Every finding on record at Autumn Lake Healthcare at Oak Manor

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's fall risk status for 1 (Resident #2) of 3 sampled residents reviewed for accidents.Findings included: A facility policy titled, Fall Risk Assessment dated 10/27/2025, specified, 3. An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. 4. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. An admission Record indicated the facility admitted Resident #2 on 04/16/2026. According to the admission Record, the resident had a medical history that included diagnoses of orthopedic aftercare following surgical amputation, iron deficiency anemia, and hypertension. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for most activities of daily living and had no falls. Resident #2's Care Plan Report with an admission date of 04/16/2026, revealed no evidence of an At Risk for Falls care plan. Resident #2's Fall Risk Evaluation dated 04/16/2026 and 05/07/2026, revealed the resident was at moderate risk for falls. During an interview on 07/23/2026 at 11:22 AM, the Regional Director of Nursing (DON) reviewed Resident #2's Care Plan Report and confirmed the resident did not have a fall care plan. The Regional DON stated all residents at risk for falls should have a fall risk care plan in place. During an interview on 07/23/2026 at 11:57 AM, the Director of Nursing (DON) stated that upon admission, residents were assessed for their risk for falls, and a fall care plan was initiated, if triggered. The DON confirmed that Resident #2 did not have an active fall risk care plan, but the resident should have. During an interview on 07/23/2026 at 1:02 PM, the Administrator stated that every resident should have a fall risk care plan.

Based on facility documentation, medical record review and interviews, it was determined the facility staff failed to treat a resident with dignity and respect. This was evident for 1 (Resident #6) of 6 residents reviewed during a compliant survey. The findings include:Review of Facility Reported Incident 3023073 was conducted on 5/27/26 regarding Physical Therapist (PT) #5 walking in on Resident #6 unclothed on 5/22/26.Review of Resident #6's medical record revealed the Resident was admitted to the facility for rehabilitation following a hospitalization in April 2026.Further review of Resident #6's medical record revealed the Resident was assessed on 4/21/26 by the facility staff to have a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating the Resident is cognitively intact.During interview with Resident #6 on 5/27/26 at 11:30 AM, Resident #6 stated last Friday (5/22/26) he/she was in the bathroom with the door closed and unclothed from the waist up. The Resident stated a man from physical therapy (PT #5) knocked on his/her door. Resident #6 stated he/she said someone is in here but the man opened the door anyway. The Resident stated PT #5 stated: I don't care I am from physical therapy, and I need to see (another resident's name which the Resident couldn't remember). The Resident stated he/she told PT #5 You don't need to be in here and turned from him to cover myself'. The Resident stated PT #5 had the door wide open and stood there for what seemed like 2-3 minutes. The Resident stated I reported it to the staff and they had me write up a grievance.During interview with PT #5 via the phone on 5/27/26 at 12:16 PM, PT #5 stated he/she got his list of residents to see and mistakenly went to the wrong floor. PT #5 stated he knocked on the door of Resident #6 twice, but no one answered so he entered the room and was expecting to see the Resident in bed. PT #5 stated he then proceeded to look around the room and didn't see the Resident. PT #5 stated as he was leaving the room he noticed the bathroom door was closed. PT #5 stated he knocked on the door and heard someone say I am in the bathroom. PT #5 stated he should have asked the Resident if they were okay but instead cracked the door open because he stated he was worried about the Resident's safety. PT #5 stated the Resident then said to him, You shouldn't have done that. PT #5 stated he/she believed the Resident was covered but could not recall what the Resident was wearing. PT #5 stated he only opened the door a few inches. PT #5 stated the Resident was seated in a wheelchair turned sideways. PT #5 stated he then closed the door and apologized to the Resident through the closed door.Interview with the Administrator on 5/27/26 at 12:56 PM confirmed PT #5 failed to treat Resident #6 with respect and dignity by opening the bathroom door without the Resident's consent.

Based on review of complaint 2997160, medical record review, and interview, it was determined that the facility staff failed to notify the resident's physician/nurse practitioner when the resident had a change in vital signs that had the potential for physician intervention. This was evident for 1 (Resident #2) of 7 residents reviewed during a complaint survey.The findings include:On 5/28/26 at 7:47 AM a review of complaint 2997160 alleged communication concerns.Review of Resident #2's medical record revealed the resident was admitted to the facility in January 2026 with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia (a heart rhythm condition where the heart beats too fast for no apparent reason, exceeding 100 beats per minute (bpm) at rest). A normal resting heart rate is 60 to 100 bpm.Review of Resident #2's heart rates from January 2026 to 3/4/26 ranged from 57 beats per minute to 89 beats per minute.Review of Resident #2's March 2026 Medication Administration Record (MAR) revealed the resident's heart rate was documented as elevated to 122 beats per minute on 3/5/26 at 9:00 AM.Continued review of Resident #2's medical record failed to produce documentation that the physician or nurse practitioner (NP) were notified of the increase in heart rate since that was the first time that the heart rate was documented over 100 bpm since the resident's admission in January 2026.On 5/28/26 an interview was conducted with Licensed Practical Nurse (LPN) #11, who was also the unit manager. LPN #11 was asked what she would expect the nurse to do if a resident's heart rate was 122 and the resident's normal range averaged in the 70s to 80s. LPN #11 stated she would expect the physician to be notified because, looking at the range of heart rates, the resident's rate was way off. LPN #11 stated, I would notify the doctor to let him know what the normal heart rate has been and if he wanted to do anything or just watch it. I would also recheck the heart rate after the medication was given to see if there was any improvement.On 5/28/26 at 12:45 PM an interview was conducted with Nurse Practitioner (NP) #13. NP #13 was asked if he would expect to be notified about a heart rate of 122 and he said, yes, I would expect to be notified because a lot of things are going through my mind right now. Is the patient symptomatic, is the respiratory rate up, is he/she septic. I always try to tell the nurse when you get an abnormal rate, is the patient stable, recheck it, maybe they have pain or are positioned incorrectly. Let us know what is going on.On 5/28/26 at 2:10 PM the Director of Nursing (DON) and the Corporate Nurse were informed of the findings. They both agreed with the findings.

Based on a review of complaint 2997160, medical record review, and interview, it was determined that the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #2) of 7 residents reviewed during a complaint survey.The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.On [DATE] at 7:47 AM a review of complaint 2997160 alleged concerns related to medications being delayed or missed.Review of Resident #2's medical record revealed the resident was admitted to the facility in [DATE] with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia (a heart rhythm condition where the heart beats too fast for no apparent reason, exceeding 100 beats per minute (bpm) at rest). A normal resting heart rate is 60 to 100 bpm.Review of Resident #2's heart rates from [DATE] to [DATE] ranged from 57 to 89 beats per minute.Review of Resident #2's [DATE] Medication Administration Record (MAR) revealed the resident's heart rate was documented as elevated to 122 beats per minute on [DATE] at 9:00 AM.Review of nursing progress notes, evaluations, and the vital sign section of the electronic medical record failed to produce documentation that the resident's heart rate was assessed between 9:00 AM and 8:00 PM on [DATE]. There was no documentation regarding whether the heart rate decreased or if Resident #2 had any symptoms related to the increased heart rate.Continued review of Resident #2's [DATE] MAR documented that on [DATE] at 8:00 PM the medications Atorvastatin, Famotidine, Metoprolol, and Acetaminophen were signed off as not given because Resident #2 had passed away suddenly.Review of a [DATE] at 22:36 (10:36 PM) change in condition note documented Resident #2 was assessed with no pulse, no BP, and no respiration at 10:00 PM. A code blue was called and 911 was called. The paramedics entered the resident's room at 10:07 PM as CPR was in progress. Paramedics took over CPR until 10:36 PM when the resident was pronounced as deceased .On [DATE] an interview was conducted with Licensed Practical Nurse (LPN) #11, who was also the unit manager. LPN #11 was asked what she would expect the nurse to do if a resident's heart rate was 122 and the resident's normal range averaged in the 70s to 80s. LPN #11 stated, I would notify the doctor to let him know what the normal heart rate has been and if he wanted to do anything or just watch it. I would also recheck the heart rate after the medication was given to see if there was any improvement. LPN #11 confirmed there was no documentation in the medical record that the resident's heart rate was reassessed after the morning medication was given.On [DATE] at 10:13 PM Registered Nurse (RN) #12 was interviewed and asked why Resident #2's 8:00 PM medications were not signed off at 8:00 PM on [DATE] but were signed off as not given due to the resident passing away at 10:36 PM on [DATE]. RN #12 stated that she gave Resident #2 the medications at 9:00 PM. RN #12 stated, I was supposed to sign the MAR afterwards, but I had to wait for [him/her] for about 15-20 minutes to swallow the medications and then I went to the next patient, so I didn't sign it off until later. RN #12 stated, the office asked me to write a statement about the medication, but before I signed the medication off the code happened, but [he/she] did take the medication. On [DATE] at 10:40 AM the Director of Nursing (DON) gave the surveyor an employee statement for the incident on [DATE] at 10:00 PM. The nurse (RN #12) documented in the statement that the evening medications were given at 9 PM. However, discussed with the DON that the medical record did not reflect that the medications were given.Further review of RN #12's written statement revealed that Resident #2 was assessed after RN #12 came on duty after 3:00 PM on [DATE]. The statement documented that vital signs were normal during her shift and that Resident #2 had no complaints or adverse effects from the elevated heart rate in the morning, however the medical record did not reflect Resident #2's health status as there was no documentation. The DON confirmed the surveyor's findings.

Based on record review and staff interview, it was determined that the facility failed to code the residents' status accurately on the Minimum Data Set (MDS) assessment. This was evident for 4 ( Resident #2, Resident #31 Resident #98 and Resident #129) of 6 residents reviewed for accuracy of assessments. The findings include: The Minimum Data Set (MDS) is a federally mandated comprehensive, standardized clinical assessment tool of all residents in nursing home. Staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care that they need. 1.) On 03/30/2026 at 11:44 AM, the surveyor observed Resident #2. The resident's room had no fall mats or bed rails up. On 03/31/2026 at 9:50 AM, a review of records was conducted. Records revealed an admission MDS that was completed on 2/20/2026. MDS for restraints under section P0200, Alarms: Resident was coded for use of floor mat alarm as used less than daily. On 03/31/2026 at 10:33 AM, an interview with the unit's manager, Staff #8, and Geriatric Nurse Assistant, Staff #4, was conducted. When asked if the resident had ever used fall mats, both staff members replied no. Staff also reported that restraints have never been used on Resident #2. On 03/31/2026 at 11:16 AM, an interview with Staff #5, MDS coordinator, was conducted. She confirmed that Resident #2 had never had any orders for restraints and acknowledged that the MDS restraints section was coded inaccurately. 2.) On 04/02/2026 at 12:44 PM, a review of Resident #31's medical records was conducted. The review indicated that Resident #31 had an active order for Seroquel Tablet 25 MG (Quetiapine Fumarate) for Brief Psychotic Disorder. Seroquel (quetiapine) is an atypical antipsychotic medication primarily used to treat schizophrenia, bipolar disorder (mania and depression), and as an add-on treatment for major depression. Review of the Medication Administration Record (MAR) indicated that Seroquel was administered daily from the time of admission. Review of the admission MDS Section N0450 - Antipsychotic Medication Review, it was coded that Resident #31 had not received any antipsychotic medications. On 04/02/2026 at 1:42 PM, an interview with Staff #5 was conducted. She confirmed that the MDS was coded incorrectly, it should have been coded that the resident was taking antipsychotics. On 04/02/2026 at 4:05 PM, the facility administrator and Director of Nursing were made aware of the concerns. 3) During survey screening on 3/30/26 at 12:06 PM, Resident 98 stated, No English when the surveyor was trying to interview him/her. Later that day at 12:51 PM, the resident's daughter arrived for visitation. When asked, Resident #98's daughter stated that her loved one [Resident #98] only speaks a few words of English and that his/her primary language was Vietnamese. She stated that the facility typically calls the family when they want to communicate information to the resident and the family informs him/her in Vietnamese. The daughter also stated that she was not aware of the facility ever using a language line to communicate directly with the resident. A review of Resident #98's medical record on 3/31/26 at 1:30 PM revealed that the annual MDS was completed on 12/25/25. The MDS coded the resident under Section A1110 (Language) with Resident 98's preferred language documented as English and as not needing an interpreter to communicate with a doctor or health care staff. During an interview on 4/3/26 at 9:31 AM, Staff #25 (GNA) who has been assigned to care for Resident #98 for years as her aide, stated that Resident #98 does not speak English. Staff #25 stated, I have Resident #98 everyday that I work. He/he has been here for years. We figure out how to communicate. We use gestures and if he/she needs something, he/she brings the wrapper of the item (like the wrapper from a briefs packet) that he/she needs. He/she only speaks a few words of English. During an interview on 4/3/26 at 12:21 PM, Staff #5 (LPN/MDS Coordinator) stated, For the MDS, we get some information from the medical records, the resident or the resident's family. Some of the information self-populates from previous MDS forms. For Resident #98, to my knowledge there is no communication board. We call the family and ask them to relay the information to the resident. After surveyor intervention, the MDS was corrected. 4) On 4/6/2026 at 9:45 AM, a review of the facility's policy stated, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gowns and gloves use during high contact resident care activities.2. Initiation of enhanced barrier precautions: . b. An order for EBP will be obtained for residents with any of the following: .ii. Infection or colonization with a CDC-(Centers for Disease Control) targeted MDRO when Contact Precautions do not otherwise apply. 8. Examples of MDROs targeted by CD include: . e. Candida auris . 10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility. Table 1: Implementing Contact versus Enhanced Barrier Precautions. This table only applies to MDROs. Infected or colonized with a CD-targeted MDRO without a wound, indwelling medical device or secretions or excretions that are unable to be covered or contained – Contact Precautions= No, Use EBP = Yes. (date revised 4/28/2025) A review of Resident #129's medical record on 4/6/26 at 9:30 AM revealed that a quarterly MDS was completed on 3/6/2026. The MDS coded the resident under Section I1700 (Active Diagnoses- Infections) as not having a multidrug resistant organism. However, a review of the physician orders on 4/6/26 at 10 AM revealed a physician order dated 3/30/26 for Enhanced Barrier Precautions to be maintained at all times MDRO (multidrug resistant organism) every shift. During an interview on 4/3/36 at 12:21 PM, Staff #5 confirmed that Resident #129's MDS had been inaccurately coded to state that the resident did not have a MDRO. After surveyor intervention, the MDS was corrected. During an interview on 4/6/26 at 12:07 PM, the DON stated that she believed the facility received an email from the Department of Public Health in 2024 notifying the facility that Resident 129 was positive for C. auris. The DON stated, Then we had to do a big workup, swabbing him/her and other residents. I am not sure what the source ended up being. I will look it up. On 4/6/26 at 12:17 PM, the DON furnished to the surveyor an email dated 6/13/2024 from the Maryland Prevention and Health Promotion Administration's epidemiologist stating that R129 was Candida auris positive and he/she can be on enhanced barrier precautions because C. auris is a CDC-targeted MDRO.

Based on record review and interview, it was determined the facility failed to notify residents receiving Medicaid benefits to spend down when their personal account reached within $200 of the SSI resource limit. It was evident for 8 residents (Resident #12, Resident #48, Resident #54, Resident #57, Resident #62, Resident #104, Resident #108, Resident #129) out of 73 residents reviewed for personal funds. The findings include: On 4/6/26 at 11 AM, a review of the facility's [fund management company] report dated 4/3/26 revealed 8 residents with personal accounts that exceed $2500, which is the SSI resource limit. Per this report:1). Resident #12 had $2625.53 in his/her personal fund account.2). Resident #48 had $3235.99 in his/her personal fund account.3). Resident #54 had $2831.18 in his/her personal fund account.4). Resident #57 had $3045.42 in his/her personal fund account. 5). Resident #62 had $2609.96 in his/her personal fund account.6). Resident #104 had $2958.31 in his/her personal fund account.7). Resident #108 had $2923.68 in his/her personal fund account.8). Resident #129 had $2734.44 in his/her personal fund account. On 4/6/26 at 12:43 PM, Staff #24 (Business office manager) stated, When the residents approach the $2500 limit, I give them a catalog and they can order items such as clothing, toothbrushes, etc using their monies. I don't have access to move the residents' monies, so I need to contact corporate for monies to be moved to burial accounts.On 4/7/26 at 10 AM, the surveyor was given copies of Resident Fund Balance Notification letters for the 8 residents (Resident #12, Resident #48, Resident #54, Resident #57, Resident #62, Resident #104, Resident #108, Resident #129). The letter stated This letter is to notify you that your Resident fund balance is within $200 or exceeding what is allowable under Medical Assistance. Please contact your Social Worker within the next 7 days to discuss ways to assure continuance of Medicaid benefits. A review of the 8 documents revealed that each document was signed by Staff #24 and each resident. A review of each document revealed: 1). Resident #12's letter was signed in illegible handwriting. A review of Resident #12's Physician Certifications form revealed that Resident #12 was certified on 8/21/24 by Staff #22 (MD) as Unable to understand and sign admission documents and other information. A review of Resident #12's facesheet (facility document that captures information such as birthdate, address, insurance, diagnoses and emergency contacts, etc) documented a daughter as emergency contact. 2). Resident #48's letter was signed with an X. A review of Resident #48's Physician Certifications form revealed that Resident #48 was certified on 2/6/25 by Staff #22 (MD) as Unable to understand and sign admission documents and other information. A review of Resident #48's facesheet documented that Resident #48 has a Court-appointed guardian.3). Resident #54's letter was signed with an X. A review of Resident #54's Physician Certifications form revealed that Resident #54 was certified on 6/27/24 by Staff #22 (MD) as Unable to understand and sign admission documents and other information. A review of Resident #54's facesheet documented a daughter-in-law as emergency contact.4). Resident #57's letter was signed with an X. A review of Resident #57's Physician Certification of Incapacity form revealed that Resident #57 was certified on 7/17/18 by a physician as He/she is incapable of making informed decision regarding treatment. A review of Resident #57's facesheet documented a friend as emergency contact.5). Resident #62's letter was signed by the resident. A review of Resident #62's Physician Certifications form revealed that Resident #62 was certified on 11/18/22 by a physician as Able to understand and sign admission documents and other information. 6). Resident #104's letter was signed by the resident. A review of Resident #104's Physician Certifications form revealed that Resident #104 was certified on 1/17/23 by a physician as Able to understand and sign admission documents and other information.7). Resident 108's letter was signed with an X. A review of Resident #108's Physician Certification of Incapacity form revealed that Resident #108 was certified on 11/16/05 by a physician as He/she is incapable of making informed decision regarding treatment. A review of Resident #108's facesheet documented a spouse as emergency contact.8). Resident #129's letter was signed by his/her spouse, who resides in the room with Resident #129. A review of Resident #129's Physician Certifications form revealed that Resident #129 was certified on 6/25/23 by a physician as Unable to understand and sign admission documents and other information. A review of Resident #129's facesheet documented that Resident #129 had a power of attorney, who was not his/her spouse as emergency contact.Of note, Resident 129's spouse was documented as having a BIMS (Basic Inventory of Mental Status, a structured assessment tool aimed at evaluating cognition in the elderly. BIMS score of 0-7 is reflective of severe cognition deficit, 8-12 reflects moderate cognition deficit and 13-15 score is reflective of normal cognition) score of 9, which was reflective of moderate cognitive impairment on a quarterly MDS (Minimum Data Set) dated 2/1/26.On 4/7/26 at 10:26 AM, Staff #24 stated that the Resident Fund Balance Notification forms were given to the 8 residents (Resident #12, Resident #48, Resident #57, Resident #62, Resident #104, Resident #108, Resident #129) on 4/2/26. When questioned regarding the residents' ability to sign the forms, Staff #24 stated, Most of these residents are alert and oriented. I deal with them all the time. No, I don't check their BIMS score. I don't even know what that is. [Resident #57] is mute but he nods his head and understands what I was saying. The ones who wrote X on the signature form are alert and oriented. All the residents signed their letter but [Resident #129] .I had [his/her loved one] sign. On 4/7/26 at 11:30 AM during the exit conference, Staff #26 (Regional nurse) stated that Staff #24 would not be expected to know the residents' BIMS score and that Staff #24 would look at the Physician Certifications form at the Certification of Ability to Comprehend Information and Make Decisions to ascertain if a resident was capable of signing a legal form.

Based on record reviews and interviews, it was determined that the facility failed to educate and provide COVID-19 immunizations to the residents. This was evident for 5 (Resident #28, #57, #48, #39, #12) out of 5 residents reviewed for immunizations during the recertification survey. The findings include: On 04/06/2026 at 2:20 PM, the surveyor requested the facility to provide COVID-19 policy and proof that Resident #28, #57, #48, #39 and #12 had been educated and offered COVID 19 vaccine in 2025. On 04/06/2026 at 2:30 PM, a review of records was conducted. Review of residents' electronic records indicated that Resident #28, #12, #48 and #57 had received COVID-19 immunizations on 11/11/2024. Resident #39 was last offered COVID-19 immunization in 2023. On 04/06/2026 at 2:55 PM, a review of the facility's COVID-19 vaccination policy indicated that all residents who are eligible for immunizations were to be educated and offered the vaccine annually. On 04/06/2026 at 2:33 PM, an interview with the Director of Nursing (DON) was conducted. She confirmed that the facility offers immunizations to residents annually. She reported that she had no documentation to support the vaccines were administered or refused. DON acknowledged that the 5 residents should have been offered COVID- 19 immunizations in 2025.On 04/06/2026 at 2:40 PM, the facility administrator was notified of the concerns.

Based on record review and interviews, it was determined that the facility 1) failed to ensure that medication was available for administration as ordered and 2) failed to administer medications on time. This was evident for 1 (Resident #31) out of 5 residents reviewed for medication administration and 1 (Resident #144) out of 3 residents reviewed for medication administration. The findings include:1) Clonazepam (brand name Klonopin) is a Schedule IV controlled substance in the United States, regulated due to risks of misuse, addiction, and physical dependence. While it has accepted medical uses for treating seizure and panic disorders, its status requires restricted, prescription-only access. On 04/02/2026 at 2:38 PM, a review of Resident #31's medical record was conducted. The review revealed an order for Clonazepam that was entered on 3/16/2026, the day the resident was admitted into the facility. The review of the Medication Administration Review (MAR) indicated that the resident was not given the medication on 3/16/20 to 3/20/2026. Review of the nurses' notes on 3/17/2026 indicated that the staff was waiting for the medication from the pharmacy. On 04/02/2026 at 2:50 PM, an interview with the Director of Nursing (DON) was conducted. When asked what the process was to obtain controlled medications for newly admitted residents, the DON reported that the provider is supposed to complete a C2 form, which is then faxed to the pharmacy. Additionally, some providers are also able to request the medications for residents electronically or alternatively call the pharmacy and give a verbal order to release the medications for the residents. The DON Acknowledged that the resident's medication should not have been delayed. She also confirmed that the facility meets in the morning to discuss any challenges or concerns for newly admitted residents. The facility staff should have discussed and addressed the lack of medication during these morning meetings. On 04/02/2026 at 3:29 PM, the facility administrator was notified of the concerns. 2) On 4/06/2026 at 10:17 AM, a review of Complaint 2701933 and an interview with the complainant was conducted. The complainant alleged that the facility did not administer Resident #144's eye medication on time. On 4/06/2026 at 10:31 AM, a review of the Medication Administration Audit Report was conducted. Resident #144 was ordered Timolol Maleate Ophthalmic Solution 0.5 % 1 drop in both eyes two times a day. Timolol Maleate was given over an hour late 22 times from 12/6/2025 to 12/21/2025 by multiple nurses. On 4/06/2026 at 11:00 AM, an Interview with the Director of Nursing (DON) was conducted. This surveyor confirmed the late administrations of Timolol with the DON. When asked when medications should be given, The DON stated medications should be given at the time they were ordered to be given. The minimal standard of practice for timely medication administration is that medications that are not time sensitive are to be given in the window of 1 hour before and 1 hour after the ordered administration time.

Based on observations, record reviews and interviews it was determined that the facility failed to maintain professional standards of practice related to oxygen orders. This was evident for 1 (Resident #49) out of 2 residents reviewed for respiratory orders. Findings include: On 03/30/2026 at 9:00 AM, an observation of Resident #49 revealed that the resident was receiving oxygen therapy. On 03/31/2026 at 9:42 AM, record review failed to reveal an active order for oxygen. On 04/01/2026 at 9:25 AM, concerns were brought up to the Director of Nursing and she indicated that she understood.

Based on record review and interview, it was determined that the facility failed to review and revise the interdisciplinary care plans to reveal accurate interventions. This was evident for 1 (Resident #129) out of 2 residents reviewed for care plans during the survey process. The findings include: A care plan is a guide that addresses the unique needs of each resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assuring the resident's needs are attended to. The care plan is to be reviewed and revised at each of the resident's quarterly assessment times to ensure the interventions on the care plan are accurate and appropriate for the resident. On 3/30/26 at 11:30 AM during screening observations, the surveyor observed that Resident #129 did not have any indwelling catheters and had wounds on his feet that were covered to contain any secretions. On 4/6/26 at 9:45 AM, the surveyor reviewed the Facility policy on Enhanced barrier precautions (EBP), which stated that EBP refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gowns and gloves use during high contact resident care activities.2. Initiation of enhanced barrier precautions: . b. An order for EBP will be obtained for residents with any of the following: .ii. Infection or colonization with a CDC-(Centers for Disease Control) targeted MDRO when Contact Precautions do not otherwise apply. 8. Examples of MDROs targeted by CD include: . e. Candida auris . 10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility. Table 1: Implementing Contact versus Enhanced Barrier Precautions. This table only applies to MDROs. Infected or colonized with a CD-targeted MDRO without a wound, indwelling medical device or secretions or excretions that are unable to be covered or contained – Contact Precautions= No, Use EBP = Yes. (date revised 4/28/2025) On 4/6/26 at 9:30 AM, a review of Resident #129's medical record revealed a physician order dated 3/30/26 for Enhanced Barrier Precautions to be maintained at all times MDRO (multidrug resistant organism) every shift. Further review of Resident #129's medical record revealed a care plan dated 6/12/24 with a focus that stated, [Resident #129] has infection positive for Candida Auris, Candida Albicans and the assigned interventions stated, Maintain Contact precautions. The care plan had not been revised to reflect the change to Enhanced Barrier Precautions that was ordered in March 2026. On 4/6/26 at 12:17 PM, the DON furnished to the surveyor an email dated 6/13/2024 from the Maryland Prevention and Health Promotion Administration's epidemiologist stating that R129 was Candida auris positive and he can be on enhanced barrier precautions because C. auris is a CDC-targeted MDRO. Cross refer F641

Based on record review and staff interview, it was determined that the facility failed to refer the residents with a serious mental disorder for a level II assessment. This was evident for 2 (Resident #1 and Resident #9) out of 3 residents reviewed for PASARR. The findings include: 1). A review of Resident #1's medical record on 4/2/26 at 1:56 PM that Resident #1 was admitted to the facility on [DATE] from a hospital with a documented diagnosis of schizoaffective disorder. Further review of Resident #1's medical record revealed a physician order on 2/2/26 for olanzapine (an atypical antipsychotic medication) 10 mg (milligrams) daily. Resident #1's admission MDS (Minimum Data Set) from 2/5/26 was coded in Section I Active Diagnoses that Resident #1 carried a diagnosis of Schizophrenia (I6000) and in Section N Medications, N0450 Review of Antipsychotic Medications coded Yes, antipsychotics were received on a routine basis. The PASARR that was initiated by the hospital on 2/1/26 at 10:07 AM contained no documentation of the schizophrenia diagnosis or the usage of antipsychotic medication for this resident with the Outcome of this PASARR evaluation stating Auto Approved- No Level II Required. During an interview on 4/3/26 at 12:33 PM, Staff #13 stated that the facility did not have an updated PASARR for Resident #1. 2). A review of Resident #9's medical record on 3/30/26 at 11:44 AM revealed Resident #9 was admitted on [DATE] with a diagnosis of bipolar disorder. Further review of Resident #9's medical record revealed a physician order on 12/18/25 for olanzapine 2.5 mg via PEG (percutaneous endoscopic gastrostomy tube- a conduit inserted into the stomach through the skin to administer food and medications to a resident) at bedtime for bipolar disorder. Resident #9's admission MDS from 12/24/25 was coded in Section I Active Diagnoses that Resident #9 carried a diagnosis of bipolar disorder (I5900) and in Section N Medications, N0415 High Risk Drug Classes that Resident #9 was taking and had indications noted for an antipsychotic medication. The PASARR that was initiated by the hospital on [DATE] at 3:19 PM contained no documentation of the bipolar disorder diagnosis or the usage of antipsychotic medication by the resident with the Outcome of this PASARR evaluation stating Auto Approved- No Level II Required. During an interview on 4/3/26 at 12:33 PM, Staff #13 stated that the facility did not have an updated PASARR for Resident #9. Staff #13 (SWS) also stated, Sometimes with PASARR, the resident comes from the hospital and the PASARR does not have a diagnosis or a med (medication) on it, so we have to resubmit. We talk about each new admission at the morning clinical meeting and the diagnoses are discussed. If there is a discrepancy, then we resubmit. During a telephone interview on 4/6/26 at 11:47 AM, Staff #23 (LCSWC, Regional SWS) stated that when a resident is admitted from a hospital with a PASARR that does not include his/her psychiatric diagnosis, the facility will update the PASARR for the resident as a new diagnosis and document in the PASARR that the facility learned of the old diagnosis including the timeline of the diagnosis. The facility cannot resubmit a new PASARR, because the system [name of the PASARR application system] will reject the request for a new PASARR as outcome not rendered. Staff #23 did also state that the facility is not able to see previous diagnoses from other PASARR in this system. Staff #23 stated that she would update the PASARR for the residents after the surveyor supplied their names. After Surveyor intervention, the PASARRs were amended.

Based on record review and interview with facility staff, it was determined that the facility failed to ensure appropriate provision and documentation of notice of hospital transfer and bed hold policy to residents' responsible party (RP). This was evident for or 1(Resident #7) out of 3 residents reviewed for discharge process during the facility's recertification/complaint survey. The findings include: Oxygen saturation (SpO2) measures the percentage of oxygen-carrying hemoglobin in the blood, with a normal reading for healthy individuals typically between 95% and 100%. Levels below 90% are considered low (hypoxemia), which can cause symptoms like shortness of breath, confusion, and rapid heart rate. Urgent medical attention is required if levels drop to 88% or lower. Aspiration pneumonia is a lung infection caused by inhaling food, liquid, vomit, or saliva into the lungs, often causing symptoms like fever, cough, chest pain, and shortness of breath. The MDS (Minimum Data Set) is a federally mandated, standardized assessment tool used in Skilled Nursing Facilities (SNFs) to comprehensively assess a resident's clinical and functional status. The MDS is used to develop individualized care plans, monitor quality of care, and determine Medicare reimbursement. A BIMS score is derived from the Brief Interview for Mental Status, a brief screening tool for assessing cognitive function in long-term care settings. A score between 0 and 15, where higher scores indicate better cognitive ability, helps facilities track cognitive changes. Scores are categorized: 0–7 is severe impairment, 8–12 is moderate impairment, and 13–15 is cognitively intact. The assessment evaluates temporal orientation and short-term recall. On 03/31/2026 at 12:12 PM, a review of his/her 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 02, indicating severe cognitive impairment. On 03/31/2026 at 12:35 PM, a review of Resident #7's electronic record revealed that on 02/01/2026 at 07:08, he/she experienced a change in condition (he/she was observed with oxygen saturation level of 76%, and restless) and Nurse Practitioner Staff #29 ordered for him/her to be transferred to the hospital for further evaluation and treatment. On 03/31/2026 at 12:48 PM, further review of Resident #7's electronic record showed the nurses' follow-up note which indicated he/she was admitted to the hospital with aspiration pneumonia. On 03/31/2026 at 1:53 PM, a review of Resident #7's medical record identified a physician's certificate of incapacity dated 01/09/2026, indicating that Resident #7 was unable to comprehend information or make decisions due to dementia. On 03/31/2026 at 2:04 PM, in an interview with the Social Services, Staff #13, when she was asked if a notice of hospital transfer and bed hold policy was provided to Resident #7's responsible party (RP), she stated that it was provided and was requested to provide the surveyor with the documents. On 03/31/2025 at 2:43 PM, a copy of the notice of hospital transfer and bed hold policy was provided and upon review, it indicated acknowledgment of receipt with Resident #7 listed as the signer. On 03/31/2026 at 2:55 PM, during an interview, Licensed Practical Nurse (LPN) #12, when she was asked for the process of discharging residents to the hospital, she stated that when a resident is alert and oriented, the bed hold policy and notice of hospital transfer are provided by the nurse to the resident for review and signature, with copies distributed to accompany the resident to the hospital, maintained by social services, and retained in the medical record. LPN #12 further stated that when a resident is unable to make decisions or has altered mental status, the responsible party (RP) was notified, and documentation is forwarded to the social worker for distribution and record retention. When asked if Resident #7 was able to understand and sign the notice of transfer and bed hold policy at the time of his/her hospital transfer on 02/01/2026, she stated that the resident could not do so. On 03/31/2026 at 3:17 PM, during an interview with the Director of Nursing (DON), when asked for the process of providing bed hold policy and notice of hospital transfer to resident, she stated that when a resident is alert and oriented, the documentation was provided for signature, and when the resident is unable due to altered mental status, the documentation was sent with the admission liaison to take to the hospital. She also added that if the residents are not their own responsible (RP), a copy was provided to the social services, who will send the documents by electronic mail or regular mail to the responsible party (RP). On 03/31/2026 at 3:20 PM, during a follow-up interview, when asked what Resident #7's cognitive status was and the reason for his/her hospital transfer, the DON confirmed the resident had a BIMS score of 02, indicating significant cognitive impairment, and added that he/she was transferred to the hospital due to low oxygen saturation and altered mental status. When asked if the resident could have signed his/her bed hold notice and understood his/her reason for hospital transfer, the DON stated Resident #7 would not have been able to understand the hospital transfer or sign the bed hold notice. When she was informed about the findings and presented with the documentation showing acknowledgment of receipt signed as self dated 03/01/2026 by Resident #7, the DON acknowledged this discrepancy as a concern.

Based on record review and staff interviews, it was determined that the facility failed to report an allegation of abuse in a timely manner. This was evident for 1 (Resident #139) out of 6 reviewed for abuse. The findings include: On 04/02/2026 8:00 AM, a review of incident 2685769 was conducted. Resident #139 alleged that a staff member hit them.On 4/02/2026 at 8:17 AM, a review of the facility investigation documentation was conducted. Staff #32 became aware of the incident on 12/4/2025 at 9:45 pm. The Nursing Home Administrator (NHA) became aware of the incident on 12/5/2025 at 10:30 am. The initial report submitted on 12/5/2025 at 12:40 pm.On 4/02/2026 at 10:21 AM, an interview with NHA was conducted. When asked how quickly staff should report an allegation of abuse when they are made aware. The staff should report the incident to the Director of Nursing (DON) or the NHA right away. When asked if the facility staff should have reported this incident to the NHA or DON sooner. Yes, typically they should notify Administration right away.On 4/02/2026 at 10:35 AM, a review of the facility's Abuse and Neglect Policy revealed that the facility staff are expected to report any allegation of abuse to the Administrator immediately.

Based on record review and interview, it was determined that the facility failed to provide services to maintain communication abilities to a resident with Limited English Proficiency (LEP). This was evident for 1 (Resident #98) out of 1 resident reviewed for communication. The findings include: During survey screening on 3/30/26 at 12:06 PM, Resident 98 stated, No English when the surveyor was trying to interview him/her. Later that day at 12:51 PM, the resident's daughter arrived for visitation. When asked, Resident #98's daughter stated that Resident #98 only speaks a few words of English and that his/her primary language was Vietnamese. She stated that the facility typically calls the family when they want to communicate information to the resident and the family informs him/her in Vietnamese. The daughter also stated that she was not aware of the facility ever using a language line to communicate directly with Resident #98. A review of Resident #98 's medical record on 3/30/36 at 1:15 PM revealed that Resident #98 was admitted to the facility on [DATE]. Further review of the records revealed that on Resident #98's admission Minimum Data Set (MDS) assessment dated [DATE], Vietnamese was documented as his/her preferred language. During an interview on 4/3/26 at 9:31 AM, Staff #25 (GNA) who has been assigned to care for Resident #98 for years as her aide, stated that Resident #98 does not speak English. Staff #25 stated, I have Resident #98 everyday that I work. He/she has been here for years. We figure out how to communicate. We use gestures and if he/she needs something, he/she brings the wrapper of the item (like the wrapper from a briefs packet) that he/she needs. No, I have never seen a communication board or the language line used to communicate with Resident #98. He/she only speaks a few words of English. He/she likes to go to the Activities because he/she likes to be around people. During an interview on 4/3/26 at 3:10 PM, the DON stated that she did not believe that the staff use a communicate board to interact with Resident #98. Cross refer F641.

Based on observations, staff interviews, and record reviews, it was determined that the facility failed to ensure that residents received oxygen therapy in accordance with physician orders for 1 (Resident #45) of 2 residents reviewed for oxygen use. The facility also failed to develop a care plan to address oxygen therapy needs and failed to ensure that residents were not connected to empty oxygen tanks. The findings include:On 03/30/2026 at 11:15 AM, Surveyor observed Resident #45 on 3L of Oxygen via Nasal Cannula. On 03/30/2026 at 11:25 AM, an interview with Resident #45 was conducted. They reported that they were supposed to be on 2L of oxygen because of pneumonia. On 03/31/2026 at 10:15 AM, Surveyor observed Resident #45 on 3L of Oxygen via Nasal Cannula. On 03/31/2026 at 11:59 AM, a review of Resident #45's medical record revealed an active order to administer Oxygen via nasal cannula at 2 L/min every shift for COPD (a chronic lung disease). Additionally, review of the care plan failed to include oxygen therapy interventions. On 03/31/2026 at 12:01 PM, Surveyor observed Resident #45 sitting on a wheelchair. Their Nasal Cannula was connected to an Oxygen tank behind the wheelchair. The oxygen tank was noted to be empty. On 03/31/2026 at 12:06 PM, an interview with Staff #11 was conducted. She reported that she was not aware that the resident was connected to an empty tank. When asked how many liters of Oxygen should be administered to Resident #45, staff stated I think 3L. On 03/31/2026 at 1:09 PM, an interview with the administrator was conducted. He reported that he had trained facility staff to always use a full tank. He acknowledged that the resident's nasal cannula should not have been connected to an empty oxygen tank. On 03/31/2026 at 1:11 PM, the Administrator and Director of Nursing were notified of oxygen concerns and associated care plan development.

Based on observations and interviews it was determined that the facility failed to ensure that a resident had access to their call bell. This was evident for 1 (Resident #49) out of 35 observations made on call bells. The findings include: On 03/30/2026 at 8:46 AM, an observation of Resident #49 revealed the call bell was on the floor and not within reach of the resident. On 03/31/2026 at 10:37 AM, an observation of Resident #49 revealed the call bell was on the floor and not within reach of the resident. On 03/31/2026 at 12:18 PM, an observation of Resident #49 revealed the call bell was on the floor and not within reach of the resident. On 04/01/2026 at 10:20 AM, an observation of Resident #49 revealed the call bell was on the floor and not within reach of the resident. On 04/01/2026 at 10:21 AM, an interview with Geriatric Nurse Assistant (Staff #15) revealed that the expectation regarding call bells is that it should be within reach at all times. At the same time, Staff #15 revealed that Resident #49 in particular does not have a clip on her call bell cord, making it difficult for the call bell to be within reach at all times. On 04/01/2026 at 10:35 AM, an interview with the Director of Nursing revealed that the expectation regarding call bells is that they should be within reach at all times and be clipped. At the same time, the concerns were brought up with the Director of Nursing and she indicated that she understood.

Based on observations, interviews and record reviews, it was determined that the facility failed to ensure that staff adhered to enhanced barrier precautions when providing care to residents. This was evident for 1 (Resident # 87) out of 6 residents reviewed for infection control practices during the recertification survey. The findings include: Enhanced Barrier Precautions (EBP) are an infection control strategy for nursing homes, requiring gowns and gloves during high-contact resident care to prevent the spread of Multidrug-Resistant Organisms (MDROs).A PICC line (peripherally inserted central catheter) is a long, thin, flexible tube inserted through a vein in the upper arm and advanced to a large vein near the heart. This tube is used to give intravenous (IV) medications to a patient. On 04/03/2026 at 08:30 AM, the surveyor observed Staff #31 give Resident #87 Fluticasone IV medication through a PICC line. Staff #31 was not wearing a gown, only gloves. Resident #87's door had a yellow sign that indicated EBP precautions to be followed when providing care or providing medications via the PICC line. On 04/03/2026 at 08:40 AM, an interview with Staff #31 was conducted. When asked if she was aware that the resident was on EBP precautions, the nurse replied no, no one had told her that information. When asked if she knew how the facility identified the residents who were on EBP, the nurse stated she was an agency nurse, and that it was her first day at the facility and that she had not been provided with training yet. On 04/03/2026 at 08:45 AM, Staff #31 was notified of the concern, and the proper personal protection equipment was reviewed with the surveyor. On 04/03/2026 at 08:49 AM, a review of Resident #87's medical record was conducted. The review confirmed that the resident had an order for EBP to be maintained at all times for PICC line use every shift for preventive measures.On 04/03/2026 at 12:33 PM, an interview with the Director of Nursing (DON) was conducted. She reported that the facility requires all staff to adhere to EBP precautions and must wear gowns and gloves when taking care of PICC lines. At this time, the DON was notified of the infection prevention concerns observed. On 04/03/2026 at 2:40 PM, the facility administrator was made aware of the concerns.

Based on interviews and record reviews, it was determined that the facility failed to provide physical therapy services as ordered. This was evident for 1 (Resident #6) out of 6 residents reviewed for therapy services during the recertification survey. The findings include: On 03/30/2026 at 8:36 AM, an interview with Resident #6 was conducted. They reported that they were supposed to receive Physical Therapy (PT) services 3 times a week, however, this rarely happened. On 04/01/2026 at 8:25 AM, a review of physical therapy notes revealed that in February Resident #6 had 3 PT sessions (17th, 18th, and 26th) and 5 sessions in March (11th, 12th, 20th, 24th, and 26th). Review of Resident #6's care plan revealed an intervention that indicated that the resident should receive physical therapy evaluation and treatment as per orders. Further review of records revealed an active order for the resident to continue skilled Physical Therapy 3-5 times per week for 90 days for therapeutic exercises. The review of a recent PT recertification completed on 3/19/26 indicated that Resident #6 should continue PT services 3-5 days a week for therapeutic exercise, Neuro re-education, therapeutic activities, gait training and wheelchair management and mobility. On 04/01/2026 at 10:20 AM, an interview with Staff #33, PT Director, was conducted. He reported that even though the resident is ordered for 3-5 PT sessions per week, since the resident is considered a long-term resident, the facility does its best to accommodate the sessions, at times that can be one or two sessions per week. On 04/01/2026 at 12:00 PM, an interview with Staff #34, Regional PT Director, was conducted. She reported that the resident's order should include as needed because Resident #45 had plateaued but could not be discharged from PT services. On 04/01/2026 at 12:20 PM, the facility administrator was made aware of the concerns.

Based on administrative and medical record review, observations and interviews with facility staff and family it was determined that the facility failed to prevent a cognitively impaired resident who is at risk for wandering from exiting the facility unsupervised. This was evident for 1 (Resident #1) of 4 residents reviewed during the facility's complaint survey. This failure resulted in an Immediate Jeopardy for Resident #1. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey; therefore, this deficiency will be cited as past noncompliance. The date of correction was 6/27/25. The findings include: Medical record review on 6/30/25 at 10:00AM revealed that Resident #1's diagnoses included but were not limited to Alzheimer's Disease (a progressive brain disorder that slowly destroys memory and thinking skills). The resident has a Brief Interview of Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment. Review of a recent wander risk assessment completed on 4/18/25 indicated the resident was at risk for wandering and the resident had a care plan to address wandering behaviors to include a wander guard placement. The facility provided a copy of a timeline of events for Resident # 1 and their investigation to the survey team on 6/30/25 at 10:20 AM and the following information was reviewed: On 6/22/25 at 2:00PM Resident #1 was last seen by 7-3 Charge Nurse (CN) #7. A statement provided by the CN #7 indicated that she returned from lunch and assisted Geriatric Nurse Assistant (GNA) #5 with a resident. Afterwards she walked down the hallway and saw Resident #1 lying on the bed in their room. Review of a statement provided by GNA #4, she indicated on 6/22/25 she arrived at work at approximately 3:05 PM and heard an alarm sound. She described it as a soft beep, like a patient call light and it did not sound urgent. She noticed the evening nurse, Staff # 6 performing rounds. The nurse asked where Resident # 1 was and GNA #4 replied she did not know as she was in the process of making rounds. GNA #4 asked the nurse where the noise was coming from and both the GNA and nurse proceeded to the exit door and noticed it was slightly open. The nurse opened the adjacent door (a door leading outside the building) and discovered that it was unlocked. The alarm continued to sound as they both entered back through the door. They began asking staff if they knew the whereabouts of Resident # 1, and the resident location was unknown. They continued to search for the resident. Review of a statement provided by the weekend RN Supervisor (RNS) #8, she stated that on 6/22/25 at approximately 3:40PM she was informed by the 3-11PM Licensed Practical Nurse (LPN), #6, that Resident # 1 was missing. The RNS (#8) activated the code purple for missing residents. A facility wide search was conducted to include the exterior and surrounding neighborhood. Further review of the investigation and timeline revealed the Director of Nursing and Administrator were notified on 6/22/25 at 4:33PM, and a voice mail message was left with the resident family at 4:36 PM. At 4:40 PM local law enforcement arrived at the facility to conduct a search. All available department managers were notified to report to the facility to assist with canvassing the facility and neighborhood. At 5:42 PM the NHA was able to reach the resident's family to inform them of the situation. At 7:30PM the staff continued searching after clearance from local law enforcement. An interview was conducted with the NHA on 6/30/25 at 10:10AM and he stated that he was notified that Resident #1 had eloped on 6/22/25 at approximately 4:30PM. He stated that he immediately came to the building and notified the resident's family. He further stated that the police came to the facility and stopped the facility staff from any further search due to this interfering with the police dog scent. The NHA went on to say that the next day, 6/23/25 at approximately 7:45 AM, a staff member was driving by and saw the resident in a wooded area near the facility. He stated that the resident had never eloped prior to this incident. Emergency Medical Services (EMT) was called, and the resident was brought back to the facility and assessed by EMS on-site. The resident did not have any injuries, however, was taken to the hospital for further evaluation. The NHA stated that the resident had a Urinary Tract Infection (UTI) and was able to leave the facility by way of the exit door located on the first floor due to a very low alarm sounding which was barely heard from the nursing station. He went on to say that the facility provided education to staff and has put stop exit alarms in the building that alarms loudly. An interview was conducted with the resident family on 7/1/25 at 9:30AM and they stated that they were notified as soon as the facility was aware of the resident leaving the building. They stated they had come to the facility and the police had a K-nine unit on the grounds. S/he stated that the search continued to approximately 9:00PM and then another person from their department was brought in with a drone that uses thermal imaging. The family said the police department provided an update at approximately 11:30-12:00AM when s/he contacted them, that they would continue to monitor but did not locate the resident. S/he stated that the facility informed him/her the next morning that the resident was located at the end of the property. They stated that Resident #1 was not injured but taken to the hospital for further evaluation. An interview was conducted on 7/1/25 at 10:41 AM with the evening nurse, LPN #6 and he stated the following: He worked on 6/22/25 and arrived on duty a few minutes after 3:00PM. He was walking down the hall doing rounds and GNA #4 came to him and reported that an alarm was sounding. He stated that when he and the GNA went to the area where the sound was coming from, the door was open. They went outside and looked around the grounds and did not see anyone. They came back into the building and began a head count of all residents and noted that the resident was missing. The nurse stated that the supervisor was notified, Administrator and 911 were called. The nurse stated that when the police arrived, the staff were made to stay inside. During observation rounds during the complaint survey on 6/30/25 and 7/1/25 accompanied by the NHA and the Director of Maintenance (DOM), the following observations were made: There are 2 exit doors located on the first floor on the Chapel Way Unit and 1 exit door on the Garden View Unit. On the second floor there were 2 Exit doors at the Nightingale Unit and 2 Exit doors at the Forest View Unit. Each of the exit doors has an egress (allows 15 seconds to alarm before it locks) once the door is pushed and then the alarm sounds. Beyond the exit door on Chapel Way and Garden View on the unit, there is another exit door that allows exit to the ground. All the exit doors have a red box stop exit alarm that sounds loud to alert the staff. Both alarms sounded and staff responded. The stop exit alarms were put into place after the resident eloped as part of an intervention. Further observations were made of the exit doors that have a wander guard system in place as follows: The Dining Room located on Chapel Way leads to a fenced courtyard with a functioning system. The wander guard located at both exit doors on the Memorial Garden Unit located across from the Laundry Room has a functioning system. The exit door that leads to the courtyard located in the dining room of the Garden View Unit has a functioning system. In addition, there are functioning wander guards located in the entrance to the kitchen/employee area and the exit door where the trash and dumpster area are located. The front entrance lobby area and the entrance door have a wander guard. All observed areas had a functioning wander guard system. During a consequential meeting with the NHA, he provided documentation on elopement prevention done by maintenance, inspection of the exit doors and door alarm response in service training for all staff prior to installation of the red stop box alarms. During another interview with the NHA on 7/1/24 at 1:30 PM he provided documentation of the elopement prevention plan that the facility put into place following the elopement. Upon review it revealed the following: On 6/23/25 education was started and provided to all facility staff. Nurses were provided education on testing wander guard bracelets for placement and function. All staff were educated on responding to door alarms immediately and notifying the supervisor. Further education on elopement prevention was provided, to all staff on emergency doors, frequent rounds and the red stop box alarms placed at exit doors. The box alarm is a loud alarm that sounds when someone is exiting the door. The alarms were installed on 6/27/25. All education was provided by the ADN, DON and Director of Maintenance. All concerns were discussed at the exit conference on 7/1/25 at 3:30PM. Based on the above actions taken by the facility and verified by the surveyor on-site, it was determined that the facility had corrected the deficient practice by 6/27/2025, prior to the start of the survey.

Based on medical record review and interviews with facility staff it was determined the facility failed to address residents with significant weight loss. This was found to be evident for 1 (Resident # 122) of 3 residents reviewed for weight loss during the survey. Findings include: Resident # 122's medical record was reviewed on 12/19/25 at 10:00AM for weight loss. Upon review, it revealed the resident with an admission weight on 1/8/25 of 229.2 pounds and a weight one month later on 2/10/25 of 216.2 pounds. The resident was noted to have a significant weight loss of 13 pounds (10%) within 1 month. Review of the resident nutrition care plan on the same date at 10:25 AM reveals the care plan was initiated on 1/8/25 and one of the interventions listed was to notify the MD and dietician if resident had any significant weight changes. Review of a discharge summary note dated 2/11/25 from the residents' previous provider service indicated that the resident was morbid obese but did not address the significant weight loss of 13 pounds for one month. An interview was conducted on 2/19/25 at 10:40AM with the Medical Director (Staff # 20) and he was asked to explain this resident's weight loss and he stated the following: The facility conducts risk management meetings every week and weight loss are addressed at that time. In addition, the facility reviews trends at the Quality Assurance and Performance Improvement (QAPI) meetings as well. He went on to say that Resident #122 was transferred to their services on 2/11/25 and services provided prior to this were under another service. He stated that he could not speak regarding the resident weight loss, but the expectation is that the resident weight loss should have been addressed. Further review of the dietitian notes on the same date reveals there was no documentation to address the resident significant weight loss. An interview was conducted with the Dietitian (Staff # 8) on 2/19/25 at 12:05 PM and he was asked to explain what is put in place for a resident that has a significant weight loss. He stated that when a resident has significant weight loss, the normal process is to talk to the resident if they can be interviewed about supplements and if the resident desires supplements, they are started. He stated that he is unsure if he spoke with the resident regarding the supplements because he did not document it. He further stated that all significant weight loss is brought to risk management meetings as well. He went on to say that he is unable to provide documentation of weight loss and any changes to the resident regimen and moving forward, all changes and interventions will be documented. All concerns were discussed with the Administration team at the time of exit on 2/19/25 at 2:30PM.

Based on surveyor review of clinical records, the review of administrative records, and interviews with staff, it was determined that the facility staff failed to ensure appropriate pain management and timely treatment was provided in accordance with professional standards for 1 of 3 residents reviewed during the complaint survey (Resident #1). The facility's failure to report a fracture to the attending physician and administer medication according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This finding of actual harm was identified during the investigation of complaints MD 661, MD 741, and facility reported incident MD 666. The findings include: On 03-30-2021 a review of Resident #1's clinical record revealed that on 02-18-2021 at 11:03 PM the resident had a fall during a self-transfer from the bed to the wheelchair. On 02-19-2021 Licensed Practical Nurse (LPN) #4 documented a change in condition and assessment of the resident. Resident #1's right thigh was noted to have tenderness to touch. The resident complained of pain at the site. Resident #1 reported a fall and injury to the right knee during a transfer attempt. A review of the Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1 's February 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Tylenol was effective for the right hip pain. Further review of the 02-19-2021 change in condition documentation for Resident #1 revealed that the on-call nurse practitioner was notified at 12:30 AM of the resident's fall, an order was given to obtain an X-ray of the right femur (hip) to rule out a fracture. A review of the 02-19-2021 X-ray results of the right femur revealed no acute fracture or dislocation. On 03-30-2021 further review of Resident #1's record revealed that on 02-25-2021 the attending physician documented a follow up visit with Resident #1 due to persistent leg pain as reported by staff and the resident's family. However, a review of the February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a visit 02-25-2021, the attending physician ordered 25 mg of [MEDICATION(S)] to be given twice daily to Resident #1 for pain. Further review of February and March 2021 MARs revealed that staff administered [MEDICATION(S)] 25 mg twice daily as ordered at 9:00 AM and 8:00 PM. In addition, during the visit, the attending physician ordered a CT scan of the right femur secondary to the resident's intermittent pain at position changes and the increase in swelling. The CT scan was to be scheduled through the resident's insurance after authorization. The continued review of Resident #1's record revealed that on 03-03-2021 the attending physician completed another follow up visit to address the resident's right hip pain and swelling. The physician documented that on exam the resident's right hip had palpable tenderness. Due to concerns voiced by the resident's responsible party of increased confusion and paranoia, the physician ordered the decrease in the resident's order for [MEDICATION(S)] from 25 mg twice a day to once a day. Further review of Resident #1's February 2021 and March 2021 Treatment Administration Record (TAR) of staff documentation of Resident #1's pain evaluation at every shift revealed a pain level rating of 0 indicated from 02-19-2021 through 03-05-2021 except on 02-25-2021 for the day shift with a pain level rating of 3 was indicated. Additionally, on 03-03-2021 the attending physician ordered another series of x-rays of the resident's right hip and pelvis area to be completed secondary to the pain/swelling and delay in the CT scan authorization. A review of the radiology report of the 03-03-2021 second set of X-rays revealed confirmed results of an acute displaced fracture of the proximal femur (hip). The X-ray result of the pelvis revealed no evidence of a fracture. However, a review of the emedical alert message sent to the attending physician by LPN #1 on 03-03-2021 at 1:01 PM, revealed the LPN's documentation of for the right femur X-ray was inaccurately reported as negative for evidence of a fracture. LPN #1's alert message stated that the right hip X-ray results had no acute fracture or dislocation, [CONDITION(S)] changes and osteopenia. Further review of the 03-03-2021emedical message revealed that the attending responded back at 1:02 PM to continue with the plan as before that included for the CT scan to be performed. LPN #1 responded to the physician at 1:13 PM that she would follow up regarding the status of the resident's insurance authorization in obtaining the CT scan for the resident. On 03-30-2021 at 2:45 PM surveyor interview with LPN #1 revealed that she sent an emedical message to the attending physician on 03-03-2021 after receiving Resident #1's X-ray result of the right femur and pelvis. However, LPN #1 had not been aware that she had inaccurately reported the right femur results until informed by facility management. Further interview revealed that the resident had pain with position change, but when at rest, the resident had no pain. On 03-31-2021 a review of Physical Therapist (PT) #3's documentation, dated 03-03-2021, revealed Resident#1 complained of right hip pain and refused of transfer training. PT #3 followed up with LPN #1, who reported that the resident had received pain medication prior to the therapy session. Further review of the March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . However, a review of PT #3's documentation of the 03-04-2021 therapy session with Resident #1 revealed the resident c/o (complained) of pain in right hip. Attempted repositioning in bed to attempt bridging to the left but resident stated was painful. PT #3 informed LPN #1 that the resident had complained of pain during the therapy session. Further review of the March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1 after 03-03-2021 at 9:00 AM. In addition, there was no documented evidence of the administration of Tylenol 650 mg PRN for Resident #1 from 03-01-2021 through 03-05-2021. Surveyor interview on 03-31-2021 at 10:15 AM with PT #3 revealed that Resident #1 complained of pain during therapy whenever the resident was moved. When the resident was not moved, then there were no complaints of pain. Further interview revealed that therapy was conducted at bedside with isolated exercises done. PT #3 reported being unaware of the resident's 03-03-2021 X-Ray results of a right femur fracture. In addition, PT #3 was unaware that no pain medication was administered to the resident prior to the 03-04-2021 therapy session. A review of Resident #1's medication orders revealed on 03-03-2021 the attending physician input an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was identified as a new order Pending Confirmation to be completed by the assigned facility nurse. However, further review revealed that on 03-03-2021 at 5:36 PM the assigned evening shift nurse, LPN #2, on 03-03-2021, discontinued Resident #1's order for 25 mg of [MEDICATION(S)] once daily for pain. According to Resident #1's March 2021 MAR, the resident's last administered dose of [MEDICATION(S)] was on 03-03-2021 at 9:00 AM. There was no evidence that staff attempted to administer the standing PRN (as needed) order for 650 mg of Tylenol to alleviate the resident's pain between 03-04-2021 and 03-05-2021. On 03-31-2021 at 2:40 PM an interview with LPN #2 revealed that Pending Confirmation indicated that a new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview revealed that on 03-03-2021 LPN #2 discontinued the order for [MEDICATION(S)] instead of decreasing the frequency of the [MEDICATION(S)] pain medication as ordered by the physician. No additional information was provided by the facility. Further record review revealed on 03-05-2021 at 11:00 AM Resident #1 was transferred from the facility for a scheduled CT scan of the right femur. A review of the 03-05-2021 change in condition by LPN #2 revealed that the attending physician notified facility staff of the CT scan results of a fracture of the right hip with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03-31-2021 at 9:20 AM an interview with the attending physician revealed that on 03-03-2021 Resident #1's order for 25 mg of [MEDICATION(S)] was decreased from twice daily to once daily, secondary to the reported confused behavior of the resident and to maintain the resident's pain management. The order had been entered directly into the electronic medical record system by the physician on 03-03-2021. The physician stated that she was unaware that LPN #2 had discontinued the resident's order for [MEDICATION(S)] prior to the interview with the surveyor. Additionally, she was unaware that the 03-03-2021 emessage from LPN #1 was inaccurate and the results of the right femur X-ray was of a fracture. The physician further stated that if the 03-03-2021 results had been accurately reported, then the she would have ordered the resident transferred to the hospital on 03-03-2021. A follow up interview with the attending physician on 04-01-2021 at 10:00 AM revealed that staff informed the physician that the resident complained of pain on movement. When the resident was assessed by the physician on 02-25-2021 and touched or moved the right lower extremity, then resident would complain of pain on touch or movement. Further interview revealed the reason for use of [MEDICATION(S)] was in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03-31-2021 at 5:00 PM and 04-01-2021 at 11:00 AM with the facility's Interim Administrator and the Director of Nursing revealed no additional information.

Based on surveyor observations, surveyor review of a closed record and interviews with facility staff, it was determined that the facility staff failed to ensure the safety of residents in the facility. The findings include: 1. Based on surveyor observations and interviews with facility staff, it was determined that the facility failed to provide the necessary supervision and ensure the safety of residents in the dining rooms while warming trays/burners were on. This finding was evident in 2 out of 4 of the facility's dining rooms. An immediate jeopardy to residents' health and safety was determined by the state Office of Health Care Quality on 01-19-16 at 5 PM. The immediate jeopardy was abated on 01-19-16 at 5:30 PM following the implementation of corrective actions to ensure the health and safety of residents' in all of the dining areas. After removal of the immediacy, the deficiency practice was lowered to a scope/severity of an E level for the residents in the facility. 1a. On 01-19-16 at 4:05 PM surveyor observation of the Garden View unit dining room revealed a kitchen staff member turning on the warming tray, and then leaving the dining area. During this observation, 3 residents were observed watching television in the dining/activity area. One of the 3 residents, resident #88 is able to self propel in her wheelchair with [DIAGNOSES REDACTED]. Further observation of the warming tray revealed that high heat could be felt with a bare hand from the warming tray. Observation at 4:19 PM revealed a kitchen staff member returning to the dining area to set up cold liquids, but then left the area again at 4:23 PM while the warming tray was still on. The initial 3 residents, including resident #88, remained in the activity area watching TV. On 01-19-16 at 4:35 PM, an alert resident self propelled her wheelchair into the dining room and positioned herself at a dining room table. At 4:40 PM, a Garden View GNA (Geriatric Nursing Assistant) entered the dining room area and began to set up for the dinner meal. Then at 4:55 PM, 2 Garden View GNAs and a kitchen staff member were present in the dining room with the residents. 1b. On 01-19-16 at 4:20 PM, surveyor observation of the Nightingale unit dining room area revealed a burner on with a small pan with water in place and steam observed from the heated pan. Staff members were present at this time within the dining area. Further observation at 4:44PM revealed that a kitchen staff member placed another pan over the water pan on the burner, and then exited the dining room. Surveyor follow up revealed the heating temperature was warm to the touch. Then at 4:45 PM, a resident with dementia was observed entering the dining room area accompanied by her daughter. However, no kitchen staff nor unit staff members were observed returning to the dining area until 4:57PM. 1c. On 01-19-16 at 4:15 PM, surveyor observation of the Chapel Way unit dining room area revealed that the warming tray and burners were not in use. In addition, observation at 4:25 PM of the Forest View unit dining room area revealed that the warming tray was in use, but both a kitchen staff member and unit staff members were in the dining area assisting residents and setting up for the dinner meal. 1d. Surveyor interviews, on 01-19-16 at 5:20 PM, with kitchen staff members in all 4 dining rooms revealed that the warming trays are unplugged when not in use. In addition, Forest View kitchen staff revealed that the warming tray is positioned so that operational knobs face the wall, and residents are unable to access the tray. Warming trays, located in the remaining dining rooms, were observed positioned where the operational knobs were facing forward in which residents could access them without difficulty. 1e. On 01-19-16 at 5 PM, interview with the facility administrator and food service manager to review the results of surveyor observations and a potential immediate jeopardy. Further interview at 5:30 PM revealed that the administrator provided a corrective action plan that implemented immediate in-servicing to all staff, including the kitchen staff and licensed nursing and GNA staff members. In addition, the plan included all warming trays/burners when turned on are to be attended to by a staff member, who will be present at all times. The warming trays' operational knobs are to be facing the wall when not in use, and licensed staff, including GNAs, are to ensure residents are not in the dining rooms unattended when warming trays/burners are on. 1f. On 01-20-16, surveyor review of the instructional manual of the facility's warming trays revealed that the warming tray has a control knob in which the heating element has a range from 155 degree to 205 degree F. 1g. On 01-20-16 at 7 AM, surveyor observations of all 4 dining rooms revealed that warming trays/burners were off and the trays' operational knobs were facing the wall away from resident access. Observation at 7:50 AM of the Garden View and Chapel Way dining rooms revealed that the warming trays were on, and a kitchen staff member was present. At 7:55 AM, observation of the Forest View and Nightingale dining room revealed that the warming trays were on with a kitchen staff member present and unit staff transporting residents into the dining areas. On 01-20-16 at 1 PM, interview with the facility administrator, Director of Nursing and the food service manager revealed no additional information. 2. Based on closed record review, surveyor observation, and facility staff interview, it was determined that the facility staff failed to ensure the safety of resident #281 who was at a significant risk for elopement from 10-11-15 to 10-17-15, at which time the resident eloped from the facility and was found walking along side the highway. These failures resulted in an immediate jeopardy, past non compliance, identified on 01-28-16 for the dates of 10-11-15 to 10-17-15. This finding was identified during the investigation of a facility reported incident and is valid. On 01-28-16, surveyor review of the closed clinical record of resident #281 revealed an MDS assessment on 10-16-15 that documented that the resident was at risk for wandering to a dangerous place. Further review of the clinical record revealed an elopement risk assessment of resident #281 completed on 10-09-15 that documented yes to Resident is wandering aimlessly and scored the resident as 1 out of 9. The section for comments stated that resident may be at risk for elopement. However, there were no evidence of interventions indicated on the assessment. Surveyor review of the clinical record revealed three occurrences when resident #281 wandered off the unit through the stairway fire exit door on the Nightingale Unit on 10-10-15, 10-11-15, and 10-17-15. 2a. Surveyor review of the nurse's notes for resident #281 revealed a note written on 10-10-15 at 4:45 PM that stated resident left the facility this morning without anybody noticing it; he was brought back to the facility and wanderguard was placed to right foot. On 10-17-15 at 3:50 PM, a late entry clarification was written in the nurses notes that stated writer noticed that the fire exit door was opened and the staff went and followed the resident who was on the stairway trying to exit the facility. A wander guard system is an alarm system used to alert staff if a resident who has been determined at risk for elopement, is trying to leave the facility or wander into a restricted area. A transmitter is placed on the at risk resident (typically on a band around the wrist or the ankle) and when the resident approaches a doorway or area equipped with a wanderguard sensor an alarm sounds to notify staff. 2b. In addition, a nurse's note stated that, on 10-11-15, resident #281 was found outside the building by his assigned GNA at about 8 PM, he was brought in the building . was angry and belligerent, was saying things like I can go anywhere I want . (Resident) had wanderguard in place . patient was given 1:1 care on the shift. 1:1 care giver also assigned to the patient on the night shift. This nurses note was written as a late entry on 10-19-15 at 6:25 PM. Surveyor review of an unplanned occurrence report for resident #281 for an incident that happened on 10-11-15 at 8 PM revealed that the resident was found/brought in from outside the building on 10-11-15 . No injury observed. Resident was assigned a 1:1 caregiver on the evening and night shift. The documentation under preventative measures and/or corrective actions taken reflected 1:1 monitoring. This report was completed on 10-19-15. However, there was no evidence that the elopement risk assessment was updated and a care plan for wandering behavior was not developed until 10-13-15 for resident #281. c. Further review of the clinical record for resident #281 revealed a nurses note written on 10-17-15 at 9:01 AM that stated patient found wandering, wanderguard intact to right ankle and functioning. Surveyor review of an unplanned occurrence report for resident #281 written on 10-17-15 revealed that at 6:40 AM the resident wandered off the premises and was found walking along the side of the highway. (The location described by staff was determined to be approximately 1.3 miles from the facility.) The documentation under preventative measures and/or corrective actions taken reflected 1:1 sitter 24/7. After the elopement on 10-17-15, an internal investigation was done by the facility and additional measures were put into place to ensure the safety of resident #281 and to prevent further risk of elopement. These measure included the 1:1 sitter at all times until the resident was discharged on [DATE], elopement risk was reassessed, care plan updated, and immediate in-service training was done on 10-17-15 for all shifts regarding pager use/function, and policy on elopement. Surveyor observation, on 01-28-17 at 3:15 PM, revealed that the fire doors at the top and the bottom of the facility's stairwells did not have wanderguard sensors. Observation of the stairwell on the Nightingale unit, where resident #281 had exited, revealed that the fire doors were alarmed and could not be opened until the exit handle was pushed in for 15 seconds, at which point the lock disengaged and the door was opened. The alarm sounded from the first attempt to open the door and continued to sound until staff entered the code to turn off the alarm. Surveyor interview with the Director of Nursing on 01-28-16 at 3:35 PM revealed that, on 10-11-15, when resident #281 left the building via the stairwell fire exit, the assigned GNA responded to the fire door alarm and followed the resident into the parking lot because the resident was unable to be redirected back to the unit from the stairwell. Once in the parking lot, different staff members were able to get the resident back into the facility. After that incident, a 1:1 sitter was put into place for a couple of days, and then discontinued, due to no further elopement attempts or verbalization of wanting to leave by the resident. It was unclear how long the 1:1 sitter was in place after the elopement attempt on 10-11-15. Surveyor interview with the facility administrator, on 01-28-16 at 3:45 PM, revealed that when an attempt is made to open a fire door, an alarm sounds an alert that is sent to the pagers that staff carry. This alert displayed egress on the pagers during the time period that resident #281 was exiting through the fire doors. The pagers were since then updated to display the specific unit and location after the elopement of resident #281 on 10-17-15 to ensure staff could easily identify where the alarm was activated. 3. Surveyor observation of the door for room #111 on Chapel Way, on 01-28-16 at 3 PM, revealed a live holiday wreath. It was observed to be dried with dropping needles, which poses a fire hazard. Live decorations are not permitted in facilities. On 01-28-16 at 3 PM, interview with staff #1 revealed yes it was a live wreath.