Every finding on record at Autumn Lake Healthcare at Glen Burnie

Based on review of complaints, 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 4 (Resident #10, #2, #7, #9) of 11 residents reviewed for complaints during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual 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. 1) On 7/27/26 at 12:21 PM a review of complaint 3040583 and Resident #10's medical record was conducted. Review of a 6/2/26 skin and wound note documented that Resident #10 was admitted with a left Achilles pressure injury that the patient stated he/she obtained in the hospital while his/her leg rested on a metal bar for a prolonged period of time. The wound was assessed to be a Stage 3 pressure ulcer that was 3 cm by 2 cm by 0.1 cm. Resident #10 was also admitted with a surgical wound on the left hip. The treatment for the pressure ulcer was to cleanse with wound cleanser/normal saline. Apply medical grade honey, calcium alginate to the base of the wound, secure with bordered gauze, and change daily and when necessary. Review of Resident #10's MDS assessment with an assessment reference date (ARD) of 6/7/26, Section M0100: Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, was coded, no. Review of M0210: Unhealed pressure ulcers/injuries: Does this resident have one or more unhealed pressure ulcers/injuries, was coded, no. M1040: other ulcers, wounds and skin problems; surgical wounds was coded no. M1200: skin and ulcer/injury treatments E. pressure ulcer/injury care was coded no. On 7/30/26 at 12:39 PM an interview was conducted with MDS Coordinator #27 who confirmed the surveyor's findings. 2) On 7/28/26 at 11:46 AM a review of complaint 3032786 and Resident #2's medical record was conducted. Resident #2 was admitted to the facility in May 2026 with diagnoses of end stage renal disease with dependence on dialysis, effusion of the right and left knee, and spinal stenosis. Review of a physician's history and physical dated 5/14/26 documented the resident received Cinacalcet at bedtime for hyperparathyroidism in chronic kidney disease on dialysis. The physician also documented the resident was to receive Dorzolamide Timolol Mal Ophthalmic solution in the left eye twice per day for glaucoma. Review of Resident #2's admission assessment with an ARD of 5/15/26, Section I, diagnoses, failed to capture glaucoma and hyperparathyroidism. Review of Section J0100A, pain management; Received scheduled pain medication regimen, was coded, No. This was inaccurate as the resident received Lidocaine External Patch 4 % (Lidocaine) that was applied to both knees every day for knee pain according to the documentation on Resident #2's May 2026 Medication Administration Record (MAR). On 7/30/26 at 12:31 PM an interview was conducted with the MDS Coordinator. The sections were reviewed along with the physician's note and the resident's MAR. The MDS Coordinator confirmed the findings. 3) On 7/29/26 at 7:58 AM a review of Resident #7's medical record was conducted along with facility reported incident 3094393. Review of Resident #7's annual MDS with an ARD of 6/3/26, Section N, Medications, had documented that Resident #7 had not received any high-risk medications. Review of Resident #7's June 2026 MAR documented that the resident received Furosemide (Lasix) 20 mg every morning for edema (fluid retention) to the right arm and bilateral lower extremities and Apixaban (Eliquis) 2.5 mg twice per day for atrial fibrillation. Atrial fibrillation is an abnormal heart rhythm that can lead to blood clots if not treated with an anticoagulant. Review of Resident #7's annual MDS assessment with an assessment reference date of 6/3/26 failed to capture the diuretic and anticoagulant. On 7/30/26 at 12:35 PM an interview was conducted with MDS Coordinator #27 who confirmed the findings. The Nursing Home Administrator was informed of the concern on 7/30/26 at 1:00 PM. 4) Review of Complaint 3044140 was conducted on 7/27/26 regarding the Resident #9's need for vision care. Review of Resident #9's medical record on 7/27/26 revealed the Resident was admitted to the facility in April 2025 with a diagnosis to include Diabetes. Further review of the Resident's medical record revealed a picture of the Resident on the admission Record where the Resident is wearing glasses. Observation of Resident #9 on 7/27/26 at 12:53 PM revealed the Resident in bed with glasses on the Resident's bedside table. During interview with the Resident at that time, the Resident stated he/she would like to be seen by the eye doctor. Further review of Resident #9's medical record revealed the facility staff completed a Quarterly MDS (Minimum Data Set) assessment on 6/28/26 and coded the Resident in Section B-Hearing, Speech and Vision B1200 Corrective Lens as No. Interview of Director of Nursing on 7/29/26 at 12:10 PM confirmed the facility staff inaccurately assessed the Resident in the 6/28/26 MDS Quarterly MDS Assessment and should have coded the Resident as yes for Corrective Lens.

Based on observations and interviews conducted during a complaint survey, it was determined that the facility failed to have an effective process to maintain resident equipment. This issue affected 6 (Resident #17, #16, #18, #19, #20, #14) of 21 residents reviewed during a complaint survey.The findings include: On 7/29/26 at 1:30 PM the following observations were made during walking rounds: Resident Wheelchairs in Disrepair: Damage or missing components (including torn vinyl covering, missing foam padding, and missing armrests) were noted on wheelchairs for Residents #17, #16, #18, #19, #20, and #14. Additionally, one unattended reclining geriatric chair in the hallway by room [ROOM NUMBER] had a missing armrest. Interviews conducted on June 29, 2026, revealed a breakdown in the maintenance reporting process: - At 1:35 PM Geriatric Nursing Assistant (GNA) #29 stated she reported repairs verbally to the charge nurse or the unit manager. -At 1:37 PM Licensed Practical Nurse (LPN) #22 stated that she will tell the Assistant Director of Nursing (ADON) or the Director of Nursing. On 7/30/26 at 12:15 PM Director of Maintenance (DOM) #21 was interviewed and asked if he did wheelchair audits. DOM #21 stated, we have a TELS (electronic work order) system so anything in disrepair staff would normally put it in TELS. For wheelchairs we do not have any processes. The way it normally works is housekeeping normally cleans them and if they are in disrepair they will put in a work order for them to be fixed. I think it is more of an education piece that we need to do with the staff. We have techs on the floor and sometimes they will tell us on the fly, but our turnaround time is 24 to 48 hours.On 7/30/26 at 2:00 PM the Nursing Home Administrator was informed of the concern.

Based on review of facility reported incidents, documentation review, and interviews, it was determined the facility failed to report an alleged abuse and misappropriation of resident property immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ) for the alleged abuse. This was evident for 2 (Residents #8, #7) of 7 residents reviewed for facility reported incidents during a complaint survey.The findings include: 1) On 7/27/26 at 9:38 AM a review of facility reported incident 3090318 was conducted. The facility documented that Geriatric Nursing Assistant (GNA) #18 alleged that she walked onto the unit for her 11:00 PM to 7:00 AM shift on 7/5/26 and found Resident #8 sitting in a chair at the nurses' station restrained by a sheet. A review of the facility's investigation documented the alleged incident took place on 7/5/26 at 11:10 PM when found by GNA #18. Review of the email confirmations documented that the initial report was not submitted to OHCQ until 7/10/26 at 6:09 PM which was not immediately or within 2 hours of the alleged abuse. On 7/30/26 at 12:43 PM an interview was conducted with the Nursing Home Administrator (NHA) regarding the late reporting to OHCQ. The NHA stated that GNA #18 stated that she reported it to the nurse, which would have been the oncoming nurse who come in at 11:30 PM. GNA #18's story changed because there was a nurse on duty when she came on duty and from the interviews conducted Resident #8 was in bed. The NHA stated, Her story changed the entire time. I am the abuse coordinator, but she should have gone to the supervisor and she didn't. This happened on the July 5th, and she told me about it on July 10th. The NHA was informed that if this allegedly happened on July 5 then the staff member should have reported it immediately, and the staff member did not. 2) On 7/29/26 at 7:58 AM a review of facility reported incident 3094393 was conducted. Resident #7 alleged that someone took $106 dollars from the resident's wallet. The facility reported the incident to OHCQ on 7/6/26 at 4:06 PM. Review of the facility's investigation revealed GNA #27's written statement that documented that he worked with Resident #7 on that day (July 3) and while working with his/her the resident told him the money was missing from his/her wallet and he told the charge nurse on that day. GNA #27 documented that the nurse told him that the resident, told her too.Review of Registered Nurse (RN) #25's written statement documented that Resident #7 reported to her on 7/3/26 that the money from the resident's wallet was missing and that the resident did not realize it until he/she went to add the monthly allowance to the wallet. The resident reported the money missing on the evening shift around 8 PM.Review of RN #15's written statement documented that on 7/3/26 she received a call from the charge nurse that the resident reported when he/she got new money for the month a few days ago that he/she lost the old money. The statement documented that RN #15 told the charge nurse to do a concern/grievance form and that RN #15 would come into the facility.Review of (9) staff statements all documented having or not having knowledge of the missing money on 7/3/26.On 7/30/26 at 10:28 AM an interview was conducted with RN #15 who stated, I did a grievance form for the Director of Nursing (DON). She wasn't here so I left it for her. When asked if she started a report she said, no, I just did the grievance form.On 7/30/26 at 12:50 PM the Nursing Home Administrator (NHA) was informed of the concern that the missing money was not reported within 24 hours to OHCQ.

Based on review of facility reported incident 3094393, medical record review, and interview, it was determined the facility staff failed to conduct a complete and accurate assessment by failing to assess a resident's cognition, mood, and behavior on an annual assessment. This was evident for 1 (Resident #7) of 7 residents reviewed for facility reported incidents during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. On 7/29/26 at 7:58 AM a review of Resident #7's medical record was conducted along with facility reported incident 3094393. Review of facility reported incident 3094393 reported that Resident #7 alleged that money was stolen from the resident's wallet. The resident initially reported it to a geriatric nursing assistant (GNA) on 7/3/26 and alleged the money had been stolen sometime over the past month. Review of Resident #7's annual MDS with an assessment reference date of 6/3/26, Section C, Cognitive Patterns was not assessed. There was no BIMS (Brief Interview of Mental Status) Summary Score. The resident's short term and long-term memory were not assessed or the resident's memory/recall ability and cognitive skills for daily decision making. Section D, Mood was also not assessed. On 7/30/26 at 12:35 PM an interview was conducted with MDS Coordinator #27. The MDS Coordinator was asked why Sections C and D were not assessed and she stated that social work was responsible for completing those sections. MDS Coordinator #27 stated at the time they missed the time period for when they could do the assessment due to staffing issues in the department. The Nursing Home Administrator was informed of the concern on 7/30/26 at 1:00 PM.

Based on observation, interview, and medical record review, it was determined that the facility staff failed to provide thorough grooming and personal hygiene services for a resident. This was evident for 1 (Resident #9) of 3 residents reviewed for activities of daily living (ADL) care during a complaint survey. The findings include: A review of Complaint 3044140 was conducted on 7/27/26 regarding the facility staff failure to provide grooming services for Resident #9. Observation of Resident #9 on 7/27/26 at 12:53 PM revealed the Resident to be unshaven and have long untrimmed fingernails with black debris under the fingernails. During interview of Resident #9 at that time the Resident was asked if he/she would like to be shaved and have his/her fingernails trimmed. The Resident stated yes. Review of Resident #9's medical record on 7/27/26 revealed the Resident was admitted to the facility in April 2025 with a diagnosis to include cerebral infarction (stroke). Further review of Resident #9's medical record revealed the facility staff completed a Quarterly MDS (Minimum Data Set) Assessment on 6/28/26 and coded the Resident in Section GG Self-Care as dependent for Personal hygiene. Review of Resident #9's care plans revealed the Resident has a care plan entitled ADL Self Care Performance Deficit related to activity intolerance initiated 4/28/25 with an intervention of Complete grooming services including beard shaving, nails trimming weekly. Observation of Resident #9 on 7/29/26 at 12:50 PM revealed the Resident to still be unshaven with long untrimmed fingernails with black debris under the fingernails. During interview of Resident #9 at that time, the Resident was asked again if he/she would like to be shaven and have his/her nails trimmed. The Resident stated yes. The Resident added, I don't feel like I should have to beg them to do it. On 7/29/26 at 12:55 PM, the Surveyor had Unit Manager #30 come to Resident #9's room and confirmed the Resident was unshaven and had dirty untrimmed nails. On 7/29/26 at 1:05 PM the Director of Nursing was advised of the Surveyor's findings that Resident #9 was unshaven with dirty untrimmed nails confirmed by Unit Manager #30.

Based on medical record review and interview, it was determined the facility staff failed to administer a resident's medication in a timely manner. This was evident for 1 (Resident #15) of 3 residents reviewed for timely medication administration during a complaint survey. The findings include: During an interview with Resident #15's responsible party (RP) on 7/29/26 at 8:00 AM the RP stated the Resident received his/her cancer medication late this past weekend. During interview with Resident #15 on 7/29/26 at 8:46 AM, the Resident stated he/she received his/her cancer medication late this past weekend. The Resident stated he/she is supposed to have his/her medication with breakfast, but he/she knows Sunday it wasn't given until after 2 PM. Review of Resident #15's medical record on 7/29/26 revealed the Resident was admitted to the facility in November 2025 with a diagnosis to include Malignant (cancerous) neoplasm of prostate. A review of Resident #15's Medication Admin Audit Report for 7/25 and 7/26/26 was completed on 7/30/26. The Resident is ordered to receive Nubeqa 300 mg give 2 tablets twice a day for prostate cancer take with breakfast and dinner. The scheduled times are 8 AM and 5 PM. Further review of the Report revealed on 7/25/26 the Resident was administered his/her 8 AM dose at 11:14 AM and on 7/26/26 at 2:54 PM. The Resident was administered his/her 5 PM dose on 7/26/26 at 4:30 PM, therefore the Resident received 2 doses of Nubeqa 1 hour and 36 minutes apart on 7/26/26. Interview with the Director of Nursing on 7/31/26 at 8:35 AM confirmed the Surveyor's findings that Resident #15 was not administered Nubeqa timely on 7/25 and 7/26/26.

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician ordered blood pressure parameters for administering blood pressure medications to a resident. This was evident for 1 (Resident #11) of 3 residents reviewed for unnecessary medications during a complaint survey.The findings include:Review of Complaint 3031582 was conducted on 7/27/26 regarding excessive dosing of medication to Resident #11.Review of Resident #11's medical record on 7/27/26 revealed the Resident was in the facility for 18 days in 2026 with a diagnosis to include Hypertensive Heart Disease.Review of Resident #11's April 2026 Medication Administration Record revealed the Resident was administered the following blood pressure medications when the Resident's blood pressure did not meet the physician ordered blood pressure parameters for administration:1) Isosorbide Mononitrate ER 30 mg in the evening for hypertension, hold for systolic blood pressure less than 100a) 4/9/26 at 8:00 PM for blood pressure 86/54b) 4/10/26 at 8:00 PM for blood pressure 94/572) Losartan Potassium 25 mg in the evening for hypertension, hold for systolic blood pressure less than 100a) 4/9/26 at 8:00 PM for blood pressure 86/54b) 4/10/26 at 8:00 PM for blood pressure 94/573) Atenolol 25 mg twice a day for hypertension, hold for systolic blood pressure less than 100a) 4/9/26 at 8:00 PM for blood pressure 86/54b) 4/10/26 at 8:00 PM for blood pressure 94/57c) 4/16/26 at 8:00 PM for blood pressure 77/52The Surveyor reviewed Resident #11 April 2026 Medication Administration Record with the Director of Nursing on 7/29/26 at 11:18 AM.Interview with the Director of Nursing on 7/29/26 at 12:31 PM confirmed Resident #11 was administered blood pressure medications on 4/9, 4/10 and 4/16/26 when his/her blood pressure did not meet the physician ordered blood pressure parameters.

Based on observation, staff interviews, and documentation review, it was determined that facility staff failed to keep medication carts locked when unattended and discard expired medications/biologicals. This was evident on 2 of 4 nursing units observed during random observations made during a complaint survey. The findings include: 1) On 7/29/26 at 11:57 AM observation was made on the Gateway nursing unit of (2) unlocked and unattended medication carts sitting at each end of the nurse's station. The surveyor was able to open the drawers in both carts and observe resident medications such as over-the-counter medications and prescription medications that included but were not limited to cardiac, blood pressure, neuropathy, antipsychotic, antidepressants, antianxiety, diabetic, and other types of medications. In the Gateway 2 medication cart, observation was made of a vial of Lidocaine 2 percent NDC 0409-4277-16 that was opened with approximately one third of the contents of the vial used. There was no date opened on the vial. The surveyor stood at the medication cart for approximately 4 to 5 minutes as residents were mobile in the area and other staff walked around the unit. No licensed staff were present at the nurse's station.On 7/29/26 at 12:02 AM Licensed Practical Nurse (LPN) #14 walked up to the Gateway 1 medication cart and the surveyor informed her that the medication cart was left unlocked. LPN #14 stated she was sorry and it was a mistake. At 12:03 PM LPN #3 walked into the nurse's station to sit at the desk. The surveyor asked which nurse was working with the Gateway 2 medication cart. LPN #14 answered the surveyor and stated it was another nurse who was currently on a different floor at the time. The surveyor informed LPN #3, who was the unit manager, that both medication carts were unlocked when the surveyor arrived on the unit. The surveyor also presented the opened vial of Lidocaine to LPN #3 to show her it was not dated. LPN #3 stated that the carts should have been locked.2) On 7/30/26 at 10:25 AM observation was made on the Gateway nursing unit of an unlocked treatment cart sitting in the hallway outside of room [ROOM NUMBER]. The surveyor opened the treatment cart and observed ointments, emollients, and other various treatment supplies. In the second drawer observation was made of an opened 100 ml. bottle of 0.9% sodium chloride irrigation, lot number 260512029, that was not dated when opened. In the fourth drawer was another opened 100 ml. bottle of 0.9% sodium chloride irrigation that was not dated when opened. On 7/30/26 at 10:28 AM, LPN #3 was given the bottles and informed of the concern. LPN #3 confirmed the surveyor's findings.An opened 100 ml 0.9% sodium chloride (normal saline) bottle without preservatives should be either discarded immediately or within 24 hours because it lacks antimicrobial agents to stop germ growth. Once the seal is broken, airborne bacteria and fungi can quickly multiply in the liquid at room temperature.3) On 7/30/26 at 10:30 AM observation was made of an unlocked and unattended medication cart sitting in the hallway outside of room [ROOM NUMBER] on the Chesapeake unit. The surveyor was able to open the drawers to the medication cart and observed in the top drawer a plastic 30 ml. medication cup with 9 pills in the cup. No name was on the medication cup. On the other side of the top drawer was another 30 ml medication cup with 6 pills in it. No name was on the cup. The surveyor stood at the medication cart approximately 2 to 3 minutes until LPN #16 rushed up to the cart and got in front of the surveyor to get an item out of the cart. LPN #16 then started to walk away, and the surveyor stopped her and asked her if she realized she had left the medication cart unlocked. LPN #16 stated, they were calling me about a dialysis patient, so I had to go check on [him/her].On 7/30/26 at 10:40 AM a review of the Medication Storage Policy that was given to the surveyor from the Director of Nursing (DON) documented, 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments, (i.e., medication carts, cabinets, drawers, refrigerators, medications rooms) under proper temperature controls. B. only authorized personnel will have access to the keys to locked compartments.On 7/30/26 at 12:17 PM the DON was informed of the concerns.

Based on observation and interviews, it was determined the facility staff failed to ensure food was served at a palatable temperature and all the items on a resident's meal ticket were delivered. This was evident for 1 (Resident #15) of 3 observations during a complaint survey. The findings include: During an interview with Resident #15's responsible party (RP) on 7/29/26 at 8:00 AM, the RP stated the Resident has complained he/she doesn't receive coffee, milk for his/her oatmeal and the food is cold at breakfast. Interview with Resident #15 on 7/29/26 at 8:30 AM the Resident stated he/she doesn't always get coffee and milk. The Resident also stated that often the food is cold so he/she doesn't eat it. On 7/31/26 at 8:28 AM the Surveyor asked Unit Manager #23 who was already in the Resident's room to observe a test temperature of the Resident's pancakes as it was served to the Resident. At that time the temperature of the pancakes was 110 degrees. Hot foods are to be maintained at 135 degrees. Observation at that time also revealed no milk on the Resident's breakfast tray. Interview with Unit Manager #23 at the time confirmed the Surveyor's findings. Review of Resident #15's 7/31/26 breakfast meal ticket revealed the Resident is to receive 8 ounces of milk. The findings were reviewed with the Administrator on 7/31/26 at 8:35 AM.

Based on observation, record review, and interviews with staff, it was determined that the facility failed to ensure residents were on time to scheduled dialysis treatment to received their full prescribed time. The facility also failed to ensure an adequate supply, and appropriate maintenance of Dialysis Chairs (Supplied by the [NAME] Lake Healthcare at Glen [NAME], and used for transport to Dialysis). This was found to be evident in 6 (#10, #127, #140, #197, #47, #175) of 17 residents reviewed for dialysis. 1. On 5/7/2026 at approximately 10:00AM, the Surveyor observed the dialysis Registered Nurse (RN #17) send a dialysis chair to the 2nd floor Gateway Unit. Unit Secretary (US #25) retrieved chair and placed it outside Resident #10's room for transport to [dialysis company] on the 1st floor of the building (East Building). During an interview with Resident #10 on 5/7/2026 at approximately 10:05AM, the resident appeared frustrated. The Surveyor asked if the resident was getting ready to go to dialysis and the resident responded, I guess so. I don't know what's going on. I'm just waiting. The resident was lying in bed with the head of the bed elevated and a Hoyer lift sling underneath him/her for mechanical transfer. On 5/7/2026 at 10:24AM, the resident was still in bed and the dialysis chair remained outside the room. An interview with Registered Nurse (RN #26) confirmed that the resident was getting ready to go to dialysis. The Surveyor observed the resident's green dialysis communication binder at the nurses' station. RN #26 reviewed the resident's dialysis communication binder with the Surveyor and stated that the required documentation has been completed on the sheet for today's dialysis session except the weight had not yet been documented. On 5/7/2026 at 10:28AM, Resident #10 was observed in bed and the dialysis chair still waiting outside the room. On 5/7/2026 at 12:25PM, an interview with RN #17 revealed that Resident #10 was upset because he/she arrived late to his/her dialysis treatment today. RN #17 informed the Surveyors that residents are late for their scheduled dialysis appointments daily due to transport issues. On 5/7/2026 at 1:17PM, the Surveyors expressed the concerns regarding residents arriving late to dialysis treatment sessions with the NHA. On 5/7/2026 at 2:45PM, a review of the Tuesday, Thursday, Saturday dialysis schedule, posted at the Gateway Unit nurses' station, revealed that Resident #10 was scheduled for dialysis treatment at 10:00AM. 2. During an interview on 5/4/26 at 9:22AM, Resident #127 reported concern to the surveyor that they were late to their dialysis appointment and their treatment had been cut short due to facility nursing staff not timely assisting them to go to their appointments. Resident #127 additionally reported concern for not being timely transferred from the dialysis chair to their bed after dialysis appointments. On 5/7/26 at 11:11AM the surveyor conducted an interview of Unit Manager (UM #16) who confirmed with the surveyor that there were dialysis appointment schedules with scheduled times for Residents requiring dialysis, and the process for communication between nursing unit staff and dialysis staff was via a dialysis communication folder and utilization of a dialysis communication form. Regarding the dialysis communication form, UM #16 stated to the survey team: We do review it and put it back in the folder. During the interview, UM #16 reported to the survey team that they did not have any Residents whose dialysis sessions were cut short due to not making it to dialysis on time. On 5/7/26 at 11:25AM the surveyor conducted an interview of Geriatric Nursing Assistant (GNA #21) who confirmed with the surveyor that the Hoyer lift and assistance by two staff were utilized to transfer Resident #127 to the dialysis chair. On 5/7/26 at 12:25PM surveyors conducted an interview of Registered Nurse (RN #17) who reported that when nursing staff are tied up with another patient, staff cannot get the Hoyer lift and get Resident #127 down to dialysis on time. During the interview, RN #17 stated to surveyors that residents were late to dialysis appointments daily due to transport. Surveyors noted that the dialysis center was located on facility grounds within the main building in which residents requiring dialysis were observed to reside. Review by the surveyor of Resident #127's dialysis communication folder on 5/7/26 at 12:35PM revealed documentation on their communication form by RN #18 as late arrival shortened tx (treatment) to their dialysis appointment on 5/2/26. Review of the dialysis appointment schedule by the surveyor revealed the Resident's dialysis treatment was scheduled for a duration of 3 hours and 30 minutes. Review by the surveyor of the dialysis documentation revealed the Resident's treatment was cut short by 1.5 hours. On 5/7/26 at 12:41PM the surveyor conducted an interview of RN #18 who reported to the surveyor regarding 5/2/26: Something went wrong that day and other Residents were late to their dialysis appointments also. On 5/7/26 at 12:58PM Resident #127 was observed laying in their bed and reported in an interview to the surveyor that there was not enough quantity of dialysis chairs and that the facility has to buy the chairs. Resident #127 reported that there were defective chairs that were unsafe and wobbly and described their legs and other Residents legs as being unsupported by the dialysis chairs at times. Resident #127 reported that they were currently due to be at dialysis at 1:00PM and noted that the current time was 12:58PM. Resident #127 stated: I have no chair yet. On 5/7/26 at 1:07PM the surveyor conducted an interview of GNA #21 who reported to the surveyor that they have to see when other Residents are done on the dialysis machine time to know when to bring the next Resident. When the surveyor inquired to GNA #21 as to where dialysis chairs were located aside from the dialysis chairs that were in use for dialysis sessions, and to show this surveyor, they reported that they would have to ask the Administrator. 3. On 5/7/26 at 1:12PM the surveyor conducted an interview of RN #19 at which time Resident #140 was observed utilizing a dialysis chair in which because the leg rest was broken, was propped up by a stool to elevate the Resident's legs. On 5/7/26 at 1:17PM the surveyor shared and observed the concern regarding Resident #140 with the facility Administrator who observed and acknowledged the concern. When the surveyor inquired as to if the facility had an additional dialysis chair, they stated :We don't have any, when I got here, they asked me for an extra chair but they didn't say it was because it was broken, I can reach out to him to ask if he got quotes, they just said they needed more chairs, they need them to put the patients into to get the next patient in. The facility Administrator reported having been notified approximately two weeks ago of the need for more dialysis chairs by a Dialysis Nurse. When the surveyor inquired as to who was assigned responsibility for maintenance oversight of the dialysis chairs, the facility Administrator reported it was the role of Maintenance Director #20. On 5/7/26 at 1:21PM the surveyor conducted an interview of Director of Maintenance #20 who reported that anytime equipment is broken or damaged, the tells system was used to get it fixed and to complete out the repair and when an item is repaired, a description is written in the comments section. When the surveyor inquired as to if the broken dialysis chair was addressed, they reported they would have to take a look at the books and see. At this time, the surveyor requested to review the maintenance records at which time, Maintenance Director #20 did not show the surveyor the requested maintenance records. When the surveyor inquired as to what process was in place for oversight of maintenance of the dialysis chairs, the Maintenance Director reported they would have to take a look at the books. The surveyor shared concerns with the facility Administrator and Director of Nursing who both acknowledged the surveyor's concerns. On 5/7/26 at 1:55PM Maintenance Director #20 and the facility Administrator informed the surveyor and survey team that the facility did not have any maintenance documentation or records for maintenance of dialysis chairs. After surveyor intervention, on 5/8/26 at 9:56AM, the facility Administrator reported to the surveyor that they ordered three more dialysis chairs and went out and got a dialysis chair to replace the broken one that was being used. 4. Review of the dialysis communication form by the surveyor on 5/11/26 at 10:47AM for Resident #197 revealed the following documentation dated 5/2/26: Late arrival no dialysis chair available. Review of the dialysis communication form by the surveyor on 5/11/26 at 10:47AM for Resident #127 revealed the following documentation dated 4/30/26: Late arrival shortened tx (treatment). Review of the dialysis communication form by the surveyor on 5/11/26 at 10:47AM for Resident #47 revealed the following documentation dated 3/23/26: Tx (treatment) shortened due to vascular appointment. Review of the dialysis communication form by the surveyor on 5/11/26 at 10:47AM for Resident #47 revealed the following documentation dated 3/18/26: Patient's tx (treatment) shortened due to cvc exchange appointment. Review of the dialysis communication form by the surveyor on 5/11/26 at 10:47AM for Resident #175 revealed the following documentation dated 5/7/26: Late arrival. Review of the dialysis communication form by the surveyor on 5/11/26 at 10:47AM for Resident #175 revealed the following documentation dated 12/22/25: Patient had 3 hours treatment due to late arrival. Review of the dialysis appointment schedule revealed Resident #175's treatment duration time was scheduled to be three hours and thirty minutes long. Review of the dialysis communication form by the surveyor on 5/11/26 at 10:47AM for Resident #140 revealed the following documentation dated 4/28/26: Patient arrived late to dialysis, shortened tx (treatment). Review of the dialysis communication form by the surveyor on 5/11/26 at 10:47AM for Resident #10 revealed the following documentation dated 5/7/26: Patient arrived late for tx (treatment) 198 minutes of treatment completed. Review of the dialysis appointment schedule revealed Resident #10's treatment duration time was scheduled to be three hours and thirty minutes long. On 5/11/26 at 3:40PM the surveyor reviewed all concerns with the facility's Administrator and Director of Nursing who acknowledged the concerns.

Based on observations, staff interviews, and record review, it was determined that the facility failed to:1.Maintain medical records in accordance with accepted professional standards and practices. This was evident for 1 (#186) of 9 residents reviewed for baseline care plans during this annual survey.2(a-c).Accurately document the baseline care plan. This was found to be evident for 8 (#193, #192, #44, #55, #78, #96, #118, #181) of 19 residents reviewed for smoking ,and 1 (#10) of 2 residents' Kardex reviewed.The findings include: 1. A tracheostomy is a hole that surgeons create in the front of the neck, into the windpipe (trachea). Surgeons place a tracheostomy tube into the hole to keep it open for breathing. The term for the surgical procedure to create this opening is tracheotomy. On 5/7/26 at 3:35 PM, the GNA (GNA #22) that had provided care to Resident #186 on the day in question was interviewed by the surveyor about what had happened. GNA 22 stated that she and the nurse had just provided tracheostomy and suction care to the resident approximately 20-30 minutes before the daughter's arrival, and the resident was not lying flat but was positioned 30-60 degrees elevated in the bed. The GNA also stated that she believes that the daughter had laid the bed flat. On 5/8/26 at 9:30 AM, the record review revealed that the nurse had documented the interaction with the daughter and the resident in the progress notes. The progress note stated in summary that the daughter came into the resident's room and immediately requested that the resident go out to the hospital due to the amount of secretions that the resident was producing, despite the resident's response of being fine. The facility complied quickly with the daughter's request to send the resident to the hospital. The facility filed a Complaint Report on 10/30/25, stating that the daughter walked into the resident's room and saw the resident lying flat, with secretions coming from the trachea. The daughter was adamant that Resident #186 needed to be sent out to the hospital. So the facility sent the resident out to the hospital. Review of the orders for Resident #186 showed that the resident was ordered for Oxygen at 5L per min via Trach continuously every shift, Suction tracheostomy tube as needed to clear the airway, Tracheostomy Care every shift and PRN, and Tracheostomy site dressing change every shift and PRN if soiled. Review of the baseline care plan revealed that under the section 3A - Health Conditions, it was documented that the resident was not on 1a. Oxygen therapy, but under 1aa. Type and L/per minute, it was documented Trach at discharge is #7 Portex cuff, less 21%. Section 1b was selected for suctioning care while a resident. Section 1c was not selected for Tracheostomy care. The facility failed to accurately document in the baseline care plan that the resident should have tracheostomy care and oxygen care. On 5/8/26 at 10 AM, the surveyor interviewed the DON about what happened with Resident #186. The DON stated that Resident #186 was only here for 2 days, and that the daughter came to the facility with a rolling cart prepared to remove Resident #186 from the facility. The DON continued to explain that Resident #186 was allegedly lying flat when the daughter came for a visit, with a large amount of secretions. The daughter had already called 911 and was requesting that Resident #186 go to the hospital. Resident #186 repeatedly stated that they were fine and did not need to go to the hospital. But the daughter was insisting that the resident be transferred out to the hospital. The facility complied, and Resident #186 was sent to the hospital. The surveyor then asked the DON to take a look at the baseline care plan for Resident #186. The surveyor asked the DON why it was not documented that Resident #186 needed tracheostomy care and oxygen care, but it was documented under oxygen, the size of the trach (#7 Portex cuff), and why it was selected for suctioning only. The DON reviewed the baseline care plan and then stated that it was a mistake. She was uncertain why the nurse had documented the baseline care plan the way she had, especially since the information was provided for trach care. 2a. On 5/5/2026 at 11:06AM, during a review of Resident #193's electronic medical record, the Surveyor discovered that the resident was admitted to the facility on [DATE]. Further review failed to reveal a Smoking Safety Screen assessment completed on admission. On 5/5/2026 at 2:10PM, during an interview with Resident #192, the Surveyor was informed that the resident likes to smoke at least one cigarette a day. A review of Resident #192's electronic medical record revealed that the resident was admitted to the facility on [DATE]. Further review failed to reveal a Smoking Safety Screen assessment completed on admission. On 5/6/2026 at 10:20AM, a review of the facility's updated Smoker's List identified Resident #192 and Resident #193 as current smokers. A review of Resident #193's electronic medical record revealed a Smoking Safety Screen assessment completed on 5/6/2026. During an interview with the Nursing Home Administrator (NHA), in the presence of the Director of Nursing (DON), the Surveyor expressed the concern that Resident #193 was admitted to the facility on [DATE], was identified as a current smoker, and failed to have a Smoking Safety Screen assessment completed until 5/6/2026; and Resident #192 was admitted to the facility on [DATE], identified as a current smoker, and failed to have a Smoking Safety Screen assessment completed. The NHA and DON acknowledged the Surveyor's concerns. 2b. Failure to complete quarterly smoking assessments for residents who smoke. On 5/6/2026 at 8:20AM a review of the facility's Smokers List as of 5/1/2026 included Resident #44, #55, #78, #96, #118, and #181. On 5/6/2026 at 8:30AM a review of the electronic medical record revealed the following overdue Smoking Safety Screen assessments: -Resident #44's last completed on 10/8/2025 -Resident #55's last completed on 10/8/2025 -Resident #78's last completed on 1/15/2026 -Resident #96's last completed on 10/8/2025 -Resident #118's last completed on 10/8/2025 -Resident #181's last completed on 10/8/2025 On 5/6/2026 at 10:20AM, during an interview with the NHA, in the presence of the DON, the Surveyor expressed the concern that the facility failed to complete quarterly Smoking Safety Screen assessments for Resident's #44, #55, #78, #96, #118, and #181. The NHA and DON acknowledged the Surveyor's concerns. 2c. A Kardex is a nursing reference (electronic or paper file summary) which includes crucial information such as diet orders, mobility aids, (e.g.,lift requirements), activity level, daily routines such as assistance with meals and other activities of daily living (ADLs), and specialized safety precautions, which are essential for fulfilling daily care duties specifically for that resident. On 5/11/2026 at 9:40AM, during a review of Resident #10's electronic medical record, the Surveyor discovered the resident's Kardex under the Tasks section for Geriatric Nursing Assistants (GNAs). The Kardex contained sections which included: Bladder/Bowel, Mobility, Hygiene/Oral Care, Resident Care, Transferring, Wake up/Bedtime, Eating, Bathing/Showering, Safety, Bed Mobility, Walking, Toileting, Dressing/Splint Care, and Bathing that failed to reveal individualized care needs for Resident #10 to reflect the comprehensive care plan and clinical record. On 5/11/2026 at 9:52AM, an interview conducted with the DON, in the presence of the NHA, the Surveyor expressed the concern that Resident #10's Kardex was not individualized based on his/her specific daily care needs. The DON reviewed the resident's Kardex and confirmed the Surveyor's findings. On 5/11/2026 at 10:31AM, during a follow-up interview with the DON, the Surveyor was informed that the resident information in the Kardex should reflect the resident's care plan. The DON stated that Resident #10's care plan and Kardex will be reviewed and updated to ensure they are accurate and individualized to reflect the resident's current daily needs.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure a resident's right to formulate an Advanced Directive. This was evident for 1 (#55) out of 9 residents reviewed for Advanced Directives during the annual recertification survey.The findings include: On 5/4/26 at 12:28 PM, the surveyor conducted a resident record review. During the resident record review, the surveyor could not locate resident #55's advance directive, nor could the surveyor locate documentation indicating that Resident #55 declined the opportunity to complete an advance directive when the facility offered the resident an opportunity to complete one. On 5/7/26 at 10:07 AM, the surveyor interviewed the Nursing Home Administrator (NHA) #1. During the interview, the NHA #1 mentioned that Resident #55 does not have an advance directive in place. The surveyor asked the NHA #1 if the facility has documentation indicating that resident #55 declined to complete an advance directive when the facility offered Resident #55 an opportunity to complete one. The NHA #1 indicated that she would check Resident #55's records. On 5/7/26 at 11:39 AM, the surveyor interviewed the NHA #1. During the interview, the NHA #1 mentioned that the facility does not have documentation indicating that Resident #55 declined to complete an advance directive when the facility offered Resident #55 an opportunity to complete one.

Based on record reviews and interviews with staff, it was determined that the facility failed to ensure residents' rights to personal privacy. This was found to be evident for 3 (#60, #122, #141) of 4 residents residing together in a room on the Shenandoah Unit.The findings include:On 5/6/2026 at 12:20PM, the Surveyor confirmed the use of a private video monitoring device for Resident #6, installed at the request of their resident representative. Resident #6 resides in a room with Resident #60, #122, and #141. During a tour of the unit, a Surveyor observed that signage of video monitoring in the shared residents' room was not present. According to the facility's Audio/Visual Recording in Resident Rooms policy revealed that, If the resident is in a shared room, recording may not occur without written consent of the roommate and A sign will be placed on the door stating, 'Electric monitoring in progress'.On 5/7/2026 at 9:54AM, the Surveyor interviewed the Nursing Home Administrator (NHA #1) and requested documentation to verify Resident #60, #122, #141 provided written consent for the use of a video monitoring device in their room.On 5/7/2026 at 2:55PM, the NHA #1 provided the Surveyor with copies of the Roommate Virtual Monitoring Technology Consent Forms for Resident #122 and Resident #141, which were only completed by their resident representatives on 5/7/2026. Upon review, these documents were not thoroughly completed and contained contradictory signatures that both granted and withdrew consent for the use virtual monitoring technology in their room. Furthermore, the facility failed to provide written consent for Resident #60. During a subsequent tour of the unit, signage for video monitoring was observed on the residents' door. The Surveyor expressed the concern that Resident #6 had a private video monitoring device in place without the necessary prior written consent from all roommates and their resident representatives.

Based on review of Facility Reported Incident (FRI) investigative file and interviews, it was determined that the facility failed to report a misappropriation of resident property to the Office of Health Care Quality (OHCQ) within the required 24 hours after the allegation was made. This was found to be evident for 1 FRI (#3004409) out 7 FRIs reviewed during the annual recertification survey.The findings include:On 5/4/2026 at 9:47AM, during an interview with Resident #158's resident representative (RP), the Surveyor was informed that the resident's rings were stolen by a facility staff member. The RP stated that he/she called the police and informed the Nursing Home Administrator (NHA #1), who is currently investigating the allegation.On 5/6/2026 at 12:00PM, a review of Resident #158's FRI #3004409 revealed that the night supervisor was made aware of the allegation on 4/26/2026 at about 8:00AM and the NHA #1 was made aware of the allegation on 4/26/2026 at about 9:00AM. Further review revealed that the facility submitted the initial report to OHCQ on 4/28/2026 at 9:48AM.On 5/8/2026 at 12:00PM, during an interview with the NHA #1, the Surveyor expressed the concern of failure to timely report Resident #158's and RP's allegation of misappropriation of resident property to OHCQ within 24 hours.

Based on record reviews and staff interviews, it was determined that the facility failed to provide written notification of transfer and bed hold policy. This was evident in 2 (#6, #19) of 3 resident records reviewed for discharge processes. The findings include: 1. On 5/11/26 at 6:37 AM, Resident #6's medical record was reviewed. The record review revealed that according to Resident #6's AUTM Change in Condition/Concurrent Review 2.0 – V 13 form, dated 1/21/26, Resident #6 was hospitalized for complaints of chest pain on 1/21/26. It is also documented that Resident #6's responsible party was onsite at the facility and aware of the resident being transferred to the hospital. On 5/11/26 at 6:59 AM, Resident #6's medical record was reviewed. The record review revealed that the facility listed Resident #6's name on the bed hold policy for when Resident #6 was being transferred to the hospital on 1/21/26; however, the facility did not have Resident #6's responsible party sign the bed hold policy, although Resident #6's responsible party was onsite at the facility during the time Resident #6 was transferred to the hospital on 1/21/26. On 5/11/26 at 10:03 AM, the surveyor interviewed the Nursing Home Administrator (NHA #1). During the interview, the NHA #1 mentioned that although Resident #6's responsibility party was present at the facility during the time Resident #6 was transferred to the hospital on 1/21/26, the facility did not have Resident #6's responsibility party sign the bed hold policy. 2. On 5/4/2026 at 8:48AM, a review of Resident #19's electronic medical record revealed that the resident was transferred to the hospital on [DATE] and 1/17/2026. There was no documentation indicating that the resident representative received written notification of these transfers or the bed hold policy upon transfer to the hospital. On 5/7/2026 at 9:54AM, the Nursing Home Administrator (NHA #1) was asked to provide the Surveyor with Resident #19's written reason for transfer/discharge notification and bed hold documentation that was sent to the resident representative for the transfer on 12/13/2025 and 1/17/2026. On 5/8/2026 at 3:00PM, a review of the documentation provided by the NHA #1 failed to reveal that the required written notifications were sent to Resident #19's resident representative for hospitalizations on 12/13/2025 and 1/17/2026. During an interview with the NHA #1 on 5/11/2026 at 8:00AM, the Surveyors findings were confirmed. The NHA acknowledged that facility was not providing written notification of transfers to the hospital and the facility's bed hold policy to the resident representatives. The NHA stated that the business office will now be responsible for sending these notifications via certified mail or the representative's preferred written method.

Based on record review and interview with staff, it was determined that the facility failed to ensure a resident's Minimum Data Set (MDS) assessments were completed and submitted in a timely manner. This was found to be evident for 1(#19) of 8 residents reviewed for accidents during the annual recertification survey.The findings include:The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. MDS assessments in Maryland should be signed and completed by the Registered Nurse (RN) Assessment Coordinator no later than 14 calendar days after the Assessment Reference Date (ARD). The signature certifies that the assessment is complete, accurate, and reflects the resident's status within the look-back period.On 5/8/2026 at 9:42AM, a review of Resident #19's Annual MDS assessment, with an ARD of 1/26/2026, revealed that the RN Assessment Coordinator signed the assessment as complete on 2/27/2026 and the assessment was accepted on 3/3/2026. Further review revealed a Discharge MDS assessment, with an ARD of 1/17/2026, signed by the RN Assessment Coordinator as completed on 2/4/2026 and was accepted on 2/6/2026.On 5/11/2026 at approximately 4:00PM, during an interview with MDS Director (MDS #33), in the presence of the Nursing Home Administrator (NHA #1), the Surveyor expressed the concern that Resident #19's Annual MDS assessment dated [DATE] and Discharge MDS assessment dated [DATE] was completed late. Section Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date) for both assessments. After review, MDS #33 acknowledged and confirmed the Surveyor's findings.

Based on record review, and interviews with residents and staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect the resident's status. This was evident for 5 (#12, #51, #55, #85, #139) of 19 residents reviewed for smoking and 1 (#195) of 3 residents reviewed for respiratory care during the annual recertification survey.The findings include:1.On 5/6/2026 at 8:20AM, a review of the facility's Smokers List as of 5/6/2026 included Resident #12, #51, #55, #85, and #139 identified as current smokers.On 5/6/2026 at 10:25AM, a review of the electronic medical records for these residents, who were identified as current smokers at the time of the Annual MDS assessment revealed the following concerns with Section J 1300 Current Tobacco Use:-Resident #12- Annual MDS assessment dated [DATE] indicated No for tobacco use-Resident #51- Annual MDS assessment dated [DATE] indicated No for tobacco use-Resident #55-Annual MDS assessment dated [DATE] indicated No for tobacco use-Resident #85-Annual MDS assessment dated [DATE] indicated No for tobacco use-Resident #139-Annual MDS assessment dated [DATE] indicated No for tobacco useOn 5/6/2026 at 12:34PM, during an interview conducted with MDS Director (MDS #33) and MDS Coordinator (MDS #34), in the presence of the Nursing Home Administrator (NHA #1), the Surveyor was informed that Section J1300 Current Tobacco Use is assessed during the comprehensive admission, annual, and significant change MDS assessments. Information to code that section should be gathered from observation, interview with the resident, and/or record review. The Surveyor expressed the concern that Residents #12, #51, #55, #85, and #139, identified as current and prior smokers, were inaccurately coded as No for tobacco use on their most recent annual MDS assessment. MDS #33, MDS #34, and the NHA #1 acknowledged the Surveyor's concerns and that these findings were made in error. MDS #33 and MDS #34 stated they would review the list of smoking residents to ensure J1300 for tobacco use reflects the resident's current status.2.On 5/4/2026 at 9:45AM and 5/5/2026 at 2:05PM, the Surveyor observed Resident #195 receiving oxygen therapy via nasal cannula.On 5/6/2026 at 1:00PM, a review of Resident #195's electronic medical record revealed that the resident was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure and dependence on supplemental oxygen. A review of the Baseline Care Plan dated 4/24/2026, under the Health Conditions section, revealed oxygen therapy at 3 liters. Further review of the admission MDS assessment completed on 4/30/2026, Section O C1. failed to indicate the use of Oxygen therapy for the resident.On 5/11/2026 at approximately 4:00PM, during an interview with MDS Director (MDS #33), in the presence of the Nursing Home Administrator (NHA #1), the Surveyor expressed the concern that Resident #195 was admitted to the facility on oxygen therapy and oxygen therapy was not coded on the admission MDS assessment dated [DATE]. After review, MDS #33 acknowledged and confirmed the Surveyor's findings.

Based on record review and interview with staff, it was determined that Preadmission Screening and Resident Review (PASARR) was not re-evaluated and updated to reflect a resident's current diagnosis of serious mental illness. This was found to be evident for 1 (#19) of 2 residents reviewed for PASARR during the annual recertification survey.The findings include:Preadmission Screening and Resident Review (PASARR) is a federal program that screens individuals applying to or residing in Medicaid-certified nursing facilities for serious mental illness (SMI) or intellectual disability (ID). The purpose is to ensure these individuals receive the most appropriate and least restrictive care setting and services.On 5/7/2026 at 11:40AM, a review of Resident #19's most recent PASARR dated 8/14/2024 showed no diagnosis of serious mental illness. However, a review of the resident's electric medical record at 12:00PM revealed the resident had been diagnosed with major depressive disorder on 12/16/2025.On 5/7/2026 at 12:55PM, during an interview with Social Worker (SW #9) and the Nursing Home Administrator (NHA #1), the Surveyor expressed the concern that Resident #19's most recent PASARR was not updated to reflect the resident's current diagnosis of major depressive disorder. After a review of the PASARR dated 8/14/2024, SW #9 and the NHA #1 acknowledged and confirmed the Surveyor's concern. The Surveyor informed the NHA #1 that Social Work Director (SW #35) completed and submitted a new PASARR for the resident which included the updated diagnosis.

Based on review of complaint #s 2723504 and 2788226, resident records, and staff interviews, it was determined that the facility failed to adhere to professional standards of practice when administering medications to residents. This was found to be evident for 1 (Resident #6) out of 1 resident reviewed for medications during the annual recertification survey.The findings include:On 5/5/26 at 2:07 PM, the surveyor reviewed complaint #s 2723504 and 2788226. Complaint #s 2723504 and 2788226 indicated that Resident #6's medication was not administered timely.On 5/7/26 at 2:36 PM, the surveyor reviewed Resident #6's medical records. Resident #6's Medication Admin Audit Report indicated that Resident #6 received the following medications late on 1/28/26:-Miconazole Nitrate External Cream 2 % (Miconazole Nitrate [Topical]) for rash, was scheduled for 3:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.-Icosapent Ethyl Oral Capsule 1 GM (Icosapent Ethyl) for hyperlipidemia, was scheduled for 5:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.-Methenamine Hippurate Oral Tablet 1 GM (Methenamine Hippurate) for recurrent UTI, was scheduled for 5:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.-Tamsulosin HCl Oral Capsule 0.4 MG (Tamsulosin HCl) for BPH, was scheduled for 5:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.-Gabapentin Capsule 300 MG for nerve pain, was scheduled for 8:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.-Memantine HCl Oral Tablet 10 MG (Memantine HCl) for dementia, was scheduled for 8:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26; Xarelto Oral Tablet 20 MG (Rivaroxaban) for A-fib, was scheduled for 9:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.-Melatonin Oral Tablet 3 MG (Melatonin) for sleep, was scheduled for 9:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26; Mirtazapine Oral Tablet 15 MG (Mirtazapine) for depression, was scheduled for 9:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.-Lactulose Solution 10 GM/15ML for bowel regimen, was scheduled for 9:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26; Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) for Alzheimer's, was scheduled for 9:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.-Ropinirole HCl Oral Tablet 2 MG (Ropinirole Hydrochloride) for restless leg syndrome, was scheduled for 9:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.On 5/7/26 at 3:03 PM, the surveyor interviewed the Nursing Home Administrator (NHA #1). During the interviewer, the surveyor mentioned to NHA #1 that according to Resident #6's Medication Admin Audit Report, resident #6 received mediation late on 1/28/26. NHA #1 indicated that medication should be administered one hour before or one hour after the mediation is due.On 5/8/26 at 6:55 AM, the surveyor interviewed Licensed Practical Nurse (LPN #11). During the interview, the surveyor mentioned to LPN #11 that according resident #6's Medication Admin Audit Report, resident #6 received mediation late on 1/28/26. LPN #11 reviewed Resident #6's Medication Admin Audit Report, and she indicated that on 1/28/26 she administered Resident #6's medication on time; however, she documented the medication administration late because it can get busy on the unit. The surveyor asked LPN #11 what the expectation is when documenting a medication administration. LPN #11 indicated that the expectation is to document a medication administration immediately after administering the medication.

Based on observation, interview and record review it was determined the facility failed to ensure a follow up medical appointment recommendation was followed and timely scheduled. This was evident for 1 (#27) out of 4 Residents reviewed for care planning during the facility's recertification survey. The findings include: During the surveyor's initial tour of the facility on 5/4/26 at 9:16AM Resident #27 expressed to the surveyor that they were concerned regarding their medical care which included an enlarged area present on their body and they did not know what the plan was for the medical care of it.Review of Resident #27's medical record by the surveyor on 5/8/26 at 1:06PM revealed diagnoses and medical history which included liver cell carcinoma, malignant ascites, and included documentation of an area having been identified on 3/17/26 as an aggressive osseous lesion on the Resident's hospital Discharge summary dated [DATE], prior to the Resident's admission to the facility on 3/25/26. Further review by the surveyor of Resident #27's hospital Discharge summary dated [DATE] revealed recommendations which included the following: Follow up with patient oncologist at JHH next available.On 5/8/26 at 1:08PM the surveyor requested to the facility Administrator to provide documentation of Resident #27's oncology follow-up appointment. On 5/11/26 at 9:34AM the surveyor conducted an interview of the Director of Nursing (DON) who after surveyor intervention, acknowledged and provided documentation of Resident #27's oncology appointment having been made on 5/8/26 at 2:10PM. The DON confirmed with the surveyor that the follow up appointment was not made until 5/8/26, and was made by Unit Clerk (#27). At this time, the surveyor shared the concern with the DON.On 5/11/26 at 9:52AM the surveyor conducted an interview of the facility Administrator who reported that Unit Clerk #27 was waiting on the Resident's wife to provide the name of the oncologist that they wanted the Resident to see, and they could not get the exact name, and reported there was no documentation of the conversation with the wife. When the surveyor inquired to the facility Administrator as to if the Resident's wife had decision making capacity for the Resident, they reported that they did not know.On 5/11/26 at 11:15AM the surveyor conducted an interview of Unit Clerk #27 who reported that they try to look at the discharge summary, and did not see information as to where the Resident was to go for the oncology follow up appointment. Unit Clerk #27 observed the discharge recommendation for the Resident to follow up at JHH documented in the discharge summary, and confirmed that they did see the discharge summary, but did not see that it included the place for the Resident to go for the follow up appointment.Review of the medical record of Resident #27 by the surveyor on 5/11/26 at 10:10AM revealed Resident #27 had certification of capacity for decision making dated 3/27/26 by Physician #28. Review of the medical record by the surveyor revealed there was no power of attorney or completed advanced directive observed to be present. Review by the surveyor of Resident #27's consult order history revealed two medical orders placed for the oncology consult for hepatocellular carcinoma, one dated as beginning 4/13/26, and one dated as beginning 5/6/26.On 5/11/26 at 11:21AM the surveyor shared the concern with the facility's Administrator, DON, and Unit Clerk #27, who acknowledged the surveyor's concern. On 5/11/26 at 11:34AM the surveyor conducted an interview of Physician #28 and inquired as to why the Resident's oncology appointment was not timely scheduled, to which they replied: I don't know.On 5/11/26 at 3:40PM the surveyor reviewed all concerns with the facility's Administrator and Director of Nursing who acknowledged the concerns.

Based on medical record review, facility investigation, and staff interviews, it was determined that the facility failed to maintain the safety of residents, who 1) required extensive assistance from staff for all activities of daily living, while providing routine care resulting in the resident sustaining a fracture and 2) required extensive assistance for transfers. This was evident for 2 of 4 residents (Resident #7 and #3) reviewed for accidents. These findings resulted in actual harm to Resident #7, found in Example #1. The finding included the following: 1) By way of history, according to the medical record, (Resident #7) had resided at the facility for several years and whose [DIAGNOSES REDACTED]. According to the facility documentation the resident allegedly sustained a fracture on 8/28/18, while receiving care. Review of the medical record on 2/8/19, revealed that on 7/29/18, an intervention was added to the care plan for two person assist for incontinent care, transfer and a physician order [REDACTED]. Resident #7's medical record review on 2/11/19 revealed the facility staff conducted a Quarterly MDS (Minimum Data Set) assessment on 11/16/18 and coded Section G-0110 A Bed Mobility as 3/3 (extensive assistance with 2-person physical assist for bed mobility and transfer. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident and to modify the care plan based on the resident's status. According to the medical record the resident has a Brief interview for Mental Status (BIMS) of 15. Continued review of the medical record on 2/11/19, revealed that on 1/3/19 the resident was diagnosed with [REDACTED]. Review of the facility investigation and other pertinent documents on 2/11/19 at 2:30pm, revealed that on 1/3/19 the resident went to a scheduled clinic appointment. Documentation indicated that during the exam by the Neurologist that there was a concerned about the resident's (RLE)- Right Lower Extremity positioning and movement. The resident was sent to the ER (emergency room ) for an X-ray. The X-ray revealed a comminuted proximal tibial shaft and fibular shaft fracture with deformity and generalized osteopenia. The resident was seen by the Orthopedic Physician on 1/3/19. The resident's right leg was splinted, and a soft cast was applied. The facility initiated an investigation on 1/3/19, after the resident returned from his/her appointment. Review of the facility investigation on 2/12/19 at 9am, revealed the resident was interviewed on 1/3/19 by Nurse #20 and reported when the Residential Care Specialist (RCS Staff #14) was turning him/her to provide incontinent care, his/her legs started to slide off the bed. The RCS Staff #14 caught the resident's left leg and then the right leg preventing the resident from falling to the floor. According to the written statement by Nurse #14, the resident, stated, the incident happened on the day the facility had their Christmas party. According to the Director of Nursing, the Christmas party was on 12/21/18. However, the resident did not experience any pain or notice any swelling after the incident. On 2/12/19 at 1pm during interview with Resident #7, the resident stated, I have another fracture caused by the staff not getting help to take care of me. The resident stated, This was the second time I have had a fracture. First the left leg now the right leg; I need to get out of here. On 2/12/19 at 2PM, during interview with Staff #17, from the Neurology clinic, s/he stated, The resident is seen once a month at the clinic. The resident normally arrives via wheelchair but came by stretcher on 1/3/19. The other leg (left) was broken months before and it had just begun to heal. Staff #17 stated, the resident informed me the break was due to a tech transferring him/her and this current break happened before 12/25/18. Review of facility documentation on 2/12/19 revealed that Resident #7 sustained a left knee fracture during routine evening care on 8/28/18. Review of the facility investigative statement revealed that the resident reported to the facility that while being turned during care on the evening of 8/28/18, his/her left knee jerked and made contact with the side rail. Resident #7 did not appear to have an injury until the following morning on 8/29/18 when he/she complained the left knee was swollen and painful, at which time the resident was assessed and seen by a physician. During an interview with RCS#14 on 2/13/19 at 3:30 PM, s/he stated, I, was changing the resident and his/her legs began to slide out of the bed. I don't remember the exact date. I grabbed the resident's legs to stop the resident from falling out of the bed. The RCS was asked if s/he had help while performing the care. The RCS stated, No, I was not aware this resident needed two people. I have taken care of the resident on many occasions and have not gotten help. Review of the facility investigation documents revealed a form labeled Teachable Moment which documented RCS #4 would ask for help when needed. The form was signed by the RCS and the Unit Manager on 1/28/19. Even after the facility staff was aware that an RCS was not using 2-person assistance for Resident #7's care, the RCS ADL (Activities of Daily Living) records for Resident #7 indicated that RCS staff were intermittently signing off on (7 am-3 pm), (3 pm-11 pm) and (11 pm-7 pm) shifts for 1-person assistance for bed mobility and incontinence care from, 1/3/19 - 2/22/19. On 2/13/13 the DON (Director of Nursing) provided the following statement: After the facility's investigation was completed on 1/4/19 to determine the origin of Resident #7's [MEDICAL CONDITION] leg, which included the resident's interview, it was concluded based on his/her statement to the Director of Nursing, Assistant Director of Nursing, the unit manager, and staff interviews that it happened during PM care. 2) The facility staff failed to provide a resident with a safe environment, during a transfer from wheelchair to bed. Review of Resident #3's fall prevention care plan initiated on 11/23/2018 revealed Resident #3 was at risk for falls. A review of Resident # 3's Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 1/7/2019 Quarterly was conducted. MDS Section G: Functional Status was coded to reflect that Resident #3 is extensive assistance on staff for transfers (how the resident moved between surfaces including to or from the bed, chair and wheelchair) and required the support of two or more individuals to transfer. Review of the complaint investigation of Resident #3's revealed a fall on 1/29/19 when Resident #3 was transferred to the side of the bed by Employee #9. Employee #9 wrote a statement that indicated that she/he was in the process of getting the resident ready for bed by asking the resident to stand so Employee #9 could remove her pants. Employee #9 sat the resident on the bed to remove the rest of his/her pants when the resident started to lean forward. Employee #9 was unable to hold the resident and therefore, Resident #3 was lowered to the floor. In an interview with Employee #9 on 2/8/19 at 3:20 PM, Employee #9 confirmed Resident #3 was leaning forward and was lowered to the floor and had no injuries to her head or leg. In an interview with Employee #10 on 2/8/19 at 3:26 PM, Employee #10 confirmed Resident #3 had no injuries to her head or leg. The Director of Nursing was informed of the findings on 2/8/18 at 4:00 PM.

Based on complaint, closed medical record review, resident and staff interview, it was determined that the facility staff failed to take steps to address a resident's pain. This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Review of complaint MD 844 on 04/11/2013 revealed an allegation that resident #2 did not receive any pain medication after being admitted to the facility on [DATE]. Review of resident #2's closed medical record on 04/11/2013 revealed that resident #2 was admitted to the facility on [DATE] at approximately 5:30 pm after a brief stay at a local hospital due to a large hematoma and swelling in the left leg. Resident #2 is capable of making decisions about his care and requires assistance from the facility staff for some aspects of his care. Review of resident #2's closed medical record revealed an admission nursing pain assessment, dated 01/08/2013, which indicated resident #2 ' s complaint of a 5 out of 10 pain upon admission to the facility. Further review of resident #2's closed medical record revealed nursing documentation, dated 01/08/2013 at 10 pm, which indicated the nursing staff administered a dose of Tylenol, 650 mg orally at 7 pm, which was effective and relieved resident #2 ' s pain. The 01/08/2013 10 pm nursing documentation indicated that resident #2 was unable to be weighed due to the pain caused by the left thigh hematoma and swelling. Further review of resident #2's closed medical record revealed a physical therapy admission assessment, date 01/09/2013, which documented resident #2 ' s pain as an 8 out of 10, shooting, throbbing, aching and sharp, and resident #2 was unable to tolerate lying on his back. The 01/09/2013 physical therapy admission assessment also documented resident #2 was unable to sit on the edge of the bed in a straight position, as able to verbalize the pain level, and the pain limited resident #2 ' s functional mobility. In an interview with the facility physical therapist, on 04/15/2013 at 9:40 am, who administered resident #2 ' s physical therapy assessment upon admission on 01/09/2013, the physical therapist stated the admission assessment was obtained between 8 and 9 am on 01/09/2013. The physical therapist stated resident #2 was in a lot of pain while lying in bed and that therapy provided a seat cushion for resident #2 ' s wheel chair. The physical therapist stated while obtaining the admission physical therapy assessment on resident #2 the facility occupational therapist also performed resident #2 ' s admission occupational therapy assessment. The 01/09/2013 physical therapist denied making resident #2 ' s nurse aware of resident #2 ' s pain level at the time of the 01/09/2013 physical therapy assessment. In an interview with resident #2 ' s occupational therapist, on 04/12/2013 at 4:20 pm, resident #2 ' s occupational therapist stated resident #2 had significant pain and the therapy staff could not keep resident #2 out of bed, unable to sit, lie in bed, or stand. The 01/09/2013 occupational therapist stated that she was working with the facility physical therapist during the 01/09/2013 assessment. The occupational therapist stated that she documented resident #2 ' s pain as an 8 out of 10 level and that resident #2 was in pain at rest and with movement. The occupational therapist denied making resident #2 ' s nurse aware of resident #2 ' s pain level at the time of the 01/09/2013 physical therapy assessment.

Based on medical record review, family interview, and staff interview, it was determined that staff failed to apply a "[MEDICAL CONDITION]" apparatus to a resident resulting in her returning to the emergency room less than ten hours after arriving at this facility. This finding was evident for one of 33 sampled residents. A [MEDICAL CONDITION] apparatus is a breathing device that helps people get more air into their lungs. [MEDICAL CONDITION] stands for Bi-level Positive Airway Pressure. The Bi-level devices work by cycling between two pressures, a higher pressure for inspiration and a lower pressure for expiration. The findings included: Resident #39 was admitted to the facility from an acute care hospital on the evening of 8/3/2010. Her [DIAGNOSES REDACTED]. She had been receiving [MEDICAL CONDITION] due to her hypercapnia (carbon [MEDICATION NAME] retention). Hypercapnia is a consequence of the cardio [MEDICAL CONDITION] system's inability to adequately blow off the CO2 (carbon [MEDICATION NAME]) that the body produces. A patient with [MEDICAL CONDITION] has a very difficult time ventilating (moving a sufficient amount of air in and out of the lungs) to "blow off" enough CO2 to normal levels. If a person works harder to ventilate, they produce more CO2- becoming a vicious cycle. A [MEDICAL CONDITION] is a "ventilator" that assists one's spontaneous effort to help "blow off" CO2 by increasing the volume of air per breathe without increasing one's effort to breathe. [MEDICAL CONDITION] devices have been found to be especially useful for patients with [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the hospital Transfer Summary revealed the resident was to be discharged to this facility and facility staff "...has accepted her pending arrangement of [MEDICAL CONDITION] prior to the patient's arrival." Discharge instructions/admission orders [REDACTED]. Her oxygen saturation (POX) was to be kept between 90 - 94%. She was also to receive multiple medications. According to the Transfer Summary, the resident's condition was "Stable" upon transfer to the nursing facility. Review of the medical record revealed Nursing Notes written by the 11-7 nurse supervisor dated 8/4/10 at 04:30 A.M. stating, "Was notified by charge nurse of resident's POX (pulse oxygenation- blood oxygen level) of 81% on 4L (liters) (via) NC (nasal cannula). Yelling out, 'Help me!'. Signs & symptoms of anxiety. Resident was placed on non-rebreather mask. Resident began pulling mask off. Prior to this episode POX was 95-97% on 4LNC. Dr (attending) was notified. Alternatives were discussed to sending to ER for evaluation and treatment of [REDACTED]. There was no indication in the nursing notes, Treatment Administration Records, nor during staff interview that the [MEDICAL CONDITION] was used for this resident, as per admission orders [REDACTED] The resident was transported to back to the acute care hospital. Review of the hospital Transfer Summary revealed the resident "was readmitted from the rehab center for acute shortness of breath (SOB) and [MEDICAL CONDITION] (oxygen deficiency). Apparently she was not receiving [MEDICAL CONDITION] at the nursing home. She was placed on [MEDICAL CONDITION] here and improved. She also had evidence of [MEDICAL CONDITION], was started on IV [MEDICATION NAME] (a diuretic medication to aid the body with excreting excess fluid) and had [MEDICATION NAME] well...". On 8/13/10 an interview of the 11-7 nursing supervisor as to why the [MEDICAL CONDITION] apparatus was not used on the resident on 8/3/10 -8/4/10 revealed the resident did not have a [MEDICAL CONDITION] mask with her. The supervisor stated the [MEDICAL CONDITION] apparatus was delivered, but there was no mask. The supervisor stated , "the son had the mask". A phone call was placed to the resident's son on 8/13/10 and he stated, "Why would I have my mother's mask? No I did not have her [MEDICAL CONDITION] mask and she was sent to the hospital because the nursing home did not set up her [MEDICAL CONDITION]." A phone call was placed to the oxygen delivery company on 8/13/10 and they stated that a [MEDICAL CONDITION] machine, tubing, and a mask were delivered to the facility on [DATE] at 5:05 PM. Review of the delivery sheet verified that a delivery of a [MEDICAL CONDITION] apparatus was received by the facility on 8/3/10 at 5:05 PM. The "Site" of delivery states "Oxygen Room". The description of the delivery is "Serialized Asset 5 checked out to customer." The facility staff failed to apply a [MEDICAL CONDITION] apparatus, as ordered, to this newly admitted resident resulting in her oxygenation levels to drop, causing anxiety and shortness of breathe. This resulted in a return to the acute care hospital for emergent treatment of [REDACTED].