Every finding on record at Autumn Lake Healthcare at Loch Raven

Based on interview and record review, it was determined that the facility failed to ensure services provided met professional standards of nursing practice by failing to administer scheduled medications in accordance with physician-ordered timeframes and established facility policy. This was evident for one (Resident #109) of one resident reviewed for medication administration delays during the investigation of a complaint (Complaint #2995912) during the facility's recertification/complaint survey. The findings include: Late administration most commonly refers to the delayed giving of a prescribed medication or medical treatment past its scheduled time.The Brief Interview for Mental Status (BIMS) is a mandatory screening tool used upon admission to long-term care facilities to assess a resident's cognitive condition. Typically administered by a social worker, the assessment uses numerically scored questions totaling 0 to 15 points to categorize cognitive status into three groups: Intact (13 to 15: normal thinking and memory), Moderate (8 to 12: moderate problems), and Severe (0 to 7: severe problems). Rather than diagnosing illnesses like dementia or Alzheimer's, it helps staff detect early symptoms and identify the need for further evaluation.On 08/20/2026 at 07:43 AM, a review of Complaint #2995912 revealed that on 04/27/2026, Resident #109 reported to the State Agency that the facility failed to administer scheduled medications on time or at all, specifically highlighting delayed administration of Alprazolam (Xanax) as an ongoing issue.On 08/20/2026 at 07:49 AM, a review of Resident #109's clinical record revealed that he/she was admitted to the facility on [DATE] and subsequently discharged home on [DATE]. A review of his/her admission Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 15 out of 15, indicating his/her cognition was intact at the time the complaint was filed.On 08/20/2026 at 09:03 AM, a review of Resident #109's Medication Administration Audit Report covering 03/26/2026 through 05/08/2026 was conducted. The audit revealed the following.Alprazolam 1 mg: Scheduled for 09:00 AM; administered past the allowed timeframe on two separate dates (05/05/2026 and 05/07/2026).Methadone 10 mg: Scheduled for 09:00 AM; administered past the allowed timeframe on eighteen separate dates (03/27/2026, 03/28/2026, 03/30/2026, 03/31/2026, 04/01/2026, 04/02/2026, 04/04/2026, 04/07/2026, 04/08/2026, 04/09/2026, 04/11/2026, 04/15/2026, 04/17/2026, 04/18/2026, 04/19/2026, 04/20/2026, 04/25/2026, and 04/27/2026).Amlodipine 5 mg and Aspirin 81 mg: Scheduled for 09:00 AM; administered past the allowed timeframe on thirteen separate dates (03/27/2026, 03/30/2026, 03/31/2026, 04/01/2026, 04/02/2026, 04/05/2026, 04/07/2026, 04/08/2026, 04/09/2026, 04/11/2026, 04/17/2026, 04/18/2026, and 04/27/2026).The medications were administered outside the facility's designated administration window without documented clinical justification.On 08/20/2026 at 09:25 AM, a review of the facility's Medication Administration policy, number 11b, revealed: Administer within 60 minutes prior to or after scheduled times unless otherwise ordered by physician.On 08/20/2026 at 10:05 AM, in an interview with Registered Nurse (RN #9). When asked about the facility's expectation regarding medication administration, he stated that medications should be administered within one hour before or after the scheduled time adding that daily medications scheduled for 09:00 AM should be administered between 08:00 AM and 10:00 AM.On 08/20/2026 at 10:14 AM, an interview was conducted with the First-Floor Unit Manager, Licensed Practical Nurse (LPN #5). LPN #5 confirmed that facility policy stated that medications should be administered within one hour before and one hour after the scheduled time. When asked to review the medication administration Audit report for resident #109, LPN #5 confirmed that the reviewed medications were administered late on the identified dates. LPN #5 stated Alprazolam was administered late on 05/05/2026 due to an offsite medical appointment but could not identify a clinical reason for the late administration on 05/07/2026, nor could she explain why the other medications were administered late.On 08/20/2026 at 01:05 PM, an interview was conducted with the Director of Nursing (DON). When questioned regarding medication administration timeframes, the DON confirmed that routine medications must be administered within one hour before and one hour after the scheduled times unless otherwise specified by a physician's order. When informed of the audit findings showing recurring late administration of Resident #109's medications, the DON acknowledged the findings as a concern and confirmed there was no documentation to support a clinical rationale for the delays.

Based on medical record review and facility staff interview, the facility staff failed ensure that residents, who are unable to ambulate using stairs, are able to exercise their right to have visitors during their stay when the facility's only elevator malfunctioned. This was evident for all residents who have 2nd floor rooms and are unable to ambulate the stairs. These residents were reviewed during a complaint survey. The findings include: Review of complaint 2981882 on 4/29/26 at 1:30pm and complaint 2970515 on 4/29/26 at 2:03pm revealed family members were unable to visit their family members in the facility when the facility's only elevator malfunctioned. Both of the complaints revealed that residents had family members that were unable to ambulate the stairs to visit residents when the elevator malfunctioned. On 4/27/26 at 9:30am, the surveyor reviewed incident report 2975971 which reported the malfunction of the facility's only elevator from 3/28/26 to 4/23/26. The surveyor reviewed the emergency plan provided by the facility on 4/27/26 at 11:00am. Review of the emergency plan found no way for 2nd floor residents, that are unable to ambulate using the stairs, to exercise their right to have visitors during their stay when the facility's only elevator malfunctions. The emergency plan states that residents that reside on the 2nd floor and cannot ambulate safely using the stairs should stay on the 2nd floor unless there is an emergency. On 4/29/26 at 11:17 am, the surveyor interviewed Resident #6 regarding his/her complaints about the facility failing to provide a visitation plan for family and friends that were unable to use the stairs when the facility's only elevator malfunctioned from 3/28/26 to 4/23/26. Resident #6 stated that his/her relatives that have mobility issues were unable to visit him/her for the month of April 2026, especially on the weekends and evenings, when the elevator was malfunctioning. The surveyor asked Resident #6 if facility staff provided him/her with options to visit his/her family and friends when the facility's only elevator was malfunctioning. Resident #6 stated that he/she asked Unit Manager #13 about the visitation plan and Unit Manager #13 was unable to provide information or options to the resident. On 4/29/26 at 11:40am, the surveyor's interview with the Director of Nursing and Unit Manager #13 regarding complaints of the facility's failure to provide a visitation plan for family and friends that were unable to use the stairs to visit residents residing on the 2nd floor when the facility's was not working. Both staff members stated they were unaware of any complaints from residents and family members about visiting 2nd floor residents when the facility's only elevator malfunctioned. The surveyor confirmed that Unit Manager #13 periodically works on the weekends and he/she also confirmed that he/she was unaware of any complaints of a lack of visitation plan from residents and family on the weekends and evenings when the facility's only elevator malfunctioned from 3/28/26 to 4/23/26. On 4/29/26 at 2:03pm, the surveyor interviewed the complainant for complaint 2970515 regarding the facility's failure to provide visitation for residents that resided on the 2nd floor when the facility's only elevator malfunctioned from 3/28/26 to 4/23/26. The complainant stated that he/she was unable to visit Resident # 13 on Sunday, 3/29/26 at approximately 3:30pm because he/she was unable to walk up the stairs. When the complainant entered the building, he/she was informed by facility staff that the elevator was malfunctioning and the only way to visit residents that reside on the 2nd floor was to walk up the stairs. The complainant explained to facility staff that he/she was unable to use the steps due to mobility issues. The complainant stated that facility staff provided no other options to visit Resident #13 on 3/29/26. On 4/30/26 at 11:30am, interview with the Administrator and the Director of Nursing (DON) regarding the emergency plan provided with incident report 2975971. The surveyor asked how would residents that reside on the 2nd floor and couldn't use the stairs safely have visitation time with family and friends. The Administrator stated that visitors could use the stairs to visit with the 2nd floor residents. The Administrator also added that residents with family members that are unable to use the stairs could be transported using the emergency chair system to the waiting visitors. The surveyor asked how many times had this chair system been used by residents being moved from the 2nd floor to the 1st floor for visitation purposes. The Administrator stated that the emergency chair system was not used because 2nd floor residents and their visitors did not require the system when the facility's elevator was malfunctioning. The surveyor also asked if there were any complaints from family not being able to visit residents on the 2nd floor when the facility's elevator was malfunctioning. The Administrator stated that he was unaware of any complaints about the facility's elevator being inoperative. The surveyor pointed out that OHCQ received two complaints from family members of residents residing on the 2nd floor not being able to visit their family member when the facility's elevator was inoperative. The surveyor also pointed out that the emergency plan does not provide a plan for visitation. The Administrator provided no additional documentation regarding the plan to provide for visitation for 2nd floor residents when the facility's elevator is inoperable.

Based on medical record review and interview, facility staff failed to assess residents (#1, #11, #13, #15, and #16) for smoking safety at least once every three (3) months between comprehensive assessments. This was evident for 5 out of 10 residents reviewed for smoking safety during the facility's complaint survey. Findings include: Surveyor review of incident report 2975971 on 4/27/26 at 9:15am revealed the facility's only elevator was inoperative from 3/28/26 - 4/23/26. On 4/27/26 at 11:30am, the surveyor reviewed the facility's investigation and emergency plan for the facility when the elevator is inoperative. The investigation included a timeline of events and documentation on actions taken to address the needs of the residents affected. The investigation revealed a group of 10 residents that resided on the 2nd floor and were identified as smokers. The smoking area is located on the 1st floor and required residents that smoke and reside on the 2nd floor to have additional accommodations to ensure that these residents can ambulate safely to the smoking area. During the review of the residents that smoke and reside on the 2nd floor, the surveyor discovered that 5 of the 10 residents didn't receive a quarterly smoking assessment. Residents (#1, #11, #13, and #15) did not have a smoking assessment since May 2025. Resident #16 did not have any smoking assessments during his/her stay in the facility. On 4/28/26 at 1:15pm, the surveyor interviewed the Director of Nursing (DON) and Unit Manager #8 regarding the facility's policy on the frequency for when residents are assessed for smoking safety. Unit Manager #8 stated that residents that are identified as smoking are assessed quarterly for smoking safety. The surveyor pointed out that 5 of the 10 residents affected by the facility's inoperative elevator had not had a smoking assessment quarterly. In fact, one of the residents had no evidence of the facility providing an smoking assessment for the resident during his/her stay. The DON reviewed the resident records and confirmed the identified residents did not receive a quarterly smoking assessment.

Based on a review of documentation and interviews it was determined that the facility staff failed to complete a thorough investigation of incidents reported to the state agency. This deficient practice was evidenced in 2 (Resident #1 and Resident #2) of 7 investigations reviewed during the complaint survey.The findings include: 1. On 04/29/26 at 9:24 am a review of the facility's investigation regarding Resident #1 revealed the alleged incident occurred on 08/26/25 about 2 pm. The five day follow up indicated Resident #1 alleged that an employee poked 2 fingers into their face and showed them their middle finger. It was unclear who was the first point of contact concerning the alleged incident. The surveyor reviewed the statements and interviews concerning the incident.On 04/29/26 at 10:30 am during an interview with Administrator #1, the surveyor asked who completed the investigation. Administrator #1 verbalized they completed the investigation. The surveyor asked who was initially made aware of the alleged incident. Administrator #1 verbalized Corporate Representative #12 was the first point of contact about the alleged incident. The surveyor reported there was not a statement in the investigation from Corporate Representative #12. The Administrator looked through the investigation and confirmed there was no statement from Corporate Representative #12. The surveyor asked Administrator #1 to explain the process they use a complete an investigation. Administrator #1 verbalized they interview the parties involved, see if there are any witnesses, look to see who was staffed during the date the alleged incident occurred. They also interview the resident's roommate. If there were no witnesses, they interview other residents who were in proximity. 2. On 04/30/26 at 11:38 am a review of the facility's investigation concerning the self-report about Resident #2 that was submitted on 12/04/25 at 3:32 pm. Resident #2 reported that on 12/03/25 during 3:00 pm - 11:00 pm shift someone wearing blue put their hand by their face & over their mouth. GNA #9 was identified as the alleged perpetrator.On 04/30/26 at 12:24 pm a review of the staffing sheet during the time of the alleged incident revealed GNA #10 and GNA #11 worked on the unit where the alleged incident occurred. There was not a statement or interview from GNA #10 or GNA #11. Prior to reviewing the investigation, the surveyor provided Director of Nursing #2 and Regional Nurse #6 the opportunity to review the investigation to ensure all the necessary documents were available for the surveyor to review.

Based on record review and interviews it was determined that the facility staff failed to document whether a resident refused a shower. This deficient practice was evident in 1 (#5) of 1 medical record reviewed for ADL care during the complaint survey.The findings include:On 04/28/26 at 12:15 pm the surveyor requested Director of Nursing #2 to provide documentation to verify Resident #5 was receiving showers. On 04/28/26 at 1:53 pm LPN Unit Manager #8 reported Resident #5 was scheduled to receive showers on Tuesday/Friday 3 pm-11 pm shift. On 04/28/26 at 2:09 pm the surveyor received copies of the shower sheets from 10/07/25, 10/10/25, 10/14/25, 10/28/25, 10/31/25, and 11/04/25. The surveyor was not provided documentation to verify the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. During an interview with Director of Nursing #2 they verbalized when a resident receives a shower it is documented on a skin sheet. The surveyor asked who ensures the showers are being provided. Director of Nursing #2 verbalized the nurse assigned to the resident, the unit manager, and they would as she collects the shower sheets. The surveyor asked where it was documented when a resident refuses a shower. Director of Nursing #2 verbalized it would be documented in the plan of care and the shower sheet when a resident refused a shower. The surveyor did not receive documentation Resident #5 received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25.

Based on medical record review and interviews it was determined that the facility staff failed to complete a person-centered care plan for residents that received peritoneal dialysis (#7) and had mobility limitations (#6) . This deficient practice was evidenced in 2 (#6 and #7) of 16 medical records reviewed for person centered care plans. Findings include: 1. On 4/29/26 at 11:01am, the surveyor reviewed complaint 2981882 which alleged the facility only had one hoyer lift for all of the residents in the facility making it difficult for the resident to get out of bed at his/her desired time. Surveyor review of Resident #6's care plan on 4/29/26 at 11:12am revealed interventions for resistance to care and adjustment issues. Surveyor interview of Unit Manager #13 on 4/29/26 at 12:15pm confirmed the Resident #6 was resistant to care. The surveyor asked Unit Manager #13 about the number of hoyer lifts in the facility. Unit Manager #13 stated that each floor of the facility had two hoyer lifts. The surveyor informed Unit Manager #13 of Resident #6's concern that he/she were unable to get out of bed at a desirable time because of the lack of hoyer lifts on the 2nd floor. Unit Manager #13 denied the facility's inability to provide timely transfer of the resident from the bed to his/her wheelchair at his/her desired time. Unit Manager #13 stated that Resident #6 does not like the hoyer lift and prefers to be transferred from the bed to the wheelchair by pivoting. Unit Manager #13 further stated that the resident was prohibited from pivoting transfer from the bed to the wheelchair by physical therapy. The surveyor pointed out that Resident #6's care plan does not have interventions for the resident's resistance to the hoyer lift and his/her insistence on pivot transfer from the bed to the wheelchair despite prohibition from physical therapy. On 4/30/26 at 9:00am, the surveyor informed the Director of Nursing and Administrator of the lack of a person centered care plan for Resident #6. 2. On 04/28/26 at 11:45 am a review of Resident #7's electronic health record (EHR) revealed the resident was ordered to receive peritoneal dialysis. A review of the resident's care plans revealed the resident did not have a person-centered care plan for the peritoneal dialysis treatment. The care plan that was initiated for dialysis did not indicate what type of treatment the resident was receiving. Also, the care plan did not include when the resident was scheduled to receive the treatment or the time frames for the cycles. On 04/28/26 at 1:34 pm during an interview with LPN Unit Manager #8 the surveyor reported the resident did not have a person-centered care plan for their dialysis treatment. LPN Unit Manager #8 verbalized they never put the prescription inside of the care plan. They go to the renal care plan & click the things that would be included in the resident's care. They have a generalized care plan.

Based on a review of the staffing sheets and interview it was determined that the facility staff failed to include the census on the unit when the staff sheets were completed. This deficient practice was evidenced in 19 of 19 staffing sheets reviewed during the complaint survey.The findings are:On 04/30/26 at 12:24 pm a review of the staffing sheet for Unit 2 dated 12/03/25 for 3:00 pm - 11:00 pm shift revealed the census was not included on the assignment sheet. The assignment sheet was reviewed by the surveyor to ascertain which staff was working during the time of an alleged incident of abuse.On 04/30/26 at 2:15 pm a review of the staffing sheets for Unit 2 dated 12/04/25 - 12/09/25 for 7:00 am - 3:00 pm, 3:00 pm - 11:00 pm, and 11:pm - 7:00 am revealed the assignment sheets did not include the census. On 04/30/26 at 4:37 pm during an interview with Scheduling Manager #14 the surveyor asked who was responsible for completing the assignment sheets on the nursing units. Scheduling Manager #14 verbalized they were not sure who completed the assignment sheets on the units. They were not aware the assignment sheet needed to include the census. Director of Nursing #2 verbalized during the previous survey they were not told the census needed to be included on the assignment sheet.

Number of residents sampled: Number of residents cited: Based on observations and staff interviews, it was determined that the facility failed to ensure food items were stored to maintain the integrity of the specific items. This was evident for 1) the initial observation of the kitchen upon facility entry, and 2) 1 of 1 observation of the second floor nourishment room. This failure has the potential to affect all residents. The findings include: 1) On 09/04/2025 at 8:03 AM, an initial observation of kitchen dry storage room revealed a bag of soft tortillas which were opened and unlabeled, a large box of rice which was opened, unsealed, and unlabeled, a large box of food thickener which was opened, unsealed, and unlabeled, and a packet of ranch dressing seasoning which was opened and labeled with 08/16/25 and 8/22/25 on a strip of white tape, but failed to reveal what each of the dates meant.On 09/04/2025 at 8:09 AM, an observation of the walk-in freezer on the first floor revealed tilapia (a type of fish) which was opened, unsealed, and unlabeled, and a box of corn which was opened, unsealed, and unlabeled. On 09/04/2025 at 8:14 AM, an interview with the Dietary Manager (Staff #31), who was present during the kitchen observation, revealed that the expectation of staff was to seal items once opened, and to label them. She was unable to identify what the white tape labeled dates indicated on the ranch dressing seasoning packet as it was not the labels provided by the kitchen.During the same interview, she further indicated that the staff should have used the kitchen labeling system for the ranch dressing seasoning packet so that the meaning of the two dates could be identified. The surveyor reviewed the concerns indicated above from the initial kitchen observation.2) On 09/04/2025 at 8:46 AM, an observation of the nourishment room on the second floor revealed a cup of soup which failed to reveal that it was labeled or have a lid, an unlabeled food substance in a tupperware container, and an opened and unlabeled bottle of RedHot sauceAt the same time, the Unit Clerk (Staff #25), who was present during the observation indicated that the expectation was to label any food item placed into the fridge with the name of the resident it belonged to and the date. The surveyor identified the items of concern to Staff #25 which she agreed with.

Based on observations, medical record reviews, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was found to be evident during the recertification survey. This deficiency has the potential to affect all residents.The findings include: 1) On 9/04/2025 at 8:07 AM, an observation was made of Resident #102. Resident #102's urinary catheter bag was observed to be lying on the floor beside the resident's bed. On 9/04/2025 at 8:09 AM, an interview was conducted with Staff #3. The surveyor expressed concern with Resident #102's urinary catheter bag, and Staff #3 recognized that the urinary catheter bag should not be on the floor and stated that they will take care of it after surveyor intervention. 09/05/2025 1:41 PM, an interview was conducted with Director of Nursing (DON). This surveyor expressed an infection control concern with Resident #102's urinary catheter being observed on the floor. The DON recognized the concern and stated that the urinary catheter bags should not be on the floor and would educate staff. 2) Enhanced Barrier Precautions (EBP) - are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Clinical Safety: Hand Hygiene for Healthcare Workers, 2/27/24, states that a healthcare worker should sanitize their hands before working directly with a resident and to sanitize their hands every time they remove their gloves. On 9/5/25 at 9:16 AM a random observation was made of Resident #55 receiving wound care. Geriatric Nursing Assistant (GNA) #11 and the facility's Wound Care Nurse (WCN) #10 were in the room at the resident's bedside. WCN #10 went to the treatment cart sitting in the doorway of the resident's room to get more supplies and failed to sanitize his hands before preparing supplies to provide wound care for the resident. He removed the gloves and without sanitizing he went back to the treatment cart to prepare a small cup of normal saline solution. He failed to sanitize his hands and came back in the room and put on new gloves. He proceeded to cut the bandages off the resident's lower right leg with bandage scissors. He removed his gloves and without sanitizing his hands he applied new gloves and proceeded to clean the wounds by dipping gauze in the saline solution and wiping the wounds starting with the middle wound moving down the leg then back up to the wound on the knee. He removed his gloves and without sanitizing his hands he started assembling the new dressings on the resident's bed. He put on a new pair of gloves and used some Alcavis 50 solution (a high-level disinfectant used to clean peritoneal dialysis ports. The solution requires vigorous scrubbing and needs 2 minutes for the disinfecting process. It was not designed to clean bandage scissors) and a gauze pad to clean the bandage scissors he used to cut the old dressing off. He wiped each blade once and then immediately started cutting the xeroform gauze (medication infused gauze to help with healing) into smaller sections to place on the wound. As he cut each piece, he would remove it from packaging and the side he touched was the side he laid on the wound and then he wrapped the leg with a gauze wrap. He proceeded to provide wound care in the same manner on the left leg. Furthermore, the resident was on Enhanced Barrier Precautions which requires staff to wear a gown while providing contact care and neither the WCN nor the GNA had on a gown. 09/09/2025 4:02 PM medical record review for Resident #55 revealed the attending physician's notes that was an accumulation of visits. According to the notes the resident had end stage renal disease and on 8/20/25 was seen for changes in his/her mental status. Review of the physician's orders revealed on 8/14/25, the resident was ordered to have Enhanced Barrier Precautions due to peritoneal dialysis. According to the wound care orders the resident had abrasions on both legs. An interview with WCN #10 on 9/5/25 at 10:00 AM regarding the observation he reported that he has been a wound nurse since January of 2025 and was a certified wound nurse. He acknowledged that he should have washed his hands or sanitized them between each glove change and that it was standard of practice to clean the wound from the top to the bottom. When asked why he had used the same bandage scissors to remove the dressing and cut the new dressing gauze, he stated that he knows the disinfectant was effective to clean the scissors because they used it for peritoneal dialysis. However, he failed to allow the 2-minute drying time for the disinfectant to work. When asked what Enhanced Barrier Precautions were, he was unable to verbalize it. When shown the sign that was on the resident's door, he stated that he was to wear and gown and gloves when in contact with the resident. When asked why he did not wear a gown to provide wound care, he stated he was not planning on providing the wound care at that time. During an interview with GNA #11 on 9/5/25 at 10:59 AM she reported that she had been educated regarding Enhanced Barrier Precautions. She stated when a resident was on EBP, she should wear and gown and gloves while providing care. She acknowledged that she should have worn one while assisting with wound care for Resident #55, but did not have a reason as to why she did not. An interview on 9/5/25 at 11:15 AM with the Infection Control Nurse revealed she was new to the position and was unable to report the last training that staff had regarding the use of Enhanced Barrier Precautions. When asked how she monitors that staff were compliant with infection control practices, she stated that she makes rounds on both units 3 to 4 times a day. However, she failed to keep documentation of these rounds and the findings. Reviewed Resident #55's wound care observation with her. She stated that WCN #10 and GNA #11 should have worn a gown and gloves. She stated that WCN #10 should have sanitized between glove changes. She reported that there were a supply of bandage scissors in the treatment cart, so staff should not use the same ones to remove the old dressing and then cut the new dressing gauze. If they would need to use the same ones they should be cleaned with the disinfectant wipes that were in the treatment cart. She reported she has not heard of using the Alcavis 50 to clean bandage scissors. On 9/9/25 at 9:39 AM the concerns were reviewed with the Director of Nursing (DON) and she acknowledged the concerns. 3) On 9/05/2025 at 10:40 AM A review of Resident #41's medical record was conducted. The review revealed an active order for Enhanced Barrier Precautions (EBP) to be always maintained, every shift for feeding tube. On 9/05/2025 at 1:40 PM An Enhanced Barrier Protection sign was observed outside Resident #41's room and above their bed. The sign showed the appropriate personal protection equipment to be worn including gloves and a gown. On 9/05/2025 at 2:00 PM The surveyor observed Staff #15 providing toileting care to Resident #41. Staff #15 wore gloves but had no gown. On 9/05/2025 at 2:20 PM An interview with Staff #15 was conducted. She confirmed that EBP precautions should have been followed when providing toileting care to Resident #41. When asked why she had no appropriate personal protection equipment, Staff #15 stated that they forgot to wear the gown. On 9/08/2025 at 8:50 AM The surveyor observed Staff #16 administer medication to Resident #41 via a feeding tube. Staff #16 had gloves on but failed to wear a gown. On 9/08/2025 at 8:54 AM A review of Resident #41's medication administration record was conducted. The review revealed that the resident was given Valproic acid. On 9/08/2025 at 8:58 AM An interview with Staff #16 was conducted. When asked if she was aware Resident #41 had EBP precaution orders, she reported yes. The staff further admitted that she was unaware that gowns were needed when caring for or using a resident's feeding tube. On 9/08/2025 at 9:10 AM An interview with the Assistant Director of Nursing (ADON) was conducted. She stated that it was the facility's expectation that all staff should wear the appropriate personal protective equipment listed on the EBP sign when caring for a resident with a feeding tube. On 9/08/2025 at 9:16 AM The surveyor discussed with the ADON the infection control concerns identified. On 9/08/2025 at 10:43 AM The Director of Nursing (DON) was made aware of the concerns. 4) On 09/05/2025 at 12:31 PM, an observation of the clean linen room revealed it was a room that was also used as a walk through to get to the Director of Housekeeping (Staff #18's) office. Further observation revealed that the front cover of the clean linen cart was folded up on top of the linen cart (exposing the clean linen), and there were clean linens (also folded) such as resident gowns, reusable bed pads, towels, and sheets at various areas in the room including on top of the clean linen cart and on the folding table. At the same time, the surveyor observed the entry way from Staff #18's office to the clean linen room, which failed to reveal that the door was closed to prevent spread of infection and contamination of the clean linen room. On 09/05/2025 at 12:33 PM, an interview with Staff #18 revealed that staff, including herself, had to walk through the clean linen room to get to her office. Further interview revealed that clean linens should be placed inside the clean linen carts and that the front cover of the clean linen cart should always be down (ensuring infection prevention of linen and safe storage). On 09/09/2025 at 6:51 AM, the surveyor reviewed the concern with the Director of Nursing and she indicated she understood. 5) C. difficile infection (CDI) refers to an infection from a bacterium that causes colitis, an inflammation of the colon, causing diarrhea. Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. A review of Resident #17's medical records on 09/05/25 at 1:31 PM revealed a physician's order for contact isolation for CDI for 10 days. The order was initiated on 08/28/25. On 09/05/2025 at 1:49 PM, the surveyor and the licensed practical nurse (LPN) # 2 donned personal protective (PPE) equipment before entering Resident #17's room. After entering the room, LPN #2 asked the resident how she could assist them, and the resident stated the contents in their bedside commode needed to be emptied so they could use it. At that time, the surveyor observed the LPN #2 removing a plastic bag from the commode. The surveyor spoke briefly with the resident. After the conversation, the surveyor removed the PPE gown, used hand sanitizer and asked the LPN #2 where handwashing could be performed. The LPN #2 directed the surveyor to a room down the hall. The surveyor walked to the room, washed hands, and upon exiting, the surveyor observed LPN #2 using hand sanitizer after exiting Resident #17's room and then returned to her medication cart. The surveyor interviewed LPN #2 regarding the hand hygiene process when exiting a resident's room on contact precautions for CDI. The LPN stated that the process was to use hand sanitizer after leaving the room. When asked if she would wash her hand with soap and water after exiting a resident's room on contact precaution for CDI. The LPN #2 again stated the process was to use hand sanitizer. The surveyor informed the LPN #2 that handwashing with soap and water is required when exiting a room of a resident on contact precautions for CDI. The surveyor immediately informed the Director of Nursing and Nurse Unit Manager #6 of the observation and interview with the LPN #2.

Based on a tour of the second floor medication storage room and staff interview, it was determined that the facility failed to discard expired supplies. This was evident for 1 of 1 medication storage rooms that were reviewed during the annual survey. The findings include: On [DATE] at 10:57 AM, a tour of the medication storage room on the second floor revealed expired supplies. The expired items that were found: 6 tubes of antifungal cream with 1% clotrimazole that expired 5/2024. 1 box of 29 xeroform gauze dressings with 3% bismuth tribromophenate and petroleum that expired on [DATE]. 1 box of 47 oil emulsion dressings that expired on [DATE]. 1 box of 5 duoderm dressings that expired on [DATE]. 4 tubes of dynagel moisturizing wound hydrogel with vitamin E and aloe vera. 3 of the tubes expired 2/2024, and 1 tube expired 12/2024. 24 32mm silicone self adhesive catheters that expired on [DATE]. 3 boxes of covid-19 BinaxNow antigen self tests that expired on [DATE]. 4 IV start kits that expired on [DATE]. 3 50unit/5ml heparin lock flush syringes that expired on [DATE]. 1 25gx5/8in 1ml tuberculin safety syringe that expired on [DATE]. 1 24gx0.75in Insyte autoguard IV needle that expired on [DATE]. 1 20gx1in Insyte autoguard IV needle that expired on [DATE]. 1 10ml syringe with 22gx1in needle that expired on [DATE]. 3 3ml syringes with hypodermic needles 25gx5/8in that expired on [DATE]. 12 optifoam gentle ex silicone faced foam and border wound dressing that expired 7/2022. 30 Maxorb II alginate wound dressings with antibacterial silver that expired on [DATE]. 19 Hydralock super absorbent wound dressings with gelling care and water proof backing that expired on [DATE]. 2 urinary drain bags with fig leaf covers that expired on [DATE]. 1 22fr silicone foley catheter that expired on [DATE]. 1 foley catheter insertion tray that expired on [DATE]. 18 [NAME] silicone super-absorbent dressings that expired on [DATE]. On [DATE] at 11:46 AM, an interview with the Nursing Home Administrator confirmed that the items were expired. At this time he was made aware of the concern and again at exit on [DATE].

Based on record review and interview, it was determined that facility staff failed to ensure that residents were free of exploitation. This was evident for 1 (#114) of 5 residents reviewed for misappropriation of resident property. The findings include:A complaint was received alleging the facility applied for Medicaid for Resident #114 without proper consent and had not used the resident's veteran benefits. They alleged that because the resident was approved for Medicaid, money was removed from the resident's personal bank accounts. On 9/4/25 at 12:11 PM an attempt to reach the complainant was unsuccessful. An email was sent to the complainant with no response received. A review of Resident #114's medical record on 9/8/25 at 9:47 AM revealed under the census tab the resident was admitted on [DATE] and had Medicare A until 1/4/24 when the resident's payment changed to Medicaid. A review of the resident's profile tab revealed the resident had 2 people listed on his/her account. Review of the admission MDS [minimum data set] with the assessment reference date of 9/25/23 revealed the resident had moderate cognitive impairment. On 9/9/25 at 12:54 PM Resident #114's paper medical record was reviewed and revealed that on 10/6/23 the attending physician and nurse practitioner had signed certifications deeming the resident incapable of making decisions to include medical decisions.An interview with the Business Office Manager (BOM) on 9/9/25 at 1:13 PM revealed that when a resident was admitted to the facility, she would have them sign the forms for Medicaid without dating them, so they were ready if the resident needed them. She stated she could not remember if Resident #114 signed them at the time of admission or when they helped him/her apply for Medicaid. She reported the signatures were sent to a financial consulting company and they complete and submit the Medicaid application. She stated that if a resident does not have capacity, then they talk to a Resident Representative (RR) for consent. She stated that she was unaware that Resident #114 lacked capacity. She stated that the resident had RR who lived with the resident and was difficult to contact. When the resident and RR decided that the resident would not stay long-term, the RR would not pick the resident up on the scheduled discharge date . She stated that the resident decided to open a personal funds account at the facility and that was how the facility obtained the resident's bank information. She stated the RR was not aware of what was going on until s/he stopped receiving the resident's social security checks. On 9/9/25 at 2:44 PM the Business Office Manager (BOM) provided financial forms for Resident #114 upon surveyor's request. In the packet was a copy of the resident's Medicare Card and a VA (veteran) benefit card. Also, there were 13 documents that were blank (except for places to fill in the facility name) that were signed by the resident but there was no date on them and pages 14-17 of a Maryland Medicaid Application that was blank and contained 2 signatures, one on page 14 and the other on page 17. The 13 documents gave consent for the facility to apply to Medicaid and appeal if needed, one gave the facility access to the resident's bank account but the information was blank, there were a few forms for notification to the Social Security Administration asking them to send the resident's benefit checks to the facility, and a Resident's Funds Management Services that was blank when the resident signed it. These forms were signed by a resident who lacked the capacity to make these financial decisions. A subsequent interview with the BOM and the Nursing Home Administrator (NHA) on 9/10/25 at 12:05 PM revealed the BOM was not sure when the forms had been signed. When asked if the facility attempted to use the resident's VA benefits, the BOM manager stated she had not tried to use the resident's VA benefits. The NHA reported that the financial consulting company was contacted about sending the resident's Medicaid application. However, there were no signatures on the form that they sent. An interview with the financial consulting firm staff on 9/11/25 at 11:00 AM revealed the blank signature pages that were provided to the surveyor earlier was the consent that they used to apply for Medicaid for the resident. He stated that he assumed the resident had capacity because the facility usually sends a form stating the resident was not capable of signing. However, at this time he was not aware that they had received one for Resident #114. The BOM was interviewed on 9/11/25 at 12:25 PM and she stated that she knew the RR was the resident's point of contact for financial needs, but she failed to look in the medical record to see if the resident had capacity to sign the forms for Medicaid. On 9/11/25 at 12:30 PM the NHA was made aware of the concerns and acknowledged them.

Based on observations and staff interview, it was determined that the facility failed to treat dependent residents with dignity while dining. This was evident for 1 (Resident #41) of 2 dependent residents observed during the dining observation, a facility task in the recertification survey.The findings include:On 9/4/2025 at 12:00 PM A dining observation was conducted on the second floor. During this lunch meal observation, the surveyor noted that independent residents were served meals as they sat on their respective tables. On 9/04/2025 at 12:08 PM The surveyor observed one table that had 2 residents who needed assistance with meals. Staff #8 was assisting one resident while Resident #41 observed and waited for their meal. On 9/04/2025 at 12:15 PM Resident #41 was observed raising their hand and making incoherent sounds. On 9/04/2025 at 12:18 PM Resident #41 was observed reaching for the other resident's food, Staff #8 redirected the resident and asked Resident #41 to wait for their turn. On 9/04/2025 at 12:31 PM Resident #41 was served their meal and Staff #8 started to assist the resident with their meal. On 9/04/2025 at 12:55 PM An interview with Staff #8 was conducted. She stated that she was the only staff assigned to dining and therefore it was her task to feed residents who needed assistance with meals. She further stated that some dependent residents had to wait longer because she could only assist one resident at a time. For this lunch meal Staff #8 reported that she had only 2 residents who needed assistance, but sometimes she could have up to 3 or 4 residents who required assistance with meals.On 9/05/2025 at 07:22 AM The Director of Nursing (DON) and Administrator were made aware of the concerns.

Based on interviews, it was revealed the facility failed to provide quarterly financial statements. This was found to be evident for 1 (Resident #10) out of 3 residents reviewed for accounting and records during the recertification survey. The findings include: On 09/04/2025 at 12:21 PM, an interview with Resident #10's family member revealed that they were not receiving the Resident's quarterly statements from the facility's business office. On 09/08/2025 at 10:33 AM, an interview with the Business Manager (Staff #17) revealed that she had not been sending quarterly statements to the residents representative. She further indicated that she doesn't send the resident's quarterly statements unless it was requested. On 09/09/2025 at 7:08 AM, the surveyor reviewed the concern with the Director of Nursing (DON), she understood the concern and indicated that the business office manager should send the statements quarterly to residents.

Based on interviews and record review, it was determined that the facility failed to protect residents' clothing from loss. This was evident for 1 (Resident #13) out of 3 residents reviewed for loss of personal property during the recertification survey.The findings include:On 9/04/2025 at 9:04 AM An interview was conducted with Resident #13's representative. They reported that the resident was admitted into the facility with gray sweatpants, 1 pair of jeans, funnel pajamas and 1 sweater and that these items were lost during laundry. The representative also stated that they had communicated these concerns to the laundry staff, Staff #12, but the facility had not found the missing clothes or replaced the items. On 9/04/2025 at 9:24 AM A review of Resident #13's admission records was conducted. The review revealed an inventory list that was dated 5/16/25. The inventory list included a sweater and 1 pair of jeans. On 9/04/2025 at 9:44 AM An interview with the Assistant Director of Nursing (ADON) was conducted. She reported that the facility process is to update each resident's inventory list as new items are received. The ADON confirmed that there was no updated inventory list for Resident #13. On 9/05/2025 at 11:03 AM An interview with laundry aide, Staff #12, was conducted. When asked if she was aware of Resident #13's missing clothes, she reported that the resident's representative had mentioned there were missing clothes a while ago. She further stated that when a resident or resident representative reports missing clothes, laundry aides will look for the missing items and if found the clothes are returned to the respective resident, if clothes are not found, the laundry aides are expected to notify the unit manager or the laundry supervisor. When asked if she had reported to anyone regarding the missing clothes for Resident #13, she stated that she had not reported to anyone yet. Staff #12 was notified that this was a concern. On 9/05/2025 at 11:41 AM The Director of Nursing (DON and the facility administrator were also notified of the concern.

Based on medical record review and staff interview, it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medications during the annual survey.The findings include:On 09/08/2025 at 9:28 AM, review of Resident #7's medical record revealed the resident had an order for Dasatinib (a chemotherapy medication pill by mouth) for everyday administration. Further review of the medical record revealed the resident received the medication everyday in August of 2025. On 9/10/25 at 1:17 PM, review of section O of the MDS assessment with an Assessment Reference Date (ARD) of 8/9/25 failed to reveal that the chemotherapy medication was coded on the assessment.The Assessment Reference Date (ARD) is the specific end point of look-back periods of resident status for the MDS assessment process.On 09/11/2025 at 9:01 AM, an interview with MDS coordinator (Staff #33) revealed that if a resident were receiving chemotherapy medication within the ARD of the MDS that it should be coded. During the same interview the surveyor reviewed the concern with Staff #33 regarding Resident #7's MDS with an ARD of 8/9/25. She indicated she understood and it should have been coded.

Based on record review and staff interviews, it was determined that the facility failed to create and implement a baseline care plan for 1) a resident with a stage 4 sacrum pressure ulcer and 2) a resident with Chronic Myeloid Leukemia (CML) requiring chemotherapy medication. This was found to be evident for 2 (Resident #73 and Resident #7) of 5 residents reviewed for care planning during the recertification survey.The findings include: 1) On 09/05/2025 at 09:00 AM, a review of the resident #73's admission MDS from 08/16/2024, revealed that the resident was admitted with a stage 4 pressure ulcer on their sacrum. On 09/05/2025 at 09:09 AM, review of the resident #73's weekly wound assessment from admission, dated 08/12/2025, revealed that the resident was admitted to the facility with the stage 4 sacrum pressure ulcer that was present on admission. On 09/05/2025 at 09:48 AM, a review of the resident #73's care plan from admission revealed a focus on a stage 4 sacrum pressure ulcer. On 09/05/2025 at 10:04 AM, a review of the resident #73's baseline care plan from admission on [DATE], failed to reflect the resident's existing stage 4 pressure ulcer on their sacrum. On 09/05/2025 at 10:14 AM, a review of the physician admission history and physical notes, dated 08/12/2024, revealed that the resident #73 was admitted from the hospital with a pressure ulcer on the sacrum. On 09/05/2025 at 11:41 AM, an interview with the Director of Nursing (DON) confirmed that resident #73 was admitted with the pressure ulcer and that it should have been reflected on the baseline care plan. At this time DON made aware of the concern. 2) CML is a slow growing blood cancer caused by abnormal white blood cells (the body's cells that fight off infection and disease). On 09/08/2025 at 9:28 AM, review of Resident #7's medical record revealed that the resident was admitted to the facility on [DATE] with an active diagnosis of CML. At the same time, review of Resident #7's baseline comprehensive care plan failed to reveal a care plan focus of the CML, and the plan of care regarding the residents diagnosis. On 09/09/2025 at 6:51 AM, an interview with the Director of Nursing revealed that if a resident were admitted with a diagnosis that was being treated at the facility, that she would expect the baseline comprehensive care plan to include it. The surveyor reviewed the concern regarding Resident #7 and she understood.

Based on record reviews and interviews, it was determined that the facility failed to revise resident's care plan after a change in condition. This was evident for 1 resident (Resident #3) out of 2 residents reviewed for hospitalization after a change in condition during the recertification survey. The findings include:The care plan provides an opportunity to see if it meets the residents' needs by reviewing what strategies are working and which are not. It can also identify changes in the resident's condition or behavior that will require revisions of the care plan.Blood glucose refers to the level of sugar (glucose) in the bloodstream. It is the primary source of energy for the body's cells, including the brain, muscles, and organs. On 09/04/2025 at 11:33 AM, review of Resident #3's electronic health record showed a progress note dated 06/21/2025 at 8:20 PM documenting that the resident was found unresponsive. Vital signs were within normal limits; blood glucose was 157 mg/dL; the resident was administered oxygen via non-rebreather mask, and oxygen saturation was 100%. Emergency medical services were called, and the resident was transferred to the hospital. A follow-up note on 06/22/2025 at 7:48 AM indicated that the resident had been admitted to the intensive care unit (ICU) and diagnosed with respiratory distress.On 09/05/2025 at 12:07 PM, review of the resident's care plan showed the last revision was completed on 04/17/2025, which included a goal stating, Resident will have no signs and symptoms of poor oxygen absorption. There was no evidence that the care plan was revised to reflect the respiratory distress event or the hospitalization that occurred on 06/21/2025.On 09/08/2025 at 8:35 AM, during an interview with the Director of Nursing (DON), when she was asked if Resident #3's care plan was revised after the respiratory distress event which led to the resident's hospital transfer and admission into the ICU, she confirmed that the care plan was not revised following the event. She acknowledged that the care plan should have been revised to reflect the change in condition and stated that the facility would ensure care plans were updated promptly in the future.

Based on record review and interview, it was determined that facility staff failed to follow a physician's order. This was evident for 1 (#111) of 2 residents reviewed for pain management.The findings include:A medical record review for Resident #111 on 9/9/25 at 9:43 AM revealed a medication administration record (MAR) for May of 2025, which noted the resident was ordered an opioid 10 mg as needed every 4 hours for a pain level of 7-10. However, on the following dates and times facility staff failed to follow the physicians orders and gave the medications for a pain level less than 7; 5/7 at 9:00 PM for pain level of 6, 5/9 at 1:22 PM for a pain level of 0, 5/13 at 12:09 AM for a pain level of 0, 5/14 at 6:30 PM for a pain level of 6, 5/17 at 1:18 PM for a pain level of 0, 5/27 at 9:44 PM for a pain level of 6, 5/28 at 6:00 PM for a pain level of 0, 5/28 at 11:59 PM of a pain level of 6, 5/29 at 2:15 PM for a pain level of 0, 5/30 at 8:41 PM for a pain level of 6, and 5/31 at 10:10 AM for a pain level of 4. The following dates were for June 2025; 6/2 at 2:17 PM for a pain level of 0 and 6/5 at 5:08 PM for a pain level of 0. An interview with Licensed Practical Nurse (LPN) #34 on 9/10/25 12:21 PM revealed that she was aware that the medication was to be given based on the physician's parameters of a pain level of a 7-10. She reported Resident #111 was demanding when s/he requested their pain medication and would not give a pain score at times. Reviewed the MAR with LPN #34 when she documented a pain score of 0 on 6/5/25 and administered the pain medication. She reported she could not recall if the resident did not give a pain score or if it was a typographical error. When asked if she had documented a pain assessment in the progress notes she reported she had not. During an interview with the Director of Nursing (DON) on 9/10/25 at 1:49 PM she reported staff were expected to provide and level of pain for the resident and then give the medication according to the parameters. The DON acknowledge the concern.

Based on surveyor observation, review of the medical records, and interview with facility staff, it was determined the facility failed to provide quality care to residents by 1) not following physician orders for oxygen therapy and 2) not reporting a change in condition. This was found to be evident for 2 residents (Residents #45 and #47) out of 4 residents observed on oxygen therapy and 1 resident (Resident #115) of 2 residents reviewed for pressure ulcer complaints during the facility's recertification survey.The findings include:1) Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from the health care provider. Oxygen saturation or SpO2, is a medical measurement that indicates the percentage of oxygen-carrying hemoglobin in the blood compared to the total amount of hemoglobin. It is a key indicator of how well oxygen is being distributed from the lungs to the rest of the body. An oxygen flow rate is the volume of oxygen delivered to a patient per minute, usually measured in liters per minute (LPM). On 09/04/2025 at 8:08 AM, during the initial tour of the facility, Resident #45 was observed in bed with a nasal cannula in place and oxygen flowing at 3.5 liters per minute (LPM). On 09/04/2025 at 8:21 AM, in an interview with Registered Nurse (RN#3), when asked how many liters of oxygen was prescribed for Resident #45, she stated it was 3 LPM. When called to verify the oxygen flow rate, she confirmed it was set to 3.5 LPM and stated she would readjust it since the surveyor had noticed the discrepancy. When asked how often oxygen flow rate was checked, she stated that it was checked every other day and that it was also checked during the tubing changes. When asked when it was last checked, she stated that she did not know. On 09/04/2025 8:23 AM, Registered Nurse (RN#3) informed the surveyor that after checking the physician's order for Resident #45, he/she was to receive oxygen at 2 LPM. She immediately adjusted the flow meter to 2 LPM. On 09/04/2025 at 8:43 AM, during the continued tour of the facility, Resident #47 was observed in bed with oxygen running at 2.5 LPM via a nasal cannula. On 09/04/2025 at 8:45 AM, in an interview with Licensed Practical Nurse (LPN#4) when asked how many liters of oxygen was prescribed for Resident #47, she stated that he/she was prescribed 2 liters of oxygen and when asked for dual observation of the oxygen flow rate, she confirmed it was set to 2.5 LPM and readjusted it to 2 LPM. On 09/04/2025 at 12:02 PM, review of Resident #45's order on 09/05/2024 showed “Oxygen Inhalation (via nasal cannula at 2 LPM) to keep oxygen saturation greater than 90% related to Chronic Obstructive Pulmonary Disease (COPD) every shift for shortness of breath”. On 09/04/2025 at 12:13 PM, reviewed of Resident #47's order on 10/06/2024 showed “oxygen at 2L/min via nasal cannula continuously every shift”. On 09/04/2025 at 1:48 PM, in an interview with the Director of Nursing (DON) while the Nursing Home Administrator (NHA) was present, when she was asked how often the oxygen flow meters were checked, she stated that the nurses checked it weekly when changing the tubing. When she was asked how the nurses would know the amount of oxygen the residents were getting every shift, if it was checked weekly, she stated “There was no how the nurses would have known.” When she was informed about the concerns with oxygen flow rate for the residents and staff not following the order for the amount of oxygen level every shift, She acknowledged the error and stated that she would provide in-service education on following physician's order and to ensure flow meters were checked every shift going forward so as to prevent future occurrences of increased or decreased oxygen rate. 2) On 9/4/25 at 10:53 AM a review of a complaint received regarding Resident #115 revealed that the resident was sent to the hospital from the facility 4 days after admission in 2023. The complainant reported that the resident had low blood sugar and was septic from his/her wounds. The complainant reported that when the facility nurse called to report the resident was being sent to the hospital but was unable to provide any details as to what was going on with the resident. A medical record review for Resident #115 on 9/8/25 at 5:03 PM revealed a discharge summary from the acute care hospital dated 6/8/23. It was documented that the resident came to the hospital due to low blood pressure and anemia. The summary read that the resident had an extended stay in the hospital between April and May of 2023 and was bedbound at home which caused a sacral pressure ulcer. A review of the history and physical conducted by the attending physician on 6/9/23, revealed the resident was being treated for the following conditions; end stage renal disease and required peritoneal dialysis, type 2 diabetes, hypothyroidism, gastrointestinal bleeding, leukocytosis, sacral ulcer, and delirium related to high doses of steroid treatment during hospitalization. Review of the admission minimum data set (MDS) with the assessment reference date of 6/12/23 revealed that the resident had no cognitive impairment. Review of the progress notes revealed that on 6/12/23 at 9:59 AM it was noted the resident was refusing to eat breakfast. Then at 1:34 PM Registered Nurse (RN) #23 wrote that the resident reported s/he had vomited 4 times in the morning but there was no evidence of emesis and no staff reported vomiting so the nurse will continue to monitor. There was no change in condition found or a progress note documenting that the nurse conducted an assessment of the resident for this change in condition or notification to a practitioner. Further review of the progress notes revealed at 4:44 PM the same nurse wrote the resident was found to be lethargic and she obtained an order to send the resident to the hospital. RN #23 started a change in condition evaluation and upon review of the document it was revealed the nurse failed to obtain vital signs at the time of the change, she failed to obtain a blood sugar level, and failed to complete a thorough assessment of the resident prior to sending them to the hospital. On 9/9/25 at 9:45 AM a review of the emergency department (ED) report dated 6/12/23 for Resident #115 revealed that EMS (emergency medical system) reported that the resident's blood sugar was 37 (normal blood sugar levels are between 70 – 110) and they administered a glucose (sugar) past and IV (intravenous) fluids prior to arrival to the ED. The ED physician documented that the resident was able to report that s/he was feeling ok but was having pain in the sacrum. On 9/9/25 at 8:56 AM and 9:39 AM contact information for RN #23 was requested, but facility staff failed to provide the information. Therefore, the nurse was unavailable for an interview. An interview with Licensed Practical Nurse (LPN) #6 on 9/9/25 at 8:56 AM revealed that as the Unit Manager she remembered Resident #115 as a pleasant person who was cognitively intact. She would have expected the nurse to complete a change in condition (an assessment form) for a resident who was complaining of vomiting and to notify the practitioner. She stated that when the nurse found the resident lethargic, she would have expected her to obtain a set of vital signs and check the resident's blood sugar since she was diabetic and reported vomiting earlier in the day. Furthermore, she stated that the change in condition form should have been fully completed prompting the nurse to do a thorough assessment. She stated that the nurse was an agency nurse and was not currently working at the facility. Requested the last known contact for the nurse. On 9/9/25 at 9:39 AM the concerns were reviewed with the Director of Nursing (DON) and she acknowledged the concerns.

Based on observation, record review, and staff interviews, it was determined that the facility 1) failed to provide services for pressure ulcer for a new admission and 2) to document and provide ordered treatment to promote healing of pressure injuries. This was found to be evident for 2 (Resident #115 and Resident #113) of 4 residents reviewed for pressure injuries during the survey. The findings include:1) On 9/4/25 at 10:53 AM a review of a complaint received regarding Resident #115 revealed that the resident was sent to the hospital from the facility 4 days after admission in 2023. The complainant reported that the resident's wounds had worsened, and s/he was diagnosed with sepsis because the wounds were infected. A medical record review for Resident #115 on 9/8/25 at 5:03 PM revealed a discharge summary from the acute care hospital dated 6/8/23. It was documented that the resident came to the hospital after being bedbound at home with a sacral pressure ulcer. The wound care was ordered as follows; clean daily with normal saline, pat dry, and apply medihoney (a wound treatment ointment or gel) and cover with bordered foam. A review of the Admit/Readmit Screener completed on 6/8/23 for Resident #115 revealed the nurse documented that the resident had a sacral wound. A review of the physician orders revealed an order dated 6/8/23, read “clean with normal saline, pat dry apply Midihoney [medihoney] on the sacral wound and cover with bordered foam. One time a day for wound care”. However, review of the treatment administration record (TAR) revealed staff failed to provide treatment to the wound until 6/10/23, 2 days after the resident was admitted . Further review revealed the resident was seen by the wound specialist on 6/12/23, and it was recommended that the resident had blood drawn and an x-ray of the sacral region to rule out an infection, however, this was not done because the resident was sent to the hospital that day for lethargy. An interview with the Director of Nursing (DON) on 9/9/25 at 9:39 AM revealed her expectation was that staff would remove the sacral wound dressing while conducting the admission assessment (admit/readmit screener) and then provide the wound treatment as ordered by the physician. She stated that it was unacceptable to wait 2 days after the admission to provide wound treatment for the resident. 2) On 9/11/25 at 10:53 AM, Complaint #344422 was reviewed. The complaint alleged Resident #113 was not receiving proper care and treatment to prevent pressure wounds. On 9/11/25 at 11:15 AM, a review of Resident #113's records was conducted. The resident has an order for wound care to be completed daily and as needed and an order for the resident to be turned and repositioned. In the Treatment administration record, the facility did not document wound care on 6/10/24 and 6/17/24. In the task documentation survey report, the facility did not document Resident #113 being turned and repositioned for 6/4/24 Night, 6/8/24 Day and Night, 6/10/24 Night, 6/12/24 Night, 6/13/24 Evening and Night, 6/14/24 Day, 6/15/24 Night, 6/16/24 Night, 6/17/24 Day and Evening. The facility documented the resident was not being turned and repositioned on 6/5/24 and 6/15/24. On 9/11/25 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). When asked what is expected from nurses when documenting wound care, The DON stated that the nurses completing the wound care are expected to document the treatment and description of the wound. When asked who is responsible for documenting the wound care is expected to document the treatment in the TAR, the Person completing wound care for resident should be documenting the wound care completed in the TAR. This surveyor told the DON of missing documentation for wound care and turning and repositioning for Resident #113. The DON was made aware of concerns with documentation and resident not being turned as evidenced by task documentation.

Based on staff interviews and review of medical record documentation the facility failed to sufficiently assess, document, plan, or provide care related to pressure ulcers. With an ineffective system in place, resident #12 had one pressure ulcer develop and advance to Stage III, another Stage III pressure ulcer advance to a Stage IV, and two additional suspected deep tissue injury wounds that were not identified, assessed or addressed. Additionally Resident #4 had a care plan generated in error for pain related to a stage I pressure ulcer, then developed an actual pressure ulcer that was not care planned, and then wound staff abruptly stopped following the resident without explanation before the wound had resolved. These interrelated concerns were evident for 2/12 residents (#4 and #12) reviewed during survey. The findings include: 1. An MDS assessment (ARD 3/19/16) submitted for resident #12 (while at another facility) revealed that resident #12 had one Stage III pressure ulcer prior to his/her April admission at this facility. Resident #12 was admitted on [DATE] with a complex clinical history including the sacral pressure ulcer. The initial Skin Integrity Report which the facility uses to document periodic skin assessments revealed that the resident was admitted with a sacral pressure ulcer that had 0 cm depth, no undermining or tunneling and healthy surrounding tissue. The skin integrity sheet is where staff would document the initial stage but it was not documented (was left blank) for resident #12. The skin integrity sheet also provided a space to document if care plans were updated, but this too was left blank. On 4/11/16 a second assessment was documented in the Skin Integrity Report documentation. This assessment documented worsening tissue type and increased depth of the wound (from 0 to 0.1 cm) but again failed to document any staging or care planning information. The initial Admission MDS assessment (ARD 4/14/16) corroborated that resident #12 had the one pressure ulcer and indicated that it was unstageable during the MDS assessment window (4/8/16 - 4/14/16). In interview at 12:00 p.m. on 6/21/16, the staff completing, and attesting to the accuracy of the MDS Section M assessment indicated that she does not actually assess resident skin when completing section M but rather she relies on the medical record documentation. With inaccurate assessment documentation, the MDS nurse did not conduct sufficient review before certifying the assessment accuracy. In item V0200 of the comprehensive MDS admission assessment for resident #12, the assessor determined that a care plan was necessary for the pressure ulcer care area. Review of care plans revealed that a care plan for risk of pressure ulcers was developed, but no care plan for managing actual skin breakdown was documented in the medical record to drive treatment decisions for the known skin breakdown concern. On 4/14/16 a third skin assessment was documented in the Skin Integrity Report documentation. This assessment documented worsening tissue type (by then necrotic); but again failed to document any staging or care planning information. On 4/19/16, resident #12 was sent out and admitted to a local hospital. With incomplete skin assessment documentation, the MDS discharge assessment (ARD 4/19/16) indicated that the pressure ulcer was unstageable . However, when the resident was assessed on the same day he/she arrived at the hospital, the pressure ulcer was assessed was determined to be Stage III. On admission to the hospital on [DATE], hospital staff also assessed that resident #12 had two additional wounds that the NH had neither identified nor assessed. The hospital record revealed assessment of a right lateral foot wound (suspected deep tissue injury (SDTI)) and a left heel wound (SDTI) that was not found documented or addressed in the nursing home record. On 4/22/16 the hospital record revealed another assessment showing the sacral wound was still Stage III when the resident was discharged from the hospital back to the nursing home. On 4/23/16 another skin assessment was documented in the nursing home ' s Skin Integrity Report documentation. This assessment failed again to document any staging or care planning information. On 4/28, the nursing home Skin Integrity Report revealed that the resident by then had another new pressure ulcer to the left buttock but this was also not staged and no care planning was noted in the section of the form where it could have been. The staging of the sacral ulcer (labeled coccyx to right buttock ) was also still not documented nor was any planning for the treatment team to follow. On 5/1/16 resident #12 was sent back out to the hospital where hospital staff assessed that the sacral wound had advanced to Stage IV (since the last hospital assessment and during the nursing home stay). However, in the nursing home 4/30/16 MDS discharge assessment, the staff completing section M documented that both pressure ulcers were still unstageable. Resident #12 returned back to the nursing home on 5/2/16. On 5/3 and 5/10 assessments for both pressure ulcers documented in skin integrity sheets indicated they were both still unstageable. On 5/11 resident #12 was sent back out to the local hospital where <his/her sacral pressure ulcer was again assessed by hospital staff at Stage IV. The hospital record also revealed that the sacral pressure ulcer had by then also become infected and required IV antibiotic treatment. However, the nursing home assessor completing section M in the MDS discharge assessment (ARD of 5/11/16) again documented that both pressure ulcers were still unstageable. On 5/25/16, resident #12 returned to the nursing home with instructions to provide wound care every 6 hours to prevent fecal contamination of <his/her> ulcer. Still no care plan was developed, and this important intervention specific to this resident ' s needs, was not found documented or implemented in the nursing home record and no rationale was found supporting the failure to implement the intervention. On 5/26, a skin integrity sheet document revealed that staff assessed the left buttock wound as Stage III and assessed the Coccyx to R Buttock wound at Stage 4. In the next quarterly MDS assessment (ARD 6/7/16) the facility inaccurately coded that both of these facility acquired pressure ulcers had been present on admission. The left buttock wound was first identified in the nursing home on 4/28 so it was not present on admission; and the coccyx wound advanced to Stage IV while in the nursing home, so it too could not be accurately coded as present on admission. 2. Resident #4 was admitted to the facility with a complex medical history during October 2015. On 1/22/16 the facility initiated a care plan for pain related to redness in the sacral area. In interview the Director of Nursing indicated that the resident had not yet developed a pressure ulcer and stated that the plan had been initiated in error. Nearly two weeks later, on 2/3/16 resident #4 returned to the facility from a short hospital stay with a new sacral wound characterized as suspected deep tissue injury (SDTI). The care plan for pain opened earlier in error continued in place after the resident developed the SDTI but no revisions to the still open care plan were found indicating an accurate date of onset. Also, although another care plan was in place for pressure ulcer risk, it was not updated and no care plan for actual skin breakdown was found in the medical record to provide staff with a clear understanding of the resident ' s needs related to the actual skin breakdown. A change in condition note was entered into the medical record on 2/13/16 indicating the sacral pressure ulcer was by then open, but no documentation of an assessment was found with measurements or staging information. Although it was documented that the ulcer had by then opened, the annual MDS assessment (ARD 2/28/16) indicated that resident #4 had an unstageable SDTI that was present on admission. On 3/4/16 orders were entered to start [MEDICATION NAME]/Zinc Oxide to bilateral buttocks, coccyx, and perineal area every shift. Documentation revealed that the order was transcribed into the treatment administration record and resident #4 received the antibiotic. On 3/15/16, skin assessment documented in the integrity report sacral wound was open and was at Stage III at that time. On 3/29/16 another skin assessment documented in the Skin Integrity Report revealed the stage III wound was healing. The depth had diminished from 0.4 cm on 3/15 to < 0.1 cm on 3/29/16. However, this was the last assessment of the wound found in the medical record. In interview the wound nurse indicated that she did not know how the wound assessments were dropped after 3/29/16 and before wound resolution. In the next MDS assessment (quarterly with an ARD of 5/1/16) the facility inaccurately documented both that there was not a current pressure ulcer and that there had not been a prior pressure ulcer that by then had healed when there actually had been a pressure ulcer evident. (The sacral pressure ulcer was evident in the prior assessment so it had to have either been healed since that assessment or still present). During survey, on 6/27/16, staff assessment of Resident #4 ' s skin revealed the wound had healed. No assessment was ever conducted and documented after 3/29/16 to reveal exactly when the pressure ulcer had fully resolved. The purpose of the MDS assessment process is to drive care planning to ensure there is one clear plan for care delivery that all staff then follow. Assessing, planning and delivering care as mandated ensures the individualized needs of residents are met. The failures to actually assess resident skin during MDS assessments, to care plan the assessed and individualized needs of residents, and to then deliver care consistent with the assessed and planned needs resulted in harm reaching resident #12. With no care planning to facilitate and coordinate treatment, Resident #12 developed a pressure ulcer that advanced to Stage III, had another pressure ulcer that advanced from Stage III to Stage IV, and developed two SDTI identified when transferred from the nursing home to a local hospital that were never identified, assessed, or planned for. Concerns with MDS assessment accuracy for resident skin ulcer concerns and concerns with inaccurate and incomplete facility Skin Integrity Reports (where more frequent skin assessments) are documented were both cited during the June 2015 survey but corrective actions made at that time failed to demonstrate sustained improvement. Cross Reference Federal Tags F0274, F0278 and F0279, and State Tag 1752.