident and /or the resident representative were given written notice of the bed hold policy. During an interview with the Administrator about Resident #2, on 12/16/2025 at 10:43 AM, she stated that she mailed the bed hold policy to the resident's representative. However, the Administrator was unable to produce written evidence that the resident/ resident representative was given/received written notice of the bed hold policy. The Administrator stated that she understood that not having written proof that the resident/representative was notified of the bed hold policy was an issue.

Based on record review and interviews it was determined that the facility staff failed to complete through investigations for allegations of abuse. This deficient practice was evidenced in 2 (#38 & #59) of 5 investigations reviewed for a through investigation during the recertification survey.The findings include:1) On 12/18/25 at 1:29 pm a review of the investigation related to an allegation of abuse concerning Resident #59 revealed twenty-one different staff worked on the unit from 03/01/25 - 03/02/25 when the alleged incident may have occurred. There were no statements from all the staff who worked when the alleged incident may have occurred. On 12/18/25 at 2:25 pm during an interview with the Administrator the surveyor asked how they determine who needs to be interviewed when they need to complete an investigation. The staff were told to write their name and title on statements. The Administration verbalized they usually get the staffing sheets to see who worked and interview the staff. 2) On 12/18/25 at 3:08 pm a review of the investigation concerning an allegation of abuse concerning Resident #38. A review of the statements from the staff indicated all the staff who worked during the time the bruise was discovered were not interviewed. A review of the staffing sheets and statements revealed all the staff who worked during the time the bruise was found on the resident were not interviewed. A CMA, GNA, and a female staff were not interviewed but worked on the unit during the time of the alleged incident. On 12/18/25 at 3:37 pm the Administrator confirmed that a GNA and dining room attendant were not interviewed, and the surveyor reported all the staff who worked during the time the bruise was discovered were not interviewed.

Based on record review and interview it was determined that the facility staff failed to assure residents whose funds are being managed by the facility have ready and reasonable access to their funds. This deficient practice has the potential to affect 58 of the 93 resident whose accounts are being managed by the facility when the recertification survey was conducted.The findings are:On 12/17/25 at 2:27 pm during an interview with Business Office Manager # 25 the surveyor asked to explain how a resident is allowed access to their funds. Business Office manager #25 verbalized they come up front and tell the receptionist or him/her they want a certain amount of cash. They have a cash box and if the money is in the cash box, the resident can have it. If not they will try to get the money by the next day. When a resident receives money, they have to sign for it. After hours and the weekend, they can get $5 or $10.On 12/17/25 at 3:00 pm the surveyor informed Business Office Manager #25 the residents are supposed to have access to their account at any time and they should be able to access up to $100 immediately ($50 Medicaid) and over $100 within three days.

Number of residents sampled: Number of residents cited: Based on the QAPI process and interview it was determined that the facility staff were unable to report what individuals are legally responsible to establish and implement policies regarding the management and operations of the facility. The findings include: On 12/19/25 at 9:14 am during an interview with the Administrator the surveyor asked questions about the governing body, the Administrator verbalized not knowing what the surveyor was speaking of. The Administrator verbalized they have corporate leadership that comes to the facility, but she was uncertain who was legally responsible for the building and the leadership.

Number of residents sampled: Number of residents cited: Based on observations, record review, and interviews, it was determined that the facility failed to maintain essential equipment in proper operating condition. This was evident for 4 of 4 pieces of equipment reviewed during the annual survey.The findings include:All essential kitchen equipment, including but not limited to walk-in coolers, steam tables, dishwashers, ovens, stoves, and warming cabinets, must be maintained in safe operating conditions in accordance with the manufacturer's specifications and remain accessible throughout kitchen operations.On 12/10/2025 at 7:40 AM, the surveyor observed an inoperable steam table located in front of the cookline. The Healthcare Service Group (HCSG) District Manager confirmed the steam table was nonfunctional.At 7:55 AM, the surveyor observed that the Type 2 ventilation system above the high-temperature mechanical dishwasher was insufficiently removing steam from the unit. The steam escaped from the sides of the dishwasher and dissipated throughout the kitchen area.At 8:20 AM, the surveyor observed that the walk-in freezer walls, floor, ceiling, and food shelving units were covered in excessive ice, frost, an ice dam, and icicles. Food boxes, ice cream/frosting tubs, food pans, and bags of ice were similarly covered due to the unit's malfunction.At 9:20 AM, the surveyor reevaluated the Type 2 ventilation over the high-temperature mechanical dishwasher by lighting a smoke stick directly below the unit. The smoke was drawn halfway toward the Type 2 ventilation opening before gradually pulling vertically into the kitchen rather than being drawn horizontally into the unit.The Administrator, Regional Maintenance Director, Maintenance Director, and the HCSG District Manager have witnessed the observations listed above.On 12/11/2025 at 8:30 AM, the surveyor conducted a follow-up on the walk-in freezer with the HCSG Regional Operational Manager. The surveyor physically verified that the unopened food boxes delivered on the morning of 12/10/2025 had been relocated to the refrigerated truck parked by the rear entrance doors. The food items were physically verified to be free from potential cross-contamination originating from the ice and frost buildup within the walk-in freezer.At 9:10 AM, the HCSG Regional Operation Manager stated that the steam table at the cookline was functional and/or potentially repairable. On 12/12/2025 at 10:39 AM, the surveyor provided the Regional Nursing Home Administrator with a copy of the Maryland Department of Health (MDH) Ventilation Criteria for Food Establishments. The MDH Criteria is intended to help ensure that ventilation systems effectively and safely remove grease vapors, smoke, heat, steam, fumes, and obnoxious odors produced during food processing activities to promote a sanitary and well-ventilated environment.At 11:30 AM, the surveyor requested a written plan and procedures detailing how to safely transport open food boxes from the food truck to the kitchen to prevent potential cross-contamination from outside elements such as snow, sleet, or rain.At 1:40 PM, the surveyor observed that the steam table at the cookline remained turned off and inoperable. The HCSG District Manager confirmed that the unit was nonfunctional. Cross reference to F812

Number of residents sampled: Number of residents cited: Based on observations, record review, and interviews with facility staff, it was determined that the facility failed to ensure a call bell system was accessible to residents. This was evident for 1 (Resident #8) of 1 resident's and 1of 1 restroom call bell systems reviewed during the annual survey.The findings include:On 12/11/2025 at 10:34 AM, the surveyor conducted an interview with Resident #8, who was seated in a wheelchair at the foot of the bed. Following the interview, the surveyor asked Resident #8 to press the call bell for assistance due to reported pain and discomfort. The resident was unable to access the call bell, which was positioned behind the wheelchair. The resident confirmed this was the designated location for the call bell each morning when seated in the wheelchair.At 11:19 AM, the surveyor once again reported to the nurses' station that Resident #8 was experiencing discomfort and requested repositioning from the wheelchair. The Assistant Director of Nursing (ADON) arrived at the room to reassess the resident and discuss the issues with the surveyor.On 12/16/2025 at 1:40 PM, the surveyor informed the Director of Nursing (DON) and the ADON of the necessity of personally calling for assistance for Resident #8. The surveyor documented the time elapsed while waiting at the resident's door to measure the staff's response time to address the resident's needs, given the inaccessibility of the call bell.On 12/17/2025 at 2:25 PM, the surveyor conducted a walk-through with the Regional Maintenance Director and noted that a restroom call bell cord in room [ROOM NUMBER] was too short to be reached by a resident on the floor. The Regional Maintenance Director agreed to extend the restroom call bell cord.

Based on observations and interviews, it was determined that the facility failed to provide residents with a homelike environment. This was found to be evident for 15 residents (#11, #20, #24, #35, #39, #52, #58, #60, #61, #62, #65, #68, #70, #79, #238) out of 94 resident environments observed by the surveyors during the survey. The findings include: During the initial screening on 02/12/24 at 10:04 AM, the surveyor observed that walls above the sink were damaged in rooms 73, 75, 80, 83, 84, 85, 87, and 89 on the Choptank Unit. The Corporate Maintenance Director was informed of the wall damage in the bathroom walls on the Choptank Unit on 02/15/24 at 09:38 AM. He stated he would investigate it and get back to the surveyor with his observations. On 02/15/24 at 11:03 AM, the Corporate Maintenance Director told the surveyor that he observed that the walls above the sinks were damaged from water splashing and the walls would be repaired and covered with fiberglass to protect the walls from future damage. During an interview with the Administrator and Director of Nursing on 2/23/24 at 11:10 AM, the surveyor was informed that they were aware of the damaged walls and that repairs were in progress.

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident's responsible party (RP) was informed of a change in the medical regimen. This was evident for 1 (#89) out of 53 residents that were part of the survey sample. The findings include: An investigation into intake #MD00178510 revealed Resident #89's primary physician prescribed Seroquel (an antipsychotic) on 4/8/21, Haldol (an antipsychotic) on 3/4/22 and Depakote (an anticonvulsant used to treat epilepsy and bipolar disorder) on 3/4/22. The resident's RP was not informed of the medications being ordered for the resident and the medications were administered before the RP was aware of the orders per the complaint. A review of Resident #89's clinical record revealed the RP was not informed of the medications being ordered. The Director of Nursing (DON) was interviewed on 3/4/24 at 1:25 PM. She was informed of the three medications that were ordered and started without informing the RP. She said she would check the Electronic Health Record because she thought it may have been noted in there. The DON was interviewed on 3/4/24 at 2:00 PM. She said she could not find in the electronic health record but would have the medical records person check the hard (paper) chart. The DON was able to show on 3/5/24 at 8:53 AM that the RP was informed of the Depakote being ordered. She was asked what the policy was on notifying a resident's RP when a medication is started. She replied when a medication is started or changed in any way, we are supposed to call the RP if the resident is not capable. These changes occurred with the prior nursing home company. She reviewed all of the progress notes and every single one of those nurses no longer works for the nursing home.

Based on clinical record review it was determined that the facility staff failed to ensure a resident's responsible party (RP) was informed of a fall. This was evident for 1 (#88) out of 53 residents in the survey sample. The findings include: An investigation into intake #MD00178237 revealed Resident #88 had a fall in April of 2022. The resident informed their cardiologist on 4/9/22 that they fell a couple of nights ago. The cardiologist assessed the resident for signs of an injury but did not observe any injury. The resident complained of left side pain along the ribcage. Cardiologist collaborated with primary physician regarding care and an x-ray was ordered for a chest x-ray. The x-ray was obtained the next day. Further review of the clinical record revealed that the resident's RP was not notified of the fall.

Based on the review of a medical record, the review of pertinent facility documentation, and interviews with facility staff, it was determined that the facility failed to initiate pain management as ordered. This was evident for 1 of 3 residents (Resident #5) reviewed for fractures during a complaint survey. The findings include: On 12/1/2021 at 1:00 PM a review of the facility's investigation related to an injury of unknown origin for Resident #5 revealed that on 8/30/2021 at 12:00 AM, a geriatric nursing assistant (GNA), Staff # 12 reported to the night shift nurse, LPN # 11, that Resident #5 vomited a large amount of brown liquid. According to the facility's investigation report documentation and nursing assessment documented by both day shift LPN #3 and LPN #11, Resident #5's thigh was noticeably swollen, and warm to the touch. The review of the facility reported investigation for Resident #5 continued on 12/2/2021 at 8:00 AM. According to the investigation, Resident #5's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 was in the facility's dementia unit. according to the GNA kardex, the resident required total assistance with care including a mechanical lift for transfer and minimum data set assessments. Staff # 11 documented that her and LPN# 3 assessed the resident at shift change at 7:00 AM, between the night and day shift on 8/30/2021. Staff #11 documented that the thigh region was noticeably swollen and very warm to the touch. It was at that time that LPN #3 notified the Nurse practitioner, Staff #14 of the changes in condition, six (6) hours after the change was first noticed. On 12/2/2021 Resident 5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse Practitioner who was requested to assess Resident #5 on 8/30/2021, documented that this noted change was likely a fragility fracture (fracture resulting from a fall from a standing height or less common when bones are weakened from underlying illness) related to [CONDITION(S)]. Will order [MEDICATION(S)] for pain control/ice. The documented assessment noted the left thigh was taut, warm, with new redness, tender to touch. On 12/2/2021 a review of Resident #5's medical record revealed that LPN #3 documented at 12:39 PM on 8/30/2021 that Resident #5 was noted with left upper leg swelling/warm and tender to touch, new PRN (as needed) [MEDICATION(S)] order, groans with repositioning. On 12/2/2021 a review of Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #5's MAR failed to reveal the administration of any additional pain medication besides his/her standing Tylenol order of three times a day for pain that was ordered since 7/2018. Resident #5 had a prior diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/2/2021 at 11:15 AM the DON was interviewed. During the interview, the surveyor and the DON reviewed the concerns related to Resident #5 not receiving any additional pain medication after a noted change in condition. The DON concurred with the surveyor findings that nothing ordered for the pain related to the fracture was administered for minimally the first 12 hours after the finding of the fracture, even with the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The dayshift nurse, LPN# 3, was interviewed on 12/2/2021 at 12:11 PM. She was asked about her interactions with Resident #5 on 8/30/2021 and her observations upon finding him/her when she started her shift on 8/30/2021. LPN #3 was also given her notes to review from 8/30/2021. LPN# 3 stated that they were log rolling (a maneuver used to move a resident without flexing the spinal column, the legs are stretched and immobilized), the resident to provide care on 8/30/2021 secondary to the change of condition of the resident's leg. She further stated that the more you moved the resident the more pain s/he appeared in, however, if the resident was just laying still s/he was ok. LPN #3 was asked how she would assess pain in a resident/person that is unable to talk or verbalize pain, as was the case with Resident #5 and she responded, If someone was guarded and moaning that would be a sign of pain. LPN #3 was asked how many times was Resident #5 was changed and received care on 8/30/2021 while in the care of LPN #3 and further if Resident #5 was medicated as ordered prior to receiving care but LPN #3 had no answer. These findings were reviewed with the facility DON and Administrator during exit from the facility on 12/2/2021.

Based on medical record and facility investigation review, observation and interview, it was determined that the facility staff failed to ensure the safety of two in 32 sampled resident records in the Stage 2 review. The findings included: 1. The Physical Therapist Assistant failed to adequately supervise a resident in order to prevent an accident which resulted in a fractured right hip. This failure resulted in a finding of harm done to resident #65. Supervision/adequate supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs. Resident #65 was admitted to the facility with multiple [DIAGNOSES REDACTED]. By way of history, this resident was initially admitted to the facility in September 2011, after a fall at home during which she sustained a pelvic fracture. This resident was admitted for physical and occupational therapy with the plan to return home. Surveyor review of the medical record( 1/23/12 through 1/30/12) revealed a Plan of Care initiated 09/29/2011, stating: " resident demonstrates capacity and motivation to improve function but exhibits or is at risk for decreasing ability to perform ADL (activities of daily living) in: (bathing, grooming, dressing, bed mobility, transfer, locomotion, toileting) due to recent hospitalization for non-displaced pelvic fx (fracture)" . A Plan of Care is an interdisciplinary individualized treatment plan that coordinates care, promotes continuity of care and communicates to other caregivers the treatment needed to promote the well-being of the resident. A written care plan decreases the risk of incomplete, incorrect or inaccurate care. The interdisciplinary team identified the following resident goals in the Plan of Care: First, " Resident will transfer to toilet with limited to supervision assistance within 30 days. Secondly, " Resident will ambulate with supervision to minimal level of assistance using a RW (rolling walker) (device) x 30 days. The facility defines the following: Supervision: " I must watch and/or talk to the resident to do the task. " Limited Assist: " I touch or guide the resident to do the task. " This Plan of Care included multiple interventions used by the facility to support her in her ADL functions related to her limited ability to perform these task safely. This resident was assessed on 09/11/2011 by the nursing staff to be at high risk for falls. It was further noted that according to the Minimum Data Set (a resident assessment tool completed by the interdisciplinary team) completed on 10/12/2011, this resident required limited assistance,whereby one person physical assistance was needed for transfers, and ambulation within the room. For toileting, this resident required extensive assistance whereby one person physical assistance was also needed. In addition, geriatric nursing assistant documentation also revealed that this resident was provided with extensive assistance and supervision for ambulation and toileting. Review of the facility incident report revealed the following: 10/12/2011 at 1:00 p.m., "Pt(patient) attempting to toilet herself c (with) RW in rm (room), fell to floor in BR (bathroom). Pt found supine (on back) on bathroom floor c c/o (complaints of) intense r (right) hip/leg pain. Obvious deformity to R hip was noted. 911 was alerted for transfer to ER (emergency room ) for eval (evaluation) & tx (treatment)." Review of the facility's investigation revealed the following statements: From the Director of Nursing (DON) dated 10/13/2011: ... " This nurse stepped out of bathroom onto corridor and noted (Physical Therapist Assistant), therapist standing near door. DON asked: '(Physical Therapist Assistant), are you supposed to be with her when she's ambulating? ' He stated, Yeah ... yes, I am. But some man was in the room when I went to get her for therapy and he got up to leave, then she said, 'I had better go to the bathroom before I go to therapy', so I told her, go ahead, I'll meet you and I'll get the other patient down here (pointing to rooms near A wing exit) and we'll go together' ... . " From the physical therapist assistant note dated 0/12/2011: "On 10/12/11 at around 12:50 p.m. when therapist entered the room pt (patient) was still in her bed with a guest visitor in her room and therapist reminded her that she will have therapy at 1:00 p.m. Pt was told to start to get ready for therapy so she could start on time. Pt was also told when she is ready she may start to come down to the gym using the rolling walker. Therapist was in the gym when he was informed that resident had fallen. Therapist was in the hallway to get another pt when a staff member (DON) asked if she was allowed to walk going to the gym. The therapist replied that resident was, however I like to keep an eye so I know we are on time. I also stated that I do not allow her to walk (willie nillie) meaning only with a task in mind. Pt was always reminded about the safety measures when walking with the RW(rolling walker)." Interview with the Physical Therapist Assistant: 01/25/2012 at 1:40 p.m.: "Went to resident's room to pick her up for therapy, she was visiting with a man. Reminded resident of time and asked to get ready. Resident got out of bed using her rolling walker to ambulate. Resident decided she needed to use the bathroom. I told her I was going to get another resident further down the hall and on the way back would pick her up." This resident was not fully supervised ambulating from her bed to the bathroom, nor was she supervised while using the toilet. Further interview with the Speech Pathologist revealed the following: 01/25/2012 at 1:35 p.m.: " I was not in room when the resident ambulated to the bathroom and not in the room when resident fell . I was in the hallway when I heard her fall." Surveyor review of the medical record(1/23/12 through 1/30/12) revealed that nursing staff assessed this resident who was found lying on the bathroom floor with complaints of intense right hip and leg pain, deformity of the hip and leg, and limited range of motion to the right hip and leg. The nursing staff notified the physician of this resident's fall and their assessment. The resident was transferred to the hospital where she was diagnosed and treated for [REDACTED]. Again, this resident had been assessed at high risk for falls. From initiation of the Plan of Care, this resident was assessed to require supervision for ambulation and toileting. The resident should not have been left unsupervised to ambulate to the bathroom or unsupervised while toileting. 2. The facility staff failed to recognize or follow-up on a resident who felt unsafe when drinking from a straw and requested not to use a straw. Resident #30 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The esophagus is the tube that carries food, liquids and saliva from the mouth to the stomach. Surveyor review of the medical record(1/23/12 through 1/31./12) revealed a nurse's progress note dated 1/8/12 at 12:56 PM that stated the following: "Pt(patient) had difficulty swallowing when offered water with straw. Pt started coughing, but after resolved pt took sip of water out of cup without any difficulty. When asked pt stated that she has difficulty when using straw. Straw removed from room and SLP (Speech Language Pathologist) notified for possible further eval." Surveyor review(1/23/12 through 1/31/12) of the "Diet Order & Communication Form" dated 1/8/12 revealed the following, "No straws- until eval from speech." Surveyor review of the medical record(1/23/12 through 1/26/12) revealed that the SLP had not evaluated the resident at that time. Surveyor review of the medical record on 1/24/12 revealed a nutritional progress note dated 1/12/12 at 10:53 AM revealed the following note: "... Trouble swallowing w/straw (order written to d/c straw 1/8); res prefers to drink out of small cups; provided several for her...." Surveyor Review of the medical record on 1/24/12 revealed that the SLP still had not evaluated the resident as to whether or not the resident was safe to drink from a straw. Observation of the resident's room on 1/24/12 at 11:00 AM revealed a cup of water with a straw on the bedside table. The Chesapeake unit manager was immediately notified of the straw by this surveyor and the straw was removed. When the manager was asked why the resident had a no straw order she replied, "The resident has an "esophageal stricture and I think the nurse (who wrote the order on 1/8/12) was using precaution due to choking." Observation of the resident's room on 1/25/12 at 11:00 AM at 10:50AM on 08/26/09 revealed a cup of water with a straw on the bedside table. A nurse on the unit was immediately notified of the straw by this surveyor. The straw was removed by the nurse. During the interview with the Chesapeake unit manager on 1/24/12 at 11:30 AM, the SLP stated that she wasn't sure why the resident wasn't using straws. On 1/24/12 in the afternoon, a speech evaluation was done and the SLP stated the resident tolerated the use of a straw, however, the resident prefers to not use straws. On 1/25/12 at 9:20 AM, the resident's drinking cup on the bedside stand was again observed with a straw. During an interview with the resident at the time of the observation, the resident stated that she didn't like to use straws because of her throat problem. She stated that she has better control sipping from a cup, and feels safer not using a straw. She likes to sip from a cup. After surveyor intervention, the resident was evaluated for safety in regards to the use of a straw by the SLP. Also, an order was written to not give straws to the resident per her request. The facility staff was now honoring the resident's wishes by making her feel safe.

Based on medical record review and interviews with facility staff, it was determined that the nursing staff failed to honor a resident's end-of-life wishes by not performing CPR when the resident was found without a pulse or respirations. This occurred in one of 32 residents reviewed in Stage 2. CPR is an emergency procedure consisting of external cardiac massage and artificial breathing. It is the first treatment for [REDACTED]. CPR attempts to restore circulation of the blood and prevent death or brain damage due to lack of oxygen. Review of the facility's investigation, inservices, and action plan related to this incident resulted in this deficiency being cited as past non-compliance. The findings included: Resident #73 was admitted to the facility for rehabilitation with the [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is a condition whereby the heart does not pump blood effectively causing fluid build up in the lungs, liver, and extremities (legs and feet). [MEDICAL CONDITION] is a disease where the lungs have diminished capacity for air exchange resulting in extreme shortness of breath and chronic cough. Review of the medical record by the surveyor took place on [DATE] through [DATE] and revealed that the resident was alert, oriented, and her own decision maker. Review of the medical record revealed that the resident had made her end-of-life decisions known to the facility staff on [DATE]. The resident completed the LSTO form (Life Sustaining Treatment Options) on [DATE] in which she stated she wanted CPR attempted in the event she was found without a pulse or respirations. Further review of the medical record revealed that the resident's wishes were documented on a care plan and in the physician's orders [REDACTED]. Surveyor review of the physician progress notes [REDACTED]. The physician documented that the resident was alert and oriented and was interactive with the physician during this examination. The physician did not document that the resident had changed her end-of -life wishes from a full code to a DNR (Do Not Resuscitate). Surveyor review of the nurses' notes([DATE] through [DATE]) revealed no documentation that the resident had changed her end-of-life wishes from a full code to a DNR. Further review of the nurses' notes revealed that, on [DATE] at 10:15PM, the resident's daughter came to the nurses' desk and stated that her mother had stopped breathing and that "my Mother is gone...she passed quietly..." Review of the medical record, the facility's investigation and interview with nurse #1 and nurse #2 on [DATE] at 11:15AM and 11:45AM, respectively, revealed that nurse #1 and #2 went into the resident's room with the daughter and found the resident to have no pulse and no respirations. Individual interviews with both nurse #1 and #2 revealed that the daughter stated she did not know how long the resident had not been breathing. No CPR or 911 call was initiated. Interview with nurse #2 on [DATE] at 11:45AM revealed that the nurse was aware that the family was thinking of changing the resident's code status from full code to no CPR based on the resident's recent decline. Despite the decline, the resident was still her own decision maker and had not changed her code status. Nurse #2 stated during the interview on [DATE], "If I hadn't known what the family wanted, I would have started CPR (based on the resident's documented end-of-life wishes)". The nursing staff failed to honor this resident's end-of-life wishes of attempting resuscitation if found without a pulse or respirations.

Based on review of the medical record and interview with the Administrator and Director of Nursing, both completed on 5/17/11, it was determined that the nursing staff failed to adequately supervise a resident in order to prevent an accident which resulted in a fractured right leg for one out of one sampled residents Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs. Resident # 1 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Review of the medical record revealed a Plan of Care, initiated 8/23/10, which identified this resident to either need assistance or be totally dependent on staff for the performance of all activities of daily living (ADL's). This care plan included multiple interventions used by the facility to assist the resident including: "Use Hoyer lift with 2 staff assist for all transfers". A Hoyer lift is a mechanical device that is used for transferring individuals who are unable to do so without assistance. On 1/23/11, a "Lift - Transfer - Repositioning Evaluation" was completed by the nursing staff. The results of this evaluation revealed the resident could not bear weight on either leg and was noted to require a total lift with two persons. Continued review of the medical record revealed the following nurses notes: 4/21/11 8:30 p.m. "Called to room (number) by cna (certified nursing assistant) stating that resident had slipped off the side of the bed. She was sitting in (on) the floor with her back against her bed and both legs out in front of her. ... ". At this time an assessment was completed which revealed the resident had no complaints of pain and her range of motion was within normal limits. 4/22/11 7:43 a.m. " ... Resident was c/o (complaining of) leg pain. ... ". At this time bruising was also noted to both legs and the right knee was rotated inward. The physician was notified and ordered an x-ray which revealed a fracture of both leg bones above the right knee. Review of the facility investigation into the resident's fall revealed the following statement from the geriatric nursing assistant (GNA) caring for the resident at the time of the injury: " ... (resident) was transfer(ed) to the bed and when she sat down she was not on the bed all the way. I told (resident) to stand up and get on the bed better. She stood up and said help me. I told her to step back. She said I can't. I said sit down and she did and started slided. I couldn't hold her. She slid down from the bed. She said I'm falling and she went to the floor. ... ". Continued review of the facility investigation into the resident's fall revealed the GNA's have access to each resident's plan of care and it is the expectation of the administrative staff that they will be knowlegeable regarding this plan. The nursing staff is deficient for failing to adequately supervise this resident during transfer which resulted in a fall causing a fractured right leg.