Every finding on record at Autumn Lake Healthcare at Chevy Chase

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#7) of 3 residents reviewed for pressure ulcers. The findings include Minimum Data Set- The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. On 3/31/26 at 1:11 PM, a review of Resident #7's medical record revealed Resident #7 was admitted to the facility in the beginning of January 2026 for rehab following an acute hospitalization. On 1/9/26 at 3:19 PM, in a Skin and Wound Note, the Nurse Practitioner (NP) indicated Resident #7 was seen as a new admission and s/he had an existing ulcer on the left heel and sacrum. The NP further documented Resident #7 had 3 pressure ulcers (PU), a Stage 1 PU on the right heel, a Stage 3 PU on the left heel, and an Unstageable PU on the coccyx. Review of Resident #7's admission MDS with an assessment reference date (ARD) of 1/14/26, Section M, Skin Conditions, documented Resident #7 had one unhealed PU that was a Stage 3. The MDS failed to capture Resident #7 had a Stage 1 PU on the right heel, and an unstageable pressure ulcer on the coccyx. The above concern was discussed with Staff #2, Registered Nurse (RN), MDS Coordinator on 4/2/26 at 12:46 PM and Staff #2 confirmed the findings at that time.

Based on medical record review and staff interview, it was determined that the facility staff failed to timely develop and implement a comprehensive, resident centered care plan for a resident admitted to the facility with preexisting pressure ulcers. This was evident for 1 (#7) of 3 residents reviewed for pressure ulcers. The findings include: The MDS (Minimum Data Set) is a federally mandated, comprehensive assessment tool to ensure each resident's needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. A baseline care plan is an immediate, preliminary plan developed within 48 hours of a resident's admission to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed. A comprehensive care plan is a guide that addresses each resident's unique needs. It is used to plan, assess and evaluate the effectiveness of the resident's care, and must be completed within 7 days after the completion of the comprehensive assessment (MDS), and no later that 21 calendar days after admission on [DATE] at 1:11 PM, a review of Resident #7's medical record revealed Resident #7 was admitted to the facility in the beginning of January 2026 for rehab following an acute hospitalization. The medical record documented Resident #7 had preexisting pressure ulcers (PU) and was followed weekly by a wound Nurse Practitioner (NP) for evaluation and treatment of the PU. In a Skin and Wound Note, on 1/9/26 at 3:19 PM, the wound NP documented Resident #7 was seen as a new admission and the resident had an existing ulcer on the left heel and sacrum. The NP further documented Resident #7 had 3 pressure ulcers, a Stage 1 PU on the right heel, a Stage 3 PU on the left heel, and an Unstageable PU on the coccyx. Review of Resident #7's MDS revealed an admission MDS with an assessment reference date (ARD) of 1/14/26 had been completed, and documented the resident was at risk for pressure ulcers and had an unhealed pressure ulcer. On 4/2/26 at 9:42 AM, a review of a baseline care plan (BCP) for Resident #7 revealed that following the resident's admission to the facility, a preliminary care plan to address Resident #7's preexisting pressure ulcer had not been implemented. Further review of Resident #7's care plans revealed care plans that addressed Resident #7's pre-existing pressure ulcers were not developed timely. The care plans, Resident #7 has skin alteration related to Left heel wound, Resident #7 has skin alteration related to the right heel, and Resident #7 has skin alteration related to wound on the coccyx, were initiated on 1/30/26, which was 16 days after the completion of the resident's admission assessment and admission. The facility failed to timely develop and implement a comprehensive care plan that addressed care and management of Resident #7's pre-existing pressure ulcers. The above concerns were discussed with the Nursing Home Administrator (NHA) and the Director of Nurses (DON) on 4/3/26 at approximately 7:00 PM. The NHA and DON acknowledged the concerns offered no further comments at that time.

Based on medical record review and staff interviews, it was determined that the facility failed to provide care consistent with professional standards of practice to prevent pressure injuries and promote the healing of a pressure injury. This was evident for 1 (#7) residents reviewed for pressure ulcers. The findings include: Pressure ulcers (bedsores) are localized skin/tissue injuries caused by prolonged pressure, staged by severity. Stage 1 involves intact skin with non-blanchable redness. Stage 2 is partial-thickness skin loss (shallow, open blister). Stage 3 involves full-thickness skin loss with visible fat. Stage 4 involves deep tissue loss with exposed muscle, tendon, or bone. A deep tissue injury (DTI) pressure ulcers are defined as purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. Once a DTI opens to an ulcer, the ulcer would be reclassified into the appropriate stage On 3/31/26 at 1:03 PM, a review of complaint #2740369 alleged the care Resident #7 received in the facility was not adequate to prevent an existing pressure ulcer from getting worse. The complaint alleged that when Resident #7 was admitted to the facility, s/he had a bedsore on the sacrum (base of spine, above the tailbone) that was the size of a quarter and later in the month, when Resident #7 transferred to the hospital for a change in condition, the resident's bedsore on the sacrum was huge. On 3/31/26 at 1:11 PM, a review of Resident #7's medical record revealed Resident #7 was admitted to the facility in the second week in January 2026 following an acute hospitalization and transferred back to the hospital at the end of January 2026 and subsequently discharged from the facility. The medical record documented Resident #7 had multiple medical diagnosis, and pre-existing pressure ulcers. 1) Review of Resident #7's medical record revealed the resident had existing pressure ulcers when s/he was admitted to the facility and was followed by the wound care Nurse Practitioner (NP). On 1/9/26 at 3:19 PM, a skin and wound note, the wound NP documented Resident #7 was a new admission with multiple wounds including a pre-existing pressure ulcers. The NP documented the resident had a right (Rt) heel Stage 1 PU, a left (Lt) heel Stage 3 PU, and an unstageable PU on the coccyx. The NP documented the pressure ulcer measurements were: Rt heel cm (centimeter) 4 cm x 4 cm x 0 cm, Lt heel 3 cm x 4 cm x 0.5 cm, and Coccyx 1.7 cm x 0.5 cm x 0.3 cm, and the NP recommended the following treatment orders:- Right heel PU - Apply Skin Prep to base of the wound, leave open to air twice per day (BID).- Left heel PU - Cleanse with normal saline, apply Silver alginate to base of the wound, secure with Rolled gauze and change daily .- Coccyx PU - Cleanse with wound cleanser, apply Manuka HS Hydrogel to base of the wound, secure with Silicone Bordered Gauze, and change the dressing daily and PRN (as needed) A review of Resident #7's medical record failed to reveal evidence that the wound treatment orders recommended by the NP on 1/9/26 had been entered into the resident's record, and 2) In a skin and wound note on 1/12/26 at 2:54 PM, the wound NP wrote that when Resident #7 was seen by a different wound NP, the resident was found to have multiple wounds. The NP wrote that during his/her visit with Resident #7, the resident was agitated and only allowed the NP to see the resident's left heel wound. The NP wrote that it was discussed with the wound nurse to continue the treatments to the rest of the wounds as ordered on 1/9/26. 2a) Review of Resident #7's January 2026 Treatment Administration Record (TAR) revealed a 1/15/26 treatment order to cleanse the left heel PU with NSS, pat dry, apply silver alginate and cover with dry dressing daily, every day shift. The order was consistent with the NP recommendation on 1/12/26, however, the order was not entered into the medical record until 1/15/26, which was not timely, resulting in a delay in care. The review of the TAR also revealed a 1/14/26 order to apply skin prep to right heel DTI every day and evening shift, however no treatments for Resident #7's coccyx PU were found for that time frame. 2b) Review of Resident #7's medical record and January TAR failed to reveal evidence that following the wound NP's visit on 1/12/26, treatments were provided to the rest of the resident's wounds as ordered on 1/9/26 as recommended by the NP and discussed with the wound nurse on 1/12/26, as none of the wound treatment recommendations from the NP on1/9/26 had not been entered as orders in the resident's medical record at that time. 3) In a skin and wound note on 1/19/26 at 4:20 PM, the wound NP documented Resident #7's right heel PU remained a Stage 1, the left heel Stage 3 PU was healing, and the Coccyx PU remained unstageable. The treatment to the Rt heel PU was unchanged, and the NP made the following treatment order recommendations:- L heel Pressure Ulcer treatment - Cleanse with normal saline, apply Calcium alginate, Medical grade honey to base of the wound, secure with rolled gauze and change daily .- Coccyx Pressure Ulcer Treatment - Cleanse with wound cleanser, apply Medical grade honey to base of the wound, secure with Silicone.,3a) Review of Resident #7's January 2026 TAR revealed a 1/19/26 order, cleanse coccyx with NSS (normal saline), pat dry, apply Medihoney and cover with silicone bordered form, daily, every day shift. This was the first coccyx PU treatment found for Resident #7 since his/her admission to the facility with an existing pressure ulcer on the coccyx. 3b) Continued review of the resident's January 2026 TAR revealed a 1/19/26 order to cleanse left heel with NSS, pat dry, apply Medihoney with calcium alginate and cover with bordered gauze daily, every day shift, however further review of the TAR revealed the 1/15/26 order to cleanse left heel with NSS, pat dry, apply silver alginate and cover with dry dressing daily, every day shift was still an active order in the TAR and the facility staff failed to discontinue the previous order when the new order was given. In addition, the TAR documented both treatments done on 6 days (1/22, 1/23,1/24, 1/25, 1/27, 1/28, 1/29) in January 2026. 4) In a skin and wound note on 1/29/26 at 14:46 PM, the wound NP documented Resident #7's right heel PU which had been a Stage 1 was now restaged as a DTI, indicating that damage had progressed from the surface to deeper soft tissues, his/her Lt heel Stage 3 PU was stable. The NP documented Resident #7's unstageable PU on the Coccyx was worsening, had increased in length and width and now measured 11 cm x 21.5 cm x 0.3 cm. The NP's treatment order recommendations for the Rt and Lt heel PU were unchanged and recommended the following coccyx PU treatment: Cleanse with wound cleanser, apply Medical grade honey, Calcium alginate to base of the wound to base of the wound, secure with Silicone Bordered Gauze, change daily and PRN. Review of Resident #5's January 2026 TAR found orders consistent with the NP's wound treatment recommendations. 5) Continued review of Resident #7's medical record revealed on 1/19/26 at 4:20 PM, in a skin and wound note, the wound NP recommended Resident #7 have an alternating air/low air loss mattress (provides pressure management to prevent and treat pressure injuries) for pressure redistribution, and on 1/29/26 at 2:46 PM, in a skin and wound note, the NP recommended the resident have an alternating air/low air loss mattress for pressure redistribution. Review of Resident #7's January 2026 TAR revealed a 1/30/26 order for Air mattress in place and settings check for optimal effectiveness, every shift for pressure reduction to prevent or heal pressure wounds every shift. Continued review of the medical record failed to reveal evidence following the NP's recommendation on 1/19/26, and prior to 1/30/26, an alternating air/low air loss mattress had been implemented for Resident #7. 6) Review of Resident #7's admission MDS (minimal data set) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date (ARD) of 1/14/26 documented Resident #7 had one unhealed Stage 3 pressure ulcer. The MDS failed to capture Resident #7 had a Stage 1 PU on the right heel, and an unstageable pressure ulcer on the coccyx. The concern with the MDS inaccuracy was discussed with Staff #2, MDS Coordinator on 4/2/26 at 12:46 PM and the MDS Coordinator confirmed the findings at that time. Cross Reference F 641 7) A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Review of Resident #7's care plans failed to reveal a comprehensive care plan with measurable goals had been developed to address Resident #7's pressure ulcers which were present when the resident was admitted to the facility. Cross Reference F656 On 4/2/26 at 12:35 PM, the Nursing Home Administrator (NHA) stated that the facility had a wound nurse who did rounds with the wound NP and put in treatment orders, the nurse on the unit who admits the resident initiates the baseline care plan, and care plans are completed by the Unit Managers. On 4/2/26 at 1:56 PM, during an interview, Staff #1, Registered Nurse (RN), evening supervisor, stated on Mondays and Thursday, residents with wounds were seen by the NP. The NP assessed & measured the wounds and recommended wound treatment orders. Staff #1 stated s/he followed the wound NP on those days, and transcribed NP's wound treatment orders into the resident's medical record. Staff #1 recalled Resident #7 came into the facility with multiple wounds, including PU on the sacrum and heels, Staff #1 stated s/he was not aware of any concerns with Resident #7's treatment orders. Staff #1 was then made aware of the above concerns with the delay in the care of Resident #7's pressure ulcers resulting from failing to have PU treatment orders entered in the medical record timely. Staff #1 indicated s/he understood and stated s/he would talk with the DON about the concerns identified by the surveyor. On 4/2/26 at 2:53 PM, Staff #1, RN returned to speak with the surveyor and indicated the reason for the delay Resident #7's wound treatment was because the resident's frequent refusal of care. Staff #1 was again made aware of the concern that PU treatment orders recommended by the wound NP were not entered in the resident's medical record, resulting in a delay in care. Staff #1 was also made aware of the concerns with failing to have a care plan that addressed the resident's pressure ulcers and failing to implement an order timely for an alternating air/low air loss mattress for pressure redistribution as recommended by the NP. Staff #1 acknowledged the concerns at that time, and stated s/he did not know why the treatments orders were not put in the resident's medical record. On 4/3/26 at 7:37 PM, the above concerns were discussed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA and DON acknowledged the concerns at that time and no further comments were offered.

Based on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of abuse to the state survey agency for 1 (Resident #1) of 7 sampled residents reviewed for abuse.Findings included: A facility policy titled, Abuse, Neglect and Exploitation, reviewed/revised 11/13/2023, revealed VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. An admission Record revealed the facility admitted Resident #1 on 04/17/2024. According to the admission Record, the resident had a medical history that included a diagnosis of other sequelae of cerebral infarction (stroke). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Contained within the facility's investigation was handwritten statement from Licensed Practical Nurse #4 dated 07/12/2025, which indicated It was about 7:10 AM (on 07/11/2025) when oncoming nurse came to the nursing station with two police officers asking for the assigned GNA [geriatric nursing assistant] for [Resident #1's room]. Writer informed them that she already left for the day; writer was unaware that the resident called 911. Writer and the policy officers went to the resident's room to ensure what happened? Resident stated that the GNA was rough during incontinence care and fastened [his/her] adult brief so [he/she] was unable to use the urinal for urine specimen. During an interview on 10/15/2025 at 10:30 AM, the Director of Nursing (DON) stated around 10:00 AM to 11:00 AM (on 07/11/2025), she and Unit Manager (UM) #1 interviewed Resident #1 and during the interview, the resident reported they had called the police. The DON stated the expectation was that abuse was reported to the state survey agency within two hours of staff becoming aware of an allegation. Contained within the facility's investigation file was a handwritten statement from UM #1 dated 07/11/2025, which indicated The resident in {Resident #1's room} was interviewed by writer and [he/she] stated the GNA was rough and rushed with [him/her] when turning [him/her] on [his/her] side for incontinence care. Contained within the facility's investigation was a typed statement signed by the DON and dated 07/11/2025, which indicated, This writer interviewed [Resident #1] in the presence of the Unit Manager, [UM #1]. {Resident #1] stated the GNA, [GNA #2], was rough when she was changing [him/her]. {Resident #1] stated [GNA #2] had taken care of [him/her] multiple times before, but it was different this time. When asked what the difference was, [Resident #1] said [GNA #2] was rushing. [Resident #1] stated that [he/she] called the policy to report her. [Resident #1] was asked if there was a reason why [he/she] did not inform the supervisor instead,. [Resident #1] said that [he/she] will call the policy anytime [he/she] feels disrespected. During an interview on 10/15/2025 at 11:21 AM, the Administrator acknowledged she was the facility's abuse coordinator. The Administrator stated allegations of abuse should be reported within two hours to the state survey agency. According to the Administrator, the incident regarding Resident #1 and GNA #2 occurred during the 11:00 PM - 7:00 AM shift; she was notified by the DON of the incident and the incident was not reported to the state agency until 07/11/2025 at 2:00 PM.

Based on observation, interview, record review, and facility policy review, the facility failed to perform hand hygiene between glove changes during wound care for 1 (Resident #4) of 3 sampled residents reviewed for pressure ulcers.Findings included: A facility policy titled, Clean Dressing Change, dated 12/13/2022, indicated, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. The policy indicated, 7. Wash hands and put on clean gloves. 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound. Pat dry with gauze. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 16. Secure dressing. [NAME] with initials and date. 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. An admission Record indicated the facility admitted Resident #4 on 05/31/2015. According to the admission Record, the resident had a medical history that included a diagnosis of peripheral vascular disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/08/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had one unstageable pressure ulcer. Resident #4's Care Plan Report included a focus area initiated 07/15/2025, that indicated the resident had an opened area to the sacrum noted on readmission. Interventions directed staff to administer treatment as per physician order. During an observation on 10/15/2025 at 11:39 AM, Registered Nurse (RN) #14 and Geriatric Nursing Assistant #15 performed wound care for Resident #4. RN #14 removed the old dressing from the resident's sacrum, which exposed a very large deep unstageable wound that was covered with yellow slough. RN #14 removed his gloves and put on a new pair of gloves without performing hand hygiene and then wiped the wound and the peri-wound with sterile water-soaked gauze then RN #14 applied body soap and a foaming cleansing soap on a 4 x 4 gauze, made the gauze sudsy, and covered the wound bed with the soap. RN #14 wiped the soap off with a gauze soaked in sterile water, not rinsing off the soap completely, and left visible soap on the wound. RN #14 patted the wound dry with gauze, removed his gloves, and put on a new pair of gloves without performing hand hygiene. RN #14 then soaked gauze with Dakin's solution then squeezed out all the liquid from the gauze and placed the gauze on the wound bed. He removed his gloves and put on a new pair of gloves without performing hand hygiene and placed dry sterile 4 x 4 gauze on top of the wet gauze. RN #14 removed his gloves and put on a new pair of gloves without performing hand hygiene then covered the wound with four individually wrapped 4 x 4 bordered gauze. He removed his gloves and retrieved a pen out of his pocket to date the dressing. RN #14 then went to the bathroom to wash his hands. During an interview on 10/15/2025 at 12:02 PM, RN #14 stated hand hygiene should occur between glove changes. He confirmed that he did not perform hand hygiene every time he changed his gloves but should have. During an interview on 10/16/2025 at 4:26 PM, the Director of Nursing stated hand hygiene should occur before the procedure and during the wound care, and anytime the staff removed their gloves they should perform hand hygiene in between the glove changes.

Based on record reviews and interviews it was determined that facility staff failed to ensure that resident records were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This deficient practice was evident for 3 (#66, #86, #101) residents out of 4 residents reviewed for care plan meetings and quarterly assessment during the facility survey. The findings include: 1.) On 04/16/25 at 10:41 AM, during an interview, Resident #66, reported that they have not participated in care plan meetings. During an interview with the Director of Social Work (SW) #3 on 04/18/25 at 09:50 AM, she stated that resident care plan meetings are conducted within 14 days of admission, quarterly, annually, and upon change in medical condition. She also reported that invitations to the meetings are sent to the residents and their families. The surveyor requested documentation verifying that comprehensive and quarterly care plan meeting were held, and invitations notices were provided for 2024 and 2025. On 04/18/25 at 12:44 PM, the SW #3 provided the surveyor with care plan meeting notes dated 6/7/23, but no meeting invitation. Additional documents included care plan meeting notes dated 8/28/24, a care plan invitation dated 8/8/24, and care plan invitations dated 11/13/24 and 4/23/25. The SW #3 stated she was unable to provide proof that a care plan meeting was conducted on 11/2004 and acknowledged that she is behind on completing resident care plans. 50573 2.) On 04/17/25 at 12:28 PM, an interview with Resident #86 revealed he/she had concerns regarding her/his routine care plan meetings not being quarterly. On 04/18/25 at 09:50 AM, an interview with the Director of Social Services (Staff #3) revealed that the expectation was for care plan meetings was that resident care plans were revised to be quarterly. During the same interview, the surveyor requested Resident #86's care plan meeting documentation for 2024. On 04/18/25 at 12:26 PM, Staff #3 provided documentation for a care plan meeting for 7/11/24, and informed the surveyor that she was only able to provide documentation for the one (7/11/24) care plan meeting. 2a.) On 04/22/25 at 9:00 AM, review of complaint intake MD00202691 revealed a concern that Resident #86 was supposed to be in rehabilitation services. On 04/22/25 at 09:27 AM, an interview with the Director of Rehabilitation Services (Staff #23) revealed that residents were screened quarterly for rehabilitation services along with the care plan revision. At the same time, further interview with Staff #23 revealed that Resident #86 was screened for rehabilitation services on 8/8/2023, was put into rehabilitation services, and was discharged on [DATE]. On 04/22/25 at 09:27 AM, during the same interview, Staff #23 indicated that the resident had not been screened again for rehabilitation services until 4/11/24. On 04/22/25 at 11:55 AM, the surveyor reviewed the concern with the Nursing Home Administrator (Staff #1). 51712 3.) On 4/22/25 at 8:40 AM, review of records revealed that Resident #101 was provided Physical Therapy (PT) and Occupational Therapy (OT) services for Contracture Management, starting on 11/4/24, and was discharged from these services on 12/13/24. OT Goals were to prevent further contractures. Discharge recommendations were for nursing to apply splints daily and remove them every night. Resident #101 was last seen by OT on 12/13/24. The review of orders did not reflect that orders were placed for nursing staff to complete the discharge recommendations. The care plan review did not reflect the discharge recommendations for therapy. On 4/22/25 at 9:47 AM, the surveyor interviewed with the Director of Rehab (DOR #23) and the OT therapist (OT #40) regarding resident #101. When asked if OT was still seeing the resident, they stated no. The surveyor inquired about whether they perform quarterly evaluations on residents that have been seen by OT, and they confirmed that they do. The surveyor then asked when was the last quarterly evaluation conducted for the resident, DOR #23 and OT #40 were unable to answer. When the surveyor asked who was responsible for entering the orders into the EMR, the DOR was unable to provide an answer. They stated that they would return with the necessary information. On 4/22/25 at 11:44 AM, the Admin was interviewed and was asked how orders from PT/OT services were entered into the Electronic Medical Record (EMR). The Admin stated that when orders are recommended for nursing, PT/OT therapy is supposed to place the orders in the EMR for nursing. On 4/22/25 at 12:53 PM, DOR #23 and OT #40 returned to the surveyor and stated that the orders were never placed for Resident #101 to get the discharged recommendations from OT therapy. OT #40 stated that she would complete Resident #101's quarterly evaluation today and enter the recommendations and orders from OT into the system for nursing to follow-up.

Based on medical record review and interview with facility staff, it was determined that the facility failed to: 1) implement wound and skin care orders for a resident admitted after a surgical amputation and identified pressure ulcer; 2) provide services as order by the physician; and 3) maintain professional standards of practice when documenting a resident's showers. This was identified for 4 of 4 (#160, #106, #66, #108) residents reviewed for orders and documentation during the survey. The findings include: 1. Review of the medical record on 4/25/25 at 12:13 PM for Resident #160 revealed admission to the facility with diagnosis including aftercare following surgical amputation, gangrene and peripheral vascular disease. The hospital discharge summaries provided in the resident's medical record stated that prior to admission to this facility, Resident #160 was admitted to the hospital for a gangrenous infection of the left first toe. The podiatry team completed multiple debridement's and then finally an amputation of the toe to prevent the infection from spreading. Resident #160 was admitted to the facility according to an admission summary with 22 staples to the amputated toe site on the left foot. Resident #160 was screened by the wound physician on 8/26/24. He verbalized wound care orders. On 4/28/25 at 9:31 AM staff #27, the wound care physician was interviewed. He reviewed his notes and returned at 9:36 AM. He stated that he only saw the resident on 8/26/24 and had made recommendations at that time. He was asked why he didn't see Resident #160 again after that and he stated that he is given a list when he comes in to the facility of who to see and checks the list off as he goes. He further stated that he is just a consultant and sees who the facility requests him to see. At 9:40 AM staff #28 the Regional Clinical Consultant was notified that for Resident #160, no wound care orders for the amputation or the identified heel wound identified on admission could be found. Staff #28 was also notified that Resident #160 was admitted to the hospital for a follow-up procedure a month after admission to the facility for another surgical procedure. Those admission assessments were requested. At 1:38 PM on 4/28/25 this surveyor met with the facility DON regarding the status of the concerns for Resident #160. She was unaware and had not been notified of the concerns from staff #28 and had not looked for information to relay to this surveyor. Prior to exiting the facility, the DON provided nursing notes from the wound care nurse that documented wound care measurements for the heel and that care was provided weekly for Resident #160. The ongoing concern was presented to the DON at this time that during Resident #160's month long stay, there were no treatment orders put in for either the monitoring of the surgical site of the amputation or the wound care of the heel and therefore there was no place for staff to sign off that either were completed consistently. 50457 2) On 04/16/25 at 10:37 AM, during the initial screening of Resident #66, the surveyor noted a past medical history of cerebrovascular disease. The resident was observed not wearing Thrombo-Embolic Deterrent Stockings (TEDS). A review of the medical records revealed that the resident was ordered for TEDS to be applied at 9:00AM and removed at 9:00PM daily. An observation on 04/18/25 at 10:54 AM, revealed that Resident #66 was not wearing TEDS. A review of the medical record did not indicate that the resident refused to wear the TEDS, and there was no evidence that the physician had been notified of a refusal. On 04/21/25 at 11:50AM, during a follow up observation, the surveyor noted that Resident #66 was not wearing TEDS. On 04/21/25 at 11:54 AM, the surveyor asked Nurse Unit Manager (UM) #18 about staff expectation regarding physician orders. The UM #18 stated that staff are expected to review orders prior to providing treatment or services and follow the written instructions. If staff are uncertain about the orders, they are expected to speak with a supervisor. The surveyor informed UM #18 of the observations made for Resident #66 and that there was no documentation explaining why the resident was not wearing TEDS. The UM #18 stated that he would review the residents medical records for supporting documentation; however, no documentation was provided by the end of the day. On 04/22/25 at 9:09AM, the surveyor informed the Administrator #1 of observations related to Resident #66 and pending documentation from the UM #18. The Administrator stated that they were not able to locate any documentation confirming that the resident refused to wear TEDS. The Administrator stated that nursing staff will receive education on following physician's orders and nursing documentation. 3) During an interview with the Administrator #1 and Director of Nursing (DON) #2 on 04/21/25 at 8:16 AM, the surveyor asked about the expectation of nursing staff prior to administering blood pressure medication. The DON #2 stated that staff are expected to review the resident's Medication Administration Record (MAR) for instructions and administer the medication according to the provider's orders. On 04/21/25 at 08:48 AM, a review of Resident #106's MAR revealed an order for clonidine Oral Tablet 0.3 milligram (mg) tablet to be administered through a Percutaneous Endoscopic Gastrostomy (PEG) tube every 8 hours for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 or if the heart rate( HR) is less than 60. Further reviews showed that the medication was administered outside of the ordered parameter on the following dates: 3/4/25=SBP 107 3/11/25=SBP 106 3/22/25=SBP 108 3/25/25=SBP 108 3/30/25=SBP 109 4/6/25=SBP 108 4/15/25=SBP 104 4/14/25=SBP 101 4/21/25=SBP 103 A review of the medical records failed to show documentation that the nurse notified the physician when the resident's blood pressure was outside the ordered parameters for the medication. On 04/21/25 at 12:19 PM, the surveyor informed the Administrator #1 that blood pressure medication had been administered for Resident #66 outside of the ordered parameters, and that there was no documentation indicating that the physician had been notified. On 04/22/25 at 9:09AM, the Administrator stated that they were not able to locate documentation confirming that the physician was notified of the resident's SBP. The Administrator #1 stated that nursing staff will receive education on following physician's orders and nursing documentation. 50573 4) On 04/17/25 at 10:39 AM, review of complaint MD00212813 revealed a concern regarding Resident #108 receiving showers between October 2023 and December 2023. On 04/17/25 at 10:42 AM, review of Resident #108's medical record revealed an order with a start date of 10/03/2023, which indicated for the resident to receive a shower on Tuesdays and Fridays. On 04/17/25 at 10:43 AM, review of Resident #108's Treatment Administration Record (TAR) from October 2023 through December 2023 revealed 8 days (Tuesday 10/10/2023, Tuesday 10/24/2023, and Tuesday 10/31/2023, 11/07/2023, 11/17/2023, 12/08/2023, 12/22/2023, and 12/29/2023) which the order was documented as N (No), but failed to reveal why the resident had not gotten a shower. On 04/21/25 at 11:34 AM, an interview with the Director of Nursing (Staff #2) revealed that when staff document N for a shower, the expectation was for staff to document why the resident had not received a shower. On 04/17/25 at 10:43 AM, review of Resident #108's TAR revealed 2 days (11/24/2023 and 12/12/2023) which the shower order failed to be documented on. On 04/21/25 at 11:34 AM, an interview with the Director of Nursing (DON) revealed that the expectation of staff was to document every shift based on orders, including shower documentation on the TAR.

Based on observation and interview, it was determined that the facility failed to maintain a homelike environment for the residents as evidenced by failure to 1) keep the utility rooms, and resident shower room clean and organized; 3) ensure that residents were provided with hot water during the survey. This was evident during multiple observations made on the Arcadia Unit and throughout the facility. The findings include: 1) On 04/16/25 at 08:43 AM, an initial observation of the Arcadia unit in rooms [ROOM NUMBERS] revealed a toilet paper roll in the bathroom that was hung by a trash bag and tied around a handrail. On 04/17/25 at 08:22 AM, a follow up observation revealed the same concern in both room [ROOM NUMBER] and 23, where their toilet paper rolls were hung by a trash bag. 2) On 04/16/25 at 08:43 AM, an observation in room [ROOM NUMBER] revealed the bottom drawer of the (A-bed) nightstand, which failed to reveal it properly fit in the dresser or had a hand knob. On 04/17/25 at 08:22 AM, a follow up observation was made, which revealed the same concern. 3) On 04/16/25 at 09:03 AM, an initial observation of the Arcadia Unit in the bathroom between 18 and 19, failed to reveal a door knob on either side of the bathroom doors, which exposed a hole on both bathroom doors. On 04/17/25 at 08:06 AM, an interview with the Arcadia Unit Manager / Registered Nurse (Staff #19) revealed the staff used an online platform, TELS to report maintenance concerns. On 04/18/25 at 11:13 AM, an interview with the Director of Maintenance (Staff #5) revealed he was unaware of any maintenance concerns on the Arcadia Unit. On 04/18/25 at 11:46 AM, the surveyor and the Director of Maintenance (Staff #5) completed a walk through on the Arcadia Unit, and reviewed the concerns noted above from examples 1 through 3. 42863 4) On 04.16.25 at 08:15 AM the surveyor initiated an observation tour of the unit Arcadia and the following maintenance issues were identified inside resident rooms: a) room [ROOM NUMBER]A/B: no chair for guests was present, the linoleum was warped and cracked outside the bathroom door and missing paint on the wall near the room entry door. b) room [ROOM NUMBER]A/B: there were scratches on the wall paint behind the resident's headboard. c) room [ROOM NUMBER]A/B: the bedside cabinet was missing the top drawer handle. The toilet paper holder was missing in the bathroom, a plastic bag was tied through the toilet paper roll to a towel holder. d) room [ROOM NUMBER]A/B: the wall behind the resident's headboard had areas of paint missing and there was a non-fitting plastic cover over the top of the toilet. e) room [ROOM NUMBER] A: toilet paper was observed on a roll with plastic bag tied to handle rail safety bar across from the toilet, the toilet roll holder was missing the tension bar piece that would hold the bath tissue. There was an blue uncovered, unprotected water shutoff valve on the right side of the sink, located near the floor. During an interview with the unit nurse manager, staff #19 she confirmed the locked unit had a census of 32 residents at the time of the observation on 04.16.25 at 09:00 AM. On 04.17.25 at 09:10 AM, the unit manager, staff #19 stated that all disrepair or maintenance concerns are reported to the maintenance department via the TELS system. These observations were discussed with the maintenance director during an observation tour of two units with another surveyor on 04.18.2025 that began at 11:39 AM. On 04.28.25 prior to the exit conference, the administrator verified that the maintenance concerns had been shared with her by the maintenance director. 50457 5) During the initial observation of unit Annapolis and Garden View on 04/16/25 at 7:59 AM, the surveyor entered the shower room and observed a basin placed on top of a trash can, wheelchair pedals placed in front of the trash can, and a mop and broom leaning against it. Next to the toilet, a clear plastic bag and trash were noted on the floor. A brown substance was present on the toilet seat. The tub in the shower room contained a bedside commode bin, a bra, a black sock, a hanger, and a seat cushion. Towels were also noted on the floor. On 04/16/25 at 8:03 AM, the surveyor entered a room labeled as the clean utility room and observed a used clear glove placed on top of a black bin. Next to the back cabinet, the surveyor noted a wall with incomplete paint and an area of the floor missing tile. A box containing papers was observed on the floor, and behind the door, six staff jackets and a fanny pack were hanging. On 04/16/25 at 8:06 AM, the surveyor entered the soiled utility room. Upon entry, a sink full of standing dirty water was observed. The surveyor opened the cabinets to the right of the sink and found soiled shelves, five empty soiled flower vases, a clear plastic bag, a rod, and two telephones. The Administrator #1 and Director of Nursing #2 were both made aware of the observation on 04/16/25 at 8:38AM. During an interview with the Housekeeping Director #21 on 04/18/25 at 1:22 PM, she stated that floor technicians are responsible for pulling trash from common areas (dining room, clean and dirty utility rooms, shower rooms) and from resident rooms, and housekeeping staff are responsible for cleaning this area throughout the shift. When asked about monitoring cleaned areas, the Housekeeping Director #21 reported that she was responsible for rounding. The surveyor informed the Director of Housekeeping of the observed conditions in the residents' shower room and the clean and dirty utility rooms. She acknowledged the observation and stated that overseeing both housekeeping and laundry services can be challenging. 30440 6) An initial tour of the facility was conducted on 4/16/25 at 7:50 AM. While screening residents on the Chesapeake Unit, residents #52 and #18 told the surveyor that the facility was without hot water for 3 days. At this time the surveyor checked the residents' water in the bathroom. The water was turned on for greater than five minutes and did not get warm. Resident #52 was asked how s/he takes a bath or shower, and the resident stated, I do what I have to do and have been taking a bath with cold water because there was no hot water. Further observations were made of the water in room [ROOM NUMBER] and the water was turned on. The water was cold for more than five minutes and it did not get warm. The residents in the room were asked if they had hot water and the residents stated, no, the water had been cold for 3 days. At this time the surveyor approached the nurse supervisor #16 and asked about the water. The nurse stated that the Administration was aware of the water concern and was looking into the issue. During a subsequent observation at 8:44 AM, resident #52 was observed walking in their room from the bathroom. The resident told the surveyor that s/he just finished taking a cold bath. The resident stated that the water was not hot. On the same date at 8:55 AM an interview was conducted with the Administrator, and she stated that she was aware that the Chesapeake Unit did not have hot water in the afternoon of the previous day (4/15/25) and that the facility had a call into a company to get the issue resolved and that they are awaiting someone to be dispatched to the facility. The Administrator was made aware that multiple residents complained of not having hot water for 3 days that was prior to her report of the concern beginning on the previous day. The survey team asked the Administrator to provide documentation of previous temperature logs for the Chesapeake unit as well as current temperatures for the unit. The Administrator and the Maintenance manager returned to the survey team at 10:00AM and provided the team with copies of the temperatures for the unit as follows. 3/28/25 the temperature varied from 103, 104, 105, 106, 108, 110 up to 115. 4/4/25 temps were 106-114. 4/10/25 the temps were 104-115. 4/14/25 the temps were 107-114. Current temperatures for 4/16/24 were as follows: room [ROOM NUMBER] was 68 degrees Room # 84 was 66 degrees room [ROOM NUMBER] was 68 degrees room [ROOM NUMBER] was 65 degrees room [ROOM NUMBER] was 66 degrees room [ROOM NUMBER] was 65 degrees room [ROOM NUMBER] was 68 degrees room [ROOM NUMBER] was 68 degrees. The Administrator stated that they are currently rerouting showers to be done on the Annapolis unit. She stated that the Plumber was scheduled to come to the facility this date. The Administrator provided updated correspondence to the survey team on 4/18/25 at 9:20 AM regarding when the company would resolve the issue. She stated that the Plumber came in and looked at the valve and was waiting for a part. In the interim, residents were being transferred to another unit to shower. Residents who required assistance with baths the water was warmed prior to their bed bath. The plumbing company came into the building on 4/28/25 to work on water concerns. The Administrator stated that the water issue would be resolved this date and hot water would be restored.

Based on observations, resident and staff interviews, it was determined that the facility failed to ensure the residents were treated with dignity. This was evident for 2 residents (#109 and #121) out of 54 residents during this recertification survey. The findings include: 1) While making observations on the Chesapeake Unit on 4/16/25 at 8:44 AM Staff # 17 a Certified Nurse Assistant (CNA) was observed feeding the resident in their room. The CNA was observed standing at the bedside above the resident's right side feeding the resident forkfuls of food and a substance that was in the resident bowl. There was a chair in the room on the left side of the resident bed. The CNA was asked at this time is there any reason why she is standing above the resident assisting with feeding. She stated that the resident had psychological issues and that the chair is too wide to fit in the area where she was standing. The GNA was made aware that standing over the resident to assist with feeding and not sitting in a chair at the level of the resident is a dignity issue. She said she was not aware. She continued to stand and feed the resident. The unit nurse supervisor (Staff # 16) who was in the hallway at this time, was made aware of the concern. He stated that all staff are to sit down with the residents when providing feeding assistance. The Nurse immediately went to the resident room and provided education to the CNA. The Administration team was made aware of all concerns at the exit conference on 4/28/25 at 2:45 PM. 51712 2) Medical record review revealed Resident #109 had the following but limited medical history of muscle spasm, congestive heart failure, fluid overload, and left leg below the knee amputation. Resident #109 was assisted with ADLs, and could transfer self in and out of bed with 1-person physical assist; toileting required extensive assistance, and the resident was wheelchair ambulatory. On 4/17/25 at 9:08 AM, Resident #109 was observed in his/her room sitting on the bedside commode next to his/her bed. Resident #109 asked the surveyor to come back in a few minutes when s/he was finished. At 9:35 AM, the surveyor returned to speak with the resident. Resident #109 stated that there was a lack of respect in this facility, and that s/he was left on the bedside commode for 2 hours before s/he got assistance back to bed one night. Resident #109 also stated that s/he felt like they treat him/her inhuman. On 4/22/25 at 9:05 AM, the Administrator and Director of Nursing (DON) were interviewed about Resident #109's care. The surveyor asked if they knew Resident #109 and if they were aware of the resident being left on the bedside commode for 2 hours one night. The Administrator and DON stated that they were not aware of this and would have a discussion with the resident. On 4/22/25 at 11:28 AM, the DON came back to the surveyor to inform the surveyor that the resident stated that the event did occur, however, s/he did not know the exact date that it occurred, only that it was 2 o'clock in the morning. Resident #109 stated that s/he had told their nurse. The DON stated that she would speak with the evening manager about educating the staff on leaving residents on the bedside commode too long and the rights of the residents.

Based on record review and staff interview, it was determined that facility staff failed to ensure written notification of transfer were provided to the resident and responsible representative upon a transfer. This was evident for 1 (Resident #86) of 2 residents reviewed for hospitalization. The findings include: On 04/21/25 at 07:42 AM, a review of Resident #86's medical record revealed that the resident was hospitalized on [DATE]. On 04/22/25 at 08:38 AM, an interview with Registered Nurse/ Unit Supervisor (Staff #16), revealed that resident representatives were verbally notified of resident transfer and reasoning, but that it was not written notification. On 04/22/25 at 08:45 AM, an interview with Licensed Practical Nurse (Staff #7) revealed that resident representatives were verbally notified of resident transfer and reasoning, but that it was not written notification. On 04/22/25 at 11:19 AM, the surveyor reviewed the concern with the Director of Nursing (Staff #2).

Based on medical record review and interviews with facility staff it was determined the facility failed to ensure accuracy when coding a resident Minimum Data Set (MDS). This was found to be evident for 1 (Resident # 107) of 6 residents reviewed for accidents during the survey. Findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The Matrix is used to identify pertinent care categories for :1) Newly admitted residents in the last 30 days who are still residing in the facility and 2) All other residents. The facility is responsible for completing this form. Column # 10 is to be completed if the resident has a Fall (F), Fall with injury (FI), Fall with Major injury (FMI). Review of the facility's matrix on 4/16/25 at 12:45 PM revealed resident # 107, column # 10 for Falls indicated F, and FI. Review of the MDS Quarterly Assessment with an Assessment Reference Date (ARD) of 1/5/25 revealed under section J1900 (B) number of falls since admission or prior assessment-injury was coded one (1) for injury. Section J0300 Pain assessment interview is coded (0) No. Continued review revealed, a nurse note with a date of 10/6/24 at 6:34 AM indicating that during morning routine check-ups, writer noted Resident # 107 sitting on the floor. Assessment done and pain score 0/10 indicating no pain. No physical injury noted. Further review of the resident falls care plan revealed the last update was on 5/8/23. Review of nurse progress notes and pain assessments revealed the resident did not have pain on the following assessments dates: 10/6/24 Day (D) Shift, 10/7/24, Day shift and 10/8/24 Day shift. The Medication Administration Record (MAR) for pain evaluation was marked zero (0) for each of the above dates. Further review of a physician note dated 10/7/24 revealed the resident indicated pain in the arm and an x-ray was ordered to rule out fracture. The results of the x-ray were negative for fracture. An interview was conducted with the NHA on 4/22/25 at 10:40 AM and she stated that the resident did not have a fall with injury and that the documentation on the matrix was incorrect. An interview was conducted with the MDS Coordinator (Staff # 22) on 4/22/25 at 11:08 AM and she was asked if the resident had a fall with injury. She stated that the resident had a fall on 10/6/25 and it was captured on the 1/5/25 assessment. She stated that if the resident has pain, it will be coded as an injury. The surveyor informed her that according to the assessment that was done after the fall, the resident did not c/o pain and there was no injury. She confirmed that the MDS was coded incorrectly. All concerns were discussed with the Administration team during the exit conference on 4/28/25 at 2:45 PM.

Based on record reviews and interviews, it was determined that the facility failed to develop a care plan to manage bowel and bladder incontinence for a resident. This deficient practice was evident for 1 (#106) resident reviewed for comprehensive care plans during the survey. The findings include: On 04/17/25 at 8:20 AM, a review of Resident #106's medical records indicated that the resident is incontinent of bowel and bladder. Further review of medical records failed to show that a care plan was developed to address bowel and bladder incontinence. During an interview with Director of Social Worker (SW) #3 on 04/22/25 at 10:46 AM, the surveyor asked who was responsible for auditing resident's medical records to ensure residents' care plans accurately address plan of care. The SW #3 explained that an interdisciplinary team meets quarterly and annually to review each resident's plan of care, and the nurse unit manager is responsible for ensuring the nursing portion of the plan is up to date. On 04/17/25 at 11:05 AM, a review of Resident #106's Minimum Data Set (MDS) section bowel continence indicated that the resident is always incontinent of bowel. Review of section urinary continence also reflected the resident is always incontinent of bladder. On 04/17/25 at 11:10 AM, during an interview with Nurse Unit Manager (UM) #18, the surveyor informed the UM #18 that the resident had been identified as incontinent of both bowel and bladder since admission, however, a review of the quarterly care plans revealed that no plan of care had been developed to address the incontinence. Both the surveyor and the UM #18 reviewed the resident's medical records, and he acknowledged that a care plan should have been created. After surveyor intervention, on 04/22/25, a care plan was initiated to address the resident's bowel and bladder incontinence.

Based on observations, staff interviews, and record review, it was determined that the facility failed to ensure that residents with a limited range of motion receive appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 out of 1 resident observed for limited range of motion during this survey. The findings include: Contracture management is a variety of techniques aimed at preventing or improving limited joint movement due to shortening of muscles, tendons, or surrounding tissues. These methods include physical therapy, splinting, medication, and in some cases, surgery. Early intervention and consistent management are crucial for maximizing functional outcomes. Review of medical record revealed Resident #101 was a long-term care resident who has the following but is limited to medical history: morbid obesity, protein-calorie malnutrition, and a PEG tube. Resident #101 was bed-bound with a limited ROM to all extremities. On 4/17/25 at 12:13 PM, Resident #101 was observed in bed resting comfortably. The surveyor observed that the resident's right hand was in contracture. On 4/22/25 at 8:40 AM, review of records revealed that Resident #101 was provided Physical Therapy (PT) and Occupational Therapy (OT) services for Contracture Management, started on 11/4/24, and was discharged from these services on 12/13/24. OT Goals were to prevent further contractures. Discharge recommendations were for nursing to apply splints daily and remove them every night. Resident #101 was last seen by OT on 12/13/24. The review of orders did not reflect that orders were placed for nursing staff to complete the discharge recommendations. The care plan review did not reflect the discharge recommendations for therapy. On 4/22/25 at 9:47 AM, the surveyor interviewed the Director of Rehab (DOR #23) and the Occupational Therapist (OT #40) regarding Resident #101. When asked if OT was still seeing the resident, they stated no. The surveyor inquired about whether they perform quarterly evaluations on residents that have been seen by OT, and they confirmed that they do. The surveyor then asked when was the last quarterly evaluation conducted for this resident completed. OT #40 was unable to provide an answer. When the surveyor asked who was responsible for entering the orders into the EMR, the DOR #23 was unable to provide an answer. They both stated that they would return with the necessary information. On 4/22/25 at 11:44 AM, the Administrator (Admin #1) was interviewed and was asked how orders from PT/OT services were entered into the Electronic Medical Record (EMR). The Admin #1 stated that when orders are recommended for nursing, PT/OT therapy is supposed to place the orders in the EMR for nursing. On 4/22/25 at 12:53 PM, DOR #23 and OT #40 returned to the surveyor and stated that the orders were never placed for Resident #101 to get the discharge recommendations from OT therapy. OT #40 stated that she would complete Resident #101's quarterly evaluation today and enter the recommendations and orders from OT into the system for nursing to follow-up.

Based on interviews, observations, and record reviews it was determined that facility staff failed to assist residents who are dependent on staff for activities of daily living (ADLs) such a bathing. This deficient practice was evident for 1 (#66) of 5 residents reviewed for ADL care during the survey. The findings include: During an interview with Resident #66 on 04/16/25 at 10:37 AM, he/she stated they had only received one shower during the month of April 2025 but reported receiving daily bed baths from staff. The resident stated they would prefer more showers in the shower room. On 04/21/25 at 09:05 AM, during an interview with the Director of Nursing (DON) #2, she stated that staff are expected to provide showers to residents as ordered and should not substitute a bed bath in place of a shower. If a resident refuses a shower, staff are expected to document the refusal in the medical records. On 04/21/25 at 1:48, a review of Resident #66's treatment administration record (TAR) revealed an ordered for showers Mondays and Thursdays. Further reviews showed that the resident received a bed bath on Thursday 04/3/25, Monday 04/07/25, Thursday 04/10/25, with no documentation of a bed bath or shower on Monday 04/14/25. Review of geriatric nursing assistant (GNA) documentation for April 2025 indicated that the resident received daily bed bath, except on 4/3/25 it was documented that the resident received a shower. There was no documentation explaining why the resident did not receive scheduled showers. On 04/22/25 at 09:13 AM, the surveyor informed DON #2 that Resident #66 reported receiving one shower in April, although resident's preference was twice a week. The DON #2 stated that she would follow up with staff regarding resident's schedule shower day.

Based on record review and interview, the facility failed to ensure that an antipsychotic medication was ordered with adequate monitoring. This was evident for 1 (Resident #16) of 5 residents reviewed for unnecessary medications. The findings include: On 04/18/25 at 10:53 AM, review of Resident #16's medical record revealed an active order for Bupropion (an antidepressant) to be administered once a day, with a start date of 3/24/2025. An antidepressant is a medication used for mental health. The medication can cause side effects that could be serious and monitoring can help identify side effects. On 04/18/25 at 10:54 AM, further review of the residents medical record failed to reveal an order for antidepressant monitoring until 4/16/2025. On 04/21/25 at 09:07 AM, an interview with the Director of Nursing (Staff #2) revealed that the expectation was for side effect monitoring to be ordered when an antipsychotic (like Bupropion) was ordered for a resident.

Based on administrative record review and interviews with facility staff it was determined the facility failed to ensure the safety of a resident after the resident reported allegations of staff abuse for Resident #146, and failed to ensure a thorough investigation was conducted for a Facility Reported Incident (FRI) regarding Resident #165. This was found to be evident for 2 of 19 residents reviewed for abuse during the survey. Findings include, 1) MD00204470 was reviewed on 4/18/25 12:00 PM for allegations of staff abuse. The abuse was unsubstantiated. A review of the facility's investigation revealed a discipline in which staff (#34) received a written warning about the following infraction: Employee (# 34) who is a nurse, was directed to leave the facility immediately and was on off duty due to an allegation of abuse made by Resident #146. The employee was told to leave the building by the Administrator and DON on 4/8/24 at approximately 12:30PM. The employee was found on another unit documenting on a resident at 2:12 PM and did not leave the building until after about 2:20 PM. Employee (#34) wrote a response stating that they were holding keys and did not give report and was waiting to do narcotic count. An interview was conducted with the NHA on 4/21/25 at 12:15 PM and she was asked to explain the facility's procedure when investigating an employee for allegations of resident abuse and she stated the following: The alleged perpetrator was asked to leave the building immediately, however, this employee did not leave and remained in the building. The Administrator was asked how the facility can keep residents safe from retaliation from their alleged perpetrator, and she stated the employee should have been escorted out of the building, and that this employee was not, he was told to leave. The NHA stated that the abuse allegation was unsubstantiated, however, this employee was later terminated for insubordination. All concerns were discussed with the administration team at the exit conference on 4/28/25 at 2:45 PM. 50573 2) On 04/23/25 at 11:09 AM, review of facility documentation for MD00212656 revealed that Resident #165's representative made the facility aware of an allegation Resident #165 had made regarding Geriatric Nursing Assistant (Staff #39). At the same time, review of the facility documentation revealed that Resident #165 indicated to their representative that Staff #39 was rough with her/him during repositioning/ morning care and that Staff #39 turned the resident on their right side during care which they did not want to be turned on. On 04/23/25 at 11:12 AM, further review of the facility documentation for MD00212656 revealed a document titled, Abuse- Investigation Statement which failed to reveal indication that the allegation was addressed (if Staff #39 was rough during Resident #165's repositioning/ morning care and/or if the staff member had turned the resident on the side they did not want to be turned on). On 04/23/25 at 11:13 AM, further review of the facility documentation failed to reveal indication that the staff was interviewed or made a statement regarding the specific allegation made. On 04/24/25 at 10:29 AM, the surveyor reviewed the concern with the Nursing Home Administrator (Staff #1). Staff #1 said they would look into it and see if they had any further documentation to provide that would address the specific allegation made. On 04/24/25 at 12:35 PM, Staff #1 indicated they had no further documentation to provide that would indicate what the surveyor requested.

Based on record review and staff interview, it was determined that the facility failed to include the resident comprehensive care plan goals with the required documentation during a transfer. This was evident for 1 (Resident #86) of 2 residents reviewed for hospitalization. The findings include: On 04/21/25 at 07:42 AM, a review of Resident #86's medical record revealed that the resident was hospitalized on [DATE]. On 04/22/25 at 08:38 AM, an interview with Registered Nurse/ Unit Supervisor (Staff #16), revealed that resident comprehensive care plan goals were not sent with residents upon transfer. On 04/22/25 at 08:45 AM, an interview with Licensed Practical Nurse (Staff #7) revealed that resident comprehensive care plan goals were not sent with residents upon transfer. On 04/22/25 at 11:19 AM, the surveyor reviewed the concern with the Director of Nursing (Staff #2).

Based on the review of complaints, interview with complainants, review of facility policy and interview with facility staff, it was determined that the facility failed to provide a resident's medical records to the identified and established representative in a timely manner. This was evident during the review of 1 of the 2 complaints regarding access to medical records (Resident #162). The findings include: Interview with a complainant on 4/23/25 at 8:53 AM regarding the complaint MD00206860 revealed concerns that upon the request for their loved one's medical records it took over 40 days. On 4/23/25 at 9:50 AM staff # 24, the Business office manager was interviewed. She reported to this surveyor at that time that requests for records would go through her. The process includes the requestor would need to fill out the appropriate paperwork, the paperwork goes to the legal department so they can determine if that individual has authorization to the records, then the legal department will let the facility know if the records can be released. The records can then be gathered for the requester. Staff #24 further reported that depending on the volume she will mail or email the information to the requester. This surveyor asked if there is certified paperwork on the chart that the facility accepted and acknowledged as Power of Attorney (POA) paperwork to make healthcare decisions for a resident, why is that not sufficient to release medical records? Staff #24 stated that that was just the facility process. This surveyor asked what the turnaround time was and if that could cause a delay in the presentation of the records, staff # 24 was unable to provide an answer. The facility policy on record requests was requested at that time. At 11:53 AM on 4/23/25, staff #24 provided this surveyor with a request for medical records for Resident #162 that was completed and requested on 6/11/24. Staff#24 was asked if she had documentation of when the requested records were provided to Resident #162's POA. She stated that it was around the beginning to the middle of July 2024. According to an interview held with the resident representative earlier this morning, it took around 40 days to acquire these records. According to the facility policy provided on 4/24/25 at 1:17 PM Release of Medical Records implemented 2/3/23, 3. Upon request to access or obtain copies of the medical record, the facility should review the authorization to ascertain access rights of that person. Authority to assess or release records is only granted by the residents or the residents legal representative. The facility should request copies of any legal papers necessary to authenticate authority. #6. Upon receipt of request for medical record copies, the facility should notify the requesting party, in writing about the cost for obtaining the records and that records are available 2 days after receipt of payment for the copies. For Resident #162, the POA paperwork was reviewed by this surveyor and identified as in place at the time of the initial request. The medical record request form provided to the POA of Resident #162 had no financial liability attached. The form that was provided on 6/11/24 was an Authorization for the release of health information records. Therefore, there should have been no delay in providing Resident #162's medical records to this POA as it was the POA signing for the release of the records. As of exit on 4/28/25 no further documentation was provided to the survey team as far as when the records were delivered and provided to the POA, however, it was established from interview with Staff #24 and the complainant that it was over the regulatory 2 days of the initial request on 6/11/24 and the POA did not receive them until sometime in July of 2024, minimally 19 days.

Based on observation, interview and record review, it was determined that facility staff failed to ensure a resident had access to their call light. This deficient practice was identified in 1 resident ( #106) out of 1 residents reviewed for accommodations during the survey. The findings include: On 04/16/25 at 10:21 AM, the surveyor entered room [ROOM NUMBER] and observed Resident # 106 resting in bed. During the observation, the surveyor noted that the resident's call light (system that allows residents to alert staff when they need help) was missing. The surveyor located Licensed Practical Nurse (LPN) #31 and requested assistance in finding the call device. The LPN #31 searched the area around the resident's bed and located the call device wrapped around the arm of a chair positioned to the right side of the bed's head. The device was not within the reach of the resident. The surveyor asked LPN #31 what staff are expected to do before exiting a resident's room. LPN #31 stated that the call device should always be within the resident's reach and that staff are expected to ensure the resident has access to the call device prior to leaving the room. On 04/23/25 at 11:30 AM, review of medical records for Resident #106 under the task section showed instructions to 'keep call light within reach at all times.' The surveyor reported the observation to the Administrator #1.

Based on record reviews, and interviews, it was determined that facility staff failed to ensure a resident who is incontinent of bowel/bladder received appropriate treatment and services. This deficient practice was evident for 1 (Resident #106) of 1 resident review for incontinent care during the survey. The findings include: On 04/17/25 at 8:20 AM, a review of Resident #106's medical records indicated that the resident had a stage 4 sacral pressure ulcer, was incontinent of bowel and bladder, and needed assistance with personal care. Further review of treatment administration records, physician orders, and resident care plan failed to show that treatment, or services were in place to address bowel and bladder incontinence. During an interview with Director of Social Worker (SW) #3 on 04/22/25 at 10:46 AM, the surveyor asked who was responsible for auditing resident's charts to ensure residents are receiving appropriate services and treatment. The SW #3 explained that an interdisciplinary team meets to review each resident's plan of care, and the unit manager is responsible for ensuring the nursing portion of the plan is accurate. On 04/17/25 at 11:10 AM, during an interview with Nurse Unit Manager #18, the surveyor informed them of the missing treatment and services to manage the resident's incontinence. The UM #18 stated that a plan should have been in place to address the residents incontinence. Both the surveyor and UM #18 reviewed the resident's medical chart and were unable to locate services or treatment addressing the incontinence. The UM #18 acknowledged that a plan should have been developed and state they would update the medical records to ensure treatment and services were addressed.

Based on staff and resident interviews and review of medical record and other documentation, it was determined that the facility staff failed to develop adequate care plans for resident #1 related to risk of falls and for safe transfers during toileting. With inadequate care planning, the facility then developed inadequate instructions for front line staff in Kardex documentation that stated that the resident "usually" requires a certain level of assistance rather than clearly defining the individualized assistance needs for resident #1. With unclear plans and unclear instructions, staff assisted resident #1 to the bathroom on 1/4/15 where he/she suffered a fall with injury. This finding was identified during the investigation of complaint MD 605 and affected 1 (#1) out of 4 residents reviewed during the on-site survey on 2/13/15. The findings included: Reference F 323 for additional information for resident #1. On 02-18-15, record review revealed that resident #1 was assessed to be fully alert and oriented, non-ambulatory, and used a wheelchair for mobility on admission to the facility several months prior. Resident #1 was at increased risk for falls due to significant number and type of diagnoses. Review of the 10-06-14 and 11-13-14 MDS (minimum data set - a mandated resident assessment tool) revealed that, under Section G, Functional Status related to transfers, resident #1 required two + persons physical assist for transfers between surfaces including to or from: bed, wheelchair, standing position (excluding to/from bath/toilet). Completed MDS assessments also revealed that, at least three times during the seven day assessment window, resident #1 required 2 person assistance for transfers and toileting. On 01-04-15, the resident was transferred from the wheelchair to the toilet in the shower room by LPN #1. This transfer was without incident. However, during the transfer back to the wheelchair from the toilet, resident #1 developed weakness in her right leg, the only leg she could stand on, and fell to the floor, fracturing both sides of her right ankle. Further record review revealed a 10-27-14 physical and occupational therapy follow up communication form. This form was completed by resident #1's physical therapist and occupational therapist and addressed the resident's needs and the level of assistance as determined and recommended by PT, for ambulation, transfers, ADLs (activities of daily living), eating, range of motion, and communication. Review of this therapy communication form revealed that resident #1 needed two + (plus) person physical assist (and consider using a mechanical lift) for transfers: from bed to chair, from wheelchair to standard chair, chair to bed and to and from the shower. This same therapy communication form revealed that the level of assistance for ADLs included: one person physical assist for bathing, grooming, upper and lower body dressing, and toileting. the toilet. Despite the recommendation from therapy staff to the interdisciplinary team, updated documentation was not found in any care plan specific to resident #1's assistance needs specific to toileting. On 02-18-15 at 2:10 PM, interview with physical therapist (PT) #4 revealed that she worked with resident #1 before and after the fracture and knew the resident well. She expressed her opinion about the resident's transfer assistance needs stating that, prior to the fracture, resident #1 had been progressing well and he/she was able to use a transfer board to move from bed to the wheelchair and back. However, for all other transfers, resident #1 required the assistance of two staff and preferably, with the use of a mechanical lift. Review of the ADL self-care deficit care plan, initiated on 09-08-14, revealed that on 01-19-15, (after resident #1's fall), staff added that resident #1 was to be transferred with a mechanical lift. Use of a mechanical lift requires the presence of two + staff. However, no guidance about what level of assistance was necessary for resident #1 regarding toileting was found by the surveyor. Another care plan for risk of complications due to musculoskeletal problems related to right ankle fracture, neck pain, lower extremity pain spinal cord injury, and chronic back pain was originally created on resident #1's admission in August 2014, initiated on 9-08-14 with a revision on 1-19-15. This care plan intervention still listed one person transfers, even after resident #1 returned from surgery with a cast and no weight bearing status on his/her right leg, and no guidance was found regarding resident #1's assistance needs during toileting. On 02-26-15 at 1:30 PM, a phone call to the Director of Care Delivery (DCD) revealed that the musculoskeletal care plan had been updated on 01-19-15 to include the ankle fracture. She was not aware that the care plan still documented that resident #1 was still a one person transfer. The DCD said that there was a care plan related to fall risk, but it did not include what level of assistance was required for transferring resident #1. On 02-25-15 at 1:30 PM, a conference call was held with the facility Administrator, DON (Director of Nursing), and the corporate RN. The corporate RN said that the 10-27-14 therapy follow up communication form indicated that the resident was a one person assist for toileting. However, according to facility policy, the communication form was not an order and was not a care plan; it was only a suggestion that was entered into the record from therapy. Following the conference call with the Administrator, DON, and corporate RN, the surveyor called the facility and spoke with the Director of Therapy Services and the OT (occupational therapist) and PT #4 who both had worked with the resident on admission and the PT after resident #1's fall with fracture. . In the opinion of the OT staff, he revealed that the level of care of one person assist under toileting, referred to care of resident #1 while in bed. This meant incontinent care, such as changing the incontinent product or the use of a bedpan and turning the resident in bed. He stated that resident #1 required the assistance of only one staff to perform this ADL care. During interview with PT #4, she indicated that, in her opinion,, resident # 1 required 2+ person assist for all transfers. She stated that this was what resident #1 required on 10-27-14, and this need had not changed since the communication form changed. In facility process, "Kardex" documentation that front line staff follow is the means by which care planning information is communicated to front line staff. "Kardex" documentation for resident #1 only indicated that resident #1 "usually" needed one person assist with toileting and "usually" needed 2 person assistance with transfers. This documentation left it to the front line staff to assess resident #1's needs on an ad hoc basis to determine when he/she might need more or less assistance, rather than following the mandated process to carefully craft and implement clear and accurate care plans based on comprehensive assessments completed by qualified staff. On 01-04-15, resident #1 was transferred from the wheelchair to the toilet in the shower room by one staff, LPN #1. During the subsequent transfer back to the wheelchair from the chair, still with only one staff, resident #1 developed weakness in her right leg and fell to the floor, fracturing both sides of his/her right ankle. The failure to develop accurate and consistent care plans contributed to inconsistent understandings of resident #1's needs for assistance, and contributed to resident #1's fall and injury, when only one staff assisted him/her in the bathroom on 1-4-15.

Based on observation, resident and staff interviews, and review of medical record documentation, it was determined that the facility failed to develop adequate care plans for resident #1 related to risk of falls and for safe transfers during toileting. With inadequate care planning, the facility then developed inadequate instructions for front line staff in Kardex documentation which stated that the resident "usually" requires a certain level of assistance, rather than clearly defining the individualized assistance needs for resident #1. With unclear plans and unclear instructions, the facility failed to communicate one consistent plan for what assistance was necessary to toilet resident #1. With unclear plans and unclear instructions, resident #1 suffered a fall with injury. On 02-18-15, record review revealed that resident #1 was assessed to be fully alert and oriented, non-ambulatory, and used a wheelchair for mobility since admission to the facility several months prior. Resident #1 was at increased risk for falls due to compromised functional status and significant number and type of diagnoses. Resident #1 was initially admitted to the facility for rehab services. Review of the 10-06-14 and 11-13-14 MDS (minimum data set - a mandated comprehensive assessment tool) revealed an aggregate score for two + person physical assist for transfers between surfaces, including to or from: bed, wheelchair, standing position (excluding to/from bath/toilet). Completed MDS assessments also revealed an assessed aggregate score for resident #1 of 2 person assistance for transfers and toileting. These aggregate scores meant that resident #1 received 2 person assistance with these ADLs three or more times during the seven day assessment window. However, when the related care plans were developed, the plans failed to incorporate these individualized assistance needs for resident #1. A care plan for risk of complications due to musculoskeletal problems related to right ankle fracture, neck pain, lower extremity pain spinal cord injury, and chronic back pain was originally created on resident #1's admission in August 2014 and initiated on 09-08-14. This care plan indicated that resident #1 needed only one-person assistance from staff even though the MDS assessment and other facility documentation showed that he/she sometimes needed two person assistance. Despite his/her assessed need and even after a 1/4/15 fall and returning post-surgery with a cast and no weight bearing status to his/ right leg this care plan intervention continued to indicate that only one-person assistance was necessary. Another care plan for risk of falls due to unsteady gait and potential medication side effects indicated "encourage to transfer and change positions slowly" but this plan also did not document the resident #1's assessed need for two-person assistance at times. Record review revealed that, on 01-04-15, resident #1 was observed by licensed practical nurse (LPN) #1 in the hall in front of the nursing station in an electric wheelchair saying she needed to go to the bathroom. LPN #1 rotated between units and was not assigned to resident #1's unit regularly. In an interview on 2/18/15, LPN #1 acknowledged that he was not familiar with resident #1 and his/her physical needs and that he did not seek assistance from another staff more familiar with resident #1. Kardex documentation ,that front line staff follow, links planned care to care actually delivered by staff. Kardex documentation from the medical record indicated that resident #1 "usually" needed 1 person assist with toileting and "usually" needed 2 person assistance with transfers. This left it to the front line staff to assess the resident's ADL needs on an ad hoc basis to determine when he/she might need more or less assistance, rather than following the mandated process to carefully craft care plans based on comprehensive assessments completed by qualified staff. In interview with resident #1 on 02-18-15 at 2:10 PM, he/she indicated that at approximately 2 PM on 01-14-15, he/she needed toileting assistance, no other staff were available, and LPN #1 said he would take her. Resident #1 stated that LPN #1 attempted to take her to the bathroom in her room, but there were no bars for her to hold onto, so LPN #1 took resident #1 to the shower room (which has a toilet) in her wheelchair. Interview with LPN #1 on this same date at 2:50 PM corroborated that LPN #1 heard resident #1 in the hallway asking for assistance to the bathroom. LPN #1 stated that he then took resident #1 to her room bathroom, but it was too small. Resident #1 told him that she could put weight on her right leg so LPN #1 took resident #1 to the shower room toilet and the resident was able to stand and pivot (standing on one leg with staff supporting the upper body) to the toilet using her right leg. Further interview with LPN #1 revealed that, when resident #1 was finished using the toilet, LPN #1 "held her under her arms to stand her up while resident #1 held onto the grab bars, placed incontinence briefs on resident #1 and pulled her pants up". At that time, LPN #1 said that resident #1's right leg "gave out" and LPN #1 stated he "lowered her gently to sit her on her bottom with her legs straight out in front of her". LPN #1 also stated that he called for the passing housekeeping staff to assist him to pick resident #1 up off the floor, which they did by placing their arms under resident #1's arms and lifting her into her wheelchair. In interview with the surveyor, resident #1 reported that when LPN #1 was transferring him/her back to her wheelchair after using the toilet, her right leg became weak and he/she fell hard on her right hip and felt pain in her right ankle. Facility investigation disputed this report from the resident to the surveyor about falling hard when he/she fell to the floor on 1-4-15, but nonetheless, corroborated that the fall occurred. After the fall, resident #1 and LPN #1 offered differing accounts, but the record revealed that, at 5:18 PM, resident #1 was assessed with [REDACTED].#1 had landed on the floor, nor after the right ankle pain was identified. Following a nursing pain assessment, the physician was contacted, and a right ankle x-ray was obtained. The x-ray revealed that resident #1 had suffered a fracture to both sides of his/her right ankle and the resident was sent to the hospital on [DATE]. Resident #1 was admitted and hospitalized for [REDACTED]. The facility did not develop accurate and consistent care plans based on comprehensive assessments, did not communicate a clear and consistent plan to front line staff in the Kardex system, and instead, relied on front line staff to determine when resident #1 might need more or less assistance on an ongoing basis. This practice greatly increased the risk for harm to the resident, and on 1-4-15, resident #1 suffered a fall with injury when only one staff assisted her in the bathroom. Reference also Federal Tag F0279.