Every finding on record at Autumn Lake Healthcare at Homewood

Based on observation and resident's interview, it was determined that the facility failed to provide a safe, functional, sanitary, comfortable and homelike environment for residents. This was evident on 3 of 4 units and 1 of 1 observation of the courtyard during the survey. The findings include: On 07/13/2026 at 8:32 AM during the initial tour of the facility, the surveyor observed that residents in rooms 46-A and B still had dirty meal trays from the previous meal sitting on their tables. The surveyor observed as breakfast tray's were brought in by the aides and placed next to the dirty dishes without removing them. On 07/13/2026 at 8:35 AM The surveyor also observed in room [ROOM NUMBER]-A what appeared to be last night's dirty meal tray on the residents table as breakfast was served next to it. In an interview with Resident #49 on 07/13.2026 at 9:05AM s/he was asked about the dirty meal trays left at the bedside and they said those were from last night's dinner and not sure why staff did not remove them after meals. In another Interview with #32 a Certified Nursing assistant (CNA) on 07/13/2026 at 8:41AM, she was asked when dirty meal trays should be removed and by who? She said they are removed by the CNA's 30-45 minutes after the residents are done eating. She said the trays were left by night shift who should have removed them. Further observation of the resident's room on 7/13/2026 at 9:05AM revealed that in room [ROOM NUMBER]'s bathroom, the bottom of the toilet bowl was dark and the base board at the back of the toilet was coming off about 2-3 feet long. The grab-rail close to the sink was wobbly and the pipe covers behind the toilet and sink were rusty. In room [ROOM NUMBER], the bottom of the toilet bowl also had dark stains and the door leading to room [ROOM NUMBER] was stuck and would not open. The resident's occupying room [ROOM NUMBER] could not open the bathroom door. The surveyor later observed the bathroom door open but the door handle was loose, the door drags onto the floor when pulled outwards. On 07/13/2026 at 9:26 AM In room [ROOM NUMBER], the bathroom had an opening in the ceiling measuring about 2.5 x 0.5 foot long and was depressed inward. The bottom of the toilet bowl was also covered with dark stains. In room [ROOM NUMBER]-B, the surveyor observed a recliner opposite the resident's bed. The leather covering on the recliner was torn at the footrest area, measuring approximately 1x 0.5 foot long exposing the white cloth film underneath. In room [ROOM NUMBER], the bathroom vent was observed hanging loose and about to fall off. In room [ROOM NUMBER], the bottom of the toilet bowl was covered in what appeared to look like black stains. Further observation on 07/13/2026 at 9:43 AM reveals that in room [ROOM NUMBER]-A, the bedroom ceiling was coming off about 4 foot long. On 07/15/2026 at 2:02 PM The surveyor did a walk around with #19 the Maintenance director and the Nursing Home Administrator ((NHA). They were asked how they kept abreast of things that needed fixing in the facility. The maintenance director stated that they have a TEL's system and a binder at the nursing station for staff to communicate issues for maintenance to follow-up, which they check on a daily basis. The NHA also said maintenance do daily walk arounds and quarterly room checks which involves looking at floors, ceiling tiles, paints, beds, furniture, lights, call bells, etc. to see if they needed fixing. The administrator took pictures of the concerns and said they will be put in TEL's so it can be fixed, they acknowledged the concerns. On 07/14/2026 at 12:38 PM, an observation of the outside courtyard during the 12:30 PM smoke break revealed a large amount (approximately 100) of cigarette butts (the end of a cigarette) that were spread across a large portion of the courtyard. On 07/14/2026 at 12:49 PM, the surveyor observed Resident #34 toss a cigarette butt onto the patio. At the same time, further observation revealed two cigarette disposal stands in the courtyard where the residents smoke. On 07/14/2026 at 12:53 PM, an interview with Geriatric Nursing Assistant (Staff #20) who supervised the smoke break revealed he was not aware of any policy that the residents followed regarding disposal of the cigarettes. On 07/14/2026 at 1:01 PM, an interview with the Nursing Home Administrator revealed that housekeeping staff clean the courtyard periodically. At the same time, during a dual observation of the courtyard, the Nursing Home Administrator indicated that housekeeping would come out and clean the cigarette butts. The surveyor reviewed the concern.

Based on staff interviews and review of facility documentation it was determined the facility failed to ensure that a Performance Improvement Project (PIP) was identified and implemented through the facility's Quality Assessment and Assurance (QAA) committee and/or Quality Assurance Performance and Improvement (QAPI) program annually. This was found evident for 1 year of QAA/QAPI notes reviewed. Findings include: On 7/17/26 at 10:38 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA stated that the Assistant Director of Nursing (ADON) was responsible for running and coordinating the QAA committee. He further stated that the ADON was out of the country, and the Director of Nursing (DON) would answer any QAA/QAPI questions. On 7/17/26 at 10:43 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked for an example of a Performance Improvement Project (PIP). The DON stated she would review the QAA/QAPI notes and follow-up. On 7/17/26 at 11:36 AM, the surveyor requested and reviewed the QAA/QAPI binder/notes. The review revealed several months of data collection; however, there was no identified PIP or evidence of implementation of a PIP. On 7/17/26 at 12:02 PM, the surveyor reviewed the concern with the NHA about the absence of a performance improvement project.

Based on record review and interview, it was determined that the facility failed to maintain and account for scheduled Quality Assessment and Assurance meetings. This was evident for 5 of the 11 months QAA meetings were held July 2025- June 2026. The findings include: On 7/17/26 at 10:38 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA stated that the Assistant Director of Nursing (ADON) was responsible for running and coordinating the QAA committee. He further stated that the ADON was out of the country, and the Director of Nursing (DON) would answer any QAA QAPI questions. The surveyor asked to see QAA attendance from the last 6 months of QAA meetings The review of the attendance revealed that the ADON was not in attendance from January 2026 through April 2026. The surveyor requested attendance sheets from July 2025 to December 2025. On 7/17/26 at 10:43 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor confirmed that ADON was the facility's QAA lead and designated to run the QAA committee and meetings. The surveyor reviewed the concern that the ADON was not in attendance for 4 of the 6 months of the 2026 committee meetings. She stated that the previous ADON left in April and that the new ADON started in April and had been in attendance in May and June. The surveyor requested to see the facility's QAA/QAPI documentation. On 7/17/26 at 11:36 AM, the surveyor reviewed the QAA/QAPI binder. No attendance forms were noted for August 2025-December of 2025. On further review, data was noted in several months however, no direct plan or leadership was identified based on the data. The months of May and June had no data in the binder. On 7/17/26 at 12:02 PM, the surveyor reviewed the concern with the NHA about the absence of documented attendance and the concern the lead for the QAA committee was only documented to be in attendance 2 out of the 11 months.

Based on record reviews and interviews it was determined that the facility failed to provide treatments and appropriate follow-up for a resident's condition. This was found to be evident of 2 (Resident #92 & #11) out of 45 residents reviewed during the survey. The findings include: 1) On 7/13/26 at 9:14AM, the surveyor conducted an interview with Resident #11. During the interview Resident #11 stated that he/she had missed two of his/her urology (urinary system specialty) appointments due to transportation issues the facility arranged. On 7/14/26 at 9:09 AM, the surveyor conducted an interview with Unit Manager (UM) #5. During the interview UM#5 stated that when residents return from outside appointments with recommendations for follow-up appointments, the unit clerk is responsible for scheduling and further stated that she was not aware of any resident missing appointments. On 7/14/26 at 9:15 AM, the surveyor reviewed a consultation note from Resident #11's urology appointment, dated 6/22/26, that stated; need to be rescheduled related to transportation issues. It further stated rescheduling for 7/9/26 at 3:20 PM and named the location. Additionally in Resident #11's medial record was a reminder note dated 7/2/26 of the upcoming appointment on 7/9/26 at 3:20PM. On 7/14/26 at 9:59 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON confirmed that Resident #11 had to have two urology appointments rescheduled. She stated that the Certified Nursing Assistant (CNA) that was scheduled to go with Resident 11 on both visits would be able to speak as to why the consultations were not done. On 7/14/26 at 11:39 AM, the surveyor conducted an interview with CNA #12. During the interview CNA#12 stated Resident #11 went to his/her appointment on 6/22/26 but when they got there the clinic was not exactly sure why the resident was there and that the resident could not be transferred off the stretcher at that location. She further stated for the second appointment on 7/9/26 she was not at the building when transport came, due to transportation showing up early. CNA #12 stated that on 7/9/26 the transportation company left because they timed out of their transportation window. CNA #12 recalled Resident # 11's scheduled pick up with transportation at 7:30 however, the transportation company came around 7AM. The surveyor noted that the appointment time for the 7/9/26 appointment was 3:30 PM. Following the interview the surveyor conducted an interview with the DON. The surveyor reviewed the concern that Resident #11 had missed two appointments related to transportation issues in which the facility arranged and requested transportation documentation. At the time of exit no additional documents were provided. 2) On 7/15/26 at 11:09 AM, the surveyor reviewed intake #3064017. The complaint alleged that Resident #92 was not receiving proper wound prevention and treatment care. On 7/16/2026 1:56 PM, the surveyor reviewed Resident #92's Treatment Administration Record (TAR) for April and May of 2026. The review revealed Resident #92 had orders for wound treatments for a mid sacral wound (to be done daily) and a coccyx wound (to be done twice a day). Additionally, a weekly skin check was completed to evaluate the wound areas. On 4/11/26, 4/18/26 and 5/4/26 the mid sacral wound care was left blank. On 4/18/26 9AM, 4/19/26, 9PM, 4/20/26 9PM, 5/4/26 9AM the coccyx wound care was left blank. On 4/22/26 the skin check list documented no skin impairments even though the wound care team evaluated Resident on 4/21/26- documenting the mid sacral wound and coccyx wound. On 7/17/26 at 9:15 AM the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor showed the blank documentation for wound care and asked if the would care was provided as ordered on the days there is no documentation. The DON stated she would review the record to see if the cares were documented in other areas but that the expectation is if cares are provided they should be documented. The surveyor also reviewed the concern about inaccurate skin check documentation. At the time of exit no additional documents were provided.

Based on observation and interview, it was determined that the facility failed to ensure that there was an effective pest control program in place at the facility to be free from pests. This was evident for several observations throughout the annual survey.The findings include:On 07/13/2026 at 11:34 AM, during an interview with Resident #9, a fly was flying around the room. Resident #9 swatted the fly away. At the same time, Resident #9 indicated that he/she had seen flies frequently in their room and that they had landed in their food and on objects around the room. On 07/13/2026 at 1:00 PM, an observation revealed a gnat (small fly) in the surveyor conference room. On 07/14/2026 at 7:30 AM, an observation revealed fly in the surveyor conference room.On 07/14/2026 at 8:05 AM, the surveyor caught and disposed of the fly. On 07/14/2026 at 10:50 AM, an observation revealed a fly in the surveyor conference room. On 07/15/2026 at 10:15 AM, an observation revealed a fly in a fresh cup of coffee in the surveyor conference room.On 07/15/2026 at 1:24 PM, an observation revealed a fly in the surveyor conference room. On 07/16/2026 at 7:44 AM, an observation revealed a fly in the surveyor conference room. On 07/16/2026 at 8:28 AM, during an observation of Certified Medication Aide (Staff #42) administer medication, there was a fly. At the same time, an interview with Staff #42 revealed she would observe a fly at least once a shift. On 07/17/2026 at 7:51 AM, an observation revealed a gnat in the surveyor conference room. On 07/17/2026 at 6:42 AM, an interview with the Nursing Home Administrator revealed he noticed the flies and gnats more during the week of the current annual survey. He further indicated the facility had pest control come frequently. The surveyor requested the last 3 months of pest control visit logs.On 07/17/2026 at 11:15 AM, review of the last 3 month pest control logs revealed that pests were addressed during several visits.On 07/17/2026 at 12:34 PM, at the time of the survey exit conference, the surveyor reviewed the concern to the Nursing Home Administrator.

Based on observation, record reviews and staff interviews, it was determined that the facility failed to carry out Pharmacist recommendations on three different occasions following the monthly medication regimen review (MRR). This was evident for 1(#6) of 5 residents reviewed for unnecessary medications. The findings includeOn 7/14/26 at 9:15 AM The facility was asked to provide the Pharmacist MMR from June 2025 to July 2026 for Resident #6. Review of the document which identifies irregularities discovered by the Pharmacist dated 3/27/25 revealed recommendations to review and change Risperidone to GT or PEG administration in PCC. This was not done by the facility. The same recommendation was noted again on next month's pharmacy review on 4/10/26 but was not acted upon. A 3rd recommendation was noted again regarding the same issue on 6/27/26. The facility still did not act on it or indicate why they did not.Review of the physician order revealed an order written on 11/20/24 that reads: Risperidone Oral Tablet 0.25 MG (Risperidone)Give 1 tablet by mouth two times a day for Schizophrenia. This was the order the Pharmacist was referencing.On 7/15/26 at 10:50 AM, the surveyor brought this concern to the attention of the Director of Nursing (DON) and the Nursing Home Administrator (NHA).On 07/15/2026 at 4:10PM In an Interview with the DON regarding Med reg review policy and process, she was asked to explain the process. She stated that after review by the Pharmacist, an email of the irregularities found with recommendations are sent to her email and that of the Unit Managers. Either she or the Unit Managers print out the recommendations and forward it to the Physicians. After physician's review, they are returned to the Unit Managers to take off any physician's orders. The DON was made aware of the concerns, she acknowledges and said she will work on it.

Based on a complaint #3055819, record review and staff interviews, it was determined that the facility failed to provide evidence that accounts for some narcotic drug record use and reconciliation. This was evident for 1 of 3 nursing units reviewed for alleged narcotic misappropriation during the annual survey. The findings includeOn 7/13/2026 at 9:00AM, review of a complaint incident #3055819 alleged that the night supervisor was misappropriating the patient's narcotic and signing out narcotics without administering them to the residents. The residents are stating they did not receive their medications.In an Interview with Resident #75 on 7/13/26 at 9:05 AM, S/he stated that they were not receiving their Suboxone as ordered, for drug dependency and that staff are not renewing their medication timely, when it runs out.Review of Resident #75's Medication orders on 7/13/26 at 9:18AM revealed orders written as: Suboxone Sublingual Film 8-2 MG (Buprenorphine HCl-Naloxone HCl Dihydrate) Controlled Drug Give 2 tablet sublingually two times a day for Opioid dependency.On 07/15/2026 at 11:22 AM Review of resident's Medication Administration Records (MAR) from May to July 2026 did not reveal any discrepancies with Suboxone administration. However, reviews also included other narcotic medications which the resident was on such as Oxycodone. The surveyor found orders written on 6/1/26 as: Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug*Give 4 tablet by mouth every 4 hours as needed for severe pain level 6-10.Further review of the narcotic and controlled substance shift to shift count sheet from February 2026 reveal different days when the shift-to-shift counts were not performed. The days included: February 2, 7, 16, 17, 18, 19, 20, 21, 22,23, 24, 25, 26, and 30th. The shift-to-shift count reconciles discrepancies with narcotic administrations and prevents misappropriation. Continuing review of the narcotic and controlled substance shift to shift count sheet also failed to reveal the count sheet for the month of May 2026. The Unit Manager #3 was asked to provide the missing document.On 07/16/2026 at 8:04 AM, License Practical Nurse (LPN) #38 an Agency nurse was asked in an interview the process for narcotic count at change of shift. He stated that the count is done by 2 nurses, the incoming and the outgoing nurse. They count the total number of all narcotic cards including liquids and Fentanyl patches and write them down. Afterwards, they do individual resident's card count which both nurses sign to indicate the count was accurate. He said this must be done every change of shift. He was asked to explain the significance of the process. He said that the count is done to avoid drug diversion, creation of discrepancies and mitigate medication shortages.On 07/17/2026 at 11:37 AM the Unit Manager #3 came back with a binder that has all the narcotic sign out sheets from Jan to July from the [NAME] station. May 2026 was still missing, she said she could not find it. She was asked if anyone provides oversight to make sure nurses are doing the narcotic reconciliation and safeguarding the documents. She said it is the responsibility of the unit managers but was not employed with the facility as of the time of the missing document. She was made aware that this was a concern. She acknowledged the concern and said she will follow up.

Based on record review and staff interviews, it was determined that the facility failed to ensure that physicians' orders are followed. This was evidenced by staff giving as needed narcotics outside of the recommended parameters for 2 (Resident $42 and #75) of 5 residents reviewed for unnecessary medications during the annual survey. The findings Include. 1). On 07/15/2026 at 4:37 PM Review of the June 2026 Medication administration records (MAR) revealed that Resident #75 was getting their PRN (as needed) narcotic pain medication when their pain level was documented as zero on 6/3, 6/7, and 6/11. The order was to give oxycodone HCL oral tablet 5MG- Give 4 tablets by mouth every 4 hours as needed for severe pain level of 6-10. Further review of July 2026 MAR revealed a second PRN order for narcotic pain medication written as: Oxycodone HCL oral tab 5MG: give 3 tablets by mouth every 4 hours as needed for moderate pain 1-5. This medication was being administered when the resident's pain level was greater than 5. The dates include: 7/2 and 7/5- Pain level was 10. On 7/9- Pain level was 8 and on 7/12 and 7/14, the pain level was 7. 2). On 07/16/2026 at 8:34 AM a review of Resident #42's physician order reveals an order dated 8/31/25. It reads: oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug*Give 1 tablet by mouth every 6 hours as needed for pain 6-10. Further review of Resident #42's June 2026 MAR reveal that this medication was given to the resident on 6/8 for a pain level of 3. On 6/15 and 6/17 for a pain level of 4, and on 6/30 for a zero-pain level which was outside the recommended 6-10 parameters In an interview with The License Practical Nurse (LPN) #38 on 07/16/2026 at 8:38 AM- he was asked about the process for administering PRN pain medications with parameters. He stated that residents are first assessed for pain to determine their pain level which is measured on a scale of 1-10, prior to administering the medication. The pain meds are administered if it falls within the ordered parameters and should not be given when the pain level is at zero. He was asked the implication of administering the PRN pain medication when not indicated. He stated that if given when out of parameters, the resident may become dependent on the narcotic or develop respiratory failure or become constipated from overuse. On 07/16/2026 at 4:15 PM The Director of Nursing (DON) was made aware that staff are not following the doctor's order and are giving PRN narcotics outside the prescribed ranges. She said the orders are spelled out on the MAR, yet staff are not doing it, she will provide more education.

Based on observation, record reviews and staff interviews, it was determined that the facility failed to 1), store and serve food in a manner that prevents foodborne illness and 2), failed to date and label resident's food stored in the nourishment refrigerator. This was evident during the annual survey.The findings include1). On 07/13/2026 at 06:56 AM an observation of the facilities kitchen refrigerator revealed food stored without a date or labels on them. They include:A container with diced carrots in an aluminum container covered with a transparent film.A Big jar of Sysco reliance Barbecue sauce 3/4 empty-not datedThree one-liter water jugs, filled with pink juice and four one-liter jugs, filled with lemon juice- not dated.Further review of the Food temp log on 07/13/2026 at 7:23 AM revealed that: on 7/3/26, breakfast food temperature was not taken or documented. on 7/6/26 breakfast and lunch food temperature was not taken or documented.In an Interview with the district manager (CDM)#35 on 07/15/2026 at 8:23 AM, he was asked about their Policy for food storage, and he said that anything placed in the fridge that is open should be labelled and dated. He was asked what plans he had in place to ensure that foods kept in the fridge are labelled and he said it's everybody's responsibility to make sure foods kept in the fridge are labelled. He Stated that he has instructed the kitchen mangers to do a morning walk through and check everything to ensure that the foods left there are labelled. He was made aware that this was a concern.2), On 07/14/2026 at 11:48 AM, an observation of the nourishment refrigerator located on the unit where foods brought in by residents or visitors are kept revealed a plate of spaghetti in a black bowl covered with a white lid dated 7/13/26 with no name on it.A white /creamy liquid in an 8 Oz plastic cup and a second 8 OZ plastic cup 3/4 filled with pink liquid with no date or name on it;A bottle of life H20 about 1/3 full with no name or date on it. At 11:52AM the staffing manager #36 was made aware of the findings, she verified that they were not labelled or dated and stated that she would discard them.On 07/14/2026 at 4:12PM In an interview with the Director of Nursing (DON), she was asked about their policy for food kept in the nourishment refrigerator. She said that any food kept there should not stay for more than 3 days. It must be labelled with a name, room number and the date it was put in the refrigerator. She was made aware of the above concerns. She said she will follow up.

Based on a complaint #3055819, record review and staff interviews, it was determined that the facility failed to employ a Registered Nurse (RN) in accordance with Maryland State laws. This was evident for 1 (Staff #2) of 3 employee files reviewed during the annual survey. The findings include On [DATE] at 9:30 AM review of a complaint incident #3055819 alleged that the Director of Nursing's (DON) RN license was supposed to be from Florida and her MD LPN License was inactive with the MD Board of Nursing. The surveyor requested Staff #2's employee files. Review of staff #2's employee files verified that the employee has a valid compact RN license from Florida and that she resides in Maryland. However, the surveyor was unable to verify staff #2's Maryland license from the MBON website, and there were no copies of their MD license on file. In an Interview with the Human Resources (HR) Director #30 on [DATE] at 12:01PM the HR director was asked about their process for verifying the validity of a nurse's license. She stated that she verifies it through the Maryland board of Nursing (MBON) website. The HR Director was asked if she hires staff who are not licensed in MD. She stated that some staff do have Multistate RN-MD licenses. They are hired as long as it's a compact multi state license. She was asked if she ensures that those nurses get an active MD License if they Physically reside in MD and she said she does. She was asked if not licensed in MD, can they work with a Compact license and she said yes. She was asked if she was aware that in Maryland a nurse is required to have an active license in the State of their primary residence. She said she was not aware. She was asked to provide a list of Nurses with RN compact license. On [DATE] at 12:36 PM- the HR Director #30 brought a list that showed that the DON was the only one working in the facility with a Florida compact license and an expired License Practical Nurse (LPN) license (expired [DATE]). The HR director was made aware that the staff (DON) needs to have an MD license in the state of primary residence, she said she will follow up. On [DATE] at 1:45PM: the DON was made aware of the concern. She was told that state law requires a nurse to have an MD license to work in the state of MD if the person resides physically in MD and claims their W2 from the state. MD state law requires that their W2 should match their state of licensure. She said she claims dual state residency in MD and Florida but has just finished her bachelor's degree and will get the MD license. The Nursing Home Administrator (NHA) was there during the discussion and acknowledged the concern.

Based on observation and interview, it was determined that the facility failed to separate the clean and soiled laundry areas with a closed barrier to prevent the potential for cross-contamination and failed to maintain a process to identify residents who required Enhanced Barrier Precaution (EBP). This was evident in the laundry room and 3 (#40, #44, and #54) out of 10 rooms observed for precaution signage.The findings include:1) On 07/14/2026 at 10:25 AM, the surveyor observed an opening between the clean and dirty areas of the laundry. Staff #9 stated that the opening needs to be there for maintenance of the dryer area and there was no way to close the opening.On 07/14/2026 at 10:35 AM, the Administrator acknowledged the concern and stated the facility would explore solutions. 2) On 07/14/2026 at 10:40 AM, the survey observed 10 rooms with Enhanced Barrier Precaution (EBP) signage. Orange dots were found on 7 rooms identifying which bed the precautions were needed. Rooms #40, #44, and #54 did not have an orange dot identifying which resident needed precautions. On 07/14/2026 at 10:45 AM, Licensed Practical Nurse (LPN) # 8 was asked how to identify which resident was on precautions for rooms [ROOM NUMBER]. LPN #8 stated, I'm not sure who is on EBP without the dot. When asked who is responsible for placing the orange dots on the signage, LPN #8 stated s/he thought the supervisors were responsible for putting the orange dot on the sign and the expectation is that every room that has an EBP sign would have an orange dot next to the name of the resident requiring precautions.On 7/15/2026 at 11:51 AM, the Director of Nursing acknowledged the confusion regarding the signage, stated the former Assistant Director of Nursing implemented the process, and noted the facility needed to clarify the procedure to staff.

Based on observation and interview it was determined the facility failed to ensure residents received reasonable accommodation of the call bell system. This was evident for 2 (Resident #5 and #32) of 24 residents observed during the initial screen process of the annual survey.The findings include:On 07/13/2026 at 11:17 AM, an observation of Resident #5 revealed their entire call light cord was rolled up hanging at the call bell wall port, out of reach of the resident.On 07/13/2026 at 11:19 AM, an observation of Resident #32 revealed their call light cord was on the floor, out of reach of the resident. On 07/13/2026 at 12:26 PM, a follow up observation of Resident #5 and #32 revealed the same status as noted above. On 07/13/2026 at 12:29 PM, the surveyor requested Licensed Practical Nurse (Staff #23) for dual observation of the follow up observation noted above. At the same time, an interview with Staff #23 revealed it was the expectation of staff to ensure resident call bells were within reach of the resident at all times.On 07/14/2026 at 1:43 PM, the surveyor reviewed the concern with the Director of Nursing and she indicated that she understood.

Based on record review and interview, it was determined that the facility failed to complete an admission comprehensive Minimum Data Set (MDS) assessment within the required timeframe. This was evident for 1 (Resident #73) of 7 residents reviewed during the survey.The findings include: The MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes. It is a tool nursing home staff use to gather information on each resident to evaluate clinical status, functional abilities, and care needs.On 7/15/2026 at 12:49 PM, surveyors reviewed Resident #73's MDS assessment. The admission assessment had an Assessment Reference Date (ARD) of 4/16/2026 and was completed on 4/24/2026, after the required completion timeframe. ARD refers to the specific endpoint for the observation periods and completion process. For an admission MDS assessment, the assessment must be completed by the end of day 14 of admission (admission date plus 13 calendar days).On 7/17/2026 at 9:01 AM, surveyors interviewed MDS Coordinator #22. The MDS Coordinator stated that the assessment was completed on time, but the Regional Director of Clinical Services (RDCS) did not sign the assessment until 4/24/2026, which resulted in a late completion date.On 7/17/2026 at 9:11 AM, surveyors informed the Regional Administrator and Administrator that Resident #73's admission MDS assessment had been completed late.

Based on observation, interviews and record review it was determined that the facility failed to develop and implement a comprehensive care plan to meet the needs of a Resident. This was found evident of 1 (Resident #13) out of 45 residents reviewed during the survey. The findings include: On 7/13/26 at 9:42 AM, the surveyor observed Resident #13 resting in bed with supplemental oxygen via nasal cannula in his/her hand along with a BiPAP (Bilevel Positive Airway Pressure) machine noted in a bag on the side rail of Resident #13's bed. A BiPAP machine is used to treat sleep and respiratory conditions by delivering pressurized air through a mask to keep airways open. Resident #13 stated he/she had concerns with the bed and falling; However could offer no other details into these concerns. On 7/15/26 at 9:11 AM, the surveyor reviewed Resident #13's medical record. The review revealed that Resident #13 had no respiratory or oxygen care plan or fall care plan. On further review it was revealed that Resident # 13 had orders that started on 7/13/26 for both supplemental oxygen as well as BiPAP at night and while resting during the day. Also noted a fall assessment date 7/3/26 that rated Resident #13 as a high fall risk. On 7/16/26 at 10:15 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON confirmed that appropriate care plans for Resident #13's were not reinitiated after the resident returned from a recent hospital stay and should have been.

Based on interviews and review of medical records it was determined that the facility failed to:1) update a care plan, 2) involve the Resident in the interdisciplinary care planning process. This was evident of 2 (Resident #7 and Resident #11) out of 45 residents reviewed during the survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team. 1) On 7/13/26 at 8:50 AM, the surveyor conducted an interview with Resident #7. During the interview Resident #7 stated that he/she could not recall having a recent care plan meeting. On 7/14/26 at 9:00 AM, the surveyor conducted an interview with Unit Manager (UM) #5. During the interview UM #5 stated that she participated in care plan meetings about once a month. She further stated that the social worker arranges them. When asked if she could recall if Resident #7 recently had a care plan meeting she could not remember. On 7/14/26 at 11:23 AM, the surveyor reviewed the last care plan sign-in sheet with the Nursing Home Administrator (NHA) and asked why Resident #7 was not part of the May 2026 care plan meeting. Resident #7 was not listed in attendance. Next the NHA shared the care plan meeting note written by the Social Worker (SW #41) that stated, SW met with the Resident in his/her room during lunch for a care plan meeting. On 7/14/26 at 11:38 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON confirmed that a care plan meeting should involve an interdisciplinary team and should not take place in the resident's room during lunch with only the social worker. 2) On 7/14/26 at 8:48 AM, the surveyor reviewed Resident #11's medical record. The review revealed a urology consult note written after a on 5/6/26 after a suprapubic catheter exchange that stated Resident #11 and a Urinary Tract Infection (UTI) in February however, no antibiotics indicated due to absence of UTI symptoms. On 7/15/26 at 8:38 AM, the surveyor reviewed Resident #11's care plan. The review revealed that Resident #11 had a care plan initiated on 6/24/25 that stated Resident # 11 had bladder incontinence with one intervention to encourage fluids during the day to promote voiding response. Additionally, a care plan that stated Resident #11 was on Intravenous (IV) antibiotics due to a UTI, last revised on 2/6/26. Next the surveyor reviewed the care plan with the Director of Nursing (DON). During the interview the DON confirmed that the care plan was not revised and up-to-date and confirmed that Resident #11 was not on antibiotics and was not voiding or currently incontinent.

Based on observation and interview, it was determined that the facility failed to ensure finger nail care was provided to residents. This was evident for 2 (Resident #24, and #71) of 2 residents observed for nail care.The findings include:On 07/16/2026 at 8:28 AM, an observation of Resident #24 revealed their finger nails were long.On 07/16/2026 at 1:42 PM, an observation of Resident #71 revealed their finger nails were long.On 07/17/2026 at 8:26 AM, a follow up observation of Resident #24 revealed their finger nails were long. At the same time, an interview revealed they felt their nails were long and would like for them to be cut down. On 07/17/2026 at 8:28 AM, a follow up observation of Resident #71 revealed their finger nails were long. At the same time, an interview revealed they would like for their nails to be cut down. On 07/17/2026 at 8:30 AM, an interview with Licensed Practical Nurse (Staff #4) revealed it was the expectation of all staff to monitor resident finger nails for length. On 07/17/2026 at 9:13 AM, an interview with the Director of Nursing revealed Resident #24 and #71's finger nails had been trimmed and acknowledged it was after surveyor intervention. The surveyor reviewed the concern.

Based on review of medical records and interviews it was determined that the facility failed to adequately assist a dependent resident during Activity of Daily Living (ADL) cares. This was found evident for 1 (Resident #11) out of 6 residents reviewed for accidents. The findings include: On 7/13/26 at 9:20 AM, the surveyor conducted an interview with Resident # 11. During the interview Resident #11 stated that a few months earlier he/she was transferred by two staff members without the use of a Hoyer lift and noted knee pain after the transfer, however an x-ray revealed no fracture. On 7/14/2026 at 9:33 AM, the surveyor reviewed Resident 11's progress notes. A progress note written on 12/6/25 documented that an order for a left knee x-ray was obtained to rule out a fracture. On 12/9/25 a provider evaluated Resident #11 and wrote Resident #11 was seen for follow up for reported left knee pain and swelling a few days ago. It further stated that the Resident #11 reported the injury to the left knee happened during a transfer with a Hoyer lift. Next, the surveyor reviewed Resident #11's care plans. Resident #11 had an Activities of Daily Living (ADL) self-care deficit care plan established on 4/12/25. One of the interventions was transfer resident with mechanical lift and the assistance of 2 initiated on 6/9/26. On 7/14/26 at 10:44 AM, the surveyor reviewed the Minimum Data Set (MDS) assessment dated [DATE] and noted Resident #11 was coded as dependent for both chair to bed transfers and toilet transfers. On 7/14/26 at 11:34 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON confirmed that the transfer in December of 2025, in which Resident #11 complained of knee pain, was done by two staff members standing the resident and pivoting rather than using a Hoyer lift. She validated that a Hoyer lift should have been utilized. She further stated that a staff member should have been aware of the mode of transfer by referring to the Resident's TASK record.

Based on observation, record review, and interview, it was determined that the facility failed to ensure respiratory care was provided in accordance with physician orders. This was evident for 3 (Resident #72, #20 & #73) of 4 residents observed during the recertification survey. The findings include: 1). Observation of resident #72 on 07/13/2026 at 8:31AM revealed that s/he was receiving oxygen at 2 Liters via a nasal cannula connected to a humidifier which helps add moisture to air by decreasing dryness to the nose caused by the supplemental oxygen. The 02 tubing and humidifier were not labelled with a change date. A review of resident #72's physician's order revealed an order written on 5/26/26 that reads: Oxygen at 2L/M as needed for COPD, O2 Concentrator at Bedside. 6/23/26: Oxygen Equipment - Change tubing every 7 days every night shift. 2). On 07/13/2026 at 8:43 AM the surveyor also observed Resident #20 receiving oxygen via nasal canula (a tube that delivers supplemental 02) at 2liters. Further observation failed to reveal a label to indicate when the O2 tubing was last changed. The humidifier bottle was empty, and the O2 tubing was not dated. A review of the physician's order revealed an order dated 2/15/24 that reads: 2L of Oxygen via nasal cannula nightly every night shift for Shortness of breath (SOB). 4/9/25: Oxygen tubing, change weekly, Label each component with date and initials. Every night shift, every Thursday, Label each component with date and initials. On 07/13/2026 at 8:55 AM the License Practical Nurse (LPN) #37 confirms the findings. He was asked the process for changing O2 tubing and he said it's supposed to be labelled including the humidifier as soon as it was placed on the resident or whenever the tubing is changed per order, he said he will change it and label them. In a separate Interview with the unit manager #3 on 07/14/2026 at 9:17 AM. She was asked about the process for changing and dating O2 tubing. She said that tubing is changed once a week on Thursdays by 11-7 shift. That staff are supposed to date the tubing together with the humidifiers when they change them. She explained that humidifiers should be changed whenever they're running low. She was made aware of the above concerns regarding resident #20 and #72. She validated the concern. On 07/15/2026 at 8:36 AM the Director of Nursing (DON) was also made aware that this was a concern, she said she will follow up. 3). On 7/13/2026 at 9:22 AM, surveyors observed Resident #73 receiving oxygen at 2.75 liters (L), as indicated by the flow meter positioned between 2.5 L and 3 L. On 7/14/2026 at 8:32 AM, surveyors observed Resident #73 receiving oxygen at 2 L. Resident #73 stated that the oxygen was supposed to be set at 3 L. Review of Resident #73's Treatment Administration Record (TAR) documented a physician's order for oxygen at 3 L. On 7/14/2026 at 8:34 AM, surveyors interviewed Staff #4 regarding the oxygen setting. Staff #4 reviewed the physician order and confirmed that oxygen was to be delivered at 3 L. Staff #4 obtained a pulse oximetry reading of 94 percent (%), increased the oxygen flow rate to 3 L, and at that time, the oxygen equipment produced a whistling sound. On 7/14/2026 at 9:15 AM, surveyors notified Staff #5 that Resident #73's oxygen was set below the ordered level and that the oxygen equipment produced a whistling sound when the flow rate was increased to 3 L. Staff #5 stated that malfunctioning equipment was to be replaced without delay.

Based on record review and interviews with staff, it was determined that the primary medical provider failed to review and revise the total program of care. This was found evident for 1 (Resident #28) out of 45 residents reviewed during the survey. The findings include: On 7/13/26, 7/14/26, 7/15/26, 7/16/26 and 7/17/26 the surveyor observed Resident #28 close to the nurses' station at some point in the day with multiple observation of staff utilizing a communication board to communicate with Resident #28. On 7/15/26 at 7:33 AM, the surveyor reviewed Resident #28's medical record. The review revealed that Resident #28 had a urology consultant at the facility on 6/29/26 related to urinary retention. The note stated that urinary retention was noted at the hospital, that the patient was unable to communicate voids, Resident #28 had diapers that were dry on assessment, and that silent retention was a concern. The plan stated to check bladder scan for post void residual (scan bladder to evaluate volume after urination) now and at reasonable intervals to establish a trend. If further stated to continue straight catheterization for urinary retention per facility's policy. On further review it was noted that a provider wrote a progress note on 7/13/26 and noted, urology evaluation on 7/1/26 noted no acute concern for retention and recommended monitoring Urinary Tract Infection (UTI) or retention symptoms. Further in the note under the urinary retention plan it stated, use bladder scan for discomfort or poor voiding and trend volumes. No where in the note did it acknowledge the recommendation for straight catheterization on retention. On 7/15/26 8:25 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked why the provider did not address all the recommendations of the urology consult. The DON stated that the facility did not have a bladder scan machine and would not be able to provide the recommendation. She further stated that if you don't have a bladder scan number you cannot note retention and wouldn't straight catheterize without a reason. She stated the facility utilized bladder ultrasounds if they need to evaluate retention. The surveyor asked if the resources were not available, was it the expectation of the provider to reach out to urology and provide an alternative plan. The DON confirmed that would be her expectation.

Based on reviews of clinical records, all pertinent facility administrative records, and interviews with the facility staff, it was determined that the facility nursing staff failed to 1) follow the physician's specific pulse and blood pressure parameters before administering cardiac medications to residents, and 2) failed to document an associated blood pressure before administering the cardiac medication. This was evident for 1 (Residents #6) of 9 residents reviewed during a complaint survey. The findings include: On 06/10/26 at 3 pm, a review of the facility policy Medication Administration, Section 7.1, under the heading of Policy Explanation and Compliance Guidelines: under #8, indicated the nursing staff must obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. A review of Resident #6's clinical record on 06/10/26 revealed that Resident #6 was admitted to the facility on [DATE] with diagnosis that included Lupus, epilepsy, hypotension, and adult failure to thrive. A) Further review of Resident #6's clinical record revealed a physician's order dated 04/29/26 that instructed the nursing staff to administer the medication, Midodrine HCl, Oral Tablet, and 5 MG, give 1 tablet by mouth, three times a day for Orthostatic Hypotension. Hold the medication for systolic blood pressure (SBP) more than 130 mm/Hg. Midodrine hydrochloride is an alpha-adrenergic agonist used to treat symptomatic orthostatic hypotension. It works by constricting blood vessels, increasing vascular tone, and raising blood pressure upon standing. It requires a prescription and is typically used when lifestyle changes are insufficient. Further review of Resident #6's May 2026 medication administration records (MAR) on 06/10/26 revealed the nursing staff failed to withhold the dose of Midodrine when Resident #6's SBP was documented above 130 mm/Hg on the following dates and times: 05/02/26, 6:30 am dose, documented blood pressure: 134/76.05/04/26, 11:30 am dose, documented blood pressure: 132/80.05/06/26, 4:30 pm dose, documented blood pressure: 132/72.05/07/26, 4:30 pm dose, documented blood pressure: 132/76.05/10/26, 4:30 pm dose, documented blood pressure: 132/71.05/12/26, 4:30 pm dose, documented blood pressure: 136/70.05/25/26, 11:30 am dose, documented blood pressure: 132/70. On 05/26/26, Resident #6's physician wrote a new prescription for the medication Midodrine. B) Further review of Resident #6's clinical record revealed a new physician's order dated 05/26/26 instructing the nursing staff to administer the medication, Midodrine HCl, Oral Tablet, 5 MG, give 1 tablet by mouth every 8 hours as needed for Hypotension. Hold for systolic blood pressure (SBP) greater than 130 mm/Hg. Midodrine HCl, Oral Tablet, and 5 MG, give 1 tablet by mouth, three times a day for Orthostatic Hypotension. Hold the medication for systolic blood pressure (SBP) more than 130 mm/Hg. Midodrine hydrochloride is an alpha-adrenergic agonist used to treat symptomatic orthostatic hypotension. It works by constricting blood vessels, increasing vascular tone, and raising blood pressure upon standing. It requires a prescription and is typically used when lifestyle changes are insufficient. A review of Resident #6's May and June 2026 medication administration records (MAR) on 06/10/26 revealed the nursing staff failed to obtain and document Resident #6's blood pressure, between 05/26/26 through 06/10/26, every 8 hours, to see if the medication Midodrine was needed to be administered. In an interview with Resident #6's physician on 06/10/26 at 3:18 pm, Resident #6's physician stated that the medication Midodrine is written as needed but the nursing staff needs to obtain Resident #6's blood pressure to determine if the medication is needed to be administered.

Based on medical record review and interview, the facility staff failed to allow a resident (Resident #1) to return to the facility after an emergency room visit. This was evident for 1 out of 8 residents reviewed during a complaint survey. As a result of these findings, an immediate jeopardy (IJ) was declared on 3/2/22 at 4:00 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy on 3/2/22 at 5:41 PM and it was not accepted. The facility submitted a second plan on 3/2/22 at 6:12 PM and it was accepted by the Office of Health Care Quality at 6:15 PM. The Immediate Jeopardy was removed on 3/4/22 at 8:45 AM after on-site confirmation of the completion of the facility's plan of removal. After removal of the immediacy, the deficient practice remained at a level of harm for the Resident with at a scope and severity of D. The findings include: Review of Resident #1's medical record on 3/1/22 revealed the Resident was admitted to the facility in May 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note also stated: Resident #1 stated they haven't used in 2 days because their drug dealer was arrested and Resident #1 reported not feeling well and is having symptoms of withdrawal, nausea, vomiting, diarrhea, chills and abdominal cramping. Resident #1 sent out 911. During interview with the Administrator on 3/1/22 at 11:30 AM, the Administrator stated Resident #1 was sent to the emergency room (ER) on 8/11/21 for withdrawal symptoms after being evaluated by Physician Assistant (PA) #1. Later, on 8/11/21, the Administrator stated he received a call from Licensed Practice Nurse (LPN) #1 who stated Resident #1 was at the door of the facility. The administrator asked LPN #1 if the hospital had called and LPN #1 stated, no. The Administrator told LPN #1 they could not let Resident #1 in without information from the hospital. The Administrator also stated to the surveyor that the facility and Resident #1 had a hearing on 7/26/21 in which the judge ordered Resident #1 to be discharged from the facility but Resident #1 had 30 days to appeal that decision. On 3/1/22 review of Resident #1's medical record revealed the facility had an administrative hearing on 7/26/21 and concluded Resident #1 was to be discharged . Review of the Administrative Law Judge's Decision form, the Appeal Rights state any party aggrieved by this final decision may file a written petition for judicial review and the original petition must be filled in the circuit court within 30 days of the date of this decision. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The judge told the Resident they have a legal right to appeal within 30 days and the Resident is choosing to do that. Further review of Resident #1's medical record revealed on 8/11/21, LPN #2 and Resident #1 signed a Notice of Bed Hold Form. The Form states In case of a Medicaid-assisted resident, the facility will hold the bed for up to seven days as long as the facility has not received information that the resident is not expected to return to the facility. Review of a psychiatric evaluation and consultation of Resident #1 on 8/6/21 revealed the Advanced Practice Registered Nurse (APRN#17) documented: Patient is assessed for psychiatric disorder and medication management follow up. Patient is alert, responsive and cooperative. APRN documented No to the question At this time is patient considered a danger to self/others. During interview with the facility's External care liaison #5 on 3/1/22 at 12:29 PM, the External care liaison stated the ER physician called them on 8/11/21 at approximately 8:00-9:00 PM at home and asked them to take the Resident #1 back. The External care liaison told the ER physician he would need to contact the facility Administrator to get approval to readmit the resident. During interview with the Hospital's ER physician on 3/1/22 at 12:50 PM, the ER physician stated the Resident #1 arrived at theER on [DATE] for opioid withdrawal. When they evaluated the Resident, he/she was stable and only had mild symptoms. The ER physician stated Resident #1 was already receiving [MEDICATION(S)] at the facility and did not meet the criteria to be admitted to the hospital. The ER physician stated they ordered Resident #1 to be sent back to the facility. The ER physician stated he spoke with LPN #1 and Admissions and they stated they would not take the Resident back. The ER physician stated the hospital had to readmit Resident #1 and the Resident was discharged from the hospital on 8/24/21 to another facility. [MEDICATION(S)] is a medication used to treat narcotic drug dependence. During interview with the facility receptionist on 3/1/22 at 1:03 PM, she stated that the hospital called on 8/11/21 and she told them Resident #1 was not allowed to return to the facility. The Receptionist was asked who told her that. The Receptionist stated she could not remember just that she knew Resident #1 was not allowed to return. The Receptionist then stated around 11:00 PM on 8/11/21 an ambulance showed up with Resident #1 and she told them the Resident couldn't come in. Resident #1 asked why, she said she didn't know and then Resident #1 jumped off the stretcher and started banging on the door yelling and cursing. The Receptionist stated as she was leaving the facility, she saw Resident #1 being loaded back into the ambulance. During interview with LPN #1 on 3/1/21 at 1:54 PM, he stated they were aware Resident #1 went to theER on [DATE] but, the next thing I knew was I saw the Resident at the front entrance with EMS [Emergency Medical Services]. LPN #1 stated the hospital never called and I didn't know the Resident was coming back. LPN #1 stated he called the Administrator and couldn't remember what he said to me but I did not let the Resident enter the building. LPN #1 was asked if they attempted to call the hospital and he stated, no. Review of Resident #1's medical record on 3/1/22 revealed a nurse's note written by LPN #1 on 8/11/21 at 11:52 PM that stated, Resident #1 was discharged from ER, and came back to the front of this building on a stretcher carried by paramedic personnel at 8:55 PM. At the same time, the doctor from the hospital called and said that we should let the Resident in but the writer informed the Center Executive Director on the phone, who told the nurse not to allow the Resident to come inside the building. Resident #1 even jumped out of the stretcher, stood in front of the entrance door looking for how to get in. At the end the ambulance took the Resident back. Review of the facility's Key Personnel list provided to the surveyors on 3/1/22 revealed the Center Executive Director is the same as the facility's Administrator. During interview with the Admissions Director on 3/2/22 at 8:15 AM, she stated the ER physician did call her but she told them they needed to call the Administrator to get permission to readmit Resident #1. The Admissions Director was asked if there was any further communication with the hospital and he/she stated all communication with the hospital was with corporate staff. During interview with the Administrator on 3/2/22 at 8:45 AM, the Administrator was asked if the facility made any attempt to contact the hospital on 8/12/21 to readmit Resident #1. The Administrator stated at that time he believed the facility told the hospital the facility would take Resident #1 back but needed insurance authorization. During an interview with the Regional Administrator on 3/2/22 at 9:20 AM, the Regional Administrator stated he could not remember if he spoke with the hospital or not but on investigating the issue today there was no referral from the hospital until 8/13/21. Review of the hospital record on 3/2/22 revealed that on 8/11/21 the ER physician documented: Assessment: Patient may be experiencing some mild withdrawal symptoms however patient is on [MEDICATION(S)] therefore patient cannot be on [MEDICATION(S)]. Patient is on [MEDICATION(S)] therefore is providing significant protection against severe withdrawal. Patient has no active vomiting, no active abdominal cramping when I saw the him/her, patient was calm with normal vital signs. Patient does not appear clinically dehydrated patient hemodynamically stable will be transferred back to the nursing home. [MEDICATION(S)] is a medication used to treat narcotic drug dependence. Review of the ambulance record for 8/11/21 revealed a narrative statement: Once patient was not allowed at [facility name], we loaded him/her back into ambulance to go back to emergency room . Once there, vitals were taken, and he/she was registered in the ER. Further review of Resident #1's hospital record revealed a case management note on 8/12/21 that stated the Case manager called the facility. Patient was allegedly verbally and physically abusive to staff and the facility would not accept the patient back. A case management note on 8/13/21 stated The case manager called the facility's External care liaison and per External care liaison, he/she was told by the director of the facility that Resident #1 was made a do not return. The case manager called the Regional Administrator and he/she stated the patient was not to return related to illegal drug issues. The case manager explained to the Regional Administrator that the patient was never admitted to the hospital and has no medical reason to be admitted . Per the Regional Administrator the patient has a court order that states the patient can not return. The Case Manager also spoke with the Director of Nursing who stated the patient can not come back per the Regional Administrator and the patient no longer has a bed. Per the patient he/she can not ambulate and will be homeless if he/she does not go to the nursing home. Per the patient everything he/she owns is at the nursing home including his/her wheelchair. The case manager met with the case management supervisor who was made aware of the conversation with the facility's Regional Administrator and Director of Nursing. Further review of Resident #1's hospital record revealed Resident #1 did not return to the facility and was discharged to another facility on 8/24/21, 13 days later. Interview with the Administrator and Director of Nursing on 3/2/22 at 2:40 PM confirmed Resident #1 did not return to the facility after an emergency room visit on 8/11/21. As a result of these findings, a state of immediate jeopardy was declared on 3/2/22 at 4:00 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy at 5:41 PM and it was not accepted. The facility submitted a second plan at 6:12 PM and it was accepted by the Office of Health Care Quality at 6:15 PM. The Immediate Jeopardy was removed on 3/4/22 at 8:45 AM after on-site confirmation of the completion of the facility's plan of removal. The provisions of the plan to remove the immediacy had a completion date of 3/3/22 and included the following: 1. Director of Nursing to conduct an audit on residents discharged to the hospital in the last 30 days to ensure that they were allowed to return when their hospitalization /evaluation ended. 2. Chief Nursing Officer and Regional Nurse has provided education on 3/2/22 to the Regional Administrator, facility Nursing Home Administrator, Director of Nursing, Admissions Director and External Care Liaison of the expectation that residents returning from the hospital will be accepted for readmission when their hospitalization /evaluation ended. 3. Director of Nursing and Unit Managers will provide education to receptionist and licensed nurses on the expectation that residents returning from the hospital will be accepted for readmission when their hospitalization /evaluation ended. 100 % of nursing staff will be educated before returning to work. 4. Director of Nursing to conduct an audit on residents discharged to the hospital daily times 14 days, then weekly times 10 weeks to ensure that they were allowed to return when their hospitalization /evaluation ended. The results will be forwarded to QAPI Committee monthly times 3 months for review and recommendations. The Immediate Jeopardy was removed on 3/4/22 at 8:45 AM after on-site confirmation of the completion of the facility's plan of removal.

Based on observation, staff interviews and review of medical record documentation, the facility failed to maintain a safe and effective system for managing medication. Over a three day period (3/16/15, 3/17/15 and 3/18/15), multiple medications were observed unattended on top of medication carts, medication carts were observed that were left unlocked and unattended, and documentation reviewed revealed that going back to December 2014, multiple controlled substances (Oxycodone and Lorazapam) were removed from storage but not documented as administered (#1 and #175). Facility staff also failed to maintain complete and accurate records of shift verification of controlled substances (evident for 2 out of the 2 controlled substance logs reviewed). Six residents (#37, #96, #103, #110, #131, and #180) with moderate and severe cognitive impairment and one resident with history of substance abuse (resident #183), were observed in the care environment with these unsafe medication management practices. With significantly impaired residents at increased risk for harm and possible death related to their access to multiple medications in and on many unlocked carts, and missing narcotic medications potentially left out in the same environment, an immediate jeopardy was called at March 18, 2015 at 1:18 PM. On 3/18/15 at 9:02 PM the facility provided an acceptable plan to remove the immediate jeopardy situation. The findings include: The following residents were observed in the care environment: 1A. Review of Resident #183's medical record revealed nurse practitioner notes from 3/9/15 that stated the resident was impulsive, compulsive with cleaning activities and had been stealing and hoarding items from the nursing cart. Further review of the medical record revealed a history of substance abuse. The resident was currently receiving Seroquel (an antipsychotic medication) two times a day for bipolar disorder/psychosis. As described in detail below, Resident #183 was observed during the survey loitering around the medication cart(s) and removing trash bags from the carts. 2A. Review of the medical record for Resident #110 revealed a BIMS score of 6 out of 15 which indicated severe cognitive impairment based on the MDS assessment during the timeframe of 12/7/14 through 12/13/14. The BIMS is the Brief Interview for Mental Status assessment tool where 0-7 reflects severe cognitive impairment, 8-12 reflects moderate cognitive impairment, and 13-15 reflects a resident considered to be cognitively intact. Further review of the medical record for Resident #110 revealed two certifications by physicians that he/she was not capable of making any informed decision about medical treatments. Resident #110 resided on the Roland Hall and was observed during the survey independently moving him/herself in his/her wheelchair in the facility hallways. 3A. Review of medical record for resident #96 revealed a BIMS score of 8 out of 15 which reflected moderate cognitive impairment. Resident #96's BIMS of 8/15 was noted in the MDS assessment covering the time frame of 12/10/14 - 12/16/14. The medical record further revealed that resident #96 was certified by two physicians as incapable of making an informed decision about medical treatments. Resident #96 resided on the Roland Hall, which was covered by the Station 2 nursing unit. Resident #96 was observed frequently throughout the survey independently moving him/herself in his/her wheelchair in the same facility hallways where unsecured and unattended medications and multiple unlocked medication carts were also observed. 4A. Review of Resident #103's medical record revealed a BIMS score of 8 out of 15 which indicated moderate cognitive impairment, based on the 2/1/15 through 2/7/15 MDS assessment. Further review of the medical record revealed that the resident had a [DIAGNOSES REDACTED]. Resident #103 resided on the York Hall, which is directly attached to and is a continuation of Charles Hall. He/she was observed ambulating independently in the same facility hallways where unsecured and unattended medications and multiple unlocked medication carts were also observed. 5A. Review of Resident #37's medical record revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment, based on the 2/7/15 Minimum Data Set (MDS) assessment. As detailed below, Resident #37 was also observed in the hallway in close proximity to an unlocked and unattended medication cart during the survey. 6A. Resident #131 resided on the York Hall and was observed during the survey independently walking in the hallways of the facility. Review of the medical record revealed that the resident had multiple diagnoses, to include depression, anxiety, intellectual disability and a history of drugs and alcohol. Further review revealed a physician certification that the resident lacked adequate decision making capacity related to cognitive impairment.7A. Review of Resident #180's medical record revealed [DIAGNOSES REDACTED]. Further review revealed that the resident was receiving Seroquel twice a day for a mood disorder. As detailed below, Resident #180 was observed in the hallway in close proximity to an unattended medication on top of a medication cart. The following unlocked, unattended, and unsecured medication carts, as well as publicly available medications were noted during the survey: 1B. On 3/16/15 at 5:30 AM upon initially entering the building surveyor #1 observed two unlocked medication carts located on the Roland Hall adjacent to the station 2 nursing unit. Nurse (staff #1) was observed at the nursing station at this time. The nurse was observed locking the two medication carts on the Roland Hall prior to escorting surveyor to the meeting room.2B. On 3/16/15 at 5:35 AM surveyor #2 observed two unlocked medication carts on Charles Hall adjacent to the station 2 nursing unit with no staff in the vicinity. At 5:40 AM the carts were noted still unlocked.3B. On 3/16/15 at 5:50 AM surveyor #3 observed two unlocked and unattended medication carts on the Charles Hall and noted that on top of one of the carts was a medication cup containing two pills labeled with the name of Resident #62. During this observation Resident #183 was observed walking in the hallway and stopped and leaned on one of the unlocked medication carts and spoke with the surveyors. Surveyor continued to observe the unlocked carts until the nurse returned to the unit at 6:05 AM.At 6:15 AM surveyor #3 informed the nurse (staff #1) of the observation of the unlocked carts. Staff #1 reported that the carts were shared with the other nurse (Staff #2). During interview with Staff #2 about the unlocked carts, he also reported that the cart was shared. At 6:30 AM in further interview, Staff #1 reported that she had unlocked the cart, pulled the medications and then went to get some information to take to another surveyor. Surveyor informed her that the medication was observed on top of the cart when she was not on the unit. Staff #1 also reported that resident #183 had been observed cleaning the medication carts in the past, that he likes to clean and stated, 'I guess it's some type of therapy for him.' The Director of Nursing was informed of this observation on the morning of 3/16/15. 4B. On 3/17/15 at 9:56 AM surveyor #1 and surveyor #3 observed several vials of insulin on an unattended medication cart located on the Charles Hall next to the station 2 nursing unit. No nursing personnel were at the station, only the unit secretary was observed. At 9:58 AM the Assistant Director of Nursing (ADON: Staff #3) was on the unit then left without addressing the insulin sitting on medication cart, which was visible from the unit. At 10:00 AM the nurse (staff #4) arrived at the medication cart and locked the insulin in the cart. At 10:07 AM surveyor #1 informed the DON of the observation of the unattended insulin. 5B. On 3/17/15 at 11:41 AM surveyor #1 observed Resident #183 remove the trash bags out of two medication carts located near the station 1 nursing unit and then walked down the hall carrying the bags. This was also observed by the wound nurse who addressed the issue with the resident. 6B. On 3/18/15 at 9:10 AM surveyor #1 and surveyor #2 observed one vial of Albuterol sulfate left unattended on a medication cart located next to room [ROOM NUMBER]. At 9:15 AM a nurse (staff #5) was observed walking past the cart with the unattended albuterol vial on it. At 9:16 AM a nurse (staff #6) used the hand sanitizer on the cart and then left the area. At 9:17 AM a nurse (staff #4) was in the hallway and was observed going into residents' rooms removing breakfast trays. At 9:21 AM resident #180 was observed walking past the unattended medication cart, no staff was noted in the area at this time. At 9:24 AM the nurse (staff #4) approached the cart and put the vial in her hand;. Surveyor asked her about the unattended medication and the nurse reported that she had picked the albuterol up off the floor earlier and left it on the cart stating, she did not know who it belonged to. She indicated that she intended to dispose of it and proceeded to throw the intact container into the open trash bag on the medication cart. At 9:27 AM nurse (staff #6) denied having seen the vial when she used the hand sanitizer during earlier observation. 7B. On 03/18/15 at 10:28 AM surveyor #1 asked the Director of Nursing (DON) what should occur if the staff finds a medication that they do not know who it belongs to. The DON reported that staff should bring it to her to complete an incident report. When asked if she was aware of surveyor observation from this morning she indicated she had not been made aware of the medication incident from that morning. Surveyor then informed the DON that Albuterol was observed for more than 10 minutes on an unattended cart, that the nurse (Staff #4) reported she had found it on the floor and that she (staff #4) had left it on the cart, and that staff #4 was then observed putting the intact container into the open trash bag on the cart. The surveyor also informed the DON of the 3/17/15 observation where resident #183 removed trash bags out of med carts and then walked down the hall with the bags. 8B. On 3/18/15 from 6:22 PM until 6:26 PM, Surveyor #2 observed an unlocked medication cart with no staff present. Resident #37 using a wheelchair was present but in the intersecting hallway by the bathroom. A medical supply delivery staff person came to the station 2 nursing unit and asked surveyor #2 for assistance. Surveyor #2 informed him that surveyor does not work for the facility and he asked, where is that lady who was here?' Surveyor pointed down the hall and he responded by waving to the nurse. She came down the hall and then went immediately into the medical supply room. A minute or so later the nurse went to the med cart, locked it, and then went down the other hall to the other nursing station. After this observation the surveyors immediately informed the DON and the administrator of the observation of the unlocked/unattended cart. The following controlled substances were noted as removed from locked storage but then were never documented as administered. 1C. On 3/18/15 review of the controlled substance log revealed that five individual doses of oxycodone 5 mg were signed out for Resident #1 on 12/3/14, 12/4/14, 1/14/15, 1/29/15 and 2/5/15. Neither Medication Administration Record [REDACTED]. This information was reviewed with the ADON (staff #3) on 3/18/15 at approximately 12:00 noon. 2C. On 3/17/15 review of the controlled substance log revealed that one dose of Lorazepam had been signed out on 3/16/15 for Resident #175. Review of the medical record revealed that the resident had an order for [REDACTED]. This information was reviewed with the DON on 3/17/15 at approximately 4:00 PM. On 3/18/15 at 1:15 PM the surveyor asked the DON if she had any additional information regarding the Lorazepam, the DON reported it was an agency nurse and that she had no additional information at present. 1D. A review of the Controlled Substance Log for station 1 on 3/18/15 revealed that nursing staff were not consistently signing and co-signing the log. On 1/26/15 the nurse going off duty at 7 AM signed the log but the nurse coming on duty did not. That nurse also did not sign the log at 3PM on 1/26/15 at the conclusion of the shift. On 2/4/15 at 7 AM the nurse coming on duty did not sign the log and did not sign it at 3 PM when the nurse went off duty. On 2/9/15 at 7 AM the nursing coming on duty did not sign the log and did not sign it when going off duty at 3 PM. On 2/11/15 at 3 PM the nurse coming on duty did not sign the log and did not sign it when going off duty. On 2/17/15 at 7 AM the nurse coming on duty did not sign the log and did not sign it when going off duty. On 2/19/15 at 7 AM the nurse coming on duty did not sign the log and does not sign it when going off duty. On 2/20/15 the nurse going off duty at 7 AM did not sign the log book. On 2/20/15 at 3 PM the nurse coming on duty did not sign the log book and did not sign it when going off duty at 11 PM. On 2/23/15 the nurse coming on duty at 7 AM did not sign the log book and did not sign it when going off duty at 3 PM. On 2/26/15 the nurse coming on duty did not sign the log book when coming on duty at 3 PM and did not sign it when going off duty at 11 PM. No nurse signed the log book at 3 PM on 3/14/15 and the nurse going off duty at 11 PM did not sign it as well. 2D. A review of the Controlled Substance Log for station 2 on 3/18/15 revealed that nursing staff were not consistently signing and co-signing the log. On 12/24/14 the nurse coming on duty at 11 PM did not sign the log book. On 12/25/14 the nurse coming on duty at 7 AM did not sign the log book. On 12/27/14 at 7 AM the nurse going off duty did not sign it. On 1/1/15 at 7 AM the nurse coming on duty did not sign the log book and did not sign it when going off duty at 3 PM. On 1/4/15 at 11 PM the nurse coming on duty did not sign the log book and did not sign it when going off duty at 7AM on 1/5/15. On 2/4/15 at 11 PM the nurse coming on duty did not sign the log book and did not sign it when going off duty on 2/5/15 at 7 AM. The nurse coming on duty at 11 PM on 2/5/15 did not sign the log book and did not sign it at 7 AM on 2/6/15. The nurse coming on duty at 11 PM on 2/11/15 did not sign the log book and did not sign it at 7 AM on 2/12/15. The nurse coming on duty at 11 PM on 3/4/15 did not sign the log book. No nurse signs the log book at 11 PM on 3/8/15. The nurse going off duty at 7 AM on 3/9/15 did not sign the book. The nurse coming on duty at 11 PM on 3/9/15 did not sign the log book. The nurse coming on duty at 11 PM on 3/11/15 did not sign the book and did not sign it when going off duty at 7 AM on 3/12/15. The nurse going off duty on 3/13/15 at 7 AM did not sign the book. The Director of Nursing (DON) was interviewed on 3/24/15 at 8:07 AM and findings were reviewed. No further information was presented at the survey exit on 3/24/15 at 5:00 PM. With significantly impaired residents at increased risk for harm and possible death related to their access to multiple medications in and on many unlocked carts, and missing narcotic medications potentially left out in the same environment, an immediate jeopardy was called on March 18, 2015 at 1:18 PM. On 3/18/15 at 9:02 PM the facility provided an acceptable plan to remove the immediate jeopardy situation. The plan included the following: 1. Immediately upon identification of the Immediate Jeopardy all medication carts were inspected by the ADON to determine that no medications were available on the top of the carts and the carts were secured appropriately. Completed March 18, 2015 at 3pm. Re inspection of all medication carts was completed on March 18, 2015 at 6:30 PM. All carts were locked and medications were secured. 2. The Nurses involved with the deficient documentation of narcotic medication administration were to be interviewed within 24 hours to determine if the medication was given to the resident as indicated, the effectiveness of the medication and the reason for administration. 3. The nurses responsible for medications on the top of unattended medication carts were suspended on March 18, 2015 immediately and the facility disciplinary process was initiated. Additional education was provided to the nurses related to medication security on March 18, 2015 at 8 PM with information related to locking the carts and rechecking that the lock is operational. The disciplinary process will also be reviewed to stress the consequences for non-compliance with policies. 4. Documentation will be completed as appropriate if indicated for Resident #1 related to the effectiveness and reason for administration of narcotic medication. 5. - Licensed staff and Certified Medication Aides (CMA) scheduled for the 3-11 and 11-7 shifts on March 18, 2015 will be educated on the Medication Administration Policy 6.0 and Disposal/Destruction of Medication Policy 8.2 by the Nurse Practice Educator (NPE). On March 19, 2015 the NPE will continue to provide education to the licensed staff and CMAs on the 7-3 shifts. Subsequent education will continue on Policy 6.0 and 8.2 until 100% Licensed staff and CMAs have been educated. -Nurses scheduled for the 3-11 and 11-7 shift on March 18, 2015 were educated on the Medication Management General Policy NSG 305 by the NPE or Nurse manager. On March 19, 2015 the NPE will continue to provide education to nurses on the 7-3 shift. Subsequent education will continue on Policy NSG305 until 100% Nurses have been educated. 6. -Medication Cart Observations will be completed every shift for 30 days, daily for 30 days, weekly for 30 days, then monthly for at least the next 3 months to monitor compliance with Medication Cart security by DON/Designee. - PRN Narcotic medication documentation will be audited daily for the next 30 days, weekly for the next 30 days and then monthly for at least the next 3 months to monitor compliance with narcotic management by DON/Designee. 7. The results of the observations will be reported to the Quality Assurance /Performance Improvement Committee, monthly to track compliance with policy, procedures, and POC for at least the next 6 months or until a 100% compliance is achieved.

Based on complaint, reviews of a closed medical record and staff interview, it was determined the facility staff failed to provide a resident with a safe environment and enough supervision, during care, to prevent the resident from rolling off the bed onto the floor and receiving an injury. This occurred for 1 of 2 resident reviewed during a complaint survey. The findings include: Review of resident #1's closed medical record, on 09/04/2013, revealed that resident #1 is totally dependent upon the facility staff for all aspects of care is unable to protect himself/herself from any accidents. Review of complaint MD 305, on 09/04/2013, revealed an allegation resident #1 fell out of bed during care and suffered bruising to the face on 06/16/2013. Review of resident #1's nursing evaluation for lifting and repositioning documentation, dated 01/01/2013, indicated resident #1 requires 2 staff members for repositioning in bed. In an interview with GNA #1 on 09/04/2013 at 3:09 pm, GNA #1 stated he/she was rendering care to resident #1 on 06/16/2013. GNA #1 stated that he/she elevated resident #1's bed to hip level to provide care. GNA #1 stated he/she rolled resident #1 towards him/her and the half rail was raised. GNA #1 stated as he/she reached for a towel at the foot of the bed, the bed slipped away and resident #1 rolled out of bed onto the floor. GNA #1 stated he/she did not have another staff member assisting him/her with resident #1's care. GNA #1 stated he/she was not aware resident #1 required two staff members to assist with repositioning in bed. In an interview with resident #1, on 09/18/2013 at 10:45 am, resident #1 stated that he/she recalled falling out of bed on 06/16/2013. Resident #1 stated he/she hit his/her head and received a black eye which took several days to heal. Resident #1 stated he/she had pain to his/her head and had to be taken to the hospital. In conclusion, the GNA #1 failed to minimally obtain assistance from another staff member on 06/16/2013, when repositioning resident #1 in bed which allowed resident #1 to roll out of bed onto the floor. Resident #1 suffered a fall which bruised resident #1's face and required transportation to the local hospital for evaluation.