Every finding on record at Autumn Lake Healthcare at Long Green

Based on record review and interview it was determined the facility staff failed to follow Nursing Standards of Practice by failing to ensure wound care treatments were completed timely, signed off at the time of completion and signed off by the person who performed the treatment. This was evident for 1 (#7) of 6 residents reviewed for Quality of Care. The findings include:During review of Complaint #2960075, Audit Reports of Resident #7's Treatment Administration Record (TAR) for April 15-30, 2026, were reviewed on 5/15/26 at 11:56 AM. The audits included a timestamp documenting the time each treatment was signed as completed by the nurse administering it.The review revealed: Resident #7's wound treatments were scheduled to be completed every day shift (7AM - 3PM). On 4/24/26 new physician orders changed several of Resident #7's wound treatments to every day shift and every evening shift (3PM - 11PM). On 7 out of 16 days from April 15 - 30, the day shift dressing changes were not completed until after 3:30 PM. On 4/25/26 the residents wound treatments scheduled for day shift were signed off at 5:11 PM his/her evening shift wound treatments were signed off at 4:54 PM, 17 minutes prior to the day shift treatments. On 4/26/26 the day and evening wound treatments were signed off as completed within 2 hours 15 minutes of one another. The Administrator was present during the review and was shown the documentation. He stated, you don't know that they just didn't sign them off at that time. When asked what he meant, he suggested that the treatments may have been completed earlier but signed off at the times reflected in the TAR Audit. He was asked if that was the case, how would anyone know when the treatments were actually done. He replied, I guess you really don't. He was made aware that the standards of practice for nursing include that medications and treatments are to be signed off at the time of administration. An interview was conducted with the Director of Nursing (DON) on 5/15/26 at 12:20 PM, the Administrator was also present. The above concerns were reviewed. The DON indicated that the wound nurse performs the day shift wound care/treatments Monday - Friday, that he (the wound nurse) is probably doing the wound care/treatments during the day and the nurse assigned to the resident signed off that they were done. She agreed that the Nursing Practice Standards include that medications and treatments are to be signed off by the person administering the medication or treatment and at the time it was done.

Based on record review and interview it was determined that the facility staff failed to notify a resident's representative when the resident was transferred to the hospital. This was evident for 1 (Resident #7) of 6 residents reviewed for Quality of Care.The findings include: During review of complaint #2960075 Resident #7's medical record was reviewed on 5/14/26 at 8:36 AM. The record revealed that Resident #7 was capable of making his/her own medical decisions, had a family member listed as their Emergency Contact #1 and a friend listed as Emergency Contact #2. An Infection note dated 5/4/26 by Staff #1 a Licensed Practical Nurse (LPN), the facility's Infection Preventionist indicated During assessment resident was noted to be lethargic and difficult to arouse. Resident responded to tactile stimulation. Provider notified. New orders were given to transfer resident out to an acute care facility for further evaluation. A Change in Condition progress note dated 5/4/26 indicated that Resident #7 was transferred to the hospital due to a change in mental status. Section M. Resident Representative Notification indicated that Resident #7 was the Resident Representative who was notified of the hospital transfer. The medical record did not reflect that one of Resident #7's designated Emergency Contacts was notified when the resident had a change in mental status, was difficult to arouse and was transferred to the hospital for evaluation on 5/4/26. During an interview on 5/14/26 at 2:55 PM the Director of Nursing was made aware of the above findings. She was unable to find documentation that either of Resident #7's emergency contacts were notified.

Based on record review and interview, it was determined the facility staff failed to ensure resolution of all grievances by failing to ensure that written grievance decisions included the steps taken to investigate a grievance. This was evident for 1 (#7) of 3 residents reviewed for neglect. The findings include:Review of a complaint #2960075 on 5/14/26 at 8:36 AM revealed concerns which included but were not limited to Resident #7 not receiving proper wound care on a daily or timely basis and being left in bed for extended periods of time. The facility's Grievance logs from 1/2026 to 5/7/26 were requested and reviewed on 5/7/26 at 10:53 AM. There were no grievances pertaining to Resident #7 in the binder. On 5/14/26 at 11:35 AM the surveyor requested any grievances filed by or on Resident #7's behalf. At 1:45 PM on 5/14/26 the Administrator provided a Grievance Form dated 4/23/26 5:38 PM. The Grievance reflected concerns that Resident #7's wound care was missed at times and was not completed that morning; and staff were not assisting the resident to get out of bed daily despite the Residents request. The Administrators signature was in the designated spaces for the Investigator, Grievance Official and Administrator.The results section stated: Wound care was completed for the date of 4/23/26. [Resident #7] gets out of bed daily. The corrective action section stated: Unit manager & supervisors are ensuring that [Resident #7] gets out of bed daily. [Resident #7's] wound care being completed & followed by the wound provider & in house wound team. The Grievance Form did not include the steps taken to investigate the grievance, including pertinent findings. There was no documentation to indicate that a written decision was issued to the person who submitted the grievance. In an interview on 5/14/26 at 1:50 PM the Administrator indicated the Grievance form for Resident #7 was not in the Grievance binder because it was on his desk. When asked what he did to investigate the concerns, he indicated that he spoke to staff, and they told him that Resident #7 got out of bed every day. When asked how and when he issued a written decision to the person who submitted the grievance, he indicated he called and left a message for them to call back but they never did. Resident #7's Treatment Administration Record Audit Reports for April 15-30, 2026, were reviewed on 5/15/26 at 11:56 AM. Resident #7's wound treatments scheduled to be completed on day shift (7AM - 3PM) were signed off at 8:39 AM on 4/23/26. However, Resident #7's wound treatments were not signed off as completed until after 3:30 PM on 7 out of 16 days during that timeframe. The Kardex is the form used by the GNA's to document the care and services they provide to the residents. Review of Resident #7's April 2026 Kardex on 5/14/26 at 8:36 AM revealed that s/he was not assisted out of bed on 6 out of 17 days from 4/14/26 - 4/30/26. A review of the facility's Resident and Family Grievances policy and procedure revealed it was implemented 12/23/22, last reviewed by the facility on 11/3/25 and included the regulatory requirements. These concerns were reviewed with the Administrator and Director of Nursing on 5/15/26 at approximately 12:00 PM.Cross reference F 684.

Based on record review and interview it was determined the facility staff failed to maintain complete and accurate medical records by failing to ensure 1) a resident's record included the actions taken to pursue a court appointed guardian, and 2) a resident's record accurately reflected their skin status upon readmission. This was evident for 2 (#5 and #2) of 6 residents reviewed for Quality of Care.The findings include:1) An Advance Directive is a legal document that allows a person to specify their medical care preferences and appoint a trusted person to make healthcare decisions for them if they become unable to communicate or make decisions themselves. Resident #5's medical record was reviewed on 5/8/26 at 12:36 PM during review of Complaint #2966326. The record revealed that the Resident did not have an Advance Directive. The resident was certified by 2 physicians as lacking capacity to make medical decisions on his/her own behalf on 4/8/26. No documentation was found in the record to indicate the resident had relatives to act as his/her surrogate decision maker or had a court appointed guardian. In an interview on 5/8/26 at 1:40 PM the Director of Nursing (DON) revealed the resident's cognitive capacity had gradually declined. Social Services and Admissions were unable to contact the only family member listed in the residents' contacts. She indicated that the Social Worker and Administrator were in the process of seeking a court appointed guardian for Resident #5 and the Medical Director was also involved. When asked where to find documentation regarding the process she indicated she knew there were emails but wasn't sure if anyone documented it in the resident's medical record. On 5/8/26 at 1:56 PM the Administrator indicated that he was in touch with the facility's legal team regarding Resident #5's guardianship, they started seeking guardianship on 4/15/26 and have been attempting but were unable to reach the resident's family member. He reported - we're in the process of trying to get places of past residences and assets. He was asked where to find documentation in the resident's record that reflected the facility's efforts and process for seeking a guardian. He stated, It's not in there. 2) A pressure ulcer is damage to the skin and underlying soft tissue caused by prolonged or intense pressure which limits blood flow to the tissue leading to tissue damage or death. Initial damage can start within 1 to 2 hours of sustained pressure, particularly in high-risk individuals. During review of Complaint #2999544 Resident #2's medical record was reviewed on 5/11/26 at 11:00 AM. The record revealed the resident had multiple pressure ulcer wounds including but not limited to both thighs, upper buttock/sacrum, right hip, left heel, and right lateral foot. The resident was hospitalized from [DATE] - 5/9/26. A Case Management Discharge Report from the hospital included multiple pressure wounds present on admission. The wounds on the resident's right foot included an unstageable pressure injury on the heel with no open areas or drainage noted. readmission physician orders dated 5/9/26 included orders for wound care of multiple sites. An admission nursing progress note dated 5/9/26 14:12 (2:12 PM) did not mention pressure ulcers but indicated On arrival, assessment completed.The Nursing Admit/Readmit Screener (admission Nursing Assessment) dated 5/9/26 21:33 (9:33 PM) was present in Resident #2's record and revealed:Section C.10. Skin Integrity, included blank diagrams of the human body, spaces and a key to identify location, type, size and stage of any skin injuries present at the time of the assessment. Section C.10 of Resident #2's assessment was blank. There was no documentation identifying the number, type, stage, size or condition of the Residents wounds at the time of his/her readmission to the facility. Review of the resident's record on 5/12/26 at 10:00 AM revealed Wound Assessment reports by Staff #2 the wound care Nurse Practitioner (NP) who documented that Resident #2 had 7 wounds which were documented as acquired before 5/9/26 and 1 unstageable wound on Resident #2's right heel with 5/9/26 as the date the wound was acquired. During an interview on 5/12/26 at 1:17 PM the Director of Nursing (DON) was made aware that there was no assessment of the presence and condition of the resident's wounds upon readmission to the facility. She indicated that the resident returned to the facility on a Saturday just before the change of shift, the resident had orders for wound treatments upon readmission, which were completed as ordered, and the Wound NP assessed Resident #2's wounds on Monday during her rounds. She confirmed that she was unable to find an assessment of the resident's wound status upon his/her readmission to the facility.

Based on observation, interviews and record review it was determined the facility staff failed to implement standard infection control practices during wound care. This was evident for 1 (#2) of 6 residents reviewed for Quality of Care.The findings include:Complaint #2999544 and Resident #2's record were reviewed on 5/11/26 at 9:15 AM. The record revealed the presence of a pressure wound on the resident's right heel that was not assessed upon readmission to the facility on 5/9/26.In an interview on 5/11/26 at 11:51 AM Licensed Practical Nurse (LPN) Staff #3, confirmed he was the facility's wound nurse. He indicated his role was to round with the Wound team and complete wound documentation. He indicated he and the wound Nurse Practitioner (NP) Staff #2 were preparing to see Resident #2. He obtained permission from the resident, for the surveyor to observe his/her wound care.Resident #2's wound care was observed on 5/11/26 at 12:55 PM. LPN #3, NP #2, Staff #4 a Unit Manager (UM) and the Surveyor donned protective gowns, masks and gloves prior to entering the resident's room.Upon entering the resident's room, Resident #2 was observed lying in his/her bed. LPN #3 advised the resident that they were there to change his/her wound dressings and the resident agreed. LPN #3 placed the dressing change supplies including wound cleanser, gauze, ointments and xeroform (Petrolatum) gauze, directly on the residents overbed table which contained multiple personal items belonging to the resident. He did not establish a clean field on which to place the clean items. LPN #3 removed the old dressing from the resident's right lateral foot and cleansed the wound. NP #2 measured the wound by placing a paper measuring tape across the wound in each direction, wrote the measurements down and took photos of the wound with a cell phone, laying the phone and the measuring tape on the resident's bottom bedsheet when finished. The prescribed treatment was obtained from the resident's overbed table and applied to the wound by LPN #3. The dressing was secured by wrapping the resident's foot with gauze and a sock was applied by NP #2 and LPN #3.This process of removing the old dressing, cleansing the wound and applying a new dressing was repeated with all of Resident #2's wounds moving from the wounds on the resident's right foot, to left heel, they removed the suprapubic catheter dressing, changed the right upper thigh dressing then applied a clean dressing to the suprapubic catheter site. The resident was assisted to roll onto his/her left side, and dressings were changed for the wounds on his/her sacrum, right and left buttocks. The resident was assisted onto his/her right side, and the dressing was changed to a large deep wound on the resident's posterior left thigh. UM #4 labeled the clean dressing with the date and time for each of these wounds. They removed their gloves, masks and gowns and sanitized their hands just prior to exiting the resident's room. NP #2 carried the cell phone out of the room touching it with her bare hand. During the process, LPN #3 and NP #2 failed to set up and utilize a clean field for the clean dressing and treatment supplies or place a clean barrier under the wounds. They wore the same pair of gloves from the time they entered the room until they exited, failing to change gloves and sanitize their hands between handling soiled and clean dressing supplies. NP #2 laid the cell phone and measuring tape onto the resident's bed sheet between each use, handling them, then touching the other wounds with the same measuring tape and gloves. Additionally, upon entering the room, the surveyor observed that Resident #2's urinary catheter collection bag was lying on the resident's groin/lap area and was approximately 1/3 full of urine. The bag remained in this area until he/she was assisted to roll from side to side when it was placed on the mattress beside the resident. After the dressing changes were completed, LPN #3 picked up the bag, struggled to manipulate the hook then hung the bag on the bed frame. While doing so, he held the bag above the resident's groin and turned it over several times causing urine to flow back into the tubing. Review of the facility policy for Clean Dressing Change on 5/12/26 at 10:08 AM revealed it included setting up a clean area with needed supplies, placing a barrier cloth or pad under the wound. It also included washing hands and donning clean gloves: prior to placing the barrier, after removing the existing dressing, after cleansing and measuring the wound prior to application of creams/ointments and clean dressing; and discarding gloves and washing hands afterward. An interview was conducted with Staff #1 the Infection Preventionist (IP) on 5/12/26 at 12:30 PM. She was asked how she monitors the practice of staff related to infection prevention. She indicated that she would make frequent rounds, watch for any concerns, provide on the spot education and monitor the need for in-service education for a larger group or all staff. She was asked if she observes wound care. She indicated that the wound nurse took care of wounds throughout the week and that she did not typically go with him. She indicated that she would check behind staff to see if the treatments have been done based on the dated and initialed dressings. She was made aware of the concerns related to Resident #2's dressing changes and handling of his/her catheter bag on 5/11/26. In an interview on 5/12/26 at 1:17 PM the Director of Nursing (DON) was made aware of the above concerns. She indicated that IP#1 informed her and the Regional DON a few minutes prior.

Based on lack of documentation and interviews it was determined that the facility staff failed to complete a yearly performance review of Geriatric Nursing Assistants. This deficient practice was discovered during the recertification survey.The findings include:On 02/02/26 at 2:09 pm the surveyor reviewed GNA#34 & GNA#35 employee records. GNA #34 was hired on 07/03/24. There was no documentation to verify the GNA received an annual evaluation since they were hired. GNA #35 was hired on 05/29/08. There was no documentation to verify the GNA received an evaluation within the past year.On 02/02/2026 at 3:52 pm during an interview with the Director of Nursing (DON) the surveyor asked does the nursing staff receive yearly evaluations? The DON verbalized after orientation they have the unit manager ask them how they are doing. If they need assistance their concerns are addressed by Human Resources Director #22 or the Administrator. A daily check-in is done with the GNA's and nurses. Every Friday they discuss a topic that needs to be addressed with the nursing staff. Technically they are supposed to meet with Assistant Director of Nursing #2 every 6 month to re-evaluate where they are from when they first started. The surveyor asked was there documentation to verify that an evaluation was done. The DON verbalized, no.On 02/03 26 at 12:37 PM a review of GNA # 39 and GNA #41 employee records; neither of the GNA's had an annual evaluation for the surveyor to review. GNA #39 was hired on 05/05/21. GNA #41 was hired on 08/01/01.

Based on observations, record review, and interviews with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the initial, and follow-up tours of the kitchen. The findings include: Cross-contamination refers to the transference of harmful substances or pathogenic microorganisms to food via hands, food contact surfaces, sponges, cloth towels, or utensils that have not been properly cleaned after contacting raw food and then touching ready-to-eat foods. Cross-contamination can also arise from inadequate dishwashing procedures that fail to effectively wash, rinse, sanitize, and air-dry all food equipment in the kitchen area. On 01/21/2026 at 7:40 AM, the surveyor conducted an initial kitchen inspection with Staff #6 after calibrating stem thermometers in a container of ice water, and the following non-compliance were identified: Unclean Equipment in the Food Preparation and Storage Areas: NOTE: 2 of 3 Cadco mobile food carts were in use for transporting hot foods to residents in designated food distribution areas for each unit.3 of 3 Cadco mobile food carts were in a state of disrepair, thus preventing the maintenance of smooth, cleanable service areas necessary to prevent the accumulation of dust, debris, food particles, and bacterial proliferation:a. Heating element dial knob faceplates were chipped and/or broken.b. The sneeze guard was broken/cracked and secured with pieces of general-purpose masking tape.c. The metal strip on the sides and the plastic corner edges of the equipment were lifted, chipped, cracked, and/or torn.d. Excessive accumulation of dust, dirt, and spilled food was observed both inside and outside the units. Food plates, cups, and utensils were stored atop the unclean and unsanitized surfaces of these mobile food carts.e. All wheels on the equipment were heavily soiled, with significant accumulation of hair wrapped around the axles. 2. Two exposed air handlers and associated exposed ductwork were located in the center of the kitchen food preparation and ware washing areas:a. The air handler with exposed ductwork in the middle of the kitchen was discharging condensation/gray water onto the kitchen floor. A cloth drape (e.g., bed sheet/blanket) had been placed on the floor next to the floor sink to prevent the spillage of gray water onto the kitchen floor.b. The contractor tapes on both air handlers and the exposed ductwork were lifted and peeling from the units.c. Excessive accumulations of dust, debris, and/or dirt were present on the exposed ductwork.d. The vent covers from these exposed ductworks showed excessive accumulations of dust, debris, and/or dirt, which was being dispersed directly onto the food preparation areas and beneath the clean dishrack. The clean dishrack was observed to be soiled with excessive dust and debris accumulation. 3. The wall adjacent to the air handler had a large hole (approximately 8 inches by 24 inches) exposing a waterline. 4. The electrical outlet cover on the floor in the center of the kitchen was lifted and rusted. 5. The electrical panel board for the food preparation line was lifted and rusted exposing wires. 6. The storage room next to the walk-in coolers was cluttered, poorly lit, and missing a light bulb. 7. The deli slicer was unclean. All kitchen equipment must be washed, rinsed, and sanitized every four hours after use. 8. The microwave was propped up on a sheet pan. The underside of the microwave was rusted. 9. Bulk food storage containers were unlabeled/not stored in a designated area. 10. The hand sink on the cookline was obstructed by a lidded 55-gallon trash can. 11. All cooking equipment beneath the canopy hood were unclean. 12. The convection oven was not positioned directly underneath the canopy hood. 13. The floor tiles beneath the convection ovens were cracked. 14. The canopy hood was missing a light bulb. 15. The canopy hood metal baffle filters were unclean. 16. The interior and exterior of the ice machine were unclean. 17. The ice scoop was stored in an unsanitary condition. 18. The coffee drip pan, drain line, and floor sink were unclean. 19. Walls, floors underneath the equipment, and ceilings throughout the kitchen were unclean. 20. Multiple cracked or chipped floor tiles and cove bases were observed throughout the kitchen. 21. The rear entrance door jamb was in a state of disrepair. 22. Wall and ceiling penetrations were observed near the food storage room (at the electrical panels).Walk - in Refrigerator 23. Compression fan covers were unclean. 24. Food items, including cups of applesauce, mashed potatoes, and pudding, were stored unlabeled. 25. Shelving units were unclean. 26. Door gaskets were unclean.Walk - in Freezer 27. Compressor fan covers were unclean. 28. The compressor evaporator cover was torn. 29. Ice buildup from the compressor was observed on top of opened food boxes. 30. Ice buildup was present underneath the shelving unit. A bag of ice on the floor, positioned on the bottom of a shelving unit, could not be removed. 31. Door gaskets were unclean and torn.Ware Washing Area: 32. The Champion rack conveyor dish machine was unclean. Excessive dust, dirt, food particles, lime, and calcium buildup were observed on the interior and exterior of the unit. 33. The dish machine curtains at both ends of the unit were warped and/or torn. 34. The wall between the dish machine prewash side was covered in rust and a mold-like substance, which had resulted in a large hole (approximately 4 inches by 7 inches). 35. The dish machine vent stacks with adjustable dampers were detached/improperly connected to the ceiling ventilation system. 36. The edges of the wall panels were unsealed, causing the wall panels to [NAME]. 37. The perimeters around the floor sinks were rusted and unclean. 38. The floor sink strainers were undersized with excessive buildup of food debris. 39. The stopper for the sanitizing water vat of the 3-compartment sink was broken. 40. Plate dome covers were observed in a condition of wet nesting. 41. Food and food contact equipment were stored less than 10 inches off the floor. The bottom shelves should be elevated at least 18 inches off the floor to prevent splashing from mop water.Nonfunctional Equipment Throughout the Kitchen Area: 42. Stem thermometer for measuring internal food temperatures. 43. Fountain soda dispenser on a rolling cart. 44. Floor Mixer situated between the walk-in coolers. 45. Two-door reach-in refrigerator located adjacent to the walk-in freezer. 46. One of two convection ovens positioned beneath the canopy hood. 47. One of three Cadco mobile food carts situated beneath the canopy hood. 48. Hand sink paper towel dispenser by the cookline. 49. Dishwasher booster heater. 50. Hot water supply needed at the ware washing area hand sink.At 9:30 AM, both the Maintenance Director and the Administrator were notified of the deficient practices listed above. The Maintenance Director confirmed that the nonfunctional equipment would be removed, repaired, and/or replaced from the kitchen. On 01/28/2026 at 11:30 AM, the surveyor conducted a follow-up inspection regarding the functionality of the dish machine, and the following concerns were identified: 51. The dish machine final rinse gauge was nonfunctional. 52. The dish machine drain line near the clean side of the conveyor line was leaking gray water onto the kitchen floor. 53. The clean side of the dish machine was spraying water directly onto the kitchen floor. 54. The dish machine final rinse temperatures did not achieve 120 degrees Fahrenheit. 55. The dish machine automatically shut off even with continuous loading of racks onto the conveyor line. Staff #6 was required to manually turn on the unit. 56. A bottle of chemical was stored on top of the clean dish side. 57. A wet rag was stored inside the hand sink. 58. The ware washing room entrance door was in a state of disrepair. On 01/29/2026 at 2:00 PM, the surveyor informed the Administrator and the Maintenance Director about the non-commercial ice cooler, which had a chipped, cracked, soiled and broken lid that was located in the first-floor Nourishment room. They both inspected the unit and confirmed that the ice cooler would be replaced with a commercial unit capable of draining melted ice, and being properly washed, rinsed, sanitized, and air-dried to prevent potential cross-contamination of ready-to-eat food, such as ice.On 02/03/2026 at 11:10 AM, during the surveyor's interview with the Ecolab technician to verify the functionality of the dish machine, it was noted that the hand sink exhibited slow cold-water pressure. Staff #6 confirmed that the Maintenance Director had been notified of the cold-water pressure issue at the hand sink and it will be repaired immediately.

Based on observation, record review, and staff interviews, it was determined that the facility failed to maintain essential equipment in proper operating conditions. This was evident for 10 of the 10 pieces of equipment reviewed during the annual survey.The findings include:All essential kitchen equipment, including but not limited to walk-in coolers, steam tables, dishwashers, convection ovens, stoves, and warming cabinets, must be maintained in safe operating condition in accordance with the manufacturer's specifications and remain accessible throughout kitchen operations.Laundry equipment (e.g., washing machines, dryers) must be used and maintained according to the manufacturer's instructions for use to prevent microbial contamination of the system. On 01/21/2026 at 7:30 AM, an initial tour of the kitchen was conducted with Staff #6. The following kitchen equipment was observed to be nonfunctional and/or not maintained in safe operating condition:A nonfunctional two-door reach-in refrigerator was located adjacent to the walk-in freezer.2 of 2 steam thermometers were non-calibrated, failing to register around 32 degrees Fahrenheit (F) in a cup of ice water.The top-level convection oven did not reach proper baking/cooking temperatures.1 of 3 Cadco mobile food carts located underneath the canopy hood was nonfunctional.An air handler with exposed ductwork in the middle of the kitchen was draining condensation/grey water onto the kitchen floor. A cloth drape (e.g., bed sheet/blanket) was placed in front of the unit floor next to the floor sink to prevent grey water spillage onto the kitchen floor.The dishwasher was in disrepair.The dishwasher booster heater was nonfunctional.At 8:45 AM, the Maintenance Director was notified of the nonfunctional kitchen equipment listed above. The Maintenance Director acknowledged that the kitchen equipment would be replaced or repaired as soon as possible. On 01/28/2026 at 11:40 AM, Staff #6 confirmed that the high-temperature dishwasher had been switched to a low-temperature chemical dishwasher, which must reach 120 degrees F in accordance with the manufacturer's specifications. Both the surveyor and Staff #6 verified the functionality of the mechanical dishwasher by placing a DishTemp thermometer and a stem thermometer through the dishwasher multiple times to measure the highest final rinse temperatures, which read 110 degrees F and 98 degrees F, respectively.In addition, the surveyor pointed out that the final rinse temperature gauge on the dishwasher unit registered zero degrees F. Staff #5 and Staff #6 confirmed that the final rinse temperature gauge was nonfunctional. On 01/29/2026 at 1:40 PM, Staff #4 obtained food temperatures from the Cadco mobile food cart in the [NAME] unit dining/activities room following the lunch service. The temperature of the remaining chicken pieces in the food bin measured 106 degrees F, which verified the residents' complaints regarding the serving of cold foods. The surveyor observed that the surface of the Cadco mobile food cart was cold to the touch. Both Staff #4 and Staff #5 confirmed the unit was cold to the touch, suggesting it may not have been connected to a power source during the lunch service. The dietary staff acknowledged that 2 out of 3 Cadco mobile food carts will be scheduled for repairs. On 01/30/2026 at 3:30 PM, the surveyor observed Staff #16 sorting clean and dirty linens from the laundry machine that had been previously washed. The surveyor observed several washcloths and a pillowcase that still had stains on them while Staff #16 was sorting and asked why the linens were coming out of the machine soiled. Staff #10 and #16 replied that the laundry aides were trained to rewash the soiled laundry from the middle unit. The surveyor asked Staff #16 to open the washing machine on the right side of the middle unit to visually inspect the washed linens and found that steam/vapors escaped into the 51 degrees F ambient room temperature. The surveyor asked whether the middle unit produced steam/vapors after the wash cycle completion and opening the unit door, and the staff replied, no. At 3:40 PM, Staff #10 was notified that 2 out of 3 laundry machines were not in working condition. The washing machine on the left side of the middle unit had been out of order for several years and had an Out of Order signage posted on the unit. The middle unit was not effectively cleaning linens; consequently, employees were trained to sort and rewash the dirty linens. Therefore, only 1 out of 3 laundry machines was in proper operating conditions to provide clean linens for over 100 residents in the facility.Furthermore, the surveyor noted that 1 of 3 dryers was not in use while clean, washed, wet linens were sitting in the rolling cart. The surveyor asked why the washed linens were not being placed in the dryer unit. Staff #16 stated that the unit near the wall was not reaching the required temperatures to properly dry the linens.On 02/02/2026 at 3:45 PM, the Administrator provided a copy of the laundry machine service report, which stated that the laundry machines' water temperatures must reach 140 degrees F with the proper dispensing of chemicals (e.g., Chlorine level of 150 parts per million) to prevent microbial contamination of the system.At 4:40 PM, the surveyor documented the completion of the wash cycles for 2 of 3 washing machine units. The following temperatures were measured by inserting a sanitized and calibrated stem thermometer between the washed linens:Middle washing machine: 110.4 degrees F.Washing machine situated on the right side of the middle unit: 121.2 degrees F.The Director of Laundry Services was also present and verified the temperatures recorded above. On 02/03/2026 at 11:45 AM, surveyors conducted a follow-up assessment of the functionality of the washing machine units, again by placing a sanitized and calibrated stem thermometer between the washing machine linens:Middle washing machine: 120.7 degrees F.Washing machine situated on the right side of the middle unit: 132.1 degrees F.The Director of Laundry Services was again present to verify the temperatures documented above. The staff confirmed that a service technician is scheduled to follow up every two months to calibrate both the laundry wash chemical solution pumps and the hot water temperatures. Cross reference to F880

Based on the lack of documentation and interviews it was determined that the facility staff failed to ensure Geriatric Nursing Assistants received the required 12 hours of yearly training. This deficient practice was discovered during the recertification survey.The findings include:On 01/28/26 at 11:44 am during an interview with Assistant Director of Nursing (ADON) #2, the surveyor asked how they ensure the Geriatric Nursing Assistants (GNA) receive their yearly 12-hour training. ADON #2 verbalized they have a log and discuss who is coming in for orientation. The log is completed and performed by the staffing coordinator and Human Resources keeps track of their hours. On 08/28/26 at 2:19 pm during an interview with Human Resources Director (HRD) #22 the surveyor asked are they ensuring the GNA's are receiving their 12-hours of yearly training. HRD #22 verbalized the only training they do is with the new hires. They see him/her and Assistant Director of Nursing (ADON) #2. They do on-boarding first and he/she doesn't have anything else to do with their training. They are not sure who is responsible for ensuring they receive their training because that was always done on the clinical side. On 02/02/26 at 2:09 pm the surveyor reviewed GNA#34 & GNA#35 health and training records. GNA #34 was hired on 07/03/24. There was no documentation to verify the GNA received 12 hours of required training in the past year. GNA #35 was hired on 05/29/08. A review of their employee record revealed there was no documentation to verify the GNA received 12 hours of required training in the past year.On 02/03 26 at 12:37 pm the surveyor requested four GNA employee records with their training for review. A review of GNA # 39 employee record revealed their hire date was 05/05/21. Their last documented competencies were completed on 07/23/23. A review of GNA #40 employee record revealed they were hired on 04/01/25. The surveyor was unable to confirm what training the GNA received upon hire. A review of GNA #41 employee record revealed the GNA was hired on 08/01/01. A review of an Resident Abuse Inservice Sheet dated 01/01/26, 01/02/26, and 01/05/26 7-3, 3-11, and 11-7 shifts revealed the GNA received abuse training on 11-7 am shift on one of the recorded dates. There was no documentation of any other training the GNA received.

Based on resident council records and interviews it was determined that the facility failed to have resident council meetings regularly as evidenced by the inability to provide resident council meeting minutes during January, February, March, and April 2025. The deficient practice was evident in 4 or 12 months of 2025. This deficient practice was discovered during the recertification survey.The findings include:On 01/30/26 at 11:10 AM during a Resident Council meeting with nine residents, the surveyor asked are resident council meetings held regularly. The residents verbalized they were not having meetings regularly until Activities Director #23 started working at the facility.On 01/30/26 at 1:28 PM during a interview with Activities Director #23 he/she verbalized they started having Resident Council meetings in May. The first meeting Activities Director #23 was held on 05/08/25. Meetings are scheduled to be held on the second Thursday of every month in the first-floor dining room. The surveyor requested to view the binder with the Resident Council meeting minutes and sign-in sheets.On 01/30/26 at 2:29 PM a review of the Resident Council binder there were no meeting minutes on sign-in sheets during the months of January, February, March, or April in 2025.

Based upon observation and interview, it was determined that the facility failed to maintain a clean and homelike environment. This was evident for 3 Resident's (Resident #8, Resident #48 and Resident #109) of 3 resident rooms and the first-floor Nourishment Room reviewed during the annual survey. On 01/22/2026 at 1:45 PM, Resident #8 was interviewed and complained of feeling cold. The door to the bathroom was open, and a cold breeze was felt by the surveyor coming from the bathroom. The window was observed to be broken with some clear tape on the broken part of the window, but the tape did not adhere to the broken piece of glass in the windowpane, allowing cold air to enter. On 01/22/2026 at 2:03 PM, the Administrator and Staff #28, the Regional Director of Nursing, were shown the broken windowpane in Resident #8's bathroom. They were asked how this window had been broken. They stated that the bathroom had just been renovated. They acknowledged that the broken window was an issue and stated the maintenance man would cover the broken window until the pane could be replaced. On 01/23/2026 at 10:03 AM, the window in Resident #8's bathroom with the broken windowpane was covered with some black tape. Before the survey was completed, a piece of wood was covering the broken windowpane, which prevented cold air from getting in. The findings include: On 01/21/2026 at 12:35 PM, the surveyor observed water damaged floor panels lifted and buckled off the floor in front of the wall-mounted heating, ventilation, and air conditioning (HVAC) unit in Resident #48's room. On 01/29/2026 at 2:00 PM, the surveyor toured Resident #48's room with the Administrator, who confirmed that the damaged floor panels in front of the HVAC unit would be replaced promptly. On 02/02/2026 at 1:30 PM, the surveyor toured the facility with the Maintenance Director, and the following environmental concerns were identified: Resident #109's Room: Multiple holes were observed on the wall in the area of the residents' headboards. Laminated floor panels behind the toilet were lifted. The toilet flange bolt was excessively rusted and protruding. The sliding closet door had fallen off the track, impeding access to the closet. First-Floor Nourishment Room: Cabinet doors were missing from the cabinets. The cabinet interiors were observed to be unclean and in an unsanitary condition. Multiple cracked floor panels were noted. A non-commercial (residential) refrigerator was unclean and had torn door gaskets. An inoperable commercial refrigerator should be removed to mitigate the potential for pest, insect, and bacterial harborage. The Maintenance Director confirmed that the identified environmental deficiencies listed above will be repaired or replaced promptly.

Based on review of the staffing sheets and interview it was determined that the facility staff failed to record the actual hours worked by categories of licensed and unlicensed nursing staff each shift. This deficient practice was discovered during the recertification survey.The findings include:On 01/23/26 at 10:45 am a review of the staffing sheets provided by the facility staff revealed the staffing sheets dated 01/21/26, 01/22/26, and 01/23/26 did not include the total number of licensed & unlicensed nursing staff providing direct nursing care each shift.On 01/23/26 at 12:42 PM during an interview with Staffing Scheduler #26 the surveyor asked if they were aware the posted daily schedule must include the facility name, date, census, and the total number of actual hours worked by licensed and unlicensed staff who provide resident care. Staffing Scheduler #26 verbalized they were not aware; that they just write the HPPD and the supervisor does not update it with the numbers. The surveyor and scheduler went to each unit and reviewed the staffing sheets. The staffing sheets on the units Main, [NAME], [NAME], and Joppa were present but failed to include the number of hours the licensed and unlicensed personnel were scheduled to work each shift. A review of the staffing sheets dated 12/25/25, 01/03/26, 01/17/26, and 01/18/26 revealed the total number of working hours of licensed and unlicensed personnel was not documented every shift.

Based on observations and medical record review it was determined that the facility failed to ensure appropriate infection control practices during the maintenance of oxygen concentrators. This was evident for 2 out of 2 residents reviewed with oxygen concentrators during the recertification survey.The findings included:During the initial resident screening, it was observed that the humidifier bottle and the oxygen delivery tubing did not have the date it had been installed. This was evident for Residents #67, and #89. With medical record review it was noted that 2 residents had provider orders that instructed staff on the amount of oxygen to be delivered and that the humidifier bottle and oxygen delivery tubing was to be changed weekly and that the date those changes were made were to be labeled on the bottle and tubing.

Based on observation and interview with facility staff, it was determined that the facility failed to maintain clean and operational ventilation systems, thereby impairing proper airflow throughout the premises. This was evident in 2 of 2 janitors' closets, 2 of 2 utility closets, 2 of 2 residents toilet and shower rooms, and the mechanical dishwasher ventilation systems reviewed during the annual survey. Local Exhaust Ventilation ([NAME]) systems are designed and engineered to capture and remove contaminants such as excessive heat, steam, condensation, vapor, smoke, odor, and fumes. This is achieved through the calibration of the total pressure, which is calculated as the sum of the static pressure exiting and entering the system, minus the velocity pressure entering the system. In addition, the fan speed, pressure, and power must be adjusted to account for the specific gravity of the contaminant being captured and removed by the [NAME] system, while considering the specific size and air changes of the room. The findings include: On 01/21/2026 at 7:30 AM, an initial tour of the kitchen was conducted with Staff #6, which included verification of [NAME] systems within the kitchen and the janitor's closet that was also used for storing cleaning chemicals. The inspection revealed that the [NAME] system in the kitchen janitor's closet was inoperable.At 8:30 AM, the Maintenance Director was notified of the concerns regarding the janitor's closet next to the kitchen. He confirmed that the noted deficiencies, such as the inoperable exhaust fan, would be repaired or replaced promptly. On 02/02/2026 at 1:27 PM, the surveyor toured the facility with the Maintenance Director to conduct visual observations of the [NAME] systems by placing a thin, paper-like product onto the exhaust fan covers:The Main Street unit soiled utility closet lacked an [NAME] system.The [NAME] unit soiled utility closet's [NAME] system was inoperable.The Jappa unit janitor's closet was in disrepair and not in use; the [NAME] system was inoperable.The second-floor residents' toilet/shower room near room [ROOM NUMBER] was inoperable.In the second-floor residents shared toilet room near room [ROOM NUMBER], the motor was producing a loud grinding noise, and the Maintenance Director stated that it would be repaired or replaced.At 1:49 PM, the Maintenance Director acknowledged that the missing and inoperable [NAME] systems would be installed, repaired, or replaced as soon as possible to ensure adequate air circulation throughout the facility for the residents, visitors, and staff members. On 02/03/2026 at 11:10 AM, the surveyor interviewed the Ecolab technician to confirm the proper operating condition of the mechanical dishwasher. The technician clarified that the mechanical dishwasher unit was not included in the services provided by the Ecolab company. The technician's services were limited to providing chemical supplies and chemical dispensing calibration of the unit. However, both the technician and Staff #6 confirmed that steam and vapors were escaping from both ends of the unit and dispersing throughout the kitchen area. The mechanical dishwasher ventilation system required repair or replacement to effectively capture and exhaust steam and vapors from the kitchen area.

Based on medical record review and staff interviews it was determined that the facility failed to developed and implement a person centered care plan. This was evident for 2 Resident's, Resident #12 and Resident #103 reviewed during the annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. On 2/3/2026 at 10:30 AM, medical records were reviewed and revealed that a care plan for Diabetes Mellitus was not developed or implemented for Resident #12. On 02/03/2026 at 11:01 AM, the Director of Nursing, DON, was interviewed and asked who was responsible for implementing and updating the care plan for each resident. The DON stated that the admitting nurse did the baseline care plan, which included skin, falls, pain, medications, and diet. The Unit Managers, UM, would then update the care plan based on the Minimum Data Set, MDS, the resident's diagnosis, and any change of condition. On 02/03/2026 at 11:34 AM, the DON was interviewed and asked if Resident #12 had a diagnosis of Diabetes Mellitus and, if so, if they could provide documentation of Diabetes Mellitus on Resident #12's care plan. On 02/03/2026 at 11:36 AM, Resident #12's records were reviewed and revealed on the Diagnosis Report for Resident #12 had an onset date of 10/5/2017 for Type 2 Diabetes Mellitus. The Medication Administration Record, MAR, had an order to check Resident #12's blood sugar three times a week. On 02/03/2026 at 12:30 PM, the DON stated that a copy of Resident #12's care plan could not be provided for Diabetes Mellitus because it was not completed. The DON verbalized that not having a care plan developed and updated based on the resident's diagnosis and change in condition was an issue. On 01/28/26 at 7:02 AM a review of Resident #103 electronic health record (EHR) revealed the resident was admitted to the facility on [DATE] status post (S/P) surgical repair L femur on 10/30/25. The surgical site had Steri-strips with bruises per provider note. Further review of the EHR revealed a person-centered care plan was not initiated to care for the surgical site. On 01/28/26 at10:45 AM during an interview with the Director of Nursing it was verbalized Resident #103 was admitted with the surgical site; and should have had a care plan initiated. The resident was seen by the wound team for the surgical site.

Based on a review of the electronic health record and interview it was determined that the facility staff failed to obtain an order to monitor a resident's blood glucose levels and obtain parameters when the physician should be contacted which is the standard for nursing practice. This deficient practice was evidenced in 1 (#103) of 4 medical records reviewed during the recertification survey. The findings include:On 01/22/26 at 12:31 PM a review of Resident #103's electronic health record (EHR) revealed the resident's glucose was being monitored at least BID (twice a day) since the resident was admitted on [DATE]. A review of the residents' diagnoses revealed the resident had a history of Diabetes Mellitus Type I. Further review of the EHR revealed there was not an order for glucose readings or parameters to notify a physician if the readings were out of a selected range.On 01/22/26 at 12:50 PM during an interview the Director of Nursing the surveyor reported the resident's glucose was being monitored without an order or parameters when the physician should be notified. The DON verbalized an order should have been written with parameters in place when the physician should have been notified. They will review the residents' EHR to verify there was an order and provide the surveyor a copy.On 02/03/26 at 3:00 PM the surveyor did not receive documentation that an order was written with the parameters of when to notify the physician or nurse practitioner.

Number of residents sampled: Number of residents cited: Based on review of residents' medical records and interview with facility staff, it was determined that the facility failed to ensure that a physician's order for daily pedal pulses and weekly abdominal girth measurements to be recorded and reviewed by the provider. This is evident in 1 of 1 residents (resident #25) reviewed in the annual certification.The findings include:During an initial interview of resident #25 it was noted that they had severe edema in both of their feet and ankles . When reviewing the medical record it it was noted that the resident's provider had ordered that the resident have pedal pulses taken every shift and that it be documented either positive or negative. That order was written on 11/13/2025. The resident also had an order for the weekly measurement of their abdominal girth dated 9/24/2025. Though in the Task Administration Record) TAR, it was documented that these tasks were completed, no data of the measurements was recorded in the TAR, the resident's chart or any other line of communication to the provider. The DON was asked about this and after their investigation stated that the provider failed to initiate the supplemental data command in PCC (the electronic medical record) and consequently the nursing staff did not have a place to document the measurements. Employee #19 was interviewed and asked if the unit had a separate place to record this data and they said no. The DON was unable to account for why in the 2 months for the pedal pulses or the 4 months for the abdominal girth measurement that neither the nursing staff or the provider had done anything to correct the issue and provide the means for measurements to be recorded.

Based on employee record review and interviews it was determined that the facility staff failed to ensure a Certified Nursing Assistant (CNA) received their Geriatric Nursing Assistant (GNA) Certification within 4 months of their hire date. This deficient practice was evidenced in 1(#32) of three CNA employee records reviewed during the recertification survey. The findings include:On 01/23/26 at 2:04 PM the surveyor requested that Human Resources Director #22 provide documentation when each CNA received their GNA certification. On 01/23/26 at 2:26 PM during an interview with Human Resource Director (HRD) #22, the surveyor asked when a CNA is hired what amount of time are they allowed to work in Long Term Care (LTC) before receiving their GNA certification. HRD #22 verbalized they believed the timeframe was four months. The surveyor reported that CNA #32's hire date was 06/27/25 and they should have received their GNA certification within four months which would have been 10/27/25. On 01/28/26 at 10:53 AM during an interview with the DON, the surveyor reported that CNA #32's employee record revealed their hire date was 06/27/25 and they should have received their GNA certification within four months. The surveyor asked the Director of Nursing (DON) if GNA #32 was working. The DON reported GNA #32 was on vacation. The surveyor checked the Maryland Board of Nursing website which confirmed that CNA #32 did not have a GNA certification. CNA #32's initial certificate was issued on 05/07/24 and their certificate expires on 01/28/27.On 02/03/25 at 9:12 AM a review of the staffing sheets on Main Street dated 01/21/26 7:00 am - 3:00 pm, 01/21/26 3:00 pm - 11:00 pm, 01/22/26 7:00 am - 3:00 pm, 01/23/26 7:00 am - 3:00 pm, and 01/26/26 7:00 am - 3:00 pm revealed that GNA #32 recently worked during those shifts and continued to work after the surveyor reported they should have their GNA certification. On 02/03/26 at 9:20 AM during an interview with GNA #36 the surveyor asked when they worked with CNA #32? Did CNA #32 receive a different assignment? GNA #36 verbalized that Main Street is LTC. They provide Activities of Daily Living (ADL) care, toileting, assistance with feeding, dressing and they use the Hoyer lift to get the residents out of bed as needed. They all provide the same type of care just different residents.

Based on observations and staff interviews it was determined that the facility failed to properly store medication. This was evident in 1 of 3 medication carts reviewed during the annual recertification.The findings include:During the review of medication administration and storage during the annual recertification, it was discovered that a large number (52) of different medication tablets and capsules had fallen into the bottom of the medication cards' drawer. The surveyor removed the tablets and capsules in the presence of employee # 12 who was administering medication at the time and made sure the employee was aware of the problem. The surveyor then spoke with the DON and employee #29 who were made aware of the loose medications found in the cart drawer and the medications were disposed of by the DON

Based on medical record review and interviews with staff, it was determined that the facility staff failed to obtain a diagnostic test and get the results as ordered for Resident (#106) in a timely manner. This was evident for 1 of 21 residents selected for review during the annual survey process. The findings include: On 2/2/2026 at 10:30 AM a review of the medical records showed that Resident #106 was admitted to the facility on [DATE]. The weekly skin evaluation documented that Resident #106's skin the color, temperature, turgor was normal and the integrity of their skin had a healed wound, which was an old scab. On 6/23/2025 an addendum note was reviewed and the note stated that On admission, the area to the sacrum was documented as scabbed area. This is consistent with the hospital discharge summary description of excoriation. As of today, the area was reassessed and was noted to have deteriorated. The scab has been noted to detached naturally. This note is intended to reflect clinical reassessment. Also, on 6/23/2025 a change of condition was completed and documented that the area had reopened to sacrum measuring 8.5cm x 8.5cm.Resident #106 was being seen by a wound practitioner Staff # 37, Nurse Practitioner, NP and on a 7/21/2025 the practitioner documented the Wound has improved again this week. Debridement performed and tolerated well. Wound culture collected. Continue current treatment. Resident # 106 was taking antibiotics pills at the facility. Further review on the medical records on 2/2/2026 revealed that a note was written on 7/24/2025 that Diamond Lab called and informed Staff # 38, Licensed Practical Nurse, LPN at 8:45 AM on 7/22/2025 that the wound culture for Resident #106 were rejected due to being collected in the wrong tube. On 2/2/2026 at 12:30 PM record review revealed that Resident #106 was sent to the hospital on 7/26/2025 by their responsible party for further evaluation of Resident #106's sacral wound. Continued review of Resident # 106 records revealed that they were admitted to the hospital with Systemic Inflammatory Response Syndrome (SIRS) related to infected stage 4 wound and sacral osteomyelitis.On 2/2/2026 at 1:31 PM the Director of Nursing, DON was interviewed and asked what happened to the wound cultures that were ordered for Resident #106 on 7/21/2025. The DON stated they were drawn in the wrong specimen tube, and the lab discarded the sample. The DON was then asked for documentation that the physician/practitioner was notified that the wound culture had been rejected and what they wanted to do. The DON stated she would check.On 2/3/2026 at 9:45 AM medical record review of the infection note revealed that Resident #106 had wound cultures at the hospital which grew pseudomonas, Acinetobacter, and Corynebacterium and was treated in the hospital with IV antibiotics.On 2/3/2026 at 2:05 PM Staff #28, the [NAME] DON and the DON were interviewed. They stated that the lab was called at the time of the incident, and they were told it would take 72 hours to get the correct specimen tube to the facility. Again, the DON and Staff #28, the Regional DON were asked if they could provide a note that the wound cultures were redrawn, and they stated no we cannot. Both the Regional DON and the DON verbalize that this was a concern.

Based on review of the facility report of abuse, medical record review and interview with the facility staff, it was determined that the facility failed to keep a resident free from abuse. The facility was aware of a situation occurring where a staff member was interacting with a resident in such a manner that did not adhere to the residents rights. The staff members actions resulted in harm to the resident when the staff member grabbed the resident under his/her arms and then by the shirt and drug the resident across the floor when the resident refused to comply with the staff members request. This was evident for 1 out of 2 residents (#82) reviewed for allegations of abuse. The findings include:On 10/28/15 Resident #82's clinical record was reviewed. This review revealed that the resident was readmitted to the facility in May 2014 with a complex medical history and multiple [DIAGNOSES REDACTED].review of the resident's medical record revealed [REDACTED]. Review of the resident's Brief Interview for Mental Status or BIMS (a test given by medical professionals that helps determine a patient's cognitive understanding) revealed a score of 07. A BIMS score of 00-07 indicates severe impairment. On 10/29/15 this surveyor reviewed facility reported incident MD 0947, along with investigative documentation (to include statements from licensed nurses and geriatric nursing assistants) about an allegation of abuse that occurred to Resident #82. Review of the nurse's statement (staff #11) revealed that on 8/17/15 at around 7:30 PM the charge nurse from the Charles unit (staff #9) called and told her that the resident from the Joppa unit was on her unit. Investigative documentation indicated that on 8/17/15 between 8:00 PM and 8:30 PM, GNA (staff #10) went to the Charles unit to bring Resident #82 back to her/his unit but the resident did not want to come back to the Joppa unit. The GNA asked the resident for permission to do evening care and the resident agreed only if it could be done on the Charles unit. Further review revealed that after the GNA completed evening care she covered the resident up making the resident comfortable and told Staff #9 that the resident was resting and wanted to stay in the dining area. Staff #9 told Staff #10 that the resident had to go back on the Joppa unit.In a written statement on 8/17/15 Staff #11 revealed that the Director of Nursing (DON) was called because Staff #9 was trying to make the resident return to the unit against the resident's will. Review of GNA (staff #10's) statement revealed that while doing PM care she heard someone cry out in the hallway on Charles unit, and as she walked towards the crying it was Resident #82 crying with Staff #9 standing over top of the resident trying to put the resident in the wheelchair by grabbing the resident by the shirt and under the arms.Further review of GNA (staff #10) statement revealed that the resident started screaming and kicking, and was heard stating that she/he did not want to go. GNA (staff #10) told staff #9 that the resident would leave when he/she was ready and the resident sat on the floor. Staff #9 grabbed the resident by the shirt and slid the resident across the floor back into the dining room. Staff #10 asked Staff #11 if she saw what happened and she replied that she did and was calling the DON. However, the DON indicated that that he was not called when this incident occurred.Further review of the statements revealed that GNA (Staff #12) heard yelling and crying from the dining area and when she went to see who was crying it was Resident #82. She revealed that the resident was on the floor and the nurse (Staff #9) grabbed the resident by the shirt and dragged the resident back into the dining area. The resident also complained of pain and the nurse (Staff #11) assessed the resident without offering any pain management.Review of the Human Resource Specialist's (Staff #15) statement revealed that on the day following the incident (8/18/15) at around 12:30 PM, he/she spoke with the resident and the resident informed her that someone had choked and pulled her/his shirt. Staff #15 attempted to interview the resident and the resident was able to demonstrate the action. Staff #15 revealed that she was officially reporting the situation to the social worker. Review of all the investigative documentation revealed that the facility staff failed did not immediately notify the facility's evening shift supervisor, nor did they immediately notify the DON. The alleged perpetrator was allowed to continue working with the resident for the remainder of the shift.During an interview with the DON on 10/30/15 at 2:30 PM he acknowledged that he did speak with Staff #9 in reference to moving the resident against the resident's wishes. The DON also acknowledged that he did not follow up with staff in reference to the resident. He reported that he was not made aware of the allegation of abuse until the social worker came to him around 3:30 PM on 8/18/15 . The DON revealed that the staff member was reported to the Board of Nursing and indicated that the police was called, but the DON failed to supply any documentation that law enforcement was called and made aware that the abuse was substantiated.Review of the facility's abuse policy/procedure (revised 7/1/09), included the following: 5.1 Anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately.On 10/30/15 review of the nurse's employee file revealed that she had been terminated on 8/24/15. Cross reference F225

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure that a penile skin tear was properly assessed and treated to prevent further skin breakdown. Without an effective plan or treatment, a skin tear first evident for resident #162 on 6/26/15, advanced to a serious full thickness wound by 10/21/15. The facility also failed to provide an ordered medication (Resident #23), and follow a plan of care for transferring (Resident #132). These concerns were evident in 3 out of the 35 residents reviewed during Stage II of the survey. The findings include: 1. A review of Resident #162's clinical record revealed an initial nursing assessment with an effective date of 6/26/15 at 4:46 PM. In item #7 under 'Skin Condition' site d14 was noted as, skin tear to tip of penis, 3.5cm x 0.5cm. The nurse wrote a progress note dated 6/27/15 at 3:17 PM indicating that the catheter was patent (open and intact). The nurse documented on 6/28/15 at 11:44 PM that the Foley catheter was intact but made no mention of the skin tear or an assessment of the genital region. The physician wrote a History and Physical (H&P) on 6/29/15. The skin section was noted as normal. The list of wounds included buttocks, left shin, left foot, and left elbow. There was no mention of the skin tear to the penis. The section entitled Genitalia was also left blank. The nurse practitioner assessed the resident on 7/1/15 at 9:14 AM. The nurse practitioner noted the resident having wounds to the sacrum, left ankle, left foot, left elbow, left knee, and right heel. No assessment of the skin tear to the penis was documented. The resident was hospitalized from [DATE] to 7/11/15. The hospital transfer summary noted the resident to have traumatic [DIAGNOSES REDACTED] (urinary opening located elsewhere on the penis) due to chronic indwelling Foley catheter. The nurse practitioner assessed the resident on 7/15/15 at 10:04 AM for an evaluation of multiple pressure ulcers. This assessment was done post hospitalization . This assessment did not include any documentation of an assessment of the skin tear to the resident's penis. An H&P was completed on 7/15/15 at 10:54 AM by the Medical Director. The physician listed the following wounds in this assessment: left lateral distal foot, left proximal foot, left ankle, left elbow, sacrum, and right lateral foot. The section for genitalia was noted as normal. There was no assessment of the penis documented as being performed at that time. On 7/31/15 at 6:32 PM the resident was noted to have a new onset skin tear measuring .5 x .5 cm on the left inner thigh. Nursing noted at 6:47 PM on 7/31/15 that there was a reddened rash scrotal and perineal area. Nursing staff treated the scrotal area with [MEDICATION NAME] powder (an antifungal) and provided incontinence care but documented no assessment of the penis. Nursing staff documented on 8/2/15 at 2:12 PM that the scrotum was no longer reddened but no further observation of the area was noted. Nursing changed the catheter on 8/3/15 at 6:49 PM but no assessment of the penis was noted in this documentation. Nursing noted in the progress notes on 8/6/15 at 5:49 AM that the resident had minute red spots above the penis along the pubic region of the body. No mention of what the actual penis looked like was available in this documentation. Nursing noted in the progress notes on 8/9/15 at 11:00 PM that catheter care was performed but no assessment of the genital area was noted. Nursing noted in the progress notes on 8/29/15 at 11:31 PM that catheter care was performed but no assessment of the genital area was noted. Nursing noted in the progress notes on 9/6/15 at 5:39 PM that catheter care was performed but no assessment of the genital was noted. Nursing listed the wounds receiving wound care on 9/10/15 at 6:32 PM but no assessment of the penis was documented. Nursing noted in the progress notes on 9/16/15 at 4:09 PM that catheter care was performed but no assessment of the genital area was noted. Nursing listed the wounds for which wound care was provided on 9/16/15 at 5:22 PM and the penile wound was not noted. Medical record review revealed a nursing progress note dated 9/19/15 at 3:57 PM documenting the following: (Resident) has a new onset/change in skin integrity as evidenced by abrasion. Location: Was told in report about resident open area to penis, assessment done 6.5cm x 1 x1.5cm. Foley cath intact and draining clear yellow urine. (Nurse Practitioner) aware. See new order. not demonstrating symptoms of pain. There has been no medication change in the past week. Physician notified of change in condition. The progress note also indicated that the responsible party was notified at this time. The following interventions were documented: New orders obtained, continued observation, seek skin assessments; Applied [MEDICATION NAME] ointment cover with dry dressing twice daily and consult physician in change on Monday. A telephone order from the Nurse Practitioner dated 9/19/15 documented the following: cleanse with vashe then apply [MEDICATION NAME] ointment twice a day penis area due to Foley; f/u (follow-up) with (physician-Medical Director) on Monday. Cover with dry dressing. On 9/21/15 at 2:10 PM the Medical Director ordered a Urology consult for s/p (suprapubic) catheter. Nursing listed the wounds receiving wound care on 9/24/15 at 5:22 PM but the penis was not mentioned on the list. On 10/21/15 at 10:45 AM the Medical Director documented the following in a physician narrative: .Genitalia- has traction injury to penis from Foley catheter that has been extended since he was last seen. Urology consult ordered on 9/7 has yet to be accomplished. Assessment/Plan & Other Information: traumatic injury to penis from Foley catheter traction injury which has resulted in meatus and penile urethra being avulsed. This will continue to get worse. DON advised of need to get urology consultation accomplished ASAP to address the situation. He will require a suprapubic cystostomy . Although the Medical Director documented that a urology consult was ordered on 9/7, review of the medical record did not reveal a physician's orders [REDACTED].>Resident #162 was sent to a urology consult on 10/26/15 to evaluate the possibility of inserting a suprapubic catheter. During the survey, the survey team made an observation of the wound on 10/29/15 at 12:15 PM. In this observation the penis was observed to be split from the top of the shaft to the base. It was split from the tip down to the penile scrotal junction. The catheter was visible. During an interview with the Director of Nursing (DON) on 10/30/15 at 11:38 AM, he stated the resident had a pressure area that formed on the posterior aspect of his penis that was caused by the catheter and the pressure put on the penis secondary to the resident's contractures. A care conference was called and change of condition was discussed. He indicated that the facility was currently seeking a plastic surgeon to evaluate possible repair of the resident's penis. In interview, the DON also stated that a nurse did a skin assessment on 9/13/15 after a Geriatric Nursing Assistant discovered it and reported that nurses do a head to toe assessment at shower time. However, review of Residnet #162's medical record failed to reveal documentation of notification from a GNA to nursing staff on 9/13/15 regarding this area. The DON was interviewed again on 10/30/15 at 12:33 PM. The DON stated, My staff should have caught it. Maybe they missed it because (resident) is mentally challenged. The DON was interviewed on 10/30/15 at 1:55 PM regarding shower sheets for Resident #162. He indicated that shower sheets were not being completed by the GNA's prior to September. Review of Resident #162's medical record failed to reveal a consistent plan and implementation of standard wound care. 2. On 10/28/15 review of Resident #23's medical record revealed a physician order, dated 10/21/15, for Sevelamer (also known as [MEDICATION NAME]) 2400 mg to be given three times a day. Review of the Medication Administration Record [REDACTED]. On 10/28/15 at 3:15 PM surveyor reviewed the MAR indicated [REDACTED]. On 10/29/15 at 2:42 PM the Director of Nursing (DON) reported that there were two or three times that faxes were sent to the pharmacy requesting the medication but it was not delivered last night when anticipated. At 2:47 PM the DON reported that the pharmacy makes two or three deliveries a day and that he would expect medications to be delivered at the next delivery after an admission. Further review of the medical record revealed that from October 1 - 19 there was an active physician order [REDACTED]. The notation written by the nurse for the 10/10/15 4 PM dose included the following: [MEDICATION NAME] 800 mg 0 available, Pharmacy contacted need prior authorization. Further review of the MAR indicated [REDACTED]. On 10/29/15 at 4:34 PM surveyor reviewed this MAR indicated [REDACTED]. The DON reported that he would be investigating the issue further. Surveyor then requested documentation of pharmacy delivery of [MEDICATION NAME] for October. On 10/30/15 review of pharmacy delivery documentation revealed that the pharmacy delivered 63 800mg tablets of [MEDICATION NAME] on the evening of 10/10/15. 63 tablets provide 21 doses, which is only a 7 day supply of the medication. The next delivery of [MEDICATION NAME] was not until 10/29/15. 3. Review of a facility reported incident regarding Resident #132 that occurred on 9/15/15, revealed that a resident was transferred by one staff via a hoyer lift from the bed to his/her wheelchair. Interview with the DON on 10/29/15 at 11:10 AM regarding the incident revealed that it was against facility policy to have only 1 staff present while using the hoyer. A review of the employees file revealed that she was trained in the facility policy of the safe transferring of a resident using 2 people on 2/7/12. A review of the residents care plan and the transfer-reposition evaluation completed on 7/9/15, revealed the resident was totally dependent on staff for ADL care, transfers and bed mobility. According to the facility investigation into the incident, it was determined that the staff involved was an agency GNA that 'did not use proper transfer techniques for a hoyer lift.'